N G H I E N CLTU L A M SANG !
Nghien culi bieh thien nhjp tim
d benh nhan tai bien mach mau nao cap bang Holter dien tim 24 gid
Le Van Minh, Huynh Vdn Minh, Nguyen Ta Oong Benh vien Trung uong Hue
T6MTAT
Dai ciitfng; Dot quy lam giam bien thien nhip tim thdng qua tdn thifdng than kinh tii dgng tim, tuy nhien chiia ed nhilu nghien edu ve bien thien nhip tim trong dpt quy. Phiitf ng phap: Nghien edu tiln cflu d t ngang phan tieh bien thien nhip tim pho tin sd vi thdi gian bang Holter dien tim 24 gid, gdm 66 benh nhan, trong dd 32 nam va 34 nS, tuoi tmng binh ehung la 66,6+11,5 tudi. Biln thien nhip tim phd tan sd va tiidi gian diidc ghi nhan tfl dien tim lien tue 24 gid d mdi benh nhan trong giai doan d p tai biln mach mau nao. Ket qua: Ty 11 giam biln thien nhip tim nhdm xuit huylt nao (65,6%) cao hdn nhdm nhdi mau nao (17,6%) (p< 0,01). Gil tri trung binh biln tiiien nhip tim phd tiidi gian va tan so cua nhdm xuat huylt nao thap hdn nhdm nhdi mau nao (p < 0,01), trii ty sd LF/HF la khae nhau khdng CO y nghia thong ke gifla hai nhdm (p > 0,05). Cac ehi sd ASDNN va LnLF (p < 0,05), rMSSD, LnHF va LnVLF (p <0,0l) thap hcfti khi tdn thtitfng ban d u nao phai so vdi ben trai trong xuat huyet nao. Q nhdm nhdi mau nao, trung binh d e ehi sd bien tiiien nhip tim gitia tdn tiiifcftig d c ban d u nao khac biet khong cd y nghia thdng kl (p > 0,05). Ket luan: Xuit huyet nao ed ty 11 giam biln thien nhip tim eao hcfti nhdm nhdi mau nao, xuat huyet ban d u nao phai giam bien thien nhip bm nhilu htfn so vdi ben trai.
BAT VAN BE BOI VMB VA PHUDNG PHAP NGHIEN CdU Anh hifdng eua tdn thddng nao tren tim dfltfc Nghien cflu tiln cflu md ta eat ngang, benh ehflng minh d dpng vat tiii nghiem tii tiiap min "han dfltfc ghi Holter dien tim ti-ong giai doan d p 1930. Den nam 1944, biln ddi dien tim trong dot ^ TBMMN. Thdi gian nghien cflu: tfl 5/2010 quy dfldc khdi dau bang nhflng nghien cflu md ^^"^ 4/2011. Gdm 66 benh nhan dfltfc chan doan . , _ ... ,^ , . . . , . T - TBMMN, trone do CO 34 tnidng hdp nhdi mlu ta cua Byer roi den eae nghien cflu eua Levme, _ f _ L ^ L - -
Burch, Cropp,.. nao (NMN) va 32 trflcftig hdp xuat huyet nao
(XHN), nhap vien tai khoa Npi Tim mach.
Giam bien thien nhip tim (BTNT) trone tai rr-. v .- v 5^. ^._, XTL-^ i.* L
^ ' e -pjeu chuan chon aoi tiipng: Nhulig benh bifamachm4unao(TBMMN),Iamtangnguycd ^ j ^ j B M M N giai do?i. cap trong vong 1 tuan, bi dpt ftj sau d«t quy, nhat la khi tfin thUtfng thuy dao ^ j - „ j;-„_ j ^ ^ ^ ^^an doan dufa vao benh sil, lam ben phii. Dot quy giy roi loan thSn kinh tU dong ^j^g va can Iim sang, trong do chan doan xac dinh (TKTD) lam giam bien thien nhip tim, nhiing dua vao ket qua chup cat liSp vi tinh. Benh nhin chila CO nhieu nghien ciiu wi r6i loan than kinh tii tti 18 tuoi trd len, co dien tim vi sieu am tim binh dgng d giai doan cap dpt quy thieu mau nao. thiidng.
