Y Hpc TP. Hb Chi Minh * Tap 15 * So 1 * 2011 N g h i e n cihi Y hoc
DAC DIEM DICH xf VA LAM SANG CUA VIEM N O I TAM MAC N H I I M K H U A N TAI BENH VIEN CHO R A Y TRONG 10 NAM (2000-2009)
Truang Quang Binh* Trdn CongDuy*
TOM TAT
Muc tieu n^ien cihi: Idido sdt dac diein djch te vd lam sdng ciia viem noi tdm mac nhiem khuan (VNTMNK) tai bmh vien Cha Rdy trong 10 ndm (2000-2009)
Doi tuang vd phuongphdp nghien cuu: nghien deu cdt ngang mo td. hoi cieu tren tai cd benh nhdn nhap khoa Noi tim mach, benh vim Cha Rdy tie 1/1/2000 den 31/12/2009 thoa tieu chuan Duke cdi bien ve chan dodn VNTMNK.
Kei qud: Co tdi cd 225 benh nhdn VNTMNK trong 10 nam. Tuoi trung binh cua benh nhdn Id 37,91 ± 15,37. Nhom tuoi mac benh nhieu nhai Id dudi 25 tuoi (24,89%), tiep dm Id nhom 26-35 tuoi (24%). Ti le nam/na mdc benh Id 1,25/1. 57,78% benh nhdn khong biei minh mdc benh tim tnedc do. Benh van tim hdu thap chiem leu the (73,78%) trong cdc loai benh tim co sdn, tivng do hd van 2ldvdha van dong mach chii chiein ti li nhieu nhai. 4,44 % trudng hap xdc dinh duac ngo vdo ciia tdc nhdn gay benh, ngo vdo thuang lien quan phau thudt thay van tim vd nhiim khuan da. Soi la trieu chung gap a 96.44% benh nhdn VNTMNK, trong do 70,67
% bctt/i nhan sdi >2 timn tnedc nhap -vien.
Kei luan: Khong co su thay doi ddng keve dac dian dich te vd lam sdng cua VNTMNK tai benh men Cha Ray so v&i nhieng ndm tnedc ddy, ngoai trie su gia tdng it cda tuoi trung binh benh nhdn.
Tit khoa: viim noi tdm nmc nhiem khuan. benh tim co sdn, ngo vdo.
ABSTRACT
EPIDEMIOLOGICAL AND CLINICAL CHARACTERISTICS OF INFECTTVE ENDOCARDmS AT CHO RAY HOSPITAL IN TEN YEARS (2000-2009)
Truong Quang Binh, Tran Cong Duy * Y hoc TP. Ho Chi Minh * Vol. 15 - No. 1 - 2011:21 - 25 Objectives: survey epidemiological and clinical characteristics of patients with infective endocarditis (IE) at Cho Ray hospital in tm years (2000-2009).
Methods: a retrospective, cross-sectional and descripti-ve study on all patients who were admitted to Department of Cardiology, Cho Ray Hospital from 1/1/2000 to 31/12/2009 and fylfilled the modified Duke criteria pr diagnosis of IE.
Results: There were 225 patimts with IE hospitalized in tm years. The mean age ofpatimts was 37.91 ± 15.37 years. Most often infected age group was under 25 (24.9%). followed by the 26-35 age gioup (24%). Male- female ratio was 1.25:1. 5778°/o of patients hadn't known their underlying heart diseases before. IE mainly occurred in patients with rheumatic va-uular heart disease (73.78%) in which mitral regurgitation and aortic regurgitation were most common. The portals of entry -a^ere detected in 4.44% of cases, most frequently associated -unth valm replacement surgery and cutaneous infection. Anwng 96.44°/o of patients who had fever, 70.67% had this symptom over two weeks before hospitalization.
Conclusions: Epidemiological and clinical characteristics of IE at Cho Ray hospital rmiain sinificantly unchanged compared to previous years except the little increase in the mean age ofpatimts.
Key words: infective mdocarditis, underlying heart disease, the portal ofentn/.
