B Y T TRNG I HC DC H NI TH THU H TN TI KHA LUN TT NGHIP DC S H NI - 2014 B Y T TRNG I HC DC H NI TH THU H KHO ST TNH HNH S DNG THUC IU TR SUY TIM TI BNH VIN HU NGH KHA LUN TT NGHIP DC S H NI - 2014 LI CM N TixinbytlngbitnsusctingiThylTS.HongThMinh Hin Trng khoa Dc bnh vin Hu Ngh v Ths. ng Th Xun Phng GingvinbmnDcLmSng,TrngihcDcHNitntnh hng dn, ch bo v ng vin ti trong sut qu trnh hc tp v thc hin kha lun tt nghip Dc s ny. Ti xin chn thnh cm n cc thy c b mn Dc Lm Sng Trng i hcDcHNichias,htrnhittnh,aranhnglikhuynqubu cng nh ng vin ti v tinh thn trong sut qu trnh hc tp v thc hin kha lun ny. Ti cng xin gi li cm n n ton th cc cn b, nhn vin khoaDcv phngKhochTnghpBnhvinHuNghngh,toiukinv gip ti trong qu trnh thc hin ti. Xin gi li cm n ti Ban gim hiu Trng i hc Dc H Ni to iukinthunlitihonthnhqutrnhhctpcngnhkhaluntt nghip ny. Cuicng,lunvncatiskhngthhonthnhnuthiusngvin, gip ca gia nh,bn b ti.c bit, timun byt lng knhyu susc n gia nh ti, nhng ngi lun bn ng vin, chm sc v gip ti vt qua nhng lc kh khn nht trong sut qu trnh hc tp, lm vic cng nh trong cuc sng. Ti xin chn thnh cm n! H Ni, ngy 14 thng 05 nm 2014 Sinh vin MC LC T VN ............................................................................................... 1 CHNG 1. TNG QUAN ....................................................................... 3 1.1.TNG QUAN V BNH SUY TIM .......................................................... 3 1.1.1.nh ngha suy tim ...................................................................................... 3 1.1.2.Dch t suy tim .............................................................................................. 3 1.1.3.Phn loi suy tim ......................................................................................... 3 1.1.4.Phn loi mc suy tim .......................................................................... 4 1.1.4.1.Phn loi mc suy tim theo triu chng c nng ca Hi tim New York (NYHA 2011) .................................................................................. 4 1.1.4.2.Phn theo giai on tin trin ca bnh ca Hip hi tim mch M ACCF/AHA 2013 ............................................................................ 5 1.2.TNG QUAN V MC TIU V CHIN LC IU TR SUY TIM6 1.2.1.Mc tiu iu tr suy tim ............................................................................ 6 1.2.2.Chin lc iu tr suy tim ........................................................................ 6 1.2.2.1.Chin lc iu tr suy tim mn ..................................................... 6 1.2.2.2.Chin lc iu tr suy tim cp ..................................................... 11 1.3.TNG QUAN V CC THUC C S DNG TRONG IU TR SUY TIM ...................................................................................................... 12 1.3.1.Cc thuc c s dng trong iu tr suy tim mn ......................... 12 1.3.1.1.Thuc c ch men chuyn (UCMC) ............................................ 13 1.3.1.2.Thuc chn AT1 ............................................................................ 14 1.3.1.3.Thuc chn beta giao cm............................................................ 14 1.3.1.5.Thuc khng aldosteron. .............................................................. 15 1.3.1.5.Thuc li tiu. ............................................................................... 15 1.3.1.6.Thuc digitalis ............................................................................... 17 1.3.1.7.Thuc nitrat v hydralazin ........................................................... 