TAP CHl TIM MACH HQC VIET NAM - SO 56 - 2010
N g h i e n Ciiu Vai Tro D y Bao Dot Tii Do Tim Bang Ket H o p Luan Phien Song T va NT-PROB d Benh N h a n Suy Tim
Hoang Anh Tien, Pliant Nhir The', Hoang Khdnh, Huynh Van Minh (Benh viin Trung irong Hue)
lUM TAT
Dat van di: Nhirng nghien ciiu trong nhiing thap nien gan day da lien ket TWA vdi roi loan nhip that do kich thieh va rdi login nhip that tien phat. Nhiing bing ehiing tren lam sang cho thay TWA, NT- ProBNP la nhung chi diem dang tin cay dol vdi nguy co dot tir do tim va la dong eo thiic day nhu cau tim mpt gia tn toi uu sy ket hop TWA va NT-ProBNP trong vi?c du bao nhiing nguy co do. Sy phoi hop hai ye'u to tien lupng co dieu kien phat huy moi uu diem ciia moi gia tri tien luong do. Do vay chiing toi tie'n harih de tai voi 3 muc tieu: Nghien ciiu vai tro du bao dot tu do tim ciia TWA. Nghien cuu vai tio dy bao ddt tii do tim ciia NT-ProBNP. Nghien ciiu vai tro dy bao ro'i loan nhip that ciia ket hop TWA va NT-ProBNP. DSi tugng vd phuong phdp nghien cuu: Phuong phap nghien ciiu doc, do'i tupng nghien ciiu cua chiing toi gom 100 ngudi chia lam 2 nhom: - Nhom nghien aiu: 82 benh nhan suy tim nhap vi?n tai khoa N^i Tim mach B|nh vien Trung uong Hue'tu thang 5 nam 2007 de'n thang 5 nam 2008. - Nhom chiing: 50 b^nh nhan khoe manh, khong co lien sir benh ly tim mach, khong dimg thudc di^u trj b^nh tim mach, dien lam do binh thuang, huyet ap lam thu va huyet ap lam truong trong gidi h?n binh thudng theo WHO/ISH 2003, cimg do luoi. Bie'n co roi loan nhip that: nhip nhanh that, rung that. Thdi gian theo doi: 2 thang Kit qud nghien cdu: Nghien aiu thye hien tren 82 benh nhan suy tim, 43 nam, 39 nu, lira tuoi tir 24-72. Gia tri TWA 6 nhom chiing 31,38+12,14 pV va nhom benh S3,24±30,98 pV (p<0,0001). Gia tri nong dp NT-ProBNP 6 nhom chiing 52,69±25,46 pg/ml va nhom b?nh 3595,41+5252,15 pg/ml (p<0,0001).
1. Diem cit tot nhat ciia luan phien song T Irong tien lupng hi vong tim mach la 93 JJV; A U C = 0,77 (95% CI: 0,66 - 0,85); D6 nhay: 81,2 % (95% CI. 54,3- 95,7); Dp dac hieu: 68,2 % (95% CI- 55,6- 79,1).
2. Diem cSt tot nhat ciia nong dp NT-proBNP trong tien lupng hi vong tim mach la 2175 pg/ml; AUC
= 0,82 (95% CI: 0,71 - 0,89); Sai sd chuan: 0,07; Do nhay: 81,2% (95%CI: 54,3- 95,7); Dp dac hieu: 69,7 % (95%CI: 57,1- 80,4). 3. Luan phien song T co gia tri tien lupng hi vong tim mach vdi OR=9,72 (p<0,001);
NT-ProBNP co gia tri lien lupng tii vong tim mach vdi OR=4,28 (p<0,01); khi ket hpp luan phien song T va NT-proBNP trong lien lupng tie'n trien xa'u tren lam sang se cho ket qua la OR=15,03 (p<0,001).
