Professional Documents
Culture Documents
COM
GII THIU
CC TI BO CO TI HI NGH TIM MCH MIN TRUNG- TY NGUYN M RNG LN TH VI TI BUN MA THUT THNG 8 NM 2011
Khuyn co ca ACCF/AHA v nh gi nguy c tim mch ngi ln khng triu chng (2010 ACCF/AHA Guideline for Assessment of
Cardiovascular Risk in Asymptomatic Adults
Developed in Collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance
M U
Blood Pressure
Diabetes
DM age Lipids BP
Lipids
sex
smoking
Trng ban bin son: - GS. TS. Phm Gia Khi Cc thnh vin:
- GS. TS. Nguyn Ln Vit - PGS. TS. Don Li - TS. BS. Phm Mnh Hng - ThS. BS. Phm Thi Sn - ThS. BS. Nguyn Th Thu Hoi - ThS. BS. Nguyn Ngc Quang
NI DUNG KHUYN CO
- Ch s nguy c ton th (v d ch s Framingham [FRS]) thng c dng nh gi nguy c chung do nn p dng cho tt c ngi ln khng c triu chng, khng c tin s lm sng bnh mch vnh. - Cc ch s ny c ch khi phi hp nh gi nguy c c nhn vi lng gi nh tnh nguy c nhm tp trung vo mc tiu ca bin php d phng.
Mc tiu
Fatal CHD
MI, stroke, coronary revascularization, cardiovascular death (CHD and CVD combined) http://www.reynoldsris kscore.org/
Tin s gia nh bnh tim mch do va x (CVD) cn lu tt c bnh nhn khng triu chng cn nh gi nguy c. Th nghim phn lp Gen trong nh gi bnh mch vnh ngi ln khng triu chng khng c khuyn co.
nh gi Lipoprotein v Apolipoprotein
nh lng cc thng s lipid, bao gm lipoproteins, apolipoproteins, kch thc v nng , ngoi bilan lipid chun khng c khuyn co trong nh gi nguy c tim mch ngi ln khng triu chng.
Copyright 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved.
Lipoprotein analysis
ApoB, like LDL cholesterol, is a powerful predictor of risk for future CVD events. One large, multinational prospective study found apoB levels to be the best predictor of risk compared with both traditional risk factors (smoking, physical inactivity, or presence of diabetes) and serum cholesterol concentrations (LDL, non-HDL, triglycerides, or HDL levels). Lancet. 2008;372:224-233. These data are in agreement with prior data from the Framingham Offspring Study, which found apoB to be a more accurate risk factor than total cholesterol or ratios of LDL cholesterol and non-HDL.
Copyright 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved.
Lancet. 2008;372:224-233.
nh lng natriuretic peptides khng khuyn co trong nh gi nguy c BMV trong nh gi nguy c tim mch ngi ln khng triu chng.
- nam 50 tui hoc n 60 tui c LDL cholesterol < 130 mg/dL; - khng dng thuc gim lipid, thuc thay th hormone, hoc thuc iu tr c ch min dch; - khng c BMV trn lm sng, T, bnh thn mn, tnh trng vim trm trng, hoc chng ch nh statins, vic nh lng CRP c th c li khi chn bnh nhn cn iu tr vi statin.
bnh nhn nam 50 tui khng triu chng hoc n 60 tui nguy c trung bnh, nh lng CRP l hp l khi nh gi nguy c tim mch. ngi ln nguy c cao khng triu chng, nh lng CRP khng khuyn co khi nh gi nguy c tim mch. nam < 50 tui hoc n < 60 tui nguy c thp, nh lng CRP khng khuyn co khi nh gi nguy c tim mch.
3
Relative Risk of MI
P = 0.03
1 <0.055
2 0.0560.114
3 0.1150.210
4 >0.211
Hypertension
Glucose Intolerance
Odds of CVD Stratified by CRP Levels in U.S. Persons (Malik and Wong et al., Diabetes Care 2005; 28: 690-3)
***
O d d s R a t i o
6 5 4 3 2 1 0 No Metabolic disease Syndrome High CRP Low CRP Diabetes
* *
*** **
*p<.05, **p<.01, **** p<.0001 compared to no disease, low CRP CRP categories: >3 mg/l (High) and <3 mg/L (Low) age, gender, and risk-factor adjusted logistic regression (n=6497)
nh lng hemoglobin A1C (HbA1C) c th hp l khi nh gi nguy c tim mch bnh nhn ngi ln khng triu chng cha c chn on i tho ng.
ngi ln khng triu chng b THA hoc T, phn tch nc tiu pht hin microalbuminuria l thch hp nhm nh gi nguy c tim mch.
ngi ln khng triu chng c nguy c trung bnh khng b THA hoc T, phn tch nc tiu pht hin microalbuminuria c th hp l nhm nh gi nguy c tim mch.
Lipoprotein- kt hp phospholipase A2 (Lp-PLA2) c th hp l khi nh gi nguy c tim mch ngi ln khng triu chng c nguy c trung bnh.
Lipoprotein-Associated Phospholipase A2
Lp-PLA2 is a novel inflammatory marker that may play a key role in the noninvasive assessment of atherosclerotic disease activity in asymptomatic individuals. Unlike CRP, Lp- PLA2 appears to be pathogenic, as it is produced by macrophages active in the atherosclerotic plaque and promotes atherosclerosis progression by inducing apoptosis of macrophages and smooth muscle cells. Lp-PLA2 has great affinity for low density LDL particles, and its enzyme activity cleaves oxidized phospholipids into pro inflammatory products: lysophospholipids and fatty acids. Circ Res. 2001; 89:763-771.
