JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY
Nhan xet dac diim xa hinh tiroi man co* tim 6* benh nhan tang huylt ap nguyen phat co chi dinh chup dong mach vanh can quang qua da
Reviews characteristics of myocardial perfusion imaging in patients with primary hypertension and indicated coronary angiography
Ha Quang Tao*, * Benh vien Ba khoa tinh Hdi Duang Pham Thai Giang ** ** Benh vien Trung uang Qudn doi 108 Tom t § t
Muc tieu: Nhan xet cac dac diem xa hinh tUdi mau cO tim d benh nhan tang huyet ap nguyen phat ed chi dinh chup ddng mach vanh. Doi tuang vd phuang phdp: Chung tdi tien hanh chup xa hinh tudi m l u ca tim cac benh nhan tang huyet I p nghi ngd benh dpng maeh vanh tren iam sang/dien tim, sau dd ed 185 benh nhan ed chi djnh chup dong mach vanh dupc lUa chpn vao nghien eUu. Kit qud: Ty le xa hinh tUdi mau ca tim duang tinh d benh nhan tang huyet ap cd chi dinh chup dpng mach vanh ia 67,6%, am tinh la 32,4%. J)/1^ xa hinh tudi mau ca tim duang tinh d thanh trudc - mdm Id 40,0%, thanh b#n la 30,3% va thanh dudi ia 53,5%. T^ le khuyet xa 1 mach la 23,8%; khuyet xa nhieu hcffi 1 vj tri la 43,8%.
Khong cd sU khac biet ve ty i^ xa hlnh tudi mau cP tim dUPng tinh giQa cac nhom cd hoae khong cd mot trong cae yeu t d nguy cO tim mach nhU: Tudi eao, beo phi, hut thudc la, dai thao dudng, roi loan lipid mau. Benh nhan cd > 2 yeu td nguy co tim mach co t^ le xa hlnh tudi m l u ca tim dUPng tinh la 63,2%
cao hon so vdi nhom chi ed 1 yeu td nguy cO tim mach \h 4,3%. Co 20% benh nhan tang huyet ap khong dau ngUc co xa hinh tudi mau ca tim duong tinh. Kit ludn: Xa hinh tu6i m l u ca tim d benh nhan tang huyet ap nguyen phdt co ty le duang tinh cao han am tinh va thudng cd tdn thuong khuyet xa da mach.
Benh nhan tang huyet ap khdng dau ngUc van cd ty ie kha cao xa hlnh tudi mau cP tim dUPng tinh nen ehua loai trQ hoan toan benh ddng mach vanh d nhUng benh nhan khdng cd tri§u chUng.
TLT^rhda.-Xa hlnh tudi maucatim, tang huyetap, dpng maeh vanh.
Summary
Objective: To review the charaeteristies of myocardial perfusion imaging (MPI) in pnmary hypertension patients who were indicated for coronary angiography. Subject and method: We performed SPECT MPI for hypertensive patients who were suspected of coronary artery disease based on clinical or ECG findings. Among them 185 patients after, coronary angiography procedure, were enrolled into this study. Result: Percentage of positive SPECT MPi among hypertension patients with indication for coronary angiography was 67.6% and negative was 32.4%. The proportion of positive SPECT MPI in the antero - apical area was 40.0%, in the lateral area was 30.3%, and in the inferior area was 53.5%. The percentage of single vessel defect was 23.8% and multivessel defect was 43.8%. There was no significant difference about positive SPECT MPI among groups with or without one of the risk factors such as old age, obesity, smoking, diabetes meilitus, and dyslipidemla. Patients have more than two risk factors had positive SPECT MPI 63.2%, which was higher compared with one risk factor 4.3%. There was 20% of hypertensive patients without chest pain had positive SPECT MPI. Conclusion: SPECT MPI among primary
Ngdynhdn bdi. 27/12/2016, ngdy chdp nhdn ddng: 05/01/2017
Nguaiphdn hdi: Hd Quang Tgo, Email: dungznh@gmail com - B^nh vien Ba khoa tinh Hdi
TAPCHfY DL/OC LAM SANG lOi T$p12-S6 2/2017 hypertension patients had a higher proportion of positive compared with negative, and often accompanied by multivessel defect. Hyperi:ensive patients without chest pain still have a high possibility of positive SPECT MPI;
therefore cannot completely exclude coronary disease in patients without symptoms.
Keywords: Myocardial perfusion imaging, hypertension, coronary artery.
