Tqp chl Y Duvc Hqc - Tru&ng Ogi hgc Y Duvc Hui- Tqp 6, so 6- thdng 1/2017
GIATR! CUA ST CHENH LEN daVRTREN BENH NHAN HOI CH&NG VANH CAP CO HEP THAN CHUNG
BONG MACH VANH TRAI VA/HOAC BENH MACH VANH BA NHANH
Bleu Thanh Hiing " , Nguyin Anh VS' (1) Binh vien Tim, An Giang (2) Tru&ng Dgi hgc Y Dugic Hui- Dgi hoc Hui Tdm tat
Myc t i l u nghiin c&u: Banh gia gii trj eua ST chgnh ign d chuyen dgo aVR tren bgnh nhan (BN) cd hpi ch&ng vanh cap (HCVC) cd hep thin chung dpng mgch vanh (DMV) trai va/hoac bgnh mach vanh (BMV) ba nhinh. Doi tupng v i phuang phip nghien c&u: 410 BN cd hdi eh&ng mach vinh cap deu dupe chijp mgch vanh dupe dua vao nghidn e&u. Ket q u i : 131 (31,9%) BN cd tac/hep than ehung DMV t r i i va/hoac BMV ba nhanh. Dogn ST ehenh len > 0,05 mV b chuyin dgo aVR la yeu td dy bio dpe lgp hep than chung DMV trai va/hogc BMV ba nhanh (p<0,001) vdi dp nhgy, dp dgc higu, gia trj dy bao duang ti'nh (GTDBDT) va gii tn dy bao am ti'nh (GTDBAT) lan lupt la 74,0%, 78,1%, 61,4% va 86,5%. Doan ST chenh lgn > 0,05 mV b aVR kit hpp vdi dau higu ST ehinh xuong b ca ba chuyin dgo V4,V5,V6 cd lign quan hep than chung DMV trai va/
hoge BMV ba nhinh (p<0,001) vdi dp nhgy, dp dgc higu, GTDBDT va GTDB&T lan lupt la 44,3%, 92,8%, 74,4%
va 75,2%. ST chgnh len >.0,1 mV d ehuyen dgo aVR ed lien quan hep than chung DMV t r i i va/hoac BMV ba nhinh (p<0,001) vdi dp nhgy, dp dgc higu, GTDBDT v i GTDBAT lln lupt la 51,9%, 87,1%, 65,1% va 79,4%. Kit lugn: Dogn ST chlnh lln > 0,05 mV b chuyin dgo aVR l i ylu td dy bio ddc lip hep than chung DMV trii v i / hogc BMV ba nhanh tren BN cd HCVC.
Td khda: Hbi ch&ng mqch vdnh cap, doqn ST chenh len, aVR Abstract
VALUE OF ST-SEGMENT ELEVATION IN LEAD aVR IN PREDICTING LEFT MAIN AND OR 3-VESSEL DISEASE
IN PATIENTS WITH ACUTE CORONARY SYNDROMES
Dieu Thanh Hung '•\ Nguyen Anh Vi^
(1) An Giong Heart Hospital (2) Hue University of Medicine and Pharmacy - Hue University Objects: VJe assessed the ability of ST-segment elevation in lead aVR to predict left main and/or 3-vessel disease (LM/3VD) in patients ViJlth acute coronary syndromes (ACS). Meterlal and Method: 410 patients with ACS who underwent coronary angiography, were evaluated. Results: 131 (31.9%) patients had LM/3VD. ST segment elevation > 0.05 mV in leads aVR was an independent predictor LM/3VD with sensitivity, specificity, positi've predictive vatue ( PPV) and negative predictive vatues were at (NPV) 74.0%, 78.1%, 61.4% and 86.5%, respectively (p<0.001). ST segment elevation > 0.05 mV in leads aVR with ST segment depression in leads V4- V6 were related to LM/3VD with the sensitivity, specificity, PPV and NPV of 44.3%, 92.8%, 74.4% and 75.2%, respectively (p<0.001). ST segment elevation > 0.1 mV m leads aVR was related LM/3VD with the sensitivity, specificity, PPV and NPV of 51.9%, 87.1%, 65.1% and 79.4%, respectively (p<0.001). Conclusions: ST segment elevation > 0.05 mV in leads aVR is an independent predictor LM/3VD in patients with ACS.
