A NGHIEN CUU LAM SANG
Nghien cuu sue cang cotim bang sieu am Speckle tracking 2D 6 cac b§nh nhan nhoi mau co tim c^p CO ST ch§nh len truoc va ngay sau can thiep dpng maeh vanh
Nguygn Anh TuSn***, Nguyin Thi Thu Hoai*, Phsm Nguyin Son**
Tg Mgnh Cudng*, Pham Thai Giang**, 06 Doan L(?i*
Vien Tim maeh Viet Nam*
Benii Vien Trung utjng Quan Su\ IDS"
Benii vien Oa kiloa tinli Ha Nam*"
TOM TAT
Muc tieu: Nghien cdu moi lien quan giiia sde cang dpc cd tim (GLS) vdi ndng dp proBNP va ndng d^ Troponm T mau, phan sd tdng mdu that trai (EF) va chi sd vgn dpng thanh (CSVDT) tren sieu am tun dbenh nMn nhdi mdu cd tim (NMCT) cap cd ST chenh Ien va khao sdt sd thay dfli cua GLS tnidc va ngay sau can thiep dpng maeh vanh (DMV),
Doi ttf^ng va phtfdng phap: 30 benh nhan NMCT cap cd ST eh^nh len lan dSu diidc di^u tn tai \^en Tim maeh Viet Nam td thang 1 nam 2016 den thang 9 nam 2016. Tat ea cac benh nhan deu difdc khdm lam sang, dien tim, sieu am tim sau dd dddc chyp va can thi^p DMV qua da. Trong vdng 24 gid sau can thiep, b^nh nhan diidc si^u dm tim Ian thd hai. Hinh anh sieu dm difdc phdn tich M.
ddnh gid GLS bang p h ^ mgm EchoPAC 112 (GE, HoaKy).
Ket qua: Tudi trung binh 65,3 ± 10,4. Nam gidi:
83,3%. GLS tnidc can thiep cd tiidng quan tuyai tinh vdi proBNP (r = 0,598; p < 0,001) va Troponin T (r = 0,375; p < 0,05). GLS cd tddng quan tuyen tinh vdi EF biplane trUdc can thi^p (r - -0,745, p
<0,001), sau can diiep (r = -0,703, p<0,00l) vavdi CSCDT trddc can thiep (r = 0,655, p <0,00l), sau can thiep (r =0,587, p<0,00l). GLS trung binh sau can thi^p tang len so vdi tnJdc can thiep (-12,66 ± 3,68 % so vdi -11,94 ± 3,25 %; p < 0,001).
Ket Iu?n: Q benh nhan NMCT elp cd ST eh&ih Mn, GLS ed tddi^ quan tuy^n tinh vdi ndng dp proBNP va ndng dp Troponin T mau, EF va CSVDT tren sieu am tim. GLS cai thien ngay sau can thiep DMV trong vdng 24 gid so vdi tnfde can thiep.
OAT VAN DE
Nhdi mau ed tim (NMCT) la mdt b&ih nang, cd ty le td vong eao. Si^u am Doppler tim la mflt phddng phap cd gia tri de ddnh gid ehdc nang tbdt trdi va phan ting nguy cd d b&nh nhdn NMCT cdp.
Trong cac thdng sfl sieu am tim, phdn sfl tdng mdu that trai (EF) va chi sd v ^ ddng thanh (CSVDT) la nhiing thflng sd thiidng dd(?c sd dyng. Tuy nhi^n, viee do dgc hai thdng sd tren phu thuflc vao kinh nghidm cua ngddi lam sieu am. Gan day, viee danh gid sde cang ed tim (hay sd bi&i dang cd tim) bang mdt sd phddng phap mdi nhd sieu am Doppler 16 I TAP CHI TIM MACH HOC VIET NAM-SO 81.2018
NGHIEN c a u LAM SANG k.
