Y HOC VIET NAM SO DAC BIET - THANG 11/2010
ROI LOAN NHjP TIM VA BIEN THIEN NHjP TIM TREN HOLTER DIEN TIM 0 BENH NHAN DAI THAO DirONG TYP 2 CO BIEN CHUNG THAN
TOM TAT
OTO typ 2 la mdt benh ly phitc tap, gay bien chu'ng d nhieu cd quan, dac biet la d tim, nao, mat, than... benh ly than kinh tU ddng tim (TKTDT), rdi loan nhip tim (RLNT) va bien chu'ng than thudng xay ra sdm d phan Idn trUdng hdp va khdng cd trieu chu'ng trong nhieu nam. Khi cd bien chu'ng d than, thi bieu hien d tim se nhU the nao?
Muc deu: Oanh gia rdi loan nhip tim va bien thien nhjp tim tren benh nhan dai thao dUdng typ 2 CO bien chu'ng than qua Holter dien tim 24h.
Doi tu'dng va phu'dng phap; 110 benh nhan OTO typ 2 dUdc dUa vao nghien eu'u. Trong dd 38 benh nhan cd bien chu'ng than va 72 benh nhan chUa cd bien chu'ng than de danh gia RLNT va giam BTNT bang Holter dien tim 24 gid.
Kit qua: Ty le RLNT tren benh nhan OTO typ 2 cd bien chiing than la le 57,8% cao hdn nhdm chUa cd bien chu'ng than (26,4%). Ty le giam BTNT tren benh nhan OTO typ 2 cd bien chirng than la 63,15% cao hcJn nhdm chUa cd bien chu'ng than (29,16%).
ABSTRACT
Background: Type 2 diabetes millitus is complex disease and causes many complications of the organs such as heart, eyes, brain and renal. Cardiovascular autonomic neuropathy (CAN), cardiac arrythmias and complications in renal often are appaired early in almost the cases and has had not any signal within many years.
How the cardiac symtoms are reconigzed in type 2 diabetes millitus with complications in renal.
Objective: To Measure cardiac arrythmias and
Nguyen Ta Dong*
heart rate variabilit/ parameters in patients with type 2 diabetes millitus with complications in renal.
Design and methods: 110 patients with type 2 diabetes millitus include 38 patients with complications in renal and 72 patients without complications in renal. All of tine patients were measured cardiac anytiimias and heart rate variability parameters by 24 houus ECG Holter recording.
Results: Rate and degree of cardiac arrythmias and decreasing of heart rate variabilit/ parameters in type 2 diabetes millitus patients with complications in renal were significantly higher than patients without complications in renal.
I. OATVXNOI
Hien nay, DTD dugc xem nhu la mdt dai dich ciia the ky XXI, nhat la dai thao dudng typ 2 la mdt trong nhQ'ng benh ly ndi tiet - chuyen boa thudng gap (chiem 60 - 80%), benh cd xu hudng tre hoa va tang nhanh trong nhu'ng nam gan day. DTD la mdt benh ly da dang, lien quan den nhieu td chirc va ca quan ciia ca the, dac biet la he thdng mach mau ma bieu hien nhieu d tim, nao, mat, than... Trong dd cac bien chimg nhu thieu mau ca tim (TMCT), va benh ly than kinh tu ddng tim (TKTDT), rdi loan nhip tim (RLNT) va bien chimg than thudng xay ra sdm d phan ldn trudng hgp va khdng cd trieu chimg trong nhieu nam trude khi cd bieu hien lam sang can phai can thiep. Bien chimg tim mach va than thudng dugc phat hien mudn hoac tu bdc Id trong nhung bdi canh
Bi'itlivicn III Hue
CHUYEN DE: P H A U THUAT TIM MACH VA LONG NGL/C VIET NAM
nhu nhiem trung. su>' tim. giai doan nang cua benh ha>" khi cd can thiep.