Key words: Acute coronary syndromes, ST-segment elevation, aVR
~Biachliiinh4 Oiiu Thanh Hung, email lxaghd@gmoll cc V12/2016: Ngdy ding v " - ' - ' ^ -
Top chl Y Duqc Hqc - Tru&ng Dqi bqc Y Duqc Hi p 6, so 6 • thdng 1/2017 1. OAT VAN OE
Cae trudng hpp sdng sdt sau tac cap ti'nh than ehung DMV trii la rat hiem. Cic BN nay thudng bj sde tim, rdi logn nhjp nhanh nguy hiem, rdi logn dan truyln,...[6].
Nhieu nghien c&u da cho thay dogn ST ehenh len d chuyen dao aVR tren BN cd HCVC cd gia tri dy bio tac/hpp than chung DMV trai va/hoge BMV ba n h i n h [ l - l l ] . Nhin dien dupc ngay cae ehi dilm tren dign t i m do se giiip thye hign kjp thdi md bae clu DMV hoae ean thigp DMV cap e&u cho cie truPng hpp nay[6].
6 Viet Nam, da cd nhieu nghien e&u ve gii tri dien tam dd trong viee dy bao vi tri tac/hep DMV a bgnh nhan nhoi miu ea tim cap, nhung nghien c&u v l gia trj dy bao eiia dpan ST chgnh lgn b aVR trong chan doan hep thin chung DMV trai va/hogc BMV ba nhinh edn it, vdi ed mlu nhd, nen ehung tdi tiln hanh nghien e&u nay vdi myc tilu' Xic djnh dp nhgy, dp dgc higu, gii trj tien doan duang va gii tri tien doan am eua dogn ST ehenh ten b aVR trong chan doan hep than chung DMV trii va/hogc BMV ba nhinh trin benh nhan cd HCVC.
2. Odi TtrONG VA PHl/aNG PHAP NGHIEN CLTU 2.1. OdI tupng nghiin c&u
2.1.1. Tieu chudn chqn ddi tu&ng nghiin c&u Chpn tat ca bgnh nhan dupe ehan doin HCVC theo tieu ehuan cua Trudng Mdn Tim Hoa Ky (Amencan College of Cardiology ~ ACC) va Higp hgi Tim Hoa Ky (American Heart Association-AHA)[5] cd chyp mgeh vanh can quang tai Bgnh vign Tim mgeh An Giang t& thing 01/2014 den thing 10/2015 dua vao nghien c&u. Cac bgnh nhan dua vao nghien e&u dupc phan thanh 2 nhdm:
- Nhdm I: benh nhin HCVC cd hep than ehung DMV trai va/ hoac bgnh DMV ba nhinh,
- Nhdm 11: bgnh nhan HCVC nhung khdng ed hep thin Chung OMV trii va/ hogc bgnh DMV ba nhinh.
2.1.2. Tiiu chudn loqi trd
Gdm nh&ng bgnh nhin du tigu ehuan ehan doin HCVC kem theo.
- Bide nhanh t r i i hoan toan - Hdi eh&ng Wolff-Parkinson-White - Ldn that trai (theo chi sd Sokolow-lyon)
• Ngudi bgnh ed cay miy tgo nhjp tim - Bgnh i n khdng day du thdng tin eho nghien C&u
2.1.3. C&mau ^-, , \
Z ^ =1.96 ( a = 0.05) w^ 0.05
p^^= 0.6 : dp dac higu tham khio t& eie nghien e&u [1-11]
p^,^= 0.1: ty Ig BN nhap vign vi HCVC tgi Bgnh vien Tim Mgch An Giang nim 2014
U'dc ti'nh ea miu . 1.96^x 0.6x0.4
: 410 ngudi bgnh
|eo
FP + TN =
JOURNAL OF MEDICINE Af
2.2. Phuang phip nghiin c&u: h&i c&u, md ta 2.2.1. Cdch tiin hdnh
- Thu thip sd lieu: Tuoi, gldi, ket qua dpe dign tam dp, ket qua chup mgeh vinh ein quang.
