IU TR NHI MU C TIM CP ST CHNH LN

ThS Bs L T Phng Thy

i cng Mc tiu iu tr NMCT cp ST chnh ln iu tr ban u NMCT cp iu tr NMCT cp sau ti ti mu iu tr lu di (sau xut vin)

i cng
CC NH NGHA
NMCT cp l 1 bin c do hu qu ca cht t bo c tim lin quan n thiu mu cc b c tim (ch khng phi do chn thng hay vim c tim).

i cng
NMCT cp ST chnh ln: th bnh quan trng trong Hi chng mch vnh cp (HCMVC) HCMVC: cp cu ni khoa. nguyn nhn hng u v bnh sut v t sut cc nc phng Ty.

i cng
Sinh l bnh NMCT cp ST chnh ln: huyt khi gy tc hon ton lng MV (90%)

i cng

i cng
Mng x va t v phi by thnh phn bn trong li mng x va vi dng mu Yu t m v hot ho ng ng mu ngoi sinh

Hot ho v kt tp tiu cu Hnh thnh huyt khi

Tc nghn c hc

Co mch (serotonine)

Gim t ngt ng knh lng MV

nh ngha NMCT cp 2012

NMCT c dng ch tnh trng hoi t c tim xy ra trong bi cnh TMCT cp Bng bn: NMCT cp xy ra t nhin

i cng
Chn on NMCT cp ST chnh ln:
au ngc>20 pht Khm thc th: bin chng, c phn bit in tm : gip chn on trong giai on sm (+++) 10 pht Men tim: khng nh chn on nhng tr

 ECG: ST 0,1mV /t nht 2 c lin tip V2,V3: ST 0,25mV (nam<40t) ST 0,2mV (nam 40t) ST 0,15mV (n ) V7-V9: ST 0,05mV ST 0,1mV (nam <40t) V3R-V4R: ST 0,05mV ST 0,1mV (nam < 30t)

Nhng biu hin khng in hnh trn ECG bn c TC in hnh TMCT m cn can thip khn
Bloc nhnh tri: nu khng c ECG c>xem nh miti ti mu CTMVCC>TSH My to nhp bung tht: chp mch vnh khn tr khi c th chnh my d thy c nhp t nhin ca bn /bn khng l thuc my ECG: khng bin i nhng TC TMCT in hnh: do tc nhnh m, nhnh bc cu. NMCT cp thnh sau n thun: ST 0,05mV V1V3 ST>0,1mV trn 8 c km ST avR v/hoc V1: tc thn chung hay nhiu nhnh

i cng
Siu m tim ti ging:
Ri lon vn ng vng (c hay mi?) Gip chn on: au ngc khng r rng Khng RLV vng loi tr TMCT cp quan trng trn bn ang au ngc cp

MC TIU IU TR
Trong vi gi u:
Gim au Chn on v iu tr kp thi cc bin chng nguy him (tt HA, ph phi cp,RN nhp) . Khi u iu tr ti ti mu trn nhng bn c ch nh (quan trng nht)

MC TIU IU TR
Cc mc tiu iu tr cn t trong vi gi u (tip theo)
S dng thuc chng huyt khi (khng ng v khng kt tp tiu cu) phng nga huyt khi trong stent hay ti pht huyt khi mch vnh. c ch bta phng nga ti pht thiu mu cc b hay lon nhp tht nguy him

MC TIU IU TR
Mc tiu trong giai on sau ca iu tr cp nhm ci thin d hu lu di
Khng kt tp tiu cu: gim nguy c ti pht huyt khi mch vnh hay huyt khi trong stent c ch men chuyn: gim ti cu trc c tim Statin Khng ng: khi c huyt khi trong bung tht tri hay rung nh mn.