\'i the. \iec phat hien sdm bien chu'ng tren la mdt dieu can thiet ddi vdi benh nhan DTD va qua do can cd iiidt che do cham soc
\a theo ddi dac biet ho'n.
2. Muc tieu nghien ciiu:
- Danh gia rdi loan nhip tim va bien tiiien nliip tim tren benh nlian dai thao dudng typ 2 cd bien chimg than qua Holter dien tim 24h .
II. OOI TUpNG VA PHUONG PHAP NGHIEN CUU 2.1. Doi tuong nghien ciiu:
110 benh nhan DTD typ 2 dugc dua \'ao nghien cim. Trong do:
2.1.1. Nhdm henh:
La benh nhan DTD typ 2 cd bien chimg than dang dieu tri \'a theo ddi ndi va ngoai tni tai khoa Ndi Ndi tiet va Ndi Tim mach - Benh vien trung uang Hue.
Benh nhan dugc chan doan cd bien cliimg than khi cd tang ure va creatinin mau \'a hoac CO protein nieu. Sd lugng 38 benh nhan.
Benh nhan DTD da dugc chin doan diu dua vao nghien cuu, ngoai trir:
Benh nhan dang diing cac thudc aiili hudng den \iec danh gia kit qua tren Holter.
Nhimg benh nhan dang dilu tri benh tim mach nang (nhdi mau ca tim ciip. con dau that ngirc khdng dn dinh. benli \ale tim, ,su\
tim nang...). benh ngi khoa khac nang (nhiem triing nang. su>- gan, suy than, benh phdi man tinh nang...)
2.1.2. Nhdm chiing:
La benh nhan DTD typ 2 dang dilu tri \a theo ddi ngi \k ngoai tni tai khoa Ngi Noi lilt
\-a Ndi Tim mach - Benh vien trung uong Hue, chua cd bien chirng than. Sd lugng 72 benh nhan.
2.2. Phuo'ng phiip nghien ciiu:
Tien hanh nghien ciru cat ngang, mo ta va so sanh. nghien ciru tai thdi dilm khi benh nhan dugc mang Holter dien tim.
Phu'O'ng phap nghien ciru Benh- Chirng, 2.2.1 Cdc tham sd nghien cuu bao gom:
Tudi. Chi so khdi ca thi (BMI), VB.
VB/VM, huyet ap ddng mach, rdi loan lipid mau. dien tim, dudng man, Ure va creatinin mau. protein nieu dai the...
2.2.2 Holter dien tim 24 gia:
Ky thudt ghi: Mac cac chuyin dao theo 3 kenh:
CH.t-) J--'\^
C l l , ( + )
CH I ( - )
• C l l , ( + ,
CM3
True ECG nhl
•4 True ECG that
CMI CMS
///////: Ciic dien cue & true dien tim cua nhl va that tren cac chuyin dao
Y HOC VIET NAM SO DAC BIET - THANG 11/2010
Cdch ddnh gid:
Roi logn nhip tim: {Remi pilliere vd J P Bourdarias)
Ddi vdi phan mim MT - 200 ciia hang Schiller (Thuy sT) cac dii lieu dien tim phan tich dugc bao gdm:
+ Ngung xoang: Khi ngii, d ngudi tre thudng cd khoang ngimg tim ngan, binh thudng khdng vugt qua 2 giay vdi ngudi >30 tudi, khdng vugt qua 2,5 giay d ngudi <30 tudi.
+ Nhip nhanh xoang: Nhip tim cd tan sd
> 1001/phut
+ Nhip cham xoang: Nhip tim cd tan sd
< 60 1 / phut
+ Ngoai tam thu nhT: Gidi ban tren ciia binh thudng la:
< 10 ngoai tam thu nh; /24h ddi vdi ngudi 20 - 40 tudi.
< 100 NTT nhT /24 gid ddi vdi ngudi 40- 60 tudi
< 1000 NTTnhT /24 gid ddi vdi ngudi
>60 tudi.