- Dign tam dd (OTD) dupe ghi d tdc dp 25mm/
giiy, vdi test chuan: ImV-lOmm. Chpn mgt OTD ro nhat trudc khi chup mgch vinh can quang d l dinh gii sy thay ddt cua dogn ST trin cic chuyen dgo. Lay TP tam dudng dang dien. M&c dg ehenh cua dogn ST b cae chuyin dgo ti'nh bang mV, do tai vj tri each diem J 0,08 giay. Ngudi lay sd ligu DTD khdng biet trudc kit qua chup DMV can quang.
2.2.2. Tiiu chudn ddnh gid cdc biin 2.2.2.1. Hqp DMV[12]
- Hep t h i n chung DMV t r i i : hep > 50% dudng kinh.
- Hep DMV khae: hep > 70% dudng kinh.
- BMV ba nhinh: hep 3 nhinh DMV ehinh, m5i DMV hep > 70% dudng kinh.
2.2.2.2. Tiiu chudn ddnh gid diin tam do Tieu chuan dign tam dd du bio tdn thuang hep than ehung DMV t r i i va/hogc BMV ba nhanh [1-10]:
1. ST chgnh lgn > 0,05mV, > 0,1 mV d chuyen dgo aVR.
2. ST chgnh xudng > 0,lmV dchuyln dgo V4, V5, V6.
3. ST ehenh xudng > O.lmV b ca ba chuyen dgo V4, V5, V6
4. ST chenh len d chuyen dgo aVR kem ST ehenh xudng > 0,lmV b cac ehuyen dao V4-V6.
2.3. Phuang phip x& ly thdng ke + Sd tigu nghien e&u dupc xur ly bang phan mim SPSS 16,0.
Tqp chl Y Duvc Hoc - Tru&ng Bgi bgc Y Duvc Hui -Tqp 6. so 6- thdng 1/2017 + Cac bien sd lien tuc dupe trinh bay bang: gii trj
trung binh ± dp Igch ehuan .
+ Cac biln sd djnh ti'nh dupe trinh biy bang ti tg phan tram (%).
+ So sanh eie biln liln tyc bang phep kiem t.
+ Kilm dmh mdi lien quan gi&a eae bien so djnh ti'nh bang phep kiem hdi quy Logistic.
+ Ngudng cd •i nghTa thdng kl cua eae phep kiem la P (2dudi) < 0,05.
+ Khi mdi Men quan gl&a dau higu ST chgnh len b ehuyen dao aVR va kit qua chup
DMV ed y nghTa thdng ke : ti'nh dp nhgy, dp dae higu , gia trj dy bio duang ti'nh
(GTDBDT), gii trj dy bao am ti'nh (GTDBAT).
3. KET QUA
Bing 1. Dae dilm chung cua nhdm nghien e&u
Tuoi
Gi6i Nam
Nu'
Nhom 1 (n= 131 ) 69,36 ±11,9
70 61
Nhom II (n= 279 ) 65,73±12,1
175 104
P 0,005
0,08 Bing 2. Oac diem cCia tdn thuang ddng mgch vanh
Bgnh than chung DMV t r i i , khdng cd BMV ba nhanh BMV ba nhanh
Bgnh than chung DMV t r i i , kem theo BMV ba nhinh Tdn thuang OMV khie
N 6 105
20 279
Tilg%
1,4 25,6
4,9 68,1 Bing 3. Bang phan ti'ch sd ligu dan biln va da bien
ST aVR t
ST,I,
ST 4, V4V5V6 i 0,05 mV
£ 0,lmV V4 V5 V6 V4V5V6 S T a V R t
> 0.05 mV S T a V R t
i O.lmV
Don bien OR(95%C.I) 10,2(6,3-16,5) 7,3(4,5-11,9)
5,3(3,4-8,3) 5,9(3,8-9,3) 6,3(4,0-10,1) 4,3(2,7-6,8) 10,3 (5,8-18,2)
9,6 (5,0-18,3) P
<0,001
<0,001
<0,001
<0,001
<0,001
<0,001
<0,001
<0,001
Da bign(*) OR (95% Cl) 5,8(3,0-11,5) 1,4(0,7-2,8) 1,6 (0,4-6,4) 0,6(0,4-9,3) 3,5(0,3-36,9)
P
<0,001
>0,05
>0,05
>0,05
>0,05
ST aVR 1^: Oogn ST ehenh lln d chuyen dgo gVR.