TAPCHiTIMMACH HOC VIET NAM-SO 68.20141177
; NGHIEN CLOJ LAM SANG
Tieu chuan Ioai trfl ddi tfltfng: TBMMN thoang qua, chin thiitfng sp nao, ddng kinh, u nao. Benh nhan dang dung d c thudc anh hifcftig din viee danh gia ket qua tren Holter ma khdng the ngflng trfldc khi thiie hien (digital, dc ehe beta adrenergic, d c thude tang nhu eau oxy ctf tim nhif adrenalin, cac thudc chdng loan nhip nhii cordarone, procoralan,...), can ngflng tiiudc trfldc khi lam Holter mot thdi gian bang 3 lan thdi gian ban huy eua thudc Tiin sd TBMMN, nhdi mdu cd tim, hinh cd tim, binh van tim, suy tim, benh ly nut xoang, rung nhi mqn tinh, hide nhi that dd II, III hodc rdi loqn nhip tim hodn todn, suy than, benh phoi man tinh, dai thao dtidng.
Phfldng tien gdm may ghi Holter dien tim GE SEER Light, ma sd P86080028, tiiupc cdng ty GE (General Electric) cua Hoa Ky. Cap quang tai dfl lieu tfl may ghi tdi may vi tinh. May tinh de ban cd khe d m , ndi may in Hewlett-Packard, ma s6 297660-002, san xuit nam 2002. Phan mem chfldng trinh dpc Holter la Mars 7.1.1., thupc cdng ty GE san xuat nam 2005, ma sd SA 206451012GA, da dflde eiii dat san vao may vi tinh. Diu ghi Holter dtitfc thao sau 24 gid va noi vdi d p quang de tai dfl lieu vao may vi tinh. Phan tich eae dfl lieu thu dfltfc trong 24 gid, ehpn phan tieh toan bp hay rieng re d c BTNT. Sau do, phan loai lai va bien tap phflc hdp QRS, phan ti'ch cac
sdng nhieu ed die nham larL Sd h?u dflpc xfl ly theo chflcftig trinh thdng ke y hpc Sfl dung phin mem Medcalc 11.6.0 va Excel 2007.
Cae sd do eua biln thien nhjp tim: Phflcftig phap do Ifldng BTNT tiieo thdi gian: MeanNN (thdi khoang NN trung binh), NN50 (tdng sd d e thdi khoang NN ke tiep cd chenh l^ch ldn htfn 50 ms), pNN50 (ty le cua NN50 ti^n tdng thdi khoang NN bmh thddng), SDNN (d^ l?ch chuan cda tat ca d c thtfi khoang NN gida d c phflc h ^ QRS binh thfldng trong toan bp Holter ECG 24 gid), SDANN (dd l^ch chuan cfla trung binh d e tiicti khoang NN mdi 5 phut trong toan bp Holter ECG 24 gid), ASDNN (trung binh dd lech chuan cua tat ca cae theft khoang NN mdi 5 phut trong toan bp Holter 24 gid), rMSSD (can bic hai cua tnmg binh tdng binh phfldng d c khde biet gifla cac thdi khoang NN).
Phfldng phap do Ifldng BTNT theo tan sd gdm d e thanh phan: HF (tin sd cao 0,15-0,40 Hz, bieu hien hoat ddng than kinh phd giao cim (TKPGC) ti-ong dilu hdahd hip), LF (tin sd thip 0,04-0,15 Hz, bieu hiin hoat ddng cua TKTD), ty sd LF/HF the hien trfltfng liie hoat dpng than kinh giao d m (TKGC), dfldc dung d l danh gia can bang ho?t dpng TKGC va TKPGC. VLF (tin sd rit thip 0,0033-0,04 Hz, bieu hien ctf che dieu hda cua TKGC va TKPGC).
90% - ' ' 80% - 70% - 60% - 50% - 40% - 30% - 20% - 10% -
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Khong giam BTNTH' •:
• NMN
• XHN
BTNT Bteudol, TyligidmBTNTihenhnhdnNMNvdXHN 178TAP CHi TIM MACH HOC VIET NAM-SO 68.2014
NGHIEN CUU LAM SANG
KET QUA VA BAN LUAN
Mlu n ^ e n cflu gdm 66 benh nhan, trong dd 32 nam va 34 nuL Tudi trung binh ehung eua mau n ^ e n cflu la 66,6± 11,5 tudi Sfl khac biet cae ty 11 gifla nhdm tuoi ciia XHN va NMN khdng ed y nghia didng ke. Tuoi trung binh eua nhdm NMN la 67+11,3, cua XHN la 66,2±1 l,9j khac nhau khdng ed y nghia thdng kl (t = 0,30, p > 0,05).
Ty li giam BTNT d nhdm XHN (65,6%) cao htfn nhdm NMN (17,6%) ed y nghia thdng ke (x^ = 13,78; p < 0,01). Theo Lafcusie va cpng sfl (es), binh nhan NMN giam toan bo BTNT dang ke, SDNN
= 96±27 ms so vdi 136+31 ms (p < 0,001). Trong nghiin cflu, ehung tdi nhan thay giam toan bd d e ehi sd BTNT ciia phd thcS gian va pho tan sd d nhdm XHN so vtfi NMN.
