Thuc Hanh Lam Sang Tim Mach - Nguyen Lan Viet

Trong tay cc bn l mt cun sch rt b ch v thc hnh trong chn
on v iu tr cc bnh tim mch thng gp. Tnh n gin, thc tin

cao nhng cng kh cp nht v y thng tin cc bn c th vn
dng c tt nht trong thc t cng vic cng nh hc tp l mong mi
ca nhng tc gi tham gia bin son quyn sch ny...
Nguyn ln vit
(Ch bin)
Thc hnh
Bnh tim mch
Nh xut bn Y hc
2003
Nguyn ln vit
(Ch bin)
Thc hnh
Bnh tim mch
Nh xut bn Y hc
2003
Bs Nguyn c Nhn - www.dany1b.com Trn trng gii thiu
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
th tc gi. y cng l phn nh s pht trin ti Vin Tim
mch Vit nam trong nhng nm gn y, mt thnh qu t s
n lc ca mi c nhn, ca tp th cc thy thuc, nhm p
ng nhu cu nng cao sc kho trong bi cnh hi nhp quc t
m nc ta l mt thnh vin.
Qua cc bi vit ny, m chnh cc tc gi cng t nhn
xt l cn b hn ch v thi gian chun b cho in n, cc th h
k tip t r kh nng gp phn y mnh v lm phong ph
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 nc
ta.
Trong thi gian gn y, cc bc s ca chng ta tip
thu v ng dng nhiu phng php, k thut tin tin trong
chn on v iu tr cc bnh tim mch, t ci thin c
hn tin lng bnh v cht lng cuc sng ca bnh nhn.
Tuy nhin, khi lng kin thc v nhng hiu bit mi
trong lnh vc tim mch th ngy cng gia tng, nhng iu kin
trang thit b thc t ti nhiu tuyn ca chng ta cn cha p
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.
Chng ti hy vng cun sch Thc hnh Bnh Tim mch

ny khng ch dnh cho cc bc s chuyn khoa tim mch m c
th cn gip ch cho cc bc s thc hnh ni chung cng nh
cc sinh vin y khoa tham kho thm trong hc tp.
Y hc l mt ngnh khoa hc c lng thng tin c b
sung v i mi hng ngy. Mt khc, s hiu bit ca chng ti
cn c hn v thi gian bin son kh st sao nn quyn sch
ny chc chn cn nhng thiu st nht nh. Chng ti rt hoan
nghnh v sn sng tip thu nhng kin ng gp qu bu ca
cc bn c ln ti bn sau c hon thin hn.
Cc tc gi
CH bin
Ph gio s, Tin s Nguyn Ln Vit
Tham gia bin son:

Thc s Nguyn Ln Hiu
Thc s Phm Mnh Hng
Tin s Don Li
Bc s Nguyn Ngc Quang
Thc s Phm Thi Sn
Ph gio s, Tin s Nguyn Ln Vit
Mc lc
1. au tht ngc khng n nh ......................................................... 1

2. au tht ngc n nh..................................................................... 17
3. Nhi mu c tim cp ....................................................................... 35
4. Bin chng ca nhi mu c tim cp.......................................... 53
5. Sc tim................................................................................................. 75
6. Ri lon lipid mu ........................................................................... 85
7. Tng huyt p .................................................................................... 95
8. Tai bin mch mu no ................................................................121
9. Tch thnh ng mch ch .........................................................139
10. iu tr mt s ri lon nhp tim thng gp .........................167
11. Thp tim ............................................................................................219
12. Hp van hai l .................................................................................231
13. H van hai l ...................................................................................253
14. H van ng mch ch .................................................................267
15. Hp van ng mch ch ...............................................................287
16. Vim ni tm mc nhim khun................................................305
17. Van tim nhn to ............................................................................321
18. Suy tim ..............................................................................................341
19. Bnh c tim gin.............................................................................379
20. Bnh c tim ph i ........................................................................387
21. Bnh c tim hn ch ......................................................................395
22. Vim mng ngoi tim cp............................................................399
23. Trn dch mng ngoi tim............................................................411
24. Vim mng ngoi tim co tht .....................................................423
25. Tm ph mn ...................................................................................431
26. Nhi mu phi ................................................................................453
27. Thng lin nh .................................................................................475

28. Thng lin tht ................................................................................485
29. Cn ng ng mch.......................................................................495
30. Bnh van ng mch phi ...........................................................503
31. T chng Fallot...............................................................................509
32. Hp eo ng mch ch .................................................................519
au tht ngc khng n nh
au tht ngc khng n nh (unstable angina, TNK)

l mt trong nhng vn kh thi s hin nay do tnh cht
thng gp ca n cng nh nhiu tin b mi trong chn on
v iu tr. Hng nm M c tnh c ti > 700 000 bnh nhn
nhp vin v TNK. Tin lng ca TNK cng nng n
khng km nu so vi NMCT.
Thut ng Hi chng mch vnh cp bao gm: NMCT
cp c ST chnh ln (hoc c Q); NMCT cp khng Q; v
TNK. Trong , ngi ta thng xp NMCT khng Q v
TNK vo cng mt bnh cnh gi l Bnh mch vnh
khng n nh v c cch x tr nh nhau.
Trong bi ny cp ch yu n TNK trong bi
cnh ca bnh mch vnh khng n nh nhng cng l p
dng cho iu tr NMCT khng c sng Q.
I. Sinh l bnh
A. Cho n nay ngi ta hiu r c ch ca TNK l
s khng n nh ca mng x va v mng ny b v ra.
S v ra ca mng x va cng gp trong NMCT cp, tuy
nhin mc v din bin c khc nhau i cht. Nu s
nt v l ln v hnh thnh mu ng t lp ton b
lng mch s dn n NMCT. Nu s nt v nh hn v
cc mu ng ny cha dn n tc hon ton MV th
l TNK. Tuy nhin, TNK c th din bin
nng v bin thnh NMCT thc s.
B. S hnh thnh cc mu ng: Nh trnh by trn, khi
mng x va b v, lp di ni mc c l ra v tip
xc vi tiu cu, dn n hot ho cc th th IIb/IIIa
trn b mt tiu cu v hot ho qu trnh ngng kt ca
tiu cu. Thm vo tiu cu ngng kt ny s gii
1
phng ra mt lot cc cht trung gian lm co mch v

hnh thnh nhanh hn cc mu ng.
C. Hu qu l lm gim nghim trng dng mu ti vng c
tim do MV nui dng, v biu hin trn lm sng
l cn au ngc khng n nh. Trong thc t mt s yu
t sau c th lm nng bnh hn: st, tng huyt p
nhiu, ri lon nhp tim, cng gip...
Hnh 1-1. S nt ra ca mng x va trong TNK.

II. Chn on
A. Triu chng lm sng
1. c im chung: so vi bnh nhn NMCT, bnh
nhn TNK thng c tui gi hn, c t l tiu
ng cao hn, t l tng huyt p (THA) v ri lon
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
b. Chn on phn bit vi cc bnh nh vim mng

ngoi tim, vim ph qun, vim khp c sn,
cc bnh tim thc tn km theo...
c. Pht hin cc triu chng ca suy tim, ting T3,
h van tim...
4. Phn loi TNK theo Braunwald: gip phn
loi bnh nhn v d on tin lng bnh cng nh
c thi x tr thch hp.
Bng 1-1. Phn loi TNK theo Braunwald.
c im
au ngc khi gng sc:
I
Mi xy ra, nng, tin trin nhanh
au ngc mi trong vng 2 thng
au ngc vi tn s dy hn
au ngc gia tng khi gng sc nh
Khng c au ngc khi ngh trong vng 2 thng
II au ngc khi ngh, bn cp:
au ngc khi ngh xy ra trong vng 1 thng
nhng khng phi mi xy ra trong vng 48 gi
III au ngc khi ngh, cp:
au ngc xy ra trong vng 48 gi
Cc hon cnh lm sng
au ngc th pht: xy ra do cc yu t khng
A
phi bnh tim mch nh thiu mu, nhim trng,
cng gip trng, thiu xy...
au ngc t pht
B
au ngc khng n nh sau NMCT: trong vng
C
2 tun sau NMCT
B. Cc xt nghim chn on
1. in tm :
a. Trong cn au c th thy s bin i ca on
ST: ST chnh xung, T o chiu, ST chnh ln
thong qua. Nu ST chnh ln bn vng hoc mi
c xut hin bloc nhnh tri th ta cn phi ngh
n NMCT.
3
b. C 20 % bnh nhn khng c thay i trn T.

c. Vic phn bit TNK vi NMCT cp khng
c sng Q ch yu l xem c s thay i ca men
tim hay khng.
Bng 1-2. Phn tng nguy c ca bnh nhn TNK
Nguy c cao
Nguy c va
Nguy c thp
C mt trong cc Khng c cc du Khng c cc
biu hin sau:
hiu nguy c cao biu hin ca
nhng c 1 trong nguy c cao hoc
cc du hiu sau:
va
au ngc khi au ngc khi C s gia tng
ngh > 20 pht,
ngh >20 pht
v tn s v
ca bnh mch
nhng t
mc au
vnh
au ngc khi
ngc
C ph phi cp
ngh >20 pht au
ngc
do bnh mch
nhng p ng
khi pht do
vnh
tt vi iu tr
gng sc nh
au ngc khi au ngc v au ngc mi
ngh c km
m
xut
hin
theo on ST au ngc c
trong vng 2
thay i > 1mm
km theo thay
tun- 2 thng
au ngc km
i ST
Khng thay
theo xut hin au ngc mi
i ST
ran phi, ting
xy ra trong
tim th 3 hoc
vng 2 tun,
HoHL mi
tnh cht nng.
au ngc km C sng Q bnh
theo tt huyt
l hoc xut
p
hin ST chnh
xung nhiu
chuyn o.
Tui > 65
2. Men tim:
a. V tnh cht kh phn bit vi NMCT (khng
sng Q) v c th tin trin n NMCT ca
TNK nn mi bnh nhn cn c lm xt
nghim men tim v theo di cc men ny.
4
b. Cc men thng c dng theo di l CK v

CK-MB; Troponin T v I.
c. V nguyn tc trong TNK khng c s thay
i cc men tim, tuy nhin trong mt s trng
hp c th thy tng i cht men Troponin I v
iu ny bo hiu tin lng xu hn.
3. Siu m tim: Siu m tim thng gip ch cho ta
chn on ri lon vn ng vng (nu c), nh gi
chc nng tht tri (c bit sau NMCT) v cc bnh
l thc tn van tim km theo hoc gip cho vic chn
on phn bit.
4. Cc nghim php gng sc:
a. Cn ch l khi chn on chc chn
TNK th khng c ch nh lm cc nghim
php gng sc do tnh cht bt n ca bnh.
b. Cc nghim php ny ch t ra khi bnh nhn
nhm nguy c thp, lm sng khng in hnh,
khng c thay i trn T v iu tr n
nh ti bnh vin trong vi ngy.
5. Chp ng mch vnh:
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
Bng 1-3. Cc ch nh ca chp MV trong TNK.

Nhm nguy c cao.
Tin s c can thip MV hoc m cu ni.
Suy tim.
Gim chc nng tht tri (EF < 50%).
Ri lon nhp tht c tnh.
Cn tn ti hoc ti pht au ngc sau dng thuc .
C vng gim ti mu c tim rng trn cc xt nghim
chn on khng chy mu (x c tim, siu m tim
stress).
C bnh van tim r rt km theo (HoHL, HoC).
III. iu tr
Tu tng trng hp c th m ta bt u bng cc phng
php iu tr thch hp. iu tr ni khoa l nn tng v bt u
cho mi trng hp. Cc bin php iu tr ti to mch (can
thip nong hoc t Stent MV, phu thut lm cu ni chvnh) rt quan trng v l iu tr mang tnh trit , cn c
cn nhc trong tng tnh hung c th.
A. Mc tiu ca iu tr ni khoa
1. Nhanh chng dng thuc chng ngng kt tiu cu.
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
3. Chng ng mu bng Heparin hoc Heparin trng

lng phn t thp (LMWH).
4. Cc thuc c ch th th GP IIb/IIIa tiu cu.
C. Thuc chng ngng kt tiu cu ng ung
1. Aspirin:
a. C ch chng ngng kt tiu cu ca Aspirin l
thng qua chn con ng Thromboxan A2 lm
bt hot tiu cu.
b. Tuy tc dng ca Aspirin c coi l yu trong
chng ngng kt tiu cu nhng nhiu nghin cu
chng minh c l n c th lm gim ti
50% t vong hoc NMCT bnh nhn
TNK.
c. Thuc c th pht huy tc dng c ch
Thromboxan A2 trong vng 15 pht, nn cn cho
ngay khi bnh nhn nhp vin. Nn cho loi hp
thu nhanh (BabyAspirin vin 81 mg nhai 4 vin).
hoc gi bt Aspegic (gi 100 mg) ung 3 gi.
d. Tuy cn bn ci v liu duy tr nhng liu lng
ngay lc u nn dng khong 300 mg c th
t c kh nng tc dng ti a chng ngng
kt tiu cu trong ngy u, nhng ngy sau c
th dng liu t 81 - 325 mg/ngy.
2. Tilcopidine (Ticlid) v Clopidogrel (Plavix):
a. Cc thuc ny chng ngng kt tiu cu thng
qua con ng c ch ADP c lin quan hot ho
tiu cu, do kh nng chng ngng kt tiu
cu mnh hn Aspirin.
b. Ticlopidine cn khong 2-3 ngy t c
hiu qu tc dng ti a. Vi Clopidogrel th thi
gian ny ngn hn i cht.
c. Tc dng ph: Ticlid c th gy h bch cu mu
(0,2 -5 % cc trng hp), c th gy h tiu cu
7
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. Cc thuc chng ng
1. Heparin:
a. V c ch hnh thnh cc mu ng trong
TNK, nn vic cho thuc chng ng l bt
buc.
b. Nhiu nghin cu ch ra rng vic dng
Heparin phi hp vi Aspirin trong TNK
lm gim nguy c t vong v NMCT ti 33 % so
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
tra thi gian aPTT mi 6 gi sao cho thi gian

ny t khong 50-70 giy.
2. Heparin c trng lng phn t thp (LMWH):
a. Li th so vi Heparin thng l: c thi gian tc
dng ko di, liu c nh do dng tim di da
m t cn theo di bng cc xt nghim lin tc,
c ch c yu t Xa v IIa ca tiu cu, t gy
gim tiu cu mu.
b. Mt s nghin cu cho thy LMWH lm gim 17
% t l NMCT hoc t vong bnh nhn
TNK so vi dng Heparin thng.
c. Liu lng: C nhiu loi LMWH trong c
nhng loi hay c dng: tim di da:
Enoxaparin (Lovenox): 1mg/kg mi 12 gi,
Dalteparin: 120 U/kg mi 12 gi,
Nadroparin (Fraxiparin): 0,1 ml/10kg cn
nng, tim di da chia 2 ln trong ngy.
3. Thuc c ch trc tip thrombin (Hirudin,
Hirulog): Cc thuc ny c ch trc tip thrombin
nn c tc dng chng ng kh mnh. Tuy nhin,
cho n nay chng cha c chp nhn dng
thng quy trong TNK thay th cho Heparin.
Chng ch nn c dng nhng bnh nhn c tin
s b gim tiu cu do dng Heparin.
E. Cc thuc c ch th th Glycoprotein IIb/IIIa
ca tiu cu
1. C ch: Trn b mt ca tiu cu c cc v tr (th
th) m khi c hot ho s gn kt vi mng fibrin
gy nn s ngng kt tiu cu, cc v tr ny gi l
cc th th Glycoprotein IIb/IIa. Vic c ch th th
ny c ch tn gc qu trnh ngng kt tiu cu
nn cc thuc nhm ny s c tc dng chng ngng
kt tiu cu rt mnh.
2. Cc loi thuc v liu:
9
a. Abciximab (Reopro): l thuc c pht hin v

dng u tin. Liu dng tn cng 0,25 mg/kg
tim thng TM sau truyn TM 10 mcg/pht
trong 12 gi tip theo.
b. Eptifibatid (Intergrilin): Liu dng tn cng 180
mcg/kg tim thng TM sau truyn TM 1,3 2,0 mcg/pht trong 12 gi tip theo.
c. Tirofiban (Aggrastat): liu tn cng 0,6 mcg/kg/
pht truyn TM trong 30 pht sau truyn TM
0,15 mcg/kg/pht trong 12 -24 gi tip theo.
d. Lamifiban: 0,1 mcg/kg/pht truyn TM/ 24 gi.
3. Cch dng: cc thuc ny c th c dng nh sau:
a. Dng trong lc can thip MV lm gim nguy c
t vong hoc NMCT (th nghim EPIC vi
Reopro lm gim ti 90 % nguy c t vong hoc
NMCT sau 30 ngy lin quan n can thip).
b. Dng trc lc can thip MV (th nghim
CAPTURE vi Reopro lm gim ti 20 % nguy
c t vong, NMCT hoc phi can thip li sau 30
ngy c lin quan n can thip).
c. Dng c lp cho TNK: lm gim 10-17 %
nguy c t vong hoc NMCT trong TNK
(th nghim PURSUIT vi Eptifibatid, th
nghim PRISM vi Tirofiban).
F. Cc Nitrates
1. Cha c nghin cu no chng minh c Nitrate
lm gim nguy c t vong hoc NMCT bnh nhn
TNK, nhng Nitrate l iu tr quan trng
gim au ngc cho bnh nhn v ci thin triu
chng.
2. Liu dng: nn bt u ngay bng xt di li (hoc
ngm) cho bnh nhn, sau thit lp ng truyn
TM truyn Nitroglycerin vi liu 10-20 mcg/pht.
C th tng liu sau mi 5-10 pht tu p ng ca
10
G. Cc thuc chn bta giao cm

1. Cc thuc chn bta giao cm gip lm gim nhu cu
xy ca c tim do gim co bp c tim v gim nhp
tim. Hn na, thuc c th lm gim p lc y
tm trng nn lm tng mu v MV trong k tm
thu. Dng chn bta giao cm bnh nhn TNK
khng nhng lm gim au ngc tt m cn c
chng minh l lm gim t l bin thnh NMCT v
gim din hoi t c tim nu b NMCT. Cc thuc
chn giao cm c coi l thuc hng u trong
iu tr TNK.
2. Nn dng cc thuc chn chn lc 1: Metoprolol,
Atenolol...
3. Chng ch nh: Nhp chm (bloc nh tht cao);
Bnh phi mn tnh tc nghn; Suy tim nng mt b;
Bnh mch ngoi vi; Huyt p thp; Sc tim.
4. Mc tiu iu tr l gim c triu chng au ngc
v gim nhp tim. Nn bt u bng liu thp v theo
di st. Thng dng Metoprolol tim TM 5 mg sau
tng dn liu theo p ng sau 5-10 pht. C th
dng gi bng vin Metoprolol liu thp 25-50 mg
mi 12 gi.
H. Cc thuc chn knh canxi
1. Cc thuc ny lm gin mch, chm nhp tim, gim
sc co bp c tim. Nu dng n c trong
TNK c th lm tng nguy c NMCT hoc t
vong.
2. Ch nn dng thuc chn knh calci trong trng hp
c THA nhiu v/hoc khi chc nng tht tri bnh
nhn cn tt, nhp khng chm v c yu t co tht
11
m t p ng vi Nitrates hoc khng th dng c

thuc chn bta giao cm.
I.
Cc thuc c ch men chuyn

1. Khng phi thuc thng quy trong iu tr
TNK.
2. Nn dng khi c km theo gim chc nng tht tri
m huyt p cn tt.
J. Vn dng cc thuc tiu huyt khi

1. Cho n nay thng nht l KHNG dng thuc
tiu huyt khi cho bnh nhn TNK v khng
nhng khng ci thin c tin lng m cn gia
tng t l NMCT v t vong (nghin cu TIMI-IIIb).
2. C ch c th l v trong TNK cha tc hon
ton MV nn thuc tiu huyt khi ny khng lm
ci thin thm dng chy m n li c th lm tan
cc mu ng bao ly ch v ca mng x va,
lm l ra li lp di ni mc ny gy hot ho
ngng kt tiu cu tr li.
K. iu tr can thip MV (nong hoc t Stent)
1. Ch nh cho chp MV: can thip MV
c bn n phn ch nh chp MV ni trn.
a. Cc tn thng MV ph hp cho can thip l:
tn thng ngn, khng vi ho, tn thng t
mch, khng phi thn chung, chc nng tht tri
cn tt...
b. Mt s trung tm c iu kin trang thit b v
kinh nghim tt ca bc s can thip th c th
xt can thip ngay (cp cu) cho mi bnh nhn
TNK khi n vin, tuy nhin kt qu cha
vt tri so vi bt u bng iu tr ni khoa.
12
Hnh 1-2. Hnh nh T ca mt trng hp TNK,

ST chnh xung v T m t V1-V6
2. Khi can thip MV, vic dng phi hp cc thuc l
rt quan trng:
a. Cc thuc chng ngng kt tiu cu ng ung :
Aspirin phi hp vi Ticlopidin hoc Clopidogrel.
b. Thuc c ch th th Glycoprotein IIb/IIIa.
c. Thuc chng ng (Heparin, LMWH).
Hnh 1-3. Hnh nh chp ng mch vnh ca bnh nhn

TNK trc (hnh tri) v sau (hnh phi) t Stent
(mi tn ch v tr thng tn).
13
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 tiu
ng hoc suy gim chc nng tht tri, c tn
thng nhiu thn MV th phu thut lm cu ni t
ra u th hn so vi can thip MV.
Ti liu tham kho
1.
Antman EM, Tanasuevic MJ, Thompson B, et al. Cardiac-specific

troponin I levels to predict the risk of mortality in patients with acute
coronary syndromes. N Engl J Med 1996;335:1342-1349.
2.
Bittl JA, Strony J, Brinker JA, et al. Treatment with bivalirudin

(Hirulog) as compared with heparin during coronary angioplasty for
unstable or ostinfarction angina. N Engl J Med 1995;333:764-769.
3.
Boden WE, O'Rourke RA, Crawford MR, et al. Outcomes in patients

with acute non-Q-wave myocardial infarction randomly assigned to
an invasive as compared with a conservative management strategy.
N Engl J Med 1998;338:1785-1792.
4.
Braunwald EG, Mark DB, Jones RH et. al. Unstable angina:

diagnosis and management. Clinical Practice Guideline Number 10.
AHCPR Publication No.94-0602. Rockville, MD: Agency for
Health Care Policy Research and the National Heart, Lung, and
Blood Institute, Public Health Service, U.S. Department of Health
and Human Services, 1994.
5.
Cohen M, Demers C, Garfinkel EP, et al. Low-molecular-weight

heparins in non-ST segment elevation ischemia: the ESSENCE trial.
Am J Cardiol 1998;82:196-246.
14
6.
EPILOG Investigators. Platelet glycoprotein Ilb/lIla receptor

blockade and low-dose heparin during percutaneous coronary
revascularization. N Engl J Med 1997; 336:1689-1696.
7.
Fuster V, Badimon L, Badimon JJ, et. al. The pathogenesis of

coronary artery disease and the acute coronary syndromes. N EngI J
Med 1992;326:242-250.
8.
Gersh BJ, Braunwald EG, Rutherford JD. Chronic coronary artery

disease: unstable angina. In: Braunwald EG, ed. Heart disease: a
textbook of cardiovascular medicine, 5th ed. Philadelphia: WB
Saunders, 1997:1331-1339.
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
cardiac troponin T or I. N Engl J Med 1997;337:1648-1653.
11. Lincoff AM, Califf RM, Moliterno DM, et al. Complementary
clinical benefits of coronary-artery stenting and blockade of platelet
glycoprotein lIb/Illa receptors. N Engl J Med 1999;341:319-327.
12. Moliterno DJ, Granger CB. Differences between unstable angina and
acute myocardial infarction: the pathophysiological and clinical
spectrum. In: Topol EJ, ed. Acute coronary syndromes, 1st ed. New
York: Marcel Dekker, 1998:67-104.
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
18. TIMI IIIB Investigators. Effects of tissue plasminogen activator and

a comparison of early invasive and conservative strategies in
unstable angina and non-Q-wave myocardial infarction. Circulation
1994;89: 1545-1556.
19. Van Miltenburg AJ, Simoons ML, Veerhoek RJ, et al. Incidence and
follow-up of Braunwald subgroups in unstable angina. J Am Coll
Cardiol 1995;25:1256A292.
20. White RD. Unstable angina: ischemic syndromes. In: Topol EJ, ed.
Textbook of cardiovascular medicine. 1st ed. Philadelphia:
Lippincott-Raven, 1998:365-393.
21. Williams DO, Braunwald E, Thompson B, et al. Results of
percutaneous transluminal coronary angioplasty in unstable angina
and non-Q-wave myocardial infarction: observations from the TIMI
IIIB trial. Circulation 1996;94:2749-2755.
16
au tht ngc n nh
(Bnh tim thiu mu cc b mn tnh)
William Heberden l ngi u tin m t thut ng au

tht ngc t hn 220 nm nay. Cho n by gi, y l loi
bnh kh thng gp cc nc pht trin v c xu hng gia
tng rt mnh cc nc ang pht trin. Theo c tnh hin
M c khong gn 7 triu ngi b au tht ngc v hng nm
c thm khong 350 000 ngi b au tht ngc mi.
au tht ngc n nh cn c gi l Bnh c tim thiu
mu cc b mn tnh hoc Suy vnh. Cn au tht ngc l
triu chng thng c trong hai tnh trng ca bnh tim thiu
mu cc b, l: au tht ngc n nh v au tht ngc khng
n nh.
A. au tht ngc n nh l tnh trng khng c nhng din
bin nng ln bt n ca cn au tht ngc trong vng
vi tun gn y. Vi au tht ngc n nh th tnh trng
lm sng thng n nh, cn au tht ngc ngn, xy ra
khi gng sc, khi ngh v p ng tt vi Nitrates.
au tht ngc n nh thng lin quan n s n nh
ca mng x va.
B. au tht ngc khng n nh l tnh trng bt n v lm
sng, cn au tht ngc xut hin nhiu v di hn, xy
ra c khi bnh nhn ngh ngi v cn au t p ng vi
cc Nitrates. Cn au ny thng lin quan n tnh
trng bt n ca mng x va ng mch vnh.
I. Triu chng lm sng
Ch khai thc k bnh s, nh gi cc yu t nguy c.
A. Triu chng c nng
1. Cn au tht ngc in hnh:
17
a. V tr: Thng sau xng c v l mt vng

(ch khng phi mt im), au c th lan ln c,
vai, tay, hm, thng v, sau lng. Hay gp hn
c l hng lan ln vai tri ri lan xung mt
trong tay tri, c khi xung tn cc ngn tay 4, 5.
b. Hon cnh xut hin: Thng xut hin khi
gng sc, xc cm mnh, gp lnh, sau ba n
nhiu hoc ht thuc l. Mt s trng hp cn
au tht ngc c th xut hin v m, khi thay
i t th, hoc khi km cn nhp nhanh.
c. Mc au v cc triu chng km theo: Hu
ht cc bnh nhn m t cn au tht ngc nh
tht li, nght, rt, b nng trc ngc v i
khi cm gic but gi. Mt s bnh nhn c kh
th, mt l, au u, bun nn, v m hi...
d. Thi gian cn au: Thng khong vi pht, c
th di hn nhng khng qu 30 pht. Nhng cn
au xy ra do xc cm thng ko di hn l au
do gng sc. Nhng cn au m ch ko di di
1 pht th nn tm nguyn nhn khc ngoi tim.
2. Phn loi au tht ngc n nh: Cho n nay cch
phn loi mc au tht ngc theo Hip hi Tim
mch Canada (Canadian Cardiovascular Society CCS) l c ng dng rng ri nht v rt thc t.
B. Khm lm sng: Khm thc th t c hiu nhng rt
quan trng, c th pht hin cc yu t nguy c hoc
nhng nh hng n tim.
1. Cc yu t nguy c cao ca bnh ng mch vnh c
th pht hin thy l: Tng huyt p, mng
Xantheplasma, bin i y mt, cc bng chng ca
bnh ng mch ngoi vi.
2. Trong cn au tht ngc c th nghe thy ting T3,
T4; ting ran phi... Ngoi ra t c triu chng thc
th no l c hiu.
18
3. Khm lm sng gip chn on phn bit cc nguyn

nhn khc gy au tht ngc nh: Hp ng mch
ch, bnh c tim ph i, bnh mng ngoi tim, vim
khp c sn...
Bng 2-1. Phn au tht ngc theo CCS.
c dim
Ch thch
Nhng hot ng th au tht ngc ch xut
I
lc bnh thng khng hin khi hot ng th
gy au tht ngc.
lc rt mnh.
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.
III Hn ch ng k hot au tht ngc khi i b
ng th lc thng di t 1-2 dy nh hoc
thng.
leo cao 1 tng gc.
IV Cc hot ng th lc au tht ngc khi lm
bnh thng u gy vic nh, khi gng sc
au tht ngc.
nh.
II. Cc xt nghim chn on
Hnh 2-1. Cc xt nghim chn on au tht ngc.

19
A. in tm lc ngh: l mt thm d sng lc trong

bnh mch vnh.
1. C ti > 60% s bnh nhn au tht ngc n nh c
in tm (T) bnh thng. Mt s bnh nhn
c sng Q (chng t c NMCT c), mt s khc c
ST chnh xung, cng, thng un. T cn gip
pht hin cc tn thng khc nh ph i tht tri,
bloc nhnh, hi chng tin kch thch...
2. T trong cn au c th thy s thay i sng T v
on ST (ST chnh xung, sng T m). Tuy nhin
nu T bnh thng cng khng th loi tr c
chn on c bnh tim thiu mu cc b.
B. Nghim php gng sc (NPGS): Rt quan trng
trong au tht ngc n nh, gip cho chn on xc
nh, tin lng cng nh iu tr.
1. NPGS s gy ra tnh trng thiu mu c tim cc b
hoc lm gin MV v c theo di lin tc bng
mt phng tin no nh T gng sc hay siu
m tim gng sc. nhy v c hiu ca tng
phng php gng sc l c s khc nhau.
2. Phng php gy thiu mu c tim cc b:
a. Gng sc th lc:
C ch: Lm tng nhu cu xy c tim, lm c
tim tng co bp, tng tin gnh v hu gnh.
Vic tng nhu cu xy c tim s dn n tng
nhp tim v nh hng n huyt p. Da vo
s tng nhp tim ny xc nh kh nng
gng sc ca bnh nhn. Mt khc, khi nhp
tim tng ln s lm cho nhu cu tiu th xy
c tim tng ln v lc s xut hin nhng
bin i trn T hoc cc hnh nh khc m
khi ngh c th s khng thy.
20
Gng sc th lc gip d on kh nng hot

ng th lc ca bnh nhn v giai on gy
ra thiu mu c tim.
Tuy nhin gng sc th lc khng th thc
hin c nhng bnh nhn c chng i
cch hi, bnh phi nng, bnh khp, hoc
nhng d tt, nhng bnh c nh hng n
kh nng thc hin gng sc ca bnh nhn.
b. Dng mt s thuc lm gin MV: nh
Adenosin v Dipyridamole.
C ch: Adenosin lm gin cc vi mch ca
h thng mch vnh, do nu c hp mt
nhnh MV th cc nhnh cn li gin ra ly
ht mu nhnh gy ra hin tng thiu
mu c tim tng ng vi nhnh MV b hp
(hin tng n cp mu).
Dipyridamole cng c c ch ging nh
Adenosin nhng xut hin tc dng chm hn
v ko di hn.
Cc thuc ny thng dng cho phng php
chn on ti mu c tim bng phng x.
c. Dng cc thuc lm tng co bp c tim v tng
nhp tim (Dobutamine v Arbutamine)
C ch: L cc thuc kch thch 1 giao cm,
lm tng co bp c tim, lm tng nhu cu xy
ca c tim.
Cc thuc ny thng dng khi lm siu m
gng sc.
3. Cc phng php gng sc:
a. in tm gng sc:
nh gi c nhng bnh nhn c nguy c
cao v bnh mch vnh. Nhng d liu trong
bng sau s gip chng ta c th d on
c nhng bnh nhn c nguy c cao b
bnh MV khi lm T gng sc.
21
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
2 pht).
ST chnh xung 3 pht sau khi ngng gng sc.
ST chnh xung kiu dc xung (down-sloping).
Thiu mu c tim xut hin mc nhp tim cn tng
i thp ( 120 ck/pht).
Huyt p khng tng hoc tt i.
Xut hin nhp nhanh tht mc nhp tim 120 chu
k/pht.
b. Siu m tim gng sc: L thm d c gi tr, n
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
C. Siu m tim thng quy

1. Tm nhng ri lon vn ng vng (nu c).
2. Gip nh gi chc nng tim, bnh km theo (van
tim, mng tim, c tim...).
D. Holter in tim: C th pht hin nhng thi im xut
hin bnh tim thiu mu cc b trong ngy, rt c
ngha nhng bnh nhn b co tht MV (Hi chng
Prinzmetal) hoc bnh tim thiu mu cc b thm lng
(khng c au tht ngc). Trong cn co tht mch vnh
c th thy hnh nh on ST chnh ln. Ngoi ra c th
thy c mt s cc ri lon nhp tim khc.
Bng 2-3. Ch nh chp MV theo AHA/ACC.
Nhm I: C ch nh thng nht
Khng khng ch c triu chng vi iu tr ni
khoa ti u.
Bnh nhn c nguy c cao khi lm NPGS (bng 2-2).
C bng chng ca ri lon chc nng tht tri t
mc va.
Chun b cho phu thut mch mu ln.
Ngh nghip hoc li sng c nhng nguy c bt
thng.
Nhm II: (Thng c ch nh, nhng cn cn nhc)
Bnh nhn tr tui c bng chng ca bnh c tim
thiu mu cc b trn NPGS hoc c tin s NMCT.
Bng chng ca thiu mu c tim nng trn NPGS.
Nhm III: (Thng khng c ch nh)
Bnh nhn au tht ngc mc nh (CCS I, II) v
triu chng, khng c ri lon chc nng tht tri v
khng c nguy c cao trn NPGS.
E. Chp ng mch vnh: l phng php quan trng
gip chn on xc nh c hp MV hay khng v mc
cng nh v tr hp ca tng nhnh MV.
1. Ch nh chp MV: Nhn chung ch nh chp
MV bnh nhn suy vnh l nhm mc ch can
thip nu c th. V y l mt thm d chy mu v
23
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.
Hnh 2-2. Tin trin ca mng x va MV.

B. La chn phng php
1. C 3 phng php iu tr: Thuc, can thip MV,
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
Ticlopidine (Ticlid): vin 250mg, dng 2

vin/ngy. Tc dng ph c th gp l h
bch cu mu (3-5%), h tiu cu. Cn phi
theo di cng thc mu khi dng.
Clopidogrel (Plavix): Vin 75mg, hiu qu
cao v t tc dng ph hn Ticlid, liu
75mg/ngy.
c. Trong trng hp c ch nh chp MV m c
can thip t stent th cn dng phi hp gia mt
trong hai loi thuc ny vi Aspirin v dng cho
bnh nhn t nht trc 2 ngy can thip. Sau can
thip MV thuc ny cng Aspirin phi c
dng thm t nht 1 thng, sau c th ch cn
dng Aspirin. Tuy nhin, nhng nghin cu gn
y cho thy rng dng thm Plavix ko di thm
9 thng cng cho li ch r rt hn.
d. Thuc c ch th th GP IIb/IIIa: Ch c dng
tim c chng minh l ci thin tt t l sng
v t bin chng bnh nhn c nong ng
mch vnh hoc t Stent.
Hnh 2-3. C ch tc dng ca cc thuc chng ngng

tp tiu cu.
25
2. iu chnh ri lon Lipid mu: c chng minh

l c kh nng phng nga c tin pht ln th pht
bnh MV.
a. Ch nh:
Bnh nhn c ri lon lipid mu m c tin s
au tht ngc hoc NMCT.
Bnh nhn sau lm cu ni MV.
b. Cc nhm thuc:
c ch men HMG-CoA: Simvastatin (Zocor),
Atorvastatin (Lipitor), Fluvastatin (Lescol)...
l nhng thuc c chng minh l rt tt
trong ngn nga bnh ng mch vnh. Th
nghim 4S vi Simvastatin cho thy gim r
rt nguy c bnh MV bnh nhn c
dng thuc so vi nhm chng.
Dn xut Fibrat: nh Gemfibrozil (Lopid),
Fenofibrat (Lipanthyl),Benzafibrat (Banzalip).
Nicotinic acid (Niacin).
Cc loi Resins gn acid mt: Colestipol,
Cholestyramine.
3. Cc dn xut Nitrates:
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
Cn thn khi ung vi cc thuc gin mch

khc. Chng ch nh dng cng vi
Sildenafil (Viagra).
Ch l thng c s quen thuc khi dng
Nitrates lin tc ko di, do cn dng ngt
qung (khng nn dng lin tc).
Bng 2-4. Cc loi Nitrates.
Tn thuc
ng
Liu
S ln/ngy
dng
Nitroglycerin Vin ngm 0,15-0,6 mg
Theo nhu cu
(Glycerin
di li
trinitrate
Dng xt
0,4 mg
Theo nhu cu
Nitrobid,
Vin
gii 2,5 - 9,0 mg
Mi 6-12 gi
Nitrostat,
phng chm
Nitrodur,
M bi
1,25 5 cm
Mi 4-8 gi
Natispray,
Ming dn
2,5 - 15 mg
Mi 24 gi
Nitromit...)
Dng tim 5-400g/pht Truyn lin
truyn TM
tc
Isosorbide
Vin ngm 2,5 - 10 mg
Mi 2 - 3 gi
dinitrate
di li
(Isosorbid,
Vin nhai
5 - 10 mg
Mi 2 - 3 gi
Lenitral,
Vin ung 10 - 40 mg
Mi 6 gi
Sorbitrate)
Vin chm
40 80 mg
Mi 8 - 12 gi
Isosorbid - 5- Vin ngm 10 - 40 mg
Mi 12 gi
mononitrate di li
(Imdur, Ismo) Vin chm
60 mg
Mi 24 gi
Erythrityl
tetranitrate
(Cardilate)
Vin ngm
Vin ung
5 - 10 mg
10 mg
Theo nhu cu
Mi 8 gi
4. Cc thuc chn giao cm:

a. C ch:
Chn 1 giao cm do lm gim nhp tim,
gim sc co c tim v lm gim nhu cu xy
c tim. N cng lm gim sc cng ln thnh
27
tht tri nn lm dng mu t thng tm mc

ti n ni tm mc nhiu hn.
Ring cc thuc c chn 2 giao cm c th
gy co mch vnh, nn khng dng bnh
nhn c co tht MV.
Thuc chn giao cm c s dng nh
thuc hng u trong iu tr suy vnh (nu
khng c chng ch nh). N c chng
minh l lm gim t l t vong v nhi mu
c tim bnh nhn au tht ngc n nh.
b. Chng ch nh:
Bnh phi mn tnh tc nghn.
Nhp chm, cc bloc nh-tht.
Suy tim nng.
Bnh mch mu ngoi vi.
i tho ng, ri lon m mu l nhng
chng ch nh tng i.
c. Cc loi thuc:
Chn lc 1.
(a) Metoprolol (Betaloc): 50 - 200 mg/ ngy.
(b) Atenolol (Tenormin): 25 - 200 mg/ngy.
(c) Acebutolol (Sectral): 200 - 600 mg
(d) Betaxolol: 20 - 40 mg/ngy
Khng chn lc (chn c 1 v 2)
(a) Propranolol (Inderal): 40 - 320 mg/ ngy
(b) Nadolol, Timolol, Pindolol
Chn c v : Labetalol, Carvedilol
5. Cc thuc chn dng canxi:
a. C ch: Chn dng canxi vo cc t bo c trn
mch mu, v vo t bo c tim nn lm gin
mch, v c th gim sc co bp c tim.
b. Cc nhm thuc:
Dihydropyridines: (Nifedipin, Amlordipine,
Felodipine, Isradipine); t tc dng ln MV.
Nifedipin v Amlordipine c th dng trong
28
mt s trng hp, c bit khi c THA v c

yu t co tht km theo.
Benzothiazepines: Diltiazem (Tildiem) 30-90
mg x 3 ln/ngy. Khng dng bnh nhn c
gim chc nng co bp tht tri, nhp chm.
Phenylalkylamine: Verapamil (Isoptine): 120
- 240 mg x 2 ln/ngy. C th lm gim chc
nng co bp tht tri v lm chm nhp tim.
Khng dng thuc ny bnh nhn suy tim.
c. Tc dng ph:
H huyt p, bng mt, chng mt, au u...
Gy gim sc co bp c tim, nhp chm, nn
thuc c coi l chng ch nh bnh nhn
c suy tim hoc nhp chm.
6. c ch men chuyn: Ch nn dng nhng bnh
nhn au tht ngc n nh sau NMCT c ri lon
chc nng tht tri hoc bnh nhn c THA km
theo. Nn khi u bng liu thp trnh tt huyt
p v suy thn.
7. iu tr Hormon thay th:
a. ph n mn kinh c s gim Estrogen do c
th ri lon Lipid mu lm tng nguy c bnh
mch vnh v THA. C nhiu nghin cu
chng minh vai tr ca iu tr thay th hormon
nhng bnh nhn n mn kinh lm gim nguy c
mc bnh THA hoc MV.
b. Hin nay thng dng l Estrogen, liu 0,625 mg
/ngy, ung trong 25 ngy lin tc, ngh 5 ngy.
8. Cc thuc chng gc xy t do: Vitamin E 400 800 n v/ngy c th lm gim mt s bin c bnh
tim mch. Tuy nhin cc nghin cu cn cha thng
nht v li ch thc s ca n trong bnh MV.
D. iu tr can thip ng mch vnh
(Nong MV bng bng, t Stent hoc dng cc thit b khc).
29
1. So snh vi dng thuc iu tr: lm gim triu chng

v gim t l t vong ng k (cc th nghim
ACME, MASS, RITA - 2). So snh vi phu thut
lm cu ni: Nu nhng bnh nhn c bnh tn
thng 1 ng mch vnh, li ch vt tri ca can
thip MV khng cn phi bn ci. Tuy nhin
nhng bnh nhn b tn thng nhiu ng mch
vnh, trc y thng ch nh cho phu thut,
nhng nay mt s nghin cu cho thy kt qu cng
tng t nh m lm cu ni (Th nghim BARI).
Ring nhng bnh nhn c km theo tiu ng th
m lm cu ni MV t ra u th hn.
2. Ch nh: (Xem cc ch nh chp ng mch vnh).
Ngoi ra, khi chp MV thy tn thng khu tr,
khng phi thn chung, khng phi bnh c 3
MV, chc nng tht tri cn tt... th nn u tin
cho can thip MV.
3. Cc phng php trong iu tr can thip ng
mch vnh bao gm: nong ng mch vnh bng
bng, t Stent trong MV, bo gt mng x va c
nh hng (Directional Coronary Angioplasty),
khoan mng x va (Rotablator)... S la chn cc
phng php ny tu thuc vo tn thng khi chp
MV, trnh , kinh nghim thy thuc cng nh
kh nng trang thit b. Hin nay, vi s pht trin
mnh m ca khoa hc k thut cho ra i nhng
dng c tin tin v vic dng cc thuc mi (v d
thuc c ch th th IIb/IIIa) phi hp vi can thip
MV cho t l thnh cng ca can thip rt cao
vi rt t bin chng.
4. Mt vn cc k quan trng l khi can thip MV
phi dng phi hp cc thuc iu tr ni khoa tt,
trong vai tr ca cc thuc chng ngng kt tiu
cu l rt quan trng ngn nga bin chng tc
mch vnh cp. Nu c t Stent th nn dng phi
30
hp Aspirin vi Ticlopidin (hoc Clopidogrel) trc t

nht 2 ngy, sau ko di thm Clopidogrel
(Plavix) hoc Ticlopidine (Ticlid) khong 2 4 tun
th dng, ch cn Aspirin l ko di mi. Tuy nhin,
nhng nghin cu gn y cho thy rng dng phi
hp Plavix v Aspirin ko di thm 9 thng cng cho
li ch r rt hn. Trong lc can thip th cn dng
Heparin, nu kt qu can thip tt, khng cn dng
tip Heparin. Cc thuc mi c ch th th GP
IIb/IIIa nu c dng phi hp s cho kt qu cao
hn v t bin chng. Tuy nhin gi cc loi thuc
ny kh t.
5. Vn ti hp (restenosis) sau khi can thip cng
rt nan gii. Mc d Stent lm gim ng k t l
ti hp nu so vi ch nong ng mch vnh n
thun, nhng t l ti hp sau 6 thng vn kh cao
(10-20%). Ngi ta ang th nghim nhiu bin php
mi ngn nga ti hp cho kt qu kh quan nh
dng phng x ti ch (Brachial Therapy) hoc k
thut gen. Gn y cc th nghim vi cc loi stent
c ph thuc khng phn bo c nhiu kt qu kh
quan trong vic chng ti hp. Cho ti nay, hu nh
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
3. K thut m lm cu ni ng mch vnh hin nay

c nhiu tin b nh vic dng cc on ng
mch quay, ng mch v trong lm gim nguy c
tc cu ni sau m so vi dng tnh mch hin theo
cch truyn thng. Hn th na, nhng k thut t
xm ln nh m vi tim vn p (khng phi dng
tim phi my) ang ha hn nhng kt qu tt p.
F. iu chnh li sng
1. Tp th dc, vn ng th lc u n.
2. iu chnh ch n cho hp l.
3. B thuc l, phi tht cng quyt.
4. Cc yu t tm l: Trnh cng thng thn kinh...
G. Mt s phng php mi
1. Ti to mch xuyn c tim bng LASER
(Directional Myocardial Laser Revascularization):
a. Dng tia Laser khoan nhiu l nh trc tip vo
cc vng c tim t trong lp ni tm mc cho n
di thng tm mc. C ch l to ra cc vi
mch nh mu t bung tim c th nui trc
tip c c tim v sau mt thi gian s xut hin
h thng vi tun hon mi ti mu cho c
tim.
b. C th thc hin k thut ny khi m tim hoc
qua ng ng thng tim.
c. K thut ny c ch nh khi vic la chon cc
phng php iu tr khc gp b tc (v d bnh
nhiu MV m tn thng phc tp khng can
thip c v on xa khng ph hp cho lm
cu ni).
2. Gene liu php: vn cn trong giai on nghin cu
vi hy vng dng gene bin i ci to h tun
hon vnh bng cc h tun hon bng h tn to.
32
Ti liu tham kho

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Alderman EL, Bourassa MG, Cohen LS, et al. Ten-year follow-up of

survival and myocardial infarction in the randomized coronary artery
surgery study. Circulation 1990;52:1629-1646.
Armstrong PW. Stable ischemic syndromes. In: Topol EJ, ed.
Textbook of cardiovascular medicine. Philadelphia: LippincottRaven, 1998:333-365.
CAPRIE Steering Committee. A randomized, blinded trial of
clopidogrel versus aspirin in patients at risk of ischemic events
(CAPRIE). Lancet 1996;345:1329-1339.
Diaz MN, Frei B, Vita JA, Keaney JF Jr. Mechanism of disease:
antioxidants and atherosclerotic heart disease. N Engl J Med
1997;337:408-4166.
Ferrari R. Major differences among the three classes of calcium
antagonists. Eur Heart J 1997;18:A56-A7O.
Furberg CD, Psaty BM, Meyer JV. Nifedipine: dose related increase
in mortality in patients with coronary heart disease. Circulation
1995;92: 1326-1331.
Gersh BJ, Braunwaid E, Rutheiford JD. Chronic coronary artery
disease. In: Braunwald E, ed. Heart disease: a textbook
o[cardiovascular medicine, 5th ed. Philadelphia: WB Saunders,
1997:1289-1366.
Guidelines and management of stable angina pectoris:
recommendations of the Task Force of the European Society of
Cardiology. Eur Heart J 1997;18:394-413.
Juul-Moller S, Edvardsson N, Jahnmatz B, et al. Double blind trial of
aspirin in primary prevention of myocardial infarction in patients
with stable chronic angina pectoris. Lancet 1992;114:1421-1425.
Kapadia SR. Stable angina. In: Marso SP, Griffin BP, Topol EJ, eds.
Manual of Cardiovascular Medicine. Philadelphia: Lippincott-Raven, 2000.
Mark DB, Nelson CL, Califf RM, et al. Continuing evolution of
therapy for coronary artery disease. Circulation 1994;59:2015-2125.
Mark DB, Shaw L, Harrell FE, et al. Prognostic value of a treadmill
exercise score in outpatients with suspected coronary artery disease.
N Engl J Med 1991;325:S4-S53.
Parker JD, Parker JO. Drug therapy: nitrate therapy for stable angina
pectoris. N Engl J Med 1995;335:520-531.
Solomon AJ, Gersh BJ. Management of chronic stable angina:
medical therapy, percutaneous transluminal coronary angioplasty,
and coronary artery bypass graft surgery, lessons from randomized
trials. Ann Intern Med 1998;125:216223.
The Bypass Angioplasty Revascularization (BARI) Investigators.
Comparison of coronary bypass surgery with angioplasty in patients
with multivessel disease. N Engl J Med 1996;335:217-225.
The Scandinavian Simvastatin Survival Study Group. Randomised
trial of cholesterol lowering in 4444 patients with coronary heart
disease: The Scandinavian Simvastatin Survival Study (4S). Lancet
1994;344:1383-1389.
33
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
thuc tiu huyt khi nhng nm 80 v hin nay l can thip
ng mch vnh cp cu v nhng tin b v cc thuc phi hp
lm cho t l t vong do NMCT cp trn th gii hin nay
gim xung ch cn khong < 7% so vi trc y l > 30 %.
I. Sinh l bnh
C tim c nui dng bi 2 ng mch vnh (MV)
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
huyt khi gy lp ton b lng mch. Nu vic nt ra ny

khng ln v hnh thnh cc mu ng cha gy lp kn ton b
lng mch, th l cn au tht ngc khng n nh trn lm
sng.
II. Triu chng lm sng
A. Triu chng c nng
1. Cn au tht ngc in hnh:
a. au nh bp nght pha sau xng c hoc hi
lch sang tri, lan ln vai tri v mt trong tay tri
cho n tn ngn eo nhn v ngn t. Nhn
chung cn au c tnh cht ging cn au tht
ngc nhng ko di hn 20 pht v khng khi
dng Nitroglycerin.
b. Mt s trng hp au c th lan ln c, cm,
vai, sau lng, tay phi, hoc vng thng v.
c. Mt s trng hp NMCT c th xy ra m bnh
nhn khng hoc t cm gic au (NMCT thm
lng), hay gp bnh nhn sau m, ngi gi,
bnh nhn c tiu ng hoc tng huyt p.
d. Trong trng hp au lan nhiu ra pha sau lng
phi phn bit vi tch thnh ng mch ch.
2. Cc triu chng khc i km theo c th gp l: v
m hi, kh th, hi hp nh trng ngc, nn hoc
bun nn, l ln... Cc triu chng ca ri lon tiu
ho thng gp trong trng hp NMCT sau di.
3. t t cng l mt trong nhng th hay gp ca
NMCT cp.
B. Triu chng thc th
1. Khm thc th trong NMCT cp ni chung t c gi
tr chn on xc nh nhng cc k quan trng
gip chn on phn bit vi cc bnh khc, gip
pht hin cc bin chng, tin lng bnh cng nh
l c s theo di bnh nhn.
36
2. Nhng triu chng hay gp l: nhp tim nhanh, ting

tim m, ting nga phi, huyt p c th tng hoc tt,
xut hin ting thi mi tim, cc ri lon nhp, ran
m phi, cc du hiu ca suy tim, ph phi cp....
Sau vi ngy c th thy ting c mng tim (hi
chng Dressler).
C. Cc yu t lm sng c gi tr tin lng bnh
Vic nh gi tin lng bnh nhn NMCT cp ng vai
tr rt quan trng gip thy thuc c thi x tr, theo
di bnh, cng nh gii thch cho bnh nhn v gia nh
tt hn. Nhng nghin cu ln trn th gii ch ra
nhng yu t sau (xp theo mc t cao n thp) c
tin lng xu i vi NMCT cp: (bng 3-1 v 3-2)
1. Tui: cng cao tin lng cng xu.
2. Huyt p tm thu tt (< 90 mmHg).
3. Killip cng cao t l t vong cng tng.
4. Nhp tim nhanh > 100 chu k /pht.
5. V tr ca NMCT.
Bng 3-1. Lin quan gia Killip v t l t vong
trong vng 30 ngy.
c im lm sng %
T l t vong
Killip
trong 30 ngy (%)
I
Khng c triu chng 85
5,1
ca suy tim tri
II
C ran m < 1/2 phi, 13
13,6
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
T cn c lm ngay khi bnh nhn nhp vin v lm

nhc li nhiu ln sau gip chn on cng nh
theo di. Nhng thay i trn T bin thin theo thi
gian mi c nhiu gi tr. Cc tiu chun ca chn on
NMCT cp trn T l:
1. Xut hin sng Q mi (rng t nht 30 ms v su 0,20
mV) t nht 2 trong s cc min chuyn o sau:
D2, D3 v aVF; V1 n V6; D1 v aVL, hoc
2. Xut hin on ST chnh ln hoc chnh xung (>
0,10 mV) t nht 2 trong s cc min chuyn o
ni trn, hoc
3. S xut hin mi bloc nhnh tri hon ton trong
bnh cnh lm sng ni trn.
Bng 3-2. Lin quan gia v tr NMCT cp v t l t vong.
T l t vong
(%)
V tr NMCT
Thay i trn
T
Trong
Trong
30 ngy 1 nm
on
gn
ca ST chnh ln V119,6
25,6
MLTT
(LAD) 6, DI, aVL hoc
(NMCT trc rng)
km theo bloc
nhnh tri
on gia ca LAD ST chnh ln V1-6,
9,2
12,5
DI v aVL
on xa ca LAD
ST chnh ln V16,8
10,2
4, hoc D1, aVL v
V5-6
NMCT sau di rng ST chnh ln D2,
6,4
8,4
(on gn ca MV D3, aVF v km
phi hoc ng mch theo mt trong cc
m)
chuyn o sau
NMCT sau di nh V1, V3R, V4R
4,5
6,7
(on xa ca MV V5-6
phi hoc M m)
R>S V1, V2 hoc
ST chnh ln ch
D2, D3 v aVF
38
Lu l: sng Q thng xut hin trung bnh sau 8-12

gi, tuy nhin trong mt s trng hp khng c sng Q
m ch c bin i ca on ST (NMCT khng Q - hay
NMCT di ni tm mc).
Trng hp NMCT tht phi th cn lm thm cc
chuyn o V3R n V6R tm cc bin i ny.
Trong trng hp km theo bloc nhnh phi hon
ton, vic chn on trn T tr nn kh khn hn.
Nu bnh nhn c NMCT trc bn c th thy hnh nh
sng T chnh ng hng vi phc b QRS V1-V4.
Hnh 3-1. NMCT sau di cp.

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
s bnh khc nh: chn thng s no, chn

thng c (k c tim truyn), tiu c vn, bnh
vim c, suy thn mn, tp th lc qu mnh...
2. Troponin: bao gm Troponin I v T, l hai loi men
c gi tr chn on cao v kh c hiu cho c tim,
hn na n cn c gi tr tin lng bnh. Cc men
ny bt u tng kh sm sau NMCT (3-12 gi) t
nh 24-48 gi v tng tng i di (5-14 ngy).
3. Lactate DeHydrogenase (LDH): bao gm 5 isoenzymes v gp mi m trong c th. LDH tng t
8-12 gi sau nhi mu, t nh 24-48 gi v ko
di 10-14 ngy. T l LDH1/LDH2 > 1 c ngha
trong NMCT.
Gi
Hnh 3-2. Thay i cc men sau NMCT cp (theo gi).

4. Cc Transaminase SGOT v SGPT: t c hiu
cho c tim. Tuy nhin iu kin ca chng ta th
xt nghim cc men ny cng vn c gi tr nht
nh. Trong NMCT th SGOT tng nhiu hn SGPT.
C. Siu m tim: cng rt c gi tr, c bit trong nhng
th NMCT khng Q hoc c bloc nhnh. Thng thy
hnh nh ri lon vn ng vng lin quan n v tr nhi
40
mu. Mc ri lon t gim vn ng, khng vn ng,

vn ng nghch thng v phnh thnh tim. Siu m tim
cn gip nh gi chc nng tht tri, cc bin chng c
hc ca NMCT (thng vch tim gy thng lin tht, h
van tim do t dy chng), trn dch mng tim, huyt
khi trong bung tim...
D. Thm d phng x ti mu c tim: thng khng
cn dng trong giai on cp ca NMCT. Cc thm d
ny c ch giai on sau nh gi mc ti mu
cho tng vng c tim v s sng cn ca c tim nhm
gip ch cho ch nh can thip mch vnh.
IV. Chn on phn bit
A. Vim mng ngoi tim: au thng lin tc v cm
gic rt, au thay i theo t th v nhp th, thng au
tng khi nm nga. Trong vim mng ngoi tim cng c
th c ST chnh ln nhng l chnh ln ng hng
cc chuyn o trc tim v khng c hnh nh soi
gng. Siu m c th gip ch cho chn on.
B. Vim c tim cp: l mt chn on phn bit kh kh
khn v cc triu chng lm sng cng nh T kh
ging NMCT. Bnh s v khm lm sng cho thy bnh
cnh nhim trng (c bit l virus) v siu m tim c
gim vn ng ng u gip thm chn on phn bit.
C. Tch thnh ng mch ch: in hnh l au d di
lan pha sau lng. Nhiu khi tch thnh MC cng gy
ra NMCT khi n nh hng n MC ln v gc MC.
Siu m tim c th thy hnh nh tch thnh MC nu
MC ln. Siu m qua thc qun rt c gi tr chn on.
Chp ct lp vi tnh (CT scan) hoc chp cng hng t
l nhng thm d tt gip chn on xc nh.
D. Nhi mu phi: thng t ngt kh th, au ngc, ho
ra mu m khng c ph phi. T l hnh nh tm ph
cp vi S1 Q3 (S su D1 v Q su D3). Chp Xquang
41
c th thy hnh nh mt m m phi v siu m tim

khng thy c ri lon vn ng vng.
E. Cc bnh cp cu bng nh thng d dy, cn au
d dy cp, vim tu cp, vim ti mt, giun chui ng
mt... cng cn c phn bit nht l vi NMCT cp th
sau di.
V. iu tr NMCT cp
A. iu tr ban u
1. Khn trng nh gi tnh trng bnh nhn v nn
chuyn ngay n nhng c s c th iu tr ti ti
mu. Kp thi nh gi cc bin chng nguy him
khng ch (lon nhp, suy tim...). Bnh nhn phi
c vn chuyn bng xe cu thng v c nhn vin
y t i cng. ng thi thc hin cc bin php iu
tr ban u.
2. Cc bin php chung, ban u cho mi bnh nhn l:
a. Bnh nhn phi c bt ng ti ging.
b. Th xy: vi liu 2-4 lt/pht qua ng mi v
trong NMCT cp thng km theo thiu xy. Mt
s trng hp suy h hp nng cn phi t ni
kh qun v cho th my ph hp.
c. Gim au y : lm gim s tng tit
cathecholamin trong mu v gp phn lm gim
nhu cu xy c tim.
Morphin sulphat l thuc c la chn hng
u, liu dng t 2-4 mg tim tnh mch sau
nhc li sau 5-10 pht nu bnh nhn vn
au. Ch nhp th ca bnh nhn v nhp
tim. Nu gy nhp chm c th cho Atropin
0,5 mg tim TM.
d. Nitroglycerin (0,4 mg) ngm di li, c th
nhc li sau mi 5 pht. cn ch huyt p ca
bnh nhn. Nu huyt p ti a cn > 90 mmHg
l tt. Tip sau cn thit lp ngay ng
42
truyn tnh mch v truyn Nitroglycerin vi tc

10 mcg/pht, c th chnh liu theo con s
huyt p ca bnh nhn. Nu bnh nhn huyt p
tt th khng th dng Nitroglycerin, khi cn
p dng ngay cc bin php vn mch tt. Lu
l Nitroglycerin c th gy nhp chm v khng
dng khi c NMCT tht phi.
e. Cho ngay thuc chng ngng kt tiu cu:
Aspirin cn cho ngay bng ng ung dng
khng bc vi liu 160 - 325 mg hoc c th cho
bng ng tim tnh mch 500 mg. C th cho
bng dng gi bt Aspegic. Nu bnh nhn c
tin s lot d dy t trng ang tin trin th c
th thay bng Ticlopidine (Ticlid) 250 mg x 2
vin/ngy hoc Clopidogrel (Plavix) cho ngay
300 mg sau 75 mg/ngy. Cc nghin cu gn
y cho thy phi hp gia Aspirin v Ticlopidin
hoc Clopidogrel lm gim ng k t l t vong.
f. Thuc chng ng: Heparin tim thng TM liu
65-70 v/kg sau duy tr liu 15-18 v/kg/gi.
Heparin t n khng lm gim t l t vong do
NMCT nhng rt quan trng nu bnh nhn c
cho thuc tiu huyt khi hoc can thip ng
mch vnh cp. Dng Heparin vi thuc tiu
huyt khi cn cho ngay 5000 v tim TM sau
truyn tnh mch liu khong 1000 v/gi (tr
trng hp cho Streptokinase th khng dng
Heparin phi hp). Khi dng Heparin cn iu
chnh liu theo thi gian APTT sao cho thi gian
ny gp 1,5 thi gian chng (50-75 giy).
g. Thuc chn bta giao cm: lm gim t l t
vong v gim din c tim b nhi mu hoi t.
Thuc hay dng l Metoprolol tim TM 5 mg sau
nhc li mi 5 pht cho n tng liu l 15
mg, trong khi bt u cho ung 25-50 mg. Cc
thuc khc c th dng l Atenolol, Esmolol.
43
Khng dng cc thuc ny khi bnh nhn c du

hiu suy tim nng, nhp tim chm < 60, huyt p
tm thu < 90 mmHg, bloc nh tht cao, bnh
phi tc nghn, bnh mch ngoi vi nng.
B. iu tr ti ti mu
Mc tiu quan trng nht trong iu tr NMCT cp
l lm ti ti mu (ti lu thng MV b tc) cng sm
cng tt. Ba bin php iu tr ti ti mu hin nay l:
dng thuc tiu huyt khi, can thip (nong, t stent)
ng mch vnh cp, m bc cu ni ch-vnh cp. Vic
iu tr sm ti ti mu lm gim mc hoi t c
tim, gim t l t vong v bo tn chc nng tht tri.
1. La chn phng php iu tr ti ti mu: Vic
la chn phng php iu tr ti ti mu ngay cho
bnh nhn NMCT cp ph thuc vo nhiu yu t
nh thi gian n vin, tnh trng bnh nhn c th,
iu kin trang thit b v trnh ca c s y t.
2. Thi im iu tr ti ti mu: Cc nghin cu
chng minh c l li ch cng ln nu tin hnh
c ti ti mu cng sm. Nu thi gian c ti
ti mu trong vng 1 gi u (k t khi au) th li
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
b. Ch nh thuc tiu huyt khi cng sm cng tt

v tt nht trong vng 6 gi u, nu bnh nhn
n mun hn v trong vng 12 gi m vn cn
tn ti du hiu ca hoi t c tim lan rng th
vn c th dng thuc tiu huyt khi .
c. Cc thuc ny c mt s chng ch nh tng
i v tuyt i (Bng 3-3).
Bng 3-3. Chng ch nh ca thuc tiu huyt khi.
Chng ch nh tuyt i
ang c bnh hoc th thut gy chy mu nng.
Thiu ht cc yu t ng mu (ri lon).
Mi b cc chn thng nng.
Mi phu thut (<10 ngy).
Cc th thut xm ln (< 10 ngy).
Phu thut thn kinh trong vng 2 thng.
Chy mu ng tiu ho trong 10 ngy.
TBMN trong vng 1 nm.
Tin s u no, phnh mch no.
Vim mng ngoi tim cp.
Nghi ng tch thnh ng mch ch.
Lot ng tiu ho ang tin trin.
Bnh mng phi cp tnh.
ang c thai.
Chng ch nh tng i:
Huyt p ti a > 180 mmHg.
Huyt p ti thiu > 110 mmHg.
Vim ni tm mc nhim khun.
Xut huyt vng mc do bnh l i tho ng.
TBMN > 12 thng.
C hi sinh tim phi trong vng 10 pht.
ang dng chng ng khng Vitamin K lu di.
Suy thn hoc gan nng.
Rong kinh rong huyt nng.
45
4.
Cc loi thuc tiu huyt khi:

a. Vic la chn cc thuc tiu huyt khi phi cn
nhc da vo hon cnh thc t v gi thnh.
Trong cc thuc trn, rt-PA c cc tc gi nc
ngoi a dng nhng gi thnh kh cao.
Streptokinase l thuc cng c dng rng ri,
gi thnh r hn v tng i t tai bin.
Bng 3-4. Cc loi thuc tiu huyt khi v liu dng.
Cc thuc c hiu vi fibrin
Alteplase (rt-PA): Tim thng TM 15 mg sau
truyn TM 0,75 mg/kg (cho ti 50 mg) trong vng 30
pht, tip theo 0,5 mg/kg (cho ti 35 mg) truyn TM
trong 60 pht tip. Liu ti a 100 mg trong 90 pht.
Reteplase (r-PA): tim thng TM 10 n v trong 2
pht, sau 30 pht li tim nh vy (10 n v).
Cc thuc khng c hiu vi fibrin
Streptokinase (SK): Truyn TM 1,5 triu n v trong
vng 60 pht.
Anistreplase (APSAC): tim thng TM 30 n v
trong vng 2 pht.
Urokinase (UK): truyn TM 3 triu n v trong vng
60 pht.
b. Khi dng cc thuc tiu huyt khi bt buc phi
phi hp vi Heparin v cc nghin cu chng
minh l lm gim nguy c b tc li mch sau
dng thuc tiu huyt khi. Heparin c dng
trc v sau khi dng thuc tiu huyt khi 4 gi
th truyn tip Heparin vi liu 1000 v/gi trong
vng 48 - 72 gi tip. Ring i vi Streptokinase
th khng cn dng Heparin phi hp v thuc
ny tc ng khng c hiu vi h fibrin nn c
th gy chy mu nhiu nu phi hp Heparin.
c. Bin chng ca cc thuc tiu huyt khi: quan
trng nht l chy mu. Chy mu ni s l bin
chng nguy him nht (gp khong 0,5% i
46
vi Streptokinase v 0,7% i vi tPA) , ngoi ra

c th gy chy mu nhiu bt k ni no. Cn
theo di thi gian aPTT. Nu b mt mu nhiu
phi truyn mu, huyt tng ti.
5. Can thip ng mch vnh trong giai on cp
cu (nong, t Stent): Mc d thuc tiu huyt khi
l tin b ng k, nhng do nhiu chng ch nh v
s bnh nhn n vin kh mun nn t l bnh nhn
c dng thuc tiu huyt khi khng cao. Hin nay
c nhiu nghin cu chng minh tnh u vit ca
phng php can thip ng mch vnh trong giai
on cp. Tuy nhin, n tu thuc nhiu vo trang
thit b v kinh nghim ca thy thuc can thip.
a. Ch nh: Can thip MV cp ch nn ch nh
nhng bnh nhn c chng ch nh ca thuc
tiu huyt khi hoc c tnh trng huyt ng
khng n nh (sc tim) hoc c ri lon nhp
tim. Hin nay, i vi mt s trung tm c kinh
nghim v c trang thit b tt, ngi ta thng
c xu hng can thip MV th u (primary
intervention) (tc l can thip ngay lp tc khi
bnh nhn n vin v cha dng thuc tiu si
huyt). Cc khuyn co gn y c xu hng
ng h cho vic can thip ny.
b. Can thip khi dng thuc tiu huyt khi tht
bi: tc l sau khi dng thuc tiu huyt khi m
bnh nhn vn cn au ngc, lm sng khng n,
ST vn chnh ln trn T th c ch nh can
thip MV.
c. Khi can thip ng mch vnh cp cn dng phi
hp vi cc thuc:
Aspirin 325 mg/ngy ko di mi, phi hp
Ticlopidin (Ticlid) 250 mg x 2 ln ngy trong
na thng hoc Clopidogrel (Plavix) 75
mg/ngy. Vai tr ca Clopidogrel ngy cng
47
c nhn mnh v tnh hiu qu v kh an

ton ca n. Nhng nghin cu gn y cho
thy li ch ca Plavix cng c khng nh
khi dng ko di n 9 thng.
Cc thuc c ch th th GP IIb/IIIa (ReoPro,
Aggrastat...) l nhng thuc chng ngng kt
tiu cu trit . Khi dng cng vi can thip
MV cp lm gim ng k t l tai bin do
can thip v t l tc mch sau can thip. Tuy
nhin cc thuc ny kh t tin.
Heparin l cn thit trong khi can thip. Nu
can thip kt qu thnh cng c th xt dng
Heparin sau can thip.
6. M lm cu ni ch - vnh cp cu:
Ch c ch nh khi bnh nhn au ngc ti
pht sau dng tiu huyt khi hoc ng mch vnh
khng thch hp cho can thip (tn thng nhiu
thn, tn thng thn chung, tn thng phc tp...),
hoc can thip tht bi, hoc bnh nhn c nhng
bin chng c hc.v.v...
Trc khi nong

Sau nong v t Stent
Hnh 3-3. Nong v t Stent ng mch lin tht trc.
C. iu tr tip theo
1. Cc bin php chung:
a. Ch vn ng: Vi nhng bnh nhn trong
giai on cp hoc cha n nh cn bt ng ti
48
ging. Tuy nhin nu nhng bnh nhn c

iu tr ti ti mu tt m khng cn au ngc
th sau 12 gi c th cho c ng nh ti
ging v ngi dy nh nhng ti ging. Sau 24
gi c th cho vn ng nh nhng v sau 48 gi
c th cho i b nh ti phng ri tng dn mc
vn ng tr v bnh thng.
b. Ch dinh dng: Trong giai on cp (au
nhiu) th khng nn cho n m nn dinh dng
bng ng truyn tnh mch. Khi bnh nhn
cn ch ch n nng lng (1200 - 1800
calorie/ngy) t cholesterol v mui. Bnh nhn
NMCT cn trnh to bn v nn cho thm cc
nhun trng.
c. An thn: nn trnh thm hi nhiu ca ngi nh
trong giai on cp. Nu bnh nhn lo lng qu
c th cho thm mt cht an thn.
2. Cc thuc:
a. Cc thuc chng ngng kt tiu cu (Aspirin,
Ticlopidin, Clopidogrel): c bit quan trng.
Liu Aspirin t 75-325 mg/ngy nhng nn
dng > 160 mg/ngy.
b. Cc thuc chng ng: Heparin cn thit khi c
dng thuc tiu huyt khi v khi can thip
MV. Heparin khng nn dng ko di > 5 ngy.
Cc thuc khng vitamin K ng ung ch dng
khi c km theo rung nh hoc c phnh vch tht
gy cc mu ng.
c. Cc Nitrates: mc d khng lm gim t l t
vong nhng chng ci thin tnh trng thiu mu
cc b, ci thin triu chng v suy tim nu c.
d. Cc thuc chn beta giao cm: nn tip tc ko
di (nu khng c cc chng ch nh).
e. Cc thuc c ch men chuyn (CMC): Nn
cho sm v bt u liu nh (trong vng 24 gi
49
u). Ch huyt p ca bnh nhn. Thuc

CMC lm gim t l t vong, bo tn chc nng
tht tri. Nn dng bt u bng thuc c tc
dng ngn nh Captopril 6,25 mg trong 24 gi
u sau nh gi tnh trng v iu chnh liu
hoc thay cc thuc CMC khc c thi gian tc
dng ko di hn.
f. iu tr tch cc cc yu t nguy c trong ch
iu tr tt i tho ng, ri lon m mu
(nu c) km theo.
D. Phc hi chc nng sau NMCT
1. Giai on ti bnh vin:
i vi nhng bnh nhn n nh cn sm
phc hi chc nng bng cch cho bnh nhn sm
vn ng nh. Ngy th ba c th cho bnh nhn i
li nh nhng trong phng. Trc khi ra vin cn gio
dc bnh nhn v ch tp luyn, loi b yu t
nguy c, iu chnh ch n v ch thuc men
hng ngy cho bnh nhn.
2. Giai on nh:
Bnh nhn cn i b sm ti thiu mi ngy 23 ln, mi ln 20-30 pht v duy tr nhp tim khng
tng qu 20 nhp so vi nhp tim lc ngh. khng
nh bnh nhn c th tr v cuc sng sinh hot
bnh thng, bnh nhn cn c lm nghim php
gng sc nh gi. Vic gio dc bnh nhn vn
c bit quan trng trong giai on ny v ch
sinh hot v thuc men.
Ti liu tham kho
1.
2.
50
Falk E, Shah PK, Fuster V. Coronary plaque disruption.

Circulation 1995;92:657-671.
Flather M, Pipilis A, Collins R, et al. Randomized controlled
trial of oral captopril, of oral isosorbide mononitrate and of
intravenous magnesium sulphate started early in acute
myocardial infarction: safety and haemodynamic effects. ISIS-4
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
(Fourth International Study of Infarct Survival) Pilot Study

Investigators. Eur Heart J 1994;15:605-619.
GUSTO Investigators. An international randomized trial
comparing four thrombolytic strategies for acute myocardial
infarction. N Engl J Med 1993;329: 673682.
Lauer MA, Lincoff AM. Acute myocardial infarction. In: Marso
SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular
Lee K, WoodliefL, Topol E, et al. Predictors of 30-day mortality
in the era of reperfusion for acute myocardial infarction.
Circulation 1995;91:1659-1668.
Lincoff A, Topol E, CaliffR, et al. Significance of a coronary
artery with thrombolysis in myocardial infarction grade 2 flow
"patency". Am J Cardiol 1995;75: 871-876.
Lincoff AM, Califf RM, Moliterno DM, et al. Complementary
clinical benefits of coronary-artery stenting and blockade of
platelet glycoprotein ub/Iha receptors. N Engl J Med
1999;341:319-327.
Mark D, Hlatky M, CaliffR, et al. Cost effectiveness of
thrombolytic therapy with tissue plasminogen activator as
compared with streptokinase for acute myocardial infarction. N
Engl J Med 1995;332:1415-1424.
Ryan TJ, Anderson JL, Antman EM, et al. ACC/AHA
guidelines for the management of patients with acute
myocardial infarction: a report of the American College of
Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee on Management of Acute Myocardial
Infarction). J Am CoIl Cardiol 1996;25:1328-1428.
Sgarbossa EB, Wagner G. Electrocardiography. In: Topol EJ,
ed. Textbook of cardiovascular medicine. New York:
Lippincott-Raven, 1998.
The EPILOG Investigators. Platelet glycoprotein IIb/IIIa
receptor blockade and low-dose heparin during coronary
revascularization
during
percutaneous
coronary
revascularization. N Engl J Med 1997;336:1689-1696.
The GUSTO IIb Angioplasty Sub study Investigators. A clinical
trial comparing primary coronary angioplasty with tissue
plasminogen activator for acute myocardial infarction. N Engl J
Med 1997;336: 1621-1628.
The GUSTO III Investigators. A comparison of reteplase with
alteplase for acute myocardial infarction. N Engl J Med
1997;337:1115-1123.
Topol EJ, Van de Werf FJ. Acute myocardial infarction: early
diagnosis and management. In: Topol EJ, ed. Textbook of
Cardiovascular Medicine. New York: LippincottRaven, 1998.
White RD, Van de Werf FJ. Thrombolysis for acute myocardial
infarction. Circulation 1998;97:1632-1646.
Woods K', Fletcher S. Long-term outcome after intravenous
magnesium sulphate in suspected acute myocardial infarction:
the second Leicester Intravenous Magnesium Intervention Trial
(LIMIT-2). Lancet 1994;343:516-S19.
51
Bin chng Nhi mu c tim
Bnh nhn NMCT thng cht ch yu l do cc bin

chng cp v nu qua khi giai on cp cng thng li mt
s bin chng i khi rt nng nu khng c iu tr mt cch
tho ng. Cc bin chng ca NMCT rt phong ph v c th
chia lm cc nhm: bin chng c hc, bin chng ri lon nhp,
bin chng thiu mu c tim, tc mch
I. Bin chng c hc
Cc bin chng c hc c th e do tnh mng bnh nhn
l: thng lin tht, h van hai l cp do t dy chng, v thnh
tim t do, phnh thnh tim...
A. Thng lin tht (TLT) do thng vch lin tht
1. Triu chng lm sng:
a. TLT xy ra khong 0,5 2% s bnh nhn
NMCT cp. T l gp ngang nhau gia cc nhm
NMCT pha trc v sau di. TLT thng xy ra
nhng bnh nhn b NMCT din rng, tc mt
mch m tun hon bng h km. TLT c th xy
ra sm ngay sau 24 gi ca NMCT nhng thng
xy ra sau khong 3-7 ngy.
b. Bnh nhn c bin chng TLT thng c du
hiu lm sng nng n hn. Cc bnh cnh lm
sng nh au ngc tng, ph phi cp, tt huyt
p, sc tim c th xy ra t ngt trong qua trnh
ang din bin bnh thng ca bnh.
c. Khi nghe tim thy mt ting thi tm thu mi
xut hin vng trc tim, ting thi r nht pha
thp bn tri xng c. Khi bnh nhn c l
thng ln vch lin tht v tnh trng suy tim
nng th c th khng nghe thy ting thi na.
d. Cn phn bit vi h van hai l hoc h van ba l.
53
2. Gii phu bnh:

L TLT l hu qu ca l thng vng c tim b
hoi t do NMCT v xy ra ch ranh gii gia vng
khng hoi t v vng b nhi mu. L ny thng
vng gn mm tim i vi nhng bnh nhn NMCT
vng trc v vng vch sau vi NMCT pha sau.
3. Cc xt nghim chn on:
a. in tm : c th thy bt thng v dn
truyn nt nh tht hoc ng dn truyn t
nh xung tht.
b. Siu m tim: l thm d c gi tr trong chn
on bnh c bit l siu m mu. i vi thng
vng gn mm, mt ct 4 bung t mm l mt
ct tt nht quan st. i vi thng vng vch
sau, mt ct trc dc c li gc i cht hoc mt
ct trc dc di mi c cho php nh gi r
nht. Trong mt s trng hp cn phi dng n
siu m qua ung thc qun nh gi r hn
v bn cht thng tn. Siu m tim c th gip
nh gi c kch thc l thng, mc ln
ca shunt. Siu m tim cng c th gip nh gi
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
b. iu tr ni khoa: iu tr ni khoa l bin php

c bn v l cu ni cho iu tr ngoi khoa. Cc
thuc gin mch lm gim lu lng shunt v
lm tng cung lng h thng do lm gim sc
cn h thng; tuy nhin, nu lm gim sc cn
ng mch phi qu li dn n lm tng lu
lng shunt. Thuc thng dng l Nitroprusside
truyn TM, bt u bng liu 0,5-3 mcg/kg/ph v
theo di huyt p trung bnh mc 70-80mmHg.
c. t bng bm ngc dng trong ng mch
ch (IABP): l bin php nn c thc hin
cng sm cng tt trc khi gi i m. IABP lm
gim sc cn h thng, gim lu lng shunt,
tng ti mu MV v duy tr uc huyt p
ng mch.
d. Phu thut: L bin php la chn mc d tnh
trng huyt ng khng c n nh. Phu thut
bnh nhn c bin chng TLT lm gim ng
k t l t vong so vi iu tr bo tn. Tuy nhin,
t l t vong vn cn cao c bit nhm bnh
nhn c sc tim, suy a ph tng, NMCT vng
sau di gy l thng vng vch sau do k thut
kh khn hn nhiu so vi vng mm...
B. H van hai l (HoHL) cp
HoHL cp do t dy chng ct c l mt bin
chng nng n v bo hiu tin lng rt xu trong
NMCT. t dy chng ct c thng xy ra trong vng
2-7 ngy sau NMCT cp v chim t l khong 1% trong
s NMCT cp.
a. HoHL cp do t dy chng ct c thng xy ra
bnh nhn b NMCT cp thnh sau.
b. Nu tnh trng t hon ton mt ct c gy
HoHL cp s dn n tnh trng sc tim nhanh
chng hoc t t. Nhng trng hp nh hn c
55
c. Nghe tim: c th thy xut hin mt ting thi

tm thu mi vng mm lan ln nch hoc ln
vng y tim. Trong trng hp NMCT vng
thnh sau gy t dy chng sau c th nghe thy
ting thi tm thu pha cnh xng c d nhm
ln vi thng lin tht hoc hp van ng mch
ch. Cng ting thi khng c ngha d
on mc nng nh ca HoHL. i khi ting
thi rt nh hoc khng thy do bnh nhn b suy
tim qu mc hoc gim cung lng tim qu.
d. Ch : t dy chng thng xy ra NMCT
vng di. NMCT vng ny (tc nhnh lin tht
sau PDA) gy hoi t ct c pha sau v gy sa
van hai l v HoHL.
a. in tm : cho thy hnh nh ca NMCT cp
thng l pha sau di.
b. Xquang tim phi c th cho thy hnh nh ca
ph phi tu mc . Mt s bnh nhn c hnh
nh ph phi nhiu thu trn phi v dng
HoHL pht trc tip nhiu v pha tnh mch phi
phi pha trn.
c. Siu m Doppler tim: l phng php rt c gi
tr trong chn on cng nh tin lng bnh.
Hnh nh sa l van hai l.
Hnh nh dng mu ca HoHL v cho php
nh gi mc HoHL.
Cho php chn on phn bit vi ting thi
do bin chng thng lin tht hoc cc bin
chng khc.
Gip nh gi chc nng tim v p lc ng
mch phi.
56
d. Thm d huyt ng: Thng thng i vi

nhng bnh nhn ny cn theo di huyt ng
cht ch bng mt ng thng Swan-Ganz theo
di p lc ng mch phi, cung lng tim v p
lc mao mch phi bt (PCW). Trn ng cong
p lc ca PCW c th thy hnh nh sng V cao
mt cch bt ng.
3. iu tr:
a. Cc u tin trong iu tr: Cn thit phi pht
hin c nhanh chng bin chng HoHL cp
kp thi i ph. Bnh nhn cn c iu tr ni
khoa mt cch ht sc tch cc v cn nhc iu
tr ngoi khoa sm nu c th.
b. iu tr ni khoa:
Cc thuc gin mch ng vai tr quan trng.
Thuc c u tin dng l Nitroprusside,
thuc ny lm gim sc cn h thng mt
cch c ngha, lm gim phn s h van hai
l v c th lm tng cung lng tim. Thuc
ny c dng bng ng truyn tnh mch
lin tc vi liu khi u l 0,5-3
mcg/kg/pht v iu chnh theo huyt p
trung bnh trong khong 70-80 mmHg.
Thuc gin mch khng nn dng cho bnh
nhn b tt huyt p. Trong trng hp
ny, gii php tt nht l nn t bng bm
ngc dng trong ng mch ch (IABP).
IABP lm gim hu gnh ca tht tri v tng
lu lng n mch vnh. Sau khi t IABP
c th cn nhc cho tip thuc gin mch.
c. Bin php can thip ng mch vnh cp cu:
Nong MV hoc t Stent cp cu lm ci thin
c tnh trng huyt ng v mc HoHL
nhng bnh nhn HoHL mi do thiu mu cc
b. Tuy nhin, khi b t hn ct c th can
57
thip MV n thun cng khng ci thin c

tnh trng bnh.
d. iu tr ngoi khoa: L bin php cn c tin
hnh sm khi c t hon ton ct c.
T l t vong khi m kh cao (20-25% cc
nc pht trin) tuy nhin vn l bin php
hiu qu nht v cn c ch nh sm.
Nn tin hnh can thip MV trc khi tin
hnh phu thut can thip van hai l.
C th tin hnh sa van hai l nhng bnh
nhn HoHL mc va m khng cn phi
thay van hai l.
C. V thnh t do ca tim
a. V thnh t do tim c th gp khong 3% s
bnh nhn NMCT cp v l mt trong nhng
nguyn nhn dn n t vong t ngt. V thnh
tim cng ch xy ra nhng bnh nhn c NMCT
xuyn thnh. Nhng yu t nguy c d xy ra v
thnh tim l: tui gi, n gii, tng huyt p qu
nhiu, NMCT ln u v h thng mch vnh
khng phong ph.
b. Triu chng ca th cp: c th thy biu hin
ca phn ly in c trn T v t t. Mt s
bnh nhn ku au ngc d di hn, ho v nc.
c. Th bn cp: gp s t bnh nhn m bnh cnh
d nhm vi vim mng ngoi tim cp, nn, tt
huyt p.
d. Khm thy cc du hiu ca p tim cp t ngt:
gin tnh mch cnh, mch o, ting tim m..
a. in tm : c hnh nh nhp b ni hoc t
tht, in th ngoi vi thp, sng T cao nhn
58
cc chuyn o trc tim. Mt s bnh nhn biu

hin nhp chm trc khi v thnh t do.
b. Siu m tim: cho php nhn thy hnh nh p tim
cp v c th cho php nhn thy ch v.
3. iu tr:
a. Bin php iu tr ti ti mu lm gim bt t l
b v thnh tim.
b. Mc ch l phi nhanh chng nhn bit c
tnh trng v tim v tin hnh m cp cu.
c. iu tr ni khoa ch ng vai tr tm thi khi hi
sc v trong lc a n phng m. Dng thuc
vn mch v truyn dch duy tr huyt p.
d. Nhanh chng chc dch mng tim nu xc nh l
c p tim cp trong lc thu xp cuc m.
e. Phu thut ti cp cu l bin php duy nht c
th cu sng c bnh nhn trong trng hp b
v thnh t do tim.
D. Gi phnh thnh tim
a. Gi phnh thnh tht thng c tin trin thm
lng v thng c pht hin tnh c khi lm cc
thm d chn on. Tuy nhin, mt s bnh nhn
c biu hin ca cc cn tim nhanh ti pht v
suy tim.
b. Thm khm c th thy ting thi tm thu hoc
tm trng hoc ting thi theo t th do dng
mu xoy qua l thng vo ch phnh.
c. Bn cht bnh l ca gi phnh thnh tht l do v
mt ch nh ca thnh t do tht v c mng
ngoi tim cng huyt khi thnh bao bc li.
Gia ti phnh v tht vn cn lin h vi nhau
nh l thng.
59
a. Xquang tim phi: thng c th thy hnh nh

bng tim bt thng vi mt ch li tng ng
vi ti phnh.
b. in tm : c th cho thy hnh nh ST chnh
vm c nh ging trng hp b phnh tht.
c. Siu m tim: c th gip chn on xc nh
bnh. Chp cng hng t (MRI) cng l mt
bin php kh chnh xc chn on bnh.
3. iu tr: Phu thut l ch nh bt buc bt k kch
c hoc triu chng ca ti gi phnh ny nh th no
ngn nga vic v th pht ca ti gi phnh ny.
E. Phnh vch tht
a. Th cp: Khi mt vng c tim rng b gin ra th
nhanh chng dn n suy tim hoc sc tim.
Nhng bnh nhn b NMCT v tr c nh hng
n vng mm thng l c nguy c cao nht.
b. Th mn tnh: L nhng th phnh vch tht tin
trin t t sau hn 6 tun. Chng xy ra 10-30%
cc trng hp NMCT. Nhng bnh nhn ny
thng c cc triu chng ca suy tim, ri lon
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
trong qu trnh ti cu trc (remodeling) c tim l

rt quan trng.
3. Cc thm d cn lm sng:
a. in tm :
Nu phnh vch tht xy ra cp tnh th sng
ST chnh ln c nh mc d MV c c
ti ti mu.
Nu phnh vch tht xy ra t t th ST chnh
ln tn ti khong hn 6 tun.
b. Xquang tim phi: thy hnh nh mt vng bng
tim phnh ra tng ng vi vng c tht b phnh.
c. Siu m tim: l mt thm d c gi tr gip chn
on xc nh bnh, nh khu, nh ga cc bin
chng, chc nng tht, huyt khi. c bit siu
m gip chn on vi ga phnh tht (trong
phnh vch tht tht th c vo rng cn gi phnh
th c vo hp).
d. Chp cng hng t: cng gip xc nh phnh
vch tht.
4. iu tr:
a. iu tr ni khoa:
Phnh cp: Nn nhanh chng iu tr tnh
trng suy tim bng cc thuc gin mch
truyn tnh mch v t bng bm ngc
dng trong MC. Cho thuc c ch men
chuyn sm l mt bin php quan trng ngn
nga c qu trnh ti cu trc v lan rng
ca vng nhi mu. V qu trnh lan rng ca
nhi mu xy ra rt sm nn cn cho thuc c
ch men chuyn sm trong vng 24 gi ca
NMCT cp (nu huyt p khng qu thp).
Phnh mn tnh: Cc thuc dng iu tr
suy tim do phnh mn tnh vch tht l: c ch
men chuyn, li tiu hoc c th cho Digoxin.
61
Chng ng: Cc thuc khng vitamin K

ng ung c ch nh nhng bnh nhn
c phnh vch tht m c huyt khi bm
thnh. Trc tin nn cho Heparin trong vng
vi ngy v cng bt u lun bng cc thuc
chng ng dng ung loi khng vitamin K.
Khi iu tr, nn chnh liu sao cho INR t
khong 2-3 trong vng 3-6 thng. i vi
nhng phnh vch tht d ln m khng thy
hnh nh huyt khi bm thnh th ngi ta
cng cha r li ch v ch nh ca khng
vitamin K. i vi nhng bnh nhn c phnh
vch tht m chc nng tht tri rt km th
nn cho thuc chng ng ng ung trong
t nht 3 thng sau NMCT cp.
b. iu tr can thip:
Nhng bnh nhn b nhi mu th can thip
MV cng sm cng tt gip ngn chn qu
trnh gin thnh tht v ti cu trc. Can thip
mun sau 12 gi vn c th c ch nhng sau
24 gi th c th khng ci thin c tnh
hnh phnh vch tht.
i vi nhng bnh nhn c phnh vch tht
m c ri lon nhp tht nguy him th c th
cn nhc vic cy my ph rung t ng trong
bung tim (ICD).
c. Ngoi khoa: i vi nhng bnh nhn phnh
vch tht c suy tim dai dng hoc ri lon nhp
tim nng n th c th cn nhc iu tr ngoi
khoa. iu tr ngoi khoa c th ct ng on
phnh hoc lm mt ming v duy tr
c th tch tht tri. Cng nn cn nhc vic
iu tr ti ti mu ng mch vnh trc .
62
II. Cc ri lon nhp

Trong NMCT, bin chng ri lon nhp tim l rt thng
gp cc mc khc nhau (90% cc trng hp). C th gp
tt c cc loi ri lon nhp khc nhau (xin tham kho chi tit
phn cc ri lon nhp tim).
A. Ri lon nhp tht
1. Ngoi tm thu tht: hay gp, cn theo di tt, iu
chnh cc ri lon in gii. Thuc chn bta giao
cm c th c tc dng tt. Mt s tc gi a dng
Amiodarone.
2. Nhp t tht gia tc: hay gp bnh nhn c hi
chng ti ti mu, phng cn nhanh tht hoc
rung tht.
3. Nhp nhanh tht v rung tht: l tnh trng cp cu
v cn x tr theo ng nh phc ngng tun hon.
B. Ri lon nhp trn tht: c th gp cc ri lon nh:
1.
2.
3.
4.
Nhp nhanh xoang.

