Y HQC VI|T NAM THAHG 7 • S6'2g014
Of 3 Vienna sample. Cleft Palate Cranlofac J, 2008.
45(1): p. 87-92.
3. Southall, P., M. Walteis, and S. Singer, The inhuence of orthodontic treatment on the goslon score of unilateral clelt Up and palate patients.
aeft Palate Craniofac J, 2012. 49(2): p. 215-20.
4. Liao, Y.F. and I.F. Lin, Dental arch relationships alter two-hap palatoplasty In Taiwanese patients wltit unllateial clelt Up and palate. Int J Oral Maxlllofec Surg, 2009. 38(11): p. 1133-6.
». Nollet, P.J., e t a t . Treatment outcome In unilateral clelt Up and palate evaluated with the eOSLON yardstick: a meta-analysis of 1236
patients. Plast Reconstr Surg, 2005. 116(5): p 1255-62.
6. Latief, B.S., C. Lekkas, and M.A. Kuijpers, Maxillary arch width in unoperated adult bilateral clelt Up and alveolus and complete bilateral cleft Up and palate. Orthod Cranlofac Res, 2010. 13(2):
p. 82-8.
7. Li, W. and J. Lin, Dental arch width stability alter quadhelix and edgewise treatinent in complete unilateral cleft Up and palate. Angle Orthod, 2007.
77(6): p. 1067-72.
NGHIEN CU'U GIA TRI C O A XET NGHIEM NT-PROBNP TRONG CHAN DOAN VA P H A N DO SUY TIM 6' NHU'NG BENH NHAN SUY THAN MAN DANG LOC MAU CHU K t TAI BENH VIENTUQD 1 0 8
T6IMTAT
Nghien alU mo tS cSt ngang 76 benh nhSn nhSm khao sat gia trj ciia xet nghiem NT-proBNP trong chan doin suy tim va xac ifinh moi lien quan glO^ NT- proBNP vdl phan dO ciia suy tim tren benh nhan suy th|n man dang Ipc mau chu ky. Kft qua cho thay dlSm cSt nSng dp NT-proBNP cd gia tri chan doan suy tim tren benh nhan suy than man gjai doan cuoi dang loc miu chu ky tot nhat l i 1802 pg/ml (xet nghiem Nt- proBNP CO do nhay la 88,64% va do dac bleu la 84,37%, dien tich du'di du'dng cong AUC la 0.945).
NSng dp NT-proBNP tSng dan theo mire do suy tim; do I (2708,25 ± 1314,36 pg/ml), do I I (8098,77 ± 4523,40 pg/ml), dp I I I (14748,50 ± 9012,24 pg/ml) va dg IV (30843,50 ± 9902,04 pg/ml). Co mffl hrong quan Oiuan r i t ch^t giii;a nong dp NT - proBNP va phSn dO suy dm (r = 0,818).
Tit khoa: suy than man, suy tim, lpc mau chu ky, NT-proBNP, benh vien Trung Udng QuSn dpi 108.
SUIVIMARY
RESEARCH VALUE OF TESTS NT-PROBNP I N THE D I A G N O S I S CLASSIFICA'nON FOR
HEART FAILURE I N PATIENTS W I T H CHRONIC RENAL FAILURE DIALYSIS SIGNATURES I N THE 1 0 8 CENTRAL
M I L H A R Y HOSPITAL Cross-sectional study of 76 patients, to identify lie role of NT-proBNP testing In heart failure diagnosis ind to determine the association between NT-proBNP ind grading of heart failure In patients with chronic
'Binh vien nfliO 108
^bin biin khoa hpc; PGS.TS Nguyen LTnh Toan
Nguyin Gia Binh*
renal failure, who were having periodic dialysis. The results showed that, the best cut point of the concentration of NT- proBNP which has diagnostic value for heart failure in patients with chronic renal failure, who were having periodic dialysis is 1802 pg/ml (NT-proBNP testing had a sensitivity of 88.64%
and a specificity of 84.37%, area under the curve AtJC is 0.945). NT-proBNP concentration increases with the level of heart failure; Level I (2708.25 ± 1314.36 pg/ml), level I I (8098.77 ± 4523.40 pg/ml), level I I I (14748.50 ± 9012.24 pg/ml) and level IV (30843.50 ± 9902.04 pg/ml). There are very tight positive correlation between the concentration of NT - proBNP and the level of heart failure (r = 0.818).