Ke't ludn: Ket hpp NT-ProBNP va TWA mang lai gia tri tien lupng cao hon khi dimg NT-ProBNP hoae TWA don dpe trong lien lupng dpi hi do tim 6 benh nhan suy ttm
B A T V A N BE ^°^ ^ ^ ^^^ ^"y * ^ 1^1' ^^^- ^^^ ^^^ 400000 trudng hgp dot tii do tim, ehie'm (50% tii vong Suy tim dang la van de Ion eua nhan loai ^ ^ ^ ^ ^ , ^ ^ bp [10]. Tai Chau Au, vdi tren vi SP ngudi suy Hm ngay cang tang. Tai My ^ ^ - ^ ^^ ^^^ ^^^^ ^ ^^^^ ^^^ ^ ^ khoang 5 trieu benh nhan dang dieu tri suy „ 4_2o/„_ j ^ do ed tu 2 den 10 trieu ngudi suy tim, mdi nam tren 500. 000 ngudi dupc ehan ^ p i ] . Tai Viet Nam chua thohg ke de ed
NGHIEN CUU LAM S
con so diinh xac, tiiy nhien neii dya tren dan so 80 trieu ngudi va tan suat ciia Chau Au, se cd tCr 320.000 dOT T.6 trieu ngudi suy tim can dieu tri [201.
Dot tu do tim da lay di han 400.000 mang sdng mdi nam d Hoa Ky, phan Idn la do nhanh tiiat va rung tiiat [29]. Giam ehiic nang that trai [18] va suy tim, rcS loan nhip that nhu nhanh that, rung tiiat [3,5] la nhiing chi diem eua nguy co dpt tir do tim. Do rdi loan nhip that la nguyen nhin hang dau eiia dpt tir do tim nen viec tim ra mpt yeii to tien lupng rdi loan nhip that duve xem la mdt viec lam ca'p bach va thiet thye tiong bdi eanh hien nay.
TWA hiia hen la mdt chi diem tot ddi vdi rdi loan nhip tha't Nhung nghien ciiu tiong nhiing thap ruen gan day da lien ket TWA vdi rdi loan nhip that do Ideh tiu'eh [19,23,26] va rdi loan nhip that tien phat [4, 8,14]. Nhiing bing chiing tren lam sang da lam TWA la mdt dii diem dang tin cay ddi vdi kha nang dpi tu do tim va la ddng eo thiic day nhu cau tim mpt gia tri tdi uu ddi vdi T\VA tiong viec dy bao nhiing nguy co do [24].
N'T-ProBNP da dupc nghien ciiu trong nhiing nam gan day nhu la mpt ehi diem tinh trang qua tai cua tim. NT-ProB\T dupe bai tiet chinh tii tam that va ehiu tiaeh nhi|m trong v i ^ tang ap suat buong tha't, siie eang thanh co tim. NT-ProBNP da dupc nhieu tnmg tam y hpe sii dyng trong chan doan suy tim, danh gia tinh tiang nang, phan loai nguy CO d su)' tim, Iheo ddi tinh tiang dien tie'n ciia benh tim va tien lupng su suy giam chiic nang that tiai [12].
Hi?n na) d tren the' gidi va o Viet Nam, chiing toi chua tim tiiay tai Ueu nao nghien
euu dimg ket hop luan phien sdng T va ProBNP trong du bao rdi loan nhip tl benh nhan suy tim. Do dd, chiing tdi hanh de tai: "Nghien ciiu vai tid dy ba loan nhip that bang ket hgp luan phien T va NT-ProBXP d berth nhan suy tim" r 3 muc heu;
- Nghien ciiu vai tid du bao dot tu d cua TWA.
- Nghien o i u vai trd dy bao dot tu d eiia NT-ProBXR
- Nghien ciiu vai tro du bao dot tit d ciia ket hpp TWA va NT-ProBNP.
BOI TUONG VA PHUQNG PHAP NGHIEN COU
Tieu chu^n chon benh nhan Ddi tuong nghien ciiu cua chiing to 100 nguoi chia lam 2 nhdm:
- Nhom nghien ctiu: 82 benh nhai tim nhap vien tai khoa Xpi Tim maeh vien Trung uong Hue' tii thang 5 nair deh thang 5 nam 2(X)8.
- XTiom diiing: 30 benh nhan khoe Ididng CO tien su benh Iv dm madi, khong thuoc dieu tri benh tim madv dien tam d Ihudng, hu\ et ap tam thu \"a hm'et ap tam i tinng gioi han binh thuong theo WTiOISl"
eimg do tuoi.
Thilt ke nghien cuu
Day la ngjiien cuu mo ta e^ngang, co ti vdi tttoi gian til thang 1,2007 deii U2009, CO:
va dci diieu vdi nhran chiing.
Cac bwcrc tidn hanh
Dung protocol de thu nhap cac tin ve benh nhan can nghien cuu.
