ca lm sng - ngua...ca lm sng bệnh nhn nữ 71 ... 4/ siu m tim: hẹp 2 l, hẹp hở chủ...

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  • Ca lm sng

    Bnh nhn n 71 tui nhp vin v hn mKhong 2 gi sng cng ngy nhp vin bnh nhn t vo nh v sinh i tiu n khong 3 gi ngi nh thy bnh nhn nm nga trong nh v sinh lay gi khng tr li bnh nhn ngay lp tc c a n nhp bnh vin

  • Khm bnh

    Lc nhp vin M: 84l/p, HA: 120/70mmHg, T: 370C NT: 20 l/pBnh hn m Glasgow 7 im (E1,M5,V1).ng t 2 bn trn u, kt #4 mm, PXAS yu

    - Lit ngi tri > phi (na ngi (P) 4/5, chn (T):2/5, tay(T):1/5- PXGC (2+)/t chi- Babinski (+) 2 bn

  • Tin s

    1. Tng huyt p 10 nm (lc cao nht 180mmHg) ung thuc u hng ngy (sng 1 vin amlodipine 5mg) o huyt p hng ngy n

  • Cn lm sng

    1/ CTM: - HC 4.85 T/L (Hb 135,1 g/l; Hct 43,8%)- BC 10.23 g/l (N: 86,8%; Lym: 6,1% Mono: 5,3% ; Eos: 1,44%- PLT: 335 g/l

    2/ Sinh ha: H: 140mg%, ALT: 13U/L, AST: 34U/L, Ure:3,82mmol/L, creatinin:73.5 mmol/l, Ion : Na: 140, K: 3.77, Cl: 102, Ca: 1.19 mmol/L

    3/ ECG: rung nh p ng tht 80l/p

    4/ siu m tim: hp 2 l, hp h ch nh, tng p MP5/ siu m mch mu: X va hnh cnh 2 bn

  • MRI

    Nhi mu no cp tnh a trn v di lu thuc

    vng cung cp tun hon sau:

    - nhi mu din rng tiu no tri, cu, cung no,

    i th 2 bn(p>t)

    - nhi mu c nh nh tri v bao ngoi thy o

    tri

    - MRA tc M cnh trong phi v M no sau 2 bn

  • Chn on xc nh

    Hn m do nhi mu no tun hon sau / rung nh

  • Cu hi

    1. nh gi t qu v nguy c chy mu BN rung nh ?

    2. iu tr ph hp khng ng BN t qu do rung nh

  • iu tr v phng nga t qu do rung nh

    PGS.TS Cao Phi Phong

  • 1. Rung nh l yu t nguy c c lp t qu,

    cao hn gp 5-6 ln

    2. T l hin mc (Prevalence) gp i trong 50

    nm ti

    3. ch li phng nga huyt khi c chng

    minh trong nhiu nghin cu ngu nhin

  • Nhp xoang bnh

    thng (sinus

    rhythm)

    Atrial fibrillation

    ECG

  • Cn

    (Paroxysmal)

    Self-Terminating

    Ko di

    (Persistent)

    Lasts > 7 Days

    Thng

    trc

    (Permanent)

    Cardioversion

    Failed or Not

    Attempted

    Normal Sinus Rhythm

    Atrial Fibrillation

    Phn loi rung nh

    Cn AF c th gy t qu nh AF ko di hay thng trc

  • Nguy c rung nh

    Magnani JW et al. Circulation 2011; 124: 1982-1993

  • Age, years

    Pre

    vale

    nce

    , perc

    ent

    Lin h gia rung nh v tui

    Go AS, et al. JAMA. 2001; 285:2370-2375.

  • Chimowitz. Stroke 1993; 24: 1015Zabalgoitia. J Am Coll Cardiol 1998; 31: 1622

    Rung nh gy t quLeft Atrial Appendage(LAA) Thrombus

  • t qu v rung nh

    Wolf PA, et al. Stroke 1991; 22: 983-988

    %

    AF prevalence

    Strokes attributable to AF

    Age Range (years)

    0

    10

    20

    30

    5059 6069 7079 8089

    Framingham

    Tng gp 5 ln nguy c t qu

    Xc nh nguy c: CHADS2/ CHA2DS2-VASc

    D hu xu

    Chi ph cao

  • t qu thiu mu do rung nh nng hn

    73

    33

    58

    16

    36

    16

    30

    11

    Framingham Heart Study

    Lin HJ, et al. Stroke. 1996;27:1760-1764.

