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DEMA-CVN.

COM
GII THIU

GII THIU CAC TAI NGHIN CU KHOA HOC TAI HI NGHI NI KHOA TOAN QUC TAI THANH PH H CHI MINH THANG 7/ 2011

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CP NHT IU TRI CN AU THT NGC N INH

PGS.TS. NGUYN QUANG TUN, FACC DEMA-CVN.COM VIN TIM MACH VIT NAM

Mc tiu ca iu tr trong TN
1.
2.

Ci thin triu chng


Gim t l t vong v cc bin c khc

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CANTHIP

NI KHOA

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Phn tng nguy c chp MV


Vn mc tn thng ca MV v ri lon chc nng tht tri l 2 yu t tin lng mnh v kt qu lm sng theo di lu di Tn thng on gn ca MLTT (LAD) Tn thng thn chung MV tri Nghin cu CASS (t l sng sau 12 nm theo di)
Coronary arteries normal coronary arteries 73% one-vessel disease 74% two-vessel disease 59% three-vessel disease 40% 91% Ejection fraction > 50% 35% to 49% <35% 54% 21%

DEMA-CVN.COM 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. Bnh nhn c au tht ngc m sng st sau cp cu ngng tun hon hoc c bit c ri lon nhp trm trng Bnh nhn au tht ngc c km theo du hiu ca suy tim Bnh nhn ang chun b cho phu thut mch mu ln Bnh nhn au tht ngc m ngh nghip hoc li sng c nhng nguy c bt thng (phi cng, din vin xic)

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HNG DN IU TRI NI KHOA BNH AU THT

NGC N INH
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Tiu chun p ng tt vi iu tr ni khoa


Ht au ngc Tr v sinh hot bnh thng Tr v mc CCS I

Bnh nhn dung np thuc tt


Mc tiu iu tr l tu thuc tng ngi bnh

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Khuyn co 2006 ca Hi Tim mch Chu u


Thuc iu tr au tht ngc n nh ch nh class I Aspirin 75mg/ng tt c b/n Statin tt c b/n c ch men chuyn b/n c km THA, suy tim, ri lon chc nng TT, tin s NMCT km RLCNTT hoc T Chn bta ng ung b/n sau NMCT hoc c km suy tim

1. 2. 3.

4.

ESC Guidelines on the management of stable angina pectoris. Eur. Heart J 2006 ; 27 : 1341-1381 DEMA-CVN.COM

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

DEMA-CVN.COM Weissberg, 1999

Mng x va n nh

LIN QUAN GIA LDL-C VA BIN CHNG TIM MACH: CANG THP CANG TT?
30 4S - Pl 25

phng nga th pht


Rx - Statin therapy Pl Placebo Pra pravastatin Atv - atorvastatin

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

Phng nga tin pht


WOSCOPS Pl

10

AFCAPS - Pl
6

WOSCOPS - Rx

DEMA-CVN.COM Rosenson RS. Exp Opin Emerg Drugs 2004;9(2):269-279, LaRosa JC et al. N Engl J Med 2005;352:1425-1435.

LDL-C achieved mg/dL (mmol/L)

LIN QUAN GIA TIN TRIN CA XVM TRN IVUS VA CAC BIN CHNG QUA 18 THNG THEO DI
60 50

Thoi trin = Phng nga

Annualized Change in Plaque + Media Cross-Sectional Area (%)

40 30 20 10 0 -10 -20 -30 -40

Individual Patients (n=56)


Myocardial infarction (n=5) Unstable angina (n=7) PCI of new de-novo lesion (n=6) No events (n=36)

Observational study of plaques in left main coronary arteries of patients with established atherosclerosis. DEMA-CVN.COM PCI=percutaneous catheter intervention. Adapted with permission from von Birgelen C, et al. Circulation. 2004;110:1579-1585.

Thoi trin = Phng nga


A direct relationship was observed between the burden of coronary atherosclerosis

1.3 1.2
Odds ratio

Baseline plague volume

Q1 Lowest Q2 Q3 Q4 Highest

Cng sm cng tt

1.1 1.0 0.9 0.8 -4 2 4 Annual Change Percent Atheroma Volume DEMA-CVN.COM Nicholls SJ et al J Am Coll Cardil 2010;55:2399-407 -2 0
Athero Athero regression progression More MACE Fewer MACE

Thoi trin = Phng nga


~Sub analysis of Extended-ESTABLISH study~ Cumulative event free survival in patients with ACS 1.0 0.9 0.8 0.7 0.6 0.5 Long-rank test: P=0.032 0.4 0.3 regression group 0.2 progression group 0.1 0.0 0 500 1000 1500 2000 2500 Days of Follow-up Cumulative event free survival

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.

