IU TR HI CHNG NG MCH VNH CP KHNG ST CHNH LN (HCMVC/KSTC)

PGS.TS. Phm Nguyn Vinh i hc Y khoa Phm Ngc Thch Bnh vin Tim Tm c Vin Tim Tp.HCM

t hi chng MV cp khng ST chnh ln

Cc nh ngha v sinh l bnh hi chng ng mch vnh cp (HCMVC)

Hi chng ng mch vnh cp

Khng ST chnh ln NMCT KSTC

au tht ngc khng n nh

ST chnh ln

NMCT khng Q

NMCT c Q

TL: De Lemos JA et al. Hurts The Heart, 13th ed 2011, McGraw-Hill. p. 1328-1351

t hi chng MV cp khng ST chnh ln

nh ngha mi ca ESC/ ACC/ AHA/ WHF/ WHO v nhi mu c tim

Tiu chun chn on NMCT cp

1. Tng v/hoc gim cht ch im sinh hc hoi t c tim*; km mt trong cc bin i sau:
a. Triu chng TMCB b. Xut hin sng Q bnh l/ ECG c. ST chnh ln hay sp xung hoc blc nhnh tri mi xut hin d. Ri lan vn ng vng/ chn on hnh nh e. Thy huyt khi khi chp MV hoc m t thi 2. Gii phu bnh pht hin NMCT cp * Mt trong cc gi tr phi trn bch phn v 99 mc cao troponin
TL: Thygesen K et al. Definition of myocardial infarction. ESC/ACC/AHA/WHF/2012
3

t hi chng MV cp khng ST chnh ln

Dch t hc
Tn sut mi mc HC MVC/KSTC > HC MVC/STC HC MVC/KSTC nhp vin: 3/1000 dn s T vong trong bnh vin HC MVC/STC > HC MVC/KSTC T vong vo thng th 6: tng ng gia 2 th bnh (12% so vi 13%) Vo nm th t, t vong HC MVC/KSTC > 2 HC MVC/STC
TL: Bassand JP et al. ESC Guidelines for the diagnosis and treatment of non ST segment elevation acute coronary syndrome. June 14, 2007

t hi chng MV cp khng ST chnh ln

Sinh l bnh
Mng x va d tn thng (the vulnerable plaque) Huyt khi MV (coronary thrombosis) Bnh nhn d tn thng (the vulnerable patient): - multiple sites of plaque rupture - various systemic markers of inflammation - coagulation system activation Ri lon chc nng dn mch ca ni mc Cc c ch th cp lm tng nhu cu oxy c tim (td: st, cng gip, stress, tng hot giao cm)

t hi chng MV cp khng ST chnh ln

Mng x va n nh so vi mng x va khng n nh

TL: De Lemos JA et al. Hurts The Heart, 13th ed 2011, McGraw-Hill. p. 1328-1351
6

t hi chng MV cp khng ST chnh ln

Biu hin lm sng

au tht ngc lc ngh ko di (> 20 pht): 80% au tht ngc nng (CCS III) mi khi pht au tht ngc n nh, nay nng hn (cn xut hin 20% gia tng), t nht CCS III au tht ngc sau NMCT

TL: Van Domburg RT et al. J Am Coll Cardiol 1998; 31: 1534 - 1539
7

t hi chng MV cp khng ST chnh ln

Cc phng tin chn on

Khm thc th ECG ECG gng sc Holter ECG Cc cht ch im sinh hc (Biomarkers) Siu m tim v phng tin hnh nh khng xm nhp khc (x k c tim, MRI) Chp MV c cn quang
8

t hi chng MV cp khng ST chnh ln

Cc c im gip ngh au ngc l do nghn MV (1)

Kh nng cao bit c BMV (c bit mi PCI) C cn au tht ngc in hnh t trc Thay i huyt ng hoc ECG/ lc au ngc ST chnh ln hay sp xung 1 mm T o, su, i xng trn nhiu C ngc Men tim tng hoc gim
PCI: nong MV
TL: De Lemos JA et al. Hurts The Heart, 13th ed 2011, McGraw-Hill. p. 1328-1351
9

t hi chng MV cp khng ST chnh ln

Cc c im gip ngh au ngc l do nghn MV (2)

