Luận Án - Trần Văn Thi

B GIO DC V O TO
I HC HU
TRNG I HC Y DC
.........................
TRN VN THI
NGHIN CU NNG hsCRP V TNF HUYT

THANH BNH NHN BNH MCH VNH C HAY
KHNG C BNH PHI TC NGHN MN TNH
LUN N TIN S Y HC
HU - 2016
B GIO DC V O TO
I HC HU
TRNG I HC Y DC
.........................
TRN VN THI
NGHIN CU NNG hs-CRP V TNF- HUYT

THANH BNH NHN BNH MCH VNH C HAY
KHNG C BNH PHI TC NGHN MN TNH
Chuyn ngnh: NI TIM MCH

M s : 62.72.01.41
NGI HNG DN KHOA HC

PGS-TS. L VN BNG
PGS-TS HONG TH THU HNG
HU - 2016
LI CAM N
Qua lun an nay, ti xin c bay to long bit n su sc n:

- Ban Giam c ai hoc Hu, Ban Sau ai hoc ai hoc Hu.
- Ban Giam Hiu Trng ai hoc Y Dc Hu, GS.TS Hoang Khanh-
Nguyn Trng phong ao tao Sau ai hoc, PGS.TS Hoang Bui
Bao-Trng Phong ao tao Sau ai hoc va Phong ao tao Sau ai
hoc Trng ai hoc Y Dc Hu.
- GS.TS Huynh vn Minh-Nguyn Chu nhim B mn Ni, PGS.TS
Trn vn Huy Chu nhim B mn Ni, PGS.TS Nguyn Anh Vu-
Pho Chu nhim B mn Ni, TS L vn Chi-Pho Chu nhim B mn
Ni; PGS.TS Hoang Anh Tin-Giao vu Sau ai hoc B mn Ni
cung toan th cac GS, PGS, TS va cac giang vin B mn Ni
Trng ai hoc Y Dc Hu a tao moi iu kin thun li cho ti
c hoc tp va nghin cu.
- PGS.TS L vn Bang- Nguyn Chu nhim B mn Ni, PGS.TS
Hoang thi Thu Hng- Nguyn Chu nhim B mn Sinh hoaTrng
ai hoc Y Dc Hu la nhng ngi a trc tip hng dn, lun
ng vin, tn tinh chi day va danh nhiu cng sc giup ti hoan
thanh lun an.
- Ban Giam Hiu Trng ai hoc Y khoa Pham Ngoc Thach, PGS.TS
Pham Nguyn Vinh-Pho Chu nhim B mn Ni, tp th B mn
Ni cung cac Thy C cua Trng ai hoc Y khoa Pham Ngoc
Thach a ng vin va tao thun li cho ti trong thi gian hoc tp.
- Ban Giam c Vin Tim thanh ph H Chi Minh, Ban Giam c va
Khoa Tim mach can thip Bnh vin Thng nht thanh ph H Chi
Minh, Ban Giam c, Khoa Tim mach can thip va Khoa Xet
nghim Bnh vin Nhn dn 115.
- Ban Giam c va Phong xet nghim Trung tm Chn oan Y khoa
Hoa Hao thanh ph H Chi Minh a tao iu kin cho ti c thc
hin lun an nay.
- Th vin Trng ai hoc Y Dc Hu.
- Th vin Trng ai hoc Y khoa Pham Ngoc Thach a cung cp
nhiu tai liu tham khao quy gia cho lun an.
- BS Nguyn An Thng-Trng Phong K hoach Tng hp Vin tim.
- Ths-BS L c Sy-Pho khoa Tim mach can thip-cp cu, BS L
Cng Vn Khoa Tim mach can thip bnh vin Thng Nht.
- BS CKII Nguyn Quang Minh-Pho Khoa H hp, Ths.BS L Ha
Hng Thanh Khoa H hp bnh vin Thng Nht.
- BS CKII Pham c at-Trng khoa Tim mach can thip; Ths.BS
Ta Cng Thanh, BS Nguyn Kim Phng, BS CKI Phan Cng Thuy
bnh vin Nhn dn 115 a h tr giup ti trong qua trinh thu
thp s liu nghin cu.
- Xin chn thanh bit n n cac bnh nhn a ng y tham gia nghin
cu ti hoan thanh lun an.
- Xin bit n b me, v va cac con cung cac ban be lun ng vin
giup ti trong thi gian hoc tp.
Xin gi n tt ca moi ngi vi long tri n v han.
Trn vn Thi
LI CAM OAN
Ti xin cam oan y la cng trinh nghin cu cua ring ti. Cac s
liu, kt qua nu trong lun an la trung thc va cha tng c ai cng b
trong bt ky cng trinh nao khac.
Tac gia Lun an
Trn vn Thi
MUC LUC
Trang phu bia
Li cam oan
Muc luc
Danh muc cac ch vit tt
Danh muc cac bang
Danh muc cac hinh, biu va s
M U ............................................................................................ 1
-Tinh cp thit cua tai ................................................................................. 1
-Muc tiu nghin cu cua lun an ................................................................... 3
-Y nghia khoa hoc va tinh thc tin cua lun an ............................................. 3
CHNG 1: TNG QUAN......................................................................... 4
1.1 Tng quan v bnh mach vanh ................................................................. 4
1.2 Tng quan v bnh phi tc nghen man tinh12
1.3 Mi lin quan gia bnh phi tc nghen man tinh va bnh mach vanh . 17
1.4 Tng quan v hs-CRP va TNF- ............................................................ 28
1.5 Cac nghin cu lin quan n tai ....................................................... 41
CHNG 2: I TNG VA PHNG PHAP NGHIN CU....... 47
2.1 i tng nghin cu.............................................................................. 47
2.2 Phng phap nghin cu ......................................................................... 51
2.3 Phng phap x ly s liu ....................................................................... 61
2.4 ao c nghin cu ................................................................................ 63
CHNG 3: KT QUA NGHIN CU ................................................. 64
3.1 c im cua cac nhom nghin cu ....................................................... 64
3.2 Nng hs-CRP va TNF- trong cac nhom nghin cu ....................... 75
3.3 Khao sat mi lin quan va tng quan gia nng hs-CRP va TNF vi
cac yu t nguy c, c im cua bnh mach vanh, bnh phi tc nghen man
tinh va bnh mach vanh co bnh phi tc nghen man tinh ......................... 77
CHNG 4: BAN LUN .......................................................................... 87
4.1 c im cua cac nhom nghin cu ....................................................... 87
4.2 Nng hs-CRP va TNF- trong cac nhom nghin cu ..................... 107
4.3 Khao sat mi lin quan va tng quan gia nng hs-CRP va TNF-
vi cac yu t nguy c, c im cua bnh mach vanh co bnh phi tc
nghen man tinh ............................................................................................ 111
KT LUN ................................................................................................ 120
KIN NGHI ............................................................................................... 123
DANH MUC CAC CNG TRINH KHOA HOC A CNG B
TAI LIU THAM KHAO
PHU LUC
CC CH VIT TT
Ch vit tt Ting Anh Ting vit

AHA: American Heart Association Hip hi Tim mach Hoa Ky
BMI: Body mass index Ch s khi c th
BMV: Bnh mach vnh
bn: bnh nhn
BPTNMT: Bnh phi tc nghn man tnh
Bnh mach vnh co bnh phi
BMV+BPTNMT:
tc nghn man tnh.
CRP: C- reactive protein Protein phn ng C
cs: cng s
MV: ng mach vnh
Forced expiratory volume in Th tch th ra gng sc trong
FEV1:
1 second 1 giy
FVC: Forced vital capacity Dung tch sng gng sc
High density lipoprotein Cholesterol ca lipoprotein c
HDL-c:
Cholesterol t trng cao
high sensitivity C reactive Protein phn ng C nhay
hs-CRP:
protein cao
HTL: Ht thuc l
IL: Interleukin
LAD: Left artery decending Nhnh lin tht trc
Nhnh mu ca ng mach
LCx: Left circumflex
vnh
Low density lipoprotein Cholesterol ca lipoprotein c
LDL-c:
cholesterol t trng thp
Thn chung ng mach vnh
LM: Main left artery
tri
LT: Lymphotoxin
OR Odds ratio Ty sut chnh
RCA: Right coronary artery ng mach vnh phi
TCYTTG: T chc Y t Th gii.
TNF-: Tumor necrosing factor alpha Yu t hoai t u alpha
XVM: X va ng mach
DANH MUC CAC BANG
Bang 1.1 Vi tri tn thng phi va s hin din cua cac loai t bao vim .. 15
Bang 1.2 anh gia nng cua BPTNMT da theo h hp ky ..................... 16
Bang 2.1 H s theo vi tri mach vanh tn thng tinh im Gensini............. 49
Bang 2.2 Phn chia giai oan bnh cua BPTNMT ......................................... 50
Bang 3.1 Ty l % bnh nhn trong cac nhom nghin cu .............................. 64
Bang 3.2 Tui trung binh cua cac i tng nghin cu ................................ 64
Bang 3.3 Ty l % gii tinh cua i tng nghin cu .................................... 65
Bang 3.4 Tnh trang hut thuc la trong nghin cu ........................................ 66
Bang 3.5 Tng quan FEV1 vi lng thuc la hut (s goi-nm) ................. 66
Bang 3.6 Lin quan hut thuc la gia nam va n gii .................................... 67
Bang 3.7 BMI cua cac i tng nghin cu ................................................. 67
Bang 3.8 Phn loai BMI cua cac nhom nghin cu ........................................ 68
Bang 3.9 Glucose huyt tng cua cac nhom nghin cu .............................. 68
Bang 3.10 Kt qua lipid mau trong cac nhom nghin cu.............................. 69
Bang 3.11 Ty s TG/HDL-c trong cac nhom nghin cu............................... 70
Bang 3.12 Ty s TG/HDL-c va BMV............................................................. 70
Bang 3.13 FEV1 trong cac nhom nghin cu ................................................. 71
Bang 3.14 Phn nng cua BPTNMT cua nhom BPTNMT thanh 2 nhom
nhe-trung binh va nng-rt nng ..................................................................... 72
Bang 3.15 S mach vanh tn thng 1 nhanh va nhiu nhanh ( 2 nhanh)
trong nhom BMV ............................................................................................ 72
Bang 3.16 Cac nhanh mach vanh tn thng trong nhom BMV ................... 72
Bang 3.17 Phn nhom thang im Gensini trong nhom BMV ....................... 73
Bang 3.18 Cac giai oan bnh cua BPTNBMT trong nhom
BMV + BPTNMT ........................................................................................... 73
Bang 3.19 Vi tri ng mach vanh tn thng trong nhom
BMV + BPTNMT ........................................................................................... 74
trong nhom BMV + BPTNMT........................................................................ 74
Bang 3.21 Thang im Gensini trong nhom BMV + BPTNMT .................... 75
Bang 3.22 Nng hs-CRP trong cac nhom nghin cu ............................... 75
Bang 3.23 Nng TNF- trong nhm nghin cu ...................................... 76
Bang 3.24 Lin quan nng hs-CRP va TNF- vi gii ............................. 77
Bang 3.25 Lin quan nng hs-CRP va TNF- vi hut thuc la ................ 77
Bang 3.26 Tng quan hs-CRP v TNF- vi FEV1 .................................... 78
Bang 3.27 Tng quan nng hs-CRP va TNF- vi nng cua BMV
theo thang im Gensini cua nhom BMV ....................................................... 79
Bang 3.28 Tng quan hs-CRP v TNF- vi thang im Gensini trong
nhom BMV + BPTNMT ................................................................................. 80
Bang 3.29 Tng quan gia nng hs-CRP va nng TNF- vi FEV1
trong nhom bnh mach vanh co bnh phi tc nghen man tinh ..................... 80
trong nhom bnh mach vanh co bnh phi tc nghen man tinh ..................... 82
Bang 3.31 S im Gensini cua nhom BMV va nhom BMV + BPTNMT .... 82
Bang 3.32 Phn tich a bin vi cac yu t nguy c kinh in cua bnh
mach vanh va cac yu t nghin cu (hs-CRP, TNF-, BPTNMT) vi bnh
mach vanh ....................................................................................................... 83
Bang 3.33 Lin quan gia BPTNMT va nhanh mach vanh tn thng ......... 84
Bang 3.34 Lin quan BPTNMT vi s mach vanh tn thng (1 nhanh va
nhiu nhanh) .................................................................................................... 85
DANH MUC CAC HINH, BIU VA S
DANH MUC CAC HINH

Hinh 1.1 Hinh anh trn CT 3 chiu cua MC xung va h mach vanh ....... 5
Hinh 1.2 Cac thay i sinh ly bnh cua BPTNMT ..................................... 15
Hinh 1.3 Vim trong BPTNMT gop phn gy cac bin c tim mach ........ 22
Hinh 1.4 C ch bnh sinh chung cua BPTNMT va BMV vi trong tm la
vim h thng gy tn thng va sa cha m, dn n hu qua la lam tn
thng nhu m va biu hin lm sang ........................................................ 27
Hinh 1.5 Phn t C Reactive Protein .......................................................... 29
Hinh 1.6 Kich thich va sinh tng hp cac protein phan ng pha cp trong
vim ............................................................................................................. 30
Hinh 1.7 CRP tham gia vao qua trinh gy x va ng mach ................... 31
Hinh 1.8 CRP tham gia vao qua trinh bnh sinh mang x va .................. 32
DANH MUC CAC BIU

Biu 3.1 Phn b tui trong nghin cu................................................. 65
Biu 3.2 Tng quan gia nng hs-CRP vi % FEV1 ..................... 78
Biu 3.3 Tng quan gia nng TNF- vi % FEV1 ...................... 78
Biu 3.4 Tng quan nng hs-CRP vi nng cua tn thng mach
vanh theo thang im Gensini trong nhom BMV ....................................... 79
Biu 3.5 Tng quan nng TNF- vi nng cua tn thng mach
vanh theo thang im Gensini trong nhom BMV ....................................... 80
Biu 3.6 Tng quan gia nng tn thng mach vanh vi nng
hs-CRP trong nhom BPTNMT+BMV ........................................................ 81
Biu 3.7 Tng quan gia nng cua tn thng mach vanh vi nng
TNF- trong nhom BPTNMT+BMV .................................................... 81
Biu 3.8: Phn tich a bin cac yu t nguy c vi bnh mach vanh ... 84
DANH MUC CAC S
S 2.1: S nghin cu ....................................................................... 61
M U
- Tinh cp thit cua tai

Bnh mach vanh la mt trong cac nguyn nhn hang u gy tan ph
va t vong cac nc a phat trin cung nh cac nc ang phat trin.
Bnh mach vanh gy ra do tin trin cua cac mang x va trong ng mach
vanh. Bnh phi tc nghen man tinh la mt bnh co th phong nga va iu
tri c vi cac bnh i kem va cac hu qua ang k trn h thng. Bnh
phi tc nghen man tinh hin nay ng th t trong cac nguyn nhn hang
u gy t vong trn toan th gii va la bnh ly duy nht trong 10 bnh ly
hang u vn con tip tuc gia tng[158]. Trong thi gian t nm 1970 n
nm 2002, ty l t vong do t quy giam 63% va t vong do bnh tim mach
giam 52% trong khi ty l t vong do bnh phi tc nghen man tinh tng
100%[158].
Bnh phi tc nghen man tinh la mt bnh ly phc tap gm cac biu
hin tai phi va cac biu hin ngoai phi. S lin kt gia cac biu hin tai
phi va cac biu hin ngoai phi vn con cha c bit ro va cac biu
hin ngoai phi trong bnh phi tc nghen man tinh c goi la cac anh
hng h thng cua bnh phi tc nghen man tinh[26]. Do o, bnh phi
tc nghen man tinh hin nay c xem la mt bnh ly a thanh phn, bnh
h thng[30],[39],[55].
Cac chng c hin nay cho thy vim h thng, c biu hin qua
s gia tng nng cua cac cht chi im vim trong mau nh protein
phan ng C, yu t hoai t u alpha, ong vai tro quan trong trong cac hu
qua trn h thng cua bnh phi tc nghen man tinh, bao gm yu cac c
ngoai bin, ri loan chc nng tim, dinh dngHn na, cac bnh nhn
bnh phi tc nghen man tinh cung hay co cac bnh ly i kem ang k nh
1
bnh ly tim mach khng nhng gy kho khn trong chn oan va iu tri
bnh ma con gop phn vao s gia tng tan tt cung nh t vong cua bnh
phi tc nghen man tinh. Nghin cu TORCH cho kt qua la trong 911
trng hp t vong co 35% do nguyn nhn h hp (75% sau mt t kich
phat cua bnh phi tc nghen man tinh), 26% do cac bin c tim mach
trong o bin c bnh mach vanh la quan trong nht, 21% do ung th, 10%
do cac nguyn nhn khac va 7% khng ro nguyn nhn[166].
Ca bnh phi tc nghen man tinh va bnh mach vanh co cung cac yu
t nguy c quan trong nh thoi quen hut thuc la, tui gia tng va u la
bnh ly vim man tinh. Nhiu nghin cu thy co phi hp bnh phi tc
nghen man tinh trn cac bnh nhn co bnh mach vanh va ngc lai. Bnh
mach vanh co th gp vi tn sut t 7 -13% cac bnh nhn c chn
oan bnh phi tc nghen man tinh va bnh phi tc nghen man tinh co th
gp trong 26 35% cac bnh nhn co bnh tim thiu mau cuc b. Tn sut
cua bnh tim thiu mau cuc b gia tng cung vi nng cua bnh phi tc
nghen man tinh, at n 60% trn cac bnh nhn co bnh phi tc nghen
man tinh tin trin. Tnh trang hut thuc la va vim h thng mc thp
c coi la c ch chinh gn kt gia hai bnh ly nay. Bnh phi tc nghen
man tinh dng nh la yu t nguy c t vong c lp trn cac bnh nhn
co bnh mach vanh. Cac bnh nhn bi nhi mau c tim hay nhp vin iu
tri bnh tim thiu mau cuc b co kem bnh phi tc nghen man tinh co
nguy c t vong trong 3 nm cao hn 50% so vi cac bnh nhn khng co
kem bnh phi tc nghen man tinh. Ngc lai, bnh mach vanh la nguyn
nhn hang u cua t vong cua cac bnh nhn co bnh phi tc nghen man
tinh mc nhe trung bnh[152].
Co nhiu nghin cu v vai tro cua cac yu t vim hs-CRP, TNF-
trn bnh nhn bnh phi tc nghen man tinh cung nh trn bnh mach
2
vnh. Tuy nhin, it co tai liu v cac yu t chi im vim nay trn cac
bnh nhn co bnh ly phi hp cua ca bnh mach vanh va bnh phi tc
nghen man tinh. Do o, chung ti tin hanh nghin cu tai Nghin cu
nng hs-CRP va TNF- huyt thanh bnh nhn bnh mach vanh co
hay khng co bnh phi tc nghen man tinh vi cac muc tiu:
1. Xac inh nng hs-CRP va TNF- ba nhom bnh mach vanh,
bnh mach vanh kem bnh phi tc nghen man tinh va nhom bnh
phi tc nghen man tinh
2. Khao sat mi lin quan va tng quan gia hs-CRP va TNF- cac
nhom bnh nhn trn vi mt s yu t nguy c, FEV1 va mc
tn thng mach vanh theo thang im Gensini.
- Y nghia khoa hoc va tinh thc tin cua lun an
+ Y nghia khoa hoc
Qua nghin cu hs-CRP v TNF- se cung cp thm cac thng tin
mi v nng cac cht gy vim h thng nay trn bnh nhn bnh mach
vanh, bnh mach vanh kem bnh phi tc nghen man tinh va bnh phi tc
nghen man tinh. ng thi, nghin cu nay cung giup anh gia cac mi
lin quan cua tn thng h ng mach vanh khi co hin din cua bnh
phi tc nghen man tinh.
+ Y nghia thc tin
Xt nghim hs-CRP va TNF- trn bnh nhn bnh mach vanh, bnh
mach vanh kem bnh phi tc nghen man tinh va bnh phi tc nghen man
tinh co th giup anh gia mc vim h thng. Qua o gop phn vao vic
anh gia mc nng cua bnh va d phong cac bin chng cua bnh
mach vanh, bnh mach vanh kem bnh phi tc nghen man tinh va bnh
phi tc nghen man tinh.
3
CHNG 1
TNG QUAN
1.1 TNG QUAN V BNH MACH VANH

1.1.1 Dch t hoc bnh mch vanh
Bnh tim thiu mau cuc b hay bnh mach vanh (BMV) theo inh
ngha cua T chc Y t Th gii la mt bnh cua cac mach mau cung cp
cho c tim[132]. Bnh mach vanh la nguyn nhn thng gp gy t vong
trn toan th gii vi c tinh 6 trng hp t vong th co mt trng hp
do BMV. Nm 2010, co hn 52,7 triu trng hp t vong trn toan th
gii trong o 15,6 triu la t vong do nguyn nhn bnh tim mach. c
tinh n nm 2030, t vong do bnh tim mach c tinh at n 23,4 triu
ngi trong o BMV chim hn 50%[61]. Mt mnh BMV chim khoang
50% cac trng hp t vong lin quan n bnh tim mach Hoa K trong
nm 2009; gy ra hn 116 trn 100.000 trng hp t vong va la nguyn
nhn hang u cua t vong sm trong nm 2010.
1.1.2 Gii phu ng mch vanh
Cac MV bnh thng phat sinh vung goc vi ng mach chu phia
di phn chuyn tip gia thn ng mach chu va xoang Valsalva.
Thng co hai l MV: mt cua MV phai va mt cua MV trai [71].
1.1.2.1 ng mach vanh tri
Thn chung cua MV trai xut phat t xoang vanh trai n ch xut
phat cua ng mach lin tht trc va ng mach mu, co ng kinh 3
6mm va dai khoang 0 10mm.
ng mach lin tht trc: i trong ranh lin tht trc n mm
tim, gm co cac nhanh chinh la cac nhanh vach va cac nhanh cho. Nhanh
4
vach cua ng mach lin tht trc co th ni vi nhanh vach cua ng
mach lin tht sau cua MV phai tao thanh h thng bang h. Nhanh cho
cua ng mach lin tht trc chay mt trc bn cua tim.
ng mach mu: bt ngun t ch phn nhanh cua thn chung MV
trai, i xung theo nhanh nh tht trai[4].
1.1.2.2 ng mach vanh phi
T xoang vanh i xung ranh lin tht n mm tim. MV phai chia
cc nhanh gm ng mach non, ng mach nut xoang nh, ng mach lin
tht sau.
Hnh 1.1 Hnh anh trn CT 3 chiu cua MC xung va h mach vanh[71].
RCA: MV phai; LM: thn chung MV trai; CX: M mu; OM: nhanh b; DB: cac
nhanh cho; LAD: nhanh lin tht trc; RV: nhanh tht phai.
1.1.2.3 Phn b cung cp mu cho cc vng ca tim