+ Rdi loan nhip hoan toan (rung nhT) + Ngoai tam thu that : Cac dang NTT that bao gdm NTT that don dang, cap ddi, cap ba, NTT that nhip ddi, nhip ba va hien thugng R/T.
Gidi ban tren ciia binh thudng la :
< 100 NTT that/24 gid, < hai d NTT, khdng cd NTT di lien nhau : d ngudi < 50 tudi
< 200 NTT thSt/24 gid, cd < 2 NTT lien tuc va < 5 NTT that /I gid d ngudi >50 tudi.
+ Con nhip nhanh tren that: Khi cd>3 NTT tren that di lien nhau.
+ Can nhip nhanh thit: Khi cd >3 NTT that di lien nhau.
Bien thien nhip tim :
Su bien tiiien nhip tim nay dugc danh gia bang nliieu phirong phap khac nhau hoac bang cac sd do theo thdi gian hoac bang cac sd do theo tan sd, trong do don gian nhat la thuc Men phuang phap do ludng theo thdi gian.
+ Phuong phap thdng ke (phan tich theo thdi gian):
SDNN: Do lech chuan ciia tat ca cac tlidi khoang NTsI binh tiiudng ti-ong 24 gid - DLCNN.
.SDANN: Do lech chuan ciia trung binh cac thdi khoang NN binh thudng mdi 5 phut trong ca 24 gid - DLCTBNN.
.SDNNidx: Trung binh ciia do lech chuan ciia cac thdi khoang NN binh thucmg moi 5 phiit trong ca 24 gid - TBDLCNN.
.rMSSD: Can bat hai trung binh binh phuang ciia cac khac biet giira cac cap thdi khoang cua NN ke can nhau - CTBBPNN.
.NN50: Tat ca thdi khoang NN ke can nliau cd lech ho'n 50 ms - NN50.
.pNN50 : Ty le phan tram cua NN ke can nhau cd chenh lech hon 50 ms vdi cac thdi khoang NN binh thudng - TLNN50).
Cac gia tri SDNN, SDANN, SDNN index, rMSSD va pNN50 la thudng dugc dimg de danh gia BTNT trong lam sang. Nhu vay, neu BTNT cimg thap thi tdn thuong TKTDTM cimg nhieu va tuy theo mirc do cac chi sd BTNT bi giam ma chung ta cd cac m.irc do tdn thuong TKTDTM khac nhau nhu trong klii lam trac nghiem EWFN 'S.
Phuo'ng phap xii' ly so lieu
Xir ly sd lieu bang phuong phap thdng ke Y hgc, ung dung phan mem SPSS 13.5, Excel 2000.
III. KET QUA NGHIEN CCfU
Nghien cii'u 110 benh nhan DTD typ 2 cd va chua cd bien chimg than, chiing tdi da ghi nhan mot sd kit qua nhu sau:
CHUYEN DE: P H A U THUAT TIM MACH VA LONG NGUC VIET NAM
3.1. Dac dilm lam sang cua ddi tugng nghien cuu:
Tudi
Bang 1: Tudi trung binh ciia ddi tugng nghien cim
Tudi trung binh Ldn nhat Nhd nhat
Nhom benh 51,04 ± 6,27
82 37
Nhom chu'ng 50,50 ± 8,17
81 39
t
1,45
P
> 0.05
Cdc chi sd nhdn trac.
Bang 2: Bang so sanh cac chi sd nhan trac giii'a hai nhdm.
