HQI NGH! KHOA HQC CCiA HQI HOA SINH Y DUOC HA N 6 | VA CAC TJNH PHfA BAC LAN THCTXVII
MOI Tl/ONG QUAN
GIQANONG DO HS-CRP Vdl MOT SO
C H ISO LIPID MAU TRONG NHOI MAU NAO CAP
Dao Van Tiing,* Tran Hoai Nam*
Tran Trinh Anh , Nguyen Thi Thu Huyen*
TOM TAT
Phan ling viem ddng vai tro rat quan trgng trong benh sinh cua dot quy thieu mau nao cap, ^ Lam tang tl le t y vong va tan phe than kinh,
Chiing toi chgn cac tru'dng hdp dot quy thieu mau nao cap nhap vien lay mau thy hs-CRP tai thdi diem nhap vien, phan tich mdi lien quan giu'a hs-CRP vdi cac chi sd lipid mau.
Ket qua: Cd 91 tru'dng hdp nghien cyu, Nong do hs-CRP d benh nhan nhoi mau nao cao hdn ngu'di binh thu'dng 6,6 lan (p < 0,001), nong do hs-CRP CO tu'dng quan thuan vdi nong do cholesterol va LDL-cholesterol; tu'dng quan nghjch vdi nong do HDL-C d nhdm benh nhan nhoi mau nao cap (p <0,05), NhChng thay doi ve chi so hs- CRP va nong do cholesterol toan phan, dac biet la nong do LDL-cholesterol giiip ta tien lu'dng cac nguy cd ciia viJa xd dgng mach, cu the la benh ly dot quy do nhoi mau nao, nguy cd benh dgng mach vanh,
SUMMARY
The relation between hs-CRP concentration and some lipidemia indexes in acute
cerebral infarction
Inflammation plays important role in the causes of stroke by acute cerebral infarction.
Stroke by acute cerebral infarction increases death ratio and damages of nervous system.
We choosed patients suffering from stroke by acute cerebral infarction to determine hs
CRP at hospitalizing time and analyzed the relationship between hs-CRP concentration with some indexes of lipid.
Results: In 91 cases, hs-CRP concentration of the cerebral infarction patients was 6.6 times higher than control group (p< 0.001), hs-CRP concentration had favorable correlation with cholesterol concentration and LDL-c; but opposite correlation with HDL-c in acute cerebral infarction (p< 0.05), The changes of Hs-CRP and total cholesterol, especially LDL-c help us to predict the risks of atheroscelerosis, specifically stroke by celebral infarction and heart artery diseases.
I. OAT V A N OE
CRP (protem phan ftng C) do tl bao gan san x d t - xet nghiem CRP rit cd gia trj trong chin doan, theo doi dien biln cua benh ly viem va nhiem triing, Trong cac truong hgrp viem do vi khuan, nong do CRP tang vira hoac tang cao, cac trudmg hgrp nhiem virus CRP chi tang nhe. Nhung xet nghiem CRP thong thuong co nguomg phat hien thip (khoang Img/L). Hien nay, nhd cong nghe phat trien, viec dinh lugng CRP do nhsiy.cao (hs-CRP) vdi nguSng phat hien la 0,Img/L, nghia la nguomg phat hien tdi thilu gip 10 lan xet nghigm CRP thdng thuomg. Ngoai danh gia va theo ddi nhiem trung, hs-CRP cdn la mgt ylu td dy bao rat cd gia tri nguy ca bgnh tim mach, dgt quy lien quan din vfta xa dgng mach, Cung vdi sy tien
' Khoa Hoa sinh. ** khoa than kinh b?nh vi$n hihi nghj Viit Ti$p Hdi Phong
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Y HQC VigT NAM T H A N G 8 - SO 2/2011
bg cua ky thuat smh hgc phan tu, nguai ta thiy viem la mgt trong cac yeu to quan trgng trong ca chi gay phii nao do nhdi mau nao [6,7], Kit qud nghien ciiu cung cho thiy dilu tri nhim vao cac yeu to viem cimg la mgt muc tieu dilu tri quan trgng giiip giam phu nao va cai thien chftc nang [4,5]. Tuy nhien hien tugng viem tix)ng xa vfta dgng mach la viem man d muc do thip nen khong nhan bilt dugc d xet nghiem CRP thdng thuong. De phat hien hien tugng viem trong xa vfta dgng mach va cung de tim soat nguy ca tim mach ngudi ta thyc hien xet nghiem hs-CRP, cho phep xac dinh dugc nong do CRP rat thap. Nhieu nghien ciru cd qui md lan da chiing minh hs-CRP cao la mgt yeu to quan trgng dy bao cac bien co tim mach nang trong tuomg lai, ngay ca d nhftng ngudi cd LDL-C thip 3-6. Hien nay, phan loai mftc do nguy ca cua hs-CRP theo AHA (American Heart Association) dugrc thong nhit nhu sau: hs-CRP dudi muc 1 mg/l nguy ca bgnh ly tun mach thip, hs-CRP trong khoang 1-3 mg/l nguy ca benh ly tim mach trung binh va hs-CRP tren 3 mg/l nguy ca benh ly tim m?ich cao, hs-CRP yen 10 mg/l nguy ca benh ly tim mach rit cao [1,4]. Trong dilu kign hign nay tai Viet Nam, cac xet nghigm danh diu viem khac khd thyc hign Igi dat tiln, hs-CRP la xet nghiem danh diu viem vfta dom gian, dl thyc hign lai vfta re tiln. hs-CRP da dugc nghien cuu nhilu trong tun mach, nhiem thing,,, nhung hong dot quy vIn cdn kha mdi me.