- Hai tm nh phai va trai c cp mau bi nhanh mu va nhanh nh
cua hai ng mach vanh.
5
- Mt trc cua vach lin tht c cp mau bi nhanh lin tht trc
cua MV trai. Nhanh ng mach vach sau cua MV phai cp mau
cho mt sau cua vach lin tht.
- Thanh t do cua tht trai c ti mau bi cac nhanh cua MV
trai. Mt hoanh cua tht trai do nhanh cua MV phai va nhanh mu
cua MV trai cung cp.
- C nhu: phia trc do MV trai cung cp; phia sau do ca MV phai
va trai cung cp.
- Tht phai: chu yu do MV phai cung cp mau nui[4].
1.1.3 Cac yu t nguy c cua bnh mch vanh
Cac yu t nguy c kinh in cua BMV la hut thuc la, ri loan lipid
mau, tng huyt ap, ai thao ng, tui, li sng it vn ng, bo ph, va
yu t gia nh[112].
1.1.3.1 Ht thuc l
Hut thuc la la mt trong cac yu t nguy c quan trong nht cua
BMV. Nguy c mach vanh tng gp i ngi hut thuc, nht la ngi
hut 40 iu/ ngay[12]. Mt s nghin cu thy tn sut HTL cua cac bn
mc BMV sm (40 50 tui) ln n 80%[167]. Kt qua cua nghin cu
INTERHEART cho thy HTL ng th hai trong cac yu t nguy c hang
u co th iu chinh c cua bnh tim thiu mau cuc b, chi ng sau
tng cholesterol mau [154]. HTL lam gia tng gp 2 ln nguy c mc tt ca
cac loai bnh tim mach trong o co bnh mach vanh. Ngi HTL co gia
tng nguy c mc BMV cao hn ngi khng HTL gp 4 ln va nguy c t
vong lin quan vi BMV gp 2 n 3 ln[107]. Cac t bao vim bi hoat hoa
do khoi thuc la gy san sinh ra cac cht trung gian gy vim nh cac
protein pha cp va cac cytokin. Gn y, cac cht trung gian gy vim c
nghin cu cho thy la cac cht chi im cua cac thay i h thng tim n
6
va ko dai. Nhiu nghin cu thy co thay i nng cua cac cht trung
gian vim khng chi phi ma con co trong h tun hoan cua ngi hut
thuc la nh CRP, TNF- va fibrinogen va s gia tng cua cac cht trung
gian gy vim nay cung kt hp vi nguy c cac bin c tim mach.
1.1.3.2 Ri loan lipid mu
y la mt trong cac yu t nguy c quan trong nht cua BMV. Noi
chung, tng LDL-c 1% lam tng nguy c bnh tim mach 2 3%[17]. Nng
cholesterol cang cao th nguy c tim mach cang cao. Giam LDL-c
1mg/% giup giam 30 35% bnh mach vanh. Nguy c bi BMV tng gn 2
ln vi nng cholesterol mau trong khoang 5,5 mmol/L (212mg/dl) n
6,5 mmol/L (250 mg/dL)[78]. Ty s cholesterol toan phn/ HDL-c la yu t
d oan nguy c BMV manh duy nht. Trn cac i tng co nng
cholesterol toan phn va nng HDL-c thp th ty s cholesterol toan
phn/ HDL-c cao co th ai din cho hi chng HDL-c thp n c
thng gp trn cac bn co BMV[83].
1.1.3.3 Tng huyt p
Co mi lin quan thun lin tuc theo ng thng gia huyt ap tm
thu va huyt ap tm trng vi tn sut nhi mau c tim moi la tui.
Trn cac bn tng huyt ap, BMV la nguyn nhn gy t vong thng gp
nht. Khoang 50% bn tng huyt ap cung co bt thng lipid mau [78].
Tng huyt ap lam tn thng ng mach, tng x va ng mach,
tng nhu cu oxy cho c tim va lam trm trong thm mc thiu mau cuc
b trn bnh nhn co BMV. Giam huyt ap tm thu 10mmHg hay huyt ap
tm trng 5mmHg trong nhom tui 40 69 kt hp vi giam 40% nguy
c t quy va 30% nguy c t vong cua bnh tim do thiu mau cuc b va
cac bin c mach mau khac.
7
1.1.3.4 i tho ng
Ca bnh ai thao ng tip 1 va tip 2 u lam gia tng nguy c mc
BMV c lp vi cac yu t nguy c khac. Cac bn bi bnh ai thao ng
tip 2 co gia tng nguy c mc BMV gp 2 4 ln va nguy c t vong do
BMV tng gp 4 ln. Tuy nhin, anh hng cua ai thao ng phu thuc
nhiu vao cac yu t nguy c khac i kem nh triglycerid mau, huyt ap,
fibrinogen, HTL, cholesterol va insulin cung vi bo ph va nng HDL-
c. Nng glucose mau sau n cung co lin quan vi bnh tim mach trn
ngi khng bi bnh ai thao ng nhng anh hng n cac bin c
mach mau nao hn la nhi mau c tim[78]. Bnh nhn ai thao ng
thng co tn thng mach vanh lan ta va phc tap. Cac nghin cu cho
thy co mi lin quan theo ng thng gia nguy c bnh tim mach vi
nng HbA1C va gia nguy c tim mach vi nng glucose mau 2 gi
sau n. Trn cac bnh nhn bi bnh ai thao ng, giam HbA1C 1% giup
giam 7% nhi mau c tim sau 5 nm.
1.1.3.5 Tui va gii tinh
Cac nghin cu cho thy ty l BMV tng theo tui. Khi tui tng,
qua trnh x va ng mach cung tng. i vi ngi trng thanh, tng
mi 5 tui kt hp vi gia tng nguy c t vong do BMV gp 2 ln ca
nam va n gii[78]. New Zealand, 85% trng hp t vong do BMV xy
ra ngi sau 65 tui. Tn sut biu hin BMV n gii xy ra sau nam
gii khoang 10 nm. Tn sut nhi mau c tim hay t t n gii chm
hn nam gii 20 nm[107]. Nam gii < 55 tui co nguy c nhi mau c tim
cao hn n gii gp gn 4 ln. Mc du s khac bit nay giam dn theo tui
nhng tn sut nhi mau c tim n gii vn thp hn so vi nam
gii[123].
8
1.1.3.6 Tin s gia nh c bnh mach vanh
Tin s gia nh co ngi quan h thn thuc bc mt mc BMV khi
con tr cung la mt trong cac nguy c cua BMV.
1.1.3.7 Cc yu t nguy c khc
Ngoai cac yu t nguy c trn, cac yu t nh tng lipoprotein,
homocystein va CRP cung c xem la cac yu t nguy c cua BMV[17].
Vim la mt yu t nguy c khac cua BMV. Vim gy bt n mang x va.
CRP cho thy la mt yu t chi im nguy c cua BMV. Co mi lin quan
cht che gia hs-CRP vi cai thin tin lng trong ap ng iu tri statin
cho thy vai tro hs-CRP la cht chi im tin lng c lp vi nng
lipid mau va vai tro cua vim h thng trong tin trin cua BMV[83].
1.1.4 Chn oan bnh mch vanh
1.1.4.1 Lm sng
S tin trin cua tn thng XVM co th gy giam lu lng mau
ng mach dn n khi phat triu chng au tht ngc. au tht ngc
in hnh thng xy ra vi tn thng gy hep 60 70% trong cac tnh
hung lam tng nhu cu oxy cua c tim nh gng sc. Khi mc hep
ng mach vanh tr nn trm trong hn, cac triu chng co th xy ra luc
nghi ngi hay chi vi gng sc nhe[78].
Cn au tht ngc in hnh co cac tinh cht: thng xut hin khi
gng sc hay tng xuc cam, bn co cam giac nng ngc hay bop nghet vung
sau xng c, lan ln c, goc ham, tay trai. Cn au tng dn v cng
trong vai phut va giam khi bn nghi ngi hay dung cac thuc gian mach
vnh nhm nitrate [131].
Trng hp nhi mau c tim bn cung co cn au tng t nhng
thi gian ko dai, thng > 30 phut, khng giam khi nghi ngi hay dung
9
cac thuc gian mach vanh nhom nitrate. Trong hi chng mach vanh cp,
cn au tht ngc co th xut hin khi nghi.
1.1.4.2 in tim
Trong cn au tht ngc, in tim co th bnh thng trong 50%
trng hp. Cac thay i in hnh trn in tim trong cn au tht ngc la
song T cao nhon (thiu mau), ST chnh ln (tn thng) va xut hin song
Q bnh ly (hoai t) trn cac chuyn ao tng ng vi mach vanh tn
thng.in tim bnh thng khng giup loai tr chn oan BMV man.
Tuy nhin, in tim bnh thng cho tin lng tt hn v thng n y
chc nng tht trai co th bnh thng[131].
1.1.4.3 Cc enzym chn on va theo di bnh tim mach
Cac enzym chi im tn thng cua c tim nh CK-MB, CK, LDH,
SGOT, Troponin tng khi co nhi mau c tim. Ngay nay, hai chi du CK-
MB v Troponin I hoc Troponin T c s dung chinh trong chn oan
nhi mau c tim cp, c bit hs-Troponin I a tr nn mt chi du sinh
hoc co ca s chn oan rng va co vai tro tin lng.
1.1.4.4 in tim gng sc Holter in tim Siu m tim gng sc Xa
hnh c tim gng sc
Cac xt nghim thm do trn co gia tri chn oan, tin lng va anh
gia iu tri. Holter tim dung theo doi chn oan cac ri loan nhip tim
khng xy ra thng xuyn. Siu m tim gng sc khng nhng co vai
trong anh gia hnh th hoc cua tim ma con cho bit chc nng. c bit
siu m tim gng sc bng dobutamine la mt phng phap anh gia tinh
sng con cua c tim, cho php chi inh can thip mach vanh co hiu qua.
in tim gng sc nhay hn va c hiu hn in tm luc nghi
trong phat hin BMV va la xt nghim c chon la trn cac bn nghi ng
BMV va anh gia kha nng gng sc cac bnh nhn a bit BMV va tin
10
lng. Xt nghim nay co nhay la 68% va c hiu la 77% trong vic
phat hin co BMV[131].
1.1.4.5 Siu m ni mach vanh
Siu m ni mach vanh cung cp cac thng tin v vi tri tn thng
cua mach vanh, thy c cac c tinh tn thng cua mach vanh nh
bong mang x va, boc tach, tu mau thanh mach. Siu m ni mach vanh
con cho php anh gia chinh xac ng kinh trong cua MV, anh gia cac
tn thng XVM. y cung la mt cng cu quan trong anh gia cac
tn thng cu truc muc tiu cn can thip va vi tri t stent. Phng phap
nay giup anh gia tt giai phu MV va gia tng hu ich khi phi hp vi
chup MV, c bit trong cac trng hp cn can thip MV[131].
1.1.4.6 Chp mach vanh
La xt nghim co vai tro quyt inh chn oan va anh gia, dung
anh gia nng cua BMV cung nh dung khng inh chn oan vi tri
hep ng mach vanh, giup cho chi inh can thip va la phng tin can
thip[13]. Chup mach vanh cung cp cac thng tin v vi tri, mc tn
thng cua h mach vanh va qua o giup hng can thip mach vanh nh
nong ng mach vanh bng bong qua da, t stent hay phu thut bc cu
ni ng mach vanh. Chup MV la phng phap chn oan giai phu
MV trn cac bn au tht ngc n inh khi nghi ng co BMV nng hay co
triu chng khng ap ng vi iu tri ni khoa ti u. Cac chi inh khac
gm: co triu chng au tht ngc va suy tim, at tiu chun nguy c cao
trn kt qua xt nghim gng sc, bn sng sot sau ngng tim, co ri loan
nhip tht va tin cn co can thip mach vanh (con au tht ngc tai i tai lai
sau can thip mach vanh qua da hay sau m bc cu mach vanh)[131].
11
1.2 TNG QUAN V BNH PHI TC NGHEN MAN TINH
1.2.1 nh nghia bnh phi tc nghen mn tinh
Bnh phi tc nghen man tinh (BPTNMT) la mt bnh thng gp
co kha nng phong nga va iu tri c, c trng bi gii han lu lng
khi dai dng, thng tin trin va kt hp vi gia tng ap ng vim cac
ng dn khi va phi vi cac cht khi hay cac phn t c hai. Cac t
kich phat va cac bnh ly i kem gop phn vao nng chung cua tng bnh
nhn[96].
1.2.2 Dch t hoc cua bnh phi tc nghen mn tinh
BPTNMT la mt trong cac nguyn nhn hang u cua bnh sut va
t sut trn th gii.Trong s cac nguyn nhn hang u gy t vong th
BPTNMT ng th sau vao nm 1990, ng th t k t nm 2000 va d
bao se ng th ba vao nm 2020. Vao nm 2030, BPTNMT se la nguyn
nhn trc tip cua 7,8% cac trng hp t vong va chim n 27% cac
trng hp t vong co lin quan vi hut thuc la [23], [44]. [23, 44].
Mt s nghin cu dich t hoc bnh phi tc nghen man tinh 12
nc khu vc chu Thai Bnh Dng cho thy ty l bnh thp nht la
3,5% (Hng Kng va Xinh-ga-po) va cao nht la 6,7% Vit Nam. Tuy
vy, mt nghin cu nm 2007 Trung Quc cho tn sut BPTNMT la
8,2%[170].Tn sut cua BPTNMT khoang 10% trn toan th gii[164].
c tinh n nm 2030, mi nm se co khoang 9 triu ngi cht do
BPTNMT[158].
Theo kt qua nghin cu c thc hin trn gn 2.600 ngi Ha
Ni, 6,8% s ngi trn 40 tui bi bnh phi tc nghen man tinh. Tai khoa
H hp cua Bnh vin Bach Mai, s bnh nhn ni tru iu tri bnh nay
chim 26%[2]. Hoa k, BPTNMT la nguyn nhn t vong ng hang th
4 sau bnh tim, ung th, bnh mach mau nao[2]. Hn 10% dn s trn 45
12
tui Hoa K bi gii han lu lng khi it nht mc trung bnh theo
tiu chun cua h hp ky. Nm 2007, chi phi y khoa va mt ngay cng lao
ng do BPTNMT vt qua 40 ty la Hoa K. Chi phi trc tip iu tri
cung gia tng do BPTNMT ngay cang nng hn va s ln nhp vin v cac
t kich phat cua bnh cung gia tng hn 1,5 ln[62].
1.2.3 Cac yu t nguy c cua bnh phi tc nghen mn tinh
Co nhiu yu t gop phn gy BPTNMT gm cac yu t di truyn va
cac yu t mi trng. S tng tac gia cac yu t nay ong vai tro quan
trong gy BPTNMT[159].
1.2.3.1 Nhng yu t c ia
+Gen: Thiu trm trong enzym 1-antitrypsin la yu t di truyn duy nht
c chng minh la yu t nguy c cua BPTNMT[2]. Tnh trang nay chi
thy 1 2% nhng bnh nhn mc BPTNMT[62],[159]. Nhng ngi nay
rt nhay vi cac tn thng do khoi thuc la va co th mc BPTNMT rt
sm.
1.2.3.2. Nhng yu t mi trng
- Ht thuc l: Hut thuc la la nguyn nhn chinh cua BPTNMT[62],[159].
Hut thuc la lin h rt cht che vi BPTNMT. 50% ngi HTL 10 goi-
nm bi BPTNMT[46]. Hut thuc la > 20 goi-nm co nguy c cao dn n
BPTNMT.Tuy nhin, khng phai tt ca ngi hut thuc la u bi
BPTNMT. Mc du 85 - 90% bnh nhn bi BPTNMT la do thuc la nhng
chi khoang 15 - 20% ngi HTL bi BPTNMT. iu nay co th con co s
tham gia cua nhng yu t di truyn[2].
Mi hi thuc la co cha hn 2000 thanh phn c hai va 10 gc t
do[132].Tip xuc thu ng vi khoi thuc la cung co th gop phn gy nn
nhng triu chng h hp va BPTNMT[2]. Hut thuc la lam giam chc
nng phi nhiu hn s suy giam chc nng phi do tui va mc suy
13
giam nay tuy thuc ca vao mc va thi gian tip xuc vi khoi thuc la.
Hut thuc la gop phn gy t vong do BPTNMT gp 10 ln so vi nhng
ngi khng HTL[166].
- Bi va cht ho hc ngh nghip: Khi tip xuc bui va cht hoa hoc ngh
nghip y u va ko dai, co th gy nn BPTNMT c lp vi HTL va
lm gia tng nguy c bnh nu ng thi HTL[2].
- nhim mi trng trong va ngoai nh: nhim mi trng trong nha
nh cht t, cht t chay t nu n va hi nong la nhng yu t nguy c
cua BPTNMT cac nc ang phat trin[2], [158]. n , 30% 50%
BPTNMT khng lin quan vi HTL[46].
1.2.4 Cac hu qu cua vim ti phi trong bnh phi tc nghen mn
tinh
Vim tai phi gy nhng bin i giai phu bnh cua BPTNMT xay
ra cac ng dn khi trung tm, ng dn khi ngoai bin, chu m phi
va h thng mach mau phi [99],[143]. Tn thng cua cac ng dn khi
gy hep va gii han lu lng khi. Tnh trang pha huy cac thanh vach cua
ph nang gy khi ph thung va lam khi phi. Giam s lng mach mau
phi va co tht mach mau phi do giam oxy mau lam tng ap ng mach
phi.
14
Hnh 1.2 Cac thay i sinh ly bnh cua BPTNMT[46].
Bang 1.1 Vi tri tn thng phi va s hin din cua cac loai t bao
vim[2].
Nhng ph quan ln + ai thc bao
+ T bao lymph T (c bit CD8+ )
+ Bach cu trung tinh (chi trong bnh nng)
+ Bach cu ai toan ( mt s bnh nhn)
Nhng ph quan nh + ai thc bao
+ Bach cu ai toan ( mt s bnh nhn)
Nhu m phi + ai thc bao
+ Bach cu trung tinh
Nhng ng mach phi + T bao lymph T (c bit CD8+ )
+ Bach cu trung tinh
15
1.2.5 Chn oan bnh phi tc nghen mn tinh
Bnh phi tc nghen man tinh c trng bi s gii han lu lng
khi va phn giai oan bnh ma hin nay ang s dung chu yu la da trn
mc gii han lu lng khi khng hi phuc mc du khng co lin quan
cht che gia mc tc nghen cua ng dn khi vi cac triu chng lm
sang. Nghin cu ECLIPSE ghi nhn mc gii han lu lng khi it lin
quan vi triu chng kho th, kha nng gng sc va s t kich phat bnh
phi tc nghen man tinh/nm[24]. S hin din cua tc nghen lu lng khi
va nng cua BPTNMT c xac inh bng o h hp ky va la tiu
chun vang cua chn oan.
Bang 1.2 anh gia nng cua BPTNMT da theo h hp ky [2].
Giai on bnh Tiu chun(sau test gian ph quan)
Giai oan 1 (nhe) FEV1/FVC <70%.
FEV1 80% so vi ly thuyt.
Co hay khng co triu chng man tinh
(ho, khac am).
Giai oan 2 (trung bnh) FEV1/FVC <70%.
50% FEV1< 80% so vi ly thuyt.
Giai oan 3 (nng) FEV1/FVC <70%.
Giai oan 4 (rt nng) FEV1/FVC <70%.
FEV1< 30% so vi ly thuyt hay <50% +
phi hp vi suy h hp man hay du
chng suy tim phai.
16
1.3 MI LIN QUAN GIA BNH PHI TC NGHEN MAN TINH
VA BNH MACH VANH
Ca BPTNMT va BMV u la cac bnh co tn sut cao trn toan th gii
va gia tng cung vi tui. i vi BPTNMT, khoang 9 10% dn s 40
tui mc bnh. Tn sut nay gia tng nhanh vi tui, co th n hn 20%
nhng ngi > 70 tui, c bit i vi nhng ngi hut thuc la > 20 goi-
nm th tn sut nay ln n 34%. Tn sut cua BMV cung gia tng theo
tui. Khoang 35 40% ngi trong nhom tui 40 59 mc bnh va co th
at n 70% nhom tui 60 70[132]. c tinh n nm 2020, BMV,
bnh mach mau nao va BPTNMT la 3 bnh ly gy t vong hang u trn
toan th gii.
BPTNMT va bnh tim thiu mau cuc b la hai nguyn nhn hang u
cua nhp vin va t vong Bc My. Ca hai bnh ly nay chim > 60% cac
trng hp t vong co lin quan vi hut thuc la. Theo Jonathan P. Man,
bnh tim thiu mau cuc b va BPTMT thng i kem vi nhau. Hn 1/3
cac bn co BMV c chng minh qua chup ng mach vanh cung co
BPTNMT c chng minh bng o h hp ky [103]. Do co gia tng tn
sut cua BPTNMT trong BMV va ngc lai cung nh ca hai bnh ly u la
vim man tinh nn Agglos S. Aggelakas t vn Bnh mach vanh la
biu hin ngoai phi cua bnh phi tc nghen man tinh[23] cung nh Don
D. Sin nghi vn bnh phi tc nghen co phai la mt bnh tim
mach?[141].
BPTNMT c coi la yu t nguy c cua BMV. Nghin cu cua
Lies Lahousse va cs trn 253 bn BPTNMT cho thy cac bn BPTNMT co
gia tng dy cua lp ni-trung mac ng mach canh va mang x va it
n inh hn[91]. Mc du co s kt hp gia BPTNMT vi bnh tim thiu
mau cuc b nhng c ch bnh sinh vn cha c hiu ro hoan toan[34].
17
Theo Sunil K. Chhabra, vim h thng la mi lin kt gia BPTNMT va
BMV bi c ch bnh sinh qua trung gian TNF-[51].
Khoi thuc la co vai tro quan trong trong khi ng qua trnh vim
cac bn BPTNMT. Vim khng chi la yu t bnh sinh chinh gy BPTNMT
ma con la mt thanh phn sinh ly bnh quan trong trong vic hnh thanh
XVM[34]. Vim h thng mc thp anh hng ca trn cac t bao ni
m tim mach va trn ng dn khi cung nh nhu m phi. Nghin cu
cho thy vim h thng co tng quan nghich vi chc nng phi[38] va
giam FEV1 co nguy c gia tng x va ng mach[34]. Ngoai ra, cac thay
i sinh ly bnh cua BPTNMT cung co th anh hng trc tip ln chc
nng tim mach. Nghin cu cua Joseph Finkelstein va cs cho thy
BPTNMT cung la mt yu t nguy c cua bnh tim mach[67]. Tuy nhin,
co kha nng a yu t nh cac yu t di truyn, thay i m co lin quan
vi tui, cac kich thich gy c t mi trng cung tham gia gy ra cac
biu hin cua BPTNMT va BMV[132].
1.3.1 Tn sut lin quan gia bnh phi tc nghen mn tinh va bnh
mch vanh
BPTNMT co c trng la gii han lu lng khi tin trin ko dai va
kt hp vi ap ng vim bt thng cua phi va ng dn khi vi cac
phn t hay cac cht khi c hai. Bnh mach vanh la hu qua cua s tich tu
cac mang x va trong thanh cua cac ng mach vanh cung cp oxy va cac
cht dinh dng cho c tim. Phn tich d liu t Nghin cu Dinh dng
va Sc khe quc gia t nm 2007 n nm 2010 ghi nhn tn sut bnh
tim mach, bnh mach mau nao la 20% trn cac bn co BPTNMT so vi
7,4% trn cac i tng khng co BPTNMT (p< 0,001). BPTNMT la yu
t nguy c c lp cua bnh tim mach, bnh mach mau nao (OR= 1,4;
khoang tin cy 95%: 1,1 1,8)[21]. Hana Mllerova va cs tng hp 25
18
nghin cu v kt hp BPTNMT vi bnh tim mach. Tn sut bnh tim
mach trong BPTNMT thay i t 28% n 70% tuy i tng nghin cu
va cac inh ngha v bnh tim mach trong o bnh tim do bnh mach vanh
(gm nhi mau c tim, au tht ngc, bnh ng mach vanh va bnh tim
thiu mau cuc b) co tn sut t 4,7% n 60% bn co BPTNMT[113].
1.3.1.1 Tn sut bnh mach vanh trn cc bnh nhn c bnh phi tc
nghen man tinh
Cac bn bi BPTNMT co tn sut cao bi bnh tim thiu mau cuc b.
Pilar de Lucas-Ramos va cs thc hin nghin cu a trung tm trn 1200
bn BPTNMT va 300 i tng lam nhom chng. Kt qua: so vi nhom
chng, cac bn bi BPTNMT co tn sut cao hn ang k cua bnh tim thiu
mau cuc b (12,5% so vi 4,7%; p < 0,001), bnh mach mau nao (10% so
vi 2%; p < 0,001) va bnh mach mau ngoai bin (16,4% so vi 4,1%; p<
0,001)[58]. Tea Yun Park va cs nghin cu 113 bn BPTNMT ghi nhn
61% bn co hep mach vanh ang k[124].
Te-Chun Shen va cs thc hin nghin cu hi cu trn cac h s cua
bao him Y t ai Loan trong thi gian t 1998 and 2008 ghi nhn tn
sut BMV trn bn BPTNMT la 38,6%, cao hn ang k so vi cac bn
khng co BPTNMT la 16,1% (p< 0,001)[138].
1.3.1.2 Tn sut bnh phi tc nghen man tinh trn cc bnh nhn c bnh
mach vanh
Cac nghin cu v tn sut cua BPTNMT trn cac bn bi nhi mau c
tim cho kt qua khac nhau. Nghin cu SPRINT nghin cu cac bn sau giai
oan cp cua nhi mau c tim cho ty l BPTNMT la 7% trong khi kt qua
nghin cu PREMIER cung trn cac bnh nhn sng sot sau nhi mau c
tim nhng tiu chun ap dung khng loai tr c bnh hen th cho ty l
19
ln n 15,6%[75]. Bursi nghin cu trn cac bnh nhn co nhi mau c
tim ln u va loai tr hen cho ty l BPTNMT la 12%[47].
Bt k s khac bit v ap dung tiu chun chn oan BPTNMT, cac
kt qua nghin cu ghi nhn co s gia tng tn sut cua bnh ly nay trong
s cac bnh nhn co bnh mach vanh. Soriano J.B. bao cao tn sut cua
BPTNMT co xac inh gii han lu lng khi ln n 33,6% trong s 119
bn BMV c theo doi tai bnh vin trng ai hoc t thang 10/ 2006 n
thang 6/2008[144]. AlaEldin H. Ahmed thc hin nghin cu tm
BPTNMT trn 59 bn co BMV. Kt qua la co n 44% bn bi BMV co
BPTNMT i kem[28].
1.3.1.3 Anh hng qua lai ca bnh phi tc nghen man tinh va bnh mach
vanh
- Anh hng cua BPTNMT ln BMV
S hin din cua ca BPTNMT va BMV trn cung mt bnh nhn co
th cho cac anh hng lam trm trong thm tng bnh[120]. S hin din
cua BPTNMT lam gia tng nguy c bin c mach vanh 30%. Vi mi 10%
giam cua FEV1 lam gia tng t vong chung cua tt ca cac nguyn nhn ln
14%, gia tng t vong do bnh tim mach ln 28% va gia tng cac bin c
mach vanh khng t vong ln 20%[49]. Gavin C. Donaldson ghi nhn vim
h thng gia tng trong cac t kich phat cua BPTNMT va nguy c NMCT
tng gp 2,27 ln trong vong 5 ngay sau t kich phat[63]. Mt khac, s
hin din cua BPTNMT lam tng nguy c t vong va nhu cu tai ti mau
mach vanh sau can thip mach vanh[66]. Pontus Andell nghin cu tm anh
hng cua BPTNMT trn tin lng lu dai cua cac bn bi NMCT trn
81.191 bn trong thi gian 2005 2010 va c chia lam 2 nhom: nhom co
tin cn c chn oan BPTNMT va nhom khng co tin cn BPTNMT.
Kt qua cho thy so vi cac bn khng co kem BPTNMT, cac bn co kem
20
BPTNMT co ty l t vong trong 1 nm cao hn (24,6% so vi 13,8%) va
co ty l suy tim mi xut hin cao hn (gp 1,35 ln)[35]. Artur Dziewierz
nghin cu 714 bn co hi chng vanh cp gm 81 bn co kem BPTNMT
(11,3%) va 633 bn khng co BPTNMT (88,7%). Kt qua nghin cu cho
thy so vi cac bn khng co kem BPTNMT, cac bn co kem BPTNMT co ty
l t vong trong thi gian nm vin cao hn (29,6% so vi 14,1%)[64].
Tomas Konecny nghin cu 14.346 bn co BMV c can thip ng mach
vanh qua da trong o co 2001 bn co kem BPTNMT (16,21%). Chi co 60%
bn BPTNMT c o h hp ky chn oan BPTNMT. Kt qua cho thy
thi gian sng 5 nm sau can thip ng mach vanh qua da la 84% i vi
cac bn khng co kem BPTNMT; 79% i vi cac bn co kem BPTNMT
nhe-trung bnh; 65% i vi cac bn co kem BPTNMT mc nng va
56% i vi cac bn co kem BPTNMT giai oan rt nng (p< 0,001)[89].
- Anh hng cua BMV ln BPTNMT
Cac bn bi BPTNMT co nguy c cao t vong do bnh tim mach gp
2-3 ln; chim khoang 50% cac trng hp t vong[120]. Antonelli Incalzi
va cs theo doi cac bn BPTNMT sau khi nhp vin v t kich phat thy
nhng bn co biu hin bnh tim thiu mau cuc b trn in tim co thi gian
sng sot ngn hn (2,19 nm so vi 3,26 nm; p< 0,01). S hin din cua
BPTNMT cung co anh hng xu trn s ln nhp vin va t vong trong
bnh vin cua cac bn bi bnh tim thiu mau cuc b[79].
1.3.2 Bnh phi tc nghen mn tinh va bnh mch vanh cung co cac
yu t gy va duy tri tinh trng vim h thng mc thp
Trong cac yu t nguy c chung gia BPTNMT va BMV gy ra vim
h thng th hut thuc la la yu t thng gp nht[97], [166]. Khoi thuc
la gy ra tn thng cua ca biu m phi va cac t bao ni m mach mau.
Khoi thuc la gy tn thng m do tac ng tai ch cua cac hoa cht trong
21
khoi thuc, va gy kich thich ap ng vim h thng anh hng trn toan
b c quan trong c th[132].
Hut thuc la ro rang la mt yu t nguy c tim mach nhng cac anh
hng cua HTL khng u giai thich nguy c tim mach gia tng trn cac
bn mc BPTNMT[82]. %FEV1 giam cung gia tng nguy c t vong trn
nhng ngi khng HTL[167]. Cung vi HTL, cac yu t nguy c khac
nh li sng it vn ng, bo ph va tnh trang khang insulin cung co lin
quan vi vim h thng mc thp va stress oxy hoa. Cac nghin cu cho
thy bo ph dang nam lam giam chc nng h hp va lam tng tnh trang
khang insulin/ ai thao ng cung hay gp trn cac bn BPTNMT.
Hnh 1.3 Vim trong BPTNMT gop phn gy cac bin c tim mach.
(GM-CSF: granulocyte-macrophage colony-stimulating factor Yu t kich thich tao
dong t bao hat-ai thc bao)[59].
22
1.3.3 Cac nh hng cua vim h thng trn ng mch vanh va trn
phi
Vim h thng gy tn thng m va hoat hoa h min dich bt
thng co th la con ng chung lin kt gia XVM va tc nghen ng
dn khi. Nhiu nghin cu cho thy co vai tro cua cac t bao vim va cac
cht trung gian gy vim tai mang x va. Vim tham gia vao qua trnh
khi u, phat trin va v mang x va[98].
Nn tang cua BMV la hang loat cac ap ng vim gy ra di tac
ng cua cac yu t kich thich nh tng cholesterol mau, bo ph, tng
ng huyt, tng huyt ap va HTL[37]. Qua trnh x va khi u vi tn
thng cua lp ni m lam thay i hang rao lp ni m. Lp ni m bc
l nhiu cac phn t kt dinh b mt va gy thm nhp cac bach cu va cac
LDL bi oxy hoa vao thanh mach mau. Cac cytokin, cac yu t tng trng
va cac cht trung gian khac t lp ni m bi vim thuc y bach cu n
nhn i vao mang x va va bit hoa ban u thanh ai thc bao va sau o
la cac t bao bot. Cac thanh phn lipoprotein cua huyt tng, LDL bi oxy
hoa va cac cht khac ong vai tro nh khang nguyn, kich thich gia tng
xm nhp thm cac t bao vim nh t bao lymph T va khuch ai phan
ng vim. ap ng min dich phi hp tai mang x va la bin c chinh
dn n hnh thanh va cui cung la v mang x va[132].
Vim h thng trong BPTNMT la mt phn quan trong cua vong
xon bnh ly.Vim ngoai phi ong vai tro quan trong trong bnh sinh cua
cac thanh phn h thng trong BPTNMT. Thanh phn h thng nay khng
chi do s gia tng cua IL-8 va TNF- phi thm nhp vao mau ma con co
s tham gia cua cac t bao vim trong tun hoan. Cac yu t khac ong gop
vao anh hng h thng cua BPTNMT gm giam oxy m, stress oxy hoa,
li sng it vn ng va cac bt thng v chuyn hoa khac. Cac anh hng
23
h thng gp trong BPTNMT gm ri loan chc nng c xng, sut cn,
cac bt thng trn h tim mach va h thn kinh, loang xng[93]. Giam
khi c va sut cn trm trong cua cac bn BPTNMT co th lin quan vi gia
tng nng cua TNF-, gy cht theo chng trnh cua cac t bao c.
Mc anh hng h thng cua BPTNMT thay i trn tng bn va tuy
thuc vao cac yu t khac nh di truyn va cac bnh ly kt hp nh bnh
tim, ai thao ng va HTL[27].
X va ng mach cung chia s nhiu c ch vim nh trong
BPTNMT. Qua trnh bnh ly gy ra do cac cht trung gian gy vim ng
mach cua XVM vi phi trong BPTNMT ging nhau[156]. Cung nh
trong XVM, tai cu truc ng dn khi va huy hoai nhu m phi co th
do cac c ch vim tai ch va vim h thng. Khi u, co s gia tng ap
ng min dich qua tng phong thich cac cytokin nh TNF- va cac
interleukin, cac ai thc bao va bach cu trung tinh tp trung tai vung vim.
Sau o, ap ng vim gy phong thich cac enzym phn huy protein va cac
gc oxy phan ng lam tn thng m hn na. Cac cht c phong thich
t m hoai t hay cac t bao tn thng va cac cht la co th ong vai tro
nh cac khang nguyn va trnh din vi t bao lymph T. Qua trnh nay
gy tng tit am, huy hoai nhu m phi gy khi ph thung, x hoa quanh
tiu ph quan, day va tai cu truc ng dn khi, giam kha nng thanh loc
cht nhy va pha v hang rao bao v lp biu m[132]. giai oan sau,
cac thay i nhu m phi va ng dn khi nh ly giai protein va thoai
bin cht nn ngoai bao cho cac biu hin ging nh trong XVM. phi,
ly giai protein gy khi ph thung con trong XVM gy nt v bao si cua
mang x va[132].
Do o, tnh trang vim man tinh cung nh tnh trang tn thng va
sa cha m tai i tai lai xy ra cac cac mach mau cua tim va nhu m
24
phi. Tin trnh nay gy ra hnh thanh, phat trin va v mang x va trong
bnh tim thiu mau cuc b va gy gii han lu lng khi va vim ph quan
man trong BPTNMT[132]. Kt qua sau 3 nm theo doi trong nghin cu
1755 bn co BPTNMT cua Agusti A. cho thy so vi cac bn khng co vim
h thng, cac bn co vim h thng co ty l t vong cao hn (13% so vi
2%; p< 0,001) va co nhiu t kich phat cua BPTNMT hn (1,5t kich
phat BPTNMT/nm so vi 0,9 t kich phat BPTNMT/nm; p< 0,001)[25].
1.3.4 Cac cht chi im vim trong tun hoan trong bnh phi tc
nghen mn tinh va bnh mch vanh
Trong ca BPTNMT va BMV co chung c s bnh ly la s gia tng
trong huyt tng nng cua cac protein pha cp va cac cht chi im
vim nh bach cu, CRP, cac interleukin 6, 7, 8 va fibrinogen[132].
CRP la cht chi im vim va cung la mt yu t trong bnh sinh cua
XVM qua hoat hoa cac t bao ni m va t bao c trn cua ng mach
vanh. S gia tng nng cua CRP co th ong vai tro quan trong trong s
tin trin cua XVM cac bn bi BPTNMT. Cac bn co tc nghen lu lng
khi mc trung bnh nng co tnh trang vim h thng mc thp lam
gia tng nguy c bi tn thng tim. Hn na, vim h thng mc thp
ko dai trong BPTNMT co th gy cac anh hng xu trn tim va cac mach
mau [156].
1.3.5 Cac c ch bnh sinh chung khac cua bnh phi tc nghen mn
tinh va bnh mch vanh
Vim h thng dng nh la c ch chinh lin kt gia BPTNMT va
BMV. Tuy nhin, cung co cac c ch khac co th gop phn:
Mt cn bng gia hnh thanh cuc mau ng va chng cuc mau ng
vi gia tng hoat tinh tin ng mau cung thy trn cac bn co BPTNMT.
Do o, cac bnh ly co lin quan vi tng ng mau nh cac ri loan tim
25
mach, nhi mau c tim va thuyn tc phi cung hay gp trn cac bn
BPTNMT[132]. Tui gia tng gy vim h thng mc thp, stress oxy
hoa man tinh cung gp trn ca cac bn co BMTNMT cung nh cac bn co
BMV. Cac yu t nay lam gia tng mt an hi cua nhu m phi, gia tng
cng cua thanh ng mach, ri loan chc nng cua lp ni m va gy
canxi hoa thanh mach[132].
26
Hnh 1.4 C ch bnh sinh chung cua BPTNMT va BMV vi trong tm la
vim h thng gy tn thng va sa cha m, dn n hu qua la lam tn
thng nhu m va biu hin lm sang[132].
27
1.4 TNG QUAN V hs-CRP VA TNF-
Khi ap ng vi tn thng, cac t bao vim tai ch (bach cu trung
tinh va ai thc bao) tit ra mt s cytokin vao mau, trong o ang chu y
nht la IL-1, IL-6 va IL-8, va TNF-. Gan ap ng gy sinh ra mt s cac
protein pha cp nh CRP. Cac protein pha cp co nhiu tac dung gop phn
vao c ch bao v c th. Chung co th trc tip trung hoa cac tac nhn gy
vim, giup giam mc tn thng m tai ch cung nh tham gia vao qua
trnh sa cha va tai tao m[54].
1.4.1 Tng quan v hs-CRP
Vao thp nin 1990, cac ky thut mi giup phat hin c nng
CRP trong huyt thanh ngng thp hn so vi cac ky thut cn lm sang
trc o (n 0,3mg/L) va c goi la hs-CRP. Cac ky thut nay c
dung anh gia nguy c tim mach kt hp vi vim mach mau man tinh
trong XVM[140]. hs-CRP la ky thut co nhay cao co th phat hin
c nng CRP trong mau ngng rt thp so vi xt nghim CRP
thng thng[129]. Theo Hip hi Tim mach va Trung tm Kim soat va
Phong nga Bnh tt cua Hoa K (AHA/CDC) th nhay cao la co kha
nng o c CRP mc thp u chinh xac phn tng ngi khe
manh theo tam phn vi, t phn vi va ngu phn vi. Trn thc t, la xt
nghim phai o c nng 0,3mg/L va lch < 10% nng CRP
t < 0,5 n 1mg/L[18].
1.4.1.1 Cu trc phn t ca CRP
CRP tn tai nhiu cu truc khac nhau trong th dich va ca trn mang
phospholipid cua t bao[5]. Dang hnh vong bc 5 cua CRP: la mt protein
cua pha cp gm 5 chui polypeptid. Mi chui co trong lng phn t
23kDa cha 1 im ni vi 1 phn t phosphocholin va 2 im ni vi
canxi. Nhng vi tri nay cho php CRP nhn din va gn vi cac vi sinh vt,
28
t bao si, cac hp cht sinh hoc khac cua mang t bao bi tn thng, cht
nhim sc va khang nguyn. Kt qua la hnh thanh phc hp CRP-phi
t.Phc hp nay co th gn trc tip vi bach cu trung tinh, ai thc bao
va cac loai thc bao khac, kich thich ap ng vim va giai phong
cytokine[5].
Hnh 1.5 Phn t C Reactive Protein[127].