Cn nhp nhanh kch pht trn tht.
Rung nh.
Nhp b ni.
C. Cc ri lon nhp chm

1. Nhp chm xoang: hay gp bnh nhn NMCT sau
di, cn iu tr khi c nh hng n huyt ng.
2. Bloc nh tht t cp I n cp III: Nu bloc cao
nh hng n huyt ng th cn cp cu theo phc
v ch t my to nhp tm thi sm. Ch nh
t my to nhp tm thi:
a. V tm thu;
b. Bloc nh tht cp III;
c. Nhp chm xoang hoc bloc nh tht thp
nhng c nh hng n huyt ng.
63
III. Suy chc nng tht tri v sc tim

Ri lon chc nng tht tri l din bin kh trnh khi
sau NMCT, ch tu theo mc nh hay nng. Mc suy chc
nng tht tri lin quan n vng tn thng nhiu hay t. Bnh
nhn NMCT vi vng tn thng nh c th gy ri lon vn
ng mt vng c tim nhng khng gy gim chc nng ng k
ton b tht tri. Tuy nhin, khi nhi mu din rng, c bit l
vng trc hoc n gii, ngi cao tui, tiu ng l nhng
yu t d bo nguy c cao ca suy tim tri nng v sc tim.
A. Phn loi
Hin nay phn loi ca Killip v Kimban (bng 4-1) l
phn loi c s dng rng ri nht trn lm sng phn
loi mc nng nh v c gi tr tin lng bnh
Bng 4-1. Mi lin quan gia Killip v t vong trong
30 ngy.
T l t vong
Killip
c im lm sng
%
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
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
B. Triu chng lm sng

1. Triu chng c nng:
a. Bnh nhn c th c cc du hiu ca suy h hp,
kh th, cm gic lnh... bn cnh cc du hiu
kinh in ca NMCT.
b. Bnh nhn sc tim c cc du hiu trm trng
hn nh kh th nhiu, tiu t, rt run, ri lon
tm thn
2. Triu chng thc th:
a. H huyt p do gim cung lng tim, gim th
tch tun hon.
b. tr tun hon phi, vi ran phi.
c. Gim ti mu ngoi vi: da lnh, u chi lnh, v
m hi.
d. Nghe tim: thy nhp tim nhanh, ting nga phi..
3. Nguyn nhn d dn n sc tim bnh nhn
NMCT cp:
a. NMCT din rng.
b. Nhi mu tht phi din rng.
c. V thnh tht.
d. H van hai l cp.
e. p tim cp c km hoc khng km v thnh tim.
C. Cc xt nghim thm d
1. Xt nghim mu: Tng acid lactic trong mu, tng
creatinin v thiu xy mu ng mch.
2. Xquang tim phi: thy hnh nh huyt phi cc
mc .
3. in tm (T): thng ch ra du hiu ca
NMCT lan rng. C th thy hnh nh ST chnh
xung (do thiu mu c tim) lan rng nhiu chuyn
o. Nu T khng bin ng c hiu khi sc tim
th phi ngh ti nguyn nhn khc gy sc tim nh
65
tch thnh MC hoc cc bin chng c hc trm

trng ca NMCT cp.
4. Siu m tim: gip nh gi mc lan rng ca
vng nhi mu, chc nng tht v tm hiu thm cc
bin chng c th gy ra sc tim.
5. Cc thm d chy mu: gip theo di v huyt
ng chnh xc. Thng th nn t mt ng thng
Swan Ganz theo di p lc ng mch phi v p
lc mao mch phi bt cng nh cung lng tim (xem
thm phn sc tim).
D. iu tr
1. Cc u tin trong iu tr: Nu bnh nhn c sc
tim nn t bng ngc dng trong MC (IABP)
trc nu c th, sau tm cch gii quyt nguyn
nhn v cc bin php iu tr ni khoa thch hp.
2. Cc thuc:
a. Cc thuc gin mch ng vai tr cc k quan
trng trong iu tr bnh nhn suy tim tri sau
NMCT. Cn theo di huyt p cht ch khi cho
cc thuc gin mch.
b. Nitroglycerin dng truyn tnh mch l thuc nn
c la chn hng u. Liu dng bt u t 10
20 mcg/pht v c th tng mi 10 mcg/pht
sau vi pht tu theo p ng v huyt p. Nn
iu chnh sao cho huyt p trung bnh ng
mch khong 70 mmHg.
c. Nitropruside c th thm vo c tc dng lm
gim hu gnh v nu dng Nitroglycerin mt
mnh ch yu lm gim tin gnh do gin h tnh
mch. Nitroprusside c dng bt u bng liu
0,3-5 mcg/kg/pht v chnh liu theo huyt p
ng mch.
d. Thuc c ch men chuyn (CMC) ci thin
c chc nng tht tri bnh nhn sau NMCT.
66
CMC nn c cho sm trong NMCT nu

huyt p khng thp qu. Ch tc dng gy tt
p liu u ca CMC, do vy nn cho bnh
nhn dng truyn TM vi liu bt u thp v
khng dng khi c sc tim.
e. Thuc li tiu c tc dng tt nhng bnh nhn
c ph phi sau NMCT. Furosemide l thuc nn
c la chn.
f. Digitalis tr tim khng nn cho rng ri trong
NMCT, nhng c tc dng tt bnh nhn suy
tim tri nhiu km rung nh hoc cung nh hoc
cc thuc khc iu tr suy tim km hiu qu.
g. Cc thuc ging giao cm (Dopamine v
Dobutamine) c ch nh cho nhng bnh nhn
suy tim nng c tt p hoc sc tim.
h. Thuc vn mch khc (Norepinephrine) c th
phi dng khi cn thit duy tr huyt p trong
sc tim (xem bi sc tim).
3. iu tr can thip ng mch vnh:
a. t ngay bng bm ngc dng ng mch ch
nu c th bnh nhn sc tim. Bin php ny rt
hu ch gip lm gim hu gnh, tng cung lng
tim, gim nhu cu tiu th xy c tim.
b. Can thip ng mch vnh tc th gip ci thin
c tin lng nhng bnh nhn c sc tim
c bit ngi khng qu gi.
4. Phu thut:
a. Phu thut lm cu ni ch-vnh trong sc tim
bnh nhn NMCT c ch nh nhng bnh
nhn b bnh nhiu MV, hoc tn thng thn
chung MV tri m khng thch hp cho can
thip MV.
b. C khi phu thut c ch nh cy ghp
nhng thit b h tr tht trong khi ch ghp tim.
67
IV. Nhi mu c tim tht phi

Ri lon chc nng tht phi nh thng gp nhng bnh
nhn b NMCT vng sau di, tuy nhin c khong 10% s bnh
nhn ny c suy tht phi cp v iu tr cn ch mt s c
im khc bit.
A. Gii phu bnh
Thnh tht phi bnh thng mng hn v t nhu cu
tiu th xy hn bung tht tri, do vy thng thng th tht
phi c th chu ng v hi phc sau khi c iu tr kp
thi. Vic suy chc nng tht phi nng xy ra ph thuc vo
mc tc nhnh ng mch vnh nui dng tht phi v
mc tun hon bng h t bn tri sang khi nhnh nui
tht phi b tc (nhnh ny thng thng bt ngun t ng
mch vnh bn phi).
B. Triu chng lm sng
1. Bnh nhn NMCT tht phi thng c triu chng
ca tr tun hon ngoi vi nhng khng kh th.
2. Bnh nhn c suy tht phi nng c th c biu hin
ca gim cung lng tim nng nh rt run, chn tay
lnh, ri lon tm thn, huyt p tt v thiu niu.
3. Thm khm thc th bnh nhn NMCT tht phi
thng thy tnh mch c ni, gan to, huyt p thp
nhng phi khng c ran. Du hiu Kussmaul (tnh
mch c ni to hn trong thi k ht vo) l kh c
hiu v bo hiu c suy tht phi nng.
C. Cc xt nghim chn on
1. in tm : thng cho thy hnh nh NMCT vng
sau di km theo ST chnh ln V1 v c bit l
V3R v V4R.
2. Xquang tim phi: khng c du hiu ca tr tun
hon phi.
3. Siu m tim: l mt thm d c gi tr trong NMCT
tht phi. Trn siu m tim thng cho thy hnh nh
68
tht phi gin, suy chc nng tht phi, ri lon vn

ng vng sau di, v c bit gip loi tr trn
dch mng tim gy p tht phi (d nhm vi NMCT
tht phi).
4. Cc thng s v huyt ng trn thm d chy mu
cho thy tng p lc ca nh phi nhng khng tng
p lc mao mch phi bt (PCWP). NMCT tht phi
cng lm gim cung lng tim do gim lng mu v
tht tri. Khi p lc nh phi trn 10 mmHg v t l
p lc nh phi/PCWP trn 0,8 l mt du hiu huyt
ng quan trng gi NMCT tht phi.
D. iu tr
1. iu tr ni khoa:
a. Truyn dch l mt bin php quan trng hng
u v trong NMCT tht phi c s gim cung
lng tim do gim th tch y tht tri. Mt
s bnh nhn nng cn cho truyn ti 1 lt dch
trong gi u. Khi truyn dch cn phi theo di
cht ch cc thng s huyt ng v nu truyn
qu nhiu dch i khi li dn n suy gim chc
nng tht tri (hin tng ny l do vch lin tht
b p qu v pha tht tri gy gim cung lng
tim). Mc tiu iu tr l a p lc tnh mch
trung tm n khong 15 mmHg.
b. Thuc tng co bp c tim: Khi truyn dch vn
khng lm tng cung lng tim th c ch nh
dng cc thuc tng co bp cm tim. Dobutamine
l thuc c la chn hng u lm tng cung
lng tim v phn s tng mu ca tht phi.
c. Mt lu rt quan trng l khng c dng cc
thuc gin mch (Nitrates, c ch men chuyn...)
v li tiu khi c suy tht phi v cc thuc ny
cng lm gim cung lng tim.
2. iu tr can thip:
69
a. Nong hoc t Stent ng mch vnh sm s gip

ci thin r rt t l t vong bnh nhn NMCT
tht phi. Vic ti ti mu MV tht phi gip
ci thin chc nng tht phi.
b. Mt s trng hp NMCT tht phi thng km
theo nhp chm hoc bloc nh tht cp III cn
c t my to nhp tm thi sm v i a s
phc hi tt sau khi can thip tt MV.
c. Mt s trng hp huyt p thp qu c th cn
phi t bng bm ngc dng ng mch ch.
3. Phu thut:
a. Mt s trng hp m tnh trng sc tim ko di
khng p ng cc bin php iu tr thng
thng c th c ch nh m ct mng ngoi tim.
b. Phu thut cy thit b h tr tim khi tnh trng
sc tim qu nng.
c. M lm cu ni ch-vnh cp khi tn thng
khng th can thip c hoc khi can thip c
bin chng hoc khi c cc bin chng c hc.
V. au ngc ti pht sau NMCT
Bin chng thiu mu c tim (au ngc) xy ra sau NMCT
cp c th do vng tn thng lan rng, thiu mu c tim ti
pht, ti NMCT...
A. Vng tn thng lan rng: Bnh nhn vn au ngc
lin tc hoc ti pht, trn in tm c thay i mi
(chnh hn v lan rng), men tim vn tng ko di. Thm
d siu m tim hoc phng x gip xc nh c
vng c tim tn thng.
B. Thiu mu c tim ti pht: Bnh nhn au ngc sau
giai on cp t vi gi n 30 ngy vi s thay i trn
in tim chng t c thiu mu c tim. Thiu mu c tim
ti pht thng hay xy ra hn bnh nhn NMCT
khng c sng Q. au ngc ti pht sau NMCT thng
c tin lng xu v c ch bnh sinh c coi nh l
70
au tht ngc khng n nh. Vic iu tr do c

coi nh l iu tr au tht ngc khng n nh.
C. Nhi mu c tim ti pht: Bnh nhn au ngc li
vi thay i mi in tim v men tim. Nu bnh nhn
nhi mu li sau khi dng thuc tiu huyt khi cn
tin hnh can thip ng mch vnh ngay.
Vn iu tr: Cn ch nh chp v can thip MV
sm cc bnh nhn ny. Cc thuc Heparin, Aspirin, Nitrates,
chn Beta giao cm cn c cho mt cch tch cc hn.
VI. Cc bin chng tc mch
Cc bin chng tc mch bnh nhn NMCT cp xy ra
trong khong 20% s bnh nhn. Nhng bnh nhn b NMCT
trc rng l c nguy c cao d b bin chng ny.
A. Triu chng lm sng
Cc biu hin lm sng hay gp nht l ca tai bin
mch no, mt s bnh nhn b tc mch chi, tc mch thn,
tc mch mc treo Hu ht cc tai bin tc mch thng
xy ra trong 10 ngy u ca NMCT cp. i vi nhng
bnh nhn nm bt ng lu, c th c cc bin chng huyt
khi tnh mch su chi di v tc mch phi. Tu theo th
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
VII. Bin chng vim mng ngoi tim

A. Vim mng ngoi tim cp
a. Bin chng vim mng ngoi tim cp xy ra
khong 10% s bnh nhn NMCT cp v l mt
trong nhng nguyn nhn gy au ngc. Bin
chng ny thng xy ra trong vng 24-96 gi
sau NMCT cp.
b. Vim mng ngoi tim cp thng xy ra bnh
nhn c NMCT xuyn thnh. Mt s khng c
triu chng lm sng m ch nghe thy ting c
mng tim.
c. a s cc bnh nhn thng c du hiu au
ngc ko di v cm gic rt bng. au ngc
tng ln khi bnh nhn ngi v ci ra pha trc
hoc ht th su, ho hay nut. au thng khng
lan v quanh qun trc ngc.
d. Nghe tim cho thy du hiu quan trng nht l
ting c mng ngoi tim. Mt s trng hp c
th khng thy ting c ny. Ting c mng tim
thng nghe r nht cnh c tri vng thp.
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.
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
ST chnh ln ng hng cc chuyn o v

kiu chnh ln hnh yn nga. Cc du hiu thay
i on ST cng thay i theo thi gian, u tin
l ST v T chnh ln, sau T dt ri ST v
ng ng in v sng T th m ri cng dng
tr li.
b. Xquang tim phi: t c gi tr chn on vim
mng ngoi tim cp.
c. Siu m tim: c th cho thy dch mng ngoi
tim, nhng cng khng th hon ton loi tr
chn on c.
3. iu tr:
a. Aspirin l thuc c la chn vi liu khong
2,5g n 4g trong mt ngy chia lm 4-6 ln.
b. Cc thuc gim vim chng au khng steroid v
steroid khng nn dng iu tr trong trng
hp ny v n c th nh hng qu trnh lin so
ca c tim v lm lan rng vng nhi mu mt
cch m thm. Mt s bnh nhn m c au ngc
ti pht nhiu khng p ng vi Aspirin th c
th cho Colchicine.
B. Hi chng Dressler
Hi chng Dressler (vim mng ngoi tim mun) xy
ra khong 1-3% s bnh nhn NMCT. Hi chng ny
thng xy ra sau t 1-8 tun sau NMCT cp. Hin c ch
bnh sinh ca bnh cha c r hon ton, nhng ngi ta
thy c nhiu bng chng lin quan n c ch t min dch
ca c th.
Bnh nhn thng c biu hin au ngc kiu vim
mng ngoi tim, c th st, au khp, au c, tng bch cu
mu, tc lng mu tng. Nghe tim c ting c mng ngoi
tim. Siu m tim cho thy c dch mng ngoi tim.
V iu tr th ging nh trong iu tr vim mng tim
cp sau NMCT. Tuy nhin, nu sau qu 4 tun ca NMCT
73
th c th cho bnh nhn c cc thuc khng vim khng

phi steroid thm ch c th cho c steroid.
Ti liu tham kho
1. Chatterjee K. Complications of acute myocardial infarction. Curr
Probi Cardiol 1993;18:1-79.
2. Mukherjee D. Complications of myocardial infarction. In: Marso SP,

Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine.
Philadelphia: LippincottRaven, 2000.
3. O'Donnell L. Complications of MI beyond the acute stage. Am J
Nurs 1996;96:25-31.
4. Reeder GS. Identification and treatment of complications of
myocardial infarction. Mayo Clin Proc 1995;70:SS0-884.
5. Subramaniam PN. Complications of acute myocardial infarction.
Postgrad Med 1994;95:143-145.
74
Sc tim
Sc l tnh trng mt cn bng gia dng tun hon v nhu

cu xy ca cc m: tnh trng ny dn ti thiu xy m, ri
lon chuyn ho m v gim chc nng ca cc c quan. V
triu chng lm sng: sc biu hin bng mch nhanh, huyt p
tt v kt, thiu niu hoc v niu, v m hi, da xanh ti, ri
lon tm thn c th gp.
Sc tim (cardiogenic shock) ch l mt trong nhiu loi sc
khc nhau. Cc c im v huyt ng ca sc tim cng nh
mt s loi sc khc c tm tt trong bng 5-1 di y. Ngy
nay mc d c nhiu tin b trong vic iu tr NMCT nhng
nu NMCT m c sc tim th t l t vong vn cn c bit
cao (60-80%).
Bng 5-1. Phn loi sc v cc c im v huyt ng.
Loi sc
C SV PV Sv R
R PA PA
I R
R O2 AP VP P W
P
Sc tim (NMCT, p
tim cp)
Sc gim th tch
(mt mu)
Sc phn b (nhim
khun, phn v)
Sc tc nghn (nhi -
mu phi rng)
Trong : CI: ch s cung lng tim; SVR: sc cn i tun

hon; PVR: sc cn tiu tun hon; SvO2: bo ho xy mch
trn; RAP: p lc nh phi; RVP: p lc tht phi; PAP: p lc
ng mch phi; PAWP: p lc ng mch phi bt. : Khng
thay i; : gim; : tng.
75
I. nh ngha v sinh l bnh ca sc tim

A. nh ngha
Sc tim l tnh trng gim cung lng tim khng p ng
c nhu cu xy ca cc m c th. Chn on sc tim gm:
1. Huyt p tm thu < 80 mmHg khi khng c mt cc
thuc vn mch hoc < 90 mmHg khi c mt cc
thuc vn mch v t nht ko di > 30 pht.
2. Gim cung lng tim (Ch s tim < 2,0 lt/pht/m2)
m khng lin quan n gim th tch tun hon
(PAWP > 12 mmHg).
3. Gim ti mu m: thiu niu (nc tiu < 30
ml/gi), co mch ngoi vi, ri lon tm thn.
B. Nguyn nhn
1. Nhi mu c tim cp: l nguyn nhn hng u ca
sc tim c bit l nhi mu trc rng v c mt
vng c tim ln b hoi t.
2. Cc nguyn nhn khc:
a. H hai l cp do t dy chng trong NMCT hoc
vim ni tm mc nhim khun.
b. Thng vch lin tht cp trong NMCT.
c. Vim c tim cp do cc nguyn nhn.
d. Giai on cui ca bnh c tim gin.
e. Cc bnh van tim nng (h van hai l, h van
ng mch ch ...).
f. p tim cp.
g. Ri lon nhp nng.
h. Mt s trng hp sau m tim phi nhn to.
C. T l gp sc tim trong NMCT cp
T nhng nm 50 cho ti nhng nm 90 ca th k va
qua, t l sc tim c thay i cht t khong 19% 6%,
nhng vn gi mt t l cao trong NMCT cp. c tnh
trong khong 1 triu bnh nhn b NMCT cp M mi nm
th c ti 70.000 n 150.000 bnh nhn b sc tim. T l t
vong bnh nhn c sc tim vn c bit cao t 60 - 90 %.
76
D. Sinh l bnh ca sc tim do NMCT cp

1. u tin l vic nhi mu gy mt mt vng c tim
ln hoc nhi mu nh bnh nhn c gim chc
nng tht tri t trc dn n gim th tch nht bp
tim v gim cung lng tim, vic ny cng dn n
gim dng mu n mch vnh b tn thng to
nn mt vng xon bnh l.
2. Vic gim cung lng tim li cng lm huyt p tt
v thiu mu cc m dn n mt lot cc p ng
cc m theo vng xon bnh l lm bnh thm nng.
II. Biu hin lm sng
A. Tnh trng sc: Nh trnh by trong phn nh
ngha, sc tim c biu hin bi:
1. Huyt p tm thu < 80 mmHg khi khng c mt cc
thuc vn mch hoc < 90 mmHg khi c mt cc
thuc vn mch v t nht ko di > 30 pht.
2. Gim cung lng tim (Ch s tim < 2,0 l/pht/m2) m
khng lin quan n gim th tch tun hon (PAWP
> 12 mmHg).
3. Gim ti mu m: thiu niu (nc tiu < 30
ml/gi), co mch ngoi vi, ri lon tm thn.
B. Khm lm sng: c th thy
Bnh nhn xanh ti, kh th, th ngoi cnh hoc ri lon
tm thn, mch nhanh, huyt p tt, v m hi...
1. Khai thc bnh s v khm lm sng pht hin
cc nguyn nhn:
a. NMCT cp:
C th au ngc in hnh ca NMCT cp.
Trong NMCT cp, sc tim thng xy ra
gi th 8-10 sau au ngc.
in tm thay i: xut hin sng Q v
on ST chnh.
Cc men tim tng.
77
b.
c.
d.
e.
Siu m cho thy c ri lon vn ng vng

ca c tim, c th thy cc bin chng c hc
km theo nh h van hai l, thng lin tht...
p tim cp:
Kh th d di.
Tnh mch c ni.
Mch o (chm hoc mt khi ht vo).
Huyt p tt, kt.
Nghe tim ting m, gan to.
Din c tim to, bng tim to trn Xquang.
Siu m gip xc nh khi lng dch nhiu
hay t.
Cc bnh van tim:
Nghe tim c th pht hin c cc tn
thng van tim.
Siu m Doppler tim c ch trong vic nh
gi chnh xc tn thng ca cc van tim.
Vim c tim cp:
Rt d nhm vi NMCT cp.
Tin s c th c cc du hiu nhim trng
mi xy ra.
C th km theo cc ri lon nhp nng n.
Cc bnh khc:
Giai on cui ca bnh c tim gin, bnh c
tim ph i.
Ri lon nhp nng: in tm gip xc
nh chn on.
Nhi mu phi gy suy chc nng tht phi
cp: bnh nhn au ngc, ho mu, kh th
nhiu, chp phim c th thy m m.
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
2. Bnh nhn cn c nm khoa iu tr tch cc.

3. xy: cn c cung cp y , nu bnh nhn t th
tt c th cho th qua ng mi, nu bnh nhn c
ri lon nhp th hoc suy h hp nng th cn t ni
kh qun v cho th my ng ch .
4. Thit lp mt ng truyn tnh mch.
5. t catherter tnh mch trung tm theo di, tt nht
l c Swan-Ganz theo di cung lng tim v p
lc ng mch phi bt.
6. Theo di bo ho xy ng mch.
7. Theo di lng nc tiu (t thng i).
8. m bo tt th tch tun hon sao cho p lc nh
phi t 10-14 mmHg v PAWP t 18-20 mmHg.
9. Kim sot tt cc ri lon nhp tim km theo nu c
(nhanh tht: sc in, nhp chm qu: t my to
nhp).
10. Kim sot cc ri lon thng bng kim toan v nc
in gii.
11. Dng cc thuc vn mch (xem phn sau).
12. Dng cc bin php h tr c hc tun hon (phn
sau).
B. Theo di huyt ng
Trong iu tr sc tim, theo di huyt ng l yu t
quyt nh iu chnh v can thip kp thi.
C. Cc thuc
1. Dobutamine:
L mt catecholamin tng hp, c tc dng
tri trn bta 1 giao cm lm tng sc co bp
c tim v tng nhp tim phn no, t nh
hng n co mch, lon nhp v dng mu
n thn.
L thuc la chn hng u trong iu tr sc
tim, ch nh ti u khi huyt p cn > 80
mmHg. Liu dng: 2 - 5 g/kg/pht.
79
Bng 5-2. Cc thuc dng trong sc tim.

Thuc
Liu thng thng
Tc dng ph
Dobutamine
5-15 g/kg/pht truyn Quen thuc, phi
TM.
tng liu dn.
Dopamine
Noradrenalin
Nitroglycerin
Nitroprussiat
2-20 g/kg/pht, truyn

TM.
2-16 g/kg/pht, truyn
TM.
10 g/pht, tng dn liu
mi 10 mcg trong 10
pht nu khng p ng.
10 g/pht, c th tng 5
g mi 10 pht.
Lm tng nhu cu
xy c tim.
Co mch ngoi vi
v mch tng.
au u, tt
huyt p.
au u, tt
huyt p, ng c
cyanid.
Amrinone
0,75 mg/kg tim TM Gim tiu cu
trong 2 pht sau mu.
truyn
TM
5-10
g/kg/pht.
Milrinone
Tim TM 50mcg trong Ri lon nhp
10 pht sau truyn tht.
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
3.
4.
5.
6.
dng kch thch giao cm gy co mch ngoi vi

mnh.
b. Ch nh tt khi huyt p tm thu < 80 mmHg,
liu dng t 2-20 g/kg/pht, ty theo p ng.
Noradrenalin:
a. Cng l mt catecholamin t nhin vi tc dng
mnh trn giao cm gy co mch nhiu.
b. Nn c ch nh khi HA tm thu < 70 mmHg v
liu dng t 2-16 g/kg/pht.
Cc thuc gin mch:
a. Cc thuc ny ch dng khi duy tr c con
s HA mc n nh.
b. Cc thuc ny gy gin mch nn lm gim tin
gnh v hu gnh cho tim, do rt c li khi b
NMCT cp hoc cc suy tim cp km theo.
c. Cc thuc thng dng l: Nitroglycerin dng
truyn hoc Nitroprussiad vi liu bt u t 10
g/pht.
Cc thuc tr tim:
a. Khng nn dng Digitalis trong NMCT cp c
sc tim d c suy tht tri nng v thuc ny lm
tng nguy c b lon nhp v tng t l t vong.
b. Trong cc trng hp khc khi c suy tim do
bnh van tim hoc bnh c tim m c km rung
nh nhanh th Digitalis rt nn dng.
c. Cc thuc lm tng sc co bp c tim do c ch
phosphodiesterase (Milrinone, Amrinone) c th
dng trong trng hp c suy tim nng.
Cc thuc li tiu:
a. Cc thuc li tiu lm gim p lc y tht
tri v nn dng khi c suy tim m c tng khi
lng tun hon v khng ch c huyt p.
81
b. Thng dng l Furosemide, Bumetanid tim tnh

mch.
D. H tr tun hon bng c hc
Khi cc thuc dng t ra t p ng hoc tht bi, cn
cn nhc sm vic dng cc bin php h tr c hc c bit
khi cn phi can thip MV hoc m cu ni.
1. Bm bng ngc dng trong ng mch ch (Intra
- Aortic Balloon Counterpulsation Pump - IABP):
a. Dng mt qu bng to v di t trong MC t
on trn ca MC xung cho n tn MC
bng trc ch chia ra ng mch chu. Vic
bm bng v lm xp nh kh heli do mt my
bm ngoi ni vi bng v lm vic theo chu
chuyn ca tim. Bng s c bm phng ln
trong thi k tm trng v lm xp i trong thi
k tm thu, do vy s lm tng dng mu n
MV trong thi k tm trng v ch yu lm
gim p lc hu gnh trong k tm thu nn lm
gim gnh nng cho tim.
b. Chng ch nh khi c h ch nng, tch thnh
ng mch ch, bnh l mch ngoi vi.
c. Cc nghin cu cho thy, t khi ra i loi bng
bm ny lm gim ng k t l t vong do
sc tim.
2. My tim phi nhn to chy ngoi (Hemopump):
ang c th nghim v cho kt qu kh tt. Ngy
nay, mt s trung tm cn c loi my xch tay rt
tin li.
E. iu tr nguyn nhn
1. NMCT cp: Khi sc tim xy ra th cc bin php ti
ti mu MV cng t ra cp thit:
a. Thuc tiu huyt khi: cha chng minh c
lm gim t l t vong trong NMCT cp c sc
tim (nghin cu GISSI-1, GUSTO-1), tuy nhin
82
nu khng c chng ch nh nn cho thuc tiu

huyt khi v lm ci thin c dng chy ca
MV ng k nu bnh nhn sng st. Nn dng
rt-PA hn l dng Streptokinase.
b. Can thip MV: Nhiu nghin cu chng
minh can thip MV khi c sc tim lm gim t
l t vong v phc hi sc tim nhanh. Tuy nhin
can thip ch t kt qu ti u khi c cc bin
php khc h tr tt v i hi th thut can thip
phi c tin hnh mt cch nhanh chng bi
nhm ngi lm c kinh nghim (nghin cu
SHOCK, SMASH). Can thip MV trong sc tim
s c th t tc dng nu qu mun (>36 gi)
hoc bnh nhn cao tui (>75 tui) (theo khuyn
co rt ra t nghin cu SHOCK).
c. M lm cu ni ch-vnh: c bit c ngha
khi c cc bin chng c hc km theo nh h
hai l cp do t dy chng, thng lin tht...
2. Cc nguyn nhn khc: cn c iu tr tch cc
theo nguyn nhn:
a. Bnh nhn c p tim cp phi xc nh v chc
dch ngay.
b. Bnh nhn c bnh van tim cn c phu thut
sa hoc thay van tim.
c. Vim c tim cp hoc bnh c tim vn cn l vn
nan gii, vic iu tr cn nhiu kh khn, ch
yu vn l iu tr triu chng.
Ti liu tham kho
1.
2.
3.
Antman E. Braunwald E. Acute Myocardial Infarction. In

Braunwald E ed, Heart Disease, a textbook of cardiovascular
medicine, 5th edition WB Saunders Philadephia, 1997.
Barron HW, Pirzada SR, Lomnitz Dj et al. Use of IABP in patients
with AMI complicated by cardiogenic shock. J Am Coll Cardiol
1998;31.
Eagle and Guyton et al.ACC/AHA Guidelines for Coronary Artery
Bypass Graft Surgery surgery JACC Vol. 34, No. 4, October
83
1999:1262-347 Recommendations of the ACC/AHA Task Force in

order to decrease morbidity and mortality in patients undergoing
CABG. Circulation 1999;100:1464-1480.
4. Goldstein JA, Barzilai B, Rosamond TL, Eisenberg PR, Jaffe AS.
Determinants of hemodynamic compromise with severe right
ventricular infarction. Circulation 1990;82:359-368.
5. Hasdai D, Holmes DR Jr, Califf RM, et al. Cardiogenic shock
complicating AMI: Predictors of death. Am Heart J 1999;138:2131.
6. Hochman JS, Buller C, Sleeper L et al. for the SHOCK
Investigators. Cardiogenic shock complicating AMI-Etiologies,
management and outcome: A report from the SHOCK trial registry.
J Am Coll Cardiol 2000; 36:1063-70.
7. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization
in acute myocardial infarction complicated by cardiogenic shock.
SHOCK Investigators. Should We Emergently Revascularize
Occluded Coronaries for Cardiogenic Shock. N Eng J Med 1999;
341: 625-634.
8. Kinch JW, Ryan TJ. Right ventricular infarction. N Engl J Med
1994;330:1211-1217.
9. Kosuge M, Kimura K. Ishikawa T et al. Implications of the absence
of ST-segment elevation in lead V4R in patients who have inferior
wall AMI with right ventricular involvement Clin Cardiol 2001;
24:225-230.
10. Menon V, Slater J, White H, et al. AMI complicated by systemic
hypoperfusion without hypotension. A report from the SCHOCK
trial registry. Am J Med 2000; 108:374-80
84
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 (>240
mg/dl)
2. Tng TG (Triglycerid) trong mu:
a. Bnh thng: TG mu <2,26 mmol/l (<200 mg/dl).
b. Tng gii hn: TG t 2,26-4,5 mmol/l (200-400
mg/dl).
c. Tng TG: TG t 4,511,3mmol/l (4001000mg/dl).
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
5. Ri lon lipid mu kiu hn hp: Khi Cholesterol >

6,2 mmol/l v TG trong khong 2,26 4,5 mmol/l.
II. Nguyn nhn gy ri lon lipid mu
A. Nguyn nhn gy tng cholesterol mu
1. Ch n:
a. n qu nhiu m ng vt.
b. n qu nhiu thc n c cha nhiu Cholesterol
(ph tng ng vt, m ngvt, trng, b, sa
ton phn...).
c. Ch n d tha nng lng (bo ph).
2. Di truyn:
a. Tng Cholesterol gia nh (thiu ht th th vi
LDL).
b. Ri lon lipid mu kiu hn hp c tnh cht gia
nh.
c. Tng Cholesterol mu do ri lon hn hp gen.
3. Th pht:
a. Hi chng thn h.
b. Suy gip.
c. i tho ng.
d. Bnh l gan tc nghn.
e. Mt s bnh gy ri lon protein mu (a u tu
xng, macroglobulinemia).
B. Nguyn nhn gy tng Triglycerid mu
1. Thiu ht gen lipase tiu hu lipoprotein hoc
apolipoprotein C-II.
2. Tng TG c tnh cht gia nh.
3. Bo ph.
4. Ung qu nhiu ru.
5. i tho ng.
6. Dng thuc chn bta giao cm ko di.
86
C. Nguyn nhn gy gim HDL-C:

1. Ht thuc l.
2. Bo ph.
3. Li vn ng th lc.
4. i tho ng khng ph thuc insulin.
5. Tng TG mu.
6. Dng thuc chn b ta giao cm ko di.
7. Ri lon gen chuyn ho HDL.
Hnh 6-1. Cu trc ca lipoprotein.

III. Nguyn tc iu tr ri lon lipid mu
A. Vic iu tr tu thuc vo tng c th bnh nhn
trn c s nh gi tnh trng ri lon Lipid mu v cc
yu t nguy c ca bnh mch vnh (bng 6-1).
Bng 6-1. Cc yu t nguy c ca bnh mch vnh.
87
Yu t nguy c dng tnh:

Nam 45 tui
N 55 tui
C tin s gia nh b bnh MV
Ht thuc l nhiu
Tng huyt p
HDL-C < 0,9 mmol/l
i tho ng
Yu t nguy c m tnh: tnh tr i 1 yu t nguy c nu c
HDL-C 60 mg/dl
B. iu tr cp mt v iu tr cp hai.
Gi l iu tr cp mt khi bnh nhn c ri lon Lipid mu
nhng cha c tin s b bnh mch vnh, iu tr cp hai khi
bnh nhn c tin s bnh mch vnh:
1. iu tr cp mt: nhm t c LDL-C mu < 4,1
mmol/l vi nhng bnh nhn c t hn 2 yu t nguy
c hoc LDL-C < 3,4 mmol/l nu bnh nhn c 2
yu t nguy c. iu tr phi bt u bng iu chnh
ch n v luyn tp. Dng thuc khi iu chnh
ch n mt thi gian m tht bi hoc phi bt u
ngay khi:
a. C qu nhiu yu t nguy c bnh mch vnh v
lng LDL-C trong mu cao (> 4,1 mmol/l), hoc
b. Khi lng LDL-C trong mu qu cao (> 5
mmol/l).
2. iu tr cp hai: Khi bnh nhn c biu hin bnh
mch vnh. Mc ch iu tr ch yu l phi lm
gim c LDL-C < 2,6 mmol/l (<100 mg/dl). Cn
iu chnh ch n tht nghim ngt cho mi bnh
nhn, ng thi cho thuc phi hp ngay khi LDL-C
> 3,4 mmol/l.
88
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.
b. Bc 2: c p dng khi thc hin bc trn
sau 6-12 tun khng kt qu. Trong bc ny lm
gim tip lng acid bo bo ho xung < 7%
khu phn v lng Cholesterol < 200 mg/ ngy.
c. Thi gian iu chnh ch n v mt s lu :
Nu ch cn iu chnh ch n theo nh ch
nh ni trn th thi gian cn t nht l 6
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
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
dng khi TG tng cao.
Liu thng dng: Questran 8 16 g/ngy
chia 2 ln dng trong ba n, Colestid: 10
30 g/ngy chia lm 2 ln. Nn khi u bng
liu thp sau tng dn.
Tc dng ph c th gp bao gm: to bn,
au bng, bun nn, nn, nng rut... Ch
khi dng chung cc thuc khc c th lm
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
Chng ch nh ca Niacin: bnh nhn b

Goutte, lot d dy t trng, bnh vim i
trng mn. Chng ch nh tng i bnh
nhn i tho ng.
c. Thuc c ch men HMG-CoA Reductase
(nhm Statin): Gm Simvastatin (Zocor);
Lovastatin; Pravastatin; Fluvastatin; Atorvastatin
(Lipitor)...
Cc thuc ny c ch hot ho men HGMCoA-reductase lm gim tng hp
Cholesterol trong t bo gan v tng hot ho
th th LDL do lm gim LDL-C trong
mu. Simvastatin v Artovastatin c th lm
gim LDL-C ti 60% v lm gim TG ti
37%. nhiu nghin cu chng minh c
l cc Statin c th lm gim t l t vong
bnh nhn c bnh mch vnh, gim t l
bnh mch vnh bnh nhn b tng Lipid
mu, v lm gim t l phi can thip li
bnh nhn sau can thip ng mch vnh
hoc m cu ni ch-vnh.
Liu dng: Simvastatin (Zocor) t 5-40
mg/ngy; Atorvastatin (Lipitor) 10-80 mg/
ngy; Lovastatin 10-20 mg/ngy; Pravastatin
10-40 mg/ngy. Cc thuc nhm ny khng
nn dng gn ba n v c th dng 1 ln
trong ngy trc khi i ng. Cc statin khc
nhau c hiu lc i vi LDL-C khc nhau
(bng 6-2).
Bng 6-2. Tc dng ca cc statin khc nhau i vi s
thay i ca LDL-C v HDL-C.
Thuc
Liu u Ti a Gim
Tng
91
(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%
Tc dng ph: Bao gm kh tiu, a chy, to

bn, bun nn, au bng, au u, mt ng.
Tng men gan c th gp 1-2% s bnh
nhn dng thuc. Khng nn dng statin cho
bnh nhn b bnh gan ang tin trin, au
c, vim a c, tiu c vn... Khng nn dng
Statin cng vi Cyclosporin, cc dn xut
Fibrat, Erythromycin, Niacin... v cc thuc
ny c th lm tng c tnh khi dng cng
nhau.
Ch : hin nay thuc Lipobay (Cerivastatin)
phi rt khi th trng do tc dng ph
nguy him gy tiu c vn khi dng cng vi
cc Fibrat.
d. Cc dn xut fibrat (acid fibric) bao gm :
Gemfibrozil (Lopid); Fenofibrat (Lipanthyl,
Tricor); Bezafibrat (Benzalip).
Cc thuc ny lm gim VLDL v do lm
gim TG khong 20-50%, lm tng HDL-C
khong 10-15%. Gemfibrozil lm gim LDLC khong 10-15%. Do vy cc thuc ny ch
nh tt trong cc trng hp tng TG mu v
c th kt hp tt vi thuc gn mui mt.
92
Liu thng dng l: Gemfibrozil 600 mg x 2

ln/ngy trc khi n; Fenofibrat 300
mg/ngy.
Tc dng ph c th gp l: sng ph mt,
au bng, bun nn, au u, mn nga...
Men gan c th tng, cn theo di men gan
khi dng cc thuc ny. Nhm thuc ny cn
lm tng nguy c si mt.
e. iu tr thay th bng hormon sinh dc n
(Estrogen): c th c ch ph n sau tui mn
kinh c ri lon lipid mu. Estrogen ung lm
gim LDL-C khong 15% v lm tng HDL-C
cng khong 15%. y l thuc nn chn la u
tin cho iu tr ph n sau tui mn kinh c ri
lon lipid mu. Tuy nhin, thuc ny c th lm
tng TG i cht.
2. Vn kt hp thuc: c th dng 2 loi thuc 2
nhm thuc iu tr ri lon lipid mu khc nhau nu
thy cn thit. Vic kt hp 2 loi thuc vi liu thp
s thay th cho vic dng 1 loi vi liu cao v kh
dung np. Trong mt s trng hp khi tng qu cao
Cholesterol mu nn kt hp 2 loi thuc. S kt hp
tt nht l gia Statin v Niacin.
3. Theo di khi dng thuc: cn kim tra Cholesterol
v TG mu mi 3-4 tun iu tr. Nu khng p ng
sau 2 thng iu tr, mc d dng liu ti u, th
nn thay bng thuc khc hoc kt hp thuc th 2.
Lu l vic iu chnh ch n v luyn tp phi
lun lun c bo m.
4. Mt s tnh hung c th:
a. iu tr bnh nhn tng Triglycerid mu: Vi
bnh nhn tng gii hn TG th ch cn iu
chnh ch n v sinh hot, c bit l gim
trng lng, ch n t tinh bt, m v khng
ung ru. Trong trng hp phi dng thuc th
93
nn la chn Niacin hoc dn xut fibrat. Khi TG

rt cao trong mu th cn phi phng nguy c
vim tu cp.
b. iu tr bnh nhn tng lipid mu hn hp (tng
c Cholesterol v TG). Mc ch th nht l phi
a LDL-C v gii hn bnh thng, sau c
gng a TG v mc bnh thng hoc gn bnh
thng nu c th. Vic iu chnh ch n v
gim cn nng vn l quan trng hng u. Khi
dng thuc nn kt hp Niacin hoc mt Fibrat
vi mt Statin.
c. iu tr bnh nhn b gim HDL-C: Ch trc
tin l loi b cc cn nguyn gy gim HDL nh
ht thuc l, bo ph, li tp th dc, i tho
ng khng c khng ch, tng TG mu,
dng chn bta giao cm ko di. C th dng
Niacin, Statin hoc Gemfibrozil.
Ti liu tham kho
1.
2.
3.
4.
5.
6.
7.
8.
94
Abramowicz M, editor. Choice of lipid-lowering drugs. Med Lett

1998;40:117-22.
American Diabetes Association. Management of dyslipidemia in
adults with diabetes. Diabetes Care 1999;22:Suppl 1:S56-S59.
Bachmaier K, Neu N, de la Maza LM, Pal S, Hessel A, Penninger
JM. Chlamydia infections and heart disease linked through antigenic
mimicry. Science 1999;283:1335-9.
Denke MA. Cholesterol-lowering diets: a review of the evidence.
Arch Intern Med 1995;155:17-26.
Diaz MN, Frei B, Vita JA, Keaney JF Jr. Antioxidants and
atherosclerotic heart disease. N Engl J Med 1997;337:408-16.
Fielding CJ, Fielding PE. Molecular physiology of reverse
cholesterol transport. J Lipid Res 1995;36:211-28.
Ginsberg HN. Is hypertriglyceridemia a risk factor for
atherosclerotic cardiovascular disease? A simple question with a
complicated answer. Ann Intern Med 1997;126:912-4.
Ginsburg HN, Goldberg IJ. Disorders of lipoprotein metabolism. In:
Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrisons
principles of internal medicine. 14th ed. Vol. 2. New York:
McGraw-Hill, 1998:2138-
9.
10.
11.
12.
13.
14.
Havel RJ, Rapaport E. Management of primary hyperlipidemia. N

Engl J Med 1995;332:1491-8. [Erratum, N Engl J Med
1995;333:467].
Illingworth DR, Tobert JA. A review of clinical trials comparing
HMG-CoA reductase inhibitors. Clin Ther 1994;16:366-85.
Levine GN, Keaney JF Jr, Vita JA. Cholesterol reduction in
cardiovascular disease: clinical benefits and possible mechanisms. N
Engl J Med 1995;332:512-21.
Lipid Metabolism Branch, Division of Heart and Vascular Diseases,
National Heart, Lung, and Blood Institute. The Lipid Research
Clinics population studies data book. Vol. 1. The Prevalence Study:
aggregate distribution of lipids, lipoproteins and selected variables
in North American populations. Bethesda, Md.: National Institutes
of Health, 1980:1-136.
Staels B, Dallongeville J, Auwerx J, Schoonjans K, Leitersdorf E,
Fruchart J-C. Mechanism of action of fibrates on lipid and
lipoprotein metabolism. Circulation 1998;98:2088-93.
Stone NJ. Secondary causes of hyperlipidemia. Med Clin North
Am1994;78:117-41.
95
tng huyt p
Tng huyt p (THA) l mt bnh rt thng gp v hin

tr thnh mt vn x hi. cc nc pht trin, t l THA
ngi ln (>18 tui) theo nh ngha ca JNC VI l khong
gn 30 % dn s v c trn mt na dn s > 50 tui c THA.
Theo thng k Vit nam nhng nm cui thp k 80 t l THA
ngi ln l khong 11% th thng k gn y t l THA H
ni cho ngi ln khong 20 %.
THA nguy him bi cc bin chng ca n khng ch c
th gy cht ngi m cn li nhng di chng nng n (vd. tai
bin mch no) nh hng n cht lng cuc sng ca bnh
nhn v l gnh nng cho gia nh x hi.
Ngy nay c kh nhiu thay i trong quan nim v
THA, phng thc iu tr cng nh vic gio dc bnh nhn
tc ng n tin lng ca THA.
I. nh ngha tng huyt p (THA)
Cho n nay, T chc Y t th gii v hi THA quc t
(World Health Organization - WHO v International Society of
Hypertension - ISH) thng nht gi l THA khi huyt p tm
thu 140 mmHg v/hoc huyt p tm trng 90 mmHg. Con
s ny c c l do da trn nhng nghin cu ln v dch t
cho thy:
C s gia tng c bit nguy c tai bin mch no
ngi ln c con s huyt p 140/90 mmHg.
T l TBMN ngi c s huyt p < 140/90 mmHg
gim r rt.
II. Giai on tng huyt p
Hu ht hin nay ngi ta s dng cch phn loi ca JNC
VI (U ban phng chng huyt p Hoa k) do tnh cht thc tin
v kh thi ca n. Thm vo WHO-ISH cng cho cch phn
1
loi tng t ch khc nhau v thut ng (bng 7-1). Nhng im

ch trong cch phn loi ny:
cp n khi nim HA bnh thng cao, v nhng
nghin cu cho thy trong mt s trng hp vi nhng
nguy c cao (v d tiu ng) th cn iu tr.
Khng cn giai on IV nh trc y (HA > 210/120
mmHg) v trong thc t trng hp ny gp khng nhiu
v phng n iu tr th ging nh giai on III.
Bng 7-1. Phn loi THA theo JNC VI (1997).
Khi nim
HA tm thu
HA tm trng
(mmHg)
(mmHg)
HA ti u
< 120
v
< 80
HA bnh thng
< 130
v
< 85
Bnh thng cao
130 - 139
v
85-89
Tng huyt p
Giai on I
140 - 159
v/hoc
90 - 99
Giai on II
160 - 179
v/hoc
100 - 109
Giai on III
180
v/hoc
110
III. Xc nh v nh gi mt bnh nhn THA
A. Chn on xc nh THA: rt n gin l o HA.
1. Nhng lu khi xc nh huyt p:
a. Bnh nhn phi trong trng thi ngh ngi (t nht
5 pht trc o), khng dng cc cht kch thch
c nh hng n huyt p (c ph, ht thuc l).
b. Bnh nhn nn t th ngi gh ta, tay trn
bn sao cho np khuu ngang vi mc tim. Trong
mt s trng hp c bit cn o HA c t th
nm v ngi hoc ng.
c. B rng bao o huyt p nn bng 80 % chu vi
cnh tay, do mt s bnh nhn tay to cn
dng loi bao rng hn.
d. Nn dng loi my o huyt p thu ngn.
e. Con s huyt p tm thu tng ng vi pha I ca

Korotkoff (xut hin ting p u tin) v huyt
p tm trng l pha V (mt ting p). Cn
ch l c th gp khong trng HA.
f. Nn o HA c hai tay v ly tr s bn c s
o cao hn.
g. Cn thit phi o t nht 2 ln cch nhau t nht 2
pht v con s cui cng l trung bnh cng nu
c s khc bit > 5 mmHg.
2. Xc nh l THA: Nu khi o ngay ln u HA >
160/100 mmHg th c th xc nh l b THA, nu
khng th nn khm li khng nh (bng 7-2).
Bng 7-2. Thi i vi bnh nhn THA khi o ln
u (theo JNC VI).
HA ti a HA ti thiu Thi
< 130
< 85
Kim tra li trong 2 nm
130-139
85-89
Kim tra li trong 1 nm
140-159
90-99
Khng nh li trong vng 2 thng
160-179
100-109
nh gi v iu tr trong vng 1
thng
180
110
Lp tc nh gi v iu tr ngay
hoc trong vng 1 tun tu tnh
hnh lm sng
3. Mt s phng php o huyt p khc:
a. Gio dc bnh nhn t o huyt p theo di, vic
ny c nhng li ch l: trnh cho bnh nhn phi
n c s y t lin tc, gim chi ph, gip theo di
iu tr tt; trnh hin tng THA o chong
trng; lm bnh nhn tch cc vi iu tr THA.
b. o huyt p lin tc (Holter huyt p). Bin php
ny khng dng p dng thng quy, n c
ch trong mt s trng hp nh nghi ng bnh
nhn c THA o chong trng, THA cn, THA
khng li iu tr, tt HA do dng thuc h HA.
3
B. nh gi mt bnh nhn THA

Vic thm khm mt bnh nhn THA nhm vo 3 mc ch sau:
Tm hiu nguyn nhn (nu c).
nh gi cc bin chng (tn thng c quan ch).
nh gi cc yu t nguy c v tim mch hoc cc ri lon
khc c thi iu tr ng mc v tin lng bnh.
1. Khai thc bnh s bao gm:
a. Khai thc tin s THA, thi gian, mc THA.
b. Tin s cc bnh tim mch, cc triu chng bnh
tim mch, suy tim, TBMN, bnh mch ngoi vi,
bnh thn, tiu ng, ri lon m mu...
c. Cc thi quen, li sng (bo ph, ht thuc l,
ung ru, ch n nhiu mui...), trnh gio
dc, iu kin sng...
d. Tin s gia nh v THA v cc bnh tim mch...
e. Cc thuc h p dng v mc p ng...
2. Thm khm thc th:
a. o HA (nu trn). Trong mt s trng hp nghi
ng cn o huyt p cc t th v o HA t chi.
b. Khm ton trng, ch chiu cao, cn nng.
c. Thm khm y mt.
d. Thm khm h tim mch, ch cc ting thi
tim, nhp tim, cc du hiu suy tim, ting thi
cc mch mu ln...
e. Thm khm bng ch ting thi ng mch
ch hay ng mch thn, thn to hay khng, cc
khi bt thng bng...
3. Cc thm d cn lm sng:
a. Cc thm d thng quy trong THA l:
Phn tch nc tiu.
Cng thc mu.
Sinh ho mu (in gii , glucose khi i,
Cholesterol ton phn v HDL- cholesterol).
in tm 12 chuyn o.
b. Cc thm d h tr: nu cn th thm d thm:

Creatinin mu, protein niu 24 gi, acid uric,
LDL-C, Triglycerid trong mu.
Nng renin, catecholamin... mu trong mt
s trng hp hn hu.
Siu m tim nh gi khi lng c tht
tri v chc nng tht tri hoc c km theo
bnh hay cc bin chng tim mch khc.
IV. Nguyn nhn tng huyt p
Bng 7-3. Mt s nguyn nhn THA th pht.
Cc bnh v thn:
Vim cu thn cp
Vim cu thn mn
Si thn
Vim thn k
Hp ng mch thn...
Cc bnh ni tit:
U tu thng thn (Pheocromocytom)
Cushing
Cng aldosteron
Cng gip
Cng tuyn yn...
Cc bnh h tim mch:
H van MC (gy THA tm thu n c)
Hp eo MC (gy THA chi trn)
Bnh v mch (Takayashu)
Hp, x va MC bng, nh hng n ng
mch thn
Do dng mt s thuc:
Cam tho
Cc thuc cng alpha giao cm (vd. cc thuc
nh mi cha ngt...)
Thuc trnh thai...
Nguyn nhn khc:
Ng c thai nghn
Ri lon thn kinh
5
A. i a s THA ngi ln l khng c cn nguyn (hay

THA nguyn pht) chim ti > 95%. Mt s yu t c
coi l yu t nguy c ca THA s c trnh by sau.
B. THA th pht hay THA c cn nguyn cn c ch
nht trong cc trng hp sau: (Bng 7-3)
1. Pht hin ra THA tui tr < 30 hoc gi > 60.
2. THA rt kh khng ch bng thuc.
3. THA tin trin nhanh hoc THA c tnh.
4. C biu hin bnh l c quan khc m c th l
nguyn nhn ca THA.
V. Phn tng mi nguy c cho bnh nhn THA
Vic phn tng cc mi nguy c cho bnh nhn THA rt
quan trng gip hoch nh chin lc iu tr THA cho bnh
nhn hp l. Vic phn tng THA da trn cc yu t nguy c v
cc tn thng c quan ch.
A. Cc yu t nguy c ca bnh tim mch bnh
nhn THA
1. Ht thuc l.
2. Ri lon lipid mu.
3. i tho ng.
4. Tui > 60.
5. Nam gii hoc n gii mn kinh.
6. Tin s gia nh c ngi thn b bnh MV: n <
65 tui hoc nam < 55 tui.
B. Tn thng c quan ch c th gp trong THA
1. Tim:
a. Cp: Ph phi cp, NMCT cp.
b. Mn: dy tht tri, suy vnh mn, suy tim...
2. No:
a. Cp: Xut huyt no, tc mch no, TBMN
thong qua, bnh no do THA...
b. Mn: TBMN, TBMN thong qua.
3. Thn: i mu, i ra protein, suy thn...

4. Mt: Soi y mt c th thy: cc mch mu co nh,
du hiu bt cho ng mch/tnh mch (du hiu
Salus Gnn), xut huyt, xut tit vng mc, ph gai
th
5. Bnh ng mch ngoi vi.
C. Phn tng mi nguy c i vi bnh nhn THA
C 3 nhm nguy c (theo JNC VI):
1. Nhm A: L nhng bnh nhn THA nh hoc THA
m khng c tn thng c quan ch, khng c cc
nguy c bnh mch vnh, khng c biu hin bnh
tim mch.
2. Nhm B: L nhng bnh nhn THA cha c tn
thng c quan ch v khng c bnh tim mch km
theo m c t nht mt yu t nguy c bnh tim mch
ni trn nhng khng phi l tiu ng.
3. Nhm C: l nhm c bnh tim mch km theo hoc
c tn thng c quan ch hoc tiu ng v c
hoc khng km theo yu t nguy c bnh tim mch.
Bng 7-4. Phn tng mi nguy c v thi iu tr THA.
Giai on
Nhm nguy c
THA
A
B
C
Bnh thng iu chnh iu chnh Dng
cao
li sng
li sng
thuc**
Giai on I
iu chnh iu chnh Dng
li sng (ti li sng (ti thuc
12 thng)
6 thng)*
Giai on II Dng thuc Dng thuc Dng
v III
thuc
Ghi ch: (*) Cho nhng bnh nhn c nhiu yu t nguy c,
cn nhc cho ngay thuc phi hp vi iu chnh li sng.
(**) Cho nhng bnh nhn c suy tim, suy thn, tiu ng.
7
VII. iu tr tng huyt p

A. Mc ch v nguyn tc iu tr
1. Ngn nga lu di cc bin chng.
2. a HA v tr s bnh thng (< 140/90 mmHg, nu
c tiu ng th s HA phi <135/85 mmHg).
3. iu tr cn ht sc tch cc bnh nhn c tn
thng c quan ch.
4. Phi cn nhc tng c th bnh nhn, cc bnh km
theo, cc yu t nguy c, cc tc dng ph v nh
hng c th ca thuc m c ch dng thuc
thch hp.
5. Nu khng c nhng tnh hung THA cp cu th
HA nn c h t t trnh nhng bin chng
thiu mu c quan ch (no).
6. Vic gio dc bnh nhn cn phi nhn mnh:
a. iu tr THA l mt iu tr sut i;
b. Triu chng c nng ca THA khng phi lc
no cng gp v khng tng xng vi mc
nng nh ca THA;
c. Ch c tun th ch iu tr thch hp mi
gim c ng k cc tai bin do THA.
B. Ch iu tr khng dng thuc (thay i li
sng): L phng php iu tr bt buc d c km theo
dng thuc hay khng.
1. Gim cn nng nu tha cn:
a. Ch gim cn cn c bit c nhn mnh
nhng bnh nhn nam gii bo ph th trung tm
(bo bng).
b. Vic gim bo ph c chng minh lm gim
c cholesterol v gim ph i tht tri.
c. Khng p dng ch ny cho ph n c thai b
THA.
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
Natri/ngy.
b. Duy tr y lng Kali khong 90 mmol/ngy,
c bit bnh nhn c dng thuc li tiu
iu tr THA.
c. Bo m y calcium v magnesium.
d. Ch n hn ch cc m ng vt bo ho, hn
ch cc thc n giu Cholesterol.
5. B thuc l: Cn ht sc nhn mnh bnh nhn
cng quyt t b ht thuc l trong mi trng hp,
v y l mt trong nhng nguy c mnh nht ca cc
bin chng tim mch.
9
C. Cc thuc iu tr tng huyt p

1. Thuc chn bta giao cm (bng 7-5):
a. L mt trong cc th thuc c la chn hng
u trong iu tr THA, c chng minh lm
gim t l TBMN v c bit l gim NMCT.
b. C ch: Lm h huyt p do chn th th bta
giao cm vi catecholamin do lm gim nhp
tim v cung lng tim. N cng lm gim nng
renin trong mu, lm tng gii phng cc
prostaglandins gy gin mch.
Bng 7-5. Cc loi thuc chn bta giao cm hay dng.
Cc loi thuc
ISA
Liu u
Liu duy tr
Atenolol
50 mg
25- 100 mg
Betaxolol
10 mg
5 - 40 mg
Bisoprolol
5 mg
2,5 - 20 mg
Metoprolol
50 mg x 2
50 - 450 mg
Metoprolol XL
50-100 mg
50 - 400 mg
200 mg x 2
200 - 1200
Propranolol
40 mg x 2
40 - 240 mg
Propranolol LA
40 - 80 mg
60 - 120 mg
Timolol
10 mg x 2
20 60
Loi chn chn lc 1
Acebutolol
Cc thuc khng chn lc
Pindolol
5 mg x 2
10 - 60 mg
Carteolol
2,5 mg
2,5 - 10 mg
Penbutolol
20 mg
20 - 80 mg
Thuc chn c bta v alpha giao cm

Labetalol
100 mg x 2
200 - 1200 mg
Carvedilol
6,25 mg x 2
12,5- 1200 mg
10
c. Phn loi: Da trn mc chn lc trn tim m c

th chia ra nhm c chn lc vi th th 1 v
khng chn lc (chn c 1 v 2). Tuy nhin vi
liu cao th cc thuc chn lc 1 s khng cn
chn lc na. Cc thuc chn bta giao cm ny
cn c phn bit bi c hot tnh giao cm ni
ti (ISA) hoc khng c. Thuc c hot tnh
ging giao cm ni ti t gy h nhp tim hn.
d. Chng ch nh v tc dng ph: cc thuc
chn bta giao cm c kh nhiu chng ch nh:
Nhp chm, c bit l bloc nh tht cao.
Suy tim nng.
Cc bnh phi co tht (hen ph qun).
Bnh ng mch ngoi vi.
Thn trng bnh nhn c tiu ng, ri
lon m mu.
Thuc dng lu c th gy hi chng
Raynaud, lit dng, mt ng, trm cm...
C hiu ng cn THA bng pht nu ngng
thuc t ngt.
2. Cc thuc chn alpha giao cm (bng 7-6):
a. C ch tc dng: Cc thuc ny c ch th th
1 giao cm lm bloc th th alpha giao cm hu
hch, dn n gin ng mch v tnh mch.
Bng 7-6. Cc thuc chn alpha giao cm thng dng.
Cc loi thuc
Bit dc
Doxazosin mesylate
Cardura
Prazosin hydrochloride
Minipress
Khi u
Duy tr
1 mg
1-16 mg
1 mg x 2
1-20 mg
Terazosin hydrochloride
Hytrin
1 mg
1-20 mg
b. c im: cc thuc chn alpha giao cm thng
c hi chng liu u tin tc l tc dng rt
mnh khi dng liu u tin, c th dn n tt
huyt p, do khi dng liu u tin cn bt u
rt thp v theo di cht ch. Cc thuc ny c
11
th gy tt huyt p t th, au u, chng mt...

Thuc chn lc 1 giao cm dng lu di c th
ci thin tnh trng ri lon m mu. Thuc cn
c tc dng tt cha triu chng nhng bnh
nhn c ph i tin lit tuyn lnh tnh.
3. Thuc chn c alpha v bta giao cm: (bng 7-5)
a. Do chn c th th bta tim v alpha mch
ngoi vi nn c c c hai c ch gy h HA ca
hai nhm ni trn.
b. Carvedilol l loi thuc hin c xut khng
nhng iu tr THA, suy vnh m cn tc dng
tt trong suy tim vi liu kim sot cht ch.
c. Tc dng ph ging nh cc thuc chn bta giao
cm, ngoi ra c th gy hu hoi t bo gan, h
HA t th, hi chng ging lupus ban , run
chn tay v bng pht THA khi ngng thuc t
ngt.
4. Cc thuc tc ng ln h giao cm trung ng:
a. C ch: cc thuc nhm ny kch thch th th 2
giao cm tin hch trong h thn kinh trung ng,
lm gim trng lc giao cm ngoi vi v lm
gim tr khng mch h thng, t h huyt p.
b. c im: Cc thuc ny khng phi l thuc la
chn u tin cho iu tr THA do c nhiu tc
dng ph nh: nhp chm, chng mt, kh ming,
h huyt p t th, trm cm, ri lon hot ng
tnh dc. Mt s thuc c th gy tng men gan,
gim chc nng tht tri v c bit l hi chng
ngng thuc t ngt- THA bng pht khi
ngng thuc t ngt.
5. Cc thuc khc tc ng ln h giao cm:
a. C ch tc dng: Cc thuc ny ngn chn gii
phng ngun Norepinephrin (Noradrenalin) tn
cng thn kinh ngoi vi. Ring Reserpine cn c
12
b. c im: hin nay cc thuc ny khng cn

c coi l thuc la chn u tin trong iu tr
THA, nhng vn cn c ch trong mt s trng
hp nht nh.
c. Tc dng ph ca cc thuc ny kh nhiu:
Reserpin gy trm cm 2 % s bnh nhn.
Ngoi ra cc thuc nhm ny c th gy bun
ng, kh ming, nght mi, h HA t th, cc ri
lon tnh dc hoc ri lon tiu ho.
Bng 7-7. Cc thuc tc ng ln h giao cm trung
ng v ngoi vi
Tn thuc
Bit dc
Liu u
Duy tr
Thuc tc ng ln h giao cm trung ng
Clonidine
Catapres
0,1 mg x 2
0,1 - 1,2 mg
Methyldopa Aldomet,
250 mg x 2-3 250-2000 mg
Dopegyt
Thuc tc ng ln h giao cm ngoi vi
Guanfacine Tenex
1 mg
1 - 3 mg
Guanabenz
Wytensin
4 mg x 2
4 - 64 mg
Thuc c tc dng hn hp
Reserpine
0,5 mg
0,01- 0,25 mg
6. Cc thuc li tiu:
a. Li tiu c coi l thuc nn la chn hng u
trong iu tr THA.
b. C ch tc dng:
Li tiu lm gim khi lng tun hon trong
lng mch, do lm h HA.
Ngoi ra, li tiu c th lm gim nh cung
lng tim v tng tr khng mch ngoi vi
nhng tc dng ny khng tri v ht nu
dng lu di.
13
Mt s loi c tc dng gy gin mch nh

(Indapamide) do c ch dng Natri vo t bo
c trn thnh mch.
c. Cc nhm thuc li tiu (bng 7-8).
Bng 7-8. Cc loi thuc li tiu thng dng.
Loi thuc
Liu u
Duy tr
Nhm Thiazide
Benzthiazide
25 mg x 2
50-100 mg
Chlorothiazide
500 mg
125-1000 mg
Chlorothalidone
25 mg
12,5-50 mg
Hydrochlorothiazide
25 mg
12,5 - 50 mg
Hydroflumethiazide
50 mg
50- 100 mg
Indapamide
1,25 mg
2,5 - 5,0 mg
Methylchlothyiazide
2,5 mg
2,5 - 5 mg
Metolazone
2,5 mg
1,25-5 mg
Quinethazone
50 mg
25-100 mg
Li tiu tc ng ln quai Henle
Bumetanide
0,5 mg ung
0,5-5,0 mg
hoc tim TM
Ethacrynic acid
50 mg ung
25-100 mg
hoc tim TM
Furosemide
20 mg ung
20-320 mg
hoc tim TM
Torsemide
5 mg ung
5-10 mg
hoc tim TM
Li tiu gi kali
Amiloride
5 mg
5-10 mg
Spironolactone
50 mg
25-100 mg
Triamterene
50 mg x 2
50 - 200 mg
d. Tc dng ph:
Khc nhau tu tng nhm.
Nhm Thiazide gy h kali mu, h magne
mu v gy ri lon m mu nu dng ko
di. C th gy yu c, chut rt, lit dng...
14
Thiazide c th lm xu chc nng thn

bnh nhn suy thn.
Li tiu tc dng trn quai l li tiu mnh,
lm mt kali v in gii khc nhiu v c th
gy ng c vi tai. N ci thin c chc
nng thn v khng nh hng n m mu.
Li tiu gi kali l li tiu yu v t khi dng
n c. Khi phi hp vi mt loi li tiu
thi kali lm tng tc dng li tiu v ngn
nga c tc dng ph gy ri lon in gii
mu. Ch khi dng bnh nhn suy thn.
7. Cc thuc chn knh canxi:
a. Cc thuc nhm ny c tc dng h HA rt r v
tng i t tc dng ph. Tc dng ca cc thuc
thuc nhm ny trn h thng tim mch rt khc
nhau tu tng loi.
Bng 7-9. Cc thuc chn knh canxi thng dng.
Tn thuc
Bit dc
Liu ban u
Duy tr
Nhm Dihydropyridine (DHP)
Nifedipine
Adalate
10 mg
10-30 mg
NifedipineXL,LL Adalate LA
30 mg
30-90 mg
Amlordipine
Amlor
5 mg
2,5-10 mg
Isradipine
2,5 mg x 2
2,5-10 mg
Nicardipine
20 mg x 4
60-120 mg
Felodipine
Plendil
5 mg
2,5-10 mg
Nhm Benzothiazepine
Diltiazem SR
60-120mgx2 120-360 mg
Diltiazem CD
180 mg
180-360 mg
Diltiazem XR
180 mg
180-480 mg
Nhm Diphenylalkylamine
Verapamil
80 mg
80-480 mg
VerapamilCOER
180 mg
180-480 mg
Verapamil SR
Isoptine
120 mg
120-480 mg
15
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.
Cc thuc chn knh canxi thng khng gy
nh hng n ng mu, lipid mu khi
dng ko di.
Nhn chung cc thuc chn knh canxi khng
c ch nh bnh nhn NMCT cp m c ri
lon chc nng tht tri.
8. Thuc c ch men chuyn (CMC):
a. L nhng thuc iu tr THA tt, t gy nhng tc
dng ph trm trng, khng nh hng nhp tim
16
b. C ch tc dng: thuc c tc dng c ch men

chuyn, l loi men gip chuyn t angiotensin I
thnh angiotensin II, do lm gin mch, gim
tit aldosterone gy h HA. N cn c ch con
ng thoi ging ca bradykinin, lm cht ny
ng li v cng gy ra gin mch, h huyt p.
Angiotensinogen
Karikinin
Renin CMC
(-)
Angiotensin I
Bradykinin
Men chuyn
Angiotensin II
Aldosterone
Cc peptid bt hot
Co mch trc tip
THA
Hnh 7-1. C ch tc dng ca thuc c ch men chuyn.
c. c im: Khng gy ri lon lipid mu, ng
mu, acid uric khi dng ko di.
Tc dng ph kh chu hay gp ca CMC l
gy ho khan, nhiu khi phi cho ngng thuc
v tc dng ph ny.
CMC gin u tin tiu ng mch i cu
thn nn c th gy suy thn t ngt do gim
dng mu ti thn nhng bnh nhn b hp
ng mch thn 2 bn. Chng ch nh tuyt
17
i ca CMC l bnh nhn c hp ng

mch thn 2 bn. CMC cng khng dng
ph n c thai. V lm tng kali mu nn thn
trng bnh nhn suy thn, ang dng thuc
li tiu gi kali, hoc ch bi ph kali.
Bng 7-10. Cc thuc tc ng ln h Renin-Angiotensin.
Thuc
Bit dc
Liu u Liu duy tr
Cc thuc c ch men chuyn
Captopril
Capoten, Lopril
25 mg
50 - 450 mg
Enalapril
Renitec
5 mg
2,5 - 40 mg
Benazepril
Lotensin
10 mg
10 - 40 mg
Fosinopril
Monopril
10 mg
10 - 40 mg
Lisinopril
Zestril
5-10 mg
5 - 40 mg
Moexipril
Univasc
7,5 mg
7,5 - 30 mg
Quinapril
Accupril
5-10 mg
5 - 40 mg
Ramipril
Altace
2,5 mg
1,25 - 20 mg
Trandolapril Mavik
1-2 mg
1 - 4 mg
Perindopril
Coversyl
2-4 mg
4 mg
Cc thuc c ch th th AT1
Losartan
Cozaar
25 - 100 mg
Valsartan
Diovan
80 - 320 mg
Irbesartan
Avapro
150 - 300 mg
Telmisartan Micardis
20 - 160 mg
9. Cc thuc i khng vi th th AT1 ca
Angiotensin II: y l cc thuc kh mi trong iu
tr THA v suy tim.
a. C ch: c ch th th AT1, ni tip nhn tc
dng ca angiotensin II (l mt cht gy co mch
mnh), t lm gin mch, h huyt p.
b. V c ch ny nn thng khng gy ra ho nh
khi dng CMC. C th c tc dng ph nh
vim ph mch ngoi vi, d ng, nga... Tc ng
ln thn v kali mu t hn khi dng CMC.
10. Cc thuc gin mch trc tip:
18
a. C ch tc dng: Cc thuc ny lm gin trc

tip c trn ng mch gy h huyt p. N c
th phn ng tng ti hp thu nc v natri v lm
tng hot ng h giao cm phn ng gy nhp
tim nhanh.
b. L thuc h huyt p mnh, nhng khng phi l
la chn hng u. Rt c ch khi bnh nhn c
biu hin khng li cc thuc h huyt p khc,
hoc c th ch nh cho ph n c thai. C th
phi hp thm loi thuc ny vi nitrate iu
tr suy tim.
c. Tc dng ph c th gp l: au u, nn, nhp
nhanh, h HA t th. C th gy hi chng ging
Lupus ban (10 % bnh nhn dng ko di, liu
cao), do khi c hi chng ny phi ngng
ngay thuc. Minoxidil c th gy tng cn, ri
lon nh v bt thng in tim, tng mc lng
tc, trn dch mng tim.
Bng 7-11. Cc thuc gin mch trc tip.
Thuc
Bit dc Liu u
Liu duy tr
Hydralazine
Apresolin
10 mg
50 - 300 mg
Minoxidil
Loniten
5 mg
2,5 - 100 mg
11. Cc thuc h huyt p dng theo ng truyn
tnh mch: cc thuc ny (bng 7-12) c th c
xp loi trong cc nhm thuc ni trn hoc khng.
a. Cc thuc nhm ny c th c ch nh trong
mt s tnh hung THA lm sng nht nh:
Tng huyt p c tnh.
Chy mu ni s do THA.
Tch thnh ng mch ch.
Suy thn tin trin nhanh.
Sn git.
THA km NMCT cp hoc suy tim tri cp.
19
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.
Bng 7-12. Cc thuc iu tr THA theo ng tnh mch.
Thuc
Liu dng
Ch
Sodium
Truyn TM: 0,5 - L thuc la chn u
Nitroprusside
10 g/kg/pht
tin, c th gy tt p,
- Tc dng:
nn, nguy c ng c
tc thi
cyanide bnh nhn suy
- Ko di:
gan, hen. Phi bc k
2-3 pht
trnh nh sng
Diazoxide
Tim: 50-100 mg, Nhp nhanh, tt HA,
- Tc dng:
nhc li 5-10 pht, nn, tng ng mu. C
1-5 pht
tng liu 600 mg. th lm tng thiu mu
- Ko di:
Truyn TM: 10-30 c tim bnh nhn
6-12 gi
NMCT, lm nng thm
mg/pht
suy tim, tch thnh MC
Labetalol
Tim: 20-80 mg, C th gy tt p, bloc
- Tc dng:
nhc li 5-10 pht, nh tht, suy tim, co tht
5-10 pht
tng liu 300mg.
ph qun, nn, THA
- Ko di:
Truyn TM: 0,5-2 bng li khi ngng. C
3-6 gi
mg/pht
th t tc dng bnh
nhn dng chn bta
20
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
Truyn TM: 5-100 au u, nn. C th

g/pht
gim tc dng nu dng
lu di.
Tim TM: 500 Tt HA, bloc nh tht,
g/kg/ph
trong suy tim, co tht ph qun
pht u
Truyn TM: 50300 g/kg/ph
Tim TM: 5-10 Tt HA, tim nhanh, au
mg mi 5-15 pht u, au ngc, p ng
THA nghch thng.
Tim TM: 10-20 u tin dng trong sn
mg sau 20 pht git. C th gy tt p,
nhc li (nu suy thai, nhp nhanh, au
khng c p ng) u, nn, vim tc TM
ti ch.
Truyn 5 mg/gi , Tt p, au u, nhp
c th tng 1,0-2,5 nhanh, nn.
mg/gi mi 15
pht, ti a 15
mg/gi
Tim TM 0,625- Tt huyt p.
2,5 mg mi 6 h
VI. Mt s tnh hung lm sng

A. THA ngi tr
1. Nn ch tm nguyn nhn.
2. c im THA ngi tr tui l c s tng trng
lc h giao cm v tng nng renin huyt tng.
3. Cc thuc nhn chung d la chn cho ngi tr.
B. THA ngi c tui
1. Thng km theo tng tr khng h mch mu, gim
nng renin mu, tng khi lng c tht tri.
21
C.
D.
E.
F.
G.
2. Hay c km cc bnh khc, nn khi cho thuc h HA

phi cn nhc cc chng ch nh v tc dng ph.
3. Li tiu hoc chn knh calci nn c la chn nu
khng c cc chng ch nh.
4. Nn trnh dng cc thuc c th gy h HA t th
hoc cc thuc tc ng ln h thn kinh trung ng
v tng nguy c gy trm cm.
THA ngi bo ph
1. Thng hay c tng tr khng mch, tng cung lng
tim, v tng khi lng tun hon.
2. Gim cn nng l mc tiu quan trng nht.
3. Thuc u tin nn la chn l li tiu.
THA ngi tiu ng
1. Thng c km theo bnh l thn do tiu ng.
2. Mc tiu l h HA v di mc bnh thng cao.
3. Thuc CMC nn c la chn hng u v tc
dng tt v lm gim protein niu.
THA c suy thn mn tnh
1. Ph thuc nhiu vo khi lng tun hon.
2. Li tiu l thuc u tin, trong li tiu quai c
bit c tc dng khi m creatinin mu > 2,5 mg/dl, n
gip ci thin c chc nng thn.
THA c ph i tht tri
1. Ph i tht tri lm tng nguy c t t, NMCT.
2. Ch n gim mui; gim cn nng v cc thuc h
HA (tr thuc gin mch trc tip) c th lm gim
ph i tht tri. Thuc CMC l loi lm gim ph
i tht tri mnh nht.
THA c km theo bnh mch vnh
1. Chn bta giao cm nn c la chn hng u nu
khng c cc chng ch nh.
2. Chn bta giao cm lm gim t l t vong do
NMCT, lm gim nguy c dn n NMCT bnh
nhn au ngc khng n nh. N cn lm gim
22
nguy c ti NMCT bnh nhn sau NMCT v lm

tng t l sng st sau NMCT.
3. CMC c ch nht l khi bnh nhn c gim chc
nng tht tri km theo.
4. Chn knh calci c th dng khi THA nhiu, nhng
cn ht sc thn trng v ch nn dng khi khng c
suy gim chc nng tht tri.
H. THA c suy tim
1. CMC v li tiu l thuc la chn hng u.
2. C th dng phi hp gia Nitrate vi Hydralazine
trong trng hp THA kh tr. Cn ht sc thn trng
vi Hydralazine v n lm tng nhp tim phn x, do
c th lm xu i tnh trng thiu mu cc b
bnh nhn c suy vnh km theo.
I. THA v thai nghn
1. Phn loi THA ph n c thai: (theo Trng mn
Sn Ph khoa Hoa k 1996) THA ph n c thai c
th gp cc tnh hung sau:
a. Tin sn git hoc sn git: l tnh trng THA khi
c thai km theo protein niu, ph v c th c
ri lon chc nng gan, thn.
b. THA mn tnh do bt k nguyn nhn no: l tnh
trng THA xut hin trc tun th 20 thai k.
c. THA mn tnh do hu qu ca tin sn git hoc
sn git.
d. THA thong qua hoc mun: L THA khng lin
quan n protein niu v khng c nh hng n
h thn kinh trung ng. THA tr li bnh thng
vi ngy sau .
2. iu tr:
a. Nn iu tr khi HA ti thiu > 100 mmHg.
b. Khng p dng ch gim cn nng v tp
luyn qu sc.
c. Methyldopa l thuc nn c la chn hng u;
Hydralazine c th c dng thay th.
THA
Bt u hoc tip tc thay i li sng

23
Khng t c ch iu tr THA (< 140/90 mmHg)

H HA thp hn vi bnh nhn i tho ng hay bnh thn
La chn thuc iu tr ban u (tr phi c chng ch nh)
Tng huyt p khng c bin chng:
Thuc li tiu
Thuc chn th th giao cm
Ch nh bt buc:
i ng tp I c protein niu: Thuc c ch men chuyn

Suy tim: Thuc c ch men chuyn, li tiu
THA tm thu n c (ngi gi): u tin thuc li tiu,
chn knh canxi loi dihydropyridine tc dng ko di.
NMCT: Thuc chn giao cm (khng c ISA),
thuc c ch men chuyn (khi ri lon chc nng tm thu)
Cc ch nh c bit cho cc loi thuc sau:
Thuc c ch men chuyn

Thuc c ch th th angiotensin II
Thuc chn th th - giao cm
Thuc chn knh canxi
Thuc li tiu
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
Khng t c ch iu tr THA
Khng p ng
C cc tc dng ph
Thay bng thuc

nhm khc
Dung np tt nhng
p ng khng
Thm thuc nhm khc

(li tiu nu cha dng)
Cha t ti ch iu tr THA
Tip tc thm loi thuc th ba khc nhm

nh gi li nguyn nhn, ch iu tr
Hnh 7- 2. Phc iu tr THA (theo JNC VI).
24
Tai bin mch mu no
Theo T chc Y t th gii (1993) tai bin mch mu

no (TBMN) hay t qu l mt trong 10 nguyn nhn gy
t vong hng u, ch ng sau bnh tim mch v ung th.
Hng nm, ti M c khong 730000 ca t qu, t l t
vong chim ti 27%. Ti Vin Tim mch Vit nam (19962000) tnh trung bnh c 2 ngy c mt bnh nhn vo vin
v TBMN. T vong do TBMN chim 1/4 t l t vong chung
ti Vin Tim mch. Ngay ti cc nc pht trin, TBMN vn
l mt bin chng nng, d t vong, nh hng ln ti sc
kho, tm thn v i sng ngi bnh, cc di chng tn ph
tr thnh gnh nng cho gia nh, x hi.
TBMN gp nam nhiu hn n gii, hay gp la tui
trung nin (> 40 tui). Tui ca nhng bnh nhn TBMN c
lin quan n tng huyt p, nhi mu c tim hay x va
ng mch thng ln hn bnh nhn TBMN c lin quan
n bnh van tim hay vim ni tm mc nhim khun.
TBMN xy ra bt k gi no trong ngy v bt c ma no
trong nm, song thng xy ra 1-10 gi sng v vo cc
thng nng nht (thng 7, 8) hay lnh nht (thng 12,1 - theo
thng k ca Vin Tim mch Vit nam).
I. Phn loi tai bin mch mu no (TBMN)
A. TBMN (hay t qu) l mt ri lon khu tr chc
nng ca no c tin trin nhanh trn lm sng, nguyn
nhn thng do mt mch mu no b v hoc tc.
TBMN c cc loi tn thng chnh l chy mu no,
chy mu mng no v nhn no hoc phi hp cc loi.
1. Chy mu no do v mch mu no, lin quan vi
huyt p cao hoc d dng mch mu no.
2. Nhn no xy ra khi mt nhnh ng mch no b
tc thng do 3 nguyn nhn chnh l mng x va,
cc tc bn t xa ti v nhn no do gim ti mu
121
no. Cc nguyn nhn him gp khc bao gm: tch

thnh ng mch no, vim mch no v huyt khi
tnh mch no.
a. Nhn no do mng x va ch yu xy ra cc
mch mu ln (ng mch cnh trong, ng
mch sng, ng mch nn) song cng xy ra
cc ng mch no nh v va bt k vng no.
Thng tn lc u ch l mng x va gy hp
dn lng mch, t to thnh huyt khi, sau
cng gy tc mch. Huyt khi c khi hnh thnh
mi d khng c x va t trc, hay gp bnh
nhn c tnh trng tng ng. Khuyt no
(lacunar stroke) thng v tc cc tiu ng mch
nm su trong no do mng x va nh hoc do
qu trnh lipohya-linolysis (hay gp bnh nhn
tng huyt p).
a. TBMN do cc tc bn t xa thng gy tc cc
ng mch no ng knh trung bnh, nht l
ng mch no gia v cc nhnh chnh ca h
thng ng mch sng nn. Ngun gc ca cc
cc tc ny ch yu t tim, mt s t hnh thnh
ngay ti vng x va ca phn u cc ng
mch no. Gn mt na nguyn nhn cc tc t
tim l huyt khi hnh thnh do rung nh, phn
cn li l huyt khi hnh thnh do ri lon chc
nng tht tri nng, do cc bnh van tim (hp van
hai l), tc mch nghch thng hoc nhi mu c
tim mi, thm ch do mng x va bn t quai
MC, cc si do vim ni tm mc nhim khun.
b. TBMN do gim ti mu no xy ra nhng
mch no hp nhiu cha n mc tc hn, gy
thiu mu nhng vng xa ni gip ranh ti
mu ca cc ng mch no. Kinh in l vng
gip ranh gia ng mch no trc v ng
mch no gia, l vng chi phi vn ng cc chi.
Hp ng mch cnh trong mc nng c th
122
gy thiu mu vng ny, nht l sau khi c tt

huyt p.
c. Tch thnh ng mch no hay gp ng
mch cnh trong hoc ng mch sng, do chn
thng hoc t pht (50%). Tch thnh ng
mch cng c th gp cc ng mch c hin
tng lon sn x c.
d. t qu cn xy ra nhng bnh nhn vim
mch mu no do cc bnh t min, nhim
trng, nghin ma tu hoc v cn. Mt s t
trng hp t qu do huyt khi trong tnh
mch hoc xoang tnh mch ni s: nhng
trng hp ny hay c km theo chy mu no,
ng kinh v cc du hiu tng p lc ni s.
3. TBMN thong qua (cn thiu mu no thong qua,
TIA: transient ischemic attack): ngi bnh t nhin
b lit na ngi hoc mt nhm c nh lit na mt,
ni nghu, t nhin khng nhai c, tay bung ri
vt ang cm; nhng cc du hiu ny thoi trin
ht ngay trong vng 24 gi. Nguyn nhn do tc mt
ng mch no nhng cc mu ng li t tiu c.
Bng 8-1. D bo v tr tn thng ng mch no.
Khi pht
ng mch
Nguyn nhn
tn thng
thng gp
Tht ngn + Lit 1/2 ng mch Cc tc t xa hoc
ngi
no gia
do mng x va
Yu na ngi n thun Khuyt no Mng x va nh
v/hoc mt cm gic
na ngi n thun
Yu chn nhiu hn tay, ng mch Cc tc t xa hoc
i dm, thay i tnh no trc
do mng x va
tnh
Mt th trng n thun ng mch Cc tc t xa hoc
no sau
do mng x va
Yu t chi, lit thn kinh ng mch Mng x va
s, tht iu
nn
123
B. Hi bnh v khm lm sng thn kinh t m cho

php xc nh s b vng mch no b tn thng v
nguyn nhn gy ra TBMN. Chng hn: bnh nhn c
tht vn ngn v lit na ngi phi s c thng tn ca
ng mch no gia bn tri, thng do cc tc t ng
mch cnh hoc ngun gc ng mch. Ngc li, yu
mt, tay v chn m khng c cc du hiu khc thng
gi tn thng khuyt no do tc cc mch nh nm
su trong no.
1. Khng th phn bit chnh xc nhn no v xut
huyt no trn lm sng d c nhiu im gi nh:
din bin ca xut huyt no thng t ngt hn,
km du hiu mng no v chc dch tu sng c
mu khng ng khi chy mu no-mng no... trong
khi nhn no thng c tin triu i trc, hay gp
bnh nhn tng huyt p (2/3 TBMN bnh nhn
THA l nhn no, ch 1/3 l xut huyt no), c cc
du hiu hp, tc ng mch cnh, c tin s i tho
ng, hay km st...
2. Nhng yu t nguy c quan trng ca TBMN l tng
huyt p, i tho ng, bnh tim (bnh van hai l,
rung nh, vim ni tm mc nhim khun, bnh c
tim gin, nhi mu c tim...), thiu mu no thong
qua, bo ph, nghin ru, ht thuc l, ri lon lipid
mu, tng axt uric mu.
II. Chn on v nh gi tai bin mch no
A. Triu chng lm sng
1. TBMN c th c cc du hiu bo trc nhng khng
c trng v rt d b b qua nh: au u, chng
mt, tai... c bit l nhc u: au nhc 2 bn
thi dng, hoc c khi au d di mt na u hay
sau gy, km theo cng ct sng. Phi ngh n
TBMN khi ngi bnh c lit na ngi, ri lon tri
gic hoc hn m. Khi bnh nhn nghi ng t qu
124
n vin th cn hi k bnh s v tin s, khm lm

sng v thn kinh t m. Vi bnh nhn tht ngn,
nn hi k ngi nh. Cn khm tim mch v thn
kinh mt cch ton din k c vic nghe mch cnh
hai bn v o huyt p c hai tay. Khm thn kinh
bao gm nh gi tri gic, vn ngn, cc dy thn
kinh s, vn ng, tiu no, tht iu, cm gic v
phn x gn xng.
2. TBMN bao gi cng c xem l mt tnh trng cp
cu ni khoa, khi pht hin cn s cu ti ch v
chuyn bnh nhn n n v chuyn bit: n v
Chm sc v iu tr TBMN (Stroke Unit).
1. Khi nghi ng bnh nhn c TBMN nn lm cc
xt nghim:
Cng thc mu.
ng mu.
in gii mu gm c magi v canxi (ri
lon hai ion magi v canxi c th gy triu
chng ging nh TBMN).
Creatinin mu.
Thi gian Quick, t l PT v thi gian aPTT.
in tm .
Xquang ngc: nh gi chung v bnh tim
mch v tnh trng vim phi do sc.
Tng phn tch nc tiu (nu thy hng cu
niu, nn i tm cc nguyn nhn gy tc c
mch thn).
Chp ct lp vi tnh (CT) hoc cng hng t
(MRI) s no.
Holter in tim, siu m mch cnh, siu m
tim (qua thnh ngc hoc thc qun), chp
mch no, chc dch tu sng - l nhm xt
nghim c ch nh trong mt s bnh cnh
lm sng nht nh.
125
2. Hi Tim mch M (AHA) khuyn co rng tt c

nhng bnh nhn nghi ng t qu nn chp ct
lp vi tnh theo t trng (CT) hoc chp cng
hng t (MRI) phn bit gia nhn no v
xut huyt no, nh khu v tr tn thng v
loi tr nhng bnh l c biu hin ging t qu.
Cc nguyn nhn gy biu hin ging TBMN gm:
Thoi ho myelin (x cng ri rc).
U no.
p xe no, vim no, cc nhim trng thn
kinh khc.
Cc ri lon chuyn ho (tng ng mu
hoc h ng mu, tng hoc h canxi mu,
tng hoc h natri mu).
Triu chng thn kinh sau ng kinh.
Chn thng (t mu di mng cng, dp
no...).
Triu chng thn kinh lin quan vi au na
u Migraine.
Hi chng phn ly (Hysteri), bnh tm cn.
3. Chp ct lp theo t trng (CT) s no rt gi tr
pht hin cc vng chy mu ln, u no hoc
nhng thng tn cu trc trong s khc gy ra cc
biu hin ging nh t qu cp tnh. Tuy nhin CT
c th b st kh nhiu (ln ti 50%) nu chp ngay
trong vng 12 gi k t khi khi pht. Hn na chp
CT khng phi l bin php l tng pht hin cc
vng nhn no nh, nhn no vng h sau hoc cc
thng tn gy mt myelin (nh trong bnh x cng
ri rc gy biu hin ging t qu). Chp CT xon
c cho nhng hnh nh chi tit v cc ng mch
trong v ngoi s, vi phn gii tt hn hn so vi
chp MRI c thuc cn quang.
4. Hnh nh chp MRI s no nhy hn so vi chp
CT, c bit trong nhng trng hp t qu cp,
126
nhi mu no nh (khuyt no) hoc vng tn thng

lin quan n khu vc thn no. Mt khc chp MRI
c thuc cn quang s cho php sng lc v kho st
c bnh l cc ng mch ln trong hoc ngoi s.
Nhng k thut MRI tin tin (MRI diffusion
perfusion, spectroscopy) cn cho bit tnh trng
chuyn ho v cp mu vng no b thiu mu. Tuy
nhin Vit nam, chp MRI t hn nhiu so vi CT
v c mt s chng ch nh. Do , nn dng cc
triu chng lm sng d on v tr thng tn v
nguyn nhn, t la chn phng tin chn on
hnh nh thch hp. Chng hn trong trng hp nghi
ng khuyt no, MRI l la chn tt nht v CT s
khng th pht hin c cc thng tn ny nu
din bin cp tnh hoc vng thn no. Ngc li,
nu TBMN do tn thng cc mch no ln, nht l
xy ra vi ngy, khng cn c ch nh can thip
thm th nn la chn chp CT s no.
5. Siu m mch cnh dng thm d v nh gi
thng tn ch chia nhnh cc ng mch cnh, h
thng ng mch sng nn. Siu m Doppler qua s
dng kho st dng chy (hng, vn tc) ca cc
ng mch ln trong s.
6. Ch nh Holter in tim 24-48 gi ( pht hin
cn rung nh kch pht hoc cc loi ri lon nhp
khc) hoc siu m Doppler tim nu nghi ng
nguyn nhn TBMN do cc tc nghn t tim. Siu m
Doppler tim qua thnh ngc c th pht hin rt
nhiu nguyn nhn tim mch gy t qu nh huyt
khi nh tri hoc tht tri, ri lon chc nng tht
tri nng, bnh van tim hoc cn l bu dc. Nu
nghi ng cn nguyn t tim m siu m tim qua
thnh ngc khng pht hin bt thng g, th cn
lm siu m tim qua thc qun. Tuy nhin i khi
khng th lm c siu m qua thc qun mt s
127
bnh nhn nng. Siu m tim qua thc qun c

nhy rt cao pht hin huyt khi nh tri, l bu
dc, mt vi bnh l van tim (nh hp h van hai l)
cng nh pht hin cc mng x va quai ng
mch ch c kh nng bn i gy tc mch.
7. Chp ng mch no vn l tiu chun vng
chn on bnh l cc mch no ln v cc mch
nh trong s. Ch nh ch yu cho nhng bnh nhn
t qu tr tui; trong trng hp nghi ng tch
thnh mch no hoc vim mch mu no hoc ch
nh trc khi phu thut bc ni mc ng mch
cnh. Siu m Doppler mch cnh, chp CT, k c
chp MRI mch no c cn quang vn c nhy
thp (15%) pht hin nhng trng hp cn m
bc ni mc ng mch cnh, v th nht thit phi
chp mch no trc loi phu thut ny.
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
tng protein. Nhng bnh nhn c lit kiu Todd (sau

ng kinh) s c bt thng trn in no .
9. Nn thm d tnh trng tng ng bnh nhn t
qu tui di 45, c tin s tc ng mch hoc tnh
mch t trc, tin s sy thai t nhin, tin s gia
nh c thuyn tc mch tui tr, t qu khng r
nguyn nhn xy ra trn bnh nhn c bnh t min...
III. iu tr
iu tr TBMN nhm mc ch phng cc bin chng,
khi phc tn thng cp tnh ca nhu m no v phng t
qu ti pht.
A. Phng bin chng
1. Chng ph no:
a. Bng cc dung dch u trng:
Mannitol truyn 0,5-1 g/kg trong 20-30 pht,
sau truyn li 0,25-0,5 g/kg c 6h/ln. Nu
truyn qu 48 h, nn gim dn liu mannitol
trnh gy ph no hi li do thuc. Ni
chung mannitol khng nn truyn qu 3 ngy,
nu mun truyn nhiu hn, nn c khong
ngh thi thuc, trnh tc dng gy tng p
lc ni s th pht.
Glycerol (1mg/kg trong vng 120 pht).
Cho n nay, mannitol vn l bin php hng
u chng ph no. Khi mannitol bt u
gim tc dng m vn cn gim p, nn cn
nhc truyn dch mui u trng hoc gim
p bng phu thut.
b. Tng thng kh c kim sot trong thi gian ngn
(mc ch h PaCO2 xung cn 25-30 mmHg),
gy kim ho mu, co mch no v gim th tch
mu no, do lm gim ng k p lc ni s,
tc dng ny xut hin ngay sau 20 pht nhng
cng nhanh chng mt i sau 1-2 gi do h thng
129
m trong c th s trung ho tc dng ny, v th

ch nn coi tng thng kh nh mt bin php cp
cu tm thi trong khi ch i hoc phi hp vi
cc bin php khc nh truyn dch u trng,
m hp s... C th truyn dung dch THAM 60
mmol pha vi 100 ml Glucose 5% truyn tnh
mch trong 45 pht sau duy tr qua tnh mch
trung tm 3 mmol/h lm kim ho mu.
c. Barbiturate: lm gim th tch dng mu no do
co mch. Liu dng 250-500 mg thiopental (tim
bolus) sau truyn tip tc 5 mg/kg/h hoc tim
bolus tng lc. Bin chng c th xy ra l gim
huyt p nng gy h p lc ti mu no.
2. Kim sot huyt p ng mch:
a. Mc d rt nhiu bnh nhn TBMN c tng huyt
p song a s trng hp huyt p s gim t
nhin. Nu tnh trng tng huyt p vn cn,
khng nn h huyt p xung t ngt v iu
ny lm ri lon c ch t iu ho mch no,
lm trm trng thm tnh trng thiu mu no
ranh gii vi tn thng, lm triu chng lm
sng nng thm. Gim mc tng huyt p bt
buc phi lm trong mt s trng hp nh c
triu chng bnh tim nng, tng huyt p c tnh,
phnh tch ng mch ch v bnh nhn iu tr
t-PA. Mt s tc gi yu cu phi h huyt p
bnh nhn dng Heparin tnh mch gim nguy
c chuyn nhn no thnh xut huyt no.
b. Duy tr huyt p tm thu < 185 mmHg v huyt
p tm trng < 110 mmHg. Nhng bnh nhn c
huyt p qu cao (HA tm thu 220 mmHg, HA
tm trng 120 mmHg) phi h p ngay, tuy
nhin nn gim t t HA tm thu xung 170-180
mmHg v HA tm trng xung 95-100 mmHg.
Sau nu vn tn ti triu chng lin quan n
130
tng huyt p, c th h tip HA tm thu cn 150160 mmHg v HA tm trng cn 90-95 mmHg.

