IEU TR SUY TIM MAT BU

CAP
(Management of acute decompensated
heart failure)

PGS.TS Pham Nguyen Vinh

Vien Tim TP Ho Ch Minh
BV Tim Tam c

IEU TR SUY TIM MAT BU CAP

Tam quan trong cua suy tim mat

bu cap
Suy tim co trieu chng c nang: My 2% dan so; 6
10%/ ngi tren 65 tuoi; > 10% dan so > 80 tuoi
Suy tim mat bu cap (STMBC): nguyen nhan nhap
vien cao nhat > 65 tuoi (80%)
Nghien cu Acute Decompensated Heart Failure
Registry (ADHERE): tuoi trung bnh 27 000 b/n nhap
vien la 75

TL: Dec G.W. Management of Acute Decompensated Heart Failure. Curr

2
Probl Cardiol 2007; 32: 319 - 366

IEU TR SUY TIM MAT BU CAP

T vong do suy tim ngay cang tang

(thong ke My)

CHF : Suy tim

CHD : Benh
MV

TL: Adams KF. Am J Med 2001; 110 (suppl 7A): 6S 13S

IEU TR SUY TIM MAT BU CAP

Suy tim ngi cao tuoi (> 65)

T vong trong BV cao nhat, tng ng NMCT cap
ac iem:
* Phan ln do THA, tai cau truc that trai sau
NMCT, giam te bao c tim theo tuoi (5%/nam/ >
65)
* 40 50%: suy tim tam trng
* suy tim tam thu hoac tam trng: nguy c tng
ng

TL:

- Fonarow GC/ the ADHERE committee. Rev Cardiovasc Med 2003; 4 (suppl 7): S21 30
- Smith GL et al. J Am Coll Cardiol 2003; 41: 1510 - 1518

IEU TR SUY TIM MAT BU CAP

Yeu to benh sinh STMBC

Hau het (> 70%) nhap vien do suy tim man nang hn.
> 60% b/n nhap vien v STMBC co benh s:
* BMV (53 70%)
* THA (> 30%)
* rung nh man hay rung nh cn (> 45%)
* T (> 20%)
* roi loan chc nang than (> 20%)
Uong ru nhieu, cocaine, amphetamine
Cng giap, suy giap
Thieu mau cap hoac man
Thuoc: c che calci the he 1, chen beta, chong loan
nhp, khang viem khong steroid
5

IEU TR SUY TIM MAT BU CAP

Cac nguyen nhan ieu tr c

cua STMBC

TL: Dec G.W. Management of Acute Decompensated Heart Failure. Curr Probl Cardiol 2007; 32:
319 - 366

IEU TR SUY TIM MAT BU CAP

Sinh ly benh STMBC

Nhieu yeu to
Sung huyet phoi va/hoac sung huyet tnh mach
(qua tai the tch)
* khong kieng c
* khong dung thuoc
* that trai roi loan hn
* roi loan chc nang than
* HA kiem soat kem; rung nh mi xuat vien;
TMCB c tim
Hoi chng tim than:
* AGII -> endothelin -1, vasopressin -> nc va
muoi, sc cang thanh tim, giam ti mau than
* Giam ti mau than -> AG II
7

IEU TR SUY TIM MAT BU CAP

Sinh benh hoc ve

ton thng c tim
trong ky STMBC
Ton thng c tim: yeu
to quan
trong trong STMBC

TL: Maylin M et al. Am J Cardiol 2005;