* Dai hoc Y Dupe TP. H6 Chi Minh
Tdc ^ lien lac. PGS TS Tnrang QuanR Binh DT: 0913.607.792 Email:
N g h i e n c u u Y hpc Y Hpc TP. H o Chi M i n h * T a p 15 * So I * 2011
D A T VAN DE
Viem noi tam mac nhiem khuan la benh gay ra boi svr phat tan cua vi khuan gay benh tir nhimg 6 nhiem khuan khu tni o noi tam mac va npi m^ic dgng mach. Theo Gordon A. Ervy<^', VNTMNK la van (fe y khoa viia ly thu, vira tram trpng, vira phuc tap. Ly thii ve phuong dien lich sii benh, ve viec thay doi ban chat va ve benh canh lam sang da dang oia benh. Tram trpng vi ti le tir vong van con cao dii da co nlueu tieh bp trong chan doan va dieu tri (npi khoa lan ngoai khoa). Phuc tgp ve sinh benh hpc va chan doan xac dinh benh nay.
Tren the gioi, nhieu cong trinh nghien ciiu ve dac diem oia VNTMNK da dupe tien hanh.
O Vi|t Nam, chua co nhieu nghien ciru ve dac diem VNTMNK trong nhiing nam gan day de danh gia sv thay doi dac diem ciia benh ly nay so vai nhihig thap nien truoc day. Vi \'ay, chiing toi tien hanh nghien cihi nay nham mvc tieu:
khao sat dac diem dich te va lam sang ciia VNTMNK tai b?nh vien Chp R5y trong 10 nam (2000-2009).
D d n U p N G - F H l / a N G PHAP NGHIEN CUU Thiet ke nghien ctru
Phuong phap hoi oiu, cat ngang mo ta Doi tupng nghien cmi
Tat ca b|nh nhan VNTMNK nhap khoa Noi tim mgch, b?nh vien Chp Riy tir 1/1/2000 den 31/12/2009 dupe dian doan xac dinh theo tieu chuain Duke cai bien.
Tieu chuan chgn lua
Tat ca b#nh nhan thoa dieu kien chan doan xac dinh ciia tieu chuah Duke cai bien"^: 2 tieu chuan chinh hoac I tieu chuan chinh va 3 tieu chuan phy hoac 5 tieu chuain phu; va co ho so benh an day dii.
Tieu chuan loai trk
Benh nhan khong thoa tieu chuan chpn lua.
Phuong phap phan tich va xd ly so li?u Su dung phan mem Microsoft Excel 2003 va
SPSS 16.0 de xir ly so lieu.
KET Q U A
So Itrong benh nhan nhap vien
Co 225 benh nhan VNTMNK nhap khoa Npi tim mach ciia benh vien Chp RSy trong 10 nam 2000 - 2009. Trung binh co khoang 23 benh nhan nhap vien moi nam.
Tuoi
Tuoi nho nhat 13, tuoi Ion nhat: 88. Tuoi trung binh: 37,91 ± 15,37, tuoi trung binh ciia nhom benh nhan nu la: 35,36 + 15,27, tuoi trung binh ciia nhom benh nhan nam la: 39,94 ± 15,21.
Gioi
Bdng 1: Phdn ho theo gioi tinh QI6<
Nam N»
Tong
Sd b#nh nhSn 125 100 225
•nie%
56 44 100 Nhdn xet: Ti le nam/nie = 1,25.
