NGHIEN CCrU L A M S A N G
NGHIEN C0U L A M S A N G
Vai tro cua dien tam do trong du doan vi tri tac dong mach vanh a cac benh nhan nhoi mau ca tim truoc vach cap chi co ton thuang a dpng mach Hen that truac.
TS. P h a m Thi H o n g Thi Vien Tim m^ch Q u o c Gia Viet n a m
TOM
TAT6 cac berJi nhan nhoi mau co tim truoc vach cap, vi tri t3c ciia dong mach lien tha't tnroc co lien quan chat che de'n pham vj hoai tu co tim va tien lugng b?nh nhan.
Muc tieu: Danh gia gia tri ciia dien tam do trong dy doan vi tri t^c dpng mach lien that truac a cac b?nh nhan nhoi mau co tim tnroc vach cap.
Phuang phdp: 48 b^nh nhan nhoi mau co tim truoc vach cap lan dau chi bi ton thuang dpng m^ch lien tha't truoc tren ke't qua chup dpng mach vanh chon loc dupc lam dien tam do truoc khi chup va can thi|p dpng mach vanh. Bieh doi ciia doan ST dup-c danh gia tren dien tam do va dirpc dot chieu voi vi tri tac ciia dpng mach Uen that truoc: doan gan cho xua't phat ciia ca nhanh vach va nhanh eheo (S + D), chi gan cho xua't phat cua nhanh vach (S), chi gan cho xua't phat ciia nhanh eheo (D), xa ca cho xua't phat ciia nhanh vach va nhanh eheo (N).
Kei qud: ST chenh xuo'ng 6 DH, Dm, aVF co gia tri trong dy doan t5c doan gan ciia dpng mach Uen tha't truoc tai cac vi tri 5+D, S, D vai dp n h | y tuang ung la 81%, 51% va 63%, dp dac hieu tuong ting la 74%, 73%, va 77%, p tuong img la 0,001,0,03 va 0,01. ST chenh len 6 chuyen d?o Vl=
3mm sau diem J 80ms co dp dac hieu cao (98%) trong dy doan vi tri tic a gan chd xua't phat ciia nhanh vach. ST chenh len 6 chuyen dao aVR co dp dac hieu cao (91%) trong du doan vi tri tac 6 doan gan cho xua't phat oia ca nhanh vach va nhanh eheo. D6i voi dij doan vi tri tac 6 d o ^ gan cho xua't phat ctia nhanh vach, dp dac hieu aia ST chenh len a chuyen dao aVR la 92% nhung dp nhay lai tha'p (34%).
Kei ludn: 6 cac benh nhan nhoi mau co tim truoc vach cap chi ton thuong dpng mgch lien that truoc, dien tam do la mpt phirong phap chain doan rat co gia tri dvr doan vi tri tSc va moi lien quan ctia vi tri tac voi cac nhanh ciia dpng mach nay.
Td khoa: Dien tam do, nhoi mau ca tim, chup dpng mach vanh
TAP CHi TIM MACH HQC VIET NAM - S6 55 - 2010
DAT VAN BE
a cac benh nhan nhoi mau ca tim cap, vi tri tac ciia dgng mach lien that truac co Uen quan chat che de'n pham vi hoai tii co tim va tien lugng cua benh nhan. Cho de'n nay, da co mgt so nghien ciiu ve gia tri ciia dien tam d6 (DTD) trong chan doan vi tri tac ciia dpng m^ch Uen that truoc 6 cac benh nhan (BN) nhoi mau co tim (NMCT) truoc vach. Tuy nhien, ke't qua ciia cac nghien ciiu nay co su khac nhau chiit it do su khac nhau ve so'lugng dgng m^ch vanh (DMV) bi ton thuang, ve viec CO hay kh6ng co tuan hoan bang he, va dgng mach vanh nao vox nang{l-6).
