KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

KHUYN CO V IU TR HI CHNG NG MCH VNH CP NGI CAO TUI

(Management of acute coronary syndrome in the Elderly)

PGS. TS. Phm Nguyn Vinh Vin Tim TP. HCM BV. Tim Tm c H Y khoa Phm Ngc Thch

KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

nh ngha v ngi cao tui

Tui > 60 hay > 65 Bn nhm trong khuyn co: < 65, 65 n 74, 75 n 84, > 85

TL: Alexander KP et al. Circulation 2007; 115: 2549 - 2569

KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Tm quan trng ca Hi chng ng mch vnh cp (HCMVC)/ ngi cao tui

US (2004): * 35% t vong/ HCMVC/ > 65 tui * t vong v bnh tim TMCB: 83% tui > 65 WHO: t vong do BMV tng 120%/ n v 137%/ nam trong 2 thp k ti Ngi gi ngy cng tng: t nm 2000 n 2030, ngi > 65 tui t 12,4% tng ln 19,6% (US)

TL: Alexander KP et al. Circulation 2007; 115: 2549 - 2569

KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

nh danh cac hoi chng ong mach vanh cap

4
TL: Braunwald E et al. J Am Coll Cardiol 2000; 36: 970

KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Hi chng MV cp khng ST chnh ln ngi cao tui (HCMVC/ KSTC)

KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Cc nghin cu chnh HCMVC/ KSTC

TL: Alexander KP et al. Circulation 2007; 115: 2549 - 2569

KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Tn sut HCMVC KSTC ngi trn 75 tui/ cc nghin cu chnh

TL: Alexander KP et al. Circulation 2007; 115: 2549 - 2569

KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Tn sut cc yu t nguy c theo nhm tui/ nghin cu CRUSADE

TL: Alexander KP et al. Circulation 2007; 115: 2549 - 2569

KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

lc cu thn c lng/ nhm tui trong n/c VIGOUR v CRUSADE

C/t Cockroft v Gault CrCl > 60 ml/min: bnh thn mn nh CrCl 30 59: BTM va CrCl < 30: BTM nng

TL: Alexander KP et al. Circulation 2007; 115: 2549 - 2569

KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Biu hin lm sng HCMVC/KSTC ngi cao tui thng khng c hiu

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

au tht ngc/ HCMVC/KSTC ngi cao tui

Nghin cu NRMI (National Registry of Myocardial Infarction): * 77% b/n < 65 tui * 40% b/n > 85 tui

TL: Alexander KP et al. Circulation 2007; 115: 2549 - 2569

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Biu hin au tht ngc v suy tim thay i/ nhm tui/ HCMVC - KSTC

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TL: Alexander KP et al. Circulation 2007; 115: 2549 - 2569

KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Tn sut cc biu hin ban u khc ca HCMVC - KSTC/ ngi cao tui
Kh th: 49% Tot m hi (diaphoresis): 26% Bun nn v i ma: 24% Ngt: 19%

TL: Brieger D et al. GRACE Investigators Chest 2004; 126: 461 - 469

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Lng nh nguy c: tui, khm thc th (tn s tim, HA tth), ECG (ST ) men tim

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

ECG u tin/ HCMVC KSTC/ n/c NRMI

Khng gip chn on: * 23% < 65 tui * 43% > 85 tui

TL: National Registry of Myocardial Infarction Website. Available at http: // www.nrmi.org. Accessed June 10, 2005 15

KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

T vong trong bnh vin v t vong trong 30 ngy/ n/c VIGOUR v n/c GRACE

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TL: Alexander KP et al. Circulation 2007; 115: 2549 - 2569

KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

T vong v HCMVC/KSTC thay i theo tui

T vong trong BV: > 85 tui gp 10 ln < 65 tui (slide 16) T vong trong 1 nm (n/c GRACE): * 75 84 tui: 15% * > 85 tui: 25%

TL: Avezum A et al. GRACE Investigators Am Heart J 2005; 149: 67 - 73

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Chy mu cn truyn mu: mt bin chng quan trng ngi cao tui

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Truyn mu thay i theo nhm tui v can thip MV/ n/c VIGOUR v n/c CRUSADE

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TL: Alexander KP et al. Circulation 2007; 115: 2549 - 2569

KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Liu lng thuc khuyn dng trong iu tr HCMVC KSTC/ cao tui (1)
1. Aspirin: (no adjustment) 81 325 mg daily 2. Clopidogrel: (no adjustment) 75 mg daily 3. UFH: weight-based bolus of 60 U/kg and infusion of 12 U.kg-1 .h-1. Suggested maxium dose of 4000-U bolus and 900-U/h infusion, or 5000-U bolus and 1000-U/h infusion if patient weight > 100 kg. 4. LMWH: weight-based dose of 1mg/kg every 12 hours, with adjustment in infusion for renal function (if CrCl < 30 mL/min) to 1 mg/kg subcutaneously every 24 hours.

