Thuc Hanh Benh Tim Mach

Nguyen Quoc Phuong K29G
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08 2
20 ocity
ht Pot
rig
py
Co
Trong tay cc bn l mt cun sch rt b ch v thc hnh trong chn

on v iu tr cc bnh tim mch thng gp. Tnh n gin, thc tin
cao nhng cng kh cp nht v y thng tin cc bn c th vn
dng c tt nht trong thc t cng vic cng nh hc tp l mong mi
ca nhng tc gi tham gia bin son quyn sch ny...
Copyright 2008. Finloev. All rights reserved

Potocity2020@yahoo.com.vn
Nguyn ln vit
(Ch bin)
Thc hnh
Bnh tim mch

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08 2
20 ocity
ht Pot
rig
py
Co
Nh xut bn Y hc
2003
Nguyn ln vit
(Ch bin)
Thc hnh
Bnh tim mch

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08 2
20 ocity
ht Pot
rig
py
Co
Nh xut bn Y hc
2003

Li gii thiu
S kt hp cht ch trong cng tc iu tr, ging dy,
nghin cu khoa hc gia cc thnh vin ca B mn Tim mch
Trng i hc Y H ni v Vin Tim mch Vit nam to
iu kin cho s ra i ca cun sch: Thc hnh Bnh Tim
mch vi s tham gia trc tip ca cc tc gi m Ph Gio s
Tin s Nguyn Ln Vit l ch bin.
Chng ta cn nh tp Bnh hc Ni khoa vi nhng
bi vit rt c bn, thc t, xc tch m c Gio s ng Vn
Chung truyn t t nhng nm 50 ca th k va qua. Ngy
nay, nhng tin b to ln ca y hc hin i trong chuyn ngnh
Tim mch c phn nh mt phn qua 32 bi vit ca tp
d
th tc gi. y cng l phn nh s pht trin ti Vin
rve Tim
e
s
re
mch Vit nam trong nhng nm gn y, mt thnh
ts vnqu t s
h
.
g
n lc ca mi c nhn, ca tp th cc thy
om nhm p
l rithuc,
l
c
.
A hohi
o nhp quc t
ng nhu cu nng cao sc kho trong bi
ev.cnh
a
o
l
y
in @
m nc ta l mt thnh vin.
. F 2020
8
0
Qua cc bi vit ny, m
y cc tc gi cng t nhn
20 ochnh
cit
t gian
t
xt l cn b hn ch v ithi
chun
b cho in n, cc th h
h
o
P
rg
y
k tip t r kh onng
gp phn y mnh v lm phong ph
p
C
thm cho nhng thnh tu ca ngi i trc, gip chng ta cp
nht v hi nhp vi y hc hin i ti khu vc.
Chng ti xin gii thiu cun Thc hnh Bnh Tim
mch mt ti liu phc v ging dy, thc hnh, mt ti liu
tham kho c gi tr, mang tnh h thng v cp nht.
Xin cm n cc tc gi v chc bn c rt ra nhng iu
b ch ca mt chuyn ngnh ang pht trin mnh m ny.
Gio s Tin s Phm Gia Khi
Vin trng Vin Tim mch Vit nam
Ch nhim B mn Tim mch - Trng i hc Y H ni

Li ni u
Bc sang thin nin k mi, chng ta vui mng chng
kin v tip thu nhng thnh tu pht trin ca khoa hc k thut
nhm khng ngng ci thin v nng cao i sng ca con
ngi.
Tuy vy, chng ta cng khng khi lo u bi m hnh bnh
tt c nhng s thay i theo chiu hng ca cc nc pht
trin. Trong cc loi bnh l , bnh tim mch l mt trong
nhng bnh ang c xu hng tng nhanh mt cch r rt d nc
rve
ta.
ese
r
hts .vnta tip
Trong thi gian gn y, cc bc s caigchng
r
om tin trong
ll o.ctin
thu v ng dng nhiu phng php, k. Athut
o
h
v
a ci thin c
oe t
chn on v iu tr cc bnh tim mch,
inl 20@y
F
. 0sng ca bnh nhn.
hn tin lng bnh v cht lng
8cuc
00 ity2
2
Tuy nhin, khi lng
oc thc v nhng hiu bit mi
t kin
gh Pot
i
r
trong lnh vc tim mch
py th ngy cng gia tng, nhng iu kin
Co ti nhiu tuyn ca chng ta cn cha p
trang thit b thc t
ng c mt cch y . V vy, cc thy thuc nhiu khi s
kh lng tng trong thc hnh chn on v iu tr cho cc
bnh nhn tim mch.
Xut pht t thc tin cng tc iu tr v ging dy trong
nhiu nm, tp th cc cn b ging dy ca B mn Tim mch,
Trng i hc Y H ni v mt s cng s c gng tham gia
bin son quyn sch ny.
Vi phng chm l bm st thc t, d dng ng dng
nhng cng khng km phn cp nht, chng ti c lm ht
sc mnh trong vic bin son ph hp vi nhng yu cu ni
trn. Trong qu trnh bin son, chng ti c gng cp nht
nhng thng tin mi nht c th c trn nn tng nhng kin
thc kinh in bit trong lnh vc tnh mch.

Chng ti hy vng cun sch Thc hnh Bnh Tim mch

ny khng ch dnh cho cc bc s chuyn khoa tim mch m c
th cn gip ch cho cc bc s thc hnh ni chung cng nh
cc sinh vin y khoa tham kho thm trong hc tp.
Y hc l mt ngnh khoa hc c lng thng tin c b
sung v i mi hng ngy. Mt khc, s hiu bit ca chng ti
cn c hn v thi gian bin son kh st sao nn quyn sch
ny chc chn cn nhng thiu st nht nh. Chng ti rt hoan
nghnh v sn sng tip thu nhng kin ng gp qu bu ca
cc bn c ln ti bn sau c hon thin hn.
Cc tc gi
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08 2
20 ocity
ht Pot
rig
py
Co

CH bin
Ph gio s, Tin s Nguyn Ln Vit
Tham gia bin son:

d
rve
e
s
e
Thc s Phm Mnh Hng hts r n
v
.
g
l ri .com
l
Tin s Don Li v. A hoo
oe ya
inl 2Quang
0@
F
Bc s Nguyn Ngc
8. 20
0
20 ocity
t Thi
Thc s Phm
Sn
h
Pot
rig
y
p
Ph gio
Co s, Tin s Nguyn Ln Vit
Thc s Nguyn Ln Hiu

Mc lc
1. au tht ngc khng n nh ......................................................... 1

2. au tht ngc n nh..................................................................... 17
3. Nhi mu c tim cp ....................................................................... 35
4. Bin chng ca nhi mu c tim cp.......................................... 53
5. Sc tim................................................................................................. 75
6. Ri lon lipid mu ........................................................................... 85
7. Tng huyt p .................................................................................... 95
8. Tai bin mch mu no ................................................................
d 121
rve
e
s
9. Tch thnh ng mch ch .........................................................
139
re
ts vn
h
.
g
i om
10. iu tr mt s ri lon nhp tim thng gp
167
ll r .........................
.c
A
o
o
.
h
v
11. Thp tim ............................................................................................
219
loe @ya
n
i
0
F
2
12. Hp van hai l .................................................................................
231
8. 0
00 ity2
2
13. H van hai l ...................................................................................
253
t toc
igh Po
r
14. H van ng mch
pych .................................................................267
Co
15. Hp van ng mch ch ...............................................................287
16. Vim ni tm mc nhim khun................................................305
17. Van tim nhn to ............................................................................321
18. Suy tim ..............................................................................................341
19. Bnh c tim gin.............................................................................379
20. Bnh c tim ph i ........................................................................387
21. Bnh c tim hn ch ......................................................................395
22. Vim mng ngoi tim cp............................................................399
23. Trn dch mng ngoi tim............................................................411
24. Vim mng ngoi tim co tht .....................................................423
25. Tm ph mn ...................................................................................431
26. Nhi mu phi ................................................................................453

27. Thng lin nh .................................................................................475

28. Thng lin tht ................................................................................485
29. Cn ng ng mch.......................................................................495
30. Bnh van ng mch phi ...........................................................503
31. T chng Fallot...............................................................................509
32. Hp eo ng mch ch .................................................................519
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08 2
20 ocity
ht Pot
rig
py
Co

au tht ngc khng n nh
au tht ngc khng n nh (unstable angina, TNK)

l mt trong nhng vn kh thi s hin nay do tnh cht
thng gp ca n cng nh nhiu tin b mi trong chn on
v iu tr. Hng nm M c tnh c ti > 700 000 bnh nhn
nhp vin v TNK. Tin lng ca TNK cng nng n
khng km nu so vi NMCT.
Thut ng Hi chng mch vnh cp bao gm: NMCT
cp c ST chnh ln (hoc c Q); NMCT cp khng Q; v
TNK. Trong , ngi ta thng xp NMCT khng Q v
TNK vo cng mt bnh cnh gi l Bnh mch
dvnh
rve
e
s
khng n nh v c cch x tr nh nhau.
re
ts vn
h
.
g
Trong bi ny cp ch yu n TNK
l ri .com trong bi
l
A hoo cng l p
cnh ca bnh mch vnh khng n nh
ev. nhng
a
o
l
dng cho iu tr NMCT khng c sng
@y
in 2Q.
0
F
8. 0
00 ity2
I. Sinh l bnh
2
t otoc
P hiu r c ch ca TNK l
ighta
A. Cho n nay ngi
r
y
p
s khng nConh ca mng x va v mng ny b v ra.
S v ra ca mng x va cng gp trong NMCT cp, tuy
nhin mc v din bin c khc nhau i cht. Nu s
nt v l ln v hnh thnh mu ng t lp ton b
lng mch s dn n NMCT. Nu s nt v nh hn v
cc mu ng ny cha dn n tc hon ton MV th
l TNK. Tuy nhin, TNK c th din bin
nng v bin thnh NMCT thc s.
B. S hnh thnh cc mu ng: Nh trnh by trn, khi
mng x va b v, lp di ni mc c l ra v tip
xc vi tiu cu, dn n hot ho cc th th IIb/IIIa
trn b mt tiu cu v hot ho qu trnh ngng kt ca
tiu cu. Thm vo tiu cu ngng kt ny s gii
1
phng ra mt lot cc cht trung gian lm co mch v

hnh thnh nhanh hn cc mu ng.
C. Hu qu l lm gim nghim trng dng mu ti vng c
tim do MV nui dng, v biu hin trn lm sng
l cn au ngc khng n nh. Trong thc t mt s yu
t sau c th lm nng bnh hn: st, tng huyt p
nhiu, ri lon nhp tim, cng gip...
d
rve
e
s
re
ts vn
h
.
g
Hnh 1-1. S nt ra ca mng x va trong
TNK.
l ri .com
l
A o
II. Chn on
ev. yaho
o
l
in @
A. Triu chng lm sng08. F 2020
ty
20 ocivi
1. c im chung:
bnh nhn NMCT, bnh
t oso
t
h
P
g
i
r
nhn TNK
thng c tui gi hn, c t l tiu
py
Co hn, t l tng huyt p (THA) v ri lon
ng cao
lipid mu cng gp nhiu hn. Thm vo , s bnh
nhn TNK sau NMCT hoc cc th thut can
thip MV cng nhiu.
2. Triu chng c nng: Triu chng au ngc cng
ging nh trong au ngc n nh m t, ch c s
khc nhau v tnh cht, trong TNK tnh cht d
di hn, ko di hn, c th xy ra c trong khi ngh,
c th khng hoc t p ng vi Nitrates.
3. Khm lm sng:
a. Khm lm sng t c gi tr chn on
TNK, nhng khm lm sng l cc k quan
trng gip chn on phn bit cng nh nh
gi cc yu t nguy c, bin chng...
2
b. Chn on phn bit vi cc bnh nh vim mng

ngoi tim, vim ph qun, vim khp c sn,
cc bnh tim thc tn km theo...
c. Pht hin cc triu chng ca suy tim, ting T3,
h van tim...
4. Phn loi TNK theo Braunwald: gip phn
loi bnh nhn v d on tin lng bnh cng nh
c thi x tr thch hp.
Bng 1-1. Phn loi TNK theo Braunwald.
c im
au ngc khi gng sc:
I
Mi xy ra, nng, tin trin nhanh
au ngc mi trong vng 2 thng
d
au ngc vi tn s dy hn
rve
e
s
au ngc gia tng khi gng sc nh s re
ht .v2n thng
Khng c au ngc khi ngh trong
igvng
r
om
l
II au ngc khi ngh, bn cp: v. Al hoo.c
a
oe trong
au ngc khi ngh xy
@y vng 1 thng
inl ra
0
F
2
nhng khng phi0mi
8. xy
20 ra trong vng 48 gi
y
0
t
2
i
III au ngc khi ngh,
t ocp:
toc
gh raPtrong
ixy
au ngc
vng 48 gi
r
py
Cc hon cnh
Co lm sng
au ngc th pht: xy ra do cc yu t khng
A
phi bnh tim mch nh thiu mu, nhim trng,
cng gip trng, thiu xy...
au ngc t pht
B
au ngc khng n nh sau NMCT: trong vng
C
2 tun sau NMCT
B. Cc xt nghim chn on
1. in tm :
a. Trong cn au c th thy s bin i ca on
ST: ST chnh xung, T o chiu, ST chnh ln
thong qua. Nu ST chnh ln bn vng hoc mi
c xut hin bloc nhnh tri th ta cn phi ngh
n NMCT.
3
b. C 20 % bnh nhn khng c thay i trn T.

c. Vic phn bit TNK vi NMCT cp khng
c sng Q ch yu l xem c s thay i ca men
tim hay khng.
Bng 1-2. Phn tng nguy c ca bnh nhn TNK
Nguy c cao
Nguy c va
Nguy c thp
C mt trong cc Khng c cc du Khng c cc
biu hin sau:
hiu nguy c cao biu hin ca
nhng c 1 trong nguy c cao hoc
va
cc du hiu sau:
au ngc khi au ngc khi C s gia tng
ngh > 20 pht,
ngh >20 pht
v tn s v
ca bnh mch
nhng t
mc au
vnh
au ngc khi
ngc
d
C ph phi cp
ngh >20 pht au serve ngc
re
do bnh mch
nhng p ng
khi
ts vnpht do
h
.
g
vnh
tt vi iu tr
om sc nh
l ri .cgng
l
A o au ngc mi
au ngc khi au ngc vv
e . yaho xut
o
l
ngh c km
m
hin
in @
. F 2020c
theo on ST au 08ngc
trong vng 2
0 ity thay
thay i > 1mm
km
tun- 2 thng
c
2 totheo
t
h
o
au ngc km rig iPST
Khng thay
theo xut hinopy au ngc mi
i ST
C
ran phi, ting
xy ra trong
tim th 3 hoc
vng 2 tun,
HoHL mi
tnh cht nng.
au ngc km C sng Q bnh
theo tt huyt
l hoc xut
p
hin ST chnh
xung nhiu
chuyn o.
Tui > 65
2. Men tim:
a. V tnh cht kh phn bit vi NMCT (khng
sng Q) v c th tin trin n NMCT ca
TNK nn mi bnh nhn cn c lm xt
nghim men tim v theo di cc men ny.
4
b. Cc men thng c dng theo di l CK v

CK-MB; Troponin T v I.
c. V nguyn tc trong TNK khng c s thay
i cc men tim, tuy nhin trong mt s trng
hp c th thy tng i cht men Troponin I v
iu ny bo hiu tin lng xu hn.
3. Siu m tim: Siu m tim thng gip ch cho ta
chn on ri lon vn ng vng (nu c), nh gi
chc nng tht tri (c bit sau NMCT) v cc bnh
l thc tn van tim km theo hoc gip cho vic chn
on phn bit.
4. Cc nghim php gng sc:
a. Cn ch l khi chn on chc chn
ed
rvnghim
TNK th khng c ch nh lm cc
e
s
re
php gng sc do tnh cht bt n ca
ts bnh.
n
h
g
i om.v
r
l
b. Cc nghim php ny ch t
l ra khi
c bnh nhn
. A ahoo.
vsng
e
nhm nguy c thp, lm
khng
in hnh,
o
nl 0@y
i
F
2
khng c thay i8. trn0 T v iu tr n
0 ty2
20 otrong
nh ti bnh vin
vi ngy.
i
t ot c
h
P
g
i
5. Chp ngyrmch
vnh:
op
C
a. Ch nh chp ng mch vnh trong TNK
c cc tc gi thng nht l nhm bnh nhn
c nguy c cao, v mc ch ca chp MV l
can thip MV nu c th. Cc ch nh khc l
khi bnh nhn khng p ng hoc ti pht au
ngc sau khi dng thuc iu tr ti u, khi
bnh nhn c suy tim, ri lon nhp, gim chc
nng tht tri... (bng 1-3). Hin nay mt s trung
tm trn th gii ch trng chp MV v can
thip cho mi bnh nhn TNK ngay th u.
Tuy nhin, cch ny cha t ra li ch vt tri so
vi cch iu tr bo tn trc, n ch vt tri
nhm c nguy c cao.
5
Bng 1-3. Cc ch nh ca chp MV trong TNK.

Nhm nguy c cao.
Tin s c can thip MV hoc m cu ni.
Suy tim.
Gim chc nng tht tri (EF < 50%).
Ri lon nhp tht c tnh.
Cn tn ti hoc ti pht au ngc sau dng thuc .
C vng gim ti mu c tim rng trn cc xt nghim
chn on khng chy mu (x c tim, siu m tim
stress).
C bnh van tim r rt km theo (HoHL, HoC).
III. iu tr
Tu tng trng hp c th m ta bt u bng cc phng
ed
ervbt u
php iu tr thch hp. iu tr ni khoa l nn tngesv
r
ts vmch
cho mi trng hp. Cc bin php iu tr tighto
(can
n
i om.
r
l
thip nong hoc t Stent MV, phu thut
c cu ni chAl hlm
oo.
v.tnh
e
a
vnh) rt quan trng v l iu tr mang
trit
, cn c
o
nl 0@y
i
F
2
cn nhc trong tng tnh hung c8.th. 0
0 ty2
20 ni
i
A. Mc tiu ca iu
tr
t otoc khoa
h
P
g
ri
1. Nhanh chng
py dng thuc chng ngng kt tiu cu.
Co
2. Lm gim au ngc bng cc thuc chng thiu mu
cc b c tim.
3. Cc bnh nhn khng p ng vi iu tr ni khoa
cn c ch nh can thip cp cu. Vi nhng bnh
nhn p ng tt vi iu tr ni khoa cng cn c
sng lc v xem xt chp ng mch vnh quyt
nh tip hng iu tr ti to mch cho bnh nhn
(nong MV v/hoc t Stent, m cu ni...).
B. Cc u tin trong iu tr
1. Aspirin.
2. Gim au ngc bng Nitrate v/hoc chn bta giao
cm.
6
3. Chng ng mu bng Heparin hoc Heparin trng

lng phn t thp (LMWH).
4. Cc thuc c ch th th GP IIb/IIIa tiu cu.
C. Thuc chng ngng kt tiu cu ng ung
1. Aspirin:
a. C ch chng ngng kt tiu cu ca Aspirin l
thng qua chn con ng Thromboxan A2 lm
bt hot tiu cu.
b. Tuy tc dng ca Aspirin c coi l yu trong
chng ngng kt tiu cu nhng nhiu nghin cu
chng minh c l n c th lm gim ti
50% t vong hoc NMCT bnh nhn
TNK.
d
rve
e
s
c. Thuc c th pht huy tc dng
re c ch
ts vn
h
. cn cho
g
Thromboxan A2 trong vng 15 rpht,
nn
l i .com
l
A Nn
o cho loi hp
ngay khi bnh nhn nhp vvin.
e . yaho
o
l
thu nhanh (BabyAspirin
0@ 81 mg nhai 4 vin).
Fin02vin
8. (gi
hoc gi bt Aspegic
100 mg) ung 3 gi.
2
0
20 ocity
t ci tv liu duy tr nhng liu lng

d. Tuy cn bn
igh Po
r
y
ngay olc
p u nn dng khong 300 mg c th
C
t c kh nng tc dng ti a chng ngng
kt tiu cu trong ngy u, nhng ngy sau c
th dng liu t 81 - 325 mg/ngy.
2. Tilcopidine (Ticlid) v Clopidogrel (Plavix):
a. Cc thuc ny chng ngng kt tiu cu thng
qua con ng c ch ADP c lin quan hot ho
tiu cu, do kh nng chng ngng kt tiu
cu mnh hn Aspirin.
b. Ticlopidine cn khong 2-3 ngy t c
hiu qu tc dng ti a. Vi Clopidogrel th thi
gian ny ngn hn i cht.
c. Tc dng ph: Ticlid c th gy h bch cu mu
(0,2 -5 % cc trng hp), c th gy h tiu cu
7
mu km theo. Tc dng ph ny t gp hn i
vi Clopidogrel.
d. Liu lng: Ticlid cho ngay 500 mg sau cho
250mg x 2 ln/ngy trong nhng ngy sau. Plavix
cho liu ban u 300 mg sau 75 mg/ngy.
e. Ch nh: V l do gi thnh cn tng i cao
v v tc dng ph nng c th xy ra nn cc
thuc ny ch nn ch nh trong trng hp bnh
nhn km dung np vi Aspirin. Trong trng
hp c can thip t Stent MV th nn cho thm
thuc ny phi hp vi Aspirin. Sau khi t Stent
cc thuc ny c dng tip trong 2-4 tun ri
ngng v ch tip tc cho Aspirin
d
D. Cc thuc chng ng
rve
e
s
re
1. Heparin:
ts vn
h
g
i om.
l rmu
l
c ng trong
a. V c ch hnh thnh cc
oo.
v. A ahchng
e
TNK, nn vic cho
thuc
ng l bt
o
inl 20@y
F
buc.
8. 0
00 ity2
2
b. Nhiu nghin
oc ch ra rng vic dng
t cu
Pot vi Aspirin trong TNK
igh hp
Heparinyrphi
op nguy c t vong v NMCT ti 33 % so
lm Cgim
vi ch dng Aspirin n c.
c. Thi gian dng Heparin nn ko di khong 3-7
ngy, nu dng di qu c th lm tng nguy c
gy h tiu cu mu ca Heparin.
d. Hiu ng bng li (rebound) thiu mu c tim
cc b khi ngng Heparin c th gp l do hnh
thnh huyt khi lin quan n kch thch hot
ho tiu cu. Do vic duy tr lin tc Aspirin l
bin php tt phng trnh hiu ng ny.
e. Nn dng Heparin theo ng truyn TM.
f. Liu dng: Liu khuyn co hin nay l liu
tng i thp, tim ngay TM 60 UI/kg sau
truyn TM lin tc liu 15 UI/kg/gi. Cn kim
8
tra thi gian aPTT mi 6 gi sao cho thi gian

ny t khong 50-70 giy.
2. Heparin c trng lng phn t thp (LMWH):
a. Li th so vi Heparin thng l: c thi gian tc
dng ko di, liu c nh do dng tim di da
m t cn theo di bng cc xt nghim lin tc,
c ch c yu t Xa v IIa ca tiu cu, t gy
gim tiu cu mu.
b. Mt s nghin cu cho thy LMWH lm gim 17
% t l NMCT hoc t vong bnh nhn
TNK so vi dng Heparin thng.
c. Liu lng: C nhiu loi LMWH trong c
nhng loi hay c dng: tim di da:
d
Enoxaparin (Lovenox): 1mg/kg mise12
rvegi,
re
Dalteparin: 120 U/kg mi 12 gi,
ts vn
h
g
ri coml/10kg
m.
Nadroparin (Fraxiparin): ll 0,1
cn
.
A hoo
.
v
nng, tim di da chia
2
ln
trong
ngy.
e
a
nlo 0@y
itip
F
3. Thuc c ch trc
thrombin
(Hirudin,
2
8. 20
0
y
0
Hirulog): Cc thuc
2 ny
it c ch trc tip thrombin
t otoc
h
P
g
nn c tc dng
chng
ng kh mnh. Tuy nhin,
ri
y
p
cho nConay chng cha c chp nhn dng
thng quy trong TNK thay th cho Heparin.
Chng ch nn c dng nhng bnh nhn c tin
s b gim tiu cu do dng Heparin.
E. Cc thuc c ch th th Glycoprotein IIb/IIIa
ca tiu cu
1. C ch: Trn b mt ca tiu cu c cc v tr (th
th) m khi c hot ho s gn kt vi mng fibrin
gy nn s ngng kt tiu cu, cc v tr ny gi l
cc th th Glycoprotein IIb/IIa. Vic c ch th th
ny c ch tn gc qu trnh ngng kt tiu cu
nn cc thuc nhm ny s c tc dng chng ngng
kt tiu cu rt mnh.
2. Cc loi thuc v liu:
9
a. Abciximab (Reopro): l thuc c pht hin v

dng u tin. Liu dng tn cng 0,25 mg/kg
tim thng TM sau truyn TM 10 mcg/pht
trong 12 gi tip theo.
b. Eptifibatid (Intergrilin): Liu dng tn cng 180
mcg/kg tim thng TM sau truyn TM 1,3 2,0 mcg/pht trong 12 gi tip theo.
c. Tirofiban (Aggrastat): liu tn cng 0,6 mcg/kg/
pht truyn TM trong 30 pht sau truyn TM
0,15 mcg/kg/pht trong 12 -24 gi tip theo.
d. Lamifiban: 0,1 mcg/kg/pht truyn TM/ 24 gi.
3. Cch dng: cc thuc ny c th c dng nh sau:
a. Dng trong lc can thip MV lm gim nguy c
d
rve vi
t vong hoc NMCT (th nghim sEPIC
e
re
Reopro lm gim ti 90 % nguy c
hoc
tstvvong
h
. n
g
m
NMCT sau 30 ngy lin quan ln
thip).
o
l ri .can
c
hoo (th nghim
v. AMV
e
a
b. Dng trc lc can thip
o
l @y
Fin0lm
20 gim ti 20 % nguy
CAPTURE vi Reopro
.
08 ty2
0
2 ihoc phi can thip li sau 30
c t vong, NMCT
t otoc
h
P n can thip).
g
ngy c lin
ri quan
y
p
Coc lp cho TNK: lm gim 10-17 %
c. Dng
nguy c t vong hoc NMCT trong TNK
(th nghim PURSUIT vi Eptifibatid, th
nghim PRISM vi Tirofiban).
F. Cc Nitrates
1. Cha c nghin cu no chng minh c Nitrate
lm gim nguy c t vong hoc NMCT bnh nhn
TNK, nhng Nitrate l iu tr quan trng
gim au ngc cho bnh nhn v ci thin triu
chng.
2. Liu dng: nn bt u ngay bng xt di li (hoc
ngm) cho bnh nhn, sau thit lp ng truyn
TM truyn Nitroglycerin vi liu 10-20 mcg/pht.
C th tng liu sau mi 5-10 pht tu p ng ca
10
G. Cc thuc chn bta giao cm

1. Cc thuc chn bta giao cm gip lm gim nhu cu
xy ca c tim do gim co bp c tim v gim nhp
tim. Hn na, thuc c th lm gim p lc y
tm trng nn lm tng mu v MV trong k tm
thu. Dng chn bta giao cm bnh nhn TNK
khng nhng lm gim au ngc tt m cn c
chng minh l lm gim t l bin thnh NMCT v
gim din hoi t c tim nu b NMCT. Cc thuc
chn giao cm c coi l thuc hng u trong
d
iu tr TNK.
rve
e
s
re
ts Metoprolol,
2. Nn dng cc thuc chn chn lc 1:
n
h
g
i om.v
r
l
Atenolol...
l .c
v. A ahoo
e
o
3. Chng ch nh: Nhp chm
l (bloc
y nh tht cao);
Fin020@Suy tim nng mt b;
.
Bnh phi mn tnh tc
nghn;
08 ty2
20 Huyt
i p thp; Sc tim.
Bnh mch ngoit vi;
toc
h
o
P
g
ri
4. Mc tiuoiu
py tr l gim c triu chng au ngc
C
v gim nhp tim. Nn bt u bng liu thp v theo
di st. Thng dng Metoprolol tim TM 5 mg sau
tng dn liu theo p ng sau 5-10 pht. C th
dng gi bng vin Metoprolol liu thp 25-50 mg
mi 12 gi.
H. Cc thuc chn knh canxi
1. Cc thuc ny lm gin mch, chm nhp tim, gim
sc co bp c tim. Nu dng n c trong
TNK c th lm tng nguy c NMCT hoc t
vong.
2. Ch nn dng thuc chn knh calci trong trng hp
c THA nhiu v/hoc khi chc nng tht tri bnh
nhn cn tt, nhp khng chm v c yu t co tht
11
m t p ng vi Nitrates hoc khng th dng c

thuc chn bta giao cm.
I.
Cc thuc c ch men chuyn

1. Khng phi thuc thng quy trong iu tr
TNK.
2. Nn dng khi c km theo gim chc nng tht tri
m huyt p cn tt.
J. Vn dng cc thuc tiu huyt khi

1. Cho n nay thng nht l KHNG dng thuc
tiu huyt khi cho bnh nhn TNK v khng
nhng khng ci thin c tin lng m cn gia
tng t l NMCT v t vong (nghin cu TIMI-IIIb).
ved hon
2. C ch c th l v trong TNK chasertc
re
ton MV nn thuc tiu huyt khi hny
lm
ts vkhng
. n
g
ri cc
mth
ci thin thm dng chy m nll li
lm
tan
o
A hoo.
.
v
cc mu ng bao ly ch
a ca mng x va,
oe v
@y ny gy hot ho
inl 2mc
0
F
lm l ra li lp di
ni
8. 20
00 li.
ngng kt tiu cu 2tr
ity
t otoc
h
P (nong hoc t Stent)
K. iu tr can thip
rig MV
y
p
Co cho chp MV: can thip MV
1. Ch nh
c bn n phn ch nh chp MV ni trn.
a. Cc tn thng MV ph hp cho can thip l:
tn thng ngn, khng vi ho, tn thng t
mch, khng phi thn chung, chc nng tht tri
cn tt...
b. Mt s trung tm c iu kin trang thit b v
kinh nghim tt ca bc s can thip th c th
xt can thip ngay (cp cu) cho mi bnh nhn
TNK khi n vin, tuy nhin kt qu cha
vt tri so vi bt u bng iu tr ni khoa.
12
Hnh 1-2. Hnh nh T ca mt trng hp TNK,

d
rve
ST chnh xung v T m t V1-V6
e
s
re
hts cc
2. Khi can thip MV, vic dng phiighp
.vn thuc l
r
m
o
l
l .c
rt quan trng:
v. A ahoo
e
o
lkt tiu
y cu ng ung :
a. Cc thuc chng ngng
Fin020@
.
8 Ticlopidin
Aspirin phi hp00vi
hoc Clopidogrel.
2
2 ocity
t thtth Glycoprotein IIb/IIIa.

b. Thuc c ch
igh Po
r
y
c. Thucopchng ng (Heparin, LMWH).
C
Hnh 1-3. Hnh nh chp ng mch vnh ca bnh nhn

TNK trc (hnh tri) v sau (hnh phi) t Stent
(mi tn ch v tr thng tn).
13
L. M lm cu ni ch-vnh
1. Cc ch nh cho phu thut:
a. Tn thng nhiu thn MV m on xa cn tt.
b. Tn thng thn chung MV.
c. Cc tn thng qu phc tp (vi ho, xon vn,
gp gc, ch chia nhnh...) m khng th can
thip nong hoc t stent c.
d. Tht bi khi can thip.
2. Cc yu t d on nguy c cao cho phu thut l:
tui cao, c nhiu bnh nng km theo, chc nng
tht tri gim nhiu, tiu ng, kinh nghim ca
phu thut vin... Tuy nhin, mt s nghin cu
(BARI, CASS) cho thy nhng bnh nhn
d tiu
rvec tn
e
ng hoc suy gim chc nng tht rtri,
s
e
s ncu ni t
tlm
h
thng nhiu thn MV th phu thut
v
.
g
l ri .com
l
ra u th hn so vi can thip MV.
A o
ev. yaho
o
l
Ti liu tham kho
Fin 0@
8. 202
0
y
1. Antman EM, Tanasuevic MJ,
B, et al. Cardiac-specific
20 Thompson
cit of mortality
t theotorisk
troponin I levels to predict
in patients with acute
h
rigN EnglP J Med 1996;335:1342-1349.
coronary syndromes.
y
p
Co
2.
Bittl JA, Strony J, Brinker JA, et al. Treatment with bivalirudin

(Hirulog) as compared with heparin during coronary angioplasty for
unstable or ostinfarction angina. N Engl J Med 1995;333:764-769.
3.
Boden WE, O'Rourke RA, Crawford MR, et al. Outcomes in patients

with acute non-Q-wave myocardial infarction randomly assigned to
an invasive as compared with a conservative management strategy.
N Engl J Med 1998;338:1785-1792.
4.
Braunwald EG, Mark DB, Jones RH et. al. Unstable angina:

diagnosis and management. Clinical Practice Guideline Number 10.
AHCPR Publication No.94-0602. Rockville, MD: Agency for
Health Care Policy Research and the National Heart, Lung, and
Blood Institute, Public Health Service, U.S. Department of Health
and Human Services, 1994.
5.
Cohen M, Demers C, Garfinkel EP, et al. Low-molecular-weight

heparins in non-ST segment elevation ischemia: the ESSENCE trial.
Am J Cardiol 1998;82:196-246.
14
6.
EPILOG Investigators. Platelet glycoprotein Ilb/lIla receptor

blockade and low-dose heparin during percutaneous coronary
revascularization. N Engl J Med 1997; 336:1689-1696.
7.
Fuster V, Badimon L, Badimon JJ, et. al. The pathogenesis of

coronary artery disease and the acute coronary syndromes. N EngI J
Med 1992;326:242-250.
8.
Gersh BJ, Braunwald EG, Rutherford JD. Chronic coronary artery

disease: unstable angina. In: Braunwald EG, ed. Heart disease: a
textbook of cardiovascular medicine, 5th ed. Philadelphia: WB
Saunders, 1997:1331-1339.
9.
Granger CB, Califf RM. Stabilizing the unstable artery. In: Califf
RM, Mark DB, Wagner GS, eds. Acute coronary care, 2nd ed. St.
Louis: Mosby, 1995:525-541.
10. Hamm CW, Goldmann BU, Heeschen C,et al. Emergency room
triage of patients with acute chest pain by means of rapid testing for
d
cardiac troponin T or I. N Engl J Med 1997;337:1648-1653.
rve
res
11. Lincoff AM, Califf RM, Moliterno DM, et al.

htsComplementary
.vn of platelet
gblockade
i
clinical benefits of coronary-artery stenting and
r
m
o
l
l o.c
glycoprotein lIb/Illa receptors. N Engl J vMed
. A 1999;341:319-327.
ho
loe
ya
in 2between
12. Moliterno DJ, Granger CB. Differences
unstable angina and
0@
. F pathophysiological
0
8the
acute myocardial infarction:
and clinical
2
0
0 ity
c
2Acute
spectrum. In: Topol EJ, ted.
coronary
syndromes,
1st ed. New
o
h Pot
York: Marcel Dekker,
rig1998:67-104.
opy
C
13. Ohman EM, Armstrong
PW, Christenson RH, et al. Cardiac troponin
T levels for risk stratification in acute myocardial ischemia. N Engl J
Med 1996;335:1333-1341.
14. Oler A, Whooley MA, Oler J, et al. Adding heparin to aspirin
reduces the incidence of myocardial infarction and death in patients
with unstable angina: a meta-analysis. JAMA 1996;276:811-515.
15. Roe MT. Unstable angina and non-ST-segment elevation MI. In:
Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular
Medicine. Philadelphia: LippincottRaven, 2000.
16. Stone PH, Thompson B, Anderson HV, et al. Influence of race, sex,
and age on management of unstable angina and non-Q-wave
myocardial infarction: the TIMI III registry. JAMA 1996;275:11041112.
17. Theroux P, Ouimet H, IvicCans J, et. al. Aspirin, heparin, or both to
treat acute UA. N Engl J Med 1988;319:1105-1111.
15
18. TIMI IIIB Investigators. Effects of tissue plasminogen activator and

a comparison of early invasive and conservative strategies in
unstable angina and non-Q-wave myocardial infarction. Circulation
1994;89: 1545-1556.
19. Van Miltenburg AJ, Simoons ML, Veerhoek RJ, et al. Incidence and
follow-up of Braunwald subgroups in unstable angina. J Am Coll
Cardiol 1995;25:1256A292.
20. White RD. Unstable angina: ischemic syndromes. In: Topol EJ, ed.
Textbook of cardiovascular medicine. 1st ed. Philadelphia:
Lippincott-Raven, 1998:365-393.
21. Williams DO, Braunwald E, Thompson B, et al. Results of
percutaneous transluminal coronary angioplasty in unstable angina
and non-Q-wave myocardial infarction: observations from the TIMI
IIIB trial. Circulation 1996;94:2749-2755.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
16
au tht ngc n nh
(Bnh tim thiu mu cc b mn tnh)
William Heberden l ngi u tin m t thut ng au

tht ngc t hn 220 nm nay. Cho n by gi, y l loi
bnh kh thng gp cc nc pht trin v c xu hng gia
tng rt mnh cc nc ang pht trin. Theo c tnh hin
M c khong gn 7 triu ngi b au tht ngc v hng nm
c thm khong 350 000 ngi b au tht ngc mi.
au tht ngc n nh cn c gi l Bnh c tim thiu
ed l
mu cc b mn tnh hoc Suy vnh. Cn au thtrvngc
e
s
re tim thiu
triu chng thng c trong hai tnh trng ca bnh
ts vn
h
.
g
mu cc b, l: au tht ngc n nh v au
tht ngc
khng
l ri .com
l
A
o
n nh.
o
.
h
v
loe @ya
n
i
0 khng c nhng din
A. au tht ngc n nh l tnh
. F 2trng
02
08cn
y
0
bin nng ln bt n ca
au
tht ngc trong vng
2 tocit
t
h
o
vi tun gn y.igVi au
P tht ngc n nh th tnh trng
r
y
p
lm sng thng
n
nh,
cn au tht ngc ngn, xy ra
Co
khi gng sc, khi ngh v p ng tt vi Nitrates.
au tht ngc n nh thng lin quan n s n nh
ca mng x va.
B. au tht ngc khng n nh l tnh trng bt n v lm
sng, cn au tht ngc xut hin nhiu v di hn, xy
ra c khi bnh nhn ngh ngi v cn au t p ng vi
cc Nitrates. Cn au ny thng lin quan n tnh
trng bt n ca mng x va ng mch vnh.
I. Triu chng lm sng
Ch khai thc k bnh s, nh gi cc yu t nguy c.
A. Triu chng c nng
1. Cn au tht ngc in hnh:
17
a. V tr: Thng sau xng c v l mt vng

(ch khng phi mt im), au c th lan ln c,
vai, tay, hm, thng v, sau lng. Hay gp hn
c l hng lan ln vai tri ri lan xung mt
trong tay tri, c khi xung tn cc ngn tay 4, 5.
b. Hon cnh xut hin: Thng xut hin khi
gng sc, xc cm mnh, gp lnh, sau ba n
nhiu hoc ht thuc l. Mt s trng hp cn
au tht ngc c th xut hin v m, khi thay
i t th, hoc khi km cn nhp nhanh.
c. Mc au v cc triu chng km theo: Hu
ht cc bnh nhn m t cn au tht ngc nh
tht li, nght, rt, b nng trc ngc v i
khi cm gic but gi. Mt s bnh nhnvec
d kh
r
e
s
th, mt l, au u, bun nn, v mrhi...
e
ts vn
h
.
g
d. Thi gian cn au: Thng khong
vi pht, c
l ri .com
l30
A
o
th di hn nhng khng qu
pht.
Nhng cn
o
.
ev yah
o
l
au xy ra do xc cm
0@ ko di hn l au
Finthng
02au m ch ko di di
8. cn
do gng sc. Nhng
2
0
20 ocity
1 pht th nn
nguyn nhn khc ngoi tim.
t tm
h
Pot
ig
r
y
2. Phn loiopau tht ngc n nh: Cho n nay cch
C
phn loi mc au tht ngc theo Hip hi Tim
mch Canada (Canadian Cardiovascular Society CCS) l c ng dng rng ri nht v rt thc t.
B. Khm lm sng: Khm thc th t c hiu nhng rt
quan trng, c th pht hin cc yu t nguy c hoc
nhng nh hng n tim.
1. Cc yu t nguy c cao ca bnh ng mch vnh c
th pht hin thy l: Tng huyt p, mng
Xantheplasma, bin i y mt, cc bng chng ca
bnh ng mch ngoi vi.
2. Trong cn au tht ngc c th nghe thy ting T3,
T4; ting ran phi... Ngoi ra t c triu chng thc
th no l c hiu.
18
3. Khm lm sng gip chn on phn bit cc nguyn

nhn khc gy au tht ngc nh: Hp ng mch
ch, bnh c tim ph i, bnh mng ngoi tim, vim
khp c sn...
Bng 2-1. Phn au tht ngc theo CCS.
c dim
Ch thch
Nhng hot ng th au tht ngc ch xut
I
lc bnh thng khng hin khi hot ng th
lc rt mnh.
gy au tht ngc.
Hn ch nh hot ng au tht ngc xut hin
II
th lc bnh thng.
khi leo cao >1 tng gc
thng thng bng cu
thang hoc i b di hn
2 dy nh.
d
rvie b
e
III Hn ch ng k hot au tht ngc rkhi
s
e
ts nh
ng th lc thng di t 1-2 gdy
h
vn hoc
.
ri cogc.
m
leo caoA1ll tng
thng.
o.
v.thtahongc
e
khi lm
IV Cc hot ng th lc au
o
y
inl 20@
nh,
khi
gng
sc
bnh thng u gy8. Fvic
20
0 tynh.
0
au tht ngc.
2 i
t otoc
h
P
g
II. Cc xt nghim chn
on
ri
y
p
Co
Hnh 2-1. Cc xt nghim chn on au tht ngc.

19
A. in tm lc ngh: l mt thm d sng lc trong

bnh mch vnh.
1. C ti > 60% s bnh nhn au tht ngc n nh c
in tm (T) bnh thng. Mt s bnh nhn
c sng Q (chng t c NMCT c), mt s khc c
ST chnh xung, cng, thng un. T cn gip
pht hin cc tn thng khc nh ph i tht tri,
bloc nhnh, hi chng tin kch thch...
2. T trong cn au c th thy s thay i sng T v
on ST (ST chnh xung, sng T m). Tuy nhin
nu T bnh thng cng khng th loi tr c
chn on c bnh tim thiu mu cc b.
B. Nghim php gng sc (NPGS): Rt quan dtrng
rve xc
trong au tht ngc n nh, gip cho chneseon
r
ts
nh, tin lng cng nh iu tr.
gh m.vn
i
r
l .coc tim cc b
1. NPGS s gy ra tnh trng thiu
Almu
oo
.
v
e theo
ah di lin tc bng
o
l
hoc lm gin MV v c
y
0@
Fin02T
mt phng tin no0
gng sc hay siu
8. nh
2
0 ity
2
cnhy v c hiu ca tng
m tim gng sc.
t
oto
gh Psc
igng
phng php
l c s khc nhau.
r
opy
C
2. Phng php gy thiu mu c tim cc b:
a. Gng sc th lc:
C ch: Lm tng nhu cu xy c tim, lm c
tim tng co bp, tng tin gnh v hu gnh.
Vic tng nhu cu xy c tim s dn n tng
nhp tim v nh hng n huyt p. Da vo
s tng nhp tim ny xc nh kh nng
gng sc ca bnh nhn. Mt khc, khi nhp
tim tng ln s lm cho nhu cu tiu th xy
c tim tng ln v lc s xut hin nhng
bin i trn T hoc cc hnh nh khc m
khi ngh c th s khng thy.
20
Gng sc th lc gip d on kh nng hot

ng th lc ca bnh nhn v giai on gy
ra thiu mu c tim.
Tuy nhin gng sc th lc khng th thc
hin c nhng bnh nhn c chng i
cch hi, bnh phi nng, bnh khp, hoc
nhng d tt, nhng bnh c nh hng n
kh nng thc hin gng sc ca bnh nhn.
b. Dng mt s thuc lm gin MV: nh
Adenosin v Dipyridamole.
C ch: Adenosin lm gin cc vi mch ca
h thng mch vnh, do nu c hp mt
nhnh MV th cc nhnh cn li gin ra ly
ht mu nhnh gy ra hin tnged thiu
rv
mu c tim tng ng vi nhnh MV
ese b hp
r
ts
(hin tng n cp mu).
gh m.vn
i
r
ll och
Dipyridamole cng c. Ac
.co ging nh
o
h
v
oehinatc dng chm hn
Adenosin nhng xut
inl 20@y
F
.
v ko di hn.
08 ty20
0
2
i
Cc thuc
t ny
tocthng dng cho phng php
h
o
P
g
i
chnyron
ti mu c tim bng phng x.
p
o
C
c. Dng cc thuc lm tng co bp c tim v tng
nhp tim (Dobutamine v Arbutamine)
C ch: L cc thuc kch thch 1 giao cm,
lm tng co bp c tim, lm tng nhu cu xy
ca c tim.
Cc thuc ny thng dng khi lm siu m
gng sc.
3. Cc phng php gng sc:
a. in tm gng sc:
nh gi c nhng bnh nhn c nguy c
cao v bnh mch vnh. Nhng d liu trong
bng sau s gip chng ta c th d on
c nhng bnh nhn c nguy c cao b
bnh MV khi lm T gng sc.
21
D on mc hot ng th lc an ton
cho bnh nhn (nht l sau NMCT).
Tuy nhin, T gng sc t c gi tr nhng
bnh nhn m T c bn c nhng bt
thng nh dy tht tri, ang c t my to
nhp, bloc nhnh tri, ri lon dn truyn...
T gng sc cng khng d on c mc
hp MV v khng nh v chnh xc
c vng c tim thiu mu.
Bng 2-2. Nhng d kin gip d on nguy c cao b
bnh mch vnh trn in tm gng sc.
Khng kh nng chy 6 pht theo phc Bruce.
Nghim php dng tnh sm ( 3 pht).
Kt qu gng sc dng tnh mnh (ST chnh xung
d
2 pht).
rve
e
s
re sc.
ST chnh xung 3 pht sau khi ngngtsgng
n
h
g
ST chnh xung kiu dc xung (down-sloping).
i om.v
r
l
l otim
c
Thiu mu c tim xut hin mc. Anhp
o . cn tng
h
v
e
a
o
i thp ( 120 ck/pht).
l @y
0
Fini.
Huyt p khng tng hoc
tt
.
0
8 2 2
0
y
0
Xut hin nhp nhanh
2 thtit mc nhp tim 120 chu
t otoc
h
k/pht.
P
g
ri
y
p
b. SiuCm
tim
gng
sc: L thm d c gi tr, n
o
gin v c th cho php d on vng c tim
thiu mu v v tr MV tng ng b tn thng.
Siu m gng sc c th lm vi gng sc th
lc (xe p nm) hoc thuc (Dobutamine).
Tuy nhin, kt qu ca thm d ny cn ph
thuc nhiu vo kinh nghim ca ngi lm
siu m v i khi kh khn nu hnh nh m
(Bnh nhn bo, bnh phi...)
c. Phng php phng x o ti mu c tim:
Thng dng Thalium201 hoc Technectium99m.
C nhy, c hiu cao, o c tng vng
ti mu c tim song nhy, c hiu b
gim nhng bnh nhn bo ph, bnh hp c 3
nhnh MV, bloc nhnh tri, n gii...
22
C. Siu m tim thng quy