Muc tieu ciia chiing toi trong nghien ctiu nay la phan tich gia tri aia DTD trong du doan vi tri tac dgng m?ch Uen that tnroc (DMLTTr) a cac BN NMCT truoc vach chi co DMLTTr bi ton thuong
DOI T M VA PHtflJNG PHAP NGHIEN CtfU:
1. Doi tiro'ng nghien ciru:
Chting toi nghien ciiu 48 BN tai Vien Tim m^ch Viet nam dugc chan doan NMCT truoc vach cap trong thoi gian tu thang 12/2004 de'n thang 11/2006. Cac doi tugmg nghien ctiu cua chiing toi chi CO ton thuong duy nha't DMLTTr tren ke't qua chup DMV chgn Ipc. Tieu chuan chan doan NMCT: dtra theo tieu chuan ciia To chtic y te the gioi (TCYTTG) nam 1971, benh nhan co NMCT cap khi co it nhat hai trong ba tieu chuaii sau:
Lam sang: Ccm dau that ngtjc keo dai tr^n SO phiit va khong mat di khi
dting Nitroglycerin.
Tang cac men tim dac hieu: CK, CKMB, SCOT, LDH, TnT (TroponinT).
Dien tam do: Co bieu hien aia NMCT tren DTD, cti the la bie'n doi aia doan ST-T va xuat hien song Q hoai tti theo ma Minnesota.
Tieu chuan loai tru: Cac BN co day that trai tren DTD, cac BN co NMCT cu hoac NMCT ban cap.
2. Phu'O'ng phap nghien ci>u:
* Phuang phap gjii va phan tich DTD:
Chiing t6i phan tich DTD ciia cac BN khi nhap vien. Cac DTD deu dugc ghi 12 chuyen dao, van toe ghi 25mm/giay, ImV = 10 mm.
Cac thong so dugc phan tich tren DTD gom: SiJ thay doi ctia doan ST sau diem J 80ms, dan truyen trong that, va song Q. Ve nhiing thay doi ciia doan ST, chting toi dac biet luu y: ST chenh len hoac chenh xuo'ng 6 DII, DII, aVF, ST chenh len hoac chenh xuong 6 DI hoac aVL, ST chenh len o aVR, ST chenh len o V2 nhieu han o VS, ST chenh len 6 VI >
2 mm, ST chenh len hoac chenh xuong 6 V4, V5, V6.
Miic dp chenh aia ST dugc do bling tay o tung chuyen dao voi thuoc do dien tim.
Moi thong so dugc do S lan va lay gia tri trung binh.
* Chup dgng mach vanh: Danh gia vi tri, miic do ton thuong DMV theo Hgi Tim mach Hoa ky.
NGHIEN CUU LAM SANG
3. Xir ly sd lieu:
Cac so'lieu dupc xii ly bang cac thuat toan thong ke y hoc tren may vi tinh bang phan m a n SPSS 10.0 va EPUNFO 2000 ciia To chiic Y te' the gioi.
KEI QIA NtllEN C l l
48 b^nh nhan nghien ciiu ciia chting toi CO tuoi trung binh 57 ( 12. 56' benh nhan nam la 37 (77%). Tren ket qua chup DMV chgn Igc, co 15 BX bi tic DMLTTr a gan ca nhanh vach va nhanh eheo, 11 BN bj tic DMLTTr doan gan cho xuat phat nhanh vach, xa cho xuat phat ctia nhanh eheo, 12 BX bi tic DMLTTr doan gan cho
xuat phat nhanh eheo, xa cho xuat phat nhanh vadi, 10 BN bi tic DMLTTr 6 xa ca cho xua't phat nhanh vach va nhanh dreo.
Nhu vay, so' BN co vimg co tim bi tcwi thuang do vi tri tac gan ca nhanh vach va nhanh eheo (S + D) la 15, so BX co vimg co tim bi ton thuong do tic gan nhanh vach (S) la 26, so BN co vimg co tim bi ton thirong do tic gan nhanh eheo (D) la 27, va 10 BN khong co \'ung co tim nao thuoc pham vi cap mau cua nhanh vadi va nhanh dieo bi ton thuong (X) (Bang
! ) •
Bang 1: Dac d i e m cua cac b ^ n h n h a n n g h i e n ciiu Dac diein cua cac BN
Tuoi trung binh Nam gioi (%) DM vanh iru nang (DMVP/DMVT/ can bing)
Tuan hoan bang he
S - D ( n = 15) 62(45-67)
88 12/2/1
6
S(n = 26) 60(47-65)
90 10/9/7
10
D ( n = 27) 56(46-61)
78 14/9/4
n
N (n=10) 59(45-63)
80 7/2/1
5 P
>0,05
>0,05
>0,05
>0,05 Gia tri ctia ST chenh xuong (ST •^) 6
cac chuyen dao DH, Dili, aVF:
Chung toi da tien hanh do doan ST 6 ca vi tri tai diem J va vi tri sau diem J 80ms.