Kh nng trung bnh Cn au tht ngc in hnh au tht ngc khng in hnh trn T hoc khng T nhng c 2 YTNC Nam Tui > 70 C bnh mch mu ngoi tim ST sp 0,5-1 mm hoc T o 1 mm Troponin tng nh, khng ln hay xung
TL: De Lemos JA et al. Hurts The Heart, 13th ed 2011, McGraw-Hill. p. 1328-1351
10

t hi chng MV cp khng ST chnh ln

Cc c im gip ngh au ngc l do nghn MV (3) Kh nng thp au vng ngc khi n T dt hoc o < 1 mm ECG bnh thng

TL: De Lemos JA et al. Hurts The Heart, 13th ed 2011, McGraw-Hill. p. 1328-1351
11

t hi chng MV cp khng ST chnh ln

Phng thch cht ch im tn thng c tim HC MVC/KSTC

TL: Bassand JP et al. ESC Guidelines for the diagnosis and treatment of non ST segment elevation acute coronary syndrome. June 14, 2007

12

t hi chng MV cp khng ST chnh ln

Cc dng ca hi chng MV cp/troponin

TL: Hamm CH et al. ESC Guidelines for the management of acute coronary syndroms in patients presenting without persistent ST segment elevation. Eur. H. J (2011); 32: 2999-3054

13

t hi chng MV cp khng ST chnh ln

Chn on nhanh NMCT da vo Troponin nhy cao

TL: Hamm CH et al. ESC Guidelines for the management of acute coronary syndroms in patients presenting without persistent ST segment elevation. Eur. H. J (2011); 32: 2999-3054

14

t hi chng MV cp khng ST chnh ln

Cc nguyn nhn tng nng Troponin ngoi HC MV cp hoc nong MV (1)

TMCB c tim khng do XVM
Thuyn tc Co MV Bc tch MV

Phu thut tim Vim c tim mng ngoi tim TD: Thp tim Bnh thm nhim c tim TD: Amyloidosis, sarcoidosis Chn thng tim

TL: Thygesen K et al. Definition of myocardial infarction. ESC/ACC/AHA/WHF/2012

15

t hi chng MV cp khng ST chnh ln

Cc nguyn nhn tng nng Troponin ngoi HC MV cp hoc nong MV (2)

Lon nhp nhanh THA km hay khng km y dy tht tri Suy tim Suy thn c tnh ca thuc (TD: adriamycin, 5-FU) Suy gip Thuyn tc phi Nhim trng huyt hoc bnh nhn tnh trng rt nng t qu U ty thng thn Hoi t c vn Thiu mu nng; suy h hp nng S dng thuc c vi c tim TD: anthracyclimes
TL: Thygesen K et al. Definition of myocardial infarction. ESC/ACC/AHA/WHF/2012
16

t hi chng MV cp khng ST chnh ln

Lng nh nguy c CTNKO

Nguy c cao: ti lu thng MV ngay. Nguy c trung bnh: TLTMV trong vng 72 gi Nguy c thp: iu tr ni khoa

17

t hi chng MV cp khng ST chnh ln

Thang iem nguy c TIMI/ hoi chng MV cap khong ST chenh len

TL: De Lemos JA et al. Hurts The Heart, 13th ed 2011, McGraw-Hill. p. 1328-1351

18

t hi chng MV cp khng ST chnh ln

Cc bin php iu tr cp thi HCMVC/KSTC

iu tr chng TMCB: chn bta, nitrates, c ch calci (nhm non-DHP), nicorandil iu tr chng ng Chng kt tp tiu cu Ti lu thng MV

19

t hi chng MV cp khng ST chnh ln

So snh hiu qu iu tr can thip vi iu tr khng can thip b/n HC MVC/KSTC

TL: Cannon CP et al. N. Engl J Med 2001; 344: 1879-1887

20

t hi chng MV cp khng ST chnh ln

So snh gia can thip sm vi can thip mun/ bnh nhn HCMVC- KSTC (t vong, NMCT, t qu)

