Y Hpc VI$T NAM THANG 5 - SO P^C BlgT/2013
DANH GIA KET QUA DIEU TRj NHOI MAU CO TIM CAP SOM DANG THUOC TENECTEPLASE TRONG 5 NAM TAI DENH VIEN VIET TIEP HAI PHONG
Nguyen Thdng Toan* va cgng sy
TOM TAT
TlT thang 01/2006 den thang 07/2011 chiing toi dieu trj 42 benh nhan nhoi mau ctf tim cap
;(NMCr) bang thuoc tieu sdi huyet tenecteplase tai benh vien Viet tiep Hal phong. Trong do tuoi tmng binh ciia 42 benh nhan 62,26 ± 12,20.
Nam 32 benh nhan (76,19%); nu" 10 benh nhan 1,(23,81%).
Ket qua: ST giam chenh 50% 26 benh nhan (51,91%). ST trd iai binh thuSng 12 benh nhan (28,57%). ST khong thay doi 4 benh nhan (9,52%) ]^ Dp giam chenh trung binh doan ST sau I h diing tenecteplase so vcfi thdi diem nhap vien la:
1,70 ± 1,25 so vdi 4,34 ± 1,43 vdi P < 0,05.
Nhom dung thuoc tru'dc 3h ty le thanh cong 93,75%. Nhom dung thuoc sau 3 - 6h ty le thanh cong 88,46%
Ket qua chup mach: Nhom dlJng thuoc tru'dc 3h ty le thanh cong 87,50%. Nhdm dung thuoc au 3h ty le thanh cong 76,92%
Bien chu'ng roi loan nhip t i m : Ngoai tam thu .hat 14 benh nhan (33,33%); nhip tiT that gla toe i benh nhan (7,14%); ctfn nhjp nhanh tren that ibenh nhan (4,76%); chay mau nhe (chan rang, ldi tiem) 5 benh nhan (11,90%)
Ket luan: Thuoc tenecteplase co tac dung tot rong i ^ u tri nhoi mau cd tim cap den sdm tru'dc 6h lii t/ le thanh cong tren lam sang la 90,48%.
iUMMARY
From 01/2006 to 07/2011 we treated 42 atients with acute myocardial infarction (MI) 'ith fibrinolytic drug tenecteplase at Viet Tiep ai Phong Friendship Hospital. In which the rerage age of the 42 patients 62,26 ± 12,20
Benh vien Viet Tiep Hai Phong
including 32 males (76,19%) and 10 females (23,81%).
Results: ST elevation reduced 50% of the 26 patients (61,91%). ST returned to normal In 12 patients (28.57%). ST doesn't change In 4 patients (9,52%)
The average reduction of ST elevation after I h using tenecteplase compared with the time of admission were: 1.70 ± 1.25 vs. 4.34 ± 1.43 with P <0.05.The group of using drug before 3-6 hours has success rate of 93,75%. The group of using drug after 3-6 hours has success r a t e o f 88,46%
Angiographic results: The group of using drug before 3hours has success rate of 87,50%.
Group of using drug after 3hours has success rate of 76,92%.
Complications of arrhythmias: there was 14 patients suffering from ventricular premature (33,33%); 3 patients suffering from ventricular free acceleration (7,14%); 2 patient suffering from severe supraventricular tachycardia (4,76%); 5 patients suffering from mild bleeding (root of teeth, injection area) (11,90%)
Conclusion: The drug tenecteplase has good effect in the treatment of acute myocardial infarction arriving before 6 hours with a success rate of 90,48%.
I. OAT VAN OE
NMCT ngay cdng tang va ty le tu vong con cao dung hdng dau cr cac nuac dang phdt triSn. Hien nay co 3 phuang phap dieu tri tdi tuoi mau trong NMCT: dung thuoc tieu sgi huy^t, can thiem dgng mach vdnh cap, mo
167
CHUYSN ti6: H^i NGH| KHKT CAC TINH VUNO puveN HAI Bfa B ^ LAN THO NH/IT
bac cau noi chu vanh.
Chung toi tien h ^ h nghien CLTU de tai "
dieu tn nhoi mdu ca tim cap s6m bang thuoc tieu sgi huyet tenecteplase" a tuyen tinh ik mpt nhu cau cap thi^t.
De tki c6 2 myc tieu: Ddnh gid hi^u qud dieu Iri .SOW! ciia lenecleplase Iren b^nh nhdn nhoi mdu co lim cdp.
Xdc dinh Idc dung khong mong muon ciia lenecleplase Iren benh nhdn nhoi mdu co tim cdp va de xual bien phdp xic tri.
II. oo'l TJ^NG NGHIEN COU
D6i tugmg nghien ciJu g5m tat ca cac benh nhan du-prc chan doan NMCT cSp diSu trj tai b$nh vien Viet -Ti^p tit thang 10/2008 den thang 7/2011.