mfl cd tim va sieu dm speckle tracking diidc cho Id c6 gid tri trong viee Iddng hda ehdc nang that trdi[l],[2],[3]. Trong dd phiidng phdp sifeu dm speckle tracking cd du viet h d n vi viec danh gid khflng p h u thupc vao gdc cua chum tia sieu am. Silc eang cd tim md ta sii thay ddi tddng ddi chieu dai cua dogn cd tim theo chu chuyen tim. Day la mdt phiidng phdp giiip liidng hda sii suy giam chdc nang CO bdp cua tim, cd tddng quan chat che vdi cdc thdng sfl chdc nang tim d o bang phddng phap cdng hiidng td hgt nhan va tu'dng quan vol kieh thddc fl nhdi mau va U^n quan chat che vcft tien Idcftig cua benh n h a n [ 4 ] . Tai Viet Nam, ehung tdi chiia thay tac gia nao nghien cdu cu the ve van de nay. Vi vay, chiing tdi t i l n hanh nghien cdu de tai nham hai myc tieu: 1. Nghien cdu mat lien quan giiHa sde eang doc ccf tim (GLS) v&i ndng d^ proBNP vd Troponin T mdu, EP vd CSVDT trin siiu dm tim cf benh nhan NMCT cdp ed ST chinh lin. 2. Ehdo sdt stf thay dSi GLS d binh nhdn NMCT cdp co ST chinh lin trtidc vd ngay sau can thiep DMV.
001 TUDNG VA PHUDNG PHAP
Ddi tiidng n g ^ ^ aia
30 b e n h nhdn N M C T cap cd ST chenh len lan dau dddc chyp va can thiep D M V qua da tgi Vi^n Tim mgch Qude gia Viet Nam trong khodng thdi gian td thdng 1/2016 den thang 9/2016.
- Tieu chuan chpn b e n h nhan
N M C T cap cd ST ehenh len Ian dau theo dinh nghia toan cau Idn thd III ve N M C T cap co ST ch^nh Ien n h d sau: [5]
+ Dau that ngde brSn 20 phut.
-I- Tang men tim (Troponin T > 0,01 n g / m l ) . -f- Di^n tim: ST chenh Ien mfll d diem J tren 2 chuy^'n dgo k^ nhau vdi diem cat > 1mm 6 tat ca cac chuyen dao trd V2-V3. N e u d V2-V3 thi d i l m cat la
> 2nim d nam gidi > 40 tudi hoge > 2,5 m m d nam gidi < 4 0 tufli hoac S: 1,5 m m d nfl gidi.
- Tifiu chuan logi trd:
C6 b^nh ly npi khoa ngng ne, rung nhi, bloc nhi thdt dfl 2,3, dgt mdy tgo nhip, hinh dnh silu am tim md, b^nh nhdn td ehfli khflng tham gia nghien eilu.
P h i i d n g p h d p n g h i a n cihi - Nghi&i cdu tiln edu, md ta cat ngang, - Phddng tien nghien cdu: May sieu am \^vid E9 (GE, Hoa Ky) cd trang bi phan m e m ddnh gid chdc nang tim bang phddng phdp speckle tracking.
- Quy trinh thiic hien silu dm specHe tracking:
-H Slide 1: Ghi hinh dpng theo thd tii mat cat 3 buflng, 4 buflng, 2 budng true dpc trong it nhat 3 chu ky vdi tdc dp quet 60-100 dnh/giay