17 1.3.1.8.Thuc ivabradin ............................................................................ 18 1.3.2.Cc thuc iu tr suy tim nhp vin .................................................... 18 1.3.2.1.Duy tr cc thuc c s dng thng quy ............................... 18 1.3.2.2.Thuc li tiu ................................................................................ 19 1.3.2.3.Thuc gin mch dng ngoi ng tiu ha ............................ 19 1.3.2.4.Thuc hng c tim dng tnh .................................................. 19 1.3.2.5.Thuc phng huyt khi tnh mch ............................................. 20 1.3.2.6.Thuc i khng arginine vasopressin ........................................ 20 1.3.2.7.Thuc opiat .................................................................................... 21 CHNG 2: I TNG V PHNG PHP NGHIN CU ..... 22 2.1.I TNG NGHIN CU .................................................................. 22 2.1.1.Tiu chun la chn .................................................................................. 22 2.1.2.Tiu chun loi tr .................................................................................... 22 2.2.PHNG PHP NGHIN CU ............................................................ 22 2.2.1.Thit k nghin cu................................................................................... 22 2.2.2.Cch ly mu ................................................................................................ 22 2.3.NI DUNG NGHIN CU ...................................................................... 23 2.3.1.Kho st c im ca bnh nhn trong mu nghin cu ............... 23 2.3.1.1.Cc tiu ch m t c im nhn khu hc ca bnh nhn ...... 23 2.3.1.2.Cc tiu ch m t c im bnh l ca bnh nhn ................... 23 2.3.2.c im s dng thuc iu tr suy tim ............................................. 23 2.3.2.1.Phn bthuc iu tr suy tim s dng trong qu trnh iu tr ... ........................................................................................................ 23 2.3.2.2.c im cc phc iu tr suy tim. ......................................... 23 2.3.2.3.c im s dng ca mt s nhm thuc c bit trong iu tr suy tim........................................................................................................ 24 2.4.MT S NH NGHA V TIU CHUN C S DNG TRONG NGHIN CU ..................................................................................... 24 2.4.1.Cc nh ngha ........................................................................................... 24 2.4.2.Mt s phng php nh gi p dng trong nghin cu ............... 25 2.4.2.1.nh gi chc nng thn ............................................................. 25 2.4.2.2.nh gi im CHA2DS2-VASc trn bnh nhn suy tim km rung nh ........................................................................................................ 25 2.5.X L S LIU ....................................................................................... 26 CHNG 3 : KT QU V BN LUN .............................................. 27 3.1.C IM CA BNH NHN KHI NHP VIN .............................. 27 3.1.1.c im chung ca bnh nhn ............................................................. 27 3.1.2.c im bnh l trn bnh nhn .......................................................... 27 3.1.2.1.L do vo vin ................................................................................ 