Bdng 1. So sdnh trung binh BTNT pho thdi gian ^Ua NMN vd XHN
Pho thdi gian SDNN(ms) SDA.NN(ms) ASDNN (ms) rMSSD (ms=) pNN50(%)
NMN(n = 34) X
87,9 71,7 49,9 27,7 7,0
SD 22,6 17,1 14,1 7,5 3,4
XHN(n = 32) X
58,7 48,6 28,0 14,0 0,9
SO 16,3 15,5 9,5 4,8 1,0
t 5,98 5,74 7,35 8,79 9,76
P -
<0,01
<0,01
<0,01
<0,01
<0,01
Bdng 2. So sdnh trung hinh cdc BTNT phd tan sdgida NMN vd XHN
Phd t ^ so LnHF (nis=) LnLF (ms-) LnVLF (ms=)
LF HF
NMN(n = 34) X
18,1 19,7 28,5 1,4
SD 10,8 '.9 6,9 0,4
XHN(n = 32) X
Si 8,0 14,3 1,5
SD 2,0 3,3 5,3 0,4
t 6,50 7,71 9,40 0,57
p
<0,01
<0,01
<0,01
>0,05 Nhdm XHN cd tiimg binh BTNT phd tiicfi gian (SDNN, SDANN, ASDNN, rMSSD va pNN50) va phd tin sd (LnHF, LnLF va LnVLF) giam htfn so vdi nhdm NMN (p < 0,01). Con ty le LF/HF khae nhau khdng cd y nghia thong ke gifla hai nhdm (p > 0,05). Mae du ty le LF/HF thfldng difdc xem la sfl d n bang TKGC va TKPGC d ngifcS khde, nhiii^ khdng phan anh dung thflc te lam sang khi giam toan bp BTNT va tang hoat dpng TKGC, die biet khi ghi Holter dien tim keo dai. Dieu nay da diitfc ghi nhan taxing righien cihi eua Lakuaeva cs, mac dil tdngphd tin sd giam, tyll LF/HF vin khdng thay ddi;
BTNT phd thdi gian cua dilu hda TKPG C giam so vcft nhdm ehifeg.
TAPCHiTIMMACH HOCVIETNAM-SO68.2014I179
( NGHIEN CtJU LAM SANG
Bdng3, Trung hinh BTNT pho thdigian theo hdn cdu NMN
Pho thdi gian SDNN (ms) SDANN (ms) ASDNN (ms) rMSSD (ms=) pNN50(%)
Ban can nao ton thtfcfog BCNP(n=14)
X 79,9 67,6 45,8 27,4 6,6
SD 22,2 16,5 14,1 7,2 3,0
BCNT X 93,5 74,6 52,8 28,0 7,2
0 = 20) SD 21,7 17,3 13,7 7,9 3,7
t
1,77 1,18 1,44 0,20 0,47
P
>0,05
>0,05
>0,05
>0,05
>0,05 Trung binh BTNT pho thdi gian gifla nhom NMN ban cau nao phai (BCNP) va bin can nao trai (BCNT) khac nhau khong co y nghia th6ng kt (p > 0,05).
Bdng 4, Trung hinh BTNT phd tdn s6 theo hdn cdu NMN
Phd tan sd
LnHF (ms') LnLF (ms') LnVLF (ms=)
LF/HF
Ban can nao tdn thtftfng BCNP (n= 14)
X 19,7 19,5 27,2 1,4
SD 13,3 6,8 5,9 0,5
BCNT (n = 20) X 17,1 19,8 29,5 1,4
SD 8,8 8,8 7,4 0,4
t
0,69 0,13 0,97 0,08
P
>o,os
>0,05
>0,05
>0,05 Tnmg binh eae BTNT phd tan sd gifla nhdm NMN BCNP va BCNT khac nhau khdng cd ^ n ^ a thdngke(p>0,05).
Bdng S. Trung hinh BTNT pho thdigian theo bdn cdu XHN
Phd thdi gian
SDNN(ms) SDANN (ms) ASDNN (ms) rMSSD (ms=) pNN50 (%)
Ban c^u nao tdn thiidng BCNP (n= 19)
X 55,1 44,6 25,2 11,6 0,8
SD 17,2 16,8 9,8 2,5 1,0
BCNT(n=13) X 63,9 54,5 32,2 17,5 0,6
SD 13,8 11,6 7,7 5,2 0,4
t
1,54 1,85 2,15 4,23 0,62
P
>0,05
>0,05
<0,05
<0,01
>0,05 ISfflTAP CHITIM MACH HOCVIETNAM- SO 68.2014
NGHIEN CLfU LAM SANG k
XHN BCNP CO trung binh ASDNN (p < 0,05) va rMSSD (p < 0,01) thap hdn ton thiiangBCNT CO y nghia thong ke. Trung binh cua BTNT phd thdi gian con Iai giQa hai nhom khac nhau khong co y n ^ a thong ke (p > 0,05).