Nhiing benh nhan duoc nghien - duge tham kham lam sang, can lam s
TAP CHi TIM MACH HOC VIET NAM - SO 56 - 2010
^S
ghi day dil cac dii lieu vao phie'u dieu tia theo Phircng phap d o luan phien s o n g T mau ve cac mue:
- Kham lam sang, lay thdng so'cem thiet - Lam cac xet nghiem: Sieu am Dop- pler tim, X-quang phdi, Dien tam dd, Ure mau, Creatinin mau, luan phien sdng T, NT-ProBNP
Luan phien sdng T duge do tren may GE T2100.
iis^k
• E^bof dau soug Q
Chuvfu (11)0
Ef
BiFin J &iriD T WA toi da
^0 0^
(cac*
ien(*
Hinh 1: Do luan phien sdng T Hinh 2: May GE T2100 Phucmg phap ehuyen vi tiung binh cd dieu chinh
A B A B A B A B . 4 . B \
101 sJni Hinh 3: Minh hoa phucmg phap ehuyen vi trung binh ed dieu chinh [6],
NGHIEN CUU LAM SANG
Ca ch4 luan phien song T
Sy thay doi ddng Ca 2+ ndi bao tiong ehu chuyeh tim hoae thoang qua ed tac dpng gian tie'p hoac tmc tie'p de'n sd'lugng ddng ion d eo that va do dd anh huemg deh thdi gian dien the' hoat ddng. Them vao do Ca 2+ ndi bao anh hudng lan truyen tir te'bao nay sang te' bao khae, do dd anh hudng de'n sue eo bop CO tim.
Kenh Kali cd the ddng vai tid quan tipng trong su luan phien song T nguyen nhan do
thieu mau. Sy khae biet dg nhay hoat hoa ve khdng gian ctia kenh Kali (vi du: noi tam mate va ngoai tam mac) cd the ben quan deh tai eye luan phien d miie te'bao trong qua trinh thie'u mau cue bp. Sy luan phien ciia di?n the'hoat dpng lien quan de'n su luan phien doan ST, va su luan phien van td'c di len ciia di?n the'hoat dpng lien quan deh hinh dang QRS.[2]
Chan doan suy tim theo tieu chuan Fram- ingham
Bdng 1: Chan doan suy tim theo tieu ehuain Framingham [1,16]
Tieu chuan ehinh
Khd thd kjch phat ve dem hoae khd thd d tu the' nam
Tinh maeh co noi.
Ran aim d phoi.
Tim to.
Phil phdi ea'p.
Tie'ng ngya phi T3 d tim.
Ap lyc tinh mach tang (>16cm H20).
Phan hoi gan - tinh maeh ed (+).
Giam 4.5 kg tiong 5 ngay dieu tii suy tim
Tieu chuan phu - Phil cd ehan.
- Ho ve dem.
- Khd thd khi gang siie.
- Gan Idn.
- Tran dieh mang phdi.
- Dung ti'eh sd'ng giam 1/3 so toi da.
- Nhip tim nhanh (>120 lan/
phiit).
Chan doan xac djnh suy tim: 2 tieu ehuan chinh hoae 1 tieu chum chinh kem 2 tieu ehuaii phu.
Co. ch§ tang NT-ProBNP
_ Hinh 4: Su tdng hpp proBNP trong eo tim va phan taeh thanh NT-ProBNP va BNP vao hf tuan hoan [11]
TAP CHl TIM MACH HOC VIgT NAM - S6 56 - 2010
Cac NP dugc phdng thich tii tam that khi ap lyc that va the tich mau fiiih mach trd ve tang len. Cae NP lam giam the tieh mau deh miic binh thudng qua tae dpng hgp dong d nao, thugng than, than va mgch mau lam giam giam huyet ap va tien ganh, giam tae dung giao cam tai eae maeh mau ngoai bien, ngan chan phan xa nhip tim nhanh, van chuyen huyet tuong tu mach mau vao khoang ke te'bao. Ben eanh do, NP con cd tae dung didhg xo hoa, chdng tang sinh te'bao, va ehdhg viem.[25]
Khuyin cao v l NT-ProBNP trong danh gia benh nhan suy tim
Bang 1.7; Khuyeh cao a i a trung tam xet nghiem sinh hda lam sang quoc gia [17]
BNP va NT-ProBNP eung ea'p mpt edng cy bd sung trong danh gia lam sang de phan tang nguy eo. (Mtic khuye'n cao: IIA, Mtic
bang chting A)
Dinh lugng BNP va NT-ProBNP hen tue cd the dimg de theo ddi dien tieh lam sang d benh nhan suy tim nham phan tang nguy co.