DEMA-CVN.COM Daida H. et al,2009

NCEP ATP III: MC TIU LDL-C


(KHUYN CO 2004 C SA I)
High Risk CHD or CHD risk equivalents Moderately High Risk 2 risk factors (10-yr risk 1020%) Moderate Risk Lower Risk < 2 risk factors
goal

2 risk factors
(10-yr risk <10%)

190 -

(10-yr risk >20%)

160
mg/dL

160 -

goal

goal

130
mg/dL

130
mg/dL

130 LDL-C level

goal

100
mg/dL

or optional

100
mg/dL*

100 or optional

70 mg/dL*

Existing LDL-C goals

Proposed LDL-C goals

70 *Therapeutic option

DEMA-CVN.COM 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 Grundy SM et al. Circulation 2004;110:227-239.

12.218 BNH NHN TN N NH


14

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

Patients at risk Placebo Perindopril

EUROPA Investigators. Lancet. 2003;362:782-788.

RRR: relative risk reduction

HIU QU CA PERINDOPRIL TRN CC IU TR PHNG NGA KHC


Gim t vong do tim mch, NMCT khng t vong hay ngng tim

Overall EUROPA population N=12.218

Patients on tritherapy* N=2.087

RRR 20%
P=0,0003

RRR 28%
P=0,004

9.9% 8.0%

8.7%
6.3%

placebo

Perindopril

placebo

Perindopril

* Tritherapy = antiplatelets + beta-blockers + lipid-lowering agents


Adapted from EUROPA Investigators. Lancet 2003;362:782-788.

CC C CH PHNG NGA BIN C MV

Tc dng qua trung gian Bradykinin

Men chuyn t chc

Tc dng qua trung gian Angiotensin II

Gin mch

nh hng n Ti cu trc

Phc hi chc nng ni mc

Chng cht theo chng trnh


n nh mng x va

Chng vim

Phc hi s cn bng tiu si huyt

Gim cc bin c tim mch

KHUYN CO THUC CMC TRONG PHNG NGA TH PHT BMV


Bnh nhn BMV c THA, suy tim, RL chc nng tht tri, tin s NMCT hay T (class I, level of evidence A) Tt c bnh nhn TN v c BMV da trn li ch mang li so vi gi thnh v nguy c b tc dng ph (class IIa, level of evidence B) Nn s dng cc thuc v liu c chng minh l c hiu qu trong phng nga th pht.
Guidelines on the management of stable angina. Eur Heart J 2006;27:1341-1381.

Bnh ng mch vnh

Cung
Khu knh MV p lc ti mu Nng Hb Thi gian TTr
DEMA-CVN.COM

Cu Tn s tim Co bp c tim Tin gnh Hu gnh

Nghin cu chng minh mi tng quan gia tn s tim v vn mch MV

3 nhm b/n:

- MV bnh thng - nghn MV < 30% - nghn MV > 70%

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%)
DEMA-CVN.COM

Nabel EG et al. Circulation 1990; 81: 850 - 859

Lin quan gia tn s tim v s nt v ca mng x va MV

DEMA-CVN.COM Heidland UE, Strauer BE. Circulation. 2001;104:1477-1482.

Gim nhp tim gp phn lm gim t vong sau NMCT

2.0 1.0

0.5

0.2 P<0.001 0.1

Phn tch gp hi cu t

12 nghin cu c i chng 0
-5 -10
DEMA-CVN.COM

HR (bpm)

-15

-20

Nhp tim gim 10 nhp/pht = gim 26% t l t vong do tim


Cucherat M et al. Eur Heart J. 2006, 27(Abstract Suppl):590.

In the treatment of stable angina, it is conventional to adjust the dose of betablockers to reduce heart rate at rest to 55 to

60 beats per min.

ACC/AHA Guideline for


the Management of Chronic Stable Angina

DEMA-CVN.COM
J AM Coll Cardiol. 2003;41:159-168

Hy nh rng tnh yu ln v thnh tu ln i hi mt gi phi tr kh cao

c t Lai Lt Ma 2009

DEMA-CVN.COM

Hn ch ca vic s dng thuc chn bta ti cng ng


55.315 bnh nhn sau NMCT; 58,3% c s dng thuc chn bta giao cm
-Blockers Liu hng ngy % Liu trung bnh/ngy Liu nghin cu lm sng mg mg

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
DEMA-CVN.COM
Gislason GH, et al. Eur Heart J. 2006;27:1153-1158.