ST i =lmm t ^ di&i J co gia tii dii doan tac DMLTTr tai vi tri doan gan ca eho xua't phat cua nhanh vach va nhanh eheo voi do nhay 81%, do dac hieu 74%, p = 0,001.
ST J- 6 Dn, m, a\T cho dii do a tai diem J hay sau diem J 80ms ciing co
gja tri du doan vi tri tac 6 doan gan cho xuat phat ciia nhanh vadi, trong do, ST ?
=lmm tai diein J co dg nhay 59%, do dac hieu 73%, p = 0,03.
ST i 6 DH, m, aVF co gia tri du doan vi tri tac DMLTTr doan gan cho xuat phat ciia nhanh eheo voi do nhay 63%, do dac hieu 77%, p = 0,01.
Gia tri ctia ST chenh len (ST t ) a chuy&i dao aVR:
ST t d chuyen dao a VR co do dac hi^u cao (91%) trong du doan vi tri tic 6 doan
TAP CHl TIM MACH HOC VIET NAM - SO 55 - 2010
gan ch6 xuat phat cua ca nharji vach va nhanh eheo. Doi vcri du doan vi tri tic 6 doan gan ch6 xua't phat cua nhanh vach, dp dac liieu cua ST ? cr chuyen d?P aVR la 92% nhung dp lAay lai tha'p (34%).
Gia tri cua ST chenh len 6 chuyen dao VI:
ST T 6 chuyen dao Vl= 3mm sau diem J 80ms cp dp dac hieu cao (98%) trpng du doan vi tri tSc 6 gan cho xuat phat ciia nhanh vach, nhung dp nhay chi la 29%
Bang 2: Gia tri cila DTD
Vi tri tac tren DMLTTr
S-^D D p n h ^ y
P S Dp n h a y
P D D p n h a y
P N Dp n h ^ y
P
Irong d u d o a n vi tri tac tren DMLTTr ST 4. o n . D m , aVF
diem J
8 1 % 74%
0,001
59%
7 3 % 0,03
63%
77%
0,01
25%
47%
0,21
> 0 , 5 m m tai did'm J
88%
52%
0,02
73%
62%
0,08
7 1 % 63%
0,04
38%
39%
0,06
>0,5 m m sau diem J
80ms 89%
53%
0,04
75%
66%
0,02
65%
6 1 % 0,02
27%
3 1 % 0,02
S T T a V R
> 0 , 5 m m sau diem
J 80 m s 45%
9 1 % 0,03
34%
92%
0,04
24%
87%
0,8
12%
8 1 % 0,4
STTVI
> 3 m m
J 80ms 40%
87%
0,4
29%
98%
0,01
18%
85%
0,6
11%
89%
0,2
BAN LUAN
Dif doan vi tri tac doan gan ctia DMLTTr a cac BN NMCT cap giiip tien lugng va dua ra cac bien phap dieu tri tai tuoi mau kip thoi cho BN. Trong nghien ciiu ciia chting toi, da'u hieu ST ? a DH,
DIII, aVF CO gia tri du doan tac doan gan ctia DMLTTr vai dp nh^y va do dac hieu kha cao (Bang 2). Giai phau hgc he dpng mach vanh cho tha'y 6 mpt so' BN, nhanh vach co vi tri xua't phat gan truac cho xua't phat ctia nhanh eheo. 6 mgt so
NGHIEN CLTU LAM SANG
BN, vi tri xuat phat nay lai nam xa vi tri xua't phat ctia nhanh eheo. Daii hieu ST
? 6 VI = Smm sau diem J 80ms co do dac hieu cao trong du doan vi tri ton thuang gai cho xua't phat aia nhanh vach. Dau hieu ST chenh len a chuyen dao aVR cung CO do dac hieu cao trong du doan vi tri ton thuang gan eho xua't phat oia nhanh vach. Nghien cuu ctia chiing toi Cling tuong tu vdi mgt so nghien ctiu tren the' gioi nhan tha'y rang a cac BN NMCT truoc vach, dau hieu ST ? o DII, DIII, aVF (ke ea do tai diem J hoac sau diem J 80ms) co gia tri du doan tac doan gan ctia DMLTTr, nai gan cho xuat phat ctia nhanh vach va/hoac nhanh eheo.