Keywords: chronic renal failure, heart feilure, periodic dialysis, NT-proBNP, the 108 Central Military Hospital.
I. BAT V A N DE
Su); than m a n j a mpt hoi chutig lam sang va sinh hoa tien trien man tinh qua nhieu nam thang, hau qua ciia s i / xd hoa cac nephron chu'c nang gay giam sut tif t i f mifc Ipc cSu than d i n den tinh trang tang nitd phi protein mau nhu' ure, creatinin mau, acid uric...
Nhifng bien chifng tim mach d benh nhan suy than nhu' benh mach vanli, dau that ngu'c, suy t i m , roi loan nhjp chiem ty le den 4 5 % 6 benh nhan suy than man giai doan cuoi, trong dd suy tim thu'dng la hau qua cuSi ciing cua cac benh tim mach khac nhau. Dii vay, viec chan doan suy tim cho cac benh nhan nay Iai khong d l dang do sif triing lap c i c trieu chung cua suy tim va suy than nhu' phii, giam gang sifc, kho thd.
Y HQC VlgT NAM T H A M G 7 - S6' 2/2014
NT-proBNP la mot chat chi dau sinh hpc cua benh suy tim, de sir" dung, nhanh chong dac biet rat tien Idi trong tn/dng hdp benh nhan nang, I<h6 tfid c^p hoac gSp kho khan de lam sieu am tim. NT-pre)BNP'cung du'dc dung trong tien lu'dng nguy cd cac bien co tim mach va ty le tC^vong d cac benh nhan co benh mach vanh, kiem soat tinh b^ng tien trien cua benh [2], [4].
Tuy nhien, vai tro cua NT-proBNP van chu'a du'dc nghien cutJ day du d benh nhan suy than man glai doan cuoi dang dieu trj thay the than.
Xuat phat tij^ cac ly do tren, chung toi tien hanh de tai, vdi 2 muc tieu:
1. Nghien cuU gia tri cua xet nghiem /VT- proBNP trong dian doan xac dinh suy tim d nhOtig benh nhan suy than man dang igc mau diuky.
2. Khao sat moi lien quan giu^ i\iT'proBNP vdiphSn tfjS a/3 suy tim tren benh nhan suy than m^n dang ioc mau diu ky.
II. Ddi Tl/QNG VA PHirCTNG PHAP NGHIEN COlf 2.1. Doi tu'dng nghien cihi
2.1.1. Nhdm chihig: gom 43 ngu'di khoe manh du'dc xac djnh khdng bj suy tiian, khong bj suy tim
III. Kfr QuA N G H I E N CU'U V A B A N LUAN
3.1. M$t sotf^c diem cua d5i tUcfng nghien cihj 3.1.1.0$c diim viStuSi
Bang 3.1: Phan bo benh nhan theo lu^a tuoi
2.1.2. Nhom nghiSn cu'u: dddc chia thanh 2 nhom
- Nhom Nl: gom 32 benh nhan suy than do 3A, 3B va 4 du'dc xac dinh la khong bj suy tim (theo lam sang, sieu am tim) dang dieu trj chay than nhan tao tai benh vien TWQD108.
- Nhom N2: gom 44 benh nhan suy than dp 3A, 3B va 4 du'dc xac dinh co suy tim (theo phan loai NYHA, sieu am tim) dang dieu trj chay than nhan tao tai benh vien TWQBIOS.
* Tren cac nhom, loai trCr' cac tru'dng hdp:
soc, tang ap phoi, hpi cliutig suy ho hap cap, COPD, benh thieu mau nang, khong dong y tham gia va khong tuan thii dung qui trinh nghien CLTU.