Hiu qu ca ivabradine v t l nhp vin do NMCT t vong/khng t vong


Tt c cc bnh nhn TN
15
Event rate (%) 15 Event rate (%)

Bnh nhn N (HR >70 bpm)

HR (95% CI), 0.58 (0.370.92), P=0.021

HR (95% CI), 0.27 (0.110.66), P=0.002

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

DEMA-CVN.COM
Fox K, et al. Eur Heart J. 2009 FASTTRACK.

iu tr nhm gim triu chng


-Blockers
Symptoms not controlled after dose optimization
HR > 60 bpm

Intolerant or contraindication
HR > 60 bpm

If inhibitor
Intolerant Symptoms not controlled after dose optimization

Add If inhibitor

Symptoms not controlled after dose optimization

Consider suitability for revascularization

Substitute calcium antagonist or long-acting nitrate

Add long-acting nitrate, calcium antagonist, or Kchannel opener

Symptoms not controlled on 2 drugs after dose optimization DEMA-CVN.COM


Modified from: Fox K. Recommendations of the Task Force of the ESC on stable angina. Eur Heart J. 2006;27:1341-1381.

Gio dc sc kho
Bin php rt hiu qu:

Bnh nhn hiu bit, ch ng phng nga, thay i li sng


thc v sc kho, mc bnh

Trnh lo lng hoc coi thng qu mc


Bnh nhn tin tng v tun th iu tr lu di

Thng b b qua
MMWR Morb Mortal Wkly Rep 1998;47:91-5 DEMA-CVN.COM

NGNG HT THUC LA

B thuc l hon ton v khng tip xc vi mi trng c khi thuc l


DEMA-CVN.COM

KIM SOAT HUYT AP


Mc tiu <140/90 mmHg hay <130/80 khi c bnh thn mn tnh hay tiu ng
Huyt p 120/80 mmHg:

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.

(INTERNATIONAL VERAPAMIL-TRANDOLAPRIL STUDY)

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)

Franz H et al. Ann Intern Med. 2006; 144:884-893

KIM SOAT I THO NG

Mc tiu Hb A1c < 7%

DEMA-CVN.COM HbA1c = Glycosylated hemoglobin

NGHIN CU ACCORD
Nghin cu a trung tm: 77 trung tm ti Hoa k v Canada.

CTION TO CONTROL CARDIOVASCULAR RISK IN DIABETES

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?

DEMA-CVN.COM February 6, 2008 ACCORD News Conference press kit

NGHIN CU ACCORD
Phng php nghin cu: cc bnh nhn c chia ngu nhin thnh 2 nhm:

ACTION TO CONTROL CARDIOVASCULAR RISK IN DIABETE

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%).

Kt qu: nghin cu phi ngng li sm hn d kin 18 thng, sau gn 4 nm nghin cu:


Nhm iu tr tch cc t vong 257 bnh nhn Nhm iu tr theo quy chun t vong 203 bnh nhn.

DEMA-CVN.COM February 6, 2008 ACCORD News Conference press kit

Nguy c t vong lin quan n mc luyn tp th lc


Observational study of self-reported physical activity in 772 men with established coronary heart disease

Light or moderate exercise is associated with lower risk


DEMA-CVN.COM Wannamethee SG et al. Circulation 2000;102:1358-1363

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.

I IIa IIb III

DEMA-CVN.COM Circulation 2006;113:2363-2372 and J Am Coll Cardiol 2006;47:2130-2139

Kim sot trng lng c th


Mc tiu: BMI 18,5-22,9 kg/m2 Vng bng < 90 cm nam gii v 80cm n gii
I IIa IIb III
nh gi BMI v vng bng mi ln thm khm, ng vin bnh nhn duy tr trng lng c th hp l qua vic cn bng gia hot ng th lc v nng lng n ung vo.

I IIa IIb III

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.

I IIa IIb III

DEMA-CVN.COM Circulation 2006;113:2363-2372 and J Am Coll Cardiol 2006;47:2130-2139

Hiu qu ca tim vaccin phng cm


Hospitalization Pneumonia or influenza Cardiac disease Ischemic heart disease Heart failure Cerebrovascular disease Death Hospitalization or death Vaccinated Subjects (N=77,738) Unvaccinated Subjects (N=62,317) Adjusted Odds Ratio 0.68 (0.600.78) 0.81 (0.730.89) 0.80 (0.700.91) P value

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. DEMA-CVN.COM Nichol et al. N Engl J Med 2003;348:1322-32.

Tim vaccin phng cm

I IIa IIb III

Cc bnh nhn b bnh tim mch nn c tim vaccin phng cm.

DEMA-CVN.COM 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.

2. Kim sot tt cc yu t nguy c v thay i li sng l ht sc quan trng.

DEMA-CVN.COM

Hy chia s kin thc. l mt cch bn bt t.


c t Lai Lt Ma 2009.

XIN CHN THNH CM N!

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