TAP CH(Y DUOC L A M SANG 108 Tap 11-Sd4/2016
Nghien cihi so sanh xa hinh Tc99m-MIBI Gated SPECT tiroi mau c<y tim tnTdc va sau tai twoi mau co* tim & benh nhan benh dong mach vanh
Comparison of Tc99m-MIBI SPECT myocardial imaging in coronary artery disease patients before and after revascularization
Lg Manh Ha, Le NgQC Ha, Pham Nguyen Son, Benh viin Trung uang Qudn d$i 108
Tom t ^ t
Muc tiiu: So s^nh cac dac diem hinh anh cCia SPECT tudi mau ca tim tnidc va sau tai tUdi mau co t i m d b e n h nhan benh dgng machvanKBdi tugng vd phuang phdp: 106 benh nhan (94 nam, 12 nOf) tuoi 65,9
± 10,4; duoc chup xa hinh Tc99m-MIB1 Gated SPECT tUdi mau cO tim triTdc va sau tai tLfdi mau 25,8 + 20,9 thang (85 benh nhan sau can thiep dong mach vanh qua da, 21 binh nhan sau bac c l u ndi chO vanh). So sanh doi chieu dac diem djnh tinh, djnh Itrgng xa hinh SPECT tUdi mau cd t i m trade va sau tai tudi m l u c o t i m . / ( e t qud: TJIe khuyet xa theo di$n rong, miJc d d thay doi rd ret tren xa hinh trudcva sau tai tiidi mciu cd tim {p<0,0001). Ty l i b§nh nhan thl^u mau mule do vCra - nang g r i m dang ke tCf 72,6% xuong cdn 37,7% sau tai tudi mau c o t i m (p<0,0001).Sautaitadi m l u c o t i m , t y ' l g b 6 n h nhan cd dien thieu mau cSi thien gISm £ 5% cd tim that trai la 54,7% va t y le benh nhSn cd di^n thieu mau tang a 5% co tim that trai la 22,6%. Doi vdi benh nhan cd dien thl^u mau Ccii thi&n £ 1 phan vung, LVEF pha gang sCfc tang len sau tai tudi mau co tim (trUdc vh sau t i l tUdi mau cd t i m : 45,9 ± 16,2% va 50 ± 15,1 %, p<0,05). Ket ludn: So sSnh xa hlnh SPECT tUdi mciu cd tim trUdc va sau tai tUdi mau cho thay ty- le benh nhSn thi^u mau mtJc dp visa ' nang gleim ro ret, t J le benh nhan cd dien thieu mau Ccil thi&n giam > 5% ca tim that trai la 54,7% va benh nhan cd dien thieu m l u tang > 5% c o t i m that trai la 22,6%.
TUkhoa: Xa hlnh tudi mau cd tim, benh dgng mach vanh, tai tUdi mau ddng mach Veinh, can thiep dgng mach vanh qua da.
Summary
Objective: To compare the qualitative and quantitative data of Tc99m-MIBI SPECT myocardial perfusion imaging in the stable coronary artery disease patients before and after revascularization (percutaneous coronary intervention and coronary artery bypass graft surgery). Subject and method: 106 patients (94 men, mean age 65.9 ± 10.4 years olds) undenwent 2 serial Tc99m-MIBI Gated SPECT myocardial perfusion imaging scans: Before and 25.8 ± 20.9 months after revasculization by stenting (85 patients) or coronary artery bypass graft surgery (21 patients). A comparison of qualitative, quantitative data of SPECT was made between before and after revascularization. Result The defect lesions proportion by extent and serverity were signicantly different (p<0.0001). After revascularization, t h e proportion of patients with moderate - severe ischemia decreased signicantly (72.6% vs 37.7%, p<0.0001). 54.7% patients had improvements in ischemia of > 5% LV myocardium and 22.6% patients
Phan biin khoa hoc: PGS TS. PHAN S"? AN
JOURNAL OF 1 OS - CLINICAL MEDICINE AND PHARMACY VoL11-N°4/2016 had worsening ischemia of a 5% LV myocardium. There was a rise in post-stress ieft ventricular ejection fraction (p<0.05) on post- revascularized SPECT MPi scan for patients w i t h ischemia improvement > 1 segment (pre and post-revascuiarized LVEF: 45.9 ± 16.2% and 50 ± 15.1%). Conclusion: By comparison between Tc99m-MiBI SPECT myocardial perfusion imaging scans before and after revascularization, there was the significant decrease of proportion of patients w i t h moderate - severe ischemia. The proportion of patients with > 5% ischemia improvement was 54.7% and with ^ 5% ischemia worsening was 22.6%.
Keywords: Myocardial Perfusion imaging (MP!), coronary artery disease. Revascularization, Percutaneous Coronary inten/ention (PCI).