II. MVC OiCH NGHIEN Cl/U
- Danh gia svr thay ddi cac chi sd lipid mdu vh hs-CRP or nhihig bgnh nhan nhdi mau nao giai do^in cip t?u Bgnh vign hftu nghi VigtTi^p Hai Phong.
Xdc djnh mdi tuomg quan gifta ndng do dudng, benh ly tuyin giap.
hs-CRP va cac chi s6 lipid mau, fren cd sd dd
de xuat bien phap phong ngfta nhdi mau nao d cac ddi tugmg nguy ca cao.
III. Odi TUONG VA PHIX3NG PHAP NGHIEN COU
3.L Doi tirgrng nghien cvu
* Nhdm chmig: gdm 62 trudmg hgp kham sue khoe tdng quat dinh ky tai phdng kham da khoa Benh vien Viet Tiep Hai Phdng, dugc kham lam sang va can lam sang diy du, dam bao khong mic cac benh nhiem trung, benh chuyen hoa do gan, than, dai thao dudng, benh tang huyet ap va cho ket qua xet nghiem lipid mau binh thuomg.
* Nhdm nghien cmi: Gdm 91 benh nhan nhdi mau nao dugc cap curu tai khoa cap ciiu va dom vi dot quy cua Benh vien Hftu nghi Viet Tiep Hai Phong tu thang 3 /2010 din thang 5/2011.
3.2. Phirong phap nghien ciru
Phtforng' phap: Chiing tdi chgn cac yudmg hgp dot quy nhdi mau nao cap, nh|.p vign trong vong 24 gid sau khdi phat, dugc chin doan xac dinh qua cac trigu chftng lam sang va CT Scanner sg nao. Tit ca benh nhan dugc liy mau thu hs-CRP va cac xet nghigm smh hoa vao luc ddi trong thdi gian khong qua 7 ngay, sau dd phan tich moi hen quan gifta hs- CRP vdi cac chi so lipid mau.
Tieu chuan lo^i trir:
Trieu chung phyc hdi hoan toan trong vong 24 gid.
Cd cac benh ly gay phan ling viem nhu: Viem phdi, nhiem trung tilu, sot, viem khdp, bgnh tu mien, chin thuomg, nhdi mau catim,.,,
- Cd cac benh vl gan nhu viem gan, xa gan - Cd tiln sy cac benh phoi hgrp vdi cac benh rdi loan chuyin hda nhu dai thao
HQI NGH! KHOA HQC COA HQI HOA SINH Y DUQC HA NOI VA CAC TINH PHIA BAC LAN THIJf XVII IV. KET QUA NGHIEN CQU
4.1. Dac diem nhdm nghien cvu
Tudi trung binh cua nhdm nghien ciiu la 66 tuoi, trong dd ngudi tre nhit la 30 tudi va
Idn nhit la 90 tudi. Ti le benh nhan nam la 51,6%, nft la 48,4%.
Trong do, 72,5% cd rdi loan lipid mau, ti le benh nhan nhdi mau nao khong cd roi loan lipid mau thap han ban chi chiem 27,47%.
4.2. Cac chi so lipid mau va nong dg hs-CRP d nhdm nghien cihi
Bang 1.1. Nong do hs-CRP va cac chi so lipid mau d cac nhdm nghien ciiu
hs-CRP (mg/L) Cholesterol (mmol/L) Triglycerid (mmol/L)
HDL-C (mmol/L) LDL-C (mmol/L)
Nhom chu'ng n = 32 1,61 ± 0,27 4,57 ±0,10
1,22 ± 0,04 1,17 ± 0,06 2,79 ± 0,09
Nhom NC n = 9 1 9,73 ± 2,2 5,48 ± 0,11 2,40 ± 0,13 1,14 ± 0,03 3,49 ± 0 , 1 1
P
< 0,001
< 0,001
< 0,001
>0,05
< 0,001
Chi s6 hs-CRP d nhdm chung thip ban so vdi nhdm benh nhan nhdi mau nao, khac bigt cd y nghia vdi p < 0,001. Cac chi s6 lipid mdu khac nhu cholesterol toan phIn, triglycerid, va LDL-C gifta 2 nhdm diu cd sy khac biet vai p < 0,001.