Chi so nhan trac BMI (Kq/m2)
VB ( cm ) VB/VM
Nhom benh ( n = 4 8 )
X
22,77 87,42 0,87
SD 3,1 9,5 0,087
Nhom chu'ng ( n = 6 2 )
X
21,57 81,27 0,87
SD 2,6 8,3 0,56
t
0,78 1,4 0,01
P
>0.05
>0,05
>0.05
Huyet dp
Bang 3.' Cac tri sd trung binh huyet ap ciia c
Tn so HA HATT (mmHg) HATTr (mmHg)
HATB (mmHg)
Nhombenh
X
151,85 82,04 111,97
SD 23,5
9,9 14,3
di tugng ng lien cim Nhom chu'ng
X
134,9 81,7 100,5
SD 21,8
9,7 13,1
t 1,98 0,57 0,61
P
<0,05
>0,05
>0,05
Dudns mdu:
Bang 4: Tri sd dudng mau trung
Nhdm chu'ng Nhdm benh
binh ciia nhdm Du'dng mau ( mmol/l)
X
8,77 13,49
SD 4,74 5,55
nghien cim
Thdi gian DTD(nam)
X
8,34 4,25
SD 2,17 3,01
P
<0,05
Bilan lipid
Bang 5: Bilan lipid ciia dd tugng nghien eu'u
Bilan Lipid (mmol/L) CT (mmol/L) TG (mmol/L) HDL-C (mmol/L) LDL-c (mmol/L) LDL/ HDL > 4,5
Nhombenh
L X
5,84 2,12 1,25 3,12 2,49
SD 1,85 1,24 0,4 1,28 1,84
Nhom
X
5,14 2,41 1,37 3,43 2,50
chu'ng SD 1,09
3,5 0,34 1,26 0,78
t 0,95 0,54 1,09 0,81 0,99
P
> 0,05
>0,05
>0,05
>0,05
> 0 , 0 5
Y HOC VIET NAM SOOAC BIET - THANG 11/2010
Tri sd trung ^ h ciia thanh ph§n lipid mau tuong duong giii'a hai nhdm va khdng cd sir khac biet ( p > 0,05).
Phdn bd cdc yeu td nguy co'
i V
^'
4^^ .J' r
x^^ ^
#
• Nhom benh n Nhom chirng
Hinh 1: Bieu dd phan bd ty le cac yeu td nguy ca cua hai nhdm
3.2. Ket qua Holter dien tim 24 gid' cua doi tuong nghien ciru:
3.2.1. Rdi logn nhjp tim Ty le rdi logn nhip tim
Biing 6: Ty le rdi loan nhip tim :
Nhdm benh (n=38) Nhdm chu'ng(n=72)
y' OR = 2,57
Co RLNT n
22 19
o/o 57,8 26,4
Khong RLNT n
16 53
o/o 42,2 73,6 3,45
( KTC 95 % = 1,25 - 5,17)
%
Co RLNT
[ ] Nhom benh
'^—X Nhom chu'ng Khong RLNT
Hmh 2: Ty le Rdi loan nhip tim d hai nhdm ciia doi tugng nghien cim
; H U Y E N DE: PHAU THUAT TIM MACH VA LONG NGUC VIET NAM
So hrang NTT:
Bang 7.' Sd l u g n g N T T that
Nhdm benh Nhdm chu'ng t
P
va nhT
So NTT that
X
358,2 56,5
SD 209 88 t =4,3 P < 0,01
So NTT nhl
X
179,8 37,2
SD 103,9
31,5 t = 3,38 P < 0,01
Ty le RLNT va sd lugng NTT that hay NTT nhT d nhdm DTD deu cao ban d nhdm khdng DTD cd y nghTa.