LSatvande
Xa hinh tiTcfi mau ccf t i m [Myocardial perfusion imaging - MPI) la p h u o n g phap co gia trj cao t r o n g chan doan thieu m^u co t i m , phan t a n g nguy co quyet d j n h dieu trj ddi vdi benh nhan (BN) benh d o n g mach vanh (DMV) [3]. V6i kha nang c u n g cap cac t h d n g t i n quan t r o n g ve dien r o n g , miJc d o bat thirSng cCia tifdi mau c o t i m , dac biet la li/ong c o t i m thieu mau cue bo, MPI ft cac t h d i d i ^ m khac nhau la p h u o n g phap duoc li/a chon t r o n g t h e o doi dien tien benh ly benh B M V va la cong cu dSng tin cay t r o n g cac nghien cufu thudc, p h u o n g phap lien quan t d i tudi-mau co t i m [4].
£)di vdi BN sau can thi#p d d n g mach vanh qua da (PCI - Percutaneous Coronary Intervention) va phau t h u l t bac cau ndi chCi - vanh (CABG - Coronary Artery Bypass Graft Surgery), MPI cd vai tro quan t r o n g t r o n g theo ddi t l n h trang thieu mau co t i m (do tai t u d i mau chua tdi Uu hoac tai hep nh^nh B M V can thiep, hep tac nhanh B M V khac, hep tSc cau ndi) va tien luong nguy co nhoi mau co t i m (NMCT), tCf v o n g [51. Mac d d thuf nghiem ngau nhien COURAGE cho thSy tai t u d i mau co t i m sdm khdng cSi thien t y le tuf vong, NMCT so vdi chi d i ^ u trj ndi khoa t d i Uu don thuan d BN benh B M V on dinh, nhUng nhanh nghien ciJu t i m mach hat n h l n cua thOf n g h i e m cdng b d nhOfng ket quS quan t r o n g t r o n g d j n h h u d n g tien lupng benh nhan [6]. Bang so sanh MPI trudc, sau di^u tri va theo ddi bien cd, nhanh nghien ciJu n h l n thay tai t u d i mau co t i m ket h o p dieu trj ndi khoa t d i Uu cd tan suat cao hon t r o n g g i l m dien CO t i m thieu mau va g i l m dien co t i m thieu mau >
5% CO t i m t h a t trai so vdi dieu tri ndi khoa tdi uu don thuan. Cac yeu t d nay cho thSy cd t h e giup cSI thien
t i e n l u p n g BN t r o n g cac p h a n tfch chua hieu ch?nh.
B a y la nhu:ng t i e n de g p i m d t r o n g nghien ciJu nhijfng yeu t d tien l u p n g t r e n ca sd thay ddi dt^n t h i ^ u mau dua trdn h l n h anh chdc nang d cac thdi d i e m khac nhau. Tiep ndi muc t i e u d d , cac nghien cdu Idn gan day c u n g s d d u n g MPI la cdng cu trong t i m hieu lien quan cua t h a y d d i dien co t i m thieu mau bang cac phUPng p h a p dieu trj khac nhau vdi tidn lupng bien cd d BN b e n h D M V [7].
Tai Vien Tim mach Quan ddi - Benh vien TI/C5D 108, MPI d p p c uYig d u n g r d n g rai, cd gia tri trong chan d o a n benh B M V va t i e n l u p n g BN nghi ngd mSc b e n h D M V trudc khi q u y e t d j n h dieu tri tai tudi m l u D M V [8]. G i l trj cda MPI t r o n g chan doan hep D M V 4 BN sau PCI c u n g da d u p c nghien cdu gan d l y . Tuy n h i e n , chUa cd n g h i d n culc nao d Viet Nam vd dac d i e m hinh I n h MPI t r u d c va sau tai t u d i mau co t i m (PCI va CABG). Chfnh vl v l y , chung tdi tien hanh d l tai "Nghidn cuU so sanh dac diem hlnh I n h xa hlnh Tc99m SPECT t u d i m a u co t i m trudc va sau tai t i f d i m a u cP t i m d b e n h n h a n b e n h d d n g mach v a n h " vdi muc tieu: So sanh dgc diem hlnh anh dinh tinh, dinh litang tudi mdu ca tim va mot so thong so the tich, chOc nang thdt trai tren SPECT tudi mdu ca tim trudc vd sau tdi tudi mducatimd benh nhan benh dgng mgch vanh.
2. Ocii tirpng va p h u o n g p h a p
2.1. Boi tuang: 106 BN b e n h D M V dupc chup MPI trudc va sau tai t u d i m a u c p t i m (85 BN di/pc PCI dat stent v l 21 BN dupc CABG) tai Benh vien TL((3B 108 t d t h i n g 5/2012 den t h i n g 5/2015.