1. Tm nhng ri lon vn ng vng (nu c).
2. Gip nh gi chc nng tim, bnh km theo (van
tim, mng tim, c tim...).
D. Holter in tim: C th pht hin nhng thi im xut
hin bnh tim thiu mu cc b trong ngy, rt c
ngha nhng bnh nhn b co tht MV (Hi chng
Prinzmetal) hoc bnh tim thiu mu cc b thm lng
(khng c au tht ngc). Trong cn co tht mch vnh
c th thy hnh nh on ST chnh ln. Ngoi ra c th
thy c mt s cc ri lon nhp tim khc.
Bng 2-3. Ch nh chp MV theo AHA/ACC.
d
Nhm I: C ch nh thng nht
rve
e
s
Khng khng ch c triu chng vi iu
tr
ni
e
sr n
t
h
khoa ti u.
ig om.v
ll r o.c(bng
Bnh nhn c nguy c cao khi lm ANPGS
2-2).
ho tht tri t
ev. yanng
C bng chng ca ri lon lochc
Fin 0@
mc va.
8. 202
0
0 ity mu ln.
Chun b cho phu thut
c
2 tomch
t
h
Ngh nghip hoc
Po sng c nhng nguy c bt
ig li
r
thng. Copy
Nhm II: (Thng c ch nh, nhng cn cn nhc)
Bnh nhn tr tui c bng chng ca bnh c tim
thiu mu cc b trn NPGS hoc c tin s NMCT.
Bng chng ca thiu mu c tim nng trn NPGS.
Nhm III: (Thng khng c ch nh)
Bnh nhn au tht ngc mc nh (CCS I, II) v
triu chng, khng c ri lon chc nng tht tri v
khng c nguy c cao trn NPGS.
E. Chp ng mch vnh: l phng php quan trng
gip chn on xc nh c hp MV hay khng v mc
cng nh v tr hp ca tng nhnh MV.
1. Ch nh chp MV: Nhn chung ch nh chp
MV bnh nhn suy vnh l nhm mc ch can
thip nu c th. V y l mt thm d chy mu v
23
kh tn km nn vic ch nh cn cn nhc n li
ch thc s cho bnh nhn. Hi Tim mch Hoa k v
Trng mn Tim mch Hoa k (AHA/ACC) c
nhng khuyn co v ch nh chp MV bnh
nhn suy vnh nh trong bng 2-3.
III. iu tr
A. Mc ch: Ngn nga nguy c t vong v bin chng,
ci thin cht lng cuc sng.
d
rve
e
s
re
ts vn
h
.
g
l ri .com
l
A o
ev. yaho
o
l
@
Fin020va
Hnh 2-2. Tin trin ca 0mng
MV.
8. 2x
0 ity
2
B. La chn phng
t php
toc
igh Po
r
py php iu tr: Thuc, can thip MV,
1. C 3 phng
Co
m lm cu ni ch vnh. Thm vo , cn phi
iu chnh cc yu t nguy c cho ngi bnh.
2. Vic ch nh ph thuc vo tnh trng bnh v nn
bt u cng nh duy tr bng iu tr ni khoa.
Trong trng hp iu tr ni khoa tht bi hoc bnh
nhn c nguy c cao trn cc thm d th cn c ch
nh chp MV v can thip kp thi.
C. iu tr ni khoa
1. Cc thuc chng ngng kt tiu cu:
a. Aspirin: Lm gim t l t vong v nhi mu c
tim ti 33% (SAPAT). Liu dng t 75 - 325
mg/ngy.
b. Nu d ng hoc dung np km vi Aspirin:
24
Ticlopidine (Ticlid): vin 250mg, dng 2

vin/ngy. Tc dng ph c th gp l h
bch cu mu (3-5%), h tiu cu. Cn phi
theo di cng thc mu khi dng.
Clopidogrel (Plavix): Vin 75mg, hiu qu
cao v t tc dng ph hn Ticlid, liu
75mg/ngy.
c. Trong trng hp c ch nh chp MV m c
can thip t stent th cn dng phi hp gia mt
trong hai loi thuc ny vi Aspirin v dng cho
bnh nhn t nht trc 2 ngy can thip. Sau can
thip MV thuc ny cng Aspirin phi c
dng thm t nht 1 thng, sau c th ch cn
dng Aspirin. Tuy nhin, nhng nghin cu
ed gn
v
r
e
y cho thy rng dng thm Plavix ko
res di thm
ts vn
9 thng cng cho li ch r rt hn.
h
.
g
l ri .comCh c dng
l
d. Thuc c ch th th GP. IIb/IIIa:
A hoo
evciyathin
o
l
tim c chng minh
l
tt t l sng
in 20@
0
v t bin chng08. Fbnh
nhn
c
nong ng
0 ity2
2
mch vnh hoc
t t
toc Stent.
igh Po
r
py
Co
Hnh 2-3. C ch tc dng ca cc thuc chng ngng

tp tiu cu.
25
2. iu chnh ri lon Lipid mu: c chng minh

l c kh nng phng nga c tin pht ln th pht
bnh MV.
a. Ch nh:
Bnh nhn c ri lon lipid mu m c tin s
au tht ngc hoc NMCT.
Bnh nhn sau lm cu ni MV.
b. Cc nhm thuc:
c ch men HMG-CoA: Simvastatin (Zocor),
Atorvastatin (Lipitor), Fluvastatin (Lescol)...
l nhng thuc c chng minh l rt tt
trong ngn nga bnh ng mch vnh. Th
nghim 4S vi Simvastatin cho thy gim r
d
rt nguy c bnh MV bnh nhn
rve c
e
s
dng thuc so vi nhm chng. s re
t n
Dn xut Fibrat: nh Gemfibrozil
ighom.v (Lopid),
r
l
l .c (Banzalip).
Fenofibrat (Lipanthyl),Benzafibrat
v. A ahoo
e
o
l
y
Nicotinic acid (Niacin).
Fin020@
.
Cc loi Resins
2 acid mt: Colestipol,
08 gn
20 ocity
Cholestyramine.
t
t
igh Po
r
y
3. Cc dn oxut
Nitrates:
p
C
a. C ch:
Lm gim nhu cu xy c tim do gy gin
mch lm gim tin gnh v mt phn hu
gnh ca tht tri.
C th lm tng dng mu ca MV do lm
gim p lc cui tm trng ca tht tri v
lm gin MV.
Ngoi ra cn c mt phn tc dng c ch
ngng kt tiu cu.
b. La chn thuc: (Bng 2-4).
c. Tc dng ph:
au u: Do gin mch no, c th gim bt
liu khi c triu chng ny.
C th gp bng mt, chng mt, h HA.
26
Cn thn khi ung vi cc thuc gin mch

khc. Chng ch nh dng cng vi
Sildenafil (Viagra).
Ch l thng c s quen thuc khi dng
Nitrates lin tc ko di, do cn dng ngt
qung (khng nn dng lin tc).
Bng 2-4. Cc loi Nitrates.
Tn thuc
ng
Liu
S ln/ngy
dng
Theo nhu cu
Nitroglycerin Vin ngm 0,15-0,6 mg
di li
(Glycerin
Theo nhu cu
0,4 mg
Dng xt
trinitrate
Mi 6-12 gi
Vin
gii 2,5 - 9,0 mg
Nitrobid,
phng chm
Nitrostat,
d
rve
e
s
Mi
1,25 5 cm
M bi
Nitrodur,
re 4-8 gi
ts v24
2,5 - 15 mg righMi
Ming dn
Natispray,
. n gi
m
o
l
l .cTruyn lin
Dng tim 5-400g/pht
Nitromit...)
v. A ahoo
e
o
l
y
tc
truyn TM
Fin020@
.
8 -210 mg
Mi 2 - 3 gi
Vin ngm 002,5
Isosorbide
ty
di liht 2 otoci
dinitrate
P 5 - 10 mg
rig
Mi 2 - 3 gi
Vin
nhai
(Isosorbid,
y
p
Co
Mi 6 gi
Vin
ung 10 - 40 mg
Lenitral,
Mi 8 - 12 gi
40 80 mg
Vin chm
Sorbitrate)
Mi 12 gi
Isosorbid - 5- Vin ngm 10 - 40 mg
mononitrate di li
Mi 24 gi
60 mg
(Imdur, Ismo) Vin chm
Erythrityl
tetranitrate
(Cardilate)
Vin ngm
Vin ung
5 - 10 mg
10 mg
Theo nhu cu
Mi 8 gi
4. Cc thuc chn giao cm:

a. C ch:
Chn 1 giao cm do lm gim nhp tim,
gim sc co c tim v lm gim nhu cu xy
c tim. N cng lm gim sc cng ln thnh
27
tht tri nn lm dng mu t thng tm mc

ti n ni tm mc nhiu hn.
Ring cc thuc c chn 2 giao cm c th
gy co mch vnh, nn khng dng bnh
nhn c co tht MV.
Thuc chn giao cm c s dng nh
thuc hng u trong iu tr suy vnh (nu
khng c chng ch nh). N c chng
minh l lm gim t l t vong v nhi mu
c tim bnh nhn au tht ngc n nh.
b. Chng ch nh:
Bnh phi mn tnh tc nghn.
Nhp chm, cc bloc nh-tht.
Suy tim nng.
d
rve
e
Bnh mch mu ngoi vi.
s
re
ts vnl nhng
h
i tho ng, ri lon m
mu
.
g
l ri .com
l
chng ch nh tng i.
A o
ev. yaho
o
c. Cc loi thuc:
l
Fin 0@
Chn lc 1. 08. 202
20 ity
(a) Metoprolol
t otoc(Betaloc): 50 - 200 mg/ ngy.
h
P (Tenormin): 25 - 200 mg/ngy.
rig
(b)pyAtenolol
Co Acebutolol (Sectral): 200 - 600 mg
(c)
(d) Betaxolol: 20 - 40 mg/ngy
Khng chn lc (chn c 1 v 2)
(a) Propranolol (Inderal): 40 - 320 mg/ ngy
(b) Nadolol, Timolol, Pindolol
Chn c v : Labetalol, Carvedilol
5. Cc thuc chn dng canxi:
a. C ch: Chn dng canxi vo cc t bo c trn
mch mu, v vo t bo c tim nn lm gin
mch, v c th gim sc co bp c tim.
b. Cc nhm thuc:
Dihydropyridines: (Nifedipin, Amlordipine,
Felodipine, Isradipine); t tc dng ln MV.
Nifedipin v Amlordipine c th dng trong
28
mt s trng hp, c bit khi c THA v c

yu t co tht km theo.
Benzothiazepines: Diltiazem (Tildiem) 30-90
mg x 3 ln/ngy. Khng dng bnh nhn c
gim chc nng co bp tht tri, nhp chm.
Phenylalkylamine: Verapamil (Isoptine): 120
- 240 mg x 2 ln/ngy. C th lm gim chc
nng co bp tht tri v lm chm nhp tim.
Khng dng thuc ny bnh nhn suy tim.
c. Tc dng ph:
H huyt p, bng mt, chng mt, au u...
Gy gim sc co bp c tim, nhp chm, nn
thuc c coi l chng ch nh bnh nhn
c suy tim hoc nhp chm.
d
rve
e
s
6. c ch men chuyn: Ch nn dng rnhng
bnh
e
ts c
n ri lon
h
v
nhn au tht ngc n nh sau NMCT
.
g
i m
ll r o.coc
chc nng tht tri hoc bnh
nhn
THA km
A
o
.
evthp
ah trnh tt huyt
o
l
y
theo. Nn khi u bng iliu
F n 0@
8. 202
p v suy thn.
0
20 ocity
t thay
7. iu tr Hormon
h
Pot th:
rig
y
p
a. ph
Co n mn kinh c s gim Estrogen do c
th ri lon Lipid mu lm tng nguy c bnh
mch vnh v THA. C nhiu nghin cu
chng minh vai tr ca iu tr thay th hormon
nhng bnh nhn n mn kinh lm gim nguy c
mc bnh THA hoc MV.
b. Hin nay thng dng l Estrogen, liu 0,625 mg
/ngy, ung trong 25 ngy lin tc, ngh 5 ngy.
8. Cc thuc chng gc xy t do: Vitamin E 400 800 n v/ngy c th lm gim mt s bin c bnh
tim mch. Tuy nhin cc nghin cu cn cha thng
nht v li ch thc s ca n trong bnh MV.
D. iu tr can thip ng mch vnh
(Nong MV bng bng, t Stent hoc dng cc thit b khc).
29
1. So snh vi dng thuc iu tr: lm gim triu chng

v gim t l t vong ng k (cc th nghim
ACME, MASS, RITA - 2). So snh vi phu thut
lm cu ni: Nu nhng bnh nhn c bnh tn
thng 1 ng mch vnh, li ch vt tri ca can
thip MV khng cn phi bn ci. Tuy nhin
nhng bnh nhn b tn thng nhiu ng mch
vnh, trc y thng ch nh cho phu thut,
nhng nay mt s nghin cu cho thy kt qu cng
tng t nh m lm cu ni (Th nghim BARI).
Ring nhng bnh nhn c km theo tiu ng th
m lm cu ni MV t ra u th hn.
2. Ch nh: (Xem cc ch nh chp ng mch vnh).
Ngoi ra, khi chp MV thy tn thng khu
d tr,
rve
e
s
khng phi thn chung, khng phi rebnh c 3
ts vn u tin
MV, chc nng tht tri cn tt...
.
ghthmnn
i
r
o
l
l
c
.
cho can thip MV.
A o
ev. yaho
o
l
@ tr can thip ng
3. Cc phng php trong
in iu
. F 2020
8
0
mch vnh bao gm:
ty ng mch vnh bng
20 cinong
t otoMV,
bng, t Stent
trong
bo gt mng x va c
h
P
ig
r
y
nh hng
p (Directional Coronary Angioplasty),
Co
khoan mng x va (Rotablator)... S la chn cc
phng php ny tu thuc vo tn thng khi chp
MV, trnh , kinh nghim thy thuc cng nh
kh nng trang thit b. Hin nay, vi s pht trin
mnh m ca khoa hc k thut cho ra i nhng
dng c tin tin v vic dng cc thuc mi (v d
thuc c ch th th IIb/IIIa) phi hp vi can thip
MV cho t l thnh cng ca can thip rt cao
vi rt t bin chng.
4. Mt vn cc k quan trng l khi can thip MV
phi dng phi hp cc thuc iu tr ni khoa tt,
trong vai tr ca cc thuc chng ngng kt tiu
cu l rt quan trng ngn nga bin chng tc
mch vnh cp. Nu c t Stent th nn dng phi
30
hp Aspirin vi Ticlopidin (hoc Clopidogrel) trc t

nht 2 ngy, sau ko di thm Clopidogrel
(Plavix) hoc Ticlopidine (Ticlid) khong 2 4 tun
th dng, ch cn Aspirin l ko di mi. Tuy nhin,
nhng nghin cu gn y cho thy rng dng phi
hp Plavix v Aspirin ko di thm 9 thng cng cho
li ch r rt hn. Trong lc can thip th cn dng
Heparin, nu kt qu can thip tt, khng cn dng
tip Heparin. Cc thuc mi c ch th th GP
IIb/IIIa nu c dng phi hp s cho kt qu cao
hn v t bin chng. Tuy nhin gi cc loi thuc
ny kh t.
5. Vn ti hp (restenosis) sau khi can thip cng
rt nan gii. Mc d Stent lm gim ng vk
d t l
r e
e
s
ti hp nu so vi ch nong ng mch
re vnh n
ts vn
n
h
thun, nhng t l ti hp sau 6 thng
g
i om.v kh cao
r
l
l nhiu
.c
(10-20%). Ngi ta ang th nghim
bin php
v. A ahoo
e
o
l
y
mi ngn nga ti hp cho
kt
qu
kh
quan
nh
Fin020@
.
dng phng x ti ch
Therapy) hoc k
2
08 ty(Brachial
20cc
ith nghim vi cc loi stent
c
thut gen. Gn hy
o
t ot
P phn bo c nhiu kt qu kh
rigkhng
c ph thuc
y
p
Co vic chng ti hp. Cho ti nay, hu nh
quan trong
cha c loi thuc ung no c th ngn ti hp tt.
E. M lm cu ni ch - vnh
1. Ch nh: Bnh nhiu ng mch vnh b hp (vd.
Tn thng 3 MV), tn thng thn chung, tn
thng phc tp khng ph hp cho can thip m
on xa cn tt...
2. So snh vi iu tr ni khoa: Lm gim triu chng
v ci thin t l t vong ng k (Nghin cu CASS,
ECSS, VACS). So vi can thip MV: Cho kt qu
tng t vi bnh tn thng khng nhiu MV, vi
bnh nhiu MV th c v c li ch hn, nhng
trong bnh MV km theo tiu ng th phu thut
lm cu ni ch-vnh t ra c li hn.
31
3. K thut m lm cu ni ng mch vnh hin nay

c nhiu tin b nh vic dng cc on ng
mch quay, ng mch v trong lm gim nguy c
tc cu ni sau m so vi dng tnh mch hin theo
cch truyn thng. Hn th na, nhng k thut t
xm ln nh m vi tim vn p (khng phi dng
tim phi my) ang ha hn nhng kt qu tt p.
F. iu chnh li sng
1. Tp th dc, vn ng th lc u n.
2. iu chnh ch n cho hp l.
3. B thuc l, phi tht cng quyt.
4. Cc yu t tm l: Trnh cng thng thn kinh...
d
rve
G. Mt s phng php mi
e
s
re
hts .vn LASER
1. Ti to mch xuyn c tim igbng
ll r o.com
(Directional Myocardial Laser .Revascularization):
A
v aho
loe @yl
a. Dng tia Laser khoaninnhiu
nh trc tip vo
F 020
.
cc vng c tim 0t
08trong
y2 lp ni tm mc cho n
cit C ch l to ra cc vi
2 tomc.
di thnght tm
Po
rig mu
mch pnh
t bung tim c th nui trc
y
o
tip Cc c tim v sau mt thi gian s xut hin
h thng vi tun hon mi ti mu cho c
tim.
b. C th thc hin k thut ny khi m tim hoc
qua ng ng thng tim.
c. K thut ny c ch nh khi vic la chon cc
phng php iu tr khc gp b tc (v d bnh
nhiu MV m tn thng phc tp khng can
thip c v on xa khng ph hp cho lm
cu ni).
2. Gene liu php: vn cn trong giai on nghin cu
vi hy vng dng gene bin i ci to h tun
hon vnh bng cc h tun hon bng h tn to.
32
Ti liu tham kho

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Alderman EL, Bourassa MG, Cohen LS, et al. Ten-year follow-up of

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Armstrong PW. Stable ischemic syndromes. In: Topol EJ, ed.
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CAPRIE Steering Committee. A randomized, blinded trial of
clopidogrel versus aspirin in patients at risk of ischemic events
(CAPRIE). Lancet 1996;345:1329-1339.
Diaz MN, Frei B, Vita JA, Keaney JF Jr. Mechanism of disease:
antioxidants and atherosclerotic heart disease. N Engl J Med
1997;337:408-4166.
Ferrari R. Major differences among the three classes of calcium
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Furberg CD, Psaty BM, Meyer JV. Nifedipine: dose related increase
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1995;92: 1326-1331.
Gersh BJ, Braunwaid E, Rutheiford JD. Chronic coronary
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re Saunders,
o[cardiovascular medicine, 5th ed. Philadelphia:ts WB
n
h
1997:1289-1366.
g
i om.v
r
l
Guidelines and management of stable
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pectoris:
l o.c
o
.A
recommendations of the Task Force eof
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v
o
Cardiology. Eur Heart J 1997;18:394-413.
inl 20@y
F
Juul-Moller S, Edvardsson N, Jahnmatz
8. 20 B, et al. Double blind trial of
00 ofitymyocardial
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infarction in patients
2
oc Lancet 1992;114:1421-1425.
t pectoris.
t
with stable chronic angina
h
o
PIn: Marso SP, Griffin BP, Topol EJ, eds.
ig
rangina.
Kapadia SR. Stable
y
p
Manual of Cardiovascular
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Raven, 2000.
Mark DB, Nelson CL, Califf RM, et al. Continuing evolution of
therapy for coronary artery disease. Circulation 1994;59:2015-2125.
Mark DB, Shaw L, Harrell FE, et al. Prognostic value of a treadmill
exercise score in outpatients with suspected coronary artery disease.
N Engl J Med 1991;325:S4-S53.
Parker JD, Parker JO. Drug therapy: nitrate therapy for stable angina
pectoris. N Engl J Med 1995;335:520-531.
Solomon AJ, Gersh BJ. Management of chronic stable angina:
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and coronary artery bypass graft surgery, lessons from randomized
trials. Ann Intern Med 1998;125:216223.
The Bypass Angioplasty Revascularization (BARI) Investigators.
Comparison of coronary bypass surgery with angioplasty in patients
with multivessel disease. N Engl J Med 1996;335:217-225.
The Scandinavian Simvastatin Survival Study Group. Randomised
trial of cholesterol lowering in 4444 patients with coronary heart
disease: The Scandinavian Simvastatin Survival Study (4S). Lancet
1994;344:1383-1389.
33
Nhi mu c tim cp
Nhi mu c tim (NMCT) cp l mt trong nhng nguyn
nhn hng u gy t vong M v cc nc chu u. c tnh
M c khong 1 triu bnh nhn nhp vin mi nm v NMCT
cp v khong 200.000 n 300.000 bnh nhn t vong hng
nm v NMCT cp. Vit nam s bnh nhn NMCT ngy cng
c xu hng gia tng nhanh chng. Nu nh nhng nm 50,
NMCT l bnh rt him gp th hin nay hu nh ngy no cng
gp nhng bnh nhn NMCT cp nhp vin (ti Vin Tim
mch). Nhng tin b trong chn on v iu tr NMCT cp
lm gim ng k t l t vong do NMCT cp. S ra i ca n
v cp cu mch vnh (CCU) u nhng nm 60, tip n l cc
d
rve thip
thuc tiu huyt khi nhng nm 80 v hin nay lsecan
re
ng mch vnh cp cu v nhng tin b v cchthuc
ts vnphi hp
g
i ogii
m. hin nay
lm cho t l t vong do NMCT cp trn
l rth
l
c
.
oo l > 30 %.
v. A ahy
gim xung ch cn khong < 7% so vi
etrc
o
l
y
Fin 0@
8. 202
0
20 ity
I. Sinh l bnh
t otoc
h
P
rig
y
p
C tim c nui
dng
bi 2 ng mch vnh (MV)
Co
l MV tri v MV phi. MV tri xut pht t l vnh tri
ca MC v MV phi xut pht t l vnh phi. Thc t, MV
tri li chia ra 2 nhnh ln l nhnh lin tht trc (LAD) v
nhnh m (LCx). Do vy ngi ta thng gi l 3 thn MV
nui c tim.
NMCT c hiu l do s tc nghn hon ton mt hoc
nhiu nhnh MV gy thiu mu c tim t ngt v hoi t
vng c tim c ti mu bi nhnh MV . Th phm
y chnh l mng x va ng mch. Nhng vn t ra l
trong thc t nu mng x va c pht trin m thm gy hp
nhiu thm ch tc hon ton MV theo thi gian cng khng
gy ra triu chng ca NMCT cp v c s thch nghi v pht
trin ca tun hon bng h. C ch ch yu ca NMCT cp l
do s khng n nh v nt ra ca mng x va hnh thnh
35
huyt khi gy lp ton b lng mch. Nu vic nt ra ny

khng ln v hnh thnh cc mu ng cha gy lp kn ton b
lng mch, th l cn au tht ngc khng n nh trn lm
sng.
II. Triu chng lm sng
A. Triu chng c nng
1. Cn au tht ngc in hnh:
a. au nh bp nght pha sau xng c hoc hi
lch sang tri, lan ln vai tri v mt trong tay tri
cho n tn ngn eo nhn v ngn t. Nhn
chung cn au c tnh cht ging cn au tht
ngc nhng ko di hn 20 pht v khng khi
dng Nitroglycerin.
d
rve
e
s
b. Mt s trng hp au c th lan sln
re c, cm,
t vn
h
. v.
vai, sau lng, tay phi, hoc vng
thng
g
l ri .com
l
A hoo xy ra m bnh
c. Mt s trng hp NMCT
ev.cyath
o
l
nhn khng hoc t Fcm
@ au (NMCT thm
in gic
. 2020
lng), hay gp 008bnh
nhn
sau m, ngi gi,
2 ocity
t tiut ng hoc tng huyt p.

bnh nhngc
i h Po
r
y
d. Trongoptrng hp au lan nhiu ra pha sau lng
C
phi phn bit vi tch thnh ng mch ch.
2. Cc triu chng khc i km theo c th gp l: v
m hi, kh th, hi hp nh trng ngc, nn hoc
bun nn, l ln... Cc triu chng ca ri lon tiu
ho thng gp trong trng hp NMCT sau di.
3. t t cng l mt trong nhng th hay gp ca
NMCT cp.
B. Triu chng thc th
1. Khm thc th trong NMCT cp ni chung t c gi
tr chn on xc nh nhng cc k quan trng
gip chn on phn bit vi cc bnh khc, gip
pht hin cc bin chng, tin lng bnh cng nh
l c s theo di bnh nhn.
36
2. Nhng triu chng hay gp l: nhp tim nhanh, ting

tim m, ting nga phi, huyt p c th tng hoc tt,
xut hin ting thi mi tim, cc ri lon nhp, ran
m phi, cc du hiu ca suy tim, ph phi cp....
Sau vi ngy c th thy ting c mng tim (hi
chng Dressler).
C. Cc yu t lm sng c gi tr tin lng bnh
Vic nh gi tin lng bnh nhn NMCT cp ng vai
tr rt quan trng gip thy thuc c thi x tr, theo
di bnh, cng nh gii thch cho bnh nhn v gia nh
tt hn. Nhng nghin cu ln trn th gii ch ra
nhng yu t sau (xp theo mc t cao n thp) c
tin lng xu i vi NMCT cp: (bng 3-1 v 3-2)
d
rve
1. Tui: cng cao tin lng cng xu.
e
s
re
2. Huyt p tm thu tt (< 90 mmHg). ights .vn
ll r o.tng.
com
A
3. Killip cng cao t l t vong
cng
o
.
h
v
loe @ya
ink
4. Nhp tim nhanh > 100 chu
F
20/pht.
.
08 ty20
0
5. V tr ca NMCT. 2 oci
ht Pot
rig quan
Bng 3-1. Lin
gia Killip v t l t vong
y
p
Co
trong vng 30 ngy.
c im lm sng %
T l t vong
Killip
trong 30 ngy (%)
I
Khng c triu chng 85
5,1
ca suy tim tri
13,6
II
C ran m < 1/2 phi, 13
tnh mch c ni, c
th c ting T3 nga
phi
III
Ph phi cp
1
32,2
IV
Sc tim
1
57,8
III. Cn lm sng
A. in tm (T): L mt trong nhng thm d rt
c gi tr chn on NMCT cp v nh khu NMCT.
37
T cn c lm ngay khi bnh nhn nhp vin v lm

nhc li nhiu ln sau gip chn on cng nh
theo di. Nhng thay i trn T bin thin theo thi
gian mi c nhiu gi tr. Cc tiu chun ca chn on
NMCT cp trn T l:
1. Xut hin sng Q mi (rng t nht 30 ms v su 0,20
mV) t nht 2 trong s cc min chuyn o sau:
D2, D3 v aVF; V1 n V6; D1 v aVL, hoc
2. Xut hin on ST chnh ln hoc chnh xung (>
0,10 mV) t nht 2 trong s cc min chuyn o
ni trn, hoc
3. S xut hin mi bloc nhnh tri hon ton trong
bnh cnh lm sng ni trn.
ved
Bng 3-2. Lin quan gia v tr NMCT cp v trel
sert vong.
n vong
htsl.vt
gT
i
r
m
o
l
V tr NMCT
Thay i trn Al o.c (%)
ho
T loev. yaTrong
Trong
in 20@ 30 ngy 1 nm
F
8. 20
y V100 ln
19,6
25,6
on
gn
ca ST chnh
2
tocit
t
h
o
MLTT
(LAD) 6,ig DI,P aVL hoc
r
(NMCT trc rng)Copykm theo bloc
nhnh tri
on gia ca LAD ST chnh ln V1-6,
9,2
12,5
DI v aVL
6,8
10,2
on xa ca LAD
ST chnh ln V14, hoc D1, aVL v
V5-6
NMCT sau di rng ST chnh ln D2,
6,4
8,4
(on gn ca MV D3, aVF v km
phi hoc ng mch theo mt trong cc
m)
chuyn o sau
NMCT sau di nh V1, V3R, V4R
4,5
6,7
(on xa ca MV V5-6
phi hoc M m)
R>S V1, V2 hoc
ST chnh ln ch
D2, D3 v aVF
38
Lu l: sng Q thng xut hin trung bnh sau 8-12

gi, tuy nhin trong mt s trng hp khng c sng Q
m ch c bin i ca on ST (NMCT khng Q - hay
NMCT di ni tm mc).
Trng hp NMCT tht phi th cn lm thm cc
chuyn o V3R n V6R tm cc bin i ny.
Trong trng hp km theo bloc nhnh phi hon
ton, vic chn on trn T tr nn kh khn hn.
Nu bnh nhn c NMCT trc bn c th thy hnh nh
sng T chnh ng hng vi phc b QRS V1-V4.
d
rve
e
s
re
ts vn
h
.
g
l ri .com
l
A o
ev. yaho
o
l
Fin 0@
8. 202
0
20 ity
t otoc
h
P
rig
y
p
Hnh 3-1. NMCT
sau di cp.
Co
B. Cc men sinh hc trong huyt thanh bnh nhn
1. Creatine Kinase (CK): 3 iso-enzyme ca men ny
l CK-MB, CK-MM, CK-BB i din cho c tim, c
vn v no theo th t trn. Bnh thng CK-MB
chim khong <5% lng CK ton phn (bnh thng
CK ton phn trong huyt thanh t 24-190 U/l 37oC
v CK-MB < 24 U/l).
a. Men ny bt u tng 3-12 gi sau nhi mu,
nh cao khong 24 gi v tr v bnh thng sau
48-72 gi.
b. Lu l men ny c th tng trong mt s trng
hp khc nh vim c tim, vim mng ngoi tim,
sau m tim, sau sc in. N cng tng trong mt
39
s bnh khc nh: chn thng s no, chn

thng c (k c tim truyn), tiu c vn, bnh
vim c, suy thn mn, tp th lc qu mnh...
2. Troponin: bao gm Troponin I v T, l hai loi men
c gi tr chn on cao v kh c hiu cho c tim,
hn na n cn c gi tr tin lng bnh. Cc men
ny bt u tng kh sm sau NMCT (3-12 gi) t
nh 24-48 gi v tng tng i di (5-14 ngy).
3. Lactate DeHydrogenase (LDH): bao gm 5 isoenzymes v gp mi m trong c th. LDH tng t
8-12 gi sau nhi mu, t nh 24-48 gi v ko
di 10-14 ngy. T l LDH1/LDH2 > 1 c ngha
trong NMCT.
d
rve
e
s
re
ts vn
h
.
g
l ri .com
l
A o
ev. yaho
o
l
Fin 0@
8. 202
0
20 ity
t otoc
h
P
rig
y
p
Co
Gi
Hnh 3-2. Thay i cc men sau NMCT cp (theo gi).

4. Cc Transaminase SGOT v SGPT: t c hiu
cho c tim. Tuy nhin iu kin ca chng ta th
xt nghim cc men ny cng vn c gi tr nht
nh. Trong NMCT th SGOT tng nhiu hn SGPT.
C. Siu m tim: cng rt c gi tr, c bit trong nhng
th NMCT khng Q hoc c bloc nhnh. Thng thy
hnh nh ri lon vn ng vng lin quan n v tr nhi
40
mu. Mc ri lon t gim vn ng, khng vn ng,

vn ng nghch thng v phnh thnh tim. Siu m tim
cn gip nh gi chc nng tht tri, cc bin chng c
hc ca NMCT (thng vch tim gy thng lin tht, h
van tim do t dy chng), trn dch mng tim, huyt
khi trong bung tim...
D. Thm d phng x ti mu c tim: thng khng
cn dng trong giai on cp ca NMCT. Cc thm d
ny c ch giai on sau nh gi mc ti mu
cho tng vng c tim v s sng cn ca c tim nhm
gip ch cho ch nh can thip mch vnh.
IV. Chn on phn bit
A. Vim mng ngoi tim: au thng lin tc v
cm
ved
gic rt, au thay i theo t th v nhp th,rethng
au
ser
s
t
n
h
tng khi nm nga. Trong vim mng ngoi
tim cng c
rig com.v
l ln
l
th c ST chnh ln nhng l chnh
ng
hng
.
. A ahoo
v
e
o
cc chuyn o trc tim v
l khng
y c hnh nh soi
0@chn on.
Fin0cho
2
.
gng. Siu m c th gip
ch
08 2
20 ocity
B. Vim c tim cp:

ht lPmt
ot chn on phn bit kh kh
rig chng
y
khn v cc otriu
lm sng cng nh T kh
p
C
ging NMCT. Bnh s v khm lm sng cho thy bnh
cnh nhim trng (c bit l virus) v siu m tim c
gim vn ng ng u gip thm chn on phn bit.
C. Tch thnh ng mch ch: in hnh l au d di
lan pha sau lng. Nhiu khi tch thnh MC cng gy
ra NMCT khi n nh hng n MC ln v gc MC.
Siu m tim c th thy hnh nh tch thnh MC nu
MC ln. Siu m qua thc qun rt c gi tr chn on.
Chp ct lp vi tnh (CT scan) hoc chp cng hng t
l nhng thm d tt gip chn on xc nh.
D. Nhi mu phi: thng t ngt kh th, au ngc, ho
ra mu m khng c ph phi. T l hnh nh tm ph
cp vi S1 Q3 (S su D1 v Q su D3). Chp Xquang
41
c th thy hnh nh mt m m phi v siu m tim

khng thy c ri lon vn ng vng.
E. Cc bnh cp cu bng nh thng d dy, cn au
d dy cp, vim tu cp, vim ti mt, giun chui ng
mt... cng cn c phn bit nht l vi NMCT cp th
sau di.
V. iu tr NMCT cp
A. iu tr ban u
1. Khn trng nh gi tnh trng bnh nhn v nn
chuyn ngay n nhng c s c th iu tr ti ti
mu. Kp thi nh gi cc bin chng nguy him
khng ch (lon nhp, suy tim...). Bnh nhn phi
d
c vn chuyn bng xe cu thng v c nhn
rve vin
e
s
y t i cng. ng thi thc hin cc bin
re php iu
ts vn
h
.
g
tr ban u.
l ri .com
l
. A ami
2. Cc bin php chung, ban u
hoo bnh nhn l:
evcho
o
l
y
0@ ti ging.
Fin02ng
a. Bnh nhn phi c
8. bt
2
0
20 oc2-4
ity lt/pht qua ng mi v
b. Th xy: vi
t liu
t
h
o
P thng km theo thiu xy. Mt
trong NMCT
rig cp
y
p
s trng
hp suy h hp nng cn phi t ni
Co
kh qun v cho th my ph hp.
c. Gim au y : lm gim s tng tit
cathecholamin trong mu v gp phn lm gim
nhu cu xy c tim.
Morphin sulphat l thuc c la chn hng
u, liu dng t 2-4 mg tim tnh mch sau
nhc li sau 5-10 pht nu bnh nhn vn
au. Ch nhp th ca bnh nhn v nhp
tim. Nu gy nhp chm c th cho Atropin
0,5 mg tim TM.
d. Nitroglycerin (0,4 mg) ngm di li, c th
nhc li sau mi 5 pht. cn ch huyt p ca
bnh nhn. Nu huyt p ti a cn > 90 mmHg
l tt. Tip sau cn thit lp ngay ng
42
truyn tnh mch v truyn Nitroglycerin vi tc

10 mcg/pht, c th chnh liu theo con s
huyt p ca bnh nhn. Nu bnh nhn huyt p
tt th khng th dng Nitroglycerin, khi cn
p dng ngay cc bin php vn mch tt. Lu
l Nitroglycerin c th gy nhp chm v khng
dng khi c NMCT tht phi.
e. Cho ngay thuc chng ngng kt tiu cu:
Aspirin cn cho ngay bng ng ung dng
khng bc vi liu 160 - 325 mg hoc c th cho
bng ng tim tnh mch 500 mg. C th cho
bng dng gi bt Aspegic. Nu bnh nhn c
tin s lot d dy t trng ang tin trin th c
th thay bng Ticlopidine (Ticlid) 250 mg
ed x 2
erv ngay
vin/ngy hoc Clopidogrel (Plavix)rescho
hts .vn cu gn
300 mg sau 75 mg/ngy. Ccignghin
r
ll o.com
y cho thy phi hp gia. A
Aspirin
o v Ticlopidin
h
v
e
a
o
hoc Clopidogrel lm gim
l ng
y k t l t vong.
Fin020@
.
8 Heparin tim thng TM liu
f. Thuc chng ng:
00 ity2
c
2 t
65-70 v/kghtsau
o
o duy tr liu 15-18 v/kg/gi.
P
g
i
r
Heparin
py t n khng lm gim t l t vong do
Co nhng rt quan trng nu bnh nhn c
NMCT
cho thuc tiu huyt khi hoc can thip ng
mch vnh cp. Dng Heparin vi thuc tiu
huyt khi cn cho ngay 5000 v tim TM sau
truyn tnh mch liu khong 1000 v/gi (tr
trng hp cho Streptokinase th khng dng
Heparin phi hp). Khi dng Heparin cn iu
chnh liu theo thi gian APTT sao cho thi gian
ny gp 1,5 thi gian chng (50-75 giy).
g. Thuc chn bta giao cm: lm gim t l t
vong v gim din c tim b nhi mu hoi t.
Thuc hay dng l Metoprolol tim TM 5 mg sau
nhc li mi 5 pht cho n tng liu l 15
mg, trong khi bt u cho ung 25-50 mg. Cc
thuc khc c th dng l Atenolol, Esmolol.
43
Khng dng cc thuc ny khi bnh nhn c du

hiu suy tim nng, nhp tim chm < 60, huyt p
tm thu < 90 mmHg, bloc nh tht cao, bnh
phi tc nghn, bnh mch ngoi vi nng.
B. iu tr ti ti mu
Mc tiu quan trng nht trong iu tr NMCT cp
l lm ti ti mu (ti lu thng MV b tc) cng sm
cng tt. Ba bin php iu tr ti ti mu hin nay l:
dng thuc tiu huyt khi, can thip (nong, t stent)
ng mch vnh cp, m bc cu ni ch-vnh cp. Vic
iu tr sm ti ti mu lm gim mc hoi t c
tim, gim t l t vong v bo tn chc nng tht tri.
1. La chn phng php iu tr ti ti mu: Vic
d
la chn phng php iu tr ti ti musengay
rve cho
re
bnh nhn NMCT cp ph thuc vo
yu t
tsnhiu
h
vn
.
g
i
r
nh thi gian n vin, tnh trngll bnh
omnhn c th,
A hoo.c
.
v
iu kin trang thit b v trnh
ca
c
s y t.
loe @ya
n
i
0
F 2mu:
2. Thi im iu tr ti8.ti
Cc nghin cu
0 ty20
0
2
i
chng minh c
l
li
ch
cng
ln nu tin hnh
t otoc
h
P
g
c ti ti
ri mu cng sm. Nu thi gian c ti
py vng 1 gi u (k t khi au) th li
ti muCotrong
ch l ln nht. Hin nay, khi can thip MV th u
c p dng nhiu trung tm, th thi gian c
c hiu qu tt nht l trc 120 pht. Ni chung
l trong vng 12 gi u th vn cn ch nh iu tr
ti ti mu. Nu sau 12 gi, m vn cn tn ti cc
triu chng th vn c th c li ch khi iu tr ti
ti mu (khng phi l thuc tiu huyt khi).
3. iu tr ti ti mu mch vnh bng cc thuc
tiu huyt khi:
a. L phng php n gin v nn c la chn
hng u. Cc th nghim ln chng minh cc
thuc ny lm gim ng k t l t vong do
NMCT cp, gii quyt c 60 - 90 % cc trng
44
b. Ch nh thuc tiu huyt khi cng sm cng tt

v tt nht trong vng 6 gi u, nu bnh nhn
n mun hn v trong vng 12 gi m vn cn
tn ti du hiu ca hoi t c tim lan rng th
vn c th dng thuc tiu huyt khi .
c. Cc thuc ny c mt s chng ch nh tng
i v tuyt i (Bng 3-3).
Bng 3-3. Chng ch nh ca thuc tiu huyt khi.
Chng ch nh tuyt i
ang c bnh hoc th thut gy chy mu nng.
Thiu ht cc yu t ng mu (ri lon).
d
Mi b cc chn thng nng.
rve
e
s
re
Mi phu thut (<10 ngy).
ts vn
h
g
Cc th thut xm ln (< 10 ngy). ll ri om.
A hoo.c
Phu thut thn kinh trong vngev2. thng.
a
o
@y
Chy mu ng tiu ho trong
ngy.
inl 210
0
F
8. 0
TBMN trong vng 1 nm.
00 ity2
2
t mch
toc no.
Tin s u no, phnh
igh Po
r
Vim mngongoi
py tim cp.
C
Nghi ng tch thnh ng mch ch.
Lot ng tiu ho ang tin trin.
Bnh mng phi cp tnh.
ang c thai.
Chng ch nh tng i:
Huyt p ti a > 180 mmHg.
Huyt p ti thiu > 110 mmHg.
Vim ni tm mc nhim khun.
Xut huyt vng mc do bnh l i tho ng.
TBMN > 12 thng.
C hi sinh tim phi trong vng 10 pht.
ang dng chng ng khng Vitamin K lu di.
Suy thn hoc gan nng.
Rong kinh rong huyt nng.
45
4.
Cc loi thuc tiu huyt khi:

a. Vic la chn cc thuc tiu huyt khi phi cn
nhc da vo hon cnh thc t v gi thnh.
Trong cc thuc trn, rt-PA c cc tc gi nc
ngoi a dng nhng gi thnh kh cao.
Streptokinase l thuc cng c dng rng ri,
gi thnh r hn v tng i t tai bin.
Bng 3-4. Cc loi thuc tiu huyt khi v liu dng.
Cc thuc c hiu vi fibrin
Alteplase (rt-PA): Tim thng TM 15 mg sau
truyn TM 0,75 mg/kg (cho ti 50 mg) trong vng 30
pht, tip theo 0,5 mg/kg (cho ti 35 mg) truyn TM
trong 60 pht tip. Liu ti a 100 mg trong 90 pht.
d
Reteplase (r-PA): tim thng TM 10 n v trong
rve 2
e
s
re
pht, sau 30 pht li tim nh vy (10 n
ts vv).
n
h
g
Cc thuc khng c hiu vi fibrin l ri om.
l o.c
o
Streptokinase (SK): Truyn TMe1,5
v. A triu
ah n v trong
o
l
y
vng 60 pht.
in @
. F 2020
8
0
Anistreplase (APSAC):
thng TM 30 n v
20 tim
ity
t otoc
trong vng 2 pht.
h
P
rigtruyn
y
Urokinase (UK):
TM 3 triu n v trong vng
p
Co
60 pht.
b. Khi dng cc thuc tiu huyt khi bt buc phi
phi hp vi Heparin v cc nghin cu chng
minh l lm gim nguy c b tc li mch sau
dng thuc tiu huyt khi. Heparin c dng
trc v sau khi dng thuc tiu huyt khi 4 gi
th truyn tip Heparin vi liu 1000 v/gi trong
vng 48 - 72 gi tip. Ring i vi Streptokinase
th khng cn dng Heparin phi hp v thuc
ny tc ng khng c hiu vi h fibrin nn c
th gy chy mu nhiu nu phi hp Heparin.
c. Bin chng ca cc thuc tiu huyt khi: quan
trng nht l chy mu. Chy mu ni s l bin
chng nguy him nht (gp khong 0,5% i
46
vi Streptokinase v 0,7% i vi tPA) , ngoi ra

c th gy chy mu nhiu bt k ni no. Cn
theo di thi gian aPTT. Nu b mt mu nhiu
phi truyn mu, huyt tng ti.
5. Can thip ng mch vnh trong giai on cp
cu (nong, t Stent): Mc d thuc tiu huyt khi
l tin b ng k, nhng do nhiu chng ch nh v
s bnh nhn n vin kh mun nn t l bnh nhn
c dng thuc tiu huyt khi khng cao. Hin nay
c nhiu nghin cu chng minh tnh u vit ca
phng php can thip ng mch vnh trong giai
on cp. Tuy nhin, n tu thuc nhiu vo trang
thit b v kinh nghim ca thy thuc can thip.
d
a. Ch nh: Can thip MV cp ch nn ch
rvenh
e
s
nhng bnh nhn c chng ch nh
re ca thuc
ts vn
h
.
g
tiu huyt khi hoc c tnh rtrng
huyt
ng
l i .com
l
A hoc
o ri lon nhp
khng n nh (sc tim) vhoc
.
loe @s
ya trung tm c kinh
tim. Hin nay, i vi
inmt
0
F
2
8. 20 b tt, ngi ta thng
nghim v c trang
y
00 itthit
2
octhip MV th u (primary
c xu hng
t can
t
h
o
P
rig (tc
intervention)
l can thip ngay lp tc khi
y
p
o
C
bnh nhn n vin v cha dng thuc tiu si
huyt). Cc khuyn co gn y c xu hng
ng h cho vic can thip ny.
b. Can thip khi dng thuc tiu huyt khi tht
bi: tc l sau khi dng thuc tiu huyt khi m
bnh nhn vn cn au ngc, lm sng khng n,
ST vn chnh ln trn T th c ch nh can
thip MV.
c. Khi can thip ng mch vnh cp cn dng phi
hp vi cc thuc:
Aspirin 325 mg/ngy ko di mi, phi hp
Ticlopidin (Ticlid) 250 mg x 2 ln ngy trong
na thng hoc Clopidogrel (Plavix) 75
mg/ngy. Vai tr ca Clopidogrel ngy cng
47
c nhn mnh v tnh hiu qu v kh an

ton ca n. Nhng nghin cu gn y cho
thy li ch ca Plavix cng c khng nh
khi dng ko di n 9 thng.
Cc thuc c ch th th GP IIb/IIIa (ReoPro,
Aggrastat...) l nhng thuc chng ngng kt
tiu cu trit . Khi dng cng vi can thip
MV cp lm gim ng k t l tai bin do
can thip v t l tc mch sau can thip. Tuy
nhin cc thuc ny kh t tin.
Heparin l cn thit trong khi can thip. Nu
can thip kt qu thnh cng c th xt dng
Heparin sau can thip.
6. M lm cu ni ch - vnh cp cu:
d
rve
e
s
Ch c ch nh khi bnh nhnsau
re ngc ti
t vn
h
. mch vnh
g
pht sau dng tiu huyt khi hocring
l .com
l
A (tn
o thng nhiu
khng thch hp cho can thip
ev. yaho
o
l
thn, tn thng thn chung,
@ thng phc tp...),
Fin020tn
8. hoc
hoc can thip tht00bi,
bnh nhn c nhng
2
2 ocity
bin chng c hc.v.v...

ht Pot
rig
y
p
Co
Trc khi nong

Sau nong v t Stent
Hnh 3-3. Nong v t Stent ng mch lin tht trc.
C. iu tr tip theo
1. Cc bin php chung:
a. Ch vn ng: Vi nhng bnh nhn trong
giai on cp hoc cha n nh cn bt ng ti
48
ging. Tuy nhin nu nhng bnh nhn c

iu tr ti ti mu tt m khng cn au ngc
th sau 12 gi c th cho c ng nh ti
ging v ngi dy nh nhng ti ging. Sau 24
gi c th cho vn ng nh nhng v sau 48 gi
c th cho i b nh ti phng ri tng dn mc
vn ng tr v bnh thng.
b. Ch dinh dng: Trong giai on cp (au
nhiu) th khng nn cho n m nn dinh dng
bng ng truyn tnh mch. Khi bnh nhn
cn ch ch n nng lng (1200 - 1800
calorie/ngy) t cholesterol v mui. Bnh nhn
NMCT cn trnh to bn v nn cho thm cc
nhun trng.
d
rve
e
s
c. An thn: nn trnh thm hi nhiu ca
re ngi nh
ts vnlng qu
trong giai on cp. Nu bnh rinhn
.
gh mlo
o
l
l
c
.
c th cho thm mt cht an. Athn.
o
ev yaho
o
l
2. Cc thuc:
Fin 0@
8. 202
0
a. Cc thuc chng
kt tiu cu (Aspirin,
y
0 ngng
2 tocit
t
h
o
Ticlopidin,
Clopidogrel):
c bit quan trng.
P
rig
y
p
Liu
Aspirin
t
75-325
mg/ngy nhng nn
Co
dng > 160 mg/ngy.
b. Cc thuc chng ng: Heparin cn thit khi c
dng thuc tiu huyt khi v khi can thip
MV. Heparin khng nn dng ko di > 5 ngy.
Cc thuc khng vitamin K ng ung ch dng
khi c km theo rung nh hoc c phnh vch tht
gy cc mu ng.
c. Cc Nitrates: mc d khng lm gim t l t
vong nhng chng ci thin tnh trng thiu mu
cc b, ci thin triu chng v suy tim nu c.
d. Cc thuc chn beta giao cm: nn tip tc ko
di (nu khng c cc chng ch nh).
e. Cc thuc c ch men chuyn (CMC): Nn
cho sm v bt u liu nh (trong vng 24 gi
49
u). Ch huyt p ca bnh nhn. Thuc

CMC lm gim t l t vong, bo tn chc nng
tht tri. Nn dng bt u bng thuc c tc
dng ngn nh Captopril 6,25 mg trong 24 gi
u sau nh gi tnh trng v iu chnh liu
hoc thay cc thuc CMC khc c thi gian tc
dng ko di hn.
f. iu tr tch cc cc yu t nguy c trong ch
iu tr tt i tho ng, ri lon m mu
(nu c) km theo.
D. Phc hi chc nng sau NMCT
1. Giai on ti bnh vin:
i vi nhng bnh nhn n nh cnd sm
e
erv sm
phc hi chc nng bng cch cho bnhesnhn
r
tsbnh
vn ng nh. Ngy th ba c th cho
.vn nhn i
gh m
i
r
o
l
li nh nhng trong phng. Trc
c vin cn gio
.ra
Alkhi
hoo loi b yu t
ev. luyn,
a
dc bnh nhn v ch ltp
o
n 0@y
Fi
2n v ch thuc men
nguy c, iu chnh ch
.
08 ty20
0
2 nhn.
hng ngy cho bnh
i
t otoc
h
P
g
i
2. Giai on y
rnh:
op
C
Bnh nhn cn i b sm ti thiu mi ngy 23 ln, mi ln 20-30 pht v duy tr nhp tim khng
tng qu 20 nhp so vi nhp tim lc ngh. khng
nh bnh nhn c th tr v cuc sng sinh hot
bnh thng, bnh nhn cn c lm nghim php
gng sc nh gi. Vic gio dc bnh nhn vn
c bit quan trng trong giai on ny v ch
sinh hot v thuc men.
Ti liu tham kho
1.
2.
Falk E, Shah PK, Fuster V. Coronary plaque disruption.

Circulation 1995;92:657-671.
Flather M, Pipilis A, Collins R, et al. Randomized controlled
trial of oral captopril, of oral isosorbide mononitrate and of
intravenous magnesium sulphate started early in acute
myocardial infarction: safety and haemodynamic effects. ISIS-4
50
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
(Fourth International Study of Infarct Survival) Pilot Study

Investigators. Eur Heart J 1994;15:605-619.
GUSTO Investigators. An international randomized trial
comparing four thrombolytic strategies for acute myocardial
infarction. N Engl J Med 1993;329: 673682.
Lauer MA, Lincoff AM. Acute myocardial infarction. In: Marso
SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular
Lee K, WoodliefL, Topol E, et al. Predictors of 30-day mortality
in the era of reperfusion for acute myocardial infarction.
Circulation 1995;91:1659-1668.
Lincoff A, Topol E, CaliffR, et al. Significance of a coronary
artery with thrombolysis in myocardial infarction grade 2 flow
"patency". Am J Cardiol 1995;75: 871-876.
Lincoff AM, Califf RM, Moliterno DM, et al. Complementary
clinical benefits of coronary-artery stenting and blockade of
platelet glycoprotein ub/Iha receptors. N Engl J Med
1999;341:319-327.
Mark D, Hlatky M, CaliffR, et al. Cost effectiveness of
thrombolytic therapy with tissue plasminogen activator
ed as
erv
compared with streptokinase for acute myocardial einfarction.
N
s
r
Engl J Med 1995;332:1415-1424.
ts vn
h
. ACC/AHA
Ryan TJ, Anderson JL, Antman EM,riget m
o al. with
l patients
l
c
.
guidelines for the management . of
acute
A hoo
myocardial infarction: a report loofev the
American
College
of
a
in 20@y Task Force on Practice
Cardiology/American Heart Association
F
8. 20
Guidelines (Committee on
of Acute Myocardial
00 iManagement
ty1996;25:1328-1428.
Infarction). J Am CoIl 2
Cardiol
c
o
t Electrocardiography. In: Topol EJ,
ht PoG.
Sgarbossa EB, iWagner
r gof cardiovascular
ed. Textbook
medicine. New York:
y
p
Co
Lippincott-Raven,
1998.
The EPILOG Investigators. Platelet glycoprotein IIb/IIIa
receptor blockade and low-dose heparin during coronary
revascularization
during
percutaneous
coronary
revascularization. N Engl J Med 1997;336:1689-1696.
The GUSTO IIb Angioplasty Sub study Investigators. A clinical
trial comparing primary coronary angioplasty with tissue
plasminogen activator for acute myocardial infarction. N Engl J
Med 1997;336: 1621-1628.
The GUSTO III Investigators. A comparison of reteplase with
alteplase for acute myocardial infarction. N Engl J Med
1997;337:1115-1123.
Topol EJ, Van de Werf FJ. Acute myocardial infarction: early
diagnosis and management. In: Topol EJ, ed. Textbook of
Cardiovascular Medicine. New York: LippincottRaven, 1998.
White RD, Van de Werf FJ. Thrombolysis for acute myocardial
infarction. Circulation 1998;97:1632-1646.
Woods K', Fletcher S. Long-term outcome after intravenous
magnesium sulphate in suspected acute myocardial infarction:
the second Leicester Intravenous Magnesium Intervention Trial
(LIMIT-2). Lancet 1994;343:516-S19.
51
Bin chng Nhi mu c tim
Bnh nhn NMCT thng cht ch yu l do cc bin

chng cp v nu qua khi giai on cp cng thng li mt
s bin chng i khi rt nng nu khng c iu tr mt cch
tho ng. Cc bin chng ca NMCT rt phong ph v c th
chia lm cc nhm: bin chng c hc, bin chng ri lon nhp,
bin chng thiu mu c tim, tc mch
I. Bin chng c hc
Cc bin chng c hc c th e do tnh mng bnh nhn
l: thng lin tht, h van hai l cp do t dy chng, v thnh
d
tim t do, phnh thnh tim...
rve
e
s
e
s r ntht
A. Thng lin tht (TLT) do thng vchhtlin
v
.
g
l ri .com
l
1. Triu chng lm sng:
. A ahoo
oev
y 2% s bnh nhn
a. TLT xy ra khonginl0,5
F 020@
.
NMCT cp. T l08gp 2ngang nhau gia cc nhm
0 ity
c sau di. TLT thng xy ra
2 tov
NMCT phahttrc
o
P
g
i
r
nhng
py bnh nhn b NMCT din rng, tc mt
Com tun hon bng h km. TLT c th xy
mch
ra sm ngay sau 24 gi ca NMCT nhng thng
xy ra sau khong 3-7 ngy.
b. Bnh nhn c bin chng TLT thng c du
hiu lm sng nng n hn. Cc bnh cnh lm
sng nh au ngc tng, ph phi cp, tt huyt
p, sc tim c th xy ra t ngt trong qua trnh
ang din bin bnh thng ca bnh.
c. Khi nghe tim thy mt ting thi tm thu mi
xut hin vng trc tim, ting thi r nht pha
thp bn tri xng c. Khi bnh nhn c l
thng ln vch lin tht v tnh trng suy tim
nng th c th khng nghe thy ting thi na.
d. Cn phn bit vi h van hai l hoc h van ba l.
53
2. Gii phu bnh:

L TLT l hu qu ca l thng vng c tim b
hoi t do NMCT v xy ra ch ranh gii gia vng
khng hoi t v vng b nhi mu. L ny thng
vng gn mm tim i vi nhng bnh nhn NMCT
vng trc v vng vch sau vi NMCT pha sau.
3. Cc xt nghim chn on:
a. in tm : c th thy bt thng v dn
truyn nt nh tht hoc ng dn truyn t
nh xung tht.
b. Siu m tim: l thm d c gi tr trong chn
on bnh c bit l siu m mu. i vi thng
vng gn mm, mt ct 4 bung t mm l mt
d
rve vch
ct tt nht quan st. i vi thng svng
e
e
s r nhoc mt
sau, mt ct trc dc c li gc ihtcht
v
.
g
i omnh
ct trc dc di mi c choll rphp
gi r
c
.
A hoo
.
v
nht. Trong mt s trng
loe hp
ya cn phi dng n
0@ nh gi r hn
Fin02qun
siu m qua ung8.thc
0 y2 Siu m tim c th gip
v bn cht thng
20 ocittn.
t ot thc l thng, mc ln
nh giric
gh Pkch
y
op Siu m tim cng c th gip nh gi
ca Cshunt.
chc nng tht tri v tht phi, t gp phn
tin lng bnh.
c. Thng tim phi: khi c ch nh chp MV
thng nn thng tim phi nh gi c
lung thng v lu lng shunt cng nh p lc
ng mch phi, cung lng tim... gip c thi
iu tr v tin lng bnh tt hn.
4. iu tr:
a. Thi : T l t vong khi c bin chng TLT
c iu tr ni khoa l khong 24% sau 24 gi,
46% sau 1 tun v 67-82% sau 2 thng. Do vy,
cn nhanh chng xc nh v c k hoch m
sm ng l thng ngay khi tnh trng bnh
nhn khng c n nh.
54
b. iu tr ni khoa: iu tr ni khoa l bin php

c bn v l cu ni cho iu tr ngoi khoa. Cc
thuc gin mch lm gim lu lng shunt v
lm tng cung lng h thng do lm gim sc
cn h thng; tuy nhin, nu lm gim sc cn
ng mch phi qu li dn n lm tng lu
lng shunt. Thuc thng dng l Nitroprusside
truyn TM, bt u bng liu 0,5-3 mcg/kg/ph v
theo di huyt p trung bnh mc 70-80mmHg.
c. t bng bm ngc dng trong ng mch
ch (IABP): l bin php nn c thc hin
cng sm cng tt trc khi gi i m. IABP lm
gim sc cn h thng, gim lu lng shunt,
tng ti mu MV v duy tr uc huyt
d p
rve
e
ng mch.
s
re
ts mc
n
h
d. Phu thut: L bin php la rchn
g
i om.v d tnh
l
ln nh.
.c
trng huyt ng khng c
Phu thut
v. A ahoo
e
o
l
y
bnh nhn c bin ichng
TLT
lm
gim
ng
F n020@
.
k t l t vong so08vi 2iu tr bo tn. Tuy nhin,
y
20 ocn
cit cao c bit nhm bnh
t l t vong
t vn
t
h
o
P suy a ph tng, NMCT vng
ig tim,
rsc
nhn c
y
p
o
sau C
di gy l thng vng vch sau do k thut
kh khn hn nhiu so vi vng mm...
B. H van hai l (HoHL) cp
HoHL cp do t dy chng ct c l mt bin
chng nng n v bo hiu tin lng rt xu trong
NMCT. t dy chng ct c thng xy ra trong vng
2-7 ngy sau NMCT cp v chim t l khong 1% trong
s NMCT cp.
a. HoHL cp do t dy chng ct c thng xy ra
bnh nhn b NMCT cp thnh sau.
b. Nu tnh trng t hon ton mt ct c gy
HoHL cp s dn n tnh trng sc tim nhanh
chng hoc t t. Nhng trng hp nh hn c
55
c. Nghe tim: c th thy xut hin mt ting thi

tm thu mi vng mm lan ln nch hoc ln
vng y tim. Trong trng hp NMCT vng
thnh sau gy t dy chng sau c th nghe thy
ting thi tm thu pha cnh xng c d nhm
ln vi thng lin tht hoc hp van ng mch
ch. Cng ting thi khng c ngha d
on mc nng nh ca HoHL. i khi ting
thi rt nh hoc khng thy do bnh nhn b suy
tim qu mc hoc gim cung lng tim qu.
d. Ch : t dy chng thng xy ra NMCT
vng di. NMCT vng ny (tc nhnh lin
d tht
rve
e
s
sau PDA) gy hoi t ct c pha sau
re v gy sa
ts vn
h
van hai l v HoHL.
.
g
l ri .com
l
2. Cc xt nghim chn on: ev. A hoo
o ya
inl hnh
a. in tm : cho thy
0@ nh ca NMCT cp
F
8. 202
0
thng l pha sau
y
0 di.
2 tocit
t
h
o
b. Xquang rtim
P c th cho thy hnh nh ca
ig phi
y
p
o tu mc . Mt s bnh nhn c hnh
ph Cphi
nh ph phi nhiu thu trn phi v dng
HoHL pht trc tip nhiu v pha tnh mch phi
phi pha trn.
c. Siu m Doppler tim: l phng php rt c gi
tr trong chn on cng nh tin lng bnh.
Hnh nh sa l van hai l.
Hnh nh dng mu ca HoHL v cho php
nh gi mc HoHL.
Cho php chn on phn bit vi ting thi
do bin chng thng lin tht hoc cc bin
chng khc.
Gip nh gi chc nng tim v p lc ng
mch phi.
56
d. Thm d huyt ng: Thng thng i vi

nhng bnh nhn ny cn theo di huyt ng
cht ch bng mt ng thng Swan-Ganz theo
di p lc ng mch phi, cung lng tim v p
lc mao mch phi bt (PCW). Trn ng cong
p lc ca PCW c th thy hnh nh sng V cao
mt cch bt ng.
3. iu tr:
a. Cc u tin trong iu tr: Cn thit phi pht
hin c nhanh chng bin chng HoHL cp
kp thi i ph. Bnh nhn cn c iu tr ni
khoa mt cch ht sc tch cc v cn nhc iu
tr ngoi khoa sm nu c th.
d
b. iu tr ni khoa:
rve
e
s
re
Cc thuc gin mch ng vai tr
trng.
ts quan
h
vn
.
g
i
Thuc c u tin dng
l
Nitroprusside,
r
ll o.com
. A acn
thuc ny lm gim evsc
ho h thng mt
o
l
y
in 2gim
cch c ngha,. Flm
0@ phn s h van hai
0
8
2
0
l v c th20lmitytng cung lng tim. Thuc
t otocbng ng truyn tnh mch
ny c
P
igh dng
r
y
lin
tc
vi liu khi u l 0,5-3
p
Co
mcg/kg/pht v iu chnh theo huyt p
trung bnh trong khong 70-80 mmHg.
Thuc gin mch khng nn dng cho bnh
nhn b tt huyt p. Trong trng hp
ny, gii php tt nht l nn t bng bm
ngc dng trong ng mch ch (IABP).
IABP lm gim hu gnh ca tht tri v tng
lu lng n mch vnh. Sau khi t IABP
c th cn nhc cho tip thuc gin mch.
c. Bin php can thip ng mch vnh cp cu:
Nong MV hoc t Stent cp cu lm ci thin
c tnh trng huyt ng v mc HoHL
nhng bnh nhn HoHL mi do thiu mu cc
b. Tuy nhin, khi b t hn ct c th can
57
thip MV n thun cng khng ci thin c

tnh trng bnh.
d. iu tr ngoi khoa: L bin php cn c tin
hnh sm khi c t hon ton ct c.
T l t vong khi m kh cao (20-25% cc
nc pht trin) tuy nhin vn l bin php
hiu qu nht v cn c ch nh sm.
Nn tin hnh can thip MV trc khi tin
hnh phu thut can thip van hai l.
C th tin hnh sa van hai l nhng bnh
nhn HoHL mc va m khng cn phi
thay van hai l.
C. V thnh t do ca tim
d
rve
e
s
re
ts vn 3% s
a. V thnh t do tim c th gp hkhong
.
g
i omtrong
bnh nhn NMCT cp v Alll rmt
nhng
c
.
o
o
.
h
v
e
nguyn nhn dn n tlovong
at ngt. V thnh
n 0@y
tim cng ch xy ra8.Finhng
bnh
nhn c NMCT
2
0
2
0
y
0
xuyn thnh. Nhng
2 ocit yu t nguy c d xy ra v
ht tui
Pot gi, n gii, tng huyt p qu
thnh timrigl:
y
p
nhiu,
Co NMCT ln u v h thng mch vnh
khng phong ph.
b. Triu chng ca th cp: c th thy biu hin
ca phn ly in c trn T v t t. Mt s
bnh nhn ku au ngc d di hn, ho v nc.
c. Th bn cp: gp s t bnh nhn m bnh cnh
d nhm vi vim mng ngoi tim cp, nn, tt
huyt p.
d. Khm thy cc du hiu ca p tim cp t ngt:
gin tnh mch cnh, mch o, ting tim m..
a. in tm : c hnh nh nhp b ni hoc t
tht, in th ngoi vi thp, sng T cao nhn
58
cc chuyn o trc tim. Mt s bnh nhn biu

hin nhp chm trc khi v thnh t do.
b. Siu m tim: cho php nhn thy hnh nh p tim
cp v c th cho php nhn thy ch v.
3. iu tr:
a. Bin php iu tr ti ti mu lm gim bt t l
b v thnh tim.
b. Mc ch l phi nhanh chng nhn bit c
tnh trng v tim v tin hnh m cp cu.
c. iu tr ni khoa ch ng vai tr tm thi khi hi
sc v trong lc a n phng m. Dng thuc
vn mch v truyn dch duy tr huyt p.
d. Nhanh chng chc dch mng tim nu xc nh
l
ed
v
r
e
c p tim cp trong lc thu xp cuc m.
res
s
t
h
e. Phu thut ti cp cu l bin php
.vn nht c
ig omduy
r
l
l o.c trng hp b
th cu sng c bnh nhn
o
. A atrong
v
e
o
v thnh t do tim. nl @y h
Fi 20
D. Gi phnh thnh tim 008. y20
2 tocit
ht sng:
1. Triu chng ilm
Po
g
r
y
op
a. Gi Cphnh
thnh tht thng c tin trin thm
lng v thng c pht hin tnh c khi lm cc
thm d chn on. Tuy nhin, mt s bnh nhn
c biu hin ca cc cn tim nhanh ti pht v
suy tim.
b. Thm khm c th thy ting thi tm thu hoc
tm trng hoc ting thi theo t th do dng
mu xoy qua l thng vo ch phnh.
c. Bn cht bnh l ca gi phnh thnh tht l do v
mt ch nh ca thnh t do tht v c mng
ngoi tim cng huyt khi thnh bao bc li.
Gia ti phnh v tht vn cn lin h vi nhau
nh l thng.
59
a. Xquang tim phi: thng c th thy hnh nh

bng tim bt thng vi mt ch li tng ng
vi ti phnh.
b. in tm : c th cho thy hnh nh ST chnh
vm c nh ging trng hp b phnh tht.
c. Siu m tim: c th gip chn on xc nh
bnh. Chp cng hng t (MRI) cng l mt
bin php kh chnh xc chn on bnh.
3. iu tr: Phu thut l ch nh bt buc bt k kch
c hoc triu chng ca ti gi phnh ny nh th no
ngn nga vic v th pht ca ti gi phnh ny.
E. Phnh vch tht
d
rve
e
s
a. Th cp: Khi mt vng c tim rngsb
re gin ra th
t vn
h
. sc tim.
nhanh chng dn n suy tim
hoc
g
l ri .com
l
A v otr c nh hng
Nhng bnh nhn b NMCT
ev. yaho
n vng mm thnginllo c
nguy c cao nht.
F 020@
.
2 th phnh vch tht tin
b. Th mn tnh: L
08nhng
20 ocity
trin t t gsau
ht hn
ot 6 tun. Chng xy ra 10-30%
ri hpP NMCT. Nhng bnh nhn ny
y
cc trng
p
Co c cc triu chng ca suy tim, ri lon
thng
nhp tht, tc mch i tun hon..
c. Khm tim: i khi c th pht hin c vng
b phnh ca tht thng qua s mm tim hoc g
tim. Cn phn ln cc trng hp l c th thy
ting nga phi nhng bnh nhn suy gim
nhiu chc nng tht tri.
2. Sinh l bnh:
Phnh vch tht l mt vng c tht b gin ra
do vng b hoi t do ng mch vnh nui dng
tng ng b tc. Nu MV b tc c gii phng
cng sm th nguy c b phnh vch tht cng thp.
Qu trnh phnh vch tht l phi hp nhiu c ch
60
trong qu trnh ti cu trc (remodeling) c tim l

rt quan trng.
3. Cc thm d cn lm sng:
a. in tm :
Nu phnh vch tht xy ra cp tnh th sng
ST chnh ln c nh mc d MV c c
ti ti mu.
Nu phnh vch tht xy ra t t th ST chnh
ln tn ti khong hn 6 tun.
b. Xquang tim phi: thy hnh nh mt vng bng
tim phnh ra tng ng vi vng c tht b phnh.
c. Siu m tim: l mt thm d c gi tr gip chn
on xc nh bnh, nh khu, nh ga cc bin
ved siu
chng, chc nng tht, huyt khi. cerbit
s
re
m gip chn on vi ga phnh
(trong
ts tht
h
vn
.
g
i
r
m gi phnh
phnh vch tht tht th c vollrngcocn
A hoo.
.
th c vo hp).
v
loe @ya
Fin0cng
d. Chp cng hng8.t:
20 gip xc nh phnh
2
0
y
0
vch tht.
2 it
t otoc
h
P
g
4. iu tr: yri
p
a. iuCotr ni khoa:
Phnh cp: Nn nhanh chng iu tr tnh
trng suy tim bng cc thuc gin mch
truyn tnh mch v t bng bm ngc
dng trong MC. Cho thuc c ch men
chuyn sm l mt bin php quan trng ngn
nga c qu trnh ti cu trc v lan rng
ca vng nhi mu. V qu trnh lan rng ca
nhi mu xy ra rt sm nn cn cho thuc c
ch men chuyn sm trong vng 24 gi ca
NMCT cp (nu huyt p khng qu thp).
Phnh mn tnh: Cc thuc dng iu tr
suy tim do phnh mn tnh vch tht l: c ch
men chuyn, li tiu hoc c th cho Digoxin.
61
Chng ng: Cc thuc khng vitamin K

ng ung c ch nh nhng bnh nhn
c phnh vch tht m c huyt khi bm
thnh. Trc tin nn cho Heparin trong vng
vi ngy v cng bt u lun bng cc thuc
chng ng dng ung loi khng vitamin K.
Khi iu tr, nn chnh liu sao cho INR t
khong 2-3 trong vng 3-6 thng. i vi
nhng phnh vch tht d ln m khng thy
hnh nh huyt khi bm thnh th ngi ta
cng cha r li ch v ch nh ca khng
vitamin K. i vi nhng bnh nhn c phnh
vch tht m chc nng tht tri rt km th
nn cho thuc chng ng ng ungdtrong
rve
t nht 3 thng sau NMCT cp.
ese
r
ts
b. iu tr can thip:
gh m.vn
i
r
l .co th can thip
Nhng bnh nhn b nhi
Al hmu
oo
.
v
e ttygip
a
o
MV cng sm cng
ngn chn qu
l
0@ti cu trc. Can thip
Fin0v
2
.
trnh gin thnh
tht
08 ty2
20 gi
i
mun saut 12
toc vn c th c ch nhng sau
h
o
P
g
24 y
gi
ri th c th khng ci thin c tnh
p
o
C
hnh phnh vch tht.
i vi nhng bnh nhn c phnh vch tht
m c ri lon nhp tht nguy him th c th
cn nhc vic cy my ph rung t ng trong
bung tim (ICD).
c. Ngoi khoa: i vi nhng bnh nhn phnh
vch tht c suy tim dai dng hoc ri lon nhp
tim nng n th c th cn nhc iu tr ngoi
khoa. iu tr ngoi khoa c th ct ng on
phnh hoc lm mt ming v duy tr
c th tch tht tri. Cng nn cn nhc vic
iu tr ti ti mu ng mch vnh trc .
62
II. Cc ri lon nhp

Trong NMCT, bin chng ri lon nhp tim l rt thng
gp cc mc khc nhau (90% cc trng hp). C th gp
tt c cc loi ri lon nhp khc nhau (xin tham kho chi tit
phn cc ri lon nhp tim).
A. Ri lon nhp tht
1. Ngoi tm thu tht: hay gp, cn theo di tt, iu
chnh cc ri lon in gii. Thuc chn bta giao
cm c th c tc dng tt. Mt s tc gi a dng
Amiodarone.
2. Nhp t tht gia tc: hay gp bnh nhn c hi
chng ti ti mu, phng cn nhanh tht hoc
rung tht.
d
rve
e
s
re cp cu
3. Nhp nhanh tht v rung tht: l tnhtstrng
n
h
.vtun
g
v cn x tr theo ng nh phc
hon.
ingng
r
m
o
l
l o.c
A
o
.
v ahcc ri lon nh:
B. Ri lon nhp trn tht: c th
loe gp
n
@y
i
1. Nhp nhanh xoang. 08. F 2020
20 ocity
2. Cn nhp nhanh
pht trn tht.
t kch
h
Pot
rig
y
p
3. Rung nh.
Co
4. Nhp b ni.
C. Cc ri lon nhp chm
1. Nhp chm xoang: hay gp bnh nhn NMCT sau
di, cn iu tr khi c nh hng n huyt ng.
2. Bloc nh tht t cp I n cp III: Nu bloc cao
nh hng n huyt ng th cn cp cu theo phc
v ch t my to nhp tm thi sm. Ch nh
t my to nhp tm thi:
a. V tm thu;
b. Bloc nh tht cp III;
c. Nhp chm xoang hoc bloc nh tht thp
nhng c nh hng n huyt ng.
63
III. Suy chc nng tht tri v sc tim

Ri lon chc nng tht tri l din bin kh trnh khi
sau NMCT, ch tu theo mc nh hay nng. Mc suy chc
nng tht tri lin quan n vng tn thng nhiu hay t. Bnh
nhn NMCT vi vng tn thng nh c th gy ri lon vn
ng mt vng c tim nhng khng gy gim chc nng ng k
ton b tht tri. Tuy nhin, khi nhi mu din rng, c bit l
vng trc hoc n gii, ngi cao tui, tiu ng l nhng
yu t d bo nguy c cao ca suy tim tri nng v sc tim.
A. Phn loi
Hin nay phn loi ca Killip v Kimban (bng 4-1) l
phn loi c s dng rng ri nht trn lm sng phn
loi mc nng nh v c gi tr tin lng bnh
ved
Bng 4-1. Mi lin quan gia Killip v trevong
ser trong
ts
30 ngy.
gh m.vn
i
r
l .co l t vong
Al hooT
.
v
Killip
c im lm sng loe% ya trong 30 ngy
Fin 0@
(%)
8. 202
0
y
I
Khng c triu20chng
85
5,1
it
t otoc
ca suy timghtri
P
ri < 1/2
II
C ranopy
m
phi, 13
13,6
tnh Cmch c ni, c
th c ting T3 nga phi
III
Ph phi cp
1
32,2
IV
Sc tim
1
57,8
Mt phn loi khc ca Forrester da trn cc thng s
huyt ng cng c gi tr tin lng bnh rt tt (bng 4-2).
Bng 4-2. Phn loi ca Forrester trong NMCT cp.
p lc mao mch
phi bt (mmHg)
I
II
III
IV
< 18
> 18
< 18
> 18
Ch s
tim
l/pht/m2
> 2,2
> 2,2
< 2,2
< 2,2
T l t vong
trong 30 ngy
(%)
3
9
23
51
64
B. Triu chng lm sng

1. Triu chng c nng:
a. Bnh nhn c th c cc du hiu ca suy h hp,
kh th, cm gic lnh... bn cnh cc du hiu
kinh in ca NMCT.
b. Bnh nhn sc tim c cc du hiu trm trng
hn nh kh th nhiu, tiu t, rt run, ri lon
tm thn
2. Triu chng thc th:
a. H huyt p do gim cung lng tim, gim th
tch tun hon.
b. tr tun hon phi, vi ran phi.
d v
c. Gim ti mu ngoi vi: da lnh, u chi vlnh,
r e
e
s
m hi.
re
ts vn
h
.
g
d. Nghe tim: thy nhp tim nhanh,l rting
phi..
i omnga
l
c
.
A
o
o
.
3. Nguyn nhn d dn noevsc atim
h bnh nhn
l @y
n
i
NMCT cp:
0
F
8. 202
0
y
0
a. NMCT din rng.
2 it
t otoc
h
P din rng.
g
b. Nhi mu
ri tht phi
y
p
Co tht.
c. V thnh
d. H van hai l cp.
e. p tim cp c km hoc khng km v thnh tim.
C. Cc xt nghim thm d
1. Xt nghim mu: Tng acid lactic trong mu, tng
creatinin v thiu xy mu ng mch.
2. Xquang tim phi: thy hnh nh huyt phi cc
mc .
3. in tm (T): thng ch ra du hiu ca
NMCT lan rng. C th thy hnh nh ST chnh
xung (do thiu mu c tim) lan rng nhiu chuyn
o. Nu T khng bin ng c hiu khi sc tim
th phi ngh ti nguyn nhn khc gy sc tim nh
65
tch thnh MC hoc cc bin chng c hc trm

trng ca NMCT cp.
4. Siu m tim: gip nh gi mc lan rng ca
vng nhi mu, chc nng tht v tm hiu thm cc
bin chng c th gy ra sc tim.
5. Cc thm d chy mu: gip theo di v huyt
ng chnh xc. Thng th nn t mt ng thng
Swan Ganz theo di p lc ng mch phi v p
lc mao mch phi bt cng nh cung lng tim (xem
thm phn sc tim).
D. iu tr
1. Cc u tin trong iu tr: Nu bnh nhn c sc
tim nn t bng ngc dng trong MC (IABP)
ed
rvnguyn
e
s
trc nu c th, sau tm cch gii quyt
e
sr n
tthch
h
nhn v cc bin php iu tr ni khoa
v hp.
.
g
l ri .com
l
A o
2. Cc thuc:
ev. yaho
o
l
a. Cc thuc gin mch
0@ vai tr cc k quan
Finng
8. 202
0
trng trong iu
0 tr ybnh nhn suy tim tri sau
2 tocit
t
h
NMCT. Cn
theo
Po di huyt p cht ch khi cho
rig
y
p gin mch.
cc thuc
Co
b. Nitroglycerin dng truyn tnh mch l thuc nn
c la chn hng u. Liu dng bt u t 10
20 mcg/pht v c th tng mi 10 mcg/pht
sau vi pht tu theo p ng v huyt p. Nn
iu chnh sao cho huyt p trung bnh ng
mch khong 70 mmHg.
c. Nitropruside c th thm vo c tc dng lm
gim hu gnh v nu dng Nitroglycerin mt
mnh ch yu lm gim tin gnh do gin h tnh
mch. Nitroprusside c dng bt u bng liu
0,3-5 mcg/kg/pht v chnh liu theo huyt p
ng mch.
d. Thuc c ch men chuyn (CMC) ci thin
c chc nng tht tri bnh nhn sau NMCT.
66
CMC nn c cho sm trong NMCT nu

huyt p khng thp qu. Ch tc dng gy tt
p liu u ca CMC, do vy nn cho bnh
nhn dng truyn TM vi liu bt u thp v
khng dng khi c sc tim.
e. Thuc li tiu c tc dng tt nhng bnh nhn
c ph phi sau NMCT. Furosemide l thuc nn
c la chn.
f. Digitalis tr tim khng nn cho rng ri trong
NMCT, nhng c tc dng tt bnh nhn suy
tim tri nhiu km rung nh hoc cung nh hoc
cc thuc khc iu tr suy tim km hiu qu.
g. Cc thuc ging giao cm (Dopamine v
d
Dobutamine) c ch nh cho nhng bnh
rve nhn
e
s
suy tim nng c tt p hoc sc tim. s re
t n
ighom.v c th
h. Thuc vn mch khc (Norepinephrine)
r
l
c
Al htr
oo. huyt p trong
phi dng khi cn thit
v.duy
e
a
o
sc tim (xem bi scFtim).
inl 20@y
.
8 20
00 itymch
3. iu tr can thip 2ng
vnh:
t otoc
h
a. t ngayrigbngPbm ngc dng ng mch ch
y
nu Ccopth bnh nhn sc tim. Bin php ny rt
hu ch gip lm gim hu gnh, tng cung lng
tim, gim nhu cu tiu th xy c tim.
b. Can thip ng mch vnh tc th gip ci thin
c tin lng nhng bnh nhn c sc tim
c bit ngi khng qu gi.
4. Phu thut:
a. Phu thut lm cu ni ch-vnh trong sc tim
bnh nhn NMCT c ch nh nhng bnh
nhn b bnh nhiu MV, hoc tn thng thn
chung MV tri m khng thch hp cho can
thip MV.
b. C khi phu thut c ch nh cy ghp
nhng thit b h tr tht trong khi ch ghp tim.
67
IV. Nhi mu c tim tht phi

Ri lon chc nng tht phi nh thng gp nhng bnh
nhn b NMCT vng sau di, tuy nhin c khong 10% s bnh
nhn ny c suy tht phi cp v iu tr cn ch mt s c
im khc bit.
A. Gii phu bnh
Thnh tht phi bnh thng mng hn v t nhu cu
tiu th xy hn bung tht tri, do vy thng thng th tht
phi c th chu ng v hi phc sau khi c iu tr kp
thi. Vic suy chc nng tht phi nng xy ra ph thuc vo
mc tc nhnh ng mch vnh nui dng tht phi v
mc tun hon bng h t bn tri sang khi nhnh nui
tht phi b tc (nhnh ny thng thng bt ngun td ng
rve
mch vnh bn phi).
ese
r
ts
B. Triu chng lm sng
gh m.vn
i
r
ll co
1. Bnh nhn NMCT tht phievthng
. A ahoo. c triu chng
y
nlonhng
ca tr tun hon ngoiFivi
0@ khng kh th.
2
.
0
8 2
y
00 phi
2. Bnh nhn c suy 2tht
cit nng c th c biu hin
o
t
t
h
o
ca gim cung
lng
P tim nng nh rt run, chn tay
rig
y
p
lnh, riClon
tm
thn,
huyt p tt v thiu niu.
o
3. Thm khm thc th bnh nhn NMCT tht phi
thng thy tnh mch c ni, gan to, huyt p thp
nhng phi khng c ran. Du hiu Kussmaul (tnh
mch c ni to hn trong thi k ht vo) l kh c
hiu v bo hiu c suy tht phi nng.
C. Cc xt nghim chn on
1. in tm : thng cho thy hnh nh NMCT vng
sau di km theo ST chnh ln V1 v c bit l
V3R v V4R.
2. Xquang tim phi: khng c du hiu ca tr tun
hon phi.
3. Siu m tim: l mt thm d c gi tr trong NMCT
tht phi. Trn siu m tim thng cho thy hnh nh
68
tht phi gin, suy chc nng tht phi, ri lon vn

ng vng sau di, v c bit gip loi tr trn
dch mng tim gy p tht phi (d nhm vi NMCT
tht phi).
4. Cc thng s v huyt ng trn thm d chy mu
cho thy tng p lc ca nh phi nhng khng tng
p lc mao mch phi bt (PCWP). NMCT tht phi
cng lm gim cung lng tim do gim lng mu v
tht tri. Khi p lc nh phi trn 10 mmHg v t l
p lc nh phi/PCWP trn 0,8 l mt du hiu huyt
ng quan trng gi NMCT tht phi.
D. iu tr
1. iu tr ni khoa:
ved
a. Truyn dch l mt bin php quanretrng
ser hng
ts vgim
u v trong NMCT tht phi c
cung
. n
gh s
i
r
m
o
l
c
lng tim do gim th tch. A
l y
tht
tri.
Mt
.
oo
h
v
e
a
o
s bnh nhn nng cn
l cho
@ytruyn ti 1 lt dch
Fin020dch
.
trong gi u. Khi
truyn
cn phi theo di
08 ty2
0
2
i
cht ch cct thng
c s huyt ng v nu truyn
h Poto
igdch
qu nhiu
i
khi li dn n suy gim chc
r
py
o
C
nng tht tri (hin tng ny l do vch lin tht
b p qu v pha tht tri gy gim cung lng
tim). Mc tiu iu tr l a p lc tnh mch
trung tm n khong 15 mmHg.
b. Thuc tng co bp c tim: Khi truyn dch vn
khng lm tng cung lng tim th c ch nh
dng cc thuc tng co bp cm tim. Dobutamine
l thuc c la chn hng u lm tng cung
lng tim v phn s tng mu ca tht phi.
c. Mt lu rt quan trng l khng c dng cc
thuc gin mch (Nitrates, c ch men chuyn...)
v li tiu khi c suy tht phi v cc thuc ny
cng lm gim cung lng tim.
2. iu tr can thip:
69
a. Nong hoc t Stent ng mch vnh sm s gip

ci thin r rt t l t vong bnh nhn NMCT
tht phi. Vic ti ti mu MV tht phi gip
ci thin chc nng tht phi.
b. Mt s trng hp NMCT tht phi thng km
theo nhp chm hoc bloc nh tht cp III cn
c t my to nhp tm thi sm v i a s
phc hi tt sau khi can thip tt MV.
c. Mt s trng hp huyt p thp qu c th cn
phi t bng bm ngc dng ng mch ch.
3. Phu thut:
a. Mt s trng hp m tnh trng sc tim ko di
khng p ng cc bin php iu tr thng
d
thng c th c ch nh m ct mng ngoi
rve tim.
e
s
e
s r ntnh trng
b. Phu thut cy thit b h tr timhtkhi
v
.
g
sc tim qu nng.
l ri .com
l
A hoo
ev. ycp
a khi tn thng
c. M lm cu ni ch-vnh
o
l
n 0@
i
F
2
khng th can thip
. c hoc khi can thip c
08 ty20
0khi
2
bin chng hoc
i c cc bin chng c hc.
t otoc
h
P
g
ri
V. au ngc ti pht
py sau NMCT
Co
Bin chng thiu mu c tim (au ngc) xy ra sau NMCT
cp c th do vng tn thng lan rng, thiu mu c tim ti
pht, ti NMCT...
A. Vng tn thng lan rng: Bnh nhn vn au ngc
lin tc hoc ti pht, trn in tm c thay i mi
(chnh hn v lan rng), men tim vn tng ko di. Thm
d siu m tim hoc phng x gip xc nh c
vng c tim tn thng.
B. Thiu mu c tim ti pht: Bnh nhn au ngc sau
giai on cp t vi gi n 30 ngy vi s thay i trn
in tim chng t c thiu mu c tim. Thiu mu c tim
ti pht thng hay xy ra hn bnh nhn NMCT
khng c sng Q. au ngc ti pht sau NMCT thng
c tin lng xu v c ch bnh sinh c coi nh l
70
au tht ngc khng n nh. Vic iu tr do c

coi nh l iu tr au tht ngc khng n nh.
C. Nhi mu c tim ti pht: Bnh nhn au ngc li
vi thay i mi in tim v men tim. Nu bnh nhn
nhi mu li sau khi dng thuc tiu huyt khi cn
tin hnh can thip ng mch vnh ngay.
Vn iu tr: Cn ch nh chp v can thip MV
sm cc bnh nhn ny. Cc thuc Heparin, Aspirin, Nitrates,
chn Beta giao cm cn c cho mt cch tch cc hn.
VI. Cc bin chng tc mch
Cc bin chng tc mch bnh nhn NMCT cp xy ra
trong khong 20% s bnh nhn. Nhng bnh nhn b NMCT
trc rng l c nguy c cao d b bin chng ny.
d
rve
e
s
re
A. Triu chng lm sng
ts vn
h
.
g
Cc biu hin lm sng hay gp lnht
omca tai bin
l ri .cl
A hoo
mch no, mt s bnh nhn b tclomch
tc mch thn,
ev. yachi,
@
Fin0tai
tc mch mc treo Hu ht8.cc
20 bin tc mch thng
2
0 tyNMCT
xy ra trong 10 ngy u
cp. i vi nhng
20ca
i
c
o
t lu,
t c th c cc bin chng huyt
h
o
bnh nhn nm bt ng
P
g
ri
opy chi di v tc mch phi. Tu theo th
khi tnh mchCsu
bnh m c cc triu chng tng ng trn lm sng.
B. iu tr
1. Truyn Heparin tnh mch lin tc trong 3-4 ngy sao
cho thi gian aPTT khong 50-65 giy.
2. Vi nhng bnh nhn b NMCT thnh trc m c
du hiu huyt khi bm thnh cn cho thuc chng
ng ng ung (khng vitamin K) t nht trong 3
thng, gi u vi Heparin.
3. Heparin trng lng phn t thp c tc dng phng
nga tt huyt khi tnh mch chi di v nhi mu
phi i vi nhng bnh nhn nm lu.
71
VII. Bin chng vim mng ngoi tim

A. Vim mng ngoi tim cp
a. Bin chng vim mng ngoi tim cp xy ra
khong 10% s bnh nhn NMCT cp v l mt
trong nhng nguyn nhn gy au ngc. Bin
chng ny thng xy ra trong vng 24-96 gi
sau NMCT cp.
b. Vim mng ngoi tim cp thng xy ra bnh
nhn c NMCT xuyn thnh. Mt s khng c
triu chng lm sng m ch nghe thy ting c
mng tim.
c. a s cc bnh nhn thng c du hiu
ed au
erv ngc
ngc ko di v cm gic rt bng.resau
tsravpha
tng ln khi bnh nhn ngi v ici
. n trc
gh m
r
o
l
l au.c thng khng
hoc ht th su, ho hay nut.
v. A ahoo
e
o
lngc.
lan v quanh qun trc
y
Fin020@
.
8 2 hiu quan trng nht l
d. Nghe tim cho thy
y
00 itdu
2ngoi
o
ting c mng
t ot c tim. Mt s trng hp c
h
rigthyPting c ny. Ting c mng tim
th khng
y
p
Co nghe r nht cnh c tri vng thp.
thng
Ting c mng tim tin trin theo thi gian, gim
hoc mt i khi lng dch mng tim nhiu.
e. C ch ca vim mng ngoi tim cp l do phn
ng vim vng mng tim tng ng vi vng b
nhi mu. S tin trin ca phn ng vim c th
lin quan n mc v din rng ca NMCT.
a. in tm : l mt thm d c gi tr trong
chn on vim mng tim cp. Tuy nhin khi
bnh nhn b vim mng ngoi tim cp sau
NMCT cp th cc du hiu vim mng ngoi tim
c th b che lp mt. Nhn chung, du hiu c
hiu ca vim mng ngoi tim trn T l on
72
ST chnh ln ng hng cc chuyn o v

kiu chnh ln hnh yn nga. Cc du hiu thay
i on ST cng thay i theo thi gian, u tin
l ST v T chnh ln, sau T dt ri ST v
ng ng in v sng T th m ri cng dng
tr li.
b. Xquang tim phi: t c gi tr chn on vim
mng ngoi tim cp.
c. Siu m tim: c th cho thy dch mng ngoi
tim, nhng cng khng th hon ton loi tr
chn on c.
3. iu tr:
a. Aspirin l thuc c la chn vi liu khong
ved
2,5g n 4g trong mt ngy chia lm 4-6erln.
s
re
b. Cc thuc gim vim chng au khng
ts vnsteroid v
h
.
g
steroid khng nn dng iu
omtrong trng
l ri tr
l
c
.
o
v. A ahoqu
hp ny v n c th nhloehng
trnh lin so
y
@
Fin0rng
ca c tim v lm8.lan
20 vng nhi mu mt
00 is
cch m thm. 2Mt
ty2bnh nhn m c au ngc
c
o
t ot
ti pht rnhiu
p ng vi Aspirin th c
igh Pkhng
y
p
th cho
Co Colchicine.
B. Hi chng Dressler
Hi chng Dressler (vim mng ngoi tim mun) xy
ra khong 1-3% s bnh nhn NMCT. Hi chng ny
thng xy ra sau t 1-8 tun sau NMCT cp. Hin c ch
bnh sinh ca bnh cha c r hon ton, nhng ngi ta
thy c nhiu bng chng lin quan n c ch t min dch
ca c th.
Bnh nhn thng c biu hin au ngc kiu vim
mng ngoi tim, c th st, au khp, au c, tng bch cu
mu, tc lng mu tng. Nghe tim c ting c mng ngoi
tim. Siu m tim cho thy c dch mng ngoi tim.
V iu tr th ging nh trong iu tr vim mng tim
cp sau NMCT. Tuy nhin, nu sau qu 4 tun ca NMCT
73
th c th cho bnh nhn c cc thuc khng vim khng

phi steroid thm ch c th cho c steroid.
Ti liu tham kho
1. Chatterjee K. Complications of acute myocardial infarction. Curr
Probi Cardiol 1993;18:1-79.
2. Mukherjee D. Complications of myocardial infarction. In: Marso SP,

Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine.
Philadelphia: LippincottRaven, 2000.
3. O'Donnell L. Complications of MI beyond the acute stage. Am J
Nurs 1996;96:25-31.
4. Reeder GS. Identification and treatment of complications of
myocardial infarction. Mayo Clin Proc 1995;70:SS0-884.
5. Subramaniam PN. Complications of acute myocardial infarction.
Postgrad Med 1994;95:143-145.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
74
Sc tim
Sc l tnh trng mt cn bng gia dng tun hon v nhu

cu xy ca cc m: tnh trng ny dn ti thiu xy m, ri
lon chuyn ho m v gim chc nng ca cc c quan. V
triu chng lm sng: sc biu hin bng mch nhanh, huyt p
tt v kt, thiu niu hoc v niu, v m hi, da xanh ti, ri
lon tm thn c th gp.
Sc tim (cardiogenic shock) ch l mt trong nhiu loi sc
khc nhau. Cc c im v huyt ng ca sc tim cng nh
mt s loi sc khc c tm tt trong bng 5-1 di y. Ngy
nay mc d c nhiu tin b trong vic iu tr NMCTednhng
rv
nu NMCT m c sc tim th t l t vong vn cn
ese c bit
r
ts
cao (60-80%).
gh m.vn
i
r
o
l
Al hoo.c
.
v
a
oe im
Bng 5-1. Phn loi sc v cc
@y v huyt ng.
inlc
0
F
2
8. 20Sv R
Loi sc
C SV200PV
R PA PA
y
cit O AP VP P W
I ghtR PotoR
2
ri
y
P
p
Co
Sc tim (NMCT, p
tim cp)
Sc gim th tch
(mt mu)
Sc phn b (nhim
khun, phn v)
Sc tc nghn (nhi -
mu phi rng)
Trong : CI: ch s cung lng tim; SVR: sc cn i tun

hon; PVR: sc cn tiu tun hon; SvO2: bo ho xy mch
trn; RAP: p lc nh phi; RVP: p lc tht phi; PAP: p lc
ng mch phi; PAWP: p lc ng mch phi bt. : Khng
thay i; : gim; : tng.
75
I. nh ngha v sinh l bnh ca sc tim

A. nh ngha
Sc tim l tnh trng gim cung lng tim khng p ng
c nhu cu xy ca cc m c th. Chn on sc tim gm:
1. Huyt p tm thu < 80 mmHg khi khng c mt cc
thuc vn mch hoc < 90 mmHg khi c mt cc
thuc vn mch v t nht ko di > 30 pht.
2. Gim cung lng tim (Ch s tim < 2,0 lt/pht/m2)
m khng lin quan n gim th tch tun hon
(PAWP > 12 mmHg).
3. Gim ti mu m: thiu niu (nc tiu < 30
ml/gi), co mch ngoi vi, ri lon tm thn.
B. Nguyn nhn
ed ca
1. Nhi mu c tim cp: l nguyn nhn hngervu
s
re c mt
sc tim c bit l nhi mu trc rng
ts vv
n
h
g
i om.
r
vng c tim ln b hoi t.
l
l
c
. A oo.
2. Cc nguyn nhn khc: loev yah
0@ trong NMCT hoc
Fin02chng
a. H hai l cp do t
8. dy
2
0
vim ni tm mc
20 nhim
ity khun.
t otoc
h
b. Thng vch
rig linP tht cp trong NMCT.
y
p
c. Vim
Coc tim cp do cc nguyn nhn.
d. Giai on cui ca bnh c tim gin.
e. Cc bnh van tim nng (h van hai l, h van
ng mch ch ...).
f. p tim cp.
g. Ri lon nhp nng.
h. Mt s trng hp sau m tim phi nhn to.
C. T l gp sc tim trong NMCT cp
T nhng nm 50 cho ti nhng nm 90 ca th k va
qua, t l sc tim c thay i cht t khong 19% 6%,
nhng vn gi mt t l cao trong NMCT cp. c tnh
trong khong 1 triu bnh nhn b NMCT cp M mi nm
th c ti 70.000 n 150.000 bnh nhn b sc tim. T l t
vong bnh nhn c sc tim vn c bit cao t 60 - 90 %.
76
D. Sinh l bnh ca sc tim do NMCT cp

1. u tin l vic nhi mu gy mt mt vng c tim
ln hoc nhi mu nh bnh nhn c gim chc
nng tht tri t trc dn n gim th tch nht bp
tim v gim cung lng tim, vic ny cng dn n
gim dng mu n mch vnh b tn thng to
nn mt vng xon bnh l.
2. Vic gim cung lng tim li cng lm huyt p tt
v thiu mu cc m dn n mt lot cc p ng
cc m theo vng xon bnh l lm bnh thm nng.
II. Biu hin lm sng
A. Tnh trng sc: Nh trnh by trong phn nh
d
ngha, sc tim c biu hin bi:
rve
e
s
re mt cc
1. Huyt p tm thu < 80 mmHg khi khng
ts vc
h
.cn mt cc
g
i khi
thuc vn mch hoc < 90 mmHg
r
m
o
l
l o.c
. A a>ho30
thuc vn mch v t nht koevdi
pht.
o
l @y
n
i
F 020tim < 2,0 l/pht/m2) m
2. Gim cung lng tim (Ch
8. 2s
0
khng lin quan n
20 gim
ity th tch tun hon (PAWP
t otoc
h
P
> 12 mmHg).rig
y
p
Co mu m: thiu niu (nc tiu < 30
3. Gim ti
ml/gi), co mch ngoi vi, ri lon tm thn.
B. Khm lm sng: c th thy
Bnh nhn xanh ti, kh th, th ngoi cnh hoc ri lon
tm thn, mch nhanh, huyt p tt, v m hi...
1. Khai thc bnh s v khm lm sng pht hin
cc nguyn nhn:
a. NMCT cp:
C th au ngc in hnh ca NMCT cp.
Trong NMCT cp, sc tim thng xy ra
gi th 8-10 sau au ngc.
in tm thay i: xut hin sng Q v
on ST chnh.
Cc men tim tng.
77
b.
c.
d.
e.
Siu m cho thy c ri lon vn ng vng

ca c tim, c th thy cc bin chng c hc
km theo nh h van hai l, thng lin tht...
p tim cp:
Kh th d di.
Tnh mch c ni.
Mch o (chm hoc mt khi ht vo).
Huyt p tt, kt.
Nghe tim ting m, gan to.
Din c tim to, bng tim to trn Xquang.
Siu m gip xc nh khi lng dch nhiu
hay t.
Cc bnh van tim:
Nghe tim c th pht hin c cc tn
d
thng van tim.
rve
e
s
re
Siu m Doppler tim c ch trong
ts vnvic nh
h
.
g
gi chnh xc tn thng ca
omvan tim.
l ri cc
l
c
.
A o
Vim c tim cp:
ev. yaho
o
l
in 0@cp.
Rt d nhm vi. FNMCT
8 202
0
Tin s c 2th
0 cy cc du hiu nhim trng
tocit
tra.
h
mi xy
Po
rig
y
Copth km theo cc ri lon nhp nng n.
C
Cc bnh khc:
Giai on cui ca bnh c tim gin, bnh c
tim ph i.
Ri lon nhp nng: in tm gip xc
nh chn on.
Nhi mu phi gy suy chc nng tht phi
cp: bnh nhn au ngc, ho mu, kh th
nhiu, chp phim c th thy m m.
III. iu tr
A. Cc bin php chung
1. Nhanh chng xc nh tnh trng sc tim ca bnh
nhn, loi tr cc nguyn nhn khc gy ra huyt p
thp.
78
2. Bnh nhn cn c nm khoa iu tr tch cc.

3. xy: cn c cung cp y , nu bnh nhn t th
tt c th cho th qua ng mi, nu bnh nhn c
ri lon nhp th hoc suy h hp nng th cn t ni
kh qun v cho th my ng ch .
4. Thit lp mt ng truyn tnh mch.
5. t catherter tnh mch trung tm theo di, tt nht
l c Swan-Ganz theo di cung lng tim v p
lc ng mch phi bt.
6. Theo di bo ho xy ng mch.
7. Theo di lng nc tiu (t thng i).
8. m bo tt th tch tun hon sao cho p lc nh
phi t 10-14 mmHg v PAWP t 18-20 mmHg.
d
rvenu c
e
9. Kim sot tt cc ri lon nhp tim km theo
s
re
ts t
(nhanh tht: sc in, nhp chm qu:
n my to
h
g
i om.v
r
nhp).
l
l o.c
o
v. A ahkim
e
o
10. Kim sot cc ri lon thng
bng
toan v nc
l
y
n 0@
i
F
2
in gii.
8. 0
00 ity2
2
mch
11. Dng cc thuc tvn
oc (xem phn sau).
gh Pot
i
r
12. Dng ccopbin
y php h tr c hc tun hon (phn
sau). C
B. Theo di huyt ng
Trong iu tr sc tim, theo di huyt ng l yu t
quyt nh iu chnh v can thip kp thi.
C. Cc thuc
1. Dobutamine:
L mt catecholamin tng hp, c tc dng
tri trn bta 1 giao cm lm tng sc co bp
c tim v tng nhp tim phn no, t nh
hng n co mch, lon nhp v dng mu
n thn.
L thuc la chn hng u trong iu tr sc
tim, ch nh ti u khi huyt p cn > 80
mmHg. Liu dng: 2 - 5 g/kg/pht.
79
Bng 5-2. Cc thuc dng trong sc tim.

Thuc
Liu thng thng
Tc dng ph
Dobutamine
5-15 g/kg/pht truyn Quen thuc, phi
TM.
tng liu dn.
Dopamine
Noradrenalin
Nitroglycerin
Nitroprussiat
2-20 g/kg/pht, truyn

TM.
2-16 g/kg/pht, truyn
TM.
10 g/pht, tng dn liu
mi 10 mcg trong 10
pht nu khng p ng.
10 g/pht, c th tng 5
g mi 10 pht.
Lm tng nhu cu
xy c tim.
Co mch ngoi vi
v mch tng.
au u, tt
huyt p.
au u, tt
d c
huyt p, ng
rve
e
s
cyanid.
re
ts vn
h
. tiu cu
g
Amrinone
0,75 mg/kg tim TM Gim
l ri .com
l
trong 2 pht sau v
oo
. A mu.
oe yah
truyn
TM inl5-10
0@
F
g/kg/pht. 008. y202
2 ocit
t 50mcg
Milrinone
Tim TM
trong Ri lon nhp
h
Pot
g
i sau
10oppht
truyn tht.
yr
C
TM
0,375 - 0,750
g/kg/pht.
Furosemide
20 - 160 mg tim TM.
H kali mu,
magi mu.
Bumetanide
1-3 mg tim TM.
Nn, chut rt.
2. Dopamine:
a. L 1 catecholamin t nhin, c tc dng trn cc
th th giao cm tu theo liu. Vi liu thp (2-5
g/kg/ph) ch yu tc dng trn th th dopamine
lm gin mch thn, tng dng mu n thn v
lm tng th tch nht bp ca tim. Vi liu trung
bnh (5-15 g/kg/pht) ch yu kch thch 1
giao cm lm tng sc co bp c tim v tng nhp
tim. Vi liu cao 15 - 20 g/kg/pht s c tc
80
3.
4.
5.
6.
dng kch thch giao cm gy co mch ngoi vi

mnh.
b. Ch nh tt khi huyt p tm thu < 80 mmHg,
liu dng t 2-20 g/kg/pht, ty theo p ng.
Noradrenalin:
a. Cng l mt catecholamin t nhin vi tc dng
mnh trn giao cm gy co mch nhiu.
b. Nn c ch nh khi HA tm thu < 70 mmHg v
liu dng t 2-16 g/kg/pht.
Cc thuc gin mch:
a. Cc thuc ny ch dng khi duy tr c con
s HA mc n nh.
b. Cc thuc ny gy gin mch nn lm gim
d tin
rve
e
s
gnh v hu gnh cho tim, do rt c
re li khi b
hts theo.
NMCT cp hoc cc suy tim cprigkm
.vn
m
o
l
l o.c
c. Cc thuc thng dng vl:
dng
. A aNitroglycerin
ho
e
o
l
y
truyn hoc Nitroprussiad
vi liu bt u t 10
Fin 0@
8. 202
g/pht.
0
20 ity
t otoc
Cc thuc tr
tim:
h
P
rig
y
p
a. Khng
Co nn dng Digitalis trong NMCT cp c
sc tim d c suy tht tri nng v thuc ny lm
tng nguy c b lon nhp v tng t l t vong.
b. Trong cc trng hp khc khi c suy tim do
bnh van tim hoc bnh c tim m c km rung
nh nhanh th Digitalis rt nn dng.
c. Cc thuc lm tng sc co bp c tim do c ch
phosphodiesterase (Milrinone, Amrinone) c th
dng trong trng hp c suy tim nng.
Cc thuc li tiu:
a. Cc thuc li tiu lm gim p lc y tht
tri v nn dng khi c suy tim m c tng khi
lng tun hon v khng ch c huyt p.
81
b. Thng dng l Furosemide, Bumetanid tim tnh

mch.
D. H tr tun hon bng c hc
Khi cc thuc dng t ra t p ng hoc tht bi, cn
cn nhc sm vic dng cc bin php h tr c hc c bit
khi cn phi can thip MV hoc m cu ni.
1. Bm bng ngc dng trong ng mch ch (Intra
- Aortic Balloon Counterpulsation Pump - IABP):
a. Dng mt qu bng to v di t trong MC t
on trn ca MC xung cho n tn MC
bng trc ch chia ra ng mch chu. Vic
bm bng v lm xp nh kh heli do mt my
bm ngoi ni vi bng v lm vic theo
chu
ed
v
r
e
chuyn ca tim. Bng s c bm esphng ln
r
ts ivntrong thi
trong thi k tm trng v lm xp
h
g
i om.
k tm thu, do vy s lmAtng
mu n
ll r o.cdng
. aho
vtrng
e
MV trong thi k tm
v
ch
yu lm
o
nl 0@y
i
F
2
gim p lc hu gnh
. trong k tm thu nn lm
08 ty20
0cho
2
gim gnh nng
i tim.
t otoc
h
P
g
b. Chng ych
ri nh khi c h ch nng, tch thnh
p
o
C
ng mch ch, bnh l mch ngoi vi.
c. Cc nghin cu cho thy, t khi ra i loi bng
bm ny lm gim ng k t l t vong do
sc tim.
2. My tim phi nhn to chy ngoi (Hemopump):
ang c th nghim v cho kt qu kh tt. Ngy
nay, mt s trung tm cn c loi my xch tay rt
tin li.
E. iu tr nguyn nhn
1. NMCT cp: Khi sc tim xy ra th cc bin php ti
ti mu MV cng t ra cp thit:
a. Thuc tiu huyt khi: cha chng minh c
lm gim t l t vong trong NMCT cp c sc
tim (nghin cu GISSI-1, GUSTO-1), tuy nhin
82
nu khng c chng ch nh nn cho thuc tiu

huyt khi v lm ci thin c dng chy ca
MV ng k nu bnh nhn sng st. Nn dng
rt-PA hn l dng Streptokinase.
b. Can thip MV: Nhiu nghin cu chng
minh can thip MV khi c sc tim lm gim t
l t vong v phc hi sc tim nhanh. Tuy nhin
can thip ch t kt qu ti u khi c cc bin
php khc h tr tt v i hi th thut can thip
phi c tin hnh mt cch nhanh chng bi
nhm ngi lm c kinh nghim (nghin cu
SHOCK, SMASH). Can thip MV trong sc tim
s c th t tc dng nu qu mun (>36 gi)
hoc bnh nhn cao tui (>75 tui) (theo khuyn
d
rve
e
co rt ra t nghin cu SHOCK).
s
re
ts c
n
h
c. M lm cu ni ch-vnh: c
bit
g
i om.v ngha
r
l
l km
.c theo nh h
khi c cc bin chng c .hc
v A ahoo
e
o
l
y
hai l cp do t dy chng,
thng
lin tht...
Fin020@
.
2. Cc nguyn nhn 0khc:
08 2cn c iu tr tch cc
2 ocity
theo nguyn nhn:

ht Pot
rig
y
p
a. BnhConhn
c p tim cp phi xc nh v chc
dch ngay.
b. Bnh nhn c bnh van tim cn c phu thut
sa hoc thay van tim.
c. Vim c tim cp hoc bnh c tim vn cn l vn
nan gii, vic iu tr cn nhiu kh khn, ch
yu vn l iu tr triu chng.
Ti liu tham kho
1.
2.
3.
Antman E. Braunwald E. Acute Myocardial Infarction. In

Braunwald E ed, Heart Disease, a textbook of cardiovascular
medicine, 5th edition WB Saunders Philadephia, 1997.
Barron HW, Pirzada SR, Lomnitz Dj et al. Use of IABP in patients
with AMI complicated by cardiogenic shock. J Am Coll Cardiol
1998;31.
Eagle and Guyton et al.ACC/AHA Guidelines for Coronary Artery
Bypass Graft Surgery surgery JACC Vol. 34, No. 4, October
83
1999:1262-347 Recommendations of the ACC/AHA Task Force in

order to decrease morbidity and mortality in patients undergoing
CABG. Circulation 1999;100:1464-1480.
4. Goldstein JA, Barzilai B, Rosamond TL, Eisenberg PR, Jaffe AS.
Determinants of hemodynamic compromise with severe right
ventricular infarction. Circulation 1990;82:359-368.
5. Hasdai D, Holmes DR Jr, Califf RM, et al. Cardiogenic shock
complicating AMI: Predictors of death. Am Heart J 1999;138:2131.
6. Hochman JS, Buller C, Sleeper L et al. for the SHOCK
Investigators. Cardiogenic shock complicating AMI-Etiologies,
management and outcome: A report from the SHOCK trial registry.
J Am Coll Cardiol 2000; 36:1063-70.
7. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization
in acute myocardial infarction complicated by cardiogenic shock.
SHOCK Investigators. Should We Emergently Revascularize
Occluded Coronaries for Cardiogenic Shock. N Eng J Med 1999;
d
341: 625-634.
rve J Med
e
s
8. Kinch JW, Ryan TJ. Right ventricular infarction. N
Engl
re
ts vn
1994;330:1211-1217.
h
.
g
9. Kosuge M, Kimura K. Ishikawa T et al. Implications
l ri .comof the absence
l
A hoo who have inferior
of ST-segment elevation in lead V4R ein
v. patients
a
o
l
wall AMI with right ventricular iinvolvement
n 0@y Clin Cardiol 2001;
F
2
24:225-230.
8. 0
0H,0 etityal.2 AMI complicated by systemic
2
10. Menon V, Slater J, White
t otoc
hypoperfusion without
A report from the SCHOCK
P
igh hypotension.
r
y
trial registry. Am
J
Med
2000;
108:374-80
p
o
84
ri lon Lipid mu
I. nh ngha
Ngi ta gi l ri lon lipid mu khi c mt hoc nhiu
cc ri lon sau:
1. Tng Cholesterol huyt tng:
a. Bnh thng: Cholesterol trong mu < 5,2 mmol/l
(< 200 mg/dl)
b. Tng gii hn: Cholesterol trong mu t 5,2 n
6,2 mmol/l (200 239 mg/dl)
c. Tng cholesterol mu khi >6,2 mmol/l d(>240
rve
mg/dl)
ese
r
s
2. Tng TG (Triglycerid) trong mu: ight .vn
r
om
l
Al hoo.c(<200 mg/dl).
a. Bnh thng: TG mu <2,26v.mmol/l
loe @ya mmol/l (200-400
b. Tng gii hn: TG tFin2,26-4,5
20
.
08 ty20
mg/dl).
0
2 toci
c. Tng TG:ight TG
Po t 4,511,3mmol/l (400r
y
p
1000mg/dl).
Co
d. Rt tng: TG mu > 11,3 mmol/l (> 1000 mg/dl).
3. Gim
HDL-C
(High
Density
Lipoprotein
Cholesterol): HDL-C l 1 Lipoprotein c tnh bo v
thnh mch. Khc vi LDL-C, nu gim HDL-C l c
nguy c cao vi x va ng mch:
a. Bnh thng HDL-C trong mu > 0,9 mmol/l.
b. Khi HDL-C mu < 0,9 mmol/l (<35mg/dl) l gim.
4. Tng LDLC (Low Density Lipoprotein Cholesterol)
a. Bnh thng: LDL-C trong mu <3,4 mmol/l (<130
mg/dl)
b. Tng gii hn: 3,4 4,1 mmol/l (130-159 mg/dl)
c. Tng nhiu khi: > 4,1 mmol/l (>160 mg/dl)
85
5. Ri lon lipid mu kiu hn hp: Khi Cholesterol >

6,2 mmol/l v TG trong khong 2,26 4,5 mmol/l.
II. Nguyn nhn gy ri lon lipid mu
A. Nguyn nhn gy tng cholesterol mu
1. Ch n:
a. n qu nhiu m ng vt.
b. n qu nhiu thc n c cha nhiu Cholesterol
(ph tng ng vt, m ngvt, trng, b, sa
ton phn...).
c. Ch n d tha nng lng (bo ph).
2. Di truyn:
a. Tng Cholesterol gia nh (thiu ht th th vi
LDL).
d
rve
e
s
b. Ri lon lipid mu kiu hn hp c tnh
re cht gia
ts vn
h
nh.
g
ri com.
l
l
.
c. Tng Cholesterol mu do ri
lon hn
hp gen.
v. A ahoo
e
o
l
y
3. Th pht:
in @
. F 2020
8
0
a. Hi chng thn2h.
0 ity
c
b. Suy gip. ight Poto

r
c. i Ctho
opy ng.
d. Bnh l gan tc nghn.
e. Mt s bnh gy ri lon protein mu (a u tu
xng, macroglobulinemia).
B. Nguyn nhn gy tng Triglycerid mu
1. Thiu ht gen lipase tiu hu lipoprotein hoc
apolipoprotein C-II.
2. Tng TG c tnh cht gia nh.
3. Bo ph.
4. Ung qu nhiu ru.
5. i tho ng.
6. Dng thuc chn bta giao cm ko di.
86
C. Nguyn nhn gy gim HDL-C:

1. Ht thuc l.
2. Bo ph.
3. Li vn ng th lc.
4. i tho ng khng ph thuc insulin.
5. Tng TG mu.
6. Dng thuc chn b ta giao cm ko di.
7. Ri lon gen chuyn ho HDL.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
t
t
igh Po
r
y
Hnh 6-1. Cu
p trc ca lipoprotein.
Co
III. Nguyn tc iu tr ri lon lipid mu
A. Vic iu tr tu thuc vo tng c th bnh nhn

trn c s nh gi tnh trng ri lon Lipid mu v cc
yu t nguy c ca bnh mch vnh (bng 6-1).
Bng 6-1. Cc yu t nguy c ca bnh mch vnh.
87
Yu t nguy c dng tnh:

Nam 45 tui
N 55 tui
C tin s gia nh b bnh MV
Ht thuc l nhiu
Tng huyt p
HDL-C < 0,9 mmol/l
i tho ng
Yu t nguy c m tnh: tnh tr i 1 yu t nguy c nu c
HDL-C 60 mg/dl
B. iu tr cp mt v iu tr cp hai.
Gi l iu tr cp mt khi bnh nhn c ri lon Lipid mu
nhng cha c tin s b bnh mch vnh, iu tr cp hai khi
d
bnh nhn c tin s bnh mch vnh:
rve
e
s
re
1. iu tr cp mt: nhm t c LDL-C
ts vmu
n < 4,1
h
.
g
i
r
mmol/l vi nhng bnh nhn c tll hn.co2myu t nguy
A hoo
c hoc LDL-C < 3,4 mmol/l
ev.nu
o
l
ya bnh nhn c 2
n
@
i
0
yu t nguy c. iu tr. Fphi
02bt u bng iu chnh
2
08 Dng
y
0
ch n v luyn
tp.
thuc khi iu chnh
2 tocit
t
h
o
ch n mt
rigthi Pgian m tht bi hoc phi bt u
y
p
ngay khi:
Co
a. C qu nhiu yu t nguy c bnh mch vnh v
lng LDL-C trong mu cao (> 4,1 mmol/l), hoc
b. Khi lng LDL-C trong mu qu cao (> 5
mmol/l).
2. iu tr cp hai: Khi bnh nhn c biu hin bnh
mch vnh. Mc ch iu tr ch yu l phi lm
gim c LDL-C < 2,6 mmol/l (<100 mg/dl). Cn
iu chnh ch n tht nghim ngt cho mi bnh
nhn, ng thi cho thuc phi hp ngay khi LDL-C
> 3,4 mmol/l.
88
IV. iu tr c th
A. Ch n v sinh hot
1. Dng ch n gim Cholesterol v calo (nu
bnh nhn bo ph). Gm 2 bc:
a. Bc 1: thnh phn cht dinh dng n hng
ngy c lng acid bo bo ho < 10 %, tng s
cc cht bo khng qu 30 % v lng
Cholesterol phi < 300 mg/ ngy. Nh vy l cn
trnh hoc gim cc cht m ng vt, trng, sa
nguyn, ph tng ng vt, cc loi pho-mat,
kem... Tng cng n hoa qu ti, rau, v cc
loi ng cc vi lng tinh bt chim khong 55 60 % khu phn.
d
rve trn
e
b. Bc 2: c p dng khi thc hin
bc
s
re
tsbc
n ny lm
sau 6-12 tun khng kt qu. Trong
h
g
i om.v
r
l
l ho
c xung < 7%
gim tip lng acid bo bo
oo.
v. A ah<
e
khu phn v lng Cholesterol
200
mg/ ngy.
o
inl 20@y
F
c. Thi gian iu chnh
8. ch0 n v mt s lu :
00 ity2
2
c
Nu chhcn
t iu
oto chnh ch n theo nh ch
P
g
i
r
nh
py ni trn th thi gian cn t nht l 6
Co
thng.
C 6-8 tun nn kim tra li lng
Cholesterol mu. Ch n phi c duy tr
lu di cho d c dng thuc hay khng dng.
Cn lu hn khi dng ch n ny ngi
gi v ph n c thai.
bnh nhn b tng TG, cn hn ch m
ng vt, ng v ru.
Gim cn nng cho nhng bnh nhn bo ph.
Nn bt u gim dn dn lng calo hng
ngy, thng hn ch mc 500 calo/ngy.
Tp th lc l rt quan trng, n c th lm
gim c LDL-C v tng HDL-C. Tp th
lc cn lm gim cn nng, gim huyt p, v
gim nguy c bnh mch vnh.
89
B. iu tr bng thuc
1. Cc nhm thuc:
a. Cc loi resins gn acid mt: nh
Cholestyramine (Questran), Colestipol (Colestid):
Cc thuc ny khng hp thu qua rut, n gn
vi acid mt lm gim hp thu ca chng. Do
vy n s lm tng chuyn ho t Cholesterol
sang acid mt trong gan, lm gim lng
Cholesterol d tr trong gan v lm tng hot
tnh ca th th vi LDL ca gan. N lm
gim LDL-C ti 30%, lm tng HDL-C
khong 5 % nhng lm tng nh TG. Do vy
thng dng kt hp vi thuc khc v khng
d
dng khi TG tng cao.
rve
e
s
e
Liu thng dng: Questran 8 t
g/ngy
s r 16
h
vn 10
.
g
i Colestid:
chia 2 ln dng trong ba ln,
r
l o.com
. A aNn
30 g/ngy chia lm 2eln.
ho khi u bng
v
o
l
y
@
liu thp sau tng
in dn.
. F 2020
8
0
Tc dng ph
th gp bao gm: to bn,
20 occ
ity
t bun
t
au bng,
nn,
nn, nng rut... Ch
h
o
P
ig
r
y
khi
p dng chung cc thuc khc c th lm
Co
gim hp thu cc thuc .
b. Nicotinic acid (Niacin): y l mt loi Vitamin
tan trong nc, c ch gan sn xut ra cc
Lipoprotein. Cc thuc ny:
Lm gim VDLD-C ti 50%, lm gim LDLC ti 25% v tng HDL-C 15-35%.
Liu bt u nn thp khong 100 mg x 3 ln/
ngy, sau c th tng liu ti khong 2-4
g/ngy.
Tc dng ph: Cm gic bng da rt hay
gp (hu nh gp tt c cc bnh nhn). C
th trnh bng cch ung thuc trong ba n
hoc ung Aspirin 100 mg trc mi ln dng
thuc 30 pht. Cc tc dng ph khc bao
90
Chng ch nh ca Niacin: bnh nhn b