1.4.1.2 Sinh tng hp CRP
CRP la mt thanh vin cua mt nhom cac cht phan ng pha cp va
nng cua no gia tng trong qua trnh vim. IL6 va TNFla cac cytokin
gy vim va la cac cht chinh gy gan tng san xut CRP[100]. CRP chu
yu do gan sinh ra ap ng vi cac yu t trung gian cua qua trnh vim,
tn thng m nh interleukin 1, interleukin 6 va TNF-[162]. Mt s c
quan ngoai gan cung tham gia tng hp CRP la t bao biu m ng h
hp va lymph T. Trn cac bn co hi chng vanh cp, CRP c phat hin
trong thanh mach mau va nng cua CRP xoang vanh cao hn ng
mach chu, gi y tim cung la ngun gc cua CRP. Tuy nhin, gan vn la c
quan chinh sinh tng hp CRP[140].
1.4.1.3 Chc nng ca CRP i vi h thng min dich
CRP la mt protein phan ng pha cp do gan tng hp ap ng
vi cac kich thich cua IL-6. CRP co thuc tinh tin vim va tin x va
29
manh trn cac t bao ni m[34]. CRP rt nhay, co th tng gp 100 ln
trong qua trnh vim. CRP bt u tng 4 6 gi sau khi co nhim khun
hay m bi tn thng. Nng CRP tng mc ti a trong vong 48 gi
va nu khng con tac nhn kich thich se tr v bnh thng sau 96 gi.
Thi gian ban huy khoang 19 gi[134], [150]. Khng ging vi cac cht
chi im pha cp khac, nng CRP tng i n inh, khng thay i
ang k trong ngay[140].
Hnh 1.6 Kich thich va sinh tng hp cac protein phan ng pha cp trong
vim[157].
1.4.1.4 CRP va bnh mach vanh
Nhiu nghin cu cho thy bnh mach vanh la mt bnh ly vim man
tinh vi s gia tng cua cac cht chi im vim, c bit la cht protein
phan ng C va yu t hoai t u[98]. CRP co cac anh hng trn bnh sinh
cua XVM va ri loan chc nng t bao ni m. CRP kich thich IL-6 va
san xut ra endothelin-1, thuc y cac bin c gy hnh thanh cuc mau
ng[98].
30
- Vai tro ca CRP trong x va ng mach
Nhiu nghin cu cho thy CRP co vai tro trc tip trong hoat hoa
lp ni mac mach mau, trong tin trnh vim va tn thng x va ng
mach.
Hnh 1.7 CRP tham gia vao qua trnh gy x va ng mach[157].

CRP lin quan n ri loan chc nng lp ni mac do lam tng stress
oxy hoa va lam giam tac dung sinh hoc cua Nitric oxyde (NO), lam giam
phong thich prostacyclin t t bao ni mac, kich thich bach cu phong thich
ET-1. CRP khng chi hoat hoa t bao ni mac ma con tham gia chu ng
trong ap ng vim ngay tai long mach[5].
31
Hnh 1.8 CRP tham gia vao qua trnh bnh sinh mang x va[85].
- Vai tro ca CRP trong bnh mach vanh
CRP c tng hp chu yu t bao gan nhng cung c phong
thich t cac t bao m m va t cac t bao c trn cua MV c nui cy
cho thy tnh trang vim tai ch co th lam tit CRP. CRP c phat hin
bng phng phap min dich hunh quang t cac mang x va cua
MV[150]. Sudha Thakur nghin cu 150 bn BMV va 50 ngi khe
manh lam nhom chng cho kt qua nng hs-CRP trung bnh trong nhom
BMV la 1,7 0,75mg/L, cao hn ang k so vi nhom chng 0,93
0,35mg/L (p<0,001)[147].
Hip hi Tim mach Hoa K (AHA) va Trung tm Kim soat va Phong
nga Bnh tt Hoa K (CDC) phn nhom nguy c bnh mach vanh theo
nng hs-CRP:
Nguy c thp: hs-CRP < 1mg/L.
Nguy c trung bnh: hs-CRP 1 3mg/L.
32
Nguy c cao: hs-CRP > 3mg/L[18],[115].
Nm 2003 AHA va CDC a khuyn cao chung v vic ng dung cac
chi im sinh hoc trong anh gia nguy c BMV, tin lng va quyt inh
iu tri gm:
(1)-hs-CRP la cht chi im vim cua bnh mach vanh c chi inh
trn lm sang.
(2)-Bnh nhn thuc nhom nguy c mach vanh trung bnh (10% - 20%)
nn c chi inh hs-CRP anh gia va quyt inh iu tri (d phong).
(3)-hs-CRP giup tin lng bn bnh mach vanh (gm t vong va bin
c mach vanh tai phat).
hs-CRP c dung tai phn b nhom nguy c trong thang im
Framingham. Thang im Framingham c chia lam 3 nhom nguy c:
thp va cao. Nhom nguy c thp c tinh co < 10% kha nng bi cac
s c mach vanh, nhom nguy c trung bnh co 10 20% va nhom nguy c
cao co > 20%. Ngi ta thy la Thang im Framingham ban u da vao
cac yu t nguy c truyn thng (khng tinh hs-CRP) la nng v tui, co
nhiu trng hp c tinh di mc nguy c tht s, nht la nhom nguy
c trung bnh. Kt qua t nhiu nghin cu cho thy hs-CRP la yu t nguy
c c lp cua bnh mach vanh va vic a hs-CRP vao giup xp xp lai
Bang phn loai nguy c, c bit la nhom co nguy c trung bnh co n
20% - 30% co hs-CRP > 3mg/L c xp lai vao nhom nguy c cao[18].
So vi cac yu t nguy c truyn thng, hs-CRP la yu t tin lng
manh nht va kt hp vi cac yu t tin lng khac nh nng
cholesterol, LDL-C, triglycerid va glucose lam tng kha nng tin lng
bnh. Trn cac bn co hi chng vanh cp, hs-CRP co lin quan n
nng, la yu t giup tin lng cac s c mach vanh va t vong. Ngng
cua hs-CRP trong trng hp nay la 10mg/L. Nhng bn c can thip
33
mach vanh qua da co nng hs-CRP cao hn cung co d hu xu hn
nhom co hs-CRP thp[18].
1.4.1.5 CRP va bnh phi tc nghen man tinh
CRP c anh gia trong nhiu bnh canh khac nhau cua BPTNMT
nhm tm s kt hp gia tnh trang vim h thng c ban trong giai oan
bnh n inh, cac bin c tim mach, tin lng bnh va xac inh cac t
kich phat nhim trung. Trong giai oan bnh n inh, nng CRP co
khuynh hng c lp vi vic HTL, chc nng h hp nhng co lin quan
manh vi phn ap oxy trong mau ng mach va kha nng i b 6 phut[90].
Cac cht trung gian gy vim nh CRP co th hin din 10 20 nm sau
khi bnh nhn a ngng HTL co th giai thich s xut hin cua BPTNMT
trn cac bn co tin cn HTL va la mi lin kt cua HTL vi tnh trang vim
c ban trn cac bn BPTNMT co cac bnh i kem[165]. S gia tng nng
hs-CRP trn ngi HTL co th d bao BPTNMT tim n[153].
- hs-CRP chi im vim trong bnh phi tc nghen man tinh
Mt s nghin cu cho thy cac cht chi im vim h thng nh hs-
CRP trong mau cao hn trn bn BPTNMT so vi ngi khng co bnh nay
va c lp vi tnh trang HTL[70].
V M Pinto-Plata nghin cu 88 bn BPTNMT so vi nhom chng
gm 33 ngi HTL va 38 ngi khng HTL. Kt qua la nng CRP cao
hn ang k trong nhom bn BPTNMT (5,03mg/L) so vi nhom chng
(2,02mg/L va 2,24mg/L) va kt lun CRP co th la cht chi im vim h
thng cua qua trnh vim trn cac bn BPTNMT[126]. Nghin cu cua Van
Durme Y. M. va cs cho kt qua nhng ngi HTL co nng hs-CRP
>3mg/L co nguy c cao mc BPTNMT (HR= 2,2; khoang tin cy 95%:
1,123,74;p< 0,01)[153].
34
- CRP gia tng cng nng ca bnh phi tc nghen man tinh
Pavol nghin cu trn 43 bn BPTNMT vi tui trung bnh la 65,
FEV1 trung bnh la 46,2%. Trong s 19 bn co tng ap phi, nng CRP
va TNF- cao hn ang k so vi cac bnh nhn khng co tng ap phi
(CRP la 3,6mg/L so vi 1,8mg/L; TNF- trung bnh la 4,2pg/ml so vi
3,1pg/ml). Khng co s khac bit v nng cua IL-6 gia 2 nhom nay. S
gia tng cua ap lc ng mach phi co kt hp vi gia tng nng cua
CRP va TNF- t ra vai tro cua vim h thng mc thp trong bnh
sinh cua tng ap phi trn bn BPTNMT[84].
Izvorni Znanstveni Clanak nghin cu 150 bn BPTNMT va nhom
chng gm 51 ngi. Kt qua cho thy nng CRP gia tng ang k trn
cac bn co BPTNMT so vi nhom chng (12,92 mg/l so vi 7,70mg/l) va s
gia tng cua CRP theo giai oan nng cua BPTNMT. Nghin cu cua J. P.
de Torres cung thy nng CRP gia tng trn bn BPTNMT so vi ngi
khe manh va co tng quan nghich vi FEV1 va FVC[60].
Khalil Ansarin nghin cu 94 bn BPTNMT cho kt qua la so vi cac
bn BPTNMT khng tng ap ng mach phi, cac bn BPTNMT co tng ap
ng mach phi co nng hs-CRP cao hn co y ngha thng k (8,8mg/L
so vi 4,07mg/L; p< 0,05)[36].
- CRP la chi im nguy c tan ph va t vong ca cc bnh nhn bnh phi
tc nghen mn tinh
Cac nghin cu gn y cho thy vim h thng kt hp vi gia tng
tan ph va t vong cua cac bn BPTNMT. Zai-Chun Deng nghin cu 116
bn BPTNMT n inh va 35 ngi khe manh vi chc nng h hp bnh
thng lam nhom chng va thi gian theo doi la 32 thang hay khi bn t
vong. BPTNMT c chn oan da theo tiu chun GOLD. Kt qua
nghin cu cho thy nng CRP cua cac bn BPTNMT cao hn ang k
35
so vi nhom chng (4,48 0,83 so vi 1,01 0,27 mg/l; p<0,05). Ngoai ra,
cac bn co nng CRP > 3mg/l co tin lng xu hn so vi cac bn co
nng CRP < 3mg/l[169].Tng t, Bartolome R. Celli nghin cu 1843
bn BPTNMT. Sau 3 nm theo doi co 168 bn t vong. Cac bn t vong co
nng CRP cao hn ang k so vi cac trng hp khng t vong
(4,6mg/L so vi 3,1mg/L; p< 0,001)[50].
Qua kt qua cua nghin cu tim mach thanh ph Copenhagen, Dahl
nhn thy, nguy c nhp vin va t vong cua BPTNMT cung cao hn i
vi cac bn co nng hs-CRP > 3mg/L. Kt qua t nghin cu sc khe
phi (The Lung Health Study) cung thy co lin quan gia s gia tng nng
cua CRP vi t vong cua BPTNMT. Nng cua CRP cung co lin
quan nghich vi kha nng gng sc cua bn BPTNMT[27].
1.4.2 Tng quan v TNF-
TNF- la cht trung gian gy vim tham gia vao nhiu qua trnh
bnh ly cua vim, nhim trung, bnh t min cung nh cac bnh ly ac
tinh.TNF- c san xut ra ap ng vi nhim trung c xem nh
ap ng min dich c th. Mc du anh hng cua TNF- trong bnh ly
nhim trung co hiu qua bao v nhng cung cn kim soat cht che s san
xut TNF- giam tac tac dung bt li cua TNF- i vi c
th[105].TNF- co th gia tng qua mc nhng ngi HTL[74]. Theo
Felipe Villar lvarez, mi lin quan gia BPTNMT va bnh tim mach co
th qua trung gian cua TNF-[34].
1.4.2.1. Ngun gc ca TNF-
Nhiu loai t bao co kha nng tit TNF- gm bach cu n nhn,
ai thc bao, bach cu trung tinh, cac t bao biu m, t bao lymph T va
cac t bao c trn cua ng dn khi va t bao c tim[40],[45]. oan gen
36
ma hoa cho TNF- nm trn nhim sc th s 6, gia cac gen HLA-DR
nhom I va cac gen HLA-B nhom II. Vi tri nay a n gia thuyt co s kt
hp cua cac allen tao TNF- vi mt s bnh ly[56],[80].
1.4.2.2 Chc nng ca TNF-
TNF- tham gia vao phan ng vim theo nhiu cach khac nhau. Cac
t bao ni m tip xuc vi TNF- dn n gia tng cac phn t kt dinh b
mt, lam gia tng s kt dinh cua bach cu trung tinh va bach cu n
nhn. TNF- gy tng san xut IL-6, mt cht gy tng san xut cac
protein pha cp gan. Ngoai ra, TNF- hoat hoa cac ai thc bao, cac t
bao biu m va trung m gy san xut cac cht hoa hng ng i vi cac
t bao vim nh IL-8 va leukotrien B4[52].
TNF- co cac thuc tinh tin vim quan trong[87]. Cytokin nay c
nhiu loai t bao bai tit ra nh ai thc bao, cac bach cu n nhn, cac t
bao lymph T, cac t bao c trn, t bao m m va cac nguyn bao si[34].
TNF- cung c tm thy mang x va[87].
1.4.2.3 TNF- tm sot bnh mach vanh
TNF- tham gia vao bnh sinh cua nhiu bnh ly tim mach nh
XVM, nhi mau c tim, suy tim va vim c tim[45]. TNF- cung vi cac
phn t vim khac ong vai tro khi phat va ko dai nhiu bnh tim mach.
Mc du tim ngi bnh thng khng sinh TNF- nhng khi tim bi tn
thng co th tit ra mt lng ang k TNF-[22]. Nng TNF- gia
tng trong tun hoan cung kt hp vi gia tng nguy c nhi mau c tim tai
phat, dy ng mach canh do x va[87].
Vim ong vai tro chinh trong bnh mach vanh. Vim tham gia tt ca
cac giai oan t luc hnh thanh mang x va n khi v mang x va gy
hi chng vanh cp. Theo Anthony S. McLean, hu ht cac bnh tim co th
37
chia lam 3 giai oan: giai oan vim, giai oan tn thng t bao c tim va
giai oan stress trn tim. Trong mi giai oan nay co cac cht chi im sinh
hoc tng ng trong o CRP va TNF- co vai tro trong giai oan vim[37].
Shubair M.K. nghin cu trn 100 bn co BMV do x va c
chng minh qua chup mach vanh va 81 ngi khe manh. Kt qua nng
TNF- trn cac bn co BMV cao hn ang k so vi nhom chng (129,13
325,29pg/ml so vi 25,90 27,76pg/ml)[111].
Mt nghin cu khac tai Trung tm nghin cu bnh tim mach cua
Iran nm 2009 do Basiri tin hanh trn 135 bn c chup mach vanh, trong
o 19 trng hp (14,1%) co mach vanh bnh thng, 6 trng hp (4,4%)
co tn thng mach vanh nhe, 43 trng hp (31,8%) co BMV 1 nhanh, 29
trng hp (21,5%) tn thng 2 nhanh va 38 trng hp (28,1%) bi tn
thng 3 nhanh mach vanh[42]. Nng CRP trung bnh trn ngi co
mach vanh bnh thng la 64 mg/L va trn bn co BMV la 179 mg/L.
Nng TNF- cua cac bn co BMV trung bnh la 6,33,8 pg/mL, con trn
ngi co mach vanh bnh thng la 4,5 2,2 pg/mL. Nghin cu cua Israel
Gotsman cung cho thy TNF- co lin quan vi nng cua BMV qua s
mach vanh bi tn thng va thang im Gensini[72]. iu nay cho thy co
s lin quan gia cac yu t vim (CRP va TNF-) vi bnh ly mach
vanh[132].
1.4.2.4 TNF- tng nguy c bin c mach vanh ti pht
Nghin cu cua Paul M. Ridker trn 272 bn sau nhi mauc tim sau
8,9 thang theo doi bin c tim mach tai phat t vong va khng t vong. Kt
qua la nng TNF- gia tng ko dai trn cac bn sau nhi mau c tim co
nguy c bi cac bin c mach vanh tai phat. Nguy c nay gia tng gn 3 ln
38
(RR = 2,7; khoang tin cy 95%: 1,4 5,2, p<0,01) trn cac bn co nng
TNF-> 4,17pg/ml[130].
Basiri nghin cu 135 bn c chup mach vanh, trong o 19 trng
hp (14.1%) co mach vanh bnh thng, 6 trng hp (4.4%) co tn
thng mach vanh nhe, 43 trng hp (31.8%) co bnh mach vanh 1
nhanh, 29 trng hp (21.5%) tn thng 2 nhanh va 38 trng hp
(28.1%) bi tn thng 3 nhanh mach vanh. Nng CRP trung bnh trn
ngi co mach vanh bnh thng la 64 mg/l va trn bn co BMV la 179
mg/L. Nng TNF- cua cac bn co BMV trung bnh la 6,33.8 pg/mL,
con trn ngi co mach vanh bnh thng la 4,5 2.2 pg/mL[42].
1.4.2.5 TNF- va bnh phi tc nghen man tinh
TNF- ong vai tro quan trong trong nhiu bnh ly h hp nh hen,
BPTNMT, tn thng phi cp va hi chng nguy kich h hp
cp[45].TNF- c cho la ong vai tro trong tm trong vim tai phi va
vim h thng cua BPTNMT[143]. TNF- gy ra cac tn thng bnh ly
ging vi BPTNMT trn ng vt thi nghim nh thm nhim cac t bao
vim phi, x hoa phi va khi ph thung[22]. Cht trung gian vim u
tin c tm thy co gia tng trn bn BPTNMT la TNF-. TNF- la mt
cytokin tin vim manh, co lin quan vi yu c va tng ap ng mach
phi trn cac bn BPTNMT. Sevenoakscoi TNF- co vai tro trong tm trong
bnh sinh cua BPTNMT, thm chi a ra thut ng vim kiu TNF- -
inflammation TNF- phenotype[88].
Thuc la la yu t nguy c chinh cua BPTNMT.Hut thuc la co th
gy vim h thng nhng trn cac bn BPTNMT, tnh trang vim h thng
nhiu hn[41]. Nhng bn bi BPTNMT co gia tng s lng bach cu trung
tinh trong phi, gia tng hoat hoa cua bach cu trung tinh trong mau ngoai
39
vi va gia tng TNF- va thu th TNF hoa tan. Khoi thuc la gy tng phong
thich TNF- va ong vai tro quan trong trong bnh sinh cua BPTNMT[3].
TNF- la mt protein ong vai tro quan trong cua vim h thng
trong BPTNMT[34]. Tanni nghin cu 53 bn BPTNMT a ngng hut
thuc la, 24 bn BPTNMT con hut thuc la, 24 ngi chng con hut thuc
la va 34 ngi chng khng hut thuc thy nng cua TNF- cao hn
trn nhng ngi con hut thuc la so vi nhng ngi a ngng hut va
khng hut (4,8pg/ml va 4,8pg/ml so vi 4,3pg/ml va 3,7pg/ml) va kt lun
la hut thuc la co th gy vim h thng qua trung gian cua TNF-[146].
Nghin cu cua Victor Pinto-Plata cho thy co mi tng quan cua TNF-
vi cac cht chi im vim khac nh IL-6, IL-8 trn bn co BPTNMT[126].
TNF- gia tng vi mc nng cua BPTNMT[90]. Pavol Joppa
nghin cu v vim h thng trn 43 bn BPTNMT trong o 19 bn
BPTNMT co tng ap ng mach phi. Kt qua la co s gia tng ang k v
nng CRP trong nhom bn BPTNMT co tng ap ng mach phi so vi
cac bn co BPTNMT khng co tng ap ng mach phi (3,6mg/L so vi
1,8mg/L) cung nh v nng cua TNF- gia 2 nhom nay (4,2pg/ml so
vi 3,1pg/ml). Tac gia cho la s gia tng ap lc ng mach phi trn cac bn
BPTNMT kt hp vi s gia tng v nng cua CRP va TNF t ra kha
nng v vai tro bnh sinh cua vim h thng mc thp trong bnh sinh
cua tng ap ng mach phi trn cac bn BPTNMT[84].
TNF cung gia tng trong cac t kich phat cua BPTNMT. Eric
Bathoorn nghin cu 45 bn BPTNMT trong luc bnh n inh va trong t
kich phat. Kt qua co s gia tng cua bach cu ai toan, bach cu trung tinh
va bach cu lymph trong cac t kich phat cua BPTNMT. S gia tng
vim h thng dng nh co lin quan vi nhim trung ng h hp di.
40
Nng TNF- chi im kha nng co nhim trung ng dn khi. Juan
Xie nghin cu 30 bn BPTNMT trong t kich phat, 30 bn BPTNMT n
inh va 30 ngi khe manh khng HTL lam nhom chng. Kt qua nghin
cu cho thy nng TNF- trong huyt thanh gia tng ang k trong t
kich phat BPTNMT va BPTNMT n inh so vi nhom chng (nng
TNF- trong t kich phat BPTNMT: 84,43 14,73pg/ml; BPTNMT n
inh: 30,59 5,62pg/ml va nhom chng: 15,12 4,62; p< 0,01)[163].
1.5 CAC NGHIN CU LIN QUAN TAI
1.5.1 Nghin cu v nng hs-CRP bnh nhn bnh tim thiu mau
cuc b
Pham Trung Ha va cs nghin cu hs-CRP bn bnh tim thiu mau
cuc b BV Thng Nht trn 74 bn co BMV man, 51 bn bi NMCT cp va
43 ngi khe manh. Kt qua nng hs-CRP trung bnh nhom bnh tim
thiu mau cuc b man tinh la 3,89 2,89 mg/L, nhom bn NMCT cp la
28,01 27,64 mg/L. Khng thy tng quan gia hs-CRP vi s nhanh
mach vanh bi hep[7].
1.5.2 Nghin cu nng TNF- trn ngi cao tui co hi chng
mch vanh cp
T vn Tun va cs nghin cu nng TNF- 30 bn bi hi chng
vanh cp co tui 70 80 va 20 ngi khe manh co tui tng
ng tai BV Trung ng Hu[19]. Kt qua nghin cu cho thy nng
cua TNF- trong nhom bnh trung bnh la 52,64pg/ml so vi nhom chng
la 13,43pg/ml (p< 0,001). im ct ROC cua TNF- la 24,50pg/ml vi
nhay gia tri chn oan la 86,7% va c hiu la 95%. Co s tng quan
cua TNF- vi CRP (r = 0,705; p<0,005). S gia tng cua nng TNF-
la mt yu t nguy c bn hi chng vanh cp.
41
1.5.3 Nghin cu lin quan nng hs-CRP vi tn thng mch vanh
Nguyn Minh c va cs nghin cu mi lin quan gia nng hs-
CRP vi tn thng giai phu ng mach vanh qua chup mach vanh can
quang bn co bnh ng mach vanh trn 129 bn BV Thng Nht gm 53
bn c chn oan la au tht ngc n inh va 76 bn co hi chng mach
vanh cp[6]. Kt qua la nng trung bnh cua hs-CRP trong nhom hi
chng vanh cp la 21,39mg/L, cao hn so vi nhom khng hep la
4,55mg/L (p< 0,001). im Gensini trung bnh trong nhom hi chng vanh
cp la 37,61. Co mi tng quan gia nng hs-CRP vi s nhanh mach
vanh hep trong nhom hi chng vanh cp (r= 0,516; p <0,001) va vi
Thang im Gensini (r = 0,518, p< 0,001).
1.5.4 Nghin cu v nng hs-CRP va nng TNF- trong bnh
mch vanh
Mahalle N. va cs nghin cu trn 300 bn bi BMV cho kt qua nng
hs-CRP trung bnh la 11,7 9,7mg/L va nng TNF trung bnh la
25,3 40,9pg/ml[100].
1.5.5 Nghin cu tn thng MV trn bnh nhn co BPTNMT
Pei-Hsun Sung va cs nghin cu 1554 bn bi NMCT co ST chnh ln
c can thip mach vanh qua da vi 124 bn BPTNMT (9,7%) va 1430 bn
khng co BPTNMT (90,3%)[145].
Tiu chun chn oan BPTNMT: co 1 trong 4 yu t: tin cn cn dung
thuc gian ph quan; tin cn FEV1 < 70%; kham thc th bn th kho khe
th th ra, khi ph thung; ang dung thuc gian ph quan trong khi bi
NMCT. Kt lun cua nghin cu la khng co khac bit v tn thng mach
vanh gia 2 nhom co va khng co kem BPTNMT.
Ngc lai, Liang B. M. nghin cu trn 354 bn c chup MDCT
ng mach vanh va o h hp ky chn oan BPTNMT cho kt lun la so
42
vi cac bn khng co BPTNMT, cac bn co BPTNMT co tn thng nhiu
nhanh MV hn va co nng CRP cao hn so vi cac bn bi BMV khng
co kem BPTNMT[95].
1.5.6 Nghin cu hs-CRP trong bnh phi tc nghen mn tinh
Reshu Agarwal nghin cu 50 bn BPTNMT n inh va 50 ngi
khe manh lam nhom chng. Kt qua cho thy nng cua hs-CRP trong
nhom BPTNMT cao hn so vi nhom chng (4,82mg/L so vi 0,88 mg/L p
< 0,01). Co mi tng quan nghich gia nng cua hs-CRP vi %FEV1
(r= 0,813; p < 0,01). Cac tac gia kt lun la nng cht chi im vim
trong tun hoan hs-CRP gia tng ang k trn cac bn co BPTNMT cho thy
BPTNMT la mt thanh phn cua ri loan vim.
SA Alavi nghin cu160 bn nhp vin v t kich phat cua
BPTNMT. Kt qua nghin cu la nng hs-CRP huyt thanh trung bnh
la 11,65 15,03mg/L. Co mi tng quan nghich gia hs-CRP vi FEV1
vi h s tng quan r= - 0,392 (p< 0,001)[32].
1.5.7 Nghin cu hs-CRP va TNF alpha trong bnh phi tc nghen
mn tinh
Nervana Samy va cs nghin cu 90 bn BPTNMT va 20 ngi khe
manh lam nhom chng ghi nhn co s gia tng ang k nng hs-CRP va
TNF- trong BPTNMT va co lin quan vi mc nng cua bnh. Co mi
tng quan nghich gia hs-CRP va FEV1[136].
Sanja Marevie va cs nghin cu 34 bn BPTNMT c chn oan
da vao kt qua o h hp ky vi FEV1 <80% d oan. Nhom chng gm
34 ngi trong o 28 ngi HTL va 6 ngi khng HTL[104]. Kt qua
nghin cu cho thy nhom BPTNMT co nng TNF- trung bnh
11,6pg/ml va hs-CRP trung bnh la 3,9mg/L.
43
Juan Xie va cs nghin cu 30 bn BPTNMT trong t kich phat, 30
bn BPTNMT n inh va 30 ngi khe manh khng HTL lam nhom
chng. Kt qua nghin cu cho thy nng TNF- trong huyt thanh gia
tng ang k trong t kich phat BPTNMT va BPTNMT n inh so vi
nhom chng (nng TNF- trong t kich phat BPTNMT: 84,43
14,73pg/ml; BPTNMT n inh: 30,59 5,62pg/ml va nhom chng: 15,12
4,62; p< 0,01)[163].
1.5.8 Nghin cu tn sut cua bnh phi tc nghen mn tinh trong
bnh mch vanh va tn thng ng mch vanh
Tn sut cua BPTNMT trong BMV thay i gia cac nghin cu tuy
thuc vao tiu chun chon bnh va phng phap nghin cu.
- Sonkamble Siddharth va cs nghin cu bn BMV. Tiu chun chn
oan BPTNMT da theo tiu chun GOLD. Tiu chun chn oan BMV:
tin cn co thay i trn in tim, stress gng sc, siu m tim hay chup
mach vanh. Kt qua cua nghin cu la co 19 bn (19%) co BPTNMT theo
tiu chun GOLD[139].
- Joan B. Soriano va cs nghin cu trn 450 ngi lam chng khng
co bnh tim mach, 52 bn bnh tim mach va 119 bn nhp vin v bnh mach
vanh. Tiu chun chn oan gii han lu lng khi cua nghin cu da
theo tiu chun GOLD. Tn sut gii han lu lng khi cua 3 nhom ln
lt la 17,5%, 19,2% va 33,6%. Ty l gii han lu lng khi khng c
chn oan trc o trong cac bn co bnh tim mach la 60% va cac bn nhp
vin v bnh mach vanh la 87,2%. 60% ngi co gii han lu lng khi
trong ca 3 nhom nghin cu cha bao gi c iu tri v gii han lu
lng khi[144].
44
- Hesham Z. Saleha nghin cu trn 11.217 bn m bc cu ng
mach vanh co o h hp ky ghi nhn co 2895 (25,8%) bn co BPTNMT
theo tiu chun GOLD[135].
- Talha Mahmud va cs nghin cu trn 124 bn co bnh tim thiu mau
cuc b ghi nhn co 47 bn (37,9%) co kem BPTNMT theo tiu chun
GOLD[101].
- Faris Muthana va cs nghin cu 59 bn co BMV 2 trung tm vi
tiu chun chn oan BPTNMT la da vao bang cu hi tm cac bn co
nguy c cao bi BPTNMT hoc o h hp ky co % FEV1 < 80% d oan.
Kt qua nghin cu cho thy trong 59 bn co BMV th co 27 bn co
kem BPTNMT (chi co 9 bn c chng minh co FEV1 < 80%), tn sut
BPTNMT trong BMV cua nghin cula 44%.18 bn BPTNMT co tn
thng 1 nhanh ng mach vanh (62%) so vi 9 bn BPTNMT co tn
thng nhiu nhanh ng mach vanh (30%). Cac tac gia kt lun la cac bn
BPTNMT thng co tn thng 1 nhanh MV [114].
1.5.9 Nghin cu lin quan nng TNF- vi nng cua bnh mch
vanh qua thang im Gensini.
Israel Gotsman va cs nghin cu nng cua TNF- trn 201 bn
BMV. Kt qua cho thy co gia tng nng cua TNF- trn cac bn BMV
va co tng quan vi nng cua BMV qua Thang im Gensini vi r =
0,23 (p< 0,05) cho qun th nghin cu; r = 0,26 (p< 0,05) i vi cac bn
BMV n inh va r = 0,15 trong hi chng vanh cp[72].
1.5.10 Nghin cu tn thng ng mch vanh trn bnh nhn bnh
phi tc nghen mn tinh
- Tae Yun Park va cs nghin cu cac bn BPTNMT c chup ng
mach vanh v au tht ngc. BPTNMT c inh ngha khi FEV1/FVC sau
test gian ph quan < 70%. Tn thng ng mach vanh ang k khi hep it
45
nht 50% cua mt nhanh mach vanh [124]. Kt qua cua nghin cu trn
113 bn BPTNMT, 88% giai oan nhe trung bnh (trong o 46% giai
oan nhe; 42% giai oan trung bnh); chi co 9% (6 bn) giai oan nng
va khng co giai oan rt nng. 100% co lin quan vi HTL vi trung bnh
la 38,95 goinm. % FEV1 trung bnh la 75,74%; FEV1/FVC trung bnh la
55,48.61% bn BPTNMT co kt qua tn thng hep ng mach vanh ang
k. 34,8% bnh 1 nhanh ng mach vanh, 65,2% co tn thng 2 nhanh
(27,5% tn thng 2 nhanh ng mach vanh va 37,7% co tn thng 3
nhanh ng mach vanh).
- Ramazan Topsakal va cs nghin cu trn 88 bn BPTNMT, 82 bn
khng co bnh phi lam nhom chng. Chn oan BPTNMT da trn kt
qua o h hp ky va theo tiu chun GOLD. Cac bn c chup MV va
tinh nng theo thang im Gensini[151].
Kt qua nghin cu la khng co s khac bit v tui gia 2 nhom
(61 7 tui so vi 63 5 tui; p> 0,05). So vi nhom BMV, cac bn co bnh
phi hp BPTNM+BMV co s nhanh mach vanh tn thng nhiu hn co
y ngha thng k (2,5 nhanh so vi 2,1 nhanh; p< 0,01). Khng co mi
tng quan co y ngha thng k gia im Gensini vi FEV1 va
FEV1/FVC (p> 0,05).
46
CHNG 2
I TNG VA PHNG PHAP NGHIN CU
2.1 I TNG NGHIN CU