IU TR BAN U NMCT CP
iu tr cp cu chung iu tr ti ti mu

IU TR BAN U NMCT CP
IU TR CP CU CHUNG:
Cc nguyn tc chung:
tin hnh ngay ti phng cp cu (hoc ngay trn xe cp cu nu phng tin).ICU hay CCU, t ng truyn tnh mch (kim ln: 18), theo di in tm v sinh hiu, SpO2 lin tc. Nu chn on NMCT cp ST chnh ln trc NV th khi n BV nn a vo thng phng thng tim nu bn ch nh lm can thip mch vnh cp cu (CTMVCC)

CCU
Theo di lin tc ECG, sinh hiu Theo di xm ln: HA M y cc lai thuc: chng RLNT, suy bm My sc in My th Bng di ngc MC

Ngng tim
Theo ESC 2012: Nn dng liu php h thn nhit cho bn hn m ngay sau hi sc ngng tim Nn chp MV khn nhng bn sau hi sc tim m ECG nghi NMCT ST hay LS nghi TMCT

IU TR BAN U NMCT CP
iu tr cp cu chung bao gm:
Oxy Gim au, gim lo u Cc thuc chng huyt khi:
Khng kt tp tiu cu Khng ng

Nitrate c ch bta

IU TR BAN U NMCT CP iu tr cp cu chung

Th oxy: khi bo ho oxy mu <90%

IU TR BAN U NMCT CP iu tr cp cu chung

Gim au - gim lo u:
Morphine
Morphine 2-4mg tim mch (c th tng ti 28mg)/ mi 5-15 pht kim sot c cn au hay xut hin tc dng ph ca thuc. Tc dng ph:
Bun nn, nn: thuc chng nn. Cng i giao cm (tt huyt p v mch chm): atropine tim mch

An thn: Nu bn qu kch ng. Ngng tt c NSAID (tr aspirine)

iu tr ban u
Nitrate:
C ch: dn tnh mch gim tin ti, dn ng mch vnh tng ti mu cho vng c tim ang thiu mu cc b.

khng c vai trkhng khuyn co dng thng quy C: ng TM

Kim sot au ngc iu tr THA, suy tim

IU TR BAN U NMCT CP iu tr cp cu chung

Nitrate
Chng ch nh:
HA tm thu <90mmHg, hay gim HA >30mmHg so vi ban u, nhp tim <50l/pht, nhp tim nhanh (>110l/pht), NMCT tht phi, mi dng c ch phosphodiesterase (sidenafil < 24 gi, tadanafil < 48 gi)

IU TR BAN U NMCT CP iu tr cp cu chung

Nitrate
Liu dng:
ngm di li nitroglycerine 0, 4mg x 3 ln cch nhau 5 pht. Sau 3 ln khng au morphine. Nu p ng vi nitroglycerine NDL truyn TM khi u 5-10 g/ph, tng dn 5-20g/ph cho n khi ht au ngc hay khi HA trung bnh gim (so vi mc ban u) 10% (bn c HA bnh thng) hay 30% (bn b THA) nhng HA tm thu khng c <90mmHg hay gim hn 30mmHg so vi ban u.

Cc thuc chng huyt khi:

Khng kt tp tiu cu Khng ng

2 c che chnh hnh thanh huyet khoi

Yeu to mo va s hoat hoa ng ong mau ngoai sinh

S hoat hoa va ket tap tieu cau

Biological changes
Inflammation, abnormal flow dynamics, LDL oxidation, infection?, etc.