Goutte, lot d dy t trng, bnh vim i
trng mn. Chng ch nh tng i bnh
nhn i tho ng.
c. Thuc c ch men HMG-CoA Reductase
(nhm Statin): Gm Simvastatin (Zocor);
Lovastatin; Pravastatin; Fluvastatin; Atorvastatin
(Lipitor)...
Cc thuc ny c ch hot ho men HGMCoA-reductase lm gim tng ed hp
rv
Cholesterol trong t bo gan v tng
ese hot ho
r
ts vn trong
th th LDL do lm gim
.
gh LDL-C
i
r
l .com c th lm
l
mu. Simvastatin v Artovastatin
A hoo
ev. v
a lm gim TG ti
o
gim LDL-C ti 60%
l
in 20@y
F
. 20 cu chng minh c
37%. nhiu
08 nghin
0
ty
2
l cc Statin
ocith lm gim t l t vong
t oc
t
h
Pc bnh mch vnh, gim t l
g
bnh
rinhn
y
p
Co mch vnh bnh nhn b tng Lipid
bnh
mu, v lm gim t l phi can thip li
bnh nhn sau can thip ng mch vnh
hoc m cu ni ch-vnh.
Liu dng: Simvastatin (Zocor) t 5-40
mg/ngy; Atorvastatin (Lipitor) 10-80 mg/
ngy; Lovastatin 10-20 mg/ngy; Pravastatin
10-40 mg/ngy. Cc thuc nhm ny khng
nn dng gn ba n v c th dng 1 ln
trong ngy trc khi i ng. Cc statin khc
nhau c hiu lc i vi LDL-C khc nhau
(bng 6-2).
Bng 6-2. Tc dng ca cc statin khc nhau i vi s
thay i ca LDL-C v HDL-C.
Thuc
Liu u Ti a Gim
Tng
91
(LB)
Lovastatin
(Mevacor)
Pravastatin
(Pravachol)
Simvastatin
(Zocor)
Fluvastatin
(Lescol)
Atorvastatin
(Lipitor)
20mg
80 mg
LDL-C
vi LT
40%
HDL-C
vi LT
9,5%
10-20
mg
20 mg
40 mg
34%
12%
80 mg
47%
8%
20-40
mg
10 mg
80 mg
36%
5,6%
80 mg
60%
5%
Tc dng ph: Bao gm kh tiu, a chy,

d to
rve ng.
e
s
bn, bun nn, au bng, au u,
mt
re
ts vn s bnh
Tng men gan c th gp igh1-2%
.
om statin cho
l r .dng
l
c
nhn dng thuc. Khng
nn
A hoo
ev. ang
a tin trin, au
o
bnh nhn b bnh
gan
l
in 20@y
F
c, vim a c,
8.tiu 0c vn... Khng nn dng
00 ity2
2
Statin cng
oc Cyclosporin, cc dn xut
t ovi
Pt
ighErythromycin,
Fibrat,
Niacin... v cc thuc
r
py
o
C
ny c th lm tng c tnh khi dng cng
nhau.
Ch : hin nay thuc Lipobay (Cerivastatin)
phi rt khi th trng do tc dng ph
nguy him gy tiu c vn khi dng cng vi
cc Fibrat.
d. Cc dn xut fibrat (acid fibric) bao gm :
Gemfibrozil (Lopid); Fenofibrat (Lipanthyl,
Tricor); Bezafibrat (Benzalip).
Cc thuc ny lm gim VLDL v do lm
gim TG khong 20-50%, lm tng HDL-C
khong 10-15%. Gemfibrozil lm gim LDLC khong 10-15%. Do vy cc thuc ny ch
nh tt trong cc trng hp tng TG mu v
c th kt hp tt vi thuc gn mui mt.
92
Liu thng dng l: Gemfibrozil 600 mg x 2

ln/ngy trc khi n; Fenofibrat 300
mg/ngy.
Tc dng ph c th gp l: sng ph mt,
au bng, bun nn, au u, mn nga...
Men gan c th tng, cn theo di men gan
khi dng cc thuc ny. Nhm thuc ny cn
lm tng nguy c si mt.
e. iu tr thay th bng hormon sinh dc n
(Estrogen): c th c ch ph n sau tui mn
kinh c ri lon lipid mu. Estrogen ung lm
gim LDL-C khong 15% v lm tng HDL-C
cng khong 15%. y l thuc nn chn la u
tin cho iu tr ph n sau tui mn kinhedc ri
v
lon lipid mu. Tuy nhin, thuc nyrec
ser th lm
ts
tng TG i cht.
gh m.vn
i
r
o
l
2. Vn kt hp thuc: c th. dng
Al hoo2.c loi thuc 2
v
oe yamu khc nhau nu
nhm thuc iu tr ri lon
inl 2lipid
0@
F
02 loi thuc vi liu thp
8. hp
thy cn thit. Vic kt
2
0
0 ity
c
2 tdng
s thay th chohtvic
1 loi vi liu cao v kh
oo
P
g
i
r
dung np. pTrong
mt s trng hp khi tng qu cao
y
Co mu nn kt hp 2 loi thuc. S kt hp
Cholesterol
tt nht l gia Statin v Niacin.
3. Theo di khi dng thuc: cn kim tra Cholesterol
v TG mu mi 3-4 tun iu tr. Nu khng p ng
sau 2 thng iu tr, mc d dng liu ti u, th
nn thay bng thuc khc hoc kt hp thuc th 2.
Lu l vic iu chnh ch n v luyn tp phi
lun lun c bo m.
4. Mt s tnh hung c th:
a. iu tr bnh nhn tng Triglycerid mu: Vi
bnh nhn tng gii hn TG th ch cn iu
chnh ch n v sinh hot, c bit l gim
trng lng, ch n t tinh bt, m v khng
ung ru. Trong trng hp phi dng thuc th
93
nn la chn Niacin hoc dn xut fibrat. Khi TG

rt cao trong mu th cn phi phng nguy c
vim tu cp.
b. iu tr bnh nhn tng lipid mu hn hp (tng
c Cholesterol v TG). Mc ch th nht l phi
a LDL-C v gii hn bnh thng, sau c
gng a TG v mc bnh thng hoc gn bnh
thng nu c th. Vic iu chnh ch n v
gim cn nng vn l quan trng hng u. Khi
dng thuc nn kt hp Niacin hoc mt Fibrat
vi mt Statin.
c. iu tr bnh nhn b gim HDL-C: Ch trc
tin l loi b cc cn nguyn gy gim HDL nh
ht thuc l, bo ph, li tp th dc, i
d tho
rve
e
s
ng khng c khng ch, tng
re TG mu,
tsCvnth dng
h
dng chn bta giao cm ko rdi.
g
i om.
l
l
.c
Niacin, Statin hoc Gemfibrozil.
v. A ahoo
e
o
l
y
Ti liu tham kho
Fin020@
.
08 2
1. Abramowicz M, editor. Choice
20 ocitofy lipid-lowering drugs. Med Lett
1998;40:117-22.
ht Pot
rigAssociation.
2. American Diabetes
Management of dyslipidemia in
y
p
adults with diabetes.
Co Diabetes Care 1999;22:Suppl 1:S56-S59.
3.
4.
5.
6.
7.
8.
Bachmaier K, Neu N, de la Maza LM, Pal S, Hessel A, Penninger

JM. Chlamydia infections and heart disease linked through antigenic
mimicry. Science 1999;283:1335-9.
Denke MA. Cholesterol-lowering diets: a review of the evidence.
Arch Intern Med 1995;155:17-26.
Diaz MN, Frei B, Vita JA, Keaney JF Jr. Antioxidants and
atherosclerotic heart disease. N Engl J Med 1997;337:408-16.
Fielding CJ, Fielding PE. Molecular physiology of reverse
cholesterol transport. J Lipid Res 1995;36:211-28.
Ginsberg HN. Is hypertriglyceridemia a risk factor for
atherosclerotic cardiovascular disease? A simple question with a
complicated answer. Ann Intern Med 1997;126:912-4.
Ginsburg HN, Goldberg IJ. Disorders of lipoprotein metabolism. In:
Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrisons
principles of internal medicine. 14th ed. Vol. 2. New York:
McGraw-Hill, 1998:2138-
94
9.
10.
11.
12.
13.
14.
Havel RJ, Rapaport E. Management of primary hyperlipidemia. N

Engl J Med 1995;332:1491-8. [Erratum, N Engl J Med
1995;333:467].
Illingworth DR, Tobert JA. A review of clinical trials comparing
HMG-CoA reductase inhibitors. Clin Ther 1994;16:366-85.
Levine GN, Keaney JF Jr, Vita JA. Cholesterol reduction in
cardiovascular disease: clinical benefits and possible mechanisms. N
Engl J Med 1995;332:512-21.
Lipid Metabolism Branch, Division of Heart and Vascular Diseases,
National Heart, Lung, and Blood Institute. The Lipid Research
Clinics population studies data book. Vol. 1. The Prevalence Study:
aggregate distribution of lipids, lipoproteins and selected variables
in North American populations. Bethesda, Md.: National Institutes
of Health, 1980:1-136.
Staels B, Dallongeville J, Auwerx J, Schoonjans K, Leitersdorf E,
Fruchart J-C. Mechanism of action of fibrates on lipid and
lipoprotein metabolism. Circulation 1998;98:2088-93.
d
Stone NJ. Secondary causes of hyperlipidemia. Med Clin
rve North
e
s
Am1994;78:117-41.
re
ts
gh m.vn
i
r
o
l
Al hoo.c
.
v
a
oe
inl 20@y
F
8. 0
00 ity2
2
c
ht Poto
rig
py
Co
95
Tng huyt p (THA) l mt bnh rt thng gp v hin

tr thnh mt vn x hi. cc nc pht trin, t l THA
ngi ln (>18 tui) theo nh ngha ca JNC VI l khong
gn 30 % dn s v c trn mt na dn s > 50 tui c THA.
Theo thng k Vit nam nhng nm cui thp k 80 t l THA
ngi ln l khong 11% th thng k gn y t l THA H
ni cho ngi ln khong 20 %.
THA nguy him bi cc bin chng ca n khng ch c
th gy cht ngi m cn li nhng di chng nng n (vd. tai
bin mch no) nh hng n cht lng cuc sng ca bnh
nhn v l gnh nng cho gia nh x hi.
Ngy nay c kh nhiu thay i trong quan nim v
THA, phng thc iu tr cng nh vic gio dc bnh nhn
tc ng n tin lng ca THA.
I. nh ngha tng huyt p (THA)
tng huyt p
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
t
h Po
rig
Cho n nay, T chc Y t th gii v hi THA quc t

(World Health Organization - WHO v International Society of
Hypertension - ISH) thng nht gi l THA khi huyt p tm
thu 140 mmHg v/hoc huyt p tm trng 90 mmHg. Con
s ny c c l do da trn nhng nghin cu ln v dch t
cho thy:

loi tng t ch khc nhau v thut ng (bng 7-1). Nhng im

ch trong cch phn loi ny:
cp n khi nim HA bnh thng cao, v nhng
nghin cu cho thy trong mt s trng hp vi nhng
nguy c cao (v d tiu ng) th cn iu tr.
Khng cn giai on IV nh trc y (HA > 210/120
mmHg) v trong thc t trng hp ny gp khng nhiu
v phng n iu tr th ging nh giai on III.
Bng 7-1. Phn loi THA theo JNC VI (1997).
Khi nim
HA tm thu
HA tm trng
(mmHg)
(mmHg)
HA ti u
< 120
v
< 80
HA bnh thng
< 130
v
< 85
Bnh thng cao
130 - 139
v
85-89
Tng huyt p
Giai on I
140 - 159
v/hoc
90 - 99
Giai on II
160 - 179
v/hoc
100 - 109
Giai on III
180
v/hoc
110
III. Xc nh v nh gi mt bnh nhn THA
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
t
h Po
rig
A. Chn on xc nh THA: rt n gin l o HA.

1. Nhng lu khi xc nh huyt p:
a. Bnh nhn phi trong trng thi ngh ngi (t nht
5 pht trc o), khng dng cc cht kch thch
c nh hng n huyt p (c ph, ht thuc l).

e. Con s huyt p tm thu tng ng vi pha I ca

Korotkoff (xut hin ting p u tin) v huyt
p tm trng l pha V (mt ting p). Cn
ch l c th gp khong trng HA.
f. Nn o HA c hai tay v ly tr s bn c s
o cao hn.
g. Cn thit phi o t nht 2 ln cch nhau t nht 2
pht v con s cui cng l trung bnh cng nu
c s khc bit > 5 mmHg.
2. Xc nh l THA: Nu khi o ngay ln u HA >
160/100 mmHg th c th xc nh l b THA, nu
khng th nn khm li khng nh (bng 7-2).
Bng 7-2. Thi i vi bnh nhn THA khi o ln
u (theo JNC VI).
HA ti a HA ti thiu Thi
< 130
< 85
Kim tra li trong 2 nm
130-139
85-89
Kim tra li trong 1 nm
140-159
90-99
Khng nh li trong vng 2 thng
160-179
100-109
nh gi v iu tr trong vng 1
thng
180
110
Lp tc nh gi v iu tr ngay
hoc trong vng 1 tun tu tnh
hnh lm sng
3. Mt s phng php o huyt p khc:
a. Gio dc bnh nhn t o huyt p theo di, vic
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
2 tocit
t
h Po
rig

B. nh gi mt bnh nhn THA

Vic thm khm mt bnh nhn THA nhm vo 3 mc ch sau:
Tm hiu nguyn nhn (nu c).
nh gi cc bin chng (tn thng c quan ch).
nh gi cc yu t nguy c v tim mch hoc cc ri lon
khc c thi iu tr ng mc v tin lng bnh.
1. Khai thc bnh s bao gm:
a. Khai thc tin s THA, thi gian, mc THA.
b. Tin s cc bnh tim mch, cc triu chng bnh
tim mch, suy tim, TBMN, bnh mch ngoi vi,
bnh thn, tiu ng, ri lon m mu...
c. Cc thi quen, li sng (bo ph, ht thuc l,
ung ru, ch n nhiu mui...), trnh gio
dc, iu kin sng...
d. Tin s gia nh v THA v cc bnh tim mch...
e. Cc thuc h p dng v mc p ng...
2. Thm khm thc th:
a. o HA (nu trn). Trong mt s trng hp nghi
ng cn o huyt p cc t th v o HA t chi.
b. Khm ton trng, ch chiu cao, cn nng.
c. Thm khm y mt.
d. Thm khm h tim mch, ch cc ting thi
tim, nhp tim, cc du hiu suy tim, ting thi
cc mch mu ln...
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b. Cc thm d h tr: nu cn th thm d thm:

Creatinin mu, protein niu 24 gi, acid uric,
LDL-C, Triglycerid trong mu.
Nng renin, catecholamin... mu trong mt
s trng hp hn hu.
Siu m tim nh gi khi lng c tht
tri v chc nng tht tri hoc c km theo
bnh hay cc bin chng tim mch khc.
IV. Nguyn nhn tng huyt p
Bng 7-3. Mt s nguyn nhn THA th pht.
Cc bnh v thn:
Vim cu thn cp
Vim cu thn mn
Si thn
Vim thn k
Hp ng mch thn...
Cc bnh ni tit:
U tu thng thn (Pheocromocytom)
Cushing
Cng aldosteron
Cng gip
Cng tuyn yn...
Cc bnh h tim mch:
H van MC (gy THA tm thu n c)
Hp eo MC (gy THA chi trn)
Bnh v mch (Takayashu)
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Vic phn tng cc mi nguy c cho bnh nhn THA rt

quan trng gip hoch nh chin lc iu tr THA cho bnh
nhn hp l. Vic phn tng THA da trn cc yu t nguy c v
cc tn thng c quan ch.
A. Cc yu t nguy c ca bnh tim mch bnh
nhn THA
1. Ht thuc l.
2. Ri lon lipid mu.
3. i tho ng.
4. Tui > 60.
5. Nam gii hoc n gii mn kinh.
6. Tin s gia nh c ngi thn b bnh MV: n <
B. THA th pht hay THA c cn nguyn cn c ch

nht trong cc trng hp sau: (Bng 7-3)
1. Pht hin ra THA tui tr < 30 hoc gi > 60.
2. THA rt kh khng ch bng thuc.
3. THA tin trin nhanh hoc THA c tnh.
4. C biu hin bnh l c quan khc m c th l
nguyn nhn ca THA.
V. Phn tng mi nguy c cho bnh nhn THA
A. i a s THA ngi ln l khng c cn nguyn (hay

THA nguyn pht) chim ti > 95%. Mt s yu t c
coi l yu t nguy c ca THA s c trnh by sau.
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C. Phn tng mi nguy c i vi bnh nhn THA

C 3 nhm nguy c (theo JNC VI):
1. Nhm A: L nhng bnh nhn THA nh hoc THA
m khng c tn thng c quan ch, khng c cc
nguy c bnh mch vnh, khng c biu hin bnh
tim mch.
2. Nhm B: L nhng bnh nhn THA cha c tn
thng c quan ch v khng c bnh tim mch km
theo m c t nht mt yu t nguy c bnh tim mch
ni trn nhng khng phi l tiu ng.
3. Nhm C: l nhm c bnh tim mch km theo hoc
c tn thng c quan ch hoc tiu ng v c
hoc khng km theo yu t nguy c bnh tim mch.
Bng 7-4. Phn tng mi nguy c v thi iu tr THA.
Nhm nguy c
Giai on
THA
A
B
C
Bnh thng iu chnh iu chnh Dng
cao
li sng
li sng
thuc**
5. Bnh ng mch ngoi vi.
3. Thn: i mu, i ra protein, suy thn...

4. Mt: Soi y mt c th thy: cc mch mu co nh,
du hiu bt cho ng mch/tnh mch (du hiu
Salus Gnn), xut huyt, xut tit vng mc, ph gai
th
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1. Ngn nga lu di cc bin chng.

2. a HA v tr s bnh thng (< 140/90 mmHg, nu
c tiu ng th s HA phi <135/85 mmHg).
3. iu tr cn ht sc tch cc bnh nhn c tn
thng c quan ch.
4. Phi cn nhc tng c th bnh nhn, cc bnh km
theo, cc yu t nguy c, cc tc dng ph v nh
hng c th ca thuc m c ch dng thuc
thch hp.
5. Nu khng c nhng tnh hung THA cp cu th
HA nn c h t t trnh nhng bin chng
thiu mu c quan ch (no).
6. Vic gio dc bnh nhn cn phi nhn mnh:
a. iu tr THA l mt iu tr sut i;
b. Triu chng c nng ca THA khng phi lc
no cng gp v khng tng xng vi mc
nng nh ca THA;
c. Ch c tun th ch iu tr thch hp mi
gim c ng k cc tai bin do THA.
B. Ch iu tr khng dng thuc (thay i li
sng): L phng php iu tr bt buc d c km theo
A. Mc ch v nguyn tc iu tr
VII. iu tr tng huyt p
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2. Hn ch ru:
a. Nu dng qu nhiu ru lm tng nguy c tai
bin mch no bnh nhn THA, lm tng tr
khng vi thuc iu tr THA.
b. Mt s iu tra cho thy nu dng lng ru
thch hp th c th lm gim nguy c bnh mch
vnh (hiu ng ngc).
c. Do lng ru nu c dng cn hn ch t hn
30 ml ethanol/ngy (t hn 720 ml bia, 300 ml
ru vang v 60 ml ru Whisky).
d. Tuy nhin, vi mt s dn tc m s cn nng
khng nhiu (nh ngi dn nc ta) th lng
ru nu c dng ch nn bng mt na lng
ru ni trn.
3. Tng cng luyn tp th lc:
a. Nu tnh hung lm sng cho php nn khuyn
khch bnh nhn tp th dc u.
b. Ch luyn tp cn u n t nht 30 - 45
pht/ngy v hu ht cc ngy trong tun.
c. Vi nhng bnh nhn c triu chng hoc nguy
c bnh mch vnh cn phi cho bnh nhn lm
cc nghim php gng sc th lc trc khi quyt
nh cho bnh nhn ch tp th lc.
4. Ch n:
a. Gim mui (Natri), c chng minh lm
gim s huyt p v nguy c bin chng bnh
nhn THA. Ch n gim mui nn thc hin
vi lng mui < 6 g NaCl/ngy hoc < 2,4 g
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ISA
Co
Loi chn chn lc 1
Cc loi thuc
Liu u
py
50 mg x 2
50-100 mg
200 mg x 2
Metoprolol
Metoprolol XL
Acebutolol
Propranolol
40 mg x 2
5 mg
Bisoprolol
Cc thuc khng chn lc
10 mg
Betaxolol
50 mg
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Atenolol
40 - 240 mg
200 - 1200
50 - 400 mg
50 - 450 mg
2,5 - 20 mg
5 - 40 mg
25- 100 mg
Liu duy tr
1. Thuc chn bta giao cm (bng 7-5):

a. L mt trong cc th thuc c la chn hng
u trong iu tr THA, c chng minh lm
gim t l TBMN v c bit l gim NMCT.
b. C ch: Lm h huyt p do chn th th bta
giao cm vi catecholamin do lm gim nhp
tim v cung lng tim. N cng lm gim nng
renin trong mu, lm tng gii phng cc
prostaglandins gy gin mch.
Bng 7-5. Cc loi thuc chn bta giao cm hay dng.
C. Cc thuc iu tr tng huyt p

c. Phn loi: Da trn mc chn lc trn tim m c

th chia ra nhm c chn lc vi th th 1 v
khng chn lc (chn c 1 v 2). Tuy nhin vi
liu cao th cc thuc chn lc 1 s khng cn
chn lc na. Cc thuc chn bta giao cm ny
cn c phn bit bi c hot tnh giao cm ni
ti (ISA) hoc khng c. Thuc c hot tnh
ging giao cm ni ti t gy h nhp tim hn.
d. Chng ch nh v tc dng ph: cc thuc
chn bta giao cm c kh nhiu chng ch nh:
Nhp chm, c bit l bloc nh tht cao.
Suy tim nng.
Cc bnh phi co tht (hen ph qun).
Bnh ng mch ngoi vi.
Thn trng bnh nhn c tiu ng, ri
lon m mu.
Thuc dng lu c th gy hi chng
Raynaud, lit dng, mt ng, trm cm...
C hiu ng cn THA bng pht nu ngng
thuc t ngt.
2. Cc thuc chn alpha giao cm (bng 7-6):
a. C ch tc dng: Cc thuc ny c ch th th
1 giao cm lm bloc th th alpha giao cm hu
hch, dn n gin ng mch v tnh mch.
Bng 7-6. Cc thuc chn alpha giao cm thng dng.
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th gy tt huyt p t th, au u, chng mt...

Thuc chn lc 1 giao cm dng lu di c th
ci thin tnh trng ri lon m mu. Thuc cn
c tc dng tt cha triu chng nhng bnh
nhn c ph i tin lit tuyn lnh tnh.
3. Thuc chn c alpha v bta giao cm: (bng 7-5)
a. Do chn c th th bta tim v alpha mch
ngoi vi nn c c c hai c ch gy h HA ca
hai nhm ni trn.
b. Carvedilol l loi thuc hin c xut khng
nhng iu tr THA, suy vnh m cn tc dng
tt trong suy tim vi liu kim sot cht ch.
c. Tc dng ph ging nh cc thuc chn bta giao
cm, ngoi ra c th gy hu hoi t bo gan, h
HA t th, hi chng ging lupus ban , run
chn tay v bng pht THA khi ngng thuc t
ngt.
4. Cc thuc tc ng ln h giao cm trung ng:
a. C ch: cc thuc nhm ny kch thch th th 2
giao cm tin hch trong h thn kinh trung ng,
lm gim trng lc giao cm ngoi vi v lm
gim tr khng mch h thng, t h huyt p.
b. c im: Cc thuc ny khng phi l thuc la
chn u tin cho iu tr THA do c nhiu tc
dng ph nh: nhp chm, chng mt, kh ming,
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b. c im: hin nay cc thuc ny khng cn

c coi l thuc la chn u tin trong iu tr
THA, nhng vn cn c ch trong mt s trng
hp nht nh.
c. Tc dng ph ca cc thuc ny kh nhiu:
Reserpin gy trm cm 2 % s bnh nhn.
Ngoi ra cc thuc nhm ny c th gy bun
ng, kh ming, nght mi, h HA t th, cc ri
lon tnh dc hoc ri lon tiu ho.
Bng 7-7. Cc thuc tc ng ln h giao cm trung
ng v ngoi vi
Tn thuc
Bit dc
Liu u
Duy tr
Thuc tc ng ln h giao cm trung ng
Clonidine
Catapres
0,1 mg x 2
0,1 - 1,2 mg
Methyldopa Aldomet,
250 mg x 2-3 250-2000 mg
Dopegyt
Thuc tc ng ln h giao cm ngoi vi
Guanfacine Tenex
1 mg
1 - 3 mg
Guanabenz
Wytensin
4 mg x 2
4 - 64 mg
Thuc c tc dng hn hp
Reserpine
0,5 mg
0,01- 0,25 mg
6. Cc thuc li tiu:
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Co
py
Mt s loi c tc dng gy gin mch nh

(Indapamide) do c ch dng Natri vo t bo
c trn thnh mch.
c. Cc nhm thuc li tiu (bng 7-8).
Bng 7-8. Cc loi thuc li tiu thng dng.
Loi thuc
Liu u
Duy tr
Nhm Thiazide
Benzthiazide
25 mg x 2
50-100 mg
Chlorothiazide
500 mg
125-1000 mg
Chlorothalidone
25 mg
12,5-50 mg
Hydrochlorothiazide
25 mg
12,5 - 50 mg
Hydroflumethiazide
50 mg
50- 100 mg
Indapamide
1,25 mg
2,5 - 5,0 mg
Methylchlothyiazide
2,5 mg
2,5 - 5 mg
Metolazone
2,5 mg
1,25-5 mg
Quinethazone
50 mg
25-100 mg
Li tiu tc ng ln quai Henle
Bumetanide
0,5 mg ung
0,5-5,0 mg
hoc tim TM
Ethacrynic acid
50 mg ung
25-100 mg
hoc tim TM
Furosemide
20 mg ung
20-320 mg
hoc tim TM
Torsemide
5 mg ung
5-10 mg
hoc tim TM
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Thiazide c th lm xu chc nng thn

bnh nhn suy thn.
Li tiu tc dng trn quai l li tiu mnh,
lm mt kali v in gii khc nhiu v c th
gy ng c vi tai. N ci thin c chc
nng thn v khng nh hng n m mu.
Li tiu gi kali l li tiu yu v t khi dng
n c. Khi phi hp vi mt loi li tiu
thi kali lm tng tc dng li tiu v ngn
nga c tc dng ph gy ri lon in gii
mu. Ch khi dng bnh nhn suy thn.
7. Cc thuc chn knh canxi:
a. Cc thuc nhm ny c tc dng h HA rt r v
tng i t tc dng ph. Tc dng ca cc thuc
thuc nhm ny trn h thng tim mch rt khc
nhau tu tng loi.
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Bng 7-9. Cc thuc chn knh canxi thng dng.

Tn thuc
Bit dc
Liu ban u
Duy tr
Nhm Dihydropyridine (DHP)
Nifedipine
Adalate
10 mg
10-30 mg
NifedipineXL,LL Adalate LA
30 mg
30-90 mg
Amlordipine
Amlor
5 mg
2,5-10 mg
Isradipine
2,5 mg x 2
2,5-10 mg
Nicardipine
20 mg x 4
60-120 mg

b. C ch tc dng:
Cc thuc chn knh calci lm gin h tiu
ng mch bng cch ngn chn dng canxi
chm vo trong t bo c trn thnh mch.
Cc tc ng trn nhp tim v sc co bp c
tim tu thuc vo tng phn nhm thuc.
c. c im:
Cc thuc nhm DHP th h sau
(Amlordipine, Felodipine, Isradipine...) tc
dng tng i chn lc trn mch v c tc
dng h HA tt, t nh hng n chc nng
co bp c tim v nhp tim, c tc dng ko di
nn c th dng liu duy nht trong ngy.
Nifedipin lm nhp tim nhanh phn ng. N
c nh hng n sc co bp c tim nhng
khng nhiu bng Verapamil v Diltiazem.
Verapamil v Diltiazem c nh hng nhiu
n ng dn truyn gy nhp chm v c
nh hng nhiu n sc co c tim.
d. Tc dng ph:
Verapamil c th gy to bn, nn, au u,
h huyt p t th.
Diltiazem c th gy nn, au u, mn
nga...
Cc DHP c th gy ph cc u chi, bng
mt, au u, mn nga.
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Co
py
THA
Aldosterone
Men chuyn
Bradykinin
Karikinin
Cc peptid bt hot
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Co mch trc tip
Angiotensin II
Angiotensin I
(-)
Renin CMC
Angiotensinogen
b. C ch tc dng: thuc c tc dng c ch men

chuyn, l loi men gip chuyn t angiotensin I
thnh angiotensin II, do lm gin mch, gim
tit aldosterone gy h HA. N cn c ch con
ng thoi ging ca bradykinin, lm cht ny
ng li v cng gy ra gin mch, h huyt p.

i ca CMC l bnh nhn c hp ng

mch thn 2 bn. CMC cng khng dng
ph n c thai. V lm tng kali mu nn thn
trng bnh nhn suy thn, ang dng thuc
li tiu gi kali, hoc ch bi ph kali.
Bng 7-10. Cc thuc tc ng ln h Renin-Angiotensin.
Thuc
Bit dc
Liu u Liu duy tr
Cc thuc c ch men chuyn
Captopril
Capoten, Lopril
25 mg
50 - 450 mg
Enalapril
Renitec
5 mg
2,5 - 40 mg
Benazepril
Lotensin
10 mg
10 - 40 mg
Fosinopril
Monopril
10 mg
10 - 40 mg
Lisinopril
Zestril
5-10 mg
5 - 40 mg
Moexipril
Univasc
7,5 mg
7,5 - 30 mg
Quinapril
Accupril
5-10 mg
5 - 40 mg
Ramipril
Altace
2,5 mg
1,25 - 20 mg
Trandolapril Mavik
1-2 mg
1 - 4 mg
Perindopril
Coversyl
2-4 mg
4 mg
Cc thuc c ch th th AT1
Losartan
Cozaar
25 - 100 mg
Valsartan
Diovan
80 - 320 mg
Irbesartan
Avapro
150 - 300 mg
Telmisartan Micardis
20 - 160 mg
9. Cc thuc i khng vi th th AT1 ca
Angiotensin II: y l cc thuc kh mi trong iu
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a. C ch tc dng: Cc thuc ny lm gin trc

tip c trn ng mch gy h huyt p. N c
th phn ng tng ti hp thu nc v natri v lm
tng hot ng h giao cm phn ng gy nhp
tim nhanh.
b. L thuc h huyt p mnh, nhng khng phi l
la chn hng u. Rt c ch khi bnh nhn c
biu hin khng li cc thuc h huyt p khc,
hoc c th ch nh cho ph n c thai. C th
phi hp thm loi thuc ny vi nitrate iu
tr suy tim.
c. Tc dng ph c th gp l: au u, nn, nhp
nhanh, h HA t th. C th gy hi chng ging
Lupus ban (10 % bnh nhn dng ko di, liu
cao), do khi c hi chng ny phi ngng
ngay thuc. Minoxidil c th gy tng cn, ri
lon nh v bt thng in tim, tng mc lng
tc, trn dch mng tim.
Bng 7-11. Cc thuc gin mch trc tip.
Thuc
Bit dc Liu u
Liu duy tr
Hydralazine
Apresolin
10 mg
50 - 300 mg
Minoxidil
Loniten
5 mg
2,5 - 100 mg
11. Cc thuc h huyt p dng theo ng truyn
tnh mch: cc thuc ny (bng 7-12) c th c
xp loi trong cc nhm thuc ni trn hoc khng.
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b. Ch nn s dng cc thuc ny ti mt s n v
hi sc tch cc (c trang thit b k thut v
iu kin theo di tt bnh nhn).
12. Cc thuc h HA dng theo ng di li:
a. Trong mt s trng hp cp cu dng thuc theo
con ng ny cho kt qu tt. Hai loi thuc hay
dng l Nifedipine v Clonidine.
b. Nifedipine cho ngm di li bt u c tc
dng trong vng 30 pht. Loi vin nang 10 mg,
cho cn, nhai v nut th tc dng cn nhanh hn.
Tc dng c th ko di n 4-5 gi theo ng
dng ny. Ch thuc c th gy tt HA qu
nhiu v nhanh. Khng nn dng trong trng
hp bnh nhn b NMCT cp hoc suy tim cp.
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Bng 7-12. Cc thuc iu tr THA theo ng tnh mch.

Thuc
Liu dng
Ch
Truyn TM: 0,5 - L thuc la chn u
Sodium
10 g/kg/pht
tin, c th gy tt p,
Nitroprusside
nn, nguy c ng c
- Tc dng:
cyanide bnh nhn suy
tc thi
gan, hen. Phi bc k
- Ko di:
trnh nh sng
2-3 pht
Tim: 50-100 mg, Nhp nhanh, tt HA,
Diazoxide
nhc li 5-10 pht, nn, tng ng mu. C
- Tc dng:

Truyn TM: 5-100 au u, nn. C th

g/pht
gim tc dng nu dng
lu di.
Tim TM: 500 Tt HA, bloc nh tht,
g/kg/ph
trong suy tim, co tht ph qun
pht u
Truyn TM: 50300 g/kg/ph
Tim TM: 5-10 Tt HA, tim nhanh, au
mg mi 5-15 pht u, au ngc, p ng
THA nghch thng.
Tim TM: 10-20 u tin dng trong sn
mg sau 20 pht git. C th gy tt p,
nhc li (nu suy thai, nhp nhanh, au
khng c p ng) u, nn, vim tc TM
ti ch.
Truyn 5 mg/gi , Tt p, au u, nhp
c th tng 1,0-2,5 nhanh, nn.
mg/gi mi 15
pht, ti a 15
mg/gi
Tim TM 0,625- Tt huyt p.
2,5 mg mi 6 h
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h Po
rig
VI. Mt s tnh hung lm sng
Nitroglycerin
- TD: 1-2 pht
- KD: 3-5 pht
Esmolol
- Tc dng:
1-5 pht
- Ko di:
10 pht
Phentolamine
- TD: 1-2 pht
-KD:3-10 pht
Hydralazine
- Tc dng:
10-20 pht
- Ko di:
3-6 gi
Nicardipine
- Tc dng:
1-5 pht
- Ko di:
3-6 gi
Enalaprilat
- TD:5-15 pht
- KD: 1-6 gi

F.
Co
E.
D.
C.
2. Hay c km cc bnh khc, nn khi cho thuc h HA

phi cn nhc cc chng ch nh v tc dng ph.
3. Li tiu hoc chn knh calci nn c la chn nu
khng c cc chng ch nh.
4. Nn trnh dng cc thuc c th gy h HA t th
hoc cc thuc tc ng ln h thn kinh trung ng
v tng nguy c gy trm cm.
THA ngi bo ph
1. Thng hay c tng tr khng mch, tng cung lng
tim, v tng khi lng tun hon.
2. Gim cn nng l mc tiu quan trng nht.
3. Thuc u tin nn la chn l li tiu.
THA ngi tiu ng
1. Thng c km theo bnh l thn do tiu ng.
2. Mc tiu l h HA v di mc bnh thng cao.
3. Thuc CMC nn c la chn hng u v tc
dng tt v lm gim protein niu.
THA c suy thn mn tnh
1. Ph thuc nhiu vo khi lng tun hon.
2. Li tiu l thuc u tin, trong li tiu quai c
bit c tc dng khi m creatinin mu > 2,5 mg/dl, n
gip ci thin c chc nng thn.
THA c ph i tht tri
1. Ph i tht tri lm tng nguy c t t, NMCT.
2. Ch n gim mui; gim cn nng v cc thuc h
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
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00 y
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t
h Po
rig

nguy c ti NMCT bnh nhn sau NMCT v lm

tng t l sng st sau NMCT.
3. CMC c ch nht l khi bnh nhn c gim chc
nng tht tri km theo.
4. Chn knh calci c th dng khi THA nhiu, nhng
cn ht sc thn trng v ch nn dng khi khng c
suy gim chc nng tht tri.
H. THA c suy tim
1. CMC v li tiu l thuc la chn hng u.
2. C th dng phi hp gia Nitrate vi Hydralazine
trong trng hp THA kh tr. Cn ht sc thn trng
vi Hydralazine v n lm tng nhp tim phn x, do
c th lm xu i tnh trng thiu mu cc b
bnh nhn c suy vnh km theo.
I. THA v thai nghn
1. Phn loi THA ph n c thai: (theo Trng mn
Sn Ph khoa Hoa k 1996) THA ph n c thai c
th gp cc tnh hung sau:
a. Tin sn git hoc sn git: l tnh trng THA khi
c thai km theo protein niu, ph v c th c
ri lon chc nng gan, thn.
b. THA mn tnh do bt k nguyn nhn no: l tnh
trng THA xut hin trc tun th 20 thai k.
c. THA mn tnh do hu qu ca tin sn git hoc
sn git.
d. THA thong qua hoc mun: L THA khng lin
quan n protein niu v khng c nh hng n
h thn kinh trung ng. THA tr li bnh thng
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
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h Po
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Thuc li tiu
Thuc chn th th giao cm
i ng tp I c protein niu: Thuc c ch men chuyn

Suy tim: Thuc c ch men chuyn, li tiu
THA tm thu n c (ngi gi): u tin thuc li tiu,
chn knh canxi loi dihydropyridine tc dng ko di.
NMCT: Thuc chn giao cm (khng c ISA),
thuc c ch men chuyn (khi ri lon chc nng tm thu)
Thuc c ch men chuyn

Thuc c ch th th angiotensin II
Thuc chn th th - giao cm
Thuc chn knh canxi
Thuc li tiu
Co
py
er
res
s
t
gh .vn
l ri .com
l
v. A ahoo
e
o
inl @y
. F 2020
8
00 y
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t
h Po
rig
Khng p ng
C cc tc dng ph
Thay bng thuc
Dung np tt nhng
p ng khng
Thm thuc nhm khc
Khng t c ch iu tr THA
Bt u loi thuc tc dng ko di, liu duy nht trong ngy, liu
thp. iu chnh liu. C th kt hp liu thp cc thuc khc
Cc ch nh c bit cho cc loi thuc sau:
Ch nh bt buc:
Tng huyt p khng c bin chng:
La chn thuc iu tr ban u (tr phi c chng ch nh)
Khng t c ch iu tr THA (< 140/90 mmHg)

H HA thp hn vi bnh nhn i tho ng hay bnh thn

Tai bin mch mu no
Theo T chc Y t th gii (1993) tai bin mch mu

no (TBMN) hay t qu l mt trong 10 nguyn nhn gy
t vong hng u, ch ng sau bnh tim mch v ung th.
Hng nm, ti M c khong 730000 ca t qu, t l t
vong chim ti 27%. Ti Vin Tim mch Vit nam (19962000) tnh trung bnh c 2 ngy c mt bnh nhn vo vin
v TBMN. T vong do TBMN chim 1/4 t l t vong chung
ti Vin Tim mch. Ngay ti cc nc pht trin, TBMN vn
l mt bin chng nng, d t vong, nh hng ln ti sc
kho, tm thn v i sng ngi bnh, cc di chng tn ph
d
rve
tr thnh gnh nng cho gia nh, x hi.
e
s
re
tsgpvn la tui
TBMN gp nam nhiu hn n gii, hay
h
g
i om.
ll r o.nhn
c
trung nin (> 40 tui). Tui ca nhng Abnh
TBMN c
ho tim hay x va
v. ac
e
lin quan n tng huyt p, nhi
mu
o
l @y
Finnhn
20 TBMN c lin quan
.
ng mch thng ln hn bnh
0
08 ty2
0
2 oci ni tm mc nhim khun.
n bnh van tim hayt vim
h
ot trong ngy v bt c ma no
g
i giPno
TBMN xy ra btyrk
p
trong nm, song
Co thng xy ra 1-10 gi sng v vo cc
thng nng nht (thng 7, 8) hay lnh nht (thng 12,1 - theo
thng k ca Vin Tim mch Vit nam).
I. Phn loi tai bin mch mu no (TBMN)
A. TBMN (hay t qu) l mt ri lon khu tr chc
nng ca no c tin trin nhanh trn lm sng, nguyn
nhn thng do mt mch mu no b v hoc tc.
TBMN c cc loi tn thng chnh l chy mu no,
chy mu mng no v nhn no hoc phi hp cc loi.
1. Chy mu no do v mch mu no, lin quan vi
huyt p cao hoc d dng mch mu no.
2. Nhn no xy ra khi mt nhnh ng mch no b
tc thng do 3 nguyn nhn chnh l mng x va,
cc tc bn t xa ti v nhn no do gim ti mu
121
no. Cc nguyn nhn him gp khc bao gm: tch

thnh ng mch no, vim mch no v huyt khi
tnh mch no.
a. Nhn no do mng x va ch yu xy ra cc
mch mu ln (ng mch cnh trong, ng
mch sng, ng mch nn) song cng xy ra
cc ng mch no nh v va bt k vng no.
Thng tn lc u ch l mng x va gy hp
dn lng mch, t to thnh huyt khi, sau
cng gy tc mch. Huyt khi c khi hnh thnh
mi d khng c x va t trc, hay gp bnh
nhn c tnh trng tng ng. Khuyt no
(lacunar stroke) thng v tc cc tiu ng mch
nm su trong no do mng x va nh hoc
ed do
erv nhn
qu trnh lipohya-linolysis (hay gp resbnh
ts
tng huyt p).
gh m.vn
i
r
l .co gy tc cc
a. TBMN do cc tc bn t .xa
Al thng
hoo
v
e yatrung
o
l
ng mch no ng
knh
bnh, nht l
n 0@
Fiv
2
.
ng mch no gia
cc
nhnh
chnh ca h
0
08 ty2
0
2
i
thng ng tmch
tocsng nn. Ngun gc ca cc
h
o
cc tcyny
rig chP yu t tim, mt s t hnh thnh
p vng x va ca phn u cc ng
ngayCoti
mch no. Gn mt na nguyn nhn cc tc t
tim l huyt khi hnh thnh do rung nh, phn
cn li l huyt khi hnh thnh do ri lon chc
nng tht tri nng, do cc bnh van tim (hp van
hai l), tc mch nghch thng hoc nhi mu c
tim mi, thm ch do mng x va bn t quai
MC, cc si do vim ni tm mc nhim khun.
b. TBMN do gim ti mu no xy ra nhng
mch no hp nhiu cha n mc tc hn, gy
thiu mu nhng vng xa ni gip ranh ti
mu ca cc ng mch no. Kinh in l vng
gip ranh gia ng mch no trc v ng
mch no gia, l vng chi phi vn ng cc chi.
Hp ng mch cnh trong mc nng c th
122
gy thiu mu vng ny, nht l sau khi c tt

huyt p.
c. Tch thnh ng mch no hay gp ng
mch cnh trong hoc ng mch sng, do chn
thng hoc t pht (50%). Tch thnh ng
mch cng c th gp cc ng mch c hin
tng lon sn x c.
d. t qu cn xy ra nhng bnh nhn vim
mch mu no do cc bnh t min, nhim
trng, nghin ma tu hoc v cn. Mt s t
trng hp t qu do huyt khi trong tnh
mch hoc xoang tnh mch ni s: nhng
trng hp ny hay c km theo chy mu no,
ng kinh v cc du hiu tng p lc ni s.
d
3. TBMN thong qua (cn thiu mu no thong
rve qua,
e
s
re
TIA: transient ischemic attack): ngi bnh
ts vnt nhin
h
.
g
b lit na ngi hoc mt nhm lc
omlit na mt,
l rinh
c
.
A hoo tay bung ri
ni nghu, t nhin khng onhai
ev. yc,
a
l
@ hiu ny thoi trin
in 2du
vt ang cm; nhng
cc
0
F
. 20
08 tgi.
ht ngay trong vng
024
2
i y Nguyn nhn do tc mt
t otoccc mu ng li t tiu c.
ng mch no
nhng
h
P
rig
y
p
Bng 8-1. D
bo
v
tr
tn thng ng mch no.
Co
Khi pht
ng mch
Nguyn nhn
tn thng
thng gp
Tht ngn + Lit 1/2 ng mch Cc tc t xa hoc
ngi
no gia
do mng x va
Yu na ngi n thun Khuyt no Mng x va nh
v/hoc mt cm gic
na ngi n thun
Yu chn nhiu hn tay, ng mch Cc tc t xa hoc
do mng x va
i dm, thay i tnh no trc
tnh
Mt th trng n thun ng mch Cc tc t xa hoc
no sau
do mng x va
Yu t chi, lit thn kinh ng mch Mng x va
s, tht iu
nn
123
B. Hi bnh v khm lm sng thn kinh t m cho

php xc nh s b vng mch no b tn thng v
nguyn nhn gy ra TBMN. Chng hn: bnh nhn c
tht vn ngn v lit na ngi phi s c thng tn ca
ng mch no gia bn tri, thng do cc tc t ng
mch cnh hoc ngun gc ng mch. Ngc li, yu
mt, tay v chn m khng c cc du hiu khc thng
gi tn thng khuyt no do tc cc mch nh nm
su trong no.
1. Khng th phn bit chnh xc nhn no v xut
huyt no trn lm sng d c nhiu im gi nh:
din bin ca xut huyt no thng t ngt hn,
km du hiu mng no v chc dch tu sng c
mu khng ng khi chy mu no-mng no...
dtrong
rve
e
s
khi nhn no thng c tin triu i trc,
re hay gp
ts vbnh
n
h
bnh nhn tng huyt p (2/3 TBMN
nhn
g
i om.
r
l
l
c
.
THA l nhn no, ch 1/3 l xut
huyt no), c cc
v. A ahoo
ecnh,
o
l
y
du hiu hp, tc ng mch
c tin s i tho
Fin020@
.
ng, hay km st...08 2
20 ocity
t oc
2. Nhng yu tgnguy
h
P t quan trng ca TBMN l tng
i
r
y
huyt p,opi tho ng, bnh tim (bnh van hai l,
C
rung nh, vim ni tm mc nhim khun, bnh c
tim gin, nhi mu c tim...), thiu mu no thong
qua, bo ph, nghin ru, ht thuc l, ri lon lipid
mu, tng axt uric mu.
II. Chn on v nh gi tai bin mch no
A. Triu chng lm sng
1. TBMN c th c cc du hiu bo trc nhng khng
c trng v rt d b b qua nh: au u, chng
mt, tai... c bit l nhc u: au nhc 2 bn
thi dng, hoc c khi au d di mt na u hay
sau gy, km theo cng ct sng. Phi ngh n
TBMN khi ngi bnh c lit na ngi, ri lon tri
gic hoc hn m. Khi bnh nhn nghi ng t qu
124
n vin th cn hi k bnh s v tin s, khm lm

sng v thn kinh t m. Vi bnh nhn tht ngn,
nn hi k ngi nh. Cn khm tim mch v thn
kinh mt cch ton din k c vic nghe mch cnh
hai bn v o huyt p c hai tay. Khm thn kinh
bao gm nh gi tri gic, vn ngn, cc dy thn
kinh s, vn ng, tiu no, tht iu, cm gic v
phn x gn xng.
2. TBMN bao gi cng c xem l mt tnh trng cp
cu ni khoa, khi pht hin cn s cu ti ch v
chuyn bnh nhn n n v chuyn bit: n v
Chm sc v iu tr TBMN (Stroke Unit).
ved cc
1. Khi nghi ng bnh nhn c TBMN nnserlm
re
xt nghim:
ts vn
h
.
g
l ri .com
Cng thc mu.
l
A o
ev. yaho
ng mu.
o
l
0@ magi v canxi (ri
Fin02c
in gii mu8.gm
2
0
20magi
lon hai ion
ity v canxi c th gy triu
t otoc
h
chngriggingP nh TBMN).
py
Creatinin
mu.
Co
Thi gian Quick, t l PT v thi gian aPTT.
in tm .
Xquang ngc: nh gi chung v bnh tim
mch v tnh trng vim phi do sc.
Tng phn tch nc tiu (nu thy hng cu
niu, nn i tm cc nguyn nhn gy tc c
mch thn).
Chp ct lp vi tnh (CT) hoc cng hng t
(MRI) s no.
Holter in tim, siu m mch cnh, siu m
tim (qua thnh ngc hoc thc qun), chp
mch no, chc dch tu sng - l nhm xt
nghim c ch nh trong mt s bnh cnh
lm sng nht nh.
125
2. Hi Tim mch M (AHA) khuyn co rng tt c

nhng bnh nhn nghi ng t qu nn chp ct
lp vi tnh theo t trng (CT) hoc chp cng
hng t (MRI) phn bit gia nhn no v
xut huyt no, nh khu v tr tn thng v
loi tr nhng bnh l c biu hin ging t qu.
Cc nguyn nhn gy biu hin ging TBMN gm:
Thoi ho myelin (x cng ri rc).
U no.
p xe no, vim no, cc nhim trng thn
kinh khc.
Cc ri lon chuyn ho (tng ng mu
hoc h ng mu, tng hoc h canxi mu,
tng hoc h natri mu).
d
rve
e
Triu chng thn kinh sau ng kinh.
s
re
n
hts .vcng,
Chn thng (t mu di imng
dp
g
r
m
o
l
l
c
no...).
.
A hoo
ev.lin
a quan vi au na
o
Triu chng thn kinh
l
in 20@y
F
u Migraine.08. 20
ty (Hysteri), bnh tm cn.
20 ocily
Hi chng
t phn
t
h
o
rigtheoP t trng (CT) s no rt gi tr
3. Chp ctplp
y
o
phtChin cc vng chy mu ln, u no hoc
nhng thng tn cu trc trong s khc gy ra cc
biu hin ging nh t qu cp tnh. Tuy nhin CT
c th b st kh nhiu (ln ti 50%) nu chp ngay
trong vng 12 gi k t khi khi pht. Hn na chp
CT khng phi l bin php l tng pht hin cc
vng nhn no nh, nhn no vng h sau hoc cc
thng tn gy mt myelin (nh trong bnh x cng
ri rc gy biu hin ging t qu). Chp CT xon
c cho nhng hnh nh chi tit v cc ng mch
trong v ngoi s, vi phn gii tt hn hn so vi
chp MRI c thuc cn quang.
4. Hnh nh chp MRI s no nhy hn so vi chp
CT, c bit trong nhng trng hp t qu cp,
126
nhi mu no nh (khuyt no) hoc vng tn thng

lin quan n khu vc thn no. Mt khc chp MRI
c thuc cn quang s cho php sng lc v kho st
c bnh l cc ng mch ln trong hoc ngoi s.
Nhng k thut MRI tin tin (MRI diffusion
perfusion, spectroscopy) cn cho bit tnh trng
chuyn ho v cp mu vng no b thiu mu. Tuy
nhin Vit nam, chp MRI t hn nhiu so vi CT
v c mt s chng ch nh. Do , nn dng cc
triu chng lm sng d on v tr thng tn v
nguyn nhn, t la chn phng tin chn on
hnh nh thch hp. Chng hn trong trng hp nghi
ng khuyt no, MRI l la chn tt nht v CT s
khng th pht hin c cc thng tn ny
nu
ed
v
r
e
din bin cp tnh hoc vng thn no.esNgc li,
r
ts ln,
nu TBMN do tn thng cc mchgno
n nht l
h
i om.v
r
l
xy ra vi ngy, khng cn A
cl ch
.cnh can thip
hoo
ev.syano.
thm th nn la chn chp lCT
o
in @
. F 2020 thm d v nh gi
5. Siu m mch cnh08dng
20 ocnhnh
ity cc ng mch cnh, h
thng tn ch
t chia
t
h
o
P
rig sng
thng ng
mch
nn. Siu m Doppler qua s
y
p
o
dng Ckho st dng chy (hng, vn tc) ca cc
ng mch ln trong s.
6. Ch nh Holter in tim 24-48 gi ( pht hin
cn rung nh kch pht hoc cc loi ri lon nhp
khc) hoc siu m Doppler tim nu nghi ng
nguyn nhn TBMN do cc tc nghn t tim. Siu m
Doppler tim qua thnh ngc c th pht hin rt
nhiu nguyn nhn tim mch gy t qu nh huyt
khi nh tri hoc tht tri, ri lon chc nng tht
tri nng, bnh van tim hoc cn l bu dc. Nu
nghi ng cn nguyn t tim m siu m tim qua
thnh ngc khng pht hin bt thng g, th cn
lm siu m tim qua thc qun. Tuy nhin i khi
khng th lm c siu m qua thc qun mt s
127
bnh nhn nng. Siu m tim qua thc qun c

nhy rt cao pht hin huyt khi nh tri, l bu
dc, mt vi bnh l van tim (nh hp h van hai l)
cng nh pht hin cc mng x va quai ng
mch ch c kh nng bn i gy tc mch.
7. Chp ng mch no vn l tiu chun vng
chn on bnh l cc mch no ln v cc mch
nh trong s. Ch nh ch yu cho nhng bnh nhn
t qu tr tui; trong trng hp nghi ng tch
thnh mch no hoc vim mch mu no hoc ch
nh trc khi phu thut bc ni mc ng mch
cnh. Siu m Doppler mch cnh, chp CT, k c
chp MRI mch no c cn quang vn c nhy
thp (15%) pht hin nhng trng hp vcn
d m
r e
e
s
bc ni mc ng mch cnh, v th nht
re thit phi
hts .vn
chp mch no trc loi phu thutrigny.
om
l
Al hoo.c
.
v
a
oe
inl 20@y
F
8. 0
00 ity2
2
t toc
igh Po
r
py
Co
A
B
C
Hnh 8-1. Hnh nh xut huyt no (A), nhn no (B), v
phnh d dng mch no (C) gy TBMN.
8. Chc dch no tu v lm in no khng cn
phi lm thng quy i vi tt c nhng bnh nhn
nghi ng t qu. D sao th chc dch no tu vn
c gi tr trong nhng trng hp nghi ng xut huyt
nh di mng nhn. Nhng bnh nhn nghi c vim
mch, cng c bt thng trong dch no tu: s
lng t bo tng cao (a s l bch cu lymph) v
128
tng protein. Nhng bnh nhn c lit kiu Todd (sau

ng kinh) s c bt thng trn in no .
9. Nn thm d tnh trng tng ng bnh nhn t
qu tui di 45, c tin s tc ng mch hoc tnh
mch t trc, tin s sy thai t nhin, tin s gia
nh c thuyn tc mch tui tr, t qu khng r
nguyn nhn xy ra trn bnh nhn c bnh t min...
III. iu tr
iu tr TBMN nhm mc ch phng cc bin chng,
khi phc tn thng cp tnh ca nhu m no v phng t
qu ti pht.
A. Phng bin chng
d
1. Chng ph no:
rve
e
s
re
a. Bng cc dung dch u trng:
ts vn
h
g
i om.20-30 pht,
Mannitol truyn 0,5-1 g/kg
l rtrong
l
.c
hoo c 6h/ln. Nu
v. A g/kg
sau truyn li 0,25-0,5
e
a
o
y
inl 2gim
0@ dn liu mannitol
truyn qu 48 h,. Fnn
0
08 ty2no hi li do thuc. Ni
trnh gy
20 oph
ci
ht Pot khng nn truyn qu 3 ngy,

chungigmannitol
r
py
nu
Co mun truyn nhiu hn, nn c khong
ngh thi thuc, trnh tc dng gy tng p
lc ni s th pht.
Glycerol (1mg/kg trong vng 120 pht).
Cho n nay, mannitol vn l bin php hng
u chng ph no. Khi mannitol bt u
gim tc dng m vn cn gim p, nn cn
nhc truyn dch mui u trng hoc gim
p bng phu thut.
b. Tng thng kh c kim sot trong thi gian ngn
(mc ch h PaCO2 xung cn 25-30 mmHg),
gy kim ho mu, co mch no v gim th tch
mu no, do lm gim ng k p lc ni s,
tc dng ny xut hin ngay sau 20 pht nhng
cng nhanh chng mt i sau 1-2 gi do h thng
129
m trong c th s trung ho tc dng ny, v th

ch nn coi tng thng kh nh mt bin php cp
cu tm thi trong khi ch i hoc phi hp vi
cc bin php khc nh truyn dch u trng,
m hp s... C th truyn dung dch THAM 60
mmol pha vi 100 ml Glucose 5% truyn tnh
mch trong 45 pht sau duy tr qua tnh mch
trung tm 3 mmol/h lm kim ho mu.
c. Barbiturate: lm gim th tch dng mu no do
co mch. Liu dng 250-500 mg thiopental (tim
bolus) sau truyn tip tc 5 mg/kg/h hoc tim
bolus tng lc. Bin chng c th xy ra l gim
huyt p nng gy h p lc ti mu no.
d
2. Kim sot huyt p ng mch:
rve
e
s
a. Mc d rt nhiu bnh nhn TBMNtscre tng huyt
vn gim t
.s
ighp
p song a s trng hp huyt
r
m
o
l
l o.c
nhin. Nu tnh trng tng
p vn cn,
ho
v. A ahuyt
e
o
l
y
n xung
@
khng nn h huytFip
t
ngt v iu
. 2020
8
0
ny lm ri lon
ych t iu ho mch no,
20 oc
cit tnh trng thiu mu no
t othm
t
lm trm gtrng
h
P
ri
ranh ogii
py vi tn thng, lm triu chng lm
C
sng nng thm. Gim mc tng huyt p bt
buc phi lm trong mt s trng hp nh c
triu chng bnh tim nng, tng huyt p c tnh,
phnh tch ng mch ch v bnh nhn iu tr
t-PA. Mt s tc gi yu cu phi h huyt p
bnh nhn dng Heparin tnh mch gim nguy
c chuyn nhn no thnh xut huyt no.
b. Duy tr huyt p tm thu < 185 mmHg v huyt
p tm trng < 110 mmHg. Nhng bnh nhn c
huyt p qu cao (HA tm thu 220 mmHg, HA
tm trng 120 mmHg) phi h p ngay, tuy
nhin nn gim t t HA tm thu xung 170-180
mmHg v HA tm trng xung 95-100 mmHg.
Sau nu vn tn ti triu chng lin quan n
130
tng huyt p, c th h tip HA tm thu cn 150160 mmHg v HA tm trng cn 90-95 mmHg.