-I- Bddc 2: Phan tich hinh anh dflng bang phan m^m AFI cd san t r i n mdy sieu dm: Vdi moi mat eat mdy se y i u cdu chpn 2 diem d vong van hai la va 1 d i l m d m d m tim, sau do may se td ddng v i l n theo ndi mac tim. Tuy nhien can phdi d i l u chinh de cd k i t qud chinh xdc nhat. Sau dd may se tii dflng phan tich d l tim ra dinh sde cang dpc toan bfl that trdi (GLS) va dinh sde cang cua tdng vung trong thi tam thu. Hinh anh cudi cimg thu dddc gpi la hinh anh bull's eye, Toan b p that trdi dddc chia thanh 17 vung theo khuyin cdo eua Hiep hdi Sieu am T u n HoaKy [7],
Hinh 1. Minh ho^phucfngphdp ddnh ^d siic cdng dgc ccf tim trin sieu dm tim spi
T A P C H i T I M M A C H H O C V I E T N A M - S O 8 1 . 2 0 I 8 l 17
A NGHIEN Cl/U LAM SANG
- Phddng phdp xd ly sd lieu: Bang cac thugt todn thdng ke tren may vi tinh vdi phan mem Stata 14,0
KET QUA
Mpt %d d%<c dicfm ldm s^s\%, cin lim s ^ g Bdng 1. D4c diim ldm sdng
D$c diem Iam sang Tuoi(X±SD) Gidi nam (n%) Tai^huyet dp (n, %) Dai thao dudng (n, %) Hiit thuoc Id (n,%) Rdi loan Lpit mau (n, %) Killipl(n,%)
ThOigiantiddiidau ngtfc dgn liic can thiep BMV(giS) (XtSD) HuySt dp tam thu (mmHg); (X ± SD) Huyet dp tam tnlong (mmHg) (X±SD)
Mach(X±SD)
K^tqua
653*10,4 25(83,3) 14(4«,6) 7(23,3) 17(56,7) 13 (43,3) 20(66,7)
14,3 ±8,8
128,3 + 21,2
78,3+13,4
86,6±16,2
Dac diem can lam sang Dac digm sinh hoa mdu
CK-MB(UI/L) TroponmT (ng/ml). (X + SD) ProBNP (pmol/l).(XtSD)
K^tqua
123,2 ±123,54 1,75 ±1,95 67,45±75,8
Dac digm t6n thudng maeh vanh Mot nhanh (n,%) Nhigu nhinh (n,%) IJ\D(n,%) RCA(n,%) LCX(n,%)
TIMI0 tnidc can thiep (n, %) Dacdigmsieuam tim
Dd(mm):(X±SD) EF biplane (X + SD) CSVDT: (X±SD) E/e GLS(%)
13(43,3) 17(56,7) 18(60) 10(33,3)
2(6,7) 20 (66,7)
46,8 ±5,9 0,465 ±0,086
1,43 ±0,23 13,8±4,67 -11,94±3,25 Nh^n xit: Dong mgch thu phgm ggp chu yiu la LAD ehilm 60%; EF biplane trddc can thi^p Id 0,465 ± 0,086. GLS tnidc can thiep Id -11,94 ± 3,25 {%).
Mdi tiln quan gifia GLS vdi ndng do proBNP 'n Troponin T mau, EF va CSVDT tren sieu am tim
Nh^n xit: Tudi trung binh eua cde ddi tddng nghiin edu la: 65,3 ± 10,4; nam gidi chiem 83,3%;
Killip I la chu yeu ehilm 66,7%.
Bdng 2. Ddc diim c4« idm sdng
Biiu dd 1. Mdi lien quan giSa GLS vd proBNP Nhdn xit: GLS cd mdi tdtmg quan chgt ehe vdi proBNP.
18 ITAP CHLTIMMACH HOC VIET NAM-SO81.2018
NGHIEN CM LAM SANG k.
' ^ •
g
§
Iu'O'ng quan giija GLS va Troponin T
• • • ^ ^ ^ - " ^ ^
J , * 1 = 0,375
Troponin T f ng/ml)
,-
2
£
'^
::.
tu'ong quan giO'a GLS
^'^^"^'H---' i
* l
EFtHpiaiH
• nmrtco • r a EF biplane
^^"\
5 saucl — 1
Biiu do 2. Moi lien quan giUa GLS vd Troponin T Biiu dd 3. MSi hin quan giUa GLS v&i EF biplane Nhdn xet: GLS cd mdi tddng quan mdc dp Nhdn xit: GLS cd mdi tddng quan rat chat che trung binh vcd Troponin T. vdi EF biplane trddc va sau can thiep.
Biiu dd 4. Mdi lien quan giita GLS vd CSVDT
Nhqn xet: GLS cd mdi tddng quan chat che vdi CSVDT trddc va sau can thiep.