c. Khng nn dng Nifedipine di li h HA
cp khi TBMN v kh nng h HA qu nhanh
cng nh tc dng bt li ln c ch iu ho
mu no s lm t qu nng hn. Nn trnh
dng cc thuc h p c th gy tng p lc ni
s nh cc thuc gin mch trc tip (Sodium
Nitroprusside, Nitroglycerin, Hydralazin) v cc
thuc chn knh canxi, nht l nhng bnh
nhn nhi mu din rng gy ph n v do tt
no. Cc nhm thuc h p khc nh c ch men
chuyn, chn bta giao cm c tc dng h p tt
m khng gy tc dng ph i vi huyt ng
ca mch mu no, c th ung (Captopril) hoc
tim tnh mch (Enalapril, Labetalol, Esmolol)...
3. Phng huyt khi tnh mch su v tc ng mch
phi: bng Heparin tim di da (5000 UI 12h/ln)
hoc Heparin trng lng phn t thp liu d phng,
hoc i ng kh p cng chn nu c chng ch
nh dng Heparin.
4. Phng vim phi do sc hoc tro ngc:
a. Gn mt na s bnh nhn TBMN c nut kh, t
c th gy sc v vim phi (15%). Nguy c
ny cao nht bnh nhn tn thng gc cc
ng mch no ln (80-90%), nguy c va
bnh nhn nhn na bn cu (40-60%) v thp
nht (10-15%) bnh nhn nhi mu no nh.
b. Bnh nhn kh nut nn cho n qua ng thng
mm trong tun u tin. Nu tnh trng kh nut
cn ko di, nn m thng d dy hoc hng
trng cho n v lm gim nguy c bin chng
tro ngc.
131
c. Phi hp thm vi cc thuc khng cholinergic

nhAatropine hoc Glyco-pyrrolate gim tit
dch v v gim nguy c vim phi do tro ngc.
5. Kim sot ng mu: rt nhiu bnh nhn TBMN
c i tho ng thc s hoc tnh trng tng ng
huyt thong qua, c hai u lm nng thm tn
thng no. Do , khuynh hng hin nay l kim
sot tch cc tnh trng tng ng mu bnh nhn
t qu, duy tr ng mu < 170 mg/dl (< 9,5
mmol/l), dng Insulin tim/truyn tnh mch nu cn.
6. Kim sot thn nhit: bng thuc h st hoc p
chn/khn lnh. Gim thn nhit t mc nhva
s hn ch lan rng tn thng no th pht, gim p
lc ni s v gim t l t vong. Tc dng ph hay
gp l gim s lng tiu cu v tng t l vim phi.
Khuynh hng h thn nhit sm ngay trong 6 gi
u k t khi khi pht ang c nghin cu.
7. Theo di v chm sc:
a. Nn bnh nhn n v TBMN, theo di st
tnh trng thn kinh, cc du hiu sinh tn v
chm sc ton din (1 y t cho 2-4 bnh nhn)
ch khng cn phi chuyn sang n v hi sc
tch cc.
b. Trong giai on cp cn p dng cc k thut cp
cu ni khoa nhm m bo ng th thng
thong (k c vic phi thng kh nhn to), duy
tr cn bng nc - in gii, kim toan, dinh
dng tt qua ng ming, qua ng thng d
dy hoc nui dng hon ton qua ng tnh
mch.
c. Thc hin tt v sinh cho ngi bnh nh v sinh
rng ming, thay qun o, v sinh ngoi da, v
sinh ng tiu, cho nm m nc v xoay tr
bnh nhn chng lot mc da cc im t ,
132
d. Phc hi chc nng sm v tch cc ngay sau khi

TBMN hi phc, luyn tp phng co cng cc c,
khp, huyt khi... Ban u vic luyn tp phi do
nhn vin y t thc hin v sau hun luyn cho
ngi nh khi v nh c th tip tc tp cho
bnh nhn.
8. Phu thut m hp s hoc dn lu no tht lm
gim p lc ni s, trnh tt no, gip cu sng bnh
nhn v ngn nga cc tn thng khng hi phc.
Tuy nhin ch nh v thi gian ti u m hp s
cn cn nghin cu thm.
9. Song song vi nhng vic ny, phi tip tc iu tr
nguyn nhn gy t qu v cc yu t nguy c ca
TBMN nh tng huyt p, i tho ng, bnh van
tim, ri lon nhp tim, ri lon lipid mu, bo ph, ht
thuc l, nghin ru...
B. Khi phc cc tn thng nhu m no cp tnh
Trong giai on sm ca TBMN, vng thng tn cha
ng nhng vng no b hu hoi vnh vin gia v
nhng vng thiu mu no c kh nng hi phc xung
quanh. Kch thc v kh nng sng ca vng thiu mu no
ranh gii ny ph thuc rt nhiu vo v tr, nng, thi
gian tai bin, tun hon bng h... Cc nghin cu cho thy
kh nng sng ca vng ny ch duy tr c trong vng 417 gi. Ti ti mu bng thuc tiu si huyt hoc can thip
mch no trong trng hp tc mch no v bo v no bng
cc thuc bo v thn kinh l hai bin php chnh khi
phc vng nhu m cn thoi thp ny.
1. Thuc tiu si huyt:
a. Trong s nhng thuc tiu si huyt, ch c rtPA (c FDA cng nhn ch nh dng thuc t
1996) vi liu 0,9mg/kg dng ngay trong vng
133
3 gi k t khi khi pht (tim bolus tnh mch

10%, sau truyn phn cn li trong vng 1
gi, liu ti a 90 mg) l liu c hiu qu
c chng minh (nghin cu NINDS), cho d c
mt t l nht nh chuyn dng nhn no thnh
xut huyt no (3% xut huyt nng). Nu tng
liu rt-PA cao hn, thi gian ca s dng thuc
di hn (trong 6 gi k t khi khi pht) th
khng h c li m cn tng nguy c xut huyt
no nng (ln n 20%, nghin cu ECASS).
b. Yu t lm tng nguy c xut huyt no th pht
l hnh nh nhn no sm trn phim CT v mc
nng ca t qu (> 20 im theo thang im
NIHS). Tuy nhin cn tun th cc ch nh,
chng ch nh v phi nh gi y cc nguy
c khi dng rt-PA.
c. Ch nh dng rt-PA:
t qu kiu thiu mu no.
C th xc nh r thi gian khi pht.
C th dng ngay rt-PA trong vng 3 gi k
t khi khi pht.
Chp CT khng c hnh nh xut huyt no
hoc cc bnh nng khc ca no.
Tui 18.
d. Tiu chun loi tr:
t qu hoc chn thng nng s no mi
trong vng 3 thng.
Tin s xut huyt no (XH mng no hoc
trong no) hoc c nghi ng XH mng no.
CT s c hnh nh chy mu no, d dng
ng-tnh mch, u no hoc cc phnh mch
no.
Huyt p tm thu > 185 mmHg hoc huyt p
tm trng > 110 mmHg (o 3 ln, mi ln
cch nhau 10 pht).
134
Tin s c hoc trong cn t qu c ng

kinh.
Chy mu trong ang tin trin.
Ri lon ng mu (aPTT hoc PT di, tiu
cu < 100000/ml).
Triu chng lm sng ci thin nhanh hoc
mc nh.
Hn m hoc ng g.
M i phu hoc can thip mi trong vng 2
tun.
Xut huyt tiu ho hoc sinh dc tit niu
mi trong vng 3 tun.
Mi chc ng mch (vng p c) hoc
mi sinh thit trong vng 1 tun.
ng mu < 50 mg/dl hoc > 400 mg/dl.
Vim ni tm mc, vim mng ngoi tim,
huyt khi nhim trng, vim rut ang tin
trin hoc ang c thai v cho con b.
Nghin ru hoc ma tu nng.
2. Heparin:
a. Heparin tim tnh mch khng lm gim mc
nng ca t qu khi xy ra, m cn lm tng
nguy c chuyn vng nhi mu no thnh xut
huyt no do tng lng mu n vng nhn no
ch khng phi do t Heparin gy chuyn thnh
xut huyt. Nhng bnh nhn c nhi mu no
din rng (> 2/3 bn cu) nu dng Heparin c
nguy c t vong cao hn hn bnh nhn nhi mu
din nh hoc trung bnh (do ph no tin trin
khi nhn no din rng chuyn thnh xut huyt
no), do khng c dng Heparin. Cng
chng ch nh dng heparin trong vng 24 gi
nu bnh nhn c dng rt-PA.
135
b. Tuy nhin, c mt s trng hp Heparin c

ch nh phng nhi mu no tin trin hoc
ti pht bao gm:
Nhn no ang tin trin.
Huyt khi gy TBMN t tim (nu vng nhn
no nh hoc va).
Huyt khi ng mch sng nn.
Phnh tch ng mch no.
Cc tc nghn di chuyn t ng mch n
ng mch no.
Tai bin mch no thong qua tin trin hn.
Huyt khi tnh mch no.
Mt vi tnh trng tng ng.
c. Bnh nhn c thi gian aPTT > 2 ln chng cng
c nguy c cao chuyn dng thnh xut huyt, v
vy gim nguy c ny nu dng Heparin,
khng nn tim bolus tnh mch m ch truyn
Heparin 15-18 UI/kg/gi, ng thi khng ch
aPTT gp 1,5 ln so vi chng.
d. Heparin tim di da khng c ch li g (nghin
cu International Stroke Trial Project).
3. Aspirin (160-300 mg/ngy) dng ngay trong giai
on cp cho thy hiu qu r rt trong vic phng
nga c ti pht t qu v gim t l t vong.
4. Thuc bo v thn kinh: nhiu thuc khc nhau
(nh Lubeluzole...) nhm vo vng t bo thn kinh
ang thiu mu c th nghim lm gim
hoc khc phc cc hu qu ca t qu vi cc c
ch nh: c ch th th p ng vi cc acid amine
vng sau xinp, c ch men glutamate release, hn
ch cc tc ng ca ion canxi v cc gc t do, c
ch hnh thnh nitric oxide. Tuy nhin vn cn qu
sm ni v hiu qu ca cc thuc ny.
136
C. Phng ti pht TBMN

1. Phng ti pht t qu chnh l kim sot v iu
tr tt cc yu t nguy c ca TBMN nh tng huyt
p, bnh tim thc tn, i tho ng, ht thuc...
2. Cn iu tr trit cc bnh van tim (hp van hai
l kht, sa van hai l) hay vim ni tm mc nhim
khun bng mt s th thut nh nong van hai l,
phu thut sa van tim hoc thay van tim nhn to.
i vi bnh nhn rung nh, sau khi iu tr
nguyn nhn, cn sc in hoc dng thuc chng
lon nhp chuyn nhp v nhp xoang. Nu chuyn
nhp tht bi, bnh nhn phi ung thm thuc chng
ng duy tr ngng c tc dng (INR t 2-3)
phng TBMN do huyt khi. Cng cn ung thuc
chng ng nu bnh nhn c bnh c tim gin nng
(bung tht tri gin, chc nng co bp km: EF <
30%), ri lon nng chc nng tht tri, NMCT c
huyt khi bm thnh, ti phnh tht tri...
3. i vi bnh tng huyt p cn phi ung thuc h
p thng xuyn v theo di huyt p nh k ti c
s y t. Phi xc nh dng thuc h p sut i km
vi ch n gim mn kt hp vi cc thuc chng
ngng tp tiu cu (nh Aspirin 325 mg/ngy,
Ticlodipine 500mg/ngy hoc Clopidogrel 75
mg/ngy). Cc thuc chng ngng tp tiu cu
chng t c vai tr d phng khng nhng TBMN
m cn cc bin c tim mch khc (Aspirin lm gim
ti 25% cc bin c), v th nn dng c h thng
cho cc bnh nhn TBMN tr phi c chng ch nh.
4. i vi bnh i tho ng cn phi thc hin
nghim ngt ch n king ca bnh nhn tiu
ng ng thi ung thuc hoc tim insulin gi
ng mu mc bnh thng v theo di ng
mu nh k ti c s chuyn khoa ni tit.
137
5. i vi ngi c nhiu yu t nguy c ca TBMN

th phi ch ti nhng triu chng bo trc nh:
nhc u ko di, hoa mt, chng mt, tai, cn
thiu mu no thong qua c bin php phng
bnh kp thi.
6. Nhng bnh nhn c hp nhiu (>70%) ng mch
cnh trong hoc ng mch cnh gc th nn ch
nh phu thut bc ni mc ng mch cnh hoc
can thip t gi qua ch hp d phng TBMN
(gim t l t vong do TBMN t 26% xung 9% sau
2 nm).
Ti liu tham kho
1.
2.
3.
4.
5.
6.
7.
8.
9.
138
Broderick J, Brott T, Kothari R, et al. The greater

Cincinnati/Northern Kentucky stroke study: preliminary first-ever,
and total incidence rates of stroke among blacks. Stroke,
1998;29:415 421.
Ameri A, Bousser MG. Cerebral venous thrombosis. Neurol Clin,
1992;10:87111.
Barnett HJM, Stein BM, Mohr JP, Yatsu FM, eds. Stroke:
Pathophysiology, Diagnosis, and Management. 2nd ed. New York:
Churchill Livingstone, 1992.
Alberts MJ, Chaturvedi S, Graham G, et al. Acute stroke teams:
results of national survey. Stroke, 1998;29:2318 2320.
McNamara RL, Lima JA, Whelton PK, Powe NR. Echocardiographic identification of cardiovascular sources of emboli to guide
clinical management of stroke: a cost-effectiveness analysis. Ann
Intern Med, 1997;127:775787.
Pulsinelli W. The ischemic penumbra: from benchtop to bedside.
Neurology, 1994;134:1 6.
Wardlaw J, Warlow C, Counsell C. Systemic review of evidence on
thrombolytic therapy for acute ischemic stroke. Lancet, 1997;350:
607614.
Adams HP, Brott TG, Furlan AJ, et al. Guidelines for thrombolytic
therapy for acute stroke: a supplement to the guidelines for the
management of patients with acute ischemic stroke. Stroke, 1996;
27:17111718.
Adams HP, Adams RJ, Brott T, et al. Guidelines for the Early
Management of Patients With Ischemic Stroke: A Scientific
Statement From the Stroke Council of the American Stroke
Association. Stroke, 2003;34:1056 1083.
10. Latchaw RE, Yonas H, Hunter GJ, et al. Guidelines and

Recommendations for Perfusion Imaging Cerebral Ischemia: A
Scientific Statement for Healthcare Professionals by the Writing
Group on Perfusion Imaging, From the Council on Cardiovascular
Radiology the American Heart Association. Stroke, 2003;34:10841104.
139
tch THNH ng mch ch
Tch thnh ng mch ch (MC) l bnh t gp (t l

hin mc khong 5-30 ca/triu ngi/nm), tn sut thay i ph
thuc vo tng qun th vi cc yu t nguy c khc nhau. Triu
chng bnh thng a dng, d nhm vi nhiu bnh cnh cp
cu khc, cn ch nghi ng mi c th chn on v x tr kp
thi, trnh nhng bin chng gy t vong. T l nam/n l 2/1,
tui hay gp nht l t 60 n 70 tui. T l t vong khong
1%/mi gi trong 48 gi u.
V tr tch thnh MC hay gp l MC ln (ch li, vng
cao trn cc xoang vnh phi v xoang khng vnh khong 1-2
cm, chim khong 60-65%), MC xung - ch xut pht (ngay
di ch xut pht ca ng mch di n tri, 20%), quai
MC (10%), cn li MC bng do nhng vng ny phi cng
gin nhiu nht di p lc cao trong k tm thu hoc l im
ni (xung yu) gia nhng vng c nh v di ng ca MC.
I. Phn loi: Tch thnh MC c th theo nhiu kiu:
A. Phn loi kinh in: theo hai kiu DeBakey v
Stanford. Tch thnh MC hay gp nht on MC
ln sau l vng ln cn vi dy chng ng mch.
1. Phn loi theo DeBakey c 3 tp:
a. Tp I: thng tn c MC ln v MC xung.
b. Tp II: thng tn ch MC ln.
c. Tp III: thng tn ch on MC xung.
2. Phn loi theo Stanford gm 2 kiu:
a. Tp A: tn thng on MC ln cho d khi
pht bt k on MC no.
b. Tp B: thng tn MC on xa k t ch xut
pht ca nhnh ng mch di n tri.
Tuy nhin c khi khng th phn nh r tp chng
hn nu tch thnh MC ch quai MC cnh vng
139
xut pht ng mch di n tri gn vi gc MC

m khng c km on MC ln. V th, c th chia
theo v tr tch thnh hai loi: tch thnh MC on
gn (tnh t gc MC ln n ch xut pht ca ng
mch di n tri) v on xa (t tr i).
Hnh 9-1. Phn loi tch thnh MC theo

DeBakey v Stanford.
3. Phn loi theo v tr gii phu, ty vo on tn
thng.
4. Phn loi theo thi gian b bnh:
a. Cp tnh: 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
theo thi gian, to ra phnh mch, lc rng, thm

ch v ra.
Hnh 9-2. Phn loi tch thnh MC theo Svensson.

b. Huyt khi hoc chy mu trong thnh MC
thng do t cc mch nui MC gy xut
huyt/huyt khi trong thnh MC, lm thnh
MC dy ln, tin trin thnh loi 1, v ra hoc
khi hn vi 2 tp khc bit theo cn nguyn:
hoi t lp gia thnh nang Erdheim-Gsell hoc
to mng x va - vi loi ny khng th chn
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
e. Tch thnh MC do chn thng hoc do th

thut, can thip trong lng mch, c th tin
trin thnh loi 1 hoc 2, thm ch v ra.
6. ng knh vng van MC ngi trng thnh
bnh thng l 2,6 0,3 cm nam, 2,3 0,2 cm
n; i vi MC ln tng ng hai gii l 2,9 0,3
v 2,6 0,3 cm. ng knh MC ln bnh thng
ti a l 2,1 cm/m2 da, ln hn l gin v nu > 4 cm
c coi l ti phnh. i vi MC xung, gi tr
bnh thng l 1,6 cm/m2, nu > 3 cm c coi l
phnh dng ti. dy thnh MC bnh thng l <
4mm. ng knh lng MC s tng dn theo tui
khong 1-2 mm/10 nm, mc tng cng ln khi
ng knh lng mch cng tng.
II. Nguyn nhn v c ch bnh sinh
Gin MC hoc tng huyt p gy rn nt ni mc
lng mch, sau mu s thm vo qua vt nt. Di tc
dng ca p lc tun hon theo nhp p, dng mu thm
vo s tch ri cc lp ca thnh MC. Mt s t cc trng
hp cn li c lin quan vi cc yu t lm yu thnh mch,
d gy nn tch thnh MC: nh hi chng Marfan (bin d
nhim sc th lm thay i tng hp polypeptide). Cc yu
t nguy c hay gp ca tch thnh MC bao gm:
1. Tng p lc ln thnh MC:
a. Tng huyt p.
b. Gin MC.
c. Van MC mt hoc hai l.
d. Hp eo MC.
e. Thiu sn quai MC.
f. Do th thut, phu thut vi MC: dng c thng
tim, bng MC, v tr phu thut tim (t canuyn,
kp ng mch ch, ni mnh ghp...).
2. Gim sc chu ti ca MC:
142
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
A. Triu chng c nng
1. au ngc l triu chng thng gp nht (95%), v
tr thng gia ngc pha trc (61%) hoc sau
(36%), ph thuc vo v tr MC b phnh tch (tch
thnh MC ln thng gy au ngc pha trc, tch
thnh MC xung thng gy au ngc pha sau,
au lng, au bng. Cm gic au c th au chi, d
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
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
ng mch di n b chn p.
2. H van MC: 18-50% cc trng hp tch MC
on gn c h van MC t nh n nng, c th
nghe thy ting thi tm trng ca h van MC
trong s 25% s bnh nhn. H van MC nng, cp
tnh l nguyn nhn gy t vong ng hng th hai
(sau v phnh MC), thng biu hin lm sng
trong tnh 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
3. C chnh lch v ny ca mch hoc huyt p

ng mch gia hai tay hoc mt mch t ngt.
Mch hai tay khc nhau l du hiu thc th c hiu
nht ca tch thnh MC, gp trong 38% cc trng
hp. Chnh lch mch v huyt p gia hai tay l do
mt hay c hai ng mch di n b chn p mt
phn, hoc c mnh nt di ng trong lng mch nn
c th nghe thy ting thi dc theo cc ng mch
ln nh ng mch cnh, di n hoc ng mch
i. Biu hin thiu mu ngoi vi, nht l chi di c
th gp trong 15 n 20% s bnh nhn phnh tch
MC. Biu hin mch p (him gp) do chnh lch
v tc dng chy gia lng gi v tht trong
trng hp lng gi tin trin vo gia lng tht.
Khm vng c c th thy cc biu hin nh gin
mch c mt bn do p ca lng gi quanh MC,
hoc gin tnh mch c hai bn do tnh mch ch trn
b chn p hoc trn dch mng tim, p tim.
4. Triu chng thn kinh gp trong s 18-30% cc
trng hp:
a. Nhn no/t qu l triu chng thng gp nht
tch thnh MC, chim 5-10% s bnh nhn.
a s bnh nhn tch thnh MC biu hin t
qu c tin s au ngc. Ngoi t qu, thay i
ti mu no c th gy thiu mu no thong
qua vi cc biu hin a dng t ri lon thc
n ngt (12% s bnh nhn).
b. Thiu mu tu sng v bnh thn kinh ngoi vi
do thiu mu hay gp nht nu tch thnh MC
on xa (ti 10%) do hu qu p vo cc ng
mch gian sn, nhnh ng mch Adamkiewicz,
hoc cc ng mch nui r tu sng. Vng ti
mu cho tu sng gip ranh gia nhnh ng
mch Adamkiewicz v cc nhnh nui r tu
sng rt d b tn thng do thiu mu khi tch
145
thnh MC. Thiu mu tu biu hin rt a dng

nh hi chng vim tu ct ngang, bnh l tu
sng tin trin, nhi mu tu sng, hi chng
sng trc tu sng, lit hai chi hoc lit t chi.
Bnh thn kinh ngoi vi trong tch thnh MC
(do thiu mu ca n-ron hoc lng gi p trc
tip vo dy thn kinh) him gp song biu hin
rt a dng, khng c nh nh: lit hai chi di,
khn ting, bnh l m ri tht lng cng v hi
chng Horner. Phn ln triu chng thn kinh
lin quan bnh nhn tch thnh MC l au.
Tuy nhin triu chng t qu, ngt hoc khn
ting cng c th l nhng triu chng u tin.
5. Cc biu hin khc:
a. Trn dch khoang mng phi tri do khi phnh
v vo khoang mng phi.
b. Ph phi mt bn hoc ho ra mu do tch thnh
MC lan vo ng mch phi.
c. Xut huyt tiu ho cp tnh do lot thc qun
hoc t trng.
d. au bng cp do phng mch lan vo ng mch
mc treo trng.
e. Kh nut do khi phng MC vo thc qun.
6. Tiu chun chn on lm sng c th xc nh ti
96% trng hp tch thnh MC (theo von
Kodolistch) da trn cc triu chng:
a. au ngc khi pht t ngt, hoc cm gic au
ngc chi d di hoc c hai.
b. Chnh lch mch, huyt p hoc c hai.
c. Trung tht hoc MC gin rng hoc c hai.
Nu ch c triu chng s 2 n thun hoc t
nht 2 trong 3 triu chng th t l ng l 83%. Nu
ch c triu chng 1 hoc 3 n thun th t l ng
146
ln lt l 31 v 39%. Chn on loi tr 93% cc

trng hp nu khng c triu chng no.
IV. Cc xt nghim chn on
1. Xquang ngc mc d c c hiu thp, song vn
c gi tr chn on ban u nu phi hp vi triu
chng c nng v thc th. Du hiu kinh in gi
tch thnh MC l bng trung tht gin rng (50%
cc trng hp). Bng trung tht to v bn tri l
chnh nu tch thnh MC ngc, to v bn phi nu
tch thnh MC ln. Cc du hiu khc l nhng
thay i v hnh dng ca MC nh: bu kh tr
quai MC, gin rng cung MC on xa ngay sau
ch xut pht ca ng mch di n tri, dy thnh
MC (tng dy ca bng MC pha ngoi im
vi ho ni mc), di lch im vi ho cung MC
(hn 1cm), hnh nh MC hai lng, khc bit v kch
thc gia cc phn MC ln v xung, thng c
trn dch mng phi tri, suy tim huyt... Tuy vy,
nhng du hiu ny ch c tnh cht gi ch khng
c gi tr chn on xc nh.
2. in tm : 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
u chng t chnh xc, nhy v c hiu cao

trong chn on. Barbant v cng s thy nhng
nhm bnh nhn nguy c cao (t l hin mc > 50%),
gi tr d bo dng tnh (kh nng pht hin bnh) >
85% cho c 4 phng tin chn on hnh nh (CT,
MRI, STQ, chp mch). Tuy nhin i vi nhm c
nguy c trung bnh (t l hin mc khong 10%), gi
tr d bo dng tnh ca CT, MRI v STQ > 90%
so vi chp mch bng thuc cn quang ch cn 65%.
Nu t l hin mc ch cn 1% (nhm nguy c thp)
th gi tr d bo dng tnh u < 50% vi CT,
STQ, hoc chp mch, ch tr MRI vn t gn
100%. Ngc li d th no, gi tr d bo m tnh v
chnh xc (kh nng loi tr bnh) vn t trn
85% trong c 4 bin php chn on hnh nh.
4. Chp ct lp vi tnh (CT) l bin php c dng
nhiu do t xm ln v cho php chn on nhanh
chng khi cp cu, pht hin c huyt khi trong
lng gi v xc nh trn dch mng tim. nhy t
83-94%, c hiu l 87-100% i vi chn on
tch thnh MC, tr nhng trng hp MC ln,
nhy gim cn < 80%. Nhc im chnh ca
chp CT, ngoi vic phi dng thuc cn quang, l
kh xc nh c nguyn u ca vt rch ni mc,
kh kho st cc nhnh bn ca MC b tn thng
v khng th nh gi mc h van MC. Cc k
thut mi nh chp CT xon c hoc chp siu nhanh
lm tng nhy ca phng php ny. So vi chp
CT c in, chp CT xon c c u th hn do chp
kiu xon c cho php ghi c nhiu hnh nh hn
lc mc cn quang t cc i, pht hin v nh
gi tt hn cc bin i theo nhp th ca bnh nhn
trn trc di. Hn na, hnh nh dng li 2D v 3D
cho php nhn r ng i ca mng nt so vi xut
pht im ca ng mch di n, mt im c
bit quan trng i vi tch thnh MC on xa
148
loi tr tch thnh MC ngc dng vo quai MC

(chim 27% cc trng hp tch thnh MC xung,
vn c t l t vong cao ti 43%). Chp CT xon c
cng nhanh hn, d thao tc hn v cht lng hnh
nh t ph thuc vo ngi lm, ng thi, do mt ct
c xc nh chnh xc nn vic so snh gia cc
kt qu vi nhau chnh xc hn (d theo di).
5. Chp cng hng t (MRI) c nhy v c
hiu rt cao t 95-100%. MRI c th xc nh chc
chn tch thnh MC, mc lan rng, xc nh
chnh xc v tr nt u tin, xc nh cc nhnh ng
mch bn c lin quan, ng thi c th nh gi
nhng tn thng c lin quan ca ng mch thn.
Cho d c mt s hn ch, song MRI tr thnh
phng php chun chn on tch thnh MC.
a. Ch chp spin echo theo in tm cho php
xc nh dng chy chm trong lng gi. Ch
chp cine v gradient recall echo cng cung cp
nhng d kin v dng chy trong lng ng
mch gi v tht, mc h van MC. Ch
tng cng hnh nh cho php chn on r hn
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
an ton cho nhng bnh nhn t my to nhp

tim, kp mch mu hoc cc thit b cy ca nhn
khoa, ca mi hng...
6. Siu m tim:
a. Siu m tim qua thnh ngc ch c nhy 3580% v c hiu 39-96%, ph thuc vo vng
MC ( nhy t 78-100% on MC ln
nhng gim hn cn 31-55% MC xung).
Siu m qua thnh ngc c th quan st thy hnh
nh mng nt ni mc di ng, cc vt nt v
lng gi ca MC ln hay quai MC, tng ng
knh gc MC, gin quai MC, tng dy
thnh MC... Tuy nhin kh nng ca siu m
gim i rt nhiu trong trng hp khoang gian
sn hp, bo ph, gin ph nang hoc bnh nhn
phi th my. Siu m tim qua thnh ngc khng
phi l phng tin chn on tt tch thnh
MC, d l tch thnh on MC ln.
b. Siu m qua thc qun (STQ) ngy nay tng
i ph bin, an ton, c th thc hin nhanh
chng v d dng ti ging k c bnh nhn
huyt ng khng n nh, vi chnh xc cao
( nhy ln ti 98%, c hiu t 63-96%).
Hn na, phng tin ny cn cho php kho st
v tr nt ni mc u tin, huyt khi trong lng
gi, thay i v dng chy, tn thng ng mch
vnh hoc quai MC phi hp, mc lan rng,
dch mng tim, mc h van MC... Triu
chng quan trng nht chn on tch thnh
MC c th quan st thy qua STQ l di ni
mch b tch trong lng MC, chia lng mch
thnh lng gi v lng tht. Hn na, c th quan
st thy ph dng chy Doppler mu khc hn
nhau gia hai lng mch. Trng hp lng gi
vi ho lu, s thy du hiu di chuyn vt vi
ho ni mc vo gia v thnh mch dy ln.
Chn on xc nh s d dng hn nu c km
theo cc du hiu ca vt nt ni mc u vo,
150
ph Doppler mu trong lng gi, hoc c km

gin gc MC. Nhc im chnh ca STQ l
ph thuc nhiu vo kinh nghim ca ngi lm
siu m, khng nh gi c MC on xa di
ng mch thn tng, khng th lm c nu c
gin tnh mch hoc cht hp thc qun, c th b
st ( vng MC ln on xa hoc quai MC
on gn do kh trong kh qun hoc nhnh ph
qun gc tri, nm gia MC v thc qun lm
gim hoc mt tn hiu siu m) thm ch chn
on sai (nhm vi vt m trung tht, mng x
va vi ho, m di ca siu m ...).
7. Chp ng mch ch bng thuc cn quang c
nhy t 86-88% v c hiu t 75-94% chn
on tch thnh MC ngc, vi cc biu hin: hnh
nh ct thuc cn quang b tch ri hoc xon vn,
dng chy l hoc khng, khng ngm ht thuc
cn quang cc mch mu chnh, h van MC...
Chp ng mch ch c nhy thp, c th b st
nu huyt khi lp kn lng gi, huyt khi trong
thnh MC... Tuy tng c coi l phng tin hng
u chn on, nht l cho php nh gi c
thng 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
trong khong 0.9 0.4g/l, ngng chn on tch

thnh MC l 2.5g/l. Xt nghim nh lng Mhc
(mt 30 pht) trong vng 3h sau khi khi pht c
nhy 91%, c hiu 98% ngi bnh thng,
nhy t 83% bnh nhn nhi mu c tim, chnh
xc chung t khong 96%. Tuy nhin nhy gim
theo thi gian: cn 72% trong vng 3 gi tip theo v
ch l 30% sau 6 gi, d vy vi mc Mhc >10g/l th
c hiu l 100%. Tuy cha c ng dng rng
ri song phng php ny c th xc nh nhng
trng hp nghi tch thnh MC trong vng 6 gi
u (l tng l 3 gi) sau khi pht, hoc gip la
chn cc bin php chn on c hiu khc.
9. hoch nh chnh xc chin lc can thip, cn
nh gi cc thng tn nh: (1) on MC b tch;
(2) v tr vt rch ni mc u tin; (3) h van MC;
(4) thng tn ng mch vnh; (5) thng tn vng
quai MC hoc ng mch thn; (6) xut hin mu
trong khoang mng tim, mng phi hay trung tht.
Cn phn bit thm:
a. Gia tch thnh MC v bnh thoi ho
MC: mng x va MC thng nhn thy r
hn, b mt x x hn nu so vi mng rch ni
mc MC thng nhn hn. Ch gp huyt khi
bm thnh MC khi c tch thnh MC. Tuy
nhin, mng x va MC khi v cng c th s
dn n lot v tch thnh MC.
b. Lng mch tht v gi: dng mu trong lng
mch gi thng c nhiu m cun, chy chm
li, thm ch chy ngc chiu so vi hng tng
mu trong lng mch tht thi k tm thu. Tuy
nhin, kh nng nhn thy r dng mu trong
lng mch gi ph thuc vo mc thng
thng gia hai lng mch: nu khng thng, s
khng thy c tn hiu dng mu. Mt im
quan trng khc l hnh thnh huyt khi ch thy
trong lng mch gi.
152
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.
Nh vy c th thy rng: mi mt trong s cc
bin php chn on hnh nh nh siu m tim qua thc
qun, chp CT, MRI v chp ng mch ch cn quang
u c nhng u hay nhc im nht nh. La chn
bin php chn on s ph thuc vo kh nng ngun
lc sn c ti ch hn l ch da thun tu theo l thuyt.
i vi phnh tch MC tp A th mc ch chnh l a
bnh nhn i m 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
siu m c a chung hn do kh nng linh hot,

nhanh chng, nhy cao, tng i an ton v cho
nhiu thng tin. D sao nu ti ch khng c siu m qua
thc qun, chp ct lp (CT) s l bin php ti u.
Chp MRI s cho nhiu thng tin chi tit nht,
nhy v c hiu cao nht song trong bi cnh cp
cu cn nhanh chng v thun tin th MRI khng ph
hp. MRI ph hp nht nh gi hng lot tin trin
ca tch thnh MC mn, d c phu thut hay ch
iu tr ni khoa.
Chp ng mch ch ch c ch nh cho nhng
bnh nhn khng th chn on xc nh bng phng
tin khc hoc bt buc phi xc nh gii phu hay
thng tn ca ng mch vnh phc v cho phu thut.
V. Tin trin t nhin
Tc ng ca dng mu lm khot su dn vo lp ni
mc vi cc mc khc nhau hoc to thnh lng mch
gi, hoc thm ch v ra ngoi gy t vong. Tch thnh on
MC ln thng nm v tr bn phi, pha sau v trn so
vi l ng mch vnh phi. Khi lan rng v pha quai MC,
vt tch thng pha sau. Tch thnh MC xung li hay
gp pha sau v bn tri nn hay lm tn thng ng
mch thn tri v ng mch chu hoc i tri. 21% bnh
nhn tch thnh MC s t vong trc khi vo vin, t l t
vong nhm tch thnh MC ln khng c iu tr
khong 1-3% mi gi v t khong 25% trong vng 24 gi
u k t khi khi pht, 70% sau tun u v 80% sau tun
th hai. < 10% bnh nhn tch thnh MC on gn sng
sau 1 nm, phn ln cht trong vng 3 thng u do h van
MC cp, tc cc nhnh ng mch chnh, v phnh MC.
90% trng hp tch thnh MC on gn c nguy c v
khi phnh, 75% s v vo khoang mng tim, mng phi tri
hoc trung tht.
Cc dng bnh lin quan n tch thnh MC:
154
1. Xut huyt v huyt khi trong thnh MC:

a. Tin trin ca huyt khi trong thnh MC cng
ging tch thnh MC kinh in, ph thuc vo
v tr huyt khi. Huyt khi thnh MC nm
gia lp ngoi v lp trong ca thnh MC, khc
vi tch thnh MC ch khng c lu thng
vi lng tht ca MC cho d c th nt mng
ni mc v pht trin thc s thnh tch MC,
hoc gy thng ra ngoi hoc to ti phnh MC.
b. D dng chn on xc nh bng siu m qua
thc qun v chp MRI. Xut huyt trong thnh
MC lm tch thnh MC thnh nhiu lp, tng
dy ca thnh MC (>5mm), tng khong
cch gia lng MC v thc qun.
c. Biu hin ca huyt khi thnh MC trn siu
m gm: dy ln khu tr thnh mt vng MC;
c khong trng siu m trong thnh MC;
khng thy vt tch ni mc song vn c tn hiu
dng chy Doppler; y lch vo gia cc vt vi
ho ni mc.
d. MRI cn xc nh hng lot cc thay i bnh l
trong khi mu t, nh nh gi c mc
thoi trin hay tin trin ca huyt khi. MRI
cng nh gi c thi gian to thnh huyt
khi da vo s hnh thnh methemoglobin. Cc
tn hiu mnh trn cc mt ct T1 v T2 do
methemoglobin cho thy tin trin bn cp ca
khi mu t, ngc li chy mu mi s c cc
tn hiu rt a dng v cng trong cc vng
khc nhau ca khi mu t.
2. Mng x va lot MC:
a. Thng gp nht MC xung, l mng x va
c lot tin trin, khot dn vo lp x chun, lp
gia, cui cng hnh thnh nn gin v ti phnh
tht/gi MC, hnh thnh huyt khi ti ch hoc
155
v bung ra... song t khi gy thng hay thc s

tch thnh MC (c th do tc dng bo v ca
lp x ho thnh MC dy sau khi b x va).
Bin chng thuyn tc mch do mng x va lot
kh him. Cc yu t nguy c ca bnh l ny l
tui cao hoc tng huyt p khng kim sot
c. Biu hin lm sng cng ging nh cc
dng tch thnh MC khc: khi pht au ngc
hoc au lng t ngt.
b. Chp CT nh gi chnh xc hnh nh lot tin
trin ca mng x va MC, tuy nhin phi dng
thuc cn quang trng y trong lng MC v
vt lot. So vi chp CT c thuc cn quang, MRI
c chnh xc cao hn, c bit c gi tr khi
chng ch nh tim thuc cn quang. Mc d
siu m thc qun cng c gi tr nht nh song
rt d dng b st nhng mng x va lot on
xa ca MC ln v on u ca quai MC.
3. Tin lng:
a. T l t vong chung ti vin xp x 30% nu tch
thnh MC on gn, 10% vi tch thnh MC
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
MC ln v bnh nhn khng c huyt khi

trong lng gi MC. Nguyn nhn chnh gy t
vong khi theo di lu di bnh nhn tch thnh
MC l v khi phnh do tch thnh th pht
hoc do to thnh ti phnh MC ri v.
VI. iu tr
A. La chn phng thc iu tr
1. T vong khi tch thnh MC khng phi do vt nt
ni mc u tin m ch yu do tin trin ca phnh
tch gy chn p cc mch mu quan trng hoc v.
a. Tch thnh MC on gn (tp A) bt buc phi
iu tr ngoi khoa cng sm cng tt gim
nguy c bin chng (h van MC cp, suy tim
huyt, p tim, triu chng thn kinh) ng thi
gim nguy c t vong (1%/gi).
b. iu tr tch thnh MC on xa (tp B) hin
cn nhiu im cha thng nht song nn khi
u bng iu tr thuc. Phu thut thng ch
nh cho nhng bnh nhn c bin chng hoc
iu tr ni khoa tht bi. V lu di, cn nghin
cu thm 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
b. Tch thnh MC c nhi mu c tim cp: chng

ch nh dng thuc tiu si huyt. Chp MC
trong giai on cp c nguy c rt cao tip tc
gy tch thnh v lm chm tr khong thi gian
qu bu dnh cho phu thut.
B. iu tr ni khoa
1. Ch nh iu tr ni khoa:
a. Tch thnh MC cp tnh tp III khng c bin
chng.
b. Tch thnh MC cp tnh on quai, n thun,
huyt ng n nh.
c. Tch thnh MC mn tnh, n nh.
2. Thc nghim cho thy dng chy theo nhp s tip
tc thc y qu trnh tch thnh ng mch theo c
hai chiu ln xung. V th phi h huyt p cp cu
bng cc thuc dng ng tnh mch mi bnh
nhn ngay khi nghi ng tch thnh MC tr khi
sc tim, nhm mc ch gim lc co bp ca tht tri,
gim mc tng p trong MC (dP/dt), gim huyt
p ng mch xung ti mc thp nht c th c
m khng gy nh hng n ti mu cc c quan
sng cn, nh vy lm gim qu trnh tin trin ca
tch thnh MC v gim nguy c v khi phnh.
3. Hin ti, phi hp chn giao cm v mt thuc gin
mch (v d Nitroprusside Natri) c coi l phng
thc iu tr ni khoa c bn i vi tch thnh
MC. Nn dng thuc chn giao cm trc khi
dng thuc gin mch trnh phn x gii phng
catecholamine th pht khi dng thuc gin mch
lm tng co bp tht tri v mc tng p trong
lng ng mch, cng lm tch thnh MC tin
trin. Liu thuc chn tng ti khi tc dng (nhp
158
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
Thuc c la chn u tin
Propanolol
1 mg TM/3-5 pht, ti a 2-6 mg tnh mch 46,15 mg/kg
6h/ln
Labetalol
10 mg TM/2 pht, sau truyn 2 mg/pht
20-40 mg 10-15
TM, chnh n 5-20
pht/ln, ti a 300mg.
mg/pht
Esmolol
30 mg TM
truyn 3-12 mg/pht
Metoprolol
5 mg TM 5 pht/ln
5-10 mg TM 46h/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,
nu khng c tc dng, tng
dn
2,5-5
nhc li 0,35 mg/kg TM mg/gi
ti
a
sau 15 pht
15mg/gi
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
on xa thng tui cao, hay c cc bnh tim mch,

h hp hoc tit niu km theo. Nhng bnh nhn
tch thnh MC on gn c nhng bnh khc
khng th phu thut c cng nn iu tr ni
khoa. Mc ch ca iu tr ni khoa khi tch thnh
MC giai on cp nhm n nh vt nt tch, phng
v ch phnh tch, thc y qu trnh lin ca vt
tch v lm gim nguy c bin chng.
5. Nguy c tim tng lun phi phng khi iu tr ni
khoa m kp thi bao gm: vt tch thnh MC
tip tc lan rng, khi phnh tch ngy cng phng
hn, nguy c p vo cc t chc ln cn gy gim
ti mu cc c quan - thng biu hin trong bnh
cnh cn au ngc/bng ti pht, chng bng, toan
chuyn ho tng, men tim tng dn v/hoc suy gim
dn chc nng thn. Nguyn nhn chnh gy t vong
bnh nhn iu tr ni khoa l v khi phnh tch
MC v gim ti mu cc c quan.
C. Phu thut
1. Ch nh m:
a. Mi bnh nhn c tch thnh MC cp on gn,
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
2. T l t vong quanh phu thut bnh nhn tch

thnh MC giao ng t 5-10%, c th ln ti 70%
nu c bin chng. Cc yu t c lp tin lng
t vong bao gm: p tim, tru tim mch, v tr vt nt,
thi im phu thut, thiu mu thn hoc tng, ri
lon chc nng thn v c bnh phi hoc bnh ng
mch vnh km theo. Thi gian tin hnh chn on
trc m cng di, t l t vong trong v sau phu
thut cng cao.
3. Phng php m ti u ph thuc tng phu thut
vin, a s u phi hp vi dn keo MC. Mc ch
ca phu thut nhm ct b v thay th on MC c
vt nt u tin, ch khng phi ton b phn MC
b tch thnh. Nu van MC khng th sa li th p
dng phu thut Bentall (thay on gc MC v van
MC, cm li ng mch vnh). Dn keo MC
chim vai tr quan trng, dng dn cc lp MC
b tch v trm kn ch chy mu ca ming ni
MC, nh lm gim t l thay van MC, gim
chy mu trong v sau m cng nh gim tn sut v
mc bin chng.
4. Bin chng ca phu thut bao gm chy mu, nhim
trng, hoi t ng thn cp v/hoc thiu mu mc
treo. Bin chng ng s nht sau m tch thnh
MC on xung l lit hai chi di do thiu mu
vo ng mch tu sng qua cc ng mch gian
sn. Cc bin chng mun bao gm h van MC
tin trin (nu khng thay van MC lun), phnh
mch ti ming ni v ti pht phnh tch MC.
Khong 50% trng hp cn tn ti mt phn phnh
tch sau m. Khong 15% bnh nhn m tch thnh
MC phi m li do tin trin tip ca tch thnh
MC cn st li; hoc do tch thnh MC mi (
vng ming ni hoc on MC khc); hoc do to
thnh ti tha MC. Cc phng php nh chp
161
MRI, siu m tim qua thc qun rt c gi tr theo

di on mch nhn to, ming ni hoc pht hin
sm gin/phng MC.
D. Can thip qua da theo ng ng thng
1. t gi (Stent) trong lng MC ch mi c
thc hin trn s t bnh nhn c nguy c cao khi
phu thut, a s l nhng bnh nhn tch thnh
MC xung c triu chng gim ti mu chi di
hoc cc tng bng (nh rut, gan, v/hoc thn).
t gi c coi l thnh cng khi bt c vt nt
ni mc u tin, gy ng lng gi trong vng 2 gi
sau t: t l thnh cng trn lm sng t 76-100%,
t l t vong sau 30 ngy l 25%. Cc bin chng
gm nhi mu rut, suy thn, thuyn tc chi di, v
lng gi, hi chng sau t Stent trong lng MC
(tng thn nhit v protein C phn ng thong qua,
tng nh bch cu a nhn), vi tn sut giao ng t
0 n 75%. Ti thi im hin nay, t Stent c coi
nh mt bin php iu tr tm thi nhng bnh
nhn c triu chng gim tui mu chi di v hoc
tng bng th pht do tch thnh MC on xa.
t Stent v/hoc c l lng gi c th p dng cho
nhng bnh nhn tch thnh MC on gn n
nh ton trng trc khi phu thut.
2. Hin ti, khong 13% bnh nhn tch thnh MC
c t on mch ghp c gi (Stent graft). Lu
di, on mch ghp c gi c th tr thnh
phng php c bn iu tr tch thnh MC on
xa, trc khi xy ra bin chng.
E. iu tr huyt khi trong thnh MC v mng x
va lot MC
1. Bin php iu tr ph thuc vo v tr thng tn
MC ging nh tch thnh MC. Huyt khi trong
thnh MC v mng x va lot MC ch yu u
162
gp MC xung, do cn iu tr ni khoa tch

cc nhm kim sot ti u huyt p, gim mc tng
p (dP/dt) trong MC, kim sot cc yu t nguy c
ca x va ng mch v theo di st v lu di.
Nguy c t vong ca huyt khi trong thnh MC
khong 21%, trong 2/3 t vong do tin trin thnh
phnh tch hoc v phnh tch MC.
2. Phu thut c ch nh bnh nhn c huyt khi
trong thnh hoc mng x va lot vng MC ln
hoc quai MC v bnh nhn c gin tng dn
hoc hnh thnh ti phnh bt k v tr no ca
MC.
F. iu tr v theo di lu di
1. Tch thnh MC ch nn coi l bin c cp tnh
trong khi a s nguyn nhn hay yu t nguy c ca
bnh li l mt qu trnh mn tnh, ton th v tin
trin dn dn, vn tn ti cho d gii quyt trit
tch thnh MC bng phu thut. Nguy c hnh
thnh ti phnh, tch thnh MC tin trin, tch
thnh MC ti pht phi lun c cnh gic v theo
di cn thn. 14-29% bnh nhn tch thnh MC
on xa hnh thnh ti phnh mch.
2. iu tr giai on sau ca tch thnh MC on xa
cng tng t nh trong giai on cp: kim sot
huyt p ng mch tch cc bng thuc chn giao
cm (Atenolol, Metoprolol, Labetalol) hay Diltiazem.
Cc thuc gy gin mch (tng dP/dt) nh
Hydralazine hay Minoxidil ch nn dng nu phi
hp vi cc thuc lm gim sc co bp (nh chn
giao cm). Trng hp iu tr ni khoa tht bi tc
l tip tc c bng chng tch thnh MC tin trin,
bin chng mch cc tng, au ti pht hoc h van
MC tin trin th xem xt iu tr bng phu thut.
163
3. iu tr chung v lu di cho cc bnh nhn tch

thnh MC d c phu thut hay khng bao gm
kim sot ti u huyt p ng mch vi mc tiu
gim huyt p tm thu ng mch 130 mmHg: (cho
php gim 2/3 t l ti pht).
4. V lu di, t vong (khong 30%) do v khi phng
th pht hoc tch thnh MC ti pht, a s trong
vng 2 nm u. Do vy mc ch ca theo di v ti
khm l pht hin sm cc phnh mch th pht:
khm lm sng, o huyt p, chp phim Xquang tim
phi... tuy nhin bt buc phi lm nhiu ln cc xt
nghim thm d MC nh siu m tim qua thc
qun, chp CT, chp MRI... Chp MRI l tiu chun
vng v l phng tin cung cp nhiu thng tin nht
v bnh. Thi gian ti khm nn vo cc mc nh 3
thng, 6 thng sau khi ra vin, sau tip tc 6
thng/ln trong vng 2 nm, ri tu thuc vo nguy
c ca tng bnh nhn m ti khm 6 thng hoc 12
thng/ln.
Ti liu tham kho
1.
2.
3.
4.
5.
6.
7.
8.
164
Amstrong WF, Bach DS, Carey L et al. Spectrum of acute aortic

dissection of the ascending aorta: a transesophageal
echocardiographic study. J Am Soc Echocardiogr 1996;9:646-656.
Barbant S, Eisenberg M, Schiller N. Diagnostic value of imaging
techniques for aortic dissection. Am Heart J 1992;124:2:541-543.
Cigarroa JE, Isselbacher EM, DeSanctis RW et al. Diagnosis
imaging in the evaluation of suspected aortic dissection: old
standards and new directions. N Eng J Med 1993;328:35-43.
Erbel R. Diseases of the thoracic aorta. Heart 2001;86:227-234.
Hagan PG, Nienaber CA, Isselbacher EM et al. The International
Registry of Acute Aortic Dissection (IRAD): new insights into an
old disease. JAMA 2000;283:879-903.
Harris JA, Bis KG, Glover JL et al. Penetrating atherosclerotic
ulcer of the aorta. J Vas Surg 1994;19:90-98.
Khan IA, Nair Chandra. Clinical, diagnostic, and management
perspectives of aortic dissection. Chest 2002;122:311-328.
Maraj R, Rerkpattanapipat P, Jacobs LE et al. Meta-analysis of 143
reported cases of aortic intramural haematoma. Am J Cardiol
2000;86:664-8.
9.
10.
11.
12.
13.
14.
15.
Meszaros I, Morocz J, Szlavi J et al. Epidemiology and

clinicopathology of aortic dissection. Chest 2000; 117:1271-1278.
Pitt MP, Bonser RS. The natural history of thoracic aortic aneurysm
disease: an overview. J Card Surg 1997;12 (suppl):270-278.
Pretre R, Segesser LV. Aortic dissection. Lancet 1997;349:146164.
Spittell PC, Spittell JA Jr, Joyce JW et al. Clinical features and
differential dignosis of aortic dissection: experience with 236
cases. Mayo Clin Proc 1993;68:642-651.
Suzuki T, Katoh H, Tsuchio Y, et al. Diagnostic implications of
elevated levels of smooth-muscle myosin heavy chain protein in
acute aortic dissection: the smooth muscle myosin heavy chain.
Ann Intern Med 2000; 133:537-541.
von Kodolitsch Y, Schwartz AG, Nienaber CA. Clinical prediction
of acute aortic dissection. Arch Intern Med 2000;160:2977-2982.
Willens HJ, Kessler KM. Transesophageal echocardiography in the
diagnosis of diseases of the thoracic aorta: part I. Chest
1999;116:1772-1779.
165
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 ht
sc tinh t v kh phc tp, i hi s hiu bit v
bnh l cng nh c im ca cc thuc chng lon
nhp. Cc nghin cu cng nh thc t lm sng
cho thy chnh cc thuc chng lon nhp cng c th
gy ra nhng ri lon nhp khc trm trng hoc cc
bin chng nguy him.
4. Trc mt trng hp c lon nhp tim i hi ngi
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
Bng 10-1. Phn loi thuc chng lon nhp theo

Vaughan William.
Nhm Tc dng ca thuc Tc dng u tin trn knh
in hc
I
Tc dng trc tip Chn knh natri nhanh
trn mng t bo
(pha 0)
II
Chn bta giao cm
ng khng trc tip knh
canxi (pha IV)
III
Ko di thi gian ti Chn knh kali ra ngoi
cc
(pha III)
IVa
Chn knh canxi
Chn dng canxi chm vo t
bo ( nt nh tht) (pha II)
IVb
Chn khng trc tip M knh kali (tng kh cc)
knh canxi
Bng 10-2. Phn nhm ca Harrison cho nhm I.
Phn
Tc dng
Thay i trn T
nhm
IA
Ngn chn va phi knh Ko di QRS v QT.
natri nhanh (pha 0)
Ko di thi gian ti cc qua
con ng c ch knh kali
IB
Chn knh natri (nhiu hn t nh hng n
trn m bnh).
QRS v QT.
Lm ngn thi gian ti cc
(gim thi gian tr).
IC
Ngn chn ng k knh Lm di QRS (QT di
natri nhanh.
ra theo do thay i
nh hng rt t n ti cc. QRS).
C. Tm tt mt s loi thuc chng lon nhp
thng dng (bng 10-3).
168
Bng 10-3. Mt s thuc chng lon nhp (TCLN) thng dng.

Thuc
Liu khi
Liu duy
Bn
Chuyn
Tc dng ph
u
tr
hu
ho v o
(gi)
thi
Nhm I
Nhm IA
Quinidine
1,2 - 1,6 7-9
Gan: 80%
Ri lon tiu ho
(Serecor, Quinidex)
g/ngy,
Thn: 20%
(RLTH),
vim
chia u
gan, c quan mu,
tt HA, xon
nh.
Procainamide
(Procan SR, Procanbid)
Disopyramide
(Norpace, Rythmodan)
TM: 17 mg/kg TM: 2-6 3,5

trong 20-30 mg/pht
pht
Ung: 300 mg Ung:
8
100-200
mg mi 6
gi
Gan : 40%
Thn: 60%
Gan: 50%
Thn: 50%
RLTH, h TK, h
mu, h HA,
Lupus.
Khng
cholinergic, gim
co bp c tim, h
HA, xon nh.
Tng tc
thuc
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.
169
Nhm IB
Lidocaine
(Xylocaine)
Mexiletine
(Mexitil)
Torcainide
(Tonocard)
Phenintoin
(Dilantin)
nng bi
chn bta giao
cm, Cimetidine
TM: 1-1,5 mg TM: 2-4 2

/kg sau 0,5 mg/kg
mg/kg mi 10
pht n tng
liu l 3mg/kg
Ung: 400 mg Ung:
10-17
100-400
mg mi 8
gi
Gan: 90%
Thn: 10%
Ung:
400- Ung:
13,5
800 mg
400-800
mg mi 8
gi
TM:
10-15 Ung:
24
mg/kg trong 1 400-600
gi
mg
mi
ngy
Gan: 40%
Thn: 60%
H TK, h tiu
ho, h mu
Gan
H TK, h HA, Tng nng

thiu mu
bi Cimetidine
Amiodarone,
Fluconazole,
Gim nng
bi Rifamycin
Carbamazepin
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
170
Gim nng
bi Rifamycin
Phenintoin;
Tng nng
do Theophyllin
Morcizine
(Ethmozine)
Nhm IC
Flecanide
(Tambocor)
Propafenone
(Rythmol)
Nhm II
Metoprolol
Ung:
6-13
200-300
mg mi 8
gi
Gan: 90%
Thn: 10%
H TK, h tiu
ho, c th gy
lon nhp
Ung: 50- 12-27

200
mg
mi 12 gi
Gan: 65%
Thn: 35%
H TK, gim co
bp c tim, gy
lon nhp. Chng
ch nh khi c
tn thng thc
th cu trc tim
Ung:
2-32
150-300
mg mi 8
gi
Gan: 50%
Thn: 50%
RLTH, gim co
bp c tim, gy
lon nhp, tng
nguy c t vong
bnh nhn sng
st sau t t
Gan
Gim co bp c Tng hot tnh
TM: 5 mg mi Ung: 25- 3-4
Tng nng
bi:
Amiodarone
Tng bloc nh
tht nu dng
thuc
cng
chn bta giao
cm hoc chn
knh canxi.
Tng nng
Digoxin; tng
hot tnh ca
thuc chn bta
giao cm.
171
(Betaloc, Lopressor)
5 pht
Propranolol
(Inderal)
TM: 5 mg mi Ung: 10- 3-4

5 pht
120
mg
mi 8 gi
Gan
Esmolol
(Breviloc)
TM:
mg/kg
Dng
esterases
trong mu
Nhm III
Amiodarone
(Cordarone, Pacerone)
100
mg
mi 8-12
gi
0,5 TM: 0,05- 9 pht

3
mg/kg/ph
t
Ung: 1,2 -1,6 Ung:

g/ngy
200-400
TM: 5mg/kg mg/ngy
sau 10-20
mg/kg/ngy
25-110 Gan
ngy
tim, gim nhp

tim, co tht ph
qun, h TK, lit
dng
Gim co bp c
tim, gim nhp
tim, co tht ph
qun, h TK, lit
dng
(ging nh trn)
Phi, mt, tuyn

gip, chc nng
gan, ko di QT,
gim co bp c
tim
172
bi thuc chn
knh can xi
(ging nh trn)
(ging nh trn)
Tng hot tnh

Warfarin; tng
nng
Flecanide
v
Digoxin; tng
nguy c xon
nh nu dng
cng vi thuc
Sotalol
(Betapace)
Bretylium torsylaye
Ibutilide
(Corvert)
Nhm IVa
Diltiazem
Ung: 80- 15-17

120
mg
mi 12 gi
TM:
5-10 TM: 1-2 7-9
mg/kg, nhc mg/pht
li ti tng
liu
l
30mg/kg
TM: 0,015 2-12
0,025 mg/kg
trong 5 pht
TM:
mg/kg
0,25 TM: 10-15 3-4

mg/gi
Ung: 30120
mg
mi 8 gi
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
Xon nh, h Trnh
dng
HA, au u, cng cc thuc
RLTH
lm ko di QT
Khng
Gim nhp tim,
chuyn ho, bloc nh tht,
thi
qua gim co bp c
thn
tim, xon nh, co
tht ph qun
Gan: 20%
Thn: 80%
Gan: 90%
Gan
Gim nhp tim,

gim co bp c
tim, lm nng suy
tim
173
Verapamil
Nhm IVb
Adenosine
(Adenocard)
thuc khc
Digoxin
TM:
mg
2,5-10 Ung: 80- 6-12

120
mg
mi 8 gi
TM: 6 mg
tim nhanh,
nu khng tc
dng nhc li
12 mg tim
nhanh
TM/Ung:
0,25-0,5 mg
Gan
10
giy
TM/Ung: 36-48
0,1-0,75
mg mi 8
gi trong
ngy
Thn
(ging nh trn)
(ging nh trn)
Nng bng, kh
th, au ngc, v
tm thu, co tht
PQ
Tng hot tnh

Dipyridamole;
b thay i tc
dng do Cafein,
Theophylline
H TK, h tiu Tng nng

ho, bloc nh tht, bi Quinidine,
lon nhp
Verapamil,
Amiodarone,
Propafenone.
Ghi ch: TM: tim Tnh mch; TK: thn kinh; RLTH: ri lon tiu ho; HA: huyt p
174
II. Thm khm bnh nhn b ri lon nhp tim

A. Lm sng
1. Khai thc k bnh s v nh gi lm sng rt quan
trng, n gip cho iu tr tt cc ri lon nhp tim.
2. Hi k tin s xut hin lon nhp, hon cnh xut
hin, thi gian, tn xut, cch bt u cng nh kt
thc, p ng vi cc iu tr (xoa xoang cnh, n
nhn cu...), cc triu chng khc i km (au ngc,
ngt, xu...).
3. Hi v tin s gia nh xem c ai mc cc RLNT nh
bnh nhn khng (mt s lon nhp bm sinh c
trong cc bnh nh bnh c tim ph i, hi chng
QT di gia nh, hi chng Wolff - Parkinson White...).
4. Hi k tin s cc bnh tim c t trc (bnh van
tim, bnh mch vnh...) hoc cc bnh khng phi
tim c th lin quan n lon nhp (bnh ni tit,
bnh vim nhim, nhim trng...).
5. Thm khm thc th cn ch n cc du hiu sinh
tn, nhp tim u hay khng, huyt p nh th no,
cc biu hin bnh tim mch, cc bnh khc...
6. Cn lm sng cn ch : in gii , cng thc mu,
mt s nng cc thuc ang dng m nghi c nh
hng n nhp tim. Trong mt s trng hp nghi
ng, c th lm thm cc xt nghim chn on bnh
tuyn gip hoc cc c t...
B. in tm (T): L mt xt nghim rt quan trng
trong chn on ri lon nhp tim.
1. in tm 12 chuyn o: L bt buc, nu c
T lc khng c lon nhp s gip ch rt nhiu cho
chn on.
2. Theo di trn monitor lin tc gip theo di nhng
bin i v tn s, hnh thi ca lon nhp; cc p
ng vi iu tr...
175
3. Cc trng hp khng r v hot ng ca nh trn

T th c th lm mt s chuyn o c bit nh:
a. Chuyn o Lewis: in cc m t b trn
phi cnh xng c, in cc dng t b di
tri cnh c.
b. Chuyn o thc qun: a mt in cc c bit
vo trong thc qun gn v tr nh tri, cho php
nhn r sng hot ng ca nh.
c. Chuyn o trc tip bung nh: dng in cc
my to nhp tm thi a vo bung nh phi.
C. Holter T: Phng php ghi li T trong sut 24
gi hoc hn, cho php ghi li c nhng on ri lon
nhp m T bnh thng khng bt c (vd. cc ngoi
tm thu, cc cn nhp nhanh kch pht...).
D. Mt s phng php khc
1. Nghim php gng sc i khi rt c ch nh
gi nhng lon nhp lin quan n gng sc, c bit
l cc ngoi tm thu tht hoc cc cn nhp nhanh
tht. N phn bit nhng ri lon nhp ny l do tn
thng thc th (xut hin hoc nng ln khi gng
sc) hoc c nng (khi gng sc mt i).
2. Thm d in sinh l tim (cardiac electrophysiology study) l phng php c ch nh khi
cc thm d khng chy mu khng nh gi
cc ri lon nhp hoc iu tr mt s ri lon
nhp. Ngi ta s dng mt s dy in cc v a
n nhiu v tr khc nhau trong bung tim nh
gi bn hot ng in hc ca tng nh, nt nh
tht, ng dn truyn nh tht, tng tht... Phng
php ny cng cho php nh v c cc v tr hoc
cc ng dn truyn bt thng, cc ngoi v v
xc nh c ch ca cc loi ri lon nhp.
176
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, Phu thut
tim mch...
6. Rung nh v cn.
B. Sinh l bnh
1. Cc gi thit v c ch gy rung nh:
a. Vng vo li ti nh, l c ch m ngy cng c
nhiu bng chng v c ch nht.
b. Gi thit 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
nhp tht nhanh th cng lm cho thi k tm trong

ngn, lng mu v tht gim i ng k.
4. Phn loi rung nh: c th phn ra cc th rung nh
(da trn kiu xut hin rung nh) nh sau tin cho
vic theo di v iu tr:
a. Cn rung nh ln u mi xy ra, l rung nh mi
thy xut hin ln u tin bnh nhn, c th
thong qua do nhng nguyn nhn c th phc
hi c hoc c th tn ti mi.
b. Rung nh kch pht, l nhng rung nh xut hin
v kt thc t pht (thng trong 48 gi) v d b
ti pht.
c. Rung nh dai dng, l nhng rung nh tn ti lu
nhng vn c th ti to nhp xoang bng thuc
hoc sc in chuyn nhp.
d. Rung nh mn tnh, l nhng rung nh lu m
chuyn nhp bng thuc hoc sc in u khng
hoc rt t thnh cng hoc khng duy tr c
lu nhp xoang.
C. Triu chng lm sng
1. C th khng c triu chng g.
2. a s bnh nhn thy hi hp nh trng ngc, kh
th, au ngc, chng mt, v m hi...
3. C th c bin chng tc mch l biu hin u tin
ca bnh.
4. Nghe tim: thy lon nhp hon ton, c th thy
nhng du hiu ca bnh van tim km theo (nu c).
D. Cc xt nghim chn on
1. in tm :
a. Sng P mt, thay bng sng f= 400 - 600 ck/pht.
b. Nhp tht rt khng u v khong cch, tn s.
178
c. Bin ca cc sng QRS trn cng mt o

trnh cng rt khc nhau.
2. Siu m tim gip chng ta nh gi xem c huyt
khi trong cc bung tim hay khng hoc c th c
nguy c hnh thnh huyt khi (gin cc bung tim,
hin tng tng ng trong cc bung tim).
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
L thuc kinh in hn ch tn s tht khi

b rung nh nhanh. N l thuc l tng cho
nhng bnh nhn b rung nh nhanh m c
gim chc nng tht tri, hoc c chng ch
nh vi cc thuc chn bta giao cm, chn
knh calci.
Thng dng loi tim tnh mch (Isolanide,
Cedilanid 0,4 mg tim TM 1/2- 1 ng). Trong
trng hp khng khn cp, c th cho dng
ung Digoxin 0,25 mg (1-2 vin/ngy), iu
chnh liu v sau theo p ng c th.
Ch nu c ch nh sc in iu tr rung
nh th phi dng Digitalis trc vi ngy.
b. Chn bta giao cm:
C th dng dng tim tnh mch
(Metoprolol, Esmolol) hoc dng ung. Cc
thuc chn bta giao cm thng c la
chn nhng bnh nhn rung nh nhanh m
c cn nguyn bnh mch vnh hoc rung nh
nhanh tin pht.
Cn ch cc chng ch nh ca cc thuc
chn bta giao cm ( cp n bi cc
thuc iu tr THA).
c. Cc thuc chn knh canxi:
Thng dng Verapamil hoc Diltiazem dng
tim tnh mch hoc dng ung. Cc thuc
ny lm gim p ng tht tt, c bit dng
tim c tc dng kh nhanh.
Chng ch nh dng khi c ri lon chc
nng tht tri, c suy tim r.
2. Ngn nga tc mch:
a. Ch nh v chng ch nh dng thuc chng
ng bnh nhn rung nh c trnh by trong
bng 10-4. Nguy c tc mch l rt d xy ra
bnh nhn b rung nh. Tuy nhin, cn cn nhc
180
gia li ch v tc hi ca vic dng cc thuc

chng ng tng bnh nhn rung nh c th.
b. Thuc v cch dng: Khng Vitamin K l thuc
c la chn hng u. Mc tiu cn t c
khi dng l m bo t l INR mc 2,0 - 3,0.
Bng 10-4. Ch nh v chng ch nh dng thuc
chng ng bnh nhn rung nh
Ch nh:
Rung nh bnh nhn c: tin s tc mch no hoc tai
bin thong qua, c suy tim huyt, bnh c tim gin,
bnh ng mch vnh, hp van hai l, c van tim nhn to,
cng tuyn gip, THA.
Dng trc khi sc in iu tr rung nh (c k hoch) t
nht 3 tun v sau sc in t nht 4 tun.
Chng ch nh tng i:
Khng c kh nng kim sot, theo di cc xt nghim v
t l Prothrombin v INR.
Bnh nhn sa st tr tu.
Ph n ang mang thai.
Lot ng tiu ho ang tin trin.
C tin s chy mu trm trng hoc b ri lon ng mu.
THA nng khng khng ch c.
Nu ch nh chuyn nhp th cn dng mt
thuc trong nhng thuc trn trc t nht 3
tun v sau t nht 4 tun.
Trong trng hp cn chuyn nhp cp cu th

cn cho Heparin v phi kim tra siu m qua
thc qun bo m khng c mu ng trong
nh tri mi chuyn nhp cho bnh nhn v
sau chuyn nhp th tip tc cho khng
Vitamin K thm 4 tun.
181
Vi nhng bnh nhn tui di 65 v t nguy c tc mch hoc

c chng ch nh dng khng vitamin K th c th cn nhc
cho Aspirin thay cho khng Vitamin K.
Bng 10-5. Cc thuc khng Vitamin K thng dng.
Loi thuc
Thi gian tc dng (gi)
Bt u
Ko di
Thi gian tc dng ngn
EthyleBiscoumacetate
28-24
24 48
(Tromexane)
Phenindione (Pindione)
48 - 96
Thi gian tc dng va
Acenocoumarol (Sintrom)
24 - 48
48 - 96
Fluindione (Previscan)
48 - 72
Tioclomarol (Apegmone)
48 - 96
Thi gian tc dng di
Warfarine (Coumadine)
36
96 - 120
3. Chuyn nhp (a v nhp xoang) v duy tr nhp
xoang: R rng l vic chuyn v nhp xoang v duy
tr nhp xoang s mang li nhiu li ch cho bnh
nhn v c huyt ng v gim cc nguy c tc mch.
Tuy nhin, phi lu l bnh nhn cn c nh gi
k lng trc khi quyt nh chuyn nhp. Trong
mt chng mc no , nu khng nh gi k lng
bnh nhn, vic c gng chuyn nhp v dng thuc
duy tr c th s tht bi hoc khng mang li li ch
g hn m lm tng nguy c do dng thuc duy tr
nhp lu di. Nhiu nghin cu chng minh rng,
i vi nhng bnh nhn b RN lu, c nhiu yu
t ti pht km theo... th vic khng ch nhp tht,
ngn nga tc mch v chung sng ho bnh vi RN
li l gii php ti u nht. Trong mi trng hp
RN, cc bnh c bn phi c xem xt gii quyt
trit trc khi iu tr rung nh.
182
a. Chuyn nhp bng thuc: L phng php nn

c la chn u tin trong vic chuyn nhp.
T l thnh cng khc nhau ph thuc vo tnh
trng c th tng bnh nhn cng nh nguyn
nhn gy rung nh v thi gian rung nh. Nhn
chung, t l thnh cng do chuyn nhp bng
thuc thp hn chuyn nhp bng sc in. Trong
trng hp dng thuc chuyn nhp khng thnh
cng th nn ch nh sc in iu tr kp thi.
Khi vai tr ca cc thuc ny kh quan trng
v n gip kh nng sc in chuyn nhp thnh
cng cao hn v duy tr tt nhp xoang sau .
Cc thuc dng tim tnh mch (bng 10-3).
Procainamide (nhm IA): l thuc c th
c chn chuyn nhp trong RN. C
khong 1/3 bnh nhn khi dng thuc ny c
tc dng ph (ri lon tiu ho, huyt hc, hi
chng ging Lupus...).
Amiodarone (Cordarone): l thuc c la
chn khi cc thuc khc khng dng c
hoc tht bi. Lu l thuc c thi gian bn
hu cc k di (120 ngy). Thn trng vi cc
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
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 tng
tc vi mt s thuc khc nh Digoxin, khng
vitamin K, Verapamin, lm tng tc dng cc
thuc ny khi dng cng vi nhau.
Sotalol l thuc thuc nhm III nhng c tc
dng chn bta giao cm. N c th dng
bnh nhn rung nh, nhng cn ch cc tc
dng ph lin quan n chn bta giao cm v
c 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
b. Chuyn nhp bng sc in: L bin php c

hiu qu cao trong chuyn nhp t rung nh v
nhp xoang vi t l thnh cng trn 80%.
Sc in iu tr rung nh nn c ch nh
khi dng thuc tht bi, c du hiu thiu
mu c tim, kh khng ch nhp tht, suy
tim... c bit khi c nhng ri lon huyt
ng trm trng th cn ch nh sm. Sc
in s thnh cng cao hn khi c dng
cc thuc trc (v d Amiodarone).
Sc in chuyn nhp ch tin hnh khi bnh
nhn c dng chng ng y (xem
phn trn). Trong trng hp cp cu th cho
Heparin v phi lm siu m qua thc qun
loi tr khng c mu ng trong nh.
Sc in phi c tin hnh nhng ni c
kh nng cp cu v theo di tt v tim mch,
bnh nhn c gy m tt. Cc nhn vin y
t phi thnh tho trong vic p dng cc bin
php h hp h tr.
Cc yu t nh hng n kt qu ca chuyn
nhp bng sc in l: thi gian b rung nh
lu hay nhanh, ln ca sng f, kch thc
nh tri, c h van hai l phi hp, c suy tim
khng ? Thi gian b rung nh cng lu, sng
f cng nh, nh tri o trn siu m ln hn
45 mm l nhng yu t d bo tht bi ca
sc in hoc kh nng ti pht rung nh cao.
Nng lng dng trong sc in iu tr rung
nh thng bt u bng liu nh 100J sau
c th tng ln ti 200J, 300J v phi l sc
in ng b.
4. Cc phng php iu tr khc:
a. t my to nhp vnh vin: Phng php ny
c ch nh khi bnh nhn khng p ng vi
cc cch iu tr trn hoc khi nhp tht b chm
185
b. Trit ph rung nh qua ng ng thng

(catheter ablation): Qua ng ng thng a cc
in cc v dng sng radio cao tn t trong nh
tri thnh tng kha to hiu qu ging nh phu
thut Maze trit ph cc vng vo li ti c
nh. Phng php ny c t l thnh cng khng
cao lm v c th c nhng bin chng, nhiu khi
phi cn n cy my to nhp vnh vin. Ngy
nay, cng vi s tin b ca k thut v cc dng
c mi cho php t l thnh cng ngy cng
cao hn v ha hn y s l mt phng php
iu tr tt cho nhng rung nh dai dng mn tnh.
c. Phu thut ct cc kha c nh (phu thut
Maze), phu thut to hnh lang nh, phu thut
c lp nh l nhng phu thut c thc hin
iu tr rung nh, tuy nhin t l thnh cng
cn ph thuc nhiu vo k thut v tnh trng
bnh 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
2. Cung nh thng ch tn ti vi gi n vi ngy, t

khi ko di hn v sau n s chuyn v nhp xoang
hoc thnh rung nh.
B. Sinh l bnh
1. Cung nh xut hin l do vng vo li nh, thng
thng nh phi v rt t khi nh tri.
2. in hnh nht l vng vo li nh phi v i theo
ngc chiu kim ng h xung theo thnh t do ca
nh phi v ln li vch lin nh.
3. Cung nh c th chia lm 2 th (type): Type I l loi
cung nh c th ct c bng to nhp nh vt tn
s v tn s nh thng mc 240-340 chu k/pht
khi cha dng thuc. Type II l loi cung nh khng
ct c bng to nhp nh vt tn s v tn s nh
thng mc cao hn 340-430 chu k/pht.
C. in tm : L thm d c bn cho php chn on
cung nh.
1. in hnh, ta s thy mt sng P v thay bng sng F
hnh rng ca, u n, rt r cc chuyn o sau
di (DII, DIII, aVF).
2. Tn s F t 240-340 ck/pht, trung bnh 300 ck/pht.
3. Phc b QRS thng ging nh lc cn nhp xoang
(khng gin rng).
4. Tn s tht thng kh u v l c s so vi nhp
nh v c th c bloc 2:1; 3:1... Tuy nhin, i khi tn
s tht khng u do s thay i mc bloc nh tht
trong cung nh.
187
Hnh 10-2. Cung nh 2:1.

5. Trong trng hp cung nh m c bloc nh tht 2:1
th i khi kh chn on do sng F ln vi sng T.
Khi cn thit lm mt s nghim php lm chm
p ng tht lm l ra sng F r hn (v d xoa
xoang cnh, 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
a. Thng dng cc thuc nhm IA (Quinidin,

Procainamid), IC (Flecainid, Propafenone) hoc
nhm III (Amiodaron).
b. Thng thng cc thuc ny c t l thnh cng
khng cao trong chuyn nhp nhng rt quan
trng gip cho sc in thnh cng, v c mt t
l nht nh khi sc in cung nh s tr thnh
rung nh v nu khng c dng cc thuc ny
trc th kh c th a v c nhp xoang.
3. Chng ng trong cung nh nn ch nh cho nhng
bnh nhn c nguy c tc mch cao (tin s tc
mch, nh tri ln...).
4. Sc in chuyn nhp: l phng php rt c hiu
qu v nn c la chn cho bnh nhn cung nh.
Thng dng nng lng thp, bt u t 50J. Mt s
trng hp sc in lm cung nh bin thnh rung
nh, khi cn sc tip nh trong iu tr rung nh
chuyn v nhp xoang.
5. To nhp nh vt tn s: C th thc hin bng
in cc p trc tip vo thnh c nh trong khi m
hoc a in cc qua ng thc qun. Vi in cc
qua ng thc qun th cn phi c dng in ln
(ti 30 mA), nn c th gy au n cho bnh nhn.
Thng dng cch to nhp tim p theo my vi tn
s nhanh hn tn s tim ca bnh nhn khong 10 20 nhp gy c ch vng vo li ri tt my t
ngt, nhp xoang ca bnh nhn s c ti lp li.
6. Trit ph vng vo li qua ng ng thng: y
l bin php hu hiu vi t l thnh cng trn 95 %
v t ti pht. Trc tin dng cc in cc thm d
bn in hc ca nh pht hin ra vng vo li,
sau nh v v tin hnh t bng sng radio cao
tn qua mt dy in cc.
189
7. Vi mt s trng hp cung nh tn ti dai dng v

khng p ng vi cc phng php iu tr trn, c
th cn phi t trit ph nt nh tht v cy my to
nhp vnh vin.
V. Cn nhp nhanh kch pht trn tht (CNNKPTT)
Thc t tim nhanh trn tht bao gm nhiu loi ri lon
nhp khc nhau nh: rung nh, cung nh, tim nhanh nh, nhp
nhanh trn tht c vng vo li nt nh tht hay qua ng dn
truyn ph... Tuy vy, trong thc hnh t trc n nay ngi ta
gi l cn nhp nhanh kch pht trn tht ch nhng cn
tim nhanh bn cht trn tht v c vng vo li nt nh tht
hoc vng vo li nh tht qua ng dn truyn ph.
A. Sinh l bnh: thng c hai loi ch yu:
1. Cn nhp nhanh kch pht trn tht (CNNKPTT)
c vng vo li ngay ti nt nh tht: vng vo li
chy qua ng dn truyn nhanh v chm nt nh
tht hoc qua ng dn truyn chm nt nh tht
v ng dn truyn ph rnh nh tht (trong hi
chng WPW). Trong i a s cc trng hp (95%)
ng i xung (xui) ca vng vo li l qua ng
dn truyn chm ca nt nh tht v i ngc ln theo
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
B. Triu chng lm sng

1. CNNKPTT thng xy ra nhng bnh nhn khng
c bnh tim thc tn. Tuy nhin c mt s trng
hp cng c th xy ra cc bnh nhn c bnh tim
thc tn.
2. Khai thc tin s c th thy bnh nhn c nhng cn
hi hp nh trng ngc, tim p nhanh, s xut hin
v kt thc cn nhp nhanh kh t ngt.
3. Trong cn bnh nhn c cm gic hi hp nh trng
ngc, lo lng, tim p rt nhanh.
4. CNNKPTT thng t nh hng n huyt ng v
thng khng ko di. Song c mt s t trng hp,
cn c th ko di hng ngy v c th gy tt p
hoc suy tim.
5. Nghe tim thy nhp tim thng rt u, tn s trung
bnh 180 - 200 ck/ pht.
6. CNNKPTT c th kt thc t ngt hoc khi bo
bnh nhn ht su vo ri th ra nhng ng cht
thanh mn (rn th) hoc khi c bc s xoa xoang
cnh hay n nhn cu...
C. in tim
1. Phc b QRS thng thanh mnh, u, tn s 180 200 ck/pht.
2. Sng P khng nhn thy do ln vo QRS hoc i khi
c th nhn thy ging nh sng r nh V1.
3. Khi kt thc cn c th thy mt on ngng xoang
ngn hoc nhp chm trc khi ti lp nhp xoang.
191
Hnh 10-3. Cn nhp nhanh kch pht trn tht.