c. Khng nn dng Nifedipine di li h HA
cp khi TBMN v kh nng h HA qu nhanh
cng nh tc dng bt li ln c ch iu ho
mu no s lm t qu nng hn. Nn trnh
dng cc thuc h p c th gy tng p lc ni
s nh cc thuc gin mch trc tip (Sodium
Nitroprusside, Nitroglycerin, Hydralazin) v cc
thuc chn knh canxi, nht l nhng bnh
nhn nhi mu din rng gy ph n v do tt
no. Cc nhm thuc h p khc nh c ch men
chuyn, chn bta giao cm c tc dng h p tt
m khng gy tc dng ph i vi huyted ng
rv hoc
ca mch mu no, c th ung (Captopril)
ese
r
ts vn
tim tnh mch (Enalapril, Labetalol,
.
gh mEsmolol)...
i
r
l .co
l
3. Phng huyt khi tnh mchvsu
oo tc ng mch
. A ahv
loe @da
y (5000 UI 12h/ln)
phi: bng Heparin timindi
. F 020 t thp liu d phng,
hoc Heparin trng 0lng
08 ty2phn
2 ocicng chn nu c chng ch
hoc i ng kh
t op
h
Pt
g
ri
nh dngpHeparin.
y
Co
4. Phng vim phi do sc hoc tro ngc:
a. Gn mt na s bnh nhn TBMN c nut kh, t
c th gy sc v vim phi (15%). Nguy c
ny cao nht bnh nhn tn thng gc cc
ng mch no ln (80-90%), nguy c va
bnh nhn nhn na bn cu (40-60%) v thp
nht (10-15%) bnh nhn nhi mu no nh.
b. Bnh nhn kh nut nn cho n qua ng thng
mm trong tun u tin. Nu tnh trng kh nut
cn ko di, nn m thng d dy hoc hng
trng cho n v lm gim nguy c bin chng
tro ngc.
131
c. Phi hp thm vi cc thuc khng cholinergic

nhAatropine hoc Glyco-pyrrolate gim tit
dch v v gim nguy c vim phi do tro ngc.
5. Kim sot ng mu: rt nhiu bnh nhn TBMN
c i tho ng thc s hoc tnh trng tng ng
huyt thong qua, c hai u lm nng thm tn
thng no. Do , khuynh hng hin nay l kim
sot tch cc tnh trng tng ng mu bnh nhn
t qu, duy tr ng mu < 170 mg/dl (< 9,5
mmol/l), dng Insulin tim/truyn tnh mch nu cn.
6. Kim sot thn nhit: bng thuc h st hoc p
chn/khn lnh. Gim thn nhit t mc nhva
s hn ch lan rng tn thng no th pht, gim p
lc ni s v gim t l t vong. Tc dng rph
ved hay
e
s
gp l gim s lng tiu cu v tng ttslrevim phi.
.vn 6 gi
Khuynh hng h thn nhit sml rngay
ighomtrong
l o.c
u k t khi khi pht ang c
cu.
ho
v. A anghin
e
o
l
y
7. Theo di v chm sc:. Fin020@
08 2
20 ocityn v TBMN, theo di st
a. Nn bnh nhn
ht ot
tnh trng
rigthnP kinh, cc du hiu sinh tn v
y
p
chm
Co sc ton din (1 y t cho 2-4 bnh nhn)
ch khng cn phi chuyn sang n v hi sc
tch cc.
b. Trong giai on cp cn p dng cc k thut cp
cu ni khoa nhm m bo ng th thng
thong (k c vic phi thng kh nhn to), duy
tr cn bng nc - in gii, kim toan, dinh
dng tt qua ng ming, qua ng thng d
dy hoc nui dng hon ton qua ng tnh
mch.
c. Thc hin tt v sinh cho ngi bnh nh v sinh
rng ming, thay qun o, v sinh ngoi da, v
sinh ng tiu, cho nm m nc v xoay tr
bnh nhn chng lot mc da cc im t ,
132
d. Phc hi chc nng sm v tch cc ngay sau khi

TBMN hi phc, luyn tp phng co cng cc c,
khp, huyt khi... Ban u vic luyn tp phi do
nhn vin y t thc hin v sau hun luyn cho
ngi nh khi v nh c th tip tc tp cho
bnh nhn.
8. Phu thut m hp s hoc dn lu no tht lm
gim p lc ni s, trnh tt no, gip cu sng bnh
nhn v ngn nga cc tn thng khng hi phc.
Tuy nhin ch nh v thi gian ti u m hp s
cn cn nghin cu thm.
ed tr
9. Song song vi nhng vic ny, phi tip tc
rviu
e
s
re
nguyn nhn gy t qu v cc yu tts nguy
c ca
h
vnbnh van
.
g
i
TBMN nh tng huyt p, i tho
ng,
r
l .com
Al homu,
o
.
tim, ri lon nhp tim, ri lon
lipid
bo ph, ht
v
e ya
o
l
thuc l, nghin ru... . Fin 20@
08 20
B. Khi phc cc tn thng
20 ocity nhu m no cp tnh
ht ot
Trong giai on
rigsmPca TBMN, vng thng tn cha
y
p
Co no b hu hoi vnh vin gia v
ng nhng vng
nhng vng thiu mu no c kh nng hi phc xung
quanh. Kch thc v kh nng sng ca vng thiu mu no
ranh gii ny ph thuc rt nhiu vo v tr, nng, thi
gian tai bin, tun hon bng h... Cc nghin cu cho thy
kh nng sng ca vng ny ch duy tr c trong vng 417 gi. Ti ti mu bng thuc tiu si huyt hoc can thip
mch no trong trng hp tc mch no v bo v no bng
cc thuc bo v thn kinh l hai bin php chnh khi
phc vng nhu m cn thoi thp ny.
1. Thuc tiu si huyt:
a. Trong s nhng thuc tiu si huyt, ch c rtPA (c FDA cng nhn ch nh dng thuc t
1996) vi liu 0,9mg/kg dng ngay trong vng
133
3 gi k t khi khi pht (tim bolus tnh mch

10%, sau truyn phn cn li trong vng 1
gi, liu ti a 90 mg) l liu c hiu qu
c chng minh (nghin cu NINDS), cho d c
mt t l nht nh chuyn dng nhn no thnh
xut huyt no (3% xut huyt nng). Nu tng
liu rt-PA cao hn, thi gian ca s dng thuc
di hn (trong 6 gi k t khi khi pht) th
khng h c li m cn tng nguy c xut huyt
no nng (ln n 20%, nghin cu ECASS).
b. Yu t lm tng nguy c xut huyt no th pht
l hnh nh nhn no sm trn phim CT v mc
nng ca t qu (> 20 im theo thang im
NIHS). Tuy nhin cn tun th cc ched nh,
rv
chng ch nh v phi nh gi y
esecc nguy
r
ts
c khi dng rt-PA.
gh m.vn
i
r
o
l
c. Ch nh dng rt-PA:
Al hoo.c
.
v
loe @no.
ya
t qu kiu thiuinmu
0
F
2
0 gian khi pht.
8. 2thi
C th xc nh
y
00 ir
t
2
oc rt-PA trong vng 3 gi k
C th hdng
t otngay
P
g
i
r
t pkhi
y khi pht.
Co CT khng c hnh nh xut huyt no
Chp
hoc cc bnh nng khc ca no.
Tui 18.
d. Tiu chun loi tr:
t qu hoc chn thng nng s no mi
trong vng 3 thng.
Tin s xut huyt no (XH mng no hoc
trong no) hoc c nghi ng XH mng no.
CT s c hnh nh chy mu no, d dng
ng-tnh mch, u no hoc cc phnh mch
no.
Huyt p tm thu > 185 mmHg hoc huyt p
tm trng > 110 mmHg (o 3 ln, mi ln
cch nhau 10 pht).
134
Tin s c hoc trong cn t qu c ng

kinh.
Chy mu trong ang tin trin.
Ri lon ng mu (aPTT hoc PT di, tiu
cu < 100000/ml).
Triu chng lm sng ci thin nhanh hoc
mc nh.
Hn m hoc ng g.
M i phu hoc can thip mi trong vng 2
tun.
Xut huyt tiu ho hoc sinh dc tit niu
mi trong vng 3 tun.
Mi chc ng mch (vng p c) hoc
mi sinh thit trong vng 1 tun.
ed
erv
ng mu < 50 mg/dl hoc > 400esmg/dl.
r
ts vngoi
Vim ni tm mc, vim mng
tim,
n
h
g
i om.
r
l
huyt khi nhim trng,Avim
l
crut ang tin
. ahoo.
vv
e
trin hoc ang c thai
cho
con
b.
o
nl 0@y
i
F
2
Nghin ru hoc
. ma tu nng.
08 ty20
0
2
i
2. Heparin:
t otoc
h
P
g
i
rtim
a. Heparin
tnh mch khng lm gim mc
opy
C
nng ca t qu khi xy ra, m cn lm tng
nguy c chuyn vng nhi mu no thnh xut
huyt no do tng lng mu n vng nhn no
ch khng phi do t Heparin gy chuyn thnh
xut huyt. Nhng bnh nhn c nhi mu no
din rng (> 2/3 bn cu) nu dng Heparin c
nguy c t vong cao hn hn bnh nhn nhi mu
din nh hoc trung bnh (do ph no tin trin
khi nhn no din rng chuyn thnh xut huyt
no), do khng c dng Heparin. Cng
chng ch nh dng heparin trong vng 24 gi
nu bnh nhn c dng rt-PA.
135
b. Tuy nhin, c mt s trng hp Heparin c

ch nh phng nhi mu no tin trin hoc
ti pht bao gm:
Nhn no ang tin trin.
Huyt khi gy TBMN t tim (nu vng nhn
no nh hoc va).
Huyt khi ng mch sng nn.
Phnh tch ng mch no.
Cc tc nghn di chuyn t ng mch n
ng mch no.
Tai bin mch no thong qua tin trin hn.
Huyt khi tnh mch no.
Mt vi tnh trng tng ng.
c. Bnh nhn c thi gian aPTT > 2 ln chng
cng
ved
rhuyt,
e
c nguy c cao chuyn dng thnh xut
v
s
re
s
t
n
h
vy gim nguy c ny nuig dng
.v Heparin,
om ch truyn
ll r o.cm
khng nn tim bolus tnh. Amch
o
ev ng
ah thi khng ch
o
Heparin 15-18 UI/kg/gi,
l
y
Fin 20@
aPTT gp 1,5 ln 0so
8. vi20chng.
20 ocda
itykhng c ch li g (nghin
d. Heparin tim
t di
t
h
o
P Stroke Trial Project).
rig
cu International
y
p
o
3. AspirinC (160-300 mg/ngy) dng ngay trong giai
on cp cho thy hiu qu r rt trong vic phng
nga c ti pht t qu v gim t l t vong.
4. Thuc bo v thn kinh: nhiu thuc khc nhau
(nh Lubeluzole...) nhm vo vng t bo thn kinh
ang thiu mu c th nghim lm gim
hoc khc phc cc hu qu ca t qu vi cc c
ch nh: c ch th th p ng vi cc acid amine
vng sau xinp, c ch men glutamate release, hn
ch cc tc ng ca ion canxi v cc gc t do, c
ch hnh thnh nitric oxide. Tuy nhin vn cn qu
sm ni v hiu qu ca cc thuc ny.
136
C. Phng ti pht TBMN

1. Phng ti pht t qu chnh l kim sot v iu
tr tt cc yu t nguy c ca TBMN nh tng huyt
p, bnh tim thc tn, i tho ng, ht thuc...
2. Cn iu tr trit cc bnh van tim (hp van hai
l kht, sa van hai l) hay vim ni tm mc nhim
khun bng mt s th thut nh nong van hai l,
phu thut sa van tim hoc thay van tim nhn to.
i vi bnh nhn rung nh, sau khi iu tr
nguyn nhn, cn sc in hoc dng thuc chng
lon nhp chuyn nhp v nhp xoang. Nu chuyn
nhp tht bi, bnh nhn phi ung thm thuc chng
ng duy tr ngng c tc dng (INR t 2-3)
d
phng TBMN do huyt khi. Cng cn ung
rve thuc
e
s
e
chng ng nu bnh nhn c bnh c ttim
s r ngin nng
h
v
.
g
(bung tht tri gin, chc nng lco
ri bp
om km: EF <
l
c
.
A hoo tri, NMCT c
30%), ri lon nng chc nng
ev. ytht
a
o
l
@tht tri...
huyt khi bm thnh, ti
phnh
in
0
F
2
. 0
08 ty2p
0huyt
3. i vi bnh tng
cn phi ung thuc h
2
i
t votheo
toc di huyt p nh k ti c
h
p thng xuyn
P
g
ri
opy xc nh dng thuc h p sut i km
s y t. CPhi
vi ch n gim mn kt hp vi cc thuc chng
ngng tp tiu cu (nh Aspirin 325 mg/ngy,
Ticlodipine 500mg/ngy hoc Clopidogrel 75
mg/ngy). Cc thuc chng ngng tp tiu cu
chng t c vai tr d phng khng nhng TBMN
m cn cc bin c tim mch khc (Aspirin lm gim
ti 25% cc bin c), v th nn dng c h thng
cho cc bnh nhn TBMN tr phi c chng ch nh.
4. i vi bnh i tho ng cn phi thc hin
nghim ngt ch n king ca bnh nhn tiu
ng ng thi ung thuc hoc tim insulin gi
ng mu mc bnh thng v theo di ng
mu nh k ti c s chuyn khoa ni tit.
137
5. i vi ngi c nhiu yu t nguy c ca TBMN

th phi ch ti nhng triu chng bo trc nh:
nhc u ko di, hoa mt, chng mt, tai, cn
thiu mu no thong qua c bin php phng
bnh kp thi.
6. Nhng bnh nhn c hp nhiu (>70%) ng mch
cnh trong hoc ng mch cnh gc th nn ch
nh phu thut bc ni mc ng mch cnh hoc
can thip t gi qua ch hp d phng TBMN
(gim t l t vong do TBMN t 26% xung 9% sau
2 nm).
Ti liu tham kho
1.
2.
3.
4.
5.
6.
7.
8.
9.
Broderick J, Brott T, Kothari R, et al. The greater

ed
Cincinnati/Northern Kentucky stroke study: preliminary rvfirst-ever,
e
s
and total incidence rates of stroke among blacks.
Stroke,
re
ts vn
1998;29:415 421.
h
.
g
i
Ameri A, Bousser MG. Cerebral venous thrombosis.
ll r o.com Neurol Clin,
A
o
.
1992;10:87111.
v ah
loe @Yatsu
y
n
Barnett HJM, Stein BM, Mohr
JP,
FM, eds. Stroke:
i
F 020
.
8 Management.
Pathophysiology, Diagnosis, 0
and
2nd ed. New York:
2
20 ity
Churchill Livingstone, 1992.
t otoc
h
Alberts MJ, Chaturvedi
rig S,PGraham G, et al. Acute stroke teams:
y
p
results of national
survey.
Stroke, 1998;29:2318 2320.
Co
McNamara RL, Lima JA, Whelton PK, Powe NR. Echocardiographic identification of cardiovascular sources of emboli to guide
clinical management of stroke: a cost-effectiveness analysis. Ann
Intern Med, 1997;127:775787.
Pulsinelli W. The ischemic penumbra: from benchtop to bedside.
Neurology, 1994;134:1 6.
Wardlaw J, Warlow C, Counsell C. Systemic review of evidence on
thrombolytic therapy for acute ischemic stroke. Lancet, 1997;350:
607614.
Adams HP, Brott TG, Furlan AJ, et al. Guidelines for thrombolytic
therapy for acute stroke: a supplement to the guidelines for the
management of patients with acute ischemic stroke. Stroke, 1996;
27:17111718.
Adams HP, Adams RJ, Brott T, et al. Guidelines for the Early
Management of Patients With Ischemic Stroke: A Scientific
Statement From the Stroke Council of the American Stroke
Association. Stroke, 2003;34:1056 1083.
138
10. Latchaw RE, Yonas H, Hunter GJ, et al. Guidelines and

Recommendations for Perfusion Imaging Cerebral Ischemia: A
Scientific Statement for Healthcare Professionals by the Writing
Group on Perfusion Imaging, From the Council on Cardiovascular
Radiology the American Heart Association. Stroke, 2003;34:10841104.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
139
tch THNH ng mch ch
Tch thnh ng mch ch (MC) l bnh t gp (t l

hin mc khong 5-30 ca/triu ngi/nm), tn sut thay i ph
thuc vo tng qun th vi cc yu t nguy c khc nhau. Triu
chng bnh thng a dng, d nhm vi nhiu bnh cnh cp
cu khc, cn ch nghi ng mi c th chn on v x tr kp
thi, trnh nhng bin chng gy t vong. T l nam/n l 2/1,
tui hay gp nht l t 60 n 70 tui. T l t vong khong
1%/mi gi trong 48 gi u.
V tr tch thnh MC hay gp l MC ln (ch li, vng
cao trn cc xoang vnh phi v xoang khng vnh khong
ed 1-2
v
r
e
cm, chim khong 60-65%), MC xung - ch xutrepht
(ngay
s
ts 20%),
n
di ch xut pht ca ng mch di n gtri,
quai
h
i om.v
r
l
MC (10%), cn li MC bng do nhng
Alvng
o.c ny phi cng
hothu
v. tm
e
a
gin nhiu nht di p lc cao trong
k
hoc l im
o
inl 20@y
F
ni (xung yu) gia nhng vng c
0 v di ng ca MC.
8. nh
00 ity2
2
tocc th theo nhiu kiu:
I. Phn loi: Tch thnhhtMC
Po
ig
r
y
p
A. Phn loiCokinh
in: theo hai kiu DeBakey v
Stanford. Tch thnh MC hay gp nht on MC
ln sau l vng ln cn vi dy chng ng mch.
1. Phn loi theo DeBakey c 3 tp:
a. Tp I: thng tn c MC ln v MC xung.
b. Tp II: thng tn ch MC ln.
c. Tp III: thng tn ch on MC xung.
2. Phn loi theo Stanford gm 2 kiu:
a. Tp A: tn thng on MC ln cho d khi
pht bt k on MC no.
b. Tp B: thng tn MC on xa k t ch xut
pht ca nhnh ng mch di n tri.
Tuy nhin c khi khng th phn nh r tp chng
hn nu tch thnh MC ch quai MC cnh vng
139
xut pht ng mch di n tri gn vi gc MC

m khng c km on MC ln. V th, c th chia
theo v tr tch thnh hai loi: tch thnh MC on
gn (tnh t gc MC ln n ch xut pht ca ng
mch di n tri) v on xa (t tr i).
d
rve
e
s
re
ts MC
n
Hnh 9-1. Phn loi tch thnh
theo
h
g
i om.v
r
l
l .c
DeBakey v Stanford.
v. A ahoo
e
o
lphu,
y ty vo on tn
3. Phn loi theo v tr gii
Fin020@
.
thng.
08 2
20 ocity
t ogian
4. Phn loi theo
b bnh:
hthi
Pt
rig
y
a. Cp Ctnh:
op thi gian k t khi khi pht 2 tun.
b. Mn tnh: thi gian > 2 tun, khong mt phn ba
s bnh nhn thuc nhm mn tnh.
T l t vong tng dn ln trong vng 2 tun l u
tin, t cc i vo khong 75-80%, to ra mt
ngng t nhin v din bin bnh.
5. Phn loi ca Svensson: mi xut gn y, nh
k thut chn on hnh nh mi, l:
a. Tch thnh MC kinh in do ni mc b tch
ra chia MC thnh hai lng gi v tht, c hoc
khng thng vi nhau qua cc vt rch ni mc,
chnh lch p lc gia hai vng ch t 15-25
mmHg nn lng gi c khuynh hng phng ln
140
theo thi gian, to ra phnh mch, lc rng, thm

ch v ra.
ed
Hnh 9-2. Phn loi tch thnh MC theoesSvensson.
erv
r
tsthnh
n MC
b. Huyt khi hoc chy mu trong
h
g
i om.v
r
l
thng do t cc mch nui
gy xut
.c
Al ooMC
ev. yahMC,
huyt/huyt khi tronglothnh
lm thnh
0@ loi 1, v ra hoc
Fin02thnh
MC dy ln, tin8.trin
2
0
ty
khi hn vit 220tp
oci khc bit theo cn nguyn:
t
h
o
P thnh nang Erdheim-Gsell hoc
hoi t lp
rig gia
y
p
to mng
x va - vi loi ny khng th chn
Co
on c khi chp mch m phi dng cc
phng php chn on khc.
c. Tch thnh MC khu tr gy phng thnh
MC: khng th chn on trn lm sng, song
pht hin c di hnh nh khi phng khi
chp mch hoc chp ct lp mch mu.
d. Lot v nt mng x va MC: thng gp
MC bng tuy cng thy MC ngc, cc mng
x va lot c th tin trin thnh tch thnh
MC kinh in hoc v bung mng x va, gy
bnh cnh tc mch do cholesterol.
141
e. Tch thnh MC do chn thng hoc do th

thut, can thip trong lng mch, c th tin
trin thnh loi 1 hoc 2, thm ch v ra.
6. ng knh vng van MC ngi trng thnh
bnh thng l 2,6 0,3 cm nam, 2,3 0,2 cm
n; i vi MC ln tng ng hai gii l 2,9 0,3
v 2,6 0,3 cm. ng knh MC ln bnh thng
ti a l 2,1 cm/m2 da, ln hn l gin v nu > 4 cm
c coi l ti phnh. i vi MC xung, gi tr
bnh thng l 1,6 cm/m2, nu > 3 cm c coi l
phnh dng ti. dy thnh MC bnh thng l <
4mm. ng knh lng MC s tng dn theo tui
khong 1-2 mm/10 nm, mc tng cng ln khi
ng knh lng mch cng tng.
d
rve
e
s
re
II. Nguyn nhn v c ch bnh sinh
ts vn
h
.
g
i omnt
Gin MC hoc tng huyt p A
gy
ni mc
ll r rn
c
.
o
o
.
h
v
lng mch, sau mu s thm vo
loe @qua
ya vt nt. Di tc
innhp
0
F
dng ca p lc tun hon theo
p,
dng mu thm
2
8. 20
0
y
0
vo s tch ri cc lp ca
2 thnh
it MC. Mt s t cc trng
t otoc
h
P
g
hp cn li c lin quan
vi
cc
yu t lm yu thnh mch,
ri
y
p
d gy nn tchCothnh MC: nh hi chng Marfan (bin d
nhim sc th lm thay i tng hp polypeptide). Cc yu
t nguy c hay gp ca tch thnh MC bao gm:
1. Tng p lc ln thnh MC:
a. Tng huyt p.
b. Gin MC.
c. Van MC mt hoc hai l.
d. Hp eo MC.
e. Thiu sn quai MC.
f. Do th thut, phu thut vi MC: dng c thng
tim, bng MC, v tr phu thut tim (t canuyn,
kp ng mch ch, ni mnh ghp...).
2. Gim sc chu ti ca MC:
142
a. Tui gi.
b. Thoi ho lp gia: hi chng Marfan, hi chng
Ehlers-Danlos.
c. Hi chng Noonan, hi chng Turner, vim ng
mch t bo khng l.
d. Thai nghn.
Trong s cc yu t ni trn th tui v tng huyt p
khng kim sot tt l hai yu t nguy c thng gp nht.
Thai nghn lm tng nguy c ca phnh tch MC: 50%
bin c xy ra tui < 40, trong ba thng cui hoc giai
on sau . Nguy c cng cao ph n c hi chng
Marfan v gin gc MC t trc.
III. Triu chng lm sng
d
rve
e
s
A. Triu chng c nng
re
ts vn
h
.
g
1. au ngc l triu chng thngllgp
ri cnht
om (95%), v
.
. A ahoo(61%) hoc sau
tr thng gia ngc phaevtrc
o
l
y
in MC
(36%), ph thuc vo v. Ftr
0@ b phnh tch (tch
2
0
08 ty2 au ngc pha trc, tch
thnh MC ln thng
20 ocigy
t
t
thnh MC ixung
gy au ngc pha sau,
gh Pothng
r
y
au lng,oau
p bng. Cm gic au c th au chi, d
C
di, nh dao m (51%), nhng ni bt l s xut
hin au t ngt nhanh chng t mc ti a (85%).
Cm gic au khi tch MC t khi lan ln c, vai,
xung hai cnh tay nh au tht ngc in hnh ca
hi chng mch vnh cp. Hng lan ca cn au
xung lng, bng, bn v i l ch im cho qu
trnh tch thnh MC lan i xa. Khng t bnh nhn
hon ton khng au. Mt s khc c khong thi
gian hon ton khng au ri au tr li. y l du
hiu bo ng cho nguy c v ca phnh tch MC.
2. Mt s biu hin him gp khc bao gm suy tim
huyt (do HoC nng khi phnh tch on MC ln),
ngt (4-5% trng hp do v vo khoang mng tim,
143
p tim), tai bin mch no, lit hai chi di, ngng
tim...
B. Triu chng thc th
1. Huyt p cao: a s l nguyn nhn, phn cn li l
hu qu ca tch thnh MC on xa do phnh tch
lan n ng mch thn gy thiu mu thn. 25%
trng hp tt HA tm thu ng mch < 100 mmHg.
Nguyn nhn tt p v sc tim trong tch thnh MC
do h van MC nng cp tnh, v khi phng, p
tim, hoc ri lon chc nng tm thu tht tri. Khi
phnh v hoc nt vo khoang mng tim c th nhanh
chng dn n trn mu v gy p tim cp, ri t
vong. Cn ch n du hiu gi tt huyt p do
d
ng mch di n b chn p.
rve
e
s
re
ts vtch
2. H van MC: 18-50% cc trng hp
h
. n MC
g
i omnng,
r
l
on gn c h van MC t nh
n
c th
Al hoo.c
.
v
nghe thy ting thi tm trng
oe ya ca h van MC
@
inl 2H
F
trong s 25% s bnh8nhn.
. 20 0 van MC nng, cp
0
tnh l nguyn nhn
20 gy
ityt vong ng hng th hai
t otoc
h
P
(sau v phnh
thng biu hin lm sng
rig MC),
y
p
trong tnh
Co trng tru tim mch cp tnh v sc tim. C
ch gy h van MC bao gm gin vng van, gin
gc MC, rch vng van hoc l van, ng khng
kn l van MC (do lng gi trong MC khng
cn, mt nng ca l van hoc chnh mnh nt ni
mc cn tr s ng kn van MC. Ri lon vn
ng thnh tim gp trong 10-15% ch yu do gim
ti mu mch vnh v: lng gi pht trin vo
mch vnh, tch thnh MC tin trin vo MV, tt
huyt p. MV bn phi thng b nh hng nhiu
hn so vi bn tri, d him khi xy ra ng thi tch
thnh MC v nhi mu c tim (1-2%). C tim thiu
mu dn ti ri lon chc nng tm thu tht tri l
yu t gp phn gy tt huyt p v sc tim bnh
nhn tch thnh MC.
144
3. C chnh lch v ny ca mch hoc huyt p

ng mch gia hai tay hoc mt mch t ngt.
Mch hai tay khc nhau l du hiu thc th c hiu
nht ca tch thnh MC, gp trong 38% cc trng
hp. Chnh lch mch v huyt p gia hai tay l do
mt hay c hai ng mch di n b chn p mt
phn, hoc c mnh nt di ng trong lng mch nn
c th nghe thy ting thi dc theo cc ng mch
ln nh ng mch cnh, di n hoc ng mch
i. Biu hin thiu mu ngoi vi, nht l chi di c
th gp trong 15 n 20% s bnh nhn phnh tch
MC. Biu hin mch p (him gp) do chnh lch
v tc dng chy gia lng gi v tht trong
trng hp lng gi tin trin vo gia lngd tht.
rve
Khm vng c c th thy cc biu hin
esenh gin
r
mch c mt bn do p ca lng ggi
htsquanh
.vn MC,
i
r
m
o
l
hoc gin tnh mch c hai bn do
Al tnh
o.c mch ch trn
hop
v. tim,
e
a
b chn p hoc trn dch mng
tim.
o
inl 20@y
F
0 trong s 18-30% cc
4. Triu chng thn kinh
8. gp
00 ity2
2
trng hp: ht otoc
P
rig qu
a. Nhnono/t
l triu chng thng gp nht
py
C
tch thnh MC, chim 5-10% s bnh nhn.
a s bnh nhn tch thnh MC biu hin t
qu c tin s au ngc. Ngoi t qu, thay i
ti mu no c th gy thiu mu no thong
qua vi cc biu hin a dng t ri lon thc
n ngt (12% s bnh nhn).
b. Thiu mu tu sng v bnh thn kinh ngoi vi
do thiu mu hay gp nht nu tch thnh MC
on xa (ti 10%) do hu qu p vo cc ng
mch gian sn, nhnh ng mch Adamkiewicz,
hoc cc ng mch nui r tu sng. Vng ti
mu cho tu sng gip ranh gia nhnh ng
mch Adamkiewicz v cc nhnh nui r tu
sng rt d b tn thng do thiu mu khi tch
145
thnh MC. Thiu mu tu biu hin rt a dng

nh hi chng vim tu ct ngang, bnh l tu
sng tin trin, nhi mu tu sng, hi chng
sng trc tu sng, lit hai chi hoc lit t chi.
Bnh thn kinh ngoi vi trong tch thnh MC
(do thiu mu ca n-ron hoc lng gi p trc
tip vo dy thn kinh) him gp song biu hin
rt a dng, khng c nh nh: lit hai chi di,
khn ting, bnh l m ri tht lng cng v hi
chng Horner. Phn ln triu chng thn kinh
lin quan bnh nhn tch thnh MC l au.
Tuy nhin triu chng t qu, ngt hoc khn
ting cng c th l nhng triu chng u tin.
5. Cc biu hin khc:
d
rve
e
s
a. Trn dch khoang mng phi tri do
rekhi phnh
ts vn
h
.
g
v vo khoang mng phi.
l ri .com
l
A hoo do tch thnh
b. Ph phi mt bn hoc ho
ev. rayamu
o
l
MC lan vo ng mch
0@
Fin phi.
8. 202
0
c. Xut huyt tiu
0ho ycp tnh do lot thc qun
2 tocit
t
h
hoc t trng.
Po
rig
y
op cp do phng mch lan vo ng mch
d. auCbng
mc treo trng.
e. Kh nut do khi phng MC vo thc qun.
6. Tiu chun chn on lm sng c th xc nh ti
96% trng hp tch thnh MC (theo von
Kodolistch) da trn cc triu chng:
a. au ngc khi pht t ngt, hoc cm gic au
ngc chi d di hoc c hai.
b. Chnh lch mch, huyt p hoc c hai.
c. Trung tht hoc MC gin rng hoc c hai.
Nu ch c triu chng s 2 n thun hoc t
nht 2 trong 3 triu chng th t l ng l 83%. Nu
ch c triu chng 1 hoc 3 n thun th t l ng
146
ln lt l 31 v 39%. Chn on loi tr 93% cc

trng hp nu khng c triu chng no.
IV. Cc xt nghim chn on
1. Xquang ngc mc d c c hiu thp, song vn
c gi tr chn on ban u nu phi hp vi triu
chng c nng v thc th. Du hiu kinh in gi
tch thnh MC l bng trung tht gin rng (50%
cc trng hp). Bng trung tht to v bn tri l
chnh nu tch thnh MC ngc, to v bn phi nu
tch thnh MC ln. Cc du hiu khc l nhng
thay i v hnh dng ca MC nh: bu kh tr
quai MC, gin rng cung MC on xa ngay sau
ch xut pht ca ng mch di n tri, dy thnh
d
MC (tng dy ca bng MC pha ngoi
rve im
e
s
vi ho ni mc), di lch im vi hotsrecung
MC
vn v kch
gh m.bit
i
(hn 1cm), hnh nh MC hai lng,
khc
r
l .co
Avl hxung,
o
.
thc gia cc phn MC ln
thng c
v
e ya o
o
l
n
@
i
trn dch mng phi tri,
suy
tim
huyt...
Tuy vy,
. F 2020
8
0
nhng du hiu ny
y tnh cht gi ch khng
0ch c
2 tocit
c gi tr chnigon
nh.
ht Poxc
r
py
2. in tm
Co : khng c hiu, hay gp nht l dy
tht tri, cc du hiu khc bao gm ST chnh xung,
thay i sng T hoc ST chnh ln. Du hiu thiu
mu c tim c th gp nu km tn thng ng
mch vnh, do vy cn ngh n kh nng ny nu
hi chng vnh cp c kiu au d di bt thng.
Cc du hiu ca vim mng tim v bloc dn truyn
nh tht cng c th gp trn in tim .
3. Tch thnh MC c th nhanh chng dn ti t vong
nu b st chn on v khng iu tr. Do la
chn phng tin chn on no ph thuc ch yu
vo kh nng thit b tng c s: thng thng l
chp ct lp vi tnh (CT), chp cng hng t ht
nhn (MRI), siu m qua thc qun (STQ) v chp
mch bng thuc cn quang. Cc phng php ny
147
u chng t chnh xc, nhy v c hiu cao

trong chn on. Barbant v cng s thy nhng
nhm bnh nhn nguy c cao (t l hin mc > 50%),
gi tr d bo dng tnh (kh nng pht hin bnh) >
85% cho c 4 phng tin chn on hnh nh (CT,
MRI, STQ, chp mch). Tuy nhin i vi nhm c
nguy c trung bnh (t l hin mc khong 10%), gi
tr d bo dng tnh ca CT, MRI v STQ > 90%
so vi chp mch bng thuc cn quang ch cn 65%.
Nu t l hin mc ch cn 1% (nhm nguy c thp)
th gi tr d bo dng tnh u < 50% vi CT,
STQ, hoc chp mch, ch tr MRI vn t gn
100%. Ngc li d th no, gi tr d bo m tnh v
chnh xc (kh nng loi tr bnh) vn t
trn
ed
v
r
e
85% trong c 4 bin php chn on hnh nh.
es
sr n
t
h
v
4. Chp ct lp vi tnh (CT) l binrigphp
m. c dng
o
l
l
c
.
nhiu do t xm ln v cho php
on nhanh
A hchn
oo
ev.c
a huyt khi trong
o
l
y
chng khi cp cu, pht ihin
F n020@
8. dch
lng gi v xc nh 0trn
mng tim. nhy t
0 ity2
c 87-100% i vi chn on
2 tol
83-94%, cht hiu
Po nhng trng hp MC ln,
rig tr
tch thnhpyMC,
o
nhyC gim cn < 80%. Nhc im chnh ca
chp CT, ngoi vic phi dng thuc cn quang, l
kh xc nh c nguyn u ca vt rch ni mc,
kh kho st cc nhnh bn ca MC b tn thng
v khng th nh gi mc h van MC. Cc k
thut mi nh chp CT xon c hoc chp siu nhanh
lm tng nhy ca phng php ny. So vi chp
CT c in, chp CT xon c c u th hn do chp
kiu xon c cho php ghi c nhiu hnh nh hn
lc mc cn quang t cc i, pht hin v nh
gi tt hn cc bin i theo nhp th ca bnh nhn
trn trc di. Hn na, hnh nh dng li 2D v 3D
cho php nhn r ng i ca mng nt so vi xut
pht im ca ng mch di n, mt im c
bit quan trng i vi tch thnh MC on xa
148
loi tr tch thnh MC ngc dng vo quai MC

(chim 27% cc trng hp tch thnh MC xung,
vn c t l t vong cao ti 43%). Chp CT xon c
cng nhanh hn, d thao tc hn v cht lng hnh
nh t ph thuc vo ngi lm, ng thi, do mt ct
c xc nh chnh xc nn vic so snh gia cc
kt qu vi nhau chnh xc hn (d theo di).
5. Chp cng hng t (MRI) c nhy v c
hiu rt cao t 95-100%. MRI c th xc nh chc
chn tch thnh MC, mc lan rng, xc nh
chnh xc v tr nt u tin, xc nh cc nhnh ng
mch bn c lin quan, ng thi c th nh gi
nhng tn thng c lin quan ca ng mch thn.
Cho d c mt s hn ch, song MRI tr
dthnh
rve
e
s
phng php chun chn on tch thnh
re MC.
ts vn
h
.
g
a. Ch chp spin echo theo in
om cho php
l ri tm
l
c
.
o
xc nh dng chy chmevtrong
gi. Ch
. A aholng
o
l
y
chp cine v gradient
@ echo cng cung cp
inrecall
. F 2020
nhng d kin 0v
chy
trong lng ng
08 tdng
2 oci y
mch gi gv
ht tht,
Pot mc h van MC. Ch
ri hnh
y
tng cng
nh cho php chn on r hn
op
C
khi kt qu ca cc ch chp trn khng th
kt lun v huyt khi hoc dng chy c hay
khng. Nhng k thut chp mi nh fastgradient echo, K-space acquistion cho php gim
thi gian xt nghim hn na m khng gim
chnh xc. So snh MRI, CT v STQ cho thy
nhy v c hiu ca MRI cao hn nhm
c bnh van MC. Hn na, MRI cho php dng
li hnh nh 3 chiu bt k gc no.
b. Hn ch ca MRI ch: khng phi c sn mi
bnh vin, thi gian thao tc lu hn, c chng
ch nh mt s nhm bnh nhn, kh theo di
cc du hiu sinh tn nht l nhng trng hp
huyt ng khng n nh, Hn na MRI khng
149
an ton cho nhng bnh nhn t my to nhp

tim, kp mch mu hoc cc thit b cy ca nhn
khoa, ca mi hng...
6. Siu m tim:
a. Siu m tim qua thnh ngc ch c nhy 3580% v c hiu 39-96%, ph thuc vo vng
MC ( nhy t 78-100% on MC ln
nhng gim hn cn 31-55% MC xung).
Siu m qua thnh ngc c th quan st thy hnh
nh mng nt ni mc di ng, cc vt nt v
lng gi ca MC ln hay quai MC, tng ng
knh gc MC, gin quai MC, tng dy
thnh MC... Tuy nhin kh nng ca siu m
gim i rt nhiu trong trng hp khoang gian
d
sn hp, bo ph, gin ph nang hoc bnh
rve nhn
e
s
re
phi th my. Siu m tim qua thnh
khng
ts ngc
n
h
vtch
.
g
i
phi l phng tin chn on
tt
thnh
r
om
ll o.cln.
A
MC, d l tch thnh on
MC
o
.
ev yah
lo(STQ)
n
b. Siu m qua thc qun
ngy nay tng
@
i
. F 202c0 th thc hin nhanh
8ton,
i ph bin, an
0
0 ity
2 tocti
chng v dht dng
ging k c bnh nhn
o
P
g
i
r
huyt png
khng n nh, vi chnh xc cao
o y ln ti 98%, c hiu t 63-96%).
( Cnhy
Hn na, phng tin ny cn cho php kho st
v tr nt ni mc u tin, huyt khi trong lng
gi, thay i v dng chy, tn thng ng mch
vnh hoc quai MC phi hp, mc lan rng,
dch mng tim, mc h van MC... Triu
chng quan trng nht chn on tch thnh
MC c th quan st thy qua STQ l di ni
mch b tch trong lng MC, chia lng mch
thnh lng gi v lng tht. Hn na, c th quan
st thy ph dng chy Doppler mu khc hn
nhau gia hai lng mch. Trng hp lng gi
vi ho lu, s thy du hiu di chuyn vt vi
ho ni mc vo gia v thnh mch dy ln.
Chn on xc nh s d dng hn nu c km
theo cc du hiu ca vt nt ni mc u vo,
150
ph Doppler mu trong lng gi, hoc c km

gin gc MC. Nhc im chnh ca STQ l
ph thuc nhiu vo kinh nghim ca ngi lm
siu m, khng nh gi c MC on xa di
ng mch thn tng, khng th lm c nu c
gin tnh mch hoc cht hp thc qun, c th b
st ( vng MC ln on xa hoc quai MC
on gn do kh trong kh qun hoc nhnh ph
qun gc tri, nm gia MC v thc qun lm
gim hoc mt tn hiu siu m) thm ch chn
on sai (nhm vi vt m trung tht, mng x
va vi ho, m di ca siu m ...).
7. Chp ng mch ch bng thuc cn quang c
nhy t 86-88% v c hiu t 75-94% chn
d hnh
on tch thnh MC ngc, vi cc biu hin:
rve
e
s
nh ct thuc cn quang b tch ri hoc
re xon vn,
ts vn
h
. ht thuc
dng chy l hoc khng, khng
ngm
g
l ri .com
l
A o h van MC...
cn quang cc mch mu vchnh,
e . yaho
o
l
Chp ng mch ch c i
nhy
thp, c th b st
F n020@
.
8 lng
nu huyt khi lp00kn
y2 gi, huyt khi trong
2tng
itc
c
o
thnh MC... Tuy
coi l phng tin hng
t
gh Pot
i
r
u chn
on, nht l cho php nh gi c
opy
thng C
tn ng mch vnh km theo nu c, song
ngy nay chp MC bng thuc cn quang t c
dng do ko di hoc tr hon khong thi gian qu
bu phu thut kp thi. Hnh nh gii phu ng
mch vnh ch ng vai tr quan trng i vi quyt
nh m khi c tc l vo ng mch vnh do mnh
ni mc hoc bnh nhn c bnh ng mch vnh
mn tnh. Chp ng mch vnh trong giai on cp
ch nn u tin cho bnh nhn bit chc chn hoc
gn chc chn bnh ng mch vnh.
8. nh lng men trong huyt thanh: c hin tng
gii phng c hiu cc myosin chui nng (Mhc) ca
t bo c trn vo huyt tng khi c tch thnh
MC (nng Mhc trong huyt tng bnh thng
151
trong khong 0.9 0.4g/l, ngng chn on tch

thnh MC l 2.5g/l. Xt nghim nh lng Mhc
(mt 30 pht) trong vng 3h sau khi khi pht c
nhy 91%, c hiu 98% ngi bnh thng,
nhy t 83% bnh nhn nhi mu c tim, chnh
xc chung t khong 96%. Tuy nhin nhy gim
theo thi gian: cn 72% trong vng 3 gi tip theo v
ch l 30% sau 6 gi, d vy vi mc Mhc >10g/l th
c hiu l 100%. Tuy cha c ng dng rng
ri song phng php ny c th xc nh nhng
trng hp nghi tch thnh MC trong vng 6 gi
u (l tng l 3 gi) sau khi pht, hoc gip la
chn cc bin php chn on c hiu khc.
9. hoch nh chnh xc chin lc can thip,
d cn
rve
e
s
nh gi cc thng tn nh: (1) on MC
re b tch;
ts vvan
(2) v tr vt rch ni mc u tin;ri(3)
. n MC;
gh h
m
o
l
l thng
.c
(4) thng tn ng mch vnh;
(5)
tn vng
v. A ahoo
e
o
l
y
quai MC hoc ng mch
thn;
(6)
xut
hin
mu
Fin020@
.
8 mng
trong khoang mng 0tim,
phi hay trung tht.
2
20 ocity
Cn phn bit thm:

t
t
igh Po
a. Gia optch
yr thnh MC v bnh thoi ho
C mng x va MC thng nhn thy r
MC:
hn, b mt x x hn nu so vi mng rch ni
mc MC thng nhn hn. Ch gp huyt khi
bm thnh MC khi c tch thnh MC. Tuy
nhin, mng x va MC khi v cng c th s
dn n lot v tch thnh MC.
b. Lng mch tht v gi: dng mu trong lng
mch gi thng c nhiu m cun, chy chm
li, thm ch chy ngc chiu so vi hng tng
mu trong lng mch tht thi k tm thu. Tuy
nhin, kh nng nhn thy r dng mu trong
lng mch gi ph thuc vo mc thng
thng gia hai lng mch: nu khng thng, s
khng thy c tn hiu dng mu. Mt im
quan trng khc l hnh thnh huyt khi ch thy
trong lng mch gi.
152
c. V tr ca vt rch ni mc u tin: cc vt
rch, nt ni mc u, cui cng nh nhiu vt
rch nt on gia c th thy trc tip trn
MRI hoc siu m qua thc qun. Dng chy qua
cc vt rch ni mc thng theo hai chiu, vi
nhiu loi ph a dng trong k tm trng.
Chnh p qua vt rch u tin him khi cao do
p lc trong lng gi cng ngang trong lng tht.
d. Tch thnh MC khng thng gia hai lng tht
v gi ch chim khong 10%, thng d hnh
thnh huyt khi trong lng gi hn (cn phn
bit vi huyt khi trong thnh MC). Loi tch
thnh MC cn thng thng thy r dng mu
v c th thy c vt rch u v cui trn vng
tch ni mc.
d
rves cc
e
s
Nh vy c th thy rng: mi mt trong
re
htstim
bin php chn on hnh nh nh siuigm
.vn qua thc
r
m
o
l
l o.cch cn quang
qun, chp CT, MRI v chp ng Amch
o
v. nht
e
ah nh. La chn
u c nhng u hay nhc im
o
l
y
Fin020@ vo kh nng ngun
bin php chn on s ph
8. thuc
2 thun tu theo l thuyt.
0
lc sn c ti ch hn 2l0 ch
da
ity
c
o
ht Pot tp A th mc ch chnh l a
i vi phnh tch
rig MC
y
p
bnh nhn i
Com cng sm cng tt.
Bng 9-1. Kh nng chn on tch thnh MC.
Kh nng chn on Chp
Chp
Chp
Siu
MC
CT
MRI m TQ
V tr rch u tin
++
+
+++
++
Lng gi/ lng tht
+++
++
+++
+
Thng tn nhnh bn
+++
++
+
Trn dch mng tim
++
+++
+++
Thng tn MV
+++
++
H van MC km theo
+++
+
+++
nhy chung (%)
88
83-94
98
98-99
c hiu chung (%)
95
87-100
98
77-97
Siu m tim qua thc qun v chp CT c th thc
hin nhanh nht i vi nhng tnh hung cp cu, trong
153
siu m c a chung hn do kh nng linh hot,

nhanh chng, nhy cao, tng i an ton v cho
nhiu thng tin. D sao nu ti ch khng c siu m qua
thc qun, chp ct lp (CT) s l bin php ti u.
Chp MRI s cho nhiu thng tin chi tit nht,
nhy v c hiu cao nht song trong bi cnh cp
cu cn nhanh chng v thun tin th MRI khng ph
hp. MRI ph hp nht nh gi hng lot tin trin
ca tch thnh MC mn, d c phu thut hay ch
iu tr ni khoa.
Chp ng mch ch ch c ch nh cho nhng
bnh nhn khng th chn on xc nh bng phng
tin khc hoc bt buc phi xc nh gii phu hay
d
thng tn ca ng mch vnh phc v cho phu
rvethut.
e
s
re
V. Tin trin t nhin
ts vn
h
.
g
om vo lp ni
l ri .dn
l
c
Tc ng ca dng mu lm khot
su
. A ahoo
mc vi cc mc khc nhau nhoc
thnh lng mch
oev to
l
i 20@y
F
gi, hoc thm ch v ra ngoi8.gy20t vong. Tch thnh on
0 ty
20tr
ibn phi, pha sau v trn so
MC ln thng nm t v
toc
h
o
P
g
i
vi l ng mch vnh
yr phi. Khi lan rng v pha quai MC,
vt tch thngCop pha sau. Tch thnh MC xung li hay
gp pha sau v bn tri nn hay lm tn thng ng
mch thn tri v ng mch chu hoc i tri. 21% bnh
nhn tch thnh MC s t vong trc khi vo vin, t l t
vong nhm tch thnh MC ln khng c iu tr
khong 1-3% mi gi v t khong 25% trong vng 24 gi
u k t khi khi pht, 70% sau tun u v 80% sau tun
th hai. < 10% bnh nhn tch thnh MC on gn sng
sau 1 nm, phn ln cht trong vng 3 thng u do h van
MC cp, tc cc nhnh ng mch chnh, v phnh MC.
90% trng hp tch thnh MC on gn c nguy c v
khi phnh, 75% s v vo khoang mng tim, mng phi tri
hoc trung tht.
Cc dng bnh lin quan n tch thnh MC:
154
1. Xut huyt v huyt khi trong thnh MC:

a. Tin trin ca huyt khi trong thnh MC cng
ging tch thnh MC kinh in, ph thuc vo
v tr huyt khi. Huyt khi thnh MC nm
gia lp ngoi v lp trong ca thnh MC, khc
vi tch thnh MC ch khng c lu thng
vi lng tht ca MC cho d c th nt mng
ni mc v pht trin thc s thnh tch MC,
hoc gy thng ra ngoi hoc to ti phnh MC.
b. D dng chn on xc nh bng siu m qua
thc qun v chp MRI. Xut huyt trong thnh
MC lm tch thnh MC thnh nhiu lp, tng
dy ca thnh MC (>5mm), tng khong
d
cch gia lng MC v thc qun.
rve
e
s
re
c. Biu hin ca huyt khi thnh MC
ts vntrn siu
h
.
g
m gm: dy ln khu tr thnh
omvng MC;
l rimt
l
c
.
A hoo thnh MC;
c khong trng siu m
ev. ytrong
a
o
l
khng thy vt tch Fni
@ song vn c tn hiu
in mc
0
2
8. 20lch vo gia cc vt vi
dng chy Doppler;
y
00 ity
2
t otoc
ho ni mc.
h
P
rig
d. MRI ocn
py xc nh hng lot cc thay i bnh l
C
trong khi mu t, nh nh gi c mc
thoi trin hay tin trin ca huyt khi. MRI
cng nh gi c thi gian to thnh huyt
khi da vo s hnh thnh methemoglobin. Cc
tn hiu mnh trn cc mt ct T1 v T2 do
methemoglobin cho thy tin trin bn cp ca
khi mu t, ngc li chy mu mi s c cc
tn hiu rt a dng v cng trong cc vng
khc nhau ca khi mu t.
2. Mng x va lot MC:
a. Thng gp nht MC xung, l mng x va
c lot tin trin, khot dn vo lp x chun, lp
gia, cui cng hnh thnh nn gin v ti phnh
tht/gi MC, hnh thnh huyt khi ti ch hoc
155
v bung ra... song t khi gy thng hay thc s

