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PGS.TS. NGUYN QUANG TUN, FACC VIN TIM MCH VIT NAM
Mc tiu ca iu tr trong TN
1.
2.
CANTHIP
NI KHOA
Circulation 1994;90:2645-57
Ch nh chp MV
Nhm A: C ch nh chp MV Bnh nhn c mc au ngc r (CCS III IV) v khng khng ch c vi iu tr ni khoa ti u. Bnh nhn c nguy c cao theo phn tng nguy c trn cc thm d khng chy mu.
NGC N NH
1. 2. 3.
4.
ESC Guidelines on the management of stable angina pectoris. Eur. Heart J 2006 ; 27 : 1341-1381
Cn bng s n nh mng x va
lipid, oxy ho Lipid Nhim trng? Tnh nhy cm di truyn Thuc gim lipid mu Chng oxy ha? Tn thng c hc
Qu trnh vim
Sa cha
Mng x va khng n nh
Weissberg, 1999
Mng x va n nh
LIN QUAN GIA LDL-C V BIN CHNG TIM MCH: CNG THP CNG TT?
30 4S - Pl 25
20
4S - Rx
LIPID - Pl 15 LIPID - Rx CARE - Rx HPS - Rx TNT Atv10 PROVE-IT - Pra TNT Atv80 PROVE-IT Atv AFCAPS - Rx ASCOT - Pl ASCOT - Rx 0 40 (1.0) 60 (1.6) 80 (2.1) 100 (2.6) 120 (3.1) 140 (3.6) 160 (4.1) 180 (4.7) 200 (5.2) CARE - Pl
HPS - Pl
10
AFCAPS - Pl
6
WOSCOPS - Rx
Rosenson RS. Exp Opin Emerg Drugs 2004;9(2):269-279, LaRosa JC et al. N Engl J Med 2005;352:1425-1435.
LIN QUAN GIA TIN TRIN CA XVM TRN IVUS V CC BIN CHNG QUA 18 THNG THEO DI
60 50
Observational study of plaques in left main coronary arteries of patients with established atherosclerosis. PCI=percutaneous catheter intervention. Adapted with permission from von Birgelen C, et al. Circulation. 2004;110:1579-1585.
1.3 1.2
Odds ratio
Q1 Lowest Q2 Q3 Q4 Highest
Cng sm cng tt
-2
The patients were enrolled if a change of 6 months in the site of the proximal reference from an ACS culprit lesion could be precisely measured by IVUS. The exclusion criteria were death and cardiovascular events before follow-up IVUS and repeat revascularization therapy at follow-up IVUS. Daida H. et al,2009
2 risk factors
(10-yr risk <10%)
190 -
160
mg/dL
160 -
goal
goal
130
mg/dL
130
mg/dL
goal
100
mg/dL
or optional
100
mg/dL*
100 or optional
70 mg/dL*
70 *Therapeutic option 70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160 mg/dL = 4.1 mmol/L
T bin c (%)
T vong do tim mch, NMCT khng t vong hay cp cu ngng tun hon RRR: 20%, P=0,0003 Placebo
12 10 8 6
9,9%
8,0%
Perindopril
2
0 0 1 2 3 4 5
nm
6108 6110 5943 5957 5781 5812 5598 5653 4450 4515 71 64
RRR 20%
P=0,0003
RRR 28%
P=0,004
9.9% 8.0%
8.7%
6.3%
placebo
Perindopril
placebo
Perindopril
Gin mch
nh hng n Ti cu trc
Chng vim
Cung
Khu knh MV p lc ti mu Nng Hb Thi gian TTr
3 nhm b/n:
Vn ng tng TS tim 150/ph Nhm MV bnh thng: tng tit din MV (+ 31%) v tng lu lng MV (+ 137%) Nhm hp nh (< 30%): tit din MV gim (- 10%) v lu lng MV tng nh (+ 10%)
Nhm hp nng (> 70%): co MV nng (- 73% tit din) v gim nng lu lng (- 70%)
2.0 1.0
0.5
Phn tch gp hi cu t
12 nghin cu c i chng 0
-5 -10 -15 -20
HR (bpm)
In the treatment of stable angina, it is conventional to adjust the dose of betablockers to reduce heart rate at rest to 55 to
c t Lai Lt Ma 2009
Metoprolol Atenolol
Bisoprolol
37 50
50
75 (50-100) 50 (25-50)
5 (5-7.5)
200 100
10
Km dung np thuc qua theo di lu di: sau 1, 3, v 5 nm theo th t 78%, 64%, v 58% nhng ngi sng st tip tc iu tr -blockers
Gislason GH, et al. Eur Heart J. 2006;27:1153-1158.