D. iu tr
1. Ct cn nhp nhanh:
a. Cc bin php gy cng ph v c th ct c
cn nhp nhanh: C th bo bnh nhn ht su vo
ri th ra nhng ng thanh mn (ng tc rn);
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
c.
d.
e.
f.
g.
nn ch tnh mch nn v khi tim phi bm

tht nhanh v thi gian bn hu ca thuc cc
nhanh. Ln u dng 6 mg, nu khng kt qu th
tim nhc li 6 mg v nu vn khng c kt qu
th dng tip 12 mg (2 ng).
Cc thuc chn knh canxi v chn bta giao
cm c th c dng khi dng Adenosine tht
bi. Thc t ngi ta thng dng Verapamil
dng tim tnh mch. Verapamil lm ko di thi
gian tr ca nt nh tht v chm dt vng vo li
ca nt nh tht. Liu lng ca Verapamil t 510 mg tim tnh mch trong 2-3 pht. Chng ch
nh bnh nhn c suy gim chc nng tht tri,
c tt p, cn thn ngi gi.
Chn bta giao cm thng dng l Propranolol
hoc Esmolol dng tim TM. Liu ca
Propranolol l 0,15 mg/kg tim TM tc 1
mg/pht. Ch cc tc dng ph v chng ch
nh ca cc thuc ny.
Digitalis, lm chm dn truyn trong nt nh tht
v c th ct c cc CNNKPTT do vng vo li
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
Thng ch cn nng lng nh (50J) v ng b

l c th ct c cn.
2. iu tr trit :
a. Hin nay, nh phng php thm d in sinh l
pht hin cc ng dn truyn ph v qua
dng sng radio cao tn trit ph (t)
(catheter ablation) cc ng dn truyn ph
c th gip cha khi bnh hon ton. y l
phng php nn c la chn hng u cho cc
bnh nhn c CNNKPTT ti pht nhiu khng
p ng vi cc iu tr ni khoa thng thng.
i vi tt c cc bnh nhn c chn on l
c CNNKPTT nn gi n nhng trung tm c
th thm d in sinh l xem xt vic iu tr
trit cc CNNKPTT cho bnh nhn.
b. Cc thuc c th dng d phng CNNKPTT
c vng vo li ti nt nh tht l chn bta giao
cm, Digitalis, hoc Verapamil... Tuy vy, vic
dng cc thuc ny lu di phi c ch ti
cc tc dng ph ca chng.
c. Hin nay, hu ht cc nghin cu u cho thy li
ch vt tri ca trit ph ng dn truyn ph
so vi dng thuc v y chnh l phng php
c th cha khi bnh hon ton.
VI. Ngoi tm thu tht
Ngoi tm thu tht (NTTT) l mt trong nhng ri lon
nhp tim cng kh thng gp. Tuy NTTT c th xut hin trn
ngi bnh thng v khng gy nguy him, nhng nhiu trng
hp NTTT thng xy ra trn mt bnh nhn c bnh tim v c
th gy nguy him n tnh mng ngi bnh nu khng c
pht hin v x tr kp thi.
Vic quyt nh iu tr cng cn phi c cn nhc k
v thng phi da trn cc triu chng do NTTT gy ra, s c
mt ca bnh tim km theo v nht l phi da trn mt s c
194
im ca NTTT trn T xem c phi l NTTT nguy

him hay khng.
A. Nguyn nhn
1. NTTT ngi bnh thng: hay gp ph n v
thng l mt dng, mt . Tin lng lnh tnh v
thng khng cn phi dng thuc chng lon nhp.
2. NTTT bnh nhn c bnh tim thc tn: hay gp
trong mt s bnh l sau:
a. Nhi mu c tim: kh hay gp v cn cnh gic
trong giai on cp cng nh phi theo di st
sau NMCT.
b. Bnh c tim gin.
c. Bnh c tim ph i.
d. Bnh van tim (do thp, sa van hai l...).
e. Tng huyt p.
f. Dng cc thuc iu tr suy tim (Digitalis, cc
thuc ging giao cm), cc thuc li tiu, cc
thuc chng lon nhp...
g. Ri lon in gii mu...
B. Triu chng lm sng
1. Bnh nhn c th khng thy c triu chng g c
bit c. Nhng a s bnh nhn thy c cm gic hi
hp nh trng ngc, hoc l cm gic hng ht
trong ngc.
2. Thm khm lm sng c th thy: s mch c nht
rt yu hoc khng thy, tip l khong ngh di
hn. C trng hp thy mch chm bng mt na so
vi tn s ca tim nu nghe tim ng thi (khi bnh
nhn c NTTT kiu nhp i). Nghe tim c th thy
nhng nht bp xy ra sm v sau thng hay c
mt khong ngh b. Khi bnh nhn b rung nh th
trn lm sng kh bit c l c NTTT hay khng.
Khi , T mi gip chn on chc chn c.
195
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).
5. Khi c mt nht bp nhp xoang xen k mt NTTT
th gi l NTTT nhp i, v khi hai nhp xoang c
mt NTTT gi l NTTT nhp ba...
Hnh 10-4. Ngoi tm thu tht.
196
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.
2. S lng NTTT nhiu.
3. NTTT i thnh tng chm hoc nhp i, nhp ba.
4. NTTT n sm (sng R (l sng R ca phc b
NTTT) s ri trn sng T ca phc b tht trc .
5. NTTT a dng, a .
F. iu tr
1. i vi NTTT 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
2. i vi NTTT thc tn (trn bnh nhn c bnh

tim thc tn) trong giai on cp tnh ca bnh:
a. Thng gp nht l trong NMCT cp v bo hiu
c th sp chuyn thnh nhp nhanh tht hoc
rung tht. NTTT cn c th xy ra khi bnh nhn
c ph phi cp do cc bnh van tim, vim c tim
cp, vim mng ngoi tim... Mt s bnh cnh
cng cn c quan tm: bnh nhn c hi chng
Prinzmetal, hi chng ti ti mu sau dng
thuc tiu huyt khi hoc sau can thip MV.
b. Thuc hng u l: Lidocain (Xylocain) tim TM
thng 80 - 100 mg sau truyn TM 1-4mg/
pht. C th gp cc tc dng ph ca Lidocain
nh chng mt, nn, o gic...
c. Procainamid l thuc c chn thay th cho
Lidocain khi Lidocain khng c tc dng hoc
bnh nhn khng th dung np c. Liu dng
l cho ngay 100mg tim thng TM mi 5 pht
cho n tng liu l 10-20 mg/kg cn nng, sau
truyn TM 1-4mg/pht.
d. Mt s nghin cu gn y cho thy Amiodarone
c th lm gim t l t vong bnh nhn NMCT
cp c 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
CAST). Do vy cc thuc nhm IC nhn chung l

chng ch nh trong NTTT sau NMCT. Thuc
c la chn l nhm chn bta giao cm hoc
Amiodarone. Nghin cu CAMIAT v EMIAT
chng minh Amiodarone c th lm gim t l t
vong bnh nhn NMCT c NTTT.
c. Bnh c tim l mt trong nhng nguyn nhn
quan trng gy NTTT. Nguy c t t s tng cao
vt nhng bnh nhn ny khi c NTTT. Trong
giai on mn tnh th nn dng Amiodarone.
d. Khi gp NTTT bnh nhn b bnh van tim c
suy tim nng th cn c x l ngay. Ch cc
ri lon in gii v bnh nhn c b ng c
Digitalis khng. Trong trng hp bnh nhn ng
c Digitalis c NTTT (hay gp nhp i) th
ngng Digitalis ngay v cho Lidocain, ng thi
iu chnh tt cc ri lon in gii. Cc trng
hp khc c NTTT bnh nhn c bnh tim mn
tnh ta c th la chn Amiodarone hoc Sotalol.
VII. Cn nhp nhanh tht
Cn nhp nhanh tht (NNT) l cn tim nhanh khi c t nht
ba nht NTTT i lin nhau vi tn s trn 100 ck/pht. C th
chia NNT ra lm hai loi da trn thi gian ko di ca NNT:
NNT thong qua (hoc khng bn b): l NNT xut hin
tng on ko di khng qu 1 pht.
NNT bn b: l khi c NNT ko di trn 1 pht.
A. Nguyn nhn
1. Bnh tim thiu mu cc b.
2. Bnh c tim (bnh c tim gin, bnh c tim ph i,
ph i ng ra tht phi, sarcoid c tim...).
3. Bnh van tim, c bit khi tht tri gin v gim chc
nng co bp.
4. NNT do dng thuc hoc c t: thuc chng lon
nhp nhm IC, Digitalis...
199
5. NNT bn b tin pht: thng xy ra bnh nhn

khng c bnh l thc tn tim.
6. Trong hoc sau phu thut tim...
B. Triu chng lm sng
1. Biu hin lm sng rt khc nhau bnh nhn c cn
NNT. N tu thuc vo hon cnh lm sng, tn s
tht, s c mt ca cc bnh tim thc tn km theo...
2. Mt s bnh nhn c th khng cm thy c triu
chng g c bit. Tri li mt s khc li c th
biu hin ngay bng ngt hoc t t.
C. in tm
1. Tn s tim thng t 130 -170 ck/pht.
2. Thng thng th nhp tim khng tht u nh trong
cn nhp nhanh kch pht trn tht, nht l khi m
trc c NNT a dng hoc c nht hn hp.
3. Phc b QRS thng gin rng, biu hin di dng
ging nh ca bloc nhnh tri hoc phi.
4. Sng P c th nhn thy vi tn s chm hn ca
QRS. Trong trng hp khng nhn r sng P, nu
lm chuyn o thc qun s thy r rng c s phn
ly gia nhp nh v tht. Trong mt s trng hp ta
thy c s dn truyn ngc dng lm cho sng P m
ngay sau QRS.
Hnh 10-5. Cn nhp nhanh tht, c lm chuyn o thc

qun bc l sng P.
200
D. Chn on phn bit quan trng nht l vi nhp

nhanh trn tht c phc b QRS gin rng (do dn truyn
lch hng, bloc nhnh...), ngi ta c th:
1. S dng chuyn o thc qun.
2. S dng tiu chun loi tr ca Brugada (hnh 10-6):
Khng c hnh nh dng RS cc chuyn o trc tim?
C
Khng
NNT
Khong cch R n S > 100 ms 1 chuyn o trc tim?

C
Khng
NNT
C nhiu phc b QRS hn l P ?

C
Khng
NNT
C tiu chun hnh thi ca NNT(*)

t nht 1 chuyn o trc tim?
C
Khng
NNT
Nhp nhanh trn tht c dn truyn lch hng

Hnh 10-6. Tiu chun Brugada chn on phn bit
NNT vi nhp nhanh trn tht c dn truyn lch hng.
201
(*) Tiu chun hnh thi ca NNT l:

a. Thi gian QRS rng > 0,14 giy
b. Trc QRS quay trn
c. Hnh thi cc chuyn o trc tim:
Ging bloc nhnh phi hon ton V1, v
R/S <1 V6.
Ging bloc nhnh tri : V1 c RT>RS; V6
c dng qR.
d. Phn ly nh tht, c nht bp hn hp, nht thot
tht.
E. iu tr
1. Chuyn v nhp xoang: Trong giai on cp ca cn
NNT, mc khn cp ca vic chuyn v nhp
xoang tu thuc vo tnh trng lm sng v nh
hng n huyt ng.
a. Cc u tin trong iu tr: Khi cn NNT m c
nh hng huyt ng nhiu, c ngt hoc mt
thc th cn x tr ngay nh mt ngng tun hon
v phi nhanh chng sc in ct cn. Sc in
cn c ch nh trong trng hp cn NNT lc
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
c. Sc in trc tip c ch nh khi tnh trng

huyt ng khng n nh v dng liu u tin
l 100J. i vi nhng trng hp c cn NNT
m mt mch th sc in ngay 200J. Nu bnh
nhn cn tnh, nn dng sc in ng b.
d. To nhp vt tn s c th hu ch trong mt s
trng hp.
e. Cc bin php h tr khc:
Th xy h tr.
iu chnh ngay cc ri lon in gii nu c.
Tm hiu cc nguyn nhn gy ra cn NNT
iu chnh kp thi nu c th. c bit trong
NMCT cp, gii quyt kp thi cc th thut
ti ti mu cho ng mch vnh l bin php
trit nht iu tr i vi cn NNT.
2. iu tr duy tr:
a. Thuc:
Nghin cu ESVEM so snh tc dng ca 7
loi thuc chng lon nhp (Imipramine,
Mexiletine, Pimenol, Quinidine, Sotalol,
Procainamide, Propafenone) iu tr ngn
nga ti pht cn NNT th thy l Sotalol c
tc dng ngn nga NNT hiu qu nht.
Cc nghin cu CAMIAT v EMIAT cho
thy Amiodarone c th ngn nga c cn
NNT sau NMCT cp v gim t l t vong.
Tuy nhin, khi dng Amiodarone lu di
chng ta phi ch n cc tc dng ph kh
phong ph ca n.
Vai tr ca cc thuc chng lon nhp trong
iu tr duy tr ngn nga ti pht cn
NNT cn cha thc s c thng nht. Thm
vo , chng ta cn ch n tc dng gy
lon nhp ca mt s thuc.
203
b. Cy my ph rung t ng trong bung tim:

Nghin cu MADIT v AVIT l hai th nghim
ln chng t rng vic cy my ph rung t
ng trong bung tim l thc s c ch v gim t
l t t r rt nhng bnh nhn thng c cn
NNT. My s c tc dng nhn bit cn NNT xy
ra v t ng pht ra sc in ct cn. Tuy
nhin, cc loi my ny cn kh t tin.
c. iu tr bng cch trit ph (hu) vng vo li
bt thng trong NNT bng sng Radio qua
ng ng thng. Thnh cng ca phng php
t c khong 50 -70%. Hin nay phng php
ny ang ngy cng c hon thin hn v cho
kt qu cao hn.
d. Phu thut: i vi mt s bnh nhn m khng
khng ch c bng thuc duy tr v c cc
so tn thng sau nhi mu gy lon nhp, ngi
ta c th phu thut ct b ni mc vng so ca
tm tht gy lon nhp m c nh v bng
thm d in sinh l trc . Ngy nay nh
phng php trit ph cc xung ng bt
thng qua ng ng thng, phu thut iu
tr NNT t cn c dng n.
VIII. Xon nh (Torsades de points)
Xon nh (X) chnh l mt loi nhp nhanh tht a hnh
thi c lin quan n hin tng ti cc chm tr ca c tim.
Hu ht xon nh c biu hin ko di on QT trc . Cn
xon nh thng ch ko di vi chc giy nhng cng c
trng hp kh bn b hoc thoi ho thnh rung tht.
Biu hin v din bin lm sng ca cn xon nh c th
l mt thc hoc t t. Trn T l hnh nh nhp tht nhanh
ti trn 200 ck/pht vi hnh thi a dng v cc nh ca QRS
xon xut quanh trc ng ng in (c lc cc nh ca phc
b QRS quay ln trn, c lc li quay xung di trc ng
ng in).
204
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...).
Thuc
khng
sinh
(Ampicillin,
Erythromycine...).
Ketoconazol, Astemizole...
b. Cc ri lon nhp chm c QT ko di.
c. Ri lon in gii mu, c bit l h kali hoc
magi mu. H canxi mu cng c th gy xon
nh.
d. Mt s nguyn nhn khc: Tai bin mch no,
dng thuc cn quang cha Iod...
Hnh 10-7. Xon nh.

B. iu tr
1. Ct cn:
205
a. C m mnh trc ngc bnh nhn i khi cng

c hiu qu.
b. Nu X ko di hoc gy ri lon huyt ng
nng cn sc in bng nng lng bt u t 50100J v c th tng ln n 360J nu cn.
2. iu chnh ngay cc ri lon in gii mu:
a. Tim Magi sulfate thng vo tnh mch vi liu
1-2 g v c th nhc li n tng liu 2-4 g trong
vng 15 pht. Vic ny c th ct c cn X
trong 75% s bnh nhn.
b. Bi ph kali v canxi theo yu cu.
c. Ngng ngay cc thuc c th gy X hoc ri
lon in gii mu.
3. iu tr cc ri lon nhp chm nu c:
a. Dng Isoproterenol truyn TM.
b. t my to nhp tm thi: l bin php rt hu
ch trong cc trng hp ny.
c. C th dng Lidocain.
IX. Mt s ri lon nhp chm
Cc ri lon nhp chm v cc bloc nh tht l nhng lon
nhp tim kh thng gp. Rt nhiu trong s cc ri lon nhp
ny thng khng c triu chng v cng khng nguy him. Tuy
vy, c mt s loi nhp chm rt nguy him c th e do tnh
mng bnh nhn. Chng ti s trnh by di y hai vn kh
quan trng trong nhp chm, l hi chng suy nt xoang v
bloc nh tht.
A. Hi chng suy nt xoang
Hi chng suy nt xoang hay cn gi l nt xoang
bnh l (SSS: Sick Sinus Symdrom) hoc ri lon chc nng
nt xoang (Sinus Node Dysfunction) l tnh trng nt xoang
khng kh nng duy tr hot ng bnh thng ca
ch nhp. Trn lm sng chng ta c th gp cc biu hin t
206
nhp chm xoang, ngng xoang, nhp thot nt hoc cn nhp

nhanh-nhp chm xen k.
a. Ngt hoc tin ngt (xu) l nhng triu chng
ng ch , ngoi ra c th thy chong vng,
chng mt, kh th...
b. Vi nhng bnh nhn c hi chng nhp nhanh nhp chm c th c nhng cn hi hp nh
trng ngc.
2. Nguyn nhn: C th do nhng nguyn nhn thc
th hoc nhng nguyn nhn bn ngoi (bng 10-6).
Bng 10-6. Nguyn nhn ca suy nt xoang.
Nguyn nhn ni ti:
Bnh l thoi ho nt xoang
Bnh ng mch vnh
Bnh c tim
Tng huyt p
Cc bnh thm nhim c tim (amyloidosis, khi u...)
Bnh cht to keo
Bnh l vim (vim c tim)
Chn thng do m x
Bnh tim bm sinh
Nguyn nhn ngoi sinh:
Do mt s thuc: Chn bta giao cm, chn knh
canxi, Digoxin, cc thuc chng lon nhp nhm IA,
IC, III...
nh hng h thn kinh t ng: cng trng lc
ph v qu mc, hi chng xoang cnh, chm xoang
ca lc s...
Ri lon in gii mu v cc cn nguyn khc: tng
kali mu, ri lon ni tit, tng p lc ni s, h thn
nhit, sc nhim khun...
3. in tm :
207
a. Nhp chm xoang thi qu (< 60 chu k /pht),

phc b QRS thanh mnh v sng P i trc.
b. C th thy nhng nht ngng xoang. Nu ngng
xoang > 3 giy l mt du hiu c gi tr v bo
hiu nguy him.
c. C th thy nhng nhp thot nt.
d. Nu thy hnh nh nhp nhanh - nhp chm xen k
th cng l mt du hiu kh c trng trong
suy nt xoang.
a. Cc thm d khng chy mu:
in tm thng quy 12 chuyn o l
mt thm d c bn.
Holter in tim cho php theo di din bin
in tim trong 24 gi v c gi tr chn
on, nht l khi thy hi chng nhp nhanh nhp chm hoc cc on ngng xoang.
Nghim php Atropine: dng phn bit l
suy nt xoang hay do cng thn kinh ph
giao cm. Bnh thng khi tim 0,04 mg/kg
Atropine cho bnh nhn th nhp tim ni sinh
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
xoa ta c th thy c nhng on ngng

xoang di hn 3 giy. y l mt thm d
kh nguy him
b. Thm d nt xoang qua ng ng thng:
thm d rt c gi tr trong chn on suy nt
xoang.
Thi gian phc hi nt xoang: l khong
thi gian phc hi li nhp p xoang sau khi
kch thch nh vt tn s v dng li. Khi
thi gian ny trn 1400 ms (mili giy) th c
th coi l c suy nt xoang. Thi gian phc
hi nt xoang c hiu chnh l thng s c
gi tr hn sau khi hiu chnh thi gian trn
theo nhp tim thc t ca bnh nhn. Nu thi
gian ny di trn 550 ms l suy nt xoang.
Thi gian dn truyn xoang nh (SACT):
Bnh thng khong cch gia cc sng P c
bn l A1-A1. Khi c kch thch to nht bp
ngoi tm thu nh (A2) v n nht tip theo
p tr li ca nh gi l A3, ta s c:
SACT = (khong A2-A3) - (khong A1-A1)
Thi gian dn truyn xoang nh ny ni ln
tnh t ng ca nt xoang v khng nh
hng bi pht nhp, thi gian dn truyn n
nt bng thi gian dn truyn ra khi nt, v
khng c thay i trong nguyn l to nhp.
5. iu tr:
a. iu tr trong cn cp cu khi suy nt xoang
nng gy nhp chm trm trng c triu chng:
Atropine: 0,04 mg/kg tim thng tnh mch.
C th t my to nhp tm thi khi khng
ci thin c bng thuc.
Isopreterenol (Isuprel) c th cho vi liu bt
u 1 mcg/ pht truyn tnh mch. Bin php
ny c th l cu ni trong lc ch cy my
209
to nhp. Khng nn dng nhng bnh nhn

c tin s cp cu ngng tim.
b. Ch nh cy my to nhp ni chung c p
dng cho mi bnh nhn suy nt xoang c
triu chng (ngt, xu...) hoc khi bt buc vn
phi dng thuc lm chm nhp tim: bng 10-7.
c. Tt c cc thuc lm chm nhp xoang cn phi
c ngng li nu c th. Nu khng th ngng
c th cn cn nhc t my to nhp ngay.
d. i vi nhng bnh nhn c hi chng nhp
nhanh - nhp chm, thng th cn t my to
nhp iu tr nhng lc nhp chm v cho
thuc iu tr cc ri lon nhp nhanh.
B. Ri lon dn truyn nh tht (bloc nh tht)
Bloc nh tht l s dn truyn t nh xung tht b chm li
hay ngng hn.
1. Phn loi: ngi ta thng chia bloc nh tht thnh 3
mc nh sau:
a. Bloc nh tht I: L hin tng dn truyn
chm tr t tm nh xung tm tht, biu hin
bng on PQ trn in tim ko di trn 0,20
giy. Hin tng ny c th gp ngi bnh
thng hoc mt s bnh l ca tim.
b. Bloc nh tht II:
Kiu Mobitz I hay cn gi l chu k
Wenckebach, biu hin bng on PQ trn
in tm b di dn ra v n mt lc no
s ch cn sng P m khng c QRS i
km (tc l c mt nhp ngh tht). Sau
chu k li c lp li ging nh trn.
Kiu Mobitz II: biu hin bng nhng nht
bp ca tim b bloc xen k vo nhng nht
nhp xoang bnh thng, mc bloc c th
l 2/1; 3/1... v d, nu bloc tun theo quy lut
210
c 2 sng P mi c mt QRS i km theo th

ta gi l bloc 2/1.
c. Bloc nh tht cp III hay bloc nh tht hon
ton l tnh trng ng dn truyn t nh xung
tht b nghn hn, nh s p theo nhp ca nt
xoang kch thch cn tht s p theo nhp ring
ca n.
2. in tm :
a. Sng P khng ng trc cc tht (QRS) v
cng khng c lin h g vi cc tht , m n
c th ri vo trc, sau hay trng ln cc phc
b QRS mt cch ngu nhin m thi.
b. Tn s ca cc sng P vn bnh thng, khong
60-80 chu k/pht.
c. Tn s cc phc b QRS rt chm (khong 30-40
chu k/pht) nhng rt u.
d. Hnh dng ca QRS c th thanh mnh bnh
thng, nhng cng c khi QRS b gin rng nu
trung tm ch nhp ca tht xut pht t pha di
ca b ni.
e. Ch : i khi ta thy c sng P ri trng pha
trc QRS vi mt khong QRS bnh thng v
lm cho nht bp ny hi sm hn so vi nhp
c s, ta gi l nht bt c tht.
a. Triu chng c nng:
Nu nhp tht ch chm t, bnh nhn c th
khng c triu chng g c.
Nhng nu nhp tim chm nhiu th lng
mu t tim n cc c quan, trong c no
b gim st. Do , bnh nhn c th thy
chong vng thong qua, mt thng bng v
c khi b xu hay thm ch b ngt (trong bnh
cnh ca hi chng Adams-Stokes).
211
Khi xy ra cn ngt, th bnh nhn mt

thc, tay chn co qup, si bt mp
b. Triu chng thc th:
Nghe tim thy nhp tim chm (30-40 ck/pht)
v u.
C th nghe thy ting i bc do c s
trng hp i gn nhau gia co bp tm nh v
tm tht.
Huyt p ti a thng tng v huyt p ti
thiu thng gim v nhp tht chm s lm
cho thi gian tm trng di ra.
4. Nguyn nhn:
a. Tc dng ca mt s thuc:
Digoxin.
Chn bta giao cm.
Chn knh canxi.
Mt s thuc chng lon nhp
b. Bnh tim thiu mu cc b:
Nhi mu c tim cp.
Bnh ng mch vnh mn tnh.
c. Thoi 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 c tim (Chagas, bnh Lyme, thp tim,
lao, si...).
212
h. Bnh van tim do bnh cht to keo.

i. Ri lon chuyn ho:
Tng kali mu.
Tng magi mu.
j. Bnh ni tit (bnh Addison).
k. Chn thng:
M tim.
iu tr phng x.
Thng tim v cc iu tr can thip, c bit
t cc ng dn truyn
l. Khi u.
m. Bnh h thn kinh t ng:
Hi chng xoang cnh.
Ngt do cng ph v.
n. Ri lon thn kinh c:
Ph i c.
5. Cc xt nghim chn on: Vic chn on ch yu
da vo in tim .
a. Bloc nh tht cp I: Ch yu da vo o on
PR trn T, PR ko di trn 0,20 giy ngi
ln v trn 0,18 giy tr em vi hnh dng ca
sng P v QRS bnh thng.
Hnh 10-8. Bloc nh tht cp I: PR=0,36 giy.

b. Bloc nh tht cp II:
Mobitz I (chu k Wenckebach):
(a) on PR s ko di dn v kt thc bi
mt nht bp khng c QRS.
213
(b) Khong cch RR s ngn dn.

(c) Khong RR ni nht bp khng c QRS
s nh hn tng 2 khong RR cnh .
(d) C s nhc li theo chu k (chu k
Wenckebach).
Hnh 10-9. Bloc nh tht cp II, Mobitz I.

Mobitz II: Cc khong PP vn u v c
nhng nht bp khng dn (khc vi ngoi
tm thu nh b bloc, khong ny khng u).
c. Bloc nh tht cp III (hon ton):
Tn s nh vn bnh thng, u.
Tn s tht rt chm v cng u.
Khng c mi lin h no gia nh v tht
Phc b QRS thng gin rng v nu bloc
cng thp th QRS cng rng v tn s tht
cng chm.
Hnh 10-10. Bloc nh tht cp III.

6. iu tr:
214
Vi bloc nh tht cp I hoc bloc nh tht cp II

kiu Mobitz I thng khng cn iu tr g c hiu.
Vi cc bloc nh tht cao (Mobitz II hoc cp III)
dai dng thng cn phi cy my to nhp (xem
phn sau).
a. Thuc: Dng trong trng hp cp cu, c bit
khi bnh nhn c ngt hoc xu. Thuc thng
ch c tc dng tm thi ch cy my to nhp
hoc trong giai on cp ca mt s bnh ch khi
hi phc. Thuc khng c li ch nu dng ko
di trong cc trng hp bloc nh tht cao c
triu chng.
Nu bnh nhn c ngt do nhp chm.
(a) Atropine l thuc nn th dng u tin,
n c th lm gim mc bloc bnh
nhn bloc do cng ph v qu ch khng
c tc dng vi nhng tn thng thc th
ng dn truyn. N c tc dng tt hn
bnh nhn c nhi mu c tim sau di.
(b) C th dng Dopamine vi liu bt u 5
mcg/kg/pht nhng bnh nhn c km
huyt p thp.
Nu bnh nhn trong tnh trng rt trm
trng, c th dng ngay Adrenaline truyn
tnh mch thay v Dopamine, Liu 1-2
mcg/pht.
Isoproterenol hydrochlorid (Isuprel), c th c
ch bnh nhn bloc nh tht khng phi do
thiu mu c tim v lm tng nhp tim kh
chn lc. Tuy nhin cn lu l bnh nhn
c bnh mch vnh th khng nn dng v n
lm tng nhu cu xy c tim. Liu ban u
nn t 2 mcg/pht tng theo p ng nhp tim
cho n 10 mcg/pht.
b. To nhp tim tm thi:
215
My to nhp qua da (hai in cc p thnh

ngc) rt c hiu qu nhng gy au n.
y l my xch tay lu ng, thng gn vi
h thng ph rung cp cu. Nhng bnh nhn
ngt cn t ngay to nhp tm thi trong lc
vn chuyn n bnh vin.
Cp cu: dng my to nhp p thnh qua da
(nu c) trong lc ch tin hnh t my to
nhp tm thi qua ng tnh mch.
To nhp tm thi qua ng tnh mch l gii
php cp cu ti u cho nhng trng hp
nhp chm c triu chng nng.
c. Ch nh cy my to nhp (bng 10-7).
Nhn chung ch nh khi bnh nhn c nhp
chm m c triu chng (ngt, xu, mt l do
nhp chm...).
Nu bloc nh tht hon ton do NMCT sau
di thng ch cn t to nhp tm thi, v
c th hi phc sau giai on cp do bloc
bnh nhn ny thng do cng ph v qu
mc. Nu l bloc cp III m do nhi mu c
tim trc bn th nn ch nh cy my to
nhp sm.
Cc trng hp bloc nh tht hon ton mc
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
xoang
khng hi phc sau khi chng chng t
(SNX)
dng thuc hoc cn phi nhp chm < 40
dng thuc gy nhp chm.
ck/pht lin quan
n SNX v cc
triu chng c th
khng ch c.
216
Bloc nh tht Bloc nh tht cp III c mt

mc phi
trong cc c tnh sau:
- C triu chng.
- C ri lon nhp km theo
hoc bnh l km theo cn
dng thuc c th gy nhp
chm.
- C on ngng tim trn 3
giy hoc nhp tim < 40
ck/pht bnh nhn khng
c triu chng.
- Bloc sau khi iu tr t
cc ng dn truyn trong
tim (catheter ablation).
- Sau m tim.
- Bnh l thn kinh c c
km theo bloc nh tht cp
III (hi chng Kearns Sayre,
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
sau
nhi Mobitz II tn ti sau nhi
mu c tim
mu c tim ti v tr b His
tr xung m c km theo
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
- Bnh nhn c
triu chng nh
hoc
khng
nhng c nhp tim
< 30 ck/pht (khi
thc gic).
- Bnh nhn bloc
nh tht cp III
m khng c triu
chng v nhp tim
trung bnh lc
thc gic l hn
40 ck/pht.
- Bloc nh tht cp
II kiu Mobitz II
khng c triu
chng.
- Bloc nh tht cp
I nhng nhp tim
rt chm v c
triu chng hoc
khi t my tm
thi c hi chng
my to nhp.
- Tn ti bloc nh
tht cp II cao
hoc cp III ti v
tr nt nh tht.
217
Mobitz II hoc cp III c

triu chng.
- C km theo bloc nh tht
cp III tng lc.
- Bloc nh tht cp II Mobitz
II.
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.
Benditt G, Remole S, Milatein S, et al. Syncope: causes, clinical

evaluation, and current therapy. Annu Rev Med 1992;43: 283-300.
2. Braunwald E, ed. Heart disease: a textbook of cardiovascular
medicine, 5th ed. Philadelphia: WB Saunders, 1997.
3. Domanski MJ, Zipes DP, Schron E. Treatment of sudden cardiac
death. Current understandings from randomized trials and future
research direction. Circulation 1997;95:269~2699.
4. Donbar SB, Ellenbogen K, Epstein AB. Sudden cardiac death: past,
present, and future. American Heart Association Monograph Series.
Armonk, NY: Futura Publishing, 1997.
5. Kowey PR. Pharmacological effects of antiarrhythmic drugs.
Review and update. Arch Intern Med 1998;158:325-332.
6. Marcus Fl, Opie LH Antiarrhythmic agents. In: Opie LH, ed. Drugs
for the heart, 4th ed. Philadelphia: WB Saunders, 1997:207-247
7. Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular
8. Nattel S. Antiarrhythmic drug classifications. A critical appraisal of
their history, present status, and clinical relevance. Drugs
1991;41:672-701.
9. Singh BN. Antiarrhythmic drugs: a reorientation in light of recent
developments in the control of disorders of rhythm. Am J Cardiol
1998;81:3D-13D.
10. Task Force of the Working Group on Arrhythmias of the European
Society of Cardiology. The Sicilian gambit. A new approach to the
classification of antiarrhythmic drugs based on their actions on
arrhythmogenic mechanisms. Circulation 1991;84:1831-1851.
11. Wein AL, Grimm RA, Black 1W, et al. Cardioversion guided by
transesophageal echocardiography: the ACUTE pilot study. Ann
Intern Med 1997;126:200-209.
12. Zipes DP, Jalife J, eds. Cardiac electrophysiology: from cell to
bedside, 2nd ed. Philadelphia: WB Saunders, 1995.
218
thp tim
Thp tim hay cn gi l thp khp cp hoc st thp khp

(rheumatic fever) c coi l mt trong nhng bnh ca h min
dch m lin kt hay thuc h thng to keo. Cho ti nay, bnh
vn kh thng gp cc nc ang pht trin (trong c Vit
nam) v l nguyn nhn hng u ca bnh van tim ngi tr
tui. Bnh thng gp la tui t 6-15 tui, nhng khng t
trng hp xy ra la tui 20 hoc hn na. Ngy nay, ngi
ta tm ra nguyn nhn gy bnh l do nhim Lin cu khun
tan huyt nhm A ng h hp trn (Streptococcus A).
I. Tiu chun chn on bnh
Cho n nay, th gii thng nht dng tiu chun Jones
c iu chnh nm 1992 (Bng 11-1). Chn on xc nh
thp tim khi c bng chng ca nhim lin cu A ng h hp
(biu hin lm sng ca vim ng h hp trn v/hoc lm
phn ng ASLO dng tnh v/hoc cy dch hng tm thy lin
cu), km theo c t nht 2 tiu chun chnh hoc c 1 tiu chun
chnh km 2 tiu chun ph.
Bng 11-1. Tiu chun Jones c iu chnh nm 1992 trong
chn on thp tim.
Tiu
1. Vim tim: gp 41-83% s bnh nhn thp tim.
chun
Vim tim c biu hin lm sng t nhp nhanh,
chnh
ri lon nhp (hay gp bloc nh tht cp 1), h van
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
4. Nt di da: nt c ng knh 0,5-2cm, ni

di da, di ng t do, khng au, c th n c
hoc tp trung thnh m, thng thy gn v tr
cc khp ln nh khp gi.
5. Hng ban vng: l nhng ban khng hoi t,
nht mu gia, v tr thng thn mnh, mt
trong cc chi v khng bao gi mt. Thng
mt i sau vi ngy.
Tiu
1. St.
chun 2. au khp: au mt hoc nhiu khp nhng khng
ph
c cc triu chng in hnh ca vim khp.
3. Tng cao protein C-reactive huyt thanh.
4. Tc mu lng tng.
5. on PQ ko di trn in tm .
Bng chng ca nhim lin cu khun nhm A trc
1. Cy dch ngoy hng tm thy lin cu hoc test nhanh
khng nguyn lin cu dng tnh.
2. Tng nng khng th khng lin cu trong mu
(Phn ng ASLO > 310 v Todd).
II. Sinh l bnh
Mi lin h cht ch gia vim hng v thp tim c
bit r t nm 1930. Ngi ta thy rng: (1) C bng chng ca
s tng r rt khng th khng streptolysin O trong huyt
thanh bnh nhn b thp tim. (2) Hiu qu r rt ca khng sinh
trong phng bnh thp tim l mt trong nhng bng chng h tr
cho c ch trn.
Thp tim khng phi do trc tip lin cu gy ra m thng
qua c ch min dch. Thng thng, sau khong 3 tun vim
ng h hp trn bnh nhn mi c biu hin ca thp tim. Mt
kha cnh na l thp tim rt t khi xy ra bnh nhn di 5
tui, khi m h min dch cha hon thin y nn phn ng
cho ca c th cha hiu lc gy ra thp tim.
Khng nguyn l cc protein M,T v R lp v ngoi ca
lin cu A l yu t quan trng nht gy phn ng cho vi c
th. Khi lin cu xm nhp vo c th chng ta, c th s sinh ra
220
cc khng th chng li vi khun , nhng v tnh chng li

lun cc protein cc m lin kt ca c th, nht l cc m lin
kt van tim. Trong , protein M l yu t khng nhng c
hiu min dch m cn l yu t gy thp mnh nht.
C khong 3% s bnh nhn b vim ng h hp trn do
lin cu nhm A m khng c iu tr trit s tin trin
thnh thp tim, v c khong 50% s bnh nhn b thp tim
s b ti pht cc t thp tim sau . Nhim lin cu ngoi da
thng t khi gy thp tim.
A. Cc biu hin chnh
1. Vim tim:
a. Vim tim l mt biu hin bnh l nng ca thp
tim v kh c hiu. C khong 41-83% s bnh
nhn thp tim c biu hin vim tim. Cc biu
hin ca vim tim c th l vim mng trong tim,
vim mng ngoi tim, vim c tim.
b. Vim tim c th biu hin t th khng c triu
chng g n cc du hiu suy tim cp nng hoc
t vong.
c. Cc triu chng lm sng c th gp l: tng nhp
tim, ting thi tm thu, ting thi tm trng,
ting rung tm trng, ri lon nhp, ting c
mng tim, suy tim
d. Suy tim thng t gp giai on cp, nhng nu
gp th thng l biu hin nng do vim c tim.
e. Mt trong nhng biu hin phi ch v l bin
chng nng ca thp tim l vim van tim. H van
hai l l mt trong nhng biu hin thng gp
nht, trong khi h van ng mch ch t gp hn
v thng km theo h van hai l.
f. Vim mng ngoi tim c th gy au ngc, ting
c mng tim, ting tim m
2. Vim khp:
221
a. Vim khp l mt biu hin hay gp nht trong

thp tim (80%) nhng li t c hiu.
b. Biu hin ca vim khp l sng, nng, , au
khp, xut hin cc khp ln (gi, c chn, c
tay, khuu, vai...) v c tnh cht di chuyn.
c. Vim khp p ng rt tt vi Salycilate hoc
Corticoid trong vng 48 gi. Nu trong trng
hp cho Salycilate y m trong vng 48
gi vim khp khng thuyn gim th phi ngh
ti nguyn nhn khc ngoi thp tim.
d. Vim khp do thp tim thng khng bao gi
li di chng khp.
3. Ma git Sydenham:
a. y l biu hin ca tn thng ngoi thp v
kh c hiu cho thp tim.
b. Cc biu hin l nhng ng tc vn ng khng
mc ch v khng t ch cc c mt, chi; gim
trng lc c, ri lon cm ng.
c. Cc biu hin ban u c th l kh vit, kh ni
hoc i li.
d. Cc biu hin ny thng r khi bnh nhn b xc
ng hoc thc tnh v mt i khi bnh nhn ng.
e. Ma git Sydenham l mt trong nhng biu hin
mun ca thp tim, n thng xut hin sau
khong 3 thng sau khi vim ng h hp trn.
Ma git Sydenham thng biu hin n c
trong thp tim v gp khong 30%. Triu chng
ny thng mt i sau 2-3 thng.
f. Cn phi chn on phn bit vi mt s bnh l
khc nh ng kinh, ri lon hnh vi tc phong...
4. Nt di da:
a. l nhng nt c ng knh khong 0,5-2 cm,
cng, khng au, di ng v thng xut hin
ngay trn cc khp ln hoc quanh cc khp. Nt
222
di da c th gp khong 20% s bnh nhn b

thp tim v thng bin mt sau khong vi ngy.
b. Da trn nt ny thng vn di ng bnh thng
v khng c biu hin vim trn.
5. Hng ban vng (erythema marginatum):
a. y l mt loi ban trn da, c mu hng v
khong nht mu gia to thnh ban vng.
Thng khng hoi t v c xu hng mt i sau
vi ngy.
b. Hng ban vng l mt du hiu kh c hiu
trong thp tim v t gp (5%), thng ch gp
nhng bnh nhn c da mn v sng mu. Hng
ban vng thng xut hin thn mnh, bng,
mt trong cnh tay, i v khng bao gi mt.
c. Khi c hng ban vng th thng c km theo
vim c tim.
6. Cc du hiu ph:
a. St thng xy ra trong giai on cp.
b. au khp c xc nh l ch au khp ch
khng c vim (sng, nng, ).
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.
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
c. xc nh bng chng nhim GAS trc c

th dng xt nghim ASLO nhc li nhiu ln
hoc mt s khng th khc nh: anti-DNAase B;
anti-hydaluronidase; anti-streptokinase; antiNADase
d. Hin nay c mt s que th nhanh c sn th
vi mt s khng th khng GAS, nhng chnh
xc khng cao v c ngha tham kho.
2. Sinh thit:
a. Sinh thit c tim c th cho thy hnh nh ht
Aschoff, l hnh nh ht thm nhim gp trong
thp tim. Ht ny gp khong 30% s bnh
nhn c cc t thp ti phi v thng thy
vch lin tht, thnh tht, tiu nh.
b. Cc hnh nh t bo hc cn cho thy hnh nh
vim ni mc tim vi c trng l ph v thm
nhim t chc mng van tim.
c. Sinh thit c tim khng c ch trong giai on cp
ca thp tim, n ch nn ch nh v c gi tr
phn bit khi thp tim ti pht v kh phn bit
vi cc bnh thp khp mn khc.
3. Mt s xt nghim mu khc:
a. Tng bch cu, thiu mu nhc sc/bnh sc.
b. Tc mu lng tng v protein C phn ng tng.
4. Xquang tim phi: Thng th khng c bin i g
c bit trong thp tim. Mt s trng hp c th
thy hnh tim to, rn phi m hoc ph phi.
5. in tm :
224
a. Thng hay thy hnh nh nhp nhanh xoang, c

khi PR ko di (bloc nh tht cp I).
b. Mt s trng hp c th thy QT ko di.
c. Khi b vim mng ngoi tim c th thy hnh nh
in th ngoi vi thp v bin i on ST.
6. Siu m Doppler tim:
a. C th gip nh gi chc nng tim.
b. Hnh nh h van tim ngay c khi khng nghe thy
c trn lm sng.
c. C th thy tn thng van hai l v van ng
mch ch. Giai on sau c th thy hnh nh van
dy ln, vi ho cng cc t chc di van.
IV. iu tr
A. iu tr t cp
Mt khi c chn on xc nh thp tim th cc bin php
sau l cn thit:
1. Loi b ngay s nhim lin cu: (xem Bng 11-3)
bng thuc kinh in Benzathine Penicillin G
600.000 n v (v) tim bp su 1 ln duy nht cho
bnh nhn di 27 kg, v 1,2 triu v cho bnh nhn
trn 27 kg, tim bp su 1 ln duy nht. Nu bnh
nhn b d ng vi penicillin th dng thay bng
Erythromycine 40mg/kg/ngy, ung chia 2 ln/ngy,
trong 10 ngy lin tc.
2. Chng vim khp: phi c bt u cng sm cng
tt ngay khi c chn on.
a. Aspirin: l thuc c chn hng u v hiu
qu nht. Liu thng dng l 90 - 100 mg/kg/
ngy, chia lm 4-6 ln. Thung dng ko di t
4-6 tun tu thuc vo din bin lm sng. C th
gim liu dn dn sau 2-3 tun. Nu sau khi dng
Aspirin 24-36 gi m khng ht vim khp th
225
cn phi ngh n nguyn nhn khc ngoi thp

tim.
b. Prednisolone c khuyn co dng cho nhng
trng hp c km vim tim nng. Liu dng l 2
mg/kg/ngy chia 4 ln v ko di 2-6 tun. Gim
liu dn trc khi dng.
c. Mt s thuc gim vim chng au khng phi
corticoid c th c dng thay th trong mt s
hon cnh nht nh.
3. iu tr ma git Sydenham: bao gm cc bin
php ngh ngi ti ging, trnh cc xc cm, dng
cc bin php bo v v c th dng mt s thuc
nh: Phenobarbital, Diazepam, Haloperidol, hoc
steroid. Vic phng bnh tip tc theo ch cng l
bin php trnh c ti pht ma git Sydenham.
4. Ch ngh ngi trong giai on cp l rt quan
trng. u tin l ngh ti ging, sau l vn ng
nh trong nh ri vn ng nh ngoi tri v tr v
bnh thng (Bng 11-2). Ch ny tu thuc vo
mc nng nh ca bnh.
Bng 11-2. Ch ngh ngi i vi bnh nhn thp tim.
Ch
Ch vim
Vim
Vim
Vim tim
khp
tim nh tim va
nng
Ngh ti
1 - 2 tun 2 3
4-6
2 - 4 thng
ging
tun
tun
Vn ng nh 1 - 2 tun 2 3
4-6
2 - 3 thng
trong nh
tun
tun
Vn ng
2 tun
24
1-3
2 - 3 thng
nh ngoi tri
tun
thng
Tr v sinh
Sau 4 - 6
Sau 6 Sau 3 - 6 Thay i
hot bnh
tun
10 tun
thng
tu trng
thng
hp
5. iu tr suy tim (nu c): ngh ti ging, th xy,
vi suy tim tri cp cho Morphin, li tiu, tr tim.
Hn ch n mn, hn ch ung nhiu nc, c th
226
dng li tiu. Digoxin c th dng nhng phi thn

trng v qu tim ca bnh nhn thp tim rt nhy
cm, nn dng liu ban u ch nn bng na liu
quy c.
6. Phng thp: Vn cc k quan trng l nhc nh
bnh nhn v gia nh s cn thit v tn trng ch
phng thp tim cp hai khi bnh nhn ra vin.
B. Phng bnh: (Bng 11-3)
1. Phng bnh cp I: Mt bc cc k quan trng l
loi tr ngay s nhim lin cu khun ( nu trn),
hay cn gi l ch phng thp cp I.
Bng 11-3. Ch phng bnh cho thp tim.
Phng thp cp I
Thuc
Liu
ng
dng
Benzathine
600.000 v (<27kg)
Tim bp
Penicillin G
1,2 triu v (27kg)
Hoc
250mg 2-3 ln/ngy Ung
Penicillin V
(tr em)
500mg 2-3 ln/ngy
(ngi ln)
Erythromycin (cho 40 mg/kg/ngy
Ung
bnh nhn d ng
vi Penicillin)
Phng thp tim cp II
Thuc
Liu lng
ng
dng
Benzathine
1,2 triu v
Tim bp
Penicillin G
Hoc
250 mg
Ung
Penicillin V
Sulfadiazine
0,5g (<27kg)
Ung
1,0g (27kg)
Erythromycin (cho 250 mg
Ung
bnh nhn d ng
vi Penicillin hoc
Sulfazidine)
Thi gian
Liu duy nht
10 ngy
10 ngy
Khong cch
dng
3-4 tun/1 ln
2 ln/ngy
hng ngy
2 ln/ ngy
227
a. Cn thit phi iu tr tht sm nu c th.

b. Penicillin l thuc la chn hng u v tnh hiu
qu v gi r. Nn dng Benzathine Penicillin G
liu duy nht tim bp (Bng 11-3). C th dng
thay th bng ung Penicillin V trong 10 ngy.
c. Cc thuc ph rng nh Ampicillin khng c li
ch g hn so vi Penicillin trong iu tr thp tim.
d. Vi bnh nhn d ng vi Penicillin, thay th
bng Erythromycin ung trong 10 ngy. C th
dng Marcrolide mi nh Azithromycin thay
th rt c tc dng, dng trong 5 ngy vi liu
500 mg trong ngy u sau 250 mg mi ngy
cho 4 ngy tip theo.
e. C th thay th bng ch khc l dng
Cephalosporin th h I dng ung (Cephalexin,
Cephadroxil), ung trong 10 ngy.
2. Phng bnh cp II: Phi bt u ngay khi chn
on xc nh l thp tim.
a. Thuc dng c nu trong Bng 11-3.
b. Thi gian dng (Bng 11-4), ni chung ph thuc
vo tng c th bnh nhn.
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
Ti liu tham kho

1.
2.
3.
4.
5.
6.
Bisno AL. Group A streptococcal infection and acute rheumatic

fever. N Engl J Med 1991; 325:783-793.
da Silva NA, de Faria Pereira BA. Acute rheumatic fever. Pediatr
Rheumatol 1997;23:545-568.
Dajani AS. Rheumatic fever. In: Braunwald E, ed. Heart disease: a
textbook of cardiovascular medicine, 5th ed. Philadelphia: WB
Saunders, 1997:1769-1775.
Dijani AS, Ayoub E, Bierman FZ, et, al, Guidelines for the diagnosis
of rheumatic fever: Jones criteria. Updated 1993. Circulation 1993;
87: 302-307.
Nader S. Rheumatic fever. In: Marso SP, Griffin BP, Topol EJ, eds.
Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven,
2000.
Stollerman GH. Rheumatic fever. Lancet 1997;349: 935-942.
229
Hp van hai l
Hp van hai l (HHL) vn cn l bnh rt ph bin nc

ta cho d t l mc bnh ny gim nhiu cc nc pht
trin khc.
I. Triu chng lm sng
A. Triu chng c nng
1. a s bnh nhn khng h c triu chng trong mt
thi gian di. Khi xut hin, thng gp nht l kh
th: mi u c trng l kh th khi gng sc, sau
l kh th kch pht v m v kh th khi nm
(do tng p lc mch mu phi). Cn hen tim v ph
phi cp kh thng gp trong HHL - l mt im
c bit ca bnh: biu hin suy tim tri m bn cht
li l suy tim phi.
2. Cc yu t lm bnh nng thm: s xut hin rung
nh trong HHL vi tn s tht p ng rt nhanh l
yu t kinh in dn n ph phi cp. S gin nh
tri l yu t d on xut hin rung nh bnh nhn
HHL. Thai k ca ph n HHL cng lm cho triu
chng nng thm.
3. C th gp cc triu chng lin quan vi nh tri gin
to nh:
a. Ho ra mu do tng p lc nh tri v tng p lc
ng mch phi.
b. Khn ting (hi chng Ortner), do nh tri gin to
vo dy thn kinh qut ngc hoc nut nghn
do nh tri to vo thc qun.
c. Tc mch i tun hon (mch no, thn, mc
treo, mch chi) do huyt khi hnh thnh trong
bung nh tri gin nht l khi c km rung nh.
231
d. Rung nh (cn kch pht hoc dai dng) gy biu

hin hi hp trng ngc, c th gy chong hoc
ngt (rung nh nhanh), gp phn hnh thnh huyt
khi v gy ra tc mch i tun hon...
4. Lu dn s c cc triu chng ca suy tht phi (gan
to, ph chi di ) do tng p ng mch phi. Khi
tng p lc ng mch phi, bnh nhn c th au
ngc gn ging cn au tht ngc, do tng nhu cu
xy tht phi.
5. Mt cng l triu chng hay gp do cung lng tim
gim thp.
B. Triu chng thc th
1. Chm pht trin th cht nu HHL c t khi nh: du
hiu ln hai l.
2. Lng ngc bn tri c th bin dng nu HHL t nh.
3. Du hiu ca tr tun hon ngoi bin khi c suy
tim phi: tnh mch c ni, phn hi gan tnh mch
c dng tnh, ph chi di, ph ton thn, gan to,
trn dch cc mng...
4. Cc du hiu ca km ti mu ngoi vi: da, u chi
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
Ting ny cng c th gp trong HoHL, thng

lin tht, teo van ba l km theo thng lin nh.
b. Ting rung tm trng mm tim: m sc
trm thp, gim dn, nghe r nht mm, thi
gian ph thuc vo chnh p (di khi HHL kht),
c ting thi tin tm thu nu cn nhp xoang.
Nghe tim sau gng sc hoc ngi Amyl Nitrate
lm tng cng ting thi do tng chnh p khi
tng dng chy qua van hai l. Tuy nhin ting
rung tm trng ny c th khng c nu van hp
qu kht hoc dy chng ct c b vi ho x
cng nhiu, hoc khi suy tim nng, km theo hp
van ng mch ch lm gim dng mu qua van.
c.
d.
e. Ting rung tm trng cn c th gp trong mt
s trung hp khc nh HoC, tng cung lng
qua van hai l... Ting thi tin tm thu cng
thng gp nht l khi bo bnh nhn gng sc
hoc dng mt t kh Amyl Nitrate. Ting thi
ny s khng c khi bnh nhn b rung nh.
f. Ting T1 anh kh quan trng trong HHL. Ting
T1 c th khng r anh na khi van vi ho
nhiu hoc gim s di ng ca l van. Nghe
y tim c th thy ting T2 mnh v tch i,
biu hin ca tng p ng mch phi.
g. Mt s tnh trng c th ging biu hin ca hp
van hai l nh u nhy nh tri hoc tim ba bung
nh. Ting p ca u nhy c th nhm vi ting
clc m van. Khi bnh nhn c rung tm trng
lun cn chn on phn bit vi u nhy nh tri.
Cc tnh trng khc c th gy nn ting rung tm
trng bao gm: thng lin nh, hoc thng lin
tht, ting thi Austin-Flint ca h ch (gim khi
233
gim hu gnh) hoc ca hp van ba l (nghe r

nht b tri xng c v tng ln khi ht vo).
II. Nguyn nhn
A. a s trng hp HHL u l do di chng thp tim d
50% bnh nhn khng h bit tin s thp khp.
1. t thp tim cp thng hay gy ra h van hai l. Sau
mt s t thp tim ti pht, hp van hai l bt u
xut hin, tip tc tin trin nhiu nm cho ti khi
biu hin triu chng.
2. Thng tn chnh l thm nhim x, dy l van. Dnh
mp van, dnh v co rt dy chng gp phn gy nn
HHL. Xut hin vi ho lng ng trn l van, dy
chng, vng van, tip tc lm hn ch chc nng bnh
thng ca van. Nhng thng tn ny to thnh van
hai l hnh phu nh hnh ming c m.
B. Cc nguyn nhn gy hp van hai l
1. Di chng thp tim.
2. Bm sinh:
a. Van hai l hnh d: do c mt ct c xut pht
cc dy chng cho c hai l van, dn n h hoc
hp van.
b. Vng tht trn van hai l.
3. Bnh h thng c th gy x ho van hai l:
a. U carcinoid.
b. Lupus ban h thng.
c. Vim khp dng thp.
d. Lng ng mucopolysaccharide.
e. Vim ni tm mc nhim khun lin so.
234
Hnh 12-1. Thng tn van hai l do thp.

III. Sinh l bnh
1. Bnh thng din tch l van hai l l 4-6 cm2. Khi
din tch l van hai l < 2cm2, dng chy qua van hai
l b cn tr to thnh chnh p qua van hai l gia
nh tri v tht tri trong thi k tm trng. Chnh
p ny v p lc nh tri s cng tng khi din tch l
van cng gim. Tu theo mc din tch ca l van
hai l m ngi ta chia thnh cc loi:
a. HHL rt kht khi din tch l van < 1,0 cm2.
b. HHL kht khi din tch l van t 1 n < 1,5 cm2.
c. HHL va khi din tch l van t 1,5-2,0 cm2.
2. Dng chy qua van hai l tng lm chnh p qua van
tng theo cp 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
4. Mc d tht tri t b nh hng bi cc qu trnh

bnh sinh trn nhng 25-30% s trng hp c gim
phn s tng mu tht tri, c l l do gim tin gnh
tht tri v gim dng chy v tht tri lu ngy.
5. Nhng trng hp hp van hai l kht c th gy
gim cung lng tim n mc gy triu chng gim
ti mu. Tnh trng cung lng tim thp mn tnh s
gy phn x tng sc cn mch i tun hon v tng
hu gnh, cng lm tip tc gim chc nng co bp
tht tri hn na. Phn s tng mu s tr li bnh
thng nu gii quyt ch hp van hai l (khi phc
tin gnh v hu gnh). Mt s bnh nhn vn tip
tc ri lon co bp c tim ko di sau khi m ch
hp, nguyn nhn hay c ngh ti l tnh trng
vim c tim m do thp tim.
A. Siu m Doppler tim: l bin php thm d cc k
quan trng chn on xc nh v chn on mc
hp van hai l, chn on hnh thi van, t chc di van
hai l v cc thng tn km theo (thng c trong HHL)
gip ch nh iu tr.
1. Kiu TM: l van dy, gim di ng, bin m van
hai l km, hai l van di ng song song, dc tm
trng EF gim (EF < 15 mm/s l HHL kht).
2. Siu m 2D: hnh nh van hai l hn ch di ng, l
van hnh vm (hockey-stick sign), vi ho l van v
t chc di van. Siu m 2D cn cho php o trc
tip din tch l van hai l, nh gi chc nng tht
tri v cc tn thng van khc c th km theo.
3. Siu m Doppler c bit quan trng nh gi
mc hp:
a. Vn tc nh dng chy qua van hai l > 1 m/giy
gi c HHL, song du hiu ny khng c hiu,
c th xy ra do nhp nhanh, tng co bp. H hai
236
l v thng lin tht cng gy tng dng chy d

khng c HHL.
b. Chnh p qua van hai l (o vin ph dng chy
qua van hai l) cho php c lng mc nng
ca hp van.
HHL nh: chnh p trung bnh qua van < 5
mmHg,
HHL va: chnh p trung bnh qua van t 512 mmHg,
HHL kht: chnh p trung bnh qua van > 12
mmHg.
c. c tnh p lc ng mch phi (MP), thng
qua vic o ph ca h van ba l km theo hoc
h van MP km theo (thng gp trong HHL).
d. Cho php nh gi tn thng thc tn km theo
nh HoHL, HoC v mc , iu ny rt quan
trng gip cho quyt nh la chn phng php
can thip van hai l thch hp.
4. Siu m Doppler tim dng nh gi din tch l
van hai l kh chnh xc, t xc nh v nh gi
mc hp. Thng c hai cch o trn lm sng:
a. o trc tip l van trn siu m 2D:
Mt ct trc ngn cnh c tri, ct qua mp
van, ly l van hai l vo trung tm, dng
hnh trong thi k tm trng khi l van m
rng nht. Sau dng con tr o c
trc tip din tch van hai l.
237
Hnh 12-2. o din tch l van hai l trn siu m 2D.

Hnh nh m (do thnh ngc dy, kh ph
thng), van, t chc di van dy, vi, mo
m hoc bin dng sau m tch van... l
nhng yu t khin rt kh xc nh c
chnh xc l van. Nu ct khng vung gc s
c lng sai din tch l van (tng ln). Vi
hoc x dy mp van cng lm sai lch (gim
i). phn gii thp lm m mp van v
tng qu din tch, phn gii cao lm din
tch gim i. Tuy vy phng php ny vn
c dng rng ri.
b. Phng php PHT (thi gian bn gim p lc):
Thi gian bn gim p lc (thi gian p lc
gim mt na so vi gi tr ban u), l thi gian
vn tc gim cn 70% vn tc nh. Hp hai l
lm thi gian gim p lc ca dng chy qua van
hai l b ko di ra. Cng hp nhiu th mc thi
gian ny cng di, Sng E ca ph hai l c
dng tnh din tch l van theo PHT:
Din tch l van hai l = 220/PHT
238
Hnh 13-3. o din tch l van hai l bng PHT.

Nu khng tnh t ng th PHT = 0,29 thi
gian gim tc sng E. Nu dng chy tm
trng khng tuyn tnh, c th dng dng
chy gia tm trng c lng ra vn tc
ti a. Nu c rung nh, cn ly trung bnh t
5-10 nht bp lin tip tnh.
Phi m bo dng Doppler song song vi
hng ca dng chy.
PHT b thay i khng phn nh ng thc t
nu c thay i nhanh chng ca huyt ng
qua van nh ngay sau nong van hai l. PHT
cng b sai lch nu nhp tim nhanh (EA gn
nh trng nhau). H van ng mch ch, lm
tht tri y nhanh, cng gy gim PHT
tng din tch l van hai l gi to.
5. Siu m tim gng sc ch nh cho bnh nhn c
triu chng song siu m tim khi ngh khng biu l
HHL kht r hoc khi c HHL kht m cha c
biu hin lm sng. C th nh gi chnh p qua
van hai l trong khi thc hin gng sc (bng xe p
lc k) hoc ngay sau khi gng sc (bng thm chy).
Siu m Doppler cng dng o vn tc dng h
239
van ba l, dng h qua van ng mch phi c

lng p lc ng mch phi khi gng sc.
6. Siu m tim qua thc qun: vi u d trong thc
qun cho thy hnh nh r nt hn, dng nh gi
chnh xc hn mc hp van cng nh hnh thi
van v t chc di van, hnh nh cc mu ng
trong nh tri hoc tiu nh tri. T gip ch nh
phng thc iu tr can thip van hai l. Siu m qua
thc qun nn c ch nh thng quy trc khi
quyt nh nong van hai l nu c iu kin. Tuy
nhin, vi cc trng hp nhp xoang v khi hnh nh
kh r trn siu m qua thnh ngc th cng
nh gi cho ch nh nong van hai l.
B. Thng tim: l phng php rt chnh xc o cc
thng s nh: p lc cui tm trng tht tri, p lc nh
tri (trc tip hoc gin tip qua p lc mao mch phi
bt), p lc ng mch phi, cung lng tim (phng
php Fick hoc pha long nhit), nhp tim v thi gian
y tm trng (giy/nhp tim). Trn c s hai ng p
lc ng thi tht tri v nh tri, c th tnh c
chnh p qua van hai l (bng phn din tch gia hai
ng p lc h s o). Nu dng ng p lc mao
mch phi bt, nn dch ng p lc sang tri 50-70 ms
l phn thi gian truyn p lc t nh tri n mng
li mao mch phi.
1. Din tch l van hai l c c tnh theo cng
thc Gorlin:
Dintchl vanhail =
Cungl ngtim / Th igiandd ytamtrong * Nhptim

37 ,7 * Ch nh ptrungbinh quavanhail
H s 37,7 c tnh t hng s Gorlin 44,3 0,85

(h s hiu chnh ca van hai l). Ngoi ra c th da
vo cng thc n gin ho do Hakki xut:
240
Dintchlvanhail =
Cungl ngtim
Ch nh ptrungbinhquavanhail
2. Khng th dng p lc mao mch phi bt tnh

din tch l van hai l nu bnh nhn c hp ng
mch hoc tnh mch phi, tc mao mch phi hoc
tim ba bung nh hay khi cung lng tim qu thp.
ng thi ng thng o p lc mao mch phi bt
phi t ng v tr. Hn th na, phng php pha
long nhit t chnh xc nu c h van ba l hoc tnh
trng cung lng tim thp. Dng h van hai l hoc
lung thng do thng lin nh gy ra ngay sau nong
c th lm c lng sai dng chy qua van hai l.
C. in tm : hnh nh P hai l (sng P rng do dy nh
tri) thng gp nu bnh nhn cn nhp xoang. Trc
in tim chuyn sang phi. Dy tht phi xut hin khi
c tng p lc ng mch phi. Rung nh thng xy ra
bnh nhn HHL.
D. Chp Xquang ngc:
1. Giai on u, c th cha thy bin i no quan
trng, b tim bn tri ging nh ng thng. Tip
, khi p lc MP tng s thy hnh nh cung MP
ni v c bit l hnh nh 4 cung in hnh b bn
tri ca tim (t trn xung: cung MC, cung MP,
cung tiu nh tri, cung tht tri). Mt s trng hp
c th thy hnh nh 5 cung khi nh tri to v l ra
bn tri di cung tiu nh.
2. Hnh nh 2 cung phn di b tim bn phi do nh
tri mu nhiu c 3 giai on: giai on u l hnh
nh song song hai cung vi cung nh tri vn bn
trong cung nh phi, giai on tip l hai cung ny ct
nhau, v sau cng l nh tri to nhiu vi hnh nh hai
cung song song, cung nh tri ngoi cung nh phi.
3. Mt s trng hp HHL rt kht c th thy tht tri
rt sng trong thi k tm trng do mu vo tht
tri t. Cng c th thy hnh nh vi ho van hai l.
241
ng Kerley B xut hin trn phim chp thng khi

c tng p lc ng mch phi. Tht phi gin (gim
khong sng sau xng c trn phim nghing tri).
4. Hnh nh gin tip khc nh nhnh ph qun gc tri
b y ln trn hoc nh tri thc qun 1/3 di,
thc qun b y ra sau trn phim chp nghing c
ung thuc cn quang.
5. C th thy hnh nh vi ho ca van hai l hoc t
chc di van trn phim chp hoc chiu di mn
tng sng.
V. iu tr
A. iu tr ni khoa
1. Nu bnh nhn khng c triu chng c nng th ch
cn iu tr khng sinh d phng vim ni tm mc
khi c km HoHL hoc HoC.
2. Nu bnh nhn mi ch kh th khi gng sc mc
nh th iu tr thuc li tiu lm gim p lc
nh tri. Phi hp thuc chn giao cm (tc dng
gim p ng tng nhp tim khi gng sc) s tng
c kh nng gng sc. Trnh dng cc thuc gin
ng mch.
3. Rung nh l nguyn nhn r rng gy nng bnh, v
th cn iu tr trit rung nh (chuyn v nhp
xoang) hoc t nht phi khng ch nhp tht tng
thi gian tm trng y tht tri v gim chnh
p qua van hai l. Nhng thuc thng dng l
digitalis v nhm chn giao cm. Dng cc thuc
chng lon nhp hoc sc in chuyn nhp c th
chuyn rung nh v nhp xoang song hiu qu lu di
trnh ti pht rung nh cn ph thuc vo vic gii
quyt mc hp van.
4. Bt buc phi iu tr chng ng bnh nhn HHL
c rung nh v nguy c huyt khi gy tc mch cao:
nn duy tr INR trong khong t 2-3. Vic iu tr d
phng huyt khi nh tri v tc mch bnh nhn
nhp xoang cn cha thng nht, song nn iu tr
242
nu bnh nhn c tin s tc mch i tun hon,

c cn rung nh kch pht hoc khi ng knh nh
tri ln ( 50-55 mm) s d dng chuyn thnh rung
nh. Mt s tc gi khc c xu hng iu tr thuc
chng ng cho tt c bnh nhn HHL cho d mc
hp v kch thc nh tri ti u.
5. Nu triu chng c nng nng ln (NYHA 2) bnh
nhn cn c ch nh m hoc can thip qua da.
Mt s tc gi cn coi tng p lc MP ( 55
mmHg) hoc rung nh cng l ch nh can thip
hoc m do vic can thip sm gip kim sot rung
nh tt hn v gim bt t l nguy c, bin chng v
lu di. Nu khng can thip hoc m th t l t
vong sau 10 nm l 40% bnh nhn tr, tng ln
gp i sau 20 nm v t l ny l 60-70% sau 10
nm bnh nhn gi.
B. Nong van bng bng qua da
1. Nong van bng bng qua da l k thut a ng
thng u c bng vo nh tri qua ch chc vch
lin nh ri li xung tht tri v i ngang qua van hai
l, sau bng s c bm ln-xung dn theo tng
c tng dn lm n phn eo ca bng gy tch hai
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
b. NVHL ci thin ng k tnh trng huyt ng v

din tch l van.
c. NVHL c kt qu trc mt v khi theo di lu
di tng t hoc thm ch cn hn nu so vi m
tch van c trn tim kn ln tim m.
d. NVHL l th thut t xm phm, nhiu u th so
vi m nh: thi gian nm vin ngn, t au,
khng c so trn ngc, tm l thoi mi hn...
e. NVHL c th thc hin c trong mt s tnh
hung c bit m phu thut kh thnh cng
trn vn hoc nguy c cao nh: ph n c thai,
ngi suy tim nng, bnh nhn ang trong
tnh trng cp cu...
Hnh 12-4. Nong van hai l bng bng Inoue.
244
HHL (NYHA 1-2)

HHL nh (MVA >1,5cm2)
HHL kht (MVA <1,5cm2)
Siu m gng sc
PAP > 60 mmHg
MVG > 15 mmHg
Hnh thivan tt cho NVHL
Khng
Khng
Theo di hng nm
Nong van hai l
Hnh 12-5a. Ch nh nong van hai l theo AHA/ACC.

HHL (NYHA 3-4)
HHL nh (MVA >1,5cm2)
HHL kht (MVA <1,5cm2)
Siu m gng sc
PAP > 60 mmHg
MVG > 15 mmHg
Khng
Hnh thi van tt cho NVHL

Khng
Nguy c cao nu m
Khng
Tm nguyn nhn khc
M sa/thay van
C
Nong van hai l
Ghi ch: MVA: din tch l van hai l; PAP: p lc tm thu

MP; MVG: chnh p trung bnh qua van hai l; NVHL: nong
van hai l qua da
Hnh 12-5b. Ch nh nong van hai l theo AHA/ACC.
245
2. Chn la bnh nhn NVHL bao gm:

a. HHL kht (din tch l van trn siu m < 1,5
cm2) v c triu chng c nng trn lm sng
(NYHA 2).
b. Hnh thi van trn siu m tt cho NVHL, da
theo thang im ca Wilkins: bnh nhn c tng
s im 8 c kt qu tt nht.
c. Khng c huyt khi trong nh tri trn siu m
qua thnh ngc (hoc tt hn l trn siu m qua
thc qun).
d. Khng c h hai l hoc h van ng mch ch
mc va-nhiu km theo (> 2/4) v cha nh
hng n chc nng tht tri.
3. Chng ch nh NVHL: bnh nhn h van hai l
va-nhiu (3/4) hoc c huyt khi mi trong nh
tri hay tiu nh tri.
4. Thang im Wilkins trn siu m: lng ho
tnh trng van v dy chng gip cho d bo thnh
cng ca NVHL (do Wilkins xut nm 1988) c
nhy cao, c hu ht cc trung tm trn th gii
s dng nh mt tiu chun quan trng trong chn
bnh nhn NVHL. Trong thang im ny th tnh
trng dy ca l van v t chc di van c nh
hng nhiu n vic ci thin din tch l van sau
nong. Cc nghin cu theo di ngn hn v trung hn
u ch ra rng vi im Wilkins trn siu m 8 th
t l thnh cng rt ng k. C mt khong xm
t 9 - 11 im, khi kt qu NVHL vn c th tt
nu c kinh nghim. Tuy nhin, vi im Wilkins >
11 th khng nn nong van hai l bng bng do kt
qu NVHL khng ti u, t l bin chng, suy tim,
ti hp sau nong rt cao. Hin nay phng php
NVHL bng dng c kim loi do Cribier xut vn
cho kt qu tt ngay c bnh nhn c tnh trng van
xu (im siu m cao).
246
Bng 12-1. Thang im Wilkins trn siu m nh gi

van hai l.
im
Di ng van
T chc
dy
di van
van
nh
t, Gn
Van di ng Dy
bnh
phn
ngay
tt, ch st b
st b van. thng: 4 van hn ch.
5 mm.
Phn
gia Dy ti 1/3 Dy t pha
thn van v chiu di b van: 5 chn van cn dy chng. 8 mm.
di ng tt.
ti Dy
lan
Van vn cn Dy
xa xung c
di ng v on
pha
trc dy chng. thn l van:
5 - 8mm.
trong thi k
tm trng,
(ch yu l
gc van).
Khng
di Dy nhiu Dy nhiu
ng hoc rt v co rt ton b c
t.
ct c dy l van: > 8
chng.
- 10mm.
Mc
vi ho
C
mt
im
vi
ho.
Vi ha di
rc pha b
van.
Vi ho lan
n on
gia l van.
Vi
ho
nhiu lan
to ton b
van.
Hnh 12-6. L van hai l trc v sau nong bng bng.

5. Bin chng sau nong van hai l:
a. T vong (< 1%) thng do bin chng p tim cp
hoc tai bin mch no.
247
b. p tim cp do chc vch lin nh khng chnh xc

gy thng thnh nh hoc do thng tht khi
NVHL bng bng/dng c kim loi (< 1%).
c. HoHL lun l bin chng thng gp nht (h hai
l nng sau nong ch t 1-6%, theo nghin cu ti
Vin Tim mch Vit nam l 1,3%).
d. Tc mch c bit l tc mch no (< 1%).
e. Cn tn lu thng lin nh: phn ln l thng ny
t ng trong vng 6 thng; nhng trng hp
cn tn lu (10%) th l nh, shunt b v dung
np tt.
6. Siu m qua thc qun: c vai tr rt quan trng
trong nong van hai l: nhm xc nh khng c huyt
khi nh tri v tiu nh tri trc khi nong. Trong
mt s trng hp c bit, siu m qua thc qun
hng dn li bng nong v nh gi kt qu sau mi
ln nong (din tch l van, mc h hai l, chnh p
qua van hai l...).
7. Din tch l van hai l sau nong: nn c nh gi
bng cch o trc tip trn siu m 2D. Din tch l
van hai l tnh bng phng php PHT thng t tin
cy trong vng 24-48 gi sau nong (do huyt ng
thay i nhanh chng).
8. HoHL: l bin chng kh kim sot nht (1-6% theo
cc nghin cu). HoHL c xu hng tng ln sau
NVHL v th HoHL > 2/4 l chng ch nh tng
i ca NVHL, tuy nhin, mc HoHL nh sau
nong l hon ton chp nhn c v d dung np.
Cc yu t nh HoHL trc nong, tnh trng van vi
ho gc mp van... c kh nng thp trong vic d
bo HoHL sau NVHL. Thang im ca Padial v
Palacios xut c kh nng d bo kh tt HoHL
nng sau NVHL.
248
Khi im Padial >10, kh nng HoHL nng sau

NVHL s tng ln nhiu. Nghin cu ti Vin Tim
mch Vit nam cho thy, vi im Padial > 10, kh
nng bnh nhn b HoHL (RR) tng 53 ln. C ch
chnh gy h van hai l sau nong l thng tn ca t
chc di van, ca mp l van hoc do l van b co
rt gy ng khng kn. Dng HoHL nh sau nong
thng xut pht t mp van trong khi dng HoHL
nng thng do t dy chng hoc rch l van. Mt
s trng hp kt qu rt tt sau nong van, khng c
hoc HoHL rt nh ngay sau nong nhng sau mt
thi gian li xut hin HoHL nhiu hn thng do
hin tng co rt l van, hoc t chc di van di
chng thp tim.
Bng 12-2. Thang im ca Padial d on HoHL.
Thng s
im
dy l van trc
14
dy l van sau
14
Tnh trng vi ho mp van
14
Tnh trng t chc di van
14
Tng
4 16
9. Ti hp sau nong van hai l: l khi nong van thnh
cng v kt qu nhng qua theo di th (1) din tch
l van hai l gim i nh hn gi tr tng din tch l
van hai l trc nong v mt na s din tch gia tng
sau nong v (2) triu chng lm sng r (NYHA >
2). V d: mt bnh nhn c din tch l van hai l
trc nong van l 1 cm2 v ngay sau nong t c 2
cm2, phn gia tng l 1 cm2, 1/2 lng gia tng l 0,5
cm2 nn gi l hp li khi din tch l van < 1,5 cm2.
T l ti hp van hai l ni chung thay i t 6-21%,
sau 4 nm t l sng cn l 84%. Nghin cu bc
u ti Vin Tim mch Vit nam (trn 600 bnh
nhn, trung bnh 2 nm) cho thy 100% s bnh nhn
sng st sau 2 nm, trong 85% bnh nhn khng
249
c nhng triu chng c nng gy ra do hp hai l,

ch c 3,4% bnh nhn ti hp van.
a. Tui cao, NYHA cao, rung nh, din tch l van
trc nong nh, p lc ng mch phi cao, h
van ba l nhiu, h van hai l tng sau nong, din
tch l van hai l sau nong thp l nhng yu t
tin lng xu v lu di.
b. Kt qu lu di (>10 nm) sau nong van tuy rt
n tng (tng ng vi m sa van tim m)
song mi ch dng li nhng bnh nhn tr tui,
van cn cha vi m cha c nghin cu mt
cch y nhng bnh nhn ln tui hn.
C. Phu thut
1. M tch van tim kn: l bin php dng mt dng
c tch van hoc nong van bng tay qua ng m
nh, thng qua ng m ngc (khng cn tun hon
ngoi c th). Hin ti phng php ny hu nh
khng c dng v c nong van hai l bng bng
qua da hoc phu thut tim m. M tch van hoc m
sa van tim c tr gip ca tun hon ngoi c th
cho php quan st trc tip b my van hai l, ly cc
vi, x v to hnh mp van v dy chng van hai l.
2. Bnh l di van nng thng u tin la chn phu
thut so vi can thip. Bnh l van tim khc km theo
HHL cn iu tr (nh h hoc hp van ng mch
ch) cng l mt u tin cho phu thut. i vi
bnh nhn tng p lc ng mch phi v h van ba
l nng th pht, nong van bng bng n thun lm
gim p lc ng mch phi cng khng lm
gim h van ba l nht l nhng bnh nhn ln
tui, v th phu thut van hai l kt hp vi to hnh
van ba l c th l chin lc iu tr ph hp hn.
3. Phu thut thay van hai l:
250
a. Thay van hai l thng c ch nh khi van vi

v co rt nhiu hoc c km HoHL phi hp.
b. La chn thay van hai l c hc hoc sinh hc tu
thuc vo nguy c ca vic dng thuc chng
ng ko di khi c van c hc so vi mc d
thoi ho ca van sinh hc. T l sng st sau
thay van 5 nm t 80-85%.
c. Quan im bo tn t chc di van trong m
hp van hai l cng ging nh h van hai l nhm
duy tr cu trc v chc nng tht tri sau m.
4. M sa van hai l: tuy kh hn song vn thc hin
c mt s trng hp. Sau 10 nm t l sng st
> 95%, t l m li do ti hp sau m < 20%.
5. Tng p lc ng mch phi lm tng nguy c ca
phu thut song tin lng ca bnh nhn sau m cn
tt hn nhiu so vi ch iu tr ni khoa.
6. Phu thut Maze iu tr rung nh mn tnh c th
kt hp ngay khi tin hnh m van hai l.
D. Theo di sau th thut
Theo di sau m hoc sau nong van hai l phi tin
hnh t nht 1 nm/1 ln, hoc nhanh hn nu nh xut
hin triu chng lm sng, nht l khi c cc du hiu
gi c ti hp van hai l hoc h van hai l phi hp.
Siu m tim cn c lm nh k theo di din bin
lm sng ca bnh nhn.
Ti liu tham kho
1.
2.
3.
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EJ, ed. Textbook of cardiovascular medicine. Philadelphia:
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,
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9.
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11.
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16.
17.
18.
angiography and intervention, 5th ed. Baltimore: Williams &

Wilkins, 1996:151-166.
Carabello BA, Crawford FA. Valvular heart disease. N Engl J Med
1997;337:32-41.
Crawford MR, Souchek J, Oprian CA. Determinants of survival and
left ventricular performance after mitral valve replacement.
Circulation 1990;81:1173-1181.
Dean LS, Mickel M, Bonan H, et al. Four-year follow-up of patients
undergoing percutaneous balloon mitral commissurotomy: a report
from the National Heart, Lung, and Blood Institute balloon
valvuloplasty registry. J Am Coll Cardiol 1996;25: 1452-1457.
Farhat MB, Ayari M, Maatouk F, at al. Percutaneous balloon versus
surgical closed and open mitral commissurotomy: seven year followup results of a randomized trial. Circulation 1995;97:245-250.
Glazier JJ, Turi ZG. Percutaneous balloon mitral valvuloplasty. Prog
Cardiovase Dis 1997;40:5-26.
Griffin BP, Stewart WJ. Echocardiography in patient selection,
operative planning, and intra operative evaluation of mitral valve
repair. In: Otto CM, ed. The practice of clinical echocardiography.
Philadelphia: WB Saunders, 1997:355-372.
Grossman W. Profiles in valvular heart disease. In: Baim DS,
Grossman W, ads. Cardiac catheterization, angiography and
intervention, 5th ed. Baltimore: Williams & Wilkins, 1996:735-756.
Mpert JS, Sabik J, Cosgrove DM III. Mitral valve disease. In: Topol
EJ, ed. Textbook of Cardiovascular Medicine. Philadelphia:
Olesen KH. The natural history of 271 patients with mitral stenosis
under medical treatment. Br Heart J 1962;24:349-357.
Reid CL. Echocardiography in the patient undergoing catheter
balloon mitral commissurotomy. In: Otto CM, ed. The practice of
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.
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IF. Percutaneous mitral balloon valvotomy in patients with calcific
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252
H van hai l
H van hai l (HoHL) l bnh kh thng gp. HoHL

thng chia thnh hai loi: HoHL thc tn (do thp tim, vim
ni tm mc, bin chng ca NMCT...) hoc HoHL c nng
I. Triu chng lm sng
A. Triu chng c nng
1. Ph phi (kh th khi ngh, khi nm) hoc sc tim
(do gim th tch tng mu) l triu chng chnh ca
h van hai l (HoHL) nng, cp, mi xut hin.
2. HoHL mn tnh thng khng biu hin triu chng
c nng g trong nhiu nm ngoi mt ting thi
tim. t tin trin ca HoHL thng xut hin kh
th khi gng sc hay gim dung np khi gng sc,
nng hn s xut hin kh th khi nm v cn kh
th kch pht v m. Lu ngy s xut hin triu
chng suy tim tri, cng nh cc triu chng suy tim
phi do tng p ng mch phi.
3. Lon nhp hon ton (rung nh) thng gp do hu
qu ca gin nh tri. Triu chng hay gp khc l
mt (do gim th tch tng mu v cung lng tim).
B. Triu chng thc th
1. S: Mm tim p mnh v ngn nu chc nng tht
tri cn tt. Mm tim p lch tri khi tht tri gin.
C th cm thy hin tng y tht nhanh v
gin nhanh nh tri.
2. Nghe tim:
a. Ting tim:
m sc T1 thng gim (HoHL mn) nhng
cng c th bnh thng nu do sa van hai l
hoc ri lon hot ng dy chng.
253
T2 thng tch i rng (do phn ch ca T2

n sm), m sc s mnh khi c tng p
ng mch phi.
Xut hin ting T3 khi tng dng chy tm
trng cho d khng phi lun lun l
biu hin ri lon chc nng tht tri. i khi
c th nghe thy ting T4 nht l trong t
HoHL cp.
b. Ting thi tm thu: ton th tm thu, m sc cao,
kiu tng mu, nghe r nht mm, lan ra nch
(xut hin gia th tm thu nu do sa va hai l
hoc ri lon chc nng c nh). Ting thi tm
thu ny c th ngn, n sm khi HoHL cp/
nng phn nh tnh trng tng p lc nh tri. Tuy
vy nu p lc nh tri tng qu nhiu s khng
cn nghe r thi tm thu na. Cn chn on
phn bit ting thi ton tm thu ca HoHL vi
h ba l (HoBL) v thng lin tht (TLT): tt c
u c m sc cao, nhng ting thi ca TLT
thng th rp hn, nghe r b tri xng c v
lan ra vng trc tim; ting thi ca HoBL nghe
r nht b di tri xng c, lan v b phi
xng c v ng gia n tri, tng ln khi ht
su trong khi thi tm thu HoHL nghe r nht
mm v lan ra nch (cng c th lan ra y tim
do dng chy hng ra trc).
c. Cc triu chng thc th ca suy tim tri v suy
tim phi (tnh mch c ni, gan to, c chng,
ph chi di) xut hin khi bnh tin trin nng.
A. Nguyn nhn gy ra HoHL
1. Bnh l l van:
a. Di chng thp tim: x ho, dy, vi, co rt l van.
b. Thoi ho nhy: lm di ng qu mc l van.
254
c. Vim ni tm mc nhim khun (VNTMNK) gy

thng l van, co rt l van khi lnh bnh.
d. Phnh l van do dng h van MC (do
VNTMNK) tc ng ln van hai l.
e. Bm sinh:
X (nt) van hai l: n thun hoc phi hp
(thng sn nh tht).
Van hai l c hai l van.
f. Bnh c tim ph i: van hai l di ng ra trc
trong k tm thu.
2. Bnh l vng van hai l:
a. Gin vng van:
Gin tht tri do bnh c tim gin, bnh tim
thiu mu cc b, tng huyt p.
b. Vi ho vng van:
Thoi ho ngi gi, thc y do tng huyt
p, i ng, suy thn.
Do bnh tim do thp, hi chng Marfan, hi
chng Hurler.
3. Bnh l dy chng:
a. Thoi ho nhy gy t dy chng.
b. Di chng thp tim: dy, dnh, vi ho dy chng.
4. Bnh l ct c:
a. Nhi mu c tim gy t ct c nh.
b. Ri lon hot ng c nh:
Thiu mu c tim: cm c nh trc c cp
mu t nhnh m v nhnh lin tht trc,
cm c nh sau t nhnh xung sau (PDA).
Bnh l thm nhim c tim: amyloid, sarcoid.
c. Bm sinh: d dng, van hnh d...
B. C ch bnh sinh
1. HoHL cp tnh: gy tng th tch cui tm trng tht
tri (v thm mt lng mu do HoHL t nh tri
255
v), tng di si c (tin gnh) v tng co bp c

tim theo nh lut Frank-Starling d hu qu l tng
p lc y tht tri v gy huyt phi. Hu
gnh gim do mu thot v nh tri v th cng lm
tht tri bp khe, tng ng tuy th tch tng mu
vn gim. Nu dung np c, bnh nhn s tin
trin thnh HoHL mn tnh.
2. Trong trng hp HoHL mn tnh, tht tri gin v
ph i lch tm. Sc p ln thnh c tim s tr li
bnh thng do ph i c tim, ng thi mc
gim hu gnh do thot mu v nh tri khng cn
nhiu nh trong pha cp. Tin gnh vn mc cao
lm nh tri gin. Tht tri khng co bp tng ng
nh trong pha cp song vn ngng bnh thng
cao. Ri lon chc nng tht tri s tin trin m
thm trong nhiu nm d khng c hoc c rt t
triu chng. Nhng thng s truyn thng nh gi
co bp c tim (nh phn s tng mu) s vn
ngng bnh thng trong thi gian di do tng tin
gnh v gim/bnh thng ho hu gnh. Lu dn ri
lon chc nng km vi gin tin trin bung tht tri
v tng sc 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
C. Siu m Doppler tim: (qua thnh ngc v qua thc

qun) ng vai tr rt quan trng, c s dng rng ri
chn on xc nh v nh gi mc h van hai l.
Mc h hai l trn siu m Doppler tim thng chia
lm 4 (t 1/4 n 4/4) hoc cc mc : nh (1+), va
(2+), nhiu (3+) v rt nhiu (4+).
1. Siu m Doppler mu: chn on HoHL bng hnh
nh dng mu pht ngc v nh tri. HoHL c
th c tnh da vo s lan ca dng mu pht ngc
trong nh tri. Lng gi mc h hai l: da vo
cc thng s nh:
Hnh 13-1. Dng mu ca HoHL trn siu m Doppler.
Hnh 13-2. Sa van hai l v ba l trn siu m 2D.

a. di ti a ca dng mu (h) pht ngc
trong nh tri hoc % din tch dng h so vi
din tch nh tri. Rt ng tin cy nu HoHL
kiu trung tm, song thng nh gi thp mc
h van nu dng h lch tm. Vi nhng dng
257
h lch tm ln, HoHL c c tnh tng thm 1

. Hng ca dng h cho php nh gi
nguyn nhn gy HoHL.
Bng 13-1. Lng gi mc h van hai l.
Chiu di ti a ca
Din tch dng
HoHL dng h (cm) pht
h so vi din
ngc vo nh tri
tch 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
dng an thn (gim hu gnh) s lm gim mc
HoHL so vi bnh thng. Tng t, nu nh gi
HoHL ngay trong m, h thay i nhiu ph
thuc vo tin gnh v hu gnh c tim. Do vy,
ngi ta thng phi hp thm nhiu phng
php khc nh gi mc HoHL.
b. rng dng h (ch hp nht) khi qua l h
(vena contracta): l mt ch s ng tin cy. Nu
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
s gii hn Nyquist), t tnh din tch l h

hiu dng (ERO = 2r2V/Vmr) v th tch dng
h (RV = ERO VTImr) trong r l chiu di
t b ngoi vng cu hi t n mt phng van
hai l, V l vn tc ti vng aliasing, Vmr l vn
tc ti a dng h xc nh bng Doppler lin
tc, VTImr l tch phn vn tc thi gian ca
dng h. Din tch l h hiu dng (ERO) l
thng s nh gi chnh xc h: nh (ERO: 010 mm2), va (10-25 mm2), nng (25-50 mm2),
rt nng (> 50 mm2). Tuy nhin thc t li c mt
vi sai s khi chn vng hi t dng cu dt, xc
nh mt phng l h, khi dng h li khng
ng nht, lch tm... v lm tng gi to h.
D vy hin tng PISA thng bo hiu mc
h hai l va nht l khi s dng Doppler xung
(PRF).
2. Siu m Doppler xung: c th gip nh gi mc
h van hai l, nht l trong nhng trng hp HoHL
nng, c th da vo dng chy tnh mch phi. Hin
tng gim ph tm thu ca dng chy tnh mch
phi khi chc nng tht tri bnh thng bo hiu
HoHL nng, tuy nhin khng chnh xc nu rung nh
hoc ri lon chc nng tht tri nng. Hin tng
o ngc ph tm thu dng chy tnh mch phi bo
hiu HoHL rt nng.
D. Thng tim
1. Sng v trn ng cong p lc nh tri (tng ng
giai on y nh tri t cc tnh mch phi trong
thi k tm thu) cho php c lng mc HoHL,
c bit l HoHL cp tnh. Bin sng v gp 2-3 ln
p lc trung bnh nh tri gi HoHL nng. Tuy
nhin nu HoHL mn tnh hoc khi gim hu gnh,
c th khng thy bt thng sng v. Khng c sng
v cng khng th loi tr HoHL nng. Mt khc sng
259
v cao cng c th gp trong nhng trng hp nh ri

lon chc nng tht tri m nh tri km gin, thng
lin tht sau nhi mu c tim hoc nhng tnh trng
tng lu lng phi.
2. Chp bung tht tri: cho php c lng mc
HoHL theo phn ca Seller:
1/4: Ch c vt cn quang m vo nh tri,
khng vin r hnh nh tri.
2/4: Cn quang trn khp nh tri nhng m
khng bng tht tri, mt i nhanh chng
sau 2-3 nht bp.
3/4: m cn quang nh tri v tht tri
bng nhau.
4/4: Cn quang nh tri m hn tht tri,
xut hin c cn quang tnh mch phi.
3. Thng tim cng dng kho st ng thi bnh
ng mch vnh khi HoHL: bnh nhn nam tui
40, n tui 50 d khng c triu chng hoc yu t
nguy c ca bnh mch vnh cng nn chp ng
mch vnh trc m. Ch nh thng tim gm:
a. Khi khng tng xng gia triu chng lm sng
v kt qu thm d khng chy mu,
b. Khi d nh phu thut nhng bnh nhn cn
nghi ng v mc nng ca h van hai l hoc
bnh mch vnh,
c. Bnh nhn h van hai l c nguy c mc bnh
mch vnh hoc nghi ng bnh mch vnh l cn
nguyn gy h van hai l.
IV. iu tr
Nm bt c ch sinh bnh l vic rt cn thit la chn
bin php iu tr ph hp.
A. H van hai l cp tnh
1. iu tr ni khoa: nu huyt p trung bnh ng
mch vn trong gii hn bnh thng, s dng cc
260
thuc h hu gnh c th lm n nh tnh trng