tch thnh MC (c th do tc dng bo v ca
lp x ho thnh MC dy sau khi b x va).
Bin chng thuyn tc mch do mng x va lot
kh him. Cc yu t nguy c ca bnh l ny l
tui cao hoc tng huyt p khng kim sot
c. Biu hin lm sng cng ging nh cc
dng tch thnh MC khc: khi pht au ngc
hoc au lng t ngt.
b. Chp CT nh gi chnh xc hnh nh lot tin
trin ca mng x va MC, tuy nhin phi dng
thuc cn quang trng y trong lng MC v
vt lot. So vi chp CT c thuc cn quang, MRI
c chnh xc cao hn, c bit c gi etr
d khi
rvMc d
e
chng ch nh tim thuc cn quang.
s
re
ts vnnh song
h
siu m thc qun cng c gi tr
nht
g
ri com.
l x
l
rt d dng b st nhng mng
. A ahoo. va lot on
v
e
o
xa ca MC ln v on
l uyca quai MC.
Fin020@
.
3. Tin lng:
08 2
20 ocity
t chung
t ti vin xp x 30% nu tch
a. T l t vong
igh Po
r
y
thnhopMC on gn, 10% vi tch thnh MC
C
on xa. T l ny khng h gim trong 3 thp k
va qua d c rt nhiu tin b trong chn
on v iu tr. Nhng yu t d bo t vong ti
vin bao gm: tch thnh MC on gn, tui >
65, cn au c tnh cht di chuyn, c sc, c
chnh lch mch gia cc chi, c du hiu thn
kinh khu tr.
b. T l sng ca nhng bnh nhn tch thnh MC
on gn c phu thut v ra vin tt l 6580% sau 5 nm v 40-50% sau 10 nm. Tin
lng ca bnh nhn tch thnh MC on xa rt
a dng ph thuc vo tng nhm bnh nhn.
Tuy nhin, tin lng xa ti hn bnh nhn c
tch lan rng ngc dng v pha quai MC hoc
156
MC ln v bnh nhn khng c huyt khi

trong lng gi MC. Nguyn nhn chnh gy t
vong khi theo di lu di bnh nhn tch thnh
MC l v khi phnh do tch thnh th pht
hoc do to thnh ti phnh MC ri v.
VI. iu tr
A. La chn phng thc iu tr
1. T vong khi tch thnh MC khng phi do vt nt
ni mc u tin m ch yu do tin trin ca phnh
tch gy chn p cc mch mu quan trng hoc v.
a. Tch thnh MC on gn (tp A) bt buc phi
iu tr ngoi khoa cng sm cng tt gim
nguy c bin chng (h van MC cp, suyedtim
rv
huyt, p tim, triu chng thn kinh) ng
ese thi
r
s
gim nguy c t vong (1%/gi). ight .vn
r
l .com
Al hooxa
b. iu tr tch thnh MCv. on
(tp B) hin
a
loe @ynht
cn nhiu im chainthng
song
nn khi
F 020
.
u bng iu tr
2 Phu thut thng ch
08thuc.
20 bnh
ity nhn c bin chng hoc
c
o
nh cho nhng
ht Pot
rig khoa
iu trpyni
tht bi. V lu di, cn nghin
o
cu Cthm xc nh nhm bnh nhn no thc
s c li nu m.
c. T l t vong sau 5 nm ra vin bnh nhn c
iu tr hp l l 75-82%.
2. Mt s bnh cnh cn lu :
a. Tch thnh MC c tt huyt p: nguyn nhn
hng u l v thnh MC hoc p tim. Cn lp
tc b mu, dch v chuyn m ngay. Nu phi
chc dch mng tim nng huyt p trc khi
chuyn n phng m th cng khng nn ly
nhiu m ch ly lng dch mng tim
huyt p mc chp nhn c. Nu phi dng
thuc vn mch nng huyt p th nn dng
Norepinephrine hoc Phenylephrine (khng nh
157
b. Tch thnh MC c nhi mu c tim cp: chng

ch nh dng thuc tiu si huyt. Chp MC
trong giai on cp c nguy c rt cao tip tc
gy tch thnh v lm chm tr khong thi gian
qu bu dnh cho phu thut.
B. iu tr ni khoa
1. Ch nh iu tr ni khoa:
a. Tch thnh MC cp tnh tp III khng c bin
chng.
b. Tch thnh MC cp tnh on quai, n thun,
huyt ng n nh.
ved
c. Tch thnh MC mn tnh, n nh. reser
ts vn
.
gh mnhp
2. Thc nghim cho thy dng chy ritheo
s tip
l .co
l
A
o
tc thc y qu trnh tch thnh
ng
mch
theo
c
o
.
ev yah
o
l
hai chiu ln xung. V Fth
@ h huyt p cp cu
in phi
. 2020tnh mch mi bnh
8ng
bng cc thuc dng
0
20 ocity
nhn ngay khi hnghi
tch thnh MC tr khi
t ong
t
rigmcPch gim lc co bp ca tht tri,
sc tim, nhm
y
p
Co tng p trong MC (dP/dt), gim huyt
gim mc
p ng mch xung ti mc thp nht c th c
m khng gy nh hng n ti mu cc c quan
sng cn, nh vy lm gim qu trnh tin trin ca
tch thnh MC v gim nguy c v khi phnh.
3. Hin ti, phi hp chn giao cm v mt thuc gin
mch (v d Nitroprusside Natri) c coi l phng
thc iu tr ni khoa c bn i vi tch thnh
MC. Nn dng thuc chn giao cm trc khi
dng thuc gin mch trnh phn x gii phng
catecholamine th pht khi dng thuc gin mch
lm tng co bp tht tri v mc tng p trong
lng ng mch, cng lm tch thnh MC tin
trin. Liu thuc chn tng ti khi tc dng (nhp
158
tim 60 hoc huyt p trung bnh ng mch 6070 mmHg). Nu c chng ch nh vi chn , c th
dng thuc chn knh canxi. Sau khi bnh nhn
dng chn , c th thm dn Natri Nitroprusside
ng tnh mch a huyt p ng mch ti
ngng mong mun ri duy tr: khi u vi liu 20
g/pht, iu chnh dn duy tr huyt p ng
mch trung bnh khong 60-70 mmHg. Trng hp
khng tc dng, c th dng Labetalol (chn c v
giao cm) hoc Trimetaphan (c ch hch thn
kinh).
Bng 9-2. Mt s thuc h huyt p ng tnh mch.
Thuc
Liu ban u
Liu duy tr
d
Thuc c la chn u tin
rve
e
s
re mch 4Propanolol
1 mg TM/3-5 pht, ti a 2-6 mgstnh
t vn
h
.
g
6,15 mg/kg
6h/ln
l ri .com
l
2 mg/pht
Labetalol
10 mg TM/2 pht, sau ev. Atruyn
oo
ah
o
l
y
20-40 mg 10-15 Fin 0@ TM, chnh n 5-20
2
.
mg/pht
pht/ln, ti a0300mg.
08 ty20
2 oci
t
t
Esmolol
30 mg TM
truyn 3-12 mg/pht
igh Po
r
y
Metoprolol
5 mgopTM 5 pht/ln
5-10 mg TM 4C
6h/ln
Nu c chng ch nh vi thuc chn giao cm
Enalaprilat
0,625 mg tnh mch
0,625 mg TM 46h/ln
Diltiazem
0,25 mg/kg TM/2 pht, Truyn 5 mg/gi,
dn
2,5-5
nu khng c tc dng, tng
ti
a
nhc li 0,35 mg/kg TM mg/gi
15mg/gi
sau 15 pht
Verapamil
0,075-0,1 mg/kg ti 2,5-5 5-15 mg/gi truyn
mg/kg /2 pht
TM
4. Bnh nhn tch thnh MC on xa, khng bin
chng, c th ch iu tr ni khoa trong giai on
cp do t l sng st vn t gn 75% d c m
hay khng. Hn na, bnh nhn tch thnh MC
159
on xa thng tui cao, hay c cc bnh tim mch,

h hp hoc tit niu km theo. Nhng bnh nhn
tch thnh MC on gn c nhng bnh khc
khng th phu thut c cng nn iu tr ni
khoa. Mc ch ca iu tr ni khoa khi tch thnh
MC giai on cp nhm n nh vt nt tch, phng
v ch phnh tch, thc y qu trnh lin ca vt
tch v lm gim nguy c bin chng.
5. Nguy c tim tng lun phi phng khi iu tr ni
khoa m kp thi bao gm: vt tch thnh MC
tip tc lan rng, khi phnh tch ngy cng phng
hn, nguy c p vo cc t chc ln cn gy gim
ti mu cc c quan - thng biu hin trong bnh
cnh cn au ngc/bng ti pht, chng bng,
d toan
rve
e
s
chuyn ho tng, men tim tng dn v/hoc
re suy gim
ts gy
n
h
dn chc nng thn. Nguyn nhn rchnh
g
i om.v t vong
l
l v khi
.c phnh tch
bnh nhn iu tr ni khoa . l
v A ahoo
e
o
lc quan.
y
MC v gim ti mu cc
Fin020@
.
08 2
C. Phu thut
20 ocity
ht Pot
1. Ch nh m:
rig
y
op nhn c tch thnh MC cp on gn,
a. MiCbnh
tr trng hp khng th phu thut do cc bnh
l nng km theo. Chng ch nh thng gp l
t qu mi do nguy c vng nhn no chuyn
thnh xut huyt no khi dng chng ng v do
hin tng ti ti mu sau phu thut.
b. Ch nh phu thut nhm tch thnh MC cp
on xa bao gm: khi phnh tch phng ln
nhanh chng, thm mu phc mc, do v, au
ko di khng kim sot c v/hoc thiu mu
chi hoc tng, tch lan ngc v MC on ln,
c h van MC hoc bnh nhn c hi chng
Marfan.
160
2. T l t vong quanh phu thut bnh nhn tch

thnh MC giao ng t 5-10%, c th ln ti 70%
nu c bin chng. Cc yu t c lp tin lng
t vong bao gm: p tim, tru tim mch, v tr vt nt,
thi im phu thut, thiu mu thn hoc tng, ri
lon chc nng thn v c bnh phi hoc bnh ng
mch vnh km theo. Thi gian tin hnh chn on
trc m cng di, t l t vong trong v sau phu
thut cng cao.
3. Phng php m ti u ph thuc tng phu thut
vin, a s u phi hp vi dn keo MC. Mc ch
ca phu thut nhm ct b v thay th on MC c
vt nt u tin, ch khng phi ton b phn MC
b tch thnh. Nu van MC khng th sa li
dth p
rve
e
s
dng phu thut Bentall (thay on gc MC
v van
re
n MC
hts .vkeo
MC, cm li ng mch vnh).rigDn
om
ll dn
chim vai tr quan trng, dng. A
o.c cc lp MC
o
h
v
e ya ca ming ni
b tch v trm kn ch ichy
nlo 0@mu
F
2
8. t0 l thay van MC, gim
MC, nh lm gim
00 ity2
2
c
chy mu tronghtv sau
oto m cng nh gim tn sut v
P
g
i
r
mc bin
py chng.
Co
4. Bin chng ca phu thut bao gm chy mu, nhim
trng, hoi t ng thn cp v/hoc thiu mu mc
treo. Bin chng ng s nht sau m tch thnh
MC on xung l lit hai chi di do thiu mu
vo ng mch tu sng qua cc ng mch gian
sn. Cc bin chng mun bao gm h van MC
tin trin (nu khng thay van MC lun), phnh
mch ti ming ni v ti pht phnh tch MC.
Khong 50% trng hp cn tn ti mt phn phnh
tch sau m. Khong 15% bnh nhn m tch thnh
MC phi m li do tin trin tip ca tch thnh
MC cn st li; hoc do tch thnh MC mi (
vng ming ni hoc on MC khc); hoc do to
thnh ti tha MC. Cc phng php nh chp
161
MRI, siu m tim qua thc qun rt c gi tr theo

di on mch nhn to, ming ni hoc pht hin
sm gin/phng MC.
D. Can thip qua da theo ng ng thng
1. t gi (Stent) trong lng MC ch mi c
thc hin trn s t bnh nhn c nguy c cao khi
phu thut, a s l nhng bnh nhn tch thnh
MC xung c triu chng gim ti mu chi di
hoc cc tng bng (nh rut, gan, v/hoc thn).
t gi c coi l thnh cng khi bt c vt nt
ni mc u tin, gy ng lng gi trong vng 2 gi
sau t: t l thnh cng trn lm sng t 76-100%,
t l t vong sau 30 ngy l 25%. Cc bin chng
gm nhi mu rut, suy thn, thuyn tc chierdi,
ved v
s
re
lng gi, hi chng sau t Stent trong
ts vlng
n MC
h
.
g
i
(tng thn nhit v protein C phn
ng
thong
qua,
r
ll o.com
A
o
.
tng nh bch cu a nhn), vi
v tnh sut giao ng t
loe @ya
n
i
0 n 75%. Ti thi im
hin
. F 2020nay, t Stent c coi
8
0
nh mt bin php20iu
ytr tm thi nhng bnh
ocit
nhn c triuigchng
tui mu chi di v hoc
ht Potgim
r
y
tng bng
p th pht do tch thnh MC on xa.
Co
t Stent v/hoc c l lng gi c th p dng cho
nhng bnh nhn tch thnh MC on gn n
nh ton trng trc khi phu thut.
2. Hin ti, khong 13% bnh nhn tch thnh MC
c t on mch ghp c gi (Stent graft). Lu
di, on mch ghp c gi c th tr thnh
phng php c bn iu tr tch thnh MC on
xa, trc khi xy ra bin chng.
E. iu tr huyt khi trong thnh MC v mng x
va lot MC
1. Bin php iu tr ph thuc vo v tr thng tn
MC ging nh tch thnh MC. Huyt khi trong
thnh MC v mng x va lot MC ch yu u
162
gp MC xung, do cn iu tr ni khoa tch

cc nhm kim sot ti u huyt p, gim mc tng
p (dP/dt) trong MC, kim sot cc yu t nguy c
ca x va ng mch v theo di st v lu di.
Nguy c t vong ca huyt khi trong thnh MC
khong 21%, trong 2/3 t vong do tin trin thnh
phnh tch hoc v phnh tch MC.
2. Phu thut c ch nh bnh nhn c huyt khi
trong thnh hoc mng x va lot vng MC ln
hoc quai MC v bnh nhn c gin tng dn
hoc hnh thnh ti phnh bt k v tr no ca
MC.
F. iu tr v theo di lu di
ved tnh
rcp
1. Tch thnh MC ch nn coi l bin c
e
s
re
ts nguy
trong khi a s nguyn nhn hay yu ht
.vn c ca
g
i ton
r
m
o
l
bnh li l mt qu trnh mn A
tnh,
l o.c th v tin
o
.
v
ed y
trin dn dn, vn tn ti cho
ahgii quyt trit
o
l
Fin020@thut. Nguy c hnh
tch thnh MC bng
8. phu
0
ty2 MC tin trin, tch
thnh ti phnh, tch
20 ocithnh
t
t
thnh MC rti
ighphtPophi lun c cnh gic v theo
y
op
di cnCthn.
14-29% bnh nhn tch thnh MC
on xa hnh thnh ti phnh mch.
2. iu tr giai on sau ca tch thnh MC on xa
cng tng t nh trong giai on cp: kim sot
huyt p ng mch tch cc bng thuc chn giao
cm (Atenolol, Metoprolol, Labetalol) hay Diltiazem.
Cc thuc gy gin mch (tng dP/dt) nh
Hydralazine hay Minoxidil ch nn dng nu phi
hp vi cc thuc lm gim sc co bp (nh chn
giao cm). Trng hp iu tr ni khoa tht bi tc
l tip tc c bng chng tch thnh MC tin trin,
bin chng mch cc tng, au ti pht hoc h van
MC tin trin th xem xt iu tr bng phu thut.
163
3. iu tr chung v lu di cho cc bnh nhn tch

thnh MC d c phu thut hay khng bao gm
kim sot ti u huyt p ng mch vi mc tiu
gim huyt p tm thu ng mch 130 mmHg: (cho
php gim 2/3 t l ti pht).
4. V lu di, t vong (khong 30%) do v khi phng
th pht hoc tch thnh MC ti pht, a s trong
vng 2 nm u. Do vy mc ch ca theo di v ti
khm l pht hin sm cc phnh mch th pht:
khm lm sng, o huyt p, chp phim Xquang tim
phi... tuy nhin bt buc phi lm nhiu ln cc xt
nghim thm d MC nh siu m tim qua thc
qun, chp CT, chp MRI... Chp MRI l tiu chun
vng v l phng tin cung cp nhiu thng vtin
d nht
r e
e
s
v bnh. Thi gian ti khm nn vo ccremc nh 3
ts vtip
thng, 6 thng sau khi ra vin, sau
. n tc 6
gh
i
r
m
o
l
ltu .thuc
c
thng/ln trong vng 2 nm, ri
vo nguy
v. A ahoo
e
o
l
y
c ca tng bnh nhn m
ti
khm
6
thng
hoc 12
Fin020@
.
thng/ln.
08 2
20 ocity
Ti liu tham kho ight Pot

yr DS, Carey L et al. Spectrum of acute aortic
1.
Amstrong WF,opBach
C
2.
3.
4.
5.
6.
7.
8.
dissection of the ascending aorta: a transesophageal

echocardiographic study. J Am Soc Echocardiogr 1996;9:646-656.
Barbant S, Eisenberg M, Schiller N. Diagnostic value of imaging
techniques for aortic dissection. Am Heart J 1992;124:2:541-543.
Cigarroa JE, Isselbacher EM, DeSanctis RW et al. Diagnosis
imaging in the evaluation of suspected aortic dissection: old
standards and new directions. N Eng J Med 1993;328:35-43.
Erbel R. Diseases of the thoracic aorta. Heart 2001;86:227-234.
Hagan PG, Nienaber CA, Isselbacher EM et al. The International
Registry of Acute Aortic Dissection (IRAD): new insights into an
old disease. JAMA 2000;283:879-903.
Harris JA, Bis KG, Glover JL et al. Penetrating atherosclerotic
ulcer of the aorta. J Vas Surg 1994;19:90-98.
Khan IA, Nair Chandra. Clinical, diagnostic, and management
perspectives of aortic dissection. Chest 2002;122:311-328.
Maraj R, Rerkpattanapipat P, Jacobs LE et al. Meta-analysis of 143
reported cases of aortic intramural haematoma. Am J Cardiol
2000;86:664-8.
164
9.
10.
11.
12.
13.
14.
15.
Meszaros I, Morocz J, Szlavi J et al. Epidemiology and

clinicopathology of aortic dissection. Chest 2000; 117:1271-1278.
Pitt MP, Bonser RS. The natural history of thoracic aortic aneurysm
disease: an overview. J Card Surg 1997;12 (suppl):270-278.
Pretre R, Segesser LV. Aortic dissection. Lancet 1997;349:146164.
Spittell PC, Spittell JA Jr, Joyce JW et al. Clinical features and
differential dignosis of aortic dissection: experience with 236
cases. Mayo Clin Proc 1993;68:642-651.
Suzuki T, Katoh H, Tsuchio Y, et al. Diagnostic implications of
elevated levels of smooth-muscle myosin heavy chain protein in
acute aortic dissection: the smooth muscle myosin heavy chain.
Ann Intern Med 2000; 133:537-541.
von Kodolitsch Y, Schwartz AG, Nienaber CA. Clinical prediction
of acute aortic dissection. Arch Intern Med 2000;160:2977-2982.
Willens HJ, Kessler KM. Transesophageal echocardiography in the
diagnosis of diseases of the thoracic aorta: part I. Chest
d
1999;116:1772-1779.
rve
e
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
165
Iu tr
Mt s ri lon nhp tim thng gp
I. Cc thuc chng lon nhp
A. i cng
1. Ri lon nhp tim (RLNT) l mt trong nhng vn
thng gp trong cc bnh ni khoa ni chung v tim
mch ni ring.
2. Cc thuc cha lon nhp tim rt phong ph v khc
bit nhau v c ch tc dng, cch dng, tc dng
ph...
3. Vn s dng cc thuc chng lon nhp cng
d ht
rvebit v
e
s
sc tinh t v kh phc tp, i hi s rhiu
e
ts n
bnh l cng nh c im ca ccrithuc
lon
gh m.vchng
l .cto lm sng
l
nhp. Cc nghin cu cng nh
thc
A hoo
ev. lon
a
o
l
cho thy chnh cc thuc chng
in 20@y nhp cng c th
F
. 0khc trm trng hoc cc
gy ra nhng ri lon08nhp
0 ity2
2
toc
bin chng nguyt him.
igh Po
r
4. Trc mt
opytrng hp c lon nhp tim i hi ngi
C
thy thuc phi c thi hp l trong vic nhn
nh kiu RLNT, la chn loi thuc ph hp, nm
vng tc dng, c tnh, tc dng ph, tng tc
thuc...
B. Phn loi thuc chng lon nhp
1. V tnh cht phc tp ca cc thuc chng lon nhp,
do vic phn loi cng c nhiu cch khc nhau.
Tuy nhin cho n nay, hu ht cc bc s thc hnh
lm sng s dng cch phn loi n gin ca
Vaughan William (bng 10-1) v phn nhm ca
Harrison trong vic phn chia mt cch chi tit nhm
I ca Vaughan William.
167
Bng 10-1. Phn loi thuc chng lon nhp theo

Vaughan William.
Nhm Tc dng ca thuc Tc dng u tin trn knh
in hc
I
Tc dng trc tip Chn knh natri nhanh
trn mng t bo
(pha 0)
II
Chn bta giao cm
ng khng trc tip knh
canxi (pha IV)
III
Ko di thi gian ti Chn knh kali ra ngoi
cc
(pha III)
IVa
Chn knh canxi
Chn dng canxi chm vo t
bo ( nt nh tht) (pha II)
IVb
Chn khng trc tip M knh kali (tng kh cc)
d
knh canxi
rve
e
s
re
ts vn
h
.
g
Bng 10-2. Phn nhm ca Harrison lcho
om I.
l ri nhm
c
.
A hoo
Phn
Tc dng
ev. Thay
a i trn T
o
l
in 20@y
F
nhm
.
08 ty20 Ko di QRS v QT.
IA
Ngn chn va phi
20 ociknh
ht ot
natri nhanh (pha
rig 0) P
y
op gian ti cc qua
Ko di Cthi
con ng c ch knh kali
IB
Chn knh natri (nhiu hn t nh hng n
QRS v QT.
trn m bnh).
Lm ngn thi gian ti cc
(gim thi gian tr).
IC
Ngn chn ng k knh Lm di QRS (QT di
ra theo do thay i
natri nhanh.
nh hng rt t n ti cc. QRS).
C. Tm tt mt s loi thuc chng lon nhp
thng dng (bng 10-3).
168

Disopyramide
(Norpace, Rythmodan)
py
Procainamide
(Procan SR, Procanbid)
Co
Gan: 50%
Thn: 50%
Gan : 40%
Thn: 60%
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
TM: 17 mg/kg TM: 2-6 3,5

trong 20-30 mg/pht
pht
8
Ung: 300 mg Ung:
100-200
mg mi 6
gi
RLTH, h TK, h
mu, h HA,
Lupus.
Khng
cholinergic, gim
co bp c tim, h
HA, xon nh.
Bng 10-3. Mt s thuc chng lon nhp (TCLN) thng dng.

Tc dng ph
Chuyn
Thuc
Liu khi
Liu duy
Bn
ho v o
u
tr
hu
thi
(gi)
Nhm I
Nhm IA
Gan: 80%
Ri lon tiu ho
Quinidine
1,2 - 1,6 7-9
Thn: 20%
(RLTH),
vim
(Serecor, Quinidex)
g/ngy,
gan, c quan mu,
chia u
tt HA, xon
nh.
ved
169
nng
Digoxin, tng
tc dng ca
Warfarin, tng
nguy c xon
nh nu phi
hp vi TCLN
nhm III.
Vi nhm III
lm tng nguy
c xon nh.
Vi nhm III
lm tng nguy
c xon nh.
Tng tc
thuc
Nhm IB
Lidocaine
(Xylocaine)

170
py
Phenintoin
(Dilantin)
Co
Torcainide
(Tonocard)
Mexiletine
(Mexitil)
TM: 1-1,5 mg TM: 2-4 2

/kg sau 0,5 mg/kg
mg/kg mi 10
pht n tng
liu l 3mg/kg
10-17
Ung: 400 mg Ung:
100-400
mg mi 8
gi
Gan
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
13,5
Ung:
400- Ung:
800 mg
400-800
mg mi 8
gi
24
TM:
10-15 Ung:
mg/kg trong 1 400-600
mg
mi
gi
ngy
Gim nng
bi Rifamycin
Phenintoin;
Tng nng
do Theophyllin
nng bi
chn bta giao
cm, Cimetidine
H TK, h HA, Tng nng

thiu mu
bi Cimetidine
Amiodarone,
Fluconazole,
Gim nng
bi Rifamycin
Carbamazepin
H TK, h tiu
ho, h mu
Gan: 40%
Thn: 60%
Gan: 90%
Thn: 10%
H TK vi liu
cao; gim dng
mu ti gan khi b
suy tim nng hoc
sc
H TK, h tiu
ho, nhp chm,
h HA
Gan: 90%
Thn: 10%
ved
Morcizine
(Ethmozine)

TM: 5 mg mi Ung: 25- 3-4
2-32
Ung:
150-300
mg mi 8
gi
Gan
Tng nng
bi:
Amiodarone
Tng bloc nh
tht nu dng
cng
thuc
chn bta giao
cm hoc chn
knh canxi.
Tng nng
Digoxin; tng
hot tnh ca
thuc chn bta
giao cm.
ved
171
Gim co bp c Tng hot tnh
RLTH, gim co
bp c tim, gy
lon nhp, tng
nguy c t vong
bnh nhn sng
st sau t t
Gan: 50%
Thn: 50%
py
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
Nhm II
Metoprolol
H TK, gim co
bp c tim, gy
lon nhp. Chng
ch nh khi c
tn thng thc
th cu trc tim
Gan: 65%
Thn: 35%
Ung: 50- 12-27

200
mg
mi 12 gi
Co
Propafenone
(Rythmol)
Nhm IC
Flecanide
(Tambocor)
H TK, h tiu
ho, c th gy
lon nhp
Gan: 90%
Thn: 10%
6-13
Ung:
200-300
mg mi 8
gi
(Betaloc, Lopressor)

172
Nhm III
Amiodarone
(Cordarone, Pacerone)
py
Dng
esterases
trong mu
Gan
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
25-110 Gan
ngy
0,5 TM: 0,05- 9 pht

3
mg/kg/ph
t
Ung: 1,2 -1,6 Ung:

200-400
g/ngy
TM: 5mg/kg mg/ngy
sau 10-20
mg/kg/ngy
TM:
mg/kg
TM: 5 mg mi Ung: 10- 3-4

5 pht
120
mg
mi 8 gi
100
mg
mi 8-12
gi
Co
Esmolol
(Breviloc)
Propranolol
(Inderal)
5 pht
Phi, mt, tuyn

gip, chc nng
gan, ko di QT,
gim co bp c
tim
tim, gim nhp

tim, co tht ph
qun, h TK, lit
dng
Gim co bp c
tim, gim nhp
tim, co tht ph
qun, h TK, lit
dng
(ging nh trn)
Tng hot tnh

Warfarin; tng
nng
Flecanide
v
Digoxin; tng
nguy c xon
nh nu dng
cng vi thuc
(ging nh trn)
(ging nh trn)
bi thuc chn
knh can xi
ved
Sotalol
(Betapace)

Nhm IVa
Diltiazem
py
Ibutilide
(Corvert)
Co
Bretylium torsylaye
Ung: 80- 15-17

120
mg
mi 12 gi
TM:
mg/kg
Gan: 20%
Thn: 80%
0,25 TM: 10-15 3-4

mg/gi
Ung: 30120
mg
mi 8 gi
Gan
Gan: 90%
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
TM:
5-10 TM: 1-2 7-9
mg/kg, nhc mg/pht
li ti tng
liu
l
30mg/kg
2-12
TM: 0,015 0,025 mg/kg
trong 5 pht
Gim nhp tim,

gim co bp c
tim, lm nng suy
tim
173
nhm IA
Tng hot tnh
ca thuc chn
canxi,
tng
nguy c xon
nh nu dng
vi thuc nhm
IA hoc li tiu
H HA, RLTH
Lm tng nguy
c h HA khi
dng vi li tiu
hoc thuc gin
mch
dng
Xon nh, h Trnh
HA, au u, cng cc thuc
lm ko di QT
RLTH
Gim nhp tim,

Khng
chuyn ho, bloc nh tht,
thi
qua gim co bp c
tim, xon nh, co
thn
tht ph qun
ved
Verapamil

py
10
giy
Thn
Gan
TM/Ung: 36-48
0,1-0,75
mg mi 8
gi trong
ngy
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
Tng hot tnh

Dipyridamole;
b thay i tc
dng do Cafein,
Theophylline
Nng bng, kh
th, au ngc, v
tm thu, co tht
PQ
H TK, h tiu Tng nng

ho, bloc nh tht, bi Quinidine,
Verapamil,
lon nhp
Amiodarone,
Propafenone.
(ging nh trn)
(ging nh trn)
174
Ghi ch: TM: tim Tnh mch; TK: thn kinh; RLTH: ri lon tiu ho; HA: huyt p
TM/Ung:
0,25-0,5 mg
TM: 6 mg
tim nhanh,
nu khng tc
dng nhc li
12 mg tim
nhanh
2,5-10 Ung: 80- 6-12

120
mg
mi 8 gi
Co
thuc khc
Digoxin
Nhm IVb
Adenosine
(Adenocard)
TM:
mg
ved
II. Thm khm bnh nhn b ri lon nhp tim

A. Lm sng
1. Khai thc k bnh s v nh gi lm sng rt quan
trng, n gip cho iu tr tt cc ri lon nhp tim.
2. Hi k tin s xut hin lon nhp, hon cnh xut
hin, thi gian, tn xut, cch bt u cng nh kt
thc, p ng vi cc iu tr (xoa xoang cnh, n
nhn cu...), cc triu chng khc i km (au ngc,
ngt, xu...).
3. Hi v tin s gia nh xem c ai mc cc RLNT nh
bnh nhn khng (mt s lon nhp bm sinh c
trong cc bnh nh bnh c tim ph i, hi chng
QT di gia nh, hi chng Wolff - Parkinson White...).
d
rve
e
s
4. Hi k tin s cc bnh tim c t trcre (bnh van
ts vn
tim, bnh mch vnh...) hoc cc bnh
phi
gh m.khng
i
r
o
ll o.c(bnh
tim c th lin quan n lon. Anhp
ni
tit,
v aho
e
o
bnh vim nhim, nhim trng...).
nl 0@y
Fich
.
5. Thm khm thc th 0cn
8 202 n cc du hiu sinh
0
2 ockhng,
ity
tn, nhp tim u
huyt p nh th no,
t hay
t
h
o
P
g
cc biu hinribnh tim mch, cc bnh khc...
opy cn ch : in gii , cng thc mu,
6. Cn lmCsng
mt s nng cc thuc ang dng m nghi c nh
hng n nhp tim. Trong mt s trng hp nghi
ng, c th lm thm cc xt nghim chn on bnh
tuyn gip hoc cc c t...
B. in tm (T): L mt xt nghim rt quan trng
trong chn on ri lon nhp tim.
1. in tm 12 chuyn o: L bt buc, nu c
T lc khng c lon nhp s gip ch rt nhiu cho
chn on.
2. Theo di trn monitor lin tc gip theo di nhng
bin i v tn s, hnh thi ca lon nhp; cc p
ng vi iu tr...
175
3. Cc trng hp khng r v hot ng ca nh trn

T th c th lm mt s chuyn o c bit nh:
a. Chuyn o Lewis: in cc m t b trn
phi cnh xng c, in cc dng t b di
tri cnh c.
b. Chuyn o thc qun: a mt in cc c bit
vo trong thc qun gn v tr nh tri, cho php
nhn r sng hot ng ca nh.
c. Chuyn o trc tip bung nh: dng in cc
my to nhp tm thi a vo bung nh phi.
C. Holter T: Phng php ghi li T trong sut 24
gi hoc hn, cho php ghi li c nhng on ri lon
nhp m T bnh thng khng bt c (vd. cc ngoi
d
tm thu, cc cn nhp nhanh kch pht...).
rve
e
s
re
ts vn
h
D. Mt s phng php khc
.
g
l ri .com
l
A rto c ch nh
1. Nghim php gng sc i vkhi
e . yaho
o
l
gi nhng lon nhp linFquan
n gng sc, c bit
in 20@
. 2hoc
0
8tht
l cc ngoi tm thu
cc cn nhp nhanh
0
20 ocity
tht. N phn bit

t nhng ri lon nhp ny l do tn
gh Pot
rith
thng thc
(xut hin hoc nng ln khi gng
y
op
C
sc) hoc c nng (khi gng sc mt i).
2. Thm d in sinh l tim (cardiac electrophysiology study) l phng php c ch nh khi
cc thm d khng chy mu khng nh gi
cc ri lon nhp hoc iu tr mt s ri lon
nhp. Ngi ta s dng mt s dy in cc v a
n nhiu v tr khc nhau trong bung tim nh
gi bn hot ng in hc ca tng nh, nt nh
tht, ng dn truyn nh tht, tng tht... Phng
php ny cng cho php nh v c cc v tr hoc
cc ng dn truyn bt thng, cc ngoi v v
xc nh c ch ca cc loi ri lon nhp.
176
III. Rung nh
Rung nh (RN) l mt trong nhng ri lon nhp rt thng
gp, chim khong 0,4 - 1,0% trong cng ng v gp khong
10% s ngi trn 80 tui.
A. Nguyn nhn
1.
2.
3.
4.
5.
Tng huyt p.
Bnh van tim (HHL).
Suy tim.
Bnh ng mch vnh.
Cc nguyn nhn khc: nhi mu phi; bnh phi
mn tnh tc nghn; cng gip; nhim trng; ri
lon chuyn ho, bnh mng ngoi tim, Phued thut
rv
tim mch...
ese
r
ts
6. Rung nh v cn.
gh m.vn
i
r
o
l
Al hoo.c
.
B. Sinh l bnh
v
e
a
nlo 0@y
i
F
2
1. Cc gi thit v c ch
8. gy0rung nh:
00 ity2
2
a. Vng vo lit ti tnh,
oc l c ch m ngy cng c
Po v c ch nht.
ighchng
nhiu bng
r
opy
b. Gi Cthit v ri lon s pht nhp, s hnh thnh
ngoi v (mt hoc nhiu) nh gy tng tnh t
ng hoc ny c hot ng. Vic t ngoi v
ny bng sng cao tn qua catheter vng vo
ca cc tnh mch phi thu c nhng thnh
cng bc u h tr cho gi thit ny.
2. Nguy c tc mch bnh nhn rung nh s tng vt,
c bit ngi c tui, bnh nhn c tiu ng,
c bnh van tim, tng huyt p, suy tim...
3. Rung nh thng km theo nhp tht nhanh lm cho
cung lng tim b gim i ng k, nht l khi bnh
nhn c cc bnh thc tn tim km theo. Bn thn
rung nh gim khong 20 % lng mu xung tht
trong thi k tm trng. Do , khi RN km theo
177
nhp tht nhanh th cng lm cho thi k tm trong

ngn, lng mu v tht gim i ng k.
4. Phn loi rung nh: c th phn ra cc th rung nh
(da trn kiu xut hin rung nh) nh sau tin cho
vic theo di v iu tr:
a. Cn rung nh ln u mi xy ra, l rung nh mi
thy xut hin ln u tin bnh nhn, c th
thong qua do nhng nguyn nhn c th phc
hi c hoc c th tn ti mi.
b. Rung nh kch pht, l nhng rung nh xut hin
v kt thc t pht (thng trong 48 gi) v d b
ti pht.
c. Rung nh dai dng, l nhng rung nh tn ti lu
d
nhng vn c th ti to nhp xoang bng
rve thuc
e
s
re
hoc sc in chuyn nhp.
ts vn
h
.
g
i omnh
l rrung
d. Rung nh mn tnh, l nhng
lu m
l
c
.
A hoo
.
v
e yasc in u khng
chuyn nhp bng thuclohoc
in hoc
0@ khng duy tr c
F
hoc rt t thnh cng
2
8. 20
0
lu nhp xoang.
20 ity
t otoc
h
P
C. Triu chng ylm
rig sng
p
Co
1. C th khng
c triu chng g.
2. a s bnh nhn thy hi hp nh trng ngc, kh
th, au ngc, chng mt, v m hi...
3. C th c bin chng tc mch l biu hin u tin
ca bnh.
4. Nghe tim: thy lon nhp hon ton, c th thy
nhng du hiu ca bnh van tim km theo (nu c).
D. Cc xt nghim chn on
1. in tm :
a. Sng P mt, thay bng sng f= 400 - 600 ck/pht.
b. Nhp tht rt khng u v khong cch, tn s.
178
c. Bin ca cc sng QRS trn cng mt o

trnh cng rt khc nhau.
2. Siu m tim gip chng ta nh gi xem c huyt
khi trong cc bung tim hay khng hoc c th c
nguy c hnh thnh huyt khi (gin cc bung tim,
hin tng tng ng trong cc bung tim).
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
Hnh 10-1. Rung nh: sng f nh r chuyn o V1.
E. iu tr
Nhm 3 mc ch:
Gim p ng (tn s) tht.
Gim nguy c tc mch.
Chuyn nhp (a v nhp xoang) v duy tr nhp
xoang.
1. Kim sot nhp tht: Thng thng th nhp tht c
th c kim sot bng bng cc thuc lm chm
ng dn truyn qua nt nh tht.
a. Digitalis:
179
L thuc kinh in hn ch tn s tht khi

b rung nh nhanh. N l thuc l tng cho
nhng bnh nhn b rung nh nhanh m c
gim chc nng tht tri, hoc c chng ch
nh vi cc thuc chn bta giao cm, chn
knh calci.
Thng dng loi tim tnh mch (Isolanide,
Cedilanid 0,4 mg tim TM 1/2- 1 ng). Trong
trng hp khng khn cp, c th cho dng
ung Digoxin 0,25 mg (1-2 vin/ngy), iu
chnh liu v sau theo p ng c th.
Ch nu c ch nh sc in iu tr rung
nh th phi dng Digitalis trc vi ngy.
b. Chn bta giao cm:
d
rve mch
e
C th dng dng tim rtnh
s
e
n
hts .vung.
(Metoprolol, Esmolol) hoc igdng
Cc
r
m
o
l
l
c
thuc chn bta giao .cm
thng
c
la
.
A hoo
v
e
a
o
chn nhng bnhnl nhn
rung nh nhanh m
i 20@y
. F 20mch
c cn nguyn08bnh
vnh hoc rung nh
y
0
t
2
i
nhanh tin
pht.c
ht oto
Cnych
rig Pcc chng ch nh ca cc thuc
p
Co bta giao cm ( cp n bi cc
chn
thuc iu tr THA).
c. Cc thuc chn knh canxi:
Thng dng Verapamil hoc Diltiazem dng
tim tnh mch hoc dng ung. Cc thuc
ny lm gim p ng tht tt, c bit dng
tim c tc dng kh nhanh.
Chng ch nh dng khi c ri lon chc
nng tht tri, c suy tim r.
2. Ngn nga tc mch:
a. Ch nh v chng ch nh dng thuc chng
ng bnh nhn rung nh c trnh by trong
bng 10-4. Nguy c tc mch l rt d xy ra
bnh nhn b rung nh. Tuy nhin, cn cn nhc
180
gia li ch v tc hi ca vic dng cc thuc

chng ng tng bnh nhn rung nh c th.
b. Thuc v cch dng: Khng Vitamin K l thuc
c la chn hng u. Mc tiu cn t c
khi dng l m bo t l INR mc 2,0 - 3,0.
Bng 10-4. Ch nh v chng ch nh dng thuc
chng ng bnh nhn rung nh
Ch nh:
Rung nh bnh nhn c: tin s tc mch no hoc tai
bin thong qua, c suy tim huyt, bnh c tim gin,
bnh ng mch vnh, hp van hai l, c van tim nhn to,
cng tuyn gip, THA.
d t
Dng trc khi sc in iu tr rung nh (c k ehoch)
rve
s
re
nht 3 tun v sau sc in t nht 4 tun.
ts vn
h
.
g
Chng ch nh tng i:
l ri .com
l
. A acc
Khng c kh nng kim sot, theoevdi
hoo xt nghim v
o
l
y
t l Prothrombin v INR. . Fin 20@
0
Bnh nhn sa st tr tu. 2008 ity2
t toc
Ph n ang mang thai.
igh Po
r
y ang tin trin.
Lot ng tiuopho
C
C tin s chy mu trm trng hoc b ri lon ng mu.
THA nng khng khng ch c.
Nu ch nh chuyn nhp th cn dng mt
thuc trong nhng thuc trn trc t nht 3
tun v sau t nht 4 tun.
Trong trng hp cn chuyn nhp cp cu th

cn cho Heparin v phi kim tra siu m qua
thc qun bo m khng c mu ng trong
nh tri mi chuyn nhp cho bnh nhn v
sau chuyn nhp th tip tc cho khng
Vitamin K thm 4 tun.
181
Vi nhng bnh nhn tui di 65 v t nguy c tc mch hoc

c chng ch nh dng khng vitamin K th c th cn nhc
cho Aspirin thay cho khng Vitamin K.
Bng 10-5. Cc thuc khng Vitamin K thng dng.
Thi gian tc dng (gi)
Loi thuc
Bt u
Ko di
Thi gian tc dng ngn
28-24
24 48
EthyleBiscoumacetate
(Tromexane)
48 - 96
Phenindione (Pindione)
Thi gian tc dng va
24 - 48
48 - 96
Acenocoumarol (Sintrom)
48 - 72
Fluindione (Previscan)
d
48 - v96
Tioclomarol (Apegmone)
r e
e
s
Thi gian tc dng di
re
ts vn
. - 120
Warfarine (Coumadine)
36 righ m96
l .co
l
A o
ev. yaho
o
l
@
3. Chuyn nhp (a v nhp
v duy tr nhp
in xoang)
. F 2020
8
0
xoang: R rng l2vic
v nhp xoang v duy
0 ichuyn
ty
oc li nhiu li ch cho bnh
t mang
t
tr nhp xoangghs
o
P
ri ng
y
nhn v c
huyt
v gim cc nguy c tc mch.
p
Co
Tuy nhin, phi lu l bnh nhn cn c nh gi
k lng trc khi quyt nh chuyn nhp. Trong
mt chng mc no , nu khng nh gi k lng
bnh nhn, vic c gng chuyn nhp v dng thuc
duy tr c th s tht bi hoc khng mang li li ch
g hn m lm tng nguy c do dng thuc duy tr
nhp lu di. Nhiu nghin cu chng minh rng,
i vi nhng bnh nhn b RN lu, c nhiu yu
t ti pht km theo... th vic khng ch nhp tht,
ngn nga tc mch v chung sng ho bnh vi RN
li l gii php ti u nht. Trong mi trng hp
RN, cc bnh c bn phi c xem xt gii quyt
trit trc khi iu tr rung nh.
182
a. Chuyn nhp bng thuc: L phng php nn

c la chn u tin trong vic chuyn nhp.
T l thnh cng khc nhau ph thuc vo tnh
trng c th tng bnh nhn cng nh nguyn
nhn gy rung nh v thi gian rung nh. Nhn
chung, t l thnh cng do chuyn nhp bng
thuc thp hn chuyn nhp bng sc in. Trong
trng hp dng thuc chuyn nhp khng thnh
cng th nn ch nh sc in iu tr kp thi.
Khi vai tr ca cc thuc ny kh quan trng
v n gip kh nng sc in chuyn nhp thnh
cng cao hn v duy tr tt nhp xoang sau .
Cc thuc dng tim tnh mch (bng 10-3).
Procainamide (nhm IA): l thuc vec
d th
r
e
s
c chn chuyn nhp trong
re RN. C
tsthuc
n
h
khong 1/3 bnh nhn khi dng
g
i om.v ny c
r
l
l ho,.c huyt hc, hi
tc dng ph (ri lon tiu
v. A ahoo
e
o
l
y
chng ging Lupus...).
Fin020@
.
8 2
Amiodarone 0(Cordarone):
l thuc c la
20 othuc
ity khc khng dng c
c
chn khi
cc
t ot
P Lu l thuc c thi gian bn
igh bi.
rtht
hoc
y
p
Co cc k di (120 ngy). Thn trng vi cc
hu
bin chng khi dng lu di (ri lon tuyn
gip, nhn m, vim phi k, vim gan, co
git...). Amiodarone c chng minh l lm
gim t l t vong do ri lon nhp tht. Tuy
nhin, trong cc ri lon nhp nhanh nh n
cng c tc dng rt tt c bit l bnh
nhn rung nh. Thng dng di dng truyn
tnh mch pha trong dung dch ng hoc
mui ng trng.
Ibutilide: l mt thuc mi v rt hu hiu
trong iu tr rung nh. Bin chng c th gp
l cn xon nh (gp 1-2%).
Cc thuc dng ung (bng 10-3).
183
C Amiodarone v Procainamide u c
dng ung, trong Amiodarone l thuc hay
c s dng hn c, nht l duy tr nhp
xoang sau khi c chuyn nhp. Lu
nhng tc dng ph ca Amiodarone khi
dng lu di v thi gian bn hu cc k di
ca n. Procainamide khi dng lu di s km
dung np hn, nn thng khng dng loi
ny duy tr nhp xoang.
Quinidine l thuc trc y thng c
dng nht chuyn nhp v duy tr nhp
xoang. Tuy nhin Quinidine c rt nhiu tc
dng ph v bn thn n cng l yu t c
th gy ra cc ri lon nhp khc. N dtng
rve
tc vi mt s thuc khc nh Digoxin,
ese khng
r
ts vndng cc
vitamin K, Verapamin, lm tng
.
gh mtc
i
r
o
thuc ny khi dng cngAvi
ll nhau.
c
.
. ahoo
evnhm
Sotalol l thuc thuc
III nhng c tc
o
l
n 0@y
i
F
2
dng chn bta8. giao0 cm. N c th dng
y2 nhng cn ch cc tc
00 itnh,
bnh nhn 2rung
c
o
t ot
P quan n chn bta giao cm v
dngrph
igh lin
y
p
c
Co th gy xon nh do lm QT ko di.
Flecainide v Propafenone l thuc thuc
nhm IC (bng 10-3) c tc dng tt bnh
nhn rung nh. Chng l thuc c kh nng
dung np tt nhng c th lm tng t l t
vong bnh nhn c ri lon nhp tht do
bnh ng mch vnh. Do , cc thuc ny
thng khng c ch nh bnh nhn rung
nh do cn nguyn bnh ng mch vnh
hoc bnh c tn thng cu trc tim.
Disopyramide thuc nhm IA, c tc dng
tng t Procainamide v Quinidine. Tuy
nhin thuc ny gy gim co bp c tim
nhiu, do khng nn dng nhng bnh
nhn c ri lon chc nng tht tri.
184
b. Chuyn nhp bng sc in: L bin php c

hiu qu cao trong chuyn nhp t rung nh v
nhp xoang vi t l thnh cng trn 80%.
Sc in iu tr rung nh nn c ch nh
khi dng thuc tht bi, c du hiu thiu
mu c tim, kh khng ch nhp tht, suy
tim... c bit khi c nhng ri lon huyt
ng trm trng th cn ch nh sm. Sc
in s thnh cng cao hn khi c dng
cc thuc trc (v d Amiodarone).
Sc in chuyn nhp ch tin hnh khi bnh
nhn c dng chng ng y (xem
phn trn). Trong trng hp cp cu th cho
Heparin v phi lm siu m qua thc qun
ed
v
r
e
loi tr khng c mu ng trong rnh.
es
n ni c
Sc in phi c tin hnhghtsnhng
i om.v
r
l
kh nng cp cu v theoAldi ott
.c v tim mch,
ho Cc nhn vin y
v. tt.
e
a
bnh nhn c gy
m
o
nl 0@y
Fitrong
2 vic p dng cc bin
.
t phi thnh tho
08 ty20
0
2 octr.
i
php h hp
t oh
t
h
P
g
Ccyyu
ri t nh hng n kt qu ca chuyn
p
nhp
Co bng sc in l: thi gian b rung nh
lu hay nhanh, ln ca sng f, kch thc
nh tri, c h van hai l phi hp, c suy tim
khng ? Thi gian b rung nh cng lu, sng
f cng nh, nh tri o trn siu m ln hn
45 mm l nhng yu t d bo tht bi ca
sc in hoc kh nng ti pht rung nh cao.
Nng lng dng trong sc in iu tr rung
nh thng bt u bng liu nh 100J sau
c th tng ln ti 200J, 300J v phi l sc
in ng b.
4. Cc phng php iu tr khc:
a. t my to nhp vnh vin: Phng php ny
c ch nh khi bnh nhn khng p ng vi
cc cch iu tr trn hoc khi nhp tht b chm
185
b. Trit ph rung nh qua ng ng thng

(catheter ablation): Qua ng ng thng a cc
in cc v dng sng radio cao tn t trong nh
tri thnh tng kha to hiu qu ging nh phu
thut Maze trit ph cc vng vo li ti c
nh. Phng php ny c t l thnh cng khng
cao lm v c th c nhng bin chng, nhiu khi
phi cn n cy my to nhp vnh vin. Ngy
nay, cng vi s tin b ca k thut v cc dng
c mi cho php t l thnh cng ngy
d cng
rve php
e
cao hn v ha hn y s l mt phng
s
re
ts vnmn tnh.
h
iu tr tt cho nhng rung nh dai
dng
g
ri com.
l
l
. (phu thut
c. Phu thut ct cc kha .A coonh
v ah
e
o
l
ylang nh, phu thut
Maze), phu thut toinhnh
F 020@
.
c lp nh l nhng
2 thut c thc hin
08 tphu
20 nh,
i ytuy nhin t l thnh cng
c
iu tr hrung
o
t ot
Pnhiu vo k thut v tnh trng
ig
rthuc
cn ph
y
p
o
bnhC nhn. Phu thut trong iu tr rung nh
thng ch c thc hin trong khi tin hnh cc
cuc phu thut khc bnh nhn (v d khi m
thay van tim, m lm cu ni...).
IV. Cung ng nh
Cung ng nh (atrial flutter) l mt hnh thi nhp nhanh
trn tht kh hay gp v thng khng tn ti lu di v c xu
hng chuyn v nhp xoang hoc chuyn sang rung nh.
A. Triu chng lm sng
1. Biu hin lm sng rt khc nhau tu theo bnh tim
thc tn c sn, theo p ng tht chm hay nhanh
m bnh nhn c th c cm gic hi hp trng ngc.
186
2. Cung nh thng ch tn ti vi gi n vi ngy, t

khi ko di hn v sau n s chuyn v nhp xoang
hoc thnh rung nh.
B. Sinh l bnh
1. Cung nh xut hin l do vng vo li nh, thng
thng nh phi v rt t khi nh tri.
2. in hnh nht l vng vo li nh phi v i theo
ngc chiu kim ng h xung theo thnh t do ca
nh phi v ln li vch lin nh.
3. Cung nh c th chia lm 2 th (type): Type I l loi
cung nh c th ct c bng to nhp nh vt tn
s v tn s nh thng mc 240-340 chu k/pht
khi cha dng thuc. Type II l loi cung nhedkhng
erv s nh
ct c bng to nhp nh vt tn s vrestn
ts
thng mc cao hn 340-430 chu k/pht.
gh m.vn
i
r
ll o.co
Acho
.
C. in tm : L thm d c bn
v
e yaho php chn on
o
l
cung nh.
Fin 0@
8. 202
0
0 itysng P v thay bng sng F
1. in hnh, ta s thy
c
2 tmt
t
h
o o rt r cc chuyn o sau
hnh rng ca,
ig uPn,
r
py
di (DII,
Co DIII, aVF).
2. Tn s F t 240-340 ck/pht, trung bnh 300 ck/pht.
3. Phc b QRS thng ging nh lc cn nhp xoang
(khng gin rng).
4. Tn s tht thng kh u v l c s so vi nhp
nh v c th c bloc 2:1; 3:1... Tuy nhin, i khi tn
s tht khng u do s thay i mc bloc nh tht
trong cung nh.
187
d
rve
e
s
re
ts vn
h
.
g
Hnh 10-2. Cung nh 2:1.
l ri .com
l
oo
v. Ac
em
ah bloc nh tht 2:1
5. Trong trng hp cung nh
o
l
y
@
Fin020sng
th i khi kh chn on
F ln vi sng T.
8. 2do
0
y s nghim php lm chm
0 mt
t
2
i
Khi cn thitt lm
toc
Po l ra sng F r hn (v d xoa
gh lm
i
p ng tht
r
y
p
xoang cnh,
Co tim Adenosin...).
D. iu tr
1. Lm gim p ng tht:
a. L bc u tin cn thc hin cho mi bnh
nhn cung nh, c bit khi p ng tht nhanh
c th gy nh hng n huyt ng.
b. Cc thuc c th dng l Digitalis loi tim, tc
dng nhanh (Cedilanide, Isolanide), hay mt s
thuc chn knh canxi hoc chn bta giao cm.
c. Digitalis nn l thuc c la chn hng u
lm gim p ng tht.
2. Cc thuc chuyn nhp v duy tr:
188
3.
4.
5.
6.
a. Thng dng cc thuc nhm IA (Quinidin,

Procainamid), IC (Flecainid, Propafenone) hoc
nhm III (Amiodaron).
b. Thng thng cc thuc ny c t l thnh cng
khng cao trong chuyn nhp nhng rt quan
trng gip cho sc in thnh cng, v c mt t
l nht nh khi sc in cung nh s tr thnh
rung nh v nu khng c dng cc thuc ny
trc th kh c th a v c nhp xoang.
Chng ng trong cung nh nn ch nh cho nhng
bnh nhn c nguy c tc mch cao (tin s tc
mch, nh tri ln...).
Sc in chuyn nhp: l phng php rt c hiu
d
qu v nn c la chn cho bnh nhn cung
rve nh.
e
s
e Mt s
Thng dng nng lng thp, bt u tt
s r50J.
n
h
vthnh
.
g
i bin
trng hp sc in lm cung nh
rung
r
m
o
l
l o.c
A
o
.
nh, khi cn sc tip nh trong
h tr rung nh
v aiu
loe
chuyn v nhp xoang. . Fin 20@y
8 20
00tn
To nhp nh vt
2
itys: C th thc hin bng
t otoc
h
P vo thnh c nh trong khi m
in cc p rtrc
ig tip
y
p
hoc aCoin cc qua ng thc qun. Vi in cc
qua ng thc qun th cn phi c dng in ln
(ti 30 mA), nn c th gy au n cho bnh nhn.
Thng dng cch to nhp tim p theo my vi tn
s nhanh hn tn s tim ca bnh nhn khong 10 20 nhp gy c ch vng vo li ri tt my t
ngt, nhp xoang ca bnh nhn s c ti lp li.
Trit ph vng vo li qua ng ng thng: y
l bin php hu hiu vi t l thnh cng trn 95 %
v t ti pht. Trc tin dng cc in cc thm d
bn in hc ca nh pht hin ra vng vo li,
sau nh v v tin hnh t bng sng radio cao
tn qua mt dy in cc.
189
7. Vi mt s trng hp cung nh tn ti dai dng v

khng p ng vi cc phng php iu tr trn, c
th cn phi t trit ph nt nh tht v cy my to
nhp vnh vin.
V. Cn nhp nhanh kch pht trn tht (CNNKPTT)
Thc t tim nhanh trn tht bao gm nhiu loi ri lon
nhp khc nhau nh: rung nh, cung nh, tim nhanh nh, nhp
nhanh trn tht c vng vo li nt nh tht hay qua ng dn
truyn ph... Tuy vy, trong thc hnh t trc n nay ngi ta
gi l cn nhp nhanh kch pht trn tht ch nhng cn
tim nhanh bn cht trn tht v c vng vo li nt nh tht
hoc vng vo li nh tht qua ng dn truyn ph.
A. Sinh l bnh: thng c hai loi ch yu:
d
rve
e
s
1. Cn nhp nhanh kch pht trn tht (CNNKPTT)
re
ts vng
n
h
c vng vo li ngay ti nt nh tht:
g
i om.v vo li
r
l
l v .chm
c
chy qua ng dn truyn nhanh
nt nh
v. A ahoo
e
o
l
y
tht hoc qua ng dn itruyn
chm
nt
nh tht
F n020@
.
v ng dn truyn08ph 2 rnh nh tht (trong hi
20 citya s cc trng hp (95%)
chng WPW). Trong
t otoi
h
P ca vng vo li l qua ng
rig (xui)
ng i xung
y
p
Co chm ca nt nh tht v i ngc ln theo
dn truyn
ng dn truyn nhanh. Vic khi pht ra cn nhp
nhanh thng l do hin tng ny c khi c mt
ngoi tm thu nh hoc ngoi tm thu tht. Ngoi tm
thu nh lm bloc dn truyn xui ng dn truyn
nhanh v khi xung ng ch xung theo ng
dn truyn chm, vng li kh cc ng dn truyn
nhanh gy vng vo li. Kt thc cn nhp nhanh l
kt qu ca vic bloc ng dn truyn chm.
2. CNNKPTT c vng vo li nh tht c lin quan
n mt ng dn truyn ph v n: khng th
hin trn in tim b mt.
190
B. Triu chng lm sng