I . D a t v a n d e
Tang huyet I p (THA) la mdt trong ele yeu t d nguy eo (YTNC) chfnh eua benh ddng maeh vanh (DMV). THA gay tdn thuang vQa xP ddng mach lan tda kem theo qua trinh t l i eau true eae ddng mach vUa va nhd nen thQdng gay t o n thQOng BMV d mQe dp vi mach va thudng ed tdn thUPng nhieu n h l n h OMV [1]. 6 bdnh n h i n THA, viee p h l t hien sdm benh OMV khi mdi chi d giai doan tdn thuong vi maeh m l ehua cd hep ele nhanh Idn £)MV ed vai trd quan trpng, gdp phan vao viec kiem s o l t benh BMV. Xa hinh tudi mau co t i m (XHTMCT) cd vai trd phat hien benh DMV ngay c l d giai doan tdn thUPng vi maeh.
Do dd, ehung tdi tien h l n h nghien cQu nay vdi muc tieu 77m hiiu cdc ddc diim XHTMCT d binh nhdn THA nguyen phdt.
2. Ddi tUtfng va phUtfng phap
185 benh nhan (BN) dUac chan d o l n THA nguydn p h l t , ed bidu hidn lam sang v a / h o l e dien tim do khi nghi cd dau hieu thieu mau cue bd co tim 6 Khoa Ndi Tim maeh, Benh vien Trung UOng Q u I n dpi 108. BN dupe tien hanh chup XHTMCT, va sau do chup BMV c l n quang. BN cd tien sQ ehan doan benh OMV (cd hep > 50% it nhat mdt nhanh BMV dQpe chan doan b i n g phuang phap ehup BMV h o l e cd tien sQ nhdi mau ca tim) bj loai khdi nghidn cUu.
Chan doan thieu mau cP t i m cue bd tren dien tim dUa theo tieu ehuan Minesota [8]. XHTMCT dupe thUc hien dUa tren hUdng dan eua cua Hdi Tim maeh Hat n h i n Hoa Ky (2008) [7]. DUpe chat phdng xa dupc xUdung de ehup XHTMCT la Sestamibi gan vdi Tc99m, ghi hinh b i n g may SPECT gammar camera Infinla Hawkeye cua h l n g GE. Phan tich ket q u i XHTMCT dUa tren hinh I n h ehup xa hinh cat Idp cP tim theo cae ldp cat true n g l n (short-axis), true dpc (vertical long-axis) va true dai (horizontal long-axis) 6ugc chia thanh 17 vung theo hUdng dan thue hanh
tim maeh hat nhan cOa ACC, AHA va ASNC n l m 2003 [6]. TQ cle hlnh anh khuyet xa se danh gia vj tri khuyet xa, mUc dp khuyet xa, dp rdng khuyet xa, sU phue hoi khuyet xa v l ket q u i XHTMCT chung bao gdm XHTMCT dUPng tinh va XHTMCT am tinh [2].
3. Ket q u i
Bang 1 . Oac diem BN nghien cuTu
\ ^ Gidi
Tudi \ ^
<65
£65 T6ng Tuoi trung binh
Nam BN 69 84 753
T^le
%
37,3 45,4 82,7 65,37 ± 9,7
na
BN 13 19 32
TJie
%
7,0 10,3 17,3 66,72 ± 6,83
T6ng BN 82 103 185
T * i e % 44,3 55,7 100 65,6 ± 9,27
Nhdn xet: Tudi trung binh eua eac ddi tUpng nghien cQu la 65,6 ± 9,27. Ty Id nam chiem 82,7% cao hPn nQ ehiem 17,3%. Benh nhan tudi eao s 65 tudi (55,7%) ehiem ty le cao ban dQdi < 65 tudi (44,3%).
Bdng 2. Ket q u i XHTMCT theo tCmg vung chi phdi D M V (n = 185)
^^^--^^ Ket qua
^^~~J(HTiVICT V j t r i ^ ^ - ~ > ^ Tlianh trUdc - mdm Tlianh ben Tiianli dudi Ket qu5 ciiung
Dircmg tinii So BN 74 56 99 125
Tyie
%
40,0 30,3 53,5 67,6
Am tinii So BN 111 129 86 60
Tyie
%
60,0 69,7 46,5 32,4 Nhgn xet Trong s6 185 benil nhan nghien cijfu, l<et quS XHTIWCr duong tfnh d 67,5%, cao hon so vdi Icet quS XHTIWa am tinh la 32,4%. Ket q u j XHTMCT
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JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY
theo phan vung tudi mau BMV cho thay, ty le khuyet xa duong tinh d thanh dudi cd t)f le cao nhat (53,5%) trong khi do ty le XHTMCT duong tinh thap n h a t d t h a n h ben (30,3%).
