NNG ACID URIC HUYT THANH BNH NHN TNG HUYT P

H Th Ng c Dung*, Chu Ng c Hoa** TM TT Tng huyt p (THA): tn sut hin mc cn cao: tng t 50 triu ngi nm1999 n 65 triu ngi nm 2000 chim 31,3% M; 28% Canada; 6 nc chu u l 44%. Ti Vit Nam, tn sut tng dn theo thi gian: cho n nm 2002 l 16,03%. Ngoi ra, tnh trng kim sot huyt p cn thp li nhiu bin chng nng n cho bnh nhn v tng gnh nng cho x hi: t l bnh nhn tun tr y M l 34% v Vit Nam l 25% v t l kim sot tt huyt p l 19,1% theo tc gi Phm Gia Khi v cs. C ch bnh sinh a yu t, trong yu t ri lon chc nng ni mc ng vai tr quan trng. Mc tiu nghin cu: Kho st nng acid uric huyt thanh bnh nhn tng huyt p nguyn pht i tng v phng php nghin cu: Tt c bnh nhn THA nguyn pht mi c chn on hoc khng c iu tr h p lin tc trc lc nhp vin, vo khoa tim mch bnh vin Nhn Dn Gia nh t thng 03 n thng 09/2007 (v khng thuc bng tiu chun loi tr). Phng php nghin cu: m t ct ngang, tin cu. Kt qu: Cc s liu nghin cu c thu thp trong 6 thng bao gm 194 bnh nhn, vi t l nam/n: 79/115 = 0,68. tui t 37 n 96 tui, trong tui 70-79 chim t l cao nht l 34,5%. a s bnh nhn c tin cn THA chim 83,6% v thi gian > 5 nm chim 41,8%. a s l THA 2 theo JNC 7 (54,6%). Nng AUHT trung bnh l 368,5 64,5 mol/l, v c s khc bit gia cc phn THA theo JNC 7 c ngha thng k vi p=0,001. T l tng AUHT kh cao dn s nghin cu l 48,5% ( nam: 46,8%; n: 49,6%); t l ny cng tng dn theo phn THA (p=0,001). Khng c s khc bit theo tui, nhng khc bit theo gii tnh. T l tng AUHT tng dn theo thi gian bit THA c ngha thng k (p=0,003). Mi tng quan gia AUHT vi tr s HA tm thu v HA tm trng mc trung bnh c ngha thng k vi p <0,01. Ngoi ra, c s khc bit c ngha thng k v AUHT trung bnh gia hai nhm c hi chng chuyn ha v khng c HCCH (p<0,01) cng nh c s tng quan gia tng AUHT v HCCH c nam v n (p<0,001). Kt lun: THA l yu t nguy c tim mch thng gp nht, nhng tn sut cha c kim sot tt huyt p cn cao. C ch bnh sinh ca THA cha r rng, a yu t, trong lin quan n ri lon chc nng ni mc mch mu. Tng acid uric huyt thanh xy ra ngi THA 2 cao hn 1 v tng vi chiu di thi gian bit THA, v xy ra hi chng chuyn ha. Do , c th ni acid uric, c xem l yu t nguy c c lp tin on THA v tin lng nng THA, c bit THA c hi chng chuyn ha. Key words: Tng huyt p, nng axit Uric huyt thanh ABSTRACT SERUM URIC ACID IN HYPERTENSIVE PATIENT Ho Thi Ngoc Dung, Chau Ngoc Hoa * Y Hoc TP. Ho Chi Minh * Vol. 13 Supplement of No 6 - 2009: 41 - 46 Backgrounds: Hypertension: high prevalence: 31% in USA; 28% in Canada; 44% in six European countries; increasingly changing up to 16.03% in 2002 in Vietnam. Certain previous studies in other countries
* Khoa Ni Tim Mch Bnh Vin Nhn Dn Gia nh ** i Hc Y Dc TP. HCM a ch lin lc: BS H Th Ngc Dung T: 0908.499.406 Email: hothingocdung@yahoo.com