HoHL cp. Truyn tnh mch Nitroprusside v
Nitroglycerin lm gim p lc mch phi v tng
cng th tch tng mu. Nu cha cn phu thut
ngay, c th chuyn sang dng thuc ung, phi hp
thuc c ch men chuyn v Hydralazin. Trong
nhng trng hp HoHL nng, cp (m tht tri cha
kp gin, ph i nh HoHL do t ct c nh sau
nhi mu c tim) nu xut hin triu chng ph phi,
sc tim th nn t bng trong ng mch ch n
nh tnh trng huyt ng trc khi gi i m.
2. iu tr ngoi khoa: a s bnh nhn HoHL nng,
cp tnh u phi m cp cu.
B. H van hai l mn tnh
1. Chn phng php v thi im iu tr ph hp:
a. Bnh nhn HoHL t va n nng nu c triu
chng th c ch nh m.
b. Bnh nhn HoHL nng khng c hoc c rt t
triu chng th ch nh phc tp hn. Vn
mu cht l xc nh c thi im can thip
trc khi chc nng tht tri gim n mc khng
hi phc. Nu ch theo di st ti khi xut hin
triu chng th vn c nguy c b qua ri lon
nng chc nng tht tri v tin lng s km i
hn. u th ca sa van i vi tnh trng suy tim
v t l t vong sau m khin cho ngy cng c
khuynh hng ch nh m sa van hai l sm
hn nu thng tn gii phu cho php.
c. Rt nhiu phng tin v thng s c xut
d bo tin trin ca ri lon chc nng tht
tri, suy tim v t vong sau m bnh nhn
HoHL nng. Song la chn thi im v bin
php iu tr cn phi hp tu tng c nhn:
261
262
Triu chng lm sng: bnh nhn tui trn 75,

c km bnh l mch vnh hoc ri lon chc
nng thn c tin lng km hn sau m v
th nn gi i m trc khi biu hin r triu
chng cc bnh km theo. Rung nh cng l
mt l do cn nhc ch nh m sm.
Thng s o bng siu m tim: rt c ch
nh gi xem bnh nhn cn gi i m hay
cha. Thng thng phn s tng mu (EF)
trn ngng bnh thng. V th EF < 50%
cho thy tnh trng ri lon chc nng tht
tri nng nn gi i m sm cho d cha c
triu chng. Ngay c khi EF t 50-60% cng
lm tng nguy c suy tim v t l t vong
sau m. Cc thng s d bo nguy c khc
bao gm: ng knh cui tm thu tht tri
(LVESD, Ds) 45 mm, phn sut co ngn si
c tht tri FS 31%, thay i p lc tht tri
theo thi gian dp/dt < 1343.
(a) Khi lm sng v siu m tim khng l r,
nn lm siu m tim gng sc: gim p
ng vi gng sc, EF tht tri khng tng
khi gng sc, ch s th tch cui tm thu
tht tri (LVESVI) 25 cm3/m2 l nhng
ch s gi cn ch nh m sm.
(b) Bnh nhn c sa l van hai l gy HoHL
nng nn ch nh m sm d khng c
hoc c rt t triu chng.
Thng s o bng thng tim:
(a) p lc trung bnh ng mch phi 20
mmHg, ch s tim (CI) < 2 l/pht, p lc
cui tm trng tht tri 12 mmHg l
cc du hiu d bo tin lng ti sau m.
(b) Cung lng tim khng tng hoc p lc
mao mch phi bt tng khi gng sc l
du hiu cho bit c ri lon chc nng

tht tri n.
(c) gin (elastance) tht tri (ng cong
tng quan gia th tch v p lc) l
thng s nh gi chc nng co bp tht
tri tt nht song t c ng dng rng
ri v phi dng cc thit b c bit.
2. iu tr ni khoa:
a. HoHL do ri lon chc nng tht tri (c gin
vng van) c iu tr bng cc thuc cha suy
tim nh :
Cc thuc gim hu gnh, c bit l c ch
men chuyn, lm gim th tch dng h v
tng th tch tng mu. Nhm ny cng c tc
dng vi bnh nhn HoHL do bnh l van tim
c triu chng ang ch m.
Thuc li tiu v nhm Nitrate c tc dng tt
trong iu tr huyt phi.
Rung nh phi c iu tr kim sot tn s
tht bng cc thuc chng lon nhp, nht l
Digitalis v thuc chn giao cm.
b. Vai tr 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
a. Kinh in l ct b b my van hai l ri thay

bng van hai l nhn to. Tuy nhin, sau m
thng c gim chc nng tht tri v suy tim
huyt. Cc k thut mi c xu hng bo tn t
chc di van nhm gim th tch tht tri v sc
p trn c tim sau m (tht tri cng c dng elp
th cng ci thin EF sau m).
b. K thut sa van lm gim ng k t l t vong
v bin chng: t l sng cn sau 5 nm > 85%
v ch c 10% bnh nhn phi m li trong 5
nm. Cc k thut bc l ti thiu cng lm gim
hn na t l bin chng v t vong. Tuy cha c
th nghim no so snh m sa v thay van song
cc nghin cu u cho thy u th ca m sa
van (phn no do s la chn bnh nhn):
T vong ca m sa van l 2% so vi 5-8%
ca thay van.
Phn s tng mu sau m thng cao hn
nhm bnh nhn sa c van.
Nguy c tc mch bnh nhn sa van thp
hn (5% trong 5-10 nm so vi 10-35% nu
thay van). Nguy c vim ni tm mc cng
gim hn (0,4% so vi 2,2%). Sau m sa van
khng cn dng thuc chng ng ko di
(ch 3 thng) nn gim nguy c khi dng
thuc chng ng.
T l phi m li tng t gia hai nhm
bnh nhn m sa v thay van.
Mt s bnh nhn ri lon chc nng tht tri
nng hoc h van hai l th pht c th p
dng th thut Batista (ti cu trc tht tri
kt hp vi m sa van) cho kt qu sm rt
tt trong khi khng th m thay van.
Tuy nhin ch nh m sm (nht l sa van)
nhng bnh nhn HoHL nng m cha c triu
chng cn gy nhiu tranh ci.
264
c. Kh nng sa van thng ph thuc vo nguyn

nhn gy HoHL, d nh gi trc m bng siu
m tim qua thnh ngc hoc qua thc qun.
Thnh cng v cc bin chng ca m sa
van/thay van c th nh gi bng siu m tim
ngay trong m. HoHL tn d l bin chng hay
gp nht sau khi ngng my tim phi nhn to.
Nu HoHL cn 2/4 nn chy li tim phi nhn
to sa tip hoc thay van hai l. Chy my
tim phi nhn to ln th hai khng tng thm t
l t vong ti vin.
d. Cn loi tr mt bin chng sau m l hp ng
ra tht tri do tha m l van sau (> 1,5 cm) y
vng ng hai l van ra trc di chuyn vo
ng ra tht tri trong thi k tm thu. Bin
chng ny rt hay gp nhng bnh nhn c tha
m l van v tht tri nh v tng ng. K thut
s bt m l van sau c p dng hn ch
bin chng ny, tuy nhin nu c cn tr ng
ra tht tri qu nhiu th nn m thay van hai l.
4. Theo di sau m:
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:
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.
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6.
7.
8.
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H van ng mch ch
H van ng mch ch (HoC) c th chia thnh 2 loi: cp

tnh v mn tnh. HoC mn thng do van ng khng kn v b
ca l van b dy ln v cun li, do gin vng van-gc ng
mch ch (MC) hoc c hai. HoC cp thng do chn thng
ngc, vim ni tm mc, tch thnh ng mch ch gy thng,
sa l van hoc gin cp tnh vng van v gn nh lun phi m
cp cu.
I. Triu chng lm sng
A. Triu chng c nng
1. Nu HoC cp do vim ni tm mc nhim khun,
mc h ban u c th khng ln, song c th tin
trin rt nhanh chng v mc HoC v suy tim, cn
theo di st.
2. HoC mn tnh thng khng biu hin g trong
nhiu nm. Triu chng c nng khi xut hin thng
lin quan n huyt phi nh kh th khi gng sc,
sau dn dn xut hin kh th khi nm, cn kh
th kch pht v m, cui cng l cc du hiu ca
suy tim ton b.
3. au tht ngc xut hin nhng bnh nhn HoC
nng (do gim ti mu mch vnh trong thi k tm
trng v gim chnh p qua li mch vnh khi
tng p lc cui tm trng tht tri v suy tim).
B. Triu chng thc th
1. HoC cp, mc nng thng c bnh cnh cp
tnh. Cn ngh ti tch thnh ng mch ch bnh
nhn HoC cp c km au ngc. Cng cn xc nh
bnh s v cc yu t nguy c ca vim ni tm mc
nhim khun. Triu chng suy tim huyt (ph
phi...) bo hiu tin lng xu trong bnh HoC cp.
267
2. HoC mn tnh thng khng biu hin triu chng

g trong mt thi gian di ngoi mt ting thi tm
trng b tri xng c. Cn tm biu hin HoC
nhng bnh nhn c hi chng Marfan hoc phnh
gin ng mch ch ln.
3. Cc triu chng bn ngoi c th gp trong HoC mn
tnh l:
a. Kiu hnh Marfan: thng ngi tr, c d tt
nhiu c quan: nt rui son, bn chn - tay v cc
ngn di nh chn tay nhn, ngc hnh phu...
b. C th km triu chng ca vim ni tm mc
nhim khun.
c. Nhn thy vng p rng trc tim hoc mm tim
lch tri do tht tri gin.
d. S o huyt p vn bnh thng nu HoC nh.
Khi HoC nng, bung tht tri gin, con s huyt
p tm thu tng cao, huyt p tm trng gim
nhiu, to ra chnh lch v s o huyt p ln.
Tnh trng tng ng tun hon ny c th gy ra
mt lot cc du hiu nh:
Du hiu Musset: u gt g theo nhp p
ca tim.
Du hiu Mller: li g p theo nhp tim.
Du hiu Hill: huyt p chn ln hn cnh
tay > 60 mmHg.
Mch Corrigan: mch p ny nhanh mnh,
chm su.
Mch Quincke: hin tng nhp nhy ca
li mao mch mng tay, mi.
Du hiu Duroziez: ting thi i ng
mch i khi p ng nghe vo.
Du hiu Trobe: ting tm thu v tm trng
ni bt ng mch i
Khi suy tim tin trin, co mch ngoi vi s lm
tng con s huyt p ti thiu, huyt p ti a
268
gim do ri lon chc nng tht tri. Trng hp

tch thnh ng mch ch km trn dch mng
tim, c th gp hin tng mch nghch thng.
4. S: mm tim thng p mnh, tng ng, lch tri,
khoang lin sn V ngoi ng gia n, do tht
tri gin. Thng c rung miu tm trng khoang
lin sn II tri, i khi c c rung miu tm thu (do
tng lu lng qua van MC). ny v thi gian
khi bt mch quay, mch i c th xc nh c
mc HoC. Kinh in l mch Corrigan (ny
nhanh, mnh, chm xung nhanh). C th gp mch
hai nh ny trong trng hp hp phi hp h van
ng mch ch. Nhp tim vn nm trong gii hn
bnh thng cho ti giai on mun ca bnh, nhp
tim thng tng ln b tr cho th tch tng mu
khi gim qu mc.
5. Nghe tim:
a. Ting tim c th dng xc nh mc HoC:
Ting T1 m khi HoC nng v ri lon chc
nng tht tri do hin tng ng sm van hai
l cng nh gim lc gy ng van.
Thnh phn ch ca ting T2 thng m do
cc l van MC ng khng kn, thnh phn
phi ca T2 cng hay b ting thi tm trng
ln p. T2 tch i st nhau hoc tch i
nghch thng (trn tm thanh c ng ,
thnh phn ch i sau thnh phn phi) do
thi gian tng mu tht tri b ko di v th
tch tng mu tng.
Ting T3 nghe c khi gim nng chc nng
tm thu tht tri. T4 hay c, do nh tri phi
bp mu xung bung tht tri gim
gin.
b. Thi tm trng kiu pht ngc, bt u ngay
sau ting T2, cng gim dn, nghe r nht
269
b tri xng c khi bnh nhn ngi nghing

ngi v pha trc v th ra ht sc. Mc
HoC lin quan cht vi di hn l cng
ca ting thi: giai on u, ting thi thng
ngn, n khi bnh tin trin, ting thi tr thnh
ton tm trng, tuy vy khi suy tim nng, giai
on cui, ting thi thng ngn li do p lc
cui tm trng tht tri tng dn ln. Vn c tnh
(bp cht tay...), ngi xm, dng thuc tng co c
tim s lm tng ting thi trong khi ang ngi
xm ng thng dy, nghim php Valsalva hoc
ht Amyl Nitrite li lm gim ting thi ny.
c. Thi tm thu y tim lan ln cc ng mch
cnh do tng lu lng tng mu qua van ng
mch ch.
d. Rung tm trng Austin Flint: nghe thy
mm tim trong trng hp HoC nng: do dng
HoC pht ngc gy rung l trc van hai l hoc
dng HoC lm ng sm van hai l v to dng
xoy qua van hai l gy rung. Khi , cn phn
bit vi rung tm trng do hp hai l phi hp.
A. Nguyn nhn gy ra HoC
1. Bnh l gc ng mch ch lm ng van khng
kn gy h:
a. H van ng mch ch cp tnh:
Phnh tch thnh ng mch ch.
Tch thnh ng mch ch do chn thng
ngc.
b. H van ng mch ch mn tnh:
Hi chng Marfan.
Gin phnh ng mch ch.
Gin vng van ng mch ch.
270
Vim thnh ng mch ch do bnh giang

mai.
Lupus ban h thng.
Lon sn xng.
Hi chng Ehlers-Danlos.
Lng ng mucopolysacharide.
Vim ct sng dnh khp.
Hi chng Reiter.
Vim ng mch t bo khng l.
Hi chng Takayashu.
2. Bnh l ti l van ng mch ch:
a. H van ng mch ch cp tnh:
Sa l van do chn thng.
b. H van ng mch ch mn tnh:
Di chng van tim do thp.
Thoi ho vi hoc thoi ho nhy.
Phnh gin xoang Valsalva.
Van ng mch ch hai l, bn l hoc mt l
van.
iu tr thuc methysergide.
B. C ch bnh sinh
1. HoC mn tnh lm tng gnh th tch tht tri, gy
ph i lch tm, gin v tng th tch cui tm
trng ca tht tri. Nu chc nng tht tri cn b,
th tch tng mu ni chung s tng ln ng k, th
tch tng mu thc s vn cn bnh thng, tht tri
c th chu c th tch mu pht ngc m khng
tng qu p lc cui tm trng tht tri. Bnh nhn
s khng thy r cc biu hin triu chng lm sng.
2. Dn dn ri lon chc nng tht tri pht trin, gin
tht tri tng dn, ri lon qu trnh tng mu tht
tri, lm gim phn s tng mu, tng th tch v p
lc cui tm trng tht tri, gim th tch tng mu.
Qu trnh tng gnh c th tch v p lc gy ph i
271
tht tri lch tm phi hp ng tm. Thi im ny

cng l lc xut hin cc triu chng lm sng.
3. HoC cp tnh gy tng th tch cui tm trng tht
tri nhanh chng, trong khi c tht tri cha th ph
i dung np, nn d dng vt qu p lc nh tri
to ra tnh trng ph phi cp. ng thi p lc cui
tm trng tht tri tng nhanh, c th gy ng sm
van ng mch ch, gim th tch tng mu, gim
cung lng tim a n tnh trng sc tim.
III. Din bin t nhin
1. Bnh nhn HoC mn tnh khi xut hin triu
chng s c khuynh hng tin trin bnh kh nhanh.
Cc yu t tin lng xu bnh nhn HoC mn
gm:
a. Triu chng c nng (NYHA >II), con s huyt
p ng mch chnh lch ln.
b. Ch s nh gi chc nng tht tri: phn s tng
mu < 50-55%, phn sut co ngn si c < 2530%, ng knh cui tm thu > 55 mm, ng
knh cui tm trng > 75-80 mm.
c. Gim phn s tng mu khi gng sc.
d. in tim c ri lon ti cc, ST chnh xung >
0,1 mV khi gng sc.
e. Rung nh.
Ni chung phn s tng mu tht tri l thng
s quan trng nht xc nh t l sng cn nhng
bnh nhn c HoC. Khi ri lon chc nng tht
tri, triu chng s xut hin trong vng 2-3 nm,
trung bnh > 25%/nm.
Bnh nhn HoC mc nh-va c t l sng
sau 10 nm t 85-95%. Bnh nhn HoC va-nng
iu tr ni khoa c t l sng sau 5 nm l 75% v
sau 10 nm l 50%. Nu c au ngc, iu tr ni
khoa cng ch ko di thi gian sng khong 5 nm.
272
i vi nhm bnh nhn HoC nng cha c triu

chng, nhng nghin cu gn y cho thy t l bin
c (t t, xut hin triu chng phi phu thut, ri
lon co bp tht tri) khong 6,2%/nm, t l xut
hin triu chng khong 10%/nm. T l t vong
tng tuyn tnh hng nm: vi bnh nhn c triu
chng khong 9,4% cn vi bnh nhn cha c triu
chng l 2,8%. Din bin t nhin ca HoC nng
mn tnh khng h tt nh trc y m t. ng ch
ch triu chng c nng tin trin khng tng
ng vi bt k ch s chc nng tht tri no.
t t c th xy ra bnh nhn HoC nng
c triu chng, thng do cc ri lon nhp tht lin
quan n ph i v ri lon chc nng tht tri hoc
th pht do thiu mu c tim.
2. T l sng cn s tng nu iu tr tch cc cc thuc
gin mch nh Nifedipine, thuc c ch men chuyn,
Hydralazine, ch nh sm thi im phu thut v
ci tin k thut m. Mc d thuc ci thin phn no
tin lng sng nhng tc dng chnh ch l ko di
thi gian ch m.
A. in tm : Hnh nh in hnh l dy tht tri, T cao
v ri lon nhp nh. Dng ri lon nhp nh hay gp nht
l rung nh, nht l khi c bnh van hai l phi hp. Bloc
dn truyn cc mc c th gp khi p xe vng van
MC.
B. Xquang tim phi: bnh nhn HoC mn c hnh nh
tim to. C th gp hnh nh gin nh tri hoc gin ng
mch ch ln.
C. Siu m tim: siu m 2D cho php xc nh nguyn
nhn HoC cp, kho st c gc MC, kch thc v
chc nng ca tht tri. Siu m Doppler tim cho php
chn on xc nh HoC v lng gi mc HoC (bng
273
nhiu phng php s dng Doppler mu, Doppler xung

v Doppler lin tc).
1. Xc nh dng pht ngc ca HoC da trn mt ct
dc cnh c v mt ct 5 bung t mm. ng thi
phi hp cc mt ct khc nh gi hnh dng van
MC (cnh c trc ngn), phn gc MC v MC
ln (trn 1 khoang lin sn so vi mt ct cnh c
trc di), quai MC v MC xung (trn hm c v
di mi c) cng nh nh gi c ch, nguyn nhn
gy h, chc nng tht tri, mc HoC nh hng
n cc bung tim v tn thng van phi hp. Du
hiu rung cnh van hai l, ng sm van hai l (trn
siu m tim kiu TM) c gi tr chn on cao.
Hnh 14-1: Dng pht ngc ca h van MC trn

Doppler mu. (A: Mt ct dc cnh c tri. B: Mt ct ngang
qua gc MC. C: Mt ct 5 bung tim t mm. D: Hnh nh
siu m TM mu ca mt trng hp h van MC).
274
2. nh gi mc HoC c rt nhiu phng php

da vo siu m Doppler song khng phng php
no c chp nhn lm tiu chun chung. Mt khc,
nhiu yu t c th nh hng ti vic dng siu m
Doppler o: thay i tu theo gin n ca tht
tri, ca MC v sc cn i tun hon. Ci chnh l
c lng mc nng ca HoC da trn c s tng
hp ca nhiu thng s trn siu m. Song cn ch :
cc thng s tng i thng nht nu mc HoC
nh hoc nng nhng thng khc nhau nhiu nu
HoC mc va, do cn phi hp thm cc triu
chng lm sng. Mt s thng s sau thng c s
dng nh gi mc h van MC:
a. Da vo siu m Doppler mu:
ng knh dng HoC/ng knh ng ra
tht tri (RTT).
Din tch dng HoC/din tch ng ra tht
tri.
Hin tng dng chy gn hi t MC ln:
tng ng vi HoC 3+ hay 4+.
Chiu di v din tch dng HoC pht ngc
vo trong tht tri: tuy nhin kt qu tnh giao
ng rt nhiu, ph thuc vo tnh trng ti
ca c tim v hng ca dng h. Dng HoC
thng b trn vi dng chy qua van hai l
v lm cho vic c lng mc h ch b
qu ln.
b. Da vo siu m Doppler lin tc:
Tng quan tn hiu gia ph Doppler lin tc
ca dng h MC so vi dng tng mu t
tht tri vo ng mch ch.
Dc gim p v thi gian bn gim p lc[PHT] (thi gian chnh p gia ng mch
ch v tht tri gim cn mt na so vi gi
tr ban u): dc gim p cng dc, PHT cng
ngn th HoC cng nng.
Dng chy ngc trong thi k tm trng
on u ng mch ch xung: tng ng
vi HoC nng.
275
T s gia tch phn vn tc theo thi gian

ca dng chy tm trng (VTId) trn tch
phn vn tc theo thi gian ca dng chy
tm thu (VTIs):
VTId / VTIs > 50% tng ng vi HoC nng.
c. Da vo huyt ng: tnh phn s h (RF) da
trn hiu s dng chy qua van ng mch phi
so vi dng chy qua van MC nu khng c
lung thng trong tim.
Qa Qp
RF =
/ 100
Qa
Trong : Qa = LVOTvti
0,785 Da v
Qp = RVOTvti 0,785 Dp
Da l ng knh ng ra tht tri (LVOT) o
mc van MC; Dp l ng knh ng ra tht
phi (RVOT) o mc ngang van ng mch
phi; vti l tch phn vn tc theo thi gian ti
LVOT hoc RVOT.
d. Cc thng s siu m tim ca HoC mn tnh mc
nng:
ng knh dng HoC / ng knh ng ra
tht tri 65%.
Din tch dng HoC / din tch bung tht tri
60%.
Dc gim tc trn ph Doppler lin tc dng
HoC 3m/giy.
PHT 300 ms.
C dng chy ngc ton tm trng on
u ng mch ch xung.
Hin tng dng chy gn hi t trn siu m
Doppler mu.
Mt tn hiu Doppler lin tc dng h
MC ging dng tng mu ln MC.
Ph dng chy qua van hai l c dng hn
ch.
Phn s h > 50%.
Th tch h > 60 ml.
ng knh cui tm trng tht tri > 65
mm.
276
Bng 14-1. Cc phng php nh gi mc HoC.

Mc HoC
Phng php
ng knh HoC
/ ng ra tht
tri (%)
Din tch HoC /
Din tch tht tri
(%)
PHT (ms)
Nh (1+)
Va (2+)
< 25
400
400170
Dc gim tc
2
Mt ph ca nht,
dng h so vi khng
mt ph dng hon ton
tng mu ln
MC
Chiu di dng ngay
HoC pht ngc di cc
v tht tri
l van
MC
ng knh dng < 8 mm
HoC trn siu m
mu kiu TM
Vn tc dng
0%
chy cui tm
trng/vn tc ti
a dng chy tm
thu
Vn tc dng
< 0,1
chy cui tm
trng (o ti eo
MC) (m/s)
25-45
Vanng (3+)
46-64
Nhiu
(4+)
65
4-25
25-59
60
300-400
37070
2-3
nht,
hon ton
300-400
25080
2-3
nht t
hn,
hon ton
300
14030
3
cng
mt
khng
qu 1/2
l trc
van hai l
8-12 mm
ti tn
vng cc
c nh
ti tn
mm
tim
12-16
mm
>16
mm
1-10%
11-20%
>2025%
0,1-0,2
0,2-0,4
> 0,4
277
D. Siu m tim qua thc qun: rt c gi tr bnh

nhn vim ni tm mc nhim khun pht hin cc si
hoc p xe vng van MC. Nu HoC n thun, si in
hnh thng mt nhn v pha tm tht ca l van. Vim
ni tm mc nhim khun d lm tn thng c l van
(thng) v cc cu trc ca gc MC gy tnh trng HoC
cp, tin trin nhanh. Siu m qua thc qun cng cho
php nh gi nguyn nhn gy HoC, xc nh cc tn
thng bm sinh v loi tr phnh tch MC.
E. Siu m gng sc: nh gi p ng ca tht tri vi
gng sc. Phn s tng mu tht tri bnh thng khi
ngh nhng khng tng khi gng sc chnh l du hiu
ri lon tim n chc nng tht tri v c ch nh m.
F. Chp x hnh kiu nhiu cng (MUGA): nh gi
chc nng tht tri, tnh phn s v th tch h.
G. Thng tim v thm d huyt ng: ch nh khi:
1. Bnh nhn nam tui 40 v n tui 50 nn chp
ng mch vnh loi tr bnh ng mch vnh
trc khi thc hin bt k can thip no.
2. Chp ng mch ch nh gi mc HoC (t
th nghing tri chch u vi ng thng trn l van
MC 1 cm). Cn cn thn khi li ng thng (do quai
ng mch ch thng gin, nht l trong hi chng
Marfan) trnh gy sang chn. Cng cn ch
bnh l hp l vo ng mch vnh phi hoc tri.
Bng 14-2. Mc h van MC khi chp MC.
Mc HoC
Mt cn quang
Tc cn
tht tri
quang nht
dn
Nh (1+)
Nht, khng vin hon
Nhanh
ton
Va (2+)
Nht, vin hon ton
Nhanh
Va-nhiu
Bng cn quang
Va
(3+)
MC
Nhiu
m hn cn quang
Chm
(4+)
MC
278
3. Huyt ng: bnh nhn HoC mn tnh cn b s c

tng p lc tm thu v gim p lc tm trng MC
trong khi p lc cc bung tim bn phi bnh thng.
Bnh nhn HoC nng s c tng p lc cui tm
trng tht tri, tng p lc mao mch phi bt, tng
p lc ng mch phi tu theo mc suy tim v
cc tnh trng bnh l van tim phi hp khc. Cng
nn c gng o chnh p qua van ng mch ch
nh gi mc hp van MC phi hp (nu c).
V. iu tr
A. La chn phng hng iu tr: ch yu l phi
xc nh nguyn nhn, n nh tnh trng huyt ng,
xc nh nhu cu v thi im phu thut tu thuc vo
bnh cnh HoC cp tnh, HoC mn tnh, cn b hoc mt
b. Phu thut l iu tr tt yu cho bnh nhn HoC
nng cho d nguyn nhn g, nht l khi suy tim.
1. Ch nh m gm:
a. H van ng mch ch nng, cp tnh.
b. Bnh MC: khi ng knh gc MC 50 mm
d h van mc no.
c. H van ng mch ch mn tnh c km theo:
Triu chng suy tim huyt (NYHA 2)
hoc c au ngc.
Phn s tng mu tht tri EF 50%.
ng knh tht tri cui tm thu 55 mm.
ng knh tht tri cui tm trng 75mm.
Phn s tng mu gim khi gng sc.
B. iu tr ni khoa
1. HoC mn tnh: bao gm:
a. Phi iu tr d phng vim ni tm mc nhim
khun nht l HoC nng.
279
b. C th duy tr hot ng th lc bnh thng

(gng sc nh, chi th thao) song nn trnh dng
gng sc tnh nu chc nng tht tri bnh thng
v cha biu hin triu chng. Nn lm nghim
php gng sc nh gi kh nng hoc mc
dung np gng sc vi yu cu hot ng c th.
c. Cc thuc gin mch nh Nitroprusside,
Hydralazine, Nifedipine tc dng chm v thuc
c ch men chuyn: c tc dng gim th tch h
v tng th tch tng mu, gim ti, gip ti cu
trc tht tri, gim th tch cui tm thu v tng
phn s tng mu. Thuc gin mch c ch
nh bnh nhn HoC c:
Tng huyt p ng mch.
Suy tim v/hoc ri lon chc nng tht tri
nhng chng ch nh m.
Ci thin tnh trng lm sng v huyt ng
trc m bnh nhn ri lon chc nng tht
tri cha xut hin triu chng c nng v
bnh nhn c triu chng lm sng nhng
chc nng tht tri cn tt hoc bt u gim.
Khng nn iu tr lu di thuc gin mch
nu c ch nh m v nhm bnh nhn ny
nn c m ngay, khng tr hon.
HoC nng, cha c triu chng, tht tri gin
(ng knh cui tm trng > 60-65 mm) vi
mc ch ci thin tin lng v tr hon thi
im phi m. Tuy nhin, khi:
(a) HoC mc nh-va: nu cha c triu
chng khng cn iu tr.
(b) HoC nng: nu cha c triu chng, chc
nng tm thu tht tri bnh thng, tht
tri khng to hoc gin nh (ng knh
280
cui tm trng < 60 mm) th cha phi

m, nn cng khng cn iu tr thuc.
d. Thuc c ch men chuyn cn c ch nh
bnh nhn c ri lon chc nng tm thu tht tri
ko di sau m thay van. Nifedipine (so vi
Digoxin) chng t li ch r rt, gim t l
xut hin triu chng, bo tn chc nng tm thu
tht tri sau m song hin cha y thng tin
v cc tc dng ca cc thuc khc nh
Hydralazine v c ch men chuyn. Khng nn
dng ko di Digoxin, Nitrate, thuc li tiu hoc
cc thuc tng co bp c tim nhm bnh nhn
khng c triu chng. Liu dng thuc phi c
iu chnh lm gim huyt p ng mch.
e. Nhng bnh nhn h van MC nng mn tnh
cn phi theo di thng xuyn nhm pht hin
s xut hin ca cc triu chng v s thay i
kch thc cng nh chc nng tht tri ch
nh thay van MC. Khong thi gian gia cc
ln theo di s tu thuc vo bnh cnh v chc
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
Ds < 45mm hoc Dd < 60mm (*)

12 thng
12 thng
Ds: 45-50mm hoc Dd: 60-70mm(*) 6 thng 6-12 thng
Ds: 50-55mm hoc Dd: 70-75mm(*) 3 thng
3-6 thng
Ds > 55mm hoc Dd > 75mm
Phu thut
281
(*)
Khi mi o ln u tin hoc khi cc gi tr cha n nh

(chng hn khi gi tr o ln trc thp hn), cn phi o li nh
k 3 thng/ln.
i vi bnh nhn HoC khng nng, phn s tng
mu tht tri bnh thng, bung tim khng gin
hoc gin rt t, ch cn lm siu m kim tra nh k
2-3 nm mt ln. Nhng bnh nhn HoC nng nn
c kim tra siu m nhiu hn, ti thiu 1 ln/nm.
Siu m Doppler tim nn c kim tra li 2-3 thng
sau ln khm u tin m bo tin trin ca bnh
khng qu nhanh. Khi ng knh tht tri thay
i so vi ln o trc, nn lp k hoch khm lm
sng v siu m tim 3 thng mt ln. Nu hnh nh
siu m tim khng r, nn theo di bng chp x
hnh bung tht. Chp x hnh bung tht cng c
ch nh nu phn s tng mu tht tri trn siu m
mc ranh gii. Nu hnh nh siu m tt, khng cn
tin hnh chp x hnh thm. Siu m cng c ch
nh theo di nh gi kch thc gc MC
nhng bnh nhn c gin gc MC. Mt khi cc du
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
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 nhn to d
mi ch dng khng sinh. (Khi van MC ng
loi/t thn thng c a chung).
3. iu tr can thip: chng ch nh t bng trong
ng mch ch (IABP) khi HoC t va-nhiu. Bnh
nhn phi hp h v hp van MC khng nn nong
van bng bng qua da do khuynh hng tng nhiu
mc HoC cp sau nong.
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
(b) Bnh nhn khng c triu chng, chc

nng tht tri bnh thng, kh nng dung
np gng sc bnh thng (t mc 8
MET theo quy trnh chun) th ch nn
theo di st v c th dng cc thuc gin
mch.
(c) Bnh nhn khng c triu chng v bt
thng dung np gng sc hoc tng
ng knh cui tm thu tht tri (>
55mm) s nhanh chng c ri lon chc
nng tht tri, do nn c xt m c
chun b.
Thay van MC phi c tin hnh ngay
trc thi im m nu tip tc tr hon c th
dn ti kt cc khng tt sau m (ch yu
lin quan vi mc ri lon chc nng tht
tri). Thi im phu thut nhng bnh
nhn khng c hoc c rt t triu chng v
chc nng tht tri trong gii hn bnh thng
vn cn nhiu bn ci. Chc nng tm thu tht
tri thng s c ci thin ng k sau m
nu ch mi ri lon trong vng 18 thng.
Chc nng tm thu v kch thc cui tm thu
tht tri l nhng yu t d bo quan trng
nht i vi thi gian sng, tin lng v chc
nng tht tri sau phu thut nn thng c
cc thy thuc dng theo di v quyt nh
thi im m trn lm sng.
b. Cc kh nng phu thut cng tng t nh hp
van ng mch ch. Nhiu bnh nhn c sa l
van MC hoc vim ni tm mc nhim khun
gy h ch th c th xem xt kh nng m sa
van MC nu thng tn ph hp.
284
Ti liu tham kho

1.
Borer JS, Hochreiter C, Herrold EM, et al. Prediction of indications

for valve replacement among asymptomatic or minimally
symptomatic patients with chronic aortic regurgitation and normal
left ventricular performance. Circulation 1998;97:525-534.
2. Brener SJ, Dufly CI, Thomas JD, Stewert WJ. Progression of aortic
stenosis in 394 patients: relation to changes in myocardial and mitral
valve dysfunction. J Am Coll Cardiol 1995;25:305-310.
3. Carabello BA, Crawford FA. Valvular heart disease. N Engl J Med
1997;337:32-41.
4. Carabello BA, Stewart WJ, Crawford FA. Aortic valve disease. In:
Topol EJ, ed. Comprehensive cardiovascular medicine.
Philadelphia: Lippincott-Raven, 1998: 563-585.
5. Carabello BA. Timing of valve replacement in aortic stenosis:
moving closer to perfection [Editorial]. Circulation 1997;95:22412243.
6. Deedy M. Aortic valve disease. In: Marso SP, Griffin BP, Topol EJ,
eds. Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven, 2000.
7. Gaasch WH, Sundaram M, Meyer TE. Managing asymptomatic
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
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.
286
Hp van ng mch ch
Hp van ng mch ch (HC) l nguyn nhn thng gp

nht gy tc nghn ng tng mu ca tht tri. Cc nguyn
nhn khc bao gm hp di van ng mch ch do mng x,
hp di van ng mch ch do c tim ph i v hp trn van
ng mch ch.
I. Triu chng lm sng
Nn ngh n chn on HC trc bt k bnh nhn no c
ting thi tm thu tng mu b phi pha trn xng c, lan ln
ng mch cnh. Phn ln bnh nhn khi i khm cha c triu
chng c nng tuy nhin buc phi hi k pht hin tin s
au ngc, chong vng, ngt hoc cc du hiu khc ca suy
tim. Tin s hp eo MC gi bnh van MC c hai l van,
ngc li nu bnh nhn c chn on van MC c hai l
van, phi o huyt p ng mch t chi loi tr hp eo MC.
Tin s thp tim gi nguyn nhn HC l di chng thp tim.
A. Triu chng c nng: thng ch gp khi hp van
MC mc nng.
1. au ngc do tng tiu th xy c tim trong khi cung
cp xy cho c tim b gim hoc do x va mch
vnh. 25% s bnh nhn khng au ngc c bnh
mch vnh, trong khi 40-80% s bnh nhn HC
au ngc c km bnh mch vnh.
2. Chong vng, ngt: do tc nghn c nh ng
tng mu tht tri v gim kh nng tng cung lng
tim, bnh nhn HC c th tt huyt p nng trong cc
tnh hung gim sc cn ngoi vi dn n chong
vng hoc ngt.
3. Biu hin ca suy tim: do ri lon chc nng tm
thu hoc chc nng tm trng. Theo tin trin ca
bnh, x ho c tim s dn ti gim co bp. Cc c
287
ch b tr nhm lm tng th tch trong lng mch s

lm tng p lc tht tri cui tm trng, tng p lc
mao mch phi bt gy huyt phi. Cc tnh trng
gy ri lon y tht tri nh rung nh hoc tim
nhanh n thun c th gy biu hin suy tim.
B. Triu chng thc th
1. Bt mch: triu chng ni bt ca HC l mch cnh
ny yu v tr (pulsus parvus et tardus), l du hiu
tt nht cho php c lng mc HC ti ging.
Mt s bnh nhn ln tui bt mch li vn thy gn
ging bnh thng do gim chun gin ca thnh
mch, nn gy c lng thp mc HC. Bt mch
ngoi vi u gim khi c HC nng. i khi s thy
rung miu tm thu dc theo ng mch cnh bnh
nhn HC kht. C th s thy rung miu tm thu
khoang lin sn II bn phi bnh nhn HC.
2. S thy mm tim p rng, lan ta nu tht tri ph
i nhng cha ln hn. i vi mt s trng hp,
s thy mm tim p p, tng ng vi sng a hay
ting T4 do tht tri gin n km.
3. Nghe tim: cc ting bnh l chnh bao gm:
a. Thi tm thu tng mu pha trn bn phi
xng c, lan ln c, t cng cao nht vo
u-gia tm thu. Mc HC cng nng, ting
thi cng di hn, mnh hn v t cc i chm
hn (cui k tm thu). Tuy nhin cng ting
thi khng lin quan cht vi mc hp do
cng ting thi c th gim nh i nu cung
lng tim gim nhiu hoc chc nng tht tri
gim nng. Trng hp van MC c hai l van,
cn di ng, c th nghe c ting m van MC
trc ting thi tm thu.
b. Ting T1 ni chung khng thay i khi HC, tuy
nhin nu chc nng tm thu tht tri ri lon
288
nng v tng p lc cui tm trng tht tri, m

sc T1 gim do hin tng ng sm v gim lc
tc ng ng van hai l. Thnh phn ch ca
ting T2 gim i khi HC kht, T2 tr nn nh v
gn (n c) do ch nghe thy thnh phn phi
ca ting T2. Mt s bnh nhn HC nng c ting
T2 tch i nghch thng do ko di thi gian
tng mu tht tri qua l van hp kht. T2 tch i
nghch thng cng gp trong cc tc nghn
ng tng mu tht tri khc v trong bloc
nhnh tri. Ting T3 l du hiu chc nng tm
thu tht tri km. Ting T4 xut hin do nh tri
co bp tng mu vo bung tht tri c gin
km khi hp van MC kht.
c. Ngoi ra, c th gp cc ting thi ca h van
MC do hp thng i km h van. Hin tng
Gallevardin xy ra trong mt s trng hp hp
van MC nng, vi ho: thnh phn m sc cao
ca ting thi li lan xung mm tim, d ln vi
ting thi ca h van hai l km theo.
d. Nhp tim nhanh lc ngh bnh nhn HC nng l
mt trong nhng du hiu u tin ca tnh trng
cung lng tim gim thp.
A. Cc nguyn nhn gy hp van ng mch ch
1. Hp van MC bm sinh: dng hp van MC hay
gp nht ngi ln l bnh van MC c hai l van,
chim 1-2% dn s, ch yu nam gii. Van MC
thng thoi ho v vi sm. Mt s dng HC khc
nh dnh l van, van mt cnh...
2. Hp van MC mc phi:
a. Hp do thoi ho v vi ho l dng bnh thng
gp nht, ni tri tui 70-80. Qu trnh ri lon
chuyn ho canxi trong bnh Paget, bnh thn
289
giai on cui lm tng qu trnh vi ho. Cc

yu t nguy c ca bnh mch vnh thc y
nhanh qu trnh vi ho cc l van b thoi ho.
b. Hp van MC do thp tim t khi n thun m
khng km bnh van hai l. Thp tim gy x ho,
vi ho, dnh cc l van v mp van MC, dy l
van nht l ti b.
Hnh 15-1. Van MC vi ho.

B. Sinh l bnh
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
trng tht tri tng lm gim p lc ti mu ng

mch vnh, gy p cc ng mch nh trong c
tim hoc pha di ni tm mc, do cng lm
gim hn na cung cp xy cho c tim, gy biu hin
au ngc...
C. Din bin t nhin ca bnh
1. Tin trin ca hp van MC c trng bi mt giai
on ko di khng biu hin triu chng c nng
cho ti khi din tch l van MC < 1,0 cm2. Ni
chung, chnh p trung bnh qua van MC tng
khong 7 mmHg/nm v din tch l van gim
khong 0,12-0,19 cm2/nm. Do tc tin trin rt
khc nhau, tt c bnh nhn HC cn c tuyn
truyn k v cc triu chng bo hiu tin trin ca
bnh. T l sng cn gn nh bnh thng khi khng
c triu chng c nng. Nguy c t t < 2%/nm
ngay c bnh nhn hp van MC nng m khng
c triu chng c nng.
2. Nhng khi pht trin triu chng c nng, t l
sng cn gim xung nhanh chng nu khng m:
a. Khi bnh nhn c au ngc th t l sng cn
ch t 50% sau 5 nm,
b. Khi c ngt th t l sng cn ch t 50% sau
3 nm,
c. Khi c suy tim th thi gian sng trung bnh <
2 nm.
d. t t c th xy ra nhng bnh nhn HC c
triu chng c nng do cc ri lon nhp tht trn
bnh nhn ph i v ri lon chc nng tht tri
hoc ri lon nhp th pht do thiu mu c tim.
A. in tm : thng c dy nh tri (80%) v ph i
tht tri (85%). Ri lon nhp t khi xy ra, ch yu giai
on cui v a s l rung nh, nht l khi c km bnh
291
van hai l. Bloc nh tht c th gp khi c pxe vng van

bin chng ca vim ni tm mc.
B. Xquang ngc: t c gi tr chn on do hnh nh c
th hon ton bnh thng. Bng tim ging hnh chic
ng nu ph i tht tri ng tm. Hnh tim thng to
nu c ri lon chc nng tht tri hoc c HoC phi
hp. Mt vi hnh nh khc c th bt gp l hnh nh vi
ho van MC ngi ln tui (phim nghing) hoc gin
on MC ln sau hp.
C. Siu m Doppler tim: siu m Doppler tim l phng
php c la chn chn on xc nh v nh gi
mc nng ca hp ch. Cc mt ct cnh c (2D hoc
TM) l nhng v tr tt nht nh gi c ch, nguyn
nhn HC v o c kch thc bung tim, thnh tim.
1. nh gi v tnh trng van, nguyn nhn gy hp
van v nh hng n cc bung tim:
a. Cc l van dy, m dng vm trong thi k tm
thu gp trong HC bm sinh v do thp tim, phn
bit bng kiu dy ca l van (mt ct trc di
cnh c tri): HC do thp thng dy khu tr b
t do nhiu hn so vi thn l van, rt hay c
HHL km theo. Ngc li, HC do thoi ho th
qu trnh vi ho thng tin trin t thn cho ti
b mp van, lm gim dn di ng l van n
gn nh c nh. C th s b nh gi mc
HC da vo bin m van trn siu m TM
(bnh thng l 16-22 mm):
HC nh: bin m van MC t 13-15 mm.
HC va: bin m van MC t 8-12 mm.
HC nng: bin m van MC < 8 mm.
Tuy nhin gi tr ny c tnh cht gi , ch
khng hon ton chnh xc, v ch nh gi c
khong cch gia 2 trong s 3 l van MC. K
thut o v v tr mt ct c th lm sai lc kt
qu o. Cung lng tim gim nhiu cng lm
292
gim bin m ca van MC d khng c HC

thc s.
b. S lng mp van, ng ng van v hnh dng
l van (mt ct trc ngn cnh c tri) cho php
chn on cc loi HC bm sinh: van MC c
hai l van, van MC dng mt l-mt mp hoc
dng mt l-khng c mp van... Tuy nhin, khi
van MC vi ho nng th vic xc nh
nguyn nhn HC tr nn rt kh khn.
c. Ph i v gin tht tri, gin nh tri trn mt ct
trc di cnh c tri nhng nu hp van MC n
thun, tht tri thng nh tuy c ph i. Mt ct
bn bung hoc nm bung t mm cho php
nh gi chung chc nng co bp v vn ng
thnh tht. Cc mt ct ny cng cho php xc
nh mc h van MC km theo bng siu m
Doppler mu.
2. nh gi v huyt ng:
a. Chnh p qua van MC: thng o bng
Doppler lin tc s dng mt ct nm bung t
mm v mt s mt ct khc nh: khoang lin
sn II b phi xng c, trn hm c... da trn
cng thc Bernoulli sa i (P = 4 V2) xc
nh chnh p trung bnh v chnh p ti a (tc
thi nh-nh) gia MC v tht tri. Mc
HC c phn loi da vo chnh p qua van
MC:
HC nh: chnh p ti a < 40 mmHg hoc
chnh p trung bnh < 20 mmHg.
HC va: chnh p ti a: 40-70 mmHg hoc
chnh p trung bnh: 20-40 mmHg.
HC nng: chnh p ti a > 70 mmHg hoc
chnh p trung bnh > 40 mmHg.
Mt s yu t lm tng gi to chnh p qua van
MC nh: c km h van MC, mng ngn di
293
van MC, tnh trng tng cung lng tim, o sau

nht ngoi tm thu, ly nht bp khng i din
(khi rung nh) hoc ln vi ph ca h van hai l.
Hnh 15-2. Ph Doppler lin tc ca hp van MC.

b. Din tch l van MC: o theo nguyn l ca
phng trnh lin tc:
Din tch van MC = r2 VTITT / VTIMC
Trong : VTITT l tch phn vn tc theo
thi gian ca dng chy tm thu ti v tr bung
tng mu ca tht tri (Doppler xung vi ca s
Doppler cch van MC 1 cm ti mt ct 5 bung
tim); VTIMC l tch phn vn tc theo thi gian
ca dng chy qua v tr van MC b hp; r l
bn knh ca bung tng mu tht tri (mt ct
trc di, ngay st vng van MC).
Mc hp van MC c phn loi da vo
din tch l van nh sau:
HC nh: din tch l van > 1,5 cm2.
HC va: din tch l van t 1-1,5 cm2.
HC nng: din tch l van < 1 cm2, khi din
tch < 0,75 cm2 (< 0,5 cm2/m2 din tch da) th
c coi l hp van MC rt kht.
c. Ch s VTITT/VTIMC: khi < 0,3 tng ng vi
hp van MC nng, khi < 0,25 tng ng vi HC
kht. Ch s ny khng ph thuc vo lu lng
294
tim v trnh c cc sai st khi o ng knh

bung tng mu tht tri, c ch trong trng hp
hp van MC kht v ri lon chc nng tht tri
nng. Tuy nhin, cn lu ch s ny c t l sai
st cao khi ng knh bung tng mu tht tri
rng > 2,2 cm hoc hp < 1,8cm.
3. Siu m tim qua thc qun: c th o trc tip din
tch l van (2D), nhng kh ly c ph Doppler
ca dng chy qua van b hp hn. Cng c ny rt
c ch nh gi hnh thi van MC trong bnh hp
van MC bm sinh.
4. Siu m gng sc: nhm phn bit nhng trng hp
hp van MC thc s c ri lon chc nng tm thu
tht tri nng (nn chnh p qua van thp) vi nhng
trng hp gi hp (bnh l nh hng n c tim t
trc, c km hp van MC nh, nn cng ri lon
chc nng tm thu tht tri v chnh p thp qua van
MC) bi trng hp gi hp khng h c ci thin
sau khi c m. Dobutamine truyn vi liu tng
dn t 5 n 20 g/kg/pht tng dn cung lng
tim, sau dng siu m tim kim tra tng bc din
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
t vong sau thng tim bnh nhn hp kht van MC

l 0,2%. Bnh nhn HC nng nn dng thuc cn
quang loi trng lng phn t thp, khng ionic
hn ch bt cc nguy c tt huyt p do gin mch
ngoi vi, ri lon nhp chm, ri lon chc nng c
tim thong qua, hn ch tc dng li tiu thm thu,
nh gim bt nguy c ca th thut. i vi bnh
nhn hp kht van MC, nn trnh chp bung tht
tri.
3. Gi tr chnh p trung bnh qua van MC o bng
thng tim rt ging vi siu m trong khi gi tr
chnh p ti a nh nh o qua thng tim thng
thp hn so vi siu m. C th lm th nghim kch
thch bng truyn Nitroprusside tnh mch nh
gi s thay i v chnh p qua van v din tch l
van mi khi c thay i cung lng tim nhm phn
bit cc trng hp hp van MC thc s vi nhng
trng hp gi hp.
4. Khi HC khng kht th phn s tng mu, cung lng
tim khi ngh, p lc cc bung tim bn phi v p lc
mao mch phi bt u bnh thng. p lc cui tm
trng tht tri thng tng do tht tri ph i
gim gin. Sng a trn ng cong p lc nh tri,
p lc mao mch phi bt thng ni r. Khi mc
HC tng ln, p lc cui tm trng tht tri, p lc
cc bung tim phi v ng mch phi cng tng ln.
Phn s tng mu v cung lng tim s gim khi
bnh tin trin n giai on cui. Trng hp HC
kht, chc nng tht tri gim nng th chnh p qua
van MC s gim. Khng bao gi nh gi mc
hp van MC ch da trn gi tr chnh p qua van
n thun m phi ch n chc nng tht tri v
mc h van hai l km theo.
296
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
bnh nhn tr m chnh p qua van MC rt cao v hn
ch c nguy c cao xut hin t t. Tng t, bnh
nhn c din tch l van MC 1,0 cm2 km theo hp
ng k ng mch vnh v cn lm cu ni ch-vnh th
nn tnh c n vic m thay van MC.
B. iu tr ni khoa
1. Bt buc phi iu tr khng sinh d phng vim ni
tm mc nhim khun.
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
trng khi dng li tiu trnh dng liu qu cao,

gy tt huyt p (do gim cung lng tim) v gim
ti mu ngoi vi. Trnh dng cc thuc nhm
Nitrates bnh nhn suy tim do HC nng v thuc
lm gim tin gnh ng k, c th gy gim ti
mu no v ngt. Digoxin thng ch c ch nh
cho bnh nhn HC suy tim nht l khi rung nh. iu
tr HC c suy tim bng thuc khng h ci thin tin
lng sng lu di ca bnh nhn. Hn na, iu tr
ni khoa bnh nhn hp van MC nng v ri lon
chc nng tht tri qu tch cc khng h c li m
cn nguy him.
4. Trnh dng cc thuc gin mch cho bnh nhn
hp ch n thun.
a. Trong mt s bnh cnh hp h van MC, HC
phi hp h van hai l, HC phi hp bnh mch
vnh th c th cn nhc vic dng cc thuc gin
mch song nn ht sc thn trng, i khi phi
theo di huyt ng cho bnh nhn ti phng hi
sc. Trn l thuyt, bnh nhn h van nhiu s c
li khi dng thuc gin mch; bnh nhn c bnh
mch vnh cng c li v gim hu gnh s lm
gim nhu cu xy c tim. D vy, thuc gin
mch ch l bin php iu tr tm thi trc
khi m lm cu ni ch vnh.
b. Liu khi u nn dng rt thp ti phng hi sc
(tt nht l nitroprusside d chnh liu), sau
khi n nh liu gin mch s chuyn dn sang
thuc ung (c ch men chuyn, Hydralazine).
5. Bnh nhn hp van MC nng chu ng rt km
tnh trng rung nh (v tin gnh tht tri ph thuc
rt nhiu vo co bp nh), nhanh chng-d dng gy
gim cung lng tim v huyt phi, ng thi tng
nhu cu xy (do nhp nhanh). Bi vy, cn iu tr
298
tch cc rung nh ngay t lc mi khi pht bnh

nhn HC nng nhm chuyn v nhp xoang.
6. i vi bnh nhn hp van MC nng v chc
nng tht tri ri lon nng, c chnh p qua van
MC thp: phu thut ch ci thin triu chng
khong 50%, 50% cn li khng h ci thin triu
chng v cht trong giai on hu phu m khng t
trong s l cc trng hp gi hp ch (ri lon
chc nng c tim nng t trc km theo gi hp van
MC do cung lng tim thp). Tuy cn nhiu im
cha thng nht song trc khi i n vic la chn
bnh nhn ph hp v quyt nh m, th:
a. Nn lm siu m tim gng sc hoc nghim php
kch thch khi thng tim nh gi nhng
trng hp hp van MC thc s gy ri lon
chc nng tht tri nng bng cch o din tch l
van v chnh p qua van MC khi cung lng
tim tng. Nu cung lng tim tng ng k m
khng gy thay i chnh p th l gi hp,
ngc li nu cung lng tim tng gy tng chnh
p qua van th l hp tht.
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
2. Nong van ng mch ch bng bng qua da: c

vai tr r rt i vi hp van MC bm sinh tr em
tuy khng c p dng tuyt i bnh hp van
MC mc phi. Mc d k thut ny c nhiu ha
hn nhng so vi m th vn cha hiu qu bng: sau
th thut, din tch l van tng ln 50% song sau 6
thng c ti 50% ti pht. V th nong van MC
bng bng ch c ch nh trong mt s trng hp
nht nh nh: hp van MC bm sinh tr em, bnh
nhn khng th m do tui cao hay c bnh phi hp,
iu tr tm thi trc khi m c chun b, iu tr
th bnh nhn c ri lon chc nng tht tri nng
(xem liu bnh nhn c ci thin sau m hay khng).
T l t vong ca th thut ny khong 2-5%.
D. iu tr ngoi khoa
1. Ch nh m thay van MC:
a. Bnh nhn c triu chng c nng:
au ngc.
Ngt.
Suy tim.
b. Bnh nhn 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
cc bnh nng khc th t l t vong quanh phu

thut khong 2-3%. T l sng cn sau m thay van
MC vo khong 85% sau 10 nm. S la chn loi
van thay ph thuc vo rt nhiu yu t nh tui,
nguy c dng/khng dng thuc chng ng, c
im gii phu, chc nng tht tri, mc hot
ng th lc, d tnh m li... Ni chung, bao gm
cc loi nh:
a. Phu thut Ross (ghp van t thn): van v thn
ng mch phi c ct lun c khi ri thay
vo v tr ca van ng mch ch ng thi cm
li hai ng mch vnh. Ch van ng mch phi
b ct s c thay th bng mt van ng mch
phi ng loi. Van ghp t thn kiu ny rt tt
v huyt ng, khng cn dng thuc chng
ng, t vi ho hn so vi cc van sinh hc khc,
c th ln ln theo pht trin ca c th, c c
tnh chng nhim trng rt cao nn rt ph hp
lm tr nh hoc bnh nhn vim ni tm
mc nhim khun song i hi k thut cao v
thi gian ko di, d gy ra nhiu ri lon sau
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
tm mc v y l thay van ng loi c ch

nh khi vim ni tm mc nhim khun trn van
nhn to.
c. Thay van sinh hc (d loi): thng c ch nh
cho bnh nhn tui > 70. Trong vng 10 nm, 8090% van thoi ho gy h hoc hp do thng l
van, gim vn ng, r quanh chn van. Khng
cn dng chng ng lu di sau thay van v nguy
c huyt khi thp. Phn ln u c chnh p qua
van ngay sau m (v b vng van, khung cn
tr mt phn), mc nhiu hn so vi van c
hc v th khi thay, cn chn loi van c kch
thc ln nht c th c gim bt chnh p
qua van.
d. Thay van c hc: cc loi van thng dng l St.
Jude Medical, Metronic-Hall v Carbomedics.
Bnh nhn sau thay van loi ny phi ung thuc
chng ng gim nguy c to huyt khi van
v cc bin chng tc mch khc. bn ca loi
van ny l cao nht nu duy tr c iu tr
chng ng v d phng khng sinh cn thn
trong nhiu nm.
3. Bin chng: nhng bin chng tim tng sau m
thay van MC l h hng cu trc van, ri lon hot
ng (huyt ng) van, huyt khi kt van, tc mch,
chy mu do dng thuc chng ng, vim ni tm
mc nhim khun van MC nhn to, huyt tn v
bloc nh tht. Phi dng thuc chng ng cn thn
(i vi bnh nhn no c ch nh) v phi dng ko
di sut thi gian tn ti van nhn to (n c i).
Bnh nhn hot ng th lc mc thp s t nh
hng hn n huyt ng ca van v do tc
thoi ho van cng s chm hn.
302
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.
Borer JS, Hochreiter C, Herrold EM, et al. Prediction of indications

for valve replacement among asymptomatic or minimally
symptomatic patients with chronic aortic regurgitation and normal
left ventricular performance. Circulation 1998;97:525-534.
Brener SJ, Dufly CI, Thomas JD, Stewert WJ. Progression of aortic
stenosis in 394 patients: relation to changes in myocardial and mitral
valve dysfunction. J Am Coll Cardiol 1995;25:305-310.
1997;337:32-41.
Carabello BA, Stewart WJ, Crawford FA. Aortic valve disease. In:
Topol EJ, ed. Comprehensive cardiovascular medicine.
Philadelphia: Lippincott-Raven, 1998: 563-585.
Carabello BA. Timing of valve replacement in aortic stenosis:
moving closer to perfection [Editorial]. Circulation 1997;95:22412243.
Deedy M. Aortic valve disease. In: Marso SP, Griffin BP, Topol EJ,
Gaasch WH, Sundaram M, Meyer TE. Managing asymptomatic
patients with chronic aortic regurgitation. Chest 1997;111:17021709.
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.
303
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.
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.
304
vim ni tm mc nhim khun
Vim ni tm mc nhim khun (VNTMNK) l tnh trng

bnh l do vim nhim vi thng tn ch yu lp ni mc ca
tim. Biu hin i th thng gp l nhng tn thng lot v si
cc van tim. y l bnh rt nng, nu khng c pht hin
v iu tr sm bnh thng dn n t vong. Ngy nay d c
nhiu tin b trong cc khng sinh iu tr cng nh phu thut
nhng t l t vong ca bnh vn cn kh cao.
I. Nguy c mc VNTMNK
A. Nguy c cao
1. Van nhn to.
2. Tin s b VNTMNK.
3. Tim bm sinh c tm.
4. Bnh h van ng mch ch v/ hoc hp van MC.
5. H van hai l.
6. Hp van hai l km h van hai l.
7. Cn ng ng mch.
8. Thng lin tht.
9. Hp eo ng mch ch.
10. Cc phu thut tim m vn tn ti tnh trng huyt
ng bt n sau m.
B. Nguy c va
1. Sa van hai l c gy h van hai l.
2. Hp hai l n thun.
3. Bnh l van ba l.
4. Hp ng mch phi.
5. Bnh c tim ph i lch tm.
6. Bnh van MC c hai l van hoc vi ho van ng
mch ch m cha nh hng nhiu n huyt ng.
7. Bnh thoi ho van ngi gi.
305
8. Cc phu thut tim m tnh trng huyt ng sau m

t bin ng (trong thi gian 6 thng sau m).
C. Nguy c thp
1. Sa van hai l khng gy h hai l.
2. H ba l trn siu m tim m khng km theo bt
thng van.
3. Thng lin nh l th hai n thun.
4. Mng x m ng mch.
5. Bnh ng mch vnh.
6. Cy my to nhp.
7. Cc phu thut tim m tnh trng huyt ng sau m
khng bin ng, thi gian > 6 thng sau m.
II. Nguyn nhn
A. Vim ni tm mc bnh nhn van t nhin: hay
gp nht l lin cu khun (viridans Streptococcus v cc
phn nhm khc) chim khong 60%, Staphylococcus
25%, Enterococcus, nhm HACEK (Haemophilus,
Actinobacillus, Cardiobacterium, Eikenella, v Kingella)
khong 3%.
B. Vim ni tm mc bnh nhn dng ma tu
ng tnh mch: thng hay b tn thng van tim
bn phi v hay gp nht l t cu vng (S. aureus), ngoi
ra i khi c th gp nm.
C. Vim ni tm mc bnh nhn van nhn to: c
th xy ra sm hoc mun. Thng hay xy ra trong 6
thng u sau thay van. Thng hay gp t cu vng (S.
aureus), vi khun gram m, c th do nm lm tin lng
bnh thm phn nng.
D. Vim ni tm mc c cy mu m tnh (10-30%):
thng gp bnh nhn dng khng sinh trc ,
cng cn ch nhm c vi khun gy bnh mc mun:
do nm, nhm HACEK, Legionella, Chlamydia psittaci,
Coxiella, Brucella, Bartonella...
306
E. Vim ni tm mc do nm: thng gp Candida v

Aspergillus, hay gp bnh nhn van tim nhn to, c
thit b c hc ci ghp trong tim, suy gim min dch,
dng thuc ma tu ng tnh mch. Bnh cnh phc tp
v tin lng rt nng.
III. Triu chng lm sng v xt nghim chn on
L biu hin bi 3 hi chng: (Bng 16-1)
1. Nhim trng h thng.
2. Tn thng ni mc mch.
3. Phn ng h min dch vi nhim trng.
Ni tm li: trc mt bnh nhn vi tam chng kinh in nh:
st, thiu mu, ting thi tim cn ngh ti kh nng VNTMNK.
Vn cy mu: l mt xt nghim cc k quan trng
chn on bnh cng nh nh hng iu tr. Phi thc hin
sm ngay khi c chn on lm sng. Ly t nht 3 mu mu
ring bit trong 24 gi, nhng v tr tnh mch khc nhau, mi
ln nn ly 2 ng nghim i kh v k kh ring. V VNTMNK
l hin tng c mt vi khun lin tc trong mu nn khng cn
phi ch lc st nh cao mi ly mu cho d cy mu khi bnh
nhn ang st th t 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
VNTMNK c th khi khng tiu chun ni trn nhng

cng khng tiu chun loi tr.
Loi tr VNTMNK khi cc du hiu lm sng c gii
quyt sau 4 ngy dng khng sinh, hoc khng c bng chng
gii phu bnh sau 4 ngy dng khng sinh.
A
B
Hnh 16-1. Si ni mc thn ng mch phi (A); Si
van ng mch phi (B).
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
Bng 16-1. Cc biu hin lm sng v cn lm sng ca VNTMNK.

Biu hin
Triu chng c nng
Thm khm
Nhim trng St ko di, rt run, v m St.
h thng.
hi, kh chu, yu c, ng Xanh ti.
lm, m sng, au u, mt St cn.
ng, st cn, au lng, au Suy nhc.
khp, au c... C th khai Lch to.
thc thy ng vo: mi Thiu mu.
hng, rng ming, ngoi
da, tit niu, tim chch...
Tn thng Kh th, au ngc, lit khu Ting thi mi tim.
ni mc tim tr, tai bin mch no, au Suy tim.
mch.
bng, au v lnh u chi.
m xut huyt di da, mt,
c.
Nt Roth.
Nt Osler.
Tn thng Janeway.
m xut huyt.
Tai bin mch no.
Phnh vi mch no.
Thiu mu hoc tc mch chi.
Cc thm d
Tnh trng thiu mu.
Tng bch cu mu.
Tng tc lng mu.
Cy mu dng tnh.
Bt thng dch no tu.
i mu vi th.
Chp tim phi.
Siu m tim.
Chp mch mu.
CT scan s no.
309
Bng 16-1. Cc biu hin lm sng v cn lm sng ca VNTMNK (tip theo).

Phn
ng au khp, au c, vim Vim khp.
Protein niu,
min dch.
bao gn.
Cc du hiu tng ur mu.
Hng cu niu, tr niu,
Mng tay khum
Tng ur mu,
Nhim toan mu.
Tng gramma globulin.
Thy c yu t dng thp,
gim b th v phc hp
min dch trong mu.
Tm khng th khng t
cu trong mu.
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.
310
Bng 16-2b. Tiu chun Duke trn lm sng.

Tiu chun chnh:
Cy mu dng tnh c trng cho VNTMNK:
Loi vi khun in hnh ( t nht 2 mu mu): viridant Streptococcus; S. bovis; nhm HACEK;
S. aureus hoc Enterococcus.
Cy mu dng tnh bn vng:
Tn ti loi vi khun hai mu mu khc nhau t nht 12 gi, hoc
Tn ti loi vi khun c 3 mu mu, hoc phn ln trong 4 hoc hn cc mu mu cch bit
m thi im ca mu u v mu cui cch nhau t nht 1 gi.
Bng chng tn thng ni tm mc: Bng chng siu m tim:
Khi si di ng lc lc trong tim, dnh vi van tim hoc cc cu trc trong tim, hoc cc cu
trc nhn to (van) m khng gii thch c v hnh dng gii phu thng thng ca tim, hoc
Hnh nh pxe, hoc
Hnh nh t tch mi mt phn van nhn to, hoc
Hnh nh h van tim mi xy ra.
Tiu chun ph:
1. Tin s:
C bnh van tim t trc.
Tim chch ma tu
311
Bng 16-2b. Tiu chun Duke trn lm sng (tip theo).

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
312
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...
chn khng sinh v liu thch hp.
4. Khng nn dng chng ng ngn nga tc mch
trong VNTMNK.
5. iu tr VNTMNK do nm thng phi kt hp iu
tr ni ngoi khoa.
6. Ch nh iu tr ngoi khoa can thip thng kh
khn nhng cng rt cn thit trong nhng hon cnh
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
Bng 16-3. La chn khng sinh cho cc loi cu khun.

Loi vi
Ch
Thi
khun
gian
Lin cu 1. Penicillin G 4 triu v tim TM mi 6 2 tun
viridant,
gi, kt hp vi Gentamycin 1 mg/kg
bovis
mi 12 gi TM, hoc
2. Penicillin G 4 triu v tim TM mi 6 4 tun
gi kt hp Gentamycin 1 mg/kg TM
mi 12 gi (ch cho 2 tun u), hoc
3. Penicillin G 4 triu v tim TM mi 6 4 tun
gi, hoc
4. Ceftriaxone 2 g tim TM hoc TB 1 4 tun
ln trong ngy, hoc
5. Vancomycine 10 mg/kg tim TM mi 4 tun
12 gi.
Enterococ 1. Ampicillin 2g tim TM mi 4 gi kt 4-6
-cus
v
hp vi Gentamycin 1 mg/kg TM mi tun
cc
cu
8 gi, hoc
khun
2. Vancomycine 15 mg/kg, tim TM mi 4-6
khng
12 gi kt hp vi Gentamycin 1 tun
Penicillin
mg/kg tim TM mi 8 gi
314
Lu
Ch chun, cho bnh nhn < 65
tui, khng c suy thn, khng c bin
chng.
Cho bnh nhn c bin chng hoc
lin cu khng Penicillin mc va.
Cho bnh nhn > 65 tui, c suy thn.
Cho bnh nhn b d ng vi
Penicillin.
Cho bnh nhn b d ng vi nhm
Lactamine.
4 tun thng cho cc trng hp
c triu chng < 3 thng.
Cho cc trng hp d ng vi
Penicillin.
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
vng (S.
hoc
aureus)
2. Nh trn kt hp vi Gentamycin 1 4-6
Cho bnh nhn nhim t cu nng.
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
tun
Cephalosporins; cho loi t cu khng
12 gi
vi Methicillin.
Lin cu 1. Penicillin G, 2 triu v tim TM mi 6 2-4
nhm A,
gi, hoc
tun
Lin cu 2. Cefazolin, 1 g tim TM mi 8 gi.
2-4
pneumon
tun
-iae
Nhm
1. Ampicillin 2 g, tim TM mi 4 gi kt 4 tun Gentamycin c th ngng nu vi
HACEK
hp vi Gentamycin 1 mg/kg TM mi
khun nhy cm vi Ampicillin.
12 gi, hoc
2. Ceftriaxone 1-2 g tim TM hoc tim
Cho bnh nhn b d ng vi
bp 1 ln trong ngy.
4 tun Penicillin.
315
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.
2. iu tr ngoi khoa:
a. Mc ch c bn ca iu tr ngoi khoa cho
VNTMNK l ly i nhng mnh si hoc hoi t
m khng th iu tr ni khoa c, sa li van
hoc thay van b tn thng.
b. Ch nh iu tr ngoi khoa cho VNTMNK l
mt quyt nh kh khn nhng rt cn thit
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
Bng 16-4. Ch nh phu thut khi VNTMNK.

Ch nh r rng:
Suy tim khng khng ch c do tn thng
van.
Van nhn to khng n nh.
Khng khng ch c hoc khng th khng ch
c nhim khun (v d do nm hoc
Enterocuccus khng thuc khng sinh).
Tc mch ti pht.
Ch nh tng i:
Tn thng lan rng quanh van (d, pxe).
Tn thng van t nhin sau khi iu tr ti u.
VNTMNK m cy mu m tnh c st dai dng
khng gii thch c.
Mnh si to (>10mm) vi nguy c tc mch cao.
VI. Phng nga VNTMNK
y l cng tc c bit quan trng i hi tt c cc thy
thuc thc hnh cn nm r. V nguy c c trnh by
bng 16-5, trong nhng bnh nhn c nguy c cao v va cn
phi c phng nga ng mc khi lm cc th thut.
Bng 16-5. Th thut c nguy c VNTMNK cao v va.
Cc th thut rng ming, hng:
Cc th thut rng ming c th gy chy mu.
Ct amidan hoc no VA.
Soi thanh qun bng ng soi cng.
Cc th thut tiu ho:
Cc phu thut lin quan n nim mc rut.
Th thut gy x trong gin tnh mch thc qun.
Phu thut ng mt.
Ni soi ng mt.
Cc th thut ng tit niu:
Soi bng quang.
Nong niu o.
Phu thut tin lit tuyn.
Cc th thut khc: Chch, dn lu cc nhim trng.
317
Bng 16-6. Ch khng sinh phng nga VNTMNK trong mt s th thut.

Bnh cnh
Loi khng sinh
Liu dng
A. Ch cho cc th thut rng,ming, ng h hp, thc qun
Ch phng chun.
Amoxicillin
2g, ung 1 gi trc khi lm th thut.
Trng hp khng Ampicillin
2g, tim TM hoc TB 30 pht trc
ung c khng sinh.
th thut.
Trng hp d ng vi Clindamycin hoc
600mg, ung 1 gi trc th thut.
Penicillin.
2g,
ung 1 gi trc th thut.
Cephalexin hoc
500 mg, 1 gi trc th thut.
Azithromycin.
B. Cho cc th thut ng sinh dc tit niu, d dy rut
2g, tim TM hoc tim bp.
bnh nhn nguy c Ampicillin kt hp vi
Gentamicin (30 pht trc th thut) 1,5mg/kg, tim TM hoc tim bp.
cao.
1g, tim TM hoc tim bp.
tip theo dng Ampicillin
1g, ung.
hoc Amoxicillin (6 gi sau).
1g, truyn TM trong vng 1-2 gi.
nhng bnh nhn Vancomycin kt hp vi
Gentamycin
(trong
vng
30
pht
1,5mg/kg tim TM hoc TB
nguy c cao, d ng vi
trc th thut).
Penicillin.
2g, ung 1 gi trc th thut.
bnh nhn nguy c Amoxicillin hoc
Ampicillin.
2g, tim TM hoc tim bp trong vng
va.
30 pht trc th thut.
Bnh nhn nguy c va, Vancomycin.
1g, truyn TM trong 1-2 gi v kt
d ng vi Penicillin.
thc 30 pht trc khi lm th thut.
318
Ti liu tham kho

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Baue A, Geha AS, Hammond GL, Laks H, Naunheim KS, eds.

Glenn's thoracic and cardiovascular surgery, 6th ed. Norwalk, CT:
Appleton & Lange, 1996:1915-1930.
Braunwald E, ed. Heart disease: a textbook of cardiovascular
medicine, 5th ed. Philadelphia: WB Saunders, 1997:1077-1104.
Child JS, ed. Diagnosis and management of infective endocarditis.
Cardiol Clin North Am 1996;14.
Dajani AS, Taubert KA, Wilson W, et at. Prevention of bacterial
endocarditis: recommendations by the American Heart Association.
Circulation 1997;96:358-366.
Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of
infective endocarditis: utilisation of specific echocardiographic
findings. Am J Med 1994;96:200-209.
Durack DT. Prevention of infective endocarditis. N Engl J Med
1995;332:38-44.
Farmer JA, Torre G. Endocarditis. Curr Opin Cardiol 1997;12:123130.
Fauci AS, ed. Harrison's principles of internal medicine, 14th ed.
New York: McGraw-Hill, 1998:785-791.
Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of
infectious diseases, 4th ed. New York: Churchill-Livingstone,
1995:740-799.
Mexander RW, Schlant RC, Fuster V, eds. Hurst's the heart. New
York: McGraw-Hill, 1998:2205-2239.
Murphy M. Infective endocarditis. In: Marso SP, Griffin BP, Topol
EJ, eds. Manual of Cardiovascular Medicine. Philadelphia:
Otto C. The practice of clinical echocardiography. Philadelphia: WB
Saunders, 1997:389-403.
Topol EJ, ed. Textbook of cardiovascular medicine. Philadelphia:
Lippincott-Raven Publishers, 1998:607-637.
319
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.
320
Van tim nhn to
I. Cc loi van tim nhn to

Cc loi van tim nhn to c chia thnh 2 nhm ln: van
c hc v van sinh hc. Mi loi van li c bn, nguy c to
huyt khi, v c im huyt ng khc nhau.
Bng 17-1. c im ca cc loi van tim nhn to.
Din tch l van hiu
Nguy
2
Loi van
dng (cm )
c
bn
V tr van V tr van huyt
khi
MC
hai l
Van bi
++++
1,2-1,6
1,4-3,1
++++
(Starr-Edwards)
Van a mt cnh
+++/
1,5-2,1
1,9-3,2
+++
(Bjrk-Shiley,
++++
Medtronic-Hall,
Omnicarbon)
Van a hai cnh
++++
2,4-3,2
2,8-3,4
++
(St. Jude Medical,
Carbomedics)
Van sinh hc d
++
1,0-1,7
1,3-2,7
+/++
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
Hnh 17-1a. Cu trc mt s loi van tim c hc.

2. Van a hai cnh: (van St. Jude Medical,
Carbomedics) gm hai cnh a bn nguyt di ng
t do mt gc 75-90o hai bn, to thnh mt din
ch nht v hai l ln hai bn cho mu lu thng khi
van m. Van c thit k c mt dng h nh
trong van nhm gim hnh thnh huyt khi trn a.
322
Hin l loi c dng ph bin do nhiu u im v

huyt ng.
3. Van bi (lng) (van Starr-Edwards): gm mt vin bi
bng silicon di ng t do trong lng chp kim loi,
mu s i xung quanh vin bi. Loi ny hin gn nh
khng cn s dng do nhiu nhc im v huyt
ng.
Hnh 17-1b. Cu trc mt s loi van bi (lng).

B. Van sinh hc: mc d rt ging van t nhin song v
huyt ng vn cha phi ti u do kch thc van b
cc thnh phn vng van, phn chng van lm nh i.
1. Van d loi: bng cch ph ln mt gi v mt
vng van kim loi mng tim b hoc van tim ln
qua x l nh van Carpentier-Edwards. Cc loi van
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
v gi c cc t chc di van, t l t vong chu

phu thp, khng cn dng thuc chng ng, t l
sng cn lu di tt. Hin nay, ch yu mi p dng
rng ri cc k thut sa van hai l, cn i vi van
MC th kh sa hn rt nhiu, ch nn lm hn ch
trong mt s trng hp khng do thp tim nh van
MC hai l bm sinh gy HoC do sa van, van khng
vi, khng hp
Bng 17-2. So snh gia m thay van v sa van.
Nn thay van
Nn sa van
1. Di chng do thp 1. Bnh sa van hai l.
tim.
2. HoHL do bnh tim thiu
2. Vim ni tm mc. mu.
3. Tn thng van hai 4. Gin vng VHL, l van
l phc tp (x, vi bnh thng.
nhiu, co rt l van, 5. Tn thng ch yu l sau
t chc di van van HL.
6. Di ng l van hai l qu
thng tn nng...).
4. Phu thut vin t mc.
kinh nghim.
7. Van MC hai l bm sinh,
sa van gy h.
2. Van sinh hc d loi: ch nh thay cho bnh nhn
khng th dng thuc chng ng ko di, bnh nhn
tui cao (> 70), cng nn cn nhc thay van sinh hc
cho nhng bnh nhn n cn mun c thai. Cn ch
nguy c thoi ho van phi m thay van li (t l
m li 40% nu tui bnh nhn < 40, 20-30% nu
tui 40-60, v 10% nu tui > 70).
3. Van ng loi (sinh hc): c bn cao hn, chnh
p qua van thp nht so vi cc loi van sinh hc
khc nhng sau 20 nm ch 10% van hot ng cn
tt. Van MC ng loi c la chn cho bnh
nhn tui < 50, ph n cn mun c thai, bnh nhn
khng th dng thuc chng ng ko di, bnh nhn
cn thay c van v on MC v c bit l bnh
324
nhn vim ni tm mc nhim khun ti van MC c

bin chng (pxe, d...).
4. Van c hc: ch nh cho bnh nhn tui < 60 (do
bn cao, t cn m li), bnh nhn phi dng thuc
chng ng (do ri lon nhp hoc t qu). Bnh
nhn cn thay c van hai l v ng mch ch nn
thay van c hc v van hai l sinh hc nhanh thoi
ho. Do cu trc gn nn bnh nhn c kch thc
tht nh nn thay van c hc. Quyt nh la chn
tng loi van c th cn ph thuc vo cu to v c
im huyt ng tng loi van: van St. Jude Medical
v Metronic-Hall c a chung nht do u th v
huyt ng, bn cao v t l bin chng thp...
III. Theo di sau m thay van
Vic theo di sau m thay van tim nhn to l ht sc cn
thit, gm theo di triu chng lm sng v xt nghim, d bnh
nhn khng c triu chng c nng. Kt qu siu m Doppler
tim trong vng 1-6 tun ngay sau m c dng lm mc
theo di v sau. Thng thng nn kim tra nh k siu m tim
1 nm mt ln hoc mau hn nu c triu chng c nng, nht l
giai on 5 nm sau 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
thng cao) ngay t 6-12 gi sau m, tng

Heparin ln liu sau rt dn lu ngc, bt
u ung thuc chng ng t 24-48 gi sau
m. D sao nn xt k nguy c huyt khi
ca tng bnh nhn v v tr van (van hai l
cao hn van MC).
V lu di: ung thuc chng ng (thuc
khng vitamin K) duy tr gi tr INR trong
ngng tc dng.
Bng 17-3. Ngng tc dng chng ng cho cc loi
van tim nhn to.
Nguy c
Loi van
INR
Phi hp
tc mch
Thp
* Van c hc:
4,0-5,0
- Van bi
- Van a 1 cnh 3,0-4,0
- Van a 2 cnh 2,5-3,0
3,0-4,5
- Nhiu van
* Van sinh hc:
- ng loi
Aspirin
2,0-3,0
- D loi
325
mg/ngy
Cao (km rung - Van c hc
3,0-4,5
Aspirin
nh, tin s tc
80-160
mch,
huyt
mg/ngy
khi nh, ri - Van sinh hc
2,0-3,0
lon chc nng
tht tri nng)
Dng thuc chng ng lu di c nguy c
chy mu nh (2-4%/nm), chy mu nng
(1-2%/nm), t vong 0,2-0,5%/nm. Nguy c
chy mu tng tui gi (5-6% bnh nhn
> 70 tui). Nguy c xy ra tc mch cho d
vn dng thuc chng ng l 1%/nm.
326
b. i vi van sinh hc: vic dng thuc chng

ng sau m thay van sinh hc cn nhiu bn ci.
Nguy c tc mch cao nht sau m v gim dn
trong 3 thng sau m, t l huyt khi v tr van
hai l (7%) cao hn so vi v tr van MC (3%).
V th cn dng thuc chng ng ng ung
sau m thay van sinh hc trong 3 thng u sau
m, ri chuyn sang Aspirin 325 mg/ngy.
Nhng bnh nhn c tin s tc mch, rung
nh, ri lon chc nng tht tri nn ung thuc
chng ng sut i.
2. iu chnh liu chng ng khi lm cc th thut
khng phi tim mch:
a. i vi cc th thut ln, mt mu nhiu, nn
dng thuc chng ng ng ung t nht 3
ngy trc khi lm th thut INR 1,6. Cn
iu tr gi bng Heparin tim tnh mch bnh
nhn c van bi, rung nh, huyt khi nh tri, ri
lon chc nng tht tri nng, tin s tc mch.
b. i vi nhng th thut nh (nh nh rng...),
nguy c chy mu t, c th vn duy tr tip liu
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
c. Nu INR > 5,0 v < 9,0 m khng chy mu ng

k, tm ngng thuc chng ng mt hoc hai
ngy, theo di thng xuyn INR, ung li thuc
vi liu thp hn khi INR v ngng iu tr
hoc tm dng mt ngy thuc, ung 1-2,5 mg
vitamin K1 nht l khi nguy c chy mu cao.
d. Nu cn nhanh hn (chng hn cn m cp) th
ung 2-4 mg vitamin K1 (INR s gim ng k
sau 24h). Nu INR vn cn cao th ch ung thm
1-2mg vitamin K1 m thi.
e. Nu INR > 9,0 m khng chy mu ng k, th
dng ngay thuc chng ng, phi hp ung 35mg vitamin K1 (INR s gim ng k sau 2448h), lp li nu cn, theo di st v dng li
thuc chng ng vi liu thp khi INR nm
trong ngng iu tr.
f. Nu INR > 20 c km chy mu nng, dng ngay
thuc chng ng, truyn tnh mch chm 10 mg
vitamin K1, phi hp vi truyn huyt tng ti
hoc ta prothrombin tu trng hp, c th lp
li 12h/ln.
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
A. Triu chng lm sng: biu hin ca ri lon hot

ng van nhn to tng i phc tp (xem thm phn
bin chng van nhn to).
1. Tin s v bnh s: nn hi k hoc kim tra h s
ra vin v cc vn lin quan n van nhn to nh:
ch nh thay van; v tr van nhn to; loi v kch
thc van; thi gian k t khi thay; cc bin chng
lin quan n dng thuc chng ng, bin chng tc
mch, vim ni tm mc, st hoc thay i m sc
ting p ca van.
2. Khm thc th: pht hin cc ting thi mi, m
nght hoc cc biu hin huyt khi kt van. Bn
thn van nhn to lm thay i ting bnh thng
do di chuyn cnh van hoc do thay i tnh cht ca
dng chy qua van. Cc ting, m sc ca van nhn
to che lp nhng ting tim bnh thng. Mt khc
nhng m sc ny c th khng h thay i cho d
ri lon nng hot ng ca van. Tuy nhin nu
quen vi cc ting van tim nhn to th nghe tim cng
gip ch c nhiu cho vic chn on bnh l ca
van nhn to trc khi s dng cc bin php chn
on hnh nh khc.
B. Cc xt nghim chn on: xc nh ri lon hot
ng van nhn to ch yu da trn hnh nh siu m
Doppler tim, cho php nh gi sm trc khi biu l ra
triu chng lm sng.
1. Siu m Doppler tim: cn nh gi y cu trc
ca van, cc thnh phn ca b my van nhn to,
chnh p trung bnh v ti a qua van, dng h trong
van hoc quanh van. Siu m tim qua thc qun c
ch nh cho nhng trng hp nghi ng hoc c
triu chng ca vim ni tm mc nhim khun. Ni
chung, k thut lm siu m khng khc g so vi cc
van t nhin, song kh hn do van nhn to gy ra
cc bng cn m.
329
a. Ri lon hot ng ca van thng biu hin

ch cc l van ng khng kn (do huyt khi, do
vi ho van sinh hc hay do ni mc tng sinh
qu mc), di ng qu mc vng van (biu hin
ca long van, c th km theo cc tn thng
xung quanh nh pxe, d, gi phnh cnh vng
van gy ra do vim ni tm mc van nhn to).
b. Siu m Doppler mu cung cp cc kt qu o
c gin tip nhng ng tin cy v hot ng
ca van nhn to: nh chnh p qua van (t
c tnh din tch l van hiu dng), dng h
trong van hoc quanh van, c ch gy h van...
c. nh gi h van nhn to:
i vi van c hc, dng h c coi l sinh
l nu din tch h < 2 cm2 v di dng h
< 2,5 cm v tr van hai l hoc din tch h <
1 cm2 v di dng h < 1,5 cm v tr van
ng mch ch. Phn ln cc van sinh hc
u c dng h nh (sinh l) ngay sau khi
thay van.
Dng h van bnh l thng rng v di hn
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
van. Chnh p qua van tnh

trn siu m Doppler lin tc sau m vi
tun c coi l gi tr tham chiu theo
di sau ny.
(b) Chnh p qua van cao khng nhng do
hp van m cn do tnh trng tng cung
lng, thiu mu, nhp nhanh, h van
nhn to nhiu hoc hin tng phc hi
p lc (rt hay gp van c hc hai cnh
v tr van MC, c hin tng p lc
tng th pht sau khi dng chy i qua l
hp, lm tng chnh p thc s qua van
ln khong 1/3 song nu hp van, th
hin tng ny gim i).
Din tch l van: Phng trnh lin tc cho
php c tnh din tch l van chc nng:
Din tchvan MC = (ng knh vng van)2
0,785 VTIRTT/VTIvan MC
Din tchvan HL = (ng knh RTT)2 0,785
VTIRTT / VTIvan HL
Trong RTT l ng ra tht tri,
VTI l tch phn vn tc theo thi gian dng
chy tnh bng siu m Doppler lin tc.
Thi gian bn gim p lc (PHT): c ch
nh gi din tch l van hai l nhn to
(=220/PHT), ng thi cho php phn bit
nguyn nhn gy tng VTI dng chy qua van
hai l (nu PHT cng tng, nguyn nhn l
hp van), nu PHT khng ko di, th nguyn
nhn ch l tng dng chy qua van. Tuy
nhin din tch l van tnh theo PHT i khi
s ln hn gi tr thc.
Ch s t sut gia vn tc dng chy ng
ra tht tri v van MC nhn to cho php
331
nh gi c hp van hay khng nht l khi

khng bit r ng knh vng van. Ch s
VRTT/Vvan MC ny cng ln th din tch l van
cng ln, nu < 0,23 th hp van ng k.
Bng 17-4. Mt s thng s bnh thng ca cc loi van
tim nhn to khi o bng siu m Doppler tim.
Loi van nhn to
Vn tc
Chnh p
ti a
trung bnh
(m/s)
(mmHg)
V tr van MC
3,1 0,5
24 0,4
Starr-Edwards
2,5
0,6
14 5
Bjrk-Shiley
3,0 0,8
11 6
St. Jude
2,6 0,3
12 3
Medtronic-Hall
2,4 0,4
73
Hancock
Carpentier-Edwards
2,4 0,5
11 2
Van ng loi
0,8 0,4
14 6
V tr van hai l
1,8 0,4
52
Starr-Edwards
1,6 0,3
52
Bjrk-Shiley
1,6 0,3
52
St. Jude
1,7
0,3
31
Medtronic-Hall
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
l cng phi lm tng t o c chnh p.

Chng ch nh a ng thng qua cc van c hc
(lng bi, lng a, mt hay hai cnh).
4. Chp cng hng t (MRI): cho php xc nh h
van, r quanh van, hoc pxe vng van nu c chng
ch nh lm siu m qua thc qun. Chp ct lp
theo t trng (CT) khng c gi tr trong vic nh
gi hot ng van nhn to.
C. Ri lon hot ng ca van nhn to v cc
bin chng lin quan
1. Rung nh: c ti mt na s bnh nhn thay/sa van
xut hin rung nh sau m. iu tr loi rung nh ny
khng khc g so vi iu tr rung nh ni chung.
a. i vi bnh nhn cha c tin s rung nh th
thng t tr v nhp xoang. Nhng nu rung nh
dai dng, ko di > 24 gi, th cn xem xt iu
tr thuc chng ng v chuyn nhp bng thuc
chng lon nhp hoc sc in.
b. iu tr d phng trc m bng thuc chn
giao cm hoc Amiodarone c tc dng r rt
lm gim t l rung nh sau m tim.
2. Ri lon dn truyn: bloc nh tht phi t my to
nhp chim khong 2-3% sau m thay van v khong
8% sau m li van. Nguyn nhn thng do sang
chn b His trong m hoc ph n t chc quanh van
sau m. Cc yu t nh vi ho vng van MC hoc
hai l, ri lon dn truyn trc m, tui cao, vim
ni tm mc nhim khun, phu thut van ba l lm
tng nguy c ri lon dn truyn sau m, c th dn
ti phi t my to nhp vnh vin.
3. Vim ni tm mc nhim khun (VNTMNK): T
l VNTMNK bnh nhn thay van nhn to xp x
3-6%, vi c im cc si rt ln (do vi khun gy
333
bnh c tr trn van, nn c th trnh khi cc c ch

bo v ca c th). Thng chia lm 2 loi:
a. VNTMNK trn van tim nhn to sm: trong vng
60 ngy sau m: ch yu do t cu da (S.
epidermidis), din bin rt nng, d dng a n
t vong (20-70%).
b. VNTMNK trn van tim nhn to mun: thng
xy ra bnh nhn c nhiu van nhn to hoc
v tr van MC. Lm sng ni chung ging
VNTMNK trn van t nhin. Tc nhn hay gp
nht l lin cu, sau l vi khun Gram m, t
cu rut v S. epidermis.
c. Chn on xc nh da vo siu m tim qua thc
qun do nhy v c hiu cao (90-95%); ng
thi xc nh cc bin chng khc nh p xe vng
van, long van, r van..; cng nh dng siu m
theo di hiu qu iu tr.
d. iu tr: nu ch dng khng sinh n thun, t l
t vong ln ti 61% (so vi 38% nu thay van) do
kh nng thnh cng rt thp (ct st) vi cc tc
nhn nh t cu, vi khun gram m hoc nm,
cn vi lin cu p ng cng ch khong 50%.
e. Bnh nhn VNTMNK van tim nhn to vn nn
dng thuc chng ng. Nu khng dng thuc
chng ng, nguy c t qu khi c thm
VNTMNK tng ln ti 50% trong khi nu dng
chng ng th t l tc mch ch l 10%. Hin
cha c kt lun chc chn no v vic tng nguy
c xut huyt no bnh nhn VNTMNK van
nhn to c dng thuc chng ng.
f. Ch nh m thay li van tim nhn to khi:
Tip tc nhim khun huyt d iu tr
khng sinh rt tch cc.
VNTMNK n thng cc t chc xung quanh
hoc to ng d.
334
Cc tc gy nghn mch ti pht.

