KHAO SAT TiNH HINH CHI DjNH CAC XET NGHIEM THUOC BO M 0 TRONG MOT SO BENH T H I A N G GAP
T 6 N T H A T Q U V N H T R U N G ' , P H A M THANH PHONG', Lfi VU HONG HAI', NGUYEN THj NGpC DUNG', T R A N HlJU T A M "
Trung tdm Y khoa Phudc An (HEPA)
~Trung tdm Kiim chuin Xdt nghi$m TP.HCM
TOM T A T
Bdn cgnh cdc xdt nghidm chuydn bidt, cac xdt nghidm lidn quan din chuyin hda md (Cholestemi, HDL - Cholestemi. LDL - Cholestemi, Lipid mdu.
Triglyceride) - thudng ggi Id xdt nghidm bd md, ta xdt nghidm tuang dii thudng quy tmng si nhdng xdt nghidm sinh hd tmng vide chin ddn. diiu tri cdc bdnh nhu tim mgch. tiiu dudng....
Nhim ddnh gid stf tuang ding (ho$c khdc bidt) trong vide ehl dinh eda bae sTIdm sSng dii vdi dc xdt nghidm thudc bd md trong vide theo doi diiu tri dc benh thudng gdp. nhdm nghidn citu da tiin hdnh khio sit tinh hinh chi dinh da bic sT dii vdi eae xdt nghidm thude bd md Id Cholestemi. HDL - ChdestemI, LDL Cholesterol. Lipid mdu.
Triglyceride, so sdnh vdi cdc khuyin eSo da quoc ti va Viet Nam, rOt ra cac kit ludn vd cung cip cae si lidu di giup eho dc nha khoa hgc. nhd quin Ip vd bae sT Idm sing d cdi nhin rd han vi tinh hinh chi dinh dc xet nghidm thude bd md dii vdi cdc bdnh thudng gdp so vdi dc hudng din diiu tri,, qua dd xdy dung dc chinh saeh, ki hoach di chuin hda cdng tac quin ly vd nang eao ehit lugng xdt nghidm, chi dmh phu hap di tUt kidm chi phi xdt nghiem eho benh nhan.
Tdkhda: Xdt nghiem bd md. Cholesterol, HDL - Cholesterol. LDL - Cholesterol, Lipid, Triglyceride.
SUMMARY:
Beside the particular tests, the tests of lipid metabolism (Cholesterol. HDL - Cholesterol, LDL - ChdestemI, Lipid, Triglyceride) - usually called the lipid metabolism tests, are the routine tests of clinical biochemistry in diagnosis, treatment of cardiac syndrome, diabetes,...
With the aim to evaluate the same (or the difference) between physicians's ordering in the test of lipid metabolism tests for treatment or controlling of Ibe usual diseases, we do the study to survey the situation of physidans's test order such as Cholestemi. HDL - Cholesterol. LDL - Cholesterol, Lipid, Triglyceride, and compare with the intemational guideline or Vietnamese guideline, so that we can give conclusions and data to help the scientists, the policymakers, physicians have a view of the situation in ordering of lipid metabolism tests for the usual diseases compare to the guidelines, in order to set up policies, plans to standardize the quality management, to impmve quality of clinical diagnosis.
to have a better test order, so that the patients can save much money for unsuitable diagnosis.
Keywords: Lipid metabolism tests, Cholestemi, HDL - Choiesteroi. LDL Cholesterol. Lipid.
Triglyceride.
OAT VA'N Oi:
Trong mot sfi bdnh \p thudng gSp nhU tim mach, t i l u dudng,...ben canh cae xet nghidm chuydn biet, cac xet nghiem thudc bfi md (Choiesteroi, H D L - cholesterol, LDL - cholesterol. Lipid mdu, Triglyceride) thudng dupc bac si" lam sing chi djnh 3$ bd sung cho vific theo doi. d i l u tri, eOng nhu danh gia k i t qua hoac di ra myc tieu i ^ l u tri.