* Cdc loai roi loan lipid mdu
Cac loai roi lo^n lipid mau (theo tieu chuin ciia Hgi tim mach Viet Nam):khi TC
> 5,3mmol/L, TG> 2,3mmol/L, LDL.C >
3,4nmiol/L, HDL< 0,9> mmol/L.
CT CTMl LDL^; HDL-C
Bieu do 1.1 Tinh trang rdi loan lipid mau
Qua bieu do l.I cho thay, tinh trang tang cholesterol hon hgrp la tuomg doi cao chiem tdi 58,24% va cac trudng hgp tang LDL-cholesterol chilm tdi 47,25%. Trong khi dd tinh trang tang hriglycerid va giam HDL-cholesterol lai chilm ti Ig thip bom.
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* Nong dp hs-CRP d cdc cdc nhdm nghiSn cuu theo chi s6 lipid mdu Bang 1.2. Nong do hs-CRP d nhdm benh nhan nhoi mau nao
^^~~--~,,,,,.^^ Nhdm chi so ^~~~~~----^
% hs-CRP (mg/L)
X ± S E P
Nhom chihig
1,61 ± 0,27
Nhom NMN khong tang lipid
37,66%
5,81 ± 1,16
Nhom NMN tang lipid 62,64%
11,6 ± 3,17 p < 0,001
Dya vao bang 1.3 ta thay, nong do hs-CRP d nhftng benh nhan nhoi mau nao cao bom so vdi nhdm ngudi binh thuomg. Dac biet nhdi mau nao cd tang lipid mau la cao nhat vdi ndng do trung binh la 11,61 mg/l, va cao horn so vdi nhdm benh nhan nhoi mau nao khong tang lipid mau gip 2 lln, vdi p < 0,001.
Bang 1.3. Nong do hs-CRP d cac cac nhdm roi loan lipid mau
\ . chi so niongTOv
% hs-CRP
mg/L
Tang TG ddn thuan n = 16 17,58%
3,58 ± 0,98
Tang CT ddn thuan n = 20 21,98%
6,03 ± 1,15
Tang CT hon hdp n = 53
58,24%
14,42 ±4,18
Tang LDL-C n = 43 47,250/0 16,73 ±
5,07
Giam HDL-C n = 27 29,67%
19,4 ± 7,99
Cac trudng hgp nhdi mau nao ma chi cd tang triglycerid dom thuin (17,58%), ciing nhu tang cholesterol dom thuin (21,98%) chilm ti le tuomg ddi thip. Trong khi do cac trudng hgp tang cholesterol hon hgrp, tang LDL-cholesterol lai chilm ti le tuomg dli cao. Ndng do hs- CRP tang cao d nhdm nhdi mau nao cd tang cholesterol hon hgp, tang LDL-cholesterol va giam HDL-cholesterol.
*M6i lien quan giita chi so hs-CRP vdi cdc chi so lipid mdu
Bing 1.4. Sy tuomg quan gifta chi so hs-CRP vdi cac chi s6 lipid mau d nhdm chung
hs-CRP
Cholesterol r
0,57
P
< 0 , 0 1
LDL-C r
0,64
P
<o,oi
HDL-c r
-0,25
P
>0,05
Triglycerid r
0,2
P
>0,05
Ndng dg hs-CRP huylt tuomg cd tuomg quan thuan chat che cd y nghia thdng ke (p<0,01) vdi nong do cholesterol va LDL-cholesterol.
HQI NGH! KHOA HQC COA HQI HOA SINH Y DJQC HA NQI vA CAC TJNH PHJA BAC LAN THifXVII
Bang 1.5. Mdi tuomg quan gifta chi s6 hs-CRP vdi chi s6 lipid mau d nhdm nhdi mau nao
Cac nhom
hs- CRP
CT CT+TG CT+LDL
cholesterol r
0,37 0,36 0,32
P
<0,01
<0,05
<0,05
LDL-C r
0,37 0,42 0,33
P
<0,01
<0,05
<0,05
HDL-C r
-0,32 -0,30 -0,35
P
<0,05
>0,05
<0,05
Triglycerid r
0,20 0,10 0,23
P
>0,05
>0,05
>0,05
Qua bang 1.6 ta thay, ndng do hs-CRP cd tuomg quan thuan vdi ndng do cholesterol va LDL- C d nhdm benh nhan nhdi mau nao cip; tuomg quan nghich vdi ndng do HDL-C.