Antiplatelets PLAQUE DISRUPTION Anticoagulant

Platelet aggregation, thrombus formation

Mechanical obstruction
with
Ischemia Opening Infarction PCI or Thrombolysis Sudden death

IU TR BAN U NMCT CP iu tr cp cu chung

Khng kt tp tiu cu:
Aspirine: c ch men cyclooxygenase c ch th th P2Y12 (ADP)
Thienopyridine: Triazolopyrimidine

c ch th th Glycoproteine (GP)IIb/IIIa

Liu ca thuc chng kt tp tiu cu

IU TR BAN U NMCT CP iu tr cp cu chung

Aspirine:
Ch nh: Mi bn nghi ng / xc nh NMCT cp vi liu t 150-300mg/uong hay 80-150mg/TM) trc lc nhp vin(ung hay TM). Khng nn dng loi aspirin c lp ph bo v Liu duy tr: 75-100mg/ngy

IU TR BAN U NMCT CP iu tr cp cu chung

c ch th th P2 Y 12
Thienopyridine:
Vai tr ch yu: gim bin chng khi CTMVCC Bao gm: Ticlopidine: tc dng ph nhiu Clopidogrel: c nghin cu nhiu Prasugrel: thuc mi Prasugrel > clopidogrel khi dng trc CTMVCC trn nhng bn khng c nguy c xut huyt cao (cn nng 60kg, tui 75, tin cn tai bin mch mu no hay thong thiu mu no)

Triazolopyrimidine: Ticagrelor

Cc loi thuc c ch th th P2 Y12

Do tc thi gian tc dng nhanh va t b bi chuyn ha, Ticagrelor v prasugrel c a chung hn clopidogrel tr khi chng ch hay khng sn c

IU TR BAN U NMCT CP iu tr cp cu chung

Thienopyridine:
Liu dng:
Clopidogrel: dng km vi aspirin hay thay th khi aspirin khng dng c.
600mg trc khi CTMVCC, sau duy tr 75mg/ngy trong 12 thng 300mg khi TSH hay khng (nu bn 75 tui), sau duy tr 75mg/ngy >75 tui: 75mg/ngy

IU TR BAN U NMCT CP iu tr cp cu chung

c ch th th Glycoproteine (GP)IIb/IIIa:
C ch: c ch s gn kt ca th th GPIIb/IIIa vi fibrinogen c ch s kt t tiu cu. Ch nh: CTMVCC trn bn c iu tr vi heparine hay bivalirudine cng vi liu php kp chng kt tp tiu cu (aspirin-thienopyridine) khi cn:
huyt khi ln bn cha c dng liu np ca thienopyridine

IU TR BAN U NMCT CP iu tr cp cu chung

Khng ng:
Ch nh: mi bn b NMCT cp Mc ch:
CTMVCC: h tr quanh th thut Tiu si huyt: h tr, duy tr hiu qu ca thuc TSH Khng iu tr ti ti mu: gip m thng ch tc hay gip duy tr m thng t nhin do qu trnh tiu huyt khi t nhin ca c th.

IU TR BAN U NMCT CP iu tr cp cu chung

Khng ng:
Phn loi: gm 3 nhm khng ng
Heparine:
Heparine khng phn on Heparine trng lng phn t thp: enoxaparine, Reviparine,

Khng thrombine trc tip: hirudin, bivalirudine Heparine pentasacharide tng hp (khng yu t Xa): fondaparinux

Liu thuc khng ng

IU TR BAN U NMCT CP iu tr cp cu chung

Khng ng:
Liu lng:
Heparine khng phn on: Nu dng trong CTMVCC c km i khng th th GPIIb/IIIa: bolus 50-60U/kg. Nu dng trong CTMVCC khng dng km i khng th th GPIIb/IIIa: bolus 70-100U/kg. Nu dng km TSH: bolus TM 60u/kg (ti a 4000u), sau truyn 12U/kg/h (ti a 1000u/h)/24-48h.Mmc tiu TCK t 50-70s. (1,5-2 ln chng h3,6,12,24) Khng TSH: ging nh TSH

Fondaparinux: 2,5mgTM bolus sau 2,5mgTDD1l/ng (TSH hay khng ti ti mu) CC: suy thn nng

IU TR BAN U NMCT CP iu tr cp cu chung

LiuKhng ng: Enoxaparine:
Nu CTMVCC: 0,5mg/kg TM Nu iu tr bng TSH:
Nu bn <75 tui, creatinine<2, 5mg/dl (nam) hay <2mg/dl(n): bolus TM 30mg, sau 15ph TDD 1mg/kg mi 12 gi (ti a 100mg cho 2 liu u) Nu bn 75 tui: khng dng liu np, 0, 75mg/kg TDD mi 12 gi (ti a 75mg cho 2 liu u Bn suy thn c thanh thi creatinin <30ml/pht (tnh theo cng thc Crockoft): khng dng liu np, 1mg/kg TDD mi 24 gi.