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TL: Alexander KP et al. Circulation 2007; 115: 2549 - 2569

KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Liu lng thuc khuyn dng trong iu tr HCMVC KSTC/ cao tui (2)
5. GP IIb/IIIa inhibitors-eptifibatide: weight-based bolus of 180 g/kg and infusion of 2.0 g.kg-1 . min-1, with adjustment in infusion for renal function (if CrCl< 50 mL/min) to 1.0 g.kg-1 . min-1 6. GP IIb/IIIa inhibitors-tirofiban: weight-based bolus of 12 g/kg and infusion of 0.1 g.kg-1 . min-1, with adjustment in infusion for renal function (if CrCl< 30 mL/min) to bolus of 6 g/kg and infusion to 0.05 g.kg-1 . min-1

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TL: Alexander KP et al. Circulation 2007; 115: 2549 - 2569

KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

iu tr chng kt tp tiu cu
Aspirin (81 325 mg/ng) phi hp clopidogrel (75 mg/ng) (Class I) Li im ca aspirin tng cao i vi b/n nguy c cao, bao gm ngi cao tui Chng kt tp tiu cu kp: aspirin > 100mg -> tng xut huyt

TL: Alexander KP et al. Circulation 2007; 115: 2549 - 2569

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Thuc c ch th th GP IIb/ IIIa tim mch

Li im tng i ca c ch GP IIb/IIIa thay i theo nhm tui Li im cao hn/ nhm tui cao hn ty thi im can thip v chc nng thn Xut huyt tng/ ngi cao tui s dng c ch GP IIb/IIIa thay i theo s lng khng huyt khi. Cn chnh liu c ch GP IIb/IIIa theo lc cu thn c lng v cn nng

TL: Alexander KP et al. Circulation 2007; 115: 2549 - 2569

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

iu tr chng thrombin
Class Ia/ ACC AHA/ HCMVC KSTC Heparin trng lng phn t thp (LMWH): cn chnh liu theo tui v lc cu thn Trong thc hnh (n/c GRACE v n/c CRUSADE): ngi > 85 tui t c dng LMWH hn ngi < 65 tui.

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Thuc c ch thrombin trc tip

Efegatran Inogatran Fondaparinux Hirudin, bivalirudin Cha nghin cu v s dng ngi cao tui

TL: Alexander KP et al. Circulation 2007; 115: 2549 - 2569

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Can thip sm tt hn can thip da theo TMCB/ HCMVC - KSTC

TL: Bach RG et al. Am Intern Med 2004; 141: 186 - 195

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Li im ca can thip MV/ HCMVC KSTC ngi cao tui/ n/c TACTICS TIMI 18

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Tm tt v can thip HCMVC-KSTC/ cao tui

Li im tuyt i v tng i tng/ can thip MV/ cao tui Nguy c chy mu tng: 17%/ > 75 tui Can thip hng dn bng triu chng: cn thn v ngi cao tui c triu chng khng c hiu Mong mun ca b/n: yu t quan trng trong ch nh can thip Cn thiu nghin cu v nhm b/n > 80 tui

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Mt vi im chnh ca HCMVC KSTC ngi cao tui

Nn phn nhm < 65, 65 74, 75 84, > 85 trong thng k Tt c b/n > 75 tui c HCMV cn c tnh lc cu thn Cn c nghin cu chuyn bit v ngi cao tui.

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Hi chng ng mch vnh cp c ST chnh ln (HCMVC STC)

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Cc nghin cu chnh v HCMVC - STC

TL: Alexander KP et al. Circulation 2007; 115: 2570 - 2589

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Tn sut b/n HCMVC STC > 75 tui/ cc nghin cu

> 75 tui: 30% HCMVC STC/ cc b/n HCMVC

TL: Alexander KP et al. Circulation 2007; 115: 2570 - 2589

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Biu hin LS v CLS HCMVC - STC

au tht ngc / tui: 89,9%/ < 65 so vi 56,8% > 85 Suy tim cp tng theo tui ST chnh/ ECG 96,3%/ < 65; 69,9%/ > 85 Blc nhnh tri 5%/ < 65; 33,8%/ > 85

TL: Alexander KP et al. Circulation 2007; 115: 2570 - 2589

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Biu hin ca NMCT STC v tui

TL: Alexander KP et al. Circulation 2007; 115: 2570 - 2589

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Ti lu thng MV/ NMCT - STC

Hai kh nng: 1. Thuc tiu si huyt 2. Can thip MV

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Ti lu thng MV/ NMCT STC gim dn theo tui cao

TL: Alexander KP et al. Circulation 2007; 115: 2570 - 2589

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Ti sao b/n cao tui t c can thip MV?

