Professional Documents
Culture Documents
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
Nguyn ln vit
(Ch bin)
Thc hnh
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
Nh xut bn Y hc
2003
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
Nguyn ln vit
(Ch bin)
Thc hnh
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
Nh xut bn Y hc
2003
Li gii thiu
S kt hp cht ch trong cng tc iu tr, ging dy,
nghin cu khoa hc gia cc thnh vin ca B mn Tim mch
Trng i hc Y H ni v Vin Tim mch Vit nam to
iu kin cho s ra i ca cun sch: Thc hnh Bnh Tim
mch vi s tham gia trc tip ca cc tc gi m Ph Gio s
Tin s Nguyn Ln Vit l ch bin.
Chng ta cn nh tp Bnh hc Ni khoa vi nhng
bi vit rt c bn, thc t, xc tch m c Gio s ng Vn
Chung truyn t t nhng nm 50 ca th k va qua. Ngy
nay, nhng tin b to ln ca y hc hin i trong chuyn ngnh
Tim mch c phn nh mt phn qua 32 bi vit ca tp
d
th tc gi. y cng l phn nh s pht trin ti Vin
rve Tim
e
s
re
mch Vit nam trong nhng nm gn y, mt thnh
ts vnqu t s
h
.
g
n lc ca mi c nhn, ca tp th cc thy
om nhm p
l rithuc,
l
c
.
A hohi
o nhp quc t
ng nhu cu nng cao sc kho trong bi
ev.cnh
a
o
l
y
in @
m nc ta l mt thnh vin.
. F 2020
8
0
Qua cc bi vit ny, m
y cc tc gi cng t nhn
20 ochnh
cit
t gian
t
xt l cn b hn ch v ithi
chun
b cho in n, cc th h
h
o
P
rg
y
k tip t r kh onng
gp phn y mnh v lm phong ph
p
C
thm cho nhng thnh tu ca ngi i trc, gip chng ta cp
nht v hi nhp vi y hc hin i ti khu vc.
Chng ti xin gii thiu cun Thc hnh Bnh Tim
mch mt ti liu phc v ging dy, thc hnh, mt ti liu
tham kho c gi tr, mang tnh h thng v cp nht.
Xin cm n cc tc gi v chc bn c rt ra nhng iu
b ch ca mt chuyn ngnh ang pht trin mnh m ny.
Gio s Tin s Phm Gia Khi
Vin trng Vin Tim mch Vit nam
Ch nhim B mn Tim mch - Trng i hc Y H ni
Li ni u
Bc sang thin nin k mi, chng ta vui mng chng
kin v tip thu nhng thnh tu pht trin ca khoa hc k thut
nhm khng ngng ci thin v nng cao i sng ca con
ngi.
Tuy vy, chng ta cng khng khi lo u bi m hnh bnh
tt c nhng s thay i theo chiu hng ca cc nc pht
trin. Trong cc loi bnh l , bnh tim mch l mt trong
nhng bnh ang c xu hng tng nhanh mt cch r rt d nc
rve
ta.
ese
r
hts .vnta tip
Trong thi gian gn y, cc bc s caigchng
r
om tin trong
ll o.ctin
thu v ng dng nhiu phng php, k. Athut
o
h
v
a ci thin c
oe t
chn on v iu tr cc bnh tim mch,
inl 20@y
F
. 0sng ca bnh nhn.
hn tin lng bnh v cht lng
8cuc
00 ity2
2
Tuy nhin, khi lng
oc thc v nhng hiu bit mi
t kin
gh Pot
i
r
trong lnh vc tim mch
py th ngy cng gia tng, nhng iu kin
Co ti nhiu tuyn ca chng ta cn cha p
trang thit b thc t
ng c mt cch y . V vy, cc thy thuc nhiu khi s
kh lng tng trong thc hnh chn on v iu tr cho cc
bnh nhn tim mch.
Xut pht t thc tin cng tc iu tr v ging dy trong
nhiu nm, tp th cc cn b ging dy ca B mn Tim mch,
Trng i hc Y H ni v mt s cng s c gng tham gia
bin son quyn sch ny.
Vi phng chm l bm st thc t, d dng ng dng
nhng cng khng km phn cp nht, chng ti c lm ht
sc mnh trong vic bin son ph hp vi nhng yu cu ni
trn. Trong qu trnh bin son, chng ti c gng cp nht
nhng thng tin mi nht c th c trn nn tng nhng kin
thc kinh in bit trong lnh vc tnh mch.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
CH bin
Ph gio s, Tin s Nguyn Ln Vit
Mc lc
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
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l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
1
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
d
rve
e
s
re
ts vn
h
.
g
Hnh 1-1. S nt ra ca mng x va trong
TNK.
l ri .com
l
A o
II. Chn on
ev. yaho
o
l
in @
A. Triu chng lm sng08. F 2020
ty
20 ocivi
1. c im chung:
bnh nhn NMCT, bnh
t oso
t
h
P
g
i
r
nhn TNK
thng c tui gi hn, c t l tiu
py
Co hn, t l tng huyt p (THA) v ri lon
ng cao
lipid mu cng gp nhiu hn. Thm vo , s bnh
nhn TNK sau NMCT hoc cc th thut can
thip MV cng nhiu.
2. Triu chng c nng: Triu chng au ngc cng
ging nh trong au ngc n nh m t, ch c s
khc nhau v tnh cht, trong TNK tnh cht d
di hn, ko di hn, c th xy ra c trong khi ngh,
c th khng hoc t p ng vi Nitrates.
3. Khm lm sng:
a. Khm lm sng t c gi tr chn on
TNK, nhng khm lm sng l cc k quan
trng gip chn on phn bit cng nh nh
gi cc yu t nguy c, bin chng...
2
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4
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t ot c
h
P
g
i
5. Chp ngyrmch
vnh:
op
C
a. Ch nh chp ng mch vnh trong TNK
c cc tc gi thng nht l nhm bnh nhn
c nguy c cao, v mc ch ca chp MV l
can thip MV nu c th. Cc ch nh khc l
khi bnh nhn khng p ng hoc ti pht au
ngc sau khi dng thuc iu tr ti u, khi
bnh nhn c suy tim, ri lon nhp, gim chc
nng tht tri... (bng 1-3). Hin nay mt s trung
tm trn th gii ch trng chp MV v can
thip cho mi bnh nhn TNK ngay th u.
Tuy nhin, cch ny cha t ra li ch vt tri so
vi cch iu tr bo tn trc, n ch vt tri
nhm c nguy c cao.
5
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III. iu tr
Tu tng trng hp c th m ta bt u bng cc phng
ed
ervbt u
php iu tr thch hp. iu tr ni khoa l nn tngesv
r
ts vmch
cho mi trng hp. Cc bin php iu tr tighto
(can
n
i om.
r
l
thip nong hoc t Stent MV, phu thut
c cu ni chAl hlm
oo.
v.tnh
e
a
vnh) rt quan trng v l iu tr mang
trit
, cn c
o
nl 0@y
i
F
2
cn nhc trong tng tnh hung c8.th. 0
0 ty2
20 ni
i
A. Mc tiu ca iu
tr
t otoc khoa
h
P
g
ri
1. Nhanh chng
py dng thuc chng ngng kt tiu cu.
Co
2. Lm gim au ngc bng cc thuc chng thiu mu
cc b c tim.
3. Cc bnh nhn khng p ng vi iu tr ni khoa
cn c ch nh can thip cp cu. Vi nhng bnh
nhn p ng tt vi iu tr ni khoa cng cn c
sng lc v xem xt chp ng mch vnh quyt
nh tip hng iu tr ti to mch cho bnh nhn
(nong MV v/hoc t Stent, m cu ni...).
B. Cc u tin trong iu tr
1. Aspirin.
2. Gim au ngc bng Nitrate v/hoc chn bta giao
cm.
6
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mu km theo. Tc dng ph ny t gp hn i
vi Clopidogrel.
d. Liu lng: Ticlid cho ngay 500 mg sau cho
250mg x 2 ln/ngy trong nhng ngy sau. Plavix
cho liu ban u 300 mg sau 75 mg/ngy.
e. Ch nh: V l do gi thnh cn tng i cao
v v tc dng ph nng c th xy ra nn cc
thuc ny ch nn ch nh trong trng hp bnh
nhn km dung np vi Aspirin. Trong trng
hp c can thip t Stent MV th nn cho thm
thuc ny phi hp vi Aspirin. Sau khi t Stent
cc thuc ny c dng tip trong 2-4 tun ri
ngng v ch tip tc cho Aspirin
d
D. Cc thuc chng ng
rve
e
s
re
1. Heparin:
ts vn
h
g
i om.
l rmu
l
c ng trong
a. V c ch hnh thnh cc
oo.
v. A ahchng
e
TNK, nn vic cho
thuc
ng l bt
o
inl 20@y
F
buc.
8. 0
00 ity2
2
b. Nhiu nghin
oc ch ra rng vic dng
t cu
Pot vi Aspirin trong TNK
igh hp
Heparinyrphi
op nguy c t vong v NMCT ti 33 % so
lm Cgim
vi ch dng Aspirin n c.
c. Thi gian dng Heparin nn ko di khong 3-7
ngy, nu dng di qu c th lm tng nguy c
gy h tiu cu mu ca Heparin.
d. Hiu ng bng li (rebound) thiu mu c tim
cc b khi ngng Heparin c th gp l do hnh
thnh huyt khi lin quan n kch thch hot
ho tiu cu. Do vic duy tr lin tc Aspirin l
bin php tt phng trnh hiu ng ny.
e. Nn dng Heparin theo ng truyn TM.
f. Liu dng: Liu khuyn co hin nay l liu
tng i thp, tim ngay TM 60 UI/kg sau
truyn TM lin tc liu 15 UI/kg/gi. Cn kim
8
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12
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
L. M lm cu ni ch-vnh
1. Cc ch nh cho phu thut:
a. Tn thng nhiu thn MV m on xa cn tt.
b. Tn thng thn chung MV.
c. Cc tn thng qu phc tp (vi ho, xon vn,
gp gc, ch chia nhnh...) m khng th can
thip nong hoc t stent c.
d. Tht bi khi can thip.
2. Cc yu t d on nguy c cao cho phu thut l:
tui cao, c nhiu bnh nng km theo, chc nng
tht tri gim nhiu, tiu ng, kinh nghim ca
phu thut vin... Tuy nhin, mt s nghin cu
(BARI, CASS) cho thy nhng bnh nhn
d tiu
rvec tn
e
ng hoc suy gim chc nng tht rtri,
s
e
s ncu ni t
tlm
h
thng nhiu thn MV th phu thut
v
.
g
l ri .com
l
ra u th hn so vi can thip MV.
A o
ev. yaho
o
l
Ti liu tham kho
Fin 0@
8. 202
0
y
1. Antman EM, Tanasuevic MJ,
B, et al. Cardiac-specific
20 Thompson
cit of mortality
t theotorisk
troponin I levels to predict
in patients with acute
h
rigN EnglP J Med 1996;335:1342-1349.
coronary syndromes.
y
p
Co
2.
3.
4.
5.
14
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
6.
7.
8.
9.
Granger CB, Califf RM. Stabilizing the unstable artery. In: Califf
RM, Mark DB, Wagner GS, eds. Acute coronary care, 2nd ed. St.
Louis: Mosby, 1995:525-541.
10. Hamm CW, Goldmann BU, Heeschen C,et al. Emergency room
triage of patients with acute chest pain by means of rapid testing for
d
cardiac troponin T or I. N Engl J Med 1997;337:1648-1653.
rve
res
loe
ya
in 2between
12. Moliterno DJ, Granger CB. Differences
unstable angina and
0@
. F pathophysiological
0
8the
acute myocardial infarction:
and clinical
2
0
0 ity
c
2Acute
spectrum. In: Topol EJ, ted.
coronary
syndromes,
1st ed. New
o
h Pot
York: Marcel Dekker,
rig1998:67-104.
opy
C
13. Ohman EM, Armstrong
PW, Christenson RH, et al. Cardiac troponin
T levels for risk stratification in acute myocardial ischemia. N Engl J
Med 1996;335:1333-1341.
14. Oler A, Whooley MA, Oler J, et al. Adding heparin to aspirin
reduces the incidence of myocardial infarction and death in patients
with unstable angina: a meta-analysis. JAMA 1996;276:811-515.
15. Roe MT. Unstable angina and non-ST-segment elevation MI. In:
Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular
Medicine. Philadelphia: LippincottRaven, 2000.
16. Stone PH, Thompson B, Anderson HV, et al. Influence of race, sex,
and age on management of unstable angina and non-Q-wave
myocardial infarction: the TIMI III registry. JAMA 1996;275:11041112.
17. Theroux P, Ouimet H, IvicCans J, et. al. Aspirin, heparin, or both to
treat acute UA. N Engl J Med 1988;319:1105-1111.
15
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ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
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l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
16
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
au tht ngc n nh
(Bnh tim thiu mu cc b mn tnh)
c dim
Ch thch
Nhng hot ng th au tht ngc ch xut
I
lc bnh thng khng hin khi hot ng th
lc rt mnh.
gy au tht ngc.
Hn ch nh hot ng au tht ngc xut hin
II
th lc bnh thng.
khi leo cao >1 tng gc
thng thng bng cu
thang hoc i b di hn
2 dy nh.
d
rvie b
e
III Hn ch ng k hot au tht ngc rkhi
s
e
ts nh
ng th lc thng di t 1-2 gdy
h
vn hoc
.
ri cogc.
m
leo caoA1ll tng
thng.
o.
v.thtahongc
e
khi lm
IV Cc hot ng th lc au
o
y
inl 20@
nh,
khi
gng
sc
bnh thng u gy8. Fvic
20
0 tynh.
0
au tht ngc.
2 i
t otoc
h
P
g
II. Cc xt nghim chn
on
ri
y
p
Co
20
Copyright 2008. Finloev. All rights reserved
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D on mc hot ng th lc an ton
cho bnh nhn (nht l sau NMCT).
Tuy nhin, T gng sc t c gi tr nhng
bnh nhn m T c bn c nhng bt
thng nh dy tht tri, ang c t my to
nhp, bloc nhnh tri, ri lon dn truyn...
T gng sc cng khng d on c mc
hp MV v khng nh v chnh xc
c vng c tim thiu mu.
Bng 2-2. Nhng d kin gip d on nguy c cao b
bnh mch vnh trn in tm gng sc.
Khng kh nng chy 6 pht theo phc Bruce.
Nghim php dng tnh sm ( 3 pht).
Kt qu gng sc dng tnh mnh (ST chnh xung
d
2 pht).
rve
e
s
re sc.
ST chnh xung 3 pht sau khi ngngtsgng
n
h
g
ST chnh xung kiu dc xung (down-sloping).
i om.v
r
l
l otim
c
Thiu mu c tim xut hin mc. Anhp
o . cn tng
h
v
e
a
o
i thp ( 120 ck/pht).
l @y
0
Fini.
Huyt p khng tng hoc
tt
.
0
8 2 2
0
y
0
Xut hin nhp nhanh
2 thtit mc nhp tim 120 chu
t otoc
h
k/pht.
P
g
ri
y
p
b. SiuCm
tim
gng
sc: L thm d c gi tr, n
o
gin v c th cho php d on vng c tim
thiu mu v v tr MV tng ng b tn thng.
Siu m gng sc c th lm vi gng sc th
lc (xe p nm) hoc thuc (Dobutamine).
Tuy nhin, kt qu ca thm d ny cn ph
thuc nhiu vo kinh nghim ca ngi lm
siu m v i khi kh khn nu hnh nh m
(Bnh nhn bo, bnh phi...)
c. Phng php phng x o ti mu c tim:
Thng dng Thalium201 hoc Technectium99m.
C nhy, c hiu cao, o c tng vng
ti mu c tim song nhy, c hiu b
gim nhng bnh nhn bo ph, bnh hp c 3
nhnh MV, bloc nhnh tri, n gii...
22
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kh tn km nn vic ch nh cn cn nhc n li
ch thc s cho bnh nhn. Hi Tim mch Hoa k v
Trng mn Tim mch Hoa k (AHA/ACC) c
nhng khuyn co v ch nh chp MV bnh
nhn suy vnh nh trong bng 2-3.
III. iu tr
A. Mc ch: Ngn nga nguy c t vong v bin chng,
ci thin cht lng cuc sng.
d
rve
e
s
re
ts vn
h
.
g
l ri .com
l
A o
ev. yaho
o
l
@
Fin020va
Hnh 2-2. Tin trin ca 0mng
MV.
8. 2x
0 ity
2
B. La chn phng
t php
toc
igh Po
r
py php iu tr: Thuc, can thip MV,
1. C 3 phng
Co
m lm cu ni ch vnh. Thm vo , cn phi
iu chnh cc yu t nguy c cho ngi bnh.
2. Vic ch nh ph thuc vo tnh trng bnh v nn
bt u cng nh duy tr bng iu tr ni khoa.
Trong trng hp iu tr ni khoa tht bi hoc bnh
nhn c nguy c cao trn cc thm d th cn c ch
nh chp MV v can thip kp thi.
C. iu tr ni khoa
1. Cc thuc chng ngng kt tiu cu:
a. Aspirin: Lm gim t l t vong v nhi mu c
tim ti 33% (SAPAT). Liu dng t 75 - 325
mg/ngy.
b. Nu d ng hoc dung np km vi Aspirin:
24
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
Cholestyramine.
t
t
igh Po
r
y
3. Cc dn oxut
Nitrates:
p
C
a. C ch:
Lm gim nhu cu xy c tim do gy gin
mch lm gim tin gnh v mt phn hu
gnh ca tht tri.
C th lm tng dng mu ca MV do lm
gim p lc cui tm trng ca tht tri v
lm gin MV.
Ngoi ra cn c mt phn tc dng c ch
ngng kt tiu cu.
b. La chn thuc: (Bng 2-4).
c. Tc dng ph:
au u: Do gin mch no, c th gim bt
liu khi c triu chng ny.
C th gp bng mt, chng mt, h HA.
26
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Vin ngm
Vin ung
5 - 10 mg
10 mg
Theo nhu cu
Mi 8 gi
thut gen. Gn hy
o
t ot
P phn bo c nhiu kt qu kh
rigkhng
c ph thuc
y
p
Co vic chng ti hp. Cho ti nay, hu nh
quan trong
cha c loi thuc ung no c th ngn ti hp tt.
E. M lm cu ni ch - vnh
1. Ch nh: Bnh nhiu ng mch vnh b hp (vd.
Tn thng 3 MV), tn thng thn chung, tn
thng phc tp khng ph hp cho can thip m
on xa cn tt...
2. So snh vi iu tr ni khoa: Lm gim triu chng
v ci thin t l t vong ng k (Nghin cu CASS,
ECSS, VACS). So vi can thip MV: Cho kt qu
tng t vi bnh tn thng khng nhiu MV, vi
bnh nhiu MV th c v c li ch hn, nhng
trong bnh MV km theo tiu ng th phu thut
lm cu ni ch-vnh t ra c li hn.
31
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32
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
8.
9.
10.
11.
12.
13.
14.
15.
16.
33
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
Nhi mu c tim cp
Nhi mu c tim (NMCT) cp l mt trong nhng nguyn
nhn hng u gy t vong M v cc nc chu u. c tnh
M c khong 1 triu bnh nhn nhp vin mi nm v NMCT
cp v khong 200.000 n 300.000 bnh nhn t vong hng
nm v NMCT cp. Vit nam s bnh nhn NMCT ngy cng
c xu hng gia tng nhanh chng. Nu nh nhng nm 50,
NMCT l bnh rt him gp th hin nay hu nh ngy no cng
gp nhng bnh nhn NMCT cp nhp vin (ti Vin Tim
mch). Nhng tin b trong chn on v iu tr NMCT cp
lm gim ng k t l t vong do NMCT cp. S ra i ca n
v cp cu mch vnh (CCU) u nhng nm 60, tip n l cc
d
rve thip
thuc tiu huyt khi nhng nm 80 v hin nay lsecan
re
ng mch vnh cp cu v nhng tin b v cchthuc
ts vnphi hp
g
i ogii
m. hin nay
lm cho t l t vong do NMCT cp trn
l rth
l
c
.
oo l > 30 %.
v. A ahy
gim xung ch cn khong < 7% so vi
etrc
o
l
y
Fin 0@
8. 202
0
20 ity
I. Sinh l bnh
t otoc
h
P
rig
y
p
C tim c nui
dng
bi 2 ng mch vnh (MV)
Co
l MV tri v MV phi. MV tri xut pht t l vnh tri
ca MC v MV phi xut pht t l vnh phi. Thc t, MV
tri li chia ra 2 nhnh ln l nhnh lin tht trc (LAD) v
nhnh m (LCx). Do vy ngi ta thng gi l 3 thn MV
nui c tim.
NMCT c hiu l do s tc nghn hon ton mt hoc
nhiu nhnh MV gy thiu mu c tim t ngt v hoi t
vng c tim c ti mu bi nhnh MV . Th phm
y chnh l mng x va ng mch. Nhng vn t ra l
trong thc t nu mng x va c pht trin m thm gy hp
nhiu thm ch tc hon ton MV theo thi gian cng khng
gy ra triu chng ca NMCT cp v c s thch nghi v pht
trin ca tun hon bng h. C ch ch yu ca NMCT cp l
do s khng n nh v nt ra ca mng x va hnh thnh
35
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c im lm sng %
T l t vong
Killip
trong 30 ngy (%)
I
Khng c triu chng 85
5,1
ca suy tim tri
13,6
II
C ran m < 1/2 phi, 13
tnh mch c ni, c
th c ting T3 nga
phi
III
Ph phi cp
1
32,2
IV
Sc tim
1
57,8
III. Cn lm sng
A. in tm (T): L mt trong nhng thm d rt
c gi tr chn on NMCT cp v nh khu NMCT.
37
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d
rve
e
s
re
ts vn
h
.
g
l ri .com
l
A o
ev. yaho
o
l
Fin 0@
8. 202
0
20 ity
t otoc
h
P
rig
y
p
Hnh 3-1. NMCT
sau di cp.
Co
B. Cc men sinh hc trong huyt thanh bnh nhn
1. Creatine Kinase (CK): 3 iso-enzyme ca men ny
l CK-MB, CK-MM, CK-BB i din cho c tim, c
vn v no theo th t trn. Bnh thng CK-MB
chim khong <5% lng CK ton phn (bnh thng
CK ton phn trong huyt thanh t 24-190 U/l 37oC
v CK-MB < 24 U/l).
a. Men ny bt u tng 3-12 gi sau nhi mu,
nh cao khong 24 gi v tr v bnh thng sau
48-72 gi.
b. Lu l men ny c th tng trong mt s trng
hp khc nh vim c tim, vim mng ngoi tim,
sau m tim, sau sc in. N cng tng trong mt
39
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Gi
ca
c
s y t.
loe @ya
n
i
0
F 2mu:
2. Thi im iu tr ti8.ti
Cc nghin cu
0 ty20
0
2
i
chng minh c
l
li
ch
cng
ln nu tin hnh
t otoc
h
P
g
c ti ti
ri mu cng sm. Nu thi gian c ti
py vng 1 gi u (k t khi au) th li
ti muCotrong
ch l ln nht. Hin nay, khi can thip MV th u
c p dng nhiu trung tm, th thi gian c
c hiu qu tt nht l trc 120 pht. Ni chung
l trong vng 12 gi u th vn cn ch nh iu tr
ti ti mu. Nu sau 12 gi, m vn cn tn ti cc
triu chng th vn c th c li ch khi iu tr ti
ti mu (khng phi l thuc tiu huyt khi).