Copyright 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved.
Copyright 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved.
Copyright 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved.
Trc nghim tim mch trong nh gi nguy c ngi ln khng triu chng
in tim khi ngh ngi (ECG) hp l khi nh gi nguy c tim mch ngi ln khng triu chng b THA hoc T.
in tim khi ngh ngi c th lu khi nh gi nguy c tim mch ngi ln khng triu chng b THA hoc T.
Siu m tim nhm pht hin ph i tht tri cn lu trong nh gi nguy c tim mch ngi ln khng triu chng b THA.
Siu m tim khng khuyn co trong nh gi nguy c BMV ngi ln b THA khng triu chng.
o b dy lp trung ni mc M cnh l hp l khi nh gi nguy c tim mch ngi ln khng triu chng nguy c trung bnh. Cc khuyn co cng b cho thy cn c phng tin, k thut v chuyn gia c kinh nghim thc hin k thut trn mt cch chc ch v kt qu cht lng cao.
Cardiovascular Health Study: Combined intimalmedial thickness predicts total MI and stroke
Cardiovascular Health Study (CHS) (aged 65+): MI or stroke rate 25% over 7 years in those at highest quintile of combined IMT (OLeary et al. 1999)
Cc nghin cu nh gi dng chy ng mch ngoi bin qua trung gian dn mch khng c khuyn co khi nh gi nguy c tim mch ngi ln khng c triu chng.
o cng ng mch ngoi cc nghin cu khng c khuyn co trong nh gi nguy c tim mch ngi ln khng triu chng.
o ch s cng chn- cnh tay l thch hp cho vic nh gi nguy c tim mch ngi ln khng triu chng nguy c trung bnh.
in tim gng sc c dng nh gi nguy c tim mch ngi c nguy c trung bnh khng triu chng (bao gm ngi ln ngi lu chun b cho chng trnh gng sc nng n), c bit ch khi cc ch im khng thuc v in tim nh kh nng gng sc.
Trc nghim gng sc bng MPI c th c dng trong nh gi nguy c tim mch tin trin ngi ln khng triu chng b T hoc khng triu chng nhng c tin s gia nh rt r b BMV hoc khi trc nghim nh gi nguy c trc gi nguy c cao BMV v d ch s canxi ha mch vnh (CAC) 400. Stress MPI khng ch nh khi nh gi nguy c tim mch ngi ln khng triu chng c nguy c thp hoc trung bnh.
o ch s CAC thch hp khi nh gi nguy c tim mch ngi ln khng triu chng nguy c trung bnh (10% n 20% 10- nm nguy c).
o CAC c th thch hp cho nh gi nguy c tim mch c nguy c thp n trung bnh (6% n 10% 10- nm nguy c). Ngi c nguy c thp (<6% 10-nm nguy c) khng nn tin hnh nh gi CAC khi nh gi nguy c tim mch.
Risk Factor-Adjusted Hazard Ratios by Coronary Calcium Score: MESA Study (Detrano et al., NEJM 2008)
Incidence and Progression of Coronary Calcium (mean 2.4 years between scans): Multiethnic Study of Atherosclerosis (n=5570)(Wong et al., AHA 2006)
160 140 120 100 80 60 40 20 0 A. New CAC (%)
A. B. P<0.001 across groups 24 P<0.001 across groups
158
110 90 56 64
P<0.01 to p<0.001 between each group
45 12 21
% with new CAC among those free of CAC at baseline% with progression of CAC (score change >0) Mean adjusted change in CAC score among those with CAC at baseline
Curved multiplanar imaging shows lesion in the right coronary artery demonstrated by multidetector row computed tomography (arrow).
Copyright 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved.
Chp cng hng t pht hin mng va khng khuyn co trong nh gi nguy c tim mch ngi khng triu chng.
Cc kh nng nh gi nguy c
bnh nhn
T
I IIa IIb III
ngi ln T khng triu chng, 40 tui, o CAC l ph hp khi nh gi nguy c tim mch.
I IIa IIb III
ngi ln T khng triu chng, nh lng HbA1c l ph hp khi nh gi nguy c tim mch. ngi ln T khng triu chng, Stress MPI l ph hp khi nh gi nguy c tim mch hoc khi cc th nghim trc y gi nguy c cao BMV v d CAC 400.
Cc kh nng nh gi nguy c
I IIa IIb III
n gii
Tin s gia nh BMV cn phi lu khi nh gi nguy c tim mch ph n khng triu chng.
KT LUN
Cc th nghim khng khuyn co nh gi nguy c tim mch ngi ln khng triu chng
Th nghim phn nhm gen (III B) nh lng cc thng s lipid (lipoproteins, apolipoproteins, particle size v density) ngoi bilan lipid chun (III C)
Cc th nghim khng khuyn co nh gi nguy c tim mch ngi ln khng triu chng
Siu m tim thng thng ngi ln khng triu chng khng THA(IIIC)
Cc th nghim v dng chy ng mch cnh tay/ngoi bin qua trung gian dn mch (III B)
o cng mch ngoi cc nghin cu (III C) Siu m gng sc ngi ln nguy c trung bnh v thp (III C) Trc nghim gng sc bng x hnh ti mu ngi ln nguy c thp v trung bnh (III C) o ch s canxi ha MV ( CAC) ngi ln nguy c thp (<6% 10 nm nguy c) (III B)