(Miic khuye'n cao: HA, Mtic bang chiing B) Khuyin cao SIP dung TWA trong XLP tri rdi loan nhip thdt va ngan ngira dot tO do tim.
Sti dung TWA la phit hgp trong cai thi|n diain doan va va phan tSng nguy eo d benh nhan rdi loan nhip that hoac ed nguy ca phat trieh rdi loan nhip that ac tinh (Miic do bang chiing: A, Nhdm na) [30].
KET QUA NGHIEN CUfU
1. D^c dilm Chung cua nhom benh va nhdm chi>ng
Bdng 1: Dae diem ehung eiia nhdm ehiing va nhdm benh
Tupi (nam)
Gidi Nam
Nii Tan sd'tim(]an/phut) HATT (mmHg) HATTr (nrniHg) BMI (kg/m2) Vong bung (em) VBA'M
Creatinin mau (fimoI/1) NT-ProBNP (pg/ml) TWA (|JV)
Nhdm ehiing (n=50) 48,82±11,50 26 (52,00%) 24 (48,00%) 77,24±10,95 113,20±8,44 76,10±4,98 22,5S±2,51 71,30±6,99 0,85±0,06 63,00 ±12,25 52,69±25,46 31,38±12,14
Nhdm benh (n=82) 51,54±13,22 43 (52,43%) 39 (47,57%) 100,74±18,]8 132,20±29,13 75,37±18,74
20,11+2,74 72,35±6,96 0,82±0,04 90,28±17,26 3595,41±5252,1S
83,24±30,98
P
>0,05
>0,05
>0,05
< 0,001
< 0,001
>0,05
< 0,001
>0,05
<0,001
< 0,001
< 0,001
< 0,001 Khdng CO sy khac biet ve tudi va gidi d nhdm benh
cd y nghia thdng ke ve tan sd' tim Iiie nghi, huyet ap tam
va nhom ehiing (p>0,05), thu, huyet ap ddng maeh
cd sy khac biet trung binh, can
N G H | £ N C I > U LAM S A N G
nang, BMI, VB/VM, ure, creatin mau.
2. Dac diem tren sieu am tim Bdng 2: Dae diem tien sieu am tim
EF(%) FS(%) AO(mm) AVO (mm) LA (mm) LVDd (mm) LVDs (mm) RV(mm)
Nhdm chung (n=50) 71,84±7,72 42,20±4,70 28,53±3,88 19,89±2,67 32,48 ±5,42 44,76±4,53 26,02±3,60 22,01±1,81
Nhdm benh (n-82) 40,65+13,11
21,07±8,19 29,77±4,40 19,33±3,07 38,54±8,99 58,92 ±11,21 46,38 ± 12,39 25,96 + 4,85
P
< 0,0001
< 0,0001
>0,05
>0,05
< 0,0001
< 0,0001
< 0,0001
< 0,0001 Gia tri EF nhdm ehiing la 71,84±7,72%, khac bi?t cd y nghia thong ke (p<0,001) so vdi nhom b?nh 71,84±7,72%. Tuong ty nhu vay, cd sy khac bi#t cd y nghia thong ke ve FS, LA, LVDd, LVDs, RV ciia nhdm b?nh so vdi nhdm ehung.
3. Phdn bd ndng dp NT-ProBNP theo t u l i , givi Bdng 3: Phan bo ndng dp NT-ProBNP theo tuoi, gidi.
17-29 tuoi 30-39 tudi 40- 49 tuoi 50- 59 tudi 60- 69 tuoi P Tong
Nu (X+SD)(1) 966,47 ±872,13 1675,90±1189,46
1095,54±964,70 6218,51+5120,74 3209,69+2171,27
>0,05 3699,14±3420,04
Nam(X+SD)(l) 3243,26+2611,10 958,80±216,66 3162,50±2458,14 2199,94+1381,85 7011,43±6528,59
>0,05 3501,10±2157,83
p(l)va(2)
>0,05
>0,05
<0,05
<0,01
>0,05
>0,05 No-ng dp NT-ProBNP d gidi nam nhdm tuoi 40-49 3162,50±2458,14 pg/ml cao hon ed y nghia so gioi nii ciing nhdm tudi 1095,54+964,70 (p<0,05) None do NT P„BMD • ••• - u- Z- e n - o i . > , o c , r , , „ . , . , . ^f^ '•^'•'^°"8 UON i - P r o B N P o g i o i n u nhom hiol 50-59 6218,51±5120,74pg/m cao honed vnehia so vdi mAi„, • L . . , . „ , , ' SUM so vol gioi nam cung nhdm tuoi 2199,94±1381,85 (p^U,UlJ