3. iu tr ti ti mu mch vnh bng cc thuc
tiu huyt khi:
a. L phng php n gin v nn c la chn
hng u. Cc th nghim ln chng minh cc
thuc ny lm gim ng k t l t vong do
NMCT cp, gii quyt c 60 - 90 % cc trng
44
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4.
50
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3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
51
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t ot thc l thng, mc ln
nh giric
gh Pkch
y
op Siu m tim cng c th gip nh gi
ca Cshunt.
chc nng tht tri v tht phi, t gp phn
tin lng bnh.
c. Thng tim phi: khi c ch nh chp MV
thng nn thng tim phi nh gi c
lung thng v lu lng shunt cng nh p lc
ng mch phi, cung lng tim... gip c thi
iu tr v tin lng bnh tt hn.
4. iu tr:
a. Thi : T l t vong khi c bin chng TLT
c iu tr ni khoa l khong 24% sau 24 gi,
46% sau 1 tun v 67-82% sau 2 thng. Do vy,
cn nhanh chng xc nh v c k hoch m
sm ng l thng ngay khi tnh trng bnh
nhn khng c n nh.
54
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58
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trin t t gsau
ht hn
ot 6 tun. Chng xy ra 10-30%
ri hpP NMCT. Nhng bnh nhn ny
y
cc trng
p
Co c cc triu chng ca suy tim, ri lon
thng
nhp tht, tc mch i tun hon..
c. Khm tim: i khi c th pht hin c vng
b phnh ca tht thng qua s mm tim hoc g
tim. Cn phn ln cc trng hp l c th thy
ting nga phi nhng bnh nhn suy gim
nhiu chc nng tht tri.
2. Sinh l bnh:
Phnh vch tht l mt vng c tht b gin ra
do vng b hoi t do ng mch vnh nui dng
tng ng b tc. Nu MV b tc c gii phng
cng sm th nguy c b phnh vch tht cng thp.
Qu trnh phnh vch tht l phi hp nhiu c ch
60
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62
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Al hooT
.
v
Killip
c im lm sng loe% ya trong 30 ngy
Fin 0@
(%)
8. 202
0
y
I
Khng c triu20chng
85
5,1
it
t otoc
ca suy timghtri
P
ri < 1/2
II
C ranopy
m
phi, 13
13,6
tnh Cmch c ni, c
th c ting T3 nga phi
III
Ph phi cp
1
32,2
IV
Sc tim
1
57,8
Mt phn loi khc ca Forrester da trn cc thng s
huyt ng cng c gi tr tin lng bnh rt tt (bng 4-2).
Bng 4-2. Phn loi ca Forrester trong NMCT cp.
p lc mao mch
phi bt (mmHg)
I
II
III
IV
< 18
> 18
< 18
> 18
Ch s
tim
l/pht/m2
> 2,2
> 2,2
< 2,2
< 2,2
T l t vong
trong 30 ngy
(%)
3
9
23
51
64
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o
t lu,
t c th c cc bin chng huyt
h
o
bnh nhn nm bt ng
P
g
ri
opy chi di v tc mch phi. Tu theo th
khi tnh mchCsu
bnh m c cc triu chng tng ng trn lm sng.
B. iu tr
1. Truyn Heparin tnh mch lin tc trong 3-4 ngy sao
cho thi gian aPTT khong 50-65 giy.
2. Vi nhng bnh nhn b NMCT thnh trc m c
du hiu huyt khi bm thnh cn cho thuc chng
ng ng ung (khng vitamin K) t nht trong 3
thng, gi u vi Heparin.
3. Heparin trng lng phn t thp c tc dng phng
nga tt huyt khi tnh mch chi di v nhi mu
phi i vi nhng bnh nhn nm lu.
71
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o
ting c mng
t ot c tim. Mt s trng hp c
h
rigthyPting c ny. Ting c mng tim
th khng
y
p
Co nghe r nht cnh c tri vng thp.
thng
Ting c mng tim tin trin theo thi gian, gim
hoc mt i khi lng dch mng tim nhiu.
e. C ch ca vim mng ngoi tim cp l do phn
ng vim vng mng tim tng ng vi vng b
nhi mu. S tin trin ca phn ng vim c th
lin quan n mc v din rng ca NMCT.
2. Cc xt nghim chn on:
a. in tm : l mt thm d c gi tr trong
chn on vim mng tim cp. Tuy nhin khi
bnh nhn b vim mng ngoi tim cp sau
NMCT cp th cc du hiu vim mng ngoi tim
c th b che lp mt. Nhn chung, du hiu c
hiu ca vim mng ngoi tim trn T l on
72
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ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
74
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Sc tim
tim cp)
Sc gim th tch
(mt mu)
Sc phn b (nhim
khun, phn v)
Sc tc nghn (nhi -
mu phi rng)
b.
c.
d.
e.
III. iu tr
A. Cc bin php chung
1. Nhanh chng xc nh tnh trng sc tim ca bnh
nhn, loi tr cc nguyn nhn khc gy ra huyt p
thp.
78
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Nitroprussiat
Lm tng nhu cu
xy c tim.
Co mch ngoi vi
v mch tng.
au u, tt
huyt p.
au u, tt
d c
huyt p, ng
rve
e
s
cyanid.
re
ts vn
h
. tiu cu
g
Amrinone
0,75 mg/kg tim TM Gim
l ri .com
l
trong 2 pht sau v
oo
. A mu.
oe yah
truyn
TM inl5-10
0@
F
g/kg/pht. 008. y202
2 ocit
t 50mcg
Milrinone
Tim TM
trong Ri lon nhp
h
Pot
g
i sau
10oppht
truyn tht.
yr
C
TM
0,375 - 0,750
g/kg/pht.
Furosemide
20 - 160 mg tim TM.
H kali mu,
magi mu.
Bumetanide
1-3 mg tim TM.
Nn, chut rt.
2. Dopamine:
a. L 1 catecholamin t nhin, c tc dng trn cc
th th giao cm tu theo liu. Vi liu thp (2-5
g/kg/ph) ch yu tc dng trn th th dopamine
lm gin mch thn, tng dng mu n thn v
lm tng th tch nht bp ca tim. Vi liu trung
bnh (5-15 g/kg/pht) ch yu kch thch 1
giao cm lm tng sc co bp c tim v tng nhp
tim. Vi liu cao 15 - 20 g/kg/pht s c tc
80
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3.
4.
5.
6.
81
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83
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84
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ri lon Lipid mu
I. nh ngha
Ngi ta gi l ri lon lipid mu khi c mt hoc nhiu
cc ri lon sau:
1. Tng Cholesterol huyt tng:
a. Bnh thng: Cholesterol trong mu < 5,2 mmol/l
(< 200 mg/dl)
b. Tng gii hn: Cholesterol trong mu t 5,2 n
6,2 mmol/l (200 239 mg/dl)
c. Tng cholesterol mu khi >6,2 mmol/l d(>240
rve
mg/dl)
ese
r
s
2. Tng TG (Triglycerid) trong mu: ight .vn
r
om
l
Al hoo.c(<200 mg/dl).
a. Bnh thng: TG mu <2,26v.mmol/l
loe @ya mmol/l (200-400
b. Tng gii hn: TG tFin2,26-4,5
20
.
08 ty20
mg/dl).
0
2 toci
c. Tng TG:ight TG
Po t 4,511,3mmol/l (400r
y
p
1000mg/dl).
Co
d. Rt tng: TG mu > 11,3 mmol/l (> 1000 mg/dl).
3. Gim
HDL-C
(High
Density
Lipoprotein
Cholesterol): HDL-C l 1 Lipoprotein c tnh bo v
thnh mch. Khc vi LDL-C, nu gim HDL-C l c
nguy c cao vi x va ng mch:
a. Bnh thng HDL-C trong mu > 0,9 mmol/l.
b. Khi HDL-C mu < 0,9 mmol/l (<35mg/dl) l gim.
4. Tng LDLC (Low Density Lipoprotein Cholesterol)
a. Bnh thng: LDL-C trong mu <3,4 mmol/l (<130
mg/dl)
b. Tng gii hn: 3,4 4,1 mmol/l (130-159 mg/dl)
c. Tng nhiu khi: > 4,1 mmol/l (>160 mg/dl)
85
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86
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ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
t
t
igh Po
r
y
Hnh 6-1. Cu
p trc ca lipoprotein.
Co
III. Nguyn tc iu tr ri lon lipid mu
87
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88
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IV. iu tr c th
A. Ch n v sinh hot
1. Dng ch n gim Cholesterol v calo (nu
bnh nhn bo ph). Gm 2 bc:
a. Bc 1: thnh phn cht dinh dng n hng
ngy c lng acid bo bo ho < 10 %, tng s
cc cht bo khng qu 30 % v lng
Cholesterol phi < 300 mg/ ngy. Nh vy l cn
trnh hoc gim cc cht m ng vt, trng, sa
nguyn, ph tng ng vt, cc loi pho-mat,
kem... Tng cng n hoa qu ti, rau, v cc
loi ng cc vi lng tinh bt chim khong 55 60 % khu phn.
d
rve trn
e
b. Bc 2: c p dng khi thc hin
bc
s
re
tsbc
n ny lm
sau 6-12 tun khng kt qu. Trong
h
g
i om.v
r
l
l ho
c xung < 7%
gim tip lng acid bo bo
oo.
v. A ah<
e
khu phn v lng Cholesterol
200
mg/ ngy.
o
inl 20@y
F
c. Thi gian iu chnh
8. ch0 n v mt s lu :
00 ity2
2
c
Nu chhcn
t iu
oto chnh ch n theo nh ch
P
g
i
r
nh
py ni trn th thi gian cn t nht l 6
Co
thng.
C 6-8 tun nn kim tra li lng
Cholesterol mu. Ch n phi c duy tr
lu di cho d c dng thuc hay khng dng.
Cn lu hn khi dng ch n ny ngi
gi v ph n c thai.
bnh nhn b tng TG, cn hn ch m
ng vt, ng v ru.
Gim cn nng cho nhng bnh nhn bo ph.
Nn bt u gim dn dn lng calo hng
ngy, thng hn ch mc 500 calo/ngy.
Tp th lc l rt quan trng, n c th lm
gim c LDL-C v tng HDL-C. Tp th
lc cn lm gim cn nng, gim huyt p, v
gim nguy c bnh mch vnh.
89
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B. iu tr bng thuc
1. Cc nhm thuc:
a. Cc loi resins gn acid mt: nh
Cholestyramine (Questran), Colestipol (Colestid):
Cc thuc ny khng hp thu qua rut, n gn
vi acid mt lm gim hp thu ca chng. Do
vy n s lm tng chuyn ho t Cholesterol
sang acid mt trong gan, lm gim lng
Cholesterol d tr trong gan v lm tng hot
tnh ca th th vi LDL ca gan. N lm
gim LDL-C ti 30%, lm tng HDL-C
khong 5 % nhng lm tng nh TG. Do vy
thng dng kt hp vi thuc khc v khng
d
dng khi TG tng cao.
rve
e
s
e
Liu thng dng: Questran 8 t
g/ngy
s r 16
h
vn 10
.
g
i Colestid:
chia 2 ln dng trong ba ln,
r
l o.com
. A aNn
30 g/ngy chia lm 2eln.
ho khi u bng
v
o
l
y
@
liu thp sau tng
in dn.
. F 2020
8
0
Tc dng ph
th gp bao gm: to bn,
20 occ
ity
t bun
t
au bng,
nn,
nn, nng rut... Ch
h
o
P
ig
r
y
khi
p dng chung cc thuc khc c th lm
Co
gim hp thu cc thuc .
b. Nicotinic acid (Niacin): y l mt loi Vitamin
tan trong nc, c ch gan sn xut ra cc
Lipoprotein. Cc thuc ny:
Lm gim VDLD-C ti 50%, lm gim LDLC ti 25% v tng HDL-C 15-35%.
Liu bt u nn thp khong 100 mg x 3 ln/
ngy, sau c th tng liu ti khong 2-4
g/ngy.
Tc dng ph: Cm gic bng da rt hay
gp (hu nh gp tt c cc bnh nhn). C
th trnh bng cch ung thuc trong ba n
hoc ung Aspirin 100 mg trc mi ln dng
thuc 30 pht. Cc tc dng ph khc bao
90
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(LB)
Lovastatin
(Mevacor)
Pravastatin
(Pravachol)
Simvastatin
(Zocor)
Fluvastatin
(Lescol)
Atorvastatin
(Lipitor)
20mg
80 mg
LDL-C
vi LT
40%
HDL-C
vi LT
9,5%
10-20
mg
20 mg
40 mg
34%
12%
80 mg
47%
8%
20-40
mg
10 mg
80 mg
36%
5,6%
80 mg
60%
5%
1998;40:117-22.
ht Pot
rigAssociation.
2. American Diabetes
Management of dyslipidemia in
y
p
adults with diabetes.
Co Diabetes Care 1999;22:Suppl 1:S56-S59.
3.
4.
5.
6.
7.
8.
94
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9.
10.
11.
12.
13.
14.
ts
gh m.vn
i
r
o
l
Al hoo.c
.
v
a
oe
inl 20@y
F
8. 0
00 ity2
2
c
ht Poto
rig
py
Co
95
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tng huyt p
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
t
h Po
rig
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
t
h Po
rig
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
t
h Po
rig
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
t
h Po
rig
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
t
h Po
rig
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
t
h Po
rig
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
t
h Po
rig
A. Mc ch v nguyn tc iu tr
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
t
h Po
rig
2. Hn ch ru:
a. Nu dng qu nhiu ru lm tng nguy c tai
bin mch no bnh nhn THA, lm tng tr
khng vi thuc iu tr THA.
b. Mt s iu tra cho thy nu dng lng ru
thch hp th c th lm gim nguy c bnh mch
vnh (hiu ng ngc).
c. Do lng ru nu c dng cn hn ch t hn
30 ml ethanol/ngy (t hn 720 ml bia, 300 ml
ru vang v 60 ml ru Whisky).
d. Tuy nhin, vi mt s dn tc m s cn nng
khng nhiu (nh ngi dn nc ta) th lng
ru nu c dng ch nn bng mt na lng
ru ni trn.
3. Tng cng luyn tp th lc:
a. Nu tnh hung lm sng cho php nn khuyn
khch bnh nhn tp th dc u.
b. Ch luyn tp cn u n t nht 30 - 45
pht/ngy v hu ht cc ngy trong tun.
c. Vi nhng bnh nhn c triu chng hoc nguy
c bnh mch vnh cn phi cho bnh nhn lm
cc nghim php gng sc th lc trc khi quyt
nh cho bnh nhn ch tp th lc.
4. Ch n:
a. Gim mui (Natri), c chng minh lm
gim s huyt p v nguy c bin chng bnh
nhn THA. Ch n gim mui nn thc hin
vi lng mui < 6 g NaCl/ngy hoc < 2,4 g
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
t
h Po
rig
ISA
Co
Cc loi thuc
Liu u
py
50 mg x 2
50-100 mg
200 mg x 2
Metoprolol
Metoprolol XL
Acebutolol
Propranolol
40 mg x 2
5 mg
Bisoprolol
10 mg
Betaxolol
50 mg
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
t
h Po
rig
Atenolol
40 - 240 mg
200 - 1200
50 - 400 mg
50 - 450 mg
2,5 - 20 mg
5 - 40 mg
25- 100 mg
Liu duy tr
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
t
h Po
rig
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
t
h Po
rig
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
t
h Po
rig
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
t
h Po
rig
Co
py
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t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
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t
h Po
rig
b. C ch tc dng:
Cc thuc chn knh calci lm gin h tiu
ng mch bng cch ngn chn dng canxi
chm vo trong t bo c trn thnh mch.
Cc tc ng trn nhp tim v sc co bp c
tim tu thuc vo tng phn nhm thuc.
c. c im:
Cc thuc nhm DHP th h sau
(Amlordipine, Felodipine, Isradipine...) tc
dng tng i chn lc trn mch v c tc
dng h HA tt, t nh hng n chc nng
co bp c tim v nhp tim, c tc dng ko di
nn c th dng liu duy nht trong ngy.
Nifedipin lm nhp tim nhanh phn ng. N
c nh hng n sc co bp c tim nhng
khng nhiu bng Verapamil v Diltiazem.
Verapamil v Diltiazem c nh hng nhiu
n ng dn truyn gy nhp chm v c
nh hng nhiu n sc co c tim.
d. Tc dng ph:
Verapamil c th gy to bn, nn, au u,
h huyt p t th.
Diltiazem c th gy nn, au u, mn
nga...
Cc DHP c th gy ph cc u chi, bng
mt, au u, mn nga.
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
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t
h Po
rig
Co
py
THA
Aldosterone
Men chuyn
Bradykinin
Karikinin
Cc peptid bt hot
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
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h Po
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Angiotensin II
Angiotensin I
(-)
Renin CMC
Angiotensinogen
Co
py
er
res
s
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v. A ahoo
e
o
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h Po
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l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
t
h Po
rig
b. Ch nn s dng cc thuc ny ti mt s n v
hi sc tch cc (c trang thit b k thut v
iu kin theo di tt bnh nhn).
12. Cc thuc h HA dng theo ng di li:
a. Trong mt s trng hp cp cu dng thuc theo
con ng ny cho kt qu tt. Hai loi thuc hay
dng l Nifedipine v Clonidine.
b. Nifedipine cho ngm di li bt u c tc
dng trong vng 30 pht. Loi vin nang 10 mg,
cho cn, nhai v nut th tc dng cn nhanh hn.
Tc dng c th ko di n 4-5 gi theo ng
dng ny. Ch thuc c th gy tt HA qu
nhiu v nhanh. Khng nn dng trong trng
hp bnh nhn b NMCT cp hoc suy tim cp.
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
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h Po
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py
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e
o
inl @y
. F 2020
8
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2 tocit
t
h Po
rig
Nitroglycerin
- TD: 1-2 pht
- KD: 3-5 pht
Esmolol
- Tc dng:
1-5 pht
- Ko di:
10 pht
Phentolamine
- TD: 1-2 pht
-KD:3-10 pht
Hydralazine
- Tc dng:
10-20 pht
- Ko di:
3-6 gi
Nicardipine
- Tc dng:
1-5 pht
- Ko di:
3-6 gi
Enalaprilat
- TD:5-15 pht
- KD: 1-6 gi
F.
Co
E.
D.
C.
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
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h Po
rig
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
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h Po
rig
Thuc li tiu
Thuc chn th th giao cm
Co
py
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l
v. A ahoo
e
o
inl @y
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h Po
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Khng p ng
C cc tc dng ph
Dung np tt nhng
p ng khng
Khng t c ch iu tr THA
Bt u loi thuc tc dng ko di, liu duy nht trong ngy, liu
thp. iu chnh liu. C th kt hp liu thp cc thuc khc
Ch nh bt buc:
A
B
C
Hnh 8-1. Hnh nh xut huyt no (A), nhn no (B), v
phnh d dng mch no (C) gy TBMN.
8. Chc dch no tu v lm in no khng cn
phi lm thng quy i vi tt c nhng bnh nhn
nghi ng t qu. D sao th chc dch no tu vn
c gi tr trong nhng trng hp nghi ng xut huyt
nh di mng nhn. Nhng bnh nhn nghi c vim
mch, cng c bt thng trong dch no tu: s
lng t bo tng cao (a s l bch cu lymph) v
128
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135
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136
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2.
3.
4.
5.
6.
7.
8.
9.
138
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ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
139
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d
rve
e
s
re
ts MC
n
Hnh 9-1. Phn loi tch thnh
theo
h
g
i om.v
r
l
l .c
DeBakey v Stanford.
v. A ahoo
e
o
lphu,
y ty vo on tn
3. Phn loi theo v tr gii
Fin020@
.
thng.
08 2
20 ocity
t ogian
4. Phn loi theo
b bnh:
hthi
Pt
rig
y
a. Cp Ctnh:
op thi gian k t khi khi pht 2 tun.
b. Mn tnh: thi gian > 2 tun, khong mt phn ba
s bnh nhn thuc nhm mn tnh.
T l t vong tng dn ln trong vng 2 tun l u
tin, t cc i vo khong 75-80%, to ra mt
ngng t nhin v din bin bnh.
5. Phn loi ca Svensson: mi xut gn y, nh
k thut chn on hnh nh mi, l:
a. Tch thnh MC kinh in do ni mc b tch
ra chia MC thnh hai lng gi v tht, c hoc
khng thng vi nhau qua cc vt rch ni mc,
chnh lch p lc gia hai vng ch t 15-25
mmHg nn lng gi c khuynh hng phng ln
140
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ed
Hnh 9-2. Phn loi tch thnh MC theoesSvensson.
erv
r
tsthnh
n MC
b. Huyt khi hoc chy mu trong
h
g
i om.v
r
l
thng do t cc mch nui
gy xut
.c
Al ooMC
ev. yahMC,
huyt/huyt khi tronglothnh
lm thnh
0@ loi 1, v ra hoc
Fin02thnh
MC dy ln, tin8.trin
2
0
ty
khi hn vit 220tp
oci khc bit theo cn nguyn:
t
h
o
P thnh nang Erdheim-Gsell hoc
hoi t lp
rig gia
y
p
to mng
x va - vi loi ny khng th chn
Co
on c khi chp mch m phi dng cc
phng php chn on khc.
c. Tch thnh MC khu tr gy phng thnh
MC: khng th chn on trn lm sng, song
pht hin c di hnh nh khi phng khi
chp mch hoc chp ct lp mch mu.
d. Lot v nt mng x va MC: thng gp
MC bng tuy cng thy MC ngc, cc mng
x va lot c th tin trin thnh tch thnh
MC kinh in hoc v bung mng x va, gy
bnh cnh tc mch do cholesterol.
141
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a. Tui gi.
b. Thoi ho lp gia: hi chng Marfan, hi chng
Ehlers-Danlos.
c. Hi chng Noonan, hi chng Turner, vim ng
mch t bo khng l.
d. Thai nghn.
Trong s cc yu t ni trn th tui v tng huyt p
khng kim sot tt l hai yu t nguy c thng gp nht.
Thai nghn lm tng nguy c ca phnh tch MC: 50%
bin c xy ra tui < 40, trong ba thng cui hoc giai
on sau . Nguy c cng cao ph n c hi chng
Marfan v gin gc MC t trc.
III. Triu chng lm sng
d
rve
e
s
A. Triu chng c nng
re
ts vn
h
.
g
1. au ngc l triu chng thngllgp
ri cnht
om (95%), v
.
. A ahoo(61%) hoc sau
tr thng gia ngc phaevtrc
o
l
y
in MC
(36%), ph thuc vo v. Ftr
0@ b phnh tch (tch
2
0
08 ty2 au ngc pha trc, tch
thnh MC ln thng
20 ocigy
t
t
thnh MC ixung
gy au ngc pha sau,
gh Pothng
r
y
au lng,oau
p bng. Cm gic au c th au chi, d
C
di, nh dao m (51%), nhng ni bt l s xut
hin au t ngt nhanh chng t mc ti a (85%).
Cm gic au khi tch MC t khi lan ln c, vai,
xung hai cnh tay nh au tht ngc in hnh ca
hi chng mch vnh cp. Hng lan ca cn au
xung lng, bng, bn v i l ch im cho qu
trnh tch thnh MC lan i xa. Khng t bnh nhn
hon ton khng au. Mt s khc c khong thi
gian hon ton khng au ri au tr li. y l du
hiu bo ng cho nguy c v ca phnh tch MC.