ST sl/! Doan ST chenh xudng.
ST ^ V4V5V6: Ooan ST chenh xudng b ea ba chuyen dgo V4, V5, V6.
(*): Da higu chinh tuoi.
Bang 4. Dd nhgy, dp dge hieu, GTDBDT GTDBAT
S T a V R t
ST4-
ST.1- V4V5V6 2 0.05 mV
>0.1mV V4 V5 V6 V4V5V6 STaVRt £ 0.05 mV ST a V R t S O.lmV
DQ nhay (%) 74.0 51,9 58,8 61.8 61.1 50.4 44.3 33.6
Dp dac hi?u (%}
78,1 87,1 78.8 78.5 80.3 90.7 92.8 95.0
GTDBDT (%) 61.4 65.4 56.6 57.4 59.3 72.5 74.4 75.9
GTDBST(%) 86,5 79.4 80.3 81.4 81.5 77.7 78.0 75.2
Tqp ch! Y Duqc Hgc - Tru&ng Bqi hqc Y Duqc Hue- Tdp 6, so 6- thang 1/2017
4. BAN LUAN
Trong hpp than ehung DMV trii, tinh trang thieu miu vach lign that vung diy tim din den vecta eua dogn ST hudng trye tiep ve chuyen dao aVR, tgo ngn hinh anh 5T chgnh lgn d aVR. Diu higu nay edn la hinh anh sol guang cua doan ST chgnh xudng d cic ehuyen dgo V4, V5,V6 do thilu mau ea tim dudi npi tam mgc [9-10].
Khi phan ti'eh dan bien, chting tdi nhgn thiy cic diu hieu ST chgnh ten > 0,05mV, > 0,1 mV b ehuyen dgo aVR; ST ehenh xudng > 0,lmV b cie ehuyen dgo V4-V6 diu ed mdi lien quan vdi hep than chung OMV trii va/hoac BMV ba nhanh (p< 0,001)( bang 3). Phan ti'ch da biln cho thay chi diu higu ST ehenh ten > 0,05mV d aVR la y l u td dy bio ddc lip vPi OR Bang 5. So sinh dp nhgy.
5,8(3,0-11,5) (p< 0,001) (bang 3). Nghiin c&u eiia Ogng Thj Thugn va cdng sy tren 86 bgnh nhin cd tdn thuPng than chung OMV t r i i , cung co kit qua ST chenh len > 0,05mV b aVR la yeu td dy bao dge lgp tdn thuang than ehung OMV trii ( p=0,001)[2].
Nghien c&u cua Kosuge va edng sy trin 501 bgnh nhan HCVC khdng ST chgnh lgn deu Su&c chyp mgch vanh, eung eho thay ST chgnh ten > 0,05mV d aVR la y l u td dy bao dpc l i p hep than chung OMV trii va/
hogc BMV ba nhinh, vdi OR 7,1 (p<0,01)[10] Bang 5 eho thay do nhgy, dd dge hieu. GTDBDT, GTDBAT eua dau higu ST ehenh len > 0,05mV d aVR trong nghien e&u cua chung tdi tuPng duang vdi nghien c&u ciJa Kosuge va Cdng sy [10], thap ban ket nghign e&u cua Ding Thj Thuin va Cpng sy [2].