10 Placebo
10
Placebo
5
42%
5
73% Ivabradine
Ivabradine
0 0 0.5 1 Years 1.5 2 0 0 0.5 1 Years
1.5
Intolerant or contraindication
HR > 60 bpm
If inhibitor
Intolerant Symptoms not controlled after dose optimization
Add If inhibitor
Gio dc sc kho
Bin php rt hiu qu:
Thng b b qua
MMWR Morb Mortal Wkly Rep 1998;47:91-5
NGNG HT THUC L
Bt u bng thay i li sng: kim sot trng lng c th, tng hot ng th lc, ung ru va phi, gim n mui, tng n rau qu ti v cc sn phm cha t cht bo.
Huyt p 140/90 mmHg (hay 130/80 vi bnh thn mn hay tiu ng) Nu dung np c, nn bt u bng thuc h p (chn bta, c ch men chuyn, thiazide) t c huyt p mc tiu.
NGHIN CU INVEST
Nghin cu a trung tm: 862 trung tm ti 14 nc.
i tng nghin cu: bao gm 22.576 bnh nhn THA v bnh MV. Mc tiu nghin cu: xc nh xem liu vic h huyt p thp c lm tng t l t vong v bin chng hay khng? (t vong, NMCT khng t vong)
NGHIN CU ACCORD
Nghin cu a trung tm: 77 trung tm ti Hoa k v Canada.
i tng nghin cu: bao gm 10.251 bnh nhn T tp 2 c nguy c cao b NMCT v t qu.
Mc tiu nghin cu: xc nh xem liu vic iu tr h ng mu tch cc hn c lm gim cc bin chng tim mch nh NMCT, t qu v t vong do tim mch cc bnh nhn T tp 2 c nguy c cao b bin chng tim mch hay khng?
NGHIN CU ACCORD
Phng php nghin cu: cc bnh nhn c chia ngu nhin thnh 2 nhm:
5.128 bnh nhn iu tr h ng mu tch cc hn cc khuyn co hin hnh (HbA1C < 6%).
5.123 bnh nhn iu tr theo quy chun (HbA1C: 7-7,9%).
Tp luyn th lc
Mc tiu: t nht 30 pht mi ngy 5 ngy mi tun
I IIa IIb III
Tp luyn vi cng trung bnh 30-60 pht mi ngy nh i b nhanh tt c cc ngy trong tun. Vi cc bnh nhn c nguy c cao nh hi chng vnh cp, ti to mch, suy tim th cn c s gim st ca nhn vin y t.
Nu vng bng > 90 cm nam gii, 80 cm n gii th bt u thay i li sng v xem xt vic iu tr hi chng chuyn ho nu c ch nh. Mc tiu ban u iu tr gim cn vo khong 10% so vi ban u, nu thnh cng th c th xem xt gim cn thm nu c ch nh.
495 (0.6)
888 (1.1) 457 (0.6) 466 (0.6) 398 (0.5) 943 (1.2) 2387 (3.1)
581 (0.9)
1026 (1.6) 535 (0.9) 538 (0.9) 427 (0.7) 1361 (2.2) 2910 (4.7)
<0.001
<0.001 0.001 0.002 0.018 <0.001 <0.001
0.81 (0.700.92)
0.84 (0.720.97) 0.52 (0.470.57) 0.65 (0.620.70)
Community cohort of 140,055 subjects in the 19981999 season of which 55.5 % were immunized. Nichol et al. N Engl J Med 2003;348:1322-32.
King III et al. PCI Focused update. JACC Vol 51, No 2, 2008.
KT LUN
1. iu tr ni khoa l c bn, chp MV bnh nhn c nguy c cao.