TAP CHl TIM MACH HOC VIET NAM - S6 56 - 2010
4. Phan b6 TWA theo tu6i, giai Bang 4: Phan bo TWA theo tudi, gidi.
17-29 tuoi 30- 39 tuoi 40- 49 tuoi 50- 59 tuoi 60- 69 tuoi P To'ng
Nft (X±SD) 81,50±40,48 90,00±35,59 73,78±36,67 78,93±25,51 76,42±22,26
>0,05 78,16±26,22
Nam (X±SD) 97,00±20,12
67,50±7,78 86,33±41,72 94,86±39,51 83,70±22,32
>0,05 88,85+33,23
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05 Khdng cd sy khac biet ve gia tri TWA theo nhdm tudi theo gidi (p>0,05).
5. NT-proBNP trong tien lu'Q'ng tu* vong tim mach
mO-th'i dac hieu
Bieu do 1: Dudng eong ROC cua NT-proBNP trong tien lugng tii vong tim maeh Diem eat tdt nhat ciia nong dp NT-proBNP trong tien lugng tii vong tim maeh la 2175 pg/ml;
AUC = 0,82 (95% CI: 0,71 - 0,89); Sai sd chuan: 0,07; Dp nhay: 81,2% (95%CI: 54,3- 95,7); Dp dac hi?u: 69,7 % (95%CI: 57,1- 80,4).
<
6. Luan phien song T trong tien liwmg t * vong tim m?ch
NGHIEN CUU LAMSANG
100-D6d>chifa Biei* do 2: Luan phien sdng T Irong tien lugng hi vong tim mach
Di«n c^t tdt nhat cua luan phien sdng T trong tien lugng tii vong lim madi la 93 pV; AUC = 0,/
(95% CL 0,66 - 0,85); Dp nhay: 81,2 % (95% Ct 5 4 > 95,7); Dp dac hi?u: 68,2 % (95% C t 55,6- 79,1).
7. Kit hqrp ^f^-proBNP va luan phien sdng T ti-ong tien l u ^ n g tip vong tim mach Bdng 5; Ket hpp NT-proBNT va luan phien sdng T trong ti«i lugng tir vong tim m a d i .
Tieh trien lam sang (n=82) Luan phien sdng T NT-proBNP Luan phien sdng T(-) NT-proBNP (-) Luan phien sdng T(-) NT-proBNP (+) Luan phien sdng T(+) NT-proBNP (-) Luan phien song T(+) NT-proBNP (+)
OR 9,72 4,28 0,19 0,13 0,43 15,03
P
<0,001
<0,01
>0,05
>0,05
>0,05
<0,001 Dp nhay
(%)
89,29 78,57
<50
<50
<50 73,21
Dp dac hieu (%)
53,85 53,85 76,92 69,23 68,29 84,62
PPV
(%)
80,65 78,57
<50
<50
<50 91,11
NPV
(%)
70,00 53,85
<50
<S0
<50 59,46 Luan phien sdng T od gia tri tien lupng tieh trien xaii tren lam sang vdi OR=9,72, p<D,01; NT-l .NT cd gii tri tien hipng tim trim xau lien lam sang vdi OR~128, p<0,01. Khi ket hop luan phien sor^' va NT-proBNT liong tien lupng tieh tri&i xaii tren lam sang se cho kei qua la OR=15,03 (p<0,001).
TAP CHl TIM MACH HOC VIET NAM - S6 56 - 2010
8. So sanh tSn suit sinh tdn giOa 3 nhom phan theo luan phien song T va NT-proBNP
^
TWA(-)NT-ProBNP(-) I TWA(+) hoac NT-ProBNP(+)
TWA(+)NT-ProBNP(+)
Biiu do 3: Tan suat sinh tdn d 3 nhdm phan ?fieo luan phien sdng T va NT-ProBNP Thdi gian sd'ng trung binh: 23 thang, sai
sdchuan 1 thang (95% CI: 21 - 26 thang). Ti le sd'ng de'n nam thii nhat la 81,5% sai sd' ehuan 5,1%, ti 1# sdhg de'n nam thii hai la 70,3% sai so ehuain 7,1%. T&i suat tii vong d nhdm luan phien sdng T(+)&NT-ProBNP(+) tha'p hon cd y nghia so vdi hai nhdm con lai (p<0,01).