Tieu chuan c h p n : BN b d n h B M V d u p c chup SPECT MPI t r u d c (trong v d n g 3 t h i n g ) va sau t i i tifdi
TAP CHlYDt/OC LAM SANG 108
Tap 11-564/2016
mau CO tim theo hudng dan thdc hanh cfla Hdi tim mach hat nhln Hoa Ky (ASNC) 2010 [8]. BN dong y tham gia vao nghidn cufu.
Tieu chuan loai trtt BN khdng tuin thu quy trtnh ging sdc. Hlnh Inh MPI nhieu, khdng cho phep phan tich kdt qui.
2.2. Phtfang phap
Thiet /ce nghien cUu: Md t l cat ngang, so sinh
trudc va sau.
Cdc budc tien hdnh
BN sau t i i tudi mau cd tim dupc chup MPI Tc99m - MIBI gated SPECT theo quy trinh 2 ngay nghl - gIng siJc. GSng sdc the lUc sd dung thdm lan hoac bing thuoc (Bipyridamole). Sd dung Tc99m - MIBI vdi lieu 0,31mCi/kg can nang, tiem tlnh mach.
Quy trinh gang sdc, thu nhan xa hinh va xd 1^ hinh
Inh theo hudng dan cua ASNC (2010) [8]. PhUOng tien chup xa hinh: May SPECT Infinia, Ventri cua hang GE (Hoa Kjf) va phan mem chuydn dung xa hlnh tim tai Khoa Y hoc Hat nhan - Benh vien TUQD 108. Banh gia hinh Inh MPI dupc phan tfch ddc lap bdi 2 bIc sT y hpc hat nhln. Kdt qui phan t(ch theo hudng dan ciia ASNC (2009)[9].
So sanh ket qui MPI sau t i i ti/di mau vdi dfl lieu MPI cua BN trudc khi t i l tudi mlu dupc luu trfl tai khoa.
23. X£rlys6lieu: Sd lieu nghidn cdu dupc xd ly
theo cic thuat toan thdng kd y hpc bang chuong trinh SPSS 23.0 va Medcalc 15.8. So sinh cac tJ le trudc - sau theo thult toln McNemar (ddi vdi bien 2 gil tri djnh danh), McNemar - Bowker Test (ddi vdi bien hon 2 gia trj dinh danh). So sinh bidn lien tuc trudc - sau theo thuat toan so sanh ghdp cap paired sample t-test.
3. Ket qui
3.1. Dgc diem ldm sang
Bang 1. Mot s6 dac diem lam sang ciia doi tuofng nghien cuTu
Oac d i l m lam s^ng
Tuoi Gidi t i n h
Con dau nguc
NCf Nam Khdng dau nguc Bau nguc dien hinh Dau ngUc khdng dien hinh Tien sd nhdi m l u CO tim
Tang huyet ap Dal thao dudng RLCH lipid
Sau PCI SdBN (n = 85)
T^ld
%
66,3 ±11,1 (nam) 10 75 5 1 79 56 60 18 27
11,8 88,2 5,9 1,2 92,9 65,9 70,6 21,2 31,8
Sau CABG SdBN (n = 21)
T y l e
%
64,1 ± 7,1 (nam) 2 19 2 2 17 12 17 7 3
9,5 90,5 9,5 9,5 81,0 57,1 81,0 33,3 14,3
Chung SdBN ( n = 1 0 6 )
T:>ld
%
65,9 ± 1 0 , 4 (nam) 12 94 7 3 96 68 77 25 30
11,3
• 88,7 6,6 2,8 90,6 64,2 72,6 23,6 28,3
80% BN CO ft nh^t 1 yeu to nguy co tang huyet noi khoa toi Uu kiem soat tai th6l diem chup sau tai ap, d^i thao dudng, rdi loan chuyen hoa lipid (RLCH tudi m^u.
lipid) trUdc khi tai tudi mau va khdng dupc dieu tri
JOURNAL OP 108 - CLINICAL MEDICINE AND PHARMACY Vol.11-N"4/2016
Bang 2 . M o t SO dac d i ^ m v e t a i t u d i m a u c a t i m cCia d o i tUofng nghien clhi
Nhlnh DMV dat stent (n = 85BNPa) Thdi gian sau PCI
Thdi 1
>2 BN 66 19
%
77,6 22,4 26.3+ 21,8 (thing)
Nhlnh DMV bac cau ndi (n = 21BNCABG) Thdi gian sau CABG gian sau tai tudi mau (PCI hole CABG) 25,8 ± 20,9 (thing)
1-2
>3 BN
9 12
%
42,9 57,1 23,4 ±17,5 (thang)
Hinh 1 . TJ le cac khuyet xa trudc va sau t i i tudi mau co tim theo dien ton thuong (Hinh A) va theo mdc dp tdn thuong (Hinh B)
88 trong tdng so 318 vdng cd khuyet xa dien rpng tren MPI trudc tai tudi m l u , 37 vCing giam dien tdn thupng (8 khuyet xa khdng cdn thay, 14 khuyet xa g i l m xudng thanh dien hep, 15 khuydt xa giam xudng thanh dien trung binh). 35 vung xuat hien khuyet xa mdi (12 vdng khuyet xa dien trung binh - rdng) va 7 vung khuydt xa dien hep - trung binh tang thanh dien rpng.