Tuy nhien, do quan diem va kinh nghiem ciia cac bac Si khae nhau, do dd cd sU k h i c nhau trong viec ehl dinh cae ch? so xet nghiem nay. Nham ed dupc cae sd lieu thdng kfi ve viec chi dmh tren, nhdm nghien eUu da tien hanh khao s i t tinh hinh ehi djnh cac chi sd xet nghiem thufic bd md ddi vdi eae nhfim benh thudng gap la: cao huyet i p ; tieu dudng type 2;
rfii loan chuyen h o i lipid; ntidi mau eo tim; suy maeh vanh tim/thieu mau eO tim cyc bp; xO vCfa ddng mach;
tai bien maeh mau nao, rdi loan tuan hoan naoAhieu mau nao; gan nhiem md. So sinh vdi c i c tai lieu eda Viet Nam va the gidi v l viec chi ^ n h eae xet nghiem nay, tu dd, ed t h i phan tfeh eu the sU khac biet hoac tUdng ddng, su phCi hpp vdi dc khuydn cao cCia Viet Nam va the gidi trong vide chi dinh ede xet nghiem theo doi cae benh \p nfiu trdn, nham giup cho cae nha quin \p, nha khoa hoc danh gia lai thue td. eung nhu xay dung eac chfnh saeh d l giiip tdi uu hda viee sCf dyng c i c xet nghiem thude bd md, phyc vu tdt nhat vide theo doi dieu tri benh, tilt kidm dugc kinh phi lam xet nghiem cho benh nhan.
D6\ jyJONG VA PHJONG PHAP NGHIEN COU:
1. Do'i tupng:
C i c xet nghiem thupc bd md bao gdm Cholesterol, HDL - Cholesterol (HDL-C), LDL - Cholesterol (LDL-C), Lipid m i u , Triglyceride.
43 b i c sT lam sang dang cfing tae trong ITnh vUe khim chiifa benh ngoai tnJ tai c i c quan 4, 6, 10 va PhtJ Nhuan-TP.HCM.
2. Phuong phip:
Phuong phip nghifin e i ^ la phuong phip cat ngang mfi ta.
Cif dieu tra vien den quan sat tinh hinh ehl iSnh
T H Q C T H ^ C H A N H (881) - S6 10/2013
cac x i t nghifim thude bfi md trfin bfinh n h i n thufic cac nhfim bdnh: cao huylt Sp ngUdI t r i ; t i l u dudng type 2; rdi loan chuyin h o i lipid; nhfii m i u cd tim; suy mach v i n h tim/thilu m i u eo tim cyc bfi; xd vCfa dfing maeh, tai b i l n maeh m i u nao; r^i loan t u i n h o i n nao/thilu m i u n i o ; gan n h i l m md.
- Sfi liSu thdng kfi tinh hinh chi djnh c i c x i t nghidm thufic bfi md lidn quan dfin c i c bdnh \p ndu trfin duoc trich x u i t tit p h i n m I m q u i n \p y khoa va
ho so bdnh an cOa ddn vi y t l dUpc khao s i t . - Phdn tfch cac sfi lifiu thu dupc bang phan mdm thfing kd Stata 10.0, excel.
K i t q u i thfing kfi se dUde quan s i t v i biin ludn, k i t hpp vdi cac tai lieu, hudng d i n ^ l u trj cOa Vifit Nam v i t h i gidi (cae hiep hfii nhU ChSu Au:
ESH/ESC; Mp: AACE, ADA, NCEP, AHA/NHLBI, ACCF. ASA, AASLD...).
K£'T QUA VA BAN L U A N :
1. Ty I9 xfit nghj$m bp m d d u ^ c c h i djnh tudng Ong vdi c i c b^nh nghien cdu
T i l n hdnh thfing kfi d l khu trti cac bdnh thudng dupe chi dmh xet nghifim bfl md trong sfi nhiifng benh khao sat.
