HNKH Y D l / g c - KY NiEM 50 WAW N G A Y T R U Y £ N T H 6 N G TRlf^TNG CAO B A W G Y T H A I NGUYEN (19W-2016) _
DAC DIEM LAM SANG VA CAN LAM SANG COA BENH NHAN SUY TIM MAN TINH TAI BENH VIEN TRUNG U-ONG T H A I NGUYEN
T6M TAT
Nghien cijru duac tien hanh tren 98 b?nh nhSn suy tim man tinh diroc dieu tri noi tni tix thang 4/2016 den thang 10/2016 tai khoa n^i Tim mach, Benh Vi$n Da Khoa Trung Uong Thai Nguyfin. Phuvng phap nghien CITU: mo t^ cSt ngang. Ket qui: Tuoi trung binh cua d6i tupng nghien ciiu la 64,4±13,0 trong d6 nh6m tuoi diroi 60 chilm 36%, tren 60 chiem 64%, niJ chilm 56,1%, nam chifim 43,9%. Nguyfin nhan suy tim, THA chiem 48%, b^nh tim mach khac (b?nh mach vinh, bfnh ca tim) chilm 33%, benh van tim chilm 18%. Miic dg suy tim theo NYHA c ^ g n ^ g thi p h ^ s6 tong man cang g i ^ . Bfnh nhan suy tim co EF<40% va nhom c6 EF > 40% CO phan lan trifiu chimg l§m sang giong nhau, ngoai tru s^ khac bi?t giua gan to (87,5% vdi 41,4%) va phO (87,5% vdi 44,8%). v l kit qua c ^ \km s ^ g , co s\r khac bift cua n6ng df NT-proBNP vk hinh kx±
tim to trfin phim Xquang nguc thing a 2 nh6m bfnh nhan suy tim vm EF trfin vk duoi 40% v6i p <0,05.
Tir khda: suy tim mgn tinh. phdn dg suy tim
* Trudng Dgi hgc Y Dugc - DH Thdi Nguyen Chju trfich nhifm chmh: Bui Thj Thu Huong Email: [email protected] Ngaynh^nbAi: 12.9.2016 Ngay phin bifn khoa hpc: 22.11.2016 Ngay duyft bii:2.12.20i6
esuiui
s i i .
N g u y k Van My*, NguySn T h | Ngfin*
Bui Thi Thu Hutmg*, Trjnh Xufin Din*
SUMMARY
CLINICAL AND SUBCLINICAL OF CHRONIC HEART FAILURE AT THAI
NGUYEN CENTRAL HOSPITAL The study was conducted on 98 patients with chronic heart failure treated boarding from 4/2016 to 10/2016 at Cardiology departement.
Thai Nguyen Central Hospital. Research methods: cross-sectional descriptive. Results and conclusion: The mean age of subjects | 64.4 ±13.0 study in which groups under agd accounted for 36%, 64% over 60, women accounted for 56.1%, men 43.9%. Causes of heart failure, hypertension accounted for 48%, other cardiovascular disease (coronary artery disease, cardiomyopathy) accounting for 33%, :J accounting for 18% of heart valve disease. The jg degree of heart failure according to NYHA heavier ejection fraction decreases. Heart failure patients with EF <40% and > 40% of the EF group had clinical symptoms largely the same, except for the difference between hepatomegaly ' (87.5% to 41.4%) and edema (87. 5% to 44.8%). , On preclinical results, the difference of NT- ^' proBNP concentration and image enlarged heart ™ on chest X-ray film in second straight group of '''i heart failure patients with EF above and below -i 40% with p <0,05.