96 (suppl): 29G

IEU TR SUY TIM MAT BU CAP

Bieu hien lam sang

Trieu chng c nang: nhay nhat trong chan oan STMBC
Kho th phai ngoi, cn kho th kch phat ve em: ac
hieu nhat (o nhay 23 66%; o ac hieu 52 81%)
Ran phoi:
- khong gap 80% suy tim man (do gia tang
lu thong bach huyet phoi)
- thng xuat hien khi STMBC
Phu ngoai vi: 25% < 70t suy tim man; xuat hien khi
STMBC
Phan hoi gan TM co: hien ro khi STMBC (do ap lc o
ay)
Phan biet STTThu vi STTTr: sieu am tim
BNP, NT pro BNP: giup chan oan va lng nh tien
lng
TL: Dec G.W. Management of Acute Decompensated Heart Failure. Curr Probl Cardiol 2007;
9
32: 319 - 366

IEU TR SUY TIM MAT BU CAP

Hai chat ch iem (biomarkers)

giup chan oan va lng nh
tien lng

BNP hoac NT pro BNP

Troponin I hoac Troponin T

10

Ch nh nhap vien trc trieu

chng STMBC

IEU TR SUY TIM MAT BU CAP

- Chng c suy tim mat bu nang :

* Ha HA
* Chc nang than
* Tri giac
- Kho th khi ngh
* Th nhanh/ngh
* SatO2 < 90%
- Loan nhp lam roi loan huyet ong
- Thieu mau cuc bo c tim cap

TL: Dec G.W. Management of Acute Decompensated Heart Failure. Curr Probl Cardiol 2007; 32:
319 - 366
11

IEU TR SUY TIM MAT BU CAP

Yeu to tien lng/ suy tim man

Nong o nor epinephrine huyet tng

BNP
PXTM
nh cao thu nhan oxy/ TNGS
Tuoi cao
Benh s loan nhp co trieu chng c nang
hoac ot t

TL: Eichhorn EJ. Am J Med 2001; 110 (7A): 14S 35S

12

IEU TR SUY TIM MAT BU CAP

Yeu to tien lng/ STMBC

13

TL: Dec G.W. Management of Acute Decompensated Heart Failure. Curr Probl Cardiol 2007; 32:
319 - 366

Tan suat t vong hoac tai

nhap vien/ nong o BNP luc
xuat vien

IEU TR SUY TIM MAT BU CAP

TL: Logeart D et al. J Am Coll Cardiol 2004; 43: 635 - 641

14

IEU TR SUY TIM MAT BU CAP

BNP va Troponins: biomarkers cua

tien lng
30 70% b/n STMBC: Troponin I hoac Troponin T*
BNP kem Troponin: 12 lan nguy c t vong/
STMBC**

TL: * Gheorghiade M et al. Circulation 2005; 112: 3958 3968

15

Roi loan chc nang than:

yeu to tien lng quan
trong/ STMBC

IEU TR SUY TIM MAT BU CAP

25% b/n nhap vien/ suy tim: giam chc nang

than du ieu tr noi ung
0.1 0.5mg/dL creatinine mau: t vong,
thi gian nam vien
0.5mg/dL creatinine mau/ lieu cao li tieu:
tang t vong va nam vien

TL: Dec G.W. Management of Acute Decompensated Heart

16

IEU TR SUY TIM MAT BU CAP

Ba yeu to tien lng xau theo

nghien cu ADHERE Registry
BUN > 43 mg/dL
Creatinine > 2.75 mg/dL
Huyet ap tam thu < 115 mmHg

17

IEU TR SUY TIM MAT BU CAP

Muc tieu ieu tr

Suy tim man: * giam trieu chng, giam nhap
vien
* gia tang song con
STMBC: * tng t suy tim man
* tuy nhien, can nhat: giam nhanh trieu chng
c nang
Mills R & Narula J: giam nhanh trieu chng va
cai thien huyet ong nhng khong lam nang
roi loan than kinh the dch (RAAS)

18

TL: Dec G.W. Management of Acute Decompensated Heart Failure.