2.2. Phu'cfng phap nghien cu'u - Phu'dng phap nghien cu^j tien CUIJ, CO so sanh vdi nhbm doi chiitig.
- Cac chi tidu nghien ctTu gom: nong dp rn"- proBNP, chi so sieu am tim (phan so tong mau EF). Trong do, xac djnh 1 ^ - proBNP theo phu'dng phap mien dich dien hoa phat quang.
- Xu' ly so lieu bang phu'dng phap thong ke y hpc tren phan mem excel 2003
Tuea 20-49 50-70
>7C
Nhoml n 8 21 14
18,6 %
48,84 32,56
Nhom 2 n 18 47 11
23,68 %
61,84 14,47
P p > 0,05 p > 0,05 p > 0,05
Trong ca hai nhom, do tuoi 50 - 70 chiem ty le nhom (p > 0,05). C^ch phan chia va ty le ciia cac cao nhat so vdi cac do tuoi khac (48,84% is do tuoi trong d l tai ciia chung toi phii hdp vdi nhdm chifng va 61,84% is nhdm nghien cifu). Cd nghien cifu cua Nguyen Thanh Tam tren ciihg doi le_xulit phat tif ly do day la dS tudi co nhieu thay tu'dng la nhuYig benh nhan suy than man tinh doi ve sifc khde, noi Bet. Ket qua clio thay, gial ddan cuoi dang dUdc loc mau chii k^ [7].
khong cd sif khac biet ve ty le cac dd tuoi giifa 2 3.1.2. t>$cdlim vigidi
Bing3.2:Phan b5 benh nhan theo gidi Nhom
Nhom chu'ng Nhom nghien cufti
Sos^nhx'
Ca hai nhdm deu od ty le nam nhieu hdn nif (ty
Gidi tinh Ty le %
65,12 15
X'. 2,19;p>'o:o5 T y l e %
34,88
, , , , . ., , . , • [1]. Tuy nhien ty le nay c6 sti khac biet so vdi tac
I? nam gkfl d nhom chutig la 65,12% con d nhom gia Tran VSn CMt va Tran Thj Thinh (1991-1995)
nghien cuU la 34,88%). Tndng nhdm nghien alli, tf tai Khoa Tiet nieu B^nh vien Bach Mai suy than
l§ nam gkSI chl&n UU the so vcS nil' gidl cQng phu man khong co s'u khac biet glDs'nam va ntf Rlgiiq
hdp vdl d^c diem djch te hgc benh suy than nnan 16-24 tuoi thi thay nam nhieu hdn nif.
Y HpC VIET NAM THANG 7 - SO 2/2014
3.1.3. Phin tto benh nhin theo/ihan ddsuy tim trong nhdm N2
Bing 3.3;i:i ie benh nhan theo phan do suv tim Mifc do suy tim
B o l S o i l Do i n Da IV
So li/tfng (n=44) 15 13 10 6
Ty le »/o 34,09 29,55 22,73 13,64
Kit qui ve phan do suy tim trong nhom nghien cifu cho thay, benh nhan suy tim dd I chlem ty le eao nhat la 34,09%, do II la 29,55%, dd III li 22,73% vi suy Um (To IV chiem ty IS thap nhat (13,64%) Nhd vay^ tl IS benh nhin suy dm glim dan t&dol din do IV. Cac tai lieu da ehi ra rang, nguyin hhin chinh giy tif vong d benh nhin loc miu li benh b'm mach.
3.2. Ket qua xac dinh c^c chi sd nghien cifu
3.2.1, Chi so NT-proBNP, EF(°/o) dia nhdm Nl, N2 va nhdm chiing Bing3.4:Cni so NT-proBNP, EF(%) ciia nhdm Nl va N2
Chisd NT-proBNP (pg/ml)
EF(%)
Nhdm N l (n=32) 2029,88 ± 1674,74
64,34±3,84 Chi so NT-proBNP ciia nhdm N2 (11555,78 ± 11976,58) cad hdn (5lan) nhom Nl (2029,88 ± 1674,74) vdi p < 0,001. NT-proBNP dUdc phdng thi'ch khi cd tSng sifc nen huyet dpng hpc tai tim (Iu'c thanh tim bj gian, phi dai hdSc tang ap life
Nhom N2 (n==44) 11555,78 ± 11976,58
52,84± 10,93
< 0,001
< 0,001 tac ddng len thanh tim). NT-proBNP gia tang nong do tren nhii'ng benh nhan suy tim (bad gBm ca suy tim tam thu va suy tim tam tru'dng).
