Bnh ng mch ngoi bin t cc yu t nguy c n chn on v iu tr

Ban M Thut, 5-6/08/2010

T l hin hnh bnh ng mch ngoi bin (BMNB)

NHANES1
Aged >40 years

4.3% 11.7% 14.5% 19.1% 19.8%

San Diego2 NHANES1

Aged 70 years

Mean age 66 years

Rotterdam3 Diehm4
Aged 65 years

dn s chm sc ban u xc nh tui v cc yu t nguy c ph bin, t l ca BMNB xp x 1/3 s bnh nhn

Aged >55 years

PARTNERS5 0%

Aged >70 years, or 5069 years with a history diabetes or smoking

29%
20% 25% 30% 35%

5%

10%

15%

NHANES=National Health and Nutrition Examination Study; PARTNERS=PAD Awareness, Risk, and Treatment: New Resources for Survival [program]. 1. 2. 3. 4. 5. Selvin E, Erlinger TP. Circulation. 2004;110:738-743. Criqui MH, et al. Circulation. 1985;71:510-515. Diehm C, et al. Atherosclerosis. 2004;172:95-105. Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192. Hirsch AT, et al. JAMA. 2001;286:1317-1324.

T l BMNB gia tng theo tui

Rotterdam Study (ABI <0.9)1 tests)2
60 50 40 30 20 10 0

San Diego Study (PAD by noninvasive

Bnh nhn BMNB (%)

55-59

60-64

65-69

70-74

75-79

80-84

85-89

Tui (nm)

ABI=ankle-brachial index 1. Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192. 2. Criqui MH, et al. Circulation. 1985;71:510-515.

T l c tnh ca BMNB trn bnh nhn i tho ng tp 2 chu trn 50 tui

40,000 35,000

Nam

Tng s

Trng hp / 100,000

30,000 25,000 20,000 15,000 10,000 5,000 0 Korea Indonesia Thailand Taiwan China Philippines Hong Kong
Sang Youl Rhee et al, Diabetes Research and Clinical Practice (2006)

Yu t nguy c
Ht thuc i tho ng Tng huyt p Tng cholesterol trong mu Tng homocystein trong mu Tng C-Reactive Protein

Hirsch AT, et al. Circulation. 2006;113:e463e465.

Ht thuc
N = 1592 Theo di 5 nm

T l pht sinh (%)

Ht thuc trung bnh: < 25 gi nm (s nm x s gi trung bnh ht mi ngy) Ht thuc nhiu: > 25 gi nm.
Price JF, Mowbray PI, Lee AJ, et al. Relationship between smoking and cardiovascular risk factors in the development of peripheral arterial disease and coronary artery disease: Edinburgh Artery Study.Eur Heart J. 1999;20:344-353.

Tng huyt p

T l pht sinh (%)

Elizabeth Selvin and Thomas P. Erlinger, Circulation 2004;110;738-743

Tng cholesterol mu

T l pht sinh (%)

Elizabeth Selvin and Thomas P. Erlinger, Circulation 2004;110;738-743

Tiu ng tng nguy c b BMNB

25

22.4* 19.9*

T l pht sinh (%)

20 15 10 5 0 Dung np glucose bnh thng

12.5

Ri lon dung np glucose

Tiu ng

Impaired glucose tolerance was defined as oral glucose tolerance test value 140 mg/dL but <200 mg/dL. *P .05 vs. normal glucose tolerance. Reprinted with permission from Lee AJ, et al. Br J Haematol. 1999;105:648-654. www.blackwell-synergy.com

CRP l yu t tin on ca BMNB

0.2

hs-CRP (mg/dL)

0.17 0.13 0.1

0.1

0.0 Bnh thng au cch hi Phu thut ng mch ngoi bin

Ridker, et al. Circulation.1998;97:425-28.