Cac trng hp c chon nghin cu la cac bnh nhn a c
chup ng mach vanh, ng y tham gia nghin cu.
2.1.1 Tiu chun chon bnh
i tng nghin cu la 193 trng hp a c chup ng mach
vanh tai 3 BV thanh ph H Chi Minh, trong o tai Vin tim co 15
trng hp; BV Thng Nht co 87 trng hp va BV Nhn dn 115 co
91 trng hp.
Cac bnh nhn c chia thanh 4 nhom:
2.1.1.1 Nhm bnh mach vanh c bnh phi tc nghen man tinh
La 33 bn co kt qua chup mach vanh co tn thng y ngha it nht
1 vi tri cua h ng mach vanh va kt qua o h hp ky co bng chng gii
han lu lng khi khng hoan toan hi phuc.
2.1.1.2 Nhm bnh mach vanh
La 86 bn co kt qua chup mach vanh co tn thng y ngha it nht
1 vi tri cua h ng mach vanh va kt qua o h hp ky khng co bng
chng gii han lu lng khi. y la cac bn bi BMV man va cac trng
hp hi chng vanh cp c loai tr nghin cu.
2.1.1.3 Nhm bnh phi tc nghen man tinh
La 21 bn co kt qua chup mach vanh khng co tn thng hay co tn
thng nhng khng co y ngha va kt qua o h hp ky co bng chng
gii han lu lng khi khng hoan toan hi phuc.
47
2.1.1.4 Nhm chng
La 53 trng hp co kt qua chup mach vanh khng co tn thng
hay co tn thng nhng khng co y ngha va kt qua o h hp ky khng
co bng chng gii han lu lng khi.
2.1.2 Tiu chun chn oan bnh
2.1.2.1 Tiu chun chn on bnh mach vanh
Chung ti chon tiu chun chn oan BMV la cac bnh nhn co bnh
mach vanh c chn oan qua chup mach vanh co bng chng x va
ng mach gy hep hoc tc it nht mt vi tri cua mach vanh.
+ Tn thng ng mach vanh c y nghia
Tn thng ng mach vanh co y ngha khi co tn thng x va
gy hep it nht 70% cua mt nhanh ng mach vanh hoc hep 50% cua
thn chung ng mach vanh trai[78].
+ Nhnh mach vanh tn thng
- LM: thn chung ng mach vanh trai.
- LAD: ng mach vanh nhanh lin tht trc.
- LCx: ng mach vanh nhanh mu.
- RCA: ng mach vanh phai.
+ nh gi nng ca bnh mach vanh theo thang im Gensini
- Mc giam khu kinh
25% - 1 im.
50% - 2 im.
75% - 4 im.
90% - 8 im.
99% - 16 im.
100% - 32 im.
48
- Vi tri mach vanh tn thng
Bang 2.1 H s theo vi tri mach vanh tn thng tinh im Gensini
V tri mch vanh b tn thng H s
Thn chung 5
ng mach lin tht trc oan gn 2,5
oan gia 1,5
Vung mm 1
Nhnh cho 1 1
Nhnh cho 2 0,5
ng mach mu oan gn 2,5 (3,5)
oan xa 1 (2)
Nhanh b 1
Nhanh sau di 1
Nhnh sau bn 0,5
ng mach vanh phai 1
- nng ca tn thng ng mach vanh

nng cua tn thng = Tng s cac im tn thng x H s[69].
2.1.2.2 Tiu chun chn on bnh phi tc nghen man tinh (GOLD 2010)
- Cc du hiu chinh chn on
Ho man tinh: cach khoang hay hng ngay. Thng bnh nhn ho ca
ngay, him khi chi ho v m.
Khac am man tinh: bt k tnh trang ho man tinh nao cung nn ngh
kha nng BPTNMT, nht la khi bnh nhn co tip xuc vi cac yu t
nguy c..
Nhiu t vim ph quan cp tai i tai lai.
49
Kho th t t (ngay cang nng dn), thng xuyn (hng ngay),
nng thm khi bnh nhn gng sc hay khi co nhim trung ng h
hp.
Tin cn tip xuc vi cac yu t nguy c: hut thuc la va cac cht
hoa hoc ngh nghip, khoi bp[96].
- Chn on va phn giai oan bnh phi tc nghen man tinh
Bnh nhn BPTNMT in hnh cho kt qua giam ca 2 tri s FEV1 va
FEV1/FVC. Mc giam FEV1 sau test gian ph quan phan anh mc
nng cua BPTNMT. Theo GOLD, BPTNMT co th chn oan xac inh
bng o h hp ky co ty s FEV1/FVC < 70% sau test gian ph quan[121].
Bang 2.2 Phn chia giai oan bnh cua BPTNMT[2].
Giai on bnh Tiu chun
Giai oan 1 (nhe) FEV1/FVC <70%.
FEV1 80% so vi ly thuyt.
Co hay khng co triu chng man tinh
(ho, khac am).
Giai oan 2 (trung bnh) FEV1/FVC <70%.
Giai oan 3 (nng) FEV1/FVC <70%.
Giai oan 4 (rt nng) FEV1/FVC <70%.
FEV1< 30% so vi ly thuyt hay <50% +
phi hp vi suy h hp man hay du
chng suy tim phai.
50
2.1.3 Tiu chun loi tr
- Cac bnh nhn suy tim (phn sut tng mau tht trai <40%), nhi
mau c tim hay au tht ngc khng n inh: con au ngc, kho th,
in tim co ST chnh ln ng hoc, tng men tim.
- Cac bnh nhn ang co nhim trung cp phat hin qua kham lm
sang hoc cn lm sang.
- St do cac nguyn nhn khac nhau.
- ang c iu tri bng cac thuc c ch min dich.
- Bnh ung th a c chn oan hay nghi ng.
- Suy thn, chn thng hay tai bin mach mau nao di 3 thang.
- Tin cn co bnh ai thao ng.
- C cc bnh kem theo nh vim khp, bnh h thng
- Cac trng hp chng chi inh o h hp ky[57]:
Mi bi nhi mau c tim (trong vong 1 thang), tng huyt ap
khng kim soat hoc t quy.
Ho ra mau lng trung bnh hay nhiu khng ro nguyn nhn.
ang bi hay nghi ng co vim phi, lao phi.
Mi bi hay ang co tran khi mang phi.
Mi phu thut ngc, bung hay mt.
- Cac bnh nhn khng ng y tham gia nghin cu.
2.2 PHNG PHAP NGHIN CU
2.2.1 Thit k nghin cu
Nghin cu m ta ct ngang.
2.2.2 C mu nghin cu
C mu: theo cng thc tinh c mu c lng mt ty l.
51
p(1-p)
n = --------------- (Z1-/ 2) 2
d2
p = 0,28; 1 p = 0,78.
= 5%
d = 10%
(p=0,28 la tn sut cua bnh phi tc nghen man tinh trn cac bnh nhn co
bnh mach vanh theo kt qua nghin cu cua AlaEldin H.Ahmed[28]).
Kt qua: n = 77,44 bnh nhn. D tru nghin cu 80 bnh nhn
co kt qua chup mach vanh co tn thng y ngha. Mt khac, trong qua
trnh thu thp s liu, cac trng hp kt qua chup mach vanh khng co tn
thng ng mach vanh co y ngha va o h hp ky khng co gii han lu
lng khi se c thu thp vao nhom chng va cac bn kt qua chup ng
mach vanh khng co tn thng ng mach vanh co y ngha nhng kt qua
o h hp ky co gii han lu lng khi khng hoan toan hi phuc c thu
thp vao nhom bnh phi tc nghen man tinh.
2.2.3 Cac bc tin hanh nghin cu
2.2.3.1 Kham lm sang
- Thu thp cac h s bnh an cua cac bnh nhn a c chup ng mach
vanh, xac inh cac tiu chun chon bnh, tm cac tiu chun loai tr nghin
cu.
- Hi bnh.
- Tin cn hut thuc la
S goi thuc la bnh nhn hut trong mt ngay. S goi tinh bng s
iu thuc hut trong ngay chia 20.
S nm hut thuc la.
52
Tinh chi s goi nm = s goi hut trong ngay x s nm hut thuc la.
- Hi va kham lm sang tm cac tiu chun loai tr nghin cu.
2.2.3.2 o chiu cao ca bnh nhn
Thc o chiu cao la thc o mu cua Vit Nam c gn lin vi
cn bn.
Bnh nhn o chiu cao trong t th ng thng thoai mai, mt nhn
v phia trc, hai got chn ng sat mt sau cua cn, ban chn t hoan
toan trn mt cn va chum lai thanh hnh ch V, am bao bn im trn c
th cham vao thc o chiu cao la vung chm, xng vai, mng va got
chn. Bnh nhn i chn trn, khng i non, khng cm bt c vt g, mc
qun ao mng.
Chiu cao c tinh bng mt (m) va sai s khng qua 0,5cm.
2.2.3.3 o trng lng c th
Cn ban cua Vit Nam c t trn mt phng n inh. Bnh nhn
ng nhe nhang trn ban cn. Khi kim bao trong lng a hoan toan ng
yn mi oc kt qua.
Kt qua c tinh bng Kg va sai s khng qua 100g.
2.2.3.4 Phn loai BMI
BMI c tinh theo cng thc
BMI = cn nng (kg)/ [chiu cao (m)]2.
Da theo tiu chun anh gia bo ph theo cac nc Asean ging vi
tiu chun Chu trng thanh[119]:
Gy: BMI < 18,5 kg/m2.
Bnh thng: BMI 18,5 22,9 kg/m2.
Tng cn: BMI 23 24,9 kg/m2.
Bo ph 1: BMI 25 29,9 kg/m2.
Bo ph 2: BMI 30 kg/m2.
53
2.2.3.5. Phng php o ng mach vanh
- o QCA: Cac bnh vin o QCA cung phng phap. ( Xin xem
phn phu luc)
- Cc my chp ng mach vanh ( xin xem phn phu luc)
+ Vin tim thanh ph H Chi Minh: May Philips ( hang Philips
Ha Lan )
+ Bnh vin Nhn dn 115: May Siemens Axiom Artis ( hang
Siemens c)
+ Bnh vin Thng Nht thanh ph H Chi Minh: May Siemens
Axiom Artis ( hang Siemens c)
Cac may chup ng mach vanh cua 3 Bnh vin noi trn u hin ai,
c bao tr va kim tra cht lng thng xuyn qua cac cng ty cung cp
my.
2.2.3.6 Phng php o chc nng h hp
o h hp ky bng may Koko, do hang san xut nSpire Health
USA ni vi may vi tinh xach tay. Cach o[108]:
- Chun bi bnh nhn:
Bnh nhn c giai thich v li ich cua vic o chc nng thng khi
phi, c hng dn cac bc tin hanh. Ngi thc hin o cn
lam mu cho bnh nhn xem va bnh nhn cn thc hin th trc
khi tin hanh o.
Bnh nhn khng th oxy it nht 15 phut trc o, khng hut thuc
la 1 gi trc khi o va khng o ngay sau khi n.
Ngng cac thuc gian ph quan tac dung ngn it nht 3 gi trc o
o chiu cao va cn nng cua bnh nhn. Bnh nhn cn c nghi
ngi it nht 15 phut trc khi o, ni lng qun ao va ly rng gia
(nu co).
54
- Cng tac chun bi may:
Ni b o lu lng tuc bin vao may.
Bt cng tc.
Nhp ngay, thang, nm va cac d liu cua bnh nhn v tn,
tui, chiu cao, cn nng, chn oan.
- Tin hanh o:
T th bnh nhn: ngi hay ng thng, thoai mai, tay cm B
o lu lng tuc bin ngang tm ming bnh nhn, ngm kin
ng thi, kep mui bnh nhn va dn bnh nhn th hoan toan
qua ng ming, khng e li vao long ng.
Ngi o nhn phim chc nng FVC.
Bnh nhn hit vao va th ra bnh thng qua ng ming
(ngm ng) 3 ln ri hit vao c ht sc sau o th ra nhanh va
hon ton.
o 3 ln va chon ra chi s tt nht cua bnh nhn. May se t
ng o cac th tich phi (L), o cac lu lng (L/giy) va
tinh ty s phn trm cac tri s o c vi cac tri s ly thuyt.
Cac i tng co gia tri FEV1/FVC < 70% tri s ly thuyt
c test gian ph quan vi thuc salbutamol hit (ventolin)
400g va o lai chc nng h hp sau 30 phut hit salbutamol.
- Cach anh gia kt qua o thng khi h hp:
Thng khi bnh thng: FEV1 80% tri s ly thuyt, FVC
80% tri s ly thuyt va ty s FEV1/FVC 70%.
Hi chng ri loan thng khi tc nghen: khi FEV1/FVC <
70% tri s ly thuyt.[62] Da vao % FEV1 so vi tri s ly
thuyt anh gia nng cua BPTNMT[96].
55
2.2.3.7 inh lng hs-CRP huyt thanh
Phng phap: hs-CRP huyt thanh c inh lng theo phng
phap min dich o uc cua Tina-Quant hs-CRP: CRP cua huyt thanh se
kt hp vi khang th khang CRP co sn trong dung dich cua Kit th. Phc
hp khang nguyn khang th nay se lam uc dung dich th. uc nay
thay i theo nng cua CRP co trong mu xt nghim. o uc bng
may quang ph va quy chiu gia tri cua CRP sang n vi mg/L.
Gia tri hs-CRP bnh thng: 0 3mg/L.
Mu bnh phm la mu mau 2ml khng co cht chng ng, quay ly
tm tach ly phn huyt thanh va bao quan 20oC cho n khi c xt
nghim. Xt nghim c thc hin trn may Olympus Model AU2700 cua
hang Beckman Coulter. Cac bnh nhn c ly mu mau ngay u tin
nhp vin. Xt nghim c thc hin tai khoa sinh hoa Bnh vin Nhn
dn 115.
2.2.3.8. inh lng TNF- huyt thanh
- Nguyn ly: TNF- c inh lng bng phng phap min dich hoa
phat quang (chemiluminescent immune Assay CLIA) vi chu trnh u la 60
phut. Xt nghim c thc hin trn may Immulite 1000 System do hang
Siemens, c san xut.
- Nguyn tc: Khang nguyn TNF- co trong huyt thanh cua bnh nhn se
ngng kt vi khang th TNF- trong kit th tao thanh phc hp khang
nguyn khang th. May min dich phat quang giup nhn bit phc hp
khang nguyn khang th, qua o o c nng TNF- trong huyt
thanh cua bnh nhn.
- Ly mu xt nghim:
56
Tt ca i tng trong mu nghin cu u c ly mu mau xt
nghim TNF- vao ngay vao vin.
Cac i tng xt nghim cn nhin oi qua m it nht 12 gi,
khng dung cac thuc co th gy anh hng n kt qua xt nghim nh
corticosteroid, cac thuc c ch min dich. Mu mau xt nghim la 2ml
mau tnh mach, c ly vao bui sang theo ung quy trnh v trung va ky
thut va c chuyn ngay n phong xt nghim. Mu mau c trong
mi trng lanh 2oC 8oC khoang 30 phut ri quay ly tm 3.500 4.000
vong/ phut trong 15 phut. Sau khi quay ly tm, tach ly 100l huyt thanh
a vao may Immulite 1000 System inh lng TNF-.
- Thuc th:
Thuc th la cac n vi test TNF-. Mi n vi ma vach c anh
du cha mt hat phu khang th n dong chut khang TNF- va c bao
quan 2oC 8oC.
Gia tri bnh thng cua TNF- theo phong xt nghim la < 8,1pg/ml.
Xt nghim nay c thc hin tai Khoa sinh hoa cua Trung tm chn
oan Y khoa Hoa Hao thanh ph H Chi Minh. Cac mu mau xt nghim
sau khi ly c bao qua trong tui cha a lanh gi nhit 2 8oC va
vn chuyn ngay n phong xt nghim.
2.2.3.9 inh lng bilan lipid mu
Ly mau cung thi im vi cac xt nghim hs-CRP, TNF- vao luc
6 gi sang, trc o bnh nhn phai nhin n it nht 12 gi. Mu mau xt
nghim la 2ml mau tnh mach, c quay ly tm tach phn huyt tng
va tin hanh inh lng ngay trn may phn tich t ng Cobas C 501. Hoa
cht s dung la kit cua hang Roch vi phng phap inh lng la phng
phap so mau dung enzym.
- inh lng Cholesterol toan phn
57
Nguyn ly: cholesterol ester c thuy phn bng enzyme cholesterol-
esterase. Cholesterol c giai phong ra c inh lng bng phng
phap so mau dung enzym (enzymatic colorometric) theo ky thut CHOD-
PAP.
Cac phan ng xy ra trong xt nghim inh lng cholesterol mau:
Cholesterol esterase
Cholesterol ester ---------------------- cholesterol + R1-COOH.
Cholesterol oxydase
Cholesterol --------------------------4-cholestentrione + H2O2
Peroxydase
H2O2 + phenol + 4-amino antipyrine ------------- quinoneinin + 4H2O
Cng mau ty l nng cholesterol huyt thanh.
Gia tri cholesterol toan phn bnh thng: <200mg/dl hay < 5,17 mmol/L.
- inh lng triglycerid:
Nguyn ly: triglycerid huyt thanh c inh lng bng phng
phap so mau dung enzyme (enzymatic colorometric).
Cac phan ng xy ra trong xt nghim triglycerid:
Lipase
Triglycerid + H2O --------------------------- glycerol + acid bo.
Glycerol kinase
Glycerol + ATP ----------------------- glycerol 3 photphat + ADP
Glycerol 3 photphat oxydase

Glycerol 3 photphat + O2---------- dihydroxyacetonphotphat + H2O2
Peroxydase
H2O2 + Parachlorophenol + 4-aminoantipyrine ---- quinoneimine + H2O2
(mau hng)
58
Cng mau ty l nng triglyceride huyt thanh.
Gia tri triglyceride bnh thng: <150mg/dl hay < 1,7mmol/L.
- inh lng HDL-c
Nguyn ly: HDL-c c inh lng bng phng phap so mau dung
enzyme (enzymatic colorometric). Cac thanh phn nh chylomicron,
VLDL va LDL-c trong huyt thanh cua bnh nhn se bi kt tua khi gp acid
phosphotungstic vi s co mt cua ion magnesium. Sau khi ly tm hn hp
nay se thu c dung dich ni cha HDL-c. Nng HDL-c trong dung
dich ni c inh lng theo ky thut CHOD-PAP nh i vi inh lng
cholesterol toan phn.
Gia tri HDL-c bnh thng: >40mg/dl (>1,03mmol/L) nam va >50mg/dl
(> 1,3mmol/L) n.
- inh lng LDL-c
Nguyn ly: LDL-c c inh lng bng phng phap enzyme. Kt
tua LDL-c bng dung dich thich hp gm cac polyanion surfactant va dung
dich m pH bng 6,1. LDL-c kt tua c hoa tan va c inh lng
bng ky thut CHOD PAP nh i vi cholesterol.
Hoc LDL-c c tinh gian tip qua cng thc FRIEDWALD:
LDL-c = Cholesterol toan phn (Triglycerid/2,2 + HDL-c) mmol/L
LDL-c = Cholesterol toan phn (Triglycerid/5 + HDL-c) mgdl.
Cng thc nay ap dung khi nng triglyceride di 400mg/dl.
Gia tri LDL-c bnh thng: <100mg/dl. ( tng ng 2,6 mmol/L)
- Ty s TG/HDL-c:
Bnh thng TG/HDL-c 3.
Ty s TG/HDL-c tng khi > 3.
2.2.3.10. inh lng glucose/ huyt tng:
59
Ly mu mau tnh mach vao bui sang sau khi nhin oi it nht 12
gi, b vao ng nghim co cht chng tiu ng Na Fluor. Glucose huyt
tng c inh lng bng phng phap so mau dung enzym GOD-PAP.
2.2.4 Cac bin s nghin cu
- Tui: tinh theo nm tui.
- Gii tinh: nam hay n.
- Hut thuc la: co hay khng hut thuc la.
- Goi nm: s goi thuc la hut trong mt ngay x s nm hut thuc la
hoc s iu thuc la hut trong mt ngay/ 20 x s nm hut thuc la.
- BMI: tinh bng cn nng/ chiu cao2theo n vi kg/m2.
- FEV1: tinh theo % cua FEV1 vi tri s tham chiu cua bnh nhn.
- hs-CRP: tinh theo n vi mg/L.
- TNF-: tinh theo n vi pg/ml.
- nng cua bnh phi tc nghen man tinh: theo FEV1 cua bnh
nhn thanh cac giai oan nhe, trung bnh, nng va rt nng.
- nng cua tn thng mach vanh: theo Thang im Gensini tuy
thuc vao mc tn thng x h s cua nhanh mach vanh tn
thng.
- Bilan lipid mau tinh theo n vi mg/dl.
+ cholesterol toan phn
+ triglyceride
+ HDL-c
+ LDL-c
- Ty l triglyceride/ HDL-c
60
2.2.6 S nghin cu
S 2.1 S nghin cu.