Thay doi GLS tnidc vi ngay sau can thi^p DMV Bdng 3. Thay doi GLS ngay sau can thiep d^ngmach vdnh
GLS(%)
GLS tnmg binh Killip
Thdi gian tii khi dau ngiic dgn luc can thiep DMV
I
>II i l 2 g i d
>12gid
»
30 20 10 17 13
Tnidc CT (XtSD) -11,94±3,25 -12,81 ±3,10 -10,19±2,94 -12,47 ±2,72 -11,24±4,10
Sau CT
(X±SD) ' ' -12,66 + 3,68
-13,69±3,38 -10,S9±3,S1 -13,31+2,59 -11,81 ±4,74
< 0,001
TAP CHI TIMMACH HOC VIET NAM-SO81.2018 I 19
A NGHIEN ClXl IAM SANG
D d i ^ maeh thu pham
SdnhdnhDMV tdn thudng
TIMI tnidc can thiep LAD RCA,LCX Inhanh 2nhanh 3nhanh 0 i,n
18 12 13 13 4 20 10
-10,51 ±2,99 -14,07±2,39 -14,52±2,33 -10,73 ±2,10 -7,44±0,61 -1231±3,13 -11,18±3,50
-11,14±3,48 -14,93 ±2,75 -15,63±2,S8 -11,32±2,19 -7,35 ±1,20 -13,09 ±3,49 -11,79±4,09 Wi^ xit: GLS ngay sau can thiep DMV co cai
thifn so vdi tnidc can thiep.
BAN LUAN
D|c diem lam sang, can lam sing
Benh nhdn trong nhdm nghien cdu cua chiing tdi cd tudi tnmg binh la: 65,3 ± 10,4; nam gicS gap chu yiu ehiSn 83,3%. Cac yiu td nguy ed tim mgch tbddng ggp la tang huylt dp chiem 46,4%; hut thudc la ehilm 56,7%; rdi logn lipit mdu chi&n 43,3%. Thdi gian td khi dau ngiic din liic md thdng dpng maeh vanh thddng mudn (14,3 ± 8,8 gid). Ket qua nghien cdu cda ehiing tdi cung tddng td nhd ngbiln cdu cua Vu Quang Ngpc trln215b?nh nhan NMCT elp cd ST dilnh lln cho thay tudi trung binh la 64,7+ 10,8;
nam gi^ ehilm 72,6% [6]. Khi tim hieu dgc diem tdn tfiddng dpng maeh vanh chung tdi thay ehu yeu ed tdn thddng nhieu nhanh chiem 56,7%. Dpng maeh thu pham ggp chu yiu la ddng maeh lien thit trddc chiem 60%; dpng maeh mii ggp it nhdt ehi&n 6,7%. Ket qua nay cung tddng td nhd kit qua nghiin cdu cda mdt sd tac gid khdc [l], [6], Ve dac dilm silu dm tim chiing tdi thdy nhin chung budng tim trdi chda gjan (Dd: 46,8 ± 5,9 mm) nhdng phan sudt tdng mdu that trai da gidm xudng (0,465 ± 0,086) vd cd rdi loan chde nang tam trddng thdt trai vdi E/e' = 13,8 ± 4,67. Khi danh gid GLS trddc can thi^p chung tdi thdy GLS giam xudng con -11,94 ± 3,25 %.
Mdi liln quan gifla GLS vcfi ndng dO proBNP vi n6ng dif Troponin T miu, EF vi CS\^T tren silu am tim
Cd tdm that dddc cau tgo bdi 3 ldp trong dd ldp cd dpc diidi ndi tam mgc cd lien quan din dp kc thanh tim. Vi vay sd giam eo bdp cua ldp ed doc se dan den tang dp ldc thanh tim do dd se lam tang san xuat proBNP ding nhd NT-proBNP [8]. Ket qua nghiin exiu cua chung tdi (bieu dd 1) eho thdy GLS cd mdi tddng quan chgt vdi ndng dp proBNP vcfl r = 0,598 va p < 0,001. Troponin T dgc hieu eho tim la mdt protein dddc sinh ra do qud trinh hoai td cd tim va ed liln quan mat thiet vdi mdc dp hogi td cd tim.
Ndng dp Troponin T mdu cang tang thi mde dp hogi td cd tim cang rdng. Kit qua d bieu dd 2 cho thd)' GSL cd tdcftig quan tuy&i tinh mdc dp trung binh vdi ndng dd Troponin T mdu (r = 0,375 vap < 0,05).