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were reported that serum uric acid (SUA) increases in patients with essential hypertension. Hyperuricemia is associated with the endothelial dysfunctions and then relates to cardiovascular events. However, serum uric acid is still not noted in these patients in Vietnam. Moreover, the test of SUA is cheap and available. That is the reason we execute this study. Objective of the study: Evaluating serum uric acid concentration in patients with essential hypertension. Methods of the study: Patients with essential hypertension newly diagnosed or who had uncontinuously antihypertensive treatment more than 4 weeks hospitalized in the cardiology service of Nhan Dan Gia Dinh hospital in March to September in 2007 (except those of excluded criteria). Methods: cross sectional description of prospective study. Results: Clinical data collected in 6 months including 194 patients, aged from 37 to 96; most of them in 7079 age range (34,5%); gender proportion: male/female: 79/115 or 0,68. Most of them belong to 2nd degree of hypertension of JNC 7 (5.6%). SUA average concentration is 368 64.5 mol/l. There are a statistically significance between severity of hypertension (p=0,001) (table 8); between two genders (table 9); the higher the SUA, the longer the hypertension (p=0,003) (table 10). Moreover, SUA is higher significantly in patients with metabolic syndrome than in who without metabolic syndrome (p<0,001) (table 12). Conclusions: Hyperuricemia is considered as an early risk factor in endothelial dysfunctions, usually found in severe hypertensive patients or long term hypertension, especially in patients with metabolic syndrome. Key words: Hypertension, serum uric acid hyperuricemia TVN Theo t chc y t th gii hng nm c khong 13 triu ngi t vong do bnh tim mch, t l kh cao hn nc ang pht trin. Tng huyt p (THA) ang e da cho x hi do tui th trung bnh v tnh trng bo ph ngy cng tng. Tn sut hin mc kh cao: chim 31.3% M; 28% Canada; 6 nc chu u l 44%(6). Ti Vit Nam, tn sut tng dn theo thi gian: 1.9% dn s nm 1982 ln n 11,79% nm 1992, v min Bc nm 2002 l 16,03%(3,10). THA y mun nhc n l THA nguyn pht chim t l 90%. Bin chng ca THA nng n cho x hi nu THA lu ngy v khng c kim sot tt. C ch bnh sinh mang tnh a dng, nhiu yu t lin quan. Nhng nm gn y, acid uric c quan tm nh mt thnh phn trong c ch bnh sinh ca THA lin quan n ri lon chc nng ni mc mch mu. Nhiu nghin cu trn th gii tin hnh v chng minh iu v cho thy rng tng acid uric mu lin quan n bin c tim mch(13,14). Ti Vit Nam, cha c nhiu nghin cu trn acid uric v bnh tim mch, c bit trong tng huyt p. Do , chng ti tin hnh nghin cu ti ny.

Mc tiu nghin cu
M c tiu t ng qut
Kho st nng acid uric huyt thanh bnh nhn tng huyt p nguyn pht.

M c tiu chuyn bi t
Xc nh nng acid uric huyt thanh trung bnh bnh nhn THA nguyn pht chung, v cc nhm theo phn THA ca JNC 7; v t l tng AUHT cc nhm ny. Xc nh mi lin quan gia acid uric huyt thanh vi thi gian pht hin tng huyt p v vi cc thng s khc: tui, gii, Tm mi lin quan gia acid uric gia nhm tng huyt p c hi chng chuyn ha v nhm khng c hi chng chuyn ha.

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I TNG- PHNG PHPNGHIN CU

i t ng nghin c u
Tt c bnh nhn tng huyt p nguyn pht mi c chn on hoc iu tr h p khng lin tc 4 tun trc nhp vin, ti khoa tim mch bnh vin Nhn Dn Gia nh, t thng 3 n thng 9/2007.

Tiu chu n lo i tr
t gt cp. Tng huyt p th pht. Bnh l nhim khun, bnh cp tnh nng n. ang iu tr vi thuc li tiu, estrogen, salicylates, allopurinol, thuc chng ung th. Nghin ru.

Thi t k nghin c u
M t c t ngang

C m u v i cng th c
Z2 1- /2 p(1 p) n --------------------------d2
v i Z (1-/2) = 1,96; p= 0,502; d=0,01

C m u n 97. Chng ti dng phng php ch n m u ng u nhin. Do , N =194. Phn tch s li u v x l s li u b ng ph n m m SPSS 15.0. S khc bi t c ngha th ng k v i p<0,05. KTQU Cc s li u nghin c u c thu th p trong 6 thng t thng 03 n thng 09/2007, bao g m 194 b nh nhn. M t s c i m d ch t h c c a dn s nghin c u: Trong 194 b nh nhn tng huy t p nguyn pht, bao g m 79 nam v 115 n , v i t l nam/n l 0,68. Bng 1: c im v gii tnh ca dn s nghin cu
Gi i Nam N T ng c ng S b nh nhn 79 115 194 T l (%) 40,7 59,3 100

Bng 2: Phn phi v tui

49 tu i 50 -59 tu i 60 69 tu i 70 - 79 tu i 80 tu i T ng c ng S b nh nhn 22 31 44 67 30 194 T l % 11,3 16,0 22,7 34,5 15,5 100,0