TJ le khuyet xa cd dien thieu m l u > 2 phan vdng ( t r e m 7 phan vung toan bd co tim) giam rd ret
ddi vdi BN sau t i i tudi mau chung, BN sau PCI chung va BN sau CABG. Ty le viing cd khuyet xa dang seo NMCT dien > 1 phan viing tren MPI trudc tai t u a m l u 10,4%
(33/318 phan vung) khdng khac bidt rd (p>0,05) so vdi sau tai tudi mau 11 % (35/318 phan vung).
Sau tai tudi m l u , ty le BN cd dien khuyet xa dang co tim thieu m l u > 2 phan vung (tuong dng 10% dien.CO tim thdt trafl g i l m tfl 72,6% xudng cdn 37,7%(p<0,0001).
1000% P^''™ r^mi 11=0.006
II II II
PCtiCABG p a Qj^gg• 1 ^ •» *> ™ " n * J ' 2 { * » viJfB • KSn «7 tim Biilu nAj i 2 f(ian ving
Hinh 1 . TJ le khuyet xa dang thieu m l u co tim theo dien rdng tren xa hinh trudc va sau tai tudi mau co tim
TAP CHIY Dl/(?C LAM SANG 1 T?p 11-564/2016
Bing 3. Ty le benh nhte theo dien ccttim thieu mau djnh lUtfng trudfcva sau tai tudi mau cot tim Dien ctf t i m
thi^u mdu ( % c a t i m that trai)
< 5 % 5 % - 9,9%
> 1 0 % P X±5D
P
T h e o T P D ( n = 61) Trudc
tai tudi mau ctf tim 44,3%
19,7%
36,1%
Sau tai tudi mau
ctf tim 45,9%
37,7%
16,4%
>0,05
7,4 ±5,4 1 4,6 ±9,2
>0,05
T h e o P D S ( n = 61) Trudrc
tai tudi mau ctf tim 3 7 7 % 16,4%
45,9%
Sau tai tudi mau
ctf tim 31,1%
37,7%
31,1%
>0,05
9,2 ±7,0 1 7,0 ±11,2
>0,05
Theo SDS (n = 6 0 ) TrUdc
tai tudi mau ctf tim 36,7%
33,3%
30,0%
Sau tai tudi mau
ctf t i m 48,3%
31,7%
20,0%
>0,05
8,4 ±6,8 1 6,0 ±4,6
>0,05 p<o,oooi p<o,oaoi p<o,05
9 iib 7 5 S iSii
0.0% ^ ^ ^ ^ ^ ^ Tnr6cl^t<r6i Sau till hiai
m^uoTlini mdu cotim PCiSCABQ
• Ol^nlhliumauclpl'
Tiudfc Sau CABG CABG
CASG limg a 1 phflnvCing<Di|nthllunidi]<2ph3nvQng • Difn thilu mdu s 2 phin vQng
Hinh 2. TJ le benh nhan theo dien khuyet xa thieu mau dinh tinh tren xa hinh trudc va sau tai tU6i mau Dien ton thu'Ong khuyet xa c6 the cfjnh lUpng gang siJc SSS (SSS x 68/ 100). Dien ca tim thieu mau bang PDS {Perfusion defect size - dien khuyet xa dUOc xac djnh bing hi$u cCiaTPD.PDS pha g^ngsijfc giam hcfn vdi mau 20% trd len), TPD (Total Perfusion - pha nghi hoac tinh tu" hieu diem giQa pha gang siJc Defect - tfnh toan k^t hop giOa di^n rpng va mu'c do - pha nghi SDS (SDS x 100/68).