Bfinq 1. T^ is (%) c^c b6nh dlftjc clll dinll c^c xet nflhiSm ttiu6c b6 mfl
Cliolesteroi HDL-C LDL-C Triqivceride
Lipid mdu GW c/ii): t9
Ting sfi chldjnii x6t ngtiiOm
tidmO nam 2012
Ca 34.069 34.466 34.463 37.500 3.700 e trgn dOd
Cao huvfil ap
57,0
(%)
58,0 58,0 57,1 52,6 : t i n t i c h o
TiSu duflng type 2 28,2
(%)
28,7 28,7 28,9 23,1 nhijfng t n .
Rtii ioan cliuyin iioa lipid
55,0
(%)
52,2 52,2 53,1 61,9 d n g hcJp
NhSi mauca
tim
(%)
0,70,7 0,7 0,7 1,1
Suymgdi vdnii tim/ttii£u mdu CO tim
cue tid 27,4
(%)
25.9 25.9 26,6 22,4
>enh c d c h i d i n h x e
III
(%|
0,5 0,5 0,5 0,5 0,2 n g h i d n rTai bidn mgcti mdu nao (%1 0,7 0,7 0,7 0,7 0,6 tuong
loan tu3n iiodn nSo {%) 3,2 2,9 2,9 3,0 1,9
Gan nhi&m md
(»
6,2 7,2 7,2 6,8 8,7 J n g , d o d o c o the t r o n g b f i n h c a o h u y e t i p , m d t s d b e n h n h i n c d k e m t h e o tieu d u d n g t y p e 2 t h i v i n dUOc t h f i n g k e .T U diJ* lieu t r o n g B a n g 1 . c a c x e t n g h i e m t h u d c b d md dupc c i c b i c sT chi dinh de chan doan v i d i l u tri chO y l u cho bfin loai bfinh sau: eao huylt ap; benh tieu dudng type 2, rdi loan chuyen hoa lipid; v i benh suy mach vanh tim/thilu mau cd tim eye bd. Trong dfi, eao huydt ap (chiem tU 52,6% den 58% tong sfi chi djnh mfii xet nghiem bo md) va rdi loan ehuyin hoa lipid (chilm tU 52,2% den 61,9% tdng sd ehi dinh mdi xet nghifim bd md) la hai loai benh cfi t^ lfi ehl djnh xet nghiem bfi md cao nhiL
2. Phan tich vj$c c h i djnh bg md trong c i c benh theo khuyen cdo cua Vi^t Nam va the gidi
E)di vdi tat ca c i c loai bfinh trong khao s i t , cac tai lieu cQa Viet Nam va qufie te ddu khuyen eao ed t h i clii djnh bfin loai xet nghiem cholesterol, HDL-C. LDL- C v i triglyceride de chan d o i n va dieu tri, trong dfi LDL-C lufin la mue tieu dieu tn cd ban. Nhu vay, trong bdn loai xet nghiem n i y , xet nghiem LDL-C l i xet nghiem dupc Uu tien chi djnh so vdi ba x i t nghifim con lai. Ngoii ra, trong t i t ea khuyfin cao cQa Vidt Nam va qufie t l , khfing cfi td chde n i o khuyfin cao sijf dung xet nghifim lipid d l chan doan va theo dfii d i l u trj eae loai bdnh tren.
c a n cLf tren k i t luan n i y , nhdm khao sat tien hanh d i n h gia viec ehl dinh xet nghifim bfi md cOa cac bae sT theo mpt trong hai tieu ehi nhu sau:
- Tieu ehi 1 (tidu chi duge khuyin cdo): \Ju tien chi djnh xet nghiem LDL-C (#95% benh nhan dUdc chi dinh bd md efi LDL-C); v i khdng
chi dmh hoac c h i dinh xet nghiem lipid vdi p h i n trSm khdng dang k l (<5% bfinh nhdn dUpc chi djnh lipid).
- Tidu ehl 2 (tidu chi khdng dugc khuyen do): Khfing Uu tien c h i djnh xet nghifim LDL-C (<95% bfinh nhan dugc ehi djnh bd md cd ehi dmh LDL-C) hoac cfi chi dinh xet nghiem lipid (#5% bfinh nhSn dupe ehi djnh lipid).