Khao sat va theo doi huyet ong: s

o 2x2 cua Nohria

IEU TR SUY TIM MAT BU CAP

Warm & Wet : phu

phoi, huyet ap
con tot
Cold & Wet : phu
phoi, HA tut
Cold & dry : HA tut

TL: Nohria A et al. JAMA 2002; 287: 628 - 640

19

IEU TR SUY TIM MAT BU CAP

Nguyen nhan va x tr/ huyet

ong
Warm and dry (am va kho): lam nang suy tim
(kho th, met) do thuyen tac phoi, benh phoi
tac nghen, nhiem trung
Warm and wet (am va t): 50 60% STMBC. Tang
tai the tch. ieu tr: giam trieu chng sung
huyet ( li tieu, duy tr UCMC)
Cold and dry (lanh va kho): < 5%. Giam cung
lng tim nhng khong tang c tien tai. ieu
tr: truyen dch, tang co c tim khi a u dch
(dobutamine)
Cold and wet (lanh va t): 20%, e doa soc tim.
Nguyen do: mi b NMCT, roi loan nhp, benh van
nang hn, khong tuan thu ieu tr
20
TL: Dec G.W. Management of Acute Decompensated Heart Failure. Curr
Probl Cardiol 2007; 32: 319 - 366

IEU TR SUY TIM MAT BU CAP

Co can at catheter MP e
hng dan ieu tr?
Nghien cu ESCAPE: 433 b/n / 26 c s
- nhom ieu tr noi khoa quy c: da vao
trieu chng c nang va thc the
- nhom co at catheter MP
Ket qua ESCAPE:
- tieu ch chnh (t vong, thi gian nam vien):
tng ng/ 6 thang
- bien co trong benh vien, thng gap
nhom catheter MP (p = 0.04)

TL: ESCAPE Investigators. JAMA 2005; 294: 1625 - 1633

21

IEU TR SUY TIM MAT BU CAP

Quy trnh ieu tr phu phoi cap,

ha HA va soc

TL : Colucci WS.
Treatment of acute
decompensated
heart failure
(Cardiogenic
pulmonary
edema). 2007 Up
to Date.
www.uptodate.com

22

IEU TR SUY TIM MAT BU CAP

Quy trnh ieu tr phu phoi cap,

ha HA va soc

TL : Colucci WS.
Treatment of acute
decompensated
heart failure
(Cardiogenic
pulmonary
edema). 2007 Up
to Date.
www.uptodate.com

23

IEU TR SUY TIM MAT BU CAP

Vai ieu can chu y khi ieu tr

STMBC
Ngng dan mach uong va chen beta khi dung
thuoc van mach
Tranh dung thuoc tang co c tim e gia tang
nc tieu/ suy tim nang va
Duy tr tang co c tim/ b/n l , vo nieu, ha
huyet ap keo dai hoac lactic acidosis
ieu tr tang co c tim ngan han: co the hu ch
b/n co hoi chng than tim (cardiorenal syndrome)
B/n warm and wet: co the can tang co c tim neu
huyet ong suy sup nang hn*

TL: * Dec GW. J Am Coll Cardiol 2005; 46: 65 - 67

24

IEU TR SUY TIM MAT BU CAP

Thuoc ieu tr STMBC: li tieu

Li tieu quai (furosemide, torsemide,
bumetanide): vai tro chnh trong STMBC
Li tieu quai + thiazide: tac dung cong hng
Furosemide TTM 1 10mg/ gi: hieu qua hn
TM
Lieu li tieu TM: toi thieu bang lieu ang
uong

25

IEU TR SUY TIM MAT BU CAP

Li tieu lieu thap hay lieu cao?