27 3.1.2.2.c im bnh l mc km........................................................... 28 3.1.2.3.c im chc nng thn ............................................................. 30 3.1.2.4.Cc c im lm sng lin quan n suy tim............................. 30 3.2.THUC S DNG TRN BNH NHN .............................................. 32 3.2.1.c im s dng thuc iu tr suy tim trong tonqu trnh iu tr ....................................................................................................................... 32 3.2.1.1.S lng thuc iu tr suy tim s dng trn bnh nhn ........... 32 3.2.1.2.Phn b cc thuc iu tr suy tim s dng trn bnh nhn ...... 33 3.2.2.c im cc phc iu tr suy tim .................................................. 36 3.2.2.1.c im phc u tin khi nhp vin .................................... 36 3.2.2.2.c im phc ngy cui cng trc khi ra vin ................... 37 3.2.3.c im s dng mt s nhm thuc c bit trong iu tr suy tim ....................................................................................................................... 41 3.2.3.1.c im s dng nhm thuc chng ng v chng kt tp tiu cung ung trn bnh nhn rung nh ................................................. 41 3.2.3.2.c im s dng cc nhm thuc khng c khuyn co hoc c th gy hi theo ESC 2012 v ACCF/AHA 2013 .................................... 41 3.3.BN LUN ......................................................................................... 43 3.3.1.c im ca bnh nhn khi nhp vin ............................................... 43 3.3.1.1.c im chung ca bnh nhn ................................................... 43 3.3.1.2.c im bnh l trn bnh nhn ................................................ 44 3.3.2.Bn lun v thuc iu tr suy tim ......................................................... 48 3.3.2.1.Bn lun thuc iu tr suy tim mn ............................................ 48 3.3.2.2.Bn lun thuc iu tr suy tim cp ............................................. 51 3.3.2.3.Bn lun v phc dng thuc .................................................. 51 KT LUN V XUT ....................................................................... 56 TI LIU THAM KHO PH LC Ph lc 1: Khuyn co iu tr bng thuc cho bnh nhn suy tim cp theo ESC 2012. Ph lc 2: Khuyn co iu tr suy tim nhp vin theo ACCF/AHA 2013. Ph lc 3: Chin lc iu tr ph phi cp/ sung huyt theo ESC 2012. Ph lc 4: Phiu kho st suy tim. Ph lc 5: Phn b phc ngy u ca ton mu nghin cu. Ph lc 6: Phn b phc ngy cui ca ton mu nghin cu. Ph lc 7: Danh sch bnh nhn trong mu nghin cu. DANH MC CC K HIU, CC CH VIT TT Tn vit ttTn y ACCF/AHA Trng mn tim Hoa K - Hi tim hc Hoa K (American College of Cardiology Foundation/American Heart Association) ESC Hi tim mch hc Chu u (European Society of Cardiology) EF Phn s tng mu (Ection fraction) LVEF Phn s tng mu tht tri (Left ventricular ejection fraction) NYHA Hi tim New York (New York Heart Association) HFrEF Suy tim gim phn s tng mu (Heart failure with reduced ejection fraction) HFpEF Suy tim bo tn phn s tng mu (Heart failure with preserved ejection fraction) CRT-D Phc ti ng b ha tim - kh rung (Cardiac resynchronization therapy-defibrillator) CRT-P Phc ti ng b ha tim - my iu ha nhp tim (Cardiac resynchronization therapy-pacemaker) ICD Cy my kh rung tim (Implantable cardioverter-defibrillator) LVAD Thit b h tr tht tri (Left ventricular assist device) COPD Bnh phi tc nghn mn tnh (Chronic obstructive pulmonary disease) Clcr H s thanh thi Creatinin (Creatinin clearance) CHA2DS2-VASc Suy tim, tng huyt p, tui 75(gp i), i tho ng, t qu (gp i)- bnh mch vnh, tui 65-74 v gii tnh (n) Cardiac failure, Hypertension, Age 75 (Doubled), Diabetes, Stroke (Doubled)-Vascular disease, Age 65 74 and Sex category (Female) THATng huyt p HHAH huyt p UCMCc ch men chuyn CCChng ch nh HAHuyt p Ti tho ng NMCTNhi mu c tim DANH MC CC BNG Bng 1.1. Phn suy tim theo triu chng c nng (NYHA 2011) .................................... 