Nu bn khng c iu tr ti ti mu: ging TSH.

La chn thuc chng huyt khi

CTMVCC:
khng kt tp tiu cu:
Aspirine ung hay TM +1 c ch th th P2Y12: Prasugrel, ticagrelor>clopidogrel (tr khi c CC hay khng sn c)

u ch TTGPIIb/IIIa khi c huyt khi ln (+/-) Khng ng:

Bivalirudine, Enoxaparine>heparine khng phn on Khng nn dng Fondaparinux

Cc thuc chng huyt khi khi CTMVCC

La chn thuc chng huyt khi

Thuc chng huyt khi dng khi TSH
Chng kt tp tiu cu:
Aspirine v Clopidogrel

Khng ng:
Enoxaparine hoc Heparine khng phn on hoc Fondaparinux

Thuc chng huyt khi dng khi CTMV sau khi TSH: ging nh khi CTMVCC

Thuc chng huyt khi cho bn khng iu tr ti ti mu

Chng kt tp tiu cu:
Aspirine v clopidogrel

Khng ng: 1 trong 3 loi

Heparine khng phn on Enoxaparine Fondaparinux

Cc thuc chng huyt khi khi CTMVCC

IU TR BAN U NMCT CP iu tr cp cu chung

Khng ng:
Thi gian dng khng ng:
i vi bn c iu tr bng CTMVCC: ngng ngay sau khi qu trnh can thip kt thc nu khng c bin chng hay nguy c ti pht thiu mu c tim cc b. i vi bn c iu tr bng TSH hay khng iu tr ti ti mu: ti thiu 48 gi, hay cho n khi xut vin, ti a 8 ngy

IU TR BAN U NMCT CP iu tr cp cu chung

Khng ng:
Lu :
Heparine khng phn on: khng nn dng cng lc vi cc thuc TSH khng c hiu (streptokinase) tr khi bn c nguy c b thuyn tc do huyt khi cao nh: NMCT cp thnh trc, rung nh hay c huyt khi trong bung tim. Nu mun dng, phi i sau truyn streptokinase 6 gi v nn kim TCK trc khi dng. Heparine khng phn on: khng nn dng >48 h (nguy c gim tiu cu) heparin trng lng phn t thp

IU TR BAN U NMCT CP iu tr cp cu chung

c ch bta:
C ch:
gim nhu cu oxy c tim (bng cch gim tn s tim, gim huyt p v gim co bp c tim). c th lm tng ti mu c tim. vai tr gim au, gim thiu mu cc b c tim, gim kch thc vng nhi mu.

Hiu qu: nhng bn NMCT cp c dng c ch bta sm c t l t vong, suy tim, ri lon nhp tht quan trng

IU TR BAN U NMCT CP iu tr cp cu chung

c ch bta:
Ch nh: ng ung dng sm (24 gi u) trn bn b NMCT cp khng c:
Suy tim xung huyt Tnh trng gim cung lng tim Tng nguy c b chong tim:
tui >70 huyt p tm thu<120mmHg nhp tim >110/pht hay <60l/pht thi gian k t lc khi pht triu chng ko di.

IU TR BAN U NMCT CP iu tr cp cu chung

c ch bta:
Chng ch nh tng i c ch bta PR>0, 24giy, blc nh tht II, III co tht ph qun nng, tim <60l/pht. Liu dng: metoprolol 50mg mi 6-12gi, sau chuyn sang 100mg/12gi atenolol 100mg/24gi.

