compared to control people (0.65 ± 0.02 m m and 0.65 ± 0.02inm correspondingly). Similar IMT results were also reported in carotid bifurcation site (0.87 ± 0.19 (R) & 0.89 ± 0.19mm (D) in I H D group compared to control group (0.78 ± 0.03 mm both in R& L). However only IMT at left common carotid considerably related to number of diseased coronary vessels. Conclusions: IMT at common carotid and carotid bifurcation increased with age, significantly higher in I H D group compared to control group. Left common carotid IMT was independent predictor of at least one diseased coronary vessel need intervention.
Keywords: Carotid Intima - Media Thickness, Coronary Artery Disease
VAI TRO CUA SIEU AM DOPPLER TRONG CHAN DOAN BENH HUYET KHOI T I N H MACH SAU CHI D U 6 |
Dinh Thi Thu Hfldng Tnfdng Dai bgc Y Ha Ngi
Muc tieu: nghien cdu gii trj ciia phuang phap sieu im Doppler mach trong chan doan benh huyet khdi tmh mach sau chi dudi. Bdi tUgng va pbuang pbap nghien cdu: md ta, tien edu tren 100 benh nhin nghi ngd bj huyet khdi tTnh mach siu chi dUdi. Cic benh nhan dugc lam sieu am Doppler mach (ddi chieu vdi ket qui chup tTnh mach d 20 benh nhan). Ket qua: de chan doin cd huyet khdi, sieu am Doppler mach co do nhay 100%o, song cdn ban che trong chan doin chinh xic vj tn tic tTnh mach viing dng chin va cic tTnh
•mach trong d bung. Tac tinh mach chin trii gap nhieu han so vdi chan phai, vimg diii khoeo nhieu han vung dng chin. Ket luan: sieu im Doppler mach la phuang phip cd gia tri cao trong chan doin huyet khdi tTnh mach chi dudi vdi do nhay cao.
Tfl khda: huye't khd'i tlnh mach, sieu am mach mau
I. DAT VAN DE
H u y i t khd'i tTnh mach s l u (HKTMS) la mdt benh thfldng gap, la nguyen nhan gay tfl vong cao dflng thfl 3 sau benh mach vanh va ung thif. Benh thifdng cd bien chflng nang nhfl t i c mach phdi hoac suy tlnh mach sau h u y i t khd'i nen viec c h i n doan sdm, chfnh xac d l d i i u trj kjp thdi I I r i t can thiet. Do dd chung tdi tien h i n h nghien cflu d l tai nay n h l m muc tieu:
Nghien cdu gia tri cua phuang phap sieu am Doppler mach trong cbin doan benh huyet khdi tinb mach sau chi dudi (HKTMSCD).
II. DOI TUONG VA PHUONG PHAP NGHIEN CLfu
1. Ddi tfldng nghien cii'u: d c benh n h i n
kham va dieu trj tai vien Tim mach Qud'c gia vdi bieu hien nghi ngd bi benh h u y i t khd'i tTnh mach sau chi dfldi.
2. Phfldng phap nghien ciJu: kham l l m sang, hdi benh tim d c yeu td nguy cd theo mau benh an.
Sieu I m Doppler mach cho t i t c l nhflng dd'i tfldng n l y bang m i y GE Logiq 500 vdi d i u dd 7,5 MHz.
Dd'i c h i i u k i t q u i sieu I m Doppler mach vdi ket q u i chup tlnh mach cua 20 benh nhan, danh gia dd n h l y , dd dac hieu cua phflong phap sieu am Doppler mach trong chan doan benh h u y i t khdi tTnh mach s l u chi dfldi.
in. KETQUA
1. Tudi va gidi: tdng sd'cd 100 benh nhan (45 nam, 55 nfl), tudi trung binh: 47,2 ± 1 5,5 nam.
30
20
f * * - * * - - ^
< 20 20 - 30 30 - 40 40 - 50 50 - 60 60 - 70 7 0 - 8 0 > 80 Nhom tudi
2. Cac yeu to' nguy cd
- CIc nguyen nhan npi khoa chiem 52% bao gdm:
+ Nhdm nguy cd dang phdi n h i i m (19%): b i t dpng do cac nguyen nhan khac nhau (13%) v l nhiem trung c i p (6%).