• C h i d j n h x e t n g h i e m bo m d t r o n g benh cao huye't ap
Ddi vdi bfinh cao huyet ap, efi 23/43 (53,5%) bac sT chi djnh xet nghifim phCi hpp vdi c i c khuyen cao ciia Viet Nam v i the gidi (tifiu chi 1); cfi 20/43 (46,5%) bae sT ehl djnh xet nghifim khdng phu hpp vdi c i c khuyin e i o (tifiu chi 2).
• C h i d j n h x e t n g h i e m bo m d t r o n g benh t i e u d u d n g t y p e 2
Ddi vdi bfinh t i l u dudng type 2, efi 19/43 (44,2%) bae sT chi djnh xet nghifim phu hpp vdi e i c khuyin c i o eda Vifit Nam va thd gidi (tieu chi 1); cd 24/43 (55.8%) bac si" chi dinh xet nghifim khfing phd hpp vdi eae khuyfin eao (tifiu chi 2).
• Chi d j n h x e t n g h i e m b o m d t r o n g rdi loan c h u y e n h o a l i p i d
Odi vdi rdi loan chuyin h o i lipid, co 20/43 (46,5%) b i c sT chi djnh xet nghifim phu hpp vdi c i c khuyen cfio ciia Viet Nam va the gidi (tifiu chi 1); efi 23/43 (53,5%) bac sF ehi (^nh xet nghifim khfing phii hop vdi cac khuyfin cao (tifiu chf 2).
Y HOC THVC HANH (881) - SO 10/2013
• Chi d j n h xfit n g h i e m b p m d d o i v d i benh nhdi mau c d t i m
Dfii vfii bfinh nhfii mau co tim, cd 17/25 (68,0%) bic si* chi djnh xfit nghiem phi^ hpp vdi cdc khuyin cao cfla Vifit Nam v i the gidi (tieu chi 1); cfi 8/25 (32,0%) b i e sT ehi <^nh xet nghiem khdng phii hpp vdi cac khuyin cao (tieu chi 2).
• Chi d j n h x e t n g h i a m bp m d t r o n g b^nh suy mach v i n h tim/thie'u mau c d t i m CMC b p
Ddi vdi benh suy mach vanh tim/thilu m i u cd tim cue bfi, cd 21/41 (51,2%) b i c sT chi djnh xet nghifim phij hpp vdi e i c khuyin edo eOa Viet Nam va t h i gidi (tieu chi 1); efi 20/41 (48,8%) b i c sT chi djnh xet nghiem khfing phu hpp vfii e i c khuyfin c i o (tifiu chi 2).
• C h i d j n h x e t n g h i a m b o m d t r o n g b^nh xOvQa d p n g m a c h
Ddi vdi benh xd vita ddng maeh. cfi 19/24 (79,2%) bac sT chi i^nh xet nghiem phij hpp vdi c i c khuydn cao efla Viet Nam v i t h i gidi (tifiu ehi 1); ed 5/24 (20,8%) bae sTchl djnh xdt nghiem khfing phu hdp vdi cac khuyin c i o (tieu chi 2).
• Chi d j n h xfit n g h i # m b p m d t r o n g b f n h tai bien mach m i u n a o
D^ vdi bfinh tai b i l n mach mau nao. cd 20/32 (62,5%) bae sT chi djnh xet nghifim phu hop vdi ede khuyen eao efla Vifit Nam va t h i gidi (tifiu chi 1); cd 12/32 (37,5%) bde sT khdng phu hdp vdi cac khuyin cao (tifiu chi 2).
• Chi d j n h x d t n g h l p m b p m d t r o n g benh rdi loan t u i n h o i n n a o / t h i e u mau nao
Q6\ vdi bfinh rdi loan t u i n h o i n nao/thie'u m i u nao, cd 18/29 (62,1%) bae sT ehl djnh xet nghiem phu hdp vdi cic khuyen c i o cOa Viet Nam va the gidi (tifiu clii 1); cd 11/29 (37,9%) bac sT chi djnh xet nghiem khdng phii hpp vdi cae khuyin e i o (tieu chi 2).