Keywords: chronic heart failure, heart failure 1.1
classification ,|,
I.OATV/(NDI ^ Suy tim la mpt hgi chiing bfnh 1^ thuimg j
gip trfin lam s ^ g , \k dien bifin cu6i cung cOa "^
nhieu bfnh ly tim m^ch vk Xk bfnh c6 tJ !f ^ mfic vS ty !f tii vong cao. T ^ MJ co khofing -^
214
Y H O C V 1 & T H A M T A P 4 4 9 . T H A M G 1 2 - S 6 D A C B 1 £ T - 2 0 1 6
5 tneu ngiroi dang diau tri suy tim va mSi nam tren 500.000 ngtrra duoc chin doan suy um lan dan. Tai Viet Nam tuy chira Co thdng ke cy the nhung sd benh nhan cin diin tri suy tim ngay cang tSng trong d6 suy tim man tUl rat phuc tgp voi diln biin tit tir, trai qua nhieu giai doan v6i nhiju nguyen nhan khac nhau lam cho co the thich nghi, diSu chinh v4 dung nap djn vol hien tirpng giam cung lltjmg tun. Viec chan doan suy tim man tinh dac biet la suy tim Ichong co uieu chiing thuc
than, mac cac benh \ i mau, cac b$nh gay rait mau d p nhu xult huyjt tieu hoa, xo gan, dang raac cac benh nhilm trung.
ThM gian va dia dilm nghien ciju Tvr thang 4 din thang 12 nam 2016 tai Khoa Tim Mach, Benh vien TU Thai Nguyen.
Phu-ong phap nghien cihi Phuong phap mo ta cit ngang C&c bave tien hanh nghien clhi Benh nhan dugc hoi b|nh, kham lam SU kho khan, hien nay viec chin doan suy sang,' can lam sanglam cac xet nghi6m nhu • nm van dua chii yeu yao trilu chiing lam sinh hoa mau(dien giai d6- Na* K* Cl) Aig cua benh nhSn, dong thai sieu am tim dien t t a dd 12 chuydn dao, chup X-quang dinh gi4 hinh M l , chiic nSng tim thong qua nguc thing, xet nghiem NT-proBNP vise danh gia roi loan chile nSng tam thu thit Cac tieu chuin danh gia
OA EF dupc coi 14 tiSu chuin vang n-ong - BSc diSm chung: tuai. gi4i, nguySn nhto Chan doan suy tim. mSc benh
Voi cdc hiin hiln I3m sang phiic tgp, tr4i qua nhieu giai dogn do do viec tim ra cac lri?u chiing hay g5p nhit tren benh nhto se giiip cho chan doto x4c djnh som phuc vy iiiu tri v4 gitoi ty Ie Hi vong. Do viy chiing t6i th^rc hi?n de tai n4y voi muc tieu: nghien ah iic iiim ldm sang vd can Idm sing cua Hnh nhdn suy lim mgn linh Igi binh viin Trung Uang Thdi Nguyen.
It B 6 | TVIilNG VA PHl/ONS PHAP NGHI6N CCTU Doi tiT^g nghiSn ciru
Gom 98 b?nh nhto suy tim man tinh co tri^u chiing dieu tri npi Uii, duoc chin doto theo tieu chuto Framingham, dtoh gia miic lip suy tim theo phto d§ chiic ntog NYHA.
Logi tiii cdc b?nh nhto: suy tim d p , suy III. Kfr QuANtjHlGN Clj'U
Bang 1. Bjc iiim ciia ioi lu^f> ngh,
- Trieu chiing Itai stog: kho tho, met moi, ho khan, phii, gan to, rales 6 ph6i,
tieng thoi, nhip tim nhanh....
- Mftc do suy tim: NYHA
-Xquang tim ph6i: hinh toh bong tim to - Dien ttoi d8: dtog gii rai logn nhip tim:
co/khong
- Sieu toi tim: dtog gia r& loan chiic ntog ttol thu that trii qua EF (EF >40% v4 EF<40%)
- Cac xit nghi?m: NT-proBNP, di|n glM ii: Na*, K*, Cl".