Bdng6. Trung binh BTNT phd tdn sd Iheo bdn cdu XHN
Phd tan so LnHF(ms') LnLF (ms') LnVLF (ms')
LF/HF
Bin can nao tdn thtftfng BCNP (n= 19)
X 4,4 6,9 12,4
1,4 SD 1,2 2,9 4,1 0,5
BCNT (n= 13) X 7,3 9,7 17,2
1,5 SD
1,8 3,3 5,6 0,3
[
5,51 2,48 2,83 0,64
P
<0,01
<0,05
<0,01
>0,0S Trung binh cua LnHF va LnVLF (p < 0,01),
LnLF (p < 0,05) d nhdm XHN BCNP tiilp htfn so vdi BCNT cd y nghia thdng ke. Ty le LF/HF gifla hai nhdm khae nhau khdng cd y nghia thdi^
kl(p>0,05).
Trung binh BTNT phd thdi gian va phd tin sd ^fla nhdm NMN BCNP va BCNT khae nhau khdng cd y nghia tiidng ke (p > 0,05). Gidng vdi kit qua n ^ l n cdu cua Korpelainen va cs, giam BTNT khdng phu .thupc vao vi tri NMN. Trong nhdm XHN, tdn thflcftig BCNP ed trung binh ASDNN va LnLF (p < 0,05), LnHF, LnVLF va rMSSD (p < 0,01) thap htfn d c chi s6 ttftfngflng tiong tdn tiidtfng BCNT. Tie gia Naver va es nhan tfily tdn dititfngBCNP giam BTNT so vdi BCNT.
Dilu nay ehflng td tdn thflcing TKPGC sau dot quyi ting hoat ddng TKGC trong tdn thiicAig nao ben phai. Theo Meyer va cs, trong vdng 24 gid ed sfl tang hoat ddng TKGC sau dot quy do tdn tiiiicftig nao phai. Tdn thflcftig thuy dao phai giam BTNT (SDNN, rMSSD) va tang tyll LF/HF, tdn thflcftig hai ben ban d u tiii d n g anh hfldng chflc nang TKTD va tang nguy ctf tim mgich. Cung theo Barron va es, giam BTNT cd the gay ra bdi NMN d BCNP va BCNT d nhflng vung vd va dfldi vd nao. Mot nghien cflu ddi chting cnia Naver va es d benh nhan dpt qti^ tdn thticftig nao phai giam BTNT hd hap Cac chi sd SDNN, rMSSD, pNN50 va HF lien quan vdi rdiip hd hap va phan anh trfldng hic TKPGC. Tae gja Tol^zoglu va cs
^ nhan rdi lo^n dilu hda BTNT (giam SDNN, HF va LF) thfldng gap khi tdn tiititfng BCNP va
vd nao thuy dao phai so vdi tiiuy dao trai, khdng phu thupc vao phfldng phap danh gia phd tan sd hay thdi gian. NMN BCNP kem tdn thfltfng thuy dao ed rdi loan chflc ning TKTD nhilu nhit, vi vd nao thuy dao thupc vung tfldi mau DM nao gifla va ddng vai trd chinh trong dilu hda TKTDT, ndi vdi d e vung dieu hda TKTD quan trpng khac. Thuy dao ben phai la trung tim dieu hda TKGC, cdn ben trai dilu hda TKPGC. Thfle te, cac tdn thfldng nao thiidng kem tiieo nhiiiig vung lan can, vdi ed chl dilu hda cua he TKTD la rit phflc t?p va liln quan nhieu vung khac nhau.Sii mit tinh bin viing cua he tim mach sau khi giai fle chl do tdn tiifldng vimg vd thuy dao hen phai, din den tang trflcft:^
Itic TKGC, vi BCNP chu ylu dieu hda hoat dpng TKGC. Khi kich thieh thuy dao ben trai se dan din nhip tim cham va giam ap liie, thdng qua ctf che dieu hda TKGC.