BAN LUAN
Chiing tdi dung don doe luan phien sdng T trong tien lupng tti vong tim maeh thi thu dugc ket qua cd dp nhay la 89,29%, dp d | e hieu la 53,85%, gia hd bao duong tinh la 80,65% va gia tii dy bao Sm tinh la 70,00%, 0R= 9,72 (p<0,001).
Neu dimg don ddc nong dp NT-proBNP tiong tien lugng hi vong tim mgeh thi ket qua cd dp nhay 78,57%, dp dac hi#u 53,85%, gia tii dy bao duong tinh 78,57%, gia tri du bao am tinh 53,85%; OR=4,28; (p<0,01). Khi dimg ket hop luan phien sdng T va NT-proBNP thi dp nhay (72,21%) va gia tri dy bao am tinh (59,46%) cd giam di nhimg dp dae hi#u (84,62%) va gia tri sy bao duang tinh (91,11%) tang len rd ret.
Theo Gold M.R. [7] (2000) khi ket hgp luan phien sdng T va dien the'mudn se cho dp nhay la 48,1%, dp dae hieu la 96,1%, gia tri dy bao duong tinh: 76,5%, gia tri dy bao am tinh: 87,5%, RR: 6,1 (p<0,001). Nhu vay, su ket hgp luan phien sdng T va dien the' mupn se eho dp dae hieu va gia tri dy bao duong tinh cao nhat so vdi khi sii dyng luan phien sdng T hoac dien the'mudn rieng re.
Hai nguyen nhan ehinh eiia tir vong d b^nh nhan suy tim la dot tii (dinh nghia la tii vong trong vong 1 gid tu khi khdi phat cac trieu chting dot quy ciia benh tim mach d benh nhan trudc dd dn dinh) chu ye'u do roi loan nhip nang va suy bam tim tieh trien (dinh nghia la tii vong do tim vdi eae trieu chiing tien trieu hoae rd'i loan huyet dpng nang) [27, 28]. Trong 38 nam theo ddi berth nhan theo ng- hien eiiu suy tim d Framingham, sy hien dien ciia suy tim tang mdt each ed y nghia ti le tii vong chung cupc va dot tii len 5 lan [13].
Mae dil ti le tii vong tai b?nh vien giam, dya tren eae nghien eiiu trong quan the.
NGHIEN CUV L^M SANG
nhung du hau aia tii vong dai han van cdn xa'u. Cac so lieu nghien ciiu dgc tir nghien cuu suy tim d Framin^iam, Mayo CUnic va Scotiand dio thay tan suat sdng cdn mot nam til 55% deh 70% d benh nhan lan dau chan doan suy tim ed trieu ehiing [9,15,22].
Trong ngjiien ciiu cua diiing toi, khi theo ddi 82 benh nhan trong thdi gjan tiTmg binh la 14±8 thang, thi nhdm benh nhan o6 hian phien sdng T duong tinh va NT-proBNP duong tuih m tiidi gian sohg con thap hon so vdi hai nhdm cdn lai (p<0,05). Day la mdt diiing minh rd rang nhat ve hi?u qua ciia sy ket hpp luan phien sdng T va NT-proBNP trong tien lugng tir vong tim mach d b?nh nhan suy tim.
K £ T LIAN:
1. Di«n cat tdt nhat cua luan phien sdng T trong tien lugng hi vong tim madi la 93 pV;
AUC = 0,77 (95°b O: 0,66 - 0,85); Dp nhay: SU
% (gS^o CI: 54,3- 95,7); Do dac hieu: 68,2 % (95%
Q: 55,6- 79,1).