  • iu tr khng ng giai an t qu cp ?

  • Ket luan va khuyen cao AHA 2007

    (7 nm trc)

    Class III

    1. Khang ong khan cap muc tieu ngan nga ot qu tai

    phat sm, lam trieu chng than kinh giam xau hn hay

    cai thien d hau sau ot quy cap, khong khuyen cao

    ieu tr BN ot qu cap.(L.A)

    2. Khuyen cao co the thay oi neu them vao d lieu

    chng minh ch li ieu tr khang ong sm BN nhoi

    mau do huyet khoi M ln hay embolism t tim(L.A).

  • Class III

    3. Khang ong khong dung khan cap cho ot qu trung

    bnh en nang v nguy c bien chng xuat

    huyet(L.A).

    4. Dung khang ong ieu tr trong 24 gi ieu tr rt-PA

    khong c khuyen cao. (L.B)

  • Khuyn co AHA-2013

    im c bn: cc nghin cu khng cung cp

    dng khng ng trong t qu cp.

    Khng thay i: dng khng ng khn cp khng khuyn co trong t qu cp v cng khng trong iu kin khng phi mch mu no BN t qu cp t trung bnh n nng do tng nguy c xut huyt noKhng ng khng khuyn co trong 24 gi dng rt-PA

  • Mi: ch li ca argatroban v cc c ch thrombin khc trong t qu thiu mu cp cha c thit lp trong thi im guideline xut bn, cng khng ch li dng khng ng cho BN hp nng ng mch cnh cng bn thiu mu no .

  • Khuyn co AHA iu tr khng ng

  • 1. Hin nay ch li ca argatroban hay cc c ch

    thrombin khc trong iu tr bnh nhn t qu

    thiu mu cp cha xc nh(Class IIb; Level of

    Evidence B). Khuyn co dng trong nghin

    cu lm sng. (New recommendation)

  • 2. ch li dng khng ng khn cp trong bnh

    nhn t qu thiu mu c hp ng mch

    cnh trong nng cng bn thiu mu no

    cha xc nh (Class IIb; Level of Evidence

    B). (New recommendation)

  • 3. Khang ong khan cap muc tieu ngan nga

    ot qu tai phat sm, lam trieu chng than

    kinh giam xau hn hay cai thien d hau sau

    ot quy cap, khong khuyen cao ieu tr BN

    ot qu cap.(C.III; L.A)

  • 4. iu tr khng ng khn cc nguyn nhn khngphi TBMMN cho bnh nhn t qu trung bnhn nng khng khuyn co do bin chng XHN (ClassIII, Level A),khng thay i so khuyn cotrc.

  • 5. Dung khang ong ieu tr trong 24 gi ieu

    tr rt-PA khong c khuyen cao. (C.III; L.B)

  • AHA khuyn co phng nga t quy

    PHNG NGA NGUYN PHT

  • Rung nh

    1. Tm sot rung nhi (theo doi mach va ECG) bnhnhn trn 65 tui (C.IIa, L.B).

    2. iu chinh Warfarin (ich INR 2.0-3.0) cho tt c bnh nhn rung nhi khng c bnh van tim c nguy c t quy cao va nhiu trng hptrung bnh c th iu tr an ton(C.I, L.A).

  • Rung nh

    3. iu tr chng tiu cu Aspirin cho bnh nhn rung nhi nguy c thp va mt s trung bnh. (C.I, L.A).

    (u tin bnh nhn, c lng nguy c xut huytnu dng khng ng, va cht lng theo doi khngng)

  • Rung nh

    4. Bnh nhn rung nhi nguy c cao khng dngc khng ng, dng kt hp Clopidogrel va Aspirin chng t quy tt hn Aspirin n thunnhng gia tng nguy c xut huyt nng va c th hp y (C.IIb, L.B).

    5. iu tr tn cng huyt p kt hp phng ngahuyt khi bnh nhn rung nhi ln tui thi c li(C.IIa, L.B)

  • iu tr phng nga th pht

  • Khuyn co- Rung nh Class/Level

    of Evidence

    Rung nh tng t hay thng trc, khuyn

    co dng khng ng i vn vitamin K (target

    INR 2.5; range, 2.0 to 3.0).