Ngu'dc Iai vdl NT-proBNP, chi so EF (%) ciia nhdm Nl cao hdn nhdm N2 vdi p < 0,001.
Bing 3.5: Oil so NT- proBNP, EF (%) trong nhdm N2 theo phan dd suy tim Cac chi sd
Nhdm N2 (n = 44] X ± SD Suy tim dd I
n = 15 (1)
Suy tim dd II I Suy tim dd III j Suy tim dp IV n = 13 (2) n = 10 (3) I n = 6 (4) NT-proBNP
2708,25±1314,36 8098,77±4523,40 14748,50±9012,24 30843,50±9902,04 p ( l - 2 ) < 0,005; p(2-3) < 0,05; p(3-4) <0,01
60,93±3,90 I 55,39±6,25 I 46,o6±B,06 I 34,80±13,14~
EF (%)
Chi so NT-prdBNP Cd sU khac biet giifa cac phan dd suy tim trdng nhdm N2 vdi p < 0,05 va p <
0,005. Tu'dng tu nhu vay doi vdi chi s6 EF(%).
Phan do suy tim ty le thuan vdi gia tri NT- prdBNP va ty !$ nghjch vdi gia tri EF(%). Ket qua
p(l-2) < 0,05; p(2-3) < 0,05; pC3-4) < 0,01
trong nghien cifu cua chung toi la phu hdp vdi cac nghien cifu tren benh nhan suy tim man, ciia cac tac gia nhu NguyJn Thi Thu Dung, Cang Van Phu'dc (2010) [5], Nguyin Minh Hong (2010) [6].
Bing 3.6: So sanh cac chi so NT - proBNP, EF% cua nhom Nl_vdijihdm^^5^
' ^ 1 NhdmtX ± s p )
Cdc chisd Nhdm chifng \ Nhom Ni (suy than, khong suytim) n = 43 n = 32 NT-proBNP
(P9/H1I) EFVo
L .
92,16 ± 80,81 67,90 ± 5,78 Ca hai nhom deu khong bj suy tim nhutig co sif khac biSt rSt Idn ve chi so rfr-proBNP va chi so EF%. Gia trj chi s5 NT-proBNP tren nhdm Nl la 1289,25 ± 636,00 cao hdn so vdi nhdm chUng (92,16 ± 80,81) vdl p < 0,0001. Bleu nay cd the
1289,25 ± 636,00
< 0,001 _ _'S ' _ ^ ' • 64,314 ± 3 , 8 1 _
< 0,005
lygiafbdi benh nhan suy than man giai doan cuoi, dang loc mau chu ky bang than nhan tao thi;
- NT-ProBNP bj tich tu lal trong mau vi thSn gan
nhu khong con chUc nSng lpc nen khong that
dUdc qua dudng tieu.
Y HQC VlgT NAM THAHG 7 - SO 2^014
- Ap lire len thanh tam that cua benh nhan suy than man dang Ipc mau bang than nhan tao luon luon cab do cac nguyen nhan t^ncj huyet ap, u"
nu'dc, muoi vi than gan nhu' khong con chii'c nang loc. Trong khi loc mau thi ap Iu'c nay Iai thay doi mot cach dot ngot. Day la yeu to chinh kfch thfch ting tiet r4t-proBNP.
- Toe dp giang hoa cua chat nay giam di trong benh canh hpi chu'ng tang Ure mau.
- boi vdi lpc mau chu ky dung phu'dng j)hap loc thong thu'o'ng, vdi mang Ipc co tinh tham thap.
thi NT-Pro 8NP khong duac toe qua man^ Ipc, do va^ nong do NT-Pro BNP trong huyet tu'dng khong qiam sau khi loc mau, luon rat cao [7].