CRP = C-reactive protein; hs-CRP = high-sensitivity C-reactive protein

Cc yu t nguy c ca BMNB
Gim Tng

Ht thuc i tho ng Tng huyt p Tng cholesterol mu Tng homocystein mu C-Reactive Protein

T l tng i

Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

Nhng i tng c nguy c mc BMNB

Da trn cc chng c dch t hc dn s c nguy c vi BMNB c th c xc nh l: :
Tui < 50 c bnh tiu ng, v mt yu t nguy c km theo (v d ht thuc, ri lon m mu, tng huyt p hay tng homocystein mu) Tui t 50 n 69 tui c tin s ht thuc hoc bnh tiu ng Tui trn 70 Triu chng chn khi gng sc (gi au cch hi) hoc au khi ngh do thiu mu Khm mch chi di c bt thng Bnh l x va bit ng mch vnh, ng mch cnh, ng mch thn

Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

Chn on bnh ng mch ngoi bin

Yu t nguy c Triu chng lm sng Ch s c chn-cnh tay (ABI) Cc k thut chn on hnh nh
Siu m mch mu Dupplex MSCT ng mch Cng hng t ng mch DSA ng mch

Triu chng lm sng

Khng triu chng thng gp ngi tiu ng, ln tui, di chng thn kinh lm cho vn ng i li t nn khng bc l c triu chng. Khp khing cch hi in hnh (au bp chn khi i li v gim khi ngh), khp khing cch hi khng in hnh (au bp chn khi i li nhng khng gim khi ngh). au do thiu mu chi di nng (au c khi ngh, vt thng lu lnh hoc hoi th). au do thiu mu chi cp 5P: au (pain), v mch (pulselessness), tm ti (palor), t (paresthesia), yu lit chi (paralysis).

Ch s c chn - cnh tay (ABI)

L ch s nh gi lm sng n gin v gi tr Phng php ny c nhy cm l 79-95% v c hiu 95 - 100% Nhng gii hn ca phng php ny l tr s o s khng chnh xc khi ng mch chy b vi ho, khng xp c v khi c hp nh ng mch di n Ga tr ca ABI:
1.00 - 1.29: 0,91 - 0,99: 0,41 - 0,90: 0,40: 1,30: Bnh thng Gii hn Bnh ng mch ngoi bin nh-va Bnh ng mch ngoi bin nng ng mch cng

Cc k thut chn on hnh nh

Siu m mch mu Dupplex: Hin nay s dng m t tnh trng gii phu, huyt ng v hnh thi tn thng. MSCT ng mch: Vi s tin b ca k thut CT scan a lt ct, nhy cm v c hiu ca k thut ny l kh cao (94 - 100% v 98 - 100%) trong chn on bnh mch mu ngoi bin. Cng hng t ng mch: nhy cm v c hiu ca k thut ny kh cao (93 - 100% v 96 - 100%) trong vic xc nh mc hp ca cc ng mch chu, i. DSA ng mch: c s dng khi c ch nh can thip, sau cc xt nghim khng xm nhp.

iu tr

iu tr, kim sot cc yu t nguy c iu tr triu chng v ci thin chc nng iu tr ti thng: can thip mch mu v phu thut mch mu

iu chnh cc yu t nguy c

Ngng ht thuc l Vic ngng thuc l cho thy gim t l t vong 10 nm t 54% cn 18% ngi 65-75 c BMNB. Ngoi ra, vic ngng thuc l cng gip lm gim triu chng bnh.

Burns P, Gough S, Bradbury AW. Management of peripheral arterial disease in primary care BMJ 2003, Mar 15:326 (7389): 584-8.

iu chnh cc yu t nguy c
iu tr tng lipid mu iu tr vi thuc c ch HMG-CoA Reductase (statin) c ch nh cho tt c bnh nhn BMNB t mc tiu LDL < 100 mg/dl. iu tr vi thuc c ch HMG-CoA Reductase (statin) c ch nh t mc tiu LDL < 70 mg/dl cho BMCD c nguy c cao cc bin c thiu mu.

Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

iu chnh cc yu t nguy c
Tng huyt p Thuc chng tng huyt p c s dng cho bnh nhn tng huyt p c BMNB chi di t mc tiu < 140/90 mmHg (khng T) hay <130/80 mmHg (T v cc bnh nhn bnh thn mn tnh) gim nguy c nhi mu c tim, t qu, suy tim sung huyt, v cht do nguyn nhn tim mch.