Phinmg p h i p xir ly si lieu
Cac kSt qui ducrc xir l^blng cdc thujt toto sir dung phin mem SPSS 20.0
Nghien cuu tuan thii cic via di vi dao dih: trong nghien cihl y h9C
1 DicdiSm ]• TuJi
X+SD 64,4±13,0 So benh nhan | Tile
215
HHKH T OUgrC - KY N I | M 50 HJM N G A Y TCUY&I THflNG TRl.rCrWG CAO B * t l S Y T H A I NGUYtW (18M-2I)16)
Gioi NguySnnhin
micbfnh
Nam Nil Ttoghuyetap Benh van tim Benhtimmachkhac
43 55 47 18 33
43,9%
56,1%
48%
18,4%
33,7%
Nhanxet: Tham gia nghiSn ciiu gBm 98 benh nhto co tudi Irung binh 64,4 ±13, vtti 43 nam chiSm 43,9% va 55 ntt chiSm 56,1%. Nguyen nhto mic benh co ttag huySt i p chiSm fi 48%, benh tim mach khac (g6m benh mach vtoh, benh ca tim) chiSm 33,7% vi thip nhit la 111 nguySn nhto do benh van tim chiSm 18,4%.
A
Biiu ii I .Bfc iiim nhdm tuii cua iil lirfng nghiin ciru Nhin xil: Trong nghien cihi, b?nh nhto c6 tuBi tren 60 chilm phin liSn 64%, tuoi duoi 60 chiem 36%.
Bang 2. Phan ig suy lim Iheo NYHA cia iii luffng nghiSn ciiu Phan «$ NYHA
Dgn Dp III Dp IV T6ng
28 45 25 98
Ty If % 28,6 45,9 25,5 100
Nhfn xit: Tham gia nghiSn cilu co 28 bjnh nhto, suy tim dO H chiira 28,6%, dO m c6 45 b^nh nhto chiSm 45,9%, d^ IV c6 25 b?nh nhto chilm 25,2%.
Bang 3, Phin logi suv lim Iheo phin si ling miu cia iii linmg nghiin ciru Phan so tong mdu
40
Ti If % 40,8%
59,2%
Nhgn xil: Tham gia nghiSn cim co 40 b?nh nhta suy tim viW phto s6 tong mdu gidm EF<
40% chilm 40,8%, 58 benh nhto suy tun voi EF > 40% chiira 59,2%.
216
1
. ^^'^"^^^'''•'•'l'°'"'t<:di suy tim Iheo phan si ling miu
Nh^xel: Co sv khic biSt co y nghia giua rauc do suy tira theo NYHA v6i suy tim voi PMn so tong mau gidm va bao ton voi p<0,05.
5. Trifu chime caning cua Si tmmg nghien cir,, Trigu chihig
Mft moi Khothfr Ichi ging sire
0 a u ngirc Ho khan
Tiig % 100 100 68,4 J A » ^ xil: Tit ca b?nh nhto vao vign vi cam thiy mgt moi, kh6 tho khi gdng sire mgt » i s Ihem nigu chiing dau ngvc (67%), va/ho}c ho khan (47%).
HNKH Y DUraC - KY NIgy 50 N A M N G A Y THUYfeN ^T^ONG TRUtWG CAO B A W G Y T H A I NGUYEN t1966-201g)_
Bang i. Trieu chung thtrc the phin bo theo phin si tins miu Trieu cbvng
Tan so tim (chu ky'/ phtit)
Tieng thoi Ran 0* phoi
Phii Gan to HATT (mmHg) HATTr (mmHg)
<100
>100 Co Khong
Co Khong
Co Khong
Co Khong
Phan so tong mau EF
<40%
25(62,5%) 15(37,5%) 25(62,5%) 15(37,5%) 22(55%) 18(45%) 35(87,5%)
5(12,5%) 35(87,5%)
5(12,5%)
> 40%
38(65.5%) 20(34.,5%) 29(50.0%) 29(50,0%) 30(51,7%) 28(48,3%) 26(44,8%) 32(55,2%) 24(41,4%) 34(58,6%)
P
>0.05
>0,05
>0,05
<0,05
<0,05 123,3 ±22
75,6 ±12,2
Nh^n xit: Co su khac bifit ciia ty If gan to v^ phu 6 2 nhom bfnh nhan suy tim v6i EF trfin vk du6i 40% vol p < 0,05.