khuyet xa theo tCrng pixel) hoac tinh tii tong diem
Bdng 4. Cac thong so chuTc nang va the tich that trai tren xa hinh Gated - SPECT tifcri mau ctf tim trUdc va sau tai tifdi mdu ctf tim
Pha gang sdc
LVEF%
(n = 94) EDVml (n = 53) ESVml (n = 53)
TruSc tai tuoi mau 49,5 + 16,2
110,1 ±38,7
62,6 ± 38,3 Sau tai tudi mau 50,6 ±13,5
106,3 ±39,5
57,7 ± 36,9 P
>0,05
>0,05
>0,05
Pha nghi LVEF%
(n = 52)
EDVml
• (n = 53) ESVml (n = 53)
Trudc tdi tudi mau 47,8 ±14,6
107,9 ±32,6
60,7 ± 30,9 Sau tai tudi mau 50,8 ±13,3
105,6 + 36,3
57,3 ± 34,4 P
<0,05
>0,05
>0,05
Soi vdi BN cd dien thieu miu cai thien giJm 1 thidu mau tang len 1 phan vung (21/94 BN) LVEF sau phan vung (53 BN/ 94 BN) LVEF sau tai tudi mau (50 tai tudi mau (53 ± 11,5%), khdng khac bien rd ret
± 15,1%) cdi thien cd j nghta (p<0,05) hon so vdi (p>0,05) so vdi trUdc tai tudi mau (56,4 ± 17,1%). 46
trudc tai tudi mau (45,9 ± 16,2%). Ddi vdi BN cd didn BN (LVEF pha gSng sdc trUdc tai tudi mau < 50%,
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.n-N°4/2016
t r u n g b i n h 35,1 ± 8,8%), t^ le BN c6 LVEF pha gang sufc Ceil thien sau tai tUdi mau t a n g 5% va giSnn 5%
tUdng Lfng 1^ 56,5% va 13%.
4 . Ban l u | i n
Nhom nghien cOfu cd nguy c d benh DMV cao, dac biet la cac y^u t d tuoi cao, da sd la nam gidi, tang huyet ap, dai thao diidng, RLCH lipid (BSng 1). Da so (80%) cac BN da cd c^c yeu t o nguy cd trUdc khi can thiep va khdng dugc kiem soat. Nhdm nghien ciJu cd t^ l# cao nam gidi v^ dai thao dudng la cac yeu t d lam sang Hen quan tang nguy co tai hep tai mach can thiep vei hep t i c cau ndi chu - v^nh.
K h i o sat 318 v u n g (106 BN x 3 v u n g t u a n g i^-ng LAD, LCx, RCA), t y le khuyet xa t h e o dien t o n thUdng (khdng khuyet xa, hep, t r u n g binh, rpng) khac biet rd ret tren MPI trudc va sau tai tUdi mau ca t i m (p<0,0001, Hlnh 1). Trong d d , khac biet chu yeu la 37/88 vung khuyet xa dien rong giam dien tdn thuong (khdng cdn thay hoac giam dien xudng mufc hep - trung binh) va 35/137 vung xuat hien k h u y l t x a mdi (12 vLing di&n trung binh - rdng) sau tai tudi mau. Danh gia theo mUc d d ton thUdng, khac biet rd ret ty' le khuyet xa (khdng khuyet xa, nhe, vCra, nang) tren MPI trudc so vdi sau tai tUdi mau (p<0,0001, hfmh 2).
MPI dua vao dac diem t o n thUdng cho phep danh gia khuyet xa dang thieu mau (khuyet xa hoi phuc) va dang seo NMCT (khuyet xa cd d m h , mUc d o nang, g l i m nang - mat van dpng). Sau tai t u d i mau cd t i m , t y le khuyet xa cd dien thieu mau > 2 phan vCing (tren 17 phan v u n g t o a n bp c d tim) giam rd ret ddi vdi BN sau tai t u d i m l u chung (p<0,0001), BN sau PCI chung (p<0,0001) va BN sau CABG (p= 0,006). Trong t h d i gian giUa 2 lan chup MPI, chung t d i khdng ghi n h l n bien co tai bien t r o n g thCi t h u a t t i i t u d i mau cP t i m va NMCT tren l l m sang. VI vay, sau tai t u d i m l u t^ le khuyet xa dang seo NMCT khdng thay doi rd ret (trUdc tai tUdi m l u : 10,4%, sau tai t u d i mau 1 1 % , p>0,05). P h i n tich t o n g h d p cho thay SPECT si!f d u n g dUpc chat p h d n g xa g i n Tc99m CTc99m-MIBI, Tc99m-Tetrofosmin,...) cd gia t n dU b i o I m t i n h hdi phuc chUc n i n g , khuyet xa dang seo NMCT la 76% (trong khi FDG PET la 87%) [10]. Trong m d t nghien cu'u ciia chOng t d i , 35,2% v u n g (tren 105 vCing t u a n g u'ng LAD, LCx, RCA) nghi n g d seo NMCT khdng cd chi d m h t i i t u d i mau dUa vao ddn thuan
SPECT MPI. Neu k^t h d p MPI va PET/CT chuyen hda FDG g i u p p h l t hi&n t h e m 27,3% vDng t r o n g sd do, CO d i e n c d t i m k h i nang song phD h d p chi djnh tai t u d i m a u [2].