^^^1 ^^^B
Khuyet X9 Sm tiiili
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Bieu do 1. So vj tri XHTMCT duong tinh tuong Ung vdi nhanh DMV chi phoi
Nhgn xet: Ty le khuyet xa da mach la 43,8% cao hon so vdi khuyet xa don mach la 23,8%.
Bing 3. lUoi iien quan gii)a cac YTNC benli DiUV vAi icet q u i XHTMCT (n = 185) K A qua XHTMCT
Cac YTNC bSnii DMV ~--~-__J Tudi
Beo phi
€)ai thao dudng (BTD) Roi loan lipid (RLLP) mau
Hut thudc la
SoYTNC
>65
<65 Cd Khong Co Khdng Cd Khong Cd Khdng
> 2 YTNC
< 2 YTNC
DUdng tinii SoBN
75 50 28 97 37 88 50 75 42 83 117 8
TJie%
40,5 27,0 15,1 52,4 20,0 47,6 27,0 40,5 22,7 44,9 63,2 4,3
Am tinii SoBN
28 32 11 49 12 48 24 36 16 44 49 11
T y i e % 15,1 17,3 5,9 26,5 6,5 25,9 13,0 19,5 8,6 23,8 26,5 5,9
P
>0,05
>0,05
>0,05
>0,05
>0,05
<0,05
Nhgnxet: Khong cd su khac biet ve ket quS XHTMCT giOa cac nhdm cd va khong cd YTNC tim mach:Tuoi cao, beo phi, DTO, RLLP mau, hut thudc la. 6 nhdm BN cd > 2 YTNC tim mach cd ty l§ XHTMCT duong tinh la
lf<P CHf Y Dl/OC LAM SANG 108 Tap 12-So 2/2017
B^ng 4. Moi li^n quan giuTa dac diem dau ngiic va Itet quS XHTMCT (n = 185)
\ Ket qua
\ x H T M C T
Oac d i e m \ dau ngUc \ Khong dau ngUc Cd dau nguc
XH duong tinh So BN
37 88
Tyie
%
20,0 47,6
XH am tinh So BN
8 52
T y i ^
%
4,3 28,1
P
<0,05
T^ le XHTMCT dUOng tfnh d BN cd dau ngUc la 47,6% eao hon 6 BN khdng dau ngUe la 20%.
Ty ie BN khdng dau ngUe ed XHTMCT dUPng tfnh la 20,0%.
4. Bcin luan
Cac BN trong nghien cQu cda chung tdi ed tudi trung blnh la 65,6 ± 9,27. Trong sd dd ed 55,7% sd BN tren 65 tudi.Tudi eao la mdt YTNC gia tang m^e benh OMV, hau het eac bien cd benh DMV deu xhy va d ngUdi > 65 tudi [3]. Ty le XHTMCT dUPng tinh la 67,6% cao hon rd ret so vdi XHTMCT am tfnh la 32,4%. Nghien cQu eua ehung tdi da loai trU cae BN ed ket qua XHTMCT am t i n h khdng cd chi dmh ehup OMV, do dd ty Id BN cd ket q u ^ XHTMCT am tfnh thSp hon duong tinh cung n h u t h a p hPn trong m d t so nghien cQu khac. 6 nhQng nghien cUu dupe tien hanh tren eac BN THA bao gdm ca nhUng BN khdng cd chi djnh chup OMV eho thay ty ie 3m tinh va duang tfnh la tuang duong hoac ty Id XHTMCT am tinh cao han duang tinh. Aiden Abidov [2] nghien cUu tren 8725 benh nhan THA, cho thay t ^ le XHTMCT duong tfnh d BN THA la 37,5%, am tinh la 55,2% va 7,3% la equivocal (khdng chac eh^n am tfnh hay duong tinh). XHTMCT dUong tinh eao nhat tai thanh dQdi vdi ty' le la 53,5%, thanh ben cd ty le duang tinh thap nhat (30,3%). Thanh dUdi cd t y Id khuyet xa duang tfnh eao nhat do vQng nay gap duong t i n h giii nhieu nhat, h)nh anh XHTMCT tai vung dudi hay cd nhieu tap (artifact) bdi tiep giap vdi CO hoanh, noi hoat tinh phdng xa ed the xuat
hIen d gan va rudt do sU bai tiet gan mat eua hoat chat phdng xa va ed the xuat hidn d da day do trao ngUOe hoat chat phdng xa vao da day tQ ta trang hoae do sQ hap thu t u do cua niem mac da day [9].