KETLUAN
Ty 11 giam biln thiln nhip tim nhdm xuat huylt nao (65,6%) cao hdn nhdm nhdi mau nao (17,6%) (p < 0,01). Gia tri tirung bmh bien tiiien nhip tim pho thdi gian va tin sd eua nhdm xuit huylt nao thip hcfti nhdm nhdi mau nao (p <
0,01), trfl ty sd LF/HF la khac nhau khdng ed y ngjila thdng kl gifla hai nhdm (p > 0,05).
Cac chi sd ASDNN va LnLF (p < 0,05), rftdSSD, LnHF va LnVLF (p < 0,01) tiiap htfn khi tdn thtitfng ban d u nao phai so vdi ben trai trong xuat huylt nao. 0 nhdm nhdi mau nao, tnmg binh TAPCHiTIMMACH HOC VIET NAM-SO 68.20141181
A NGHIEN ClAJ U M SANG
eae ehi sd biln tiniln nhip tira gifla tdn thfltfng eae ban d u nao khae biet khong cd y nghia thdng ke (p>0,0S).
SUMMARY
B a d ^ r o u n d and Purpose: Stroke has been shown to decrease heart rate variability as a result of cardiovascular autonomic dysregulatioa However, information regarding heart rate variability is hmited. Methods: This prospective study analyzed the time and frequency domain measures of heart rate variability by 24-hoiir electrocardiography Holter in 66 patients suffered tiie acnite cerebral stroke, including 32 men and 34 women with averaged age 66,6+11,5. Time and frequency domain heart rate variability measures were derived for the filtered and recrtified ECG data for eacJi patient witiiin 1 week of the onset of neurological symptoms.
Results: Overall, the percentage of decrease of heart rate variability in tiie group of patients with hemorrhagic cerebral stroke (65,6%) was higher
dian that in ischemic subjects (17,6%) (p <
0,01). In the group of patients witii hemorrfiagie cerebral stroke, all heart rate variability variables, except low to high frequency ratio (LF/HF), were significantiy lower than those in the group of ischemic cerebral stroke patients (p < 0,01).
We found a statistically significant reduction in some measured components of heart rate variability such as ASDNN and LnLF (p < 0,05), rMSSD, LnHF and LnVLF (p < 0,01) in patients with right hemisphere hemorrhage compared witii left stroke localization. In ischemic group, whedier the stroke is located in the left or the right hemisphere, all the measured components ofheart rate variability were statistically nonsignificant different (p > 0,05).
Conclusions: Hemorrhagic cerebral stioke patients hadmore significantreductioninheartrate variability than ischemic group. In comparison with the left, the right hemorrhagic hemisphere leads to more decreased heart rate variability.
TAI LI$U THAM K H A O
Nguyin Ta Dong (2009), Nghiin aiu rdi loqn nhip tim va thiiu mdu ccf tim im lang d binh nhdn ddi thdo dudng typ 2 hdng Holter diin tim 24 gid, Luan an tien siy hgc, Tnfdng Dai hpc Y-Dutfe Hui, tr.1-61.
Hnynh Van Minh (2009), "Biin thien nhip tim", Holter dien tdm do 24 ^d trong benhly tim moc/i, Nxb DaihpcHue,tr.I30-170.
Adamec J., Adamec R. (2008), Electrocardiographic Interpretation, ECG Holter-Guide to Electrocardiographic Interpretation, Springer, pp.9-68.
CoUvicchl R, Bassi A., Santini M., Caltagirone C. (2005), Prognostic Implications of Right-Sided tisular Dam^e, Cardiac Autonomic Derangement, and Arrhythmias After Acute Ischemic Stroke, Stroke, 36,ppl717-1722.
Gujjar A.R., Sathyaprabha T.N., Nagaraja D. et al. (2004), Heart Rate Variability and Outcome in Acute Severe Stroke-Role of Power Spectral Analysis, Neurocritical Care, 1, pp.347-353.
Kleiger R^., Stein P.K., Bigger J.T. (2005), Heart Rate Variability: Measurement and Clinical Utility, AJs/^,10(l),pp.88-101.
Korpelainen J.T., Sotaniemi K.A., Huikuri H.V. et al. (1996), Abnormal Heart Rate Variability as a Manifestation of Autonomic Dysfiinction In Hemispheric Brain Inferetion, Stroke, 27, pp.2059-2063.
Malik M. (1996), Heart Rate Variability-Standards of Measurement, Physiological Interpretation, and Clinical Use, Eur Heart/, 17,pp.354-381.
Naver H. K., Blomstrand C, Wallin G. (1996), Reduced Heart Rate Variability After Right-Sided Stioke, S(rofc<i27,pp247-251.
ISaTAP CHiTIM MACH HOC VIET NAM-SO 68.2014