1. CNNKPTT thng xy ra nhng bnh nhn khng
c bnh tim thc tn. Tuy nhin c mt s trng
hp cng c th xy ra cc bnh nhn c bnh tim
thc tn.
2. Khai thc tin s c th thy bnh nhn c nhng cn
hi hp nh trng ngc, tim p nhanh, s xut hin
v kt thc cn nhp nhanh kh t ngt.
3. Trong cn bnh nhn c cm gic hi hp nh trng
ngc, lo lng, tim p rt nhanh.
4. CNNKPTT thng t nh hng n huyt ng v
thng khng ko di. Song c mt s t trngd hp,
e
erv tt p
cn c th ko di hng ngy v c th esgy
r
ts
hoc suy tim.
gh m.vn
i
r
o
ll u,
Art
o.c tn s trung
5. Nghe tim thy nhp tim thng
o
.
h
v
e
a
bnh 180 - 200 ck/ pht. Finlo 0@y
2
. 20
08 tthc
0kt
6. CNNKPTT c th
2
i y t ngt hoc khi bo
t otoc
h
bnh nhn ht
rig suPvo ri th ra nhng ng cht
y
p
thanh mn
Co (rn th) hoc khi c bc s xoa xoang
cnh hay n nhn cu...
C. in tim
1. Phc b QRS thng thanh mnh, u, tn s 180 200 ck/pht.
2. Sng P khng nhn thy do ln vo QRS hoc i khi
c th nhn thy ging nh sng r nh V1.
3. Khi kt thc cn c th thy mt on ngng xoang
ngn hoc nhp chm trc khi ti lp nhp xoang.
191
d
rve
e
s
re
ts vn
h
.
g
Hnh 10-3. Cn nhp nhanh kch pht ltrn
ri ctht.
om
l
.
A o
D. iu tr
ev. yaho
o
l
in @
1. Ct cn nhp nhanh:08. F 2020
y
20 ocitcng
a. Cc bin php
ph v c th ct c
t gy
t
h
o
P
g
i
r
cn nhp
py nhanh: C th bo bnh nhn ht su vo
Co ra nhng ng thanh mn (ng tc rn);
ri th
c th xoa xoang cnh (ch trc khi xoa phi
nghe khng thy hp ng mch cnh v xoa
tng bn mt. Xoang cnh nm v tr ngang sn
gip, khi xoa bo bnh nhn nghing u mt
bn, bc s dng ngn tay ci n ln xoang cnh
v day). n nhn cu l mt bin php kh hiu
qu v hay c dng nhng cng kh th bo,
i khi c th gy bong vng mc ca bnh nhn.
b. Thuc u tay nn dng l Adenosine dng ng
tim 6mg. Adenosine gy bloc nh tht hon ton
tm thi v nhiu khi gy tm ngng xoang, do
lm ngng dn truyn trong nt nh tht v
lm ct t vng vo li nt nh tht. V tr tim
192
c.
d.
e.
f.
g.
nn ch tnh mch nn v khi tim phi bm

tht nhanh v thi gian bn hu ca thuc cc
nhanh. Ln u dng 6 mg, nu khng kt qu th
tim nhc li 6 mg v nu vn khng c kt qu
th dng tip 12 mg (2 ng).
Cc thuc chn knh canxi v chn bta giao
cm c th c dng khi dng Adenosine tht
bi. Thc t ngi ta thng dng Verapamil
dng tim tnh mch. Verapamil lm ko di thi
gian tr ca nt nh tht v chm dt vng vo li
ca nt nh tht. Liu lng ca Verapamil t 510 mg tim tnh mch trong 2-3 pht. Chng ch
nh bnh nhn c suy gim chc nng tht tri,
c tt p, cn thn ngi gi.
d
rve
e
s
Chn bta giao cm thng dng l rPropranolol
e
ts n
hoc Esmolol dng tim riTM.
ca
gh m.vLiu
o
l
l
c
.
Propranolol l 0,15 mg/kg. Atim
TM tc 1
v ahoo
edng
o
l
y
mg/pht. Ch cc tc
ph
v chng ch
Fin020@
.
nh ca cc thuc
08ny.2
20 ocity
Digitalis, lm
t chm dn truyn trong nt nh tht
gh Pot
rict
v c oth
c cc CNNKPTT do vng vo li
y
p
C
ti nt nh tht. Tuy nhin, cn thn trng khi
bnh nhn c hi chng WPW hoc c nh
xoa tip xoang cnh sau v Digitalis c th lm
tng nhy cm ca xoang cnh.
Amiodarone l thuc c th cn nhc khi cc
bin php trn tht bi. Nhiu khi bn thn
Amiodarone cng khng ct cn c nhng sau
khi dng thuc ny th c th tin hnh li cc
bin php gy cng ph v, khi s c hiu
qu.
Sc in ct cn c ch nh khi CNNKPTT dai
dng, c nh hng n huyt ng (gy suy tim,
tt huyt p) hoc cc thuc khng ct c cn.
193
Thng ch cn nng lng nh (50J) v ng b

l c th ct c cn.
2. iu tr trit :
a. Hin nay, nh phng php thm d in sinh l
pht hin cc ng dn truyn ph v qua
dng sng radio cao tn trit ph (t)
(catheter ablation) cc ng dn truyn ph
c th gip cha khi bnh hon ton. y l
phng php nn c la chn hng u cho cc
bnh nhn c CNNKPTT ti pht nhiu khng
p ng vi cc iu tr ni khoa thng thng.
i vi tt c cc bnh nhn c chn on l
c CNNKPTT nn gi n nhng trung tm c
th thm d in sinh l xem xt vicrviu
ed tr
e
s
trit cc CNNKPTT cho bnh nhn.
re
ts vn
h
g
b. Cc thuc c th dng dl phng
ri com.CNNKPTT
l
A holo. chn bta giao
c vng vo li ti nt nh
v. tht
e
a
o
nl 0@y
cm, Digitalis, hocFiVerapamil...
Tuy vy, vic
2
. 20
8
0
dng cc thuc20nytylu di phi c ch ti
tca
oci chng.
tph
cc tc dng
h
o
P
g
ri
py hu ht cc nghin cu u cho thy li
c. HinConay,
ch vt tri ca trit ph ng dn truyn ph
so vi dng thuc v y chnh l phng php
c th cha khi bnh hon ton.
VI. Ngoi tm thu tht
Ngoi tm thu tht (NTTT) l mt trong nhng ri lon
nhp tim cng kh thng gp. Tuy NTTT c th xut hin trn
ngi bnh thng v khng gy nguy him, nhng nhiu trng
hp NTTT thng xy ra trn mt bnh nhn c bnh tim v c
th gy nguy him n tnh mng ngi bnh nu khng c
pht hin v x tr kp thi.
Vic quyt nh iu tr cng cn phi c cn nhc k
v thng phi da trn cc triu chng do NTTT gy ra, s c
mt ca bnh tim km theo v nht l phi da trn mt s c
194
im ca NTTT trn T xem c phi l NTTT nguy

him hay khng.
A. Nguyn nhn
1. NTTT ngi bnh thng: hay gp ph n v
thng l mt dng, mt . Tin lng lnh tnh v
thng khng cn phi dng thuc chng lon nhp.
2. NTTT bnh nhn c bnh tim thc tn: hay gp
trong mt s bnh l sau:
a. Nhi mu c tim: kh hay gp v cn cnh gic
trong giai on cp cng nh phi theo di st
sau NMCT.
b. Bnh c tim gin.
d
c. Bnh c tim ph i.
rve
e
s
re
d. Bnh van tim (do thp, sa van hai l...).
ts vn
h
.
g
e. Tng huyt p.
l ri .com
l
. A atim
hoo (Digitalis, cc
f. Dng cc thuc iu tr
evsuy
o
l
y
0@ thuc li tiu, cc
thuc ging giao cm),
Fin cc
8. 202
0
thuc chng lon
20 nhp...
ity
t otoc
h
P mu...
g. Ri lon rin
ig gii
y
p
Co lm sng
B. Triu chng
1. Bnh nhn c th khng thy c triu chng g c
bit c. Nhng a s bnh nhn thy c cm gic hi
hp nh trng ngc, hoc l cm gic hng ht
trong ngc.
2. Thm khm lm sng c th thy: s mch c nht
rt yu hoc khng thy, tip l khong ngh di
hn. C trng hp thy mch chm bng mt na so
vi tn s ca tim nu nghe tim ng thi (khi bnh
nhn c NTTT kiu nhp i). Nghe tim c th thy
nhng nht bp xy ra sm v sau thng hay c
mt khong ngh b. Khi bnh nhn b rung nh th
trn lm sng kh bit c l c NTTT hay khng.
Khi , T mi gip chn on chc chn c.
195
C. in tm
1. T l thm d rt quan trng trong chn on
NTTT.
2. Nht NTT c biu hin l mt nht bp n sm,
phc b QRS thng gin rng, hnh th khc bit so
vi nht bp t nhin ca bnh nhn, sng T v on
ST o hng so vi QRS, khng c sng P i trc.
3. Phc b QRS ca NTTT ny thng n kh sm.
Mt NTTT in hnh thng hay c thi gian ngh
b, tc l khong RRR = 2RR.
4. NTTT c th c nhiu dng (hnh dng khc nhau
trn cng chuyn o), nhiu (cc khong ghp
khc nhau).
d
rve
e
s
5. Khi c mt nht bp nhp xoang xen k
remt NTTT
ts vn
h
. xoang c
g
th gi l NTTT nhp i, v khi hai
nhp
l ri .com
l
A o
mt NTTT gi l NTTT nhp ba...
ev. yaho
o
l
Fin 0@
8. 202
0
20 ity
t otoc
h
P
rig
y
p
Co
Hnh 10-4. Ngoi tm thu tht.
196
D. Cc thm d khc
1. Cn lm y cc xt nghim c bn, nht l ch
cc ri lon in gii mu.
2. Siu m tim rt hu ch gip ta pht hin cc tn
thng thc th tim.
3. Holter in tim xc nh cc thi im xut hin,
mc nguy him v s lng NTTT trong 24 gi.
4. Nghim php gng sc th lc c th c ch nh
trong mt s tnh hung nht nh phn bit cc
NTTT c nng (khng c bnh tim thc tn) hay thc
tn (c bnh tim thc tn)...
E. Cc du hiu bo hiu mt NTTT nguy him
1. Xy ra bnh nhn c bnh tim thc tn.
d
rve
e
2. S lng NTTT nhiu.
s
re
hts nhp
3. NTTT i thnh tng chm hoc nhprigi,
.vn ba.
m
o
l
.c ca phc b
Al hooR
4. NTTT n sm (sng R (l
v. sng
e
a
o
y
NTTT) s ri trn sng TFica
nl phc
0@ b tht trc .
2
.
0
5. NTTT a dng, a 2.008 ity2
t toc
F. iu tr
igh Po
r
py
1. i viCoNTTT c nng ( bnh nhn khng c
bnh tim thc tn):
a. Thng l lnh tnh, tin lng tt v khng cn
iu tr c hiu.
b. Ch nn iu tr khi bnh nhn c triu chng c
nng dn dp (au ngc, kh th...).
c. Vic iu tr nn bt u bng loi b cc cht
kch thch (cph, ru, thuc l...). Tp th dc
u n. Nu bnh nhn ang dng cc thuc
khc cn lu n kh nng cc thuc ny c th
gy ra NTTT (li tiu, cocaine, thuc cng giao
cm...). Ch iu chnh in gii trong mu.
d. Thuc la chn (nu cn) hng u cho iu tr
NTTT c nng l mt loi chn bta giao cm
liu thp.
197
2. i vi NTTT thc tn (trn bnh nhn c bnh

tim thc tn) trong giai on cp tnh ca bnh:
a. Thng gp nht l trong NMCT cp v bo hiu
c th sp chuyn thnh nhp nhanh tht hoc
rung tht. NTTT cn c th xy ra khi bnh nhn
c ph phi cp do cc bnh van tim, vim c tim
cp, vim mng ngoi tim... Mt s bnh cnh
cng cn c quan tm: bnh nhn c hi chng
Prinzmetal, hi chng ti ti mu sau dng
thuc tiu huyt khi hoc sau can thip MV.
b. Thuc hng u l: Lidocain (Xylocain) tim TM
thng 80 - 100 mg sau truyn TM 1-4mg/
pht. C th gp cc tc dng ph ca Lidocain
nh chng mt, nn, o gic...
c. Procainamid l thuc c chn thayrvth
ed cho
e
s
Lidocain khi Lidocain khng c tc
redng hoc
ts n
bnh nhn khng th dung npric.
dng
gh m.vLiu
o mi 5 pht
l TM
l
c
.
l cho ngay 100mg tim thng
A hoo
ev. mg/kg
a
o
cho n tng liu l 10-20
cn nng, sau
l
in 20@y
F
.
truyn TM 1-4mg/pht.
0
8 2
00 gn
2cu
ity y cho thy Amiodarone
d. Mt s nghin
o
t ot c
h
c th lm
riggimP t l t vong bnh nhn NMCT
y
p
cp c
Co NTTT (liu lng xem bng 10-3).
e. Ch iu chnh tt cc ri lon in gii (nu
c) v nhanh chng gii quyt cc cn nguyn
nu tm thy.
3. NTTT bnh nhn c bnh tim mn tnh:
a. Vic la chn cc thuc chng lon nhp cho cc
bnh nhn ny phi da trn tnh trng bnh c
th, c bit l chc nng tim cn tt khng, tc
dng ca thuc v kh nng gy lon nhp ca
cc thuc.
b. i vi NTTT sau NMCT: cc thuc nhm IC
(Flecanide, Encainid) hoc IB (Mexitil) khng
nhng khng ci thin t l t vong m c khi
cn lm tng t vong do kh nng gy ra lon
nhp ca chnh cc thuc ny (th nghim
198
CAST). Do vy cc thuc nhm IC nhn chung l

chng ch nh trong NTTT sau NMCT. Thuc
c la chn l nhm chn bta giao cm hoc
Amiodarone. Nghin cu CAMIAT v EMIAT
chng minh Amiodarone c th lm gim t l t
vong bnh nhn NMCT c NTTT.
c. Bnh c tim l mt trong nhng nguyn nhn
quan trng gy NTTT. Nguy c t t s tng cao
vt nhng bnh nhn ny khi c NTTT. Trong
giai on mn tnh th nn dng Amiodarone.
d. Khi gp NTTT bnh nhn b bnh van tim c
suy tim nng th cn c x l ngay. Ch cc
ri lon in gii v bnh nhn c b ng c
Digitalis khng. Trong trng hp bnh nhn ng
c Digitalis c NTTT (hay gp nhp vi)
d th
r e thi
e
s
ngng Digitalis ngay v cho Lidocain,
ng
re
iu chnh tt cc ri lon iniggii.
hts .Cc
vn trng
r
m
o
l
hp khc c NTTT bnh nhn
l c.c bnh tim mn
v. A ahoo hoc Sotalol.
e
tnh ta c th la chn Amiodarone
o
inl @y
VII. Cn nhp nhanh tht 08. F 2020
20 ity
Cn nhp nhanh tht h(NNT)
t otocl cn tim nhanh khi c t nht
P
rig vi
ba nht NTTT i linpynhau
tn s trn 100 ck/pht. C th
Coloi da trn thi gian ko di ca NNT:
chia NNT ra lm hai
NNT thong qua (hoc khng bn b): l NNT xut hin
tng on ko di khng qu 1 pht.
NNT bn b: l khi c NNT ko di trn 1 pht.
A. Nguyn nhn
1. Bnh tim thiu mu cc b.
2. Bnh c tim (bnh c tim gin, bnh c tim ph i,
ph i ng ra tht phi, sarcoid c tim...).
3. Bnh van tim, c bit khi tht tri gin v gim chc
nng co bp.
4. NNT do dng thuc hoc c t: thuc chng lon
nhp nhm IC, Digitalis...
199
5. NNT bn b tin pht: thng xy ra bnh nhn

khng c bnh l thc tn tim.
6. Trong hoc sau phu thut tim...
B. Triu chng lm sng
1. Biu hin lm sng rt khc nhau bnh nhn c cn
NNT. N tu thuc vo hon cnh lm sng, tn s
tht, s c mt ca cc bnh tim thc tn km theo...
2. Mt s bnh nhn c th khng cm thy c triu
chng g c bit. Tri li mt s khc li c th
biu hin ngay bng ngt hoc t t.
C. in tm
1. Tn s tim thng t 130 -170 ck/pht.
2. Thng thng th nhp tim khng tht u nh
edtrong
ervkhi m
cn nhp nhanh kch pht trn tht, nhtresl
ts vn
trc c NNT a dng hoc c nht
. hp.
ghhn
i
r
m
o
l
l .chin di dng
3. Phc b QRS thng gin rng,
biu
v. A ahoo
e
o
l hoc
y phi.
ging nh ca bloc nhnhintri
F 020@
.
8 2vi tn s chm hn ca
4. Sng P c th nhn00thy
2 hp
ity
o
QRS. Trong trng
t ot c khng nhn r sng P, nu
h
P qun s thy r rng c s phn
rig thc
lm chuyn
o
y
p
o nh v tht. Trong mt s trng hp ta
ly gia C
nhp
thy c s dn truyn ngc dng lm cho sng P m
ngay sau QRS.
Hnh 10-5. Cn nhp nhanh tht, c lm chuyn o thc

qun bc l sng P.
200
D. Chn on phn bit quan trng nht l vi nhp

nhanh trn tht c phc b QRS gin rng (do dn truyn
lch hng, bloc nhnh...), ngi ta c th:
1. S dng chuyn o thc qun.
2. S dng tiu chun loi tr ca Brugada (hnh 10-6):
Khng c hnh nh dng RS cc chuyn o trc tim?
C
Khng
NNT
Khong cch R n S > 100 ms 1 chuyn o trc tim?

d
rve
e
s
re
C
Khng
ts vn
h
.
g
NNT
l ri .com
l
A o
ev. yaho
o
l
0@l P ?
C nhiu phc b QRS
Fin hn
8. 202
0
20 ity
t otoc
h
P
rig Khng
y
C
p
Co
NNT
C tiu chun hnh thi ca NNT(*)

t nht 1 chuyn o trc tim?
C
Khng
NNT
Nhp nhanh trn tht c dn truyn lch hng

Hnh 10-6. Tiu chun Brugada chn on phn bit
NNT vi nhp nhanh trn tht c dn truyn lch hng.
201
(*) Tiu chun hnh thi ca NNT l:

a. Thi gian QRS rng > 0,14 giy
b. Trc QRS quay trn
c. Hnh thi cc chuyn o trc tim:
Ging bloc nhnh phi hon ton V1, v
R/S <1 V6.
Ging bloc nhnh tri : V1 c RT>RS; V6
c dng qR.
d. Phn ly nh tht, c nht bp hn hp, nht thot
tht.
E. iu tr
1. Chuyn v nhp xoang: Trong giai on cp ca cn
NNT, mc khn cp ca vic chuyn v
ed nhp
rvv
e
s
xoang tu thuc vo tnh trng lm sng
nh
e
sr n
t
h
hng n huyt ng.
.v
g
l ri .com
l
AKhi ocn NNT m c
a. Cc u tin trong iu tr:
ev. yaho
o
l
nh hng huyt ng
@ c ngt hoc mt
innhiu,
20
. F 20nh
8ngay
thc th cn x tr
mt ngng tun hon
0
20 ocity
v phi nhanh
t chng sc in ct cn. Sc in
gh Pot
rich
cn c
nh trong trng hp cn NNT lc
y
op
C
u n nh nhng dng thuc tht bi v c xu
hng nh hng n huyt ng. Thuc s c
ch nh khi c cn NNT nhng tnh trng huyt
ng cn tng i n nh.
b. Thuc:
Lidocaine (Xylocaine) l thuc c la chn
u tin: Tim thng TM 1 - 1,5 mg/kg cn
nng sau truyn TM 1-4 mg/pht.
Procainamid: c dng khi Lidocaine tht
bi hoc c th cho ngay t u.
Amiodarone l thuc nn la chn, nht l
trng hp cn NNT do bnh tim thiu mu
cc b hoc khi dng cc thuc trn tht bi.
202
c. Sc in trc tip c ch nh khi tnh trng

huyt ng khng n nh v dng liu u tin
l 100J. i vi nhng trng hp c cn NNT
m mt mch th sc in ngay 200J. Nu bnh
nhn cn tnh, nn dng sc in ng b.
d. To nhp vt tn s c th hu ch trong mt s
trng hp.
e. Cc bin php h tr khc:
Th xy h tr.
iu chnh ngay cc ri lon in gii nu c.
Tm hiu cc nguyn nhn gy ra cn NNT
iu chnh kp thi nu c th. c bit trong
NMCT cp, gii quyt kp thi cc th thut
d php
ti ti mu cho ng mch vnh l bin
rve
e
s
trit nht iu tr i vi cn
reNNT.
ts vn
h
.
g
2. iu tr duy tr:
l ri .com
l
A o
a. Thuc:
ev. yaho
o
l
0@ snh tc dng ca 7
Nghin cu ESVEM
Fin so
8. 202
0
loi thuc 20chng
ty lon nhp (Imipramine,
oci
t
t
h
o
Mexiletine,
P Pimenol, Quinidine, Sotalol,
rig
y
p
Procainamide,
Propafenone) iu tr ngn
Co
nga ti pht cn NNT th thy l Sotalol c
tc dng ngn nga NNT hiu qu nht.
Cc nghin cu CAMIAT v EMIAT cho
thy Amiodarone c th ngn nga c cn
NNT sau NMCT cp v gim t l t vong.
Tuy nhin, khi dng Amiodarone lu di
chng ta phi ch n cc tc dng ph kh
phong ph ca n.
Vai tr ca cc thuc chng lon nhp trong
iu tr duy tr ngn nga ti pht cn
NNT cn cha thc s c thng nht. Thm
vo , chng ta cn ch n tc dng gy
lon nhp ca mt s thuc.
203
b. Cy my ph rung t ng trong bung tim:

Nghin cu MADIT v AVIT l hai th nghim
ln chng t rng vic cy my ph rung t
ng trong bung tim l thc s c ch v gim t
l t t r rt nhng bnh nhn thng c cn
NNT. My s c tc dng nhn bit cn NNT xy
ra v t ng pht ra sc in ct cn. Tuy
nhin, cc loi my ny cn kh t tin.
c. iu tr bng cch trit ph (hu) vng vo li
bt thng trong NNT bng sng Radio qua
ng ng thng. Thnh cng ca phng php
t c khong 50 -70%. Hin nay phng php
ny ang ngy cng c hon thin hn v cho
kt qu cao hn.
d
rve
e
s
d. Phu thut: i vi mt s bnh nhn
re m khng
ts vvnc cc
h
khng ch c bng thuc duy
tr
g
ri com.
l
l
.
so tn thng sau nhi mu
gy lon
nhp, ngi
v. A ahoo
e
o
l
y
ta c th phu thut ct
b
ni
mc
vng
so ca
Fin020@
.
tm tht gy lon08nhp2 m c nh v bng
y
20 ocitl
thm d in
trc . Ngy nay nh
t sinh
t
h
o
P
g
i
r
phngpy php trit ph cc xung ng bt
Co qua ng ng thng, phu thut iu
thng
tr NNT t cn c dng n.
VIII. Xon nh (Torsades de points)
Xon nh (X) chnh l mt loi nhp nhanh tht a hnh
thi c lin quan n hin tng ti cc chm tr ca c tim.
Hu ht xon nh c biu hin ko di on QT trc . Cn
xon nh thng ch ko di vi chc giy nhng cng c
trng hp kh bn b hoc thoi ho thnh rung tht.
Biu hin v din bin lm sng ca cn xon nh c th
l mt thc hoc t t. Trn T l hnh nh nhp tht nhanh
ti trn 200 ck/pht vi hnh thi a dng v cc nh ca QRS
xon xut quanh trc ng ng in (c lc cc nh ca phc
b QRS quay ln trn, c lc li quay xung di trc ng
ng in).
204
A. Nguyn nhn
1. Bm sinh:
a. Hi chng QT ko di bm sinh c km theo ic
(Hi chng Jervell-Lange-Niesel).
b. Hi chng QT ko di bm sinh khng km theo
ic (Hi chng Romano-Ward).
2. Mc phi:
a. Thuc: mt s thuc sau i khi c th gy nn
xon nh:
Cc thuc chng lon nhp: nhm IA, Sotalol,
Amiodarone, Mexiletine, Flecainide...
Mt s thuc hng thn v chng trm cm
(Haloperidol, Amitriptiline...).
d
rve
e
Thuc
khng
sinh
(Ampicillin,
s
re
ts vn
h
Erythromycine...).
.
g
l ri .com
l
Ketoconazol, Astemizole...
. A ahoo
evQT
o
b. Cc ri lon nhp chm
c
l
y ko di.
Fin020@
.
8 2 c bit l h kali hoc
c. Ri lon in gii
y
00 mu,
cit mu cng c th gy xon
2 canxi
o
magi mu.htH
t
o
P
g
nh. pyri
o
d. MtCs nguyn nhn khc: Tai bin mch no,
dng thuc cn quang cha Iod...
Hnh 10-7. Xon nh.

B. iu tr
1. Ct cn:
205
a. C m mnh trc ngc bnh nhn i khi cng

c hiu qu.
b. Nu X ko di hoc gy ri lon huyt ng
nng cn sc in bng nng lng bt u t 50100J v c th tng ln n 360J nu cn.
2. iu chnh ngay cc ri lon in gii mu:
a. Tim Magi sulfate thng vo tnh mch vi liu
1-2 g v c th nhc li n tng liu 2-4 g trong
vng 15 pht. Vic ny c th ct c cn X
trong 75% s bnh nhn.
b. Bi ph kali v canxi theo yu cu.
c. Ngng ngay cc thuc c th gy X hoc ri
lon in gii mu.
ed
3. iu tr cc ri lon nhp chm nu c:reserv
s
a. Dng Isoproterenol truyn TM. right m.vn
l .co
All hbin
o php rt hu
b. t my to nhp tm thi:
.
v
e ya o
o
l
ch trong cc trng Fhp
@
in ny.
. 2020
8
0
c. C th dng Lidocain.
y
0
2 tocit
t
h
o
IX. Mt s ri lon nhp
P
rig chm
y
p
Co chm v cc bloc nh tht l nhng lon
Cc ri lon nhp
nhp tim kh thng gp. Rt nhiu trong s cc ri lon nhp
ny thng khng c triu chng v cng khng nguy him. Tuy
vy, c mt s loi nhp chm rt nguy him c th e do tnh
mng bnh nhn. Chng ti s trnh by di y hai vn kh
quan trng trong nhp chm, l hi chng suy nt xoang v
bloc nh tht.
A. Hi chng suy nt xoang
Hi chng suy nt xoang hay cn gi l nt xoang
bnh l (SSS: Sick Sinus Symdrom) hoc ri lon chc nng
nt xoang (Sinus Node Dysfunction) l tnh trng nt xoang
khng kh nng duy tr hot ng bnh thng ca
ch nhp. Trn lm sng chng ta c th gp cc biu hin t
206
nhp chm xoang, ngng xoang, nhp thot nt hoc cn nhp

nhanh-nhp chm xen k.
a. Ngt hoc tin ngt (xu) l nhng triu chng
ng ch , ngoi ra c th thy chong vng,
chng mt, kh th...
b. Vi nhng bnh nhn c hi chng nhp nhanh nhp chm c th c nhng cn hi hp nh
trng ngc.
2. Nguyn nhn: C th do nhng nguyn nhn thc
th hoc nhng nguyn nhn bn ngoi (bng 10-6).
Bng 10-6. Nguyn nhn ca suy nt xoang.
Nguyn nhn ni ti:
d
rve
e
s
Bnh l thoi ho nt xoang
re
ts vn
h
Bnh ng mch vnh
.
g
l ri .com
l
Bnh c tim
A o
ev. yaho
o
Tng huyt p
l
in 20@
. F 2(amyloidosis,
Cc bnh thm nhim c08tim
khi u...)
0
0 ity
2
Bnh cht to keo t toc
h
o
Bnh l vim y(vim
rig cP tim)
p
Co do m x
Chn thng
Bnh tim bm sinh
Nguyn nhn ngoi sinh:
Do mt s thuc: Chn bta giao cm, chn knh
canxi, Digoxin, cc thuc chng lon nhp nhm IA,
IC, III...
nh hng h thn kinh t ng: cng trng lc
ph v qu mc, hi chng xoang cnh, chm xoang
ca lc s...
Ri lon in gii mu v cc cn nguyn khc: tng
kali mu, ri lon ni tit, tng p lc ni s, h thn
nhit, sc nhim khun...
3. in tm :
207
a. Nhp chm xoang thi qu (< 60 chu k /pht),

phc b QRS thanh mnh v sng P i trc.
b. C th thy nhng nht ngng xoang. Nu ngng
xoang > 3 giy l mt du hiu c gi tr v bo
hiu nguy him.
c. C th thy nhng nhp thot nt.
d. Nu thy hnh nh nhp nhanh - nhp chm xen k
th cng l mt du hiu kh c trng trong
suy nt xoang.
a. Cc thm d khng chy mu:
in tm thng quy 12 chuyn o l
mt thm d c bn.
d
rve bin
Holter in tim cho php theo diesedin
r
ts tr
in tim trong 24 gi v c hgi
.vn chn
g
i omnhp
r
l
on, nht l khi thy hi
chng
nhanh Al hoo.c
.
v
nhp chm hoc cc lon
xoang.
a
oe yngng
in 20@dng
F
Nghim php Atropine:
phn bit l
8. 20
0
y
0
t do cng thn kinh ph
suy nt xoang
2 ihay
t otoc
h
P
g
giao rcm.
Bnh
thng khi tim 0,04 mg/kg
i
y
p
Atropine
cho bnh nhn th nhp tim ni sinh
Co
ca bnh nhn s tng ti thiu theo cng
thc: Nhp tim tng = 118,1 - (0,57 x tui)
Nu sau tim m nhp tim thp hn nhp ni
trn th chng t c suy yu nt xoang
(nghim php dng tnh).
Nghim php bn nghing (Tilt-table testing):
gip phn bit ngt do cng ph v hay do
suy nt xoang. Nu c nhng cn nhp chm
xut hin khi lm bn nghing, chng t ngt
lin quan n h thn kinh t ng (cng
ph giao cm) hn l do suy nt xoang.
Xoa xoang cnh gip phn bit nhng on
ngng xoang l do cng xoang cnh hay do
suy nt xoang. Trong cng xoang cnh, khi
208
xoa ta c th thy c nhng on ngng

xoang di hn 3 giy. y l mt thm d
kh nguy him
b. Thm d nt xoang qua ng ng thng:
thm d rt c gi tr trong chn on suy nt
xoang.
Thi gian phc hi nt xoang: l khong
thi gian phc hi li nhp p xoang sau khi
kch thch nh vt tn s v dng li. Khi
thi gian ny trn 1400 ms (mili giy) th c
th coi l c suy nt xoang. Thi gian phc
hi nt xoang c hiu chnh l thng s c
gi tr hn sau khi hiu chnh thi gian trn
theo nhp tim thc t ca bnh nhn. Nu
ed thi
erv
gian ny di trn 550 ms l suy ntresxoang.
tsnh
Thi gian dn truyn xoang
.vn (SACT):
gh m
i
r
o
l
l o.c cc sng P c
Bnh thng khong cch
o
. A agia
hthch
v
e
o
bn l A1-A1. Khinc
kch
to nht bp
l
y
i 20@
. F 2(A2)
ngoi tm thu08nh
0 v n nht tip theo
y
20 onh
p tr li
cit gi l A3, ta s c:
t ca
t
h
o
P
SACT
A2-A3) - (khong A1-A1)
rig= (khong
y
p
o
C
Thi gian dn truyn xoang nh ny ni ln
tnh t ng ca nt xoang v khng nh
hng bi pht nhp, thi gian dn truyn n
nt bng thi gian dn truyn ra khi nt, v
khng c thay i trong nguyn l to nhp.
5. iu tr:
a. iu tr trong cn cp cu khi suy nt xoang
nng gy nhp chm trm trng c triu chng:
Atropine: 0,04 mg/kg tim thng tnh mch.
C th t my to nhp tm thi khi khng
ci thin c bng thuc.
Isopreterenol (Isuprel) c th cho vi liu bt
u 1 mcg/ pht truyn tnh mch. Bin php
ny c th l cu ni trong lc ch cy my
209
to nhp. Khng nn dng nhng bnh nhn

c tin s cp cu ngng tim.
b. Ch nh cy my to nhp ni chung c p
dng cho mi bnh nhn suy nt xoang c
triu chng (ngt, xu...) hoc khi bt buc vn
phi dng thuc lm chm nhp tim: bng 10-7.
c. Tt c cc thuc lm chm nhp xoang cn phi
c ngng li nu c th. Nu khng th ngng
c th cn cn nhc t my to nhp ngay.
d. i vi nhng bnh nhn c hi chng nhp
nhanh - nhp chm, thng th cn t my to
nhp iu tr nhng lc nhp chm v cho
thuc iu tr cc ri lon nhp nhanh.
d
B. Ri lon dn truyn nh tht (bloc nh tht)
rve
e
s
re
ts b
Bloc nh tht l s dn truyn t nh xung htht
n chm li
g
i om.v
r
l
hay ngng hn.
l
c
. A ahoo.
v
e
o
1. Phn loi: ngi ta thngnlchia@ybloc nh tht thnh 3
Fi 0
mc nh sau:
8. 202
0
20 ocI:
ity L hin tng dn truyn
a. Bloc nh tht
t
t
h
o
P
rigt tm
chm ptr
nh xung tm tht, biu hin
y
o
bngC on PQ trn in tim ko di trn 0,20
giy. Hin tng ny c th gp ngi bnh
thng hoc mt s bnh l ca tim.
b. Bloc nh tht II:
Kiu Mobitz I hay cn gi l chu k
Wenckebach, biu hin bng on PQ trn
in tm b di dn ra v n mt lc no
s ch cn sng P m khng c QRS i
km (tc l c mt nhp ngh tht). Sau
chu k li c lp li ging nh trn.
Kiu Mobitz II: biu hin bng nhng nht
bp ca tim b bloc xen k vo nhng nht
nhp xoang bnh thng, mc bloc c th
l 2/1; 3/1... v d, nu bloc tun theo quy lut
210
c 2 sng P mi c mt QRS i km theo th

ta gi l bloc 2/1.
c. Bloc nh tht cp III hay bloc nh tht hon
ton l tnh trng ng dn truyn t nh xung
tht b nghn hn, nh s p theo nhp ca nt
xoang kch thch cn tht s p theo nhp ring
ca n.
2. in tm :
a. Sng P khng ng trc cc tht (QRS) v
cng khng c lin h g vi cc tht , m n
c th ri vo trc, sau hay trng ln cc phc
b QRS mt cch ngu nhin m thi.
b. Tn s ca cc sng P vn bnh thng, khong
d
60-80 chu k/pht.
rve
e
s
re
c. Tn s cc phc b QRS rt chmh(khong
ts vn 30-40
.
g
chu k/pht) nhng rt u. ll ri .com
A hoo
ev.th
d. Hnh dng ca QRS c
o
l
ya thanh mnh bnh
@QRS
in khi
0
F
thng, nhng cng
c
b gin rng nu
2
8. 20
0
y
0
trung tm ch nhp
2 ca
it tht xut pht t pha di
t otoc
h
P
g
ca b ni.
ri
opyi khi ta thy c sng P ri trng pha
e. ChC:
trc QRS vi mt khong QRS bnh thng v
lm cho nht bp ny hi sm hn so vi nhp
c s, ta gi l nht bt c tht.
a. Triu chng c nng:
Nu nhp tht ch chm t, bnh nhn c th
khng c triu chng g c.
Nhng nu nhp tim chm nhiu th lng
mu t tim n cc c quan, trong c no
b gim st. Do , bnh nhn c th thy
chong vng thong qua, mt thng bng v
c khi b xu hay thm ch b ngt (trong bnh
cnh ca hi chng Adams-Stokes).
211
Khi xy ra cn ngt, th bnh nhn mt

thc, tay chn co qup, si bt mp
b. Triu chng thc th:
Nghe tim thy nhp tim chm (30-40 ck/pht)
v u.
C th nghe thy ting i bc do c s
trng hp i gn nhau gia co bp tm nh v
tm tht.
Huyt p ti a thng tng v huyt p ti
thiu thng gim v nhp tht chm s lm
cho thi gian tm trng di ra.
4. Nguyn nhn:
a. Tc dng ca mt s thuc:
d
Digoxin.
rve
e
s
re
Chn bta giao cm.
ts vn
h
.
g
Chn knh canxi.
l ri .com
l
A hoo
Mt s thuc chng lon
ev. ynhp
a
o
l
b. Bnh tim thiu mu. cc
0@
Fin0b:
2
2
08 ty
Nhi mu c
20tim
i cp.
c
o
ht mch
Bnh ing
Pot vnh mn tnh.
rg
y
p
c. Thoi
Co ho tin pht ng dn truyn nh tht:
Bnh Lenegre
d. Bnh tim bm sinh:
Bloc nh tht hon ton bm sinh.
Thng lin nh l th nht.
o gc cc ng mch ln.
Bnh h thng.
e. Bnh van tim.
f. Bnh c tim:
Bnh c tim thm nhim: Nhim bt.
Sarcoidosis, Hemochromatosis
g. Nhim trng, vim c tim:
Vim c tim (Chagas, bnh Lyme, thp tim,
lao, si...).
212
h. Bnh van tim do bnh cht to keo.

i. Ri lon chuyn ho:
Tng kali mu.
Tng magi mu.
j. Bnh ni tit (bnh Addison).
k. Chn thng:
M tim.
iu tr phng x.
Thng tim v cc iu tr can thip, c bit
t cc ng dn truyn
l. Khi u.
m. Bnh h thn kinh t ng:
Hi chng xoang cnh.
d
Ngt do cng ph v.
rve
e
s
re
n. Ri lon thn kinh c:
ts vn
h
.
g
l ri .com
Ph i c.
l
oo
v. A ahchn
eVic
on ch yu
o
l
y
in 20@
F
da vo in tim . 8. 20
00 ity
2cp
c
a. Bloc nh tht
ht Poto I: Ch yu da vo o on
g
i
r
PR trn
pyT, PR ko di trn 0,20 giy ngi
Co trn 0,18 giy tr em vi hnh dng ca
ln v
sng P v QRS bnh thng.
Hnh 10-8. Bloc nh tht cp I: PR=0,36 giy.

b. Bloc nh tht cp II:
Mobitz I (chu k Wenckebach):
(a) on PR s ko di dn v kt thc bi
mt nht bp khng c QRS.
213
(b) Khong cch RR s ngn dn.

(c) Khong RR ni nht bp khng c QRS
s nh hn tng 2 khong RR cnh .
(d) C s nhc li theo chu k (chu k
Wenckebach).
Hnh 10-9. Bloc nh tht cp II, Mobitz dI.

ve
Mobitz II: Cc khong PP vn eu
ser v c
r
nhng nht bp khng dn g(khc
hts .vnvi ngoi
i
r
m
l .cokhng
tm thu nh b bloc, khong
u).
Al hny
o
o
.
v
a
c. Bloc nh tht cp III (hon
oe ton):
inl 20@y
F
. 20thng, u.
Tn s nh vn08bnh
0 chm
2
ity v cng u.
Tn s tht
rt
t otoc
h
P lin h no gia nh v tht
Khng
rigc mi
y
p
Co b QRS thng gin rng v nu bloc
Phc
cng thp th QRS cng rng v tn s tht
cng chm.
Hnh 10-10. Bloc nh tht cp III.

6. iu tr:
214
Vi bloc nh tht cp I hoc bloc nh tht cp II

kiu Mobitz I thng khng cn iu tr g c hiu.
Vi cc bloc nh tht cao (Mobitz II hoc cp III)
dai dng thng cn phi cy my to nhp (xem
phn sau).
a. Thuc: Dng trong trng hp cp cu, c bit
khi bnh nhn c ngt hoc xu. Thuc thng
ch c tc dng tm thi ch cy my to nhp
hoc trong giai on cp ca mt s bnh ch khi
hi phc. Thuc khng c li ch nu dng ko
di trong cc trng hp bloc nh tht cao c
triu chng.
Nu bnh nhn c ngt do nhp chm.
(a) Atropine l thuc nn th dng u
d tin,
rve bnh
e
s
n c th lm gim mc bloc
re
ts vch
n khng
h
nhn bloc do cng ph v
qu
g
i om.
r
l
ltn .thng
c
c tc dng vi nhng
thc th
v. A ahoo
e
o
l N
ng dn truyn.
y c tc dng tt hn
0@
Finnhi
2
.
0
bnh nhn
c
mu
c tim sau di.
8
00 ity2
2
(b) C th
t dng
toc Dopamine vi liu bt u 5
igh Po
mcg/kg/pht
nhng bnh nhn c km
r
py
Co huyt p thp.
Nu bnh nhn trong tnh trng rt trm
trng, c th dng ngay Adrenaline truyn
tnh mch thay v Dopamine, Liu 1-2
mcg/pht.
Isoproterenol hydrochlorid (Isuprel), c th c
ch bnh nhn bloc nh tht khng phi do
thiu mu c tim v lm tng nhp tim kh
chn lc. Tuy nhin cn lu l bnh nhn
c bnh mch vnh th khng nn dng v n
lm tng nhu cu xy c tim. Liu ban u
nn t 2 mcg/pht tng theo p ng nhp tim
cho n 10 mcg/pht.
b. To nhp tim tm thi:
215
My to nhp qua da (hai in cc p thnh

ngc) rt c hiu qu nhng gy au n.
y l my xch tay lu ng, thng gn vi
h thng ph rung cp cu. Nhng bnh nhn
ngt cn t ngay to nhp tm thi trong lc
vn chuyn n bnh vin.
Cp cu: dng my to nhp p thnh qua da
(nu c) trong lc ch tin hnh t my to
nhp tm thi qua ng tnh mch.
To nhp tm thi qua ng tnh mch l gii
php cp cu ti u cho nhng trng hp
nhp chm c triu chng nng.
c. Ch nh cy my to nhp (bng 10-7).
Nhn chung ch nh khi bnh nhn c nhp
chm m c triu chng (ngt, xu, mt
ed l do
v
r
e
nhp chm...).
res
ts NMCT
Nu bloc nh tht hon ton hdo
sau
g m.vn
inhp
r
di thng ch cn t to
tm
thi,
v
o
l
Al hoo.c
.
v
c th hi phc saulogiai
on
cp
do
bloc
e ya
n
@
i
bnh nhn ny . thng
F 020 do cng ph v qu
2 III m do nhi mu c
08 tycp
mc. Nu l
bloc
0
2 oci
t bnt th nn ch nh cy my to
tim trc
igh Po
rsm.
y
nhp
p
Co trng hp bloc nh tht hon ton mc
Cc
phi thng cn cy my to nhp, trong khi
bloc nh tht bm sinh thng khng cn cy
my to nhp do bnh nhn c s thch nghi
bng cc nhp thot.
Bng 10-7. Cc ch nh cy my to nhp lu di.
Nhm bnh
Ch nh bt buc
C th ch nh
Suy
nt SNX km triu chng nng, - Khng c bng
khng hi phc sau khi chng chng t
xoang
dng thuc hoc cn phi nhp chm < 40
(SNX)
ck/pht lin quan
dng thuc gy nhp chm.
n SNX v cc
triu chng c th
khng ch c.
216
- Bnh nhn c
triu chng nh
hoc
khng
nhng c nhp tim
< 30 ck/pht (khi
thc gic).
Bloc nh tht Bloc nh tht cp III c mt - Bnh nhn bloc
nh tht cp III
mc phi
trong cc c tnh sau:
m khng c triu
- C triu chng.
- C ri lon nhp km theo chng v nhp tim
hoc bnh l km theo cn trung bnh lc
dng thuc c th gy nhp thc gic l hn
40 ck/pht.
chm.
cp
- C on ngng tim trn 3 - Bloc nh tht
ved
r
e
giy hoc nhp tim < 40 II kiuresMobitz II
ts
ck/pht bnh nhn khng khng
gh m.vnc triu
i
r
l .co
c triu chng.
Al chng.
o
.
v
etya-hoBloc nh tht cp
o
- Bloc sau khi iu tr
l
Fin020@ I nhng nhp tim
cc ng dn truyn
8. 2trong
0
y
0
rt chm v c
tim (cathetert ablation).
2 tocit
h
o
P
g
triu chng hoc
- Sau m
ritim.
py
- Bnh
Co l thn kinh c c khi t my tm
km theo bloc nh tht cp thi c hi chng
III (hi chng Kearns Sayre, my to nhp.
ph i Erb...)
b. Bloc nh tht II c km
theo triu chng do nhp
chm (bt k th v v tr).
Bin chng - Bloc nh tht cp II kiu - Tn ti bloc nh
sau
nhi Mobitz II tn ti sau nhi tht cp II cao
mu c tim ti v tr b His hoc cp III ti v
mu c tim
tr xung m c km theo tr nt nh tht.
bloc 2 nhnh hoc Bloc nh
tht cp III ti v tr b His
tr xung sau NMCT.
- Tn ti bloc nh tht cp II
217
Mobitz II hoc cp III c

triu chng.
- C km theo bloc nh tht
cp III tng lc.
- Bloc nh tht cp II Mobitz
II.
Bloc
2
nhnh hoc
3
phn
nhnh mn
tnh
Hi chng - Ngt ti pht nhiu ln do
cng xoang kch thch xoang cnh. Kch
cnh v ngt thch nh xoang cnh c th
gy ngng tht trn 3 giy.
Ti liu tham kho
1.
Benditt G, Remole S, Milatein S, et al. Syncope: causes, clinical

evaluation, and current therapy. Annu Rev Med 1992;43: 283-300.
d
2. Braunwald E, ed. Heart disease: a textbook of cardiovascular
rve
e
s
medicine, 5th ed. Philadelphia: WB Saunders, 1997. s re
3. Domanski MJ, Zipes DP, Schron E. Treatmentigh
oft sudden
.vn cardiac
r
m
o
l
death. Current understandings from randomized
trials
and future
Al hoo.c
.
research direction. Circulation 1997;95:269~2699.
v
e ya
4. Donbar SB, Ellenbogen K, Epstein iAB.
cardiac death: past,
nlo 0Sudden
@
F
2
. 2Association
present, and future. American 8
Heart
Monograph Series.
0
y
00 i1997.
Armonk, NY: Futura Publishing,
t
2
t otoc effects of antiarrhythmic drugs.
5. Kowey PR. Pharmacological
P Med 1998;158:325-332.
igh Intern
r
Review and update.
Arch
y
p
6. Marcus Fl, Opie
Co LH Antiarrhythmic agents. In: Opie LH, ed. Drugs
for the heart, 4th ed. Philadelphia: WB Saunders, 1997:207-247
7. Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular
8. Nattel S. Antiarrhythmic drug classifications. A critical appraisal of
their history, present status, and clinical relevance. Drugs
1991;41:672-701.
9. Singh BN. Antiarrhythmic drugs: a reorientation in light of recent
developments in the control of disorders of rhythm. Am J Cardiol
1998;81:3D-13D.
10. Task Force of the Working Group on Arrhythmias of the European
Society of Cardiology. The Sicilian gambit. A new approach to the
classification of antiarrhythmic drugs based on their actions on
arrhythmogenic mechanisms. Circulation 1991;84:1831-1851.
11. Wein AL, Grimm RA, Black 1W, et al. Cardioversion guided by
transesophageal echocardiography: the ACUTE pilot study. Ann
Intern Med 1997;126:200-209.
12. Zipes DP, Jalife J, eds. Cardiac electrophysiology: from cell to
bedside, 2nd ed. Philadelphia: WB Saunders, 1995.
218
thp tim
Thp tim hay cn gi l thp khp cp hoc st thp khp