2. Mt s biu hin him gp khc bao gm suy tim
huyt (do HoC nng khi phnh tch on MC ln),
ngt (4-5% trng hp do v vo khoang mng tim,
143
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p tim), tai bin mch no, lit hai chi di, ngng
tim...
B. Triu chng thc th
1. Huyt p cao: a s l nguyn nhn, phn cn li l
hu qu ca tch thnh MC on xa do phnh tch
lan n ng mch thn gy thiu mu thn. 25%
trng hp tt HA tm thu ng mch < 100 mmHg.
Nguyn nhn tt p v sc tim trong tch thnh MC
do h van MC nng cp tnh, v khi phng, p
tim, hoc ri lon chc nng tm thu tht tri. Khi
phnh v hoc nt vo khoang mng tim c th nhanh
chng dn n trn mu v gy p tim cp, ri t
vong. Cn ch n du hiu gi tt huyt p do
d
ng mch di n b chn p.
rve
e
s
re
ts vtch
2. H van MC: 18-50% cc trng hp
h
. n MC
g
i omnng,
r
l
on gn c h van MC t nh
n
c th
Al hoo.c
.
v
nghe thy ting thi tm trng
oe ya ca h van MC
@
inl 2H
F
trong s 25% s bnh8nhn.
. 20 0 van MC nng, cp
0
tnh l nguyn nhn
20 gy
ityt vong ng hng th hai
t otoc
h
P
(sau v phnh
thng biu hin lm sng
rig MC),
y
p
trong tnh
Co trng tru tim mch cp tnh v sc tim. C
ch gy h van MC bao gm gin vng van, gin
gc MC, rch vng van hoc l van, ng khng
kn l van MC (do lng gi trong MC khng
cn, mt nng ca l van hoc chnh mnh nt ni
mc cn tr s ng kn van MC. Ri lon vn
ng thnh tim gp trong 10-15% ch yu do gim
ti mu mch vnh v: lng gi pht trin vo
mch vnh, tch thnh MC tin trin vo MV, tt
huyt p. MV bn phi thng b nh hng nhiu
hn so vi bn tri, d him khi xy ra ng thi tch
thnh MC v nhi mu c tim (1-2%). C tim thiu
mu dn ti ri lon chc nng tm thu tht tri l
yu t gp phn gy tt huyt p v sc tim bnh
nhn tch thnh MC.
144
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huyt...
Tuy vy,
. F 2020
8
0
nhng du hiu ny
y tnh cht gi ch khng
0ch c
2 tocit
c gi tr chnigon
nh.
ht Poxc
r
py
2. in tm
Co : khng c hiu, hay gp nht l dy
tht tri, cc du hiu khc bao gm ST chnh xung,
thay i sng T hoc ST chnh ln. Du hiu thiu
mu c tim c th gp nu km tn thng ng
mch vnh, do vy cn ngh n kh nng ny nu
hi chng vnh cp c kiu au d di bt thng.
Cc du hiu ca vim mng tim v bloc dn truyn
nh tht cng c th gp trn in tim .
3. Tch thnh MC c th nhanh chng dn ti t vong
nu b st chn on v khng iu tr. Do la
chn phng tin chn on no ph thuc ch yu
vo kh nng thit b tng c s: thng thng l
chp ct lp vi tnh (CT), chp cng hng t ht
nhn (MRI), siu m qua thc qun (STQ) v chp
mch bng thuc cn quang. Cc phng php ny
147
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mch gi gv
ht tht,
Pot mc h van MC. Ch
ri hnh
y
tng cng
nh cho php chn on r hn
op
C
khi kt qu ca cc ch chp trn khng th
kt lun v huyt khi hoc dng chy c hay
khng. Nhng k thut chp mi nh fastgradient echo, K-space acquistion cho php gim
thi gian xt nghim hn na m khng gim
chnh xc. So snh MRI, CT v STQ cho thy
nhy v c hiu ca MRI cao hn nhm
c bnh van MC. Hn na, MRI cho php dng
li hnh nh 3 chiu bt k gc no.
b. Hn ch ca MRI ch: khng phi c sn mi
bnh vin, thi gian thao tc lu hn, c chng
ch nh mt s nhm bnh nhn, kh theo di
cc du hiu sinh tn nht l nhng trng hp
huyt ng khng n nh, Hn na MRI khng
149
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o
thnh MC... Tuy
coi l phng tin hng
t
gh Pot
i
r
u chn
on, nht l cho php nh gi c
opy
thng C
tn ng mch vnh km theo nu c, song
ngy nay chp MC bng thuc cn quang t c
dng do ko di hoc tr hon khong thi gian qu
bu phu thut kp thi. Hnh nh gii phu ng
mch vnh ch ng vai tr quan trng i vi quyt
nh m khi c tc l vo ng mch vnh do mnh
ni mc hoc bnh nhn c bnh ng mch vnh
mn tnh. Chp ng mch vnh trong giai on cp
ch nn u tin cho bnh nhn bit chc chn hoc
gn chc chn bnh ng mch vnh.
8. nh lng men trong huyt thanh: c hin tng
gii phng c hiu cc myosin chui nng (Mhc) ca
t bo c trn vo huyt tng khi c tch thnh
MC (nng Mhc trong huyt tng bnh thng
151
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c. V tr ca vt rch ni mc u tin: cc vt
rch, nt ni mc u, cui cng nh nhiu vt
rch nt on gia c th thy trc tip trn
MRI hoc siu m qua thc qun. Dng chy qua
cc vt rch ni mc thng theo hai chiu, vi
nhiu loi ph a dng trong k tm trng.
Chnh p qua vt rch u tin him khi cao do
p lc trong lng gi cng ngang trong lng tht.
d. Tch thnh MC khng thng gia hai lng tht
v gi ch chim khong 10%, thng d hnh
thnh huyt khi trong lng gi hn (cn phn
bit vi huyt khi trong thnh MC). Loi tch
thnh MC cn thng thng thy r dng mu
v c th thy c vt rch u v cui trn vng
tch ni mc.
d
rves cc
e
s
Nh vy c th thy rng: mi mt trong
re
htstim
bin php chn on hnh nh nh siuigm
.vn qua thc
r
m
o
l
l o.cch cn quang
qun, chp CT, MRI v chp ng Amch
o
v. nht
e
ah nh. La chn
u c nhng u hay nhc im
o
l
y
Fin020@ vo kh nng ngun
bin php chn on s ph
8. thuc
2 thun tu theo l thuyt.
0
lc sn c ti ch hn 2l0 ch
da
ity
c
o
ht Pot tp A th mc ch chnh l a
i vi phnh tch
rig MC
y
p
bnh nhn i
Com cng sm cng tt.
Bng 9-1. Kh nng chn on tch thnh MC.
Kh nng chn on Chp
Chp
Chp
Siu
MC
CT
MRI m TQ
V tr rch u tin
++
+
+++
++
Lng gi/ lng tht
+++
++
+++
+
Thng tn nhnh bn
+++
++
+
Trn dch mng tim
++
+++
+++
Thng tn MV
+++
++
H van MC km theo
+++
+
+++
nhy chung (%)
88
83-94
98
98-99
c hiu chung (%)
95
87-100
98
77-97
Siu m tim qua thc qun v chp CT c th thc
hin nhanh nht i vi nhng tnh hung cp cu, trong
153
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t chung
t ti vin xp x 30% nu tch
a. T l t vong
igh Po
r
y
thnhopMC on gn, 10% vi tch thnh MC
C
on xa. T l ny khng h gim trong 3 thp k
va qua d c rt nhiu tin b trong chn
on v iu tr. Nhng yu t d bo t vong ti
vin bao gm: tch thnh MC on gn, tui >
65, cn au c tnh cht di chuyn, c sc, c
chnh lch mch gia cc chi, c du hiu thn
kinh khu tr.
b. T l sng ca nhng bnh nhn tch thnh MC
on gn c phu thut v ra vin tt l 6580% sau 5 nm v 40-50% sau 10 nm. Tin
lng ca bnh nhn tch thnh MC on xa rt
a dng ph thuc vo tng nhm bnh nhn.
Tuy nhin, tin lng xa ti hn bnh nhn c
tch lan rng ngc dng v pha quai MC hoc
156
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o
nh cho nhng
ht Pot
rig khoa
iu trpyni
tht bi. V lu di, cn nghin
o
cu Cthm xc nh nhm bnh nhn no thc
s c li nu m.
c. T l t vong sau 5 nm ra vin bnh nhn c
iu tr hp l l 75-82%.
2. Mt s bnh cnh cn lu :
a. Tch thnh MC c tt huyt p: nguyn nhn
hng u l v thnh MC hoc p tim. Cn lp
tc b mu, dch v chuyn m ngay. Nu phi
chc dch mng tim nng huyt p trc khi
chuyn n phng m th cng khng nn ly
nhiu m ch ly lng dch mng tim
huyt p mc chp nhn c. Nu phi dng
thuc vn mch nng huyt p th nn dng
Norepinephrine hoc Phenylephrine (khng nh
157
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tim 60 hoc huyt p trung bnh ng mch 6070 mmHg). Nu c chng ch nh vi chn , c th
dng thuc chn knh canxi. Sau khi bnh nhn
dng chn , c th thm dn Natri Nitroprusside
ng tnh mch a huyt p ng mch ti
ngng mong mun ri duy tr: khi u vi liu 20
g/pht, iu chnh dn duy tr huyt p ng
mch trung bnh khong 60-70 mmHg. Trng hp
khng tc dng, c th dng Labetalol (chn c v
giao cm) hoc Trimetaphan (c ch hch thn
kinh).
Bng 9-2. Mt s thuc h huyt p ng tnh mch.
Thuc
Liu ban u
Liu duy tr
d
Thuc c la chn u tin
rve
e
s
re mch 4Propanolol
1 mg TM/3-5 pht, ti a 2-6 mgstnh
t vn
h
.
g
6,15 mg/kg
6h/ln
l ri .com
l
2 mg/pht
Labetalol
10 mg TM/2 pht, sau ev. Atruyn
oo
ah
o
l
y
20-40 mg 10-15 Fin 0@ TM, chnh n 5-20
2
.
mg/pht
pht/ln, ti a0300mg.
08 ty20
2 oci
t
t
Esmolol
30 mg TM
truyn 3-12 mg/pht
igh Po
r
y
Metoprolol
5 mgopTM 5 pht/ln
5-10 mg TM 4C
6h/ln
Nu c chng ch nh vi thuc chn giao cm
Enalaprilat
0,625 mg tnh mch
0,625 mg TM 46h/ln
Diltiazem
0,25 mg/kg TM/2 pht, Truyn 5 mg/gi,
dn
2,5-5
nu khng c tc dng, tng
ti
a
nhc li 0,35 mg/kg TM mg/gi
15mg/gi
sau 15 pht
Verapamil
0,075-0,1 mg/kg ti 2,5-5 5-15 mg/gi truyn
mg/kg /2 pht
TM
4. Bnh nhn tch thnh MC on xa, khng bin
chng, c th ch iu tr ni khoa trong giai on
cp do t l sng st vn t gn 75% d c m
hay khng. Hn na, bnh nhn tch thnh MC
159
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ht Pot
1. Ch nh m:
rig
y
op nhn c tch thnh MC cp on gn,
a. MiCbnh
tr trng hp khng th phu thut do cc bnh
l nng km theo. Chng ch nh thng gp l
t qu mi do nguy c vng nhn no chuyn
thnh xut huyt no khi dng chng ng v do
hin tng ti ti mu sau phu thut.
b. Ch nh phu thut nhm tch thnh MC cp
on xa bao gm: khi phnh tch phng ln
nhanh chng, thm mu phc mc, do v, au
ko di khng kim sot c v/hoc thiu mu
chi hoc tng, tch lan ngc v MC on ln,
c h van MC hoc bnh nhn c hi chng
Marfan.
160
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163
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Potocity2020@yahoo.com.vn
164
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
9.
10.
11.
12.
13.
14.
15.
e
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
165
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
Iu tr
Mt s ri lon nhp tim thng gp
I. Cc thuc chng lon nhp
A. i cng
1. Ri lon nhp tim (RLNT) l mt trong nhng vn
thng gp trong cc bnh ni khoa ni chung v tim
mch ni ring.
2. Cc thuc cha lon nhp tim rt phong ph v khc
bit nhau v c ch tc dng, cch dng, tc dng
ph...
3. Vn s dng cc thuc chng lon nhp cng
d ht
rvebit v
e
s
sc tinh t v kh phc tp, i hi s rhiu
e
ts n
bnh l cng nh c im ca ccrithuc
lon
gh m.vchng
l .cto lm sng
l
nhp. Cc nghin cu cng nh
thc
A hoo
ev. lon
a
o
l
cho thy chnh cc thuc chng
in 20@y nhp cng c th
F
. 0khc trm trng hoc cc
gy ra nhng ri lon08nhp
0 ity2
2
toc
bin chng nguyt him.
igh Po
r
4. Trc mt
opytrng hp c lon nhp tim i hi ngi
C
thy thuc phi c thi hp l trong vic nhn
nh kiu RLNT, la chn loi thuc ph hp, nm
vng tc dng, c tnh, tc dng ph, tng tc
thuc...
B. Phn loi thuc chng lon nhp
1. V tnh cht phc tp ca cc thuc chng lon nhp,
do vic phn loi cng c nhiu cch khc nhau.
Tuy nhin cho n nay, hu ht cc bc s thc hnh
lm sng s dng cch phn loi n gin ca
Vaughan William (bng 10-1) v phn nhm ca
Harrison trong vic phn chia mt cch chi tit nhm
I ca Vaughan William.
167
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168
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Disopyramide
(Norpace, Rythmodan)
py
Procainamide
(Procan SR, Procanbid)
Co
Gan: 50%
Thn: 50%
Gan : 40%
Thn: 60%
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
RLTH, h TK, h
mu, h HA,
Lupus.
Khng
cholinergic, gim
co bp c tim, h
HA, xon nh.
ved
169
nng
Digoxin, tng
tc dng ca
Warfarin, tng
nguy c xon
nh nu phi
hp vi TCLN
nhm III.
Vi nhm III
lm tng nguy
c xon nh.
Vi nhm III
lm tng nguy
c xon nh.
Tng tc
thuc
Nhm IB
Lidocaine
(Xylocaine)
170
py
Phenintoin
(Dilantin)
Co
Torcainide
(Tonocard)
Mexiletine
(Mexitil)
Gan
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
13,5
Ung:
400- Ung:
800 mg
400-800
mg mi 8
gi
24
TM:
10-15 Ung:
mg/kg trong 1 400-600
mg
mi
gi
ngy
Gim nng
bi Rifamycin
Phenintoin;
Tng nng
do Theophyllin
nng bi
chn bta giao
cm, Cimetidine
H TK, h tiu
ho, h mu
Gan: 40%
Thn: 60%
Gan: 90%
Thn: 10%
H TK vi liu
cao; gim dng
mu ti gan khi b
suy tim nng hoc
sc
H TK, h tiu
ho, nhp chm,
h HA
Gan: 90%
Thn: 10%
ved
Morcizine
(Ethmozine)
2-32
Ung:
150-300
mg mi 8
gi
Gan
Tng nng
bi:
Amiodarone
Tng bloc nh
tht nu dng
cng
thuc
chn bta giao
cm hoc chn
knh canxi.
Tng nng
Digoxin; tng
hot tnh ca
thuc chn bta
giao cm.
ved
171
RLTH, gim co
bp c tim, gy
lon nhp, tng
nguy c t vong
bnh nhn sng
st sau t t
Gan: 50%
Thn: 50%
py
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
Nhm II
Metoprolol
H TK, gim co
bp c tim, gy
lon nhp. Chng
ch nh khi c
tn thng thc
th cu trc tim
Gan: 65%
Thn: 35%
Co
Propafenone
(Rythmol)
Nhm IC
Flecanide
(Tambocor)
H TK, h tiu
ho, c th gy
lon nhp
Gan: 90%
Thn: 10%
6-13
Ung:
200-300
mg mi 8
gi
(Betaloc, Lopressor)
172
Nhm III
Amiodarone
(Cordarone, Pacerone)
py
Dng
esterases
trong mu
Gan
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
25-110 Gan
ngy
TM:
mg/kg
100
mg
mi 8-12
gi
Co
Esmolol
(Breviloc)
Propranolol
(Inderal)
5 pht
Flecanide
v
Digoxin; tng
nguy c xon
nh nu dng
cng vi thuc
(ging nh trn)
(ging nh trn)
bi thuc chn
knh can xi
ved
Sotalol
(Betapace)
Nhm IVa
Diltiazem
py
Ibutilide
(Corvert)
Co
Bretylium torsylaye
TM:
mg/kg
Gan: 20%
Thn: 80%
Gan
Gan: 90%
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
TM:
5-10 TM: 1-2 7-9
mg/kg, nhc mg/pht
li ti tng
liu
l
30mg/kg
2-12
TM: 0,015 0,025 mg/kg
trong 5 pht
nhm IA
Tng hot tnh
ca thuc chn
canxi,
tng
nguy c xon
nh nu dng
vi thuc nhm
IA hoc li tiu
H HA, RLTH
Lm tng nguy
c h HA khi
dng vi li tiu
hoc thuc gin
mch
dng
Xon nh, h Trnh
HA, au u, cng cc thuc
lm ko di QT
RLTH
ved
Verapamil
py
10
giy
Thn
Gan
TM/Ung: 36-48
0,1-0,75
mg mi 8
gi trong
ngy
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
Nng bng, kh
th, au ngc, v
tm thu, co tht
PQ
(ging nh trn)
(ging nh trn)
174
Ghi ch: TM: tim Tnh mch; TK: thn kinh; RLTH: ri lon tiu ho; HA: huyt p
TM/Ung:
0,25-0,5 mg
TM: 6 mg
tim nhanh,
nu khng tc
dng nhc li
12 mg tim
nhanh
Co
thuc khc
Digoxin
Nhm IVb
Adenosine
(Adenocard)
TM:
mg
ved
175
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Potocity2020@yahoo.com.vn
176
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
III. Rung nh
Rung nh (RN) l mt trong nhng ri lon nhp rt thng
gp, chim khong 0,4 - 1,0% trong cng ng v gp khong
10% s ngi trn 80 tui.
A. Nguyn nhn
1.
2.
3.
4.
5.
Tng huyt p.
Bnh van tim (HHL).
Suy tim.
Bnh ng mch vnh.
Cc nguyn nhn khc: nhi mu phi; bnh phi
mn tnh tc nghn; cng gip; nhim trng; ri
lon chuyn ho, bnh mng ngoi tim, Phued thut
rv
tim mch...
ese
r
ts
6. Rung nh v cn.
gh m.vn
i
r
o
l
Al hoo.c
.
B. Sinh l bnh
v
e
a
nlo 0@y
i
F
2
1. Cc gi thit v c ch
8. gy0rung nh:
00 ity2
2
a. Vng vo lit ti tnh,
oc l c ch m ngy cng c
Po v c ch nht.
ighchng
nhiu bng
r
opy
b. Gi Cthit v ri lon s pht nhp, s hnh thnh
ngoi v (mt hoc nhiu) nh gy tng tnh t
ng hoc ny c hot ng. Vic t ngoi v
ny bng sng cao tn qua catheter vng vo
ca cc tnh mch phi thu c nhng thnh
cng bc u h tr cho gi thit ny.
2. Nguy c tc mch bnh nhn rung nh s tng vt,
c bit ngi c tui, bnh nhn c tiu ng,
c bnh van tim, tng huyt p, suy tim...
3. Rung nh thng km theo nhp tht nhanh lm cho
cung lng tim b gim i ng k, nht l khi bnh
nhn c cc bnh thc tn tim km theo. Bn thn
rung nh gim khong 20 % lng mu xung tht
trong thi k tm trng. Do , khi RN km theo
177
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Potocity2020@yahoo.com.vn
178
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Potocity2020@yahoo.com.vn
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
Hnh 10-1. Rung nh: sng f nh r chuyn o V1.
E. iu tr
Nhm 3 mc ch:
Gim p ng (tn s) tht.
Gim nguy c tc mch.
Chuyn nhp (a v nhp xoang) v duy tr nhp
xoang.
1. Kim sot nhp tht: Thng thng th nhp tht c
th c kim sot bng bng cc thuc lm chm
ng dn truyn qua nt nh tht.
a. Digitalis:
179
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Potocity2020@yahoo.com.vn
181
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
182
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
chn khi
cc
t ot
P Lu l thuc c thi gian bn
igh bi.
rtht
hoc
y
p
Co cc k di (120 ngy). Thn trng vi cc
hu
bin chng khi dng lu di (ri lon tuyn
gip, nhn m, vim phi k, vim gan, co
git...). Amiodarone c chng minh l lm
gim t l t vong do ri lon nhp tht. Tuy
nhin, trong cc ri lon nhp nhanh nh n
cng c tc dng rt tt c bit l bnh
nhn rung nh. Thng dng di dng truyn
tnh mch pha trong dung dch ng hoc
mui ng trng.
Ibutilide: l mt thuc mi v rt hu hiu
trong iu tr rung nh. Bin chng c th gp
l cn xon nh (gp 1-2%).
Cc thuc dng ung (bng 10-3).
183
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Potocity2020@yahoo.com.vn
C Amiodarone v Procainamide u c
dng ung, trong Amiodarone l thuc hay
c s dng hn c, nht l duy tr nhp
xoang sau khi c chuyn nhp. Lu
nhng tc dng ph ca Amiodarone khi
dng lu di v thi gian bn hu cc k di
ca n. Procainamide khi dng lu di s km
dung np hn, nn thng khng dng loi
ny duy tr nhp xoang.
Quinidine l thuc trc y thng c
dng nht chuyn nhp v duy tr nhp
xoang. Tuy nhin Quinidine c rt nhiu tc
dng ph v bn thn n cng l yu t c
th gy ra cc ri lon nhp khc. N dtng
rve
tc vi mt s thuc khc nh Digoxin,
ese khng
r
ts vndng cc
vitamin K, Verapamin, lm tng
.
gh mtc
i
r
o
thuc ny khi dng cngAvi
ll nhau.
c
.
. ahoo
evnhm
Sotalol l thuc thuc
III nhng c tc
o
l
n 0@y
i
F
2
dng chn bta8. giao0 cm. N c th dng
y2 nhng cn ch cc tc
00 itnh,
bnh nhn 2rung
c
o
t ot
P quan n chn bta giao cm v
dngrph
igh lin
y
p
c
Co th gy xon nh do lm QT ko di.
Flecainide v Propafenone l thuc thuc
nhm IC (bng 10-3) c tc dng tt bnh
nhn rung nh. Chng l thuc c kh nng
dung np tt nhng c th lm tng t l t
vong bnh nhn c ri lon nhp tht do
bnh ng mch vnh. Do , cc thuc ny
thng khng c ch nh bnh nhn rung
nh do cn nguyn bnh ng mch vnh
hoc bnh c tn thng cu trc tim.
Disopyramide thuc nhm IA, c tc dng
tng t Procainamide v Quinidine. Tuy
nhin thuc ny gy gim co bp c tim
nhiu, do khng nn dng nhng bnh
nhn c ri lon chc nng tht tri.