Mdi lien quan giiia GLS •ra EF, CSVDT: Ket qud bieu dd 3 cho thay GLS ed mdi tdcftig quan tuyen tinh rat chat che vdi EF biplane trddc can thilp DMV (r - -0,745; p < 0,001) va sau can thilp DMV (r = -0,703; p < 0,001), Kit qua nghiin eijfti cua chiing tdi ciii^ phii h ^ vdi kit qua n ^ l n cdu cua mdt sd tac gja khde nhd S,Cimino nghiin edu tren 20 binh nhan NMCT cap cd ST chinh lln dddc lam silu am speckle tracking va danh gid EF bing edng hddng td sau can thiep eho thdy EF cd tddng quan tuyen tinh rat chat che vdi GLS vdi r = -0,878 [9]. Amira M va cpng sd ddnh gid sieu am specHe tracking trong vdng 24 gid sau can thiep DMV d 30 benh nhan NMCT cdp cd ST chinh Ien cho thay GLS cd mdi tddng quan tuyln tinh vdi EF tren silu am 2D vdi r = -0,35; p = 0,01 [lO]. Khi tim hilu mdi tddng quan gifla GLS vdi CSVDT trddc va sau
20 ITAPCHITIMMACH HOCVIET NAM-S681.2018
NGHIEN c u l l LAM SANG k.
can thilp DMV ehiing tdi thay GLS ed mdi tddng quan chgt vdi CSVDT trddc can thilp DMV (r = 0,655; p < 0,001) vd sau can thiep DMV (r = 0,587;
p < 0,001). Kit qui nghiin cu^ cua chiing tdi cung tddng td vdi kit qua nghiin cdu cua mdt sd tie gii khdc nhd S.Cimino va cdng sd cho thay CSVE)T danh gid bang c^ng hddng td cd tddng quan tuyen tinh rdt chat ehe vdi GLS vdi i - 0,807 [9]. Amira M va cdng suf eho thdy GLS cd mdi tddng quan tuyln tinhehatvdiCSVDTvdir = 0,507; p = 0,04 [10].
Biln ddi cua GLS trfldc va sau can thiep DMV Kit qua nghiin edu oia chung tdi d bang 3 eho thSy GLS trung binh trong vdng 24 gid dau sau can thiep DMV cai thien rd so vdi trddc can thiep (-12,66 ± 3,68 so vdi -11,94 + 3,25; p < 0,001). Khi tim hieu ve sd thay ddi GLS sau can thilp theo tdng phan nhdm chdng tdi thay GLS sau can thilp eda cae phan nhdm trin deu cd xu hddng tang, dac biet d mpt sd phdn nhdm nhd: KiUip I, nhdm dddc can
thiep sdm trddc 12gidkltdkhidaungi^e, nhdmcd tdn thddng 1 hoge 2 nhdnh DMV va nhdm ed TIMI 0 lue vao viln. Nhd vay ed thi ndi GLS trong 24 gid dau sau can thiep DMV cd xu hddng cai thi?n so vdi trddc can thiep. Do dd GLS la mdt thdng sd kha nhay cho thay s\i thay ddi ehdc nang tim sdm ngay sau can thi^p DMV.
KET LUAN
Qua nghien cdu 30 benh nhan nhdi mdu cd tim edp cd ST chenh Ien trddc va sau can thilp ddng mgch
•ranh qua da, ehung tdi nit ra mot sd kit luan sau:
- Sde cang dpc toan bd thdt trai ed tddng quan tuyen tinh vdi ndng dd proBIsTP \^ Troponin T mdu, phan sd tdng mdu EF va chi sd vgn ddng thdnh tren sieu am.
- Sde cang dpc todn bd fMt trdi ngay sau can diiep dpng mgch vanh trong 24 gid dau cd cdi thi^n so v& trddc can thiep.
ABSTRACT
Investigate myocardial strain by 2D speckle tracking echocardiography in patients with acute ST elevation myocardial in&rction before and after percutaneous coronary intervention
Nguyen Anh Tuan, Nguyen Ihi Thu Hoat, Pham Nguyen Son, Ta Manh Cuong, Pham Thai Giang, Do Doan Loi Objectives:
1/ To study the correlations between global longitudinal strain (GLS) and proBNP, Troponin T, and ejection fraction EF, wall motion score index (WMSI) by 2D echocardiography in patients with acute ST elevation myocardial irJarction (STEMI)
2/ To investigate the variation in GLS in patients witii STEM! before and after percutaneous coronary intervention (PCI).
Methods: 30 STEMI patients hospitalized in Vietnam National Heart Institute from January 2016 to September 2016 were included. Clinical exanimation,12-Iead EGG, pre and post PCI echocardiography, PCI were done for all patients. Echocardiography images were analyzed to assess global longitudinal strain (GLS) by EchoPAC 112 software (GE, USA).