VNTMNK do nm.
Long van hoc tc van nhn to.
Tc nghn ng dn truyn mi hoc ri
lon dn truyn nng hn.
Suy tim huyt tin trin hoc ri lon huyt
ng nng.
4. Tan mu: gp rt nhiu bnh nhn thay van c hc
nhng him khi biu hin ra triu chng lm sng.
a. T l thiu mu do tan mu gp 6-15% bnh
nhn thay van bi, song him gp hn van a
hoc van sinh hc. Thiu mu do tan mu thng
gp bnh nhn c nhiu van nhn to, van nhn
to c nh, h quanh van v VNTMNK trn van
nhn to... vi c ch lin quan n dng mu
xoy c p lc cao p vo cc t chc kim loi.
b. Chn on xc nh khi c tng men LDH, tng
hng cu li, tng bilirubin gin tip,
haptoglobin niu v xut hin cc mnh v hng
cu trn lam mu. Siu m tim thng pht hin
thy c hin tng va p ca dng mu c tc
cao (dng h lch tm hoc quanh van) va vo
cc t chc van nhn to.
c. Thiu mu tan mu nh c th iu tr b sung
vi st, acid folic v truyn mu. Dng thuc
chn bta giao cm v kim sot tt huyt p c
th lm gim mc nng ca tn huyt.
d. M li sa h quanh van hoc thay van c
ch nh cho nhng bnh nhn thiu mu tan mu
nng cn phi truyn mu nhiu ln hoc c suy
tim huyt.
5. Huyt khi: t l huyt khi ti van chim khong
0,2-1,8%/nm, hay gp nht v tr van ba l, sau
l v tr van hai l v cui cng l v tr van MC.
335
a. Nn ngh ti huyt khi kt van bnh nhn c

triu chng khi pht t ngt, c tin s tc
mch hoc dng thuc chng ng khng .
Siu m tim qua thc qun l bin php thng
dng nht chn on huyt khi ti van, tuy c
th pht hin hnh nh hn ch vn ng ca van
nhn to khi soi trn mn chiu Xquang. Hnh
nh trn siu m gi huyt khi l mt khi di
ng, mt mm, khng ng u.
b. iu tr: cch thc x tr ph thuc vo v tr
huyt khi ca van ch khng ph thuc vo loi
van hay thi gian gi nh hnh thnh huyt khi.
Trc khi iu tr:
(a) Heparin c dng sm ngay t khi ngh
ti v kho st bnh. Tip tc dng chng
ng ng ung (thuc khng vitamine
K) tr phi c ch nh m li r.
(b) Siu m tim qua thc qun hoc t nht l
soi di mn tng sng nn lm trong
vng 24 gi k t khi khi pht v lp li
thng xuyn nu cn huyt khi.
c. iu tr ni khoa:
Ch nh dng thuc tiu si huyt cho huyt
khi van nhn to tim phi do hu qu t
nghim trng nu huyt khi bn i xa khi so
vi bn tim tri. T l thnh cng ln ti 82%,
t l bin chng tc mch khong 12% v
bin chng chy mu nng khong 5%.
Cc thuc hay dng nht l: Streptokinase
(250.000 n v tim trc tip tnh mch/30
pht, sau truyn tnh mch 100.000 n
v/gi) hoc Urokinase (4.400 n v/kg/gi).
Thi gian dng thuc tiu si huyt thng t
2 n 120 gi, song nn dng nu khng ci
thin v huyt ng sau 24 n 72 gi.
336
Sau khi dng thuc tiu si huyt thnh cng,

cn theo di st hiu qu iu tr chng ng
ng ung cng nh siu m Doppler tim li
nhiu ln.
Chng ng bng Heparin v Wafarin ni
chung c khuyn dng cho cc huyt khi
nh ( 5mm): s dng Heparin tim tnh
mch, sau tim di da 17.000 n v 2
ln/ngy kt hp ung thuc khng vitamin K
(duy tr INR t 2,5-3,5) trong vng 3 thng.
d. Phu thut: t l t vong quanh phu thut thp
nht cng l 5% v th cn cn nhc nguy c ca
tng bnh nhn so vi kh nng v iu kin ca
tng trung tm. Ch nh thay van v ly b huyt
khi cho trng hp huyt khi van nhn to tim
tri tr phi huyt khi nh hoc khng th m do
nguy c phu thut qu cao. Cng ch nh m
nu iu tr tiu huyt khi khng thnh cng,
m sau khi ngng truyn thuc 24 gi.
6. Hng hc c hc: bong vng van nhn to c th gp
ngay trong giai on sm sau phu thut do k thut
m km, vng van qu vi ho, bnh nhn dng
steroid lu di, m van qu mn (c bit nu m li)
hoc nhim trng. Hin tng bong van cng c th
xy ra mun do nhim trng. Hnh nh van ung a
(lc l) trn siu m tim hay khi soi di mn tng
sng l mt ch nh m li cp cu.
7. Mt tng xng gia kch thc van nhn to so
vi bnh nhn:
a. Tt c cc loi van nhn to tr van t thn MC
(khng c vng kim loi) u c din tch l van
hiu dng thp hn hn do vi van t nhin. V
th lun lun c hin tng chnh p qua van
nhn to v hp van tng i. Nu thay vo mt
van nhn to c ng knh qu nh th s gy ra
337
tnh trng gim ng k cung lng tim, gy ra

cc triu chng lm sng. Hin tng ny hay gp
nht khi thay van ng mch ch bnh nhn
hp van ng mch ch.
b. V vy, nu bnh nhn c vng van nh, nn
dng van ng loi hoc van a v tr van MC
do cc u th v huyt ng. Van MC nhn to
c ng knh 21mm cng khng nn thay cho
bnh nhn cao ln hoc hot ng th lc nhiu.
Nguyn l chung l nn c gng thay van bng
mt van nhn to c ng knh ln hn, nu cn
th phi hp vi to hnh (m rng) vng van.
8. Pannus (hin tng tng sinh ni mc qu mc
ph trm ln van): thng phi hp vi huyt khi
gy tc van (t l c th ti 5% vi van c hc).
C ch hnh thnh pannus cn cha r, c th lin
quan vi hin tng tng sinh nguyn bo si do
phn ng min dch vi d vt (l van nhn to) hoc
phi hp vi cc tc nhn nh dng thuc chng
ng khng liu, vim ni tm mc nhim khun,
tc ng ca dng mu xoy qua van hai l... Ni
chung, phi lm siu m tim qua thc qun xc
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
ti pht t qu d dng liu thuc chng

ng.
b. Vi bnh nhn c nhn no ln, nn tm dng
thuc chng ng trong vng 5-7 ngy ng thi
cng nn ngng thuc chng ng 1-2 tun nu
c chuyn dng nhn no thnh xut huyt.
Ti liu tham kho
1.
Acar J, Iung B, Boissel JP, et al. Multicenter randomized comparison

of low-dose versus standard-dose anticoagulation in patients with
mechanical prosthetic heart valves. Circulation 1996;94:2107-2112.
2. Akins CW. Results with mechanical cardiac valvular prosthesis. Ann
Thorac Surg 1995;60:1836-1844.
3. Cannegieter SC, Rosendaal FR, Wintzen AR, et al. Optimal oral
anticoagulant therapy in patients with mechanical heart valves. N
Engl J Med 1995;333:11-17.
4. Davis EA, Greene PS, Cameron DE, et al. Bioprosthetic versus
mechanical prosthesis for aortic valve replacement in the elderly.
Circulation 1996;94:II-121-125.
5. Garcia MJ. Principles of Imaging. In: Topol EJ. Comprehensive
Cardiovascular Medicine. Philadelphia: Lippincott-Raven, 1998:
609-35.
6. Green CE, Glass-Royal M, Bream PR, et al. Cinefluoroscopic
evaluation of periprosthetic cardiac valve regurgitation. Am J Radiol
1988;151:455-459.
7. Israel DR, Sharma SK, Fuster V. Anti-thrombotic therapy in
prosthetic heart valve replacement. Am Heart J 1994;127:400-411.
8. Jaeger FJ, Trohman RO, Brener S, et al. Permanent pacing following
repeat cardiac valve surgery. Am J Cardiol 1994;74:505-507.
9. Lengyal M, Fuster V, Keitni M, et al. Guidelines for management of
left-sided prosthetic valve thrombosis: a role for thrombolytic
therapy. J Am Coll Cardiol 1997;30:1521-1526.
10. Lin S, Wong J. Prosthetic heart valves. In: Marso SP, Griffin BP,
339
11. Rahimtoola SH. Prosthetic heart valve performance: long-term

follow-up. Curr Probl Cardiol 1992:33406.
12. Shaff IW. Prosthetic Valves. In: Giuliani ER, Oersh BJ, McOoon
MD, et al., eds. Mayo Clinic Practice of Cardiology, 3rd ed. St.
Louis: Mosby, 1996:1484-1495.
13. Vogel W, Stoll HP, Bay W, et al. Cineradiography for determination
of normal and abnormal function in mechanical heart valves. Am J
Cardiol 1993;71:225-232.
14. Vongratanasin W, Hillis LD, et al. Prosthetic heart valves. N Engl J
Med 1996;335: 407-416.
15. Zabalgoitia M. Echocardiographic assessment of prosthetic heart
valves. Curr Probl Cardiol 1992:270-325.
340
suy tim
Suy tim l mt hi chng bnh l thng gp trong nhiu

bnh v tim mch nh cc bnh van tim, bnh c tim, bnh mch
vnh, bnh tim bm sinh v mt s bnh khc c nh hng
nhiu n tim.
Bnh thng khi chng ta cn lm mt hot ng gng sc
no (lao ng, chy nhy...) th lp tc tim s tng tn s v
tng sc co bp a c nhiu mu (tc l a c nhiu
xy) n cho cc m ca c th. Nhng khi tim b suy, th tim
khng cn kh nng cung cp mu theo nhu cu ca c th na.
V vy ngi ta c th nh ngha: Suy tim l trng thi bnh l
trong cung lng tim khng p ng vi nhu cu ca c
th v mt xy trong mi tnh hung sinh hot ca bnh nhn.
Suy tim l mt tnh trng bnh l rt thng gp trn lm
sng. Theo nghin cu Framingham th c khong 2,3 triu
ngi M b suy tim (1981) v cng M mi nm c khong
400.000 bnh nhn mi mc suy tim (thng k nm 1983).
Gn y, trn c s nhng hiu bit su sc hn v c ch
bnh sinh ca suy tim, v tnh nng v tc dng ca mt s loi
thuc mi trong iu tr suy tim, ngi ta thu c nhng kt
qu kh quan trong vic iu tr hi chng ny.
I. Sinh l bnh
Chng ta bit trong suy tim thng l cung lng tim b
gim xung. Khi cung lng tim b gim xung th c th phn
ng li bng cc c ch b tr ca tim v ca cc h thng ngoi
tim, c duy tr cung lng ny. Nhng khi cc c ch b tr
ny b vt qu s xy ra suy tim vi nhiu hu qu ca n.
341
A. Cc yu t nh hng n cung lng tim: Qua

nghin cu, ngi ta hiu r c cung lng tim ph
thuc vo 4 yu t: Tin gnh, hu gnh, sc co bp ca
c tim v tn s tim.
Sc co bp c tim
Tin gnh
Cung lng tim
Hu gnh
Tn s tim
1. Tin gnh: (Preload)
a. Tin gnh c nh gi bng th tch hoc p
lc cui tm trng ca tm tht.
b. Tin gnh l yu t quyt nh mc ko di
si c tim trong thi k tm trng, trc lc tm
tht co bp. Tin gnh ph thuc vo:
p lc y tht, tc l lng mu tnh
mch tr v tm tht.
gin ca tm tht, nhng mc t quan
trng hn.
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
b. Qua y ta c th hiu c mt vn quan

trng trong suy tim l: p lc hoc th tch cui
tm trng trong tm tht tng do cc nguyn
nhn khc nhau, s lm th tch nht bp tng,
nhng sau mt thi gian s dn n suy tim v sc
co bp ca c tim km dn v khi th tch nht
bp s gim i. Tim cng suy th th tch nht
bp cng gim.
3. Hu gnh (Afterload): Hu gnh l sc cn ca cc
ng mch i vi s co bp ca tm tht. Sc cn
cng cao th s co bp ca tm tht cng phi ln.
Nu sc cn thp qu c th s lm gim s co bp
ca tm tht, nhng nu sc cn tng cao s lm tng
cng ca tim cng nh tng mc tiu th xy ca c
tim, t s lm gim sc co bp ca c tim v lm
gim lu lng tim.
4. Tn s tim: Trong suy tim, lc u nhp tim tng
ln, s c tc dng b tr tt cho tnh trng gim th
tch nht bp v qua s duy tr c cung lng
tim. Nhng nu nhp tim tng qu nhiu th nhu cu
xy ca c tim s li tng ln, cng ca c tim cng
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
Vic tng b dy ca cc thnh tim ch yu l

i ph vi tnh trng tng hu gnh. Ta bit rng
khi hu gnh tng s lm gim th tch tng mu,
do b li c tim phi tng b dy ln.
c. H thn kinh giao cm c kch thch: Khi c
suy tim, h thn kinh giao cm c kch thch,
lng Catecholamin t u tn cng ca cc si
giao cm hu hch c tit ra nhiu lm tng sc
co bp ca c tim v tng tn s tim.
2. Bng ba c ch thch ng ny, cung lng tim s
c iu chnh li gn vi mc bnh thng. Tuy
nhin cc c ch ny cng ch c th gii quyt trong
mt chng mc no m thi. Thc vy, nu tm
tht gin n mc ti a v d tr co c b gim
th lut Starling s tr nn rt t hiu lc. Cng tng
t nh vy, ph i cc thnh tim s lm tng cng
ca tim. H thn kinh giao cm b kch thch lu ngy
cng s dn n gim mt cm th bta trong cc
si c tim v gim dn p ng vi Catecholamin.
3. C ch b tr ngoi tim: Trong suy tim, i ph
vi vic gim cung lng tim, h thng mch mu
ngoi vi c co li tng cng th tch tun hon
hu ch. C th c ba h thng co mch ngoi vi
c huy ng:
a. H thng thn kinh giao cm: Cng giao cm
s lm co mch ngoi vi da, thn v v sau
khu vc cc tng trong bng v cc c.
b. H Renin-Angiotensin-Aldosteron: Vic tng
cng hot ha h thn kinh giao cm v gim
ti mu thn (do co mch) s lm tng nng
Renin trong mu. Renin s hot ha
Angiotensinogen v cc phn ng tip theo
tng tng hp Angiotensin II. Chnh Angiotensin
II l mt cht gy co mch rt mnh, ng thi n
li tham gia vo kch thch sinh tng hp v gii
344
phng Nor-adrenalin u tn cng cc si thn

kinh giao cm hu hch v Adrenalin t ty
thng thn. Cng chnh Angiotensin II cn kch
thch v thng thn tit ra Aldosteron, t lm
tng ti hp thu Natri v nc ng thn.
c. H Arginin-Vasopressin: Trong suy tim giai
on mun hn, vng di i - tuyn yn c
kch thch tit ra Arginin - Vasopressin, lm
tng thm tc dng co mch ngoi vi ca
Angiotensin II, ng thi lm tng ti hp thu
nc ng thn.
d. C 3 h thng co mch ny u nhm mc ch
duy tr cung lng tim, nhng lu ngy chng li
lm tng tin gnh v hu gnh, tng nc v
Natri, tng cng v mc tiu th xy ca c tim,
to nn mt "vng lun qun" bnh l v lm cho
suy tim ngy mt nng hn.
4. Ngoi ra, trong suy tim, nhm c gng b p li vic
co mch khu tr hay ton b ni trn, cc h thng
gin mch vi Bradykinin, cc Prostaglandin (PGI2 ,
PGE2) v Yu t nh lm tng o thi Natri (Atrial
Natriuretic Peptid) vit tt l APN, cng c huy
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
c. Nu cung lng tim rt thp th lu lng nc

tiu c lc ra khi ng thn cng s rt t.
2. Tng p lc tnh mch ngoi vi:
a. Suy tim phi: Tng p lc cui tm trng tht
phi s lm tng p lc nh phi ri t lm
tng p lc cc tnh mch ngoi vi v lm cho
tnh mch c ni, gan to, ph, tm ti...
b. Suy tim tri: Tng p lc cui tm trng tht
tri s lm tng p lc nh tri, ri tip n lm
tng p lc tnh mch phi v mao mch phi.
Khi mu cng cc mao mch phi s lm th
tch kh cc ph nang b gim xung, s trao i
xy phi s km i lm bnh nhn kh th. c
bit khi p lc mao mch phi tng n mt mc
no s ph v hng ro ph nang - mao mch
phi v huyt tng s c th trn vo cc ph
nang, gy ra hin tng ph phi.
II. Phn loi v nguyn nhn
A. Phn loi suy tim: C th c nhiu cch phn loi suy
tim khc nhau, da trn c s:
1. Hnh thi nh khu: Suy tim phi, suy tim tri v suy
tim ton b.
2. Tnh trng tin trin: Suy tim cp v suy tim mn
tnh.
3. Lu lng tim: Suy tim gim lu lng v suy tim
tng lu lng.
4. Suy tim do tng tin gnh v suy tim do tng hu
gnh.
5. Tuy nhin, trn lm sng ngi ta thng hay chia ra
ba loi: suy tim tri, suy tim phi v suy tim ton b.
B. Nguyn nhn suy tim
1. Suy tim tri:
346
a. Tng huyt p ng mch: l nguyn nhn

thng gp nht gy ra suy tim tri. Chnh tng
huyt p lm cn tr s tng mu ca tht tri
tc l lm tng hu gnh.
b. Mt s bnh van tim:
H hay hp van ng mch ch n thun
hoc phi hp vi nhau.
H van hai l.
c. Cc tn thng c tim:
Nhi mu c tim.
Vim c tim do thp tim, nhim c hay
nhim khun.
Cc bnh c tim.
d. Mt s ri lon nhp tim: c ba loi ri lon
nhp tim ch yu c th a n bnh cnh ca
suy tim tri:
Cn nhp nhanh kch pht trn tht, nht l
cn rung nh hay cn cung ng nh.
Cn nhp nhanh tht.
Bloc nh - tht hon ton.
e. Mt s bnh tim bm sinh:
Hp eo ng mch ch.
Cn ng ng mch.
ng nh - tht chung...
f. Ch : Trng hp hp van hai l, do tng cao p
lc trong nh tri v mao mch phi nn dn n
nhng triu chng ging nh suy tim tri. Nhng
s thc th hp hai l n thun khng gy c
suy tim tri theo ng ngha ca n v hp hai l
to nn mt s cn tr dng mu i ti tht
tri, lm cho p lc (hay th tch) cui tm trng
ca tht tri li b gim hn bnh thng; tm tht
tri khng b tng gnh nn khng suy c.
2. Suy tim phi:
347
a. Cc nguyn nhn v phi v d dng lng

ngc, ct sng:
Cc bnh phi mn tnh : Hen ph qun, vim
ph qun mn, gin ph nang, gin ph qun,
x phi, bnh bi phi... dn dn a n
bnh cnh ca tm ph mn.
Nhi mu phi gy ra bnh cnh tm ph cp.
Tng p lc ng mch phi tin pht.
G vo ct sng, cc d dng lng ngc khc.
b. Cc nguyn nhn tim mch:
Hp van hai l l nguyn nhn thng gp
nht.
Mt s bnh tim bm sinh: hp ng mch
phi, tam chng Fallot. Mt s bnh tim bm
sinh khc c lung shunt triphi (thng
lin nh, thng lin tht vv...) n giai on
mun s c bin chng ca tng p ng
mch phi v gy suy tim phi.
Vim ni tm mc nhim khun gy tn
thng nng van ba l.
Mt s nguyn nhn t gp: u nhy nh tri, v
ti phnh xoang Valsalva vo cc bung tim
bn phi, tng p lc ng mch phi tin
pht v
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
c. Vim tim ton b do thp tim, vim c tim.

d. Cui cng cn phi nhc n mt s nguyn nhn
c bit gy suy tim ton b vi "lu lng tng":
Cng gip trng.
Thiu Vitamin B1.
Thiu mu nng.
D ng - tnh mch.
III. Triu chng
A. Suy tim tri
1. Triu chng c nng:
a. Kh th: L triu chng hay gp nht. Lc u
ch kh th khi gng sc, v sau kh th xy ra
thng xuyn, bnh nhn nm cng kh th nn
thng phi ngi dy th. Din bin v mc
kh th cng rt khc nhau: c khi kh th mt
cch dn dn, nhng nhiu khi n t ngt, d
di nh trong cn hen tim hay ph phi cp.
b. Ho: Hay xy ra vo ban m hoc khi bnh nhn
gng sc. Thng l ho khan nhng cng c khi
ho ra m ln t mu.
a. Khm tim: Nhn, s thy mm tim p hi lch
sang tri. Nghe tim: Ngoi cc triu chng c th
gp ca mt vi bnh van tim gy nn suy tht
tri, ta thng thy c ba du hiu:
Nhp tim nhanh.
C th nghe thy ting nga phi.
Cng thng nghe thy mt ting thi tm thu
nh mm, du hiu ca h van hai l c
nng v bung tht tri gin to.
b. Khm phi:
Thng thy ran m ri rc hai bn y phi.
Trong trng hp cn hen tim c th nghe
c nhiu ran rt v ran m hai phi, cn
349
trong trng hp ph phi cp s nghe thy

rt nhiu ran m to, nh ht dng nhanh t hai
y phi ln khp hai ph trng nh "thy
triu dng".
Trong a s cc trng hp, huyt p ng
mch ti a thng gim, huyt p ti thiu
li bnh thng nn s huyt p chnh lch
thng nh i.
a. Xquang:
Tim to ra nht l cc bung tim bn tri. Trn
phim thng: tm tht tri gin biu hin bng
cung di bn tri phng v ko di ra.
C hai phi m nht l vng rn phi. i khi
c th bt gp ng Kerley (do ph cc
khong k ca h thng bch huyt ca phi)
hoc hnh nh "cnh bm" kinh in hai
rn phi trong trng hp c ph phi.
b. in tm : Thng ch thy du hiu tng gnh
cc bung tim bn tri: Trc tri, dy nh tri, dy
tht tri.
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
B. Suy tim phi

1. Triu chng c nng:
a. Kh th: t hoc nhiu, nhng kh th thng
xuyn, ngy mt nng dn v khng c cc cn
kch pht nh trong suy tim tri.
b. Ngoi ra, bnh nhn hay c cm gic au tc
vng h sn phi (do gan to v au).
a. Ch yu l nhng du hiu mu ngoi bin:
Gan to u, mt nhn, b t, au mt cch t
pht hoc khi s vo gan th au. Lc u gan
nh i khi c iu tr v gan to li trong t
suy tim sau, nn cn gi l gan "n xp". V
sau, do mu lu ngy nn gan khng th
nh li c na v tr nn cng.
Tnh mch c ni to v du hiu phn hi
gan-tnh mch c dng tnh. p lc tnh
mch trung ng v p lc tnh mch ngoi
bin tng cao.
Tm da v nim mc: Tm l do mu b tr
ngoi bin, nn lng Hemoglobin kh tng
ln trong mu. Ty mc suy tim m tm
nhiu hay t. Nu suy tim nh th ch thy tm
t mi v u chi. Cn nu suy tim nng th
c th thy tm r ton thn.
Ph: Ph mm, lc u ch khu tr hai chi
di, v sau nu suy tim nng th c th thy
ph ton thn, thm ch c th c thm trn
dch cc mng (trn dch mng phi, c
chng...). Bnh nhn thng i t (khong
200 - 500ml/ngy). Nc tiu sm mu.
b. Khm tim:
S: c th thy du hiu Hartzer (tm tht
phi p vng mi c), nhng khng phi
bnh nhn no cng c du hiu ny.
351
Nghe: ngoi cc triu chng ca bnh gy

ra suy tim phi ta cn c th thy:
(a) Nhp tim thng nhanh, i khi c ting
nga phi phi.
(b) Cng c khi nghe thy ting thi tm thu
nh trong mm hoc vng mi c do
h van ba l c nng. Khi ht vo su,
ting thi ny thng r hn (du hiu
Rivero-Carvalho).
(c) Huyt p ng mch ti a bnh thng,
nhng huyt p ti thiu thng tng ln.
3. Cc xt nghim chn on: tr trng hp suy tim
phi do hp ng mch phi c nhng c im ring
ca n, cn trong a s cc trng hp khc ta thy:
a. X quang:
Trn phim tim phi thng:
(a) Cung di phi (tm nh phi) gin.
(b) Mm tim nng cao hn pha trn vm
honh tri, do tm tht phi gin.
(c) Cung ng mch phi cng gin to.
(d) Phi m nhiu do mu phi.
Trn phim nghing tri: Tht phi to lm cho
khong sng sau xng c b hp li.
b. in tm : Thng thy cc du hiu ca trc
phi, dy nh phi, dy tht phi.
c. Siu m tim: ch yu thy kch thc tht phi
gin to. Trong nhiu trng hp c th thy cc
du hiu ca tng p ng mch phi.
d. Thm d huyt ng: c th thy:
p lc cui tm trng ca tht phi tng
(thng l trn 12 mmHg).
p lc ng mch phi cng thng tng.
C. Suy tim ton b: Thng l bnh cnh ca suy tim
phi mc nng:
1. Bnh nhn kh th thng xuyn, ph ton thn.
352
2. Tnh mch c ni to, p lc tnh mch tng rt cao.

3. Gan to nhiu..
4. Thng c thm trn dch mng phi, mng tim hay
c chng.
5. Huyt p ti a h, huyt p ti thiu tng, lm cho
huyt p tr nn kt.
6. X quang: Tim to ton b.
7. in tm : C th c biu hin dy hai tht.
IV. nh gi mc suy tim
C nhiu cch nh gi mc suy tim, nhng trn y
vn th gii ngi ta thng hay dng cch phn loi mc
suy tim theo Hi Tim mch hc New York (New York Heart
Association) vit tt l NYHA, da trn s nh gi mc hot
ng th lc v cc triu chng c nng ca bnh nhn.
A. Phn loi mc suy tim theo NYHA
Bng 18-1. Phn loi mc suy tim theo NYHA.
Biu hin
I
Bnh nhn c bnh tim nhng khng c triu chng c
nng no, vn 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
vy, s b trn lm sng cc thy thuc thng qui c mc

suy tim theo khuyn co ca Hi Ni khoa Vit nam nh sau:
Bng 18-2. Phn loi mc suy tim trn lm sng.
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 loi
nguyn nhn gy ra suy tim, nhm gim tr tun hon
v tng cng kh nng co bp ca c tim.
Nhng bin php iu tr c bit p dng cho tng
trng hp c th ty theo nguyn nhn ca suy tim.
A. Nhng bin php iu tr chung
1. Cc bin php khng dng thuc:
a. Ch 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
Ch n gim mui l cn thit, v mui n

(NaCl) lm tng p lc thm thu trong mu,
do lm tng khi lng tun hon, t
gy tng gnh nng cho tim.
Mt ngi bnh thng hp thu khong 6 18g mui NaCl/ ngy, tc l 2,4 - 7,2g (100 300mmol) Na+ / ngy. i vi bnh nhn suy
tim, ty tng trng hp c th m p dng
ch n gim mui hoc ch n gn nh
nht hon ton.
Ch n gim mui: Bnh nhn ch c
dng < 3g mui NaCl /ngy, tc l < 1,2g (50
mmol) Na+ /ngy.
Ch n gn nh nht hon ton: Bnh nhn
ch c n < 1,2g mui NaCl /ngy tc l <
0,48g (20mmol) Na+ /ngy.
c. Hn ch lng nc v dch dng cho bnh
nhn:
Cn hn ch lng nc v dch dng cho
bnh nhn hng ngy nhm gim bt khi
lng tun hon v gim gnh nng vi tim.
Ni chung ch nn dng cho bnh nhn
khong 500 - 1000ml lng dch a vo c
th mi ngy.
d. Th xy: l bin php cn thit trong nhiu
trng hp suy tim v n tng cung cp thm xy
cho cc m, gim bt mc kh th ca bnh
nhn, ng thi lm hn ch s co mch phi
thng gp nhng bnh nhn thiu xy.
e. Loi b cc yu t nguy c khc:
B ru, thuc l, c ph...
Gim cn nng nhng bnh nhn bo ph.
Trnh cc xc cm mnh (stress).
Ngng nhng thuc lm gim sc bp ca c
tim nu ang dng, v d: cc thuc chn bta
355
giao cm hoc Verapamil hay Disopyramide,

Flecainide...
iu tr nhng yu t lm nng thm tnh
trng suy tim nh nhim trng, ri lon nhp
tim...
B. Cc thuc trong iu tr suy tim
1. GLUCOSID tr tim:
a. Cc dng Glucosid tr tim c dng trn lm
sng l:
Digitalis vi cc dng Digitalin hay Digitoxin
ly t Digitalis Purpurea; Digoxin v Isolanid
ly t Digitalis Lanata.
Strophanthus vi cc dng G Strophantin (tc
Uabain) ly t Strophantus Kombe.
Trong thc hnh lm sng hin nay
DIGOXIN l loi thuc tr tim tiu biu
thng c cc thy thuc hay s dng
nhiu nht.
b. C ch tc dng:
Digoxin lm tng sc co bp ca c tim gin
tip thng qua vic c ch men Natri - Kali Adenosine Triphosphatase (Na+-K+-ATPase)
ca bm ion mng t bo c tim, t cn
tr vic ion Na+ thot ra ngoi mng t bo.
Do s c ch ny lm cho nng Na+ trong
t bo tng cao, v vy s vn chuyn Na+ Ca++ qua mng t bo cng b ri lon, lm
tng nng Ca++ trong t bo c tim, t
thc y cc si c tim tng cng co bp.
Mt khc Digoxin cn tc ng trn h thng
thn kinh t ng ca tim, lm gim nhp tim
v gim tc dn truyn nh - tht.
Ngoi ra Digoxin cn lm tng trng lc h
ph giao cm v lm gim hot tnh ca h
giao cm.
356
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 ca
Digoxin (theo ng ung) l 36 gi.
Mt s nghin cu cho thy l nng
trung bnh trong huyt tng ca Digoxin c
tc dng iu tr thng trong khong t 0,5
hoc 0,8 n 2,0ng/ml. Tuy nhin khong
cch gia nng iu tr v nng ng
c l rt hp. C bnh nhn phi dng trn
2,0 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
cc trng hp, cc thy thuc thng bt u

ngay bng liu duy tr nh trnh by trn
t dn ti liu c hiu lc iu tr.
Vic theo di nng Digoxin trong huyt
tng s gip ta iu chnh c ti liu iu
tr ti u. Nng Digoxin huyt tng trong
khong t 1,8 - 2 ng/ml c coi l nng
c hiu lc iu tr, qu nng th d b
nhim c Digoxin.
e. Tng tc thuc:
Mt s thuc c th lm gim vic hp thu
Digoxin nh: Cholestyramine, Cholestipol,
Kaolin-pectin, Sulfasalazine, Neomycine v.v...
Ngc li, mt s thuc c th lm tng vic
hp thu Digoxin nh Tetracycline hoc
Erythromycine. Mt s thuc khc c th lm
gim ng k thanh thi Digoxin, do c
th lm tng nng ca Digoxin trong mu
nh: Quinidine, Verapamil, Spironolactone,
Amiodarone...
Cn c bit ch khng bao gi c dng
phi hp Digoxin vi cc mui Canxi (ng
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
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.
Yu t thun li cho nhim c Digoxin l :
(a) Ri lon in gii: h K+ mu, h Mg++
mu, tng Ca++ mu.
(b) Tui cao: lm tng nhy cm vi
Digoxin do gim lc ca thn, t d
lm ng thuc.
(c) Nhim kim chuyn ha.
(d) Gim xy mu.
(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
360
ii. Nhp nhanh b ni, nhp nhanh tht.

iii. Bloc xoang - nh.
iv. Bloc nh - tht cc loi.
v. Xon nh, rung tht.
X tr nhim c Digoxin:
(a) Ngng ngay vic iu tr bng Digoxin.
(b) Theo di cht ch nhng din bin trn
in tm .
(c) iu chnh kp thi cc ri lon v in
gii v thng bng toan kim, trong
cn c bit lu c tnh trng h K+ mu
khng? Nu c h K+ mu cn cho bnh
nhn ung khong 20 - 50 ml dung dch
Kalichlorua 10%. Trng hp cn thit c
th truyn nh git Kalichlorua vo tnh
mch sau khi pha thuc trong dung
dch ng trng, nhng vi iu kin
m K+ truyn tnh mch khng c
vt qu 13 - 15mmol/gi.
(d) C th dng Atropin tim tnh mch vi
liu t 0,5 - 1mg khi c nhp chm xoang
hoc nhp chm do Bloc nh - tht.
(e) Vi cc loi ri lon nhp tht, c bit l
ngoi tm thu tht, ta c th iu tr bng
cch truyn Lidocaine vi m
2mg/pht.
(f) Gn y ngi ta cn dng mt phng
php kh mi na iu tr nhng
trng hp nhim c Digoxin. l
dng khng th c hiu ca Digoxin
(Fab fragments, Digibind) v thng c
vit tt l Fab. Thng Fab c dng
theo ng truyn tnh mch.
i. C ch: Phc hp Digoxin kt hp vi
Fab s c o thi qua thn, lm
mt tc dng ca Digoxin. Mt ng
Fab 40mg trung ha 0,6mg Digoxin.
ii. Vi ng c mn Digoxin: S ng Fab

cn dng = [nng Digoxin mu
(ng/ml) cn nng c th (kg)] / 100.
iii. Vi ng c cp Digoxin: S ng Fab
cn dng = [liu lng Digoxin dng
cho bnh nhn (mg) 0,8] / 0,6.
2. Thuc li tiu:
a. Thuc li tiu lm tng o thi nc tiu, qua
lm gim khi lng nc trong c th, gim
khi lng mu lu hnh, lm bt lng mu tr
v tim v lm gim th tch cng nh p lc cui
tm trng ca tm tht, lm gim tin gnh, to
iu kin cho c tim b suy yu hot ng
c tt hn.
b. Bin chng c th gp khi dng cc thuc li tiu
l h K+ mu, h Na+ mu, lm gim th tch v
kim ha mu. H K+ mu l mt bin chng
quan trng, c th e do tnh mng ca bnh
nhn, nht l khi dng cng vi Digoxin. Do
khi iu tr bng thuc li tiu, cn phi theo di
cht ch in gii mu. Vic b mui Kali hoc
phi hp vi li tiu gi Kali l vn lun lun
phi nh n.
c. Nhm thuc li tiu Thiazide (Chlorothiazide,
Hydrochlothiazide, Metolazone, Indapamide):
Thng c dng mt cch kh ph bin
trong iu tr suy tim nhng bnh nhn m
chc nng thn cn bnh thng.
V tr tc ng ca thuc l ng ln xa
(ring Metolazone cn tc ng trn c ng
ln gn), vi c ch lm tng bi tit mui,
do s lm tng thi nc.
Hydrochlothiazide cn c dng nhiu v gi
kh r.
Bin chng c th gp khi dng Thiazide l
h K+, Na+, Ca++ mu. Thuc cng c th lm
tng ur, creatimin mu, c khi gy vim ty,
vim mch. Gn y ngi ta cp n tc
361
d. Nhm thuc li tiu tc dng ln quai Henle

(Furosemid, Bumetanide, Acid Ethacrynic...):
V tr tc ng ch yu ca thuc l nhnh
ln ca quai Henle. Li tiu nhm ny lm
tng thi Natri ln n 25%, ngoi ra chng
cn c tc dng lm tng dng mu n thn
do lm tng hot ha Prostaglandin PGE c
tc dng gin mch thn. V c tc dng li
tiu mnh v khng lm gim chc nng thn
nn li tiu nhm ny c ch nh bnh
nhn suy tim m i hi phi gim th tch
tun hon nhanh hoc bnh nhn suy thn.
Furosemide ngoi kh nng lm gim tin
gnh nhanh, khi dng tim tnh mch n cn
c tc dng gy gin mch trc tip. V vy,
Furosemide c bit c hiu qu trong iu tr
bnh nhn suy tim nng hoc b ph phi cp.
Li tiu nhm ny c th gy h K+, Na+,
Ca++, Mg++ mu. Ngoi ra mt s bnh nhn
i khi c th c biu hin ni ban, vim
mch...
e. Nhm thuc li tiu gi Kali (Spironolactone,
Triamterene, Amiloride):
Li tiu nhm ny tc ng trn on cui
ca ng ln xa. Spironolactone tc ng
thng qua vng nhy cm aldosterone;
Triamterene v Amiloride cng tc ng
vng cui ca ng ln xa nhng khng chu
s kim sot ca aldosterone.
Tc dng li tiu ca cc thuc thuc nhm
ny yu nu ch dng mt mnh. Nhng v li
ch gi Kali nn chng thng c phi hp
vi li tiu Thiazide hoc li tiu quai Henle.
Li tiu gi Kali thng tc dng chm v
362
ko di. Ni chung vi loi li tiu gi Kali

ny, khi dng cng phi theo di Kali mu,
c bit ch khi dng cng vi thuc c ch
men chuyn, hoc thuc gim vim khng
Steroide. Ngoi ra nhm li tiu gi Kali ny
cng i khi cng c th gy ra tng ur mu,
si thn (vi Triamterene) hoc chng v to
nam gii (vi Spironolactone).
Bng 18-3. Mt s thuc li tiu dng trong suy tim.
Thuc
ng Liu TB Bt u
Tc
dng ngy (mg)
tc
dng
dng
ko di
Thiazide
Chlorothiazide
U
250
2h
6 - 12h
500
TM
500
15ph
1h
Hydrochlothiazi U
25 100 2h
12h
-de
Metolazone
U
2,5 - 20,0 1h
24 - 48h
Indapamide
U
2,5 5,0 2h
24h
Li tiu quai
Furosemide
U
20 80
1h
6 - 8h
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
OLX: ng ln xa, OLG: ng ln gn, QH: Quai Henle, U: ng

ung, TM: tim tnh mch, TB: tim bp, h: gi, ph: pht, ng: ngy.
3. Cc thuc gin mch trong iu tr suy tim:

a. Nh chng ta r, c ch b tr bnh nhn
suy tim bao gm c s co tht h ng mch v
tnh mch. S co tht h ng mch lm tng hu
gnh v s co h tnh mch lm tng tin gnh.
Hn na trong suy tim, s co tht h mch phi
cn l hu qu ca thiu xy mu, hoc s p
ng lu di vi vic tng dng mu qua phi (v
d khi c Shunt tri phi trong tim) hoc p
ng lu di vi vic tng p lc nh tri (V d:
Hp hai l, suy tim tri...).
b. Cc thuc gin mch c th u tin tc dng gim
hu gnh, tin gnh hoc c hai. Nhng thuc
lm gin tnh mch nhiu hn s lm gim tin
gnh v p lc y tht. Cn cc thuc lm
gin ng mch s lm gim hu gnh. V vy,
ni chung cc thuc gin mch s ci thin c
cung lng tim, gim p lc y tim v gim
sc p ln thnh tim. nhng bnh nhn h van
tim, suy tim nng hoc c tng tr khng mch,
hoc suy tim c tng huyt p th dng cc thuc
gin ng mch rt c hiu qu.
c. Tc dng ph ni chung ca cc thuc gin mch
trong iu tr suy tim thng l: H huyt p
(nht l h huyt p trong t th ng), tng nh
ur mu... Dng thuc gin mch cn ht sc
thn trng nhng bnh nhn c hn ch cung
lng tim (V d: Hp van ng mch ch, bnh
c tim ph i tc nghn) hoc nhng bnh nhn
c ri lon chc nng tm trng (Bnh c tim
hn ch).
d. Thuc c ch men chuyn dng angiotensin:
364
Cc thuc thuc nhm ny c tc dng c ch

men c nhim v chuyn t Angiotensin I
thnh Angiotensin II t c ch s tng hp
Angiotensin II, l mt cht gy co mch,
ng thi li lm tng Bradykinin, l mt cht
gy gin mch. Kt qu chung l cc thuc c
ch men chuyn ny s lm gin mch nhiu,
lm gim hu gnh, t gp phn ci thin
tnh trng suy tim. Trong nhng nm gn y,
vai tr ca thuc c ch men chuyn trong
iu tr suy tim ngy cng c nhn mnh
nht l trong nhng trng hp suy tim tr
vi nhng bin php iu tr kinh in.
Chng ch nh dng khi: Hp ng mch
thn hai bn, ph n c thai.
Nhng tc dng ph c th gp l: ho, ni
ban, tt huyt p, lon v gic, tng creatinin
mu, tng kali mu
Thn trng khi dng thuc c ch men
chuyn cng vi loi li tiu gi kali hoc
dng thuc cho bnh nhn c huyt p thp.
Bng 18-4. Mt 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
e. Nhm thuc c ch trc tip th th AT1 ca

angiotensin II:
Cc thuc nhm ny kh mi v c ch l c
ch trc tip th th AT1. Khc vi thuc c
ch men chuyn, cc thuc c ch th th
AT2 khng lm tng bradykinin nn c th
khng gy ra cc triu chng ph nh l ho
khan (mt tc dng ph rt ph bin khi dng
CMC v l hn ch ng k ca CMC).
Cc thuc ny c dng ch yu iu tr
bnh nhn THA nhng cc nghin cu mi
y cng chng minh vai tr tt trong iu tr
suy tim v l thuc thay th cho CMC khi
khng dung np c.
Bng 18-5. Mt s thuc c ch th th AT1 ca
angiotensin II trong iu tr suy tim.
Thuc
Liu ban u Liu trung bnh
Candesartan
8-16 mg
2-32 mg
Eprosartan
200-400 mg
400-800 mg
Irbersartan
75-150 mg
75-300mg
Losartan
25 mg
25-100 mg
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
Dinitrat Isosorbide (ung)

5 - 20
30- 60 4 - 8 h
Mononitrat Isosorbide (ung) 10 - 20
30- 60 6 - 8h
Nitroglycerin (cao dn)
5 - 15
> 30
12 - 14h
Tc dng ph c th gp ca thuc l: nhc
u, h huyt p, ni ban
Nitrat c th c dng di dng ung, m
bi da, cao dn, ngm di li hoc tim
truyn tnh mch.
g. Hydralazine:
Lm gin h ng mch do tc dng lm gin
trc tip c trn ca thnh mch mu, t
lm gim hu gnh. V vy, Hydralazine rt
c ch trong iu tr suy tim do h van tim.
Ch : thuc c th gy tng nhp tim phn
x, au u, nn, lm xut hin cn au tht
ngc. Liu dng trung bnh l ung 20 100mg, chia thnh 2 - 3 ln trong ngy.
h. Mt s thuc gin mch dng ng tim
truyn: Cc thuc ny thng c ch nh cho
nhng bnh nhn suy tim nng hoc bnh nhn
suy tim m khng th ung c thuc. Khi
dng, cn bt u bng liu nh v theo di cht
din bin v huyt ng. Khi ngng thuc, cn
gim liu dn dn trnh cc phn x co mch
t ngt.
Nitroglycerin: lm gin h thng tnh mch
v c tc dng gin trc tip mch vnh.
(a) Nitroglycerin c ngh trong iu tr
suy tim nhng bnh nhn b nhi mu
c tim cp hoc bnh nhn au ngc
khng n nh.
(b) Thi gian bt u tc dng ca thuc rt
nhanh; bn hy thng t 1 - 3 pht.
(c) Liu dng ban u thng l 10g/pht
(dng bm tim in). Bin chng nguy
him c th gp l tt huyt p.
367
Natri Nitroprusside: gy gin trc tip ng

mch lm gim hu gnh, cn tc dng gin
h tnh mch thng khng nhiu.
(a) Thuc c ch nh nhng bnh nhn
suy tim cp, nng do tng huyt p hoc
h van tim nng.
(b) Liu ban u thng l 10 g/pht (ti a
300 - 400 g/pht). Thi gian bn hy ca
thuc l 1-3 pht.
(c) Tt huyt p cng l bin chng quan
trng cn theo di. V thuc c chuyn
ha di dng Cyanide, nn c th gy
ng c vi nng Thiocyanate trn 10
ng/dl, do cn thn trng bnh nhn
suy thn.
Enalaprilat:
(a) L dng hot ha mt este ca Enalapril
dng tim tnh mch. Thi gian bt u
tc dng nhanh, thi gian bn hy ngn.
(b) Liu ban u thng l 1,25mg tim tnh
mch cho mi 6 gi. nhng bnh nhn
c dng km li tiu hoc suy thn nn
gim liu (0,025mg tim TM/6gi).
4. Thuc chn bta giao cm:
a. Trong nhng nm gn y, vai tr ca thuc chn
bta giao cm trong iu tr suy tim ngy cng
c nhn mnh. C ch l ngn chn tc dng
kch thch thi qu ca h thn kinh giao cm
trong suy tim huyt mn tnh.
b. Cc thuc chn bta giao cm c ch nh trong
iu tr suy tim mn, nng khi dng y
cc thuc khc, nhng cng khng nn dng khi
suy tim qu nng mt b.
c. Hin nay mi ch c 3 loi thuc chn bta giao
cm c chng minh l c th dng trong
368
iu tr suy tim l: Carvedilol (Dilatrend);

Metoprolol (Betaloc) v Bisoprolol (Concor).
d. Khi dng thuc chn bta giao cm trong iu tr
suy tim nn bt u bng liu rt thp, theo di
cht ch v tng dn liu chm. Li ch thc t
ca khi dng chn bta giao cm ch xut hin
chm v lu di.
5. Cc thuc chn knh canxi:
a. Tuy l cc thuc gin mch nhng cc thuc chn
knh canxi khng c dng iu tr suy tim
v n c th nh hng sc co c tim, nht l cc
thuc th h th nht.
b. Mt s thuc th h th hai (Amlodipine) khng
nh hng n sc co c tim nhng cng khng
ci thin c suy tim.
6. Cc thuc lm tng sc co bp c tim khc:
a. Cc thuc ging giao cm: thng c dng
iu tr trong cc trng hp suy tim nng m cc
thuc thng thng khng c hiu qu. Mt s
tc dng ph ca thuc c th gp l: lm tng
thiu mu c tim, nhp tim nhanh, ri lon nhp
tht, co mch ngoi bin. Khi iu tr ta cn phi
theo di cht ch tnh trng huyt ng v in
tim ca bnh nhn.
Dopamine:
(a) Liu 1- 3 g/kg/pht c tc dng lm gin
mch thn v mc treo, thng qua kch
thch th th Dopamine, kt qu lm tng
dng mu n thn v s lng nc tiu.
(b) Liu 2-5g/kg/pht lm tng sc co bp
ca c tim do kch thch th th bta.
(c) Liu cao hn 5-10 g/mg/pht th thuc
s kch thch th th alpha giao cm gy
co mch ngoi bin, tng tr khng h
mch nh hng xu n cung lng tim.
369
(d) Dopamine rt c ngha khi ta dng cho

bnh nhn suy tim c h huyt p. Mt
nhc im ca thuc l hay lm cho nhp
tim nhanh nhiu.
Dobutamine:
(a) Ch yu kch thch chn lc 1-giao cm,
tc dng trn 2 v -giao cm yu hn
nhiu. Thuc c tc dng ci thin tnh
trng huyt ng, thng qua vic kch
thch trc tip tc dng co c tim v lm
gin h ng mch phn x, t lm
gim hu gnh v tng cng ci thin
cung lng tim. Khi dng thuc ny
thng huyt p v nhp tim thay i
khng qu nhiu. Tuy nhin nhp tim
nhanh vn c th xy ra khi dng liu cao.
(b) Liu dng ban u, bng ng truyn
tnh mch hng nh t 1-2 g/kg/pht v
iu chnh cho n khi t c hiu qu
huyt ng cn thit.
(c) Nhng bnh nhn suy tim nng, mn tnh,
c th dng tng t Dobutamine trong
2-4 ngy, gim mt cch ng k cc
triu chng ca suy tim. Nhng bnh
nhn phi dng Dobutamine ko di, cn
theo di cht ch v khng nn vt qu
liu 10 g/kg/pht.
(d) Dobutamine khng c vai tr tt trong
iu tr suy tim nhng bnh nhn c ri
lon chc nng tm trng (v d: bnh c
tim ph i) hoc bnh nhn suy tim c
tng cung lng.
b. Cc thuc c ch men Phosphodiesterase: lm
tng sc co bp ca c tim v gin mch do lm
tng adenosin mono phosphate vng (AMPc).
370
Hai loi thuc c s dng trong lm

sng l Amrinone v Milrinone. Chng c
ch nh trong nhng t iu tr ngn ngy
bnh nhn suy tim dai dng, kh iu tr.
Amrinone c tc dng ci thin huyt ng
nh Dobutamin, nhng lm gin mch mnh
hn. V vy, h huyt p c th xy ra
nhng bnh nhn c dng thuc ny cng vi
mt thuc gin mch khc.
Liu lng :
(a) Amrinone tim tnh mch 750 g/kg
trong 2 - 3 pht sau truyn tnh mch
vi liu 2,5 - 10,0 g/kg/pht.
(b) Milrinone: liu ban u l 50 g/kg, tim
tnh mch trong 10 pht sau truyn TM
vi liu 0,375-0,750 g/kg/pht.
Tc dng ph ca cc thuc c ch men
phosphodiesterse: c th gy lon nhp nh
hay tht v i khi gy tc mch.
c. Vesnarinone: l mt dn xut ca Quinoline,
thuc c tc dng lm tng co bp c tim. Khi kt
hp vi Digoxin v thuc c ch men chuyn
trong iu tr suy tim, thuc c th ci thin c
tt hn tnh trng suy tim. Liu trung bnh l
60mg/ngy, dng ko di. Tc dng ph c th
gp l gim bch cu ht.
7. Thuc chng ng:
a. Trong suy tim, mu thng li cc c quan
ngoi bin nn rt d to thnh cc cc mu ng
trong h thng tun hon v t gy ra nhng
tai bin tc nghn mch mu. V vy, ngi ta
phi dng thuc chng ng khng nhng trong
nhng trng hp cp tnh nh tc ng mch
phi, no, chi... m cn phi iu tr d phng
371
trong cc trng hp suy tim c tim to, nht l

trong cc trng hp c thm rung nh.
b. Bn cnh Heparin c s dng trong cc trng
hp tc mch cp, ngi ta cn s dng cc thuc
chng ng thuc nhm khng vitamin K.
C. iu tr nguyn nhn
Ngoi cc bin php iu tr chung (nh trnh by
trn), ta cn phi p dng mt s bin php iu tr c bit
ty theo tng nguyn nhn:
1. Suy tim do cng gip: Phi iu tr bng khng
gip trng tng hp hoc phng php phng x hay
phu thut.
2. Suy tim do thiu vitamin B1: cn dng vitamin B1
liu cao.
3. Suy tim do ri lon nhp tim ko di th phi c
bin php iu tr cc ri lon nhp tim mt cch hp
l: dng thuc, sc in hay t my to nhp.
4. Suy tim do nhi mu c tim : ngi ta c th can
thip trc tip vo ch tc ca ng mch vnh bng
thuc tiu si huyt, nong v t Stent ng mch
vnh hoc m bc cu ni ch vnh...
5. Suy tim do mt s bnh van tim hoc d tt bm
sinh: nu c th, cn xem xt sm ch nh can thip
qua da (nong van bng bng) hoc phu thut...
D. Mt s bin php iu tr c bit khc
1. Bin php h tr tun hon c bit: c th c
p dng nhng bnh nhn suy tim m nhng bin
php iu tr khc tht bi hoc t hiu qu.
a. t bng trong ng mch ch: Bng phng
php thng tim, ngi ta a mt ng thng c
gn mt qu bng c bit, t ng mch i,
ng thng c y ln ti ng mch ch. Bng
s c t v tr trong lng ng mch ch
372
di ch phn nhnh ra ng mch di n tri.

Bng s c bm cng ra mt cch ng b vo
thi k tm trng ca chu chuyn tim. Kt qu
l n s lm tng lng mu n ti cho ng
mch vnh v lm gim nhu cu xy ca c tim.
Thm vo , n lm gim ng k tin gnh v
hu gnh, ci thin mt cch r rt cung lng
tim cho bnh nhn.
b. Thit b h tr tht: L thit b phi m cy
ghp gip cc bnh nhn suy tim qu nng ko
di thm thi gian ch thay tim.
2. Thay (ghp) tim:
a. L bin php hu hiu cui cng cho nhng bnh
nhn suy tim giai on cui, khng li vi tt
c cc bin php iu tr ni, ngoi khoa thng
thng. thng l nhng trng hp c tn
thng c tim rt rng v nng n.
b. Mt thng k gn y cho thy k t khi c thuc
gim min dch Cyclosporine, t l sng st sau
mt nm ghp tim l 90% v sau 5 nm l 6570%. Ni chung th chc nng v cht lng cuc
sng ca bnh nhn c ci thin ng k sau
ghp tim.
c. Cc thuc thng hay dng nht iu tr gim
min dch sau ghp tim l: Glucocorticoids,
Cyclosporine v Azathioprine. Mt s loi thuc
gim min dch mi khc cn ang trong giai
on th nghim.
d. Nhng bin chng c th gp sau ghp tim bao
gm: thi ghp sm, nhim trng do dng thuc
gim min dch. S pht trin ca bnh mch
vnh sau m cng l mt nguyn nhn quan trng
gy t vong sau nm u tin c ghp tim.
373
VI. Suy tim cp v ph phi cp do tim

A. Sinh l bnh
1. Ph phi cp xy ra khi p lc ca mao mch phi
tng qu ngng gy thot dch ra khi lng mch
vo trong khong k v ph nang. T gy ri lon
trm trng s trao i kh.
2. Vic tng p lc mao mch phi ny ch yu gy ra
l do tnh trng suy tim tri cp v mt s bnh l tc
nghn ng ra ca ca tnh mch phi c bit l
bnh hp van hai l.
B. Chn on
a. Tnh trng kh th nhiu, i khi d di v t
ngt, pht trin nhanh chng.
b. Km theo bnh nhn lo lng, vt v, tm ti
c. Mt s ho ra mu hoc thm ch tro bt hng ra
ming.
d. Khm thy bnh nhn kh th nhanh, nng. Nghe
phi c th thy ran rt, ran ngy v c bit l
ran m to nh ht hai bn ph trng (c th din
bin kiu nc thu triu dng t hai y phi).
2. Chp Xquang phi:
a. Hnh nh bng tim to, huyt qun phi tng m.
b. M hnh cnh bm lan to t hai rn phi.
c. i khi thy hnh nh ng Kerley B.
d. Tin trin theo tnh trng lm sng.
C. iu tr
1. Cc bin php h tr ban u:
a. Cung cp xy y .
b. t ni kh qun v thng kh nhn to nu cn.
c. bnh nhn t th na ngi.
374
d. C th tin hnh gar ba chi lun phin hoc

chch mu nu khng c iu kin thuc men tt.
2. Dng thuc:
a. Morphine sulphate l thuc rt quan trng v
lm gim lo lng cho bnh nhn v gin h tnh
mch phi, tnh mch h thng. Morphine c
dng bng ng tim tnh mch 2-5mg mi ln
v nhc li sau 10-25 pht nu cn cho n khi c
tc dng.
b. Furosemide lm gim gnh nng tun hon v c
hiu lc tc thi gin ng mch phi nhanh khi
tim tnh mch. Liu ban u t 20-40 mg tim
thng tnh mch sau c th tng liu v nhc
li sau vi pht cho n khi p ng u . Liu
c th tng n ti a l 2000mg.
c. Nitroglycerin l thuc gin ch yu h tnh mch
lm gim tin gnh v c tc dng hip ng vi
Furosemide. Nn dng ng truyn tnh mch
vi liu bt u l 10 g/pht v tng dn tu
theo p ng.
d. Nitroprusside rt c hiu qu iu tr ph phi
cp bnh nhn tng huyt p hoc h van tim
cp. Khi dng thuc ny cn theo di cht ch
p ng ca bnh nhn da trn cc thng s
huyt ng. Liu khi u l 0,25 g/kg/pht.
e. Cc thuc tng co bp c tim c ch nh sau
khi dng cc bin php ban u trn v bnh
nhn b huyt p thp hoc sc tim.
3. Chy thn nhn to cp hoc siu lc mu c
ch nh nhng bnh nhn c bnh thn hoc khng
p ng vi li tiu.
4. Theo di huyt ng bng ng thng tim phi
(Swan-Ganz) c th c ch bnh nhn p ng km
vi iu tr. Theo di p lc ng mch phi v mao
375
mch phi bt cn gip phn bit c nguyn nhn

gy ph phi cp l do tim hay khng phi do tim.
5. Ch v gii quyt cc nguyn nhn nu c th.
Cc nguyn nhn gy ph phi cp huyt ng
thng gp l:
a. Tng huyt p.
b. NMCT cp hoc bnh mch vnh cp.
c. H van tim cp (do NMCT, vim ni tm mc...)
d. Cc bnh vim c tim, bnh c tim
e. Cc ri lon nhp tim mi xy ra hoc qu ti th
tch (truyn nhiu dch qu) bnh nhn c
ri lon chc nng tht tri.
Ti liu tham kho
1.
2.
3.
4.
5.
6.
376
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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.
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1996;335:490-498.
Doval HC, Nul DR, Grancelli HO, et al., For Gruppo de Estudio de
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amiodarone in severe congestive heart failure (GESICA). Lancet
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Hosenpud JD, Greenberg BR. In: Hosenpud J, ed. Congestive heart
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Lenihan DJ5 Gerson MC, Hoit BD, Walsh, RA. Mechanisms,
diagnosis, and treatment of diastolic heart failure. Am Heart J
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Medicine. Philadelphia: Lippincott-Raven, 2000.
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survival with an implanted defibrillator in patients with coronary
disease at high risk for ventricular arrhythmias. N Engl J Med
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health and disease: Doppler echocardiography is the clinician's
Rosetta stone. J Am Coll Cardiol 1997; 30:8-18.
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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
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Randomized Amlodipme Survival Evaluation Study Group
(PRAISE). Effect of amlodipine on morbidity and mortality in severe
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Losartan in the Elderly Study, ELITE). Lancet 1997;349:747-752.
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378
Bnh c tim gin

Bnh c tim gin khng r nguyn nhn l bnh cha r
bnh nguyn gy ra hu qu lm mt dn chc nng co bp ca
c tim. Chn on xc nh khi c du hiu suy gim chc nng
tm thu v gin bung tht tri m khng tm thy cc nguyn
nhn thng thng nh bnh ng mch vnh, bnh tim bm
sinh, bnh van tim, tng huyt p hoc bnh mng ngoi tim.
Trong mt vi trng hp bnh c tim gin thy c cc yu t
thun li trn lm sng nh nghin ru, thai sn hoc tin s
gia nh c mc bnh c tim. Tuy nhin ngi ta cha tm ra mt
nguyn nhn c mi lin quan chc chn no dn n bnh c
tim gin. Gii khoa hc vn ang tip tc nghin cu cc mi
lin quan n bnh c tim gin ca h thng to keo, t min,
thn kinh c, cc qu trnh vim, hay chuyn ha nhm gp
phn l gii bnh sinh phc tp ca bnh ny.
I. Gii phu bnh
A. Gii phu bnh ca hu ht cc trng hp bnh c tim
gin sau khi bnh nhn t vong u cho thy cc bung
tim gin nhiu. Tng nhiu trng lng ton b, khi c,
v th tch t bo c tim trong bnh c tim gin, tuy
nhin dy ca thnh tht tri khng tng thm ch cn
mng v dt xung.
B. Huyt khi trong bung tim v huyt khi bm thnh
ni mc ca tim thng thy trong hn 50% cc trng
hp bnh c tim gin.
C. Tn thng vi th trong bnh c tim gin thng thy t
bo c tim ph i v kch thc ln, c hnh bu dc rt
k l.
D. Cu to bn trong ca t bo c tim cng rt bt thng,
c th thy bin i gin phn, ng ch T gin, v c cc
ht lipid bn trong. Trng hp nhng bnh tim khc
thng khng c cc du hiu ny. S tng si ha
379
thng xuyn thy trong bnh c tim gin, tuy nhin cc

tiu ng mch xuyn thnh v cc mao mch li c cu
trc bnh thng trong bnh c tim gin.
II. Sinh l bnh
A. C ch sinh bnh hng u ca bnh c tim gin l gim
kh nng co bp ca t bo c tim. Hu qu l lm gim
phn s tng mu v tng th tch cui tm trng tht
tri, nh tt c cc nguyn nhn khc dn n hu qu
cui cng l suy tim. Tuy nhin do qu trnh ny din ra
t t lm bnh nhn thch ng tt, v vy c rt nhiu
trng hp tuy chc nng tm thu tht tri gim nhiu
nhng bnh nhn vn c rt t triu chng lm sng.
B. Thay i ng k nht c nhn thy trong bnh c tim
gin khng r nguyn nhn l phc hp th th
adrenergic G protein adenylate ca c tim. Trong cc
bnh nhn suy tim nng thy c gim 60 n 70% th
th bta 1 adrenergic v tng th th bta 1 mRNA.
A. Triu chng c nng
1. Tt c cc la tui u c th gp bnh c tim gin,
tuy nhin la tui thng gp nht l tui trung nin.
Cc du hiu thng din ra rt t t v bnh nhn
thng c mt giai on di t vi thng n vi nm
hon ton khng c triu chng. Mt vi trng hp
bnh khi pht t ngt nh cc bnh nhn sau mt
thi k tng nhu cu hot ng ca tim nh sau phu
thut hay nhim trng. i vi cc bnh nhn tr tui
nhiu khi b chn on nhm vi cc bnh phi thng
thng nh vim phi, vim ph qun...
2. Dn dn sau bnh nhn thng c cc biu hin
ca suy tim tri nh kh th khi gng sc, kh th
khi nm v kh th v m.
380
3. Giai on nng ln ca bnh s thy cc du hiu ca

suy tim phi nh ph ngoi bin, nn, cng tc bng
do gan to, i tiu m v c chng. Cc du hiu
khc c th gp l biu hin ca hi chng cung
lng tim thp nh mt mi v suy nhc c th. au
ngc cng c th gp mc d h thng ng mch
vnh hon ton bnh thng. Cc du hiu ngt v xu
thng c ngun gc do ri lon nhp hoc do dng
thuc gy h huyt p t th ng.
B. Triu chng thc th
1. Khm lm sng thng khng c du hiu c hiu
v thng ch lin quan n mc suy tim ca bnh
nhn. Huyt p bnh nhn thng bnh thng nhng
nu tnh trng ri lon chc nng tht tri tin trin
c th dn n h huyt p, mch nh v yu.
2. Khm tim thng thy nhp tim nhanh, i khi c
ting nga phi. Thng nghe thy ting thi tm thu
ca h van hai l v ba l do gin cc bung tim.
Ngoi ra cn thy cc du hiu bung tim gin vi
mm tim xung thp v sang tri (gin tht tri) hay
gin v pha mi c ca tht phi.
3. Khm phi trong trng hp tr tun hon nhiu
c th thy xut hin cc ran m, bnh nhn kh th
kiu nhanh nng, th kh kh v thng c trn dch
mng phi phi hp.
4. Khm bng nhm pht hin cc du hiu ca suy
tim phi vi gan to. Trong cc trng hp nng c th
dn n x gan tim vi bng c chng trn lm
sng. Phn hi gan tnh mch c dng tnh, nhng
a phn cc bnh nhn c tnh mch phi ni t
nhin.
5. Khm ngoi bin pht hin ph chi di sau c
th dn n ph ton thn. Hay gp du hiu gim
ti mu ngoi bin vi chi lnh, ti hay tm. y
381
chnh l nhng bng chng th hin mc cung

lng tim gim cc bnh nhn bnh c tim gin
khng r nguyn nhn.
Khng c mt xt nghim no c coi l tiu chun
vng chn on xc nh bnh c tim gin. Vic chn
on cn phi kt hp gia lm sng v cc xt nghim cn
lm sng.
1. in tm (T): Khng c du hiu T in
hnh cho bnh c tim gin. Chng ta c th thy du
hiu nhp xoang nhanh nhng cng c th gp cc ri
lon nhp nh v tht phc tp. Ri lon dn truyn
trong tht hay gp m in hnh l bloc nhnh, on
ST v sng T cng rt hay bin i. Mt vi bnh
nhn li c sng r nh v Q su cc chuyn o
trc tim lm ta d nhm ln vi cc trng hp nhi
mu c tim c. Du hiu dy tht tri v trc tri
cung hay gp.
2. Chp tim phi: Bng tim to, vi ch s tim ngc ln.
Ph phi l du hiu c th thy trn phim do tng p
h tnh mch phi. Tnh mch ch trn v tnh
mch n (azygos) gin do tng p h tnh mch ch.
C th gp trn dch mng phi.
3. Siu m tim: L phng php hu hiu nht chn
on v theo di tin trin ca bnh c tim gin cng
nh loi tr cc nguyn nhn c th dn n gin cc
bung tim nh bnh tim bm sinh, bnh van tim,
bnh mch vnh...
a. Siu m hai chiu: cho thy cc bung tim gin
nht ct 4 bung tim t mm v cnh c tri.
dy ca vch lin tht v tht tri vn trong gii
hn bnh thng, nhng bin di ng ca ton
b cc vch tim thuc tht tri u gim. C th
thy dch mng ngoi tim trong mt s cc trng
382
b. Siu m Doppler: gip nh gi dng h van hai

l, ba l v c tnh p lc ng mch phi.
4. Thng tim v chp bung tim:
a. Hnh nh chp bung tht tri thy tht tri gin
v gim vn ng ton b.
b. V mt huyt ng, thy c suy tht tri hay suy
c hai tht vi tng p lc cui tm trng ca
tht tri trong khi p lc tm thu li gim nhiu.
c. H thng ng mch vnh bnh thng hay hp
khng ng k (hp di 50%).
5. Sinh thit c tim: xc nh nhng nguyn nhn
dn n suy tim d nhm vi bnh c tim gin khng
r nguyn nhn nh vim c tim, sarcoidose,
hemosiderosis...
V. Din bin t nhin v tin lng
1. Din bin t nhin ca bnh s dn n suy tim tng
dn v c th b t vong trong bnh cnh suy tim
nng hay ri lon nhp.
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
nh b bnh c tim, kch thc bung tht tri gin

nhiu, p lc nh tri tng, rung nh, tng hm lng
norepinephrine mu. Cc yu t sau y khng c
lin quan n tin lng l tui, thi gian mc bnh,
tin s nhim virus, ngoi tm thu tht n gin.
VI. iu tr
A. iu tr ni khoa
Nhm mc ch n nh tnh trng suy tim. Vic iu
tr bao gm ch n hn ch mui v nc, gim hot ng
ca tim bng gim tin gnh, hu gnh v nhp tim, tng sc
co bp ca c tim.
1. Thuc li tiu khi cho phi cn c vo chc nng
thn v th tch dch trong c th. Ch nh tt trong
trng hp tng p MP, tr ti phi v ngoi bin
r rng. Qu liu li tiu s lm ri lon in gii v
ur mu t lm gim cung lng tim. Li tiu
c la chn l cc loi li tiu quai nh Furosemid,
Torsemid hay Bumetanide. Cn Thiazid thng
khng c khuyn dng do hiu qu km.
2. Thuc gin mch lm gim gnh cho tim nh c ch
men chuyn dng Angiotensin, Nitrat v Hydralazin
trong c ch men chuyn dng Angiotensin l
thuc nn c la chn hng u. Cn ch tc
dng h huyt p t th ca thuc gin mch.
3. Digitalis l thuc c la chn trong cc trng hp
rung nh c tn s tht cao. Hn na cc nghin cu
cn ch ra rng n c tc dng ci thin phn s tng
mu, ci thin kh nng gng sc ca bnh nhn v
triu chng lm sng ngay c i vi cc bnh nhn
c nhp xoang. Tuy nhin trong nghin cu mi y
(nghin cu DIG) Digoxin khng lm thay i t l
t vong cc bnh nhn suy tim khi so snh vi gi
dc. Do cc trng hp nhp xoang ch nn
dng Digitalis khi bnh nhn c tim to, ri lon chc
nng tht tri nhiu v khng p ng vi iu tr li
384
tiu cng nh thuc c ch men chuyn dng

Angiotensin.
4. Thuc khng vitamin K cn c s dng khi bnh
nhn c huyt khi trong bung tim, c rung nh hay
c tin s tc mch.
5. iu tr ri lon nhp trong bnh c tim gin thng
gp nhiu kh khn. Trong s cc loi thuc chng
lon nhp th Amiodaron l thuc dng nh c hiu
qu v t tc dng ph nht. Ti cc nc pht trin
vic s dng my ph rung t ng cho kt qu tng
i kh quan i vi cc ri lon nhp phc tp.
6. Thuc chn bta giao cm. Hin ti duy nht ch c
Carvedilol l thuc c chp nhn dng iu tr
suy tim ti Hoa K. Tuy nhin, cc nghin cu mi
y cng ch ra rng cc thuc khc nh Bisoprolol
hay Metoprolol cng c hiu qu lm gim t l t
vong cc bnh nhn suy tim. Liu khi u cn rt
thp v ht sc thn trng khi nng liu iu tr.
B. iu tr phu thut ghp tim
Ch nh trong cc trng hp NYHA 3 hoc 4 khng
p ng vi iu tr ni khoa ( bao gm c chn bta). Tuy
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.

medicine, 5th ed. Philadelphia: WB Saunders, 1997:1077-1104.
Fauci AS, ed. Harrison's principles of internal medicine, 14th ed.
New York: McGraw-Hill, 1998:785-791.
Kopecky SL, Gersh BJ. Dilated cardiomyopathy and myocarditis:
natural history, etiology, clinical manifestations, and management.
Curr Probl Cardiol 1987;12:573 647.
Alexander RW, Schlant RC, Fuster V, eds. Hurst's the heart. New
York: McGraw-Hill, 1998:2205-2239.
385
6.
7.
386
Otto C. The practice of clinical echocardiography. Philadelphia:

WB Saunders, 1997:389-403.
Bnh c tim ph i
Bnh c tim ph i l bnh cha r bnh nguyn gy ra

hu qu lm ph i c tim m khng c s gin cc bung tim.
Chc nng tm thu tht tri thng trong gii hn bnh thng
nhng cc thnh tim co bp mnh. y l nguyn nhn hng u
gy t t cc bnh nhn tr di 35 tui.
I. Nguyn nhn
Thng mang tnh cht gia nh, hin ti ngi ta tm thy 6
gen c lin quan n bnh c tim ph i. Trong s gen
bta myosin trn nhim sc th 14q1 chim tn sut gp cao
nht (35 n 45%).
II. Gii phu bnh
Gii phu bnh ca hu ht cc trng hp bnh c tim ph
i thy cc du hiu:
1. Ph i khng ng tm ca tm tht tri vi vch
lin tht ph i nhiu hn thnh t do ca tht tri.
2. Bung tht tri nh hoc c kch thc bnh thng.
3. X ha thnh ni mc ca tim t vch lin tht trn
ng ra tht tri cho n l trc ca van hai l.
4. Van hai l rng v gin ra, c th dy hoc khng
dy th pht.
5. Gin bung nh.
6. Bt thng lng ng mch vnh vi s dy ln ca
thnh mch v hp lng mch.
7. X ha cc m k v ri lon cu trc ca tht tri.
A. Triu chng c nng
1. Triu chng suy tim: bao gm kh th khi gng sc
hay xut hin v m, mt mi, nguyn nhn thng
387
do tng p lc cui tm trng ca tht tri v gim

kh nng gin ca tm tht.
2. Thiu mu c tim vi biu hin au ngc: C th
gp trong c cc trng hp bnh c tim ph i tc
nghn hay khng. C ch chnh xc ca hin tng
ny cn cha r nhng ngi ta cho rng cc yu t
sau c th nh hng n du hiu au ngc ca
bnh nhn:
a. H thng mch vnh kch thc nh, gim kh
nng gin ra khi nhu cu xy c tim tng.
b. Tng p lc ca thnh tim do hu qu ca thi
gian gin tm trng tht tri chm v do cn tr
ng tng mu ca tim.
c. Gim t l gia h mao mch v m tim.
d. Gim p lc ti mu ca ng mch vnh.
3. Ngt v xu: Nguyn nhn do gim ti mu no v
cung lng tim thp hay lin quan vi ri lon nhp
tim hoc gng sc. Ngt bnh nhn tr tui khng
nht thit l yu t tin lng nguy him cc bnh
nhn c bnh c tim ph i. Ngc li tr em v
thiu nin y l yu t lm tng nguy c t t.
4. t t hay nhng ri lon nhp nng c th gp trong
khong 1 n 6% cc trng hp.
B. Triu chng thc th
i vi cc bnh nhn c chnh p qua ng ra tht
tri, khm lm sng c th pht hin thy cc du hiu:
1. Ting thi tm thu pha thp dc theo b tri
xng c, cng gim khi bnh nhn ngi xm v
nm cht tay, cng tng ln khi bnh nhn lm
nghim php Valsalva, ng ln v sau cc ngoi tm
thu tht.
388
2. Du hiu mch ngoi bin ny mnh vi dng hai

pha, pha th nht nhanh mnh v pha th hai ko di
nh nc thy triu.
3. Mm tim p hai v tr, thng thy nht bp tin
tm thu mnh hn, du hiu ny lin quan n ting
th ba nghe c trn lm sng.
1. in tm (T): T bt thng trong khong
90 n 95% cc trng hp. Tuy nhin khng c du
hiu T c hiu cho bnh c tim ph i. Dy tht
tri vi tng bin ca phc b QRS v bin i bt
thng on ST, T l cc du hiu thng gp. Cng
hay gp bloc phn nhnh tri trc v sng Q su
cc chuyn o pha sau, sng T o ngc, dy nh
tri v du hiu gi nhi mu vi gim bin sng
R cc chuyn o trc tim bn phi.
2. Chp tim phi: Bng tim to vi ch s tim ngc ln.
Ph phi l du hiu c th thy trn phim do tng p
h tnh mch phi. Gin bung nh tri cng hay
gp. Tuy nhin bng tim to t c gi tr trong vic
nh gi s tin trin ca bnh, ngi ta thng s
dng siu m Doppler tim nh gi vn ny.
on v theo di tin trin ca bnh c tim ph i
cng nh loi tr cc nguyn nhn khc nh hp van
MC, hp trn van MC...
a. Siu m hai chiu: nh gi mc ph i ca
thnh tim. Thng c s ph i khng ng tm
ca thnh tht tri, vi u th vt tri ca vch
lin tht so vi thnh sau tht tri. Tht tri
thng khng gin v khng c cc bnh l khc
c th dn n tng dy ca thnh tim. Thnh
tim c th dy khu tr tng phn tuy nhin thng
thng c s dy lan ta ca tt c cc thnh tim,
389
nht l ca vch lin tht. S di ng ra trc

trong th tm thu ca van hai l thng gp c
gi tt l du hiu SAM. Du hiu ny lin
quan n s cn tr ng ra tht tri v thng
i km vi vic ng sm van ng mch ch.
Hnh 20-1. Du hiu SAM (mi tn) trn siu m TM.
Hnh 20-2. Mt ct dc trn siu m 2D c ph i ton

b cc thnh tht tri (LV) trong th tm trng (A), tm thu (B).
b. Siu m Doppler: cho php nh gi mc
chnh p ng ra tht tri, dng h van hai l,
ba l v p lc ng mch phi, t nh gi
mc tin trin ca bnh.
4. Thng tim: Ch nh trong cc trng hp chun b
phu thut, t my to nhp, gy tc nhnh vch th
nht ca ng mch lin tht trc hay cc trng
hp kh khn cn chn on phn bit.
a. Chp bung tht tri s gip nh gi kch thc
tht tri v sc co bp ca tht tri.
390
b. V mt huyt ng thy c chnh p trong bung

tht tri v do c cn tr ng ra tht tri nn c
c chnh p gia tht tri v ng mch ch. Nu
chnh p ny khng r rng th c th lm cc
nghim php lm tng chnh p trong bnh c
tim ph i nh nghim php Valsalva, truyn
Isoproterenol hay ngi Amyl Nitrite, gy ngoi
tm thu tht.
c. H thng ng mch vnh thng bnh thng
hay hp khng ng k (hp di 50%). Cn ch
quan st nhnh vch th nht ca ng mch
lin tht trc.
d. Khng c ch nh sinh thit mt cch c h
thng tt c cc trng hp bnh c tim ph i.
5. Holter in tim: Cn tin hnh nh gi mc
v s xut hin ca cc cn nhp nhanh tht. y
chnh l yu t nh gi mc nguy c t t trong
bnh c tim ph i.
V. Din bin t nhin v tin lng
1. y l mt trong nhng bnh tim din bin ht sc
phc tp. N l mt nguyn nhn hng u dn n
t t cc bnh nhn tr tui. Tuy nhin nhiu
trng hp bnh nhn vn c th chung sng ha
bnh vi bnh m khng cn i hi cc phng php
iu tr c bit.
2. t t: c th gp cc bnh nhn tr (t 12 n 35
tui). Cc du hiu suy tim c th din bin tng dn
sau tui 35 n 40 tui. Cng c mt nhm bnh
nhn hon ton khng c triu chng c nng. Cc
bnh nhn ln tui c th c biu hin suy tim nng
sau mt giai on hon ton khng c triu chng
lm sng. Cn ch t t c th gp c cc bnh
nhn bnh c tim ph i c hay khng c tc nghn
ng ra tht tri. Mt s t cc bnh nhn tr tui
391
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
ng mch phi.
2. au ngc trong bnh c tim ph i c th rt in
hnh nh cn au tht ngc v i khi ngay trn T
cng c hnh nh ca NMCT vi sng Q hoi t.
VII. iu tr
A. Bnh nhn khng c triu chng: c th khng
cn iu tr thuc c hiu nhng cng c th iu tr d
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
3. Thuc gin mch khng nn s dng m ch nn s

dng li tiu nu cn cc bnh nhn c hn ch
ng ra tht tri.
4. Digitalis c th lm tng chnh p ng ra tht tri,
do chng ch nh dng cc thuc ny cc bnh
nhn bnh c tim ph i c hp mg ra tht tri.
5. Cc bnh nhn c nguy c t t cao (tin s ngng
tun hon, tin s gia nh c t t, c nhp nhanh
tht trn lm sng) cn d phng bng Amiodarone
v my ph rung t ng nu c iu kin.
C. Phu thut v cc can thip xm ln khc
1. Phu thut Morrow (ct b phn c ph i ca
vch lin tht): c ch nh cc bnh nhn c
triu chng nng n vi chnh p ng ra tht tri
trn 50mmHg khng p ng vi iu tr thuc. Phu
thut ci thin tt cht lng cuc sng nhng khng
loi tr hon ton s tin trin ca bnh (ti pht
bnh) v nguy c t t ca bnh nhn. Trong phu
thut nu c h hai l nng c th thay bng van hai
l c hc.
2. t my to nhp hai bung loi DDD c th ch
nh trong cc trng hp nhp chm, bloc nh tht v
gip cho ci thin triu chng lm sng v chnh p
qua ng ra tht tri.
3. Gy tc nhnh vch th nht ca ng mch lin
tht trc bng cch bm cn chn lc vo nhnh
ng mch ny. y l phng php c thc hin
trong phng thng tim sau khi chp MV. Cc
nghin cu gn y thy rng phng php ny
cho cc kt qu ht sc ng khch l trong vic lm
gim chnh p ng ra cc bnh nhn c bnh c
tim ph i.
393
Ti liu tham kho

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
394
Alessandri N, Pannarale G, Del Monte F, et al. Hypertrophic

obstructive cardiomy-opathy and infective endocarditis: a report of
seven cases and a review of the literature. Eur Heart J 1990;11:
1041-1048.
Almendral JM, Ormastre J, Martinez-Abby JD, et al. Treatment of
ventricular
arrhythmias
in
patients
with
hypertrophic
cardiomyopathy. Eur Heart J 1993;14:71-72.
medicine, 5th ed. Philadelphia: WB Saunders, 1997, 1414-1426.
Fananapazir L, Epstein ND. Prevalence of hypertrophic
cardiomyopathy and limitations of screening methods. Circulation
1995;92:700-704.
Lakkis N, Kiemman N, Killip D, et al. Hypertrophic obstructive
cardiomyopathy: alternative therapeutic options. Clin Cardiol
1997;20:417-418.
Maron JM, Cerchi F, McKenna WS, et al. Risk factors and
stratification for sudden death in patients with hypertrophic
cardiomyopathy. Br Heart J 1994;72 (Suppl):S13-Sl8.
Maron JM, Gardin JM, Flack JM, et al. Prevalence of hypertrophic
cardiomyopathy in a general population of young adults. Circulation
1995;92:785-789.
Maron JM, Isner JM, et al. Task Force 3: Hypertrophic
cardiomyopathy, myocarditis, and other myopericardial diseases and
mitral valve prolapse. J Am Coll Cardiol 1994;24: 880-885
Maron JM, Pelliccia A, Spirito P. Cardiac disease in young trained
athletes: insights methods for distinguishing athlete's heart from
structural heart disease, with particular emphasis on hypertrophic
cardiomyopathy. Circulation 1995;91:15961601.
Morten ET. Hypertrophic obstructive cardiomyopathy: problems in
management. Chest 1997;112:262-264.
Posma JL, van de Wall EE, Blauksma P. New diagnostic options in
hypertrophic cardiomyopathy. Am Heart J 1996;132:1031~1041.
Robbins M. Hypertropic cardiomyopathy. In: Marso SP, Griffin BP,
Schlant RC, Alexander RW, eds. Hurst's The Heart, 8th ed. New
York: McGraw-Hill, 1621-1635.
Smolders W, Redemakers F, Conraads V, et al. Apical hypertrophic
cardiomyopathy. Acta Cardiol 1993;48: 369-383.
Spirito P, Seidman CE, McKenna WS, et al. The management of
hypertrophic cardiomyopathy. N Engl J Med 1997;336:775-784.
Watkins H. Multiple disease genes cause hypertrophic
cardiomyopathy. Br Heart J 1994;72:54-59.
Wigle D, Rakowski H, Kimball B. Hypertrophic cardiomyopathy:
clinical spectrum and treatment. Circulation 1995;92: 1680-1692.
Bnh c tim Hn ch
Bnh c tim hn ch l bnh c t l gp rt thp nhng l

mt nhm bnh quan trng trong suy tim tm trng. N c
nh ngha l bnh c tim tin pht hay th pht gy ra ri lon
chc nng tm trng tht tri nhng khng phi l vim mng
ngoi tim co tht. Cc bung tht khng gin hay ph i, tng
p ng v tnh mch phi, p lc cui tm trng tht tri tng.
Tuy nhin tm nh c th gin nhiu, i khi rt to a n hnh
nh tim to trn phim chp Xquang. Chc nng tm thu tht tri
thng bnh thng.
I. Nguyn nhn
Mt vi trng hp khng r nguyn nhn (v cn), nhng
nhiu trng hp thng do nhim amyloid. Hemochroatosis
l nguyn nhn hay gp gy bnh c tim gin nhng li t
gp hn trong bnh c tim hn ch. Cc nguyn nhn gy
bnh khc c th l vim c tim, sau ghp tim, sarcoidose,
Loffler, x ha ni mc, bnh Gaucher tr em
Du hiu ch yu l tr ngoi bin nh gin tnh mch c,
huyt phi v gan to, c chng.
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
3. Siu m tim: Tm tht thng c kch thc bnh

thng vi chc nng tm thu trong gii hn bnh
thng. Trn dch mng tim i khi gp. Khng thy
cc bt thng cu trc tim khc, c bit l khng
thy cc tn thng van tim. ng knh tht tri
tng trong th tin tm trng tuy nhin khng tng
ln na trong thi k gia v cui tm trng. Dng
chy trong tm tht c trng bi sng E rt u th
do ko di thi gian gim tc.
Hnh 21-1. Ph Doppler ca dng chy qua van hai l

ngi mc bnh c tim hn ch do amyloidosis (A) v ngi
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
ch hn l vim mng ngoi tim co tht. Phim chp

bung tht tri thy tht tri kch thc v sc co bp
ca tht tri trong gii hn bnh thng v khng c
vng ri lon vn ng khu tr ca thnh tim.
6. Sinh thit ni mc c tim cho php chn on xc
nh v c th hng n chn on nguyn nhn.
IV. Chn on phn bit: ch yu l phn bit vi vim
mng ngoi tim co tht.
1. Nu c tin s lao, chn thng, vim mng ngoi
tim cp, bnh h thng, sau chy tia x, sau phu
thut... thng ngh n vim co tht mng ngoi tim.
Nu c tin s ghp tim, nhim amyloid,
hemochromatosis... th thng ngh n bnh c tim
hn ch.
2. Tc dng chy qua van hai l s tng khi ht vo
su bnh nhn vim mng ngoi tim co tht, cn
trong bnh c tim hn ch th hin tng ny s
khng thay i theo h hp.
3. Chn on xc nh bng sinh thit ni mc c tim.
V. iu tr
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
2. Trng hp hemochromatosis th hay gp bnh c

tim gin hn l bnh c tim hn ch.
Ti liu tham kho
1.
Aroney C, Bett N, Radford D. Familial restrictive cardiomyopathy.