184
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Potocity2020@yahoo.com.vn
iu tr hrung
o
t ot
Pnhiu vo k thut v tnh trng
ig
rthuc
cn ph
y
p
o
bnhC nhn. Phu thut trong iu tr rung nh
thng ch c thc hin trong khi tin hnh cc
cuc phu thut khc bnh nhn (v d khi m
thay van tim, m lm cu ni...).
IV. Cung ng nh
Cung ng nh (atrial flutter) l mt hnh thi nhp nhanh
trn tht kh hay gp v thng khng tn ti lu di v c xu
hng chuyn v nhp xoang hoc chuyn sang rung nh.
A. Triu chng lm sng
1. Biu hin lm sng rt khc nhau tu theo bnh tim
thc tn c sn, theo p ng tht chm hay nhanh
m bnh nhn c th c cm gic hi hp trng ngc.
186
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Potocity2020@yahoo.com.vn
187
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
d
rve
e
s
re
ts vn
h
.
g
Hnh 10-2. Cung nh 2:1.
l ri .com
l
oo
v. Ac
em
ah bloc nh tht 2:1
5. Trong trng hp cung nh
o
l
y
@
Fin020sng
th i khi kh chn on
F ln vi sng T.
8. 2do
0
y s nghim php lm chm
0 mt
t
2
i
Khi cn thitt lm
toc
Po l ra sng F r hn (v d xoa
gh lm
i
p ng tht
r
y
p
xoang cnh,
Co tim Adenosin...).
D. iu tr
1. Lm gim p ng tht:
a. L bc u tin cn thc hin cho mi bnh
nhn cung nh, c bit khi p ng tht nhanh
c th gy nh hng n huyt ng.
b. Cc thuc c th dng l Digitalis loi tim, tc
dng nhanh (Cedilanide, Isolanide), hay mt s
thuc chn knh canxi hoc chn bta giao cm.
c. Digitalis nn l thuc c la chn hng u
lm gim p ng tht.
2. Cc thuc chuyn nhp v duy tr:
188
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Potocity2020@yahoo.com.vn
3.
4.
5.
6.
189
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
nt
nh tht
F n020@
.
v ng dn truyn08ph 2 rnh nh tht (trong hi
20 citya s cc trng hp (95%)
chng WPW). Trong
t otoi
h
P ca vng vo li l qua ng
rig (xui)
ng i xung
y
p
Co chm ca nt nh tht v i ngc ln theo
dn truyn
ng dn truyn nhanh. Vic khi pht ra cn nhp
nhanh thng l do hin tng ny c khi c mt
ngoi tm thu nh hoc ngoi tm thu tht. Ngoi tm
thu nh lm bloc dn truyn xui ng dn truyn
nhanh v khi xung ng ch xung theo ng
dn truyn chm, vng li kh cc ng dn truyn
nhanh gy vng vo li. Kt thc cn nhp nhanh l
kt qu ca vic bloc ng dn truyn chm.
2. CNNKPTT c vng vo li nh tht c lin quan
n mt ng dn truyn ph v n: khng th
hin trn in tim b mt.
190
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Potocity2020@yahoo.com.vn
191
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
d
rve
e
s
re
ts vn
h
.
g
Hnh 10-3. Cn nhp nhanh kch pht ltrn
ri ctht.
om
l
.
A o
D. iu tr
ev. yaho
o
l
in @
1. Ct cn nhp nhanh:08. F 2020
y
20 ocitcng
a. Cc bin php
ph v c th ct c
t gy
t
h
o
P
g
i
r
cn nhp
py nhanh: C th bo bnh nhn ht su vo
Co ra nhng ng thanh mn (ng tc rn);
ri th
c th xoa xoang cnh (ch trc khi xoa phi
nghe khng thy hp ng mch cnh v xoa
tng bn mt. Xoang cnh nm v tr ngang sn
gip, khi xoa bo bnh nhn nghing u mt
bn, bc s dng ngn tay ci n ln xoang cnh
v day). n nhn cu l mt bin php kh hiu
qu v hay c dng nhng cng kh th bo,
i khi c th gy bong vng mc ca bnh nhn.
b. Thuc u tay nn dng l Adenosine dng ng
tim 6mg. Adenosine gy bloc nh tht hon ton
tm thi v nhiu khi gy tm ngng xoang, do
lm ngng dn truyn trong nt nh tht v
lm ct t vng vo li nt nh tht. V tr tim
192
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Potocity2020@yahoo.com.vn
c.
d.
e.
f.
g.
Digitalis, lm
t chm dn truyn trong nt nh tht
gh Pot
rict
v c oth
c cc CNNKPTT do vng vo li
y
p
C
ti nt nh tht. Tuy nhin, cn thn trng khi
bnh nhn c hi chng WPW hoc c nh
xoa tip xoang cnh sau v Digitalis c th lm
tng nhy cm ca xoang cnh.
Amiodarone l thuc c th cn nhc khi cc
bin php trn tht bi. Nhiu khi bn thn
Amiodarone cng khng ct cn c nhng sau
khi dng thuc ny th c th tin hnh li cc
bin php gy cng ph v, khi s c hiu
qu.
Sc in ct cn c ch nh khi CNNKPTT dai
dng, c nh hng n huyt ng (gy suy tim,
tt huyt p) hoc cc thuc khng ct c cn.
193
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C. in tm
1. T l thm d rt quan trng trong chn on
NTTT.
2. Nht NTT c biu hin l mt nht bp n sm,
phc b QRS thng gin rng, hnh th khc bit so
vi nht bp t nhin ca bnh nhn, sng T v on
ST o hng so vi QRS, khng c sng P i trc.
3. Phc b QRS ca NTTT ny thng n kh sm.
Mt NTTT in hnh thng hay c thi gian ngh
b, tc l khong RRR = 2RR.
4. NTTT c th c nhiu dng (hnh dng khc nhau
trn cng chuyn o), nhiu (cc khong ghp
khc nhau).
d
rve
e
s
5. Khi c mt nht bp nhp xoang xen k
remt NTTT
ts vn
h
. xoang c
g
th gi l NTTT nhp i, v khi hai
nhp
l ri .com
l
A o
mt NTTT gi l NTTT nhp ba...
ev. yaho
o
l
Fin 0@
8. 202
0
20 ity
t otoc
h
P
rig
y
p
Co
196
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Potocity2020@yahoo.com.vn
D. Cc thm d khc
1. Cn lm y cc xt nghim c bn, nht l ch
cc ri lon in gii mu.
2. Siu m tim rt hu ch gip ta pht hin cc tn
thng thc th tim.
3. Holter in tim xc nh cc thi im xut hin,
mc nguy him v s lng NTTT trong 24 gi.
4. Nghim php gng sc th lc c th c ch nh
trong mt s tnh hung nht nh phn bit cc
NTTT c nng (khng c bnh tim thc tn) hay thc
tn (c bnh tim thc tn)...
E. Cc du hiu bo hiu mt NTTT nguy him
1. Xy ra bnh nhn c bnh tim thc tn.
d
rve
e
2. S lng NTTT nhiu.
s
re
hts nhp
3. NTTT i thnh tng chm hoc nhprigi,
.vn ba.
m
o
l
.c ca phc b
Al hooR
4. NTTT n sm (sng R (l
v. sng
e
a
o
y
NTTT) s ri trn sng TFica
nl phc
0@ b tht trc .
2
.
0
5. NTTT a dng, a 2.008 ity2
t toc
F. iu tr
igh Po
r
py
1. i viCoNTTT c nng ( bnh nhn khng c
bnh tim thc tn):
a. Thng l lnh tnh, tin lng tt v khng cn
iu tr c hiu.
b. Ch nn iu tr khi bnh nhn c triu chng c
nng dn dp (au ngc, kh th...).
c. Vic iu tr nn bt u bng loi b cc cht
kch thch (cph, ru, thuc l...). Tp th dc
u n. Nu bnh nhn ang dng cc thuc
khc cn lu n kh nng cc thuc ny c th
gy ra NTTT (li tiu, cocaine, thuc cng giao
cm...). Ch iu chnh in gii trong mu.
d. Thuc la chn (nu cn) hng u cho iu tr
NTTT c nng l mt loi chn bta giao cm
liu thp.
197
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Potocity2020@yahoo.com.vn
o
t ot c
h
c th lm
riggimP t l t vong bnh nhn NMCT
y
p
cp c
Co NTTT (liu lng xem bng 10-3).
e. Ch iu chnh tt cc ri lon in gii (nu
c) v nhanh chng gii quyt cc cn nguyn
nu tm thy.
3. NTTT bnh nhn c bnh tim mn tnh:
a. Vic la chn cc thuc chng lon nhp cho cc
bnh nhn ny phi da trn tnh trng bnh c
th, c bit l chc nng tim cn tt khng, tc
dng ca thuc v kh nng gy lon nhp ca
cc thuc.
b. i vi NTTT sau NMCT: cc thuc nhm IC
(Flecanide, Encainid) hoc IB (Mexitil) khng
nhng khng ci thin t l t vong m c khi
cn lm tng t vong do kh nng gy ra lon
nhp ca chnh cc thuc ny (th nghim
198
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199
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o
QRS. Trong trng
t ot c khng nhn r sng P, nu
h
P qun s thy r rng c s phn
rig thc
lm chuyn
o
y
p
o nh v tht. Trong mt s trng hp ta
ly gia C
nhp
thy c s dn truyn ngc dng lm cho sng P m
ngay sau QRS.
200
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Khng
NNT
Khng
NNT
v phi nhanh
t chng sc in ct cn. Sc in
gh Pot
rich
cn c
nh trong trng hp cn NNT lc
y
op
C
u n nh nhng dng thuc tht bi v c xu
hng nh hng n huyt ng. Thuc s c
ch nh khi c cn NNT nhng tnh trng huyt
ng cn tng i n nh.
b. Thuc:
Lidocaine (Xylocaine) l thuc c la chn
u tin: Tim thng TM 1 - 1,5 mg/kg cn
nng sau truyn TM 1-4 mg/pht.
Procainamid: c dng khi Lidocaine tht
bi hoc c th cho ngay t u.
Amiodarone l thuc nn la chn, nht l
trng hp cn NNT do bnh tim thiu mu
cc b hoc khi dng cc thuc trn tht bi.
202
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203
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A. Nguyn nhn
1. Bm sinh:
a. Hi chng QT ko di bm sinh c km theo ic
(Hi chng Jervell-Lange-Niesel).
b. Hi chng QT ko di bm sinh khng km theo
ic (Hi chng Romano-Ward).
2. Mc phi:
a. Thuc: mt s thuc sau i khi c th gy nn
xon nh:
Cc thuc chng lon nhp: nhm IA, Sotalol,
Amiodarone, Mexiletine, Flecainide...
Mt s thuc hng thn v chng trm cm
(Haloperidol, Amitriptiline...).
d
rve
e
Thuc
khng
sinh
(Ampicillin,
s
re
ts vn
h
Erythromycine...).
.
g
l ri .com
l
Ketoconazol, Astemizole...
. A ahoo
evQT
o
b. Cc ri lon nhp chm
c
l
y ko di.
Fin020@
.
8 2 c bit l h kali hoc
c. Ri lon in gii
y
00 mu,
cit mu cng c th gy xon
2 canxi
o
magi mu.htH
t
o
P
g
nh. pyri
o
d. MtCs nguyn nhn khc: Tai bin mch no,
dng thuc cn quang cha Iod...
206
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207
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phn bit l
8. 20
0
y
0
t do cng thn kinh ph
suy nt xoang
2 ihay
t otoc
h
P
g
giao rcm.
Bnh
thng khi tim 0,04 mg/kg
i
y
p
Atropine
cho bnh nhn th nhp tim ni sinh
Co
ca bnh nhn s tng ti thiu theo cng
thc: Nhp tim tng = 118,1 - (0,57 x tui)
Nu sau tim m nhp tim thp hn nhp ni
trn th chng t c suy yu nt xoang
(nghim php dng tnh).
Nghim php bn nghing (Tilt-table testing):
gip phn bit ngt do cng ph v hay do
suy nt xoang. Nu c nhng cn nhp chm
xut hin khi lm bn nghing, chng t ngt
lin quan n h thn kinh t ng (cng
ph giao cm) hn l do suy nt xoang.
Xoa xoang cnh gip phn bit nhng on
ngng xoang l do cng xoang cnh hay do
suy nt xoang. Trong cng xoang cnh, khi
208
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o
ht mch
Bnh ing
Pot vnh mn tnh.
rg
y
p
c. Thoi
Co ho tin pht ng dn truyn nh tht:
Bnh Lenegre
d. Bnh tim bm sinh:
Bloc nh tht hon ton bm sinh.
Thng lin nh l th nht.
o gc cc ng mch ln.
Bnh h thng.
e. Bnh van tim.
f. Bnh c tim:
Bnh c tim thm nhim: Nhim bt.
Sarcoidosis, Hemochromatosis
g. Nhim trng, vim c tim:
Vim ni tm mc nhim khun.
Vim c tim (Chagas, bnh Lyme, thp tim,
lao, si...).
212
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a. Bloc nh tht
ht Poto I: Ch yu da vo o on
g
i
r
PR trn
pyT, PR ko di trn 0,20 giy ngi
Co trn 0,18 giy tr em vi hnh dng ca
ln v
sng P v QRS bnh thng.
e ya
n
@
i
bnh nhn ny . thng
F 020 do cng ph v qu
2 III m do nhi mu c
08 tycp
mc. Nu l
bloc
0
2 oci
t bnt th nn ch nh cy my to
tim trc
igh Po
rsm.
y
nhp
p
Co trng hp bloc nh tht hon ton mc
Cc
phi thng cn cy my to nhp, trong khi
bloc nh tht bm sinh thng khng cn cy
my to nhp do bnh nhn c s thch nghi
bng cc nhp thot.
Bng 10-7. Cc ch nh cy my to nhp lu di.
Nhm bnh
Ch nh bt buc
C th ch nh
Suy
nt SNX km triu chng nng, - Khng c bng
khng hi phc sau khi chng chng t
xoang
dng thuc hoc cn phi nhp chm < 40
(SNX)
ck/pht lin quan
dng thuc gy nhp chm.
n SNX v cc
triu chng c th
khng ch c.
216
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- Bnh nhn c
triu chng nh
hoc
khng
nhng c nhp tim
< 30 ck/pht (khi
thc gic).
Bloc nh tht Bloc nh tht cp III c mt - Bnh nhn bloc
nh tht cp III
mc phi
trong cc c tnh sau:
m khng c triu
- C triu chng.
- C ri lon nhp km theo chng v nhp tim
hoc bnh l km theo cn trung bnh lc
dng thuc c th gy nhp thc gic l hn
40 ck/pht.
chm.
cp
- C on ngng tim trn 3 - Bloc nh tht
ved
r
e
giy hoc nhp tim < 40 II kiuresMobitz II
ts
ck/pht bnh nhn khng khng
gh m.vnc triu
i
r
l .co
c triu chng.
Al chng.
o
.
v
etya-hoBloc nh tht cp
o
- Bloc sau khi iu tr
l
Fin020@ I nhng nhp tim
cc ng dn truyn
8. 2trong
0
y
0
rt chm v c
tim (cathetert ablation).
2 tocit
h
o
P
g
triu chng hoc
- Sau m
ritim.
py
- Bnh
Co l thn kinh c c khi t my tm
km theo bloc nh tht cp thi c hi chng
III (hi chng Kearns Sayre, my to nhp.
ph i Erb...)
b. Bloc nh tht II c km
theo triu chng do nhp
chm (bt k th v v tr).
Bin chng - Bloc nh tht cp II kiu - Tn ti bloc nh
sau
nhi Mobitz II tn ti sau nhi tht cp II cao
mu c tim ti v tr b His hoc cp III ti v
mu c tim
tr xung m c km theo tr nt nh tht.
bloc 2 nhnh hoc Bloc nh
tht cp III ti v tr b His
tr xung sau NMCT.
- Tn ti bloc nh tht cp II
217
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Bloc
2
nhnh hoc
3
phn
nhnh mn
tnh
Hi chng - Ngt ti pht nhiu ln do
cng xoang kch thch xoang cnh. Kch
cnh v ngt thch nh xoang cnh c th
gy ngng tht trn 3 giy.
Ti liu tham kho
1.
218
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thp tim
t ochun
cu), km theo c t nht g2htiu
chnh hoc c 1 tiu chun
Pt
i
rph.
y
chnh km 2 tiu chun
p
Co
Bng 11-1. Tiu chun Jones c iu chnh nm 1992 trong
chn on thp tim.
1. Vim tim: gp 41-83% s bnh nhn thp tim.
Tiu
Vim tim c biu hin lm sng t nhp nhanh,
chun
ri lon nhp (hay gp bloc nh tht cp 1), h van
chnh
hai l hoc van ng mch ch, vim mng ngoi
tim, vim c tim, n suy tim...
2. Vim khp: Gp khong 80 %, l triu chng rt
c ngha nhng khng phi c hiu hon ton.
Biu hin l sng au khp kiu di chuyn v
khng bao gi li di chng khp.
3. Ma git ca Sydenham: l ri lon vn ng
ngoi thp, vi vn ng khng mc ch v
khng c .
219
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b. au khp hc
t otxc nh l ch au khp ch
P
ig
khngopc
yr vim (sng, nng, ).
C
c. Ngoi ra, c th gp cc biu hin nh au bng,
vim cu thn cp, vim phi cp do thp tim, i
mu, hoc vim mng no y l nhng du
hiu khng trong tiu chun chn on thp tim.
B. Cc xt nghim chn on
1. Cc du hiu l bng chng ca nhim lin cu
nhm A (GAS):
a. C th xc nh thng qua ngoy hng tm thy
lin cu (nui cy hoc xt nghim khng nguyn
nhanh) hoc cc phn ng huyt thanh thy tng
nng khng th khng lin cu.
b. Xt nghim ASLO (AntiStreptoLysin O) l mt
phn ng thng dng hin nay. S tng nng
223
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225
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Khong cch
dng
3-4 tun/1 ln
250 mg
Ung
2 ln/ngy
Ung
hng ngy
Ung
2 ln/ ngy
0,5g (<27kg)
1,0g (27kg)
Erythromycin (cho 250 mg
bnh nhn d ng
vi Penicillin hoc
Sulfazidine)
227
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t (Bng
b. Thi gian gdng
11-4), ni chung ph thuc
t
i h Po
rc
y
vo tng
th
bnh
nhn.
p
Co
c. Ni chung nn dng ng tim. Ch nn dng
ng ung cho cc trng hp t c nguy c ti
pht thp tim hoc v iu kin khng th tim
phng c, v t l ti pht thp tim bnh nhn
dng ng ung cao hn ng tim nhiu.
Bng 11-4. Thi gian tin hnh ca phng thp cp II.
Tnh trng bnh
Thi gian ko di
Thp tim c vim c tim v
li di chng bnh van
tim.
Thp tim c vim tim
nhng cha li di chng
bnh van tim.
Thp tim khng c vim
tim.
Ko di t nht 10 nm v t nht
phi n 40 tui. C th tim rt lu
di (nn p dng).
10 nm hoc n tui trng thnh,
mt s trng hp ko di hn.
5 nm hoc n 21 tui, c th di
hn tu trng hp.
228
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ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
229
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Hp van hai l
ht Poto
trn dch cc imng...
g
r
opy ca km ti mu ngoi vi: da, u chi
4. Cc duChiu
xanh tm.
5. S c th thy rung miu tm trng mm tim. Mt
s trng hp khi tng p ng mch phi nhiu c
th thy ting T2 mnh v tch i cnh c tri.
6. G din c ca tim thng khng to.
7. Nghe tim: l bin php quan trng gip chn on
bnh HHL.
a. Ting clc m van hai l, nghe r mm tim,
khong cch t T2 n ting ny cng hp th mc
HHL cng nhiu (<80 ms trong HHL kht).
Tuy nhin, mt s trng hp khng nghe thy
ting ny khi van hai l vi cng, m km.
232
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b.
c.
d.
e.
f.
g.
233
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234
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t ot c
h
P
g
2. Dng chy qua
van
hai
l tng lm chnh p qua van
ri
y
p
tng theo
Cocp s nhn (v chnh p l hm bc hai ca
dng chy). V vy, gng sc hoc thai nghn (tng
th tch v dng mu lu thng) s lm tng ng k
p lc nh tri. Nhp tim nhanh lm gim thi gian
y tm trng cng lm tng chnh p qua van v
p lc trong nh tri. Do trong giai on sm, hi
chng gng sc rt thng gp bnh nhn HHL.
3. Tng p lc nh tri dn n tng p trong h thng
mch phi gy ra cc triu chng huyt phi. Tng
p lc th ng trong h mch phi s gy tng sc
cn mch phi (tng p ng mch phi phn ng,
hng ro th hai). Tnh trng ny c th mt i v tr
v bnh thng nu tnh trng hp van c gii
quyt. Tuy nhin, nu hp van hai l kht ko di s
dn n bnh cnh tc nghn mch mu phi.
235
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237
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238
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239
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240
Dintchlvanhail =
Cungl ngtim
Ch nh ptrungbinhquavanhail
lm
n
phn
eo ca bng gy tch hai
o
mp van cho n khi kt qu nong van t nh
mun. Nong van hai l qua da (NVHL) tr thnh
phng php c la chn hng u cho cc bnh
nhn HHL trn ton th gii v y l th thut
chim v tr th 2 (v s lng cng nh ngha)
trong can thip tim mch. Ti Vit nam, NVHL bt
u t 1997, n nay tr thnh phng php iu
tr thng quy. Kt qu nong bng bng (tch hai
mp van b dnh) thng tt, din tch l van tng 1-2
cm2, chnh p qua van hai l v p lc ng mch
phi gim khong 1/3 so vi p lc ng mch phi
trc . NVHL c u tin la chn v:
a. NVHL c t l thnh cng cao, t bin chng qua
nhiu nghin cu.
243
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244
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Siu m gng sc
PAP > 60 mmHg
MVG > 15 mmHg
Khng
Khng
Theo di hng nm
ht Pot
rig
y
p
PAP > 60 mmHg Co C
Hnh thi van tt cho NVHL
MVG > 15 mmHg
Khng
Khng
Nguy c cao nu m
Khng
Tm nguyn nhn khc
M sa/thay van
C
Nong van hai l
Di ng van
T chc
dy
Mc
di van
van
vi ho
mt
nh C
t, Gn
Van di ng Dy
im
vi
bnh
phn
ngay
tt, ch st b
st b van. thng: 4 - ho.
van hn ch.
5 mm.
Phn
gia Dy ti 1/3 Dy t pha Vi ha di
thn van v chiu di b van: 5 - rc pha b
van.
chn van cn dy chng. 8 mm.
di ng tt.
ti Dy
lan Vi ho lan
Van vn cn Dy
xa xung c n on
di ng v on
pha
trc dy chng. thn l van: gia l van.
d
5 - 8mm.
trong thi k
rve
e
s
re
tm trng,
ts vn
h
(ch yu l
.
g
l ri .com
l
gc van).
. A ahoo
oev ynhiu
Vi
ho
Khng
di Dy nhiu nDy
l
@
i ton
0
F
nhiu
lan
b
c
ng hoc rt v co 8rt
2
. 20
0
y
0
t.
ct c
2 dy
it l van: > 8 to ton b
t otoc
h
van.
- 10mm.
chng.
P
g
i
py
Co
248
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250
Copyright 2008. Finloev. All rights reserved
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Alpert JS, Sabik J, Cosgrove DM III. Mitral valve disease. In: Topol
EJ, ed. Textbook of cardiovascular medicine. Philadelphia:
Lippincott-Raven, 1998:503-532.