2.3 PHNG PHAP X LY S LIU NGHIN CU
Cac s liu c nhp vao may vi tinh va s dung phn mm thng
k SPSS (Statistical Package for Social Science) n ban 17.0 for window.
Cac bin s inh lng co phn phi chun c trnh bay di dang
cac tri s trung bnh va lch chun. Cac bin s inh lng co phn phi
61
khng chun c trnh bay di dang trung bnh va lch chun, trung
vi, trung bnh va lch chun cua log cua bin s o.
Cac bin s inh tinh c trnh bay di dang ty l phn trm (%).
So sanh cac tri s trung bnh i vi cac bin s inh lng co phn
phi chun dung php kim T Test i kim inh 2 tri s trung bnh va
phn tich phng sai ANOVA so sanh nhiu tri s trung bnh. i vi
vi cac bin s co phn phi khng chun dung php kim Mann
Whistney so sanh 2 tri s trung bnh va dung php kim Kruskal
Wallis khi so sanh hn 2 tri s trung bnh.
Dung php kim Chi bnh phng tm mi tng quan gia cac
bin inh tinh.
S dung h s tng quan Spearmans rho xac inh mi tng
quan gia nng hs-CRP vi s nhanh mach vanh bi hep va im s
Gensini.
i vi bin inh lng co phn phi chun c trnh bay bng
biu Histogram; cac bin inh lng co phn b khng chun c trnh
bay qua biu Boxplot so sanh cac tri s trung bnh.
Cac bin inh tinh c trnh bay qua biu tron vi ty l phn
trm (%).
Tng quan gia cac yu t c biu hin qua h s tng quan r
+ r> 0 tng quan thun.
+ r = 0 khng tng quan.
+ r< 0 tng quan nghich.
+ r< 0,3: tng quan rt it.
+ r: 0,3 - < 0,5: tng quan mc va.
+ r: 0,5 - < 0,7: tng quan kha cht che.
+ r 0,7 tng quan rt cht che.
62
Gia tri cua p
+ p 0,05: khac bit khng co y ngha thng k
+ p< 0,05: khac bit co y ngha thng k.
+ p< 0,01: khac bit rt co y ngha thng k.
2.4 AO C CUA NGHIN CU
Nghin cu c thc hin thng qua Hi ng khoa hoc Trng
ai hoc Y Dc Hu. Nghin cu cung c chp thun bi Hi ng Y
c cua bnh vin Nhn dn 115 va c s cho php ly mu nghin cu
cua Ban giam c Vin tim thanh ph H Chi Minh, Ban Giam c bnh
vin Thng Nht thanh ph H Chi Minh va Ban Giam c bnh vin
Nhn dn 115.
Nghin cu chi thc hin khi co s ng y tham gia nghin cu cua
cac bnh nhn.Nghin cu s dung cac kt qua chup ng mach vanh cua
cac bn a c chup ng mach vanh. o chc nng h hp c tin hanh
ung chi inh, bng may o H hp ky in t va la ky thut khng xm
nhp. inh lng hs-CRP va TNF- qua 5ml mau tnh mach khng gy
nguy him cho bnh nhn.
63
CHNG 3
KT QUA NGHIN CU
Chung ti thu thp c 193 trng hp tham gia nghin cu, gm
119 trng hp tn thng ng mach vanh. Cac trng hp tham gia
nghin cuc chia lam 4 nhom vi cac c im sau:
3.1 C IM CUA CAC NHOM NGHIN CU
3.1.1 Ty l % bnh nhn trong cac nhom nghin cu
Bang 3.1 Ty l % bnh nhn trong cac nhom nghin cu.
Nhom n Ty l %
chng 53 27,46
BPTNMT 21 10,88
BMV 86 44,56
BMV +BPTNMT 33 17,10
Tng cng 193 100,00
Nhom BMV chim 44,56%; nhom BMV+ BPTNMT chim 17,10%.
3.1.2 Tui cua cac i tng nghin cu
Tui trung bnh cua cac i tng nghin cu la 62,41.
Bang 3.2 Tui trung bnh cua cac i tng nghin cu
Nhom chng BPTNMT BMV BMV+ BPTNMT p
n 53 21 86 33

X SD 60,47 64,14 62,11 65,21
(tui)
11,65 9,82 10,64 9,92 >0,05
Ln nht 88 83 84 87
Nh nht 32 45 42 44
Khng co s khac bit co y ngha thng k v tui trong cac nhom nghin
cu (p >0,05).
64
Biu 3.1 Phn b tui trong nghin cu.
3.1.3 Gii tinh cua cac nhom nghin cu
Bang 3.3 Ty l % gii tinh cua i tng nghin cu
Nhom chng BPTNMT BMV BMV +BPTNMT
n 53 21 86 33
nam 31 21 69 33
Gii (58,50%) (100%) (80,20%) (100%)
tinh n 22 0 17 0
(41,50%) (0,00%) (19,80%) (0,00%)
S bn nam tham gia nghin cu la 154 trng hp, chim 79,80%.
S bn n trong nghin cu la 39 trng hp, chim 20,20%. Trong nhom
chng, s trng hp nam va n xp xi (58,50% va 41,50%) nhng trong
cac nhom bnh ly, nam gii chim u th ro rt vi 80,20% trong nhom
BMV, 100% trong nhom BPTNMT va 100% trong nhom BMV+BPTNMT.
65
3.1.4 Tinh trng hut thuc la cua cac i tng nghin cu
Bang 3.4 Tnh trang hut thuc la trong nghin cu.
Nhom chng BPTNMT BMV BMV+BPTNMT p
n 53 21 86 33
Khng 33 1 31 0 <0,01
(62,30%) (4,80%) (36%) (0,00%)
Hut co 20 20 55 33
thuc (37,70%) (95,20%) (64%) (100,00%)
la Goi- 22,95 35,45 29,16 29,16 >0,05
nm
16,02 14,25 20,38 20,38
66,3% (128/193) i tng nghin cu cua chung ti co HTL. Trong
khi nhom chng chi co 37,70% co HTL th ty l nay trong nhom BMV la
64,0%; trong nhom BPTNMT la 95,2% va trong nhom BMV+BPTNMT la
100%. Khng co khac bit v s goi-nm thuc la gia cac nhom khao sat
(p>0,05).
Bang 3.5 Tng quan FEV1 vi lng thuc la hut (s goi-nm) cua cac
i tng nghin cu.
Tng quan(Spearmans rho) r p
FEV1 - 0,22 <0,05
S goi-nm
Co mi tng quan nghich gia s goi-nm vi gia tri % FEV1 (r =
- 0,22, p < 0,05).
66
Bang 3.6 Lin quan hut thuc la gia nam va n gii
Hut thuc la Tng s p
khng co
Gii tinh nam 28 (18,20%) 126 (81,80%) 154 (100%) <0,05
n 37 (94,90%) 2 (5,10%) 39 (100%)
Tng s 65 128 193
126/ 154 bn nam trong nghin cu co HTL, chim 81,80% trong khi
chi co 5,10% bn n co HTL (p< 0,05).
3.1.5 Chi s khi c th (BMI) cua cac i tng nghin cu
3.1.5.1 BMI cua cac nhom nghin cu
Bang 3.7 BMI cua cac i tng nghin cu.
Nhom chng BPTNMT BMV BMV+BPTNMT
BMI 53 21 86 33
SD
X 23,35 4,09 22,25 3,62 23,32 3,21 20,74 2,81
(kg/m2)
Ln nht 38,54 27,34 34,89 27,18
Nh nht 15,06 15,05 16,41 13,67
p (so vi nhom chng) >0,05 >0,05 <0,01
>0,05
<0,01
p so vi nhom BPTNMT.
p so vi nhom BMV.
Khng co s khac bit co y ngha thng k v BMI gia nhom chng
so vi cac nhom BPTNMT va nhom BMV (p>0,05). BMI trung bnh trong
nhom BMV+BPTNMT thp hn BMI trung bnh cua nhom chng va nhom
BMV (p<0,01).
67
3.1.5.2 Phn loi BMI trong cac nhom nghin cu
Bang 3.8 Phn loai BMI cua cac nhom nghin cu.
Nhom chng BPTNMT BMV BMV+BPTNMT p
BMI 53 21 86 33
Gy 27 10 38 26
bnh (50,90%) (47,60%) (44,20%) (78,80%)
thng <0,05
Tng cn 26 11 48 7
bo ph (49,10%) (52,40%) (55,80%) (21,20%)
Cac bn bi BMV+ BPTNMT co BMI thp hn cac nhom khac (p< 0,05).
3.1.6 Glucose huyt tng
Bang 3.9 Glucose huyt tng cua cac nhom nghin cu (mmol/L)
Nhom chng BPTNMT BMV BMV+ BPTNMT p
n 53 21 86 33

X 5,87 5,82 5,88 5,54 >0,05
SD 1,27 1,38 1,86 0,99

S khac bit v glucose huyt tng gia cac nhom khng co y
ngha thng k (p>0,05).
3.1.7 Bilan lipid mau
Trong nghin cu, chi co 180 bn c xt nghim lipid mau.
68
3.1.7.1-Cac kt qua lipid mau trong cac nhom nghin cu
Bang 3.10 Kt qua lipid mau trong cac nhom nghin cu
Thng s Gia tri chng BPTNMT BMV BMV
+BPTNMT
n 49 20 82 29
SD
X 169,96 162,86 170,06 159,90
Cholesterol 39,65 43,24 41,33 56,47
mg/dl Trung vi 169,99 159,03 160,57 151,92

X SD 167,06 151,35 207,99 247,20
Triglycerid 121,81 88,49 130,98 271,85
mg/dl Trung vi 134,00 131,00 175,83 168,00

X SD 42,39 40,05 37,80 36,75
HDL-c 9,35 7,25 7,45 9,57
mg/dl Trung vi 41,61 40,25 36,78 36,00

X SD 99,79 94,42 97,84 85,01
LDL-c 33,60 34,83 32,76 43,11
mg/dl Trung vi 101,00 97,50 93,51 77,60
Khng khac bit co y ngha thng k so vi nhom chng (p>0,05).
Khac bit co y ngha thng k so vi nhom chng (p<0,05).
Khng co s khac bit co y ngha thng k v nng cholesterol
toan phn,nng triglyceride va nng LDL-c gia cac nhom khao
sat (p> 0,05).Khng co s khac bit co y ngha thng k v nng
HDL-c gia nhom chng vi nhom BPTNMT (p > 0,05).
Nng HDL-c trong nhom BMV va nhom BMV+ BPTNMT thp
hn co y ngha thng k so vi nhom chng (p< 0,05).
69
3.1.7.2 Ty s TG/HDL-c trong cac nhom nghin cu
Bang 3.11Ty s TG/HDL-c trong cac nhom nghin cu.
Thng s chng BPTNMT BMV BMV+BPTNMT p
TG/HDL-c
n 49 20 82 29 va >0,05;

X 4,15 3,94 5,72 6,96 va >0,05;
va <0,05;
SD 2,91 2,50 3,81 6,60
va <0,05;
va <0,05
Khng co khac bit co y ngha thng k v ty s TG/HDL-c gia

nhom chng vi nhom BPTNMT (p> 0,05); gia nhom BMV vi nhom
BMV+ BPTNMT (p> 0,05).
Co khac bit co y ngha thng k v ty s TG/HDL-c gia nhom
chng vi cac nhom BMV (p< 0,05) va nhom BPTNMT+BMV: nhom
BMV va nhom BMV + BPTNMT co ty s TG/HDL-c cao hn so vi
nhom chng.
Co s khac bit co y ngha thng k v ty s TG/HDL-c gia nhom
BPTNMT vi BMV + BPTNMT (p<0,05): nhom bnh phi hp co ty
s TG/HDL-c cao hn.
3.1.7.3 Ty s TG/HDL-c va BMV
Bang 3.12 Ty s TG/HDL-c va BMV.
BMV Tng s p
khng co
3 30 (50,0%) 30 (50,0%) 60(100%) <0,05
TG/HDL-c >3 39(32,5%) 81(67,5%) 120(100%) OR=2,07
Tng s 69 111 180 (1,10-3,91)
70
120/180 bn trong nghin cu co ty s TG/HDL-c > 3, chim 66,7%.
Trong s 60 bn co TG/HDL-c 3 th co 30 bn (50,00%) co BMV trong
khi 81/120 bn co TG/HDL-c > 3 co BMV, chim 67,50%. Cac bn co ty
s TG/HDL-c> 3 co nguy c bi BMV cao hn (OR=2,07; khoang tin
cy 95%: 1,10 - 3,91).
3.1.8 FEV1 cua cac nhom nghin cu
Bang 3.13 FEV1 trong cac nhom nghin cu
Nhom chng BPTNMT BMV BMV + BPTNMT
FEV1
n 53 21 86 33
SD
X 97,22 59,00 88,97 61,48
(%)
21,19 13,66 20,99 13,79
p (so vi nhom chng) <0,001 <0,05 < 0,001
va va va >0,05
<0,01 <0,01
% FEV1 trong cac nhom bnh ly u giam co y ngha so vi nhom

chng. Co s giam co y ngha cua % FEV1 gia cac nhom BPTNMT vi
nhom BMV va nhom BMV + BPTNMT vi nhom BMV (p <0,001).
Khng co s khac bit v % FEV1 gia nhom BPTNMT va nhom BMV +
BPTNMT (p >0,05).
3.1.9 c im nhom bnh phi tc nghen mn tinh
Trong 21 trng hp BPTNMT trong nghin cu c phn thanh
cac giai oan cua bnh, tuy thuc vao % FEV1, theo phn nng GOLD.
71
Bang 3.14 Phn nng cua BPTNMT cua nhom BPTNMT thanh 2 nhom
nhe-trung bnh va nng-rt nng
Giai oan n Ty l %
Nhe Trung bnh 16 76,2
Nng Rt nng 5 23,8
Tng s 21 100
Hu ht cac bn BPTNMT trong nghin cu thuc nhom bnh nhe-

trung bnh theo phn loai bnh GOLD.
3.1.10 c im nhom bnh mch vanh
3.1.10.1 S mach vanh tn thng trong nhm bnh mach vanh
trong nhom BMV
S mach vanh tn thng n Ty l %
1 60 69,80
2 nhanh 26 30,20
Tng s 86 100
Phn ln bn bi tn thng 1 nhanh ng mach vanh (69,80%).

3.1.10.2 Nhnh mach vanh tn thng trong nhm bnh mach vanh
Bang 3.16 Cac nhanh mach vanh tn thng trong nhom BMV
Nhanh mach vanh n Ty l %
LAD 60 69,8
LCx 22 25,6
RCA 38 44,2
Tn thng thng gp nht la nhanh LAD (69,8%) va nhanh RCA

(44,2%).
72
3.1.10.3 Thang im Gensini trong nhm bnh mach vanh
Thang im Gensini trung bnh trong nhom BMV la 27,59 28,24
Bang 3.17 Phn nhom thang im Gensini trong nhom BMV
im n Ty l %
< 10 24 27,9
10 29 32 37,2
30 49 16 18,6
50 69 3 3,5
70 89 7 7,1
90 4 4,7
Tng 86 100
65,1% bn trong nhom BMV co thang im Gensini < 30.
3.1.11 c im nhom bnh mch vanh co bnh phi tc nghen mn
tinh
Chung ti thu thp c 33 trng hp co kt qua chup ng mach
vanh co tn thng y ngha ng thi tha tiu chun BPTNMT thanh
nhom BMV + BPTNMT, 100% la nam gii vi tui trung bnh la 65,21;
ngi ln tui nht la 87 (tui) va nh tui nht la 44 (tui); 100% co HTL
vi trung bnh s thuc la hut la 33,36 12,40 goi-nm.
3.1.11.1 Cc giai oan bnh ca bnh phi tc nghen man tinh trong nhm
bnh mach vanh c bnh phi tc nghen man tinh
Bang 3.18 Cac giai oan bnh cua BPTNBMT trong nhom BMV + BPTNMT
BMV + BPTNMT Ty l % p
Giai oan nhe-trung bnh 26 78,80 >0,05
Giai oan nng-rt nng 7 21,20
Tng s 33 100
78,8% bn thuc giai oan nhe-trung bnh cua BPTNMT.
73
3.1.11.2 Vi tri ng mach vanh tn thng trong nhm bnh phi tc nghen
man tinh c bnh mach vanh
Bang 3.19 Vi tri ng mach vanh tn thng trong nhom BMV +BPTNMT
Nhanh mach vanh n Ty l %
LAD 22 66,70
LCx 12 36,40
RCA 21 63,60
Tn thng nhanh LAD thng gp nht (66,60%); nhanh RCA chim
63,60%.
3.1.11.3 S nhnh mach vanh tn thng trong nhm bnh mach vanh c
bnh phi tc nghen man tinh
trong nhom BMV + BPTNMT
S mach vanh tn thng n Ty l %
1 15 45,50
2 nhanh 18 54,50
Tng s 33 100
54,5% trng hp co tn thng 2 nhanh ng mach vanh.
3.1.11.4 Thang im Gensini cua nhom bnh mch vanh co bnh phi
tc nghen mn tinh
Thang im Gensini trung bnh trong nhom BMV + BPTNMT la
33,66 27,43.
74
Bang 3.21 Thang im Gensini trong nhom BMV + BPTNMT
im n Ty l %
< 10 8 24,20
10 29 9 27,30
30 49 9 27,30
50 69 3 9,10
70 89 2 6,10
90 2 6,10
Tng 33 100
51,5% bn co thang im Gensini < 30 im. 78,8% bn co thang im
Gensini < 50 im.
3.2 NNG hs-CRP VA TNF- TRONG CAC NHOM NGHIN
CU
3.2.1 So sanh nng hs-CRP cua cac nhom nghin cu
3.2.1.1 So snh nng hs-CRP gia cc nhm bnh phi tc nghen man
tinh, nhm bnh mach vanh va nhm bnh mach vanh c bnh phi tc
nghen man tinh
Bang 3.22 Nng hs-CRP trong cac nhom nghin cu
hs-CRP n=53 n=21 n=86 n=33
SD
X 2,382,58 4,18 3,94 9,9112,97 12,15 18,91
(mg/L)
Trung vi 1,30 3,20 4,54 5,20
(mg/L)
p (so vi nhom chng) <0,05 <0,001 <0,01
p gia cac nhom bnh va va va >0,05
<0,01 <0,05
75
Co s gia tng nng cua hs-CRP trong cac nhom bnh ly khao sat
so vi nhom chng (p<0,05).
Co s khac bit v nng hs-CRP gia nhom BPTNMT vi BMV
(p < 0,001) va vi nhom bnh phi hp BMV + BPTNMT (p < 0,05)
nhng khng co s khac bit v nng hs-CRP gia nhom BMV vi
nhom BMV + BPTNMT (p > 0,05).
3.2.2 So sanh nng TNF- cua cac nhom nghin cu
3.2.2.4 So snh nng TNF- gia cc nhm bnh phi tc nghen man
tinh, nhm bnh mach vanh va nhm bnh mach vanh c bnh phi tc
nghen man tinh
Bang 3.23 Nng TNF- trong cac nhom nghin cu
TNF- n=53 n=21 n=86 n=33

X SD 18,84 38,62 28,35 33,26
(pg/ml)
8,67 24,29 29,07 18,60
Trung vi 16,8 29,60 21,00 26,10
(pg/ml)
p (so vi nhom chng) <0,05 <0,01 < 0,001
p gia cac nhom bnh >0,05
Co s gia tng nng cua TNF- trong cac nhom bnh ly khao sat
so vi nhom chng (p< 0,05).
Nng TNF- nhom BPTNMT cao hn nhom BMV va nhom
BMV + BPTNMT nhng cha co y ngha thng k (p >0,05).
76
3.3 KHAO SAT MI LIN QUAN VA TNG QUAN GIA NNG
hs-CRP VA TNF- VI CAC YU T NGUY C, C IM
CUA BNH PHI TC NGHEN MAN TINH, BNH MACH VANH
VA BNH MACH VANH CO BNH PHI TC NGHEN MAN
TINH
3.3.1 Lin quan gia hs-CRP va TNF- vi gii
Bang 3.25 Lin quan nng hs-CRP va TNF- vi gii
Gii n
X SD p
hs-CRP Nam 154 8,18 12,91 > 0,05
(mg/L) N 39 5,34 9,54
TNF- Nam 154 29,94 25,63 < 0,01
(pg/ml) N 39 18,82 7,20
Nng TNF- nam gii cao hn n gii co y ngha thng k (p< 0,01).
3.3.2 Lin quan gia hs-CRP va TNF- vi tinh trng hut thuc la
Bang 3.26 Lin quan nng hs-CRP va TNF- vi hut thuc la
HTL n
X SD p
hs-CRP khng 65 5,27 8,19 < 0,05
(mg/L) co 128 8,79 13,86
TNF- khng 65 20,72 12,11 < 0,01
(pg/ml) co 128 31,24 26,94
Nng hs-CRP va TNF- co lin quan vi HTL (p<0,05) va p<0,01).
3.3.3 Tng quan gia hs-CRP va TNF- vi FEV1 cua nhom bnh
77
Bang 3.27 Tng quan hs-CRP v TNF- vi FEV1
Tng quan FEV1 vi r p
(Spearmans rho)
hs-CRP(mg/L) - 0,240 <0,05
TNF-(pg/ml) - 0,531 <0,001
Co mi tng quan nghich gia nng hs-CRP v nng TNF-
vi % FEV1 (p< 0,05).
Biu 3.2 Tng quan gia nng hs-CRP vi % FEV1.
Biu 3.3 Tng quan gia nng TNF- vi % FEV1.
78
3.3.4 Tng quan gia nng hs-CRP va nng TNF- vi nng
cua bnh mch vanh theo thang im Gensini nhom bnh mch vanh
Bang 3.28 Tng quan nng hs-CRP va TNF- vi nng cua BMV
theo thang im Gensini cua nhom BMV
Tng quan vi Gensini r p
(Spearmans rho)
hs-CRP(mg/L) 0,407 < 0,001
TNF-(pg/ml) 0,208 < 0,05
Co mi tng quan thun gia nng hs-CRP va nng TNF-
vi nng cua tn thng mach vanh theo thang im Gensini (p< 0,05).
Biu 3.4 Tng quan nng hs-CRP vi nng cua tn thng mach
vanh theo thang im Gensini trong nhom BMV.
79
Biu 3.5 Tng quan nng TNF- vi nng cua tn thng mach
vanh theo thang im Gensini trong nhom BMV.
co bnh phi tc nghen mn tinh
Bang 3.29 Tng quan hs-CRP v TNF- vi thang im Gensini trong
nhom BMV + BPTNMT
Tng quan thang im Gensini vi r p
(Spearmans rho)
hs-CRP(mg/L) 0,402 < 0,001
TNF-(pg/ml) 0,422 < 0,001
Co mi tng quan thun gia nng hs-CRP va nng TNF-
vi nng cua tn thng mach vanh theo thang im Gensini (p<
0,001).
80
Biu 3.6 Tng quan gia nng tn thng mach vanh vi nng
hs-CRP trong nhom BMV + BPTNMT.
Biu 3.7 Tng quan gia nng cua tn thng mach vanh vi nng
TNF- trong nhom BMV + BPTNMT.
81
3.3.6 Tng quan gia nng hs-CRP va nng TNF- vi FEV1
trong bnh mch vanh co bnh phi tc nghen mn tinh
trong nhom bnh mach vanh co bnh phi tc nghen man tinh
Tng quan FEV1 r p
(Spearmans rho)
hs-CRP(mg/L) - 0,394 < 0,001
TNF-(pg/ml) - 0,503 < 0,001
Co mi tng quan nghich gia nng hs-CRP va nng TNF-

vi % FEV1 (p< 0,001).
3.3.7 So sanh thang im Gensini cua nhom bnh phi tc nghen mn
tinh va nhom bnh mch vanh co bnh phi tc nghen mn tinh
Bang 3.31 S im Gensini cua nhom BMV va nhom BMV + BPTNMT
P
n BMV BMV + BPTNMT
> 0,05
86 33