Triu chng c nng khng c hiu ECG u tin khng biu hin r Bnh i km tui gi mun ca bnh nhn

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

iu tr Tiu si huyt (TSH)/ NMCT STC cao tui

Nghin cu Fibrinolytic Therapy Trialists (FTT): TSH gim t vong b/n > 75 tui 15% (p = 0,003) Bin chng xut huyt no do TSH: 1,5% ton b qun th so vi 2,9%/ > 85tui

TL: FTT Collaborative Group. Lancet 1994; 343: 311 - 322

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Hiu qu iu tr bng TSH thay i theo tui/ NMCTC - STC

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TL: FTT Collaborative Group. Lancet 1994; 343: 311 - 322

KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Tm tt v TSH/ NMCTC - STC

Li im gim t vong ca TSH so vi iu tr ni n thun, cho ti tui 85, c chng minh t qu khng t vong: him (< 3%/ b/n > 85 tui) Cn chnh liu heparin Heparin trng lng phn t thp c chnh liu > heparin khng phn on Cn cn nghin cu v b/n > 85 tui v v tim hoc xut huyt nng/ TSH

TL: Alexander KP et al. Circulation 2007; 115: 2570 - 2589

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

iu tr TSH so vi can thip MV/ cao tui

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Can thip MV so vi tiu si huyt

Nghin cu Primary Coronary Angioplasty Trialist (PCAT): * n/c gp 11 n/c phn phi ngu nhin * 2635 b/n * t vong PCI/ 30 ngy: 13,3% so vi 23,6% TSH (p < 0,05) b/n > 75 tui * nguy c t qu xut huyt thp hn PCI (RR = 0,34 p = 0,009)

TL: Grines C et al. Am Heart J 2003; 145: 47 - 57

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

t qu v t vong nhnh iu tr/ PCAT - 2

TL: Boersma E. Eur Heart J 2006; 27: 779 - 788

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Ti lu thng MV sau 12 gi khi bnh c cn hiu qu

N/c PRAGUE 2*: trong vng 3 gi u, t vong PCI 7,4%, strepokinase 7,3% N/c CAPTIM**: trong vng 2 gi u, t vong PCI 5,7%, TSH 2,2% p = 0,058 N/c BRAVE 2***: PCI/ NMCT > 12 gi, cn gip gim vng nhi mu

TL:* Widunsky P et al. Eur Heart J 2003; 24:94 104 ** Steg PG et al. Circulation 2003; 108: 2851 2856 *** Schomig A et al. JAMA 2005; 293: 2865 - 2872

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Tm tt v can thip MV so vi tiu si huyt/ ngi cao tui

PCI li hn TSH: gim ti NMCT, ti lu thng MV mc tiu PCI v TSH: tng ng hiu qu/ 3 gi u khi bnh PCI li hn > 6 gi v cn cu c tim khi > 12 gi Cn thm n/c ngi > 80 tui

TL: Alexander KP et al. Circulation 2007; 115: 2570 - 2589

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Cc iu tr ni khoa khc
Chn bta UCMC hoc chn th th angiotensin II Nitrates Statins Spironolactone, eplerenone

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Nghin cu GISSI - 3
Nitroglycerin qua da/ NMCTC STC > 70 tui trong vng 24 gi u Gim t vong, suy tim, ri lon CNTTr thng 6 khong 12% (p = 0,04)

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Hiu qu ca cc iu tr ni khoa (NMCTC STC ngi cao tui)

Chn bta li im cao trong phng ti NMCT v t vong: cao tui > ngi tr UCMC v chn th th AGII: hiu qu; c bit suy tim hoc ri lon CNTTr Statins: li im ngi cao tui > ngi tr Nitrates: hiu qu cao (n/c GISSI 3)

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

o c y khoa trong chm sc HCMV cp/ ngi cao tui: rt quan trng

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Y c v chm sc HCMVC/ cao tui

Ct ngha cho b/n v li im v nguy c ca bin php iu tr Can thip: li im cn cha r hoc nguy c cao cn trnh Cn thm d kin v cht lng cuc sng mun ca bnh nhn: hng u Cn nhc b/n bn lun v quyt nh vi ngi thn yu

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KHUYN CO V IU TR HI CHNG MV CP NGI CAO TUI

Kt lun
iu tr ngi cao tui: cn trng trong bin php v liu lng thuc; trnh bi quan HCMVC/ KSTC: * li im ca can thip MV cao hn ngi tr * lc cu thn c lng > 75 tui: cn thit NMCTC STC: * 3 gi u: TSH tng ng PCI * > 12 gi: cn cu vn c tim * cn nghin cu > 85 tui o c y khoa trong quyt nh iu tr +++
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