Phdn logi RLNT theo Lown:
Bang 8: Phan loai cac RLNT
Phan do roi loan nhjp that ( t h e o Lown )
£)p 1 ( < 30 NTT/1 gid, ddn dang )
£>p2( > 30 NTT/1 gid, ddn dang ) Dg3{ NTT da dang )
Dp4a{<2 couplet) 4b{ > 2 couplet)
£>p5( NTT dang R/T) Tong cong
Nhom benh N = 38 n
9 5 4 2 1 22
o/o 23J 15,8 10,5 5,2 2,6 57,8
Nhom chu'ng N = 7 2 n
11 7 1 0 0 19
o/o 15,3
9,7 1,4 0 0 26,4
P
>0,05
<0,05
<0,05 0 0
<0,01
3.2.2. BTNT :
Ty le cd gidm BTNT & hai nhdm cua ddi tirang nghien cuu
Bang 9: Ty le cd giam bien thien nhip tim cua ddi tugng nghien ciixi:
Nhdm benh Nhdm chu'ng
Tong cdng
.22_
Ty suat chenh (0R)=
Co giam BTNT
2 4
21
o/o
63,15 29,15
55
Khong giam BTNT o/o
14 ,37,85
51 70,84
55
3,42
2,13( khoang tin cay 95%: 0,92 - 5,35) Tong cong 38 72
• • - " ' *^ -^ ^^i-L ~ , -ZJ-ZJZ^ 1
Ty le benh nhan DTD typ 2 cd bien chirng than cd giam BTNT qua Holter la 63,15 %, cao hon nhdm chua cd biln chung than (29,16) cd y nghTa.
Y HOC VIET NAM SO D A C BIET - THANG 11/2010
Giam BTNT Khong giam BTNT Dnhom benh [3nh6mchu'ng
Hinh 3: Ty le giam BTNT d hai nhdm ddi tugng nghien cim Bang 10: Cac chi sd BTNT qua Holter cua ddi tugng nghien cu'u:
SDNN SDANN SDNN index rMSSD PNN50
Nhom benh
X
73,60 45,95 42,55 30,15 3,58
SD 41,35 35,35 15,54 15,04 4,59
Nhom chu'ng
X
85,1 73,48 84,58 41,59 5,71
SD 31,49 28,53 47,53 38,72 7,73
t 2,307 4,143 5,325 2,137 2,387
P
<0.01
<0.01
<0.01
<0.01
<0.01 Cac chi sd BTNT d nhdm benh thap hon nhdm chiing cd y nghTa.
IV. BAN LUAN
1. Roi loan nhjp tim 6' benh nhan DTD typ 2 CO bien chiing than:
d benh nhan DTD typ 2, rdi loan nhip tim thudng xay ra d phan ldn trudng hgp ma khdng cd trieu chimg hay de dimg bi bd qua trong thirc hanh lam sang. Mdt nghien cu'u trude day cua chiing tdi cho thay ty le RLNT d benh nhan DTD typ 2 cao ban han so vdi ngudi binh thudng. Va Dodn Qudc Himg (2006) cung da ghi nhan ty le RLNT d benh nhan DTD la 30,2 % qua Holter dien tim 24 gid va chii yeu la nhip nhanh (13,9 %). Da cd nhieu nghien cim cho rang d ngudi binh thudng van cd nhung NTT tren that hay NTT thdt vdi sd lugng/24 gid chua dii vdi tieu chuan ciia Rend Rillier vd J P Bourdarias (2000 )nay, cung nhu khoang ngung xoang
<2.0 giav la binh thudng. Ket qua tren Holter
trong nghien cim cua chiing tdi cd 22 benh iihan/38 benh nhan DTD typ 2 cd bien chirng than (chiem ty le 57,8 %) cd bieu hien RLNT so vdi 19/72 benh nhan DTD typ 2 chua cd bien chu'ng than (chiem ty le 26,4
%). Dieu khac biet nay rat cd y nghia khi gia tri kiem dinh ^ =3,45 vdi ty suat chenh ddi vdi RLNT la 2,57 (khoang tin cay 95 % tir 1.25 - 5,17)(p < 0,05). Ddng thdi sd lugng NTT that va NTT nhT trung binh d nhdm benh nhan DTD typ 2 cd bien chimg than cao hon nhdm chua cd bien chimg than cd y nghia (p < 0,05). Dieu nay cd the dugc ly giai vdi nhieu nguyen nhan khac nhau: Trude tien la do nhirng benh nhan DTD typ 2 cd bien chung than thudng cd thdi gian DTD lau hon nhdm chua cd bien chimg than. Khi da keo dai. thi bien chimg tim mach nhieu hon vdi benh mach vanh, benh ca tim DTD. benh ly
CHUYEN BE: P H A U THUAT TIM MACH vA LONG NGlJC VIET NAM
than kinh tu ddng tim.. .Ca ba y^u td tren deu cd M lam tang kha nang bi RLNT. Mac khac, mdt nghien cim trude day ciia Hodng Viit Thdng vd Cs da chirng minh d nhung benh nhan suy than man cd mdt ty le RLNT cao ban ngudi binh thudng do tinh trang rdi loan nudc dien giai, su u dgng cac chat ddc thai qua than ma dac biet la cac chat kich thich giao cam. adrenergic...Ddng thdi cac bien chimg than ciing la hau qua ciia benh than do tang hu)'et ap ma yeu td nay cd anh hudng ldn den RLNT tren lam sang.