IU TR BAN U NMCT CP iu tr cp cu chung

c ch bta:
Lu : CC trong vng 24 gi u s c nh gi li s dng c ch b ta nh liu php phng nga th pht. Nhng bn b suy tim nng hay trung bnh s c dng thuc c ch bta nh liu php phng nga th pht vi liu thp tng dn. dng c ch bta ng tnh mch: c th dng (class II) trn nhng bn km THA v khng c CC

IU TR TI TI MU
Tm quan trng ca thi gian ti ti mu:
Phc hi sm ti mu c tim
kch thc vng nhi mu bo tn chc nng tht tri t sut ngn hn v di hn.

Mc tiu v thi gian

IU TR TI TI MU
Tm quan trng ca thi gian ti ti mu:
TG khi pht TC thi im TTM cng lng c tim c cu vn cng (90 ph #50%, 4-6h: rt t).. TG ti u cho ti ti mu: TSH (Thi gian ca-kim): (tip xc bn bt u TSH) 30 ph CTMVCC: thi gian ca-bng ( tip xc bn bm bng u tin) 90 pht. , ti u 60 pht (bn n sm , nguy c cao)

Hu cn cc chm sc trc khi n BV

IU TR TI TI MU
Ch nh ti ti mu:
C cn au ngc ko di >20 pht trong vng 12 gi km vi ST chnh ln >0,1mV (>1mm) t nht 2 chuyn o gn nhau. au ngc ko di trong vng 12 gi km blc nhnh tri mi xut hin.

IU TR TI TI MU
Cc phng thc iu tr ti ti mu:
CTMVCC cp cu Tiu si huyt Phu thut bc cu mch vnh

IU TR TI TI MU
CTMVCC cp cu (CTMVCC)
u im:

Ti thng mch mu vi dng chy bnh thng trong hn 95% cc trng hp NMCT cp ST chnh ln. Xc nh c cc tn thng nhng mch vnh khc nu c. nh gi chc nng co bp tht tri nh chp bung tht tri cn quang. Nguy c xut huyt t hn.

IU TR TI TI MU
CTMVCC cp cu (CTMVCC) Nhc im: Thi gian chun b lm th thut >thi gian chun b thuc tiu si huyt (TSH) Ch c th p dng c nhng trung tm c phng thng tim v nhn s c hun luyn tt

IU TR TI TI MU
CTMVCC cp cu (CTMVCC) Ch nh: Mi bn b NMCT ST vi iu kin thi gian ca-bng < 120 ph v ti phng thng tim c kinh nghm. Bn nv t 12-24 gi k t lc khi pht TC: vn cn triu chng TMCT tip din suy tim nng RL huyt ng hc hay in hc quan trng

Tiu si huyt
Khi CTMVCC khng thc hin c trong thi gian khuyn co. Li ch:
gim 30 ca t vong sm/1000 bn (gi dc) nu TSH 6 h sau khi pht TC C li ngay c /bn >75 t c TC km ST chnh ln hay Blc nhnh tri mi xut hin

Thi im TSH: trc NV, tt nht trong 2 gi u sau khi pht TC

IU TR TI TI MU Tiu si huyt
u im: c th s dng mi c s v s dng sm cho bn. Nhc im:
Nguy c XH nng khang 10%, trong xut huyt no: 0,7-0,9% Ch phc hi dng chy bnh thng mch mu th phm trong 30-60% trng hp trong vng 90 pht ty theo loi thuc. 10-20% bn s tc li sau ti ti mu thnh cng trong vng 24gi