5 Bng 1.2. Phn suy tim theo giai on tin trin .............................................................. 5 Bng 1.3. So snh phn theo NYHA v theo giai on tin trin bnh ............................ 6 Bng 3.1. c im chung ca bnh nhn ........................................................................... 27 Bng 3.2. L do vo vin ..................................................................................................... 28 Bng 3.3. Cc bnh l mc km .......................................................................................... 29 Bng 3.4. c im chc nng thn .................................................................................... 30 Bng 3.5. Mt s c im cn lm sng ............................................................................ 31 Bng 3.6. S lng thuc iu tr suy tim s dng trn bnh nhn trong thi gian nm vin ............................................................................................................................................. 33 Bng 3.7. Cc nhm thuc iu tr suy tim mn s dng trn bnh nhn ........................... 34 Bng 3.8. Cc thuc iu tr suy tim nhp vin trn bnh nhn .......................................... 35 Bng 3.9. Phn b loi phc u trn ton mu nghin cu ........................................... 36 Bng 3.10. Phc u ph bin ca ton mu nghin cu ............................................... 37 Bng 3.11. Phn b loi phc cui trn ton mu nghin cu ........................................ 38 Bng 3.12. Cc phc cui ph bin ca ton mu nghin cu ....................................... 39 Bng 3.13. So snh c im s dng ca mt s thuc trong phc ngy u v ngy cui ca ton mu nghin cu ............................................................................................. 40 Bng 3.14. S dng thuc chng ng v chng kt tp tiu cu trn bnh nhn suy tim rung nh trong thi gian nm vin ........................................................................................ 41 Bng 3.15. Thuc c th gy hi trn bnh nhn suy tim theo ESC 2012 v ACCF/AHA 2013 ..................................................................................................................................... 42 DANH MC CC HNH V, TH Hnh 1.1. Chin lc iu tr suy tim gim phn s tng mu ca ESC 2012 ...................... 8 Hnh 1.2. Cc giai on iu tr theo khuyn co ca Hi tim mch M 2013 ................... 10 Hnh 1.3. Chin lc iu tr suy tim gim phn s tng mu giai on C theo ACCF/AHA 2013 ..................................................................................................................................... 11 Hnh 1.4. Cc nhm thuc iu tr suy tim v mi lin quan vi c ch bnh sinh ............ 