Li tieu ngan han: tang hoat than kinh the dch
(RAAS, endothelin, BNP)
Li tieu lieu cao: tang nhay cam vi UCMC va
chen beta
Nghien cu ADHERE*: b/n co s dung li tieu
TM co t vong trong b/n cao hn va nam vien
lau hn nhom khong LT
Tot nhat: li tieu lieu thap nhat co hieu qua
Na+ < 130mEq/L: dch < 2L/ngay
Na+ < 120 mEq/L: han che dch nhieu hn
26

TL: * Abraham WT et al. J Am Coll Cardiol 2005; 46: 57 - 64

IEU TR SUY TIM MAT BU CAP

Thuoc oi khang aldosterone

Khong s dung spironolactone hoac
eplerenone/ STMBC
Lieu spironolactone 25mg/ngay: khi ra vien
B/n ang dung spironolactone b STMBC:
* tiep tuc s dung
* ngng spironolactone neu huyet ong khong
on, roi loan ien giai hoac chc nang
than xau hn.

27

IEU TR SUY TIM MAT BU CAP

Digoxin
Cha ro hieu qua tren STMBC
Nong o digoxin mau > 1ng/dL: tang t vong
/ moi nguyen nhan
Chu y: verapamil, flecainide, spironolactone va
amiodarone gia tang nong o digoxin mau.

28

IEU TR SUY TIM MAT BU CAP

B/n STMBC ang s dung chen

beta
Trieu chng c nang nhe, ap ng ngay vi
li tieu: khong can ngng chen beta
Giam 50% lieu chen beta/ b/n nhap vien ban
au v STMBC
Ngng chen beta khi STMBC dang lanh va
t (cold and wet)
Nen khi au chen beta lai trc xuat
vien

29

IEU TR SUY TIM MAT BU CAP

Nghien cu IMPACT HF
(The Initiation Management Pre-Discharge: Process for
Assessment of Carvedilol Therapy for Heart Failure)

a trung tam, m, 363 b/n PXTM < 40% nhap vien

v STMBC
2 nhom:
* nhom khi au carvedilol trc xuat vien (1)
* nhom carvedilol 2 4 tuan sau xuat vien (2)
Sau 6 ngay:
* 91% nhom 1 con s dung chen beta so vi
73% nhom 2 (p< 0.001)
* at lieu muc tieu: 36%/ nhom 1; 28% nhom 2

TL: Gattis W et al. J Am Coll Cardiol 2003; 43: 1534 - 1541

30

IEU TR SUY TIM MAT BU CAP

Thuoc dan mach uong

BN ang s dung UCMC hoac chen thu the
AGII (uong) :
Tiep tuc, can than
Ngng, neu :
Ha HA
Suy than cap
Kali mau
Khong khi au UCMC hoac chen thu the
AGII/benh nhan mi STMBC
TL : Colucci WS. Treatment of acute decompensated heart failure (Cardiogenic pulmonary 31
edema). 2007 Up to Date. www.uptodate.com

IEU TR SUY TIM MAT BU CAP

Thuoc dan mach TTM: vai tro

chnh trong STMBC

32

IEU TR SUY TIM MAT BU CAP

Cac dan mach trong STMBC

Nitroglycerine: Nitroprusside; Nesiritide (BNP)
Chau Au: 32% b/n STMBC s dung nitroglycerine
Elkayem va c/c (AJC 2004; 93: 237 240): Nitroglycerine
du lieu cao (160m/ml) sau 4 6 gi ieu tr van
tang ap lc bt mao mach phoi (PCWP)
Nitroprusside: hieu qua, nhng can theo doi huyet
ong xam nhap
Nghien cu VMAC*: nesiritide co hieu qua tng
ng nitroglycerine

* VMAC Publications Commettee. JAMA 2002 ; 287 ; 15311540

33

IEU TR SUY TIM MAT BU CAP

Hieu qua sinh ly benh cua dan

mach/ suy tim
Dan tnh mach (td: nitrates)
* ap lc o ay
* cai thien sung huyet phoi
Dan ong mach:
* sc can mach ngoai vi
* cung lng tim
STMBC: giam hoac ngng dan mach neu
* roi loan nang chc nang c quan muc tieu
(td: than)
* ha huyet ap keo dai (td: HA tth < 85mmHg)
* huyet ong khong on
34