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Nh n xt: Nhm tu i c t l cao nh t trong nghin c u chng ti l 70-79 tu i (34,5%). Tu i trung v l 70. Bng 3: Ch s khi c th
< 23 23 24,9 25 T ng Nam 36 (45,6) 34 (43,0) 9 (11,4) 79 (100,0) N 58 (50,4) 43 (37,4) 14 (12,2) 115 (100,0) T ng 94 (48,5) 77 (39,7) 23 (11,8) 194 (100,0)

Nh n xt: a s b nh nhn trong nghin c u c ch s kh i c th bnh th ng (<23 kg/m2), chi m 48,5%. M t s c i m tng huy t p: a s b nh nhn c ti n cn tng huy t p chi m 83,5%, cho th y vi c b nh nhn b thu c tr li u r t l n v c n c quan tm. Bng 4: Thi gian bit tng huyt p
Th i gian bi t THA Khng bi t < 1 nm 1-5 nm > 5 nm T ng c ng S b nh nhn 29 24 60 81 194 T l % 14,9 12,4 30,9 41,8 100,0

Nh n xt: a s b nh nhn l bi t THA trn 5 nm (41,8%), m v n khng tun th vi c i u tr . Bng 5: Phn tng huyt p theo JNC 7
Ti n THA 1 2 T ng c ng S b nh nhn 2 86 106 194 T l % 1,0 44,3 54,6 100,0

Nh n xt: a s b nh nhn phn THA 2 theo JNC 7 (54,6%). Ngoi ra, t l ph i th t tri l 21,6%; thi u mu c tim l 40,7%; c tai bi n m ch mu no c l 10,8%; c h i ch ng chuy n ha l 44,3%. Bng 6: Tn sut hi chng chuyn ha theo gii tnh
HCCH Gi i Nam N T ng c ng 34 (39,5) 52 (60,5) 86 (44,3) 45 (41,7) 63 (58,3) 108 (55,7) 79 115 94 C Khng T ng

Nh n xt: T n su t b nh nhn c h i ch ng chuy n ha l 44,3%, trong , nam l 39,5%; n l 60,5%. M t s lin quan gi a acid uric huy t thanh v tng huy t p: K t qu cho th y n ng acid uric huy t thanh trung bnh c a dn s nghin c u l 368,5 64,5 mol/l; gi tr nh nh t: 162 mol/l; gi tr l n nh t: 535mol/l Bng 7: Tng quan gia AUHT vi phn THA theo JNC 7
AUHT S ng i Tr TB LC

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 THA Ti n THA 1 2 ANOVA

N = 194 2 86 106 F = 20,24;

332 28,3 339 64,8 393 53,9 p= 0,001

Nh n xt: C s khc bi t c ngha th ng k (p=0,001) v n ng AUHT trung bnh gi a cc phn tng huy t p theo JNC 7. Bng 8: T l tng AUHT cc phn THA theo JNC 7
AUHT Tng THA N (%) Ti n THA 0 1 28 (29,8) 2 66 (70,2) T ng c ng 94 (48,5) Bnh th ng T ng c ng N (%) 2 (2,0) 2 58 (58,0) 86 40 (40,0) 106 100 (51,5) 194

Nh n xt: T l tng AUHT b nh nhn THA chung l 48,5%; v t l ny cng tng phn THA 2 theo JNC 7 (70,2%) (c ngha th ng k v i php ki m Chi bnh phng, v i p=0,001). Bng 9: Tng quan AUHT vi gii tnh v tui.
Gi i tnh Acid uric (mol/l) Nam N =79 394,2 69,1 N N = 115 350,8 54,7 p 0,000

AUHT Tu i (N) 49 (N=22) 50 59 (N=31) 60 69 (N=44) 70 79 (N=67) 80 (N=30) T ng (N=194)

AU (tr TB LC) 369,1 64,8 377,9 88,8 381,1 58,5 364,1 60,0 349,6 49,6 368,5 64,5

ANOVA

p=0,268

Nh n xt: C s khc bi t c ngha th ng k (p<0,001) v n ng acid uric huy t thanh trung bnh gi i nam v gi i n (php ki m t=4,67). Khng c s khc bi t gi a cc l p tu i. Ngoi ra, cn c s khc bi t gi a cc nhm theo ch s kh i c th (p=0,003). Bng 10: Tng quan gia tng AUHT vi thi gian pht hin THA:
AU Th i gian THA Khng bi t < 1 nm 1 5 nm > 5 nm T ng Tng N (%) 6 (6,4) 12 (12,8) 27 (28,7) 49 (52,1) 94 (48,5) Bnh th ng N (%) 23 (23,0) 12 (12,0) 33 (33,0) 32 (32,0) 100 (100,0) T ng N (%) 29 24 60 81 194