(rheumatic fever) c coi l mt trong nhng bnh ca h min
dch m lin kt hay thuc h thng to keo. Cho ti nay, bnh
vn kh thng gp cc nc ang pht trin (trong c Vit
nam) v l nguyn nhn hng u ca bnh van tim ngi tr
tui. Bnh thng gp la tui t 6-15 tui, nhng khng t
trng hp xy ra la tui 20 hoc hn na. Ngy nay, ngi
ta tm ra nguyn nhn gy bnh l do nhim Lin cu khun
tan huyt nhm A ng h hp trn (Streptococcus A).
I. Tiu chun chn on bnh
d
rve
e
s
re
Cho n nay, th gii thng nht dng tiu
Jones
ts chun
n
h
v
.
g
c iu chnh nm 1992 (Bng 11-1). Chn
i on xc nh
ll r o.com
A
thp tim khi c bng chng ca nhim lin
cu
o
.
ev yah A ng h hp
o
l
(biu hin lm sng ca vim ng
@hp trn v/hoc lm
Fin0h
20
8. cy
2
phn ng ASLO dng tnh v/hoc
dch
hng tm thy lin
0
20 ocity
t ochun
cu), km theo c t nht g2htiu
chnh hoc c 1 tiu chun
Pt
i
rph.
y
chnh km 2 tiu chun
p
Co
Bng 11-1. Tiu chun Jones c iu chnh nm 1992 trong
chn on thp tim.
1. Vim tim: gp 41-83% s bnh nhn thp tim.
Tiu
Vim tim c biu hin lm sng t nhp nhanh,
chun
ri lon nhp (hay gp bloc nh tht cp 1), h van
chnh
hai l hoc van ng mch ch, vim mng ngoi
tim, vim c tim, n suy tim...
2. Vim khp: Gp khong 80 %, l triu chng rt
c ngha nhng khng phi c hiu hon ton.
Biu hin l sng au khp kiu di chuyn v
khng bao gi li di chng khp.
3. Ma git ca Sydenham: l ri lon vn ng
ngoi thp, vi vn ng khng mc ch v
khng c .
219
4. Nt di da: nt c ng knh 0,5-2cm, ni

di da, di ng t do, khng au, c th n c
hoc tp trung thnh m, thng thy gn v tr
cc khp ln nh khp gi.
5. Hng ban vng: l nhng ban khng hoi t,
nht mu gia, v tr thng thn mnh, mt
trong cc chi v khng bao gi mt. Thng
mt i sau vi ngy.
1. St.
Tiu
chun 2. au khp: au mt hoc nhiu khp nhng khng
c cc triu chng in hnh ca vim khp.
ph
3. Tng cao protein C-reactive huyt thanh.
4. Tc mu lng tng.
5. on PQ ko di trn in tm .
d
rve
e
Bng chng ca nhim lin cu khun nhm A trc
s
re
n nhanh
hts .vtest
1. Cy dch ngoy hng tm thy lin cuighoc
r
m
o
l
khng nguyn lin cu dng tnh.. Al oo.c
v ah cu trong mu
2. Tng nng khng th khng
loe @ylin
n
i
20
(Phn ng ASLO > 310 v
. FTodd).
08 ty20
0
2 i
II. Sinh l bnh
t otoc
h
P
g
i
rch
y
Mi lin h cht
gia
vim hng v thp tim c
p
Co
bit r t nm 1930. Ngi ta thy rng: (1) C bng chng ca
s tng r rt khng th khng streptolysin O trong huyt
thanh bnh nhn b thp tim. (2) Hiu qu r rt ca khng sinh
trong phng bnh thp tim l mt trong nhng bng chng h tr
cho c ch trn.
Thp tim khng phi do trc tip lin cu gy ra m thng
qua c ch min dch. Thng thng, sau khong 3 tun vim
ng h hp trn bnh nhn mi c biu hin ca thp tim. Mt
kha cnh na l thp tim rt t khi xy ra bnh nhn di 5
tui, khi m h min dch cha hon thin y nn phn ng
cho ca c th cha hiu lc gy ra thp tim.
Khng nguyn l cc protein M,T v R lp v ngoi ca
lin cu A l yu t quan trng nht gy phn ng cho vi c
th. Khi lin cu xm nhp vo c th chng ta, c th s sinh ra
220
cc khng th chng li vi khun , nhng v tnh chng li

lun cc protein cc m lin kt ca c th, nht l cc m lin
kt van tim. Trong , protein M l yu t khng nhng c
hiu min dch m cn l yu t gy thp mnh nht.
C khong 3% s bnh nhn b vim ng h hp trn do
lin cu nhm A m khng c iu tr trit s tin trin
thnh thp tim, v c khong 50% s bnh nhn b thp tim
s b ti pht cc t thp tim sau . Nhim lin cu ngoi da
thng t khi gy thp tim.
A. Cc biu hin chnh
1. Vim tim:
a. Vim tim l mt biu hin bnh l nng rca
ved thp
e
s
tim v kh c hiu. C khong 41-83%
re s bnh
ts vn
h
. Cc biu
g
nhn thp tim c biu hin vim
tim.
l ri .com
l
A omng trong tim,
hin ca vim tim c th l
vim
ev. yaho
o
l
vim mng ngoi tim,Fivim
n @c tim.
. 2020
8
0
b. Vim tim c th
ty hin t th khng c triu
20 biu
oci hiu suy tim cp nng hoc
t ccotdu
chng g n
h
P
rig
y
t vong.
p
Co
c. Cc triu chng lm sng c th gp l: tng nhp
tim, ting thi tm thu, ting thi tm trng,
ting rung tm trng, ri lon nhp, ting c
mng tim, suy tim
d. Suy tim thng t gp giai on cp, nhng nu
gp th thng l biu hin nng do vim c tim.
e. Mt trong nhng biu hin phi ch v l bin
chng nng ca thp tim l vim van tim. H van
hai l l mt trong nhng biu hin thng gp
nht, trong khi h van ng mch ch t gp hn
v thng km theo h van hai l.
f. Vim mng ngoi tim c th gy au ngc, ting
c mng tim, ting tim m
2. Vim khp:
221
a. Vim khp l mt biu hin hay gp nht trong

thp tim (80%) nhng li t c hiu.
b. Biu hin ca vim khp l sng, nng, , au
khp, xut hin cc khp ln (gi, c chn, c
tay, khuu, vai...) v c tnh cht di chuyn.
c. Vim khp p ng rt tt vi Salycilate hoc
Corticoid trong vng 48 gi. Nu trong trng
hp cho Salycilate y m trong vng 48
gi vim khp khng thuyn gim th phi ngh
ti nguyn nhn khc ngoi thp tim.
d. Vim khp do thp tim thng khng bao gi
li di chng khp.
3. Ma git Sydenham:
ed v
rvthp
a. y l biu hin ca tn thng ngoi
e
s
re
kh c hiu cho thp tim.
ts vn
h
.
g
omng khng
l ri vn
b. Cc biu hin l nhng ngAltc
c
.
oo
ev. cc
ah c mt, chi; gim
mc ch v khng t ch
o
l
y
Fin020@ng.
trng lc c, ri lon
8. 2cm
0
20 ocu
ity c th l kh vit, kh ni
c. Cc biu hin
t ban
t
h
o
P
hoc iyli.
rig
p
o
d. Cc Cbiu hin ny thng r khi bnh nhn b xc
ng hoc thc tnh v mt i khi bnh nhn ng.
e. Ma git Sydenham l mt trong nhng biu hin
mun ca thp tim, n thng xut hin sau
khong 3 thng sau khi vim ng h hp trn.
Ma git Sydenham thng biu hin n c
trong thp tim v gp khong 30%. Triu chng
ny thng mt i sau 2-3 thng.
f. Cn phi chn on phn bit vi mt s bnh l
khc nh ng kinh, ri lon hnh vi tc phong...
4. Nt di da:
a. l nhng nt c ng knh khong 0,5-2 cm,
cng, khng au, di ng v thng xut hin
ngay trn cc khp ln hoc quanh cc khp. Nt
222
di da c th gp khong 20% s bnh nhn b

thp tim v thng bin mt sau khong vi ngy.
b. Da trn nt ny thng vn di ng bnh thng
v khng c biu hin vim trn.
5. Hng ban vng (erythema marginatum):
a. y l mt loi ban trn da, c mu hng v
khong nht mu gia to thnh ban vng.
Thng khng hoi t v c xu hng mt i sau
vi ngy.
b. Hng ban vng l mt du hiu kh c hiu
trong thp tim v t gp (5%), thng ch gp
nhng bnh nhn c da mn v sng mu. Hng
ban vng thng xut hin thn mnh, bng,
d
mt trong cnh tay, i v khng bao giervemt.
s
re
c. Khi c hng ban vng th thng
tscvnkm theo
h
.
g
vim c tim.
l ri .com
l
A o
ev. yaho
6. Cc du hiu ph:
o
l
Fin 20@
a. St thng xy ra0trong
on cp.
8. 20giai
20 ocity
b. au khp hc
t otxc nh l ch au khp ch
P
ig
khngopc
yr vim (sng, nng, ).
C
c. Ngoi ra, c th gp cc biu hin nh au bng,
vim cu thn cp, vim phi cp do thp tim, i
mu, hoc vim mng no y l nhng du
hiu khng trong tiu chun chn on thp tim.
1. Cc du hiu l bng chng ca nhim lin cu
nhm A (GAS):
a. C th xc nh thng qua ngoy hng tm thy
lin cu (nui cy hoc xt nghim khng nguyn
nhanh) hoc cc phn ng huyt thanh thy tng
nng khng th khng lin cu.
b. Xt nghim ASLO (AntiStreptoLysin O) l mt
phn ng thng dng hin nay. S tng nng
223
c. xc nh bng chng nhim GAS trc c

th dng xt nghim ASLO nhc li nhiu ln
hoc mt s khng th khc nh: anti-DNAase B;
anti-hydaluronidase; anti-streptokinase; antiNADase
d. Hin nay c mt s que th nhanh c sn th
vi mt s khng th khng GAS, nhng chnh
xc khng cao v c ngha tham kho. ved
er
res
2. Sinh thit:
s
ht .vn
rig com
a. Sinh thit c tim c th choll thy
hnh nh ht
A honhim
o.
.
Aschoff, l hnh nh ht
thm
gp trong
v
loe @ya
n
i
thp tim. Ht ny . gp
F 0 khong 30% s bnh
8 202
0thp
nhn c cc t
y ti phi v thng thy
0
2 tocit
t
h
o
vch lin itht,
thnh
tht, tiu nh.
P
rg
y
p
o
b. Cc Chnh
nh t bo hc cn cho thy hnh nh
vim ni mc tim vi c trng l ph v thm
nhim t chc mng van tim.
c. Sinh thit c tim khng c ch trong giai on cp
ca thp tim, n ch nn ch nh v c gi tr
phn bit khi thp tim ti pht v kh phn bit
vi cc bnh thp khp mn khc.
3. Mt s xt nghim mu khc:
a. Tng bch cu, thiu mu nhc sc/bnh sc.
b. Tc mu lng tng v protein C phn ng tng.
4. Xquang tim phi: Thng th khng c bin i g
c bit trong thp tim. Mt s trng hp c th
thy hnh tim to, rn phi m hoc ph phi.
5. in tm :
224
a. Thng hay thy hnh nh nhp nhanh xoang, c

khi PR ko di (bloc nh tht cp I).
b. Mt s trng hp c th thy QT ko di.
c. Khi b vim mng ngoi tim c th thy hnh nh
in th ngoi vi thp v bin i on ST.
6. Siu m Doppler tim:
a. C th gip nh gi chc nng tim.
b. Hnh nh h van tim ngay c khi khng nghe thy
c trn lm sng.
c. C th thy tn thng van hai l v van ng
mch ch. Giai on sau c th thy hnh nh van
dy ln, vi ho cng cc t chc di van.
IV. iu tr
d
rve
e
s
re
A. iu tr t cp
ts vn
h
g
i om.
Mt khi c chn on xc nh thp Atim
ll r th
.c cc bin php
v. ahoo
e
sau l cn thit:
o
nl 0@y
Filin
2
.
1. Loi b ngay s nhim
08 ty20 cu: (xem Bng 11-3)
0
2 oci Benzathine Penicillin G
bng thuc kinh
t oin
t
h
g
600.000 n
riv (v)P tim bp su 1 ln duy nht cho
y
p
Co di 27 kg, v 1,2 triu v cho bnh nhn
bnh nhn
trn 27 kg, tim bp su 1 ln duy nht. Nu bnh
nhn b d ng vi penicillin th dng thay bng
Erythromycine 40mg/kg/ngy, ung chia 2 ln/ngy,
trong 10 ngy lin tc.
2. Chng vim khp: phi c bt u cng sm cng
tt ngay khi c chn on.
a. Aspirin: l thuc c chn hng u v hiu
qu nht. Liu thng dng l 90 - 100 mg/kg/
ngy, chia lm 4-6 ln. Thung dng ko di t
4-6 tun tu thuc vo din bin lm sng. C th
gim liu dn dn sau 2-3 tun. Nu sau khi dng
Aspirin 24-36 gi m khng ht vim khp th
225
cn phi ngh n nguyn nhn khc ngoi thp

tim.
b. Prednisolone c khuyn co dng cho nhng
trng hp c km vim tim nng. Liu dng l 2
mg/kg/ngy chia 4 ln v ko di 2-6 tun. Gim
liu dn trc khi dng.
c. Mt s thuc gim vim chng au khng phi
corticoid c th c dng thay th trong mt s
hon cnh nht nh.
3. iu tr ma git Sydenham: bao gm cc bin
php ngh ngi ti ging, trnh cc xc cm, dng
cc bin php bo v v c th dng mt s thuc
nh: Phenobarbital, Diazepam, Haloperidol, hoc
ed l
steroid. Vic phng bnh tip tc theo ch rvcng
e
s
re
bin php trnh c ti pht ma git Sydenham.
ts vn
h
.
g
4. Ch ngh ngi trong giai on
oml rt quan
l ri cp
l
c
.
A o
trng. u tin l ngh tiloging,
ev. yaho sau l vn ng
0@ ngoi tri v tr v
nh trong nh ri vn .ng
Fin nh
8 202
0
0 ity Ch ny tu thuc vo
bnh thng (Bng
2 11-2).
oc
t
h
mc nng inh
Pot bnh.
g ca
r
opy ngh ngi i vi bnh nhn thp tim.
Bng 11-2. CCh
Ch
Ch vim
Vim
Vim
Vim tim
khp
tim nh tim va
nng
Ngh ti
1 - 2 tun 2 3
4-6
2 - 4 thng
ging
tun
tun
Vn ng nh 1 - 2 tun 2 3
4-6
2 - 3 thng
trong nh
tun
tun
Vn ng
2 tun
24
1-3
2 - 3 thng
nh ngoi tri
tun
thng
Sau 4 - 6
Sau 6 Sau 3 - 6 Thay i
Tr v sinh
tun
10 tun
thng
tu trng
hot bnh
hp
thng
5. iu tr suy tim (nu c): ngh ti ging, th xy,
vi suy tim tri cp cho Morphin, li tiu, tr tim.
Hn ch n mn, hn ch ung nhiu nc, c th
226
dng li tiu. Digoxin c th dng nhng phi thn

trng v qu tim ca bnh nhn thp tim rt nhy
cm, nn dng liu ban u ch nn bng na liu
quy c.
6. Phng thp: Vn cc k quan trng l nhc nh
bnh nhn v gia nh s cn thit v tn trng ch
phng thp tim cp hai khi bnh nhn ra vin.
B. Phng bnh: (Bng 11-3)
1. Phng bnh cp I: Mt bc cc k quan trng l
loi tr ngay s nhim lin cu khun ( nu trn),
hay cn gi l ch phng thp cp I.
Bng 11-3. Ch phng bnh cho thp tim.
d
Phng thp cp I
rve
e
s
Thuc
Liu
ngre
Thi gian
ts vn
h
dng
.
g
ri com
Benzathine
600.000 v (<27kg) AllTim
. bp Liu duy nht
.
v ahoo
Penicillin G
1,2 triu v (27kg)
e
o
inl 20@y Ung
Hoc
250mg 2-3. Fln/ngy
10 ngy
0
Penicillin V
(tr em) 2008 ity2
toc ln/ngy
500mg
ht Po2-3
g
i
r
ln)
y
p(ngi
Erythromycin (choCo 40 mg/kg/ngy
Ung
10 ngy
bnh nhn d ng
vi Penicillin)
Thuc
Benzathine
Penicillin G
Hoc
Penicillin V
Sulfadiazine
Phng thp tim cp II

Liu lng
ng
dng
1,2 triu v
Tim bp
Khong cch
dng
3-4 tun/1 ln
250 mg
Ung
2 ln/ngy
Ung
hng ngy
Ung
2 ln/ ngy
0,5g (<27kg)
1,0g (27kg)
Erythromycin (cho 250 mg
bnh nhn d ng
vi Penicillin hoc
Sulfazidine)
227
a. Cn thit phi iu tr tht sm nu c th.

b. Penicillin l thuc la chn hng u v tnh hiu
qu v gi r. Nn dng Benzathine Penicillin G
liu duy nht tim bp (Bng 11-3). C th dng
thay th bng ung Penicillin V trong 10 ngy.
c. Cc thuc ph rng nh Ampicillin khng c li
ch g hn so vi Penicillin trong iu tr thp tim.
d. Vi bnh nhn d ng vi Penicillin, thay th
bng Erythromycin ung trong 10 ngy. C th
dng Marcrolide mi nh Azithromycin thay
th rt c tc dng, dng trong 5 ngy vi liu
500 mg trong ngy u sau 250 mg mi ngy
cho 4 ngy tip theo.
e. C th thay th bng ch khc l
d dng
rve
e
s
Cephalosporin th h I dng ung (Cephalexin,
re
ts vn
h
Cephadroxil), ung trong 10 ngy.
g
ri com.
l
l
. khi chn
2. Phng bnh cp II: Phi bt .u
ngay
v A ahoo
e
o
on xc nh l thp tim.inl @y
F 020
8. trong
a. Thuc dng c
Bng 11-3.
2
0nu
0
2 ocity
t (Bng
b. Thi gian gdng
11-4), ni chung ph thuc
t
i h Po
rc
y
vo tng
th
bnh
nhn.
p
Co
c. Ni chung nn dng ng tim. Ch nn dng
ng ung cho cc trng hp t c nguy c ti
pht thp tim hoc v iu kin khng th tim
phng c, v t l ti pht thp tim bnh nhn
dng ng ung cao hn ng tim nhiu.
Bng 11-4. Thi gian tin hnh ca phng thp cp II.
Tnh trng bnh
Thi gian ko di
Thp tim c vim c tim v
li di chng bnh van
tim.
Thp tim c vim tim
nhng cha li di chng
bnh van tim.
Thp tim khng c vim
tim.
Ko di t nht 10 nm v t nht
phi n 40 tui. C th tim rt lu
di (nn p dng).
10 nm hoc n tui trng thnh,
mt s trng hp ko di hn.
5 nm hoc n 21 tui, c th di
hn tu trng hp.
228
Ti liu tham kho

1.
2.
3.
4.
5.
6.
Bisno AL. Group A streptococcal infection and acute rheumatic

fever. N Engl J Med 1991; 325:783-793.
da Silva NA, de Faria Pereira BA. Acute rheumatic fever. Pediatr
Rheumatol 1997;23:545-568.
Dajani AS. Rheumatic fever. In: Braunwald E, ed. Heart disease: a
textbook of cardiovascular medicine, 5th ed. Philadelphia: WB
Saunders, 1997:1769-1775.
Dijani AS, Ayoub E, Bierman FZ, et, al, Guidelines for the diagnosis
of rheumatic fever: Jones criteria. Updated 1993. Circulation 1993;
87: 302-307.
Nader S. Rheumatic fever. In: Marso SP, Griffin BP, Topol EJ, eds.
Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven,
2000.
Stollerman GH. Rheumatic fever. Lancet 1997;349: 935-942.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
229
Hp van hai l
Hp van hai l (HHL) vn cn l bnh rt ph bin nc

ta cho d t l mc bnh ny gim nhiu cc nc pht
trin khc.
I. Triu chng lm sng
A. Triu chng c nng
1. a s bnh nhn khng h c triu chng trong mt
thi gian di. Khi xut hin, thng gp nht l kh
th: mi u c trng l kh th khi gng sc, sau
l kh th kch pht v m v kh th khi nm
d
rvev ph
(do tng p lc mch mu phi). Cn hen tim
e
s
re mt im
phi cp kh thng gp trong HHLht-s l
.vn
g
i tri
r
m
c bit ca bnh: biu hin suy tim
m
bn cht
o
l
Al hoo.c
.
v
li l suy tim phi.
a
oe
inl 20@y
F
. 20thm: s xut hin rung
2. Cc yu t lm bnh08nng
0
ty
2
nh trong HHL tvi
tn
oci s tht p ng rt nhanh l
t
h
o
P n ph phi cp. S gin nh
ig dn
yu t kinhyrin
p
Co t d on xut hin rung nh bnh nhn
tri l yu
HHL. Thai k ca ph n HHL cng lm cho triu
chng nng thm.
3. C th gp cc triu chng lin quan vi nh tri gin
to nh:
a. Ho ra mu do tng p lc nh tri v tng p lc
ng mch phi.
b. Khn ting (hi chng Ortner), do nh tri gin to
vo dy thn kinh qut ngc hoc nut nghn
do nh tri to vo thc qun.
c. Tc mch i tun hon (mch no, thn, mc
treo, mch chi) do huyt khi hnh thnh trong
bung nh tri gin nht l khi c km rung nh.
231
d. Rung nh (cn kch pht hoc dai dng) gy biu

hin hi hp trng ngc, c th gy chong hoc
ngt (rung nh nhanh), gp phn hnh thnh huyt
khi v gy ra tc mch i tun hon...
4. Lu dn s c cc triu chng ca suy tht phi (gan
to, ph chi di ) do tng p ng mch phi. Khi
tng p lc ng mch phi, bnh nhn c th au
ngc gn ging cn au tht ngc, do tng nhu cu
xy tht phi.
5. Mt cng l triu chng hay gp do cung lng tim
gim thp.
B. Triu chng thc th
1. Chm pht trin th cht nu HHL c t khi nh:
d du
rve
e
hiu ln hai l.
s
re
ts vn
h
.
g
2. Lng ngc bn tri c th bin dngrinumHHL
t nh.
l .co
l
A
o
o
.
3. Du hiu ca tr tun hon
h bin khi c suy
v ngoi
loe @ya
n
i
tim phi: tnh mch c. Fni, 2phn
hi gan tnh mch
0
20 ph ton thn, gan to,
08 tdi,
c dng tnh, ph20chi
y
ci
ht Poto
trn dch cc imng...
g
r
opy ca km ti mu ngoi vi: da, u chi
4. Cc duChiu
xanh tm.
5. S c th thy rung miu tm trng mm tim. Mt
s trng hp khi tng p ng mch phi nhiu c
th thy ting T2 mnh v tch i cnh c tri.
6. G din c ca tim thng khng to.
7. Nghe tim: l bin php quan trng gip chn on
bnh HHL.
a. Ting clc m van hai l, nghe r mm tim,
khong cch t T2 n ting ny cng hp th mc
HHL cng nhiu (<80 ms trong HHL kht).
Tuy nhin, mt s trng hp khng nghe thy
ting ny khi van hai l vi cng, m km.
232
b.
c.
d.
e.
f.
g.
Ting ny cng c th gp trong HoHL, thng

lin tht, teo van ba l km theo thng lin nh.
Ting rung tm trng mm tim: m sc
trm thp, gim dn, nghe r nht mm, thi
gian ph thuc vo chnh p (di khi HHL kht),
c ting thi tin tm thu nu cn nhp xoang.
Nghe tim sau gng sc hoc ngi Amyl Nitrate
lm tng cng ting thi do tng chnh p khi
tng dng chy qua van hai l. Tuy nhin ting
rung tm trng ny c th khng c nu van hp
qu kht hoc dy chng ct c b vi ho x
cng nhiu, hoc khi suy tim nng, km theo hp
van ng mch ch lm gim dng mu qua van.
d
rve
e
s
re
ts vn
h
g
i ogp
Ting rung tm trng cn cl rth
m. trong mt
l
c
.
o
. A ahotng
s trung hp khc nhevHoC,
cung lng
o
l
y
n
@
qua van hai l... Ting
thi
tin
tm
thu cng
i
. F 2020
8
0
thng gp nht
y bo bnh nhn gng sc
20 l itkhi
t ottockh Amyl Nitrate. Ting thi
hoc dngghmt
P
i
yr
ny sopkhng
c khi bnh nhn b rung nh.
C
Ting T1 anh kh quan trng trong HHL. Ting
T1 c th khng r anh na khi van vi ho
nhiu hoc gim s di ng ca l van. Nghe
y tim c th thy ting T2 mnh v tch i,
biu hin ca tng p ng mch phi.
Mt s tnh trng c th ging biu hin ca hp
van hai l nh u nhy nh tri hoc tim ba bung
nh. Ting p ca u nhy c th nhm vi ting
clc m van. Khi bnh nhn c rung tm trng
lun cn chn on phn bit vi u nhy nh tri.
Cc tnh trng khc c th gy nn ting rung tm
trng bao gm: thng lin nh, hoc thng lin
tht, ting thi Austin-Flint ca h ch (gim khi
233
gim hu gnh) hoc ca hp van ba l (nghe r

nht b tri xng c v tng ln khi ht vo).
II. Nguyn nhn
A. a s trng hp HHL u l do di chng thp tim d
50% bnh nhn khng h bit tin s thp khp.
1. t thp tim cp thng hay gy ra h van hai l. Sau
mt s t thp tim ti pht, hp van hai l bt u
xut hin, tip tc tin trin nhiu nm cho ti khi
biu hin triu chng.
2. Thng tn chnh l thm nhim x, dy l van. Dnh
mp van, dnh v co rt dy chng gp phn gy nn
HHL. Xut hin vi ho lng ng trn l rvan,
ved dy
e
s
chng, vng van, tip tc lm hn ch chc
re nng bnh
ts vn
h
g
thng ca van. Nhng thng tn rny
to. thnh van
l i .com
l
Ac m.
o
hai l hnh phu nh hnh ming
ev. yaho
o
l
0@ hai l
B. Cc nguyn nhn gy hp
Fin van
8. 202
0
20 ity
1. Di chng thp tim.
t otoc
h
P
2. Bm sinh: yrig
p
o
a. VanChai l hnh d: do c mt ct c xut pht
cc dy chng cho c hai l van, dn n h hoc
hp van.
b. Vng tht trn van hai l.
3. Bnh h thng c th gy x ho van hai l:
a. U carcinoid.
b. Lupus ban h thng.
c. Vim khp dng thp.
d. Lng ng mucopolysaccharide.
e. Vim ni tm mc nhim khun lin so.
234
Hnh 12-1. Thng tn van hai l do thp.

III. Sinh l bnh
1. Bnh thng din tch l van hai l l 4-6 cm2. Khi
din tch l van hai l < 2cm2, dng chy qua van hai
l b cn tr to thnh chnh p qua van hai l gia
nh tri v tht tri trong thi k tm trng. Chnh
p ny v p lc nh tri s cng tng khi dinvetch
d l
er l van
van cng gim. Tu theo mc din tchresca
ts
hai l m ngi ta chia thnh cc loi:
gh m.vn
i
r
o
ll o<.c1,0
Avan
a. HHL rt kht khi din tch vl
cm2.
o
.
h
e
a
o
l van
2
y
b. HHL kht khi din tch
0@ t 1 n < 1,5 cm .
Finl
2
.
0
08 ty2l van t 1,5-2,0 cm2.
c. HHL va khi din
20 otch
i
t ot c
h
P
g
2. Dng chy qua
van
hai
l tng lm chnh p qua van
ri
y
p
tng theo
Cocp s nhn (v chnh p l hm bc hai ca
dng chy). V vy, gng sc hoc thai nghn (tng
th tch v dng mu lu thng) s lm tng ng k
p lc nh tri. Nhp tim nhanh lm gim thi gian
y tm trng cng lm tng chnh p qua van v
p lc trong nh tri. Do trong giai on sm, hi
chng gng sc rt thng gp bnh nhn HHL.
3. Tng p lc nh tri dn n tng p trong h thng
mch phi gy ra cc triu chng huyt phi. Tng
p lc th ng trong h mch phi s gy tng sc
cn mch phi (tng p ng mch phi phn ng,
hng ro th hai). Tnh trng ny c th mt i v tr
v bnh thng nu tnh trng hp van c gii
quyt. Tuy nhin, nu hp van hai l kht ko di s
dn n bnh cnh tc nghn mch mu phi.
235
4. Mc d tht tri t b nh hng bi cc qu trnh

bnh sinh trn nhng 25-30% s trng hp c gim
phn s tng mu tht tri, c l l do gim tin gnh
tht tri v gim dng chy v tht tri lu ngy.
5. Nhng trng hp hp van hai l kht c th gy
gim cung lng tim n mc gy triu chng gim
ti mu. Tnh trng cung lng tim thp mn tnh s
gy phn x tng sc cn mch i tun hon v tng
hu gnh, cng lm tip tc gim chc nng co bp
tht tri hn na. Phn s tng mu s tr li bnh
thng nu gii quyt ch hp van hai l (khi phc
tin gnh v hu gnh). Mt s bnh nhn vn tip
tc ri lon co bp c tim ko di sau khi m ch
hp, nguyn nhn hay c ngh ti l tnh
dtrng
rve
e
s
vim c tim m do thp tim.
re
ts vn
h
.
g
l ri .com
l
A hoo
ev.php
a thm d cc k
A. Siu m Doppler tim: l bin
o
l
in 20@y
F
. 2nh
quan trng chn on 8xc
0 v chn on mc
y thi van, t chc di van
00 hnh
t
2
i
hp van hai l, chnton
toc
igh tnPokm theo (thng c trong HHL)
hai l v cc thng
r
py
gip ch nh
Coiu tr.
1. Kiu TM: l van dy, gim di ng, bin m van
hai l km, hai l van di ng song song, dc tm
trng EF gim (EF < 15 mm/s l HHL kht).
2. Siu m 2D: hnh nh van hai l hn ch di ng, l
van hnh vm (hockey-stick sign), vi ho l van v
t chc di van. Siu m 2D cn cho php o trc
tip din tch l van hai l, nh gi chc nng tht
tri v cc tn thng van khc c th km theo.
3. Siu m Doppler c bit quan trng nh gi
mc hp:
a. Vn tc nh dng chy qua van hai l > 1 m/giy
gi c HHL, song du hiu ny khng c hiu,
c th xy ra do nhp nhanh, tng co bp. H hai
236
l v thng lin tht cng gy tng dng chy d

khng c HHL.
b. Chnh p qua van hai l (o vin ph dng chy
qua van hai l) cho php c lng mc nng
ca hp van.
HHL nh: chnh p trung bnh qua van < 5
mmHg,
HHL va: chnh p trung bnh qua van t 512 mmHg,
HHL kht: chnh p trung bnh qua van > 12
mmHg.
c. c tnh p lc ng mch phi (MP), thng
qua vic o ph ca h van ba l km theo hoc
h van MP km theo (thng gp trong HHL).
d
rve
e
s
d. Cho php nh gi tn thng thc stn
re km theo
t vn
h
. rt quan
g
nh HoHL, HoC v mc , iu
ny
l ri .com
l
A chn
o phng php
trng gip cho quyt nhv.la
e yaho
o
l
can thip van hai l thch
@
in hp.
. F 2020
8
0
4. Siu m Doppler tim
y nh gi din tch l
20 odng
cit
t otxc,
van hai l khighchnh
t xc nh v nh gi
P
r
y
mc hp.
p Thng c hai cch o trn lm sng:
Co
a. o trc tip l van trn siu m 2D:
Mt ct trc ngn cnh c tri, ct qua mp
van, ly l van hai l vo trung tm, dng
hnh trong thi k tm trng khi l van m
rng nht. Sau dng con tr o c
trc tip din tch van hai l.
237
Hnh 12-2. o din tch l van hai l trn siu m 2D.

Hnh nh m (do thnh ngc dy, kh ph
thng), van, t chc di van dy, vi, mo
m hoc bin dng sau m tch van... l
d
nhng yu t khin rt kh xc nh
rve c
e
s
re
chnh xc l van. Nu ct khngtsvung
gc s
h
vn
.
g
ri c(tng
c lng sai din tch lllvan
ln).
Vi
m
.o
A
o
o
.
hoc x dy mp vanoecng
hlm sai lch (gim
v
l @ya
n
i
i). phn gii
thp
lm
m mp van v
. F 2020
8
0
tng qu din
y phn gii cao lm din
20 tch,
cit
t i.otoTuy
h
tch gim
vy phng php ny vn
P
rig
y
p
c
Co dng rng ri.
b. Phng php PHT (thi gian bn gim p lc):
Thi gian bn gim p lc (thi gian p lc
gim mt na so vi gi tr ban u), l thi gian
vn tc gim cn 70% vn tc nh. Hp hai l
lm thi gian gim p lc ca dng chy qua van
hai l b ko di ra. Cng hp nhiu th mc thi
gian ny cng di, Sng E ca ph hai l c
dng tnh din tch l van theo PHT:
Din tch l van hai l = 220/PHT
238
Hnh 13-3. o din tch l van hai l bng PHT.

Nu khng tnh t ng th PHT = 0,29 thi
d
gian gim tc sng E. Nu dng echy
rve tm
s
re
trng khng tuyn tnh, c th
dng
ts vdng
n
h
.
g
i
chy gia tm trng c
lng
ra
vn
tc
r
ll o.com
A
o
.
ti a. Nu c rung nh,
v cn
ah ly trung bnh t
loe
ytnh.
n
@
i
5-10 nht bp lin
tip
. F 2020
08dng
Phi m bo
0
2 ocity Doppler song song vi
t dng
hng gca
h
Pot chy.
i
r
y
PHT
p b thay i khng phn nh ng thc t
Co
nu c thay i nhanh chng ca huyt ng
qua van nh ngay sau nong van hai l. PHT
cng b sai lch nu nhp tim nhanh (EA gn
nh trng nhau). H van ng mch ch, lm
tht tri y nhanh, cng gy gim PHT
tng din tch l van hai l gi to.
5. Siu m tim gng sc ch nh cho bnh nhn c
triu chng song siu m tim khi ngh khng biu l
HHL kht r hoc khi c HHL kht m cha c
biu hin lm sng. C th nh gi chnh p qua
van hai l trong khi thc hin gng sc (bng xe p
lc k) hoc ngay sau khi gng sc (bng thm chy).
Siu m Doppler cng dng o vn tc dng h
239
van ba l, dng h qua van ng mch phi c

lng p lc ng mch phi khi gng sc.
6. Siu m tim qua thc qun: vi u d trong thc
qun cho thy hnh nh r nt hn, dng nh gi
chnh xc hn mc hp van cng nh hnh thi
van v t chc di van, hnh nh cc mu ng
trong nh tri hoc tiu nh tri. T gip ch nh
phng thc iu tr can thip van hai l. Siu m qua
thc qun nn c ch nh thng quy trc khi
quyt nh nong van hai l nu c iu kin. Tuy
nhin, vi cc trng hp nhp xoang v khi hnh nh
kh r trn siu m qua thnh ngc th cng
nh gi cho ch nh nong van hai l.
d
B. Thng tim: l phng php rt chnh xc
rveo cc
e
s
re p lc nh
thng s nh: p lc cui tm trng tht tri,
ts vn
h
.
g
tri (trc tip hoc gin tip qua p llc
om mch phi
l ri mao
c
.
A hoo tim (phng
bt), p lc ng mch phi, cung
ev. yalng
o
l
in 0@ tim v thi gian
php Fick hoc pha long nhit),
. F 202nhp
8
0
y tm trng (giy/nhp
y Trn c s hai ng p
0 tim).
2 tocit
lc ng thi igtht
v
nh tri, c th tnh c
ht tri
o
P
r
y
chnh p quaop van hai l (bng phn din tch gia hai
C
ng p lc h s o). Nu dng ng p lc mao
mch phi bt, nn dch ng p lc sang tri 50-70 ms
l phn thi gian truyn p lc t nh tri n mng
li mao mch phi.
1. Din tch l van hai l c c tnh theo cng
thc Gorlin:
Dintchl vanhail =
Cungl ngtim / Th igiandd ytamtrong * Nhptim

37 ,7 * Ch nh ptrungbinh quavanhail
H s 37,7 c tnh t hng s Gorlin 44,3 0,85

(h s hiu chnh ca van hai l). Ngoi ra c th da
vo cng thc n gin ho do Hakki xut:
240

Dintchlvanhail =
Cungl ngtim
Ch nh ptrungbinhquavanhail
2. Khng th dng p lc mao mch phi bt tnh

din tch l van hai l nu bnh nhn c hp ng
mch hoc tnh mch phi, tc mao mch phi hoc
tim ba bung nh hay khi cung lng tim qu thp.
ng thi ng thng o p lc mao mch phi bt
phi t ng v tr. Hn th na, phng php pha
long nhit t chnh xc nu c h van ba l hoc tnh
trng cung lng tim thp. Dng h van hai l hoc
lung thng do thng lin nh gy ra ngay sau nong
c th lm c lng sai dng chy qua van hai l.
C. in tm : hnh nh P hai l (sng P rng do dy
ed nh
v
r
e
tri) thng gp nu bnh nhn cn nhp xoang.
Trc
res
tsxut
n
in tim chuyn sang phi. Dy tht phi
hin
khi
h
ig om.v
r
l
lnh .thng
c
c tng p lc ng mch phi. Rung
xy ra
v. A ahoo
e
bnh nhn HHL.
o
l
y
Fin020@
.
D. Chp Xquang ngc:008 y2
2 ocit
tc th
1. Giai on u,
h
Pot cha thy bin i no quan
g
i
r
y
trng, boptim bn tri ging nh ng thng. Tip
C lc MP tng s thy hnh nh cung MP
, khi p
ni v c bit l hnh nh 4 cung in hnh b bn
tri ca tim (t trn xung: cung MC, cung MP,
cung tiu nh tri, cung tht tri). Mt s trng hp
c th thy hnh nh 5 cung khi nh tri to v l ra
bn tri di cung tiu nh.
2. Hnh nh 2 cung phn di b tim bn phi do nh
tri mu nhiu c 3 giai on: giai on u l hnh
nh song song hai cung vi cung nh tri vn bn
trong cung nh phi, giai on tip l hai cung ny ct
nhau, v sau cng l nh tri to nhiu vi hnh nh hai
cung song song, cung nh tri ngoi cung nh phi.
3. Mt s trng hp HHL rt kht c th thy tht tri
rt sng trong thi k tm trng do mu vo tht
tri t. Cng c th thy hnh nh vi ho van hai l.
241
ng Kerley B xut hin trn phim chp thng khi

c tng p lc ng mch phi. Tht phi gin (gim
khong sng sau xng c trn phim nghing tri).
4. Hnh nh gin tip khc nh nhnh ph qun gc tri
b y ln trn hoc nh tri thc qun 1/3 di,
thc qun b y ra sau trn phim chp nghing c
ung thuc cn quang.
5. C th thy hnh nh vi ho ca van hai l hoc t
chc di van trn phim chp hoc chiu di mn
tng sng.
V. iu tr
A. iu tr ni khoa
1. Nu bnh nhn khng c triu chng c nng th ch
ved mc
cn iu tr khng sinh d phng vim niertm
s
re
khi c km HoHL hoc HoC.
ts vn
h
.
g
2. Nu bnh nhn mi ch kh th khi
om sc mc
l ri gng
l
c
.
oo
nh th iu tr thuc lioetiu
v. A
ah lm gim p lc
l
y
in 20@ giao cm (tc dng
nh tri. Phi hp thuc
. F chn
0
8
0
gim p ng tng20nhp
y2tim khi gng sc) s tng
t
i
oc Trnh dng cc thuc gin
t otsc.
c kh nngghgng
P
i
r
ng mch.
py
Co
3. Rung nh l nguyn nhn r rng gy nng bnh, v
th cn iu tr trit rung nh (chuyn v nhp
xoang) hoc t nht phi khng ch nhp tht tng
thi gian tm trng y tht tri v gim chnh
p qua van hai l. Nhng thuc thng dng l
digitalis v nhm chn giao cm. Dng cc thuc
chng lon nhp hoc sc in chuyn nhp c th
chuyn rung nh v nhp xoang song hiu qu lu di
trnh ti pht rung nh cn ph thuc vo vic gii
quyt mc hp van.
4. Bt buc phi iu tr chng ng bnh nhn HHL
c rung nh v nguy c huyt khi gy tc mch cao:
nn duy tr INR trong khong t 2-3. Vic iu tr d
phng huyt khi nh tri v tc mch bnh nhn
nhp xoang cn cha thng nht, song nn iu tr
242
nu bnh nhn c tin s tc mch i tun hon,

c cn rung nh kch pht hoc khi ng knh nh
tri ln ( 50-55 mm) s d dng chuyn thnh rung
nh. Mt s tc gi khc c xu hng iu tr thuc
chng ng cho tt c bnh nhn HHL cho d mc
hp v kch thc nh tri ti u.
5. Nu triu chng c nng nng ln (NYHA 2) bnh
nhn cn c ch nh m hoc can thip qua da.
Mt s tc gi cn coi tng p lc MP ( 55
mmHg) hoc rung nh cng l ch nh can thip
hoc m do vic can thip sm gip kim sot rung
nh tt hn v gim bt t l nguy c, bin chng v
lu di. Nu khng can thip hoc m th t l t
vong sau 10 nm l 40% bnh nhn tr, tng ln
gp i sau 20 nm v t l ny l 60-70%vesau
d 10
r
e
s
nm bnh nhn gi.
re
ts vn
h
.
g
B. Nong van bng bng qua da
l ri .com
l
A hoo
1. Nong van bng bng qua oda
k thut a ng
ev. l
l
ya
n
@
i
0 qua ch chc vch
thng u c bng vo. Fnh02tri
8 2
0tht
y
0
lin nh ri li xung
tri
v i ngang qua van hai
2 tocit
t
h
o
l, sau bng
s c
bm ln-xung dn theo tng
P
rig
y
p
c tng Cdn
lm
n
phn
eo ca bng gy tch hai
o
mp van cho n khi kt qu nong van t nh
mun. Nong van hai l qua da (NVHL) tr thnh
phng php c la chn hng u cho cc bnh
nhn HHL trn ton th gii v y l th thut
chim v tr th 2 (v s lng cng nh ngha)
trong can thip tim mch. Ti Vit nam, NVHL bt
u t 1997, n nay tr thnh phng php iu
tr thng quy. Kt qu nong bng bng (tch hai
mp van b dnh) thng tt, din tch l van tng 1-2
cm2, chnh p qua van hai l v p lc ng mch
phi gim khong 1/3 so vi p lc ng mch phi
trc . NVHL c u tin la chn v:
a. NVHL c t l thnh cng cao, t bin chng qua
nhiu nghin cu.
243
b. NVHL ci thin ng k tnh trng huyt ng v

din tch l van.
c. NVHL c kt qu trc mt v khi theo di lu
di tng t hoc thm ch cn hn nu so vi m
tch van c trn tim kn ln tim m.
d. NVHL l th thut t xm phm, nhiu u th so
vi m nh: thi gian nm vin ngn, t au,
khng c so trn ngc, tm l thoi mi hn...
e. NVHL c th thc hin c trong mt s tnh
hung c bit m phu thut kh thnh cng
trn vn hoc nguy c cao nh: ph n c thai,
ngi suy tim nng, bnh nhn ang trong
tnh trng cp cu...
d
rve
e
s
re
ts vn
h
.
g
l ri .com
l
A o
ev. yaho
o
l
Fin 0@
8. 202
0
20 ity
t otoc
h
P
rig
y
p
Co
Hnh 12-4. Nong van hai l bng bng Inoue.
244
HHL (NYHA 1-2)

HHL nh (MVA >1,5cm2)
HHL kht (MVA <1,5cm2)
Siu m gng sc
PAP > 60 mmHg
MVG > 15 mmHg
Hnh thivan tt cho NVHL
Khng
Khng
Theo di hng nm
Nong van hai l
Hnh 12-5a. Ch nh nong van hai l theo AHA/ACC.

d
rve
e
s
re
HHL (NYHA 3-4)
ts vn
h
.
g
l ri .com
l
2
HHL nh (MVA >1,5cm )
HHLvkht
<1,5cm2)
oo
. A ah(MVA
e
o
l
y
Fin020@
.
Siu m gng sc
08 2
20 ocity
ht Pot
rig
y
p
PAP > 60 mmHg Co C
Hnh thi van tt cho NVHL
MVG > 15 mmHg
Khng
Khng
Nguy c cao nu m
Khng
Tm nguyn nhn khc
M sa/thay van
C
Nong van hai l
Ghi ch: MVA: din tch l van hai l; PAP: p lc tm thu

MP; MVG: chnh p trung bnh qua van hai l; NVHL: nong
van hai l qua da
Hnh 12-5b. Ch nh nong van hai l theo AHA/ACC.
245
2. Chn la bnh nhn NVHL bao gm:

a. HHL kht (din tch l van trn siu m < 1,5
cm2) v c triu chng c nng trn lm sng
(NYHA 2).
b. Hnh thi van trn siu m tt cho NVHL, da
theo thang im ca Wilkins: bnh nhn c tng
s im 8 c kt qu tt nht.
c. Khng c huyt khi trong nh tri trn siu m
qua thnh ngc (hoc tt hn l trn siu m qua
thc qun).
d. Khng c h hai l hoc h van ng mch ch
mc va-nhiu km theo (> 2/4) v cha nh
hng n chc nng tht tri.
d
rve hai l
3. Chng ch nh NVHL: bnh nhn h svan
e
e
s r ntrong nh
va-nhiu (3/4) hoc c huyt khihtmi
v
.
g
tri hay tiu nh tri.
l ri .com
l
hoo lng ho
v. A am:
esiu
o
4. Thang im Wilkins trn
l
y
in @
. F 2020gip cho d bo thnh
tnh trng van v dy
8chng
0
y
20 oWilkins
cng ca NVHLt (do
xut nm 1988) c
cit
t
h
o
Phu ht cc trung tm trn th gii
g
ic
nhy cao,
r
py
s dngConh mt tiu chun quan trng trong chn
bnh nhn NVHL. Trong thang im ny th tnh
trng dy ca l van v t chc di van c nh
hng nhiu n vic ci thin din tch l van sau
nong. Cc nghin cu theo di ngn hn v trung hn
u ch ra rng vi im Wilkins trn siu m 8 th
t l thnh cng rt ng k. C mt khong xm
t 9 - 11 im, khi kt qu NVHL vn c th tt
nu c kinh nghim. Tuy nhin, vi im Wilkins >
11 th khng nn nong van hai l bng bng do kt
qu NVHL khng ti u, t l bin chng, suy tim,
ti hp sau nong rt cao. Hin nay phng php
NVHL bng dng c kim loi do Cribier xut vn
cho kt qu tt ngay c bnh nhn c tnh trng van
xu (im siu m cao).
246
Bng 12-1. Thang im Wilkins trn siu m nh gi

van hai l.
im
Di ng van
T chc
dy
Mc
di van
van
vi ho
mt
nh C
t, Gn
Van di ng Dy
im
vi
bnh
phn
ngay
tt, ch st b
st b van. thng: 4 - ho.
van hn ch.
5 mm.
Phn
gia Dy ti 1/3 Dy t pha Vi ha di
thn van v chiu di b van: 5 - rc pha b
van.
chn van cn dy chng. 8 mm.
di ng tt.
ti Dy
lan Vi ho lan
Van vn cn Dy
xa xung c n on
di ng v on
pha
trc dy chng. thn l van: gia l van.
d
5 - 8mm.
trong thi k
rve
e
s
re
tm trng,
ts vn
h
(ch yu l
.
g
l ri .com
l
gc van).
. A ahoo
oev ynhiu
Vi
ho
Khng
di Dy nhiu nDy
l
@
i ton
0
F
nhiu
lan
b
c
ng hoc rt v co 8rt
2
. 20
0
y
0
t.
ct c
2 dy
it l van: > 8 to ton b
t otoc
h
van.
- 10mm.
chng.
P
g
i
py
Co
Hnh 12-6. L van hai l trc v sau nong bng bng.

5. Bin chng sau nong van hai l:
a. T vong (< 1%) thng do bin chng p tim cp
hoc tai bin mch no.
247
b. p tim cp do chc vch lin nh khng chnh xc

gy thng thnh nh hoc do thng tht khi
NVHL bng bng/dng c kim loi (< 1%).
c. HoHL lun l bin chng thng gp nht (h hai
l nng sau nong ch t 1-6%, theo nghin cu ti
Vin Tim mch Vit nam l 1,3%).
d. Tc mch c bit l tc mch no (< 1%).
e. Cn tn lu thng lin nh: phn ln l thng ny
t ng trong vng 6 thng; nhng trng hp
cn tn lu (10%) th l nh, shunt b v dung
np tt.
6. Siu m qua thc qun: c vai tr rt quan trng
trong nong van hai l: nhm xc nh khng c huyt
d
khi nh tri v tiu nh tri trc khi nong.
rve Trong
e
s
re
mt s trng hp c bit, siu m qua
qun
ts vthc
n
h
.
g
i
hng dn li bng nong v nhlgi
kt
qu
sau
mi
r
l .com
A
o
o
.
ln nong (din tch l van, mc
h hai l, chnh p
v h
loe @ya
n
i
qua van hai l...).
0
F
8. 202
0
y
0
7. Din tch l van hai
2 l
citsau nong: nn c nh gi
ht Ptip
oto trn siu m 2D. Din tch l
bng cch origtrc
y
van hai Cloptnh bng phng php PHT thng t tin
cy trong vng 24-48 gi sau nong (do huyt ng
thay i nhanh chng).
8. HoHL: l bin chng kh kim sot nht (1-6% theo
cc nghin cu). HoHL c xu hng tng ln sau
NVHL v th HoHL > 2/4 l chng ch nh tng
i ca NVHL, tuy nhin, mc HoHL nh sau
nong l hon ton chp nhn c v d dung np.
Cc yu t nh HoHL trc nong, tnh trng van vi
ho gc mp van... c kh nng thp trong vic d
bo HoHL sau NVHL. Thang im ca Padial v
Palacios xut c kh nng d bo kh tt HoHL
nng sau NVHL.
248
Khi im Padial >10, kh nng HoHL nng sau

NVHL s tng ln nhiu. Nghin cu ti Vin Tim
mch Vit nam cho thy, vi im Padial > 10, kh
nng bnh nhn b HoHL (RR) tng 53 ln. C ch
chnh gy h van hai l sau nong l thng tn ca t
chc di van, ca mp l van hoc do l van b co
rt gy ng khng kn. Dng HoHL nh sau nong
thng xut pht t mp van trong khi dng HoHL
nng thng do t dy chng hoc rch l van. Mt
s trng hp kt qu rt tt sau nong van, khng c
hoc HoHL rt nh ngay sau nong nhng sau mt
thi gian li xut hin HoHL nhiu hn thng do
hin tng co rt l van, hoc t chc di van di
chng thp tim.
d
rve
e
Bng 12-2. Thang im ca Padial d on
HoHL.
s
re
ts vn im
h
Thng s
g
ri com.
l
l
.
dy l van trc
14
v. A ahoo
e
o
l
y
dy l van sau
14
in 20@
. Fvan
Tnh trng vi ho 0mp
20
08 ty
14
2 oci
Tnh trng tgchc

14
ht Pdi
ot van
ri
y
Tng
p
4 16
Co
9. Ti hp sau nong van hai l: l khi nong van thnh
cng v kt qu nhng qua theo di th (1) din tch
l van hai l gim i nh hn gi tr tng din tch l
van hai l trc nong v mt na s din tch gia tng
sau nong v (2) triu chng lm sng r (NYHA >
2). V d: mt bnh nhn c din tch l van hai l
trc nong van l 1 cm2 v ngay sau nong t c 2
cm2, phn gia tng l 1 cm2, 1/2 lng gia tng l 0,5
cm2 nn gi l hp li khi din tch l van < 1,5 cm2.
T l ti hp van hai l ni chung thay i t 6-21%,
sau 4 nm t l sng cn l 84%. Nghin cu bc
u ti Vin Tim mch Vit nam (trn 600 bnh
nhn, trung bnh 2 nm) cho thy 100% s bnh nhn
sng st sau 2 nm, trong 85% bnh nhn khng
249
c nhng triu chng c nng gy ra do hp hai l,

ch c 3,4% bnh nhn ti hp van.
a. Tui cao, NYHA cao, rung nh, din tch l van
trc nong nh, p lc ng mch phi cao, h
van ba l nhiu, h van hai l tng sau nong, din
tch l van hai l sau nong thp l nhng yu t
tin lng xu v lu di.
b. Kt qu lu di (>10 nm) sau nong van tuy rt
n tng (tng ng vi m sa van tim m)
song mi ch dng li nhng bnh nhn tr tui,
van cn cha vi m cha c nghin cu mt
cch y nhng bnh nhn ln tui hn.
C. Phu thut
ed
1. M tch van tim kn: l bin php dngesmt
erv dng
r
ts vng
c tch van hoc nong van bng tay hqua
m
. n
g
i ocn
r
m
l
nh, thng qua ng m ngc (khng
tun
hon
l o.c
ho ny hu nh
v. A aphp
e
ngoi c th). Hin ti phng
o
l
y
0@
Finnong
khng c dng v 8.c
02 van hai l bng bng
2
0
ty m. M tch van hoc m
qua da hoc phu thut
20 itim
t otoc
h
sa van tim rc
ig trPgip ca tun hon ngoi c th
y
p
cho phpCoquan st trc tip b my van hai l, ly cc
vi, x v to hnh mp van v dy chng van hai l.
2. Bnh l di van nng thng u tin la chn phu
thut so vi can thip. Bnh l van tim khc km theo
HHL cn iu tr (nh h hoc hp van ng mch
ch) cng l mt u tin cho phu thut. i vi
bnh nhn tng p lc ng mch phi v h van ba
l nng th pht, nong van bng bng n thun lm
gim p lc ng mch phi cng khng lm
gim h van ba l nht l nhng bnh nhn ln
tui, v th phu thut van hai l kt hp vi to hnh
van ba l c th l chin lc iu tr ph hp hn.
3. Phu thut thay van hai l:
250
a. Thay van hai l thng c ch nh khi van vi

v co rt nhiu hoc c km HoHL phi hp.
b. La chn thay van hai l c hc hoc sinh hc tu
thuc vo nguy c ca vic dng thuc chng
ng ko di khi c van c hc so vi mc d
thoi ho ca van sinh hc. T l sng st sau
thay van 5 nm t 80-85%.
c. Quan im bo tn t chc di van trong m
hp van hai l cng ging nh h van hai l nhm
duy tr cu trc v chc nng tht tri sau m.
4. M sa van hai l: tuy kh hn song vn thc hin
c mt s trng hp. Sau 10 nm t l sng st
> 95%, t l m li do ti hp sau m < 20%.
d
5. Tng p lc ng mch phi lm tng nguy
rvec ca
e
s
re m cn
phu thut song tin lng ca bnh nhn
ts sau
n
h
g
i om.v
r
tt hn nhiu so vi ch iu tr ni
khoa.
l
l
c
. A ahoo.
6. Phu thut Maze iu trnlrung
mn tnh c th
oev ynh
@
Fi 020van
kt hp ngay khi tin hnh
hai l.
8. 2m
0
0 ity
2
toc
D. Theo di sau thhtthut
Po
ig
r
y
p
Theo di
Co sau m hoc sau nong van hai l phi tin
hnh t nht 1 nm/1 ln, hoc nhanh hn nu nh xut
hin triu chng lm sng, nht l khi c cc du hiu
gi c ti hp van hai l hoc h van hai l phi hp.
Siu m tim cn c lm nh k theo di din bin
lm sng ca bnh nhn.
Ti liu tham kho
1.
2.
3.
Alpert JS, Sabik J, Cosgrove DM III. Mitral valve disease. In: Topol
EJ, ed. Textbook of cardiovascular medicine. Philadelphia:
Braunwald E. Valvular heart disease. In: Braunwald E, sd. Heart
disease: a textbook of cardiovascular medicine, 5th ed. Philadelphia:
WB Saunders, 1997:1007-1076.
Carabello B, Grossman W. Calculation of stenotic valve orifice area.
In: Baim DS, Grossman W, eds. Cardiac catheterization,
251
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
angiography and intervention, 5th ed. Baltimore: Williams &

Wilkins, 1996:151-166.
Carabello BA, Crawford FA. Valvular heart disease. N Engl J Med
1997;337:32-41.
Crawford MR, Souchek J, Oprian CA. Determinants of survival and
left ventricular performance after mitral valve replacement.
Circulation 1990;81:1173-1181.
Dean LS, Mickel M, Bonan H, et al. Four-year follow-up of patients
undergoing percutaneous balloon mitral commissurotomy: a report
from the National Heart, Lung, and Blood Institute balloon
valvuloplasty registry. J Am Coll Cardiol 1996;25: 1452-1457.
Farhat MB, Ayari M, Maatouk F, at al. Percutaneous balloon versus
surgical closed and open mitral commissurotomy: seven year followup results of a randomized trial. Circulation 1995;97:245-250.
Glazier JJ, Turi ZG. Percutaneous balloon mitral valvuloplasty. Prog
Cardiovase Dis 1997;40:5-26.
Griffin BP, Stewart WJ. Echocardiography in patient selection,
operative planning, and intra operative evaluation of mitral valve
repair. In: Otto CM, ed. The practice of clinical echocardiography.
Philadelphia: WB Saunders, 1997:355-372.
ved DS,
rBaim
e
Grossman W. Profiles in valvular heart disease. In:
s
re
Grossman W, ads. Cardiac catheterization, hangiography
and
ts vn
.
g
intervention, 5th ed. Baltimore: Williams & Wilkins,
1996:735-756.
i
r
om
l .cdisease.
Mpert JS, Sabik J, Cosgrove DM III. Mitral
In: Topol
Alvalve
o
o
.
h
v
e
EJ, ed. Textbook of Cardiovascular
Medicine.
Philadelphia:
a
o
l
y
Lippincott-Raven, 1998:503-532. Fin 20@
.
0
Olesen KH. The natural history
271
2 patients with mitral stenosis
08 of
20Heart
ityJ 1962;24:349-357.
under medical treatment. Br
c
o
ht Pot in the patient undergoing catheter
Reid CL. Echocardiography
rig
balloon mitral commissurotomy.
In: Otto CM, ed. The practice of
y
p
Co
clinical echocardiography.
Philadelphia: WB Saunders, 1997:373388.
Reyes VP, Raju BS, Wynee J, et al. Percutaneous balloon
valvuloplasty compared with open surgical commissurotomy for
mitral stenosis. N Engl J Med 1994;331: 961-967.
Stewart WJ: Intraoperative echocardiography. In Topol EJ, ed.
Textbook of cardiovascular medicine. Philadelphia: LippincottRaven, 1998: 1492-1525.
Thamilarasan M. Mitral valve disease. In: Marso SP, Griffin BP,
Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia:
LippincottRaven, 2000.
Tuzcu EM, Block PC, Griffin B, Dinsmore H, Newell JB, Palacios
IF. Percutaneous mitral balloon valvotomy in patients with calcific
mitral stenosis: immediate and long-term outcome. J Am Coll
Cardiol 1994;23:1604-1609.
Wilkins GT, Weyman AE, Abascal VM, Block PC, Palacios IM.
Percutaneous balloon dilatation of the mitral valve: an analysis of
echocardiographic variables related to outcome and the mechanism
of dilatation. Br Heart J 1985;60:299-308.
252
H van hai l
H van hai l (HoHL) l bnh kh thng gp. HoHL

thng chia thnh hai loi: HoHL thc tn (do thp tim, vim
ni tm mc, bin chng ca NMCT...) hoc HoHL c nng
I. Triu chng lm sng
A. Triu chng c nng
1. Ph phi (kh th khi ngh, khi nm) hoc sc tim
(do gim th tch tng mu) l triu chng chnh ca
h van hai l (HoHL) nng, cp, mi xut hin.
2. HoHL mn tnh thng khng biu hin triuedchng
rv
c nng g trong nhiu nm ngoi mt rting
ese thi
ts vnhin kh
tim. t tin trin ca HoHL thng
gh xut
i
r
m.
l np.cokhi
l
th khi gng sc hay gim dung
gng sc,
. A ahoo
v
e
o
nng hn s xut hin kh
l th@ykhi nm v cn kh
0
Fin02ngy
.
th kch pht v m.
Lu
s xut hin triu
08 ty2
0
2
i
chng suy tim tri,
oc nh cc triu chng suy tim
t cng
Potmch phi.
ighng
phi do tng
p
r
opy
C
3. Lon nhp hon ton (rung nh) thng gp do hu
qu ca gin nh tri. Triu chng hay gp khc l
mt (do gim th tch tng mu v cung lng tim).
B. Triu chng thc th
1. S: Mm tim p mnh v ngn nu chc nng tht
tri cn tt. Mm tim p lch tri khi tht tri gin.
C th cm thy hin tng y tht nhanh v
gin nhanh nh tri.
2. Nghe tim:
a. Ting tim:
m sc T1 thng gim (HoHL mn) nhng
cng c th bnh thng nu do sa van hai l
hoc ri lon hot ng dy chng.
253
T2 thng tch i rng (do phn ch ca T2

n sm), m sc s mnh khi c tng p
ng mch phi.
Xut hin ting T3 khi tng dng chy tm
trng cho d khng phi lun lun l
biu hin ri lon chc nng tht tri. i khi
c th nghe thy ting T4 nht l trong t
HoHL cp.
b. Ting thi tm thu: ton th tm thu, m sc cao,
kiu tng mu, nghe r nht mm, lan ra nch
(xut hin gia th tm thu nu do sa va hai l
hoc ri lon chc nng c nh). Ting thi tm
thu ny c th ngn, n sm khi HoHL cp/
nng phn nh tnh trng tng p lc nh tri.
ed Tuy
v
r
e
vy nu p lc nh tri tng qu nhiu
res s khng
ts vchn
n
cn nghe r thi tm thu na. gCn
on
h
i om.
r
l
cca HoHL vi
phn bit ting thi ton tm
Al thu
oo.
htht
v.lin
e
a
h ba l (HoBL) v thng
(TLT): tt c
o
inl 20@y
F
u c m sc cao,
ting thi ca TLT
0
8. nhng
y2 r b tri xng c v
00 inghe
t
2
thng th rp
hn,
t otoc
P tim; ting thi ca HoBL nghe
ightrc
lan ra vng
r
y
p
r nht
Co b di tri xng c, lan v b phi
xng c v ng gia n tri, tng ln khi ht
su trong khi thi tm thu HoHL nghe r nht
mm v lan ra nch (cng c th lan ra y tim
do dng chy hng ra trc).