IEU TR SUY TIM MAT BU CAP

Hieu qua dan mach so vi tang

co c tim/ STMBC
Nghien cu ADHERE registry: ieu tr bang
dan mach TM giam t vong trong benh vien
cao hn thuoc tang co c tim

35

IEU TR SUY TIM MAT BU CAP

Thuoc tang co c tim/ STMBC: tang

t vong

36

IEU TR SUY TIM MAT BU CAP

Thuoc tang co c tim/ STMBC

Dobutamine; milrinone
Nghien cu cua Liang va c/s:
* dobutamine TTM 72 gi/ 15 b/n suy tim NYHA III, IV
* theo doi 4 tuan:
- khong t vong
- PXTM / nhom dobutamine
Nghien cu OPTIME CHF: milrinone tang t vong
va tai nhap vien/ 60 ngay/ benh tim TMCB
Poole Wilson (JAMA 2002: 287:1587 1580): tat ca
thuoc tang AMP vong/ te bao c tim -> t vong
STMBC
37

IEU TR SUY TIM MAT BU CAP

Ch nh thuoc tang co c tim/

khuyen cao

Khuyen cao cua ACC/AHA*: thuoc tang co c

tim s dung trong G D cua suy tim (class IIB)
giup giam trieu chng hoac ch ghep tim.
Khuyen cao ESC**: tang co c tim s dung khi
giam ti mau kem hay khong sung huyet,
khang vi li tieu va dan mach (class IIA)

TL: * Hunt SA et al. J Am Coll Cardiol 2005; 46: 1116 1143 38

** Nieminen MS et al. Eur Heart J 2005; 26: 384 - 416

IEU TR SUY TIM MAT BU CAP

ieu tr loan nhp/ STMBC

Rung nh:
* Digoxin + chen beta ; kiem soat tan so tim
* Amiodarone: lieu nap < 1000 mg/ngay neu suy tim
mat bu nang
* chuyen nhp/ soc ien: au that ngc hoac huyet
ong khong on/ rung nh (Heparin khong phan oan
neu RN > 48 gi)
NTT that hoac nhanh that khong keo dai:
* khong x tr neu khong trieu chng
* can tm nguyen nhan: K+, Mg++, hoat giao
cam
* Amiodarone (0.5 1mg/ ph TTM) hoac Lidocaine 0,5 mg
2mg/ph TTM
* ieu tr duy tr: chen beta, sotalol, amiodarone
39

IEU TR SUY TIM MAT BU CAP

Cac thuoc ieu tr STMBC con

ang nghien cu
oi khang endothelin 1: Tezosentan,
bosentan
Chat nhay cam calci: Levosimendan
oi khang vasopressin: Conivaptan,
lixivaptan, tolvaptan
Khong thuoc nao c chng minh giam
t vong

40

IEU TR SUY TIM MAT BU CAP

ieu tr bang dung cu

(Tr giup tim bang c hoc)
Ch nh : ch so tim < 2L/ph/m 2, HA
tthu<90mmHg, ap lc bt MM phoi > 18mmHg
(mac du u thuoc)
Bong doi ngc noi MC
Dung cu tr that trai (LVAD left ventricular
assist device)
CAFA : continuous aortic flow augmentation
Sieu loc (ultrafiltration) : thai dch khong
anh hng en chat ien giai, hormones
System 100 from CHF Solutions Inc : dung cu
sieu loc t xam nhap.
TL : Colucci WS. Treatment of acute decompensated heart failure (Cardiogenic pulmonary 41
edema). 2007 Up to Date. www.uptodate.com

IEU TR SUY TIM MAT BU CAP

Tom tat ieu tr / Ket luan

Th oxy : mask, thong kh tr giup

Li tieu quai TM hoac TTM
Morphin sulfate 2-4mg TM
Dan mach TTM (Nitroglycerine, Nesiritide)
Tang co c tim TTM
Tr giup tim bang c hoc
Sieu loc

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