Braunwald E. Valvular heart disease. In: Braunwald E, sd. Heart
disease: a textbook of cardiovascular medicine, 5th ed. Philadelphia:
WB Saunders, 1997:1007-1076.
Carabello B, Grossman W. Calculation of stenotic valve orifice area.
In: Baim DS, Grossman W, eds. Cardiac catheterization,
251
Copyright 2008. Finloev. All rights reserved
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4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
o
ht Pot in the patient undergoing catheter
Reid CL. Echocardiography
rig
balloon mitral commissurotomy.
In: Otto CM, ed. The practice of
y
p
Co
clinical echocardiography.
Philadelphia: WB Saunders, 1997:373388.
Reyes VP, Raju BS, Wynee J, et al. Percutaneous balloon
valvuloplasty compared with open surgical commissurotomy for
mitral stenosis. N Engl J Med 1994;331: 961-967.
Stewart WJ: Intraoperative echocardiography. In Topol EJ, ed.
Textbook of cardiovascular medicine. Philadelphia: LippincottRaven, 1998: 1492-1525.
Thamilarasan M. Mitral valve disease. In: Marso SP, Griffin BP,
Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia:
LippincottRaven, 2000.
Tuzcu EM, Block PC, Griffin B, Dinsmore H, Newell JB, Palacios
IF. Percutaneous mitral balloon valvotomy in patients with calcific
mitral stenosis: immediate and long-term outcome. J Am Coll
Cardiol 1994;23:1604-1609.
Wilkins GT, Weyman AE, Abascal VM, Block PC, Palacios IM.
Percutaneous balloon dilatation of the mitral valve: an analysis of
echocardiographic variables related to outcome and the mechanism
of dilatation. Br Heart J 1985;60:299-308.
252
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H van hai l
gnh v gim/bnh
ho
hu gnh. Lu dn ri
o
ht Pot
g
i
r
lon chc pnng
km vi gin tin trin bung tht tri
oy
v tng Csc p ln thnh tim cng lm HoHL tng
ln, thnh mt vng xon tip tc gy gim chc
nng tht tri, gy mt b. Khi cc triu chng c
nng r th c khi ri lon chc nng tht tri
khng hi phc, lm tng nguy c suy tim, tng t l
bin chng v t vong d phu thut gii quyt
bnh van hai l.
III. Cc xt nghim chn on
A. in tim: cc biu hin khng c hiu nh dy nh
tri, dy tht tri, rung nh u c th gp bt k giai
on no ca HoHL.
B. Xquang ngc: thng c gin tht tri v nh tri nu
HoHL mn tnh. Hnh nh ph khong k v ph ph
nang gp khi HoHL cp hoc khi suy tht tri nng.
256
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d
rve
e
s
re
ts vn
h
.
g
l ri .com
l
A o
ev. yaho
o
l
Fin 0@
8. 202
0
20 ocity
t ca
Hnh 13-1. Dng gmu
h
Pot HoHL trn siu m Doppler.
ri
y
p
Co
Chiu di ti a ca
h so vi din
HoHL dng h (cm) pht
tch nh tri (%)
ngc vo nh tri
1
< 1,5
< 20
2
1,5 2,9
20 40
3
3,0 4,4
4
> 4,4
> 40
Cn ch : vi phng php ny, khi dng
siu m qua thc qun nh gi HoHL, nu
d
dng an thn (gim hu gnh) s lm gim
rve mc
e
s
HoHL so vi bnh thng. Tng t,snu
re nh gi
t vn
h
g
HoHL ngay trong m, h thay
i. nhiu ph
l ri .com
l
A
thuc vo tin gnh v hu
gnhoc tim. Do vy,
ev. yaho
o
l
ngi ta thng phi
in hp
0@ thm nhiu phng
. F 2mc
02 HoHL.
8gi
php khc nh
0
20 ocity
t h
b. rng dng
h
Pot (ch hp nht) khi qua l h
ig
r
y
(venaocontracta):
l mt ch s ng tin cy. Nu
p
C
rng > 0,5 cm l bng chng ca HoHL nng.
Tuy nhin phng php ny i hi my siu m
phi c phn gii cao v phi phng hnh to,
nn d c xu hng nh gi qu mc h.
c. Din tch l h hiu dng (ERO) tnh theo
phng php PISA (Proximal Isovelocity Surface
Area): da trn hin tng dng chy qua l hp
hnh phu: khi ti gn l h, vn tc ca dng h
gia tng hi t c dng bn cu, ti phn ra vng
hi t vn tc dng chy chm, dng cu ln
trong khi ti vng st l h vn tc dng chy
nhanh, dng cu nh. C th o chnh xc vn tc
dng chy v ng knh vng cu ti im u
tin c hin tng aliasing ca ph Doppler (tn
258
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261
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262
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tht bng
ht ccot thuc chng lon nhp, nht l
rig vPthuc chn giao cm.
Digitalis
y
op
b. Vai Ctr ca thuc vi bnh nhn HoHL mn tnh
do bnh van tim, cha c triu chng, ni chung
cn cn nhiu th nghim chng minh nht l v
kh nng lm chm tin trin ca HoHL hoc
phng ri lon chc nng tht tri. iu tr cc
thuc gim hu gnh qu tch cc c th che bt
cc triu chng, t a ra cc quyt nh sai
lm v thi im v bin php can thip.
c. Phi d phng vim ni tm mc nhim khun
cho tt c trng hp HoHL do bnh van tim
ngoi tr h do gin tht tri m cc van tim bnh
thng.
3. iu tr phu thut:
263
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o
t
gh Pot
i
r
4. Theo di sau
py m:
Co
Siu m tim sau m 4-6 tun c dng lm mc
theo di. HoHL ti pht do sa khng tt hoc do
nguyn nhn gy bnh tip tc tin trin. Bnh nhn
nn c theo di lm sng v siu m tim (nh gi
kt qu m sa van, c ch v mc h van, chc
nng tht tri, huyt khi hay vim ni tm mc) t
nht 1 nm/1 ln.
Ti liu tham kho
1.
2.
Alpert JS, Sabik J, Cosgrove DM III. Mitral valve disease. In: Topol
EJ, ed. Textbook of cardiovascular medicine. Philadelphia:
Lippincott-Raven, 1998:503-532.
Bach DS, Boiling SF. Improvement following correction of
secondary mitral regurgitation in end-stage cardiomyopathy with
mitral annuloplasty. Am J Cardiol 1996;78:966-969.
265
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3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
266
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H van ng mch ch
270
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274
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Nh (1+)
Va (2+)
25-45
Vanng (3+)
46-64
Nhiu
(4+)
65
< 25
4-25
25-59
60
400
300-400
300-400
300
400170
37070
25080 14030
Dc gim tc
2
2-3
2-3
3
nht,
nht t
cng
Mt ph ca nht,
d
hon ton hn,
mt
dng h so vi khng
rve
e
s
hon ton
mt ph dng hon ton
re
ts vn
h
.
tng mu ln
g
l ri .com
l
A o
MC
ev. yaho
o
l
Chiu di dng ngay
khng
ti tn
ti tn
Fin020@
.
HoC pht ngc di cc008 qu
vng cc mm
21/2
2 ociltytrc
v tht tri
l van
c nh
tim
t
gh Pot
i
r
MC
van hai l
opy
C
8-12 mm
12-16
>16
ng knh dng < 8 mm
mm
mm
HoC trn siu m
mu kiu TM
0%
1-10%
11-20%
>20Vn tc dng
25%
chy cui tm
trng/vn tc ti
a dng chy tm
thu
Vn tc dng
< 0,1
0,1-0,2
0,2-0,4
> 0,4
chy cui tm
trng (o ti eo
MC) (m/s)
277
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t MC.
t
nh thay gvan
Khong thi gian gia cc
i h Po
r
y
ln theo
p di s tu thuc vo bnh cnh v chc
Co
nng ca tht tri.
Hnh 14-2.Theo di bnh nhn HoC cha c triu chng.
Bnh cnh
Ch nh
Xut hin triu chng c nng
Phu thut
Chc nng tht tri gim (EF < 50%) Phu thut
Chc nng tht tri bnh thng,
Theo di & Siu m
v khng c triu chng c nng
lm sng
tim
281
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(*)
t nh
nh theo di h
gi kch thc gc MC
Pot
ig
rnhn
y
nhng bnh
c
gin
gc MC. Mt khi cc du
p
Co
hiu ca tnh trng ri lon chc nng tm thu tht
tri xut hin, cn xem xt kh nng phu thut ngay
c khi bnh nhn cha c triu chng. Bnh nhn sau
m thay van hoc sa van th chm sc v theo di
nh quy trnh bnh thng.
2. HoC cp tnh:
a. Trng hp HoC cp do phnh tch ng mch
ch, nu tnh trng huyt ng cn n nh, cn
iu tr tch cc bng thuc chn giao cm
kim sot c huyt p trc khi khi dng thuc
gin mch.
b. Cn nhc ch nh m ngay nu chn on HoC
cp do phnh tch ng mch ch hoc do chn
282
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thng. Mc ch ca iu tr ni khoa ch l
tng ti a th tch tng mu v hn ch ti a
tin trin lan ca phnh tch MC. Dng ng
tnh mch cc thuc gin mch v chn giao
cm nu bnh cnh c tnh cht cp tnh. Nu n
nh, c th dng thuc ung nh Nifedipine, c
ch men chuyn, Hydralazine lm gim tin
gnh, ci thin th tch tng mu v cung lng
tim.
c. HoC cp lin quan n vim ni tm mc nhim
khun, cn iu tr thuc khng sinh ngay (sau
khi cy mu). Nu tnh trng huyt ng km,
vn c th phu thut thay van MC nhnedto d
v
mi ch dng khng sinh. (Khi vanreMC
ser ng
ts
loi/t thn thng c a chung).
gh m.vn
i
r
ll o.co
Anh
3. iu tr can thip: chng ch
.
v
e yaho t bng trong
o
l
@ t va-nhiu. Bnh
ng mch ch (IABP) Fkhi
in HoC
. 2020
8
0
nhn phi hp h 2v0 hp
tyvan MC khng nn nong
ocido khuynh hng tng nhiu
t oda
t
h
van bng bng
qua
P
rig
y
p
mc CHoC
cp
sau
nong.
o
4. Phu thut:
a. Thi im phu thut ph thuc vo nhiu yu
t bao gm triu chng c nng, kch thc v
chc nng tht tri. C th l:
Vi HoC cp, phu thut vn c li cho d
chc nng tht tri ra sao.
HoC khng c triu chng:
(a) Bnh nhn khng c triu chng nhng
ri lon chc nng tht tri khi ngh s d
c nguy c cao xut hin cc triu chng
suy tim trong vng 2-3 nm, do nn
c m c chun b.
283
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Potocity2020@yahoo.com.vn
t
t
Raven, 2000.
igh Po
r
y
7. Gaasch WH, Sundaram
M, Meyer TE. Managing asymptomatic
p
Co
patients with chronic aortic regurgitation. Chest 1997;111:17021709.
8. Kelly TA, Rothbart RM, Cooper CM, Kaiser DL, Smucker ML,
Gibson RS. Comparison of outcome of asymptomatic to
symptomatic patients older than 20 years of age with valvular aortic
stenosis. Am J Cardiol 1988;61:123-130.
9. Otto CM, Burwash IG, Legget ME, et al. Prospective study of
asymptomatic valvular aortic stenosis: clinical, echocardiographic,
and exercise predictors of outcome. Circulation 1997;95:2262-2270.
10. Otto M. Aortic stenosis: echocardiographic evaluation of disease
severity, disease progression, and the role of echocardiography in
clinical decision making. In: Otto CM, ed. The practice of clinical
echocardiography. Philadelphia: WB Saunders, 1997:405-32.
285
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11. Pellikka PA, Nishimura RA, Bailey KR, Tajik AJ. The natural
history of adults with asymptomatic, hemodynamically significant
aortic stenosis. J Am Coll Cardiol 1990;15:1012-1017.
12. Weyman AE, Griffin BP. Left ventricular outflow tract: the aortic
valve, aorta, and subvalvular outflow tract. In: Weyman AE, ed.
Principles and practice of echocardiography, 2nd ed. Philadelphia:
Lea & Febiger, 1994:498-574.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
286
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Hp van ng mch ch
d
rve
e
s
re
ts vn
h
.
g
l ri .com
l
A o
ev. yaho
o
l
Fin 0@
8. 202
0
20 ocity vi ho.
Hnh 15-1. Van
t oMC
h
Pt
rig
y
B. Sinh l bnh
p
Co
1. Hp van MC c trng bi qu trnh hp dn l van
MC gy tng dn hu gnh cho tht tri. duy tr
cung lng tim, tht tri phi bp vi sc bp tm thu
cao hn, lm tng p lc ln thnh tim, dn n ph
i ng tm, nh bnh thng ho sc p ln
thnh tim (theo nh lut Laplace: sc p ln thnh
tim = p lc ng knh + 2 dy tim), song li
lm gim gin n ca tht tri.
2. Tht tri gin km s lm gim qu trnh y tht
tri th ng trong giai on u ca thi k tm
trng. Tin gnh tht tri ph thuc rt nhiu vo co
bp nh tri. Tht tri cng dy, lc bp cng gia
tng, thi gian tm thu ko di, cng lm tng mc
tiu th xy c tim. Khi suy tim, p lc cui tm
290
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dn t 5 n g20
tng dn cung lng
ht g/kg/pht
Pot
ri siu
y
tim, sau
dng
m
tim
kim tra tng bc din
op
C
tch l van v chnh p qua van MC. Cn ngng
ngay nghim php khi bnh nhn tt p, au ngc
hoc xut hin ri lon nhp tim.
D. Thng tim: trc y thng tim l tiu chun vng
chn on v lng gi hp van ng mch ch. Tuy
nhin ngy nay, siu m tim dn dn c chp nhn
rng ri nh mt phng tin chn on v nh gi
HC thay th cho thng tim.
1. Thng tim c ch nh khi c nghi ng v mc
hp van trn siu m tim hoc chp ng mch
vnh cho bnh nhn nam tui > 40 v n tui > 50
trc khi m thay van.
2. Cn cn nhc gia cc li ch ca thng tim v nguy
c bin chng nht l bnh nhn HC kht. Nguy c
295
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296
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IV. iu tr
A. La chn bin php iu tr: ct li ca iu tr hp
van MC nng l phu thut thay van MC. Ni chung
phu thut u tin cho nhng bnh nhn c triu
chng c nng, do thay van MC c nguy c bin chng
kh cao v t l sng cn ch thc s ci thin r rt khi
bnh nhn bc l triu chng c nng. Ngy cng c
nhiu bng chng cho thy khi hp van MC ti mc
nng, th xu hng s xut hin triu chng v phi m
thay van ch trong vng 3 nm. i vi bnh nhn ln
tui hp kht van MC, vic m khi cha c triu
chng xem ra c li hn so vi vic i n khi xut hin
triu chng c nng. M sm cng c li i vi nhng
d
bnh nhn tr m chnh p qua van MC rt cao
rvev hn
e
s
e
ch c nguy c cao xut hin t t. Tng
s r n t, bnh
2t
h
v theo hp
.
g
nhn c din tch l van MC 1,0 cm
km
l ri .com
l
Acu oni ch-vnh th
ng k ng mch vnh v cn lm
ev. yaho
o
l
nn tnh c n vic m thayFvan
in MC.
0@
8. 202
0
B. iu tr ni khoa 20 city
ht Ptr
oto khng sinh d phng vim ni
igiu
1. Bt buc phi
r
py khun.
tm mcConhim
2. Vi bnh nhn cha c triu chng c nng (din
tch l van MC > 1,0 cm2) th iu tr c mc ch
phng tin pht bnh l ng mch vnh, duy tr nhp
xoang v khng ch huyt p. Tt c bnh nhn phi
c hng dn v cc du hiu v triu chng ca
au tht ngc, ngt hoc suy tim i khm li ngay
v xt m nu xut hin cc triu chng c nng ny,
v khi nguy c phu thut thp hn cc nguy c
ca vic tip tc iu tr ni khoa.
3. iu tr suy tim nhm vo vic kim sot cn bng
dch gim huyt phi, thng bng thuc li
tiu. Tuy nhin, cung lng tim bnh nhn HC
nng ph thuc nhiu vo tin gnh, nn cn rt thn
297
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298
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Potocity2020@yahoo.com.vn
t cung
ngc li nu
t lng tim tng gy tng chnh
igh Po
yr th l hp tht.
p quaopvan
C
b. Nn th nong van bng bng qua da: nu triu
chng suy tim v cung lng tim ci thin sau
can thip th kh nng hi phc sau m thay van
MC s ln hn.
C. iu tr can thip
1. t bng trong ng mch ch (IABP): nhm n
nh tm thi tnh trng huyt ng bnh nhn hp
van ng mch ch nng, suy tim mt b chun b
m. Hiu qu ca t bng trong ng mch ch l
nh tng ti mu mch vnh trong k tm trng,
lm gim tnh trng thiu mu ca ton th c tim khi
hp van MC kht, suy tim mt b.
299
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ht Pot
Suy tim.
rig
y
p
b. BnhConhn
khng c triu chng c nng:
Tui tr v chnh p qua van MC > 100
mmHg.
Cn lm th thut/phu thut ln, c nguy c
cao.
C ch nh bc cu ni ch vnh.
Ri lon chc nng tm thu tht tri.
2. Cc loi phu thut thay van ng mch ch: thay
van ng mch ch c a chung hn m sa van
v sau khi gt mng v ly vi l van, cc l van
hay co rt, gy h van ngay sau phu thut v dn
dn mc h s tng ln. Tuy nhin, vi hp van
MC bm sinh m van cha vi th vn c th sa
van tu theo tng trng hp c th. M thay van
MC n thun khng km bnh mch vnh hoc
300
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mc nhim khun
ht Poto
igko
thi gian
di,
d gy ra nhiu ri lon sau
r
py
o
C
m. Tin lng lu di ph thuc vo mc h
van ng mch ch, bnh l van ng mch phi
(h, hp) hay cc ri lon chc nng tht phi
(th pht sau bnh van MP).
b. Thay van MC ng loi: c dng rng ri
cc bnh nhn tr tui do c im huyt ng
tt v khng cn dng thuc chng ng. Tuy
nhin theo thi gian, cc van loi ny khng h
ln ln, s b thoi ho, vi v gy h. Bn thn
k thut thay van loi ny cng kh phc tp v
thng phi hp vi vic to hnh mt phn gc
ng mch ch v cm li ng mch vnh, cho
d vn n gin hn so vi phu thut Ross. Tui
th trung bnh ca van l 15 nm. Phu thut ny
c t l nhim trng rt t khi ang c vim ni
301
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302
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E. Theo di
1. Bnh nhn hp van ng mch ch nng cha c
triu chng c nng nn c theo di st v hng
dn ti khm ngay khi c bt k triu chng c
nng no.
2. Siu m Doppler tim 1-6 tun sau m thay van
MC nh gi hot ng ca van v chnh p qua
van nhn to lm mc theo di. Sau bnh nhn
c kim tra siu m nh k 1-2 ln/nm.
3. Kim tra hiu qu chng ng mu (t l
prothrombin, INR) nh k iu chnh liu ph
hp bnh nhn c ch nh dng thuc chng ng.
Ti liu tham kho
1.
2.
3.
4.
5.
6.
7.
8.
rve
303
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Potocity2020@yahoo.com.vn
9.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
304
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Potocity2020@yahoo.com.vn
o
ht ot
phi ch lc st nh cao
rigmi Ply mu cho d cy mu khi bnh
y
p
nhn ang st th t
Co l dng tnh s cao hn. Cn lu l khi
cy mu gi l m tnh trong nhng ngy u th phi tip tc
cy tip v mt s vi khun nh ni trn mc rt mun.
IV. Tiu chun chn on VNTMNK
Ngy nay, hu ht cc tc gi dng tiu chun Duke ci
tin v c nhy v c hiu cao nht (Bng 16-2a v16-2b).
Tiu chun bao gm: VNTMNK chc chn (v gii phu bnh
v v lm sng), VNTMNK c th v loi tr VNTMNK.
i vi VNTMNK chc chn trn gii phu bnh th ch
cn 1 trong 2 tiu chun l .
i vi VNTMNK chc chn trn lm sng th cn c 2
tiu chun chnh, hoc 1 tiu chun chnh v 3 tiu chun ph,
hoc c 5 tiu chun ph.
307
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d
rve
e
s
re
ts vn
h
.
g
A
l riB.com
l
A hoophi (A); Si
Hnh 16-1. Si ni mc thn ng
ev.mch
a
o
l
in 20@y
van ng mch phi (B).
F
8. 0
00 ity2
2
t toc
igh Po
r
py
Co
C
D
Hnh 16-2. Si van ng mch ch (C) gy h van ng
mch ch nng (D). LA: nh tri, MV: van hai l, V: si, AV:
van ng mch ch, Ao: ng mch ch, RV: tht phi, LV:
tht tri, AR: h van ng mch ch.
308
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Co
i mu vi th.
Chp tim phi.
Siu m tim.
Chp mch mu.
CT scan s no.
309
Cc thm d
Tnh trng thiu mu.
Tng bch cu mu.
Tng tc lng mu.
Cy mu dng tnh.
Bt thng dch no tu.
ved
py
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
Co
py
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
310
Bng 16-2a. Tiu chun Duke chn on chc chn VNTMNK trn gii phu bnh.
Tm thy vi khun (nm) bng nui cy hoc soi t bo :
Cc si trong tim.
Cc si bn i gy tc mch.
p xe trong tim.
Hnh nh tn thng gii phu bnh:
Thy cc si hoc pxe trong tim c hnh nh t bo hc ca vim ni tm mc ang tin
trin.
ved
ved
Co
py
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
311
Co
312
2. St trn 38oC.
3. Tn thng mch mu:
Tc mch ln.
Nhi mu phi nhim khun.
Phnh mch hnh nm.
Xut huyt ni s.
Xut huyt m lin kt.
Tn thng Janeway.
4. Hin tng min dch:
Vim cu thn.
Nt Osler.
Chm Roth.
Yu t dng thp.
5. Bng chng vi khun:
Cy mu dng tnh nhng khng tiu chun chnh.
Xt nghim huyt thanh vi cc tc nhn gy VNTMNK c bng chng ang hot ng.
6. Siu m tim nghi ng hnh nh ca VNTMNK nhng khng bng chng quy nh trong tiu
chun chnh
ved
py
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
V. iu tr
A. Nguyn tc iu tr
1. Khng sinh cn c cho sm ngay sau khi cy mu
kt thc. Trong lc ch kt qu cy mu th cho
khng sinh theo quy c: thng dng quy c l
Ampicilin 2g tim tnh mch (TM) mi 4 gi kt hp
vi Gentamycin 1,0 mg/kg cn nng TM mi 8 gi.
C th thay th bng Nafcillin 1,5 g tim TM mi 4
gi hoc Vancomycin 1 g tim TM mi 12 gi.
2. Khi c khng sinh cn iu chnh khng sinh theo
ch chun (trnh by k phn sau).
3. Ch kim tra v theo di cc chc nng thn, gan...
d
chn khng sinh v liu thch hp.
rve
e
s
re
4. Khng nn dng chng ng ngnhnga
ts vntc mch
.
g
trong VNTMNK.
l ri .com
l
A o
ev. yahophi kt hp iu
5. iu tr VNTMNK do nm
thng
o
l
Fin 0@
tr ni ngoi khoa.