Nhom tuoi mac benh Bdng 2: Phdn bo theo nhom tudi
Nhdm tu6i
<25 26-35 36-45 46-55 i 5 5 T6ng
sa bfnh nhSn 56 54 52 32 31 226
T l l f % 24,89
24 23,11 14,22 13,78 100 Thoi gian b^nh nhan biet mkc b?nh tim Bdng 3: Thdi gian benh nhdn biei mac binh tim
Thdi gian Khong biet s5nam 6 - 1 0 nam
> 10 nam Tong
S6 benh nhdn 130
31 12 52 225
Ti ie (%) 57,78 13,78 5,33 23,11
100 Benh tim co s i n
Bdng 4: Phdn bo ciia cdc loai binh tim co sdn Lo9i benli tim
Benh van tim Benh tim bam sinh
Van nhdn tao Kh6ng c6 b#nh tim
Tong
So b#nh nhdn 166
62 5 2 225
Tii#%
73,78 23,11 2,22 0,89 100
Y Hpc TP. Ho Chi M i n h * Tap 15 * So 1 * 2011 N g h i e n c u u Y hpc
Trong cac benh van hm mac phai, ho van 2 la va ho van dpng mach chu dong thoi: 37,35%;
ho van 2 la don thuan: 35,54%; ho van dpng mach chu don thuan: 9,04%; ho hep van 2 la va ho van dpng mach chii: 4,82%; ho hep van 2 la:
4,22%, khac: 9,03%.
Trong cac benh tim bam sinh, thong lien that don thuan: 36,54%; con ong dpng mach don thuan: 19,23%; thong lien that va ho chu: 13,46%;
thong lien that va ho 2 la: 9,62%; con ong dpng mach va ho 2 la: 7,69%; khac: 13,46%.
Ngo vao cua tac nhan gay benh
10 truong hpp xac dinh dirpc ngo vao oia tac nhan gay benh chiem ti le 4,44 %, co 5 truong hop thay van tim, 3 truong hpp nhiem khuan da, 1 tnrong hpp viem nuou, 1 truong hpp nghien chich ma hiy duong finh mach.
Trieu chung co nang
Cac tri|u chung co nang g | p 6 bfnh nhan VNTMNK: sot (96,44%), met moi (40%), kho tho (32,44%), ho (23,11%), chan an (12,89%), nhiic dau (11,11%), dau CO khop (10,22%), xanh xao .(7,56%), dau bung (6,67%), sut can (5,33%), dau nguc (5,33%), va mb hoi (3,11%), Iii lan (2,67%), buon non hoac non (1,78%), tieu mau dai the (1,33%).
Trieu chung thvrc the
Cac trieu chiing thuc the gap 6 b | n h nhan VNTMNK: am thoi o tim (99,56%), sot > 38'C (95,56%), xuat huyet ke't mac (21,78%), liet nira nguoi (15,56%), lach to (7,56%), tir ban xuat huyet 6 chi (6,22%), roi loan tri giac (5,78%), not Osier (4,89%), ngon tay diii ti-ong (3,11%), ton thuong vong mac/dom Roth (0,89%), xuat huyet dudi mong (0,44%).
Thai gian sot truoc nh|,p vien Bdng 5: Thdi gian sot tnedc nhap vien
Thbi gian sdt
<1tiJ^n 1 - < 2 tuSn 2-<4tudn
>4tiiln Tong
S6 b$nh nhdn 8 50 66 93 217
Tii?%
3,56 22,22 29,33 41,33 96,44
BANLUAN Tuoi
Qua cac nghien ciiuf^.'^), chiing toi nhan thay: 6 phuong Tay, tuoi mac b | n h VNTMNK ngay cang cao vi ti le benh van tim do benh mach vanh va xo hoa van tuoi gia ngay cang tang trong quan the benh tim mach. Khac voi cac nuoc phuong Tay, trong cac nghien cim tgi Viet Nam**-'°'">, benh van tim hau thap la nhom benh chii yeu bi mac benh VNTMNK, do do dp tuoi mac benli tre hon nhieu so vol nhom benh nhan ciia cac nuoc phtrong Tay. Tuy nhien, chiing toi nhan thay co su gia tang ve tuoi benh nhan mac benh VNTMNK tir nam 1978 den nay (1978 - 1982: 29,3 hiS*); 1986 - 1989: 32 hi6i<"fl;
1994^ 1998: 36,5 tiioiO"; 2000 - 2009: 37,91). Mac du su gia tang nay chira nhieu nhimg cung the hien xu huong theo qui luat: tuoi trung binh mac benh VNTMNK ngay cang tang nhu o cac nude phuong Tay.