IU TR TI TI MU Tiu si huyt
Ch nh TSH: khng c CC NMCT ST nv<12h+thi gian ca- bng >120ph hay khng c phng thng tim c kinh nghim au ngc ko di+bloc nhnh tri mi xut hin nv<12h+thi gian ca- bng >120ph hay khng c phng thng tim c kinh nghim Bn nv sm( au ngc <2h), NMCT rng v nguy c chy mu thp, nn TSH nu thi gian- ca bng>90 ph

Khuyn co ESC 2012 v TSH

Chng ch nh tuyt i
Tin s xut huyt ni s Nhi mu no trong vng 6 thng (tr mi Nm no trong vng 3 gi) D dng mch mu no hay khi u c tnh ni so nguyn pht hay di cn Chn thng s no hay phu thut u<3 tun XHTH < 1thng Ri lon ng mu Nghi bc tch ng mch ch Mi chch m khng p c <24 gi (sinh thit gan, chc d ty sng)

Chng ch nh tng i
Cn thong thiu mu no <6 thng ang iu tr bng khng ng ng ung C thai hay mi sanh <1 tun Tng huyt p nng khng kim sot c lc nhp vin (>180/110mmHg) Bnh gan tin trin Vim ni tm mc nhim trng Chng mt tr Bt k bnh l ni s no m khng phi l chng ch nh tuyt i Xut huyt ni trong vng 2-4 tun Lot d dy t trng ang hot ng i vi Streptokinase/anistreplase: c tip xc trc (c bit l trong vng 5 ngy-2 nm) hoc c phn ng d ng trc

Chng ch nh TSH

IU TR TI TI MU Tiu si huyt
La chn thuc TSH:
Ty thuc:
hiu qu, t l bin chng s sn c v gi thnh. Alteplase t gp 8-10l > streptokinase, Alteplase hiu qu > streptokinase 1% Alteplase tai bin XH no >streptokinase 0,3%.

Vit nam ; ch c Streptokinase v Alteplase.

IU TR TI TI MU Tiu si huyt
nh gi hiu qu ca thuc TSH:
triu chng au ngc
gim chnh ST >50% sau khi bt u dng TSH 60-90 pht.

ri lon nhp sau dng TSH khng l du hiu ng tin cy cho s ti thng.

Nhng bn TSH tht bi (cn au ngc v ST vn cn chnh cao sau 90 pht) chp mch vnh khn v CTMVCC cu vn.

Liu TSH

La chn gia CTMVCC v TSH

Phu thut bc cu MV
t dng trong cp cu Ch nh:
Khng tr hay chong tim m gii phu hc ca mch vnh khng thch hp cho k thut can thip hay can thip tht bi. C bin chng c hc: h van hai l cp, thng vch lin tht, v tim, phnh vch tht

Nn ngng khng th th P2Y12 tiu cu (clopidigrel: 5 ngy, prasugrel: 7ngy, ticagrelor: 3-5 ngy)

IU TR NMCT CP GIAI ON SAU TI TI MU

KHNG KT TP TIU CU C CH BTA NITRATE UCMC-I KHNG TT ANGIOTENSIN II THUC C CH ALDOSTERONE STATIN PHNG NGA HKTM CHI DI KiM SOT TNG NG HUYT NHNG CHM SC KHC

IU TR NMCT CP GIAI ON SAU TI TI MU

KHNG KT TP TIU CU C CH BTA NITRATE
tip tc truyn TM trong 24-48 gi u
au ngc ti pht tng huyt p hay suy tim.

IU TR NMCT CP GIAI ON SAU TI TI MU

c ch men chuyn Nn s dng trong 24 gi u khi khng tt HA (HA tm thu<100mHg hay <30mmHg so vi ban u) hay nhng CC khc v s dng sut i ch li ln nht:
nguy c cao: NMCT cp thnh trc, suy tim, EF 40%. THA. T, bnh thn mn.

khi u liu thp (trnh tt HA) v tng dn. Khng nn dng ng TM (nguy c tt HA)

IU TR NMCT CP GIAI ON SAU TI TI MU

Thuc i khng th th angiotensin II: ch nh: khng dung np UCMC km
suy tim trn lm sng hay Xquang, EF tht tri 40% hay THA.