Tieu chuan chpn benh nhan: Benh nhan dupc chin doan NMCT cjp co ST chenh len nhap vien truac 6 gia. ChAn doan NMCT cip dua vao cac tieu chuin kinh iiin theo WHO.
Tieu chuan loai trir: Cac ch6ng chi dinh vai thu6c tieu spi huySt
III. PHUONG PHAP NGHIEN CC(U Thiet ke nghien cij'u:
Nghien cihi tien cim thir nghiem lam sang, can thiep, sp sanh tu chimg, theo doi dpc tir khi vao vien cho den khi ra vien hoSc tir vong.
Danh gia ket quii dieu trj sdm NMCT cap bang tenecteplase.
Thuoc tenecteplase (Metalyse): ong tiem tTnh mach 50mg (lO.OOOUl) cua hang IV. KET QUA NGHIEN COU
Phan bo b|nh nhan theo tu8i vk %\iA Bdng 3,1: Phan b6 benh nhan theo tu6i.
Boehringer Ingelheim (Dire).
• Cdch diing: Pha loSng lp thuflc boi v6i 10ml nirdc dung moi di kem, lac d^u ciio tan thu6c, tifim tinh m^ch true tiep mpt iieu duy nhat, thai gian tidm 5-10 giay.
• Lieu luang: 0,5mg /kg.
- Ddnh gia ket qua nghiSn cihi:
..- Thanh cong: Lam sang: hit dau ngyc, cai thipn huyflt dpng, co the co h0i chiing tai tudi mau. ECG: ST trcr ve binh thuong liojc gidm chenh ro > 50%. Chup vanh: TIMI 2-3, ..- That bai: Lam sang: dau ng\rc van tdn tsii, khong cai thipn huyfit dpng. ECG: ST van chenh nhu cu. Ch\ip vanh: TIMI 0-1.
Xac dinh tac dyng khong mong mu^n cua tenecteplase tren benh nhan nhoi mau Cff tim cap va d l xuat bien phap xii' tri;
- Xuat huyet ngoai ndo: Theo doi tren lam sang chdy mau chan rang, ddi man, clliiy mdu cho tiem thuoc, xual huyfit tieu hoa...
sau diing tenecteplase Igia, 3 gid, 6gid, 12gid, 18gid, 24gi6 vd hdng ngdy.
Xudt huyfit nao: theo doi diln bijn bang thang difim Glasgow sau dimg tenecteplase. Chup cat Idp vi tinh sp nao nSu cd nghi ngd.
- Theo doi roi loan nhip tim lifin tyc bJng monitoring vd difin tam dd, do huyfit ap, theo.
ddi phan iing dj iing va soc phan ve ngay sau diing thudc tenecteplase Igid, 3 gio, 6giii, 12gid, 18gid, 24gid vd hdng ngay.
Xir ly sd lieu nghien ciru theo phuong:-:
phdp thdng kfi y hpc SPSS 16.0.
Nhom tuoi 40-49 50-59
Ty le C/o) 14,29 31,43
Y HOC VIET NAM THANG 5 • s 6 DljS^ BlgT/2013
6 0 - 6 9 7 0 - 7 9
> 8 0 Tonq A ' i S D
9 9 1 35 35
25,71 25,71 2,86 100 61,26 ± 10,27 Nhgn xit: Tudi trung binh: 61,26 ± 10,27.
Sijrthay doi di^n tim sau dung tenecteplase
Dien t i m
ST qiam chenh > 5 0 % ( 1 ) ST t r i lai binh thu'dnq (2) ST khonq thav doi (3) Tonq
n 22 10 3 35
T y le ( % ) 62,86 28,57 8,57
100
P
Po-2) < 0,05 P(i-3) < 0,05
Nhgn xit: Ca 2 nhom ST giam chenh>50% va ST tro ve binh thuong ciiiem 91,43%.
Ket qua Bdng 3,3
chup dpng mach vanh kiem tra sau dimg tenecteplase
• Lien quan thay ddi gii^a ST va ket qua chup mach vanh.
Dien tim
Khong chup iMc DMV
Chup vanh
TIMIO TIMIl TIMI 2 TIMI 3 Tonq
STtrdve binh thu'dng
3 (30%) 7 (70%) 10 (100%)
ST giam chenh
> 5 0 %
1 (4,55%) 13 (59,09%)
8 (36,36%) 22 (100%)
ST khong thay doi
1 (100%)
1(100%) Tong
2 1 1 16 15 35 Nhgn xet: Nhom ST tra ve binh thuong, Icet qua chup dpng mach vanh kiem tra ty le TIMI 2 va 3 dat 100% trong do TIMI 3 dat 70%.