Thanh trudc cung cd mdt t J le dUPng tinh kha eao bdi dUPng tfnh giS d nhQng BN beo cd thanh ngUc day, phu nQ cd tuyen vu to [4].
BN cd khuyet xa da maeh ed t y le eao han khuyet xa don maeh (43,8% so vdi 23,8%). Elhendy.
A (2005) [5] eho thay d cae BN XHTMCT dUPng tfnh, tudi mau bat thUdng d 1 vj trf la 45,6% va da maeh la 54,4%. BN THA thUdng ed ty le eao ton thUong benh BMV da mach do THA gay ra tdn t h u a n g xa vQa ddng mach lan tda kem theo qua trinh tai cau true cciC ddng mach vQa va nhd, do do thudng cd nhieu ddng maeh bi tdn thuong [1 ].
Ty le BN dau ngUc cd XHTMCT duong tinh cao ban BN khdng dau nguc (47,6% so vdi 20,0%), ed den 20% BN khdng dau nguc cd ty le XHTMCT duong tfnh, didu nay eho thay rang khdng dau ngUc eung chua the loai trU hoan toan benh DMV. Mac du khdng cd sU khac biet ve ket qui XHTMCT ddi vdi eae BN cd hoac khdng cd YTNC tim mach bao gom tudi cao, beo phi, OTD, RLLP mau, tuy nhien nhdm cd > 2 YTNC t i m maeh ed ty le XHTMCT dUong tinh eao hon so vdi nhdm chi cd 1 YTNC tim mach, dae diem nay eung eho thay su phd hpp vdi ty le tdn thuang DMV tang len theo sd YTNC t i m mach.
Tomislav Jakljevie (2012) [10] eho thay, mac du nhdm BN OTO cd ty- le THA, BMI, mUc cholesterol cao hon d nhdm khdng DTD tuy nhien khdng ed sU khae nhau ve ket quS XHTMCT d BN DTD so vdi nhdm khdng DTD.
5. Ket iuSn
Ty le X H T M a dUPng tinh d benh nhan THA la 67,6%. Thanh dQdi ed ty le XHTMCT dQong tinh eao nhat (53,5%). Tly' le khuyet xa da mach la 43,8% gap nhieu hon so vdi ty Id khuyet xa don mach la 23,8%.
Ty le XHTMCT dUOng tinh d nhdm cd > 2 YTNC benh DMV eao hPn so vdi nhdm chi ed i YTNC (63,2% so vdi 4,3%). TJ le XHTMCT dUOng tinh d nhdm ed dau ngue eao hPn d nhdm khdng cd dau ngUe (47,6% so vdi 20,0%).
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Cd 20% XHTMCT dUOng tinh d benh nhan THA khdng ed dau ngUc, do dd khdng the loai trU hoan toan benh DMV d benh nhan cd nhieu YTNC DMV ma khdng ed dau ngUc.
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290-298.
3. Allison, Thomas G (2007) Coronary Heart Disease Epidemiology. Mayo Clinic Cardiology, third edition 687-694.
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5. Elhendy A et al (2005) Risk Stratification of Patients with Angina Pectoris by Stress 99m Tc-
Tetrofosmin. Myocardial Perfusion Imaging. J NucI Med 46: 2003-2008.
6. Klocke et al (2003) ACOAHA/ASNC Guidelines for the Clinical Use of Cardiac Radionuclide Imaging.
JACC 42(7): 1318-1333.
7 Robert C, Hendel et al (2009) ACCF/ASNaACR/AHA/ ASE/SCCT/SCMR/5NM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging. Circulation 119: 561 -587.
8. Ronald J, Prineas, Richard S Crow/, Zhu-Ming Z (2010) The Minnesota Code Manual of Electrocardiographic Findings: Standards and Procedures for Measurement and Classification.
Springer 2010.
9. Steven B and MacDonald A (2006) Artifacts and Pitfalls in Myocardial Perfusion Imaging. J NucI Med 34:193-211.
10. Tomislav J et al (2012) Detection of Myocardial Ischemia in Diabetic Patients: The Limitations of Myocardial Perfusion Imaging. Coll. Antropol 36(3):
821-826.