Bdng 7. Bgc diim cgn lam sdng phdn bo theo phdn s6 tong mdu
„
,
NT-proBNP (pg/ml) Natri mau
(mmoI/1) Kali miu (mmol/l) Roi togn nhjp tim Tim to
Binh thutmg Giam Binh thucmg
Ttog Co Khang
Co Khong
Phin sS ting miu
< 40%
8143 (418-35000)
19(47,5%) 21(52,5%) 38(95,0%) 2(5,0%) 15(37,5%) 25(62,5%) 36(90%) 4(10,0%)
> 4 0 % 1530 (185-35000)
32(55,2%) 26(44,8%) 56(96,6%) 2(3,45) 23(39,7%) 35(60,3%) 30(51,7%) 28(48,3%)
P
<0,05
>0,05
>0,05
>0,05
<0,05 Nhfn xil: Co sir khic biet ciia nong dp NT-proBNP vd hinh dnh tim to tren phim Xquang
ng\rc thing 6 2 nhom benh nhto suy tim v6i EF tren vd dudi 40% voi p < 0,05. ^•
IV. BAN LUAN 11,6 %O a tuoi 85 tni len [3]. Qua khio sdt ' /. Bfc diem chung vi mil, gidi va nguyin trSn 98 bgnh nhto suy tira mgn tinh, chung ' nhdn suy tim toi ghi nhto kit qud nghiSn ciru nhu sau: n ( t ' Cimg voi s\r phit triSn cua x5 hgi, s l gi6i chiem 56,1%, nam gi6i chilm 43,9%,"
lirpng bgnh nhto rale suy tim ngay ctoggia tuii trung binh 64,4±13,0 tiong da nhomluAi' ttog. Ty lg mai rale tdng theo tali, chi tir >60 chilm 64%. Alan S. Go vd cgng sv •' 0,02% moi ndm 6 nhom tuii 25-34 ISn den nghiSn cdu 59.772 bgnh nhdn suy tim mgn "
Mtt^Wj
Y HOC VlgTHAM TAP449-THANG 1 2 - s 6 P A C B l g T - M I S
f ; ^ . " ^ y ""« tnu-g binh 14 72. phu nii chiem 46% (sj. Ngoys„ ^ ^ y,^^ ^lei ^ . gioi hien chua dupe ro hoto toto nhung co dJiklgn cho thay phu nil co do trp ciing mach mdu va that trdi thi ttoi thu vi tam truong cao hon nam v4 sir tro cimg nay tang manh (theo taoi 6 nO gidi. Ngoai ra, cac thay dli Chile ntog mgch v4iih chi co a nu cflng co Ihe 14 loi gidi thi'ch cho hign tupng ndy.