+ Nhdm nguy cd da m l c (33%): tien sfl bi HKTMS (10%), hien dang bj ung thfl (10%) va cac nguyen nhan lien quan d i n s i n khoa (1 3%).
- Cac nguyen nhan ngoai khoa: t i i n sfl p b l u thuat (1 7%).
- Khdng tim t h i y y i u t d nguy cd: 31 % 4. Ket qua sieu am Doppler tinh mach
%
100
Bieu dd 1. Phan bd tudi
3. Tri^u chu'ng lam sang
H l u h i t d c benh nhan de'n kham d vien Tim mach khi chan da sflng dau n b i l u khdng di lai dflpc. Thdi gian tfl khi bat d i u x u i t hien trieu chflng de'n khi vao vien I I 13,3 ± 14,6 ngay. C I c trieu chflng hay gap n h i t bao gdm: bd tflc c h i n (89%), dau c h i n (99%), sflng chan (99%). Trieu chflng te chan ft gap bdn (28%), khd thd (4%). Sd benh nhan cd trieu chflng d c h i n trai I I 74%, 18% cd trieu chflng d c h i n p h i i va 8% cd trieu chflng d d 2 chan.
[IJBen phai • Ben trai
ao
80 70 60 SO 40 30 20 10 0
T a c T M chau
TMdui chung
TM diji TM dii nong sau
Bieu do 2. Pban bd buyet kbdi finh mach tren sieu am
TM TM chay TM chay TM mac TM cd TM hien TM hien khoeo tru'dc sau dep ngoai frong
Trong tdng sd 100 BN ddac sieu am co 74,7%, bi tic TM chan trai, 15,2% tic TM chin phai va 10,1%, bi tacTM ca 2 chan. -' . •
Bang 1. Ket qua pbat hien huyet khdi tren sieu am Doppler mach
Tac T M chau T M dui chung T M dui ndng T M dui s l u T M khoeo T M chay trfldc T M chay sau T M m l c T M cd dep T M hien ngoai T M h i i n trong
Hoan toan 3 18 20 3 19
4 5 5 3 3 9
Tdc ben phai Mgt phan
1 2 2 1 1 0 1 0 0 0 1
Khong tac 95 80 78 96 80 96 94 95 97 97 90
Hoan toan 14 68 70 15 67 15 32 37 7 6 29
TSc ben Mpt ph
0 9 5 2 7 1 2 2 0 0 2
trai
an Khdng tdc 86 23 25 83 26 84 66 62 93 94 59
Ket qua sieu am lan dau khi vao vien cho tha'y sd TM bi tic hoan toan d cac chi dddi chiem da sd, sd TM bj tic 1 phan it han.
5. Ket qua chup tmh mach
Bang 2. Ket qua pbat hien huyet khdi tTnh mach khi chup macb
Tac T M chau T M dui chung T M dui ndng T M dui sau T M khoeo T M chay trfldc T M chay sau T M mac
cat cut
0 1 1 1 0 0 0 0
Tdc ben phai Khuyet
0 0 0 0 Q 0 0 0
BT 19 18 15 18 17 19 19 19
Cat cut 0 3 3 1 4 2 4 5
Tac ben trai Khuyet
0 0 0 0 0 0 0 0
BT 18 15 15 17 14 14 14 13
T M cd dep 18 18
T M hien ngoai 19 18
T M hien trong 17 17
Cac tTnh mach khdng bi tac se n g i m thud'c d n quang d i u t o l n bd Idng tTnh mach (neu Ifldng thud'c c l n quang vfla du va ngfldi tiem thud'c c l n quang bdm thud'c vdi ap Iflc vfla du).. Nhflng hinh I n h thdng thfldng cua huye't khd'i tTnh mach tren sieu I m khi chup tTnh mach d n quang I I : hinh I n h khuyit cua long tTnh mach (tfldng flng vdi mflc dp tac khdng hoan toan Idng tTnh mach), hinh I n h cat cut hoan toan cua tTnh mach (tfldng flng vdi mflc dd tac hoan toan Idng tTnh mach).