13 1 T VN Suy tim ang ngy cng tr thnh mt vn ln ca nhn loi, l mi quan tm ca tt c cc quc gia do s ngi suy tim ngy cng tng ln cng vi nhng gnh nng khng nh v chi ph iu tr. Khng nhng th, suy tim cn lm gim ng k cht lng cuc sng ngi bnh v l mt trong nhng nguyn nhn t vong hng u, khong 7% tng t vong do nguyn nhn tim mch l do suy tim [14]. Suy tim l mt hi chng phc tp, l hu qu ca nhiu bnh l khc nhau nh bnhvantim,ctim,mngngoitim,lonnhptim,tnghuytp,bnhng mch vnh Nguyn nhn gy rasuy tim ti cc nc pht trin l do bnh ng mch vnh, bnh tng huyt p, bnh c tim gin n v mt s bnh tim khc. Ti Vit Nam, do tn sut bnh van tim do thp cn cao, s phn phi nguyn nhn suy timcthkhc,tuynhinccnguynnhnchnhcasuytimvnlbnhtng huyt p, bnh ng mch vnh, bnh van tim do thp, bnh c tim.. Ngoi tr mt s bnh nhn van tim c iu tr ngoi khoa sm, cc bnh nhn cn li u cn iu tr suy tim lu di. Do , yu t hiu qu v tn km chi ph iu tr ng mt vai tr quan trng [6]. Nm2012,HiTimhcChuu(EuropeanSocietyofCardiology-ESC)v nm2013,TrnghitimHoaKvHitimhcHoaK(AmericanCollegeof CardiologyFoundationandAmericanHeartAssociation-ACCF/AHA)ara nhngkhuyncominhttrongiutrsuytim,cbitlvnqunlsuy timcp(suytimnhpvintrongACCF/AHA2013).Viccpnhtnhnghng dn iu tr mi nht l mt vn quan trng trong iu tr suy tim. Hinnay,mtsqucgiatrnthgiitinhnhrtnhiuccnghincu dchttrnquymlnvcimbnhnhnsuytimvccbinphpqunl bnh nhn khi nhp vin. Nhng s liu ny gp phn vo vic iu tr v qun l bnh nhn tt hn. Tuy nhin nc ta, cc nghin cu ny hin cn rt hn ch,BnhvinHuNgh,mttrongnhngbnhvintuynTrungngci tngphcvchyulcccnblntuivhu,ctl bnhnhnnhp vindosuytimhngnmkhcaovitnhtrngbnhtnginng.Viccung 2 cp cc s liu v c im bnh nhn cng nh cch thc iu tr suy tim hin nay ti bnh vin ny l ht sc cn thit. Tnhngnhucuthctktrn,tinghincu:Khosttnhhnhs dng thuc iu tr suy tim ti bnh vin Hu Ngh c thc hin vi cc mc tiu sau: -M t c im lm sng ca bnh nhn suy tim nhp vin ti bnh vin Hu Ngh-M t thc trngs dng thuc iu tr suy tim trn bnh nhn suy tim nhp vin ti bnh vin Hu Ngh. 3 CHNG 1. TNG QUAN 1.1.TNG QUAN V BNH SUY TIM 1.1.1.nh ngha suy tim Suy tim l mt hi chng lm sng phc tp, l hu qu ca tn thng thc th hay ri lon chc nng qu tim, dn n tm tht khng kh nng tip nhn mu (suy tim tm trng) hoc tng mu (suy tim tm thu) [6]. 1.1.2.Dch t suy tim TheotrngmntimHoaK-HitimhcHoaK(AmericanCollegeof CardiologyFoundationandAmericanHeartAssociation-ACCF/AHA)2013,ti M, nguy c pht trin suy tim l20% vingi M t 40 tui tr ln. T lmi mc suytimduy trn nh quamt vi thp k, vi trn 650000 trng hpmc suy tim mi hng nm. Suy tim ph bin nht bnh nhn trn 65 tui v t l mc mi suy tim tng ln theo tui, tng t khong 20/1000 ngi t 65 n 69 tui ln n80/1000ngitrn85tui.Mcdtlsngxtccithin,tlt vong do suy tim vn duy tr khong 50% trong vng 5 nm. Suy tim cng l nguyn nhn chnh ca hn mt triu ca nhp vin mi nm. Tng chi ph dnh cho suy tim M vt qu 40 triu la M, cng vi hn mt na trong s dnh cho bnh nhn nhp vin [14]. NhngconscngcHitimmchhcChuu(Europeansocietyof cardiologyESC)aranm2012.Khong1-2%caqunthngilncc nc pht trin b mc suy tim, vi t l hin hnh tng ln 10% nhng ngi 70 tui [24]. Ti Vit Nam, cha c cc con s thng k chnh xc v c th v nguy c mc bnh cng nh iu tr bnh suy tim.1.1.3.Phn loi suy timC nhiu cch phn loi suy tim, da trn cc c s sau : -Theo hnh thi nh khu: suy tim phi, suy tim tri v suy tim ton b[2].-Theo tnh trng tin trin: suy tim cp v suy tim mn [24]. 4 + Suy tim mn: l tnh trng suy tim n nh nu cc du hiu v triu chng casuytimkhngthayitrongtnhtmtthnghoctnhtrngikhibnh nhn xut hin cc triu chng suy tim. +Suytimcp:ltnhtrngnnhcabnhnhnbphv,bnhnhn chuyn sang tnh trng mt b, cc triu chng t ngt v yu cu phi nhp vin -Theo lu lng tim: suy tim gim lu lng v suy tim tng lu lng [12]. -Theo phn s tng mu:+Suytimtmthu(suytimgimphnstngmuviphnstngmu (ejection fraction- EF) 40%). + Suy tim tm trng (suy tim bo tn phn s tng mu vi EF 50%). Suy tim bo tn phn s tng mu mc gii hn: 41% EF 49%. Suy tim bo tn phn s tng mu c ci thin: EF>50% [14]. 