Nh n xt: T l tng AUHT tng d n theo th i gian pht hi n THA c ngha th ng k v i test chi bnh phng, p=0,003. Bng 11: Tng quan gia AUHT vi tr s HATT v HATTr
HA (mmHg) AU (mol/l) HA tm thu HA tm trng

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H s tng quan

r = 0,583; p=0,000

r = 0,506; p=0,004

Nh n xt: C s tng quan thu n m c trung bnh gi a n ng AUHT v i HATT; v HATTr v i p<0,01. Bng 12: Tng quan AUHT vi hi chng chuyn ha
C HCCH Khng c HCCH Php ki m t N = 86 N = 108 AU (mol/l) 400,4 55,2 343,1 60,1 p= 0,000 Nhm

Nh n xt: C s khc bi t c ngha th ng k gi a n ng AUHT trung bnh c a nhm THA c HCCH v i nhm THA khng c HCCH (p<0,01). BN LUN

c im chung ca dn s nghin cu
V gi i tnh
C 194 b nh nhn trong nghin c u c a chng ti, trong c 79 nam v 115 n ; v i t l nam/n =0,68. a s n tu i mn kinh.

V tu i Chng ti c 5 nhm tu i: 49; 50 -59; 60-69; 70- 79; v 80 tu i. C 50% dn s nghin c u t 70 tu i tr ln, ch ng t dn s ny tng i thu c l n tu i, trong chi m a s l tu i 70 -79, chi m 34,5%. tu i trung bnh l 67,4 12,3; v i tu i nh nh t l 37 v tu i l n nh t l 96. i u ny cng ph h p v i tnh hnh hi n nay, dn s ni chung tng tu i th trung bnh. So snh v i nghin c u c a Viazzi F v cs., tu i th p hn l 47,0 9,0 tu i, tng ng v i tu i trong nghin c u c a tc gi N.. Cng v cs.(56,7 9,6 tu i), v c a tc gi H. Q. Ha v cs. (68 13 tu i).

c im v tng huyt p
V th i gian pht hi n tng huy t p a s b nh nhn c ti n cn tng huy t p chi m 83,5%, cho th y b nh nhn bi t tng huy t p, nhng v n khng c i u tr t t. Quan tr ng hn n a l a s b nh nhn l bi t THA trn 5 nm (41,8%), m v n khng tun th vi c i u tr . i u ny l gi i cho nh ng bi n ch ng x y ra nh tai bi n m ch mu no, nh i mu c tim, gy nn gnh n ng cho x h i. V m c tng huy t p Chng ti d a theo phn tng huy t p c a JNC 7, ghi nh n c 2 tr ng h p l ti n tng huy t p, chi m t l 1%; tng huy t p 1 (44,3%); tng huy t p 2 (54,6%). i u ny ph h p v i nghin c u th c hi n t i b nh vi n.