• Chi d j n h x e t n g h i p m bp m d t r o n g benh gan nhifim m d
Ddi vdi benh gan nhilm md, cfi 16/32 (50,0%) bac sT chi djnh xet nghiem phu hpp vdi c i c khuyen cao ciia Vifit Nam va thfi gldi (tieu chi 1); cfi 16/32 (50,0%) bic sT chi djnh xet nghifim khfing phu hdp vdi cae khuyen c i o (tifiu chi 2).
TO
M 10
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Hntm bfnfi khio • « 1
Hinh 1. Bieu do thfing kfi tp le (%) bac sT ehi <^nh phii hpp tieu chi 1 hoac 2
Kir LUAN
• Cae xet nghiem bfi md duOc b i c sT chi djnh di chin d o i n va ffleu tri bdn loai benh chfl yeu sau: benh cao huyet ap. tilu dudng type 2, rdi loan chuyin fioa lipid v i nhfii mau cd tim. Trang dd. bfinh eao huyet i p va rfii loan chuyen hoa lipid la hai loai bfinh ed tf le ehi djnh xet nghiem bd md eao nhat
• Theo khuyen cdo efla Vifit Nam va qudc te, xet nghiem lipid khong dupe chi i^nh d l chin doan va dieu trj cac loai bfinh trong khao sat. Tuy nhifin, qua khio sat nhan thiy, xet nghifim lipid v i n eon dupc mdt sfi bicsTchi^nh,maedu vdi t^ Ifi tuOng ddi thip.
• Jp lfi bac sT chi djnh xet nghiem bfi md khdng phu hpp vdi c i c khuyen eao (khfing uu tien chi dinh xfit nghiem LDL-C hoac cd chi dinh xet nghifim lipid) edn cao (tU20,8-55,8%).
KIEN NGHj
- Md rdng pham vi nghifin eUU them nhilu qufin huyen tai TP.HCM hoac nhieu tinh khic d l efi sfi liiu Idn hdn trang ddnh gia va phan tfeh.
- C i n ban hanh eae phit dd chi dinh cae can lam sang va xet nghiem chuan tuong Ung vdi timg benh, tU dfi iam can ei^ phap \p hoac chuyfin mfin de eae bac sT tham khao, chi djnh thfing nhit, phii hpp vdi e i c khuyen cdo.
T A I L I $ U T H A M K H A O :
1. Hoi Tim mach hpc Viet Nam (2011), "Khuyen eao 2010 v l cac benh 1;^ tim mach va ehuyen hoa", NXB Y hoc Chi nhanh Tp. HCM,
2. American Diabetes Association. "Standards of Medical Care in Diabetes—2013." Diabetes Care 36.Supplement 1 (2013): S11-S66.
3. Gnjndy, Scott M., et al. "Diagnosis and management of the metabolic syndrome an American Heart Association/National Heart, Lung, and Blood Institute scientific statement." Cimulation 112.17 (2005):
2735-2752.
4. Handelsman, Yehuda, et al. "American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan." Endocrine Pmctice 17 (2011). 1-53.
5. Panel, Adult Treatment. "III." Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and trealrnent of high blood cholesterol in adults (adult treatment panel III). JAMA 285 (2001): 2486-2497.
6. Smith, Sidney C , et al. "AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease:
2011 UpdateA Guideline From the American Heart Association and American College of Cardiology Foundation Endorsed by the Worid Heart Federation and the Preventive Cardiovascular Nurses Association."
Joumal of the American College of Cardidogy 58.23 (2011): 2432-2446.
7. The Task Force for the management of arterial hypertension of Uie European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).
"2013 ESH/ESC Guidelines for the management of arterial hypertension". European/Vear/Joi/ma/(2013).
T H Q C THirc HANH (881) - S6 10/2013