Results: Mean age: 65.3 ± 10.4 years. Male: 83.3%. Killip I: 66.7%. GLS correlated well witii proBNP (r = 0,598; p < O.OOl) and Troponin T (r = 0.375; p < 0.05), GLS correlated well with EF biplane before PCI (r = -0.745; p < 0.001); after PCI (r = -0.703; p < 0.001) and WMSI before PCI (r = 0.655; p < O.OOl);
TAPCHITIMMACHHOCVl|TNAM-SO81.2018l 21
A NGHIEN CljfU LAM SANG
after PCI (r = 0.587; p < 0.001). GLS obtained 24 hour after PCI was higher than GLS before intervention (-12.66 ± 3.68 % vs -11.94 + 3.25 %; p < O.OOl),
Conclusions: GLS correlatedweIlwithproBNP,TroponinT and EF, WMSI by 2D echocardiography in patients with STEMI. GLS obtained 24 hour after PCI was higher than GLS before intervention in patients with STEMI.
Keywords: Speckle tracking, global longitudinal strain.
TAI LIEU THAM KHAO
1. Nguyen Thi Thu Hoii, NguySn Ihi Thu Thuy, Nguyin Quang Tudln, D6 Doan L0, Nguyin Lan
•\^|t (2015) "Nghien cdu sd thay ddi sde cdng ed tim d benh nhan nhdi mau cd tim cap ed ST chinh lln sau can thilp ddng mgch vanh". Tap ehi Tim maeh hpc Viet Nam, sd 69, trang 76-83.
2. Ola G)esdal; Thomas Helle-VaUe; Einar Hopp et al (2008), "Noninvasive Separation of Large, Medium, and Small Myocardial Infarcts in Survivors of Reperfiised ST-Elevation Myocardial Inferction A Comprehensive Tissue Doppler and Speckle-Tracking Echocardiography Study. Circ Cardiovasc Imaging;
1:189-96.
3. SjoliB, Gretine B, Smiseth OA Edvardsen T, Brunvand (2011), "The advantage of global strain compare to left ventricular ejection fraction to predict outcome after acute myocardial infarction"
Echocardiography; 28: 556-63
4. Tomasz Bochenek, Krystian \>^ta, Zbigniew Tabor et al (20Il), "Value of speckle-tracking Echocardiography for prediction of left ventrichlar remodeling in patients with ST-elevation myocardial infarction treated by primary percutaneous intervention" Joumal of the American Society of Echocardiography volume 24 number 12.
5. Kristian Ihygesen, Joseph S. Alpert, Allan S. Jaffe et al (2012), "Third universal defnition of myocardial inferction" European Heart Joumal (2012) 33,2551-2567.
6. Vu Quang Ngpc (20Il), "Nghien edu mdc dp tddi mau ed tim sau can thiep ddng mgch vanh dbenh nhan nhdi mau cd tim cap cd ST chenh len" Ludn vdn tot nghiep bdc sy ndi trd, Trddng Dgi hpc YHi Ndi.
7. Roberto M. Lang; Lugi P. Badano; Victor Mor-Avi et al (2015), "Recommendation for cardiac chamber Quatifieation by Echocardiography in Adults. An updates from American Society of Echocardiography and the European Association of Cardiovascular Imaging" journal of American Society of Echocardiography Volume 28 number 1.
8. Mad Kristian Ersbell (2013), "Left ventricular global longitudinal strain in acute myocardial inferction"Dti«is/iMeiiica/>uniij/ (2013); 60(8): B4d97,
9. S. Cimino; E. Canali; V. Petronilli et al (2013), "Global and regional longitudinal strain assessed by two-dimentional speckle tracking echocardiography identifies early myocardial dysfanction and transmural extent of myocardial sear in patients with acute ST elevation myocardial infarction and relatively preserved LV ftinction" European Heart Journal (2013) 14, 805-811.
10. Amira M. Ismail; Wael samy, Randa Aly et al (2015), "Longitudinal stram in patient with STEMI using speckle tracking echocardiography. Correlation with peak in&rction mass and ejection fraction" The Egyptian Journal of Critical CareMedicine (2015) 3,45-53,
22 I TAP CHI' TLM MACH HOCVIET NAM - 5081.2018