c im lin quan gia acid uric huyt thanh v tng huyt

N ng acid uric huy t thanh trung bnh c a dn s nghin c u l: 368,5 64,5 mol/l

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nam l 394,2 69,1 mol/l; n l 350,8 54,7 mol/l. Nh v y n ng AUHT nam cao hn n , v c s khc bi t c ngha th ng k v i php ki m t=4,67 v p<0,001 (b ng 9). Tng acid uric huy t thanh khi AUHT 360 mol/l (hay 6mg/l) n ; v khi AUHT 420 mol/l (hay 7mg/l) nam, theo nhi u ti li u th ng k v phng xt nghi m. Nh v y t l tng AUHT nam v n l n l t l: 46,8% v 49,6%. S khc bi t ny khng c ngha th ng k. Trong dn s nghin c u ny, t l tng AUHT b nh nhn THA l 48,5%. Khc v i k t qu nghin c u c a tc gi Zoccali l 25%; nhng gi ng v i nghin c u c a N. . Cng v cs. l 50,2%. N ng AUHT trung bnh theo phn THA theo JNC 7 l n lt l: 332 28,3 ti n THA; 339 64,8 THA 1; v 393 53,9 THA 2. C s khc bi t c ngha th ng k v i p= 0,001 (b ng 7). Tng t v i k t qu nghin c u c a tc gi H.Q. Ha v cs. T l tng AUHT tng d n theo m c n ng c a phn THA c a JNC 7 (b ng 8) l n l t l: 29,2% THA 1 v 70,2% THA 2, s khc bi t r t c ngha th ng k (p=0,001). C tng quan thu n gi a acid uric v i tr s HA tm thu v HA tm trng v i p < 0,01. Cho ta ph h p v i nghin c u c a N. . Cng v cs.. Nh v y, c th ni, khi tng AUHT, th ta nn ch b nh nhn r ng vi c i u tr cha hi u qu . Chng ti nh n th y t l tng AUHT tng d n theo th i gian pht hi n THA, v i s khc bi t c ngha th ng k p = 0,003. Th i gian THA cng lu, th cc bi n ch ng xy ra n u khng i u tr t t. Do , acid uric tng c xem l d u n giai o n s m trong t n thng c quan tim m ch[1]. Tr c kia, acid uric l m t thnh ph n trong h i ch ng chuy n ha, nhng theo th i gian, thnh ph n ny b sao lng. nghin c u chng ti cho th y n ng AUHT trung bnh cao hn nhm THA nguyn pht c HCCH so v i nhm khng c HCCH v i p<0,001 (b ng 12). Khi xt theo gi i tnh, th s khc bi t th y r hn c hai gi i nam v n . k t qu ny ph h p v i cc nghin c u c a Viazzi v cs. Nh v y acid uric l ch t song hnh trong h i ch ng chuy n ha. KTLUN Qua nghin c u 194 b nh nhn THA nguyn pht, chng ti rt ra vi k t lu n nh sau: (i) C s tng acid uric huy t thanh b nh nhn THA, nh t l THA lu nm khng i u tr lin t c. (ii) Acid uric lin quan n m c THA, phn THA cng cao th s tng AU cng nhi u. Tuy nhin, v th i gian nghin c u cn h n ch v thi t k nghin c u, chng ti cha nh gi m i lin quan n cc bi n ch ng c a THA. Ki n ngh : vi c lu n xt nghi m acid uric huy t thanh trn nh ng b nh nhn THA, c h ng i u tr , c bi t THA giai o n s m. TI LIU THAMKHO
1. 2. 3. 4. 5. AldermanMH.(2002), Uric acid and cardiovascular risk, Curr Opin Pharmacol, 2:12630. B mn N i (1998), B nh h c N i khoa, Nxb Mi C Mau, tr. 143-160. ng V n Ph c (2008), Tng huy t p trong th c hnh lm sng, Nxb Y h c, tr. 1 27. Fang J, Alderman MH (2000), Serum uric acid and cardiovascular mortality. The NHANES I epidemiology followup study 1971 - 1992, JAMA, 283 (18): 2404 10. Hong Qu c Ha (2007), Kh o st n ng AU HT b nh nhn tng huy t p. Chuyn h i ngh khoa h c k thu t BV Nhn Dn Gia nh, T p ch Y h c Tp H Ch Minh t p 11, ph b n 4: tr. 39-43.

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6. 7. 8. 9. 10. 11. 12. 13. 14.

Kaplan NM., MD et al. (2006), Kaplans clinical hypertension, Lippincott Williams and Wilkins, Philadelphia, United States, 9th edition, pp. 124. Nguy n c Cng (2006), M i lin quan gi a n ng acid uric v i huy t p b nh nhn tng huy t p nguyn pht. T p ch Tim M ch H c Vi t Nam thng 3, 43: 56 60. Nguy n M nh Phan v c ng s (2004), K t qu chng trnh kh o st tnh hnh i u tr tng huy t p t i thnh ph H Ch Minh. Th i s Tim M ch H c thng 4/2004, 78: 2 -6. Nguy n Thy Khu (2006), H i ch ng chuy n ha. Trong N i ti t h c i cng, Nxb Y h c, tp H Ch Minh, tr. 503 508. Ph m Gia Kh i, Nguy n Ln Vi t v cs. (2003), T n su t tng huy t p v cc y u t nguy c cc t nh pha B c Vi t Nam nm 2001- 2002. T p ch Tim M ch H c Vi t Nam thng 3, 33: tr. 9- 34. Ph m T Dng (1999), B nh tng huy t p, Nxb Y h c, H N i, tr. 5- 7. Tr n Trinh v cs. (1992), i u tra d ch t h c b nh tng huy t p t i Vi t Nam. ti thu c chng trnh nghin c u cc b nh tim m ch c a B Y t , T li u B Y t thng 6, tr. 20. Viazzi F., Parodi D., et al (2005), Serum uric acid and target organ damage in primary hypertension, Hypertension, 45: 991 996. Zoccali C, Maio R, Mallamaci F, et al (2006), Uric acid and endothelial dysfunction in essential hypertension, J Am Soc Nephrol, 17:1466 71.

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