Hirsch AT, et al. Circulation. 2006;113:e463e465.

iu chnh cc yu t nguy c
Kim sot glucose huyt Chm sc bn chn ng cch bao gm s dng v ph hp, thuc chm sc bn chn, quan st chn hng ngy, lm sch da, v dng cht lm m, nn c khuyn khch v cc sang thng da v lot nn c pht hin kp thi tt c bnh nhn T c BMNB. iu tr T c BMNB bng cc thuc h ng huyt gim HbA1C < 7% c th hiu qu gim bin chng mch mu nh v ci thin bnh tim mch.
Hirsch AT, et al. Circulation. 2006;113:e463e465.

iu chnh cc yu t nguy c
Thuc khng tiu cu
Thuc khng tiu cu c ch nh gim nguy c nhi mu c tim, t qu v cht do mch mu bnh nhn BMNB (Level of Evidence: A). Aspirin, liu hng ngy 75 n 325 mg, c ngh nh liu php khng tiu cu hiu qu v an ton gim nguy c nhi mu c tim, t qu, v cht do mch mu bnh nhn BMNB (Level of Evidence: A). Clopidogrel (75 mg/ngy) c ngh nh liu php khng tiu cu thay th hiu qu cho aspirin gim nguy c nhi mu c tim, t qu v cht do mch mu bnh nhn BMNB (Level of Evidence: B).
Hirsch AT, et al. Circulation. 2006;113:e463e465.

iu tr ci thin chc nng

Mt chng trnh hun luyn tp luyn c gim st c ngh nh l mt phng thc iu tr u tin cho cc bnh nhn au cch hi (Level of Evidence: A). Mt chng trnh hun luyn tp luyn c gim st nn c thc hin ti thiu 30 n 45 pht, trong mt chng trnh t nht 3 ln/tun trong ti thiu 12 tun (Level of Evidence: A). S hiu qu ca chng trnh tp luyn khng c gim st th cha c tha nhn nh l mt phng thc iu tr u tin hiu qu cho cc bnh nhn au cch hi (Level of Evidence: B).
Hirsch AT, et al. Circulation. 2006;113:e463e465.

iu tr triu chng au cch hi

Cilostazol Cilostazol (100 mg ung ngy 2 ln) c ch nh nh l mt thuc hiu qu ci thin triu chng v gia tng khong cch i li bnh nhn BMNB v au cch hi ( cc bnh nhn khng suy tim) (Level of Evidence: A). Pentoxifyline Pentoxifyline (400 mg 3 ln mt ngy) c th xem xt nh mt liu php thay th th 2 cho cilostazol ci thin khong cch i li nhng bnh nhn au cch hi (Level of Evidence: A). Khng c bng chng cho cc thuc sau L-arginine, propionyl-L-carnitine, gingko biloba, Hirsch AT, et al. Circulation. 2006;113:e463e465. prostaglandins, vitamin E

iu tr ti thng: can thip mch mu v phu thut mch mu

Theo AHA/ACC v TASC II, ti thng c xut cho nhng trng hp sau: Cn can thip sm vi nhng BN c thiu mu e da chi nh au khi ngh, lot chn do thiu mu, hoi th. BN khng p ng vi tr liu phc hi chc nng gng sc v thuc. BN b gii hn hot ng bi au khp khing cch hi. La chn ti thng bng can thip ni mch hoc phu thut ph thuc vo tui, bnh km, dng tn thng (theo phn loi tn thng TASC).

iu tr ti thng: can thip mch mu v phu thut mch mu

Phu thut thng t ra nhng ngi c gii phu ng mch chi m d t c kt qu lu di v nguy c tim mch thp i vi phu thut. Ni chung, ngi ta u nht tr rng can thip ni mch nn l iu tr chn la cho phn loi tn thng A, B ca TASC v phu thut mch mu l chn la cho phn loi tn thng C, D ca TASC.

Cm n s theo di ca qu ng nghip!