X 27,59 33,66
SD 28,24 27,43
Thang im Gensini trong nhom phi hp BMV + BPTNMT cao
hn nhom BMV nhng khng co y ngha thng k (p > 0,05).
82
3.3.8 Phn tich a bin vi cac yu t nguy c kinh in cua bnh mch
vanh va cac yu t nghin cu (hs-CRP, TNF-, BPTNMT) vi bnh
mch vanh
Bang 3.32 Phn tich a bin vi cac yu t nguy c kinh in cua bnh
mach vanh va cac yu t nghin cu (hs-CRP, TNF-, BPTNMT) vi bnh
mach vanh
Yu t BMV BMV OR Khong tin p
(+) (-) cy 95%
Hut thuc la 69,2% 30,8% 3,27 1,22-8,74 <0,05
BPTNMT 59,2% 40,8% 0,33 0,14-0,81 <0,05
Gii (n/ nam) 44,7% 55,3% 0,87 0,29-2,57 >0,05
Tui 70 63,6% 36,4% 1,55 0,68-3,53 >0,05
ng huyt 5,6mmol/L 59,2% 40,8% 0,78 0,39-1,57 >0,05
TG/HDL-c >3 67,5% 32,5% 2,32 1,14-4,71 <0,05
hs-CRP >3mgl/L 75% 25% 3,28 1,65-6,52 <0,01
TNF- >17pg/ml 66,9% 33,1% 2,55 1,19-5,46 <0,05
Nhn xt: Cac yu t nguy c d bao BMV la:
- Hut thuc la (OR=3,27; 95%: 1,22-8,74; p<0,05)
- BMTNMT (OR=0,33; 95%: 0,14-0,81; p<0,05)
- Ty s TG/HDL-c >3 (OR=2,32; 95%: 1,14-4,71; p<0,05)
- Nng hs-CRP >3mg/L (OR=3,28; 95%: 1,65-6,52; p<0,01)
- Nng TNF-> 17pg/ml (OR=2,55; 95%: 1,19-5,46; p<0,05)
83
Biu 3.8: Phn tich a bin cac yu t nguy c vi bnh mach vanh.
3.3.9 Lin quan cac v tri ng mch vanh tn thng gia nhom bnh
mch vanh va nhom bnh mch vanh co bnh phi tc nghen mn tinh
Bang 3.33 Lin quan gia BPTNMT va nhanh mach vanh tn thng
BPTNMT n p
khng co
Tn thng khng 26 (30,20%) 11 (33,30%) 37 > 0,05
nhanh co 60 (69,80%) 22 (66,70%) 82
LAD
Tn thng khng 64 (74,40%) 21 (63,60%) 85 > 0,05
84
nhanh LCx co 22 (25,60%) 12 (36,40%) 34
Tn thng khng 48 (55,80%) 12 (36,40%) 60 <0,05
nhanh co 38 (44,20%) 21 (63,60%) 59 (php
RCA kim 1
Tng s 86 (100%) 33 (100%) 119 ui)
Trong s cac nhanh mach vanh tn thng khng co s khac bit v
tn thng cac nhanh LAD, LCx gia cac bn bi BMV khng co BPTNMT
va cac bn bi BMV co kem BPTNMT. Tuy nhin, co s khac bit v vi tri
tn thng nhanh RCA gia cac bn nay: Trong s 33 bn bi
BPTNMT+BMV th co 21 bn (63,60%) co tn thng nhanh RCA so vi
38/86 (44,20%) bn bi BMV ma khng co BPTNMT (p< 0,05).
3.3.10 Lin quan s tn thng mch vanh gia nhom bnh mch vanh
va nhom bnh mch vanh co bnh phi tc nghen mn tinh
Bang 3.34 Lin quan BPTNMT vi s mach vanh tn thng (1 nhanh va

nhiu nhanh).
S nhanh mach vanh Tng s p
1 2
BPTNMT Khng 60 26 86 < 0,05
(69,80%) (30,20%) (100%) OR= 2,77;
Co 15 18 33 (1,21- 6,32)
(45,50%) (54,50%) (100%)
Tng s 75 44 119
Cac bn bi BMV co kem BPTNMT co khuynh hng tn thng
nhiu nhanh mach vanh hn (OR= 2,77; 1,21- 6,32).
85
Trong 86 trng hp BMV khng co BPTNMT th co 26 trng hp
co tn thng t 2 nhanh mach vanh nhng trong 33 trng hp
BMV + BPTNMT th co 18 BN co tn thng t 2 nhanh mach
vanh (30,20% so vi 54,50%; p< 0,05). Trung bnh, mi bn trong
nhom BMV co tn thng 1,39 nhanh trong khi mi bn trong nhom
BMV + BPTNMT co tn thng 1,66 nhanh. Nhng bn bi BMV co
kem BPTNMT co khuynh hng tn thng nhiu nhanh mach vanh
hn so vi cac bn bi BMV khng kem BPTNMT.
86
CHNG 4
BAN LUN
4.1 C IM CUA CAC NHOM NGHIN CU