IV. BAN LUAN
1 . Cac yeu td nguy cd gay tac tlnh mach
Tudi > 55 la y i u to' nguy cd g l y t i c tTnh mach, trong nghien cflu cua chung tdi tudi hay gap n h i t la dp tudi 30 - 50. Theo d c nghien cflu tren t h i gidi, d nhflng ngfldi tren 30 tudi thi cfl sau 10 nam, nguy cd t i c tTnh mach lai tang g i p 2. Ty le suy tTnh mach d ngfldi sau 50 tudi d d c nfldc phat trien k h i ldn (> 5 0 % dd'i vdi nfl gidi), m l suy tTnh mach I I y i u to nguy cd g l y tac tTnh mach [5].
Trong khi dd, r i t it benh nhan cua chung tdi dflpc kham p h l t hien suy tTnh mach trfldc khi bj tac tTnh mach. Cac nguyen nhan npi khoa chiem 52%, d c nguyen n h i n ngoai khoa la 1 7%. Khdng tim t h i y y i u t d nguy cP la 3 1 % , cd the do v i o thdi diem dd benh vien Bach Mai khdng the lam d c xet nghiem de tim nguyen nhan rd'i loan ddng mau bam sinh nhfl sfl thieu hut Protein C, Protein S, anti thrombin HI... nen trong so' 3 1 % benh nhan khdng ro can nguyen tren khdng hieu cd bao nhieu benh nhan cd rd'i loan ddng m l u b i m sinh.
Samuel Z. v l cdng sfl khi lam sieu I m c h i n d o l n huyit khd'i tTnh mach cho 5.451 benh nhan thi thay d c benh thfldng di kem vdi h u y i t khd'i tlnh mach s l u chi dfldi la tang huyet I p (50%), mdi p h i u thuat trong vdng 3 thang (38%), b i t ddng trong vdng 30 n g l y (34%), ung thfl (32%), beo phi (27%). Trong sd' 2.726 benh nhan dfldc chan d o l n HKTMSCD thi chi cd 1.147 (42%) dfldc d i i u
tri dfl phdng 30 ngay trfldc khi dflpc phat hien benh [8].
2. Gia tri cua sieu am Doppler mach trong chan doan HKTMSCD
Phan Idn d c benh nhan bi tac tTnh mach vung dui khoeo. Dieu nay cung phu hpp vdi Hirsh v l cdng sfl nghien cflu 1000 benh n h i n nghi ngd cd HKTMS da tim t h i y 3 0 % cd HKTMS, trong sd dd cd 9 0 % h u y i t khd'i tfl T M kheo trd len va 10%
huyet khd'i gidi ban d vung cang chan [5].
Cd 1 4 % sd' benh nhan cd dau tren cua h u y i t khd'i nam d tTnh mach chau n g o l i t r i i v l 4 % d tTnh mach chau n g o l i p h i i . Trong cac T M sau d cang c h i n thi hay bi tac n h i t la T M mac va chay sau, cd 1 sd it cd t i c T M ndng kem theo, T M hien trong hay gap hdn hien n g o l i . K i t qua nay phu hdp vdi Pham M i n h Thdng, Bui M i n h Giang, Trinh Trung Phong [ 1 , 2 ] .