dp dgc higu. GTDBDT, GTDBAT Tac gia
Kosuge va Cpng stf [10]
Dang Thj Thuan va Cong su'[2]
Chung toi
Do nhay
(%)
76 81,6 74,0
Do dac hieu
(%)
36 94,6 78,1
GTDBDT
(%)
95,2 61,4
GTDBST
(%)
79,5 86,5 Nghien c&u cua Kosuge v i Cpng sy tren 572
bgnh nhan HCVC khdng ST chdnh lgn deu duac chyp mgeh vanh, edng bd nam 2011 cho thay ST chenh len > 0,lmV b aVR la yeu td dy bio manh hep t h i n ehung DMV trai vi/hogc BMV ba nhanh ngng ( hep >
75% dudng kinh than chung OMV trai va/hoac BMV ba nhinh vdi hep > 90% dudng kinh dogn gan cua DM lien that trudc trai va them it nhat dogn gan cua OM vanh khac)( p< 0,001) vdi dp nhgy va dp dac higu tan lupt la 80% va 93% [3]. Nghien c&u eua ehOng tdi, khdng ghi nhgn dau higu ST chgnh lgn > 0,lmV b aVR la yeu td dy bio dpe lgp nhung cd mdi lien quan vdi hep thin chung OMV trai va/hogc BMV ba nhanh vdl dp nhgy, dp chuyen, GTDBDT va GTDBAT lan tupt la 51,9% , 87,1%, 65,4 va 79,4 (p<0,001) (bang 4). Mdt phin ti'ch gpp eua Fabrizio va Cpng sy trgn 17.896 bgnh nhan HCVC cung eho thay dau higu ST ehenh lgn b aVR l i yeu td du bio mgnh hep than Chung DMV trii va/hoac BMV ba nhanh, vdl OR 29,l(p<0,05)[ll],
Nhieu nghien e&u cho thay dau higu ST chgnh ten > 0,05 mV b aVR ket hpp vdi dau higu ST chgnh xudng d ea ba chuyen dgo V4,V5,V6 ed gia trj dy bio hep than chung DMV trai va/hogc BMV ba nhanh [1-11]. Trong nghien e&u cua ehiing tdi, dau higu kit hpp niy cd lign quan vdi tdn thuang hep than chung DMV trai va/hogc BMV ba nhinh (p<0,001) (bang 3), vdi dg nhay, dp die hieu, GTDBDT va GTDBAT
I 6 2 JOURNAL OF MEDICINE Al
lln lupt l i 44,3%, 92,8%, 74,4% va 75,2% (bang 4).
Nghign e&u eiia Ogng Thj Thugn va Cpng sy tren 85 bgnh nhan HCVC tdn thuang thin ehung OMV t r i i , khdng cd BMV ba nhinh, cd dd nhgy, dp dgc higu la 81,6%va94,6%[2].
Nghien c&u eua chung tdi ed mdt sd hgn che:
DTO dupc chon d l thu thgp sd ligu khdng eung mdt thdi diem ke t& lue khdt phat HCVC, mgt sd BN cd HCVC nhung khdng dupe chpn vao nghien c&u do hinh inh DTD khdng con rd de thu thgp sd ligu, chua logi tr& BN ed Idn that trai theo ehi sd LVMI trin sieu am ti'm, ehua dinh gii anh hud'ng eua OMV uu the tudi miu eho thanh sau va thanh dudi that trii len m&e dp ehenh cua dogn ST d eie chuyen dgo.
5. K^t LUAN Trgn BN ed HCVC:
• Dau higu ST chenh len > 0,05 mV d chuyen dgo aVR ta y l u td dy bao dpc lgp hpp than chung OMV trai vi/hogc BMV ba nhinh (p < 0,001) vdi do nhgy, dp dae higu, GTDBDT va GTDBAT lan lupt la 74,0%, 78,1%, 61,4% v i 86,5%.