Chi so EF% cua nhom Nl (64,34 ± 3,84) oo sy" khac biet so vdi nhdm chCmg (67,90 ± 5,78) vdi p < 0,005. Do ap liTe len thanh tam that cua benh nhan suy than man dang Ipc mau bang than nhan tao luon cao (do tang huyet ap, (1 nuicfc, muoi), nen tSm that dan gian mong va phan tram phan suat tong mau that trai giam dan.
3.2.2. Tu'dng guan aia nong dp NT-proBNP vdi phan dp suy tim va gia tri Ef/o cua cac bpnh nhan trong nhdm nghien cuii.
Hinh3.1:TMng quan glD'a I^-proBNP vdi phan dp suy tim
ft
XT-proI
4 0 0 0 0 3 5 0 0 0 3 0 0 0 0
0 en o (Jl
§88 8
0 0 0 0sooo
o
l -
-
?
V
r
=
-
- -IS ^.SSPJt 0.51 S
-
B "-t-
'
5S4 1.-»09
1 1 ^ -^^ "
s
X
«
- - I - - " "
°
o
•>
Hinh 3.2: JittSnq quan giifa NT-proBNP vdi EF%
OOOO 5 0 0 0 o o o o o o o o 5 0 0 0 o o o o 5 0 0 0
y = - I S 3 9 9 . 3 4 1 - - - " ^ O . - I S ^ S . N , l i ' °
- a
. ^,
7 5 0 9
. «:.
- - ° " ^ = =,
='S--5aaBag=a-ee'=g
Co moi tUdng quan thuan rat chat glQS nong do NT-pnoBNP va phan do suy tim vcli r = 0,818.
Nong do NT-prdBNP va EF(%) cd moi tUdng quan nghich mUc trung binh vdi r = - 0,7809.
Trondcac nghien cuU, cac tac gia nudc ngdai de cap den tam quan trdng ciia sU lien he giifa ndng dd NT-prdBNP vdi cac bien cS tim mach.
su^ tim sunj huyet vJ ty le tif vdng 6 nhdm benh nhan suy than man gial doan cudi. Ban than cila NT-prdBNP khdng gay doc cho tim, nhUng NT- proBNP chinh la san pham ciia tinh frang tang ganh cho tim gay ra, no la hau qua ciia rihung roi roan_^tlm mach frong suy th$h man va cung cninh la dau an chi diem cho tmh tirang benh sau nay.
3.3. G i i trj ChSn doin suy tim ciia chi sd NT-proBNP huySt tu'dng Bang3.6: Gia tri chan doan suv tim ciia chi so NT-proBNP huyet tUdnq Oiem cat NT
proBNP (P9/ml) 1530 1802 2152
Od nh^y (%) tCI 95»/o]
§5;45 r84,5-'99.41
88,64 [75,4-96,21
81,82 [67,3-91,8
0 6 d i e hidu (''/o)[CI 9 5 % ]
65,62 [46,8-81,41
84,37 [ 6 7 , 2 - 9 4 , 7 1
93,75 [79,2-99,21
UR(+) [CI 95°/o]
5,67 LRT7
[CI 9 5 % ]
Di|n tich du'di du'dng cong [CI 95%]
0,945
Y HQC VlgT NAM THAWG 7 • SO 2/2014
Hmh 3.3:06 nhay, do dSc hieu cua NT-proBNP tnang chan doan suy tim
B N P
S t h = 1 -I OO
SO
J 40
2 0
2 0 4 0 6 0 SO 1 O O - S p e c i f i c i t y
Tl so kha (IR du'dng va am la hai thong so npitai cua xet nghl§m, nd khdng chju anh hu'dng bdi tan suat cua mau nghien culi. Hai thong so nay tuUng doi de siy dung nen ngay cang du'dc khuyen cao trong y van. Neu t l so kha di du'dng
> 10 thi xac suat mac benh rat cao khi ket qua du'dng, neu t l so kha di am < 0,1 thi xac suat mac benh rat thSp khi ket qua am (vdi dieu kien xac suat mSc b^nh tru'dc khi lam xet nghiem la tren du'di 5 0 % [ 7 ] .