2. Diem cSt tot nhat cua ndng dp NT-proB- XP tiong tien lugng tu vong tim mach la 2175 pg/ml; AUC = 0,82 (95% CI: 0,71 - 0,89); Sai 50 chuan: 0,07; Do nhay: 81,2% {95%a: 54,3- 95,7); Dp dac hieu: 69,7 % (95%CI: 57,1- 80,4) 3. Luan phien SOTig T cd ^ tri tien lupng tii
\ ong tim mach \-6i OR=9,72 (p<0,001); NT-ProBXP CO gia tri ben luong tu \"ong tim mach \'di 0RH2S (p<0,01), khi ket hpp luan phien song T va XT- proB.VP trong tien lupng tieh trieh xaii tren lam sangsechoketqua]aOR=15,03 (pO.OOl).
flE XUAT
Kef hpp danh gia TWA va NT-ProBXP cho gia tri tien lupng dot tu do tim cao nha't tren lam sang.
ABSTRACT
Background: Decades of researdi now link TWA wifri inducible and spontaneous clinical \'entricular ar- ihythmias. This bendi-to-bedside foundation makes T\^'A, NT-ProBNP a very plausible index of suscep- tibility to ventricular arrythmia, and motivates the need to define optimal combination of TVv'A and NT- ProBNP in predicting ventricular arrythmia m heart feilure patients. We research this study \vith 2 target 1 Evaluate the role of TWA in predicting sudden|gffidiac death in heart failure patients 2. E\aluate the role of NT-ProBNP in predicting sudden cardiacdeathmheart failure patients 3. Evaluate the role of the combined NT-ProBNP and TWA in predicting sudden cardiac death in heart failure patients Methods: Prospective study 82 chronic heart failure patient admitted to hospital horn 5/2007 to 5/2008 and 50 healthv person was done treadmill test to caeulate TWA, ECG, j ^ ^ ^ ^ o g r a p h y , .\T-ProB\P Results: Cut-off point of NT- ProBNP in predicting sudden cardiac death is 2175 pg ml, AUC - 0,82 (95% CI. 0,71 - 0,89), Cut-off pomt of TWA in predicting sudden cardiac death is 93 jiV; AUC = 0,77 (95% CI. 0,66 - 0,85
NT-ProBNP can predict sudden cardiac death with OR= 9,72 (p<0,001); T\VA can predict sudden car- diac death witii OR= 4,28 (p<0,01). The combined NT-ProB\P and TWA in predicting \entricu!ar ar- rytiimia in heart failure patients: 0R= 15,03, p<0,001, Conclusions: The combined XT-ProB\P and TW.A have the best predict value of sudden cardiac death in heart failure patients, compare with XT-ProBNT or TWA alone.
TAP CHi TIM MACH HOC VIET NAM - S6 56 - 2010
TAl LIEU TKAM KHAO
1. American Heart Assodation (2005), "Heart E)isease and Stroke Statistics - 2008 Update".
2 Antonis A.Armoimdas, Gordon F. Tomaselli (2002), "Pathophysiological basis and clinical apphcation of T-wave altemans", AmCollCar- diol,40,pp.207-217.
3. Bardy GH Lee KL, Mark DB, et al, (2005),
"Amiodarone or an implantable cardioverter- defibrillator for congestive heart failure", N Engl J Med, 352, pp.225-237.
4. Bloomfield DM, Steinman RC, Namerow PB, et al, (2004), 'TSlicrovolt T-wave altemans distin- guishes between patients likely and patients not likely to benefit from implanted cardiac defibril- lator therapy: a solution to the Multicenter Auto- matic Defibrillator Implantation Trial (MADIT) n conundrum". Circulation 110, pp,1885-1889.
5 Bristow MR Saxon LA, Boehmer J, et al, (2004), "Cardiac-resjmchronization therapy with or without an implantable defibrillator in advanced chronic heart failure", N Engl J Med, 350, pp.2140 -2150.
6 GE Medical Systems (2O06), "T-wave Alter- nans physician's Guide".
7. Gold MR, Bloomfield DM Anderson KP et al.
(2000), "A comparison of T-wave altemans, signal averaged electrocardiography and pro- grammed ventricular stimulation for arrhyth- mia risk stratification", J Am CoU Cardiol, 36, pp.2247-2253.
8 Gold MR, Bloomfield DM, Anderson KP, et al, (2000), "A comparison of T-wave altemans, signal averaged electrocardiography and pro- grammed ventricular stimulation for arrhyth- mia risk stratification", J Am Coll Cardiol, 36, pp.2247-2253.
9. Ho KK, Anderson KM, Karmel WB et al.
(1993), "Survival after the onset of congestive heart failure in Framingham Heart Study sub- jects". Circulation, 88, pp.107-115.