Nhom tuoi thudng mac benh nhieu nhat la dudi 25 tuoi (24,9%), tiep den la nhom 26-35 tuoi (24%). Ti le Gia 2 nhom nay la 48,9%. Theo nghien dm oia Dang Thi Bao Toan^", ti 1# nay la 70%, Truong Quang Binh'"> la 56%.
Gidi
Ti le nam/nu mac benh trong nghien cuu nay la 1,2A (56% /44%). Ti le m^c benh nam/nii gan bang nhau phii hpp vdi cac nghien cuu khac: Dang Thi Bao Toan (54%/46%)(3', Dang Van Phudc (49%/51%)w, Truong Quang Bmh (47%/53%)f").
Benh tim san co
Trong nghien oiu nay va cac nghien ciiu khac d Viet NamP.*-'0'i), benh van tim hau tiiap chiem ti le cao nhat (76 - 92,3%) va cao gap doi so vdi ti le cua cac nghien cuu phuong Tay*'^'.
Nguyen nhan co the do d cac nude phuong Tay, ti le benh van tim do xa mo dpng mach va xo hda van d ngudi Idn tuoi ngay cang cao, trong khi do ti le b | n h van tim hau thap ngay cang giam nen benh van tim do xo hoa van d ngudi Idn tuoi chiem ti le ngay cang cao; con d Viet
21
N g h i e n c u u Y hoc Y H p c T P . H b C h i M i n h * T a p 15 * So 1 * 2011*
Nam, benh van tim hau thap van chiem ti le chii yeu ti-ong benh tim mach do di chiing cua benh thap tim tir nho.
Trong phan bd ciia benh van tim, hd van 2 la don thuan chiem ti le cao nhat (35,54%) trong cac ton tiiuong van don thuan, tiep den la hd van dpng mach chu (9,04%). Hd van 2 la va hd van dpng mach chii la ton thuong van phoi hpp nhieu nhat (37,35%). Dieu nay phii hpp vdi cac nghien o i u ciia Ange]o<i^', Truong Quang Binh"".
Thai gian b?nh nhan biet mac b^nh tim Nghien cuu ciia chiing toi co 57,78% benh nhan VNTMNK khong biet minh m k b^nh tim trudc do. Ti 1# nay phii hpp vdi nghien cim oia Truong Quang Binh vao cac nam 1986-1989 (53%)("^, 1994-1998 (48,7%)"". Ly do co tiie do he thdng y te cpng ddng d nude ta chua phat trien manh va rpng rai, trinh do dan tri chua cao va ddi sdng kinh te con ngheo, vi the ngudi dan chua quan tam diing miic den tinh trang siic khoe ciia minh, khong kham va phat hien sdm benh tim san co.
Ngo vao cua tac nhan gay b?nh
95,56% hirdng hop VNTMNK khong xac dinh dupe ngo vao oia tac nhan gay benh, 4,44%
trudng hpp ghi nhan dupe ngo vao. Ket qua nay ciing tuong tu nghien oiu ciia Truang Quang Binh"", CO 89,5% trudng hpp khong ro dudng vao oia vi khuan gay benh, 7 trudng hop (10,5%) ro ngo vao.
Ngo vao trong nghien cuu nay thudng lien quan den phlu thuat thay van tim va nhiem khuan da. Cac tac gia Dang Thi Bao Toani^), Phgm Gia Khai''*, Truong Quang Binh"" nhan thay cac trudng hpp ro ngo vao thudng lien quan den van de sanh, say thai, nao thai. Ngo vao dupe ghi nhan trong nghien euu nude ngoai'*', da so la nhiem khuan rang mieng va nhiem khuan da. Chiing toi chua ly giai dupe sir khac biet nay.