* Danh gid nguy ca nhdi mdu nao cap theo chi so Hs-CRP huyit thanh
Nhumg thay ddi v l chi s6 hs-CRP va ndng do cholesterol toan phIn, dac biet la ndng do LDL-cholesterol giup ta tien lugmg cac nguy ca cua vfta xa dgng mach, cy thi la benh ly dot quy do nhdi mau nao, nguy ca benh dgng mach vanh. Ngoai ra cdn cd vai tro quan trgng trong danh gia higu qua dilu tri cua cac benh ndi tren.
V. BAN LUAN
1. Nong do cac hs-CRP it nhdm benh nhan nhoi mau
Nong do hs-CRP trung binh cua nhdm nhoi mau nao cao hom nhdm chiing 6,6 lin va su khac biet cd y nghia thdng ke vdi p<0,001. Ket qua cua chiing toi ciing phu hgp vdi Modrego (so vdi 7,8 mg/Lvdi p=0,001). Kit qua so sanh cua chiing toi va Modrego chi mang tinh tham khao chu khong so sanh true tilp dugrc, do ngoai sy khac nhau vl phuang tien do ludmg ndng do hs-CRP con khac nhau d cho mlu phan tich cua Modrego bao gom ca nhoi mau va xuit huylt trong khi mlu cua chiing toi chi gdm nhumg benh nhan nhdi mau nao. Nhu vay,
nghien ciiu cua chiing toi thay rang ndng do hs-CRP cd lien quan manh vdi nhoi mau nao.
2. Moi lien quan va gia tri tien doan nguy cor nhoi mau nao vdi nong do hs- CRP:
Trong nghien ciiu cua chiing tdi ndng do hs-CRP trung binh cua nhdm benh nhan nhdi mau nao la 9,73 mg/L, ket qua nay cua chiing tdi thap horn so vdi mgt so tac gia khac khi Le Chuyin (14,64 mg/L), cua Winbeck (3) (12,2 mg/L) cua Modrego (2) (11,6mg/L). Sy khac bigt nay cd le do su khac nhau vl thdi diem lay mlu huylt tuomg xet nghiem va sy khac nhau vl phuang tien dl thii nong do Hs- CRP. Nhu chung ta biet rang sau mgt tin thuomg viem, CRP bit diu tang din va dat dinh sau khoang 48 gid. Trong nghien ciiu cua chiing toi, mlu huyet thanh dugc thu thap trong vong 24 gid dau tien sau khdi phat, con cua Winbeck tu 12-24 gid, cua Le Chuyin la thdi diem nhap vien (ma khong co sy giai ban ve thdri gian nhu chiing toi).
Ngoai ra, nghien ciiu cua chiing toi sft dung bg kit ciia hang san xuit khac vdi trong nghien ciiu cua Napoli va Modrego.
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VI. KIEN NGH!
Dua xet nghiem hs-CRP thuc hien cvmg vdi nhihig xet nghigm cholesterol va triglycerides vao sii dung de xac dinh miic do rui ro tiem tang cho cac benh tim mach, dau tun, va dot quy.
TAI LIEU THAM KHAO
1. Le Chuyen. (2008). Nghien Ciiu Sy Biln Doi Ndng Do Protein Phan iTng C (CRP) Huylt Thanh 6 Benh Nhan nhdi mau nao. Luan an Tien Sy Y Khoa, Dai Hgc Hul.
2. Beatriz Boned Pedro J Modrego, Juan J Berlanga, Mercedes Serrano. (2008).
Plasmatic B-Type Natriuretic Peptide and C-Reactive Protein in Hyperacute Stroke as Markers of Ct-Evidence of Brain Edema. International Journal of Medical Sciences, 5(1), pp. 18-23.
3. Mario Di Napoli, Vittorio Bocola, et al (2001). Prognostic Influence of Increased C-Reactive Protein and Fibrinogen
Levels in Ischemic Stroke. Stroke, 32, pp.
133-138.
4. Miguel Blanco Joaqui n Serena, Mar Castellanos, et al. (2005). The Prediction of Malignant Cerebral Infarction by Molecular Brain Barrier Disruption Markers. Stroke, 36, pp. 1921-1926.
5. Toma s Sobrino Octavio Moldes, et al.
(2008). High Serum Levels of Endothelin-1 Predict Severe Cerebral Edema in Patients With Acute Ischemic Stroke Treated With t-PA. Stroke, 39, 2006-2010.
6. Ulrich Dirnagl Matthias Endres, Michael A. Moskowitz. (2009). The ischemic cascade and mediators of ischemic injury. In M. Fisher (Ed.), Handbook of Clinical Neurology (3rd series ed.. Vol. 92, pp. 32): Elsevier B.V.
7. Ya Hua Guohua Xi, Richard F. Keep, John G. Younger and Julian T. Hoff.
(2001). Systemic Complement Depletion Diminis hes Perihematomal Brain Edema inRats.Sh-oke, 32,162-16.