1.1.4.Phn loi mc suy tim 1.1.4.1.Phn loi mc suy tim theo triu chngcnngca Hi tim New York (NYHA 2011) Phn chc nng tim theo hi tim New York (New York Heart Assossiation-NYHA)csdngtlu,davotriuchngcnngvkhnnggngsc (bng 1.1).u im ca phn loi mc suy tim theo NYHA: -n gin v tin dng nn c chp nhn v s dng ph bin nht Nhc im ca phn loi mc suy tim theo NYHA: -Ch quan. -i khi khng phn nh c mc nng ln ca bnh do cc tn thng hoc ri lon trn tim thng c xu hng xu i theo thi gian, nhng khng phi lc no cng c nhng biu hin tng ng vi triu chng c nng. 5 Bng 1.1. Phn suy tim theo triu chng c nng (NYHA 2011) Mc Triu chng I Khngctriuchng.Hotngthlcbnhthng,khnggyra kh th,mt hoc timp nhanh. Khng c triu chng ca ri lon chc nng tht tri. II Hnchvnngthlc.Bnhnhnkhekhinghngi.Vnng thlcthngthngdnnmt,hihp,khthhocaungc (suy tim nh) III Hnchnhiuvnngthlc.Mcdbnhnhnkhekhingh ngi,nhngchvnngnhctriuchngcnng(suytim trung bnh) IV Khngthhotngthlc.Cctriuchngxuthinngayckhi ngh ngi (suy tim nng) 1.1.4.2. Phn theo giai on tin trin ca bnh ca Hip hi tim mch M ACCF/AHA 2013Suy tim l mt hi chng ca nhiu bnh l khc nhau, c th tin trin khng ngng.Qutrnhtintrincabnhsuytimkhnghontontngngvibiu hin triu chng c nng trn lm sng, nhng li l c s quan trng quyt nh phc iu tr. Do , t nm 2001 n nay,ACCF/AHAphn suytim ranhiu giaion:A,B,C,D(bng1.2)ikmvinhgiiutrtheotnggiaion (hnh1.1)[14].Hinnay,nhiukhuynco,trongckhuyncocaHitim mch Vit Nam nm 2008[6], khi mun phn suy tim theo giai on tin trin ca bnh, thng p dng cch phn ny ca ACCF/AHA. Bng 1.2. Phn suy tim theo giai on tin trin Giai onTriu chng AC nguy c suy tim cao nhng khng c triu chng suy tim BC tn thng nhng cha c du hiu hoc triu chng suy tim CC tn thng cu trc tim, hoc ang c triu chng suy tim DSuy tim khng tr 6 Bng 1.3. So snh phn theo NYHA v theo giai on tin trin bnh Giai on bnhPhn NYHA Giai on AKhng cp Giai on BNYHA I Giai on C NYHA I NYHA II NYHA III NYHA IV Giai on DNYHA IV Phn suytim ca ACCF/AHA bao gm c giai on khibnh nhn cha b suy tim thc s (giai on A) v bnh nhn cha c cc triu chng c nng (giai onB).PhnsuytimcaNYHApdngtrnbnhnhnsuytimthcs, tng ng vi giai on C trong phn theo tin trin bnh. Giai on D - suy tim khng tr trong ACCF/AHA tng ng vi NYHA IV. 1.2.TNG QUAN V MC TIU V CHIN LC IU TR SUY TIM 1.2.1.Mc tiu iu tr suy tim -Mc tiu iu tr suy tim mn: ci thin cht lng cuc sng, lm mt hoc gim triu chng, phng hoc lm ti thiu t l nhp vin do suy tim, chm s pht trin ca bnh, v ko di s sng [14, 24]. -Mc tiu iu tr suy tim cp: lm mt cc triu chng ng thi ti u ha tnh trng dch v lu lng tim bnh nhn c th s dng n nh phc thuc ngung.Mtmctiuquantrngkhcltithiunhngnguyclinquan n vic s dng cc thuc iu tr tnh trng cp nh ri lon chc nng thn, au c tim, ri lon in gii, h huyt p v ri lon nhp [14]. 1.2.2. Chin lc iu tr suy tim 1.2.2.1.Chin lc iu tr suy tim mn Hai hng dn iu tr mi nht ca Trng mn tim Hoa K/Hip hi tim Hoa K ACCF/AHA 2013 v Hi tim Chu u ESC 2012 u a ra chin lc iu tr 7 suytimmntnh.Cchtipcnchinlciutrsuytimcahaitiliuccc nt tng ng nht nh, tuy nhin c mt vi im khc bit.ACCF/AHA 2013 a ra chin lc iu tr suy tim cn c vo 4 giai on bnh, kim sot bnh ngay t khi bnh nhn ch c nguy c mc bnh (giai on A), cha c triu chng c nng ca bnh suy tim (giai on B), cc giai on khc nhau i hi iu tr khc nhau. ACCF/AHA cn a ra cc chng trnh qun l ton din bnh nhn nh gio dc bnh nhn bin php khng dng thuc, bin php theo di bnh nhn v chm sc gim nh.