8. 202
0
20 ocitykhoa can thip thng kh
6. Ch nh iu htr
t ngoi
Pot
ig rt
rcng
khn nhng
cn thit trong nhng hon cnh
y
p
Co
nht nh.
7. Vic phng nga VNTMNK nhng bnh nhn c
nguy c l vic ht sc cn c ch n.
B. iu tr c th
1. iu tr ni khoa:
a. Ch dng khng sinh cho cc loi cu khun
(Bng 16-3).
b. Ch dng khng sinh cho Trc khun m xanh
(Pseudomonas aeruginosa) v cc vi khun gram
m khc.
Nn dng loi Penicillin c ph rng
(Penicillin mi): Ticarcillin hoc Piperacillin),
hoc Cephalosporin th h 3, hoc Imipenem
Phi hp vi Aminoglycoside.
313
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Co
314
Cho cc trng hp d ng vi
Penicillin.
Lu
ved
py
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
ved
Co
py
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
315
Bng 16-3. La chn khng sinh cho cc loi cu khun (tip theo).
Ch chun.
T
cu 1. Nafcillin 1,5 g, tim TM mi 4 gi, 4-6
tun
hoc
vng (S.
Cho bnh nhn nhim t cu nng.
2. Nh trn kt hp vi Gentamycin 1 4-6
aureus)
mg/kg tim TM mi 8 gi trong 3-5 tun
ngy, hoc
D ng vi Penicillin.
3. Cefazolin 2 g tim TM mi 8 gi, hoc 4-6
tun
D
ng
vi
Penicillin
v
4. Vancomycin 15 mg/kg tim TM mi 4-6
Cephalosporins; cho loi t cu khng
tun
12 gi
vi Methicillin.
Lin cu 1. Penicillin G, 2 triu v tim TM mi 6 2-4
tun
gi, hoc
nhm A,
2-4
Lin cu 2. Cefazolin, 1 g tim TM mi 8 gi.
tun
pneumon
-iae
Nhm
1. Ampicillin 2 g, tim TM mi 4 gi kt 4 tun Gentamycin c th ngng nu vi
khun nhy cm vi Ampicillin.
HACEK
hp vi Gentamycin 1 mg/kg TM mi
12 gi, hoc
Cho bnh nhn b d ng vi
2. Ceftriaxone 1-2 g tim TM hoc tim
4 tun Penicillin.
bp 1 ln trong ngy.
c. iu tr VNTM do nm.
Thng dng Amphotericin B, c th kt hp
vi Flucytosine.
(a) Amphotericin B: ho trong Dextro 5%
truyn TM trong 2-4 gi vi liu 0,5
mg/kg/ngy.
(b) Thuc c c tnh nhiu n thn.
(c) Flucytosine c c tnh lm c ch tu
xng, cn theo di cng thc mu khi
iu tr thuc ny.
Sau khi dng thuc 1-2 tun nn tnh n vic
phu thut thay van.
Mt s thuc dng ung nh Fluconazole
hoc Itraconazole c th dng phi hp.ed
rv
2. iu tr ngoi khoa:
ese
r
hts .vnkhoa cho
gngoi
a. Mc ch c bn ca iu tr
i
r
l .com
Al hoosi
VNTMNK l ly i nhng
mnh
hoc hoi t
.
v
e ya
o
l
m khng th iu tr
c, sa li van
@
inni khoa
. F 2020
hoc thay van b0tn
08 tthng.
y
2 toci
b. Ch nh igiu
ht Ptr
o ngoi khoa cho VNTMNK l
r
mt quyt
py nh kh khn nhng rt cn thit
Co
trong mt s hon cnh. Khi ch nh phi cn
nhc nhiu yu t v phi ch ti thi im can
thip (bng 16-4).
c. Suy tim tin trin l mt trong nhng ch nh
chnh, v c ti 90 % cht v suy tim nu khng
c can thip kp thi.
d. VNTMNK van nhn to thng i hi kt hp
iu tr ni v ngoi khoa.
e. Thi khong dng khng sinh sau khi m bnh
nhn VNTMNK cn cha thng nht. Cc tc gi
cho rng, nu mnh si (hoc p xe ly ra trong
m cy c vi khun th thi gian iu tr sau m
phi di bng mt liu trnh y cho iu tr
VNTMNK.
316
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Co
318
ved
py
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
319
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14. Von Reyn CF, Levy BS, Arheit RD, Friedland G, Crumpacker CS.
Infective endocarditis: an analysis based on strict case definitions.
Ann Intern Med 1981;94: 505-518.
15. Wilson WR, Karchmer AW, Dajani AS, et al. Antibiotic treatment
of adults with infective endocarditis due to streptococci, enterococci,
staphylococci, and HACEK microorganisms. JAMA 1995;274:
1706-1713.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
320
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bn
V tr van V tr van huyt
khi
MC
hai l
d
Van bi
++++
1,2-1,6
1,4-3,1 erve++++
s
re
(Starr-Edwards)
ts vn
h
g
ri com.
+++/
1,5-2,1
+++
Van a mt cnh
l1,9-3,2
l
A hoo.
.
++++
(Bjrk-Shiley,
v
a
oe
inl 20@y
Medtronic-Hall,
F
8. 0
Omnicarbon)
00 ity2
2
t toc
++++
2,8-3,4
++
Van a hai cnh
igh Po 2,4-3,2
r
(St. Jude Medical,Copy
Carbomedics)
++
1,0-1,7
1,3-2,7
+/++
Van sinh hc d
loi (IonescuShiley, Hancock,
CarpentierEdwards)
Van sinh hc
+++
3,0-4,0
+
ng loi
A. Van c hc
1. Van a mt cnh: (van Bjrk-Shiley, MedtronicHall v Omnicarbon) c cu to gm mt vng van
bng kim loi gn vi mt cnh a bng pyrolytic
carbon di ng t do mt gc 60-85o xung quanh mt
trc, to thnh hai l ln mu lu thng.
321
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ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
d
rve
e
s
re
Hnh 17-1b. Cu trc mt s loi van bi (lng).
ts vn
h
g
m. song v
B. Van sinh hc: mc d rt ging van
l rit.conhin
l
oo
v. Ado
huyt ng vn cha phi tiloeu
ahkch thc van b
y
Fin020@ van lm nh i.
cc thnh phn vng van, phn
8. 2chng
0
20 ocityph ln mt gi v mt
1. Van d loi: bng
t cch
h
ot
vng van kim
rigloi Pmng tim b hoc van tim ln
y
p
Co nh van Carpentier-Edwards. Cc loi van
qua x l
mi nh Hancock II hoc Medtronic Freestyle, St.
Jude-Medical c ci tin huyt ng do cch gn van
trc tip vi MC hoc t van ngi trn vng van...
2. Van ng loi: ch yu v tr van MC bng cch
ly van t ngi hin tng, c th km thm mt
on MC, bo qun lnh trong ngn hng m. Vic
pht trin cn gp nhiu kh khn v hn ch.
II. La chn loi van thay
1. Sa van:
Cn phi xem xt kh nng van cn sa c hay
khng trc khi quyt nh thay van, do sa van c
u th hn hn nh: bo tn c chc nng tht tri
323
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t otoc
h
P
g
1 nm mt ln hoc mauri hn nu c triu chng c nng, nht l
py
giai on 5 nm sau
Co m tr i. Tuyn truyn cho bnh nhn v
nguy c v s cn thit phi iu tr d phng vim ni tm mc.
Ring vi bnh nhn c van c hc, cn theo di nh k
hiu qu ca thuc chng ng bng xt nghim t l
Prothrombin v INR.
1. Dng thuc chng ng sau m thay van:
a. i vi van c hc:
Ngay sau m thay van c rt nhiu cch dng
thuc chng ng. Dng sm qu s lm tng
nguy c trn mu mng tim, p tim hoc chy
mu sau m. Mt s ni ch bt u dng
thuc chng ng ng ung 3-4 ngy sau
m thay van. Mt s khc dng Heparin tnh
mch liu thp ( aPTT t ngng bnh
325
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326
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
t th
t thut nh (nh nh rng...),
b. i vi nhng
igh Po
r
y
nguy oc
p chy mu t, c th vn duy tr tip liu
C
chng ng ang dng.
c. Sau m, dng li Heparin ngay khi c th, sau
gi tip bng thuc chng ng ng ung
duy tr lu di.
3. iu chnh qu liu chng ng:
a. Liu thuc chng ng khi u nn l 5 mg
Warfarin (tng ng 1 mg Acenocoumaron
(Sintrom) hay 5 mg Fluindione (Previscan).
Phi gim bt liu ngi gi, ngi c bnh gan
mt phi hp hoc c nguy c chy mu cao.
b. Nu INR vt ngng iu tr v < 5,0 th nn h
bt liu iu tr hoc tm dng mt ngy v ung
vi liu h thp hn.
327
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hoc ta prothrombin
tu trng hp, c th lp
ht Pot
rig
li 12h/ln.
y
p
Co
4. Thuc chng ng v thai nghn: t l bin chng
tc mch do huyt khi tng ln khi c thai. Tuy
nhin do tc dng gy d tt bm sinh, nn ngng
thuc chng ng ng ung (khng vitamin K)
trong ba thng u sau khi c thai, thay bng Heparin
tim di da 15.000 n v 2 ln/ngy nhm duy tr
thi gian aPTT gp 1,5-2,0 ln so vi chng (ly xt
nghim sau tim 6 gi) t nht cho n 3 thng gia,
khi c th quay li ung thuc chng ng tip
cho ti gia 3 thng cui. n lc , chuyn li tim
di da Heparin 5.000 n v 2 ln/ngy cho ti lc
chuyn d. C th phi hp vi Aspirin liu thp.
IV. Triu chng lm sng v xt nghim bnh nhn
c van tim nhn to
328
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thay van.
t
gh Pot
rih
Dng
van bnh l thng rng v di hn
y
p
Co
nhiu,
c th c nhiu dng h, thng lin
quan n hin tng vi, so ho vng van,
h hi cu trc van, p xe vng van, t chc
ln cn... Siu m tim qua thc qun s gip
lng gi kh chnh xc mc h van c
bit l trong trng hp h chn (quanh) van.
HoHL c coi l nng khi vn tc ti a u
tm trng 2,5 m/giy hoc PHT dng chy
qua van hai l 150 miligiy.
HoC c coi l nng khi PHT dng chy qua
van MC 250 miligiy hoc c dng chy
ngc trong ng mch ch xung.
d. nh gi hp van nhn to:
Chnh p qua van:
330
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0,6
14 5
Bjrk-Shiley
3,0 0,8
11 6
St. Jude
2,6 0,3
12 d3
Medtronic-Hall
rve
2,4 0,4
Hancock
e7se 3
r
Carpentier-Edwards
2,4 0,5 ghts .1vn
12
i om
r
Van ng loi
l
l .c 14 6
0,8 A0,4
v. ahoo
e
V tr van hai l
o
l @y0,4
52
Fin01,8
20
Starr-Edwards
.
8 2 1,6
0
0,3
52
20 ity
Bjrk-Shiley
t otoc
h
1,6 0,3
52
P
St. Jude rig
y
p
1,7
0,3
31
Medtronic-Hall
Co
1,5 0,3
42
Hancock
Carpentier-Edwards
1,8 0,2
72
2. Soi di mn tng sng: ch c ch trong trng hp
cc van c hc. Nu chnh chm tia X i song
song vi mt phng ca van th hnh nh ng m
cc cnh van l r nht. Di ng cnh van gim l
du hiu ca tc nghn van, ngc li di ng vng
van qu ln (> 7o i vi van MC v > 11o i vi
van hai l) l du hiu ca long (hng) van mt phn.
3. Thng tim tri vo tht tri c th tin hnh an
ton bnh nhn c van MC sinh hc o chnh
p qua van, nhng i vi van MC c hc (chng
ch nh a ng thng qua) th phi xuyn vch lin
nh ri a ng thng xung tht tri. i vi van hai
332
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333
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
o
ng khng hliu,
t ot
rigdngP mu xoy qua van hai l... Ni
tc ng c
a
y
p
Co lm siu m tim qua thc qun xc
chung, phi
nh v kho st cn nguyn gy tc van nhn to.
9. t qu do cc mu ng bnh nhn c van tim
nhn to:
a. Nguy c t qu ti pht khong 1%/ngy trong
2 tun u. Nu chp phim CT trong vng 24 v
48 gi m khng c chy mu no hoc nhn no
din ln th nn dng Heparin ng tnh mch.
Duy tr ung thuc chng ng s lm gim nguy
c ti pht t qu xung mt phn ba song li
tng t 8-24% nguy c chuyn dng nhn no
thnh xut huyt no nht l trong vng 48 gi
u tin. B sung Aspirin hoc Clopidogrel nu
338
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339
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Potocity2020@yahoo.com.vn
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
340
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suy tim
341
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Hu gnh
Tn s tim
1. Tin gnh: (Preload)
a. Tin gnh c nh gi bng th tch hoc
p
ved
r
e
lc cui tm trng ca tm tht.
es
sr n
t
h
b. Tin gnh l yu t quyt nhigmc .v ko di
ll r o.com
si c tim trong thi k tm. Atrng,
trc lc tm
v aho
e
o
l thuc
y vo:
tht co bp. Tin gnhinph
F 020@
.
8 tht, tc l lng mu tnh
p lc y
00 ity2
c
2tm
mch trhtv
o
ot tht.
P
g
i
r
pygin ca tm tht, nhng mc t quan
Co hn.
trng
2. Sc co bp ca c tim:
a. Trc y bng thc nghim ni ting ca mnh,
Starling cho ta hiu r c mi tng quan
gia p lc hoc th tch cui tm trng trong
tm tht vi th tch nht bp. C th l:
Khi p lc hoc th tch cui tm trng trong
tm tht tng, th s lm tng sc co bp ca
c tim v th tch nht bp s tng ln.
Nhng n mt mc no , th d p lc
hoc th tch cui tm trng ca tm tht c
tip tc tng ln i na, th th tch nht bp
s khng tng tng ng m thm ch cn b
gim i.
342
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tim. Nhng nu
htnhp
Pot tim tng qu nhiu th nhu cu
rig s li
y
xy ca c
tim
tng ln, cng ca c tim cng
op
C
phi tng cao v hu qu l tim s cng b suy yu i
mt cch nhanh chng.
B. Cc c ch b tr trong suy tim
1. C ch b tr ti tim:
a. Gin tm tht: Gin tm tht chnh l c ch
thch ng u tin trnh qu tng p lc cui
tm trng ca tm tht. Khi tm tht gin ra, s
lm ko di cc si c tim v theo lut Starling,
s lm tng sc co bp ca cc si c tim nu d
tr co c vn cn.
b. Ph i tm tht: Tim cng c th thch ng
bng cch tng b dy cc thnh tim, nht l
trong trng hp tng p lc cc bung tim.
343
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t ot
gin mch vighBradykinin,
cc Prostaglandin (PGI2 ,
P
i
yr t nh lm tng o thi Natri (Atrial
PGE2) vopYu
C Peptid) vit tt l APN, cng c huy
Natriuretic
ng song hiu qu thng khng nhiu.
C. Hu qu ca suy tim: Khi cc c ch b tr (c ch
thch ng) ni trn b vt qua th s xy ra suy tim vi
cc hu qu nh sau:
1. Gim cung lng tim: cung lng tim gim s gy:
a. Gim vn chuyn xy trong mu v gim cung
cp xy cho cc t chc ngoi vi.
b. C s phn phi li lu lng mu n cc c
quan trong c th: lu lng mu gim bt da,
cc c, thn v cui cng mt s tng khc
u tin mu cho no v ng mch vnh.
345
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v...
c. Ch : Trng hp trn dch mng ngoi tim
hoc vim mng ngoi tim co tht s c biu hin
ging nh suy tim phi, nhng thc cht ch l
nhng trng hp thiu nng tm trng ch
khng phi suy tim phi theo ng ngha ca n.
3. Suy tim ton b:
a. Thng gp nht l cc trng hp suy tim tri
tin trin thnh suy tim ton b.
b. Cc bnh c tim gin.
348
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cc bunggtim
ht bn
Pot tri: Trc tri, dy nh tri, dy
ri
y
tht tri.
p
Co
c. Siu m tim: Thng thy kch thc cc bung
tim tri (nh tri, tht tri) gin to. Ngoi ra siu
m cn gip ta bit c s co bp ca cc vch
tim cng nh nh gi c chnh xc chc nng
tm thu ca tht tri. Trong nhiu trng hp siu
m tim cn gip cho ta khng nh mt s
nguyn nhn gy ra suy tim tri.
d. Thm d huyt ng cho php:
nh gi mc suy tim tri thng qua vic
o ch s tim (bnh thng t 2-3,5 l/pht/m2)
v o p lc cui tm trng ca tht tri.
nh gi chnh xc mc nng nh ca mt
s bnh van tim.
350
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Biu
ty
20 ihin
t otoc
h
I
Bnh nhn c bnh
rig timPnhng khng c triu chng c
y
p
nng no, vn
Co sinh hot v hot ng th lc gn nh
bnh thng.
II
Cc triu chng c nng ch xut hin khi gng sc
nhiu. Bnh nhn b gim nh cc hot ng v th lc.
III Cc triu chng c nng xut hin k c khi gng sc
rt t, lm hn ch nhiu cc hot ng th lc.
IV Cc triu chng c nng tn ti mt cch thng xuyn,
k c lc bnh nhn ngh ngi khng lm g c.
Trong thc t lm sng, cch phn loi ny rt tt i vi
suy tim tri, nhng khng tht thch hp lm i vi cc bnh
nhn suy tim phi.
B. Phn loi mc suy tim trn lm sng
nc ta, s lng cc bnh nhn suy tim phi thng
chim mt t l kh ln trong s cc bnh nhn b suy tim. V
353
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Biu hin
I
Bnh nhn c kh th nh nhng gan cha s thy.
II
Bnh nhn kh th va, gan to di b sn vi cm.
III Bnh nhn kh th nhiu, gan to gn st rn nhng khi
c iu tr gan c th nh li.
IV Bnh nhn kh th thng xuyn, gan lun to nhiu
mc d c iu tr.
V. iu tr
iu tr suy tim bao gm:
Nhng bin php iu tr chung cho tt c cc
d loi
rve hon
e
s
nguyn nhn gy ra suy tim, nhm gim tr
tun
re
ts vn
h
v tng cng kh nng co bp ca c tim.
.
g
l ri .com
l
A po dng cho tng
Nhng bin php iu tr c bit
ev. yaho
o
l
trng hp c th ty theo nguyn
nhn ca suy tim.
Fin 0@
8. 202
0
A. Nhng bin php iu
20 tr
ity chung
t otoc
h
P dng thuc:
1. Cc bin php
rig khng
y
p
a. ChCo ngh ngi: Ngh ngi l mt vic kh
quan trng v n gp phn lm gim cng ca
tim. Ni chung bnh nhn cn gim hoc b hn
cc hot ng gng sc. Trong trng hp suy
tim nng th phi ngh ti ging theo t th na
nm na ngi. Tuy nhin, trong trng hp suy
tim m bnh nhn phi nm iu tr lu ngy th
khi hon cnh cho php, nn khuyn khch bnh
nhn xoa bp, lc u l th ng, sau l ch
ng cc chi, nht l hai chi di lm cho
mu tnh mch tr v tim c d dng hn, gim
bt cc nguy c huyt khi tnh mch thng hay
gp nhng bnh nhn ny.
b. Ch n gim mui:
354
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c. Dc ng hc:
Digoxin thng c dng di dng ung
(vin nn, vin nang, dng cn) hoc tim.
dng ung, phn ln Digoxin c hp thu
rut non sau s c phn b tip ti mt
s m. Nng Digoxin thng c tp
trung ch yu thn, tim, gan, tuyn thng
thn, ng tiu ha...
Digoxin c chuyn ha ch yu ti gan.
Phn ln Digoxin c thi tr qua ng
nc tiu, ch c mt phn nh (khong 25%)
c thi tr qua ng phn.
ngi ln, vi chc nng gan, thn bnh
thng th thi gian bn hy trung bnh
ed ca
v
r
e
Digoxin (theo ng ung) l 36 gi.
res
ts l
n nng
Mt s nghin cu cho thy
h
ig om.v
r
l
l o.ca
c Digoxin c
trung bnh trong huyt tng
ho khong t 0,5
v. Atrong
e
a
tc dng iu tr thng
o
inl @y
. F 2020 Tuy nhin khong
hoc 0,8 n 82,0ng/ml.
0 y
20 ocit
cch gia
nng
iu tr v nng ng
t ot
h
P
g
cyl
ri rt hp. C bnh nhn phi dng trn
p
2,0
Co ng/ml mi c tc dng iu tr, ngc li
mt s bnh nhn khc nng 0,8 - 1,5
ng/ml c triu chng ca ng c Digoxin.
d. Liu lng v cch dng:
Trc y ngi ta hay dng bt u bng
liu tn cng sau chuyn sang liu duy tr.
Liu tn cng thng l 0,25 - 0,5mg, ri c
sau 6 gi c th cho thm 0,25mg t tng
liu l 1 - 1,5 mg/ngy.
Khi t c hiu qu, thng chuyn sang
liu duy tr t 0,125 - 0,375mg/ngy.
Ngy nay ngi ta thng khng cn dng
liu tn cng vi mt lng thuc ln trong
mt thi gian ngn nh trn v cch ny rt d
gy nguy him cho bnh nhn. Trong a s
357
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ht Poto
Cnyc
ch khng bao gi c dng
rig bit
p
Co hp Digoxin vi cc mui Canxi (ng
phi
tnh mch) v s phi hp ny c th gy nn
nhng ri lon nhp tim nng n, thm ch c
th gy t vong.
f. Ch nh:
Suy tim vi cung lng tim thp, c bit khi
c rung nh nhanh.
Cc ri lon nhp trn tht, c bit trong
rung nh hay cung ng nh.
Ch : Nhng trng hp suy tim vi cung
lng tim cao (thiu mu nng, nhim c
gip, d ng - tnh mch, bnh thiu vitamin
B1...) hoc suy tim c lin quan n mt tc
nghn c hc hay suy tim trong tm ph mn
khng phi l nhng ch nh ca Digoxin.
358
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g. Chng ch nh:
Nhp tim chm.
Bloc nh - tht cp II, cp III cha c t
my to nhp.
Ngoi tm thu tht.
Nhp nhanh tht v rung tht.
Hi chng Wolff - Parkinson - White.
Bnh c tim tc nghn.
Cn thn trng trong trng hp: Nhi mu
c tim cp (v Digoxin lm tng nhu cu xy
ca c tim) v cc ri lon in gii, c bit
l h K+ mu v / hoc h Mg ++ mu.
h. Nhim c Digoxin: mt s thng k cho thy
s bnh nhn dng Digoxin b nhim c chim
khong 5 - 15% tng s bnh nhn dng thuc.
d
rve l :
e
s
Yu t thun li cho nhim c Digoxin
e
s r n h Mg++
(a) Ri lon in gii: h Kig+ htmu,
v
.
mu, tng Ca++ mu.All r o.com
ho nhy cm vi
ev. ya
(b) Tui cao: lm lotng
in 0@lc ca thn, t d
Digoxin do8gim
. F 202
0
0 ity
lm ng
2 tocthuc.
t
h
o
(c) Nhim
chuyn ha.
Pkim
rig
y
(d)
Gim
xy
mu.
p
Co
(e) Suy thn, suy gan...