Nhieu nghien ctiu da nh|n thay da'u hi^u ST chenh xuohg 6 cac chuyen dao viing sau duoi co Uen quan deh vi tri tac doan gan DMLTTr, vdi miic do chenh len ciia ST 6 cac chuyen dao truac tim, voi mtic do nang ctia thieu mau thanh truac, voi dien tich 6 nhoi mau, vdi ty le tii vong va voi cac bie'n chiing nang oia BN NMCT (5,6,8,9,10,11,13). Da'u hieu nay cung co Uen quan deh ty le BN bi ton thuang ea 3 nhanh DMV (4,14,15).
Dau hieu ST ? a VI = Smm sau diem J 80ms CO dp dac hi$u cao trong di^ doan ton thuong doan gan ch6 xuat phat cua nhanh vach. Nghien oiu ctia Engelen cho thay ST ? 6 VI = 2,5 mm neii di kem voi ST
? 6 V5 CO gia tri du doan ton thucmg doan gan ch6 xuat phat ciia nhanh vach (4).
Nghien ctiu aia chiing toi cung nhu ctia Engelen deu eho tha'y ST ? 6 chuyen dao aVR rat die hi?u trong du doan vi
tri tac 6 doan gan cho xuat phat ciia ca nhanh vach va nhanh eheo, hoae chi o doan gan cho xua't phat ciia nhanh vach.
Khi nghien ctiu ve tinh trang tuan hoan bang he aia cac BN, chiing toi nhan thay cac BN CO tuan hoan bang he khong co ST ch^nh len 6 aVR cho du nhanh vach CO bi ton thuang hay khong. 6 cac BN khong CO tuan hoan bang he, dau hieu ST chenh len 6 aVR co do dac hieu 93% trong dtr doan vi tri tac gan cho xua't phat cua nhanh vach.
Cac nghien ctiu truoc day ciing da cho tha'y song Q 6 V4 den V6 khong co Uen quan chat che de'n vi tri ton thuong ctia DMLTTr. Trong nghien ciiu oia chiing toi, song Q 6 cac chuyen dao truoc tim chi CO 6 8 BN, khong co Uen quan deh miic do va vi tri ton thuong dpng mach vanh va viec co hay khong co tuan hoan bang h?.
KET LUAN:
a cac benh nhan nhdi mau co tim truoc vach cap chi ton thuong dgng mach lien that truoc, dien tam do la mgt phuong phap ehan doan rat co gia tri di;e doan vi tri tac va moi Uen quan ctia vi tri tac voi cac nhanh ctia dgng mach nay.
TAP CHl TIM MACH HQC VIET NAM - SO 55 - 2010
ABSTRACT
Usefulness of the electrocardiogram in predicting the occlusion site in acute anterior myocardial infarction with isolated disease of the left anterior descending coronary artery
Introduction and objectives: In acute anterior myocardial infarction (AMI), the site of occlusion in the left anterior descending coronary artery (LAD) is related to the extension of myocardial necrosis and the prognosis. The aim of this study was to assess the value of the electrocardiogram (ECG) as a predictor of tiie LAD occlusion site in patients with anterior AMI.
Methods: 48 consecutive patients with a first anterior AMI and isolated disease of the LAD were included. We evaluated retrospectively the ECG with the most pronounced ST-segment changes before reperfusion and correlated the findings with the site of LAD occlusion in angiography before hospital discharge in relation to the first dominant septal and first diagonal branch: first septal affected (S), first diagonal affected (D), both affected (S + D), or neither affected were con- sidered.
Results: ST depression in leads H, HI, or aVF strongly predicted proximal LAD occlusion in S + D, S, and D (p = 0,001, p = 0,03, and p = 0,01, respectively). ST elevation > 3 mm in lead VI was a specific predictor of occlusion proximal to first septal (S, p = 0,01). ST elevation in aVR was associ- ated with proximal LAD occlusion in S + D and S (p= 0,03 and p = 0,04, respectively).
Conclusions: In anterior AMI and isolated LAD disease, the ECG can be useful in predicting the LAD occlusion site in relation to its major side branches.
Key words: Electrocardiography. Myocardial infarction. Coronary angiography.
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NGHI6N CCrU LAM SANG
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