Aust N Z J Med 1988;18:877-8.
2. Buxbaum J. The amyloidoses. Mt Sinai J Med 1996;63:16-23.
3. Cetta F, OLeary PW, Seward JB, Driscoll DJ. Idiopathic restrictive
cardiomyopathy in childhood: diagnostic features and clinical
course. Mayo Clin Proc 1995;70:634-40.
4. Goodwin JF. Cardiomyopathies and specific heart muscle diseases:
definitions, terminology, classifications and new and old approaches.
Postgrad Med J 1992;68:Suppl 1:S3-S6.
5. Hirota Y, Shimizu G, Kita Y, et al. Spectrum of restrictive
cardiomyopathy: report of the national survey in Japan. Am Heart J
1990;120:188-94.
6. Katritsis D, Wilmshurst PT, Wendon JA, Davies MJ, Webb-Peploe
MM. Primary restrictive cardiomyopathy: clinical and pathologic
characteristics. J Am Coll Cardiol 1991;18:1230-5.
7. Kushwaha SS, Fallon JT, Fuster V. Restrictive cardiomyopathy. N
Engl J Med 1997;336:267-276.
8. Lewis AB. Clinical profile and outcome of restrictive
cardiomyopathy in children. Am Heart J 1992;123:1589-93.
9. Pellikka PA, Tajik AJ, Khandheria BK, et al. Carcinoid heart
disease: clinical and echocardiographic spectrum in 74 patients.
Circulation 1993;87:1188-96.
10. Richardson P, McKenna 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
Vim mng ngoi tim cp
Vim mng ngoi tim l mt tnh trng bnh l c ngun

gc do phn ng vim ca mng ngoi tim vi cc triu chng
chnh l au ngc, ting c mng ngoi tim v cc bin i in
tm . Bnh hay gp nam gii hn so vi n gii.
Cc th bnh v nguyn nhn gy bnh ca vim mng
ngoi tim cp rt a dng. Nguyn nhn hay gp nht l: vim
mng ngoi tim cp v cn, do virus, do vi khun (nht l vi
khun lao), tng ur mu, sau nhi mu c tim, ung th v chn
thng.
I. Vim mng ngoi tim cp khng r cn nguyn
C kh nhiu cc trng hp vim mng ngoi tim cp
khng tm thy nguyn nhn gy bnh, ngi ta cho rng i
a s cc trng hp ny c ngun gc do virus. Tuy nhin
vic phn lp tm ra chnh xc virus gy bnh hin cn gp
nhiu kh khn v mt k thut.
A. Triu chng lm sng
1. Triu chng c nng:
a. au ngc do vim mng ngoi tim thng au
sau xng c, au but, c th mc nng d
di nhng cng c th m ko di sut ngy,
au thng lan ln c v ra sau lng. Kinh in
au thng tng ln khi ho v khi ht vo su.
b. Thng km theo st v du hiu au mi c nh
cc trng hp nhim virus thng thng.
c. Kh th i khi c th gp nhng thng thng
xut hin sau giai on au ngc khi vim mng
ngoi tim cp din bin thnh trn dch mng
ngoi tim.
d. Bnh nhn thng cm gic cng thng, bun b
v kh chu.
399

a. Nghe tim l du hiu ch yu chn on. Nghe
thy c ting c mng ngoi tim. Ting c thng
th, rp, rt, c m cao. N c th thay i
theo thi gian v t th bnh nhn hoc khi bnh
nhn ht vo su. Kinh in ting c s c ba thi
k tng ng vi tm nh co, tm tht co v tin
tm trng. Tuy nhin, thng thng chng ta
ch nghe thy ting c trong thi k tm nh v
tm tht co, thm ch ch nghe thy trong mt
thi k nht nh m thi.
b. V tr tt nht nghe thy ting c mng ngoi
tim l pha thp ca b tri xng c, khi bnh
nhn ngi hi ci ra trc v ht su vo ri nn
th.
1. in tm (T): Kinh in T s din bin
qua 4 giai on. y l xt nghim rt c gi tr
chn on xc nh, chn on phn bit v nh gi
giai on vim mng ngoi tim cp.
a. Giai on u thng xut hin vi gi sau cn
au ngc u tin. y l giai on rt kh phn
bit vi du hiu ti cc sm hay nhi mu c tim
cp trn in tm . Kinh in giai on 1 s
gm cc du hiu on ST chnh ln ng hng
vi sng T dng cc chuyn o trc tim.
b. Giai on th hai xut hin vi ngy sau vi on
ST tr v ng ng in, sng T dt xung.
c. Giai on ba l giai on sng T m o ngc.
d. Sau vi ngy n vi tun sng T s dng tr li,
y l giai on cui cng ca bnh.
e. Nu vim mng ngoi tim cp c trn dch mng
tim, T c th c du hiu in th gim (nht
l cc chuyn o ngoi vi) v du hiu lun
phin in hc.
400
Hnh 22-1. Tin trin trn in tim t giai on

VMNT cp (trn) chuyn sang giai on bn cp (di).
2. Chp tim phi: hnh tim to thng ch thy trong
cc trng hp c trn dch mng ngoi tim phi hp
v y cng khng phi l du hiu c hiu gip
chn on.
3. Cy mu, cy m v dch ht d dy c kh nng
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
ngoi tim cp). Him gp hn c th c du hiu

mng ngoi tim dy hn so vi bnh thng.
b. Mt khc trong cc trng hp bnh nhn mi
phu thut tim hay nghi ng c trn dch mng
tim, lc ny siu m tim tr thnh xt nghim kh
quan trng, cn thc hin nhiu ln nh gi
s tin trin ca bnh.
6. Cc xt nghim khc nh siu m tim qua thc
qun, chp ct lp vi tnh, cng hng t ht nhn c
th p dng trong mt vi trng hp c bit
nghin cu k hn v mng ngoi tim.
C. Chn on phn bit
1. au ngc do tch thnh ng mch ch, nhi mu
phi, vim phi hay nhi mu c tim.
2. Bin i T cn phn bit vi cc bin i do thiu
mu c tim cc b gy ra. Din bin ca on ST v
sng T cho php phn bit trong i a s cc trng
hp. Tuy nhin cc trng hp ST chnh ln lan ta
cc chuyn o cn lm siu m chn on loi
tr nhi mu c tim (tm ri lon vn ng vng trn
siu m tim).
D. iu tr
1. Nguyn l chung: i a s cc trng hp vim
mng ngoi tim cp khng c bin chng, bnh s t
khi v p ng tt vi iu tr ni khoa.
a. Thuc iu tr ch yu l thuc khng vim
khng steroid.
b. iu tr vim mng ngoi tim c bin chng trn
dch mng ngoi tim hay vim mng ngoi tim co
tht s c bn lun nhng bi sau.
2. iu tr ni khoa:
402
a. Ibuprofen 600 n 800mg ung chia 3 ln trong

ngy, trong 3 tun hay Indomethacin 25 n
50mg ung chia 3 ln trong ngy, trong 3 tun.
b. Trong cc trng hp bnh nhn khng p ng
vi khng vim khng steroid hay trong trng
hp ti pht vim mng ngoi tim c th s dng
prednisone ung trong 3 tun, cng c th dng
ng tim tnh mch vi Methylprednisone
trong cc trng hp nng. Colchicine 1mg trong
ngy cng c mt vi nghin cu ch ra tnh
hiu qu trong iu tr vim mng ngoi tim cp.
3. iu tr chc dn lu dch mng ngoi tim qua da
(trn dch mng tim c p tim): Ch p dng trong
cc trng hp vim mng ngoi tim c trn dch
nhiu, c nh hng n huyt ng hay trong trng
hp cn chc d chn on bnh nguyn. Chc
dn lu vi gy t ti ch c th t dn lu trong cc
trng hp dch nhiu, ti pht lin tc.
4. Phu thut:
a. M dn lu mng ngoi tim di xng c
thng ch p dng trong cc trng hp vim
mng ngoi tim do ung th.
b. Phu thut ct mng ngoi tim thng p dng
trong trn dch ti pht nhiu hay vim co tht
mng ngoi tim.
II. Vim mng ngoi tim do virus
Nguyn nhn ch yu do Coxackie virus nhm B v
Echovirus gy ra. Chn on da vo du hiu nhim virus
ng h hp, au ngc xut hin sau vi bin i T
v cui cng l cc xt nghim huyt thanh chn on. i
a s cc trng hp bnh t khi. i khi c th dn n
cc bin chng nh vim c tim, ti pht vim mng ngoi
tim, trn dch mng tim, p tim v vim mng ngoi tim co
403
tht. Du hiu lm sng v iu tr nh trong cc trng hp

vim mng ngoi tim khng r nguyn nhn.
III. Vim mng ngoi tim do lao
A. Triu chng lm sng
Tt c cc trng hp vim mng ngoi tim c st lai dai,
nht l v chiu th trc ht cn phi ngh n vim
mng ngoi tim do lao.
1. Du hiu lm sng in hnh thng n mun, i
a s cc bnh nhn ch c biu hin kh th, st, n
lnh v ra m hi v chiu ti.
2. Du hiu tr ngoi bin trn lm sng hay gp hn
du hiu au ngc v ting c mng ngoi tim.
B. Nguyn nhn: Vim mng ngoi tim do lao l nguyn
nhn hng u dn n vim mng ngoi tim co tht.
Vim mng ngoi tim gp khong t 1 n 2% cc
trng hp lao phi.
1. in tm : on ST chnh ln kinh in thng
khng thy trong vim mng ngoi tim do lao.
2. Chp tim phi: thy du hiu ca lao phi mi hoc
c trong mt s cc trng hp v du hiu bng tim
to ra do c dch mng ngoi tim.
3. Cy tm vi khun lao BK (AFB): l xt nghim c
hiu cho chn on. Dch cy c th ly t cc dch
tit ca c th (m, dch d dy, dch mng phi...)
hay t chnh dch chc ht ca mng ngoi tim.
4. Xt nghim mu: thng tng bch cu a nhn giai
on sm v bch cu lympho giai on mun hn,
mu lng thng tng trong a s cc trng hp.
5. Siu m tim: Thy du hiu c dch khoang mng
tim vi nhiu si fibrin, ng thi c th c du hiu
mng ngoi tim dy hn so vi bnh thng.
404
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 nhi
mu c tim cp c ti ti mu (tiu si huyt hay nong
ng mch vnh), t l vim mng ngoi tim thp hn
nhm iu tr bo tn.
Vim mng ngoi tim hay gp trong cc trng hp
nhi mu c tim thnh trc rng ko di vi gi n vi
ngy sau nhi mu.
A. Triu chng lm sng
Tt c cc trng hp sau nhi mu c tim cp m
thy bnh nhn c ti pht au ngc v nghe tim c ting
c mng ngoi tim th cn phi ngh n vim mng
ngoi tim sau nhi mu c tim.
in tm cho thy sng T c th dng cao hn
trong hai ngy hoc sng T o ngc trc tr nn
dng. Tuy nhin, cc du hiu T in hnh cho vim
mng ngoi tim thng khng thy r.
C. iu tr
1. Aspirin l la chn iu tr hng u.
405
2. Chng ch nh cc thuc khng vim khng steroid

do c th gy co tht ng mch vnh, cn cc thuc
steroid th li c th gy thng tim trong vim mng
ngoi tim sau nhi mu co tim cp.
V. Hi chng Dressler
Xut hin vi tun cho n vi thng sau nhi mu c
tim vi t l gp khong 1%. Sinh bnh hc cn cha r
rng tuy nhin ngi ta ngh nhiu n nguyn nhn do c
ch t min. Bnh nhn thng c biu hin st, trn dch
mng phi, ting c mng tim, mng phi, xu v au ngc
nhiu. iu tr bng Aspirin v thuc chng vim khng
steroid, ngh ngi ti ging. Nu dng thuc chng ng
c th d gy ra trn mu mng ngoi tim tuy nhin tin
lng ca hi chng ny thng rt tt. Hn hu cc trng
hp khng khng ch c phn ng vim mi phi dng
steroid iu tr.
VI. Hi chng sau m mng ngoi tim
Hi chng ny cng gn ging hi chng Dressler,
xut hin mt tun sau phu thut. T l gp khong 10 n
40% cc trng hp. Bnh thng t khi song i khi ko
di vi tun. iu tr bng Aspirin, chng vim khng
steroid, Corticoid ch dng trong cc trng hp khng p
ng vi iu tr. Bin chng c th gp l p tim v him gp
hn l vim mng ngoi tim co tht.
VII. Vim mng ngoi tim do tng ur mu
A. Triu chng lm sng
1. Hay gp cc bnh nhn va bt u lc mu, rt
hay nghe thy ting c mng tim trn lm sng.
2. Thng gp trn dch mng ngoi tim s lng nhiu
sau giai on vim cp.
406
B. Sinh bnh hc: Cn cha tht r rng c ch sinh

bnh hc ca bnh v khng thy mi lin h vi nng
ur mu cng nh ng c vi s xut hin ca vim
mng ngoi tim.
C. iu tr
1. iu tr ni khoa: Hn ch s dng chng vim
khng steroid; steroid nhiu khi t hiu qu tt.
2. iu tr dn lu dch mng ngoi tim qua da: Lc
mu l la chn hng u cho cc bnh nhn vim
mng ngoi tim do tng ur mu nu c triu chng.
Nu khng c triu chng ca hi chng ur mu cao
th lc mu khng phi l bt buc. Nu trn dch
mng tim s lng nhiu vi tng bch cu, st hay
c p tim th vic chc dn lu dch mng tim l cn
thit.
3. iu tr ngoi khoa. M mng ngoi tim di xng
c, ct mng ngoi tim ti thiu c ch nh cho
cc trng hp ti pht nhiu ln hoc khng ht dn
lu dch qua da c.
VIII. Vim mng ngoi tim do ung th
i a s cc trng hp l do di cn n mng ngoi tim
(ung th phi, ung 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.
1. in tm (T): Cc du hiu T in hnh
cho vim mng ngoi tim thng khng thy r. Bin
407
i on ST-T khng c hiu, i khi c th thy

du hiu lun phin in hc.
2. Xt nghim gii phu bnh vi th: tm t bo ung
th trong dch chc ht mng ngoi tim hoc cc dch
tit khc ca c th. T l gp t bo c tnh cao
trong dch mng ngoi tim cc bnh nhn ung th
phi, ung th v nhng t l ny thp cc bnh
nhn ung th mu v cc ung th khc.
3. Siu m tim: gip nh gi mc trn dch mng
tim, huyt ng v theo di s din bin ca bnh.
C. iu tr
1. iu tr dn lu dch mng ngoi tim qua da:
a. Chc dn lu dch mng tim: Rt tt nu c s
hng dn ca siu m, ch nh cho cc bnh
nhn c triu chng lm sng ca trn dch mng
ngoi tim m s lng kh nhiu.
b. Dng bng nong mng ngoi tim l k thut nguy
him hn, ch nn p dng cc bnh nhn ti
pht trn dch mng ngoi tim nhiu ln.
2. Phu thut: c th p dng mt vi th thut sau
trong nhng trng hp cn thit:
a. M mng ngoi tim di xng c.
b. Lm cng mng ngoi tim bng Tetracycline vi
nc mui sinh l. Bin chng c th gp ca th
thut ny l au nhiu trong th thut, ri lon
nhp v st.
c. Ct mng ngoi tim. Phu thut ny khng l la
chn hng u cho cc bnh nhn trn dch mng
ngoi tim do ung th.
IX. Theo di cc trng hp vim mng ngoi tim
Cc bnh nhn vim mng ngoi tim do virus hay
khng r nguyn nhn cn c theo di trong vng mt
thng k t sau khi ht cc triu chng lm sng khng
nh khng c ti pht bnh v khng c vim mng ngoi
tim co tht.
408
Cc bnh nhn c trn dch mng ngoi tim cn phi

theo di nh k bng siu m khng nh khng c ti
pht hay tng mc dch trong khoang mng tim.
X. Bin chng
A. Ti pht vim mng ngoi tim
Thng gp vi t l 20 n 30% cc trng hp, hay
gp trong vim mng ngoi tim khng r nguyn nhn,
sau phu thut tim h, chn thng, hi chng Dressler.
iu tr nu khng p ng vi khng vim khng
steroid c th dng Prednisone 40-60mg/ngy t 1 n 3
tun. Phu thut c ch nh trong cc trng hp ti
pht nhiu ln vim mng ngoi tim c au ngc nhiu
m khng p ng vi iu tr ni khoa. Phng nga ti
pht c th s dng Colchicine 1mg/ngy trong mt thi
gian vi vic gim dn liu trc khi dng hn. Tuy
nhin cn cn c thm mt s cc nghin cu lm sng
khng nh vn ny.
B. p tim: chim khong 15% cc trng hp.
C. Vim mng ngoi tim co tht: khong 9% cc
trng hp vim mng ngoi tim s b vim dnh mng
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.
3. Braunwald E, ed. Heart disease: a textbook of cardiovascular

medicine, 5th ed. Philadelphia: WB Saunders, 1997.
4. Fowler NO. Tuberculous pericarditis. JAMA 1991;266:99-103.

5. Kirkland LL, Taylor RW. Pericardiocentesis. Crit Care Clin
1992;8:669-711.
6. Shabetai R. Diseases
1990;8(4):579-716.
of
the
pericardium.
Cardiol
Clin
409
7. Spodick DH. Pericarditis, pericardial effusion, cardiac tamponade,

and constriction. Crit Care Clin 1989;5:455~75.
8. Topol EJ, ed. Textbook of cardiovascular medicine. Philadelphia
Lippincott-Raven Publishers, 1998.
9. Wu J. Acute pericarditis. In: Marso SP, Griffin BP, Topol EJ, eds.
Manual of Cardiovascular Medicine. Philadelphia: Lippincott-Raven, 2000.
410
Trn dch mng ngoi tim
Trn dch mng ngoi tim l mt tnh trng bnh l kh

thng gp trn lm sng. Bnh c th hon ton thm lng,
khng c triu chng nhng cng c th nguy kch n tnh
mng bnh nhn trong bnh cnh p tim. Biu hin lm sng ty
thuc vo s lng dch cng nh bn cht ca dch.
I. Trn dch mng ngoi tim khng c du p tim
Khoang mng ngoi tim cha ng t 15 n 30 ml dch
gip cho hai l thnh v l tng khng c st vo nhau. Kh
nng cha ti a ca khoang mng ngoi tim l t 80 n
200ml dch, vi s lng dch ny trn lm sng hu nh
khng nhn thy cc bin i v huyt ng. Cc bnh nhn
vim mng ngoi tim cp p lc tnh mch trung tm tng
lm gim s tr v ca h tnh mch do kh nng cha
dch ca khoang mng tim s tng ln. Vi s tng dn ca
lng dch nhiu trng hp khoang mng tim c th cha
n 2 lt dch m vn cha c bin i huyt ng trn lm
sng. Chn p huyt ng hay gp trong cc trng hp dch
qu nhiu hay tng 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
nc do chn p vo dy thn kinh honh, nn v

cng bng do chn p cc tng trong bng.
a. Dch mng tim s lng t thng kh thy cc
du hiu trn khm thc th.
b. Dch mng tim s lng nhiu c th thy cc
du hiu ting tim m, du hiu ca Edwart (g
c, ting thi ca ph qun) v ran phi do
chn p th pht.
B. Nguyn nhn
Cc nguyn nhn hay gp gy trn dch mng ngoi tim
nhiu l vim mng ngoi tim khng r nguyn nhn,
tng ur mu, hi chng thn h, vim mng ngoi tim
do ung th hay u nhy, suy tim huyt, x gan, suy gip,
sau phu thut tim v do thuc.
Bng 23-1. Cc nguyn nhn gy trn dch mng tim
1. V cn
2. Nhi mu c tim cp
3. Cc hi chng sau tn thng c tim-mng tim: hi
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
10. Do nm su, nm ph tng: Histoplasmosis,

Aspergillosis, Blastomycosis, Coccidiodomycosis
11. Cc loi nhim trng khc: amp, Echinococcus, st
Lyme, M. pneumonia, Rickettsia
12. U tin pht (mesothelioma, teratoma, fibroma,
leiomyofibroma, sarcoma, lipoma, angioma...) v di
cn (ung th v, ph qun, l-x-mi, u lympho...)
13. Cc bnh min dch (thp tim, lupus ban h
thng, vim ct sng dnh khp, vim khp dng
thp, vim mch, vim nt quanh ng mch, x
cng b, vim da v c, bnh Whipple, Behcet,
Reiter, st a Trung Hi, vim ng mch thi
dng, amyloidosis
14. Do thuc: Procainamide, Hydralazine, Heparin,
Warfarin, Phenytoin, Phenylbutazone, Dantrolene,
Methysergide, Doxorubicin, Penicillin, Minoxidil,
Interleukin
1. in tm (T): Kinh in s thy du hiu
in th thp lan ta. Du hiu lun phin in hc
hay gp trong cc trng hp dch mng tim nhiu.
2. Phim chp tim phi: bng tim khng thay i khi
dch mng tim ch dy 1 n 2mm, tim to thng ch
thy trong cc trng hp c trn dch mng ngoi
tim s lng nhiu hn 250ml. Tim to vi du hiu
gin rng cung ca tnh mch ch trn, tnh mch
n (azygous) v gim ti mu phi gi cho chn
on trn dch mng ngoi tim.
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 t
413
c gi tr chn on sinh bnh hc ca cc loi

dch mng tim khc nhau.
a. Siu m hai bnh din cn tm cc du hiu sau:
Khong trng siu m gia l thnh v l tng
ca mng ngoi tim.
Hnh 23-1. Khong trng siu m khi c TDMT.

Tng vn ng ca cc thnh tim
Khi dch mng tim nhiu c th thy du hiu
qu tim lc lc trong khoang mng tim. y
chnh l c ch ca hin tng lun phin
in hc thy c trn in tm .
b. Kch c ca lng dch mng ngoi tim c th
xc nh thng qua khong cch gia hai l ca
khoang mng tim ( dy ca lng dch) v kiu
lan ta ca dch mng tim.
Lng dch t (di 100ml) tp trung ch yu
pha sau v dy thng di 1 cm.
Lng dch trung bnh (t 100 ti 500ml).
Lng dch thng bc xung quanh tim
nhng dy vn di 1 cm hoc ch c t
xung quanh cc mch mu ln.
Lng dch nhiu (hn 500ml) qu tim b y
ra sau vi lng dch bc xung quanh lan ln
ti c cc mch mu ln, c bn, mm v
pha trc ca tim. dy ca lng dch ln
hn 1cm mi v tr.
4. Cc xt nghim khc nh siu m qua thc qun,
chp ct lp vi tnh, cng hng t trng ht nhn
414
c th p dng trong mt vi trng hp c bit

nghin cu k hn v mng ngoi tim.
5. Xt nghim dch mng tim nhng trng hp dch
nhiu c chc ht dn lu. Cc xt nghim cn lm l
tm trc khun lao, sinh ha, vi khun v t bo hc.
a. Xt nghim dch s cho php xc nh mt s cc
nguyn nhn gy bnh gip ch rt nhiu cho vic
iu tr. Dch mng tim l mu thng gi c
chy mu mi vo trong khoang mng tim, tuy
nhin nu dch mu mu c th gp trong cc
trng hp bnh ung th, nhim khun hay vim
nhim. Nu dch c rt nhiu mu, cn gi mu
mu lm xt nghim kh mu. Nu c dy c
mu cc r rng th rt c th chc vo mch
mu hay bung tim. Dch m nguyn nhn l do
vi khun nhim trng. Dch dng chp thng
do tn thng hay tc ng ngc.
b. Cy dch c ch nh trong cc trng hp nghi
ng c ngun gc gy bnh l do nhim trng,
bao gm c nhim virus v nhim nm.
D. iu tr
1. Nguyn l chung: iu tr bao gm iu tr bnh
nguyn, iu tr cc bin ng v huyt ng do dch
mng tim gy ra.
2. iu tr chc dn lu dch mng ngoi tim qua
da:
a. Ch nh trong cc trng hp ung th, nhim
khun vi khun, nm.
b. Trong cc trng hp trn dch mng ngoi tim
s lng dch nhiu, d triu chng lm sng
khng in hnh cng vn c th ch nh chc
dn lu mng ngoi tim.
c. Chc dch mng ngoi tim khng nn ch nh
cc trng hp dch mng tim t.
415
3. iu tr thuc chng ng: cn hn ch s dng

thuc chng ng trong tuyt i a s cc trng
hp trn dch mng ngoi tim.
II. Trn dch mng ngoi tim c du hiu p tim
Khi dch mng tim s lng nhiu s dn n hin tng
tng p lc trong khoang mng ngoi tim v t s dn
n hn ch tm trng ca tim, qu trnh p tim bt u
xy ra. Bnh cnh p tim c xc nh bng cc triu
chng ca tng p lc trong cc bung tim, hn ch s gin
ra ca tm tht trong thi k tm trng v lm gim cung
lng tim.
A. Triu chng lm sng
1. Triu chng c nng:
Biu hin trn lm sng l bnh cnh ca cung lng
tim thp: bn chn, lo lng hoc kch thch, l m
ng g, c th xu i; gim th tch nc tiu; c
bit l biu hin kh th; cm gic chn p ngc; suy
sp, chn n v gy st trong cc trng hp trn
dch mng ngoi tim mn tnh.
a. Tng p lc ca tnh mch trung tm, th nhanh;
nhp tim nhanh; ting c mng ngoi tim; ting
tim m.
b. Cc triu chng ging nh suy tim phi: gan to,
tnh mch c ni, c th c trn dch mng phi
phi hp...
c. Tt huyt p v du hiu mch o c xc nh
l huyt p gim thp hn 10mmHg khi bnh
nhn ht vo su. C ch ca hin tng ny l
khi ht vo su s lm tng lng mu tnh mch
tr v tht phi, do xung quanh tim l dch p
khng cho tim n ra nn tht phi phi n v pha
tht tri lm gim s y ca tht tri, hu qu
cui cng l gim s tng mu ngoi bin gy
416
gim huyt p. Mch o khng c hiu trong

p tim, n c th gp trong bnh phi tc nghn,
nhi mu tht phi, nhi mu phi hoc hen ph
qun. S khng thy c mch o trn bnh nhn
c p tim nhng chc nng tht tri gim nhiu
v c tng p lc tm trng hoc trong thng
lin nh, h ch hay p tng vng tim.
1. Siu m tim qua thnh ngc: l phng php bt
buc phi thc hin khi nghi ng c p tim trn lm
sng. N s gip khng nh chn on khi thy c
nhiu dch trong khoang mng tim.
a. Siu m hai bnh din cn phn bit cc trng
hp c tng p lc tnh mch trung tm v h
huyt p nh nhi mu c tim tht phi, vim co
tht mng ngoi tim.
b. Cc du hiu ca p tim bao gm:
C dch trong khoang mng ngoi tim (biu
hin bng cc khong trng v siu m tim).
Du hiu p nh phi th tm trng thng
bt u t cui tm trng v thy r nht
mt ct cnh c tri trc ngang, di sn v
4 bung t mm. y l du hiu c nhy
cao tuy nhin c hiu ch l 82% vi gi
tr d bo dng tnh l 50%.
A
B
Hnh 23-2. Du hiu p tht phi (A) v p nh phi (B).
417
Du hiu p tht phi thng quan st thy ti

thnh trc tht phi v vng phu trong t
th nm nga. Trc ngang v trc dc cnh c
tri l hai mt ct thun li nht quan st
du hiu ny. Cn s dng siu m TM
khng nh du hiu ny. Du hiu p tht
phi n c trn siu m c th c trc biu
hin p tim trn lm sng.
Du hiu p nh tri.
Tng kch thc tht phi v gim kch thc
tht tri mt cch bt thng khi bnh nhn
ht vo su.
Thay i theo nhp th ca cc dng chy qua
van nh tht, tng bt thng dng chy qua
van ba l v gim bt thng dng chy qua
van hai l khi bnh nhn ht vo su. Bnh
thng khi ht vo dng chy qua van ba l
khng tng qu 7%, cn dng chy qua van
hai l khng gim qu 10%. Nu khi ht vo,
sng E qua van hai l gim hn 25% th rt
gi c biu hin p tim trn siu m.
Hnh 23-3. Thay i theo h hp th ht vo (INSP) v

th ra (EXP) ca ph Doppler xung dng chy qua van
hai l (pha trn) v van ba l (pha di) bnh nhn
TDMT p tim.
418
Gin tnh mch ch di. Tnh mch ch di

gin hn 50% khi bnh nhn ht vo su l
du hiu rt nhy (97%) nhng c hiu
ch l 40% trong chn on p tim.
Tht tri gi ph i.
2. Thng tim phi: quan trng cho chn on v ra
hng iu tr. N khng nh chn on p tim,
nh gi s cn tr huyt ng v xc nh cung
lng tim, theo di s tin trin ca huyt ng sau
khi c chc dn lu dch mng ngoi tim.
a. Cc du hiu huyt ng cn xc nh l p lc
nh phi, p lc mao mch phi bt, p lc tm
trng ca ng mch phi, p lc gia tm
trng ca tht phi, vi ch s bnh thng t 10
n 30mmHg. Trong khi th ra p lc mao mch
phi bt tng nh so vi p lc trong khoang
mng tim do hot ng n ra ca tht tri. Khi
bnh nhn ht vo p lc mao mch phi bt s
tng dn n chnh p rt thp, thm ch l m
gia h thng tnh mch phi v tht tri.
b. Khi chc ht dn lu mng ngoi tim cn xc
nh s gim ca hu ht cc p lc trong thng
tim (nh phi, tht phi tm trng, khoang mng
tim, p lc mao mch phi bt v p lc cui tm
trng ca tht tri).
C. iu tr
1. Nguyn l chung. Khi c chn on p tim th u
tin hng u l cn phi ht dn lu dch mng
ngoi tim. Phng php c th thc hin l chc ht
qua da vi gy t ti ch, phu thut dn lu (m
khoang mng tim di xng c, m ca s mng
tim v ct mng tim gn ton b), nong mng ngoi
tim qua da bng bng. Trong cc trng hp trn
419
dch mng ngoi tim sau m, phu thut dn lu

mng ngoi tim hay c ch nh; cc trng hp
khc vic chc ht qua da l phng php u tin
c la chn vi bc s c kinh nghim, theo di
huyt ng lin tc v c siu m kim tra. Soi lng
ngc di mn tng sng s gip hn ch ti a cc
bin chng ca th thut.
2. iu tr ni khoa: Bao gm bi ph dch, thuc
nng huyt p nu c tt p nh Norepinephrine,
Dobutamine, trnh dng cc thuc gin mch nh
Nitroglycerine, Nitroprusside...
3. iu tr chc dn lu qua da: C th thc hin
nhanh chng trong iu kin cp cu, t xm ln hn
cc phng php khc v ch cn s chun b ti
thiu. Bin chng c th gp l chc vo tim v cc
mch mu ln, chc vo phi, phn ng cng ph
v... C th t dn lu lin tc nhng nn trnh trong
cc trng hp b dy dch t hn 1cm, dch khu tr
hay c nhiu si fibrin dnh cht.
4. Nong mng ngoi tim bng bng qua da: Ch nn
p dng khi c nhiu kinh nghim v cc bnh
nhn ung th gy trn dch mng ngoi tim. Bng
nong c th s dng l bng ngoi bin nh
Mansfield kch c t 18 n 30mm hay bng Inoue.
Sau khi nong c th t dn lu mt thi gian
hon ton ht dch trong khoang mng ngoi tim.
5. Phu thut: Trong cc trng hp trn dch phc
tp, sau m hay ti pht dch th c th ch nh phu
thut dn lu dch mng ngoi tim.
a. M dn lu mng ngoi tim di xng c. C
th thc hin bng gy t ti ch. K thut thc
hin bng cch m mt ng rch nh di
420
xng c nhn thy mng ngoi tim trc tip,

sau s a ng dn lu vo khoang mng tim.
b. M ca s mng ngoi tim. Nhm mc ch to
ra s thng thng gia khoang mng tim v
mng phi tri. Kt qu ngay lp tc l lm gim
bt p lc trong khoang mng tim, hn na do
lm tng din tip xc nn s lm tng s hp thu
dch, t trnh c hin tng ti pht trn
dch mng tim. ng rch thng v tr ca
ngc tri.
c. Ct mng ngoi tim ton b hay gn ton b.
Phu tch mng ngoi tim v tr st tnh mch
ch di gn c honh cho n cc mch mu
ln. Phu thut ny c la chn trong cc
trng hp trn dch khu tr hay trn dch phi
hp vi co tht mng ngoi tim.
Ti liu tham kho
1.
2.
3.
4.
5.
Chetcuti S. Pericardial effusion. In: Marso SP, Griffin BP, Topol EJ,
Feigenbaum H. Pericardial disease. In:Feigenbaum H, ed.
Echocardiography, 5th ed. Baltimore: Williams & Wilkins, 1994.
Lorell BH, Grossman W. Profiles in constrictive pericarditis,
restrictive cardiomyopathy and cardiac tamponade in cardiac
catheterization. In: Bairn DS, Grossman W, eds. Angiography and
Lorell BH. Pericardial diseases. In: Braunwald E, ed. Heart disease:
a textbook of cardiovascular medicine. 5th ed. Philadelphia: WB
Saunders, 1997:1478-1534.
Pericardial heart disease. Curr Probl Cardiol 1988 (Aug);22.
421
6.
7.
422
Riem A, Scalia G. The pericardium, restrictive cardiomyopathy, and

diastolic flinction. In: Topol EJ, ed. Textbook of cardiovascular
medicine. Philadenphia: LippincottRaven Publishers, 1998:639-707.
SanFillpo AJ, Weyman AE. Pericardial disease. In: Weyman AE, ed.
Principles and practice ofechocardiography, 2nd ed. Philadelphia:
Lea & Febiger, 1994:1102-1134.
vim mng ngoi tim co tht
Vim mng ngoi tim co tht l hu qu ca qu trnh x

ho lm dy ln v dnh ca mng ngoi tim, l hu qu th pht
ca qu trnh vim mn tnh do nhiu nguyn nhn gy ra. Lc
ny qu tim c mt mng ngoi tim c nh cng nhc bao
bc, lm hn ch tim gin ra trong th tm trng, tng cc p
lc trong bung tim v lm mt tng ng gia p lc trong cc
bung tim v p lc ca lng ngc. S tng p lc trong bung
tim v gim s gin th tm trng ca tim lm hn ch s v
ca mu tnh mch ch v phi, gy ra du hiu ca suy tim
huyt ca c tim bn phi v bn tri. Rt nhiu cc trng hp
b b st chn on vim mng ngoi tim co tht v khng c
ngh n nn dn ti hu qu nng n cho bnh nhn.
I. Nguyn nhn
Cc nguyn nhn hay gp gy vim mng ngoi tim co tht
c lit k bng di y:
1. Khng r nguyn nhn (idiopathy).
2. Nhim trng: lao, vi khun, virus, nm v k sinh
trng. Trong s lao vn l nguyn nhn hng u
dn n vim mng ngoi tim co tht.
3. Chn thng (bao gm c phu thut tim) trong
cc trng hp phu thut tim c trn mu mng tim
l yu t thun li dn n vim mng ngoi tim co
tht sau ny.
4. Sau chy tia x iu tr. y l bin chng mun ca
x tr liu dn n vim co tht mng ngoi tim,
nhiu khi vi nm sau.
5. Vim nhim/ri lon min dch: thp tim, lupus ban
, sarcoidose.
6. Bnh ung th: v, phi, hch lympho, u sc t, u
trung biu m.
423

A. Triu chng c nng
1. Cc du hiu sm ca vim mng ngoi tim co tht
thng rt khng c hiu nh xu, mt, v gim kh
nng gng sc.
2. Dn dn sau bnh nhn thng c cc biu hin
ca suy tim tri nh kh th khi gng sc v kh th
v m.
3. Giai on nng ln ca bnh s thy cc du hiu
ging nh ca suy tim phi nh ph ngoi bin, cng
tc bng v c chng.
B. Triu chng thc th
1. Tnh mch c ni, phn hi gan tnh mch c dng
tnh gp gn nh tt c cc bnh nhn. Rt nhiu
cc trng hp c du hiu mch o ca Kussmaul
(ht su vo li lm gim cng to ca tnh mch
c). Du hiu ny c nhy cao nhng c hiu
thp do n c th gp trong cc trng hp ph i
tht phi v nhi mu c tim tht phi. Nguyn nhn
ca tt c cc hin tng ny l do s gin nhanh ca
tm tht trong thi k u tm trng.
2. Khm tim: thng thy ting tim m do mng ngoi
tim dy. Ting ng van hai l v ba l gn nh xut
hin cui th tm trng, gy ra ting T1 rt nh.
i khi c th nghe ting g ca mng ngoi tim
ngay u tm trng (60 n 120 ms sau ting T2).
Ting ny c ngun gc do s gin ra t ngt ca
tm tht sau mt giai on b mng tim cng hn ch
gin. Cn phn bit ting ny vi cc ting tm
trng sm khc nh ting T3, ting m van hai l.
Thng thng ting g mng ngoi tim c m sc cao
hn v n sm hn ting T3 v ting m van hai l
lun lun i km vi ting rung tm trng.
424
3. Khm phi thng thy gim r ro ph nang hai

y phi, nguyn nhn l do xung huyt phi hay
trn dch nh y mng phi hai bn. Trong trng
hp tr nhiu, c th thy ph phi vi cc ran m
xut hin.
4. Khm bng nhm pht hin cc du hiu ging nh
suy tim phi vi gan to. Trong cc trng hp nng
c th dn n x gan tim vi bng c chng r.
5. Khm ngoi bin pht hin ph hai chi di, sau
c th dn n ph ton thn.
khng nh chn on vim mng ngoi tim co tht th
vn khng c mt xt nghim no c coi l tiu chun
vng c. V vy, cn phi kt hp gia lm sng v cc xt
nghim cn lm sng.
1. in tm : Kinh in thy c du hiu in th
thp lan ta. Sng T thng dt, c th thy du hiu
dy nh tri v cng hay gp rung nh phi hp.
2. Chp tim phi:
a. Mng 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.
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
tim t c gi tr chn on nguyn nhn ca cc

loi dch mng tim khc nhau.
a. Siu m TM cn tm cc du hiu sau:
Thnh t do tht tri dt.
dy ca mng ngoi tim thng tng ln
v c th thy c du hiu vi ho ca mng
ngoi tim (mng ngoi tim dy v sng hn so
vi bnh thng). Tuy nhin vic o b dy
mng ngoi tim mt cch tht chnh xc bng
siu m TM nhiu khi cng gp kh khn.
Lc ny cc phng php chn on hnh nh
khc c nhiu u im hn nh CT Scanner,
MRI, siu m thc qun.
Van ng mch phi m sm. Do tng p lc
cui tm trng ca tht phi dn n nh
hng ti p lc ng mch phi.
Vn ng nghch thng ca vch lin nh
trong th tm thu.
b. Siu m 2D: cn c th thy thm mt s du
hiu khc nh:
Vch lin tht ny ln trong th tm trng:
thy mt ct 4 bung tim t mm.
Gin tnh mch ch di.
Gim gc hp gia nh tri v tht tri. Gc
ny b nhn hn so vi bnh thng do s vn
ng bt thng ca tm tht v tm nh.
c. Siu m Doppler: Siu m TM v 2D cho php
gi vim mng ngoi tim co tht. Tuy nhin cc
du hiu va nu ch c nhy v c hiu
thp. Trong khi siu m Doppler l phng
php cho php nh gi tt nht chc nng tm
trng ca tm tht. C th l:
S thay i theo h hp ca dng chy qua
van hai l v van ba l. Khi bnh nhn ht vo
su, p lc trong lng ngc gim, p lc ny
426
ko theo p lc trong tnh mch phi gim

nhng khng lm thay i p lc tht tri.
Chnh do nguyn nhn ny nn trong giai
on ht vo, tc dng chy qua van hai l
tng ln cn tc dng chy qua van ba l
gim i: Tc sng E qua van hai l tng
ln khong 33%, cn tc qua van ba l li
gim i.
Dng chy trong tnh mch phi gim trong
giai on th ra.
C s thay i theo h hp ca dng chy
trong tnh mch gan.
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
4. Thng tim: y l phng php quan trng chn

on phn bit vim co tht mng ngoi tim v bnh
c tim hn ch.
a. p lc tm nh: sng nh s c dng ch W, do
sng a chim u th.
b. p lc tm tht:
p lc tht c biu hin b nho-cao
nguyn (dip-plateau), l mt du hiu kinh
in ca vim mng ngoi tim co tht.
Hnh 24-2. Du hiu b nho cao nguyn biu hin r

hn sau mt nht bp ngoi tm thu.
p lc cui tm trng ca hai tm tht
khng ch tng cao m cn cn bng gia tht
tri v tht phi, chnh p cui tm trng
gia hai tht nh hn 5mmHg vi p lc cui
tm trng tht phi ln hn 1/3 p lc tm
428
thu ca tht phi. y chnh l du hiu kinh

in chn on phn bit gia vim mng
ngoi tim co tht v bnh c tim hn ch.
IV. iu tr
A. iu tr ni khoa
Cc bnh nhn giai on u vi mc kh th
NYHA 1 c th iu tr ni khoa bo tn bng li tiu v
ch n hn ch mui. Ngoi ra iu tr ni khoa cng
c ch nh cc bnh nhn qu nng khng cn ch
nh m hay khng chp nhn nguy c ca cuc m.
B. iu tr phu thut
1. Phu thut ct mng ngoi tim l phu thut c
la chn. Hn 90% c ci thin triu chng ng k
sau phu thut.
2. T l t vong trong v ngay sau m tng i cao (5
n 20%) l mt yu t cn thn trng cn nhc.
Cng chnh v nguyn nhn ny cc phu thut vin
thng quyt nh m sm cho cc bnh nhn ch
khng i n khi th trng bnh nhn b suy sp
do bnh din bin ko di.
Ti liu tham kho
1.
2.
3.
4.
5.
Brockington GM, Zebede J, Pandian NG. Constrictive pericarditis.

In: Shabetaj R, ed. Diseases of the pericardium. Cardiol Clin
1990;8(4):6454561.
Fewler N. Constrictive pericarditis: its history and current status.
Clin Cardiol 1995;18:841-B50.
Klein AL, et at. Differentiation of constrictive pericarditis from
restrictive
cardiomyopathy
by
Doppler
transesophageal
echocardiographic measurements of respiratory variations in
pulmonary venous flows. J Am Coll Cardiol 1993;22:1935-1943.
Klein AL, Cohen GI. Doppler echocardiographic assessment of
constrictive pericarditis, cardiac amyloidosis, and cardiac
tamponade. Cleveland Clin J Med 1992;59:27&290.
Oh J, et at. Diagnostic role of Doppler echocardiography in
constrictive pericarditis. J Am Coll Cardiol 1994;23:154-162.
429
6.
Braunwald E, Lorell BH. Pericardial diseases. In: Braunwald E, ed.

Heart disease: a textbook of cardiovascular medicine, 5th ed.
Philadelphia: WBSaunders, 1997:1496-1505.
7. Feigenbaum H. Pericardial disease-constrictive pericarditis. In:
Feigenbaum H, ed. Echocardiography. Baltimore: Williams &
Wilkins, 1994:577-583.
8. Grossman W, Lorell BH. Profiles in constrictive pericarditis,
restrictive cardiomyopathy, and cardiac tamponade. In: Balm DS,
Grossman W, eds. Cardiac catheterization, angiography, and
intervention. Baltimore: Williams & Wilkins, 1996:801-821.
9. Topol EJ, Klein AL, Scalia GM. Diseases of the pericardium,
restrictive cardiomyopathy, and diastolic dysfunction. In: Topol EJ,
ed. Comprehensive cardiovascular medicine. Philadelphia:
10. Reginelli JP, Grady TA. Constrictive pericarditis. In: Marso SP,
Philadelphia: Lippincott-Raven, 2000.
430
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.
Cc du hiu lm sng ca TPM thay i theo cung lng tim,
cn bng nc in gii v trong hu ht cc trng hp l s
thay i trao i kh phi.
Ri lon chc nng tim phi th pht sau suy tim tri, cc
bnh l van tim, bnh tim bm sinh u khng nm trong nh
ngha ca TPM. Tnh mch phi b nghn hp l mt nguyn
nhn ca TPM. Bnh tnh mch phi tc nghn thng c xem
l nm trong bnh cnh 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
TPM thng gp nht nhng ngi n ng ht thuc l,

tuy nhin t l ny ph n cng ang tng ln, do ph n ht
thuc ngy cng nhiu.
Bng 25-1. Cc nguyn nhn ca TPM phn loi theo c
ch tng p ng mch phi.
1. Co mch do gim xy mu:
a. Vim ph qun mn v kh ph thng, x nang phi.
b. Gim thng kh phi mn.
Bo ph.
Kh th khi ng.
Bnh thn kinh c.
Ri lon chc nng thnh ngc.
c. Bnh m yu mn tnh vng ni (bnh Monge).
2. Tc nghn h thng mch mu phi:
a. Thuyn tc ng mch phi, nhim trng k sinh trng,
tc nghn mch mu phi do u.
b. Tng p ng mch phi nguyn pht.
c. Bnh tc tnh mch phi / Gin mao mch phi.
d. Bnh hng cu hnh lim / Tc nghn tu.
e. Vim trung tht x ho, u trung tht.
f. Vim mch mu phi do bnh h thng:
Bnh collagen mch.
Bnh phi do thuc.
Vim hoi t v nt ng mch.
3. Bnh nhu m phi c mt din tch ti mu:
a. Trn kh hnh bng, bnh thiu anpha1 antiproteinase.
b. Gin ph qun lan to, x nang phi.
c. Bnh m k lan to.
Bnh bi phi.
Sarcoid, bnh x phi t pht, chng m bo huyt X.
Lao phi, nhim trng nm mn tnh.
Hi chng suy gim h hp ngi ln.
Bnh collagen mch mu (bnh phi t min).
Vim phi qu mn cm.
432
T nm 1950 - 1964 ti khoa ni bnh vin Bch Mai c

200 trng hp tm ph mn (ng Vn Chung). Bnh TPM
chim 7% bnh phi ti khoa h hp bnh vin Bch Mai (Chu
Vn - 1986).
A. Bnh phi tc nghn mn tnh (COPD)
1. Cc bnh phi tc nghn mn tnh (BPTNMT) gy ra
TPM qua mt vi c ch c tc ng qua li bao
gm: gim thng kh phi, gim xy mu do t l
thng kh/ti mu (V/Q) khng tng ng nhau, v
gim din tch b mt c ti mu.
a. Bnh nhn vi gim xy mu v gim thng kh
ph nang l chnh thng c chng a hng cu,
ph, v sm c biu hin TPM, TPM xanh.
b. Bnh nhn vi triu chng chnh l kh th khi
gng sc thng c gim thng kh t hn v
gim xy mu lc ngh t hn v vy thng c
biu hin TPM mun hn, TPM hng.
2. Mt vi s khc bit gia TPM xanh v TPM hng c
th lin quan n cch thc thng kh phi. Bnh
nhn c thng kh phi thp c v thch ng vi loi
TPM xanh, trong khi loi TPM hng vn gi c pH
v nng kh mu ng mch bnh thng. Mt gi
thit khc l nhng ngi b TPM xanh thng do
vim ph qun v nhm TPM hng thng do gin
ph nang n thun hn.
3. Khm thc th tt c cc th BPTNMT u thy
tng ng knh lng ngc, c honh h thp, g
vang, r ro ph nang gim vi m th kh kh th
th ra, ting tim nghe m, tnh mch c ni trong th
th ra v gan to. Gan to v ph chn l du hiu
ng dch v suy tim phi.
4. Xquang lng ngc c th thy cc c im ca kh
ph thng nh hai trng phi sng, tng ng knh
trc sau ca lng ngc v cc c honh nm phng
433
5. Thm d chc nng phi cho thy tng th tch cn

(RV) v dung tch phi ton phn (TLC); gim mnh
dung tch sng (VC) v kh gim cc t l lu lng
th ra (FEV1, FEF).
6. Xt nghim v kh mu ng mch thng l bnh
thng nhng trng hp bnh nh v i vi
nhng trng hp nng th PaO2 gim, PaCO2 tng v
pH gim. Cc bnh nhn TPM thng c PaO2 thp
di 55 mmHg. T l V/Q khng tng xng v
gim thng kh ph nang, c hai gp phn lm gim
xy mu. PaO2 lc ngh khong 45 mmHg chng t
gim thng kh ph nang r.
7. Hen l mt dng BPTNMT nhng him khi dn n
TPM, c l do hen thng ch l bnh tc nghn
ng h hp tng lc.
8. TPM trong BPTNMT c lin quan n mc nng
ca ri lon chc nng phi v TAMP l biu hin
ca bnh. Hn ch kh nng gng sc trong
BPTNMT thng do hn ch kh nng thng kh phi
m khng lin quan n d tr tim mc d cc bnh
nhn ngi nhiu l t th lm gim kh nng gng
sc. Khng c mt thm d n c no v phi nh
o cc dung tch v th tch chc nng ca phi, kh
nng khuych tn CO (DL CO), cc nng kh mu
hay Xquang phi l c gi tr d bo nhiu v TPM v
nhng bt thng nh gim din tch b mt trao i
kh v co mch do gim xy t chc xy ra c lp
vi p lc ng mch phi.
B. Bnh m k phi lan to
1. Bnh nhn thng kh th, th nhanh, khng c kh
nng gng sc v i khi c ngn tay, chn hnh di
434
2.
3.
4.
5.
trng. Nghe phi thng c ran m, ran n v c th

nghe thy c trong th ht vo.
Phim Xquang phi thng c cc tn thng nh
mng ph huyt qun m, tn thng dng li-nt
hoc x ho lan to. Cc du hiu ny khng phi lc
no cng c m s xut hin lin quan cht ch vi
cc tn thng sinh l phi. Trong mt s bnh nh
vim phi k bc vy, chng ta c th thy hnh ph
nang y cng vi hnh ph qun y kh.
Sinh thit phi l cn thit xc nh nguyn nhn
chnh xc ca bnh, nhng khng phi lc no sinh
thit cng em li kt qu ng. Sinh thit phi qua
ph qun c th chn on c mt s bnh m k
phi nh bnh sacoide v ra ph qun ph nang c
th a ra chn on trong nhiu trng hp.
Cc xt nghim chc nng phi cho thy tnh trng
tc nghn phi vi gim dung tch phi, gim n
hi phi v gim kh nng khuych tn kh cc
ng th khng tc nghn. Dung tch sng gim, v
t l th tch th ra ti a trong mt giy vi dung
tch sng ti a thng di 80%. Lc u, PaO2
gim khi gng sc nhng vn gi c mc bnh
thng lc ngh bng cch tng thng kh. Khi bnh
tin trin nng hn, PaO2 s thp trong c lc ngh.
Tin trin v tin lng bnh m k phi ph thuc
vo cn nguyn bnh v nhiu yu t khc ca bnh.
Biu hin ca TPM trong cc bnh m k phi
thng l cc ri lon chc nng phi mc nng
hn, c l c lin quan n mch mu (nh lupus ban
h thng) v TPM cng c th khng xy ra ngay
c khi bnh giai on cui.
435
C. Cc hi chng gim thng kh

1. Mt s d tt (nh g vo ct sng) c th lm suy
gim v hn ch thng kh phi dn n gim thng
kh chung ca ph nang v gim xy ph nang.
2. Bo ph nhiu c th c thng kh phi km, tm, a
hng cu v bun ng (khng c s tht nght phi)
thng c gi l Hi chng Pickwick. Bnh nhn
bun ng ngy, au u vo bui sng, ri lon v
nhn cch c nhn v c nhng giai on kh th
trong khi ng kt hp vi mt ng, ngy to, gim xy
mu v tng CO2 mu do tc nghn ng h hp
trn (do li, a-mi-an to hoc sp thnh kh qun).
3. Mt s bt thng v no nh bt thng Arnold Chiari cng c th lm suy gim trung tm h hp v
gim thng kh phi nguyn pht. Cc bnh thn kinh
c nh hi chng sau vim tu xm, hi chng
Guillain-Barre mn tnh c th dn n TPM v suy
tim phi.
4. Chn on gim thng kh c xc nh qua phn
tch kh mu, p ng thng kh gim sau th nghim
ht CO2, cc thm d v gim thng kh phi hoc cc
thm d v gic ng. Ri lon thng kh trong khi
ng l mt biu hin kh thng gp nhiu hi
chng gim thng kh.
5. Trong tt c cc trng hp gim thng kh, nguyn
nhn chnh lm tng p lc ng mch phi l co
mch do gim xy t chc, mt p ng ca cc tiu
ng mch phi i vi gim xy ph nang. Tnh
trng toan h hp, i km vi gim thng kh, c th
lm tng p ng co mch i vi gim xy t chc.
D. Cc bnh mch mu phi
1. Tm ph mn l hu qu ca mt vi bnh mch mu
phi. Tng p ng mch phi tin pht v thuyn tc
ng mch phi l nhng bnh cnh hay gp.
436
2. Bnh t bo hnh lim, do c hemoglobin SS hoc SC,

c th gy ra tm ph mn sau mt thi gian di b
nhi mu phi nh, khu tr v thuyn tc ng mch
phi do m hay huyt khi.
3. Tc tnh mch phi l bnh him gp, thng c tng
p ng mch phi v thm nhim phi nhiu ni,
p ng tt vi iu tr bng thuc gim min dch.
4. X gan thng c km vi gin cc mch mu phi.
5. Nhim HIV cng l nguyn nhn gy bnh mch
mu phi, ging vi TAMP tin pht.
6. Bnh collagen mch mu c th dn n TPM do
vim mch tin pht cng nh do x ho t chc k
lan to. Bnh x cng b, lupus ban h thng v
vim khp dng thp l cc bnh collagen mch mu
thng gy ra vim tiu ng mch phi nht. Bnh
nhn b lupus ban h thng hoc b vim khp
dng thp thng c bnh phi k tin pht.
II. Sinh l bnh
ng mch phi c lu lng cao, p lc dng chy thp,
sc cn mch mu thp vi chc nng cung cp mu cho trao i
kh v c 3 c im: (1) thnh mng vi trng lc c lc ngh
thp, (2) ngi ln, lc ngh c s iu chnh nh vn mch
phi nh h thng thn kinh t ng, (3) c nhiu tiu ng
mch v mao mch ph nang khng tham gia vn chuyn mu
lc ngh v c th hot ng li khi cn thit m rng mng
li mao mch phi v nh vy lm gim sc cn mch mu
phi. Bnh thng, p lc ng mch phi trung bnh khong 12
- 17 mmHg, khi p lc ng mch phi lc ngh ln hn 20
mmHg th cn phi ngh ti c tng p ng mch phi. Sc cn
ca h mch mu phi tng v TAMP l nhng c ch bnh
sinh chnh trong tt c cc trng hp TPM.
A. C ch tng p ng mch phi
1. Suy h hp tng phn gy thiu xy mu, thiu xy
t chc, lm co tht cc tiu ng mch phi v t
dn n tng p lc ng mch phi. Nguyn nhn
quan trng nht gy co cc tiu ng mch phi l
thiu xy cc ph nang. C ch co mch do thiu
xy t chc cn cha c r. Ngi ta cho l c th
437
2. Mc co mch do gim xy t chc ph thuc ch

yu vo PaO2 ph nang v khi PaO2 ph nang < 55
mmHg th p lc ng mch phi tng rt nhanh. Khi
p lc ng mch phi ln hn 40 mmHg th bo
ho xy ng mch c th thp hn 75%.
3. Suy h hp ton b s lm tr CO2 v gy toan h
hp. Toan mu lm co tht cc tnh mch phi v
phi hp vi co tht tiu ng mch phi do thiu
xy t chc s lm tng p lc ng mch phi.
Suy h hp
Suy h hp tng phn
Suy h hp tng phn
Thiu xy mu
Tng CO2
Thiu xy t chc
Toan mu
Co tht tiu ng mch phi
Co tht tiu tnh mch phi
Tng p ng mch phi
Ph i tht phi
Suy tim phi
Hnh 25-1. S v c ch tng p lc ng mch phi v suy

tim phi trong TPM.
438
4. Mt s c ch khc lm tng p lc ng mch phi

nh tng lu lng tim do tng chuyn ho, hot
ng gng sc, nhim khun phi cp tnh...; Tng
qunh ca mu: a hng cu th pht; Nhp tim
nhanh do thiu xy hoc do suy tim...
B. C ch gy suy tim: Tng p lc ng mch phi l
tr lc chnh lm tng cng ca tim phi. Tnh trng
thiu xy, tng th tch, tng cung lng tim cng gp
phn lm tng cng ca tim. Tng cng ca tim ko di
lm ph i tht phi, sau gin tht phi v cui cng
l suy tim phi.
A. Triu chng c nng
1. Biu hin lm sng ca tm ph mn thng b che
du bi cc triu chng ca bnh phi thc th c
sn. Cn phi xc nh loi bnh v mc nng ca
cc bnh phi sau mi xem xt bnh nhn c b
tm ph mn khng.
2. Bnh nhn c th c nhng t ph chn, au ngc
khng in hnh, kh th khi gng sc, tm ngoi vi
lin quan n gng sc.
a. au ngc c th do lng ngc b cng phng (au
c xng) hoc c th lin quan n thiu mu c
tim tht phi.
b. Ho v cm gic d b mt mi l cc triu chng
ph bin.
c. Mt s bnh nhn c biu hin gim thng kh
ban m, kh th khi ng v c th c thay i
nhn cch c nhn, tng huyt p nh v au u.
d. Th ngn l triu chng lun c cc bnh nhn
tm ph mn. Cn phi xem xt mc hot
ng no lm cho bnh nhn kh th v bnh
nhn thng gim hot ng trnh kh th.
439
e. i khi c au tc vng bng do mu gan.

B. Triu chng thc th
1. Hai phi cng phng c tnh cht mn tnh nn lng
ngc thng bin dng hnh thng v g vng
ngc hai bn u thy rt vang. Ting tim thng hi
m do hin tng gin ph nang ca phi.
2. Cc du hiu sm nht l cc du hiu c lin quan
n tng p lc ng mch phi ko di.
a. Du hiu nhy nht ca tng p ng mch phi
l thnh phn phi ca ting T2 vang mnh, c th
nghe c v tr van ng mch phi v
vng tht phi trn xng c.
b. Khi p lc ng mch phi tng rt cao, c th c
ting thi tm trng van ng mch phi v
ting thi tm thu van ba l do h phi v h
van ba l, ng thi cng c th nghe thy ting
tng mu tm thu v ting nga phi T3 tht phi.
3. Khi c suy tim phi bnh nhn thng c tim to,
tnh mch c ni, gan to v ph ngoi bin. Du
hiu tnh mch c ni c trong th ht vo v th ra l
du hiu ch im chc chn c suy tim phi. Trong
cc trng hp suy tim phi nng, bnh nhn c th
c ph ton thn v trn dch c mng phi, mng
tim, c chng
4. Cc u chi c th m do gin mch ngoi bin v
tng CO2 mu; hoc cng c th tm do lu lng
mu thp hoc gim xy mu.
5. Nhng bnh nhn c TPM lu c th b tm en nh
ngi en, mt li v do tng sinh ca cc mch
mu mng tip hp trng nh mt ch v thng c
ngn tay, ngn chn di trng.
A. in tm
440
1. in tm ca bnh nhn TPM b nh hng bi

nhiu yu t nh p lc ng mch phi, s quay v
thay i v tr ca tim do hai phi cng phng, thay
i kh mu ng mch, thiu mu c tim v cc ri
lon chuyn ho. V vy gi tr ca in tm trong
chn on bnh tm ph mn cn ph thuc vo bnh
phi nn v cc bin chng ca n.
2. Hnh thi ph i tht phi thng gp nhng
trng hp c tc hp h mch mu phi. Hai phn
ba bnh nhn b bnh phi tc nghn mn tnh c ph
i tht phi khi m t thi nhng trn in tm li
khng c hnh nh ca tht phi ph i. Khi khng
c hnh nh ph i tht phi in hnh th vic chn
on phi da vo mt lot cc du hiu in tm
nh rS V5, V6; qR aVR; v P ph. Sng P cao
nhn DII v aVF chng t dy nh phi. Bloc nhnh
phi gp 15% bnh nhn TPM.
Hnh 25-2. in tm ca mt bnh nhn b TPM.

3. Ri lon nhp khng phi lun c bnh nhn TPM
khng bin chng, nhng khi c ri lon nhp th hu
441
nh l ri lon nhp trn tht v chng t c bt

thng v kh mu, h kali mu hoc dng qu liu
cc thuc nh Digitalis, Theophyllin v cc thuc
kch thch giao cm. Cn tim nhanh nh a
thng gp bnh nhn b bnh phi tc nghn mn
tnh v iu tr tt nht l kim sot bnh phi nn
hn l dng cc thuc chng lon nhp. Bnh nhn
TPM khi ri lon nhp tht thng c tin lng
xu v t l t vong cao.
B. Xquang tim phi
1. Phn ln cc bnh gy ra TPM u c hnh nh hai
trng phi sng hn bnh thng trn phim Xquang
lng ngc v v vy vic chn on tng p ng
mch phi trn phim s gp kh khn hn.
2. Tht phi gin c th kh xc nh c vi bng tim
trn phim thng nm thng ng do kh ph thng
v so snh vi cc phim c c th gip ch cho vic
chn on. Hu ht bnh nhn TPM u c tht phi
v ng mch phi gin to, nhng tng p ng mch
phi thng c trc gin tht phi.
3. Mt ch im v tng p ng mch phi l o ng
knh ca ng mch phi phi v tri. ng mch
phi phi gin khi c ng knh ngang > 16mm v
i vi ng mch phi tri l > 18mm. Du hiu ny
gp 43 - 46% bnh nhn bit c tng p ng
mch phi, nhng nhy v c hiu tht s ca
php o ny vn cha c xc nh.
C. Siu m tim: rt hu ch bnh nhn b TPM.
1. Siu m tim kiu TM cho php xc nh tht phi
gin v cng c th xc nh c tng p ng mch
phi qua hnh thi vn ng ca van ng mch phi
(mt sng a).
2. Siu m tim 2 bnh din c th nhn thy c ton
b bung tht phi, o c dy thnh tht cng
442
nh xc nh c nhng thay i ca vch lin tht

do ph i tht phi. V tht phi c hnh dng khng
i xng nn vic o th tch tht phi rt kh. Tng
gnh p lc tht phi thng c xc nh bng ph
i thnh trc tht phi v bung tht phi gin.
Trng hp TPM nng c th thy ph i vch lin
tht v di ng nghch thng ca vch vo tht tri.
Tng gnh th tch tht phi thng lm gin bung
tht v c vch lin tht di ng nghch thng.
3. Siu m Doppler tim: l phng php thm d
huyt ng khng chy mu tin dng xc nh
tng p ng mch phi v cung lng tim. Phng
php ny kh chun xc khi p lc ng mch phi >
30mmHg v km chun xc hn i vi p lc ng
mch phi thp hn mc ny. Siu m Doppler cng
hu ch theo di hiu qu lu di ca mt tr liu
bng thuc.
D. Thng tim phi
1. Thng tim phi ch c gi tr xc nh p lc
ng mch phi, p lc ng mch phi bt v cung
lng tim. Bnh nhn TPM c p lc ng mch phi
trung bnh cao hn nhiu so vi p lc ng mch
phi bt, khng ging vi suy tim tri hay hp van hai
l ch c s chnh lch nh gia p lc ng mch
phi trung bnh v p lc phi bt.
2. p lc ng mch phi trung bnh rt cao trong
cc trng hp bnh mch mu phi tc nghn nhng
ch tng nh cc bnh m phi k. Trong giai on
u ca bnh TPM, p lc ng mch phi ch t 25 30mmHg v khi c suy tim phi thng tng trn
40mmHg.
E. Kh mu ng mch
1. Giai on u: suy h hp tng phn, p sut xy
mu ng mch (PaO2) thng gim, nht l khi
443
2. Giai on suy h hp ton b: PaO2 gim nhiu <

70mmHg; PaCO2 tng cao 50 - 80mmHg; SaO2 gim
<75%; pH gim di 7,2.
F. Cng thc mu: thng thy biu hin ca a hng
cu v tng hematocrit.
V. Chn on
A. Chn on xc nh TPM da vo:
1. Tin s mc bnh phi mn tnh hoc bnh ca h
thng c xng lng ngc.
2. Hi chng suy tim phi.
3. in tm : P ph, dy tht phi, tng gnh tht
phi.
4. Phim Xquang lng ngc: bng tim to, cung ng
mch phi ni, cc ng mch phi phi, tri gin.
5. Thm d 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
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.
VI. Tin trin v tin lng
Bnh phi mn tnh tin trin t t, chm chp, dn lm
tn thng n chc nng h hp ca phi dn n suy gim
chc nng phi tng phn, ri suy gim chc nng phi ton b
v cui cng l tng p ng mch phi, ri suy tim phi.
S tin trin ca bnh ph thuc vo ngi bnh c c
pht hin bnh sm, c 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
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
mn. c bit dng xy liu php lin tc c th lm
gim t l t vong r hn dng xy liu php ngt
qung vo ban m.
3. xy liu php cng lm ci thin chc nng tm thn
kinh ca bnh nhn TPM v s ci thin ny thng
c c sau mt thng dng xy.
4. V sao xy liu php lm ci thin tnh trng sng
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
6. xy liu php ko di ban m c vai tr quan trng

cc bnh nhn c ri lon bo ho xy mu khi
ng. Bnh nhn gim bo ho xy khi gng sc
ch cn cung cp b sung xy khi gng sc v hiu
qu ca liu php xy ko di cha c chng minh
trong trng hp ny.
B. Thuc li tiu v tr tim
1. Thuc li tiu loi c ch men anhydrase carbonic
nh Diamox, hoc li tiu nh Aldacton t ra c ch
bnh nhn TPM, liu 10 mg/kg cn nng cho tng
t 3-4 ngy. Khng nn dng thuc li tiu khi pH
mu < 7,30.
2. Thuc tr tim nhm Digitalis: Tc dng ca cc
thuc ny ln chc nng tht phi rt phc tp. Cc
thuc Digitalis lm tng kh nng co bp ca c tim
phi nhng ng thi cng lm tng co tht mch
mu phi, lm gim s tr v ca mu tnh mch
ngoi bin do lm tng th tch d tr ca tnh mch
v v vy c th nh hng n cung lng tim.
a. Ch nn dng tr tim nhm Digitalis bnh nhn
TPM khi c suy tim tri ng thi. Mathur v
cng s theo di tc dng ca Digoxin liu
0,25mg/ ngy cc bnh nhn TPM trong 8 tun
th nhn thy Digoxin khng lm ci thin phn
s tng mu tht phi khi phn s tng mu tht
tri bnh thng; ch cc bnh nhn c phn s
tng mu tht tri gim t u th Digoxin c lm
ci thin phn s tng mu tht phi. S dng
thuc tr tim phi rt thn trng, Digitalis c th
gy ri lon nhp tim, ch nn s dng khi suy tim
cn b tr v liu nh.
447
b. Khng dng khi suy tim mt b. Thuc li tiu v

Digitalis trong trng hp ny khng quan trng
bng cc bin php ci thin thng kh ph nang
nh xy liu php. Mc d cc thuc tr tim
nhm Digitalis khng phi l thuc iu tr thng
thng ca bnh tm ph mn, nhng mt nghin
cu cho thy dng Digoxin ng tnh mch
trong nhng t suy h hp cp bnh nhn TPM
c th lm tng sc cng ca c honh v tng
cung lng tim.
3. Cc thuc gin ph qun:
a. Theophylline: y l thuc c tc dng lm gin
ph qun c s dng nhiu nht. Tuy nhin,
Theophylline c tc dng lm gim kh th ch
yu nhng bnh nhn b bnh ng th tc
nghn. Aminophylline dng ng tnh mch c
th lm gim nhanh p lc ng mch phi v
lm tng phn s tng mu ca c tht phi v
tht tri. Ung Theophylline ko di bnh nhn
TPM cng c tc dng tt ln chc nng tht
phi. C nghin cu cho thy bnh nhn dng
Theophylline trong 4 thng lm ci thin r
phn s tng mu tht phi. Phn s tng mu
tht tri cng tng ln r. Cc nghin cu in vivo
cho thy Theophylline v Aminophylline u lm
gim hu gnh (do lm gim sc cn mch mu
phi v mch mu h thng) v lm tng sc co
c tim, v vy, mt tr liu Theophylline ko di
c th lm tng r chc nng bm mu ca hai
tht. Tuy nhin, Theophylline khng lm gim
hin tng co mch mu phi do thiu xy t
chc.
b. Cc thuc kch thch th th -adrenergic nh
Salbutamol, Terbutaline, Pirbuterol c s dng
nh thuc lm gin ph qun v c tc dng tt
448
4. Cc thuc gin mch:

a. Rt kh khn khi nh gi tc dng ca cc thuc
gin mch trong iu tr TPM v nhng thay i
huyt ng trong iu tr rt phc tp. Mc ch
ca vic dng cc thuc gin mch l lm gim
p lc ng mch phi ang tng cao bnh
nhn TPM. Gin mch lm gim sc cn ca
mch mu nhng b li l cung lng tim tng v
cui cng l p lc ng mch phi khng thay
i. C th gin mch l tc dng c li (v lm
tng s vn chuyn xy) mc d tng p ng
mch phi khng h bt. Cc thuc lm gim s
tr v ca mu tnh mch (nhm Nitrate) hoc
cc thuc lm gim chc nng tht phi
(Nifedipine) c th lm gim bt tng p ng
mch phi do lm gim cung lng tim. Cc
nghin cu theo di ko di cho thy cn thit
phi nh gi cc p ng v mt huyt ng khi
dng cc thuc gin mch v cn nh gi tc
dng ln t l sng cn ca tng loi thuc khc
nhau.
b. Dng cc thuc gin mch c th c tc dng ph
nh h huyt p v gim bo ho xy mu
ng mch. Phn ln cc thuc gin mch c tc
449
dng mnh ln mch mu h thng hn l mch

mu phi. cc bnh nhn c tng p ng mch
phi nhiu v cung lng tim bn phi gim th
co mch h thng nh l mt c ch bo v chnh
duy tr huyt p ng mch h thng. cc
bnh nhn ny, gin mch mu h thng chn lc
c th lm gim huyt p v khi u cho vng
xon bnh l ca suy tht phi (do gim lu
lng mch vnh phi) v tru mch. Cc thuc
gin mch cng c th lm gim xy mu ng
mch do trng lc mch mu phi b ph v lm
mt cn bng thng kh - ti mu ca phi.
c. Kt qu nghin cu iu tr TPM vi cc thuc
gin mch ny u khng c kt lun r rng v
khng c mt thuc no trong cc thuc trn
c khuyn co s dng thng quy trong thc
hnh lm sng. Cc nitrate c v c tc dng tt
nhng thc cht u khng c vai tr r rng v
lm gim nng xy mu ng mch v lm
gim c ch s tim.
d. iu tr TPM vi cc thuc gin mch cn phi
xem xt v cn nhc k v ch dng khi cc iu
tr thng quy v xy liu php khng lm ci
thin tnh trng suy tim phi v tng p ng
mch phi. V cc thuc ny c nhiu tc dng
ph nn hiu qu ca chng v mt huyt ng v
vn chuyn xy cn c nh gi cn thn,
thng sau 4 - 5 thng iu tr v tt nht l nh
gi qua thng tim phi.
5. Khng sinh: Vai tr khng sinh trong iu tr t bi
nhim rt quan trng. Thuc khng sinh nn dng
loi c ph khng khun rng, dng ko di v liu
lng cao trong 2-3 tun (tim, ung, kh dung).
Nhiu tc gi ch trng dng khng sinh ngoi t
bi nhim phng nht l cho ung khng sinh
450
vo nhng thng ma lnh (mi t ung 10 ngy

trong 3 thng).
6. Corticoid: C hiu qu trong iu tr t cp: dng
Prednisolon ung, Hydrocortison kh dung,
Depersolon hay Solu-Medron tim tnh mch.
Corticoid va c tc dng chng vim, chng d ng
v lm gim tit dch.
7. Chch mu: t dng, ch nh khi hematocrit ln hn
65%. Ly khong 300ml mu mi ln. Sau chch
mu, p lc ng mch phi trung bnh v sc cn
mch mu phi thng gim, cung lng tim thay
i khng ng k, s vn chuyn xy gim nhiu v
s tiu th xy lc ngh c th tng nh hoc khng
thay i. Chch mu c tc dng r rt i vi kh
nng gng sc ca bnh nhn TPM. Nhiu nghin
cu cho thy kh nng gng sc, thi gian gng sc
v mc tiu th xy ti a u tng ln ng k
sau khi chch mu cc bnh nhn TPM c a huyt
cu. Chch mu lm gim hematocrit cn khong
50% c tc dng tt v mt huyt ng trong thi
gian ngn, nht l khi c gng sc. Tuy nhin, tc
dng lu di ca vic chch mu lp li nhiu ln vn
cha c xc nh.
8. Ch d n ung v ngh ngi: Nhng ngi b bnh
phi mn tnh khi xut hin kh th th nn lm
vic nh, khng phi gng sc. Khi c du hiu
suy tim phi th phi ngh vic hon ton. n t mui.
9. Khng dng cc thuc sau: Morphin, gardenal v
cc thuc an thn khc khng c dng cho cc
bnh nhn TPM v s gy suy trung tm h hp.
10. Tp th: Rt quan trng, lm tng gin n ca
phi v lng ngc, tng thng kh ph nang, nht l
tp th bng c honh.
11. Loi b cc yu t kch thch: Thuc lo, thuc l...
451
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 ng tc
ng mch phi ln.
Ti liu tham kho
1.
2.
3.
4.
5.
6.
7.
8.
9.
452

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Nhi mu phi
Tc ng mch phi hay thng gi l nhi mu phi

(NMP) l mt bnh l ht sc nng n, thng dn n t vong
nu khng c pht hin v x tr kp thi. Mc d c nhiu
bin php iu tr kh tch cc hin nay, nhng t l t vong
chung (ti Hoa k) bnh nhn NMP vn khong 20-30%. Tc
mch phi l mt bnh l kh thng gp, bnh cnh lm sng
a dng, d b b st hoc chn on nhm, t vong thng do
ri lon huyt ng khi tc mch phi din rng. Nn coi huyt
khi tnh mch su v tc mch phi l cng mt qu trnh bnh
l. Tin lng sm ty vo cc loi ri lon huyt ng. Chn
on v x tr tc mch phi i theo hai hng khc nhau ty
theo s n nh huyt ng trn lm sng. Chp ct lp vi tnh
xon c, thuc tiu si huyt v can thip qua ng ng
thng... l nhng bin php tin tin c th lm thay i hn din
bin v tin lng khi x tr tc ng mch phi.
I. Sinh l bnh
Vic tc t ngt mt mch ca phi dn n tng t
ngt tr khng ca mt vng h mao mch phi, tng gnh cho
tim phi, tht phi gin v suy cp, lm gim cung lng tim v
h huyt p ng mch. Thm vo c hin tng gim xy
mu ng mch v s mt tng xng gia thng kh v ti
mu cng lm bnh thm trm trng.
Tc mch phi biu hin lm sng rt a dng, c th
khng h c triu chng lm sng nhng cng c th c suy
huyt ng nhanh chng dn n t vong.
Hai biu hin bnh l chnh khi tc mch phi l ri lon
chc nng tht phi v ri lon trao i kh. Tc mch phi lm
453
tng sc cn mch phi, tng hu gnh tht phi, tng p lc v

sc p ln thnh tim ca bung tht phi, tng nhu cu xy c
tim... a n thiu mu c tim v ri lon chc nng tht phi,
gim th tch tng mu tht phi. Tht phi gin gy y vch
lin tht sang tri lm gim y v tin gnh tht tri (cn do
gim th tch tng mu tht phi), t cung lng tim, huyt
p ng mch ch, p lc ti mu mch vnh u gim. Nhp
tim nhanh, nhu cu xy tng, bung tim qu gin, ti mu vnh
gim... l nhng yu t lm nng thm ri lon chc nng tht
phi v to vng xon bnh l dn n cung lng tim gim
sc tim. Ri lon trao i kh bnh nhn tc mch phi rt
phc tp, lin quan n kch thc v tnh cht ca cc nghn,
mc lan rng, thi gian tc cng nh tnh trng bnh tim phi
trc . Gim xy mu thng do tng khong cht ph nang,
lung thng t phi sang tri, bt tng hp gia thng kh vi
ti mu (V/Q) v bo ha xy mch trn (MvO2) thp (ch yu
l hai c ch cui). T l thng kh/ti mu thp do ti phn b
dng mu phi (gim lng mu n vng tc mch, tng qu
mc lng mu n vng phi lnh) v do xp phi khng hi
phc sau khi ly gii cc tc. Xp phi cn do mt lp surfactant,
xut huyt ph nang hoc tnh trng gim CO2 ph nang, do co
tht ph qun, tt c u c s tham gia ca cc yu t th dch
do tiu cu trong li cc huyt khi gy ra. PaO2 c th gim
hn na sau dng thuc vn mch do tng lung thng sinh l
khi tng dng mu qua vng phi c t l V/Q thp. Cc hin
tng khc cng c nhc n nh: ph phi sau tc mch phi
do p lc nh phi tng v hu qu ca lung thng t phi sang
tri qua l bu dc hoc l thng lin nh gy tc mch nghch
thng hoc gy gim nng PaO2.
Tc mch phi nh khi din tc mch 20% hoc p lc
mch phi (ALMP) trung bnh < 20 mmHg. Tc mch phi
din rng c nh ngha khi din tc mch 50% hoc tc 2
ng mch ca hai thy phi.
454
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
Cao
- Kh th t ngt, th nhanh (> 20 ln/pht) hoc
> 85% au ngc (kiu mng phi hoc sau xng c) khng
gii thch c, km theo t nht 2 trong s nhng
biu hin sau:
- C yu t nguy c (khng vn ng, tr tun hon,
tin s vim tc tnh mch, sau m xng khp hoc
tiu khung, sau chn thng, khi u c tnh, suy tim,
dng thuc trnh thai...).
- Thu km theo du hiu tng gnh tht phi mi c
trn in tim.
- 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
Hu ht bnh nhn c biu hin m h vi rt nhiu mc

khc nhau, nn rt cn c cc thm d thm loi tr hay
khng nh chn on. Nhiu nghin cu cho thy phi hp cc
triu chng lm sng, yu t nguy c, vi thm d n gin cho
php phn loi kh tin cy kh nng tc mch phi, t s la
chn nhanh chng, chnh xc, t tn km cc bin php chn
on khc. Xc nh kh nng tc mch phi trn lm sng c
bit c ch khi phi hp nh gi kt qu x hnh phi-mt
phng tin chn on c in.
Ngoi tr bnh l tng ALMP do thuyn tc mn tnh,
tc mch phi c th chia thnh ba loi chnh:
1. Tc MP nh, cp tnh:
Nu din tc nghn mch t hn 50% mch phi,
th thng khng c triu chng. Triu chng c nng
hay gp nht l kh th ngay c khi gng sc nh. Mt s
khc xut hin biu hin ca nhi mu phi (NMP) ngay
t u (khi tc nhnh MP c trung bnh): au chi
ngc, c th km ho khan hoc ho ra mu. T l NMP
ch chim khong 10% s bnh nhn khng c bnh tim
phi t trc, trong khi t l ny c th n 30% nu c
bnh tim tri hoc ng h hp. Triu chng thc
th ch c khi NMP: kh th nhanh, nng do au ngc
song cha tm, hi chng ng c ln vi trn dch
mng phi, c th c c mng phi. Thng st nh v
nhp tim nhanh (do au+st). p lc MP t khi > 25
mmHg, cung lng tim khng gim, khng tt huyt p,
ting tim v p lc tnh mch hon ton bnh thng.
2. Tc MP din rng cp tnh:
Nu tc cp tnh trn 50% din mch phi th biu
hin ch yu l hi chng tm ph cp kt hp vi try
mch, tt huyt p. Thng gp nht l du hiu kh th
t ngt, nhp tim nhanh (> 100 chu k/pht) v triu
chng suy tht phi (TM c ni cng, tht phi p
mnh, nhp nga phi b tri xng c, T2 tch i rng
hoc mnh ln, thi tm thu do h van ba l, gan to).
456
Nng hn na l biu hin try mch: mch nhanh nh,

trng ngc, tt huyt p, v m hi, u chi lnh, tm ti,
ngt/thu hoc l ln... Gn 22% s bnh nhn tc mch
phi din rng c au ngc tri ging NMCT. Tht
phi gin cng, p lc tht phi v ALMP tm thu tng,
song t khi >55 mmHg; p lc nh phi v cui tm
trng tht phi tng (15-20mmHg), ch s tim v huyt
p ng mch gim, sc cn ngoi vi tng. Mt s trng
hp p lc mao mch phi bt bnh thng, nht l khi
th tch bung tht tri nh (do mt tng quan gia p
lc v th tch tht tri khi vch lin tht b y sang
tri). Triu chng s y nu biu hin 24 gi k t
khi khi pht, song t khi y nu xut hin sau 24
gi.
Try mch, tt huyt p (sc) khi huyt p tm thu
ng mch 90 mmHg v/hoc phi dng thuc vn
mch. Sc bnh nhn tc mch phi cp tnh (mt cn
bng gia cc c ch b tr duy tr huyt p v/hoc ti
mu m ca c th) l hu qu ca tc mch phi din
rng bnh nhn khng c tin s bnh phi tc nghn
mn tnh (COPD) hoc tc din nh hn bnh nhn c
tin s COPD. T l t vong tng thm 3 n 7 ln nu
c sc tim (22-40%), a phn t vong ngay trong gi
u. Tuy nhin a s (97%) trng hp tc mch phi
din rng li khng c sc trn lm sng. Nu khng c
sc th t l t vong tng ng gia tc mch phi din
rng v din nh hn (0-8%). Cc ri lon huyt ng
khc bao gm tt huyt p khng cn dng vn mch;
thu/ngt (do phi hp gia gim xy mu v tt huyt
p, chim ti 13%), ri lon nhp v dn truyn, ngng
tim (ch yu do phn ly in c) hoc t vong. Cc ri
lon ny chim khong 10% (thm ch cao hn) tng s
trng hp tc mch phi ni chung, trong khi t l ny
tng cao nhm nng c suy tim phi cp hoc tng p
lc ng mch phi: t l ngng tim chim ti 18-29%,
457
sc phi dng vn mch l 10% (theo cc nghin cu

UPET, UPSET, ICOPER, PIOPED, MAPPET).
3. Tc MP din rng bn cp:
Thng do nhiu cc tc kch thc nh hoc trung
bnh din ra trong vi tun, do c qu trnh thch nghi
ca tht phi. Triu chng ch yu l kh th tng ln v
gim dung np vi gng sc, thng km theo ho khan,
c th c tm kiu trung ng. Mc kh th khng
tng xng vi cc triu chng thc th. Mch v huyt
p vn trong gii hn bnh thng. Khm thng thy
tnh mch c ni, ting T3 phn di mi c tng ln
khi ht vo, thnh phn phi ca ting T2 mnh. Tin s
c nhiu t NMP xen k, cui cng tin trin nng dn
dn n suy tim phi v gim cung lng tim ging bnh
cnh cp tnh. p lc tht phi v p lc tm thu MP
cao hn trong khi p lc nh phi thp hn so vi tc
MP din rng cp tnh.
1. in tm : D khng c bnh tim phi t trc,
in tim bnh thng ch gp trong 6% tc mch phi
ln cp tnh v 23% tc mch phi bn cp. Nu tc
mch phi nh, huyt ng n nh thng ch gp
nhp nhanh xoang. Cc ri lon nhp nh bloc nh
tht cc cp hoc ri lon nhp tht rt t gp, t l
rung/cung nh ch chim 0-5%. Du hiu thng
gp nht ( 50%) l thay i khng c hiu on ST
v T, thng thong qua, cc thay i giai on kh
cc tr li bnh thng sm hn so vi ti cc, mc
thoi trin sng T lin quan cht vi hiu qu iu
tr ca thuc tiu si huyt. Hnh nh tm ph cp
(trc QRS quay phi, bloc nhnh phi, P ph,
SIQIIITIII-S su rng DI, Q su DIII, T m o chiu
DIII) ch chim khong mt phn ba cc trng hp
tc mch phi din rng. in tm ch yu loi
tr cc chn on khc nh NMCT hoc vim mng
458
Tc mch phi thng nng hn nu: xut hin

sm ( 24 gi) o ngc sng T V1-V4, ri lon
dn truyn v ti cc ca tht phi, dng SISIISIII. Tuy
nhin biu hin trn in tim vn c th tn ti nhiu
ngy sau khi bnh thoi trin.
2. Xquang tim phi: Hnh nh phim chp Xquang phi
bnh thng c th gp trong tt c cc dng tc
mch phi (16-34%) nn khng th dng bin php
ny xc nh hoc loi tr tc mch phi ln. D
khng c hiu, chp Xquang phi cng gip chn
on tc mch phi ln nh loi tr cc bnh ging
tc mch phi (vim phi, trn kh mng phi, suy
tim tri, u, gy xng sn, trn dch mng phi
nhiu, xp phi thy), xc nh nhng tn thng
nghi ng cn thm d tip v cho php c lng
nng ca bnh ng thi cng cn c phim chp
Xquang nh gi y phim chp x hnh phi.
Hnh nh xp phi, trn dch mng phi s
lng t, c honh nng cao l nhng du hiu c
nhy thp. Du bu ca Hamptons (nt m ngoi vi
hnh ch V hoc bn nguyt, nm dc cnh mng
phi, hng v rn phi, hay gc sn honh), du
Westermark (vng phi b gim ti mu khu tr)
hoc phng on gn MP hay gp bnh nhn tc
mch phi din rng.
3. Cc xt nghim mu:
Men LDH tng, bilirubin gin tip tng v
SGOT bnh thng l b ba xt nghim gp trong
trng hp tc mch phi, tuy khng nhy song kh
c hiu, thng gp nht l tng LDH. Bch cu
tng nh (12.000-13.000/ml) trong khi hematocrit
gim nh (30-35%). Tiu cu cng gim nh
459
(100.000-200.000/ml) c khi khng c bin chng do

dng heparin.
Sn phm lin kt cho thoi ging ca fibrin
c cha D-dimer (c trng cho qu trnh tiu hy
fibrin ni sinh) tng > 500 ng/ml trong > 90% bnh
nhn tc mch phi. Tuy D-dimer tng c khi c
huyt khi tnh mch, ng mu ni qun ri rc
(DIC), sau chn thng, phu thut hay c khi u c
tnh... song c nhy cao (nht l khi nh lng
bng k thut ELISA) nn c th dng lm xt
nghim sng lc loi tr tc mch phi, c bit l
nhm c biu hin trn lm sng v/hoc hnh nh c
nguy c thp-va.
4. Kh mu ng mch: Bin i c trng l PaO2
gim v PaCO2 bnh thng hoc gim do tng thng
kh. PaCO2 gim v kim chuyn ha vn xy ra
bnh nhn c ng CO2 trc . Tc mch phi
din rng c th gy c toan h hp (do tng khong
cht sinh l VD/VT v mt c h hp) v toan chuyn
ha (do gim ti mu m khi sc). 14-38% nhng
trng hp tc mch phi vn c kt qu kh mu
bnh thng (PaO2 80 mmHg, PaCO2 35 mmHg,
chnh lch gia phn p xy ph nang v ng mch
phi P(A-a)O2 bnh thng). PaO2 khng bao gi
bnh thng bnh nhn tc mch phi ln nhng
vn bnh thng nu tc mch nh do tng thng kh,
khi P(A-a)O2 > 20 mmHg l du hiu nhy hn.
Song PaO2 gim v P(A-a)O2 tng thng do nhiu
nguyn nhn, nn kt qu kh mu ng mch khng
mnh loi tr hoc xc nh tc ng mch
phi.
McIntyre v Sasahara ghi nhn tng quan
tuyn tnh gia mc nng ca tc mch phi (o
bng ch s tc mch khi chp mch, p lc MP
trung bnh, ch s tim) v gi tr PaO2 bnh nhn
460
khng c tin s COPD. Ngoi ra cc tc gi ny cn

thy tng quan cht gia P(A-a)O2 vi ALMP
trung bnh v s thng tn trn phim chp mch.
Thng kh khong cht sinh l (VD/VT) tng (o
gin tip qua th tch v p lc ring phn ca CO2
ton phn hoc cui k th ra ETCO2) l mt ch s
rt nhy v c hiu chn on tc mch phi, lin
quan cht vi mc tc v tin trin bnh.
5. Siu m tim: Siu m tim (qua thnh ngc hoc thc
qun) dng nh gi tnh trng tng gnh tht
phi, tm huyt khi bung tim v loi tr nhng
bnh l khc (phnh tch ng mch ch, bnh mng
ngoi tim, sc gim th tch, ri lon chc nng/nhi
mu c tim, h van tim - trong 2 bnh l cui
chim gn mt na s bnh nhn nghi ng tc mch
phi c lm siu m). Siu m tim ch nn coi l
phng tin ph tr hn l phng tin chn on
chnh, xc nh tc mch phi.
Nhng du hiu ca tng gnh tht phi do
tc mch phi trn siu m gm: gin/gim vn ng
tht phi (gin TP hay gp nht: 50-100%), tng t l
ng knh TP/TT, di ng nghch thng vch lin
tht, h van ba l... Nhng du hiu ny t khi gp
nu tc mch phi din nh. Gin tht phi cn c
th gp trong cc nguyn nhn khc: NMCT tht
phi, bnh c tim, tm ph mn hay TALMP, song
c th ngh n tc mch phi cp nu c km cc
du hiu nh: tht phi khng ph i ( dy 57mm) km khng xp TMC di khi ht su, di ng
vch lin tht nghch thng, vn tc ti a dng
chy ca h van ba l mc trung bnh (>2,5-2,8 m/s
v <3,5-3,7m/s), hoc ri lon vn ng vng c
bit ca tht phi (mt vn ng vng gia thnh t
do, vn ng bnh thng vng mm: do tng co bp
b ca tht tri).
461
Siu m tim qua ng thc qun c th thy

huyt khi thn hoc on gn ch chia ng mch
phi (chim 50-90% cc trng hp gin tht phi)
vi chnh xc cao ( nhy: 80-96,7%, c
hiu: 84-100%), tuy nhin nhy gim vi nhng
huyt khi nhnh nh ca MP, hoc on gia
v xa ca MP tri. Siu m tim cho php xc nh
tnh trng huyt khi ang di chuyn (emboli-intransit) tim phi, chim ti 17% s bnh nhn tc
mch phi cp, vi hai tp A v B khc nhau v hnh
thi v tin lng (theo phn loi ca European
Cooperative Study). Tp A (gp trong 18% tc mch
phi ln c sc) l cc huyt khi di (2-10cm), rt di
ng, ngun gc t h tnh mch su ngoi vi, thng
thy nh phi (84%) th vo tht phi, nguy c cao
(mt phn ba cht trong vng 24 gi, t l t vong
40% k c khi dng tiu si huyt), v y thng l
nhng trng hp c ch nh tuyt i m cp cu
ly huyt khi (t l t vong cn 15-25%). Tp B l
cc huyt khi thng nh hn, hnh trn/van, t di
ng, nm trong tht phi, lin quan n cc ri lon
tng ng trong tht phi (suy tim huyt, in cc
to nhp vnh vin, d vt...), thng tin lng tt (d
gy tc mch phi trong 40% cc trng hp). Tuy
nhin Kinney v Wright li khng thy s khc bit
r v t l t vong gia cc loi huyt khi.
Siu m cng xc nh nhm bnh nhn c
nguy c cao nh: cn l bu dc (tng t l t vong,
tc mch no v cc bin chng gn khc). Ri lon
chc nng tht phi l yu t nguy c ng ch
khc: d bo tin lng xu, c bit bnh nhn
huyt ng khng n nh. 10% bnh nhn huyt
ng n nh c ri lon chc nng tht phi s tin
trin thnh sc tim, vi t l t vong vt qu 50% do
tc mch phi ti pht, nht l bnh nhn tui cao,
mi sau phu thut xng hoc chn thng, huyt
462
p thp. Tuy cn phi nghin cu thm na, song

dng nh thuc tiu si huyt gp phn lm gim
t l t vong nhm tc mch phi huyt ng n
nh c ri lon chc nng tht phi (MAPPET).
6. X hnh phi (scintigraphy): X hnh phi l
phng tin chn on gin tip v khng th pht
hin c bn thn huyt khi m ch pht hin hu
qu l cc vng khuyt v ti mu. Hnh nh x
hnh ti mu phi bnh thng cho php loi tr
chn on tc mch phi. Kh nng chn on tc
mch phi ca hnh nh vng khuyt ti mu c th
chia thnh 3 loi: cao, trung bnh v thp. Hnh nh
c kh nng cao cho php chn on ng ti 85%.
Tuy nhin phn ln (60%) bnh nhn nghi tc mch
phi trn lm sng ch c nhng hnh nh c kh
nng chn on thp hoc trung bnh nht l bnh
nhn c tin s COPD, m trong tc mch phi
thc s ch chim 25%. Mc d kt hp vi kh nng
chn on tc mch phi da vo lm sng s nng
cao chnh xc song cng ch chn on ng
khong mt phn ba s bnh nhn. Ngc li, d
hnh nh x c kh nng thp cng khng loi tr
c chn on v c ti 40% l tc mch phi nu
kh nng tc mch trn lm sng cao.
D vy, x hnh phi vn rt c ch quyt
nh hng x tr: hnh nh x hnh ph hp vi lm
sng c kh nng thp cho php loi tr tc mch
phi, hnh nh x hnh ph hp vi lm sng c kh
nng ng cao ng ngha vi vic phi iu tr.
Nhng phng tin khc nh siu m tm huyt khi
tnh mch su, chp ng mch phi hay phim CT s
dng la chn phng php iu tr cho hai nhm
trn cng nh gip cho chn on khi khng ph hp
kh nng chn on gia lm sng v nh x hnh
phi, ch khng nn ch da vo lm sng...
463
7. Chp ct lp t trng vi tnh (CT thng, CT

xon c, CT chm in t): Chp CT xon c c
dng thuc cn quang hoc chp CT chm in t
(electron beam CT) l bin php chn on khng
xm ln c nhiu u th, b sung hoc thay th cho
ghi hnh phng x phi kinh in. CT xon c c
nhiu ni coi l bin php u tay chn on do
k thut chp nhanh (ch trong mt ln nn th),
phc tp v t ph thuc hn, pht hin c gin tht
phi so vi phng php chp mch phi truyn
thng; hnh nh r nt v y hn (c nhu m v
mch mu) so vi ghi hnh phng x.
Biu hin ca tc mch phi trn phim CT r
rng trong a s (90%) trng hp: cc hnh khuyt
mt phn hay hon ton trong lng mch, hay du
hiu ng ray (dng chy gia huyt khi bp
bnh trong lng mch v thnh mch). i vi tc
thn MP, tc MP ti thy hoc phn thy phi th
chp CT c chnh xc 85% ( nhy v c hiu
u 94%, thm ch 100% nhm bnh nhn nng
hoc c tng gnh tht phi). Hnh nh dng tnh
gi c th do hch rn phi to gy xp phi, m trung
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
gian (5 pht), rt cn nu bnh nhn c ch nh t

dng c lc trong TMC di.
8. Chp cng hng t ht nhn (MRI): Chp cng
hng t ht nhn cng l mt bin php chn on
khng xm ln, cho php nh gi v hnh thi gii
phu-chc nng ca ti mu phi cng nh chc
nng tht phi. So vi chp CT hay chp mch phi,
MRI cn c cc u im nh: trnh ng c thn do
thuc cn quang, chp h tnh mch ngay trong mt
th, nhy v c hiu rt cao pht hin huyt
khi tnh mch su v huyt khi MP. Tuy nhin
thi gian chp ko di (15-30 pht) gy nhiu bt li
nht l nhm bnh nhn c huyt ng khng n
nh. Do , MRI cng t c ng dng trong chn
on tc mach phi.
9. Chp ng mch phi: Chp chn lc ng mch
phi c th coi l tiu chun vng chn on xc
nh hoc loi tr tc mch phi. Nn ch nh khi
c tt huyt p, try mch hoc khng chn on
c bng phng tin khc. Tuy nhin khng phi
ch no cng thc hin c v lun c nguy c t
vong d nh (< 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
huyt ng v nguy him phng nga, chn loi

v lng thuc cn quang... Nhng thay i huyt
ng ty vo mc tc (bn nh lng trn phim
chp) bao gm: tng p ng mch phi (th pht do
tc mch ln), p lc nh phi v cui tm trng tht
phi tng, p lc cui tm trng tht tri v cung
lng tim gim. Huyt khi th hin qua hnh nh ct
ct hoc khuyt trn trong lng mch km theo gim
ti mu vng phi chi phi.
Nhiu tc gi t du hi v s cn thit
phi chp ng mch phi trc khi can thip tch
cc nh dng thuc tiu si huyt thm ch phu
thut ly huyt khi do nguy c chy mu, bin
chng v lm chm tr chn on trong khi c nhng
bin php khng xm ln chnh xc khc. Tuy nhin,
chp ng mch phi s l bt buc nu p dng cc
bin php ly huyt khi hoc nong huyt khi theo
ng ng thng.
10. Pht hin huyt khi tnh mch su: a phn
huyt khi tnh mch chi di (HKTMCD) khng c
triu chng r rng m vic pht hin phi da vo:
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
mch phi, ngc li nu khng c huyt khi TM

gc chi, bn, chu..., khng cn nguy c tc mch
thm th d c tc mch phi nh vn c th b
qua thuc chng ng. Tt nhin phi rt thn trng
khi kt lun nhm bnh nhn c chc nng tim
phi hn ch, t hot ng hoc huyt khi hnh
thnh t ni khc (nh phi, TMC...). Mt khc siu
m mch c th lm li nhiu ln nu vn nghi ng.
C. Chn on phn bit
1. Nhi mu c tim cp.
2. Vim phi thu.
3. Suy tim tri cp.
4. Tng p ng mch phi tin pht.
5. Cn hen ph qun.
6. Vim mng ngoi tim.
7. Trn kh mng phi.
8. Gy xng sn.
9. Vim khp sn sn.
10. au c, au thn kinh lin sn.
III. iu tr
Bnh nhn tc ng mch phi c nguy c t vong, huyt
khi ti pht hoc bin chng mn tnh. T l t vong c th ln
ti 30% nu khng iu tr.
Ngay khi nghi ng tc mch phi nn tim trc tip tnh
mch ngay 5.000-10.000 n v Heparin nu khng c chng ch
nh, ri tip tc chn on xc nh. Nu loi tr tc mch
phi th dng Heparin, nu c chn on xc nh th la chn
iu tr ph thuc vo tnh trng huyt ng ca bnh nhn. Khi
huyt ng suy sp nng gy tt huyt p hoc sc, cn nhanh
chng m thng ch tc mch phi bng thuc tiu huyt khi
v/hoc th thut can thip iu tr huyt khi. Nu tht bi hoc
chng ch nh, nn tin hnh phu thut cp cu ly huyt khi.
467
Nu thnh cng, tip tc duy tr bng Heparin v thuc khng

vitamin K. Bnh nhn tc mch nh hoc thm ch tc mch din
rng nhng huyt ng n nh c iu tr bng Heparin gi
vi thuc chng ng ng ung. Tc mch phi ti pht hoc
chng ch nh dng khng vitamin K, th nn xem xt t dng
c lc (filter) tnh mch ch di phng huyt khi.
A. Cc bin php hi sc cho NMP din rng
1. Bnh nhn nghi ng tc mch phi din rng thng
phi hi sc tch cc n nh huyt ng ngay c
trong lc chn on.
2. Nu au ngc nhiu c th dng thuc gim au.
3. Nu xy mu gim nng, t p ng vi th xy qua
mt n p vo mi, cn t ng ni kh qun v thng
kh nhn to. t ni kh qun v thng kh nhn to
c th lm nng thm tnh trng suy sp huyt ng
do: (1) thuc gy ng dng khi t ng ni kh qun
hoc th my s gy gin mch ng thi lm
gim/tr tc dng ca catecholamine, (2) th my
lm gim lng mu TM tr v v tng sc cn mch
phi. Do cn cn nhc thn trng gia li ch v
nguy c ca bn thn vic t ni kh qun, k thut
tin hnh v cc thuc h tr. Etomidate l thuc
gim au gy ng l tng v t nh hng n huyt
ng. Th my p lc dng lm ci thin tt xy
mu do tc mch phi hay c xp phi.
4. Thng thng, truyn 1-2 lt dch mui s nng c
huyt p bnh nhn sc khng r nguyn nhn.
Cung lng tim s tng ln bnh nhn tc mch
phi din rng khi cha tt huyt p nu truyn
500ml Dextran. Tuy nhin, bnh nhn tt huyt p
c ri lon chc nng tht phi nng, th tch v p
lc bung tht phi cao lm tng sc p ln thnh tim
v/hoc gy thiu mu tht phi, y lch vch lin
tht qu mc sang tri gy ri lon kh nng gin
v/hoc y tht tri. Khi truyn dch qu mc
468
cng lm nng thm tnh trng trn cng nh ri lon

chc nng tht phi nhiu hn, v th nu p lc
bung tim phi cao hoc c biu hin suy tim phi th
vic truyn dch cn phi rt thn trng v nn dng
thuc vn mch sm.
5. T l sng ca bnh nhn tc mch phi din rng
ph thuc vo vic duy tr p lc ng mch ch
cp mu mch vnh nui dng cho tht phi ang
suy. Noradrenaline thng qua th th (gy co ng
mch-tng p lc ti mu mch vnh v gy co tnh
mch-tng lng mu tnh mch tr v tim) ng thi
thng qua th th 1 (tng co bp c tim hn na)
cho php ci thin r rt chc nng tht phi.
Dobutamine tuy tng cung lng tim v kh nng vn
chuyn xy song li thay i t l thng kh/ti mu
(V/Q) v lm gim PaO2 bnh nhn tc mch phi
din rng c sc, hn na thuc gy gin mch ngoi
vi thng qua th th 2. V th nu tc mch phi
din rng, nn chn Dobutamine nu h huyt p tva v Noradrenaline nu sc nng, tuy nhin khi
nng catecholamine ni sinh t n mc rt
cao nn p 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
NMP ln - 7000 -10 000 v tim thng TM, sau truyn

(din rng) tc 1000 - 2000 v/gi, kim tra thi gian
aPTT iu chnh liu Heparin sao cho aPTT
trong khong 1,5 - 2,5 ln thi gian chng.
- Dng khng vitamin K, gi t ngy th 3-4,
ngng heparin sau 7-10 ngy (khi n nh).
Cc thuc khng vitamin K (Warfarin, Cumadin...) cn
c dng gi vo t ngy th 3-4 sau khi dng Heparin v
thi gian c tc dng ca cc thuc ny mun. Cn iu
chnh liu sao cho INR trong khong 2,0 n 3,0. Warfarin
nn dng bt u bng liu 5 mg/ngy. Thi gian dng thuc
ny t 3-6 thng sau khi bnh nhn ra vin. Nu bnh nhn
cn c nhng tnh trng tng ng ( ni trn) th vn nn
tip tc ko di.
C. Thuc tiu huyt khi
1. Tc dng nhanh chng lm tan cc huyt khi gy
nghn MP, gim ti v hi phc tnh trng suy tim
phi cp. Thuc tiu huyt khi so vi Heparin lm
gim ng k t l t vong sau 30 ngy (4,7 so vi
11,1%), gim nguy c ti pht nghn mch phi (7,7
so vi 18,7%) v gim nguy c pht trin bnh l
tng p ng mch phi do thuyn tc mn tnh.
2. iu tr tiu huyt khi c ch nh cho bnh nhn
suy sp huyt ng: tt huyt p, thiu niu, gim
xy mu nng. Mt s tc gi cn ch nh cho
nhng trng hp ri lon chc nng tht phi trn
siu m.
3. Cc thuc tiu si huyt dng nh u c hiu qu
v an ton nh nhau nu s dng vi liu tng
ng (Bng 26-3). Nu dng Streptokinase hoc
APSAC (Anistreplase hay Antisoylated Plasminogen
Streptokinase Activator Complex) th nn phi hp
100 mg Hydrocortisone gim cc tc dng ph.
4. Chng ch nh bao gm: cc bnh l ni s, ni
ty, chy mu trong, mi phu thut ln hoc chn
470
thng nng (< 10 ngy), tng huyt p khng kim

sot c, tin s d ng hoc mi dng thuc (ring
vi Streptokinase hoc APSAC). Ngc vi NMCT,
tiu huyt khi vn c tc dng iu tr trong vng
10-14 ngy cho cc bnh nhn nhi mu phi k t
khi khi pht. Hiu qu l tng ng d dng
ng tnh mch ngoi vi hay trc tip qua ng thng
vo MP. Ngng Heparin trc v sau khi dng
thuc tiu si huyt, o aPTT v fibrinogen mu
quyt nh thi im dng tip Heparin. Nu aPTT
vn gp i chng hoc fibrinogen < 1g/l th lm xt
nghim ny 4gi/ln cho ti khi c th dng li an
ton Heparin, sau gi vi khng vitamin K t nht
trong nm ngy. Bin chng chnh khi dng thuc
tiu si huyt l chy mu nng (12%, tng ng
gia cc thuc tiu si huyt), trong xut huyt
ni s khong 0,5-2,1%. Streptokinase hoc APSAC
c th gy d ng nh nng bng, ni ban, st (57%), p ng tt vi corticoid v khng histamine d
sc phn v rt him khi xy ra (<0,5%).
Bng 26-3. Liu thuc tiu si huyt cho NMP.
Streptokinase Liu np 250.000-500.000 n v/15 pht,
duy tr 100.000 n v/gi 24 gi
Urokinase
Liu np 4.400 n v/kg/10 pht,
duy tr 4.400 n v/kg/gi 12 gi
rt-PA
Liu np 10mg, sau truyn lin tc 90
mg/2 gi
APSAC
30mg/5 pht
Reteplase
2 mi tim trc tip 10 n v cch nhau 30
pht
D. Can thip qua da v phu thut
1. t dng c lc tnh mch ch di xuyn qua
da ngn nga nguy c tc thm MP khi bnh
nhn c biu hin ca HKTMCD. Ngy nay ngi ta
thng dng loi lc (Green Field) t ngay tnh
mch ch di, di ch vo ca hai tnh mch
471
thn. C th i bng ng tnh mch i bn khng

b tc hoc i t ng tnh mch nn.
Hin nay ngi ta ang th nghim dng dng
c c bit (Angio - Jet) ht cc mu ng qua
ng thng tim (catheter), phng php ny bc u
t ra c trin vng.
2. Phu thut ly cc mu ng trong ng mch
phi l phu thut nng vi t l t vong rt cao, kh
thc hin cc trung tm y t nh. Phu thut ch
c ch nh khi bnh nhn c tnh trng rt nng
vi suy tht phi nhiu, huyt p tt v chp mch
phi hoc cng hng t chng minh c cc tc
mch ln (thn ng mch phi hoc nhnh ln).
E. Ngn nga nguy c v iu tr HKTMCD
V HKTMCD l mt trong nhng nguyn nhn
hng u gy NMP, nn vic ngn nga v iu tr kp
thi HKTMCD cng l ngn nga NMP.
1. Yu t nguy c ca HKTMCD:
a. Tnh trng bnh l h tnh mch, tn thng
mch, hoc tnh trng tng ng th pht:
Cc phu thut nng (c bit l cc phu
thut vng chi di, tiu khung).
Chn thng (c bit l gy xng i, chn
thng s no, v tu sng).
Suy tim huyt, gim cung lng tim.
Cc bnh c tnh.
Ph n c thai.
Dng thuc trnh thai ko di.
Bo ph.
Gin tnh mch chi di.
Bnh vim i trc trng.
Tui gi.
Hi chng thn h.
Nhim trng.
b. Tnh trng tng ng tin pht:
Thiu ht yu t Antithrombin III.
Thiu ht Protein C.
Thiu ht Protein S.
Ri lon Plasminogen v s hot ho.
Bnh i ra hemoglobin kch pht v m.
472
Bnh gim tiu cu gy ra bi Heparin.