vk phan loai cac RLNT thi chii yeu la cac RLNT do I va 11 theo Lown va hiem hon la do IV va V. Nhdm benh nhan DTD typ 2 cd bien chimg than cd RLNT day dii cac phan do theo Lown, nhdm chua cd bien chimg than thi khdng thay cac RLNT do IV va V theo Lown.
Tdn thuang than trong DTD la mdt van de rat ldn, nd xuyen sudt qua trinh dien tien ciia benh DTD \'a la mdt trong nhung tieu clii danh gia dien tien benli DTD cung nhu dien tien ciia tang huyet ap, hay danh gia hieu qua ciia mdt lieu phap dieu tri. Chimg tdi dat van de nay vao trgng tam cua cac nghien ciai ve sau, nen tien hanh nghien ciai RLNT tren benh nhan DTD typ 2 theo cac giai doan Ichac nhau ciia benh nhu giai doan tien DTD, giai doan RLDNG. giai doan DTD chua cd bien chimg, cd bien chimg mach mau ldn, mach mau nhd...
De danh gia tdn thuang than tren benh nhan DTD typ 2 thi nen dung xet nghiem microalbumin nieu thi viec danh gia tdn thuong than trong DTD mdi chinh xac hon chir nhu ure. creatinin mau hay protein nieu dai the nhu the na\- thi se bi bd qua phhn chim cua tan bang trdi khi vi nd nhu la tien triln ciia benli than DTD. Rat tiet, trong nghien cim nay chiing tdi chua lam dugc dieu do.
2. Bien thien nhip tim :
Ty le gidm BTNT vd benh ty TKTD tim mgch:
Trong nghien ciru nay chung tdi sir dung BTNT qua Holter dien tim de danh gia t6n thuong TKTDTM. Bdi vi nhieu nghien cini trude da> da chii'ng minh viec phan tich BTNT cd the dugc dimg de chan doan benh ly TKTDTM va da chung minh dugc r3ng giam BTNT ludn ludn di kem vdi benh TKTDTM. Trong mdt nghien ciru ve benli TKTDTM d Oxford (Anh), tren mdt mau dai dien cho cdng ddng benh nhan DTD da xac dinh cd ket qua bat thudng la giam bien thien nhip tim. Ket qua nghien ciru ciia chung toi ghi nhan ty le giam BTNT tren benh nhan DTD typ 2 cd bien chung than la 63,15 % cao hon nhdm chua cd bien chimg than (29,16 %) cd y nghTa vdi ty suat chenh 3,42 va x2 = 2,13(p < 0,01). Dieu nay cd the lien tudng den benh ly TKTD than trong DTD.