    Class I;

    LOE A

    Bnh nhn khng dng c khng ng

    ung, khuyn co dng aspirin

    Phi hp clopidogrel vi aspirin nguy c xut

    huyt cao, khng c khuyn co cho bnh

    nhn xut huyt chng ch nh warfarin

    Class I;

    LOE A

    Class III;

    LOE B

    Khuyn co

    mi

  • Khuyn co - Rung nh Class/Level of Evidence

    Bnh nhn rung nh c nguy c cao (t qu

    hay TIA trong 3 thng, CHADS2 im 5 hay 6,

    valve tim c hc hay bnh valve tim hu thp)

    Tm thi ngng khng ng ung, iu tr

    bc cu (bridging therapy) vi heparin trong

    lng phn t thp(LMWH ) tim di da

    Class IIa;

    LOE C

    Khuyn co

    mi

  • Warfarin (Class I; Level of Evidence A), dabigatran (Class I; Level of Evidence B), apixaban (Class I; Level of Evidence B), v rivaroxaban (Class IIa; Level of Evidence B) c chi nh trong phng nga th pht bnh nhn rung nh khng do van tim

    (s la chn antithrombotic ty thuc tng c nhn d trn c s: risk factors, cost, tolerability, s thch hn ca bnh nhn, kh nng tng tc thuc v c im khc ca lm sng bao gm INR nu BN dng warfarin)

  • AF PIE:FUTURE

    AF PIE:PAST

    Fuster V. Circulation 2012; epubl April 18

  • Cp nht guideline ESC* 2012

    nh gi nguy c t qu vi CHA2DS2-VAScv khng cn dng CHADS2

    ESC Guidelines khuyn co khng ngphng nga t qu vi CHA2DS2-VASc lnhn hay bng 1

    u tin khng ng mi, non-monitored anticoagulants: apixaban, rivaroxaban, vdabigatran

    * European Society of Cardiology

  • Thuc khng ng mi(Novel Oral Anticoagulants)

    Oral direct thrombin inhibitor

    Twice daily dosing

    Renal clearanceDabigatran

    Direct factor Xa inhibitor

    Once daily (maintenance), twice daily (loading)

    Renal clearanceRivaroxaban

    Direct factor Xa inhibitor

    Twice daily dosing

    Hepatic clearanceApixaban

    Direct factor Xa inhibitor

    Once daily dosing

    Hepatic clearanceEdoxaban

    Circulation 2010;121:1523

  • Hin nay ch DTI (dabigatran etexilate) c nghin cu pha III nh gi lm sng phng nga t qu trong rung nh

  • C ch tc ng khng ng mi

    Hankey GJ and Eikelboom JW. Circulation 2011;123:1436-1450

    RivaroxabanApixabanEdoxabanBetrixaban

    Xa

    IIa

    TF/VIIa

    X IX

    IXaVIIIa

    Va

    II

    FibrinFibrinogen

    Dabigatran

    Khi u

    Nhn ging

    Hnh thnh Fibrin

    Cc bc ng mu thuc

  • NOAC phng nga t qu

  • So snh khng ng mi vi Warfarin

    Warfarin New Agents

    Khi pht Slow Rapid

    Liu Variable Fixed

    nh hng thc n Yes No

    Tng tc thuc Many Few

    Theo di Yes No

    Half-life Long Short

    Antidote Yes No

  • Cc vn ca Warfarin

    1) Tr hon trong khi u/b tr

    2) Khng tin lng liu p ng

    3) Ch s iu tr hp

    4) Tng tc thuc-thuc, thc n-thuc

    5) Vn theo di

    6) T l chy mu cao

    7) o ngc chm

  • Hi chng suy phng nga (A Failure to Prophylax Syndrome )

    Trn mt thp k qua, 40% BN rung nh khngkhng c phng nga t qu do khng kn khng ng.

  • SPAF 2012: kt lun

    1. T l rung nh ang gia tng ko theo t t qu

    cng gia tng

    2. Anticoagulants c th gim nguy c t qu

    nhng rt t s dng.

    3. NOACs t nguy c chy mu hn warfarin v trn

    hay t nht khng thp hn trong phng nga

    t qu

    4. Chng ta phi khc phc hi chng suy phng

    nga rung nh (

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