Ve nguyen nhan suy tim, ttog huyit ap co ty lg cao nhit chilm 47%, cic nguySn nhto tim tngchkhdc (bgnh mgch vtoh, bgnh co tim ) chilm 33% vd thip nhit la cdc bgnh I^ van
Clhl cua Zile voi phin Ion benh nhta suy tim voi NYHA m-IV la 78% con NYHA 11 14 22%[8]. Su> dm voi phto sd ting mau gidm EF< 40% Chilm 40,8%. suy tim voi EF 40%
chiem 59.2%. Theo cac khao sat Ion tten thi gioi, t\ le lim hinh ciia su\ tim EF giam it hcm ro rgt ( giam hon mmg suy tim tam truong) v4 thuong gdp nhilu o nu hcm 14 nam p moi liia tuoi [6], [7]. NghiSn ciiu cua chung tai cho thiy co su khic bigt giiia cic mile dp suy tim theo NYHA voi phta s3 tong mdu CO y nghia thing kS voi p<0,C5 va chiing tei nhto thdy iic dp suy tim theo nm ChiSm 18»/.. Theo nghiSn ciiu cua Jiang NYHA ctog nang thi phto s l ting mfa ctag He vi cs, hmi 60% tntong hpp suy tim sung gidm, cu thi suy tim vai phto sd ting mta
L m
L « L •
huyet xdy ra o nguoi MJ la do bgnh mgch vtoh, 14% do ttog huyit ap v4 vai tro cua bgnh ly van tim chi thil ylu [4]. Sir khac bigt giOa cdc nghien ciru co thi do co mau ciia cliiing toi nha hon, m l hinh benh tat khac vol cdc nuoc cang nghigp phdt ttiln. Trong
gidm <40% thi trong do chilm 87,5% la suy tim do 111, IV va suy tim voi phdn s i ting miu > 40% thi 86,2% 14 suy tim dp II, III.
3. Trieu chirng ldm sang
Trong nghiSn ciru cua chung toi khong thdy CO sir khic bigt ra rtag vS cic ttigu w e n nhan htog dau cua suy tim m p , phU hai nhom suy tim tam ttuong vd suy tin, lam
bgnh b^ thuimg gdp nhat va hien dign a 70- a nhom suy tim tim thu. 06 su khic biSt 1 " E p t n ' ^ l n r'.T r T . ™ " " f ' ° '*"« ^'^ " ^ ^ " ' ^ B ldm stag phu vd gan to vai miu EF bdo tin [6], [7], dupc xdc djnh bli phto s l ting rata c l y nghia thing ke vol pliidgi that ttai ttag dp ciing mach rata vd p<0,05. Hiu hit benh nhta vdo vign vi cdm mal trii ^lam thu, rti logn chuc ntog tdm thiy mgt raoi, kho tho khi gjng siic mpl s l lramg,tatcacdcyeutondydSuc61iSnquan co them uieu chung dau nguc (67%) aijt ChS vai sinh bgnh hpc suy tim tam vaAoac ho khan (47%). Do do chiing ta kha tniong
CO the phto bigt gitta suy tim tam thu vd suy 2 Mdc dg suy lim theo NYHA va phdn tim tam ttuong khi chi dua v4 cdc trieu Ti suy lim Iheo phin so long mdu
Ve phto dp suy tira, ttong nghien ciiu cua
^chiing tdi ghi nhto suy tira dg 11 chiSra '"1,6%, dg III chiira 45,9%, dp IV chilm S,2%. Nhu vgy trong nghiSn ciiu ndy chu 1 niw»"jp^u 1^ lj|nh nhan suy tim miic dg trung binh.
i ^ Kit qua cud chiing toi taong ddng vol nghien Iim I*
ehiing ldm stog. Vi vgy cau hai ddt ra 14 ligu cdc xet nghigm thang thuong co giiip ich trong vigc xdc djnh suy tim hay khang?
-I. Ve kel qud cdn Idm sdng
Kit qui btag 7cho thiy xet nghigm nong dp NT-ptoBNPo nhom phto s l ting miu (EF) duoi 40 % ca gid tri ttnng vj ( 8143 219
HNKH Y D U y C - K V NIEM 50 NAM N G A Y T R U Y £ N T H O N G TRl/CfNG CAO O A N G Y THAI NGUYgN (1966-2qi6)_
(418-35000)) cao hcm nhom EF tren 40 % (1530 (185-35000)), sir khac biel co y nghta thong kfi voi p<0,05.Nhu vay, suy tim cang nang thi nong dp NT-proBNP cang cao, Difiu nay cung phu hop voi nghien cuu cua tac gia Huynh Kim Gan va cong sir [2] khao sat trfin 59 benh nhan, cho thAy viec dinh lugng n6ng do NT-proBNP la phuong phap hGu ich, phu hop voi lam sang, giup chan doan va danh gia mijrc do suy tim.