Qiung ^ i chon diem cat nong dp NT-proBNP cd gia t n c h i n doan suy tim t o t nhat tren benh nhan suy than man la 1802 (pg/ml). Tai dd xet nghiem IMT-proBNP cd dp nhay la 88,64% va dp dac hieu la 84,37%. Khi nong dp nong dp NT- praBNP du'di 1530 (pg/ml), cd the gan nhu' loai tor suy tim (tl so kha <T\ am bang 0,07). Khi nong dp nong dp NT-proBNP tren 2152 (pg/ml), cd the chan doan suy tim rat chac ch3n (tl so kha di duyng bSng 13,09).
Dien ti'ch du'di du'dng cong ROC- Area under the ROC curve (AUC) la 0.945 (nam trong khoang 0,9-1,0) nhU vay dp chfnh xac cua xet nghiem l^-proBNP trong chan doan suy tim la rat tot.
IV. KCT L U ^ N
1. Oiem cat nong dp NT-proBNP cd gia trj chan doan suy tim tren benh nhan suy than man giai doan cuoi dang Ipc mau chu ky tot nhat la 1802 pg/ml (Xet nghiem NT-proBNP cd dp nhay la 88,64% va dp dac hieu la 84,37%, dien tfch dtrdi du'dng cong AUC ta 0.945).
2. Nong 6o NT-ProBNP d benh nhan khong bj suy tim nhu'ng suy than man giai doan cuoi dang Ipc mau chu ky (1289,25 ± 636,00 pg/ml) cd
khac s y biet so vdi nhdm chung (92,16 ± 80,81 pg/ml) vdi p < 0,0001. Nong dp l^-proBNP tSng dan theo miTc dp suy t i m : dp I (2708,25 ± 1314,36 pg/ml), dp I I (8098,77 ± 4523,40 pg/ml), do I I I (14748,50 ± 9012,24 pg/ml) va do IV (30843,50 ± 9902,04 pg/ml).
Cd mdi tu'dng quan thuan rat chat giO^ ndng dp NT-proBNP va phan dp suy tim (r = 0,818).
T A I L I | U T H A M K H A O
1. Dinh Thj Kim Dung (2008), "Suy than man tfnh", Benh than noi khoa. Nha xuat b^n Y hpc, Ha Npi, tr. 311-331.
2. D^ng Van Phu'dc (2009), Dau an sinh hpc NT- proBNP trong chan doan suy tim.
3. Hoang Anh Tien, Huynh Van Minh, Ld Thj Phu'dng Anh, Pham Nhu* The (2009), Oanh gia sy" bien doi nong dp NT-proBNP tn/dc va sau dieu tri noi khoa tich cu'c d benh nhan suy tim m?n.
Tap chf Npi khoa, tr. 823-829.
4. Hoang Anh Tien, Huynh Van Minh, Lg Thj Phu'dng Anh, Pham NhU The (2006), Danh gia SLf bien doi nong dp NT-pnDBNP d ddt cap cua binh nhan suy tim man, Tap chi Tim mach hpc Viet nam, so 43, tr. 48-55.
5. Nguyen Thj Thu Dung, Dang V i n Phu'dc (2010), MOI tVdng quan giiJa NT-proBNP vdi cac giai doan trong qua trinh tien trien ciia suy tim.
Hoi Tim mach Hoa Ky, Chuyen de Tim mach hoc, 3-2010, tr. 22-28.
6. Nguyen Minh Hong, N g u y i n Thj Thfiy, Nguyen Van Quynh, Nguyen Gia Binh (2012), Nghien CLTU SI/ bien doi nong dp NT-proBNP d benh nhan suy tim m?n tinh do tSng huyet ap, Tap chi Y di/pc lam sang 108, so 05, tr.8-13.
7. Nguyen Thanh Tam (2011), Gia trj chan doan suy tim cua BNP huyet tu'dng d benh nhan suy than man giai doan cuoi chu^ dieu tri thay the than. Tap chi Y Hpc TPHCM, 15(1):461.