Nhom ST giam chenh tren 50%, k^t qua chup dong mach vanh kiem tra ty le TIMI 2 va 3 l^t 95,45% trong do TIMI 3 dat 36,36%.
Bang 3.4; Lien quan giira thdi gian dung thudc va Thdi gian
Ket qua
Thanh conq (TIMI 2 va 3) . That bai (TTMI 0 va 1)
Tonq
S 3 c n 11
1 12
id
»/o 91,67
8,33 100
ket qua chup vanh.
3 - 6 gid n 20 1 + 2 = 3 21+2=23
%
86,95 13,05 100
P
>0,05
>0,05
Nhdn xet: Dimg thufic mrdc 3 gid ty lfi thanh cdng 91,67%. Sau 3 - 6 gid thanh cong 86,95%.
CHUYfeN pg; Hpl NGH| KHKT CAC TJNH VUNG PUY£N HAr BAC BQ LAN THlf NHAT Sir thay doi nhip (im sau diing tenecteplase
Bdng 3.5: Su thay doi nhip tim sau diing tenecteplase Thay
doi nhjp Sau 1 qid Sau 3 qid
Xda block A-V n 1 0
%
2,80 0
Ngoai tdm thu that n 13 0
»/o 37,14
0
Nhjp tir that qia tdc n 2 0
%
5,60 0
Cdn nhjp nhanh tren that n 1 0
o/o 2,80 0
Rung thSt n 0 0
%
0 0 Nhdn xet: Gap nhieu nhat la xuat hi$n ngoai tam thu that chifim ty le 37,14%.
Cac tac dung khong mong muon
Bdng 3.6: Cdc rdi loan ddng mau va phdn irng di irng sau diing tenecteplase.
Tac dung khdng mong mudn Chav mau chan ranq Dal mau Chay mau ndi tiem Xuat huvet tlfiu hda Xuat huyet nao Di irnq thuoc, soc phan ve Tonq sd
n 3 1 1 0 0 0 5
Ty le (%) 8,57 2,86
2,86 ' 0
0 0 14,29 Nhdn xet: Xuat huyet ngoai nao (14,29%), khong co trucmg hop nao xu4t huygt nSo. C^
phan ung di ung thuoc va soc phan ve khong gap trucmg hop nao.
Cac bien phap xu' tri cac tac dung Tac dung khong mong muon Chay mau chan rang Dai mau Chay mau ncJi tiem
Roi loan nhip: ngoai tam thu that, nhjp tu"
that gia toe, cdn nhip nhanh tren that
khong mong muon Bien phap xiT tri
Giam lieu heparin, dap bong tam adrenaiin cho chay mau chan rang
Giam lieu heparin
Giam lieu heparin, bSng ep vi trf chay mau ndi tiem
Xylocain 2% Img/kg tiem tTnh mach
A
%
Nhgn xet: Cac rfii loan dong mau: chdy mau chan rang, chdy mdu nai tiem, dai mau mirc dp nhe dp qua Iifiu heparin chi cdn giam lieu heparin (dua theo APTT 1,5-2 ldn chimg), bang ep vi tri chdy mau noi tifim, ddp bdng tdm adrenalin cho chdy mdu chan rang.
Cac rdi loan nhip: ngoai tam thu thdt.
nhip tu thdt gia tfic. can nhip nhanh hen thil dupc xir tri tifim xylocain 2% I mg/kg tiem tTnh mach, dfiu hfit sau vai phut.
V, BAN LUAN * 1. Phan bo benh nhan theo tuoi: St
tudi thudng gJp tir 40 dfin 79. Nhdm tu6i ^ | 170
Y HOC VlgT NAM T H A N G 5 - SO O^C 8ieT/2013
nhiSu nhat tir 50 - 59 tuoi. Tu6i cao nh^t: 81,
^u6i thap nhit: 46. Tu6i trung binh: 61,26 ± ,,10,27. K^t qua nghien cuu tuong duong voi jac gia khac.
1, 2. Su thay doi dien tim: Ca 2 nh6m ST
^am chenh >50% va ST tro ve binh thucmg
^chiSm 91,43%. Co su khac biet giOa nhom ST giam chenh > 50% voi cac nhom ST tro Iai binh thuang va ST khong thay doi, su khdc biet CO y nghia thong ke (p < 0,05). Sau 1 gi6f Jiing tenecteplase, ST giam chenh so voi thai 3ilm nhap vien tu 4,34 ±1.43 mV xu6ng con 1,10 ± 1,25 mV. Co su khac biet do giam ciienh doan ST sau 1 gicr dung thuoc tieu soi huyet tenecteplase so vai thoi diem vao vien :6 y nghta thong ke so voi p < 0,05.