-ESC 2012 a ra hng iu tr suy tim mn cho nhng bnh nhn suy tim thc s, c nhng triu chng c nng ca suy tim (tng ng vi giai on C ca ACCF/AHA 2013) Trongchinlciutrsuytimmnctriuchngcnng,c2hng dn iu tr u cn c vo loi suy tim a ra khuyn co (suy tim tm thu suy tim gim phn s tng mu HFrEF v suy tim tm trng suy tim bo tn phn s tng mu HFpEF). Chin lc iu tr suy tim mn ca ESC 2012 Chin lc iu tr suy tim gim phn s tng mu (HFrEF) 8 Hnh 1.1. Chin lc iu tr suy tim gim phn s tng mu ca ESC 2012 Ch thch: CRT-D: ti ng b ha tim - khrung. CRT-P: phc ti ng b ha tim - my iu ha nhp tim. ICD: cy my kh rung tim. LVAD: thit b h tr tht tri. 9 Chin lc iu tr suy tim bo tn phn s tng mu (HFpEF) Theo ESC, khng c iu tr no gip gim trnh trng bnh v t l t vong trn bnh nhn suytim bo tn phn s tngmu. Li tiu c s dng kim sot mui v nc, gip gim kh th v ph n. iu tr y THA v nhi mu c tim gip kim sot nhp tht trn bnh nhn rung nh l quan trng. Chnknhcalcicthhiuqukimsotnhpthttrnnhngbnhnhn rungnhvTHA,nhimuctim(trongkhisdngchnknhcalcitrnbnh nhn suy tim gim phn s tng mu c th c hi). Chn beta c th c s dng kimsotnhpthttrnbnhnhnsuytimbotnphnstngmuvrung nh. Cc thuc nn c trnh trn suy tim gim phn s tng mu cng nn c trnh trn suy tim bo tn phn s tng mu, tr chn knh calci [24]. Chin lc iu tr suy tim mn ca ACCF/AHA 2013 Nh trnh by trn, chin lc iu tr suy tim mn ca ACCF/AHA l mt chinlctondintngngvi4giaionphttrinbnhsuytim(hnh1.2) 10 Suy tim tm trng Hnh 1.2. Cc giai on iu tr theo khuyn co ca Hi tim mch M 2013 Suy tim tm trngSuy tim tm thu 11 Tng ng vi chin lc iu tr suy tim mn ca ESC 2012, ACCF/AHA 2013 cng a ra chin lc iu tr trn bnh nhn suy tim giai on C. Tng t ESC 2012, ACCF/AHA cng phn ra chin lc iu tr cho suy tim gim phn s tng mu v suy tim bo tn phn s tng mu. Chinlciutrchosuytimgimphnstngmu(suytimtm thu) giai on C Chin lc iu tr cho suy tim bo tn phn s tng mu (suy tim tm trng) giai on C Chin lc iu tr suy tim bo tn phn s tng mu ca ACCF/AHA 2013 tng t vi chin lc iu tr ca ESC 2012. S dng li tiu v qun l ttccbnhmckmnhTHA,bnhmchvnh,rungnhlccnhng iu tr quan trng nht vi bnh nhn suy tim bo tn phn s tng mu.1.2.2.2. Chin lc iu tr suy tim cpHnh 1.3. Chin lc iu tr suy tim gim phn s tng mu giai on C theo ACCF/AHA 2013 12 ESCaracckhuyncoiutrsuytimcpchotngtnhtrngcabnh nhn: bnh nhn huyt/ph phi khng c sc; h huyt p, gim ti mu v sc; bnhnhnctriuchngmchvnhcp;bnhnhncrungnhvnhptht nhanh; bnh nhn c chm nhp tim nghim trng hoc block tim (Ph lc 1).ACCF/AHA2013khngaracckhuyncotheocctngtnhtrngcpca bnhnhn nh ESC 2012 m ch a cc cc khuyn co qun l tnh trng qu ti dch trn bnh nhn (ph lc 2). Nh vy, chin lc iu tr suy tim nhp vin caACCF/AHA2013tngngvichinlciutrtnhtrnghuyt/ph phi ca ESC 2012 (ph lc 3). Khi so snh hai chin lc thuc iu tr tnh trng qu ti dch ca hai hng dn iu tr ta thy hai chin lc c nhng im tng ng v khc bit ring.Ging nhau: -Cc thuc quan trng trong qun l suy tim l li tiu v gin mch.Khc nhau: -ESC a ra chin lc iu tr da trn tnh trng bnh v p ng ca bnh nhn.Bncnhnhngiutrquantrngnhthoxy,litiuvccthucgin mch; opiat v thuc hng c tim cs dngmt cch c lachn hn.ESC khuyncobnhnhntiptcsdngccthucnnsaukhibnhnhnttnh trng n nh. -ACCF/AHA khuyn co bnh nhn khi nhp vin tip tc s dng cc thuc iu tr suy tim theo hng dn iu tr ang s dng trn bnh nhn, chi tit cch s dng li tiu trong qun l qu ti dch v xem xt vasopressin trong trng hp h natri mu nghim trng do qu ti dch.1.3.TNG QUAN V CC THUC C S DNG TRONG IU TR SUY TIM 1.3.1. Cc thuc c s dng trong iu tr suy tim mn Suy tim l mt hi chng lm sng phc tp, l hu qu ca tn thng thc th hayri lonchc nng tim dn n suy gim kh nng ca tm tht. Khi tm tht suy gim chc nng s c mt s phn ng b tr c tim v ngoi bin nhm duy 13 tr cung lng tim. Tuy nhin, lu ngy, chng li lm tng tin gnh, hu gnh, to thnh vng xon bnh l v lm suy tim nng hn. Chnh v vy, cc thuc iu trsuytimcsdngnhmtcngvoccchkhcnhaucavngxon