Valsartan

IU TR NMCT CP GIAI ON SAU TI TI MU

THUC C CH ALDOSTERONE: (EPLERENONE, ALDOSTERONE) Ch nh:
NMCT cp khng b suy thn (creatinine<2, 5mg/dl i vi nam v <2mg/dl i vi n) v khng tng kali mu (>5mmol/) iu tr vi UCMC v c ch bta vi phn sut tng mu tht tri 40% km T hay triu chng suy tim.

IU TR NMCT CP GIAI ON SAU TI TI MU

Thuc captopril lisinopril ramipril Liu khi u Liu ch 6,25mg, tng dn 25mg x 3l/ngy 50mg x 3ln/ngy 5mg/ngy 2, 5mg x 2l/ngy 20mg tng dn 4 mc 10mg/ngy 5mg x 2l/ngy 4mg/ngy 160mg x 2l/ngy

trandolapril Test th 0, 5mg valsartan

eplerenone

25mg

50mg/ngy

IU TR NMCT CP GIAI ON SAU TI TI MU

STATIN: gim ti pht cc bin c tim mch mi v gim t vong sau NMCT cp. khi u cng sm cng tt cho mi bn NMCT cp. Atorvastatine vi liu 80mg/ngy. Cholesterol nn c kim tra li sau t nht46 tun sau NMCT cp iu chnh liu vi mc tiu LDLc< 70mg/dl

IU TR NMCT CP GIAI ON SAU TI TI MU

IU TR PHNG NGA HUYT KHI TNH MCH CHI DI: NMCT cp khng bin chng: khng cn NMCT cp c bin chng, phi nm ti ging sau 24 gi u: enoxaparine 40mg TDD/ ngy cho n khi bn i li c.

iu tr tng ng huyt trong g cp NMCT

Tng H khi NV tin lng xu (T v khng T) C th l du hiu ca RLDN glucose trong tg di hay T cha c chn on cn o HbA1C v ng huyt i Nghim php dung np glucose:
khi kt qu 2 XN trn khng thng nht Sau 4 ngy

iu tr tng ng huyt trong g cp NMCT

Mc tiu H trong NMCT cp ST chnh ln: cha r Nguyn tc: khng qu cht ch 11mml/l nhng cn trnh h H (<5mm/l) Truyn glucose-Insuline-Kali thng quy khng c li m cn c th c hi

iu tr tng ng huyt trong g cp NMCT

IU TR NMCT CP GIAI ON SAU TI TI MU

NHNG CHM SC KHC: Nm ngh ti ging: NMCT cp khng bin chng
sau 12 gi u, ngi dy, chn thng xung ging sau 24 gibt u i li vi mc tng dn.

IU TR NMCT CP GIAI ON SAU TI TI MU

NHNG CHM SC KHC: n ung v chng to bn:
khng nn cho n trong 4-12 gi u (bun nn v ht sc) khu phn n gim bo (<30% nng lng), nhiu kai li, magn, gim mui v nhiu cht x. Do bn nm lu, cng thm tc dng ph ca morphine c th to bn cn cho thm thuc lm mm phn hay thuc x nu cn.

IU TR NMCT CP GIAI ON SAU TI TI MU

NHNG CHM SC KHC: An thn:
Trn an bn, gip bn d ng Thuc: diazepam hay lorazepam 0,5-2mg, 34ln/ngy.