4.1.1 Tui
Tui trung bnh cua cac i tng trong nghin cu cua chung ti la
62,41 (bang 3.2) . Tui nh nht la 32 va tui ln nht la 88. Tui trung
bnh trong nhom chng la 60,47; trong nhom BPTNMT la 64, trong nhom
BMV la 62 va trong nhom BMV + BPTNMT la 65. Khng co s khac bit
v tui trong cac nhom nghin cu (p > 0,05). Kt cua nghin cu cua Tae
Yun Park va cs cung khng thy s khac bit v tui gia nhom BPTNMT
vi nhom phi hp BMV + BPTNMT (67,07 tui 7,80 so vi 68,84 tui
7,61; p> 0,05)[124].
Tui trung bnh trong nhom BPTNMT cua chung ti la 64 tui, cung
tng t nh tui trung bnh trong nhiu nghin cu khac v BPTNMT:
cua Henrik Watz va cs la 64 tui [161]; cua Funda Aksu va cs la 60,6
tui[30]; cua Eagan T. M. va cs la 60,9 tui [65]; cua Mette Thomsen va cs
la 65 tui[148], cua Alvar Agusti va cs la 63,4 tui [24] va nghin cu cua
Mette Thomsen la 65 tui[148].
Tui trung bnh trong nhom BMV cua chung ti (62 tui) thp hn
tui trung bnh cua cac bn BMV trong nghin cu cua Lng thi Kim Lin
va cs la 65 tui[10]; cua Nguyn Quang Tm la 65 tui; cua Trn Vit An
la 68 tui[1] (p< 0,05) nhng tng t nh cac kt qua v tui cua Nguyn
c Hai la 63 tui cung nh cac kt qua cua nghin cu ngoai nc nh
Changlei Guo va cs la 61,13 tui (p> 0,05)[73], nghin cu cua Mahalle N.
va cs la 60,9 tui (p> 0,05)[100].Trong nhom BMV + BPTNMT cua chung
87
ti co tui trung bnh la 65. Kt qua nay tng t nh kt qua v tui trong
nghin cu cua Anand A. Dalal va cs la 64 tui, nghin cu cua Liang Bin-
miao va cs la 67 tui (p> 0,05)[95].
Cac kt qua nay cung phu hp vi Y vn la cac bn BPTNMT cung
nh nhng bn bi BMV thng la ln tui. Tui la mt trong cac yu t
nguy c quan trong cua BMV cung nh BPTNMT. Theo M. Malerba va G.
Romaelli, tui la mt yu t quyt inh quan trong trong ca cng ng
mach va khi ph thung. Mc du tip xuc vi khoi thuc la la nguyn nhn
chinh cua BPTNMT nhng mc anh hng cua khoi thuc la khng
ging nhau. Nhiu biu hin cua BPTNMT cung co th gp trn nhng
ngi ln tui khng HTL. Giam chc nng phi tin trin la mt c
trng cua BPTNMT nhng cung la mt din tin bnh thng theo tui trn
nhng ngi khe manh. Phi cua nhng ngi ln tui cung co hin
tng phnh gian cac ph nang ngoai vi kt hp vi thoai bin cua elastin
va giam kha nng an hi gy ra biu hin ging khi ph thung[102].
Tui gia tng cung co c im la rut ngn cac oan cui cua nhim
sc th (telomers), ni co vai tro trong s thoai hoa va lao hoa. Trn hu ht
cac t bao, cac oan cui cua nhim sc th se ngn dn theo chu k t bao
va stress oxy hoa cung nh vim lam gia tng qua trnh rut ngn nay.
Lao hoa t bao kt hp vi s rut ngn hay tn thng cua cac oan cui
nhim sc th, lam thay i cu truc hay chc nng t bao. Cac t bao lao
hoa cung gia tng phong thich cac cytokin, cac chemokin va tng hoat tinh
enzym metalloprotease la cac cht tham gia vao c ch gy gia tng hin
tng vim va pha huy m trong khi ph thung. S rut ngn cua cac oan
cui nhim sc th do tui tac cung gn kt vi bnh tim mach. Chiu dai
cua oan cui nhim sc th la mt yu t d oan cac bin c tim mach va
giam chiu dai cua oan cui nhim sc th cua t bao bach cu kt hp vi
88
tt ca cac nguyn nhn gy t vong trn cac bn co BMV n inh. Mt khac,
ngi ta cung thy cac oan cui cua nhim sc th cua cac t bao ni m
va t bao c trn mach mau lao hoa cua mang x va ng mach cung
ngn hn. Cac t bao lao hoa gy ri loan chc nng lp ni m, gy x
va ng mach va dng nh cung co vai tro trong s bt n cua mang x
va. Do o, tui gia tng co th co vai tro trong s gn kt gia BPTNMT
vi gia tng nguy c mc cac bnh tim mach[81],[102].
Kt qua nghin cu cua chung ti v tui gia cac nhom BPTNMT,
nhom BMV va nhom BPTNMT+BMV khac bit khng co y ngha thng
k (p > 0,05). iu nay cho thy tui khng quyt inh s phn bit bn mc
BPTNMT, BMV hay phi hp ca 2 bnh ly trn.
4.1.2 Gii tinh
Theo kt qua nghin cu (bang 3.3), nhom chng co ty l nam/n la
1,4/1 (31/22). So vi nhom chng, cac nhom bnh ly trong khao sat cua
chung ti u co nam gii chim u th vi nhom BMV la 80,2% nhom
BPTNMT va nhom BMV + BPTNMT la 100%. Kt qua nghin cu cua
chung ti thy co s khac bit v gii tinh gia nhom BMV vi cac nhom
BPTNMT va nhom BMV + BPTNMT (p< 0,05). iu nay co th do u th
HTL trong dn s nam gii cua nghin cu chung ti. Kt qua nghin cu
cua Tae Yun Park va cs cung thy nam gii chim u th trong nhom
BPTNMT va nhom BMV + BPTNMT nhng khng thy s khac bit v
gii tinh gia nhom BPTNMT vi nhom phi hp BMV + BPTNMT (96%
nam gii so vi 93% nam gii; p> 0,05)[124].
Cac nghin cu v BPTNMT cung nh cac nghin cu v BMV
cung cho thy nam gii chim u th trong 2 bnh ly nay. Trong nghin
cu cua Liang Bin-miao va cs, nam gii cung chim 67% trong nhom phi
hp BMV + BPTNMT [95].
89
Theo Y vn, gii tinh nam la mt yu t nguy c quan trong cua
BMV va c cho la do hormon n co vai tro bao v. Tuy nhin, sau man
kinh do giam estrogen nn n gii cung gia tng nguy c mc bnh tim
mach. Trong BPTNMT, nam gii mc bnh u th la do nam gii co thoi
quen HTL nhiu hn n gii. HTL ng thi cung la yu t nguy c cua
BMV. iu nay co th thy qua kt qua nghin cu la trong s 154 nam
gii cua nghin cu th co n 81,8% (126/154) co HTL trong khi trong 39
ngi n gii th chi co 5,1% (2/39) la co HTL. Trong kt qua nghin cu
cua chung ti, 100% bn trong nhom phi hp BMV + BPTNMT la nam
gii. Tuy nhin, chung ti cho la do do mu nghin cu con it nn cha u
rut ra kt lun.
4.1.3 Hut thuc la
66,3% i tng nghin cu cua chung ti co HTL trong o ty l
thp nht la nhom chng 37,7%, 64% trong nhom BMV co HTL, 95,2% bn
trong nhom BPTNMT co HTL va cao nht la nhom BMV + BPTNMT
100% co HTL (bang 3.4).
Kt qua v HTL cua chung ti cung ging vi kt qua HTL cua tac
gia oan vn Phc trong nghin cu v bnh tim mach va ri loan chuyn
hoa trn bn co BPTNMT[14]. Trong nghin cu nay, tac gia ghi nhn
89/99 bn co HTL. Cac tac gia nc ngoai nghin cu v BPTNMT cho cac
kt qua vi ty l khac nhau nhng cung thy co ty l cao HTL trong
BPTNMT nh ty l 46% cua Pei-Hsun Sung va cs [145], 36% trong nghin
cu cua Liang Bin-Miao va cs[95]; 69% cua Victor Pinto-Plata va cs[126];
86,5% trong nghin cu cua Funda Aksu[30].
Chung ti khng ghi nhn s khac bit co y ngha thng k v s
goi-nm thuc la gia cac nhom khao sat (p > 0,05). Kt qua nghin cu
cua Tae Yun Park va cs cung cho thy khng co s khac bit co y ngha
90
thng k v s goi nm gia nhom BPTNMT vi nhom BMV + BPTNMT
(38,95 21,51 so vi 38,95 21,51; p> 0,05)[124]. Tuy nhin, chung ti
ghi nhn co mi lin quan nghich gia s goi-nm vi gia tri % FEV1 (r = -
0,222, p < 0,05). Theo Sara Roversi, %FEV1 giam co lin quan vi s
lng goi-nm cua thuc la hut la 8ml/ goi-nm i vi nam gii va 10ml/
goi-nm i vi n gii[132].
HTL la mt trong cac thoi quen gy nghin thng gp va nguy
him cua con ngi t hn 4 th ky qua va hin nay vn con gia tng cac
nc ang phat trin. D oan n nm 2030, nu xu hng HTL vn con
tng th se gy t vong cho hn 9 triu ngi mi nm[165].
Theo y vn th HTL la yu t nguy c chinh cua BPTNMT va
BMV[75]. Nhiu nghin cu cho thy khoi thuc la khi ng qua trnh
vim khng chi phi ma con gy vim h thng va gy ra nhiu bnh ly
man tinh, c goi la cac bnh gy ra do thuc la. Tai phi, khoi thuc la
co th tac ng trc tip do cac c cht co trong khoi thuc. Cac bnh ly
ngoai phi co lin quan n HTL c cho la do khoi thuc la gy hin
tng vim h thng c nhiu nghin cu chng minh qua s gia tng
trong tun hoan ca cac t bao vim va cac cht trung gian gy vim nh
CRP, fibrinogen, TNF-Mt nghin cu Anh thy nng CRP trong
mau vn con gia tng ang k 10 19 nm sau khi ngng HTL va sau 20
nm, nng CRP vn khng tr v mc c ban nh ngi khng
HTL[165].
Kt qua nghin cu cua chung ti ghi nhn ty l cao HTL vi s
lng goi-nm ang k cac nhom bnh ly. iu nay c bit quan trong
vi nc ta v theo tac gia Lng Ngoc Khu th Vit Nam, ty l ngi
trn 15 tui HTL thng xuyn la 19,5% va khng thng xuyn la 4,3%.
38,7% nam gii va 1,2% n gii HTL hng ngay[9]. Theo iu tra toan
91
cu nm 2010 v s dung thuc la ngi trng thanh (>15 tui) th Vit
Nam la 1 trong 15 quc gia co ty l ngi HTL cao nht th gii[9].
4.1.4 BMI (kg/m2)
Kt qua trong nghin cu cua chung ti (bang 3.7) cho thy BMI
trung bnh cua cac i tng nghin cu la 22,77 3,57 kg/m2; trong o
BMI trung bnh cua nhom chng la 23,35 kg/m2; cua nhom BPTNMT la
22,25 kg/m2; cua nhom BMV la 23,32 kg/m2 va cua nhom phi hp BMV
+ BPTNMT la 20,74 kg/m2.
Khng co s khac bit co y ngha thng k v BMI gia nhom chng
so vi cac nhom BPTNMT va nhom BMV nhng co cao hn so vi nhom
BMV + BPTNMT (p> 0,05). Khng co khac bit v BMI gia nhom
BPTNMT va nhom BMV. BMI cua nhom BPTNMT cao hn nhom BMV
+ BPTNMT nhng khng co y ngha thng k (p> 0,05). Co s khac bit
co y ngha thng k v BMI gia nhom BMV vi nhom BMV + BPTNMT
(p<0,01). BMI trung bnh trong nhom co bnh phi hp thp hn ang k
so vi nhom chng va nhom BMV. 78,8% bn trong nhom BMV +
BPTNMT cua chung ti thuc nhom gy-bnh thng so vi 44,2% trong
nhom BMV va 47,6% trong nhom BPTNMT (p< 0,05). Nhiu nghin cu
ghi nhn vim h thng man tinh ong vai tro quan trong trong sut cn cua
cac bn BPTNMT. S hin din cua ca hai bnh ly vim man tinh trn cung
mt bn co th anh hng ang k n BMI.
BMI trong nhom BPTNMT cua chung ti khng co khac bit co y
ngha thng k so vi BMI cua nhom BPTNMT trong nghin cu cua Tae
Yun Park va cs (22,25 kg/m2 so vi 23,68 kg/m2;p > 0,05)[124].Tuy nhin,
BMI trong nhom BMV + BPTNMT cua chung ti thp hn co y ngha
thng k so vi BMI trong nhom BMV + BPTNMT cua Tae Yun Park va
cs (20,74kg/m2 so vi 23,41kg/m2; p <0,001). S khac bit co th do s bn
92
thuc giai oan nng rt nng cua BPTNMT trong nhom BMV +
BPTNMT cua chung ti nhiu hn so vi s bn thuc giai oan nng rt
nng cua BPTNMT trong nhom BMV + BPTNMT cua Tae Yun Park va cs
(20,59% so vi 15,94%) cung nh co FEV1 thp hn (61,48% so vi
75,84%; p <0,001)[124].
4.1.5 Lipid mau
Nghin cu v bilan lipid mau cac nhom BMV, BMV+BPTNMT va
BPTNMT (bang 3.10) cho thy:
4.1.5.1 Cholesterol toan phn
Nng cholesterol toan phn trong nghin cu cua chung ti la
167,59mg/dl. Chung ti khng thy co s khac bit co y ngha v nng
cholesterol toan phn gia nhom khng co BMV va nhom co BMV
(169,96mg/dl so vi 170,06mg/dl; p>0,05).
Kt qua v cholesterol toan phn cua nhom BMV trong nghin cu
cua chung ti tng ng vi kt qua v cholesterol toan phn trong
231.986 trng hp nghin cu BMV cua Amit Sachdeva va cs
(170,06mg/dl so vi 174,4mg/dl; p >0,05)[133] va kt qua cholesterol toan
phn trong nghin cu cua Alberto Cordero va cs (170,06mg/dl so vi
162,20mg/dl; p>0,05)[53].
Kt qua cholesterol toan phn trong nghin cu cua chung ti thp
hn ang k so vi nng cholesterol toan phn trong nghin cu cua
Protasio Lemos da Luz va cs (170,06/dl so vi 210mg/dl; p<0,001)[53].
56% i tng nghin cu cua Protasio Lemos da Luz va cs co tng
cholesterol toan phn trong khi kt qua nghin cu cua chung ti chi co
19,1% cac bn co BMV (nhom BMV va nhom BMV + BPTNMT) co tng
cholesterol toan phn. Kt qua nghin cu cua Nguyn Cu Li[11] cung
ghi nhn co 15,75% bn BMV co tng cholesterol toan phn.
93
Nng cholesterol toan phn trung bnh trong nhom BPTNMT cua
chung ti la 162,86mg/dl. Kt qua cua chung ti cung ging vi kt qua
cholesterol toan phn cua 50 bn trong nghin cu cua Niranjan M.R. va cs
(162,86mg/dl so vi 178,36mg/dl; p> 0,05)[118]. Kt qua t nghin cu
chung ti tng t vi kt qua nghin cu cua Niranjan M.R. va cs la
khng co khac bit co y ngha v nng cholesterol toan phn cua cac bn
BPTNMT vi nhom chng. Tuy nhin, nng cholesterol cholesterol
toan phn trong nhom BPTNMT cua chung ti thp hn so vi kt qua
nghin cu cua Shah Mohammad Abbas Waseem va cs (162,86mg/dl so
vi 241,08mg/dl; p< 0,001)[160] va kt qua nghin cu cua Hwa Mu Lee
va cs (168,62mg/dl so vi 214,2mg/dl; p<0,001)[92].
4.1.5.2 Triglycerid
Nng triglycerid trung bnh trong nghin cu cua chung ti la
196,87mg/dl. S khac bit khng co y ngha thng k v nng
triglycerid mau gia nhom chng vi nhom BPTNMT (167,06mg/dl so vi
151,35mg/dl; p> 0,05); gia nhom chng vi nhom BMV (167,06mg/dl so
vi 207,99mg/dl; p > 0,05); gia nhom chng vi nhom BMV + BPTNMT
(167,06mg/dl so vi 247,20mg/dl; p> 0,05). Nng triglycerid co khuynh
hng thp trong nhom BPTNMT. Nng triglycerid mau trong nhom
BPTNMT cua chung ti tng ng vi kt qua triglycerid trong nghin
cu cua Niranjan M.R. va cs (151,35mg/dl so vi 129,38mg/dl; p
>0,05)[118] va nghin cu cua Shah Mohammad Abbas Waseem va cs
(151,35mg/dl so vi 132,65mg/dl; p> 0,05)[160]. Nng triglycerid mau
trong nhom BPTNMT cua chung ti thp hn so vi nhom chng nhng
khng co y ngha thng k (151,35mg/dl so vi 167,06mg/dl; p> 0,05). Kt
qua t nghin cu cua Hwa Mu Lee va cs cho kt qua nng triglycerid
mau trong nhom co BPTNMT thp hn so vi nhom chng (158,3mg/dl
94
cua cac bn BPTNMT nhe va 154,2mg/dl cua cac bn BPTNMT trung bnh
nng so vi 165,9mg/dl so vi nhom chng; p< 0,05)[92]. Xiaoou Li va cs
nghin cu 62 bn BPTNMT (gm 34 bn giai oan nhe; 16 bn giai oan
trung bnh va 12 bn giai oan nng) so vi 64 i tng cua nhom chng
cung cho kt qua nng triglycerid mau cua cac bn BPTNMT thp hn
ang k so vi nhom chng va giam dn theo giai oan nng cua BPTNMT
(nng triglycerid cua giai oan nhe la 1,02mmol/L; giai oan trung bnh
la 0,78mmol/L va giai oan nng la 0,71mmol/L so vi nhom chng la
1,43mmol/L; p< 0,05). Theo Xiaoou Li, giam nng triglycerid mau cua
cac bn BPTNMT phan anh tnh trang gia tng di hoa[94].
4.1.5.3 HDL-c
Nng HDL-c trung bnh trong nghin cu cua chung ti la
39,13mg/dl. Nng HDL-c trong nhom BPTNMT thp hn so vi nhom
chng nhng khng co y ngha thng k (40,05mg/dl so vi 42,39mg/dl;
p> 0,05). Kt qua nghin cu cua chung ti cho thy s khac bit khng co
y ngha thng k v nng HDL-c gia nhom BPTNMT vi nhom BMV
(40,05mg/dl so vi 37,80mg/dl; p >0,05) va nhom BMV + BPTNMT
(40,05mg/dl so vi 36,75mg/dl; p> 0,05). Do o, chung ti cho la HDL-c
khng phai la yu t lam gia tng nguy c mc BMV trn cac bn co
BPTNMT.
Cac bn co BMV (nhom BMV va nhom BMV + BPTNMT) trong
nghin cu cua chung ti co nng HDL-c thp hn ang k so vi nhom
chng (37,80mg/dl va 36,75mg/dl so vi 42,39mg/dl; p < 0,05). Kt qua
nghin cu cua chung ti cung phu hp vi y vn la HDL-c co vai tro bao
v i vi h tim mach. Mi lin quan gia giam nng HDL-c vi gia
tng nguy c mc bnh tim mach a c xac lp t cac nghin cu khac
nhau. Nghin cu Framingham a nu ln vai tro bao v tim mach cua
95
HDL-c. Theo nghin cu Framingham, vi giam HDL-c mi 5mg/dl lam
gia tng nguy c nhi mau c tim 25%. Mi lin quan gia HDL-c va bnh
tim mach rt phc tap va bao gm it nht 3 yu t: (1)-giam nng HDL-
c trong tun hoan chi im ri loan chuyn hoa gy XVM bao gm bo
ph, tng huyt ap, khang insulin va tng triglycerid mau; (2)-giam nng
HDL-c trong mau chi im XVM tin trin qua vai tro c ch phan ng
pha cp va (3)-mt s chng c cho thy giam nng HDL-c trong mau
co lin quan nhn qua vi s phat trin cua XVM.
4.1.5.4 LDL-c
Nng LDL-c trung bnh trong nghin cu cua chung ti
la95,92mg/dl. Chung ti ghi nhn khng co s khac bit co y ngha thng
k v nng LDL-c gia cac nhom nghin cu (p> 0,05).
4.1.5.5 Ty l triglycerid/ HDL-c
Tng ty l triglycerid/ HDL-c c coi la mt chi s anh gia nguy
c cua BMV. Ty l triglycerid / HDL-c trung bnh trong nghin cu cua
chung ti la 5,29. Cac bn co BMV (nhom BMV va nhom BMV +
BPTNMT) co ty l triglycerid/ HDL-c cao hn co y ngha thng k so vi
cac nhom chng va nhom BPTNMT (ty s triglycerid/ HDL-c cua nhom
BMV la 5,72 va nhom BMV + BPTNMT la 6,96 so vi nhom chng la
4,15 va nhom BPTNMT la 3,94; p <0,05).
Ty l triglycerid/ HDL-c cua nhom BMV trong nghin cu cua
chung ti cung ging vi kt qua cua Nguyn Cu Li trn 292 bn bi BMV
(5,72 so vi 5,04; p > 0,05)[11] va kt qua nghin cu cua Protasio Lemos
da Luz va cs trn 374 bn bi BMV (5,72 so vi 5,1; p> 0,05)[128].
Ty l triglycerid/ HDL-c trong nhom BPTNMT cua chung ti thp
hn so vi nhom chng nhng khng co y ngha thng k (3,94 so vi
4,15; p > 0,05). Tuy nhin, co s khac bit co y ngha thng k v ty l nay
96
gia nhom BPTNMT vi nhom BMV (,3,94 so vi 5,72; p <0,05) va vi
nhom BMV + BPTNMT (3,94 so vi 6,96; p< 0,05). S khac bit nay co
th la do nhom BPTNMT trong nghin cu cua chung ti co nng
triglycerid co khuynh hng thp ma chung ti a ban phn triglycerid.
Tom lai, qua khao sat cac thanh phn lipid mau, chung ti ghi nhn
co ri loan cac thanh phn lipid mau trong cac nhom bnh ly khao sat. Tuy
nhin, nghin cu cua chung ti khng thy s khac nhau v lipid mau lam
gia tng nguy c mc BMV trn cac bn co BPTNMT. Anup N. Nillawar va
cs nghin cu 45 bn BPTNMT va 45 ngi khe manh cung kt lun la
khng co s khac bit v lipid mau gia nhom BPTNMT vi nhom
chng[117].
4.1.6 %FEV1
FEV1 trung bnh trong nghin cu cua chung ti la 83,28% (bang
3.13). Co s khac bit co y ngha thng k v FEV1 gia nhom chng vi
nhom BPTNMT (97,22% so vi 59,00%; p <0,001), vi nhom BMV
(97,22% so vi 88,97%; p< 0,05) va vi nhom BMV + BPTNMT (97,22%
so vi 61,48%; p< 0,001). Tt ca cac nhom bnh ly khao sat cua chung ti
u co FEV1 giam hn so vi nhom chng. Giam FEV1 trong cac nhom
BPTNMT va nhom BMV + BPTNMT co th hp ly do ban cht cua
BPTNMT co gii han lu lng khi. Tuy nhin, ngay ca i vi nhom
BMV trong nghin cu cua chung ti cung co giam FEV1.
Mt s nghin cu trn th gii khao sat s lin quan cua FEV1 vi
bnh tim mach cung rut ra kt lun la giam FEV1 la yu t nguy c cua
bnh tim mach. Higgins va Keller nghin cu thy nhng ngi co FEV1
<2L co gia tng nguy c t vong do bnh tim mach ln gp 5 ln so vi
nhng i tng co FEV1 2L (RR= 5,03; khoang tin cy 95%: 3,07
8,22). Hole va cs thc hin nghin cu nc Anh thy giam FEV1 gy
97
26% cac trng hp t vong do bnh tim thiu mau cuc b nam gii va
24% n gii. Mc gop phn gy t vong cua giam FEV1 tng t nh
mc gop phn gy t vong do tng cholesterol mau. Thm chi tc
giam FEV1 cung la vn cn quan tm. Mt nghin cu Baltimore sau
16 nm theo doi thy so vi nhng ngi co tc giam FEV1 chm,
nhng ngi co tc giam FEV1 nhanh co nguy c t vong do bnh tim
mach tng gp 3 5 ln. Ngay ca nhng ngi khng bao gi HTL th vic
giam nhanh FEV1 cung gy gia tng nguy c nay ln gp 5 10 ln[142].
Vi giam FEV1 mi 10% lam tng nguy c t vong do bnh tim mach ln
28% va tng nguy c cac bin c mach vanh khng t vong ln 20%.
Nghin cu cua Lies Lahousse va cs trn 253 bn BPTNMT va 920
ngi co chc nng h hp bnh thng lam nhom chng thy cac bn co
BPTNMT co nguy c day thanh ng mach canh trn siu m gp 2 ln so
vi nhom chng (OR= 2,0; khoang tin cy 95%: 1,44 2,85; p< 0,001)
[91]. Hn na, trn kt qua chup MRI, cac bn BPTNMT cung thng co
mang x va khng n inh hn so vi nhom chng (OR= 2,1; khoang tin
cy 95%: 1,25 3,69; p <0,05). iu nay cho thy giam FEV1 la yu t
nguy c t vong c lp cua bnh tim mach va co th la mt trong cac yu
t gop phn lam gia tng nguy c bnh tim mach trn cac bn co BPTNMT
[49].
4.1.7 c im nhom bnh phi tc nghen mn tinh
Chung ti thu thp c 54 trng hp tha man tiu chun chn
oan BPTNMT. Trong 54 trng hp nay, co 33 trng hp co kt qua
chup ng mach vanh cho thy co tn thng ng mach vanh co y ngha.
Do o, khao sat s khac bit v vim h thng nn chung ti tach 33
trng hp nay thanh nhom bnh phi hp va con lai 21 trng hp thanh
nhom BPTNMT vi tui trung bnh la 64,14, ngi ln tui nht la 83
98
(tui) va nh tui nht la 45 (tui); 100% la nam gii; 95,2% co HTL vi
trung bnh s thuc la hut la 33,76 15,9 goi-nm.
Phn giai oan cua BPTNMT (theo GOLD) trong nghin cu cua
chung ti giai oan nhe chi co 1 bn (4,8%); giai oan trung bnh co 15 bn
(71,4%); giai oan nng co 4 bn (19,0%) va giai oan rt nng co 1 bn
(4,8%). Nh vy, 76,2% cac bn trong nhom BPTNMT cua chung ti giai
oan nhe-trung bnh cua bnh (bang 3.14). Nghin cu cua Pilar de Lucar-
Ramos va cs nghin cu a trung tm trn 1200 bn BPTNMT thy giai
oan nhe cung chi co 1,3% (13/1200)[58].
4.1.8 c im nhom bnh mch vanh
Chung ti thu thp c 119 trng hp co kt qua chup ng mach
vanh co tn thng y ngha. Trong s 119 trng hp nay, co 33 bn tha
tiu chun BPTNMT nn chung ti tach ring thanh nhom phi hp BMV
+ BPTNMT. Nh vy, nhom BMV cua chung ti co 86 bn vi tui trung
bnh la 62,11, ngi ln tui nht la 84 (tui) va nh tui nht la 42 (tui);
nam gii chim 80,2% (69/86); 64,0% co HTL vi trung bnh s thuc la
hut la 20,38 goi-nm.
4.1.8.1 S nhanh ng mch vanh tn thng trong nhom bnh mch
vanh
Theo kt qua nghin cu cua chung ti th trong nhom BMV tn
thng 1 nhanh ng mach vanh chim nhiu nht vi 60/86 trng hp
(69,8%); tn thng 2 nhanh co 18/86 trng hp (20,9%) va tn thng 3
nhanh chim it nht vi 8/86 trng hp (9,3%). 69/8% bn cua nhom BMV
co tn thng 1 nhanh ng mach vanh va 30,2% bn co tn thng 2
nhanh ng mach vanh (bang 3.15).
Kt qua t nghin cu cua Nguyn Minh Tri cung cho thy tn thng
1 nhanh ng mach vanh chim nhiu nht vi 36,4%, tn thng 2 nhanh
99
ng mach vanh chim 26,4% va tn thng 3 nhanh ng mach vanh
chim it nht vi 17%. Kt qua nghin cu cua Lng thi Kim Lin cung
cho ty l tn thng 1 nhanh ng mach vanh nhiu nht vi 37%[10]. Tuy
nhin, ty l phn trm cua cac nhanh ng mach vanh tn thng cua
chung ti cao hn do chung ti chi xt cac trng hp tn thng co y
ngha (70%) trong khi cac tac gia trn xt tn thng 50% va con chia
s ty l phn trm vi cac bn co tn thng 0 nhanh ng mach vanh.
Kt qua nghin cu cua L thi Bich Thun la tn thng 1 nhanh > tn
thng 3 nhanh > tn thng 2 nhanh vi ty l ln lt la 41,1%; 34,5% va
25,7% trong khi kt qua cua chung ti tn thng 1 nhanh > tn thng 2
nhanh > tn thng 3 nhanh vi ty l la 47,78%; 31,11% va 21,11%[16].
Kt qua nghin cu cua Nguyn c Khanh cung cho hep 1 nhanh chim
a s vi 36,3%, hep 2 nhanh co 33,8% va hep 3 nhanh co 30%[8].
4.1.8.2 Vi tri ng mch vanh tn thng trong nhom bnh mch vanh
Theo kt qua nghin cu cua chung ti (bang 3.16), tn thng
nhanh LAD thng gp nht vi 60 trng hp (69,8%); nhanh RCA
chim 38 trng hp (44,2%); LCx co 22 trng hp (25,6%). Kt qua cua
chung ti khng co tn thng nhanh LM. iu nay co th do nhanh LM la
nhanh chinh cung cp mau cho tm tht trai, vi tiu chun chon bnh cua
nghin cu cua chung ti la tn thng co y ngha khi hep 70% nhanh
mach vanh th cac bn co tn thng nhanh LM co th kem suy tim hay co
kho th trn lm sang va cac c im nay la tiu chun loai tr trong
nghin cu cua chung ti.
Kt qua nghin cu cua chung ti cung khng co s khac bit vi kt
qua cua L thi Bich Thun trong o tn thng gp nhiu nht la nhanh
LAD chim 84,7%, nhanh RCA chim 55,6%, nhanh LCx chim 34,7% va
it nht la LM chim 6,94%[16]. Kt qua t nghin cu cua Nguyn c
100
Khanh cung thy la tn thng cua nhanh LAD thng gp nht vi
78,8%, tn thng nhanh RCA chim 62,5%, tn thng nhanh LCx chim
47,5% va it nht la LM vi 6,3%[8].
4.1.8.3 Thang im Gensini trong nhom bnh mch vanh
Thang im Gensini trong nhom BMV trung bnh la 27,59. 27,98% bn
nhom BMV co thang im Gensini < 10 im; t 10 29 im chim
37,2%. 65,1% bn trong nhom BMV trong nghin cu cua chung ti co
thang im Gensini < 30 (bang 3.17). Kt qua cua chung ti cung ging vi
kt qua cua L thi Bich Thun vi tn thng < 10 im chim 27,8%, t
10 29 im chim 30,6%[16].
im s Gensini trung bnh trong nghin cu cua chung ti thp hn
so vi im s Gensini cua nhom bn au tht ngc n inh cua Nguyn
Minh c (27,59 so vi 35,75; p< 0,01)[6]. im Gensini cua chung ti
cung thp hn ang k so vi kt qua cua Nguyn c Khanh (27,59 so
vi 43,63; p< 0,001)[8]. Chung ti cho la s khac bit do nghin cu cua
cac tac gia trn co ca cac bn bi nhi mau c tim cp. Cac bn bi nhi mau c
tim cp thuc i tng loai tr trong nghin cu cua chung ti do nhng
bn nay co chng chi inh o h hp ky anh gia chc nng h hp.
Kt qua nghin cu cua Mohammad Assadpour Piranfar trn 85 bn
co sang thng mach vanh do x va ng mach cung cho kt qua hep nhe
vi Gensini < 10 chim 34,1%, hep va vi Gensini 10 50 im chim
37,7% va hep nng vi Gensini > 50 im chim 28,2%[109].
4.1.9 c im nhom bnh mch vanh co bnh phi tc nghen mn
tinh
Chung ti thu thp c 33 bn co kt qua chup ng mach vanh co
tn thng y ngha ng thi tha tiu chun BPTNMT thanh nhom BMV
+ BPTNMT, 100% la nam gii vi tui trung bnh la 65,21; ngi ln tui
101
nht la 87 (tui) va nh tui nht la 44 (tui); 100% co HTL vi trung bnh
s thuc la hut la 33,36 12,40 goinm.
4.1.9.1 Tn sut bnh phi tc nghen man tinh trong bnh mach vanh
Kt qua nghin cu thu c 193 trng hp tham gia nghin cu
cua chung ti cho thy co 119 bn co tn thng ng mach vanh co y
ngha. Trong s 119 bn nay, co 33 bn tha tiu chun chn oan BPTNMT
khi o h hp ky vi FEV1/FVC <70% sau test gian ph quan. Do o, tn
sut cua BPTNMT trn cac bn co BMV trong nghin cu cua chung ti la
27,73% (33/119). Chung ti cho la tn sut nay vn cha phan anh ung
thc t v cac ly do:
Cac i tng nghin cu cua chung ti c ly t cac bn nhp
vin tai khoa tim mach can thip cua cac bnh vin nn khng phan
anh c tnh hnh BPTNMT.
Chung ti loai tr cac bn bi NMCT cp va cac bn kho th luc nghi v
trong nghin cu chung ti cn o h hp ky va test gian ph quan
do o thiu phan anh tn sut cua BPTNMT trong nhom bn nay.
iu nay co th thy c la cac bn BPTNMT giai oan nng va
rt nng trong nghin cu cua chung ti rt it, chi chim co 22,2%
cac bn bi BPTNMT (12/54).
Kt qua nghin cu cua chung ti cung xp xi vi tn sut BPTNMT
trong s cac bn co BMV trong nghin cu cua Hesham Z. Saleha va cs la
25,8%[135] va nghin cu cua AlaEdin H. Ahmed va cs la 28%[28].
Rafael Garcia Fuster va cs nghin cu 1412 bn m bc cu ng mach
vanh t nm 1993 n nm 2004 co o h hp ky trc m cung ghi nhn
co 26% bn co tc nghen ng dn khi (FEV1/FVC <70%)[68].
Tuy nhin, kt qua cua chung ti cao hn so vi kt qua cua tac gia Pei-
Hsun va cs la chi co 9,7% co kem BPTNMT trn cac bn c can thip
102
mach vanh qua da[145]. Chung ti cho la s khac bit do i tng nghin
cu cua Pei-Hsun l cc bn bi nhi mau c tim cp co ST chnh ln va tiu
chun chn oan BPTNMT la khi co 1 trong 4 yu t:
- Tin s cn dung thuc gian ph quan.
- Tin s FEV1 < 70%.
- Kham thc th bn co th kho khe th th ra, khi ph thung.
- ang dung thuc gian ph quan trong khi bi NMCT
Cac tac gia khng dung tiu chun chn oan BPTNMT theo khuyn
cao la FEV1/FVC <70% sau test gian ph quan chng minh co tc
nghen lu lng khi. Theo cac Y vn th cac bn giai oan nhe va trung
bnh cua BPTNMT co th khng co triu chng hoc chi co ho va khac
am ma cha biu hin kho th trn lm sang. Mt khac, cung nh theo ghi
nhn cua cac tac gia nay th i tng nghin cu cua cac tac gia la nhng
bnh nhn c can thip mach vanh qua da sau nhi mau c tim cp nn
co mt ty l cac bn t vong sau can thip ng mach vanh ma khng th
khao sat c[145].
Kt qua nghin cu cua chung ti cung cao hn kt qua cua Liang Bin-
Miao va cs: chi co 29 trong 245 bn co BMV co kem BPTNMT, chim
11,83%[95]. S khac bit nay co th do nghin cua cua Liang Bin-Miao va
cs chn oan BMV da vao kt qua chup MDCT, trong khi chung ti dung
tiu chun vang la kt qua chup ng mach vanh can quang chn oan.
Mt khac, s khac bit v kt qua cua chung ti so vi 2 nghin cu trn
cung co th do chung ti dung tiu chun co BMV khi co tn thng co y
ngha la 70%, trong khi hai nghin cu trn dung tiu chun co BMV khi
hep ng mach vanh 50%. Tn sut BPTNMT trong BMV cua nghin
cu cua chung ti cung cao hn so vi kt qua nghin cu cua Sonkamble
Siddharth va cs (27,73% so vi 19%)[139] va nghin cu cua Gianluca
103
Campo va cs (27,73% so vi 18,2%)[48]. Trong nghin cu cua
Sonkamble Siddharth va cs, tiu chun chn oan BPTNMT da theo tiu
chun GOLD nhng tiu chun chn oan BMV cua nghin cu nay da
vao tin cn co thay i trn in tim, stress gng sc, siu m tim hay
chup mach vanh. Trong nghin cu cua Gianluca Campo va cs, i tng
nghin cu la cac bn bi nhi mau c tim va chn oan BPTNMT da vao
tin cn bn tng nhp vin v BPTNMT. Kt qua cua chung ti cung cao
hn kt qua nghin cu cua Francesca Bursi va cs (27,73% so vi 12%)
[47]. S khac bit nay la do cac tac gia chon phng phap nghin cu hi
cu vi i tng la cac bn bi nhi mau c tim cp va tiu chun BPTNMT
cua nghin cu da vao h s ma khng o h hp ky.
Tn sut BPTNMT trn cac bn BMV trong nghin cu cua Joan B.
Soriano va cs cao hn cua chung ti[144]. Trong s 119 bn nhp vin v
BMV cua tac gia, co n 33,6% co BPTNMT. Nghin cu nay cung ghi
nhn co n 60% bn bi gii han lu lng khi (trong o 42,3% tc nghen
ng dn khi mc trung bnh va 5,8% co tc nghen ng dn khi mc
nng ) c chn oan bng o h hp ky a khng c chn oan va
iu tri[144]. Tng t, kt qua t nghin cu cua Talha Mahmud va cs
cung cho kt qua tn sut cua BPTNMT trong cac bn co bnh tim thiu
mau cuc b ln n 37,9% va cac bn nay cha tng c chn oan co
BPTNMT[101].
Kt qua t mt iu tra trong dn s thy tn sut cua BPTNMT
trong bnh tim thiu mau cuc b (nhi mau c tim, au tht ngc va hep
ng mach vanh) thay i t 26% n 35%[132].Katsuya Onishiva cs
nghin cu tai 17 trung tm Nht Ban trn 995 bn n kham v bnh tim
mach. Kt qua cho thy tn sut BPTNMT la 27% va 87,7% cac bn nay
cha tng c chn oan BPTNMT trc o[122].
104
Tn sut cua BMV trong BPTNMT thm chi con cao hn.Tae Yun
Park va cs nghin cu 113 bn BPTNMT.Kt qua chup ng mach vanh
phat hin BMV chim 61% trong cac bn BPTNMT. Mt nghin cu khac
trn 60 bn cho ty l BMV trong BPTNMT la 53,3%[124]. Kt qua nghin
cu cua Nguyn Ngoc Phng Th va cs trn 96 BN BPTNMT tai BV
Nhn dn 115 cung cho ty l BMV cac bn co BPTNMT la 48,9%[15].
T kt qua nghin cu cua chung ti va tham khao cac nghin cu
khac cho thy co s kt hp BPTNMT vi BMV vi ty l cao.
4.1.9.2 Giai oan bnh ca bnh phi tc nghen man tinh trong nhm bnh
mach vanh c bnh phi tc nghen man tinh
Cung tng t nh nhom BPTNMT, nhom BMV + BPTNMT cua
chung ti cung co s bn thuc giai oan nhe-trung bnh cua BPTNMT
chim a s vi 78,8%, giai oan nng-rt nng chi co 21,2%. Chung ti
thy khng co s khac bit co y ngha thng k v giai oan bnh cua
BPTNMT cua 2 nhom nay (p> 0,05).
Nghin cu cua Pei-Hsun Sung va cs co 129 bn co BPTNMT nhng
cac bn nay khng c o h hp ky nn khng co giai oan BPTNMT
[145]. Trong nghin cu cua Liang Bin-Miao va cs th 29 trng hp
BPTNMT co c o h hp ky nhng khng thy tac gia phn giai oan
bnh cua BPTNMT[95].
S khng khac bit v giai oan cua BPTNMT gia 2 nhom
BPTNMT va nhom BPTNMT+BMV cua chung ti co th do mu nghin
cu cua chung ti it nn cha phan anh ung. Trong BPTNMT, cac bn
thuc giai oan nhe thng khng co triu chng hoc triu chng it nn
khng i kham bnh. Con cac giai oan nng-rt nng thng co kho th
va thuc tiu chun loai tr trong nghin cu cua chung ti.
105
4.1.9.3 %FEV1 trong nhm bnh mach vanh c bnh phi tc nghen man
tinh
FEV1 trung bnh trong nhom BMV + BPTNMT cua chung ti la
61,48 13,79%. FEV1 trong nhom BMV + BPTNMT cua chung ti thp
hn ang k so vi nhom chng (61,48% so vi 97,22%; p< 0,001) va thp
hn so vi nhom BMV (61,48% so vi 88,97%; p< 0,001). Tuy nhin, so
vi nhom BPTNMT th khng co s khac bit co y ngha thng k (61,48%
so vi 59,00%; p> 0,05). FEV1 trong nhom BMV + BPTNMT cua chung
ti thp hn co y ngha thng k so vi FEV1 trong nghin cu cua Tae
Yun Park va cs (61,48% so vi 75,84%; p <0,001) co th do s bn thuc
giai oan nng rt nng cua BPTNMT cua nhom BMV + BPTNMT trong
nghin cu cua chung ti nhiu hn so vi giai oan nng-rt nng cua
BPTNMT trong nghin cu cua Tae Yun Park va cs (22,20% so vi
15,94%)[124].
4.1.9.4 Vi tri va s nhnh ng mach vanh tn thng trong nhm bnh
mach vanh c bnh phi tc nghen man tinh
Trong nhom BMV + BPTNMT, tn thng nhanh LAD thng gp
nht (66,70%); nhanh RCA chim 63,60% va it nht la nhanh LCx (36,4%)
(bang 3.19). 45,5% co tn thng mt nhanh ng mach vanh; 54,5% co
tn thng 2 nhanh ng mach vanh (bang 3.20).
4.1.9.5 Thang im Gensini ca nhm bnh mach vanh c bnh phi tc
nghen man tinh
Thang im Gensini trung bnh trong nhom BMV + BPTNMT cua
chung ti la 33,66 27,43. Thang im Gensini trong nhom phi hp BMV
+ BPTNMT cao hn nhom BMV nhng s khac bit khng co y ngha
thng k (27,59 27,24 so vi 33,66 27,43; p> 0,05).
106
4.2 NNG hs-CRP VA TNF- TRONG CAC NHOM NGHIN
CU
4.2.1 So sanh nng hs-CRP cua cac nhom nghin cu
4.2.1.1 So snh nng hs-CRP gia nhm bnh thng vi nhm bnh
phi tc nghen man tinh
Nng hs-CRP trung bnh trong nhom BPTNMT cua nghin cu
chung ti cao hn ang k so vi nng hs-CRP cua nhom chng (4,18
3,94 mg/L so vi 2,38 2,58mg/L; p< 0,05). Khng co khac bit co y
ngha thng k v nng hs-CRP gia giai oan nhe trung bnh vi
nng rt nng (p> 0,05) (bang 3.22).
Nng hs-CRP trong nhom BPTNMT cua chung ti cung ging
vi nng hs-CRP trong nghin cu cua cac tac gia Sarya Marevie
[104][) la 3,9 mg/L (3,9 4,9), cua tac gia Anup N. Nillawar la 4,6 mg/L
[116]; cua Surya P Bhatt la 4,59mg/L[43] va cua V M Pinto-Plata la
5,03mg/L[126].
Nervana Samy va cs cung cho kt qua nng hs-CRP la 4,30 mg/L
nhng kt qua cua cac tac gia Nervana Samy va cs cho thy co s gia tng
nng hs-CRP theo giai oan cua BPTNMT (vi nng trung bnh cua
cac giai oan nhe, trung bnh, nng va rt nng ln lt la 1,19 mg/L; 2,93
mg/L; 6,13 mg/L va 6,96 mg/L)[136]. Chung ti cho la co th do nhom
BPTNMT cua chung ti con it (16 bn thuc giai oan nhe trung bnh va 7
bn giai oan nng rt nng) nn khng cho thy s khac bit nay. Fisun
Karadag va cs nghin cu nng CRP trn 35 bn BPTNMT va 30 ngi
khe manh cung thy co s gia tng nng cua CRP trn cac bn
BPTNMT so vi nhom chng nhng khng thy co s khac bit co y ngha
thng k v nng nay trong nhom BPTNMT co FEV1 > 50% va nhom
FEV1< 50% (10,89mg/L so vi 11,09mg/L, p> 0,05) va cung c tac gia
107
cho la mu nh nn cha thy c s khac bit[86]. Nng hs-CRP
trong nhom BPTNMT cua chung ti thp hn so vi nng hs-CRP trong
nghin cu cua SA Alavi va cs (4,40mg/L so vi 11,65mg/L; p< 0,001). S
khac bit nay co th la i tng nghin cu cua SA Alavi la cac bn
BPTNMT trong t kich phat[32].
Tuy nhin, cac kt qua nay cung cho thy co s gia tng cua nng
hs-CRP trn cac bn bi BPTNMT so vi chng.
4.2.1.2 So snh nng hs-CRP gia nhm bnh thng vi nhm bnh
mach vanh
Nng hs-CRP trung bnh trong nhom BMV cua chung ti la 9,91
12,97mg/l, cao hn ang k so vi nhom chng (p< 0,001) (bang 3.22).
Kt qua hs-CRP trong nhom BMV cua nghin cu chung ti ging vi
kt qua v nng hs-CRP trong nghin cu cua Mahalle N. va cs
(9,91mg/L so vi 11,7mg/L; p> 0,05)[100] va nhom au tht ngc n inh
(9,91mg/L 12,97so vi 7,79 5,15mg/L; p>0,05) nhng thp hn so vi
nng hs-CRP cua nhom au tht ngc khng n inh trong nghin cu
cua Nguyn Minh c (9,91mg/L so vi 12,8mg/L; p< 0,05)[6].
So vi kt qua cua tac gia Pham Trung Ha, nng hs-CRP trong
nghin cu cua chung ti cao hn kt qua hs-CRP trong nhom bnh tim
thiu mau cuc b man tinh (9,91mg/L so vi 3,89mg/L; p< 0,01) nhng
thp hn so vi nhom bn bi nhi mau c tim cp (9,91mg/L so vi
28,01mg/L; p< 0,001)[7]. Kt qua hs-CRP cua chung ti cung thp hn so
vi kt qua cua Nguyn c Khanh (9,91mg/L so vi 42,96mg/L; p<
0,001)[8]. S khac bit la do cac i tng BMV cua chung ti la cac bn
khng co nhi mau c tim cp.
108
4.2.1.3 So snh nng hs-CRP gia nhm bnh mach vanh c bnh phi
tc nghen man tinh vi nhm bnh thng, nhm BPTNMT va nhm bnh
mach vanh
Nng hs-CRP trong nhom BMV + BPTNMT cua chung ti cao
hn so vi nhom chng (12,15mg/L so vi 2,38mg/L; p< 0,01) va nhom
BPTNMT (12,15mg/L so vi 4,18mg/L; p< 0,05). Tuy nhin, so vi nhom
BMV th s khac bit khng co co y ngha thng k (12,15mg/L so vi
9,91mg/L; p> 0,05) (bang 3.22).
4.2.2 So sanh nng TNF- cua cac nhom nghin cu
4.2.2.1 So snh nng TNF- gia nhm chng vi nhm bnh phi tc
nghen man tinh
Nng TNF- trung bnh trong nhom BPTNMT la 38,62pg/ml va
tng hn co y ngha thng k so vi nng TNF- trong nhom chng (p<
0,05) (bang 3.23). Kt qua nng TNF- trong nhom BPTNMT cua
chung ti cung ging vi kt qua nghin cu cua Fisun Karadag va cs trn
35 bn co BPTNMT n inh (38,62pg/ml so vi 32,87pg/ml; p> 0,05)[86].
Cac nghin cu v nng cua TNF- trong BPTNMT cua cac tac
gia khac cung cho thy co s gia tng cua cht chi im vim nay so vi
nhom chng. Nervana Samy va cs nghin cu tm mi lin quan gia cac
cht chi im vim vi tc giam chc nng phi cung thy nng cua
TNF- gia tng t 3,62pg/ml i vi BPTNMT giai oan nhe va 7,84pg/ml
i vi BPTNMT giai oan rt nng so vi nhom chng cua tac gia la
3,12pg/ml[136]. Nghin cu cua Suzana E Tanni trn 77 bn BPTNMT
cung thy co gia tng nng cua TNF- so vi nhom chng (4,8pg/ml so
vi 3,7pg/ml; p< 0,05)[146].
109
Tuy nhin, kt qua nghin cu cua Sanja Marevie va cs cho thy s
khac bit khng co y ngha thng k v nng cua TNF- gia cac bn
BPTNMT vi nhng ngi chng co HTL va ngi chng khng HTL
(nng TNF- trong cac nhom ln lt la 11,6pg/ml; 15,0pg/ml va
12,8pg/ml; p> 0,05)[104]. S khac bit v kt qua nay cua tac gia so vi
kt qua cua chung ti cung nh cac tac gia khac co th do tiu chun chn
oan BPTNMT. Trong nghin cu cua Sanja Marevie, cac bn c chn
oan la BPTNMT khi kt qua h hp ky co FEV1 < 80% d oan[104].
Trong BPTNMT, chn oan co tc nghen lu lng khi khng hi phuc
cn da vao ty s FEV1/FVC < 70% sau test gian ph quan. %FEV1 giam
so vi d oan co th xy ra vi cac bnh phi han ch trong o ty l
FEV1/FVC bnh thng. Mt khac, phn giai oan bnh cua BPTNMT,
theo GOLD, giai oan nhe cua bnh th FEV1 80% d oan.
4.2.2.2 So snh nng TNF- gia nhm chng vi nhm bnh mach
vanh
Nng trung bnh cua TNF- trong nhom BMV cua nghin cu
chung ti la 28,35pg/ml, gia tng so vi nhom chng la 18,84pg/ml (p<
0,01) (bang 3.23).
chung ti khng khac bit co y ngha thng k vi nng TNF- trong
nghin cu cua Mahalle N. va cs (28,35pg/ml so vi 25,3pg/ml; p>
0,05)[100].
chung ti thp hn ang k so vi nng trung bnh TNF- trong nghin
110
4.3 KHAO SAT MI LIN QUAN VA TNG QUAN GIA NNG
hs-CRP VA TNF- VI CAC YU T NGUY C, C IM
CUA BNH PHI TC NGHEN MAN TINH, BNH MACH VANH
4.3.1 Lin quan gia hs-CRP va TNF- vi gii va hut thuc la
Chung ti khng ghi nhn co lin quan gia gii tinh vi nng hs-
CRP (p>0,05). Tuy nhin, kt qua nghin cu cho thy nam gii co nng
TNF- cao hn so vi n gii (29,94pg/ml so vi 18,65pg/ml; p<
0,001) (bang 3.25) va nhng i tng HTL co nng TNF- cao hn so
vi nhng ngi khng HTL (34,13pg/ml so vi 20,67pg/ml; p< 0,05)
(bang 3.26). iu nay co th do tac ng cua thuc la lam gia tng TNF-
va nam gii la i tng thng co thoi quen HTL. Florin Petrescu va cs
nghin cu 43 ngi khe manh co HTL va 19 ngi khe manh khng
HTL ghi nhn nng TNF- trong mau cua cac i tng HTL cao hn
ang k so vi nhng i tng khng HTL (p< 0,05)[125]. Nghin cu
cua Juan Diez-Pina cung thy co gia tng nng cua TNF- trn nhng
ngi HTL nhng khng co lin quan vi lng thuc la hut.
TNF- la mt yu t tin vim manh va cac nghin cu cho thy co
gia tng nng cua TNF- trong am, dich ra ph quan-ph nang, m
phi sinh thit va trong huyt thanh cua bn co BPTNMT. iu nay cho
thy vai tro khi ng va tin trin vim cua TNF- khng chi tai ch ma
con gy vim h thng [125]. Nghin cu cua chung ti cung thy co mi
tng quan nghich gia nng cua TNF- vi %FEV1 (h s tng quan
r= - 0,268; p< 0,001).
111
4.3.2 Tng quan gia hs-CRP va TNF- vi FEV1 cua nhom bnh
Kt qua nghin cu cua chung ti cho thy co mi tng quan
nghich gia nng cua hs-CRP vi FEV1 (h s tng quan r = - 0,240;
p < 0,05) cung nh gia nng cua TNF- vi FEV1 (h s tng quan r
= - 0,531; p < 0,001) (bang 3.27).
Mt s cng trnh nghin cu khac cung cho thy mi tng quan
nghich cua cac cht chi im vim vi FEV1. Krystyna Komnata nghin
cu anh hng cua qua trnh vim trn suy giam chc nng thng khi phi
60 bn BPTNMT thy co gia tng nng cua hs-CRP va TNF-trong
mau[88]. Cac tac gia cung thy co mi tng quan nghich gia nng
cua hs-CRP va cac du hiu khi phi (h s tng quan r = - 0,29; p<
0,05) va co mi tng quan thun gia nng TNF- vi PaCO2 (h s
tng quan r = 0,281; p< 0,05) va ap sut tm thu tht phai trn siu m (h
s tng quan r = 0,332; p< 0,01). Nghin cu cua Nervana Samy trn 96
bn BPTNMT va nhom chng gm 20 ngi khe manh co chc nng h
hp bnh thng thy co mi tng quan nghich gia nng cua hs-CRP
vi FEV1 (h s tng quan r = - 0,63; p < 0,05)[136]. J.P. de Torres
nghin cu trn 130 bn BPTNMT cung thy co tng quan nghich gia
nng hs-CRP vi % FEV1 (h s tng quan r = - 0,20; p< 0,05) [60].
Tng t, Reshu Agarwal va cs nghin cu tm mi lin quan gia nng
cua hs-CRP va cac yu t tin lng trong BPTNMT trn 50 bn BPTNMT
n inh so vi 50 ngi khe manh lam nhom chng cung cho kt qua
nng cua hs-CRP trong nhom BPTNMT cao hn so vi nhom chng
(4,82mg/L so vi 0,88 mg/L p < 0,01) va co mi tng quan nghich gia
nng cua hs-CRP vi %FEV1 (r= 0,813; p < 0,01)[20].
112
Mohammad Shameem va cs nghin cu s kt hp gia nng
CRP va cac cht chi im d oan tin lng cua bn BPTNMT trn 50 bn
ghi nhn nng CRP co tng quan nghich vi FEV1 (h s tng quan r
= - 0,736; p< 0,001) nhng khng co tng quan vi tui cua bn (p> 0,05)
[110]. Alavi SA. va cs nghin cu trn 160 bn BPTNMT cung thy co
tng quan nghich gia nng hs-CRP va FEV1 (h s tng quan r = -
0,392; p< 0,001)[32]. Abdelsadek H. Al-Aarag va cs nghin cu nng
CRP trn 40 bn BPTNMT thy nng CRP gia tng ang k trn nhom
BPTNMT (31,09 mg/l so vi 6mg/dl) va co tng quan nghich vi FEV1
(h s tng quan r = - 0,61; p < 0,001)[31].
Mi tng quan nghich gia nng cua cht chi im vim h
thng vi chc nng phi cung co gia tri theo doi chc nng phi. Rafea
Shaaban va cs nghin cu s thay i cua nng hs-CRP va FEV1 theo
thi gian trn 531 i tng vi tui trung bnh la 37. Sau 8,5 nm theo doi
cho kt qua la % FEV1 co tng quan nghich vi s gia tng cua nng
hs-CRP (p< 0,05)[137]. Mt nghin cu khac cua Yuji Higashimoto nghin
cu trn 96 bn BPTNMT cung ghi nhn co tng quan nghich gia s thay
i v nng hs-CRP vi s thay i cua % FEV1 trong thi gian theo
doi trung bnh la 25 thang vi h s tng quan r = - 0,354; p< 0,01[76].
Qua kt qua nghin cu cua chung ti va cua cac cng trnh nghin
cu trn, chung ti thy co s hin din cua vim h thng trn cac bn
BPTNMT va tnh trang vim nay gy anh hng ang k trn chc nng
cua phi. Mt khac, hs-CRP co th dung theo doi chc nng phi trn
cac i tng co nguy c cao nh HTL nhng ni khng co iu kin o
h hp ky.
113
Chung ti ghi nhn co mi tng quan thun gia nng hs-CRP
vi thang im Gensini trong nhom BMV (h s tng quan r = 0,407, p<
0,001) cung nh tng quan thun gia nng TNF- vi im Gensini
(h s tng quan r = 0,208; p< 0,05) (bang 3.28).
Mi tng quan thun gia nng hs-CRP vi mc trm trong
cua tn thng ng mach vanh a c ghi nhn qua kt qua cua nhiu
nghin cu nh nghin cu cua L thi Bich Thun (h s tng quan r =
0,256); nghin cu cua Nguyn Minh c (h s tng quan r = 0,574; r =
0,516 i vi hi chng vanh cp va h s tng quan r = 0,756 i vi
au tht ngc n inh)[6]; nghin cu cua Nguyn c Khanh (r = 0,546;
p< 0,001)[8].
Cac kt qua nghin cu cua Mohammad Assadpour Piranfar [109] va
nghin cu cua Arslan Masood [106] cung thy co lin quan gia nng
cua hs-CRP vi mc nng cua hep ng mach vanh tinh theo thang
im Gensini.
Israel Gotsman va cs nghin cu trn 201 bn c chup ng mach
vanh cung cho thy co mi tng quan thun gia nng TNF- vi
thang im Gensini (h s tng quan r = 0,23 trong o h s tng quan r
= 0,26 i vi cac bn BMV n inh va h s tng quan r = 0,15 i vi
cac bn co hi chng vanh cp; p < 0,05)[72].
co bnh phi tc nghen mn tinh
Chung ti ghi nhn co mi tng quan thun gia thang im
Gensini vi nng cua hs-CRP nhom BMV+BPTNMT (h s tng
114
quan r = 0,402; p< 0,001) va vi nng TNF- (h s tng quan r =
0,422; p < 0,001).
Chung ti cung ghi nhn co tng quan thun v nng cua hs-
CRP va nng TNF- trong nghin cu nay (h s tng quan r = 0,327;
p< 0,05).
Nh vy, chung ti thy la co s phi hp ang k cua BPTNMT
trong cac bn co BMV. Cac bn co phi hp BMV + BPTNMT co c im
cua bn co BPTNMT va c im cua bn co BMV. Mc du nng cua cac
cht chi im vim h thng khng co s khac bit ang k so vi tng
bnh ly ring bit nhng nhng bn co phi hp BMV + BPTNMT cua
chung ti co tn thng nhiu nhanh ng mach vanh hn va thng co
phi hp vi tn thng cua nhanh ng mach vanh phai hn.
4.3.5 So sanh thang im Gensini cua nhom bnh mch vanh va nhom
bnh mch vanh + bnh phi tc nghen mn tinh
Thang im Gensini trong nhom BMV + BPTNMT cao hn thang
im Gensini trong nhom BMV nhng khng co y ngha thng k (33,66
27,43 so vi 27,59 28,24; p> 0,05) (bang 3.31).
4.3.6 Phn tich a bin vi cac yu t nguy c kinh in cua bnh mch
vanh va cac yu t nghin cu (hs-CRP, TNF-, BPTNMT) vi
nng cua bnh mch vanh
T kt qua phn tich tng quan mt s yu t nguy c, hs-CRP,
TNF- va BPTNMT cho d bao bnh mach vanh cho thy: hut thuc la
(OR=3,27; 95%: 1,22-8,74; p<0,05); BMTNMT (OR=0,33; 95%: 0,14-
0,81; p<0,05); ty s TG/HDL-c >3 (OR=2,32; 95%: 1,14-4,71; p<0,05);
nng hs-CRP >3mg/L (OR=3,28; 95%: 1,65-6,52; p<0,01) va nng
TNF-> 17pg/ml (OR=2,55; 95%: 1,19-5,46; p<0,05) (Bang 3.32).
115
Hut thuc la va ri loan lipid mau la cac yu t nguy c quan trong
cua BMV. Nghin cu INTERHEART ghi nhn sau tng cholesterol mau,
hut thuc la ng th hai trong cac yu t nguy c cua BMV[154]. Trong
cac ri loan lipid mau, ty s TG/HDL-c > 3 c xem la yu t d bao
nguy c BMV manh[83]. BPTNMT, mt bnh ly thng i kem vi BMV,
theo kt qua phn tich tng quan cung cho thy co anh hng n d bao
cua BMV. Ca BMV va BPTNMT co cung yu t nguy c quan trong la hut
thuc la va co cung c ch bnh sinh, hin tng vim h thng mc
thp. Hai yu t chi im vim h thng trong nghin cu nay gm hs-CRP
va TNF- cung thy co vai tro trong d bao BMV. Nng hs-CRP >
3mg/L lam tng 3,28 ln ty s chnh v nguy c BMV. Nng hs-CRP
>3mg/L cung a c Hip hi Tim mach Hoa K (AHA) va Trung tm
Kim soat va Phong nga Bnh tt Hoa K (CDC) phn nhom nguy c cao
cua BMV[147]. TNF- trong nghin cu chung ti cung cho thy co vai
tro trong d bao nguy c BMV. Nng TNF- > 17pg/ml lam tng 2,55
ln ty s chnh v nguy c BMV. Cht chi im TNF- cho vim h thng
co lin quan cht che vi hut thuc la va vic gia tng nng TNF- co
th khi ng qua trnh vim h thng trong o co vai tro cua hs-CRP va
gy gia tng nguy c BMV.
4.3.7 So sanh cac giai on cua bnh phi tc nghen mn tinh gia 2
nhom bnh phi tc nghen mn tinh va nhom bnh mch vanh co bnh
Trong nhom BPTNMT cua chung ti, 76,20% bn thuc giai oan
nhe-trung bnh; 23,80% thuc giai oan nng-rt nng. Trong nhom BMV
+ BPTNMT, 78,80% bn thuc giai oan nhe-trung bnh va 21,20% bn
thuc giai oan nng-rt nng. Chung ti khng ghi nhn co s khac bit co
116
y ngha thng k v giai oan bnh cua BPTNMT gia 2 nhom BPTNMT
va nhom BMV + BPTNMT (p> 0,05).
4.3.8 So sanh cac v tri ng mch vanh tn thng gia nhom bnh
mch vanh va nhom bnh mch vanh co bnh phi tc nghen mn tinh
Kt qua nghin cu cua chung ti thy s khac bit khng co y ngha
thng k v vi tri ng mach vanh bi tn thng gia cac bn BMV +
BPTNMT so vi cac bn bi BMV cac nhanh LAD (p> 0,05) va vi tri
LCx (p> 0,05) (bang 3.32). Tuy nhin, co s khac bit co y ngha thng k
v vi tri tn thng nhanh RCA gia cac bn nay: trong s 33 bn bi BMV +
BPTNMT th co 21 bn (63,60%) co tn thng nhanh RCA so vi 38/86
(44,20%) bn bi BMV ma khng co BPTNMT. Nh vy, cac bn co BMV co
kem vi BPTNMT co khuynh hng tn thng nhanh RCA i kem nhiu
hn so vi cac bn bi BMV khng co BPTNMT. Mansoor Ahmed va cs
nghin cu 400 bn co BMV trong o 184 bn co HTL va 216 bn khng HTL
ghi nhn co s khac bit co y ngha v vi tri nhanh mach vanh bi tn
thng gia nhom co HTL va nhom khng HTL: tn thng nhanh LAD
71% so vi 59% (p<0,005); tn thng nhanh LCx 56% so vi 37%
(p<0,001) va tn thng nhanh RCA 59% so vi 46% (p< 0,05). Mt khac,
so vi nhng bn khng HTL, nhng bn HTL co s mach vanh tn thng
nhiu hn (tn thng 3 nhanh: 42% so vi 29%)[29]. Nghin cucua
Roger Vander Zwaag va cs tm mi tng quan gia HTL va vi tri tn
thng ng mach vanh cho kt qua cac i tng HTL co nguy c tn
thng MV phai nhiu hn (OR = 5,8; khoang tin cy 95%: 4,6-7,2; p<
0,05)[155]. Hussein A. Fakhir Nafakhi nghin cu 393 bn BMV gm 198
bn co HTL va 195 bn khng HTL. Kt qua cung cho thy cac bn co HTL
co tn thng nhanh RCA nhiu hn (58%) va tn thng nhiu nhanh
MV hn nhom khng HTL (tn thng 2 nhanh 63% so vi 37%;
117
p<0,05)[77]. Tng t, Rahel Alemu va cs thc hin nghin cu tai Hoa
K va tng hp cac nghin cu t Ireland, Uruguay va Israel nhm tm s
khac bit v vi tri nhi mau c tim thanh trc vi nhi mau c tim thanh
di gia nhom co HTL va nhom khng HTL. Kt qua ghi nhn nhng
ngi HTL co nguy c bi nhi mau c tim thanh di nhiu hn so vi
nhng ngi khng HTL vi OR thay i t 1,15 n 2,00 (trung bnh
1,32). Cac tac gia kt lun la HTL lam anh hng n tun hoan cua ng
mach vanh phai nhiu hn ng mach vanh trai[33].
Kt qua nghin cu cua chung ti khac vi kt qua cua Pei-Hsun