Qua khao sat 98 benh nhan suy tim man tinh chiing tdi thdy ti 1? co r6i loan nhip, giam NEI, tang K d bfinh nhan co suy tim EF<40% nhieu hon so voi suy tim c6 EF>40%. Tuy nhifin cac xet nghiem tren khong phai la cac marker co gid tri trong chSn doan suy tim ma co the la bifiu hi?n hau qua cua suy tim vi dong mau den gan va thSn CO the giam nhifiu hon a ckc b?nh nhSn c6 g i ^ chuc nSng t ^ thu va vi?c su dimg nhi^u horn thuoc uc chfi men chuydn a cdc b?nh nhan nay. Chung toi n h ^ thdy trong hinh anh Xquang bat g§p ty If b6ng tim to 6 bfnh nhan suy tim co chtrc nang tam thu gidra<40% (90%) nhifiu hcm so v6i benh nhan c6 suy tim mk EF > 40% (51,7%), s\r khde bi?t c6 y nghia voi p<0,05.
V. K ^ LUAN
Tuoi trung binh cua doi tucmg nghien cijru 1^ 64,4±I3 voi nhom tu6i du6i 60 chifim 36%, tren 60 chilm 64% trong d6 nQ- chilm 56,1%, nam chifim 43,9%. Nguyen nhan suy tim do tang huyit dp chifim 48%, bfnh tim m ^ h khde nhu bfnh m?ich vanh, bfinh ca tim chiem 33% vd thap nhat !a bfnh van tim chiem 18%. Miic dp suy tim theo NYHA cdng n|ing thi phdn s6 t6ng mdu cang gidm.
220
Bfnh nhSn suy tim co EF<40% va nh6m CO EF >40% phdn Ion trieu chihig lam sang ](
gi6ng nhau, ngoai trir sy khac bifit giila tJ If c6 gan to (87,5% voi 41,4%) va phii (87,5%
v6i 44,8%), c6 sy khac bifit ciia n6ng dO NT- proBNP va hinh anh tim to tren phim ^ Xquang ngyc thdng a 2 nhom bfnh nhan suy ^ tim v6i EF yfin va dudi 40% v6i p < 0,05. 0 TAI U | U THAM K H A O
1. Chu Thi Giang, 2009, "Nghien ctru tinh tr?ng thi^u mau d bfnh nhan suy tim m^in tlnh", Lu§n v5n th^c sy y hpc, Tru6ng Dgi hpc Y HS Nfi.
2. Huynh Kim Gkn, Nguylo Phii Quf, Pham Nggc Dang vk CS (2008), Nong df NT- ProBNP a bfnh nhan suy tim. ^^k 3. Horwich TB, Hernandez AF (2008).
Cliolesteroi levels and in-hospital mortality inpatients with acute decompensated heart failure, yim/feorr J, 156(6): 1170-6.
4. Jiang He, Lorraine G. Ogden (2001). Risk Factors for Congestive Heart Failure in USMen and Women. NHANES 1 Epidemiologic Follow-up Study. Arch /n/emMerf, 161:996-1002.
5. Alan S. Go, Jingrong Yang (2006).
Hemoglobin Level, Chronic Kidney Disease, and the Risksof Death and Hospitalization in Adults With Chronic Heart Failure.
Circulation,] 13:2713-2723.
6. JH Gurwitz, David JM, David HS (2013).
Contemporary Prevalence and Correlates of Incident Heart Failure with Preserved Ejection Fraction. y4m./Afei:/, 126:393-400.
7. Owan T, Hodge D, Herges D, Jacobsen SJ, et al (2006) . Heart Failure with Preserved Ejection Fraction: Trends in Prevalence and Outcomes. NEnglJMed,'355:25]-259.
8. Zile MR, Baicu CFGash WH (2004).
Diastolic heart failure. A' Engl J Med 350"
1953-9.