BN t h i ^ u m a u c d t i m vCra - nang tUdng Ung dien t h i e u m a u ca t i m > 10% d i e n c d t i m that t r l i ( k h o i n g 2 p h a n vung) dUdc c i c nghien cu'u quan sat nhan t h a y cd Ich Idl cai t h i e n t h d i gian song khdng bien cd h d n neu tai t u d i m a u c d t i m so vdi chl dieu ^ t n ndi khoa d d n t h u l n . T r o n g n g h i e n C L ^ cCia chiing t d i , tai t u d i m a u ca t i m g i i i p g i a m t y 1$ nay tis 72,6%
x u d n g c d n 37,7% vdi p<0,0001 t h e o phan tich djnh t i n h hlnh I n h tr§n 106 BN (Hlnh 3). Phan tich djnh lupng dien t h i e u m l u t h e o TPD ( B I n g 3) t r ^ n 61 BN t r o n g nghien cufu cOa c h i i n g t o i , t ^ le nay trUdc va sau tai tUdi m l u ca t i m 1136,1 %, 16,4% (p>0,05 cung tUdng t u n h u Shaw (2008) v d i t ^ le tUdng Ung la 31,0%, 15,8%(p<0,0001)[6][4].
Nghien cUu cua Shaw/ (2008) va Farzaneh-Far (2012) b i n g xa h i n h trUdc, sau t i l t u d i mau (6 - 1 8 t h i n g ) va t h e o ddi bien cd t U v o n g , NMCT sau 5 nam. Cac t i c gia deu c u n g n h a n t h i y dien cd tim thieu m l u tren xa h i n h sau tai tUdi mau la yeu t d nguy c d ket h d p t r o n g t a n g bien cd tii" vong va NMCT. Tuy n h i ^ n , yeu t d nay chua dCi manh de la y ^ u t d n g u y cd ddc lap t r o n g mSu p h a n tich da bien bao g o m c l b i ^ n t a n g dien c d t i m t h i ^ u m l u sau dieu t r i [6]. Trong n g h i e n cUu cua c h i i n g t o i , t i l tudi m l u lam g i l m dien c d t i m t h i e u mau cd ^ nghla^
t h o n g ke (p<0,05) khi t i n h b a n g TPD (trUdc 7,4 + 5,4% va sau tai t u d i m a u 4,6 ± 9,2%) va SDS (trUdc 8,4 ± 6,8% v l sau t i i tUdi m l u 6,0 ± 4,6) (BIng 3).
Trong nghien cUu cCia Farzaneh-Far (2012), dien cd t i m t h i ^ u mau (% c d t i m t h a t trai) t i n h t h e o SDS trudc khi PCI 13,1 ± 1,6% va trUdc CABG 16,4 + 13,4% rdng h d n so vdi nghien c i i u cDa c h i i n g t d i , BN trudc PCI 8,5 ± 7 , 1 % v l n h d m c h u n g 8,4 ± 6,8%. Sau t i i t u d i mau, dien cd t i m t h i e u m l u tren xa hlnh t r o n g nghidn cUu c h i i n g t d i n h d m sau PCI 5,9 ± 4 , 9 % va n h d m chung 6,0 ± 4,6% gan tUdng t U v d i tac gia nay tUdng Ung vdi BN sau PCI la 5,2 ± 8,2%, sau CABG 5,9 ± 8 , 5 % [7].
B i n g so sanh dien c d t i m thieu m l u trUdc va sau tai t u d i m l u cd t h e x l c d m h dUdc dien t h i e u m a u cd t i m t i n g len hoac g i l m d i . Theo cac nghien cufu g i n day, c i i thl§n g i l m t h i e u m l u > 5% dign ca t i m t h i t
TAP CHf Y Dl/OC L A M SANG 108 Tap 11-So 4/2016
trai t r e n xa h l n h cd li^n q u a n t d i g i a m ty' l§ NMCT, tiJf v o n g d o t i m mach t r o n g m a u p h i n tich chUa hieu chinh. Lien quan n l y khdng c d n khi hi$u chinh c i c bien lam sang (tu6i, d l i t h i o d u d n g , t i e n sCr NMCT, t a n g h u y ^ t I p , ...)[6], [7]. Trong nghien cufu cOa c h i i n g t d i (Hlnh 6), t y I& BN cd xa hlnh c i i t h i e n g i l m dien t h i e u m a u > 5% ca t i m t h i t trai (1 phan v u n g b i n d m h luong) tren 106 BN n h d m chung (sau PCI va CABG) la 54,7% v l tren 85 BN sau PCI I I 57,6%
tUPng t u n h u nghien cUu cda Farzaneh-Far (2012).
Theo t i c g i l n l y t i n h bang SDS, t ^ le I I 52,3% doi vdi 419 BN sau PCI va 54,7% ddi vdi 554 BN chung (sau PCI v l CABG) [5]. B I n g phUdng p h i p d i n h lUdng t r o n g nghien cUu cOa c h i i n g tdi tren 61 BN n h d m chung, t y le nay la 37,7% t h e o TPD (31,7% t h e o SDS) va tren 50 BN sau PCI la 38,0% t h e o TPD (36% t h e o SDS) cung t U d n g t U nhU vdi Shaw (2008) tfnh t h e o TPD la 33,3% ddi vdi 159 BN sau PCI [6].