TL: Mehta SR et al.N Engl J Med 2009; 288: 1851-1858

21

t hi chng MV cp khng ST chnh ln

iu tr ban u HCMVC/KSTC

TL: Bassand JP et al. ESC Guidelines for the diagnosis and treatment of non ST segment elevation acute coronary syndrome. June 14, 2007

22

t hi chng MV cp khng ST chnh ln

Khuyn co s dng thuc chng TMCB trn b/n HCMVC/KSTC

Chn bta (I-B) Nitrates gip gim triu chng au tht ngc (I-C) c ch calci, kt hp vi chn bta v nitrate. Hu ch b/n c CC chn bta (I-B) Nifedipine hoc cc DHPs khc, khng c dng, tr phi phi hp vi chn bta

TL: Bassand JP et al. ESC Guidelines for the diagnosis and treatment of non ST segment elevation acute coronary syndrome. June 14, 2007

23

t hi chng MV cp khng ST chnh ln

Cc thuc chng ng/ HCMVC/KSTC

Heparin khng phn on (TTM) Heparin TLPT thp (TDD) Fondaparinux (TDD): c ch yu t Xa Cc cht c ch trc tip thrombin (TTM): hirudin, bivalirudin, argatroban Thuc i khng vit K (ung): warfarin, acenocoumarol

24

t hi chng MV cp khng ST chnh ln

So snh hiu qu iu tr cc thuc chng kt tp tiu cu mi vi clopidogrel

TL: De Lemos JA et al. Hurts The Heart, 13th ed 2011, McGraw-Hill. p. 1328-1351

25

t hi chng MV cp khng ST chnh ln

Cc ch im tin on nguy c huyt khi hay nguy c cao dn n NMCT cn chp MV khn cp
au tht ngc ti din hoc ko di ST thay i t nhin (chnh ln hay sp xung > 0,1 mV) ST sp xung su t V2- V4, chng t TMCB xuyn thnh vng sau din tin Huyt ng khng n nh Lon nhp tht nng
TL: Wijns W et al. ESC/ EACTS Guidelines on Myocardial revascularization. Eur. Heart J 2010; 31: 2501-2555
26

Cn v c v t sm hi chng MV cp khng ST chnh ln

Khuyn co ti thng MV/ HC MV KSTC

Ch nh
Can thip MV bnh nhn: -Ch s GRACE > 140 hoc c t nht mt nguy c cao - Triu chng c nng ti din -TMCB trn trc nghim gng sc Can thip sm MV (< 24 gi) bnh nhn: -Ch s GRACE > 140 hoc -Nhiu tiu chun nguy c cao Can thip mun MV (trong vng 72 gi) bnh nhn -Ch s GRACE < 140 hoc -Khng c nhiu tiu chun nguy c cao nhng c triu chng c nng ti din hoc TMCB trn trc nghim gng sc Bnh nhn nguy c TMCB rt cao (au tht ngc khng tr km suy tim, lon nhp hay huyt ng khng n): Can thip khn cp (< 2 gi) Khng can thip: -Nguy c thp -Nguy c chp mch hay can thip cao

Loi

MCC

I
I IIa III

A
A C A
27

TL: Wijns W et al. ESC/ EACTS Guidelines on Myocardial revascularization. Eur. Heart J 2010; 31: 2501-2555

t hi chng MV cp khng ST chnh ln

Bng tnh im ch s GRACE(1)

TL: Granger C B et al. Arch Intern Med 2003; 163: 2345-2353

28

t hi chng MV cp khng ST chnh ln

Bng tnh im ch s GRACE (2)

TL: Granger C B et al. Arch Intern Med 2003; 163: 2345-2353

29

t hi chng MV cp khng ST chnh ln

Qui trnh ch nh loi I v loi IIa trong x tr ban u HCMVC- KSTC (1)

TL: Wright RS et al. 2011 ACCF/AHA Focus up date of Guideline for the management of patients with unstable Angina/ Non ST Elevation Myocardial Infareter(Updating the 2007 Guideline)JACC vol 57, No18 2011, May 3, 2011: xxx
30

t hi chng MV cp khng ST chnh ln

Qui trnh ch nh loi I v loi IIa trong x tr ban u HCMVC- KSTC (2)