3. Ket qua chup dong mach vanh:
Nhom ST tro ve binh thuang. ket qua chup dgng mach vanh kiem tra ty le TIMI 2 va 3 lat 100% trong do TIMI 3 dat 70%. Nhom 3T giam chenh tren 50%, ket qua chup dong nach vanh kiem tra ty Ie TIMI 2 va 3 dat
^5,45% trong do TIMI 3 dat 36,36%. Nhom
^^N dugc diing thuoc truoc 3 gio ty le thanh ing sau chup DM vanh ki^m tra la 91,67%.
hom sau 3 - 6 gio co ket qua chup DM bih thanh cong la 86,95% (2 BN dugc danh li la that bai do BN tu vong khong chup irpc). Su khac biet ty le thanh cong giu'a 2 liom truoc va sau 3 gia khong co y nghTa i6ngke voi p> 0,05.
4. Su- thay doi nhip tim: Roi loan nhip tl sau dung thuoc tenecteplase gap nhieu tiat la xuat hien ngoai tam thu thit chi^m ty ' 37,14%. Xuat hien roi loan nhip tim chi g^p gid dSu tien sau dung tenecteplase,, khong iay roi loan nhip tim 6 cac gid sau.
5. Cac tac dung khong mong muon:
i- - Cac roi loan dong mau: chi gap xuat
huyet ngo^i nao (14,29%), khong co truang hgp nao xuat huyet nSo. Cac phan ung di ung thuoc va soc phan ve khong gap truang hgp nao. Cac roi loan dong mau: chdy mau chan rang, chay mau noi tiem, dai mau muc do nhe do qud lieu heparin chi can giam lieu heparin (d\ra theo APTT 1,5-2 Ian chung), bang ep vi tri chay mau noi tiem, dip bong tam adrenalin cho chay mau chan rang.
- Cac roi loan nhip: ngoai tam thu that, nhjp tu that gia toe, can nhip nhanh tren that dugc xir tri tiem xylocain 2% Img/kg tiem tTnh mach. deu het sau vai phut.
VI. KET LUAN
1. Tenecteplase co tac dung tot trong dieu trj nhoi mau cff tim cap den som trirdfc 6 gid".
- Tenecteplase dugc cbi dinh dua vao 2 trieu chuan chan doan la lam sang va dien tim.
- Thanh cong cua thuoc dugc danh gia Iam sang va dien tim la 91,43%. Truoc 3 gia thanh cong 91,67%, sau 3 gio thanh cong 91,30%.
- Thanh cong dugc danh gia tren ket qua chup dong mach vanh (TIMI 2-3) la 88,57%.
Truoc 3 gio thanh cong 91,67%, sau 3 gio thanh cong 86,95%.
2. Tenecteplase trong dieu tri NMCT cap it gay tac dung khong mong muon.
- Bi6n chung tim mach, roi loan nhip tim: ngogi tam thu thdt (37,14%), nhip tu thdt gia t6c (5,72%), nhip nhanh tren that (2,86%). Tdt ca cac loan nhip deu khong nguy hi^m, xu tri tiSm xylocain 2% lieu 1 mg/kg can nang. cac loan nhip deu bet sau vai phut.
CHUVeN pg: Hpr NGHj KHKT CAC TIWH VUNG DUVfeN HAI BAC BQ LAN THCT NHAT
- Bien chung xuat huyet, roi loan dong mau: Xuat huyet ngoai nSo 5 benh nhan (14,29%) do qud lieu heparin, giam li^u heparin h^t chdy mau. Khong co xudt huylt nSo.
- Bi^n chung di img: Khong gdp s6c phdn ve mdc du khong diing Solu-medrol va Dimedrol nhu khi diing streptokinase.
TAI LIEU THAM K H A O
1 Aldrovandi A. ct al. (2011), "Acute myocardial infarction without significant coronary stenosis: evaluation by LE-CMR and CT coronary angiography", .Journal of Cardiova.scular Magnetic Resonance 2011.
13 (Suppl I), pp. 76.
2. Andersen H. R. et al. (2003), "A
Comparison of Coronary Angiopjas^ wjih Fibrinolytic Therapy in Acute Myocanliai Infarction", N Eng J Med. 349, pp. 733-742.
Bartecchi C E . (2001), "Thrombolyg therapy in the setting of acute myocardial infarction", J. Am. CoU. Cardiol.200\, pp.
77-92
Bonnefoy E., Steg P. G., Boutitie F. et al (2009), "Comparison of primary angioplas^' and pre-hospital fibrinolysfs in acute myocardial infarction", Eur Heart J (2009) 30. pp. 1598-1606.
Callff R., Gibler W.B., Gibsson M. et al (2000), "Myocardial reperfusion: New strategies for Ihe new century". Clinician, 2000, 18, pp. 4-23.
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