Trong khi dien c d t i m thieu m a u t d n dU hoac dien ca t i m thieu m l u c i i t h i d n a 5% c d t i m that trai chUa dd m a n h la yeu t d nguy co ddc lap, nghien cUu Farzaneh-Far (2012) cho thay xa hinh t a n g dien t h i ^ u mau s 5% c d t i m t h a t trai la yeu t d manh va ddc lap t r o n g tien lUdng bien cd ti!f v o n g , NMCT.
Tang dien cP t i m thieu mau > 5% c d t i m t h a t t r l i cd t h e la y e u t d ch] t h j BN cd dien tien nhanh benh I;? xa vufa mach [7]. Trong nghien cUu cCia t i c g i l n l y , ty' I&
BN t a n g dien thieu mau > 5% cP t i m that t r l i t i n h t h e o SDS I I 6,2% ddi vdi 419 BN sau PCI v l 6,3% ddi vdi 554 BN chung (sau PCI v l CABG). Tuy nhi§n, t r o n g nghien cUu ciia c h i i n g tdi t h e o c i c each t i n h , t ^ le nay ddi vdi BN sau PCI tU 18 - 28% v l ddi vdi n h d m chung (sau PCI v l CABG) I I 15 - 29,5%. Ngay c l ddi vdi n h d m BN sau PCI chup MPI t r o n g v d n g 18 t h i n g (tuong tU so vdi c i c nghidn cUu trdn) t y le BN cd MPI t a n g didn thieu mau cO t i m > 5% cd t i m t h i t t r l i I I 13,6 - 22,7% cung cao hdn rd ret. Phan tich c i c d i e d i e m mau nghien cUu, phan Idn (80%) BN t r o n g nghien ciiu cCia chiing tdi khdng kiem soat duoc cac yeu t d nguy ca bdnh DMV, ydu t d nguy co
t i i h e p mach can t h i e p h o l e tac hep cau ndi (dai t h i o d u d n g , t a n g huyet a p , rdi loan chuyen hda lipid,...). T r o n g khi BN nghidn cUu cCia cac tac gia tren dUdc ket h o p tai tUdI m l u cP t i m va didu t n ndi khoa t o i Uu nen kiem soat t d t c i c y d u t d n g u y c d nay. Ben canh d o , t r o n g nghien cO'u cda Shaw 93% t o n t h u o n g mach v a n h (tUdng i j n g 8 7 % BN) dUPc can t h i e p PCI t h a n h cdng hoan t o a n . NhUng ddi v d i BN duoc PCI t r o n g nghien cu'u cCia c h i i n g t d i , 32,9% BN t u o n g Ung 12,6% n h l n h D M V chinh cd t o n t h U d n g hep > 7 5 % d u d n g kinh n h u n g k h d n g d u p c can t h i e p . NhQng yeu t d n g u y c d khdng dupc kid'm s o l t se dan t d i tien trien b d n h DMV, hep t i e mach can t h i d p , mach cau ndi va nhOfng t d n thUPng D M V hep dang ke nhUng khdng can t h i d p kdt h d p cd t h e dan t d i t^ le BN t i n g dien thieu m a u > 5% ed t i m t h a t t r l i eao h o n t r o n g nghidn eUu cOa c h i i n g t d i .
So s i n h t h e tich va chiie nang t i m t h u t h a t t r l i ( b i n g ECG gated SPECT) trUdc va sau can t h i d p tai t u d i mau ( B i n g 4), c h i i n g t d i n h l n t h a y chl cd LVEF (%) pha nghl (tren 52 BN) c i i thien sau tai tUdi mau cd "jf nghTa t h d n g kd (p<0,05). Ddi vdi BN cd didn t h i d u m l u e l l thidn hon 1 p h i n vCmg, t i l tUdl m a u g i i i p e l i thidn LVEF pha g i n g sUc (trUdc t i l t u d i m a u 45,9 ± 16,2%, sau t i l tUdi m l u 50 ± 15,1, p<0,05).
Trong nghidn cUu cCia Shaw (2008) LVEF (pha g a n g sUc) sau PCI I I 54,8 ± 10% e l l thien so vdi trudc dieu t n la 51,0 ± 1 1 % (p=0,001)[6]. Trong nghien eUu ciia c h i i n g t d i tren 46 BN cd LVEF pha gang sdc trUdc tai t u d i m l u < 50%, t ^ Id BN cd LVEF pha gang sUe cai thien sau t i i t u d i m l u t a n g 5% va g i l m 5 ^ tUdng Ung la 56,5% v l 13%. C I I t h i d n chUe nang t h i t trai sau dieu trj la m o t t r o n g nhCfng t i d u e h u I n danh gia k h i nang p h l t hidn c O t i m sdng eua SPECT MPI, FDG PET/CT phii h p p cho can thiep tai t u d i m l u . Tuy nhien, cac nghien eUu eung cho thay tai t u d i m l u c i i thien chUc n i n g leh Ipi nhat ddi vdi BN g i l m n a n g LVEF (< 30%) t r o n g khi chua rd Idi ich t r o n g e l i t h i d n ehUe nang ddi vdi n h d m c d n lai [10].
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o o o o S A S o Hinh 3. Xa hlnh SPECT tUdi m i u ca tim trUdc va sau tai tUdi mau eo tim
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.n-N°4/2016
Khuyet xa dang t h i e u mau eO t i m , dien rdng (tuong ling vdi hep 9 5 % doan g i n LAD) trdn xa hinh trUdc PCI (hlnh trai). Khuyet xa khdng eon thay tren xa hlnh 18 t h i n g sau PCI (hinh p h l i ) .
5. Ket l u a n
Cd sU thay doi rd ret giCfa t y Id c i c khuydt xa theo dien rdng, mUe d d tren xa hlnh trUde va sau tai t u d i m l u c d t i m (p<0,0001).TIi t u d i m l u g i i i p g i l m rd ret (p<0,0001) ty' le BN thieu mau mUc d p vUa t r d Idn, cd didn thieu m l u ^ 2 p h i n vung (trUdc tai tUdi mau; 72,6%, sau tai tUdi m l u 37,7%) va g l i m dien co t i m thieu mau (p<0,05). Ty Id BN ed dien thieu m l u giam s 5% co t i m that trai sau tai tUdi m l u t h e o b i n djnh lupng (1 phan viing) tren 106 BN I I 54,7% v l dinh lupng TPD trdn 61 BN la 37,7%. Ty Id BN ed didn thieu m l u tang s 5% ed t i m t h i t trai sau tai t u d i m l u ddi vdi BN sau PCI la 18 - 28% va BN ehung (sau PCI v l CABG) la 15 - 29,5%. D d i vdi BN cd didn thieu m l u eai thien hdn 1 p h i n vCing, t i l t u d i m l u g i i i p e l i thidn LVEF pha g I n g sUc (trUdc tai t u d i m l u 45,9 ± 16,2%, sau tai tUdi mau 50 ± 1 5 , 1 , p<0,05).
Tai lieu t h a m k h d o
1. Le Ngoc Ha v l cs (201OJ Gid tn eCia xg hinh gated SPECT tudi mdu ea tim trong chdn dodn vd tien lugng binh ddng mgch vdnh. Tap chi Y Duoc lam s i n g 108. Tap 6 - Sd dac bidt thang 3 - 2011.
2. Ld Manh Ha, Le Ngpc Ha, Nguyen Kieu Ly (2013) Budc ddu nghiin cdu dgc diem hinh dnh FDG PET/CT ddnh gid khd ndng sdng cua ea tim. Tap chi Y Duac lam s i n g 108. Tap 8 - Sd dac biet thang 12 - 2013:
tr. 76-83.
3. James E. Udelson Vasken Dilsizian, Robert O.
Bonow (2014J Nuclear cardiology. In braunwald's heart disease: A textbook of cardiovascular
medicine, D.L. Mann, et al., Editors., Elsevier Health Sciences: 271-316.
4. Iskandrian AE et al (2014) Serial myocardial perhision imaging: Defining a significant change and targeting management decisions. JACC Cardiovasc Imaging 7(1): 79-96.
5. Kikut Kenneth A, Brown and Janusz K (2010) Nuclear imaging in revascularized patients with coronary artery disease. Clinical nuclear cardiology:
State o f the art and future directions. B.L Zaret and G.A. Beller, Editors., Elsevier Health Sciences:
450-458.
6. Shaw LI et al (2008) Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation 117(10): 1283-1291.
7. Farzaneh-Far Afshin e t a l (2012) Ischemia change in stable coronary artery disease is an independent predictor of death and myocardial infarction. JACC:
Cardiovascular Imaging 5(7): 715-724.
8. HollyTA etal (2010) S/ng/ep/jofon-em/ss/on computed tomography J NucI Cardiol 17(5): 941 -973.
9. Tilkemeier Peter L et al (2009) ASNC Imaging Guidelines for Nuclear Cardiology Procedures:
Standardized reporting of radionuclide myocardial perfusion and function. A m Soc NucI C a r d i o l d o i 1 0 : 1 0 0 7 .
10. Arend FL, Schinkel l5on P, Ernst E, van der Wall, and Jeroen J. Bax (2008) Myocardial Viability/Hibernation. Nuclear cardiac imaging:
Principles and applications, A. E. and E.V.G.
Iskandrian, Editors., Oxford University Press, Inc:
573-589.