Nghien fliuoc chich dudng finh mach Theo tieu chuan Duke cai bien, nghien
thude chich dudng tinh mach la mpt tieu chuain phu de chain doan VNTMNK. Chiing toi ghi nhan co 1 trudng hpp nghien thuoc chich dudng tinh mach (0,44%), cac nghien ciiu oia Dang Thi Bao Toan^^), Dang Van Phudd*' cung CO 1 trudng hpp nghi#n thuoc chich dudng finh mach vdi ti le Ian lupt la 2,4%; 2%. Truang Quang Binh ghi nhan 5 trudng hpp nghi?n thuoc chich dudng tinh mach (1986-1989) (12,8%)"°', 0 tiirdng hpp (1994-1998)'"). Cac tac gia phuong Tay ghi nhan nhieu trudng hpp nghien thuoc chich dudng finh mach hon:
Bayer<" (24 trudng hpp chiem 38%), Cecchi va es.(2' (15 trudng hpp chiem 10,2%).
Trieu chung cff nang
Bpnh nhan VNTMNK co cac trieu chung co nang dia nhilm khuain h# thong (sot, va mo hoi, met mdi, chan an, sut can, dau co...), ciia ton thuong mach mau (khd thd, dau nguc, yeu liet khu tni, dau bung, dau dau ehi...) va oia phan ling miln dich (dau khop, dau co...). Cac tri?u chung nay ciing duoc ghi nhan trong cac nghien cuu khac va ti le eiia eac trieu chiing khong kha(;
bi#t nhieu so vdi tac gia Heiro va cs.'*", Karelimer<^.
Trieu chung thuc the
Sdt (95,56%) va am thdi d tim (99,56%) la 2 trieu chiing thue the thudng gap nhat d benh nhan VNTMNK. Dieu nay phu hpp vdi cac nghien euu khad'^. Xuat huyet ket m^c cung thudng gap (21,78%), trieu chung nay ciing chiem ti le cao trong cac nghien ciiu ciia Dang Thi Bao Toan (29%)<3>, Dang Van Phudc (37%)(*', Truong Quang Binh (37,8%)"" nhimg chiem ti l§
thap (5%) theo David va cs^. Trieu chung liet nira ngudi bieu hien oia tac mach nao chiem ti ]E 15,56 %, tri so nay nam trong khoang cac ket qua nghien ciiu khac tir 11% ciia Dang Thi Bao Toant'J den 40% oia Karchmert^. Bieu hien than kinh trung uong chiem ti le cang cao cang noi len tinh chat nguy hiem oia VNTMNK. Mot dieu dang chii y khac la mot sd dau hieu ngoai bien va phan u n g mien dich (tir ban xuat huyet 6 ehi, not Osier, ngdn tay diii trong, xuat huyet
Y Hpc TP. Hb Chi Minh * Tap 15 * So 1 * 2011 N g h i e n ciru Y h p c
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dudi mdng, ton thucmg vong mao'ddm Roth, sang thuong Janeway...) ciia nghien o i u nay thap hon so vdi cac tac gia nude ngoait^.
Trieu chung sot
96,44% benh nhan co trieu ehung sot trong qua trinh benh, 3,56% benh nhan khong sdt. Day la mpt trong nhirng trieu chung co nang va thuc the thudng gap nhat ciia benh nhan VNTMNK.
Va sdt > 3&C la mot tieu chuan phu giiip chaji doan benh ly nay. 70,67% benh nhan sdt keo dai
> 2 tuan trudc khi n h | p vien, trong do 41,33%
sdt > 4 tiian. Dieu nay cho thay trieu chiing sot am i keo dai lam cho benh nhan it quan tam den benh ciia minh khien benh nhan nhap vien tri.
Ket qua nay cung phii hpp vdi ket qua nghien ciiu oia cae tac gia tiong va ngoai nudd^'". Dac diem ehung ciia 3,56% benh nhan khong sot la Idn tudi va benh nang. Dieu nay phii hpp vdi nhan xet ciia cac tac gia khad^-^.
KET LUAN
Qua hdi ciiu 225 benh nhan VNTMNK nhap khoa Npi tim mach, benh vien Chp Ray trong 10 nam (2000 - 2009), chiing tdi nit ra duoc mot sd ket luan sau:
- Tudi trung binh oia benh nhan la 37,91
± 15,37. Nhom tudi mac benh nhieu nhat la dudi 25 tudi (24,89%), tiep den la nhdm 26-35 tudi (24%).