• Dau higu ST chgnh lgn > 0,05 mV d ehuyen dgo aVR kem theo ST chlnh xudng b cae ehuyin dgo V4 V5 V6 ed llln quan hep than ehung DMV trai va/
hoge BMV ba nhanh (p < 0,001) vdi dp nhay, dp dgc higu, GTDBDT v i GTDBAT lan lupt l i 33,6%, 95,0%, 75,9%, v i 75,2%.
Tqp cbi Y DUVC Hge - Tru&ng Dgi hqc Y Dugc Hui - Tgp 6, so 6 - thdng 1/2017
• Dau higu ST chenh len >0,1 m V b e h u y i n d g p aVR cd lien q u a n hep t h i n ehung O M V trai va/hogc BMV ba
nhanh (p<0,001) v d i d p nhgy, d p dgc higu, GTDBDT va G T D B A T lan l u p t la 51,9%, 8 7 , 1 % , 6 5 , 1 % va 79,4%.
T A I L I E U T H A M KHAO
1. Phgm N g u y i n Vinh va cgng sy (2011)," Nghign c&u g i i tri dign tam do trong vigc xae dinh vi t r i tac nghen ddng mgch vanh d b^nh nhan nhoi m i u eo tim cSp ST chenh len", Tgp chi Tim Mgch Hoc Viet Nam, So 59, tr. 267-272.
2. Dgng Th| Thugn, Phgm Mgnh Hiing, Phgm N h u Hiing ( 2015), " B l l n ddi dogn ST tren chuyen dgo aVR b bgnh nhan hgi ch&ng vanh d p c6 tdn t h u a n g than chung ddng mgch vanh", Tgp chi Tim Mgch Hgc Viit Nam, So 59.
tr 69-75.
3. Kosuge et al (2011), An Early and Simple Predictor of Severe Left Main and/or Three-Vessel Disease in Patients W i t h Non-ST-Segment Elevation Acute Coronary Syndrome, AmJ cadiol, Feb 15,107(4), pp.495-500.
4. Akira Tamura (2014), Significance of lead aVR in acute coronary syndrome. World J Cardiol, Jul 26, pp. 630-637.
5. Ezra A. Amsterdam, Nanette K Wenger, Ralph G.
Brindis, et at ( 2014), 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, Circulati'on, 130, e344-e426.
6. Patrick T. O'Gara, Fredenck G, Kushner, Deborah D. Aseheim, et al (2013), 2013 ACCF/AHA Guideline for the IVlanagement of ST-Elevation Myocardial Infarction, Circulation, 127, pp.e362-e425.
7. Nikus KC (2007), Acute total occlusion of the left main
coronary artery with emphasis on electrocardiographic manifestations, Timely Top Med Cardiovasc Dis, Aug 1 , 1 1 , pp. E22.
8. Vorobiof Gabriel, Chandrashekhar & Jagat Narula (2011), "Intermediate lesions", J Am Coll Cardiol Intv, 4{2), pp.209-212.
9 Kjell C. Nikus, Markku J Eskola (2008), Electrocardiogram patterns in acute left main coronary artery occlusion, Journo/o/E/ectrocord/o/ogy, 4 1 , pp. 626 - 6 2 9 .
10. IVlasami Kosuge, Toshiaki Ebina, Kiyoshi Hibi, et al ( 2009), Early, Accurate, Non-Invasive Predictors of Left Main or 3-Vessel Disease in Patients W i t h Non-ST- Segment Elevation Acute Coronary Syndrome, Circ J 2009, 73, p p . 1 1 0 5 - 1 1 1 0 .
11. Fabnzio D'Ascenzo, Davide Giacomo Presutti, Elisa Picardi et al ( 2012), Prevalence and non-invasive predictors of left main or three-vessel coronary disease:
evidence from a collaborative international meta-analysis including 22 740 patients. Heart, 98, pp. e914-e919.
12. Gienn N Levine, James C Blankenship, Steven R.
Bailey, et al (2011), 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, Circulation, 124, pp.e574-e651.
63 I