Biu hin lm sng ca nhim c Digoxin:
khi bnh nhn ang dng Digoxin, t nhin
thy mt s biu hin sau :
(a) Ri lon tiu ha: chn n, bun nn, nn
ma, a chy.
(b) Ri lon thn kinh: c th ch l au u,
chng mt nhng c th nng hn nh o
gic, mt phng hng, m sng...
(c) Ri lon tim mch: do tng tnh kch
thch, tng tnh t ng v gim tnh dn
truyn ca t bo c tim:
i. Ngoi tm thu nh v tht, hay gp l
ngoi tm thu tht nhp i, ngoi tm
thu tht a dng hoc tng chm.
359
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360
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5,0
2h
24h
2 it
t otoc
h
Li tiu quai
P
g
ri
y
p
Furosemide
U
20
80
1h
6 - 8h
Co
TM,
10 80
5ph
2 - 4h
TB
Ethacrynic
U
25 100 30ph
6 - 8h
acide
TM
50
5ph
2 - 4h
Bumetanide
U
0,5 - 2,0
30ph
2h
TM,
0,5 - 2,0
5ph
30ph
TB
Torsenide
U
5 - 10
2h
8 - 12h
TM
5 - 10
5ph
6 - 8h
Nhm gi kali
Spironolactone
U
50 - 200
1 - 2ng
2 - 3 ng
Triamterene
U
100 - 200 2 - 4 ng 7 - 9 ng
Amiloride
U
5 - 10
2h
24h
363
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364
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t ot
dngrthuc
bnh nhn c huyt p thp.
igh Pcho
y
p
Bng 18-4. Mt
Co s thuc c ch men chuyn thng dng.
Thuc
Liu u Trung bnh
(mg/ngy) (mg/ngy)
Benazepril (Cibace, Cibacen,
5 - 10
10 - 40
Lotensin)
Captopril (Capoten, Lopril, 12,5 - 25
12,5 - 100
Lopiril, Captopril)
Enalapril (Innovace, Pres,
2,5 - 5
2,5- 40
Renitec, Renivace, Vasotec)
Fosinapril (Monopril, Staril)
10
10 - 40
Lisinopril (Prinivil, Zestril)
10
5 - 40
Quinapril (Accupril, Acuitel)
10
5 - 80
Ramipril
(Altace,
Delix, 1,25 - 2,5
1,25 - 20
Ramace, Triatec, Tritace)
365
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o
Irbersartan
mg
75-300mg
t
gh Pot
i
r
Losartan
25 mg
25-100 mg
py
Co
Telmisartan
20-40 mg
40 80 mg
Valsartan
80 mg
80-320 mg
f. Nhm Nitrates:
Nhm Nitrat ch yu lm gin h tnh mch,
t lm gim tin gnh. Nhm ny cn lm
gim bt tnh trng thiu mu c tim do lm
gim p lc y tim, ngoi ra chng cn
lm gin trc tip ng mch vnh.
Bng 18-6. Mt s Nitrat thng dng.
Ko di
Dng thuc
Liu
Bt
(mg)
u
(pht)
Nitroglycerin (ngm)
0,3 - 0,6 2 - 5
10-30ph
Dinitrat Isosorbide (ngm)
2,5 - 10 10- 30 1 - 2 h
366
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371
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373
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4.
5.
6.
376
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Potocity2020@yahoo.com.vn
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Cohen GI, Pietrolungo JF, Thomas JD, Klein AL. A practical guide
to the assessment of ventricular diastolic dysfunction using Doppler
echocardiography. J Am Coll Cardiol 1996;27:1753-1760.
Cohn 'IN. The management of chronic heart failure. N Engl J Med
1996;335:490-498.
Doval HC, Nul DR, Grancelli HO, et al., For Gruppo de Estudio de
la Insuficiencia Cardiaca en Argentina. Randomized trial of low dose
amiodarone in severe congestive heart failure (GESICA). Lancet
1994;344:493-498.
Hosenpud JD, Greenberg BR. In: Hosenpud J, ed. Congestive heart
failure. New York: Springer-Verlag, 1994.
Lenihan DJ5 Gerson MC, Hoit BD, Walsh, RA. Mechanisms,
diagnosis, and treatment of diastolic heart failure. Am Heart J
1995;130:153-166.
d
rve
e
Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular
s
re
Medicine. Philadelphia: Lippincott-Raven, 2000. hts .vn
g
ri com Automatic
Moss AJ, Hall AJ, Cannom DS, et al. for the
llMulticenter
A
oo.
.
v ah(MADIT).
e
Defibrillator Implantation Trial Investigators
Improved
o
nl 0@y
i
F
2
survival with an implanted defibrillator
in patients with coronary
.
08 20
20 ocity arrhythmias. N Engl J Med
disease at high risk for ventricular
ht Pot
1996;335:1933-1940.
rig
y
p
Nishimura RA,
Co Tajik AJ, Evaluation of diastolic dysfunction in
health and disease: Doppler echocardiography is the clinician's
Rosetta stone. J Am Coll Cardiol 1997; 30:8-18.
Packer M, Bristow MR, Cohn JN, et al. for the U.S. Carvedilol Heart
Failure Study Group. The effect of carvedilol on morbidity and
mortality in patients with chronic heart failure. N Engl J Med
1996;334:1349-1355.
Packer M, Gheorghiade M, Young JB, et al. for the RADIENCE
Study. Withdrawal of digoxin from patients with chronic heart
failure treated with angiotensin-converting-enzyme inhibitors. N
Engl J Med 1993;329:1-7.
Packer M, O'Conner CM, Ghali JK, et al. for the Prospective
Randomized Amlodipme Survival Evaluation Study Group
(PRAISE). Effect of amlodipine on morbidity and mortality in severe
chronic heart failure. N Engl J Med 1996;335: 1107-1114.
377
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378
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380
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o
t totvong trong bnh cnh suy tim
hb
dn v c th
P
rig
y
p
nng hay
ri
lon
nhp.
Co
2. T l t vong trong vng 5 nm l 40 n 80%.
Trong i a s cc nghin cu cho thy t l t vong
trong vng 1 nm l 25% v 2 nm l 35 n 40%.
Tuy nhin cc tc gi cng ch ra rng cc bnh nhn
sng qu 2 hoc 3 nm u c tin lng lu di tt
hn rt nhiu. Tnh trng n nh s gp trong
khong 20 n 50% cc trng hp nhng chc nng
tht tri tr v bnh thng rt him gp trong thc t.
3. Tin lng da vo cc yu t sau: triu chng ca
bnh nhn, phn s tng mu ca tht tri, ch s tim,
ri lon dn truyn nh tht, ngoi tm thu tht a ,
h natri mu v tng yu t ANF (atrial natriuretic
factor). Ngoi ra cc yu t khc cng c th nh
hng n tin lng nh nghin ru, tin s gia
383
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t trng
t hp NYHA 3 hoc 4 khng
Ch nh trong gcc
i h Po
r
y
p ng vi iuotr
p ni khoa ( bao gm c chn bta). Tuy
C
nhin, phu thut ny tn km v mi ch c thc hin ti
mt s trung tm y hc ln.
Ti liu tham kho
1.
2.
3.
4.
5.
385
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6.
7.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
386
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Bnh c tim ph i
388
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3. Rung nh lm mt s co bp hiu qu ca tm nh c
th l nguyn nhn ca suy tim nng trn lm sng v
tc mch. Vim ni tm mc nhim khun c th gp
cc bnh nhn c h hai l. Qu trnh thai sn c
th vn c din bin tt, ngay c khi cho bnh nhn
thng.
VI. Chn on phn bit
1. Ting thi tm thu trn lm sng cn phn bit vi
hp van MC, thng lin tht, hay h hai l. Mt vi
bnh nhn tr em b bnh c tim ph i c hn ch
ng ra tht phi cn c phn bit vi hp
van
ed
v
r
e
ng mch phi.
es
sr n
t
h
2. au ngc trong bnh c tim ph i
.v rt in
rig cc
mth
o
l
l
.
hnh nh cn au tht ngc v i
khi ngay trn T
v. A ahoo
evi
o
l
y
cng c hnh nh ca NMCT
sng
Q hoi t.
Fin020@
.
08 2
VII. iu tr
20 ocity
ht Pc
ot triu chng: c th khng
A. Bnh nhn khng
rig
y
op c hiu nhng cng c th iu tr d
cn iu tr Cthuc
phng bng chn bta giao cm hoc Verapamil nhm
mc ch gim s tin trin ca bnh.
B. Bnh nhn c triu chng kh th v au ngc
1. Cn iu tr bng chn bta giao cm. Thuc chn
knh canxi nh Verapamil c th lm gim triu
chng v tng kh nng gng sc ca cc bnh nhn
khng p ng vi thuc chn bta giao cm. Mt vi
trung tm ang th s dng Disopyramid ci thin
cc triu chng lm sng.
2. Thuc chng ng cn ch nh trong cc bnh nhn
c rung nh hoc c ri lon nhp trn lm sng.
Khng sinh dng trong cc trng hp cn d phng
vim ni tm mc nhim khun.
392
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393
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2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
394
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Bnh c tim Hn ch
Loffler, x ha ni mc,
ht bnh
Pot Gaucher tr em
rig
y
p
II. Triu chng lm
Co sng
Du hiu ch yu l tr ngoi bin nh gin tnh mch c,
huyt phi v gan to, c chng.
III. Cc xt nghim chn on
1. in tm (T): Hu nh lun c T bt
thng. Bloc nhnh tri v dy nh l cc du hiu
hay gp. Trong nhim amyloid hay c du hiu gim
bin cc sng ngoi bin i ngc vi hnh nh
dy cc thnh tim trn siu m tim. Ri lon nhp tim
nht l rung nh rt hay gp, c bit l trong nhim
amyloid.
2. Chp tim phi: Bng tim thng khng to tr khi c
gin rng hai nh, huyt phi thng nng.
395
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d
rve
e
s
re
ts vn
h
.
g
l ri .com
l
A o
ev. yaho
o
l
Fin 0@
8. 202
0
20 city
t otoca
Hnh 21-1. Ph Doppler
dng chy qua van hai l
h
righn Pch do amyloidosis (A) v ngi
y
ngi mc bnh c otim
p
C
bnh thng (B). T l E/A (A) cao hn (B).
4. Chp ct lp t trng (CT) v cng hng t
trng ht nhn (MRI): Cho hnh nh gip phn
bit vi bnh vim mng ngoi tim co tht nh du
hiu dy mng ngoi tim.
5. Thng tim: Ch nh trong cc trng hp cn chn
on phn bit vi vim co tht mng ngoi tim v
cng phc v cho mc ch sinh thit c tim chn
on nguyn nhn bnh c tim hn ch. ng cong
p lc ca tm nh ging ht nh trong bnh vim
mng ngoi tim co tht, p lc cui tm trng ca
tm tht cng c dng cao nguyn. Tuy nhin nu
dng cao nguyn tht tri cao v r rng hn so vi
tht phi th lc ny ngh nhiu n bnh c tim hn
396
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t obng
3. Chn on xcghnh
sinh thit ni mc c tim.
Pt
ri
y
p
V. iu tr
Co
A. Khi bnh nhn c tng p cui tm trng tht
tri nhiu: c th iu tr bng li tiu. Cc loi thuc
tng co bp c tim thng khng c hiu qu. Cc thuc
gin mch cn s dng ht sc thn trng. Thuc chn
knh Canxi c th tng sc gin n cui tm trng ca
tm tht nhng cha c khng nh trn lm sng v
hiu qu iu tr.
B. iu tr bnh nguyn
1. Nhim amyloid hay gp cc nc khng thuc
vng nhit i. C th ch nh hng n tim nhng
cng c th c nh hng n cc h thng khc.
Hay gp ri lon nhp km theo, tin lng khng tt,
hu nh ch c cch iu tr hiu qu l ghp tim.
397
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t ot
disease: clinical and hechocardiographic
spectrum in 74 patients.
P
rig
Circulation 1993;87:1188-96.
y
op
10. Richardson P,CMcKenna
W, Bristow M, et al. Report of the 1995
World Health Organization/International Society and Federation of
Cardiology Task Force on the Definition and Classification of
Cardiomyopathies. Circulation 1996;93:841-2.
398
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d
rve on
Hnh 22-1. Tin trin trn in tim tesegiai
r
ts cp
VMNT cp (trn) chuyn sang giai on gbn
n (di).
h
i om.v
r
l
l .cch thy trong
2. Chp tim phi: hnh tim to .thng
v A ahoo
e
o
cc trng hp c trn dch
l mng
y ngoi tim phi hp
0@
Finl02du
.
v y cng khng 0phi
hiu c hiu gip
8
0 ity2
2
chn on.
t toc
igh Po
r
3. Cy mu,opy
cy m v dch ht d dy c kh nng
C
gip chn on mt s cc trng hp vim mng
ngoi tim phc tp nh do lao (sau 1 tun), nhim
khun huyt hay vim ni tm mc nhim khun.
4. Xt nghim mu: thng c tng bch cu, mu
lng tng v tng men creatine phosphokinase MB.
5. Siu m tim:
a. Siu m tim thng c ch nh trong cc
trng hp giai on sau ca bnh (vi tun sau
du hiu lm sng u tin xut hin) hay khi c
bin i huyt ng tuy nhin cng c th thc
hin thng quy trong tt c cc trng hp
chn on loi tr. Du hiu c th gp trn siu
m l khong trng siu m do dch mng ngoi
tim gy ra (8 n 15% cc trng hp vim mng
401
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402
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403
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D. iu tr
1. Rifampicin 600mg/ngy, Isoniazid 300mg/ngy,
Pyridoxine 50mmg/ngy phi hp vi Streptomycin
1g/ngy hoc Ethambutol 15mg/kg/ngy trong 6 n
9 thng.
2. Cn sm phu thut ct mng ngoi tim trong cc
trng hp trn dch ti pht gy p tim nhiu ln hay
mng ngoi tim dy nhiu dn n vim mng ngoi
tim co tht.
IV. Vim mng ngoi tim sau nhi mu c tim
Do vim mng ngoi tim phi hp vi hoi t c tim
nn bnh nhn c nguy c suy tim huyt v t l t vong
trong vng mt nm cao. Trong nhm cc bnh nhn
d nhi
rve
e
s
mu c tim cp c ti ti mu (tiu si huyt
re hay nong
ts thp
n hn
h
ng mch vnh), t l vim mng ngoi
tim
g
i om.v
r
l
l .c
nhm iu tr bo tn.
v. A ahoo
e
o
l @trong
y
Vim mng ngoi tim hay
cc trng hp
0
Fingp
2
.
0
8 rng
2
nhi mu c tim thnh trc
ko
di
vi
gi n vi
0
20 ocity
405
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406
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o
ht ot
righp Pl do di cn n mng ngoi tim
i a s cc trng
y
op
(ung th phi, Cung th v, Hodgkin v khng Hodgkin, lx-mi...). Ung th nguyn pht mng ngoi tim him gp c
th do sarcome, mesothelioma, teratoma hay fibroma.
A. Triu chng lm sng
1. Bnh nhn thng khng c triu chng lm sng g
c bit, ngoi cc triu chng ca bnh l ung th.
Vim mng ngoi tim thng pht hin kh mun.
2. C th gp du hiu c nng l kh th, trn dch
mng phi v i khi bnh nhn n vin v p tim.
3. Cn sm pht hin p tim cc bnh nhn ung th
khi t ngt xut hin kh th, mt mi hoc ph.
B. Cc xt nghim chn on
1. in tm (T): Cc du hiu T in hnh
cho vim mng ngoi tim thng khng thy r. Bin
407
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t
t
C. Vim mng ngoi
igh Potim co tht: khong 9% cc
r
y
trng hp vim
p mng ngoi tim s b vim dnh mng
Co
ngoi tim mc t trung bnh tr ln.
Ti liu tham kho
1. Adler Y, Finkelstein Y, Guindo J, et al. Colchicine treatment for
recurrent pen-carditis. Circulation 1998;97:2183-2185.
2. Alexander RW, Schiant H, Fuster V. Hurst's the heart, 9th ed. New
York: McGraw-Hill, 1998.
of
the
pericardium.
Cardiol
Clin
409
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ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
410
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Potocity2020@yahoo.com.vn
o
.
ev yah kh nng cha
o
l
dch ca khoang mng tim s tng
in ln.@ Vi s tng dn ca
. F 2020
8khoang
lng dch nhiu trng hp
mng tim c th cha
0
20 ocity
t oc
n 2 lt dch m vnghcha
t bin i huyt ng trn lm
ring Phay gp trong cc trng hp dch
y
sng. Chn p huyt
op
qu nhiu hay Ctng qu nhanh hoc trong cc trng hp
dch c nhiu si fibrin, trn dch mng tim do ung th.
A. Triu chng lm sng
1. Triu chng c nng:
a. Dch mng tim tng dn khng lm bin i p
lc trong bung tim thng khng c biu hin
triu chng lm sng.
b. i khi bnh nhn c biu hin au m , p
nng ngc.
c. C th c cc biu hin do dch mng tim p
vo cc c quan ln cn. Kh nut do chn p vo
thc qun, kh th do chn p phi v xp phi,
411
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ht ot
3. Cc hi chng
rig sauPtn thng c tim-mng tim: hi
y
p
Co
chng Dressler;
sau m mng tim
4. Nguyn nhn chuyn ho: hi chng ur mu cao,
ph nim, gim albumin mu
5. Do tia x
6. Phnh tch ng mch ch ngc
7. Chn thng: ng dp, do dng c, th thut..)
8. Do virus: Coxsackie cc tp A, B5, B6; Echovirus;
Adenovirus, virus cm, quai b, thu u, vim gan
B, HIV
9. Do vi khun: t cu, ph cu, lin cu, H. influenzae,
no m cu, lu cu, lao, thng hn, vi khun gy
st m, st vt, L. hemophilia, vim ni tm mc
nhim khun
412
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A
B
Hnh 23-2. Du hiu p tht phi (A) v p nh phi (B).
417
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4.
5.
421
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6.
7.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
422
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ht Pot
2. Chp tim phi:
rig
y
p
a. Mng
Co ngoi tim canxi ho l du hiu hay gp
trn lm sng. du hiu ny thng thy trn
phim chp nghing v hay thy v tr ca tht
phi v rnh nh tht.
b. Trn dch mng phi cng l du hiu hay gp.
c. Gin nh phi v nh tri c th thy r rng trn
phim chp Xquang.
d. Ph phi l du hiu him thy trn phim.
3. Siu m tim: L phng php hu hiu nht chn
on v theo di trn dch mng ngoi tim. Ngoi gi
tr chc chn trong chn on, siu m cn gip cho
vic t dn lu mng tim v nh gi s lng dch
cn li trong khoang mng tim. Tuy nhin siu m
425
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ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht APot
rig
opy3
Hnh 24-1. Thay i theo h hp ca dng chy qua van hai l (A),
qua van ba l (B), trong tnh mch phi (C), trong tnh mch trn gan
(D): lc ngng th (trn), khi ht vo (gia) v khi th ra (di),
ngi bnh thng (1), bnh nhn VMNT co tht (2) v bnh c tim
hn ch (3).
427
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ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
4.
5.
429
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6.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
430
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Tm ph mn
Tm ph mn (chronic cor pulmonale) l mt thut ng
m t cc nh hng ca ri lon chc nng phi ln tim phi.
Tng p ng mch phi (TAMP) l cu ni gia ri lon chc
nng phi v tim phi trong tm ph mn (TPM). Do cc ri lon
chc nng phi dn n TAMP nn TPM l mt dng bnh tim
th pht, nh l mt biu hin mun ca nhiu bnh phi v
trong tng trng hp bnh c th th tng hu gnh tht phi l
biu hin chung nht. Tu theo mc v thi gian b m
TAMP s dn n gin tht phi v c hoc khng c ph i
tht phi. Suy tim phi khng phi l yu t cn thit chn
on TPM, nhng suy tim phi l biu hin ph bin ca bnh.
d
rve tim,
Cc du hiu lm sng ca TPM thay i theo cung slng
e
re
cn bng nc in gii v trong hu ht cc trng
ts vnhp l s
h
.
g
thay i trao i kh phi.
l ri .com
l
A hoo
ev. ysau
a suy tim tri, cc
Ri lon chc nng tim phi th
pht
o
l
in 20@
F
bnh l van tim, bnh tim bm sinh
0 khng nm trong nh
8. 2u
y nghn hp l mt nguyn
00 ib
t
2
ngha ca TPM. Tnh mch
phi
toc
ht Pophi
igmch
nhn ca TPM. Bnh tnh
tc nghn thng c xem
r
py
l nm trong bnh cnh
Co TAMP nguyn pht.
I. Nguyn nhn
Gin ph nang v vim ph qun mn tnh l nguyn nhn
ca hn 50% cc trng hp tm ph mn Hoa K. Tn xut
ca TPM rt kh xc nh v TPM khng phi xy ra tt c cc
trng hp b bnh phi mn tnh. Hn na, cc thm khm thc
th v xt nghim thng qui th thng kh xc nh c
TAMP. Tn xut bnh phi tc nghn mn tnh Hoa K
khong 15 triu ngi, l nguyn nhn trc tip ca 70.000 ca t
vong mi nm v gp phn gy t vong 160.000 trng hp
khc. TPM chim t 5-10% bnh tim thc tn. Trong mt
nghin cu ngi ta thy TPM l nguyn nhn ca 20 n 30%
cc trng hp nhp vin.
431
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432
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2.
3.
4.
5.
435
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d
rve
e
s
re
ts vn
h
.
g
Suy h hp
Suy h hp tng phn
om phn
l ri .ctng
l
A o
ev. yaho
o
l
Fin 0@
8. 202
0
Thiu xy mu
Tng CO2
20 ity
t otoc
h
P
g
ri
py
Co
Suy h hp
Thiu xy t chc
Toan mu
Ph i tht phi
Suy tim phi
ht Pot
rig
y
p
Co
t ng
toc mch phi phi, tri gin.
mch phi ni,ghcc
o
P
ri
py
5. Thm d
Co huyt ng (siu m tim hoc thng tim
phi): p lc ng mch phi tng.
B. Chn on phn bit
1. Suy tim ton b do bnh van tim mc phi (hp van
hai l), bnh tim bm sinh, bnh c tim.
2. Suy tim do suy vnh, nhi mu c tim : cn au tht
ngc in hnh, bin i on ST -T v cc men tim
tng.
3. Hi chng Pick: Vim mng ngoi tim co tht.
4. Tim ngi gi: ngi ln tui, khng c tin s b
bnh phi mn tnh.
444
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C. Chn on giai on
1. Giai on sm: Ch c bnh phi mn tnh vi
nhng t suy h hp kch pht, cha c tng p
ng mch phi, cn pht hin sm phng.
2. Giai on tng p ng mch phi: Thng lm
sng khng th pht hin c, thm d bng thng
tim phi hoc siu m Doppler tim th c tng p
ng mch phi, c th iu tr tt v tr v n nh.
3. Giai on suy tim phi cn hi phc: c biu hin
tng p ng mch phi v suy tim phi, iu tr c
kt qu.
4. Giai on suy tim phi khng hi phc: iu tr
khng c kt qu.
d
rve
e
s
re
VI. Tin trin v tin lng
ts vn
h
.
g
Bnh phi mn tnh tin trin t t, chm
om dn lm
l ri .cchp,
l
oo n suy gim
v. A ahdn
tn thng n chc nng h hp caloephi
y
@ nng phi ton b
Fin020chc
chc nng phi tng phn, ri suy
8. gim
2
0
v cui cng l tng p ng mch
ty ri suy tim phi.