Chiing ta van biet, su ket hgp giira benh TKTDTM vdi benh than DTD da dugc mot sd nghien cim de cap den [80]. Cd mot he thdng than kinh thuc vat lan khap than lam nhiem vu dieu boa chirc nang than, nen khi kich thich than kinh than se dua den tang sir de khang mach mau, lam giam ca luu lugng mau den than va ca muc lgc cau than. Hon nira, tang boat than kinh giao cam than lam tang tai hap thu va giam tiet mudi d dng than va neu giam boat than kinh giao cam than se cd tac dung ngugc lai.
Tuy nhien de cd sir lien quan giira TKTDT va benh than DTD trong nghien ciru nay thi phai cd su tdn thuang ddng thdi TKTDTM va thin kinh tu ddng than, ma dieu nay thudng duac tim thay d benh nhan DTD.
Theo Moreover, Sundk\>ist vd Lilja (2003) da ghi nhan d beriVi nhan DTD typ 2 cd benh Iv TKTDTM sau 10 - 11 nam se bi
Y HOC VIET NAM SOOAC BIET - T H A N G 11/2010
giam mirc lgc cau than di 4 \hn so vdi benh nhan khdng cd benh th4n kinh tu ddng, ddng thdi khi cd benh than kinh tu ddng ndi chung se la giam lugng nudc tieu 24 gid. Didu nay giai thich cho ket qua nghien cim ciia chiing tdi la giam BTNT cd lien quan vdi chirc nang than
V. KET LUAN
Qua khao sat Holter dien tim 24 gid tren 110 benh nhan DTD typ 2 trong dd 38 benh nhan cd bien chirng than (cd giam chirc nang than) va 72 benh nhan chua cd bien chimg than, chung tdi di den mdt sd ket luan nhu sau:
* RLNT: Cd 22 benh nhan/38 benh nhan DTD typ 2 cd bien chirng than (chiem ty le 57,8 %) cd hidu hien RLNT so vdi 19/72 benh nhan DTD typ 2 chua cd bien chung than (chilm ty le 26,4 %).
* BTNT: Ty le giam BTNT tren benh nhan DTD typ 2 cd bien chimg than la 63,15 % cao hon nhdm chua cd bien chimg than (29,16 %).
Kien nghi ciia chiing tdi la can phat hien sdm cac bieu hien ciia bien chimg than d benh nhan DTD typ 2 de gdp phan chan doan, dieu tri va tien lugng du hau cho benh nhan. Holter dien tim can dugc sir dung rdng rai nhu la mdt bilan can thiet de tham dd cac bien chirng tim mach d benh nhan DTD typ 2 cd bien chimg than.
TAI UEU THAM KHAO
1. Nguyen Dii'c Cong (2000), " Phan tich biln tiiien nhjp tim de danh gia chuc nang than kinh tir ddng tim". Tgp chi tim mgch hoc Viet Nam thdng 12/2000. (24), tr. 63-67.
2. Nguyen Ta Dong, Nguyen Hai Thuy, Huynh Van Minh, Le Thj Bich Thuan (2004),"
Nghien ciru rdi loan nhip tim d benh nhan DTD
typ 2 qua Holter dien tim 24 gid", Tgp chi tim mach hoc 2004 (phu san dac biet cua dgi hpi hm mgch quoc gia) (37), tr. 300 - 308.
3. Doan Quoc Hung (2006), "Lgi ich kilm soat tiin mach bang Holter cho benh nhan DTD".
Hgi nghi khoa hoc mien trung chuyen nghdnh npi tiet chuyen hod ldn thd 5, Tgp chi Yhoc thuc hdnh (548), ISSN 0866 - 7241, tr.
616-624.
4. Nguyin Thj Nhan (2003)," Biln chirng thSn kinh tu dong giao cam va ddi giao cam d benh nhan dai thao dudng typ 2", Hpi nghi khoa hpc todn qudc ldn thd II, thdng 4 / 2003, tr. 126- 134.
5. Peter Kempler (2002), " Benh thin kinh tim do tieu du'dng, "Hpi thdo nhdn phien hpp thuang nien cua hiep hpi DTD chdu Au, Hungary; tr. 32 -35.
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