bnh l ny. Hnh 1.4miu t mi lin quan ca cc thuc iu tr vi c ch bnh sinh ca suy tim [7]. Hnh 1.4. Cc nhm thuc iu tr suy tim v mi lin quan vi c ch bnh sinh 1.3.1.1. Thuc c ch men chuyn (UCMC) C ch tc dng- Menchuyncnhiutronghuyttngvccmkhc,cbitthnh mch,tim,thn,tuynthngthn,no.Menchuynxctcchoqutrnhto AngiotensinIIvginghabradykinin.Do,khidngthucUCMC, Angiotensin II khng c hnh thnh v bradykinin b ngn cn ging ha dn n ginmch,tngthiNa+lmhhuytp.CcthucUCMCgimplcy thtvgimsccnmchngoivi(gimctingnhvhugnh),dogim Hu gnh 14 gnhnngchotim,giatngcunglngtimmkhnglmthayitnstim. Ngoi ra, chng cn gim ph i thnh mch, tng tnh n hi ca ng mch, ci thin chc nng nimc v gim ph i vx ha tht tri, vch lin tht [6, 10, 14, 44]. Cc khuyn co. UCMClnhmthuccbnhngutrongiutrsuytim,csdng ngay c khi cha c cc triu chng c nng ca suy tim. Trn tt c bnh nhn suy tim gim phn s tng mu giai on B,C. Bnh nhn suy tim bo tn phn s tng mugiaionCbTHA,UCMCnncsdngphngsuytimctriu chng v gim t l t vong [6, 14, 24]. 1.3.1.2. Thuc chn AT1 C ch tc dng Tc dng ca Angiotensin II (AII) hu ht thng qua receptor AT1. Thuc c ch receptorAT1lmmttcdngcaAngiotensinII.ThucchnAT1ctcdng tng t nh thuc UCMC nhng c hai u im hn: khng gy ho, tc ng hon ton hn trn Angiotensin II (s dng UCMC khng ngn chn hon ton s to lp Angiotensin II) [6, 10, 31]. Cc khuyn co -Thuc chn AT1 c khuyn co trn bnh nhn suy tim gim phn s tng muctinsnhimuctimhocanghoctngctriuchngvkhng dung np vi UCMC hoc thay th cho UCMC, tr khi c chng ch nh, gim tnh trng bnh v t l t vong. Chn AT1 c th c cn nhc thm votrn bnh nhn suy tim gim phn s tng mu c triu chng dai dng mc d c iu tr bng UCMC v chn beta v khng c dng aldosteron hoc cn nhc s dng trn bnh nhn suy tim gim bo tn phn s tng mu kim sot huyt p v gim t l nhp vin[6, 7]. 1.3.1.3. Thuc chn beta giao cm C ch tc dng 15 Ccthucchnbetagiaocmngnchnhotngthiqucahthnkinh giaocmtrongsuytimmntnh,lmbnhthnghachcnngcaknhgii phngcalci,lmgimnhptim,bovtimkhichcnnggyccca catecholamine, chng nhp nhanh, chng li s cht t bo theo chng trnh v c ch h Renin-Angiotensin [1, 2, 8, 10, 31]. Cc khuyn co Cc thuc c s dng:metoprolol succinat, bisoprolol, carvedilol, nebivolol. Tt c bnh nhn suy tim mn v gim chc nng tht tri (EF 40%) nn c cn nhc s dngchn beta. Vi bnh nhn suy tim giai on C bo tn phn s tng mu b THA, chn beta nn c s dng. Bnh nhn nn c s dng chn beta sm, c th s dng kt hp cng vi UCMC ngay khi bt u iu tr suy tim [6, 14, 24]. 1.3.1.4.Thuc khng aldosteron C ch tc dng Aldosterongygimuivnc,hotngcahthnkinhgiaocmvc ch hot ng ca h thn kinh ph giao cm, t gy ra nhng nh hng bt li cho bnh nhn suy tim. Bn cnh , do c ch t b tr ca c th, trong suy tim thng xut hin hin tng cng aldosteron th pht. Do c cng thc tng t aldosteronnnthuctranhchpvialdosterontireceptornglnxa,vvy, thuc khng li cc tc dng trn ca aldosteron [8, 10, 29]. Cc khuyn co C 2 thuc c s dng: spironolacton v eplerenon. Thuc c khuyn co sdngchobnhnhnsuytimgimphnstngmu(35%),suytimttrung bnhnnng(NYHAII-IV);bnhnhntngbnhimuctimcpvc LVEF 40% c triu chng suy tim hoc T; v iu tr vi chn beta v c chmenchuyn(hocchnAT1).Chnnkkhngaldosterontrnnhngbnh nhnccreatinine25mg/dLtrnnam,hoc20trnn(hocnhgimclc cu thn >30ml/pht/173m2) v kali 140mmHg.iunychothybnh 47 nhn c kim sot huyt p kh tt do bnh nhn nhp vin Hu Ngh l cn b nhncnghhu,cchbohimytnnciukincquantm, chmscsckhe.Huytptmthulmttrongnhngyuttinlngbnh suytim[33].Mtnghincuhicuvtinlngtltvongtrongccnhm bnh nhn nhp vin do suy tim ch ra rng: t l t vong gim c ngha thng k cmi10mmHgtnglncahuytptmthu(tinlngnbinOR=0,85; 95% CI: 0,81- 0,88; P