20 iphi,
t otoc
h
P thuc vo ngi bnh c c
S tin trin caybnh
rig ph
p
pht hin bnh sm,
Coc iu tr v theo di thng xuyn hay
khng. Nhn chung, nhng bnh phi mn tnh gy suy tim phi
c tin trin nhanh nu nhng t kch pht xy ra nhiu ln.
Ngc li, khi bnh nhn c theo di v iu tr tt th c th
n nh c t 5 n 20 nm v hn na.
Tin lng bnh ph thuc ch yu vo vic kim sot
bnh phi nn hn l iu tr tng p ng mch phi. Trong
nhm bnh phi tc nghn, vim ph qun mn tnh tin trin
nhanh hn, bnh hen ph qun tin trin chm hn nht l th
hen d ng. Trong nhm bnh phi hn ch c bit l cc bnh
c lin quan n tnh cht c hc ca h hp nh g vo, d dng
lng ngc nu khng b bi nhim phi th c th sng lu m
khng c biu hin TPM. Bnh tc mch mu phi tin lng
xu hn.
445
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VII. iu tr
A. xy liu php
1. Rt quan trng, c th cho th xy bng ng thng
qua mi, bng xy, th xy trong vng kn. xy nn
dn qua bnh nc lm m, khng cho th xy
100% trong trng hp suy h hp ton b c tng
CO2 v nh vy d c ch trung tm h hp. S tng
p lc xy trong mu ci thin tnh trng thiu xy t
chc s lm gim p lc ng mch phi.
2. Cc nghin cu ln ti Anh v Hoa K u cho thy
dng xy liu php liu thp (1 -2 lt/pht), ko di
(12 - 24 gi/ngy, trong vi thng n nhiu nm)
lm ci thin r t l sng cn bnh nhn tm
ph
ed
v
r
e
mn. c bit dng xy liu php lin tcesc th lm
r
ts vn
gim t l t vong r hn dng xyghliu
php ngt
i om.
r
l
qung vo ban m.
l .c
v. A ahoo
e
o
l thiny chc nng tm thn
3. xy liu php cng lm ci
Fin020@
.
8 v s ci thin ny thng
kinh ca bnh nhn TPM
00 ity2
2 tocdng
c c sau mthtthng
xy.
Po
ig
r
4. V sao xy
py liu php lm ci thin tnh trng sng
Co
cn ca bnh nhn TPM n nay vn cha c r.
C hai gi thit chnh: (1) xy lm gim tnh trng
co mch phi, gim sc cn mch mu phi v vy
chc nng tht phi c ci thin v th tch tng
mu tht phi tng; (2) xy liu php lm ci thin
nng xy mu ng mch nn cung cp tt xy
cho cc c quan sng cn nh no, tim, gan, thn...
5. Liu php xy ko di c khuyn co cc bnh
nhn TPM c PaO2 lc ngh di 55mmHg v
c iu tr n nh trong 3 tun vi cc thuc nh
thuc gin ph qun, khng sinh, li tiu... Bnh nhn
c PaO2 lc ngh ln hn 55mmHg th cn phi xem
xt cn nhc khi dng xy liu php ko di v ch
dng khi bnh nhn c a hng cu hoc c cc du
446
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C. iu tr tm ph mn mt s th c bit
1. Tm ph mn bnh nhn hen ph qun: cho
Hemisucinat Hydrocortison, Depersolon tim tnh
mch.
2. Bnh nhn x phi thng khng c tr CO2, nn
ch cn cho th xy rng ri v cho corticoid.
3. Ngi bo bu: cho n ch lm gim cn.
4. Ngi g vo ct sng d dng lng ngc: tp th,
chng bi nhim phi l rt quan trng, c th cho
iu tr chnh hnh t sm.
5. Do tc mch phi: ngh ngi tuyt i, n ch
khng mui, dng thuc chng ng, tr tim
digitalis, th xy. Phu thut ly cc mu rng
ved tc
e
s
ng mch phi ln.
re
ts vn
h
.
g
Ti liu tham kho
l ri .com
l
. A ahoo of Cardiovascular
1. Marso SP, Griffin BP, Topol EJ, eds.
evManual
o
l
y
Medicine. Philadelphia: Lippincott-Raven,
Fin020@2000.
.
2. Topol E, ed. Textbook of 0cardiovascular
medicine. Philadelphia:
08 ty2
Lippincott-Raven, 1997.t 2 toci
h Po pulmonary hypertension. New York:
3. Rubin LJ, Rich S, eds.
rig Primary
y
p
Marcel Dekker;
Co1997.
4.
5.
6.
7.
8.
9.
452
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Nhi mu phi
454
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II. Chn on
Chn on nhi mu phi va d b st va d chn on
nhm. Rt d b st chn on bnh nhn c bnh tim phi t
trc, ngi gi, hoc khi ch c duy nht triu chng kh th.
10% trng hp t vong ti vin l do tc mch phi cp, a s
ch c chn on khi m t thi. Mt khc, cng d chn on
nhm. Ngay c cc nc tin tin, chn on xc nh bng
chp ng mch phi ch chim xp x mt phn ba s bnh
nhn nghi ng.
A. Triu chng lm sng
Bng 26-1. c lng kh nng tc mch phi
- Kh th t ngt, th nhanh (> 20 ln/pht) hoc
Cao
> 85% au ngc (kiu mng phi hoc sau xng c) ekhng
d
erv nhng
gii thch c, km theo t nht 2 trongress
ts
biu hin sau:
gh m.vn
i
r
o
l
- C yu t nguy c (khng vn ng,
Al hoo.c tr tun hon,
.
v
e ma xng khp hoc
tin s vim tc tnh mch, lsau
n o 0@y
i
F
2
tiu khung, sau chn thng,
8. 0 khi u c tnh, suy tim,
00 ity2
2
dng thuc trnhtthai...).
toc
- Thu km theo
igh duPohiu tng gnh tht phi mi c
r
opy
trn inCtim.
- Triu chng vim tc tnh mch su (sng, nng, ,
au mt chn).
- Phim Xquang c du hiu nhi mu phi, bu
vng rn phi hoc vng gim ti mu.
Trung C cc biu hin nm gia hai nhm thp v cao.
bnh
Thp
- Khng c kh th t ngt, th nhanh (> 20
< 15% ln/pht) hoc au ngc.
- Kh th t ngt, th nhanh hoc au ngc nhng
do l do khc.
- Khng c yu t nguy c.
- Bt thng trn phim Xquang do nguyn nhn khc.
- INR > 2 hoc aPTT > 1.5 ln chng trong vng 1
tun trc .
455
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u 94%, thm
ch
ht ot
riggnhP tht phi). Hnh nh dng tnh
hoc c tng
y
p
Co do hch rn phi to gy xp phi, m trung
gi c th
tht, ph quanh mch (suy tim huyt), bm thuc
cn quang chm... Hnh nh m tnh gi c th gp
khi nh gi cc ng mch nh ca h phn thy
phi, hoc nhng vng MP xut pht khng theo
chiu dc, hoc khi c tc TMC trn, c lung thng
trong tim, trong phi gy gim cn quang cc MP.
chnh xc ca chp CT ch gim nhm bnh
nhn tc mch phi nh (di h phn thy), l nhm
chim t l t (6% cc trng hp tc mch phi) v
tin trin vn tt d khng dng thuc chng ng.
Sau khi chp CT phi c bm thuc, lng cn quang
trong h tnh mch vn nh gi tip huyt
khi trong tnh mch su vng chn, vng bng,
khung chu v TMC di m khng tn thm thi
464
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c bng phng
ht tin
ot khc. Tuy nhin khng phi
rigthcPhin c v lun c nguy c t
y
ch no cng
op
vong dCnh (< 0,3%) khi chp, nht l nhm nng
c p lc cui tm trng tht tri cao hoc tng p
ng mch phi. Chng ch nh tng i bnh
nhn c thai, nguy c chy mu cao, suy thn v c
huyt khi trong tim phi. C th chp bng ng
thng i qua tnh mch i (khng th nu bnh nhn
t li lc TMC di, c nguy c lm bong huyt
khi vng chu i hoc TMC di v d chy mu
nu dng thuc tiu si huyt), ng TM cnh tay
(kh li ng thng, d co tht TM nht l khi sc
hoc dng thuc vn mch liu cao) hoc TM cnh
trong v TM di n (chng ch nh nu dng
chng ng liu). Trc khi chp nn thng tim
nh gi cung lng tim, shunt, mc ri lon
465
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t
huyt khi tnh
mch
t chi di (HKTMCD) khng c
igh Po
rr
y
triu chng
rng
m
vic pht hin phi da vo:
op
C
siu m Doppler mu mch mu, MRI hay chp cn
quang h tnh mch. Chp cn quang h tnh mch
hin rt t c s dng, MRI li qu phc tp, nn
siu m Doppler mu mch mu l phng tin l
tng pht hin huyt khi tnh mch su, cho d
t tin cy nhm khng biu hin triu chng hoc
khi nh gi huyt khi TMC di. 40% bnh nhn
huyt khi TM su c tc mch phi khi lm x hnh
d khng c triu chng lm sng. Cho d cc bin
php trn khng th chn on xc nh tc mch
phi, song vic pht hin huyt khi TM su rt quan
trng quyt nh hng x tr. Bn thn vic tn
ti huyt khi TM on gn c ch nh iu tr
thuc chng ng d lm sng khng biu hin tc
466
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va v Noradrenaline
ht Pot
rig
nng catecholamine
ni sinh t n mc rt
y
op
cao nnCp ng vi cc thuc vn mch s km, c
khi khng c tc dng m cn gy ri lon nhp.
B. Heparin
Bng 26-2. Liu Heparin trong HKTMCD v NMP
Chn on
Liu heparin
HKTMCD - Tim thng TM 5000 v tip theo truyn TM
khng km 1000 v/gi, kim tra thi gian throboplastin bn
theo NMP phn (aPTT) iu chnh liu Heparin sao cho
hoc NMP aPTT trong khong 1,5 - 2,5 ln thi gian chng.
nh
- C th thay bng dng Heparin trng lng
phn t thp liu 1 mg/kg tim di da x 2
ln/ngy.
- Dng khng vitamin K, gi t ngy th 3-4,
ngng Heparin sau 7-10 ngy.
469
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Reviparin
3.5
<60kg: 4.200 U/12h
1750 U/24h
>60kg:6.300 U/12h
(Clivarin)
Tinzaparin
1.9
175 U/kg/24h
3.500 U/24h
50 U/kg/24h
(Innohep)
c. Dng gi t ngy th 3-4 mt loi khng vitamin
K (Warfarin, Sintrom) v ko di vi thng.
d. Hin nay mt s tc gi a dng cc thuc tiu
si huyt (Streptokinase, Urokinase, rt-TPA...),
tuy nhin kt qu cha vt tri hn phng thc
iu tr thng thng v rt t tin.
e. Can thip t dng c lc (phin lc) tnh mch
ch di ngn nga cc mu ng bn ln
d
ng mch phi gy NMP.
rve
e
s
re
Ti liu tham kho
ts vn
h
g
i om. Opinions
1. ACCP Consensus Commitee on pulmonary
l rembolism.
l
.c
regarding the diagnosis and management
hoo thromboembolic
v.ofAvenous
e
a
o
disease. Chest, 1996;109:233-7. inl 0@y
.F 2
2. Britist Thoracic Society, Standards
08 ty20of Care Commitee. Suspected
0
2 i a practical approach. Thorax,
acute pulmonary embolism:
t otoc
h
1997;52(suppl 4):S1-24.
P
g
ri
3. Fitzmaurice D,opy
Hobbs FDR, McManus R. Thromboembolism.
C
Clinical Evidence, 2001;5:158-68.
Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous
thromboembolism. Chest, 2001;119:132S-175S.
5. Goldhaber SZ. Pulmonary embolism. N Eng J Med, 1998;339:93104.
6. Hyers TM, Agnelli G, Hull RD, et al. Antithrombotic therapy for
venous thrombo-embolic disease. Chest, 2001;119:176S193S.
7. Layish DT, Tapson VF. Pharmacologic hemodynamic support in
massive pulmonaryembolism. Chest, 1997;111:218-24.
8. Mercat A, Diehl JL, Meyer G, et al. Hemodynamic effects of fluid
loading in acute massive pulmonary embolism. Crit Care Med,
1999; 27:540-4.
9. Riedel M. Emergency diagnosis of pulmonary embolism. Heart,
2001;85:607-9.
10. Riedel M. Venous thromboembolic disease. Acute pulmonary
embolism 1: pathophysiology, clinical presentation, and diagnosis.
Heart, 2001;85:229-40.
4.
474
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ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
475
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Potocity2020@yahoo.com.vn
Thng lin nh
d
rve
e
s
e phi.
Hnh 27-3. Hnh nh ra bt cn m trongs rnh
t vn
h
.
g
i
D. Thng tim
ll r o.com
A
o
.
1. Mc ch ca thng tim: loev yah
Fin020@ch yu da vo siu
a. Chn on xc nh
8. TLN
2
0
20 o2D,
ity Doppler, siu m cn m,
m tim (siut m
c
Pot qun). Thng tim c th gip
igh thc
siu myrqua
p
Co vic nh gi mc shunt, ngoi ra cn
ch cho
xc nh chnh xc p lc ng mch phi, o
cung lng ng mch phi, cung lng ng
mch ch...
b. Vit nam do c rt nhiu cc trng hp n
mun nn vic thng tim xc nh chnh xc mc
shunt, p lc MP, t l cung lng QP/QS v
c bit l sc cn mch phi c vai tr quyt
nh xem bnh nhn c cn ch nh phu thut
hay khng. Vi cc bin php th xy, thuc gin
MP lm gim p MP s l nhng nghim php
cui cng quyt nh chn on bnh nhn c
tng p lc ng mch phi c nh (hi chng
Eisenmenger) hay khng ?
480
Copyright 2008. Finloev. All rights reserved
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o
t otbnh
d. Cui cng
nhn c tui (nam hn 40,
P
igh cc
r
y
p
n hn
Co 45), cn chp MV mt cch h thng
xc nh c bnh ng mch vnh phi hp hay
khng.
V. Ch nh iu tr v tin trin
A. ng l TLN c th thc hin bng phu thut tim h vi
tun hon ngoi c th (ng m dc xng c, di
sn hoc sau bn lng). y l phng php iu tr
kinh in c p dng t lu. Hin nay ngi ta c
th ng qua da cc l TLN th pht m cn c g
xung quanh l thng bng cc loi dng c c bit.
B. Ch nh iu tr
1. i vi cc l thng b: ting thi nh, ting T2 tch
i, ng knh tht phi/ tht tri nh hn 2/3 th
cn theo di nh k thng xuyn.
481
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482
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
ht Pot
rig
y
p
Co
484
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
o
gii phu cc loi
t
t
igh Po
r
thng lin tht.
py
Co
tdo bnh
cn ca mch phi
l MP tc nghn c nh
t
igh Po
rshunt
y
lm gim dng
tri
489
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
ht ot
b. Chp MC
rig Pxc nh c h ch phi hp hay
y
p
khng?
Co c bit trong cc th TLT kiu di cc
gc ng mch, hi chng Laubry - Pezzy.
c. Chp bung tht phi xc nh xem c hp ng
ra tht phi khng, c h van ba l khng v xem
c phi ch vo ca dng shunt trc tip vo
tht phi hay khng.
V. Ch nh iu tr v tin trin
A. iu tr ni khoa
1. TLT vi tng p MP nhiu tr nh cn c iu
tr bng li tiu, tr tim v gim tin gnh trc khi
phu thut.
2. Sau phu thut v cc trng hp cha phu thut
(hoc khng cn phu thut) cn phng bin chng
490
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491
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Potocity2020@yahoo.com.vn
492
Copyright 2008. Finloev. All rights reserved
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2.
3.
4.
Ellis JH, Moodie DS, Sterba R, Gill CC. Ventricular septal defect in
the adult: natural and unnatural history. Am Heart J 1987;114:115120.
5.
6.
ed
rv
Gumbiner CH, Takao A. Ventricular septal defect. In:seGarson
A,
re
g
ri com.
lWilliams
l
pediatric cardiology; 2nd ed. Baltimore:
& Wilkins,
.
v. A ahoo
e
o
l
y
1998:1119-1140.
Fin020@
.
7. Lock JE, Block PC, McKay
08RG, 2et at. Transcatheter closure of
20 ocity
9.
Moore JD, Moodie DS. Ventricular septal defect. In: Marso SP,
Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine.
Philadelphia: LippincottRaven, 2000.
493
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12. Perloff
JK.
Survival
patterns
without
cardiac
surgery
or
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
494
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Cn ng ng mch
t ot mch s t ng t gi th 15
hng
A. Thng thng ng
P
rig
y
p sau khi sinh. Cc yu t thc y vic
n gi thCo16
ng ng ng mch l p lc ring phn ca xy trong
mao mch phi tng, gim nng prostaglandine lu
hnh trong mu do tng chuyn ha tun hon phi v
do cc hiu ng nhau thai gy ra. Cc yu t ny c th
ko di tc dng n ngy th 21 sau khi sinh nhng nu
cn thy tn ti ng ng mch sau 3 thng tui th gn
nh chc chn ng ng mch khng th t ng, tr
mt s rt him cc trng hp t ng ng ng mch
do phnh ng bnh nhn c tui v thng sau vim ni
tm mc nhim khun.
B. V gii phu, ng ng mch nm quai MC ngay ch
chia ra ca ng mch di n tri v c vo thn
hoc MP tri. ng ng mch thng c chiu di thay
i v c th phi hp vi gin MC khi MC quay
495
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vo MP ca ng ng mch. nh gi chnh p
qua ng ng mch bng siu m Doppler, t xc
nh mt cch gin tip p lc ng mch phi (cn
o huyt p ng mch khi lm siu m tim). Quan
st quai MC tm cc tn thng phi hp.
2. Hnh nh gin tip: Gin bung tim tri v MP c
th gp trng hp ng ng mch c shunt ln.
d
rve
e
s
re cnh c
Hnh 29-1. Hnh nh ng ng mch: mt
ts ct
h
.vn
g
i phi).
trc ngn (hnh tri) v mt ct hm trn c (hnh
r
m
o
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
Hnh 29-2. Dng
t ot
h
P
g
chy qua ng ng
ri
py
mch trn siu m
Co
Doppler mu.
498
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D. Thng tim
1. Ch nh thng tim: Khi khng thy ng ng mch
trn siu m tim mt bnh nhn c ting thi lin
tc hoc cn ng ng mch nhng p lc MP tng
nhiu trn siu m Doppler tim. Ngoi ra thng tim
cn ng ng ng mch qua da bng dng c
(Coil, Amplatzer...).
2. Cc bc tin hnh thng tim:
a. Thng tim phi theo cc phng php kinh in
(nh trong thng lin nh): ng thng ln MP
thng d dng qua ng ng mch xung MC
xung (nu thng tim theo ng TM di n
phi s thy hnh ch kinh in). Nu gp kh
ed ly
khn c th dng dy dn iu khin.
rvKhi
e
s
re
mu mu cn phi ly on xa hca
ts vcc
n nhnh
.
g
i
r
MP do dng shunt thngllchy
lch, nn
om
A hoo.c
.
v
bo ho xy thn v on
gn
ca
MP khng
loe @ya
n
i
0 c nh ca MP.
phn nh ng bo. Fho02xy
08 ty2nhiu c th s dng cch
0
Nu c tng p
MP
2 toci
ht Pmch
o
ng ngigng
tm thi bng bng v theo
r
y
p
di p
lc
MP
trong
khi bm bng, nu p lc
Co
h xung tt th c th ch nh ng ng ng
mch.
b. Thm d huyt ng:
Thy c bc nhy xy MP. o QP/QS vi
bo ho xy on xa ca MP. a s
cc trng hp ALMP thng bnh thng,
i khi ng ng mch ln c th dn n
tng ALMP. Trng hp p lc qu cao c
th lm nghim php ng ng tm thi bng
bng c l bn (ng thng u c gn bng,
on gn u c l bn theo di p lc).
Trong hi chng Eisenmenger c s o
chiu dng shunt t phi tri, bo ho
499
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2.
d
Conference on Adult Congenital Heart Disease 1996. CanrvJeCardiol
e
res
s
t
gh m.vn
3. Fisher RG, Moodie DS, Sterba R, Gill CC. lPatent
arteriosus
l ri .coductus
A hoo
.
v
a
in adults: long-term follow-up-nonsurgical
versus surgical
oe
inl 20@y
F
management. J Am Coll Cardiol
0
8.1986;8:280284.
00 ity2
2
4. Harrison DA, Benson LN,
oc C, et al. Percutaneous catheter
t Lazzam
gh Pot
i
r
closure of the persistently
patent ductus arteilosus in the adult. Am J
opy
C
Cardiol 1996;77:1084-1097.
1998;14:395-452.
5.
6.
7.
Moore JD, Moodie DS. Patent ductus arteriosus. In: Marso SP,
Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine.
Philadelphia: Lippincott-Raven, 2000.
8.
501
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
Perloff
JK.
Survival
patterns
without
cardiac
surgery
or
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
502
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
t ot(HoP)
II. H van ng mch
hphi
P
rig
y
p
A. Triu chng
Co lm sng
1. Thng c biu hin kh th khi gng sc v triu
chng ca suy tim phi.
2. Nghe tim:
a. Thi tm trng m sc thp, nghe r nht
khoang lin sn 3-4 tri km T2 tch i, tng
ln khi ht vo v nu c tng p ng mch phi
th T2 mnh.
b. Ting thi ca Graham Steell l ting thi tm
trng gim dn v cng , c m sc cao, xut
hin ngay sau ting T2, l ting thi in hnh khi
p lc ng mch phi vt qu 70 mmHg ng
thi c h van MP.
505
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3.
4.
507
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
5.
6.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
508
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
T chng Fallot
d
rve
e
s
re
Hnh 31-1. Hnh phim Xquang tim phi thng.
ts vn
h
.
g
l ri .com
C. Siu m Doppler tim
l
A hoo
ev.quanh
a mng.
o
l
1. TLT rng, cao, thng l iphn
n 0@y
F
2
8. 20ci nga ln VLT.
2. MC gin rng c hnh
y
00 itnh
2
c
t otovan
3. Hp MP: hp
phu,
MP (phi o c ng
h
P
ig
r
y
knh vngopphu, vng van v 2 nhnh MP). Siu m
DopplerC khng nh mc hp ng mch phi
bng cch o chnh p qua phu v van MP (p lc
MP thng bnh thng).
514
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518
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn
Hp eo ng mch ch
d
A. Du hiu c nng: Hp eo ng mch ch pht
rve hin
e
s
c ngi ln thng bi du hiu tng shuyt
re p, au
t vn
h
g
u hay l du hiu au cch hi. i rvi
cc. bnh nhn
l i .com
l
A suyotim huyt.
tr tui hay phi nhp vin v cc vt
e . yaho
o
l
B. Triu chng thc th . Fin020@
08 ty2
20mnh
i
1. Mch chi trn ny
525
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2.
3.
4.
5.
6.
7.
8.
9.
.F 2
08 ty20
0
2 i
t otoc
h
P
g
ri
py
Co
526
Copyright 2008. Finloev. All rights reserved
Potocity2020@yahoo.com.vn