10. Huynh Van Minh, Tran Lam (2006), Dot hi do tim, Dgt tii do tim va hpi chiing Brugada, NXBYHpc.
11. James A de Lemos (20088), Biomakers of heart failure. The AHA Qinical Series.
12. Januzzi, JL, van Kimmenade, R, Lainchbury, J, et al. (2006), "NT-proBNP testing for diag- nosis and short-term prognosis in acute desta- bilized heart failure: an international pooled analysis of 1256 patients: The International Collaborative of NT-proBNP Study", Eur Heart J, 27, pp.330.
13. Kannel WB, WUson PWF, D'Agostino RB et al.
(1998), "Sudden coronary death in women".
Am Heart J, 136, pp.205-212
14. Kleinfeld MJ, Rozanski JJ (1977), "Altemans of the ST segment in Prinzmetal's angina". Cir- culation 55, pp.574 -577.
15. Madntyre K, Capewell S, Stewart S et al. (2000),
"Evidence of improving prognosis in heart failure: trends in case fatality in 66 547 patients hospitalized between 1986 and 1995", Circula- tion, 102, pp.lI26-1131.
16. McKee PA, CasteUi WP McNamara PM (1971), "The nature history of congestive heart failure: the Framingham study", N Engl J Med 285, pp.1441-1446.
17. MorrowDA, Braunwald E (2003), "Future of biomarkers in acute coronary S5mdromes.
moving toward a multimarker strategy". Cir- culation, (108), pp.250-252.
18 Moss AJ, Zareba W, Hall WJ, et al, (2002),
"Prophylactic implantation of a defibrillator in patients with myocardial infarction and re- duced ejection fraction", N Engl J Med, 346, pp 877- 883.
NGHIENCU'U LAM
J
19. Narayan SM Smith JM (2000), "Exploiting rate hysteresis in repolarization altemans to optimize the sensitivit>' and specifidty for ventricular tachycardia", J Am Coll Cardiol, (35), pp.1485-1492.
20. Pham Nguyin Vinh (2006), "Khuyeh cao ve ehah doan va dieu tri suy tim "
21. RemmeW.J.,SwedbergK (2001), "Guidelines for the diagnosis and treatment of chronic heart failure", European Society of Cardiol- ogy
22. Rodeheffer RJ, Jacobsen SJ, Gersh BJ et al (1993), "The inddence and prevalence of con- gestive heart failure in Rodiester, Minnesota", Mayo d i n Proc, 68(12), pp.1143-1150.
23. Rosenbaum DS, Jackson LE, Smith JM, Garan H. Ruskin JN, Cohen RJ, (1994), " Dectrical altemans and vulnerability to ventricular ar- rhythmias." N Engl J Med, 330, pp.235- 241.
24. Sanjiv M. Narayan (2006), "T-Wave Altemans and the Susceptibility to Ventricular Arrhyth- mias", JACC, 47(2), pp.269-281.
25. Sergei ]ofy, Mitchell H. Rosner (2005), "Natri- uretic peptides m ESRD", American Joumal of Kidney Diseases, 46(1), pp.1-10.
26. Smitii JM,aancyE,ValenC, Ruskin J, Cohen R (1988), "Electrical altemans and cardiac electrical instability". Circulation, 77, pp.110 -121.
27. The CONSENSUS Trial Shidy Group (1987),
"Effects of enalapril on mortality in severe
congestive heart failure. Results of the Co- operative North Scandinavian Enalapril Sur- vival Shidy (CONSENSUS)", N En^ J Med, 316(23), pp.1429-1435.
28. The SOLVD Investigators (1991), "Efect of enalapril on survival in patients with reduced left ventricular ejection fractions and con- gestive heart failure", N Engl J Med, 325(5), pp.293-302.
29. Zheng Z-J, Croft JB, Giles WH, Mensah GA (2001), "Sudden cardiac death in the United States 1989 to 1998." Circulation 104, pp215&- 2163.
30. ZipesDP,CammAJ,BorggrefeM,etal,(2006),
"ACC/AHA/ESC 2006 Guidelines for Manage- ment of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death:
a report of the American College of Cardiol- ogy/American Heart Assodation Task Force and the European Sodety of Cardiology Com- mittee for Practice Guidelines (writing com- mittee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death):
developed in collaboration with the Europe an Heart Rhythm Association and the Heart Rhythm Sodety", Circulation, 114(e385).