Khng th khng lupus (anticoagulant hoc
anticardiolipin).
Ri lon tng sinh tu xng.
Bnh a hng cu.
2. Chn on HKTMCD
a. Lm sng thng l xut hin sng, au, cng
mt chi. Mt s trng hp triu chng lm sng
khng r rng m ch n khi xut hin NMP mi
pht hin ra c HKTMCD.
b. Chn on xc nh da vo chp h tnh mch,
tuy nhin y l thm d chy mu v gy kh
chu cho bnh nhn.
c. Siu m Doppler tnh mch l xt nghim rt hu
ch, cho php chn on tt.
3. iu tr HKTMCD
a. Heparin tim TM 5.000 n v sau truyn TM
tc 1.000 v / gi lin tc trong 7 - 10 ngy.
b. Heparin trng lng phn t thp (LMWH) hin
c coi l thuc tt iu tr thay cho Heparin
thng trong iu tr huyt khi tnh mch chi
di. Cc thuc ny c nhiu u im hn l tc
dng ko di, khng phi theo di bng cc xt
nghim khi dng, ngoi tc dng chng yu t Xa
cn c tc dng chng yu t II tiu cu.
Bng 26-3. Heparin trng lng phn t thp trong iu
tr huyt khi tnh mch.
LMWH
Xa/IIa
iu tr
D phng
Adreparin
1.9
130 U/kg/12h
50 U/kg/12h
(Normiflo)
Certoparin
8000 U/12h
3.000 U/24h
(MonoEmbolex)
Dalteparin
2.7
120 U/kg/12h
2.500200 U/kg/24h
5.000 U/24h
(Fragmin)
Enoxaparin
3.8
100 U/kg/12h
2.000-4.000
U/24h
(Lovenox)
Nadroparin
3.6
<55kg:4.000 U/12h
3.100 U/24h
55-80kg:6.000 U/12h 40-60U/kg/24h
(Fraxiparin)
473
>80kg: 8.000 U/12h
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
ng mch phi gy NMP.
Ti liu tham kho
1.
ACCP Consensus Commitee on pulmonary embolism. Opinions

regarding the diagnosis and management of venous thromboembolic
disease. Chest, 1996;109:233-7.
2. Britist Thoracic Society, Standards of Care Commitee. Suspected
acute pulmonary embolism: a practical approach. Thorax,
1997;52(suppl 4):S1-24.
3. Fitzmaurice D, Hobbs FDR, McManus R. Thromboembolism.
Clinical Evidence, 2001;5:158-68.
4. 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.
474
11. Riedel M. Venous thromboembolic disease. Acute pulmonary

embolism 2: treatment. Heart, 2001;85:351-60.
12. Wood KE. Major pulmonary embolism: Review of a
pathophysiologic approach to the golden hour of hemodynamically
significant pulmonary embolism. Chest, 2002;121:877-905.
475
Thng lin nh
Thng lin nh (TLN) chim khong t 5% n 10% cc

trng hp tim bm sinh. Cng vi bnh van ng mch ch hai
l van v sa van hai l, TLN l bnh tim bm sinh cn hay gp
nht ngi ln. Bnh ch yu gp n gii: t l gp n so
vi nam l 2 so vi 1.
i a s cc bnh nhn TLN khng c triu chng c
nng m ch c cc triu chng lm sng rt kn o do
thng b b st chn on cho n tui trng thnh.
i vi cc trng hp TLN khng c iu tr trit ,
cc bnh nhn s dn dn c cc triu chng lm sng. Lu di
cc bnh nhn s biu hin cc du hiu ca s qu ti bung
tim phi nh ri lon nhp nh (tng dn nguy c theo tui ca
bnh nhn), tng p ng mch phi v tng sc cn mch phi,
cui cng hu qu tt yu l dn n suy tim xung huyt. Vic
tn ti l thng lin nh cng l mt yu t thun li dn n tc
mch nghch thng.
I. Gii phu bnh: c bn dng thng lin nh thng thng:
TLN kiu l th hai, TLN kiu l th nht, TLN kiu xoang
tnh mch v TLN th xoang vnh.
A. TLN kiu l th hai hay TLN th pht (l bu dc)
l tn thng hay gp nht chim khong t 60% n
70% cc trng hp. L thng nm v tr gn l oval,
trung tm vch lin nh (VLN). C th gp phi hp vi
sa van hai l, c bit ph n (t l 2:1 so snh gia n
v nam gii).
B. TLN kiu l th nht hay TLN tin pht chim
15% n 20% cc trng hp. L thng nm thp, gc
hp bi vch lin nh v mt phng ca vch ngn nh
tht (mt phng van nh tht). Chnh v v tr thp nn
loi ny hay i km vi khuyt tt ca van nh tht v
vch lin tht. Khi c TLN l th nht th rt thng gp
475
h van hai l i km do c k h ca l trc van hai l.

Lc , bnh l ny c phn loi trong nhm c bit
gi l thng sn nh tht (ng nh tht chung), c c ch
sinh l bnh, din bin lm sng v phng hng iu
tr khc.
C. TLN th xoang tnh mch l loi TLN t gp, chim
khong t 5% n 10% cc trng hp. L thng nm
cao v ra sau ca VLN, n nm ngay st vi tnh mch
(TM) ch trn do vy rt hay gp hin tng tnh mch
phi (TMP) qua l thng vo nh phi (TMP lc
ch). Ngoi ra c th gp cc th rt him ca TLN nh:
TLN nm rt thp pha di st vi TM ch di (pha
sau v di ca VLN).
D. TLN th xoang vnh l th him gp nht, l thng
nm ngay st pha trn xoang TM vnh, do dng
shunt t nh tri s trc tip vo ''cu trc'' ny. Tn
thng ny hay phi hp vi cc d tt bm sinh khc
nh ng nh tht chung, tnh mch ch trn lc ch.
Hnh 27-1. V tr gii phu ca cc dng TLN.

II. Sinh l bnh
A. TLN thng dn n dng shunt t nh tri sang nh phi,
lu lng shunt ph thuc vo ng knh l thng v
ph thuc gin tip vo gin n ca tht tri v tht
476
phi. Lung thng c th ngay lp tc (di 1 nm) hoc

dn dn (nhiu nm) dn n s tng gnh ca bung tim
phi lm ph i tht phi, tng ti mu phi v cui
cng s dn n tng p lc ng mch phi (MP).
cc bnh nhn ngi ln hoc do p lc bung tim phi
tng ln hoc/v kh nng co bp ca tim tri gim
xung (c tim b nh hng do tng cng hay do bnh
ng mch vnh, tng huyt p... phi hp), lc ny dng
shunt thng s gim xung dn dn v c th dn n
shunt hai chiu hay o chiu dng shunt (him gp).
B. Nguy c chnh ca vic khng ng l thng lin nh l
s gy suy tim th pht do tng gnh mn tnh, tng p
MP, ri lon nhp nh v tc mch.
A. Triu chng c nng: thng kn o, i khi bnh
nhn n khm v kh th khi gng sc, vim ph qun
phi nhiu ln hoc chm ln. Mt s t cc trng hp
vi l TLN ln c th dn n shunt tri sang phi nhiu
v tr c du hiu c nng rt sm khong t 6 n 12
thng, cn li i a s cc trng hp bnh thng pht
hin mun nh thm khm thng k. Cc trng hp
bnh din bin lu di c th c cc biu hin ca ri
lon nhp nh rung nh hay cung nh, tng p ng
mch phi nng v suy tim xung huyt.
B. Khm lm sng: Nghe tim c ting thi tm thu cng
nh van MP do tng lu lng mu qua van
MP. Ngoi ra cn nghe thy ting T2 tch i do s
ng mun ca ba l van MP; ting T1 mnh v rung
tm trng do tng lu lng van ba l c th gp
trong cc trng hp dng shunt ln lm tng nhiu s
y v tht phi.
A. in tm (T)
477
1. TLN l th hai: in tm thng c dng:

a. RSR hay rSR V1.
b. QRS ln hn 0,11 giy.
c. Trc phi.
d. i khi c th km theo PR ko di (khong 20%
cc trng hp, hay gp cc bnh nhn TLN
mang tnh cht gia nh).
e. Dy nh phi trong khong 50% cc trng hp.
2. TLN l th nht: in tm c dng
a. RSR V1.
b. Trc tri.
c. Bloc nh tht cp I.
d. C th thy dy c 2 tht.
B. Chp Xquang tim phi: Tim to va phi vi gin
cung MP. i khi thy du hiu gin b di phi ca
tim do gin bung nh phi. Tng ti mu phi hay gp.
C. Siu m tim: y l phng php ch yu v chnh xc
nht chn on thng lin nh. i vi cc bnh nhn
nh tui c th ch cn dng siu m qua thnh ngc cn
i vi cc bnh nhn ln tui, thnh ngc dy, i khi
cn lm siu m qua thc qun.
1. Siu m qua thnh ngc: Mt ct siu m in hnh
quan st l TLN l trc ngn cnh c tri, bn
bung t mm v nht l mt ct di sn.
a. Hnh nh gin tip s thy du hiu gin bung
tht phi v nh phi. Mc gin bung tim phi
ph thuc vo mc dng shunt tri phi hay
kch thc l TLN.
b. Thy hnh nh trc tip ca l TLN trn siu m
2D: bn bung t mm, 4 bung di mi c,
hay trc ngn cnh c tri. Hnh nh TLN th
xoang tnh mch kh thy hn, c bit ngi
ln tui.
478
c. Tm kim s bt thng ca TM phi v TM ch:

TM ch trn tri vo nh phi khng c thn
TM v danh; TM phi lc ch vo TM ch
trn, TM v danh, TM ch di hay nh phi... l
cc bt thng bm sinh c th gp phi hp vi
TLN. Cn quan st bng siu m 2D v c bit
l siu m Doppler mu.
d. nh gi mc ca dng shunt: gin tip thng
qua kch thc tht phi so vi tht tri.
Nu thy t l kch thc tht phi/tht tri t
1/2 n 2/3: TLN l nh.
Nu t l ny t 2/3 n 1: TLN l trung bnh.
Nu t l ny trn 1: TLN l rng.
e. Nn tin hnh o cung lng phi, so snh vi
cung lng ch. Nu tng cung lng phi nhiu:
TLN c dng shunt tri phi ln.
f. nh gi p lc MP: bng dng chy qua van
ba l v dng chy qua van MP (trong TLN p
lc MP thng tng tng i mun).
Hnh 27-2. Hnh nh thng lin nh trn siu m 2D.

2. Siu m qua thc qun: c p dng vi cc
trng hp thng lin nh m siu m qua thnh ngc
cn cha r. Siu m qua thc qun rt hu ch trong
vic o chnh xc kch thc l thng lin nh cng
nh kch thc cc ra pha trn v pha di ca l
thng chun b bt cc l thng bng dng c.
Siu m qua thc qun cng cn c p dng i
479
vi cc th TLN him gp c bit l TLN th xoang

tnh mch vi bt thng s v ca tnh mch
phi.
3. Siu m cn m: Siu m vi tim cht cn m c
bit rt hu ch cho vic chn on xc nh v loi
tr cc bt thng bm sinh phi hp khc.
Hnh 27-3. Hnh nh ra bt cn m trong nh phi.

D. Thng tim
1. Mc ch ca thng tim:
a. Chn on xc nh TLN ch yu da vo siu
m tim (siu m 2D, Doppler, siu m cn m,
siu m qua thc qun). Thng tim c th gip
ch cho vic nh gi mc shunt, ngoi ra cn
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
c. Ngoi ra trong nhng nm gn y, thng tim cn

nhm mc ch ng l TLN bng dng c
qua da (Amplatzer, CardioSeal...).
2. Chp bung tim:
a. Nu l thng thy r trn siu m, c th khng
cn thc hin chp bung tim.
b. Khi c du hiu ca TM phi lc ch, c th
chp MP cho hnh nh r rng v xc nh
lung thng ( th thuc ''chm'' khi mu v TM
phi). L thng lin nh s thy r gc chp
nghing tri 20 n 450 nghing u 250, ng
thng bm thuc cn quang nm tnh mch
phi phi.
c. Chp bung tht tri c th thc hin nh gi
co bp tht tri v mc h van hai l. Nu
nghi ng thng lin tht v h cc van nh tht
phi hp th cn chp bung tht tri t th
thng mt v nghing tri 60 70o, chch u
khong 250.
d. Cui cng cc bnh nhn c tui (nam hn 40,
n hn 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
2. Vi cc l thng kch thc trung bnh: khng c du

hiu c nng, bloc nhnh phi khng hon ton, t l
ng knh tht phi/tht tri t 2/3 n 1, c tng
ti mu phi trn phim chp Xquang: nu l n gii
th nn phu thut khong nm 15 tui (phu thut
ng ngang di v); nu l nam gii th nn phu
thut lc 5 tui. Nu c kh nng ng qua da bng
dng c (Amplatzer, CardioSeal...) th nn thc hin
ngay khi c th cc l thng loi ny.
3. Vi cc l thng ln: ting T1 mnh, rung tm trng
do tng lu lng, t l ng knh tht phi/tht tri
ln hn: nu c tng p MP cn ng l thng ny
cng sm cng tt. Nu khng tng p MP, ng l
thng mt cch h thng lc tr 5 tui.
4. TLN nghi ng c tng p MP c nh: cn lm
thng tim chn on. Ch phu thut khi cha c tng
p MP c nh, lu lng mch phi vn tng hn
lu lng i tun hon (vn cn shunt tri phi l
ch yu) v sc cn mch phi vn cn trong gii hn
cho php (cha tr thnh phc hp Eisenmenger).
5. Tin trin ca TLN thng dung np tt v vy i
khi pht hin bnh rt mun tui trng thnh.
Tng p MP c nh (khng cn ch nh phu
thut) c th gp tui 20 n 30. Suy tim v ri lon
nhp tim c th bt u xy ra tui 30 n 40. Nu
l thng lin nh c ng kn (bng phu thut hay
bng dng c qua da) th c th coi nh bnh nhn
c cha khi hon ton. Ri lon nhp cc bnh
nhn ny l hn hu.
482
C. Phu thut ng TLN vi tun hon ngoi c th t rt

lu tr thnh mt phu thut kinh in. Ty theo kch
thc v v tr ca l TLN m phu thut vin c th
khu trc tip hoc lm ming v bng mng ngoi tim
ng kn hon ton l TLN.
1. Nguy c phu thut lin quan n c a bnh nhn
nh tui, rung nh, p lc ng mch phi v sc cn
mch phi tng cao.
2. Sau m, bnh nhn cn c th b nguy c mc hi
chng sau m mng ngoi tim (hay gp hn cc phu
thut tim bm sinh khc). Ri lon nhp nh c th
vn ko di mt thi gian sau cho n khi kch
thc ca nh v tht phi tr v kch thc bnh
thng. Ti mt vi trung tm, thuc chn bta giao
cm c s dng t 3 n 6 thng sau m phng
nga cc ri lon nhp nh.
Hnh 27-4. Trc (A) v sau (E) ng l TLN bng Amplatzer.

D. ng l TLN qua da bng dng c l th thut ngy
cng c p dng nhiu nc trn th gii. Ti Vit
Nam phng php ny hin nay c tin hnh
thng quy ti Vin Tim mch Vit Nam. Tt c cc
trng hp TLN l th hai c kch thc khng qu ln
v g xung quanh l ln (hn 5mm) u c kh nng
ng bng dng c qua da di mn tng sng. Phng
483
php ny ngy cng chng minh c tnh hiu qu nh

thi gian nm vin ngn, t au, khng c so m, t bin
chng ngay c nhm bnh nhn c nguy c cao.
Ti liu tham kho
1.
Brecker S,ID. Atrial septal defect. In: Redington A, Shore D,

Oldershaw P, eds. Congenital heart disease in adults: a practical
guide. London: WB Saunders, 1994:103-110.
2. Connelly MS, Webb GD, Sommerville J, et al. Canadian Consensus
Conference on Adult Congenital Heart Disease 1996. Can J Cardiol
l998;14:395-452.
3. Gatzoulis MA, Redington AN, Somerville J, Shore DF. Should atrial
septal defects in adults be closed? Ann Thorac Surg 1996;61:657659.
4. Latson LA. Per-catheter ASD Closure. Pediatr Cardiol 1998;19:8693.
5. Mahoney LT. Acyanotic congenital heart disease: atrial and
ventricular septal defects, atrioventricular canal, patent ductus
arteriosus, pulmonic stenosis. Cardiol Clin 1993;11:603-616.
6. Mandelik J, Moodie DS, Sterba R, et al. Long-term follow-up ef
children after repair of atrial septal defects. Cleveland Clin J Med
1994;61:29-33.
7. Moore JD, Moodie DS. Atrial septal defect. In: Marso SP, Griffin
BP, Topol EJ, eds. Manual of Cardiovascular Medicine.
8. Perloff JK. Survival patterns without cardiac surgery or
interventional catheterization: a narrowing base. In: Perloff JK,
Child JS, eds. Congenital heart disease in Adults, 2nd ed.
9. Snider AR, Serwer GA, Ritter SB. Defects in cardiac septation. In:
Snider AR, Serwer GA, Ritter SB, eds. Echocardiography in
pediatric heart disease, 2nd ed. St. Louis: Mosby, 1997:235-246.
10. Vick GW. Defects of the atrial septum including atrioventricular
septal defects. In: Garson A, Bricker JT, Fisher DJ, Neish SR, eds.
The science and practice of pediatric cardiology, 2nd ed. Baltimore:
Williams & Wilkins, 1998:1141-1179.
484
Thng lin tht
Ngoi tr bnh van ng mch ch (MC) ch c hai l

van th thng lin tht (TLT) l bnh tim bm sinh hay gp nht,
n chim khong 25% cc bnh tim bm sinh.
Do cc triu chng lm sng c hiu (ting thi tm thu
to vng gia tim) v cc bin chng sm ca n nn thng lin
tht hay c chn on sm t khi bnh nhn cn nh. Chn
on TLT t khi cn trong thai nhi c th thc hin c bng
siu m tim bi cc bc s c kinh nghim.
TLT l nh rt hay gp v thng dung np rt tt. Do
n c th gp ngi trng thnh v c kh nng t ng. T
l t ng li ca cc trng hp TLT l nh tr em ln n
75%. Ngc li TLT l ln s nh hng nhanh n h hp v
p lc ng mch phi (MP) c th tng mt cch c nh rt
sm t 6 n 9 thng. i vi cc trng hp sc cn mch phi
tng c nh (hi chng Eisenmenger) bnh nhn him khi sng
c qu tui 40. Cc bin chng hay gp nhm bnh nhn
ny l chy mu phi, vim ni tm mc, p xe no, ri lon
nhp tht v cc bin chng ca a hng cu. Tin lng s rt
km cc bnh nhn c cc biu hin ngt, suy tim xung huyt
v ho ra mu.
Ngi ta nhn thy ngoi nguyn nhn do m b cm trong
ba thng u, TLT hay gp trong cc hi chng bnh l, c bit
l hi chng c ba nhim sc th 21, hi chng do m nghin
ru khi mang thai...
I. Gii phu bnh
A. Phn loi: C rt nhiu cch phn loi gii phu bnh
v TLT khc nhau c t ra nhng nhn chung li c 4
loi TLT chnh v gii phu bnh l: TLT phn quanh
mng, TLT phn c, TLT phn bung nhn v TLT phn
phu (TLT pha trn ca ca Wolff).
485
1. TLT phn quanh mng l loi TLT hay gp nht,

chim khong 70-80% cc trng hp, nm cao
thuc phn mng ca vch lin tht (VLT), ch ni
gia van 3 l v van MC. Tuy nhin n c th dch
chuyn ra sau, ra trc hay xung di mt cht ty
tng trng hp. Tn thng thng phi hp to
thnh mt ti nh di van 3 l hay xung quanh b
van (thng cng c gi l ti phnh phn mng
vch lin tht). N c th gy h van MC v hp
phn thp ca ng ra tht phi. y l loi TLT c
kh nng t ng cao.
2. TLT phn c hay TLT gn mm tim. N c th
bt c v tr no ca phn thp VLT cho n mm
tim. Th bnh ny chim khong 5 n 20% cc
trng hp TLT v cng c kh nng t ng cao tr
cc trng hp c nhiu l TLT.
Hnh 28-1. V tr
gii phu cc loi
thng lin tht.
3. TLT phn bung nhn hay TLT kiu ng nh tht

chung chim khong t 5 n 8% cc trng hp.
TLT loi ny thng v tr cao ca VLT, rng, t
kh nng t ng v hay i km tn thng ca cc
van nh tht. Hay gp phnh vch lin tht v tr ny.
486
4. TLT phn phu hay TLT di van MC hoc

di van MP: him gp hn (5 n 7%), l loi
TLT m l thng nm phn rt cao ca vch lin
tht ni c tip gip vi van MC v van MP (nn
cn c gi l thng lin tht kiu ''di cc i
ng mch''). im c bit quan trng ca loi TLT
ny l l thng thng phi hp vi tn thng l van
MC v c h ch i km (hi chng Laubry-Pezzy).
B. Cc tn thng khc phi hp c th gp: hp van MP,
hp trn van MP, h 3 l, thng trc tip t tht tri
sang nh phi, mng ngn di MC
II. Sinh l bnh
A. Lung thng ca shunt c lu lng ph thuc vo kch
thc l TLT v sc cn h MP cng nh p lc tht
phi. Lung shunt s gy ra qu ti phi, nh tri v
tht tri.
B. Din bin xu dn s l tng p MP gy suy tim phi v
v sau s chuyn thnh hi chng Eisenmenger (tng sc
cn ca mch phi do bnh l MP tc nghn c nh
lm gim dng shunt tri phi, lm tng dng shunt
phi tri).
A. Triu chng c nng: hay gp nht bnh nhn ln
tui l kh th, mt kh nng gng sc. Cc triu chng
thng lin quan n mc ca lung thng tri
phi, p lc v sc cn ca ng mch phi.
B. Triu chng thc th: Nghe tim l du hiu ch yu
chn on. Thng nghe thy c ting thi ton tm
thu, cng mnh cnh c tri, tng i thp v lan
ra tt c xung quanh. Ting thi ny c th nh hn
nhng c m sc cao hn trong cc trng hp l thng
nh phn c v c th ch lan ra mm hay sang tri nu
l TLT mm tim. Nu l TLT qu ln, c th nghe thy
487
C. Chn on phn bit trn lm sng vi h van ba l,

t chng Fallot khng tm (Fallot trng), hp di van
ng mch phi n thun v bnh c tim ph i.
A. in tm (T): thy hnh nh tng gnh bung
tim tri vi dy tht tri, dy nh tri. Trc tri hay gp
trong cc trng hp TLT phn bung nhn hoc ng nh
tht chung. Dy tht phi v trc phi gp trong cc
trng hp tng gnh bung tim phi vi tng p ng
mch phi.
B. Chp Xquang tim phi
1. Hnh tim khng to v h mch phi bnh thng hay
thy cc trng hp TLT l nh khng gy tng p
ng mch phi.
2. Tim to va phi vi gin cung di tri. i khi thy
du hiu gin cung MP. Tng ti mu phi hay
gp cc bnh nhn c lung thng tri phi ln.
3. Bng tim khng to nhng c du hiu huyt phi
nhiu thng gp trong cc trng hp TLT l rng
c tng sc cn mch phi c nh (hi chng
Eisenmenger).
C. Siu m tim
1. Hnh nh gin tip: Kch thc bung tim tri v
thn MP u gin.
2. Hnh nh trc tip ca l TLT trn siu m 2D:
mt ct trc di cnh c tri (TLT phn phu); mt
ct qua cc gc ng mch (TLT quanh mng, phu);
488
mt ct di c, bn bung t mm (TLT phn c,

quanh mng v bung nhn).
Hnh 28-2. TLT phn quanh mng: mt ct cnh c trc

ngn (hnh tri) v mt ct 5 bung tim t mm (hnh phi).
3. nh gi mc ca dng shunt: dng shunt tri
phi ln khi gin bung nh tri, tht tri v MP.
o chnh p qua l TLT nh gi p lc MP
(nu khng c cn tr ng ra tht phi) v mc
bnh. Nu chnh p cn ln chng t l thng nh v
khng c qu ti tim phi. Cn nh o huyt p ng
mch khi lm siu m Doppler tim.
4. Trong trng hp p lc MP tng c nh: thnh
tht phi dy, dng chy qua l TLT yu hoc hai
chiu, p lc MP tng nhiu gn bng hay vt p
lc i tun hon.
5. Siu m Doppler tim cn cn phi loi tr cc tn
thng phi hp nh thng lin nh, cn ng ng
mch, h ch, cn tr ng ra tht phi v tht tri.
D. Thng tim
1. Ch nh:
a. Cc trng hp TLT vi cc du hiu qu ti ca
tht tri (tim to, thi tm trng mm tim, suy
tim huyt) hoc tng p MP m cn phi c
cc bng chng khng nh mc lung shunt,
489
b. Cc trng hp TLT vi nghi ng c cc tn

thng khc phi hp nh h ch, hp ng ra
tht phi, hp di van MC... cng l cc trng
hp c th ch nh thng tim.
c. Thng tim ng l TLT bng dng c
(Amplatzer, Coil, Buttoned device...).
2. Chp bung tim:
a. Chp bung tht tri s gip xc nh chnh xc
v tr, kch thc ca l thng lin tht v c bit
gip cho chn on thng lin tht c nhiu l.
T th chp hay dng nht l nghing tri 45 700, nghing u 250. Tuy nhin ty loi l thng
c th thay i cht t. TLT kiu quanh mng:
thy r nghing tri 60-450. TLT phn c, ra
pha trc chp nghing tri 450. TLT kiu di
cc gc ng mch ln chp t th nghing 900
v nghing phi.
b. Chp MC xc nh c h ch phi hp hay
khng? 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
vim ni tm mc nhim khun (rt d xy ra vi cc

trng hp TLT).
B. ng l thng qua da bng dng c
Hin nay c th ch nh cc trng hp TLT l nh
phn c, mm hoc sau NMCT c bin chng. Tng
lai nhiu loi dng c ang c nghin cu ng
TLT phn quanh mng-bnh bm sinh c tn sut gp
cao nht.
C. iu tr ngoi khoa
ng l TLT c th thc hin bng phu thut tim h vi
tun hon ngoi c th (ng m dc xng c). Cn
lu c mt t l kh ln l TLT c th t ng li.
1. i vi cc l thng b, shunt nh, p lc MP bnh
thng cn theo di nh k thng xuyn hng nm,
phng chng vim ni tm mc nhim khun. Nguy
c gp nhm ny l Osler, h ch (TLT phn phu)
v hp phn phu MP (TLT phn quanh mng).
2. Khi l thng lin tht ln s nh hng r n ton
trng tr di 6 thng: iu tr ni khoa vi li tiu,
tr tim, c ch men chuyn. Nu khng p ng vi
iu tr ni th cn ng l TLT.
3. Khi l TLT ln, nh hng r n ton trng tr
trn 6 thng th cn phu thut ng l TLT.
4. Khi l thng ln, c tng p MP trn 50mmHg tr
hn 6 thng: phu thut ng l TLT.
5. Khi l TLT phi hp vi h van MC va hoc hp
ng k ng ra tht phi th cn phu thut ng l
TLT.
491
6. Nu TLT c nhiu l, c nh hng n ton trng

th cn lm phu thut nh ai (banding) MP cc
tr nh di 6 thng v sau phu thut sa cha
ton b.
Tin trin ca TLT nu c ng kn (bng phu
thut hay ng l thng qua da) c th coi nh bnh
nhn c cha khi hon ton. Ri lon nhp cc
bnh nhn ny l hn hu nh bloc nh tht sau phu
thut.
7. Cc trng hp TLT nghi ng c tng p MP c
nh: cn thng tim vi nghim php th xy v
thuc gin mch, chp mao mch phi, o sc cn
mch phi v cui cng c th sinh thit phi. Nu
sc cn mch phi khng tng c nh th c th
phu thut, nu tng c nh th l mt chng
ch nh ca phu thut. Trong trng hp nghi ng
c th phu thut nh ai MP v lm li cc thm
d sau vi nm. i vi cc trng hp khng cn
ch nh m na th thng din bin c th nng ln
bng cc du hiu suy tim phi, hn ch gng sc, a
hng cu vi biu hin tm nhiu da v nim mc.
Cc bin chng c th gp l chy mu phi, pxe
no v t t. Gii php iu tr ch ng duy nht
trong trng hp ny l phu thut ghp c tim v
phi cho ngi bnh.
Ti liu tham kho
1.
Brecker SJD. Ventricular septal defect. In: Redington A, Shore D,

492
2.
Bridges ND, Perry SB, Keane JF, et at. Preoperative transcatheter

closure ofcongenital muscular ventricular septal defects. N Engl J
Med 1991;324:1312-1317.
3.
Connelly MS, Webb GD, Sommerville J, et at. Canadian Consensus

1998;14:395-452.
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.
Folkert M, Szatmari A, Utens E, et at. Long-term follow-up after

surgical closure of ventricular septal defect in infancy and
childhood. J Am Coll Cardiol 1994;24:1358-1364.
6.
Gumbiner CH, Takao A. Ventricular septal defect. In: Garson A,

Bricker JT, Fisher DJ, Neish SR, eds. The science and practice of
pediatric cardiology; 2nd ed. Baltimore: Williams & Wilkins,
1998:1119-1140.
7.
Lock JE, Block PC, McKay RG, et at. Transcatheter closure of

ventricular septal defects. Circulation 1985;78:361-368.
8.
Mahoney LT. Acyanotic congenital heart disease: a trial and

ventricular septal defects, atrioventricular canal, patent ductus
9.
Moore JD, Moodie DS. Ventricular septal defect. In: Marso SP,
10. O'Fallon MW, Weidman WH, eds. Long-term follow-up of

congenital aortic stenosis, pulmonary stenosis, and ventricular septal
defect. Report from the Second Joint Study on the Natural History of
Congenital Heart Defects (NHS-2). Circulation 1993;87[Suppl II]:II1-II-126.
11. O'Laughlin MP, Mullins CE. Transcatheter closure of ventricular
septal defect. Catheter Cardiovasc Diagn 1989;17:175-179.
493
12. Perloff
JK.
Survival
patterns
without
cardiac
surgery
or

Child JS, eds. Congenital heart disease in adults, 2nd ed.
pediatric heart disease, 2nd ed. St. Louis:Mosby, 1997:246-265.
14. Somerville J. How to manage the Elsenmenger syndrome. Int J
Cardiol 1995;63:1-8.
494
Cn ng ng mch
Cn ng ng mch (COM) (TBS) chim khong 10%

cc bnh tim bm sinh (1 trong 2000 n 5000 tr s sinh).
Dng shunt thng nh v t triu chng lm sng, tr khi c
bin chng.
Din bin t nhin ca bnh ph thuc vo kch thc ca
ng ng mch v mc dng shunt triphi. Nu khng
c iu tr c th dn n suy tim huyt do qu ti bung
tim tri. Trong thc t rt t gp ng ng mch t ng sau khi
tr ra i (tr cc trng hp rt sm) m thng phi ng ng
bng phu thut hay ng qua da bng dng c. Nu ng ng
mch qu mun m cha c can thip nh ngi trng
thnh th c th gp cc ri lon nhp nh cung nh hoc rung
nh, vim ni tm mc nhim khun, tng sc cn mch phi c
nh (hi chng Eisenmenger).
I. Gii phu bnh
A. Thng thng ng ng mch s t ng t gi th 15
n gi th 16 sau khi sinh. Cc yu t thc y vic
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
phi, ng ng mch c th xut pht t pha trc ni

hnh nh soi gng ca thn ng mch khng tn tri
hoc t pha sau ng mch di n tri bt thng
hoc him gp hn l t quai MC bn tri.
II. Sinh l bnh
A. Lung thng ca ng ng mch thng nh, nhng i
khi lung thng ln c th gy qu ti phi v tng gnh
nh tri, tht tri. Cui cng c th dn n huyt phi
v suy tim huyt, tng p MP, hi chng
Eisenmenger.
B. Rt hay gp hin tng huyt phi, d dn n vim
phi v c th gy Osler bt k loi ng ng mch
no. N cn lm gim p lc tm trng ca ng mch
ch do hiu ng ca dng pht ngc tm trng.
C. Tn thng phi hp hay gp l: Hp MC bm sinh,
hp eo MC. Nu c TLT phi hp: c th che lp ting
tm trng ca ting thi lin tc do thi tm thu ca
TLT qu to. Khi hp eo MC phi hp hp MP: hi
chng Rubella.
A. Triu chng c nng: Cng nh cc bnh tim bm
sinh khng tm khc, ng ng mch rt t cc triu
chng c nng c hiu. Cc du hiu c th gp l gim
kh nng gng sc, kh th...
B. Triu chng thc th
1. Nghe tim l du hiu ch yu chn on:
a. Nghe thy c ting thi lin tc cng ln
di xng n bn tri. Ting thi ny c th
ch c trong th tm thu, hi ko di ra trong th
tm trng trong cc trng hp ng ln v c
tng p MP nhiu. Ngoi ra c th nghe thy
ting thi nh trong cc trng hp ng nh.
496
tr s sinh, ting thi thng v tr thp v

thng ch c th tm thu.
b. C th nghe thy ting rung tm trng do tng
lu lng mu qua van hai l.
c. Nu lung shunt ln gy tng p MP th c th
thy ting thi nh i, khng ko di v c ting
th hai mnh ln.
2. Mch ngoi bin ny mnh v chm su, hay gp
du hiu ny khi dng shunt tri phi ln.
3. Mm tim xung thp v sang tri do gin bung tim
tri. Nu bnh nhn c tng p MP, tht phi s
gin vi mm tim sang phi.
C. Chn on phn bit: vi d ng-tnh mch phi,
d ng mch vnh vo cc bung tim bn phi, d ng
tnh mch h thng, v ti phnh xoang Valsalva, thng
lin tht vi h van ng mch ch phi hp, tun hon
bng h ch-phi cc bnh nhn thng lin tht vi
thiu sn van ng mch phi...
A. in tm (T): thng khng c hiu, c th
thy hnh nh tng gnh bung tim tri vi trc tri v
dy tht tri. Ph i tht phi c th thy giai on
mun vi tng p MP nhiu.
B. Chp Xquang tim phi: tim to va phi vi gin cung
di tri. i khi thy du hiu gin cung MP. C th
thy gin nh tri vi hnh nh hai b. Hnh nh tng ti
mu phi cng hay gp. Phim Xquang c th cho ta thy
s b mc nh hng n huyt ng ca bnh.
C. Siu m Doppler tim
1. Hnh nh trc tip ca ng ng mch trn siu m
2D thy c mt ct trn c v qua cc gc ng
mch ln. o ng knh v nh gi hnh thi ca
ng. Siu m Doppler mu xc nh chnh xc v tr
497
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.
Hnh 29-1. Hnh nh ng ng mch: mt ct cnh c

trc ngn (hnh tri) v mt ct hm trn c (hnh phi).
Hnh 29-2. Dng

chy qua ng ng
mch trn siu m
Doppler mu.
3. nh gi mc ca dng shunt: dng shunt

tri phi ln khi thy gin bung nh tri, tht tri
v thn MP. Cn nh gi p lc MP tng c
nh cha, dy ca thnh tht phi, dng chy qua
ng ng mch yu hoc hai chiu, p lc MP tng
nhiu gn bng hay vt p lc i tun hon.
498
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
khn c th dng dy dn iu khin. Khi ly
mu mu cn phi ly on xa ca cc nhnh
MP do dng shunt thng chy lch, nn
bo ho xy thn v on gn ca MP khng
phn nh ng bo ho xy c nh ca MP.
Nu c tng p MP nhiu c th s dng cch
ng ng ng mch tm thi bng bng v theo
di p lc MP trong khi bm bng, nu p lc
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
xy MC xung s thp hn MC ln,

lc ny khng cn ch nh ng ng.
c. Chp bung tim: bng cch bm trc tip thuc
cn quang vo ng ng mch t th ngang 900.
Nu nghi ng hp eo MC cng chp MC t
th ny. ng ng ng mch cng dng t th
ny nhng bm thuc t MC sang MP.
V. Ch nh iu tr
1. Ch nh ng ng ng mch l bt buc nu cn
dng shunt tri phi.
2. ng bng thuc: s dng prostaglandine trong cc
trng hp tr s sinh (bit dc l Indocid 0,2mg/kg
c th tim nhc li sau 8 gi). Cn ch l thuc
cng c th gy suy thn hoc hoi t rut.
3. ng qua da bng dng c: C th dng coil hay
cc loi dng c th h mi khc nh: Amplatzer,
Buttoned Device, CardioSeal... Coil thng c ch
nh trong cc trng hp ng ng mch kch thc
b trn phim chp (di 4mm). Cn cc dng c
khc dc bit l Amplatzer th rt tt cho cc trng
hp ng ln, ngn.
Hnh 29-3. ng ng ng mch bng Amplatzer.

4. ng ng ng mch bng phu thut theo ng
bn sau ca lng ngc. Hin nay ti Vit Nam vn l
phng php iu tr ch yu nhng trong tng lai
500
gn y th ch l phng php c la chn th hai

sau khi khng ng c ng qua da hoc khi c cc
d tt bm sinh khc phi hp cn phu thut.
5. Phng vim ni tm mc nhim khun cn ko di
6 thng sau khi ng ng bng phu thut hay bng
dng c qua ng ng thng.
Ti liu tham kho
1.
Burke RP, Wernovaky G, van der Velde M, et al. Video-assisted

thoracoscopy surgery for congenital heart disease. J Thorac
Cardiovasc Surg 1995;109:499-505.
2.
Connelly MS, Webb GD, Sommerville J, et al. Canadian Consensus

1998;14:395-452.
3.
Fisher RG, Moodie DS, Sterba R, Gill CC. Patent ductus arteriosus
in
adults:
long-term
follow-up-nonsurgical
versus
surgical
management. J Am Coll Cardiol 1986;8:280284.

4.
Harrison DA, Benson LN, Lazzam C, et al. Percutaneous catheter

closure of the persistently patent ductus arteilosus in the adult. Am J
Cardiol 1996;77:1084-1097.
5.
Ing FF, Mullins CE, Rose M, et al. Transcatheter closure of the

patent ductus arteriosus in adults using the Gianturco coil. Clin
Cardiol 1996;19:875-879.
6.
Mahoney LT. Acyanotic congenital heart disease: atrial and

ventricular septal defeczs, atrioventricular canal, patent ductus
7.
Moore JD, Moodie DS. Patent ductus arteriosus. In: Marso SP,
8.
Mullins CE, Pagotto L. Patent ductus arteriosus. In: Garson A,

Bricker JT, Fisher DJ, Neish SR, eds. The science and practice of
501
pediatric cardiology, 2nd ed. Baltimore: Williams & Wilkins,

1998:1181-1197.
9.
Perloff
JK.
Survival
patterns
without
cardiac
surgery
or

10. Schenk MH, 0 Laughlin MP, Rokey R, et at. Transcatheter occlusion
of patent ductus arteriosus in adult patients. Am J Cardiol
1993;72:591-595.
502
Bnh van ng mch phi
Van ng mch phi l van t chim ngn cch ng mch

phi vi tht phi. Ri lon hot ng van ng mch phi s
gy tc ng c hi ln chc nng ca tht phi. Bnh thng, t
l h van ng mch phi pht hin bng siu m Doppler tim
ngi bnh thng kh cao, song ch c mt s t bnh l van
ng mch phi (h hoc hp) thc s gy nh hng n tnh
trng huyt ng ca tim phi v gy ri lon chc nng tht
phi.
I. Hp van ng mch phi n thun (HP)
A. Triu chng lm sng
1. Cc triu chng suy tim phi v kh th khi gng sc
thng xut hin tui 30-40 nu bnh khng c
pht hin v iu tr t trc.
2. Triu chng in hnh l ting thi tm thu tng mu
khoang lin sn 3-4 tri, gim cng khi ht
vo (do gim chnh p qua van ng mch phi)
ng thi gim cng hoc mt hn ting T2.
3. Triu chng suy tim phi biu hin giai on mun.
B. in tm
1. Hnh nh in tim bnh thng nu HP nh.
2. Trc phi, dy tht phi khi HP mc t va-nng.
Mc dy tht phi trn in tim c lin quan kh
cht vi mc nng ca HP. Trng hp hp kht
van MP, c th gp hnh nh dy nh phi.
C. Chp tim phi: bng tim khng to, cung ng mch
phi phng r (gin MP sau hp), mu ln phi t. Bng
tim s to khi c suy tim.
D. Nguyn nhn
503
1. Hp van ng mch phi bm sinh l dng bnh l

hay gp nht (chim t l 10% trong s cc bnh tim
bm sinh).
2. Di chng thp tim: dnh mp van gy hp van. Cn
lu rng van ng mch phi l van t b nh hng
nht do bnh thp tim.
3. Hp th pht do hi chng u carcinoid gy thm
nhim l van MP.
4. Gi hp van ng mch phi trong trng hp tc
nghn ng tng mu tht phi do u trong tim hoc
ti phnh xoang Valsalva.
E. Chn on:
1. Siu m Doppler tim rt c gi tr chn on xc
nh v lng gi mc hp van ng mch phi.
a. Van ng mch phi thy r nht mt ct trc
ngn cnh c tri hoc di sn. Nu hnh nh
qua thnh ngc c cht lng km, c th dng
siu m tim qua thc qun.
b. Siu m Doppler tim cho php nh gi tnh trng
van ng mch phi (van dy, vi, hn ch vn
ng ngi ln; l van khng vi, m dng vm
tr con) v tht phi (bnh thng hoc ph i
ph thuc vo mc hp van ng mch phi
v thi gian b bnh).
2. Mc hp van ng mch phi c phn loi da
trn chnh p ti a nh-nh qua van ng mch
phi o bng ph Doppler lin tc (tnh theo cng
thc ca Bernoulli). Hin ti, siu m Doppler tim
c xem nh mt phng php chun nh gi
mc hp van (tng quan rt cht so vi tiu
chun vng l thng tim). Hp van MP chia thnh
cc mc nh sau:
a. Hp nh: khi chnh p ti a qua van MP < 40
mmHg
504
b. Hp va: khi chnh p ti a t 40 n 80 mmHg

c. Hp kht (nng): khi chnh p ti a 80 mmHg.
F. iu tr
1. Hp van ng mch phi mc t nh n va c
tin lng rt tt v rt t khi cn can thip.
2. Hp van ng mch phi nng hoc suy tim phi th
pht thng biu hin sau tui 40 hoc 50 d c
nhiu dng bnh biu hin ngay t nh. Phng php
iu tr chnh l nong van ng mch phi bng bng
qua da, c kt qu kh quan, ni chung gim c
75% chnh p qua van. Tin lng lu di v t l
sng cn sau can thip hon ton ph thuc vo tnh
trng chc nng tht phi khi nong van.
3. Hp van ng mch phi th pht do hi chng
carcinoid c tin lng rt xu (thi gian sng st
trung bnh sau khi chn on bnh ch c 1,6
nm), hu nh khng p ng vi nong van bng
bng nn ni chung phi thay van.
II. H van ng mch phi (HoP)
A. Triu chng 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
3. Ngoi ra c th pht hin c cc triu chng ca

suy tim phi.
B. Nguyn nhn
1. Khc vi hp van, h van ng mch phi rt t khi
do nguyn nhn bm sinh nh khng c l van, thiu
sn hay thng l van MP.
2. Thng gp l cc bnh tim mc phi gy h van
ng mch phi: hng u l hp van hai l, u nhy
nh tri gy tng p lc ng mch phi, sau l do
vim ni tm mc nhim khun. U carcinoid hoc
thp tim cng c th gy HoP song thng gy hp
van nhiu hn. Cn gp HoP th pht trong hi
chng Marfan do gin ng mch phi.
C. Chn on: ch yu bng siu m Doppler tim.
1. Van ng mch phi nhn thy r nht mt ct trc
ngn cnh c tri hoc di sn. a s ngi bnh
thng u c mt dng pht ngc nh do h van
ng mch phi rt nh. Dng HoP ny ch c coi
l ng k khi pht su vo tht phi 1-2 cm v ko
di 75% thi k tm trng. Doppler xung cng c
th dng thm d dng pht ngc trong thi k
tm trng.
2. Khng gim vn tc dng h trong thi k tm
trng l du hiu gi tng p lc ng mch phi
gy ra h van. Biu hin khc ca tng p lc ng
mch phi trn siu m tim l hin tng mt sng a
v s ng nh van MP gia tm thu trn siu m
TM cng nh trn ph Doppler dng chy qua van.
3. p lc MP tm thu c th c tnh da trn ph
Doppler ca dng h van ba l. p lc MP cui tm
trng (ALMPCTTr) c th tnh c khi ghi c
ph ca h van ng mch phi, da theo cng thc:
506
ALMPCTTr = 4(VPR-E)2 + ALTP

Trong ALTP l p lc tht phi v thng = 10
mmHg; VPR-E l vn tc dng HoP cui tm trng.
Tng t nh vy, ta cng c th tnh c p lc
trung bnh ca MP (ALMPTB) cn c vo vn tc
u tm trng ca dng h phi da theo cng thc
sau:
ALMPTB = 4(VPR-P)2 + ALTP
Trong ALTP l p lc tht phi v thng = 10
mmHg; VPR-P l vn tc dng HoP u tm trng.
4. Hin tng gim vn tc dng h phi k tm
trng thng gi c d dng ca van MP.
D. iu tr
1. H van ng mch phi tin pht c tin lng rt
tt, t khi cn x tr tr phi gy ra suy tht phi.
2. H van MP th pht: tin lng hon ton ph
thuc vo din bin ca bnh chnh nh hp van hai
l kht, vim ni tm mc nhim khun, u carcinoid,
tng p lc ng mch phi... iu tr ngoi khoa
bng thay van hoc sa vng van ng mch phi ch
c p dng trong mt s trng hp rt hn hu.
III. Ti liu tham kho
1.
2.
3.
4.
Braunwald E. Heart disease: a textbook of cardiovascular medicine,

5th ed. Philadelphia: WB Saunders; 1997.
Cheitlin MD, MacGregor JS. Acquired tricuspid and pulmonary
valve disease. In: Topol EJ, ad. Textbook of cardiovascular
medicine. Philadelphia: Lippincott-Raven Publishers, 1998:557-578.
Feigenbaum H. Echocardiography, 5th ed. 1994. Baltimore:
Williams & WilkinB.
Reynolds T. The echocardiographer's pocket reference. Arizona
Heart Institution Foundation, 1993:23-29.
507
5.
6.
508
Topol EJ, ad. Textbook of cardiovascular medicine. Philadelphia:

Weyman AE. Principles and practice of echocardiography, 2nd ad.
Philadelphia: l,ea & Febiger, 1994:chapter 26, 824-862.
T chng Fallot
T chng Fallot l bnh tim bm sinh c tm hay gp nht,

chim khong 10% cc bnh tim bm sinh. C th chn on
c bnh ny t trc khi sinh bng siu m tim thai.
Din bin t nhin ca bnh thng l tm ngy cng tng,
i khi c cn mt xu. Chn on lm sng hay da vo cc du
hiu tm da, ting thi cao ca hp ng mch phi, phi sng
v tng gnh tht phi. Siu m tim thng gip khng nh chn
on.
Phu thut sa ton b c kt qu tt tr t 6 n 9
thng. Phu thut sa ton b hoc lm cu ni cp cu trong
trng hp c cn xu, ngt do thiu oxy. T l t vong khi phu
thut thp, tin lng tt.
T chng Fallot l bnh tim bm sinh hay i km vi cc
tn thng ngoi tim. C th c lin quan n: hi chng nhim
c ru bo thai, hi chng Goldenhar, hi chng Cardiofacial,
hi chng c 3 nhim sc th 21 (thng i cng vi ng nh
tht chung) v c th c tnh cht gia nh.
I. Gii phu bnh
A. T chng Fallot gm 4 chng
Hp ng ra ca ng mch phi (MP).
Thng lin tht (TLT).
ng mch ch (MC) lch sang phi v ci
nga ngay trn l thng lin tht.
Ph i tht phi.
1. Trong s cc chng ny th 2 "chng" quan trng
nht l hp ng ra ca MP v TLT. Hp ng ra
MP c rt nhiu th nhng bao gi cng c hp
phn phu MP. Hp c th di hay ngn, cao hoc
thp, kht hoc va. Ngoi ra c th hp ng ra
MP phi hp vi hp van MP, hp trn van v cc
509
nhnh MP. C th hp va hoc hoc rt kht, thm

ch thiu sn nhnh MP. L TLT trong Fallot 4
thng rt rng, b ca c, ngay pha di ca ca
Wolf (loi quanh mng chim khong 80% cc
trng hp).
2. Chnh do 2 thng tn hp MP v TLT ny s dn
n ph i tht phi, dng shunt t phi tri s c
xu hng ko ng mch ch lch sang phi v dn
dn "ci nga" trn l TLT. Mc lch phi ca
MC ph thuc vo 2 yu t: kch thc ca MC
v kch thc ca l thng lin tht (t l thun vi 2
thng s ny).
B. Cc thng tn phi hp
1. MC quay phi (25% cc trng hp).
2. Hp MP (10 - 20%).
3. Thiu sn MP vi nhiu tun hon bng h (510%).
4. TLT phn c phi hp (5 - 10%).
5. Tun hon bng h ch - phi (5- 10%).
6. Bt thng MV (1 - 2%) trong hay gp l
MVLTT bt u t MV phi. y c th l mt
kh khn cho phu thut t chng Fallot.
II. Sinh l bnh
A. Hp MP ngn cn dng mu ln MP v gy ra ting
thi tm thu van MP. Tng gnh bung tim phi do
hp MP, tuy nhin tn thng ny c dung np tt
nh c l thng lin tht rng do mu s c "thot"
sang i tun hon (do p lc tm thu bung tim phi cn
bng vi p lc i tun hon).
B. Lung thng qua l TLT s lin quan n mc hp
MP v sc cn ca h mch i tun hon. Khi tc
nghn ca ng ra tht phi tng ln (theo thi gian s
pht trin ca c vng ph i tng) v sc cn ca h
mch i tun hon gim (v d khi gng sc) dng shunt
510

A. Bnh s: mc tm nhiu hay t thng ph thuc vo
mc hp ng mch phi. Tm thng i km vi
gim vn ng. Tm c c im l khng hng nh,
tng ln khi gng sc hoc khi lnh. Cn tm kch pht
km ngng th v ngt, c th dn n t vong, co git
v li triu chng thn kinh, nhng thng hi phc.
Du hiu ngi xm v du hiu ngn tay di trng cng
thng gp trn lm sng.
B. Khm lm sng
1. Ting thi tm thu tng mu (do hp ng mch
phi): cng t 3 n 5/6, thng nghe thy
khoang lin sn II - IV st b tri xng c. C th
nghe c ting clc tng mu MC, ting T2 mnh
duy nht. Nu T2 tch i, loi tr chn on teo tt
van MP. i khi c th nghe c thi lin tc di
xng n (do cn ng ng mch), hoc vng
lng (do tun hon bng h ch - phi).
2. Tm nhiu da v nim mc; ngn tay di trng rt
thng gp.
3. th khng tm: thi tm thu do TLT v hp phu,
c th nghe c dc b tri xng c v bnh nhn
khng tm (du hiu lm sng ca Fallot 4 khng tm
ging vi TLT shunt nh).
A. Xquang ngc
1. Bng tim bnh thng vi mm tim ln cao, cung
gia tri lm, ph trng sng.
2. 20% quai MC bn phi kh qun.
511
B. in tm : ph i tht phi n thun, ph i 2 tht

c th gp th khng tm.
Hnh 31-1. Hnh phim Xquang tim phi thng.

C. Siu m Doppler tim
1. TLT rng, cao, thng l phn quanh mng.
2. MC gin rng c hnh nh ci nga ln VLT.
3. Hp MP: hp phu, van MP (phi o c ng
knh vng phu, vng van v 2 nhnh MP). Siu m
Doppler khng nh mc hp ng mch phi
bng cch o chnh p qua phu v van MP (p lc
MP thng bnh thng).
Hnh 31-2. Mt ct trc dc vi hnh nh thng lin tht

cao (mi tn) v MC ci nga r.
512
4. Cn phi thm d trn siu m xem c hay khng cc

tn thng sau: hp cc nhnh MP, thng lin tht
nhiu l, thng lin nh, dng chy lin tc trong
MP chng t cn ng ng mch hoc tun hon
bng h ch phi.
5. Xc nh cc tn thng phi hp nh thng lin nh,
thng lin tht phn c...
D. Thng tim
1. Ch nh: Trc phu thut tt c bnh nhn t
chng Fallot nn c thng tim xc nh s tc
nghn ca ng ra tht phi, c hp MP on gn
hay cc nhnh ca n hay khng, v loi tr cc bt
thng v v tr xut pht v ng i bt thng (nu
c) ca ng mch vnh.
2. Cc thng s huyt ng:
a. o bo ho xy c th thy dng shunt 2
chiu qua l TLT vi bc nhy xy tht phi
v gim bo ho xy tht tri cng nh MC.
b. p lc tht phi, tht tri v MC bng nhau do
l thng lin tht rng.
c. Hp ng mch phi thng mc va, vi p
lc MP t mc thp n bnh thng.
3. Chp bung tim:
a. Chp bung tht phi t th nghing phi 30o,
quay ln u 25 v t th nghing tri 60o
n 70o, chch u 250. T th nghing phi s
thy ng ra tht phi v MP, t th nghing
tri s thy l thng lin tht. Nu cha r, c th
chp t th nghing tri nh 30o v chch u
25o, t th ny thy r MP v ch phn i.
b. Chp bung tim tri (nghing phi v/hoc
nghing tri 60-75o chch u 25o) nh gi chc
nng tht tri v xc nh cc dng ca l TLT.
513
c. Chp MC t th nghing phi, nghing tri v

chp MV chn lc l cn thit v t l bt
thng ca n kh thng gp bnh nhn Fallot
4 (ch ng mch lin tht trc).
d. Nu c nghi ng shunt t MC - MP cn chp
MC xc nh cu trc ny (nh chp chn
on cn ng ng mch).
V. Tin trin t nhin
A. Tm ngy cng tng vi cc hu qu:
1. a hng cu, nguy c gy TBMN, nht l nhng
trng hp hng cu nh, s lng hng cu ln hn
7 triu/mm3. Tng hng cu lm thay i cc xt
nghim v ng mu v gim tc mu lng.
2. Thng c ngn tay di trng.
3. Hn ch hot ng th lc do thiu xy mn tnh.
4. Bnh nhn rt d b p xe no, hu qu ca shunt phi
sang tri.
5. Thay i tun hon mao mch phi.
6. Bnh c tim th pht c th c sau nhiu nm tin
trin (10 - 20 nm).
7. Bnh nhn rt d b lao phi do gim tun hon phi.
B. Cn thiu xy: thng xut hin vo bui sng khi
ng dy hoc sau gng sc: khc, cu gin, kch thch
au, st... Cn thiu xy thng c lp vi mc tm
v c th dn n t vong hoc b TBMN. Cn thiu xy
thng bt u bng pha "cng" vi kch thch, khc,
tm tng ln v nhp tim nhanh. Sau l pha c ch":
da xm v nht, th nhanh v su do toan chuyn ho,
nhp tim nhanh vi gim hoc mt ting thi do hp ng
mch phi, gim trng lc c. Nu cn qua i, tr s
ng v bnh tnh li.
514
VI. iu tr t chng Fallot

A. iu tr d phng: pht hin v iu tr thiu mu
thiu st tng i, phng thiu mu hng cu nh ca
ph n mang thai.
B. iu tr cn thiu xy
1. a tr ln vai hoc cho tr ngi u gi vo
ngc.
2. Morphin sulfat 0,1 - 0,2 mg/kg tim di da hay tim
bp c ch trung tm h hp, ct cn kh th
nhanh, khng nn c gng tim tnh mch m nn s
dng ng tim di da.
3. iu tr nhim toan bng natri bicarbonate 1 mEq/kg
tnh mch, nhm lm gim kch thch trung tm h
hp do toan chuyn ho.
4. Th xy cn hn ch v trong bnh l ny c gim
dng mu ln phi ch khng phi do thiu cung cp
xy t ngoi vo.
5. Nu khng p ng vi cc phng php trn, c th
dng Ketamin 1-3 mg/kg tim TM chm thng c
kt qu (gy tng sc cn i tun hon, an thn).
Thuc co mch nh Phenylephrine. (Neo synephrine) 0,02 mg/, Propranolol: 0,01 - 0,25 mg/kg
tim TM chm thng lm gim tn s tim v c th
iu tr cn thiu xy.
6. Ung Propranolol 2-4mg/kg/ngy c th dng
phng cn thiu xy v tr hon thi gian m sa
cha ton b. Hot tnh c li ca Propranolol l lm
n nh phn ng ca mch ngoi vi.
C. Phng vim ni tm mc nhim khun: Nh trong
cc bnh tim bm sinh c tm khc.
D. iu tr ngoi khoa
1. Phu thut tm thi: c ch nh tng dng
mu ln phi tr tm nng v khng kim sot c
cn thiu xy nhng bnh nhn m phu thut sa
ton b kh thc hin an ton v tr nh hay phu
thut sa ton b gp kh khn v mt k thut.
515
a. Cu ni Blalock Taussig (ni gia ng mch

di n v mt nhnh MP) c th thc hin
tr nh.
b. Cu ni Gore - Tex: ng Gore - Tex gia ng
mch di n v mt nhnh MP.
c. Phng php Waterston: ni gia MC ln v
MP phi nhng phng php ny khng cn
thng dng na do c nhiu bin chng.
d. Phu thut Potts: ni gia MC xung v MP
cng him khi c s dng. Tt c cc phu
thut to cu ni ch phi u c m ngc theo
ng bn, thi gian nm vin t 8 - 10 ngy; t
l t vong rt thp, bin chng c th gp l trn
kh, trn dch v dng chp mng phi; xon vn
nhnh ca MP l bin chng lu di c th gp.
2. Phu thut sa ton b: bao gm ng l TLT bng
ming v, m rng ng ra tht phi bng vic ct
t chc c phn phu, thng t mt ming patch
lm rng ng ra ca tht phi. C th m rng
vng van MP bng ming patch nu cn thit. Phu
thut c thc hin khi 2 nhnh MP v h lu pha
xa tt, khng c bt thng MV.
Phu thut c thc hin vi tun hon ngoi
c th v ng m dc gia xng c. Thi gian
nm vin trung bnh t 12 - 15 ngy v t l t vong 1
- 5%. Bin chng c th gp l bloc nh tht cp III,
l TLT tn lu, nht l cn hp ng mch phi.
3. Nong van MP: ch p dng trong trng hp hp
van ng mch phi, c nguy c gy cn thiu xy
nng. Ch ginh k thut ny cho nhng trng hp
c chng ch nh phu thut.
E. Ch nh iu tr
1. T chng Fallot thng thng (MP tt, MV bnh
thng, 1 l TLT) c tm nhiu v hng cu hn 6
triu/mm3: phu thut sa ton b bt k tui no.
2. T chng Fallot thng thng (MP tt, MV bnh
thng, 1 l TLT) vi cn thiu xy: phu thut tm
516
thi vi cu ni Blalock-Taussig hoc sa ton b ty

theo kh nng ca tng bnh vin.
3. T chng Fallot thng thng: phu thut sa ton b
c thc hin mt cch h thng khi tr c t 6 9 thng tui.
4. T chng Fallot c bit (hp nhnh MP, TLT
nhiu l), bt thng MV v d tt khc): Nu trc
2 tui th c th lm phu thut tm thi (cu ni
Blalock). Nu sau 2 tui th ty tng trng hp v
kh nng ca bnh vin m quyt nh phng php
iu tr thch hp cho tng ngi bnh.
F. Sau khi phu thut
1. Nu kt qu phu thut tt thng a bnh nhn tr
v cuc sng bnh thng. Khi c hn ch kh nng
gng sc th khng nn luyn tp th thao. C th c
h van ng mch phi do m rng phu gy tng
gnh tm trng tht phi. Theo di hng nm bng
siu m tim v Holter in tim c th thy s tin
trin ca hp ng mch phi hoc xut hin cc ri
lon nhp: ngoi tm thu hoc nhp nhanh tht...
Thng xut hin cc ri lon nhp nhng trng
hp cn hp MP.
2. Trong mt s trng hp, nht l nhng trng hp
MP m qu rng, suy tht phi do tng gnh tm
trng nhiu v trong vi trng hp do h van ng
mch phi nhiu.
3. Cc bc s tim mch s ngy cng gp nhiu cc bnh
nhn b Fallot 4 m, nhng vn cn tn ti hp
MP, cn l TLT, hoc h MP nng gy gin
bung tht phi, ri lon chc nng tht phi v h
van ba l (c nng hay thc th). Thng tim c th
c ch nh nu cc bt thng cn nng n c
ch nh m li. Ri lon nhp tht cng nh hng
nhiu n tin lng xa do cng c th c ch nh
thm d in sinh l cc bnh nhn Fallot 4 m
sa cha ton b.
517
Ti liu tham kho

1.
Connelly MS, Webb GD, Somerville J, et at. Canadian Consensus

1998;14:395-452.
2. Cullen S, Celermajer DS, Franklin RCG, et at. Prognostic
significance of ventricular arrhythmia after repair of tetralogy of
Fallot: a 12-year prospective study. J Am Coll Cardiol 1994;23:
1151-1155.
3. Harrison DA, Harris L, Siu SC, et at. Sustained ventricular
tachycardia in adult patients late after repair of tetralogy of Fallot. J
Am Coll Cardiol 1997;30:1368-1373.
4. Murphy JG, Gersh BJ, Mair DD, et at. Long-term outcome in
patients undergoing surgical repair of tetralogy of Fallot. N Engl J
Med 1993;329:593-599.
5. Nollert G, Fischlein T, Bouterwek 5, et at. Long-term survival in
patients with repair of tetralogy of Fallot: 36-year follow-up of 490
survivors of the first year after surgical repair. J Am Coll Cardiol
1997;30:1374-1383.
6. Yemets IM, Williams WG, Webb GD, et at. Pulmonary valve
replacement late after repair of tetralogy of Fallot. Ann Thorac Surg
1997;64:526-530.
7. Neches WH, Park S, Ettedgni JA. Tetralogy of Fallot and Tetralogy
of Fallot with pulmonary atresia. In: Garson A, Bricker JT, Fisher
DJ, Neish SR, eds. The science and practice of pediatric cardiology,
2nd ed. Baltimore: Wmiams & Wilkins, 1998:1383-1411.
8. Perloff JK. Survival patterns without cardiac surgery or
9. Redington A, Shore D, Oldershaw P. In: Tetralogy of Fallot.
Redingion A, Shore D, Oldershaw P, eds. Congenital heart disease
in adults: a practical guide. London: Mm Saunders, 1994:57-67.
pediatric heart disease, 2nd ed. St. Louis: Mosby, 1997:235-246.
11. Moore JD, Moodie DS. Tetralogy of Fallot. In: Marso SP, Griffin
BP, Topol EJ, eds. Manual of Cardiovascular Medicine.
518
Hp eo ng mch ch
L bnh tim bm sinh (TBS) cng thng gp, chim

khong 8% cc bnh TBS. Cn pht hin sm tr s sinh hay
tr nh v l bnh nguy him c th dn n t vong. Chn on
lm sng thng da vo du hiu khng c hay yu ca mch
bn so vi mch cnh tay, ting thi tm thu thng kh in
hnh. Hp eo MC rt hay i km vi cc bnh TBS phc tp
khc m c bit hay gp trong hi chng Turner (20%), hi
chng Noonan.
Cc bin chng mun ca bnh c th gp l phnh mch
ti ch hp, tch thnh ng mch ch ln, gin phnh v v cc
mch mu no, tng huyt p ng mch. Tng huyt p c th
cn tn ti ngay c sau khi phu thut sa cha ton b c bit
cc bnh nhn can thip mun.
I. Gii phu bnh
A. i a s cc trng hp hp eo MC nm ngay trc
v tr xut pht ca ng ng mch ngha l gn st vi
ch bt u ca MC xung. Thng gp c s ph i,
co tht thnh sau ca MC gy hp lng mch MC
v tr ny. Cng c th gp s thiu sn ca eo MC vi
cc mc khc nhau. Bnh c th t ngt hoc t t
dn n suy tim huyt tr nh. ng mch di n
tri thng xut pht ngay gn ch hp ca eo MC.
Trong mt s him cc trng hp, v tr hp nm
MC ngc hay MC bng.
B. Tun hon bng h thng gp bnh nhn ln tui.
in hnh nht l xut pht t ng mch di n, ng
mch v trong, gian sn, ng mch gip trng xung,
ng mch ch xung sau ch hp eo ng mch ch.
C. Cc tn thng phi hp: a s l cc bt thng
ca bung tim tri; van MC c 2 l van chim khong
519
50% cc trng hp, hp di van MC, bt thng hnh

dng van 2 l (hi chng Shone), TLT, ng nh tht
chung, tm tht duy nht, bt thng ch xut pht ca
ng mch di n phi.
II. Sinh l bnh
Hp eo MC dn n tng huyt p vi s chnh lch
huyt p tm thu tay v chn. Tng hu gnh do dn n
ph i tht tri v cui cng dn n gin bung tim tri v suy
tim tri dn n suy tim ton b vi tng p MP. Hp eo MC
mn tnh s dn n hin tng pht trin tun hon bng h t
MC ln sang MC xung.
A. Du hiu c nng: Hp eo ng mch ch pht hin
c ngi ln thng bi du hiu tng huyt p, au
u hay l du hiu au cch hi. i vi cc bnh nhn
tr tui hay phi nhp vin v cc t suy tim huyt.
B. Triu chng thc th
1. Mch chi trn ny mnh hn nhiu so vi mch chi
di. Nhng trng hp hp nng c th khng thy
mch bn. Tuy nhin mt s trng hp m ng
mch di n tri xut pht t ngay ch hp ca eo
MC th mch quay tri cng khng c hoc yu nh
ng mch bn. Cn trng hp ng mch di n
phi qut ngc thc qun, mch cnh tay phi cng
nh v M cnh phi p rt mnh.
2. Huyt p chi trn thng tng t l thun vi mc
hp eo MC. Cn phi o huyt p tay bn phi,
thng thch ng tt khi huyt p tm thu cha vt
qu 150mmHg.
3. Ting thi tm thu thng nghe thy vng di
n bn tri, c th lan ra lng v tr cnh ct sng.
Ngoi ra c th nghe thy cc ting thi lin tc do
tun hon bng h gy ra. Trong cc trng hp phi
520
hp vi van ng mch ch c hai l van chng ta c

th nghe thy ting thi tm trng, thi tm thu do
h, hp van MC gy nn.
A. in tm : Thng c du hiu tng gnh tht tri.
Nu c du hiu tng gnh tht phi nhng bnh nhn
hn 2 tui th cn tm cc tn thng phi hp.
B. Xquang ngc: C th bnh thng hay bin i nh vi
cung di tri gin. Kinh in c th thy du hiu 3
cung ng mch ch, quan st thy t th thng mt.
Sau vi tui c th thy cc du hiu c hiu hn nh:
du n xng sn, ch s tim ngc tng r rt.
Hnh 32-1. Du n sn trn phim tim phi thng.

C. Nghim php gng sc: C th thy du hiu tng
huyt p tm thu cc bnh nhn hp eo MC.
D. Siu m Doppler tim: L xt nghim quyt nh chn
on tr nh, tuy nhin c th gp kh khn cc bnh
nhn ln tui.
1. Siu m TM xc nh dy ca cc vch tim, sc co
bp ca tm tht tri.
2. Siu m Doppler mu v siu m 2D cho php xc
nh v tr v hnh thi ca ch hp eo MC, c bit
521
l tr nh. Siu m Doppler khng nh chn on

v o mc chnh p qua eo MC.
3. Siu m cn gip loi tr hay pht hin ra cc tn
thng phi hp. c bit cn pht hin mt s bt
thng nh van ng mch ch c hai l van, hp van
hai l, tc nghn ng ra tht tri v thng lin tht
phi hp.
4. Cn ch quan st trn siu m pht hin cc tn
thng ca ng mch ch bng, cung ng mch
ch v cc mch mu vng u v c. Siu m cng
c th pht hin s tn ti ca ng ng mch cng
nh cc tun hon bng h nu c.
E. CT Scanner xon c, 3 chiu v cng hng t
trng ht nhn (MRI) l nhng thm d rt hu ch
cho vic xc nh hnh thi ca ch hp eo MC, cc tn
thng phi hp, dng hp eo MC vi cc nhnh ca
ng mch di n, c hay khng c tun hon bng
h. Vi cc th h my mi chng ta cn c th quan st
hnh nh quay phim trn cng hng t, y l cc hnh
nh rt hu ch cho vic chn on v ra phng php
iu tr.
Hnh 32-2. Hp eo MC trn phim MRI v chp mch.

F. Thng tim v cc bc tin hnh thng tim
1. Thng tim v chp bung tim c ch nh khi:
522
a. Nghi ng c tn thng phi hp.

b. Cc thm d khng chy mu cha xc nh r
rng hoc khng thng nht v kt qu.
c. Xc nh mc tun hon bng h chun b
phu thut.
d. Can thip bng bng v Stent qua da.
2. K thut thng tim
a. Thng tim phi nu c tn thng phi hp ti
tim.
b. Thng tim tri qua ng ng mch i c th
gp kh khn khi qua ch hp eo nhng vi dy
dn mm thng vn c th thc hin c i
a s cc trng hp. Cn o chnh p qua eo
MC v chp MC.
c. Nu khng th qua ch hp ca eo MC theo
ng ng mch i th c th thng tim theo
ng ng mch cnh tay chp ch hp eo
MC v tun hon bng h.
d. bo ho xy v cung lng tim cn c o
trc khi phu thut.
3. Cc thng s huyt ng:
a. Hp eo MC c chn on khi c chnh p ln
hn hay bng 10mmHg gia MC ln v MC
xung.
b. Chnh p qua eo MC khng phi lun lun c
mi tng quan trc tip vi mc hp eo
MC, do c rt nhiu tun hon bng h pht
trin lm thay i thng s ny.
4. Chp ng mch:
a. ng thng ''ui ln'' c a n gn st ch
hp (pha trn). Chp t th nghing phi v
nghing tri.
b. Tun hon bng h cng hay thy c cc t
th ny.
523
c. Cc phim chp bung tim c th thc hin nu

nghi ng c bt thng bm sinh khc phi hp.
V. Tin trin t nhin
A. Suy tht tri c bit nhng trng hp hp nhiu c
th dn n din bin lm sng nng n ngay nhng
tun u tin ca tr (sau khi ng ng mch ng). Trn
lm sng thy du hiu suy tim tri vi ting nga phi
tri, ran phi; T, Xquang v siu m tim khng nh
du hiu qu ti bung tim tri. Din bin lm sng tip
theo thng rt nng n vi t l t vong cao. Vic iu
tr tch cc suy tim c th gip tr thot khi suy tim cp
nhng thng li hu qu trn tht tri v tng huyt
p ng mch (cnh tay) nng n. i vi cc trng hp
nhiu tui hn, suy tim tri thng din bin thm lng
vi kh nng thch ng tt, do vic b st chn on
c th gp v bnh nhn thng nhp vin khi c tht
tri gin nhiu.
B. Tng huyt p ng mch: Thng xut hin sau 15
ngy tui. Thng thng huyt p tm thu vn di
150mmHg. Nu huyt p tm thu t 150 n 200mmHg
th s c dy tht tri nhiu trn T, Xquang v siu
m tim. Nu huyt p tm thu trn 200mmHg, c th
thy du hiu m mt. Khi t tui 15 tr ln, tng huyt
p ng mch thng s tr nn c nh, khng gim
xung c sau khi iu tr nguyn nhn.
C. Bin chng khc c th gp l Osler. Phnh ng mch
ch ch xut hin sau mt thi gian di tin trin bnh.
VI. iu tr
A. iu tr ni khoa l iu tr triu chng nhm bo tn
bnh nhn chun b can thip. iu tr suy tim tri l
vn quan trng nht. i vi tr s sinh,
Prostaglandine E1 gip m ng ng mch s ci thin
nhanh chng triu chng lm sng. Thuc li tiu,
Digoxin v thng kh nhn to l cc bin php phi hp
524
B. Ch nh phu thut: trong cc trng hp:

1. Tr s sinh m iu tr ni khoa t kt qu.
2. Tr nh nhi v tr nh: c du hiu suy tim tri trn
lm sng v cn lm sng.
3. Tr c huyt p ng mch tm thu ln hn
150mmHg.
4. i vi cc trng hp hp eo MC khc th phu
thut mt cch h thng khi tr t 6 n 9 thng tui.
5. Vi ngi ln th ch nh can thip kinh in khi
chnh p qua eo MC ln hn 20 n 30mmHg. Tuy
nhin cn phi hp vi cc du hiu khc nh suy tim
xung huyt, ph i tht tri, tng huyt p kh khng
ch...
6. Trng hp ti hp eo ng mch ch sau khi can
thip th c nhiu trung tm ch nh nong bng bng
qua da c hay khng km vic t gi (Stent). Cc
nghin cu ngn hn ch ra kt qu kh tt, t bin
chng, tuy nhin vn cn phi c cc nghin cu lu
di hn khng nh vn ny.
C. Theo di
Tt c cc bnh nhn hp eo MC cn c theo
di lu di. Theo di bng lm sng (tnh trng suy tim
tri, tng huyt p, mch bn) v cn lm sng (S,
T) mi nm mt ln.
Ti liu tham kho
1.
Breelver SJD. Coarctation of the aorta. In: Redingion A, Shore D,

525
2.
3.
4.
5.
6.
7.
8.
9.
526
Connelly MS, Webb GD, Sommerville J, et al. Canadian Consensus

1998;14:395-452.
Ebeid MR, Prieto LR, Latson LA. Use of balloon expandable stents
for coarctation of the aorta: initial results and intermediate-term
follow-up. J Am Coll Cardiol 1997; 80:1847-1852.
Kaplan S. Natural history and postoperative history across age
groups. Cardiol Clin 1993;11:543-556.
Mathew P, Moodie D, Blechman C, Gill CC. Long-term follow-up of
aortic coarctation in infants, children and adults. Cardiol Young
1993;3:20-26.
Mendelsoha AM. Balloon angioplasty for native coarctation of the
aorta. J Intervent Cardiol 1995;8:487-508.
Moore JD, Moodie DS. Coarctation of the aorta. In: Marso SP,
Morriss MJH, McNamara DG. Coarctation of the aorta and
interrupted aortic arch. In: Carson A, Bricker JT, Fisher DJ, Neish
SR, eds. The science and practice ofpediatric cardiology, 2nd ed.
Baltimore: Williams & Wilkins, 1998:1317-1346.
Ovaett C, Benson LN, Nykanen, Freedom RM. Transcatheter
treatment of coarctation of the aorta: overview. Pediatr Cardiol
1998;19:27-44.

Thuc Hanh Lam Sang Tim Mach - Nguyen Lan Viet

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Trong tay cc bn l mt cun sch rt b ch v thc hnh trong chn

on v iu tr cc bnh tim mch thng gp. Tnh n gin, thc tin

Bnh tim mch

Bnh tim mch

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Chng ti hy vng cun sch Thc hnh Bnh Tim mch

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Tham gia bin son:

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1. au tht ngc khng n nh ......................................................... 1

27. Thng lin nh .................................................................................475

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au tht ngc khng n nh

au tht ngc khng n nh (unstable angina, TNK)

phng ra mt lot cc cht trung gian lm co mch v

Hnh 1-1. S nt ra ca mng x va trong TNK.

b. Chn on phn bit vi cc bnh nh vim mng

b. C 20 % bnh nhn khng c thay i trn T.

b. Cc men thng c dng theo di l CK v

Bng 1-3. Cc ch nh ca chp MV trong TNK.

3. Chng ng mu bng Heparin hoc Heparin trng

tra thi gian aPTT mi 6 gi sao cho thi gian

a. Abciximab (Reopro): l thuc c pht hin v

G. Cc thuc chn bta giao cm

m t p ng vi Nitrates hoc khng th dng c

Cc thuc c ch men chuyn

J. Vn dng cc thuc tiu huyt khi

Hnh 1-2. Hnh nh T ca mt trng hp TNK,

Hnh 1-3. Hnh nh chp ng mch vnh ca bnh nhn

Antman EM, Tanasuevic MJ, Thompson B, et al. Cardiac-specific

Bittl JA, Strony J, Brinker JA, et al. Treatment with bivalirudin

Boden WE, O'Rourke RA, Crawford MR, et al. Outcomes in patients

Braunwald EG, Mark DB, Jones RH et. al. Unstable angina:

Cohen M, Demers C, Garfinkel EP, et al. Low-molecular-weight

EPILOG Investigators. Platelet glycoprotein Ilb/lIla receptor

Fuster V, Badimon L, Badimon JJ, et. al. The pathogenesis of

Gersh BJ, Braunwald EG, Rutherford JD. Chronic coronary artery

18. TIMI IIIB Investigators. Effects of tissue plasminogen activator and

William Heberden l ngi u tin m t thut ng au

a. V tr: Thng sau xng c v l mt vng

3. Khm lm sng gip chn on phn bit cc nguyn

Hnh 2-1. Cc xt nghim chn on au tht ngc.

A. in tm lc ngh: l mt thm d sng lc trong

Gng sc th lc gip d on kh nng hot

C. Siu m tim thng quy

Hnh 2-2. Tin trin ca mng x va MV.

Ticlopidine (Ticlid): vin 250mg, dng 2

Hnh 2-3. C ch tc dng ca cc thuc chng ngng

2. iu chnh ri lon Lipid mu: c chng minh

Cn thn khi ung vi cc thuc gin mch

4. Cc thuc chn giao cm:

tht tri nn lm dng mu t thng tm mc

mt s trng hp, c bit khi c THA v c

1. So snh vi dng thuc iu tr: lm gim triu chng

hp Aspirin vi Ticlopidin (hoc Clopidogrel) trc t

3. K thut m lm cu ni ng mch vnh hin nay

Ti liu tham kho

Alderman EL, Bourassa MG, Cohen LS, et al. Ten-year follow-up of

huyt khi gy lp ton b lng mch. Nu vic nt ra ny

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2. Nhng triu chng hay gp l: nhp tim nhanh, ting

T cn c lm ngay khi bnh nhn nhp vin v lm

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