TL: Wright RS et al. 2011 ACCF/AHA Focus up date of Guideline for the management of patients with unstable Angina/ Non ST Elevation Myocardial Infareter(Updating the 2007 Guideline)JACC vol 57, No18 2011, May 3, 2011: xxx 31

Cn v c v t sm hi chng MV cp khng ST chnh ln

iu tr bng thuc lu di sau ti ti mu c tim (1)

Loi UCMC lin tc trn b/n c PXTM 40% v cho b/n c THA, T hoc bnh thn mn (tr phi c chng ch nh) UCMC cho tt c b/n, tr phi c chng ch nh Chn th th AG II/bnh nhn khng dung np UCMC v c suy tim hoc NMCT km PXTM 40% Chn th th AG II/tt c bnh nhn khng dung np UCMC I MCC A

IIa

IIa

TL: Wijns W et al. ESC/ EACTS Guidelines on Myocardial revascularization. Eur. Heart J 2010; 31: 25012555

32

Cn v c v t sm hi chng MV cp khng ST chnh ln

iu tr bng thuc lu di sau ti ti mu c tim (2)

Loi Chn beta cho tt c b/n sau NMCT hoc HCMVC hoc ri lon chc nng tht tri (tr phi c CC) Thuc gim lipid mu liu cao/tt c bnh nhn bt k mc lipid (tr phi c CC) Cn nhc s dng fibrates v omega-3 (1g/ngy)phi hp vi statin hoc b/n khng dung np c statin Cn nhc s dng niacin nhm tng HDL-C I I IIa MCC A A B

IIb

TL: Wijns W et al. ESC/ EACTS Guidelines on Myocardial revascularization. Eur. Heart J 2010; 31: 2501-2555

33

Cn v c v t sm hi chng MV cp khng ST chnh ln

Chin lc theo di v x tr b/n khng triu chng c nng sau ti ti mu c tim

Loi TNGS hnh nh (siu m, x k) cn c thc hin thay v ECG gng sc Bnh nhn nguy c thp: ti u iu tr ni km thay i li sng Bnh nhn nguy c trung bnh hay cao: chp MV TNGS hnh nh cn c thc hin sm/nhm b/n c bit TNGS thng quy cn cn nhc sau nong MV 2 nm v sau BCMV 5 nm
Nguy c thp: TMCB/ gng sc vi cng cao, khi u TMCB mun, 1 vng TMCB Nguy c trung bnh hay cao: TMCB/gng sc cng thp; nhiu vng TMCB TL: Wijns W et al. ESC/ EACTS Guidelines on Myocardial revascularization. Eur. Heart J 2010; 31: 2501-2555
34

MCC A C

I IIa

IIa IIb

C C

t hi chng MV cp khng ST chnh ln

Cc bnh nhn c bit cn kho st TNGS bng hnh nh sm

-Tt c b/n ST chnh sau can thip hoc BCMV ti khn cn kho st trc ra vin hoc rt sm sau ra vin -Bnh nhn c ngh nghip cn an ton cao (TD: phi cng, ti x)hoc vn ng vin -S dng thuc c ch 5 phosphodiesterase (sildenafil, tadalafil) -Bnh nhn t t c cu sng -Bnh nhn ti lu thng MV khng hon ton -Bnh nhn c bin chng khi can thip (bc tch, NMCT chu phu, g b ni mc khi BCMV) -Bnh nhn T -Bnh nhiu nhnh MV km tn thng cn st li hoc TMCT yn lng

35 TL: Wijns W et al. ESC/ EACTS Guidelines on Myocardial revascularization. Eur. Heart J 2010; 31: 2501-2555

t hi chng MV cp khng ST chnh ln

Kt lun
Chn on v lng nh HCMVC-KSTC: lm sng, cn lm sng, ch im sinh hc, thang im TIMI, GRACE hsc TnT: gip chn on sm Chng kt tp tiu cu (aspirin, clopidogrel, prasugrel; ticagrelor, c ch th th GP 2b, 3a) iu tr chng ng:
Heparin, fondaparinux (c ch Xa), c ch trc tip thrombin; thuc khng Vit K

Ti ti mu c tim: PCI hoc BCMV iu tr lu di sau NMCT:rt quan trng

36