- Ti le nam/nii mac benh trong nghien ciiu nay la 1,25/1 (56% /44%).
- 57,78 % benh nhan khdng biet minh mac benh tim trudc do.
- Benh van tim hau thap chiem uu the tiong cac loai benh tim sin co, tiong dd hd van 2 la va hd van dpng mach chu chiem ti Ie nhieu nhat.
- 4,44% trudng hpp xac dinh dupe ngo vao ciia tac nhan gay benh, ngo vao thudng gap lien quan p h l u thuat thay van tim va nhiem khuan da.
- Sdt la trieu chiing gap d hau het benh nhan VNTMNK, tiong do 70,67% benh nhan sot > 2 tuan trudc nhap vien.
TAI LIEU THAM KHAO
I Bayer AS, Lam K, Ginzton L, et al (1994). Evaluaaon of n e w dimcal criteria for diagnosis of infective endocarditis. A m J Med, 96:211-219.
2. Cecchi E, Fomo D, I m a a o M, Migliardi, Gnavi R, et al (2004).
N e w trends in the epidemiological and clinical features of infective endocarditis: results of a multicenter prosp>ective study. Ilal H e a r t ] , 5(4): 249-256.
3 D a n g Thi Bao Toan (1933). Mot so nhan d | n h ve viem npi tam mac nhiem trimg d o vi trimg qua 50 trutmg h o p tai Benh vien Q K J Kay. Luan van tot nghiep bac sT npi tni. BQ mon Npi, D ^ hoc Y Duoc TP.Ho Chi Minh.
4 Dang Van Phuoc (1996). Viem npi tam m^c do vi khuan (41 truong h o p t^i Benh vi^n Qiq Ray). Tai lieu lam sang chpn loc B?nh vien C h p Riy, so 16:57-60.
5 Gordon A.E (1997). Q a s s i c teachmg in clinical cardiology:
Infective endocarditis. Cardiovascular reviews and reports;
18:41-46.
6 Heiro M, Helenius H, et al (2006) Infective endocarditis in a Finnish teaching hospital: a study on 326 episodes treated during 1980-2004. Heart; 92:1457-1462
7 Karchmer A.W (2005). Infective endocarditis. Braunwald's heart disease 7* edition. Elsevier Saunnders-1633-1658.
8 Korzeniowski OM, Kaye D (1992). Infective endocarditis.
Braunwald's heart disease 4''' edition, WB Saunders Company: 1078-1105.
9 P h a m Gia Khai va cpng sa (1997). Tmh hinh benh dgng m^ch vanh, suy tim va benh tim bi nhiem khuan tai Vi?n Tun Ha Npi va Benh vien Bach Mai tir 1991-19%. Tai lieu toan v a n hpi thao chuyen de benh ly tim m ? d i Benh vien C h g Riy: 115- 117
10, Truong Quang Binh (1989). Mpt so dac diem lam sang, c^n lam sang va gia tri cua Sieu am tim 2 chieu trong chan doan viem npi tam mgc nhiem khuan ban cap. Luan van tot nghi?p bac a noi tni. Bo mon Npi, Dai hpc Y dupe TP J f i Chi Mmh.
I I T m o n g Quang Binh (2000). Khao sat dac diem lam sang, c ^ lam sang ciia bgnh n h a n viem npi tam mac nhiem khuan tgi benh vien C h p Ray trong 5 nam (1994-1998). Tap chi Tim mach hpc, 21:1304-1313
12. Vlessiss AA, Hovoguinian H, et al (1996). Infective endocarditis. Ten-year review of medical and surgical flierapy. Ann Thorac Surg; 61:1217-1222.
13. Von Reyn CF, Levy BS, Arbeit RD, et al (1981). Infective endocarditis: an analysis based on strict case definitions. A m Intern Med; 94:505-518.
14. Weinstem L (1988) Infechve endocarditis Heart disease, a textbook of cardiovascular medicine. E. Braunwald (ed), Philadelphia Saunders. 1093-1134