Khi dd'i chidu kdt q u i sieu I m vdi ke't q u i chup tTnh mach ve dp nhay v l dp dac hieu, chung tdi t h i y : tdng so' cd 20 benh h h i n dflpc chup tTnh m a c h , trong dd cd 19 benh nhan tren sieu I m t h i y cd tac t l n h mach thi tren chup tTnh mach cung t h i y tac tTnh mach va 1 benh nhan thi dfldc c h a n doan tac tTnh mach qua sieu am d 1 phdng sieu am m a c h khac trong Ha Ndi nhflng khi de'n vien T i m mach chung tdi sieu I m khdng t h i y tac tTnh mach va khi chup tTnh m a c h can quang cung khdng t h i y tac tTnh m a c h . Do vay, dp nhay cua sieu am se I I 1 0 0 % . So s i n h v d i cac nghien cflu khac tren the gidi: B i r d w e l l BG va cdng sfl t h i y sieu am c h i n d o l n huye't khd'i tTnh m a c h cd dp n h l y 9 5 % va dp dac hieu 9 6 % [4] va 97 - 9 8 % theo 1 nghien cflu k h l c tai Bi cua Michels va cdng sfl [6]. Vdi nhflng benh nhan ft cd kha nang bj benh kiem d i n h qua test l l m sang thi sieu I m c h i n d o l n cd dp nhay la 9 2 % (Bucek RA v l cdng sfl) [7]. Tuy n h i e n sieu I m Doppler se cd
han che trong vide phat hien huye't khd'i tTnh mach d c l e tTnh mach chfl dfldi, tTnh mach chau, dac biet khi ngfldi benh cd thai va bung chfldng hdi. Khi dd CT xoan d'c hoac chup tTnh mach d n quang ke't hdp vdi xet nghiem D - dimer rat cd gia trj chan doan [7, 9].
V. KET LUAN
Sieu I m Doppler mach II mdt phfldng phip tham dd cd gia tri cao trong chin doan xlc djnh cung nhfl theo ddi diiu tri huyet khdi tTnh mach slu chi dfldi.
TAI LIEU THAM KHAO
1. Trinh Trung Phong (2000). "Nghien cflu mdt sd dac diem lam sang va sieu I m Doppler tTnh mach tren benh nhin huyet khd'i tTnh mach slu chi dfldi". Luan van thae sT y khoa.
2. Pham Minh Thong, Biii Minh Giang (1996).
Vai trd cua sieu am Doppler mau trong chin doan viem tac tTnh mach chi dfldi. Cdng trinh nghien cflu khoa hpc benh Vien Bach Mai. Nha xuit b i n Y hpc. Tap 2, 1996: tr. 109-114.
3. Birdwell BG, Raskob GE, Whitsett TL, et all. (1998). "The clinical validity of normal compression ultrasonography in outpatients
suspected of having deep venous thrombosis" Ann Inter Med; 1 28: 1 - 7.
4. Hirsh J. (1990). Diagnosis of venous throm- bosis and Pulmonary Embolism. Am. J. Cardiol;
65: pp. 45 - 4 9 .
5. Michels JJ, Kasbergen H, Oudega R, et all.
(2002 Mar). "Exclusion and diagnosis of deep vein thrombosis in , outpatients by sequential noninvasive tool". Int Angiol; 21 (1): pp. 9-1.9.
6. Nicola Perone, Henri Bounameaux, Arnaud Perrier. (2001). Comparison of Four Strategies for Diagnosing Deep Vein Thrombosis: A Cost - effectiveness Analysis. Am. J. Med; 110: pp. 33 - 40.
7. Samuel Z, Goldhaber, Victor F, Tapson and DVT Steering Committee. (15 January 2004). A prospective registry of 5,451 patients with ultrasound - confirmed deep vein thrombosis. The American Journal of Cardiology, volume 93.Issue 2, pp. 2 5 9 - 2 5 2 .
8. Tick LW, Ton E, Van Voorthulzen T, et all.
(Dec 2002). Pratical diagnostic management of patients with clinically suspected deep vein thrombosis by clinical probability test, compression ultrasonography, and D - dimer test.
Am J Med; 113 (8): pp. 5 8 7 - 8 .
Summary
ROLE OF THE ULTRASOUND IN LOWER LIMB DEEP VEIN THROMBOSIS DIAGNOSIS
Objective: to determine the value of the vascular ultrasound in diagnosis of lower limb deep vein thrombosis. Methods: observational prospective study. Vascular ultrasound was done for 100 patients with susspision of lower limb deep vein thrombosis in comparison to the veinous radiography. Results and conclusion: ultrasound has 100% sensibility in lower limb deep vein thrombosis with some limitation in diagnosis and location of thrombosis in hinhleg and abdominal vein thrombosis.
Keywords: lower limb, deep vein thrombosis, ultrasound