Sung va cs [145]. Kt qua cua cac tac gia nay cho thy s khac bit khng
co y ngha thng k v vi tri mach vanh tn thng trong nhom BMV co
BPTNMT va nhom BMV khng co BPTNMT. Nh chung ti a ban, s
khac bit co th do tiu chun chn oan BPTNMT cua cac tac gia khng
ging vi cac tiu chun chn oan BPTNMT cua chung ti.
4.3.9 So sanh s tn thng mch vanh gia nhom bnh mch vanh va
nhom bnh phi tc nghen mn tinh co bnh mch vanh
Trong nhom BMV, tn thng mt nhanh ng mach vanh chim a
s vi 69,80% (60/86); tn thng 2 nhanh ng mach vanh chim
30,20% (26/85). Trong nhom BMV + BPTNMT, tn thng 1 nhanh chi
chim 45,50% (15/33) trong khi tn thng 2 nhanh ng mach vanh
chim 54,50% 18/33) (bang 3.33). Trung bnh mi bn trong nhom BMV
cua chung ti co tn thng 1,39 nhanh ng mach vanh trong khi mi bn
trong nhom BMV + BPTNMT cua chung ti co tn thng trung bnh 1,66
nhanh va s khac bit nay co y ngha thng k (p< 0,05). Nh vy, s hin
din ng thi cua BPTNMT trong BMV lam gia tng nguy c tn thng
s nhanh mach vanh (OR=2,77; khoang tin cy 95%: 1,21 6,32). Kt qua
nghin cu cua Xiao Lei Zhang va cs cung ghi nhn cac bn BMV co kem
BPTNMT co tn thng nhiu nhanh ng mach vanh hn so vi cac bn bi
118
BMV khng kem BPTNMT. Theo s liu t nghin cu cua Xiao Lei
Zhang va cs trn 378 bn BPTNMT c iu tri can thip ng mach vanh
qua da t thang 4 nm 2007 n thang 4 nm 2012 cho thy co 26,72%
(101/378) co tn thng 1 nhanh ng mach vanh; 73,28% (277/378) co
tn thng > 2 nhanh ng mach vanh. Trung bnh mi bn BPTNMT cua
nghin cu nay co tn thng 2,33 nhanh ng mach vanh[168]. Kt qua
nghin cu cua Ramazan Topsakal va cs cung cho thy la so vi nhom
BMV, cac bn co bnh phi hp BMV + BPTNMT co s nhanh mach vanh
tn thng nhiu hn co y ngha thng k (2,5 nhanh so vi 2,1 nhanh; p<
0,01)[151].
119
KT LUN
Qua nghin cu nay, chung ti rut ra mt s kt lun sau:

1-Nng hs-CRP va TNF- trong cac nhom bnh ly
-Nng hs-CRP trong cac nhom bnh ly gia tng so vi nhom chng
Nhom bnh mach vanh: 9,91 12,97mg/L ( trung vi 4,54 mg/L); nhom
bnh mach vanh + bnh phi tc nghen man tinh: 12,15 18,91mg/L(
trung vi 5,20 mg/L) va nhom bnh phi tc nghen man tinh: 4,18 3,92
mg/L (trung vi 3,20 mg/L) so vi nhom chng: 2,38 2,57mg/L(trung vi
1,30 mg/L)
Nng hs-CRP nhom bnh mach vanh va nhom bnh mach vanh +
bnh phi tc nghen man tinh cao hn nhom bnh phi tc nghen man tinh
Nng hs-CRP nhom bnh mach vanh thp hn so vi nhom bnh mach
vanh + bnh phi tc nghen man tinh, tuy nhin s khac bit cha co co y
ngha thng k.
-Nng TNF- trong cac nhom bnh ly gia tng so vi nhom chng
Nhom bnh mach vanh: 28,35 29,07pg/ml (trung vi 21,00pg/mL);
nhom bnh mach vanh + bnh phi tc nghen man tinh: 33,26
18,60pg/ml ( trung vi 26,10 pg/mL) va nhom bnh phi tc nghen man
tinh: 38,62 24,29pg/ml (trung vi 29,60 pg/mL) u cao hn so vi nhom
chng: 18,84 8,67pg/ml; ( p<0,01).
TNF- cua nhom BPTNMT cao hn so vi nhom BMV va BMV+
BPTNMT, TNF- cua nhom BMV + BPTNMT cao hn so vi nhom
BMV n thun , tuy nhin s khac bit cha co y ngha thng k.
120
2-Mi lin quan va tng quan hs-CRP va TNF- vi cac c im
bnh ly:
- Lin quan hut thuc la vi hs-CRP va TNF-: Ngi hut thuc la co
gia tng ang k nng hs-CRP (5,27 12,11mg/L so vi 8,79
13,86mg/L; p<0,05) va TNF- trong mau (20,72 12,11pg/ml so vi
31,24 26,94pg/ml; p<0,01).
- Lin quan chc nng thng khi phi (FEV1) va thang im Gensini
(tim mach ) vi hs-CRP va TNF-:
+ Nhom bnh mach vanh + bnh phi tc nghen man tinh:
Co mi tng quan nghich gia FEV1 vi nng hs-CRP (r= - 0,394;
p<0,001) va nng TNF- (r = - 0,503; p<0,001).
Co mi tng quan thun gia nng cua bnh mach vanh theo thang
im Gensini vi nng hs-CRP (r = 0,402; p<0,001) va vi nng
TNF- (r = 0,422; p<0,001).
-Nhom bnh mach vanh: Co mi tng quan thun gia nng cua
bnh mach vanh theo thang im Gensini vi nng hs-CRP (r= 0,407;
p<0,001) va vi nng TNF- (r= 0,208; p<0,05).
- Nhom bnh phi tc nghen man tinh: Co mi tng quan nghich gia
FEV1 vi nng hs-CRP (r= - 0,240; p<0,05) va nng TNF- (r= -
0,531; p<0,001).
- Phn tich a bin vi cac yu t nguy c kinh in cua bnh mach
vanh va cac yu t nghin cu (hs-CRP, TNF-, BPTNMT) trong d bao
bnh mach vanh
Hut thuc la (OR=3,27; 95%: 1,22-8,74; p<0,05)
BMTNMT (OR=0,33; 95%: 0,14-0,81; p<0,05)
Ty s TG/HDL-c >3 (OR=2,32; 95%: 1,14-4,71; p<0,05)
121
Nng hs-CRP >3mg/L (OR=3,28; 95%: 1,65-6,52; p<0,01)
Nng TNF-> 17pg/ml (OR=2,55; 95%: 1,19-5,46; p<0,05)
- Vi tri mach vanh tn thng gia nhom bnh mach vanh va nhom
bnh mach vanh + bnh phi tc nghen man tinh: khng co s khac bit v
tn thng cac nhanh LAD, LCx nhng co s khac bit v vi tri tn thng
nhanh RCA: cac bn bnh mach vanh + bnh phi tc nghen man tinh co tn
thng nhanh RCA nhiu hn (63,6% so vi 44,2%; p< 0,05)
- S nhanh mach vanh tn thng gia nhom bnh mach vanh va nhom
bnh mach vanh + bnh phi tc nghen man tinh: Cac bnh nhn bi bnh
mach vanh co kem bnh phi tc nghen man tinh co khuynh hng tn
thng nhiu nhanh mach vanh hn (OR= 2,77; 95%: 1,21- 6,32).
122
KIN NGHI
hs-CRP va TNF- la hai cht chi im vim h thng giup lm sang

tm soat nhng ngi hut thuc la co bnh mach vanh co hay khng co
kem bnh phi tc nghen man tinh.
123
DANH MUC CAC CNG TRINH KHOA HOC
A CNG B
1. Trn vn Thi, L vn Bang, Hoang thi Thu Hng (2013): Nghin

cu mi lin quan gia ri loan lipid mau va tn thng mach vanh,
Tap chi Y Dc hoc, Trng ai hoc Y Dc Hu, 15, 178-185.
2. Trn vn Thi, L vn Bang, Hoang thi Thu Hng (2014): Nghin
cu nng hs-CRP va TNF- bnh nhn bnh phi tc nghen
man tinh co bnh mach vanh, Tap chi Y Dc hoc, Trng ai hoc
Y Dc Hu, 22+23, 48-56.
TAI LIU THAM KHAO
TING VIT
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(2010), "Nghin cu gia tri nng hs-CRP va s lng bach cu
trong d bao tn thng ng mach vanh". Y hoc Vit Nam, tr 581-586.
2. L vn Bang, Phan thi Hng Dip, Trn Mn (2009), Bnh phi tc
nghen man tinh. H hp hoc - Giao trinh Sau ai hoc. NXB ai hoc
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3. L vn Bang, Phan thi Hng Dip, Trn Mn (2009) Vim trong Bnh
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Cng (2011), "Mi lin quan gia Nng hs-CRP vi Tn thng giai
phu ng mach vanh qua chup mach vanh can quang bnh nhn co
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7. Pham Trung Ha, Dip Quang Minh (2011), "Khao sat Nng hs-CRP
bnh nhn bnh tim thiu mau cuc b". Y hoc TP. H Chi Minh,
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ng mach vnh qua chp ng mach vnh cn quang trong hi chng
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Mc ngi hut thuc la ngi Vit Nam". Y Hoc TP. H Ch
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PROTOCOL NGHIN CU
tai: Nghin cu nng hs-CRP va TNF- huyt thanh bnh nhn
bnh mach vanh co hay khng co bnh phi tc nghen tinh.
Ma s nghin cu:
Ma H s bnh an:
Bnh vin:
I-PHN HANH CHANH

1-Ho tn:
2-Tui:
3-Gii: nam n
4-Ngh nghip:
5-ia chi:
6-Ngay vao vin:
II-TIN CN
1-Hut thuc la: co khng
2-S goi-nm:
3-Chiu cao:
4-Cn nng:
5-BMI:
III-KT QUA O H HP KY
1-Trc test gian ph quan
FEV1
FVC:
FEV1/FVC:
2-Sau test gian ph quan (nu co)
FEV1:
FVC:
FEV1/FVC:
3-Kt qua:
Hi chng tc nghen: Co Khng
Hi phuc vi test gian ph quan: Co Khng
IV-XET NGHIM
1-Nng hs-CRP:
2-Nng TNF-:
3-Lipid mau:
Cholesterol toan phn:
Triglyceride:
HDL-c:
LDL-c:
4-ng huyt:
V-KT QUA CHUP NG MACH VANH
a-Vi tri nhanh mach vanh tn thng va mc tn thng
Tn thng Mc hep (%)
Nhanh LM
Nhanh LAD
Nhanh LCx
Nhanh RCA
b-S nhanh mach vanh tn thng y nghia:
1 nhanh.
2 Nhanh
>2 nhanh
VI-PHN NHOM
1-BT
2-BPTNMT
3-BMV
4-BMV + BPTNMT
Ngi lp Bang nghin cu

PHU LUC
CAC MAY DUNG TRONG NGHIN CU
Hinh may o h hp ky kt ni vi may vi tinh xach tay.
Hinh may xet nghim hs-CRP.

Hinh may xet nghim TNF-.
Hinh Phong va May chup ng mach vanh tai Vin tim.
Hinh Phong va May chup ng mach vanh tai bnh vin Nhn dn 115.
Hinh Phong va may chup ng mach vanh tai bnh vin Thng Nht thanh
ph H Chi Minh.
QUY TRINH THC HIN O QCA
Bc 1: Chn hnh cn o
Chn vo QCA (quantitative coronary analysis)
Bc 2: Chn phn catheter ly chun theo Kich thc catheter ang
dng
Bc 3: Ly mc catheter
Bc 4: Chn oan mach mu cn o
Bc 5: Automatic obstruction my t tnh
Bang Quy i gia cac n vi cua catheter.

Luận Án - Trần Văn Thi

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B GIO DC V O TO

NGHIN CU NNG hsCRP V TNF HUYT

NGHIN CU NNG hs-CRP V TNF- HUYT

Chuyn ngnh: NI TIM MCH

NGI HNG DN KHOA HC

Qua lun an nay, ti xin c bay to long bit n su sc n:

Tac gia Lun an

Ch vit tt Ting Anh Ting vit

DANH MUC CAC HINH

DANH MUC CAC BIU

- Tinh cp thit cua tai

1.1 TNG QUAN V BNH MACH VANH

1.1.2.3 Phn b cung cp mu cho cc vng ca tim

Hnh 1.5 Phn t C Reactive Protein[127].

Hnh 1.7 CRP tham gia vao qua trnh gy x va ng mach[157].

2.1 I TNG NGHIN CU

- nng ca tn thng ng mach vanh

Glycerol 3 photphat oxydase

S 2.1 S nghin cu.

SD 1,27 1,38 1,86 0,99

Khng co khac bit co y ngha thng k v ty s TG/HDL-c gia

% FEV1 trong cac nhom bnh ly u giam co y ngha so vi nhom

Hu ht cac bn BPTNMT trong nghin cu thuc nhom bnh nhe-

Phn ln bn bi tn thng 1 nhanh ng mach vanh (69,80%).

Tn thng thng gp nht la nhanh LAD (69,8%) va nhanh RCA

Biu 3.2 Tng quan gia nng hs-CRP vi % FEV1.

Biu 3.3 Tng quan gia nng TNF- vi % FEV1.

Tng quan FEV1 r p

hs-CRP(mg/L) - 0,394 < 0,001

TNF-(pg/ml) - 0,503 < 0,001

Co mi tng quan nghich gia nng hs-CRP va nng TNF-

Bang 3.34 Lin quan BPTNMT vi s mach vanh tn thng (1 nhanh va

4.1 C IM CUA CAC NHOM NGHIN CU

Kt qua nghin cu cua chung ti khac vi kt qua cua Pei-Hsun

Qua nghin cu nay, chung ti rut ra mt s kt lun sau:

hs-CRP va TNF- la hai cht chi im vim h thng giup lm sang

1. Trn vn Thi, L vn Bang, Hoang thi Thu Hng (2013): Nghin

I-PHN HANH CHANH

6-Ngay vao vin:

Ngi lp Bang nghin cu

Hinh may o h hp ky kt ni vi may vi tinh xach tay.

Hinh may xet nghim hs-CRP.

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