IU TR LU DI (SAU XUT VIN)

THUC NHNG BIN PHP KHC

iu tr thng thng lu di
Thuc chng huyt khi: (ESC 2012)
Aspirine 75-100mg/ngy, sut i
Khng dng np Aspirine: Clopidogrel 75mg/ng

c ch th th P2 Y12
Dng km vi Aspirine CTMVCC: prasugrel, ticagrelor, clopidogrel stent ph thuc: ti thiu 6 thng12 thng Stent thng: ti thiu 1 thng12 thng Tiu si huyt: ch dng clopidogrel, c th 12 thng (d liu chc chn 1 thng) Khng ti ti mu: ch dng clopidogrel, ti thiu 1 thng12 thng Tin s XHTH: c th dng km c ch bm proton

IU TR LU DI (SAU XUT VIN) Thuc

c ch bta: mi bn nu dung np c v khng c CC bt k mc huyt p v chc nng tht tri Ri lon lipid mu:
Statin:
Mi bn tr khi c CC, bt k mc cholesterol vi mc tiu LDLc<70mg/dL (1, 7mmol/L) Thay i li sng nu TG>150mg/dL (>1,7mmol/L) v/hoc HDLc<40mg/dL.

Nu bn khng dung np statin, c th dng ezetimibe

IU TR LU DI (SAU XUT VIN) Thuc

c ch men chuyn: mi bn khng c CC, i khng TT angiotensin II: khi khng dung np UCMC m khng c CC Chng nga cm: cho mi bn

IU TR LU DI (SAU XUT VIN)

NHNG BIN PHP KHC

Ngng ht thuc l Vn ng th lc:

Theo mc gng sc trung bnh ca nghim php gng sc kim tra sau NMCT cp, 5ln/tun. Theo nhng chng trnh phc hi chc nng trn nhng bn nguy c cao.

Tng huyt p: kim sot tt HA vi mc tiu Ha tm thu <140mm Hg nhng>110mmHg bng nhng bin php khng dng thuc v thuc

IU TR LU DI (SAU XUT VIN)

NHNG BIN PHP KHC i thi ng: kim sot tt ng huyt vi mc tiu ti u HbA1C<6, 5% cng cc yu t nguy c khc Ch n v gim cn: Nn gim cn khi BMI 30kg/m2 hay vng eo >102(nam) v >88 (n) Ch n: gim mui, gim m bo ho, nn thng xuyn n rau, tri cy v c. Gim ung ru

nh gi nguy c v hnh nh hc
Mc tiu: xc nh nhng bn c nguy c cao b NMCT ti pht hay t vong Siu m tim trc xut vin: kch thc vng NM, chc nng tht tri khi ngh Cc yu t tin lng nng khc: ln tui, nhp tim nhanh, Killip>I, NMCT cp thnh trc,tin s b NMCT, suy tim trc , tng creatinine /mu, lon nhp tht c tnh, au ngc ko di hay xut hin li khi gng sc nh

nh gi nguy c v hnh nh hc
Nu nghi ng cn TMCT: lm sau 4-6 tun
Nghim php gng sc: r tin nhng chnh xc km Xt nghim gng sc bng hnh nh hc:
chnh xc hn v nh v vng TMCT X hnh hay siu m tim gng sc

Nu lo ngi v BC lon nhp: c th thm d in sinh l v lp li SAT sau xut vin xt kh nng cy my ph rung

nh gi tnh sng cn ca c tim

RL chc nng tht tri sau NMCT cp c th do: 1,2 hay c 3:
Hoi t c tim C tim b chong: phc hi 2tun nu khng cn TMCT C tim b ng ng: do TMCT lu ngy

nh gi sng cn c tim s gip quyt nh CTMV thm sau NMCT Phng tin: PET, SPECT, ( nhy cao nhng tn km),siu m tim vi dobutamine (d lm VN do gi thnh r)

Tm tt ch nh v hnh nh hc v trc nghim gng sc

Kt lun
NMCT cp ST l c/c ni khoa quan trng Thi gian ti ti mu l quan trng nht Ty iu kin m la chn pp ti ti mu tt nht Cc bin php iu tr chung cn bn l nn tng cho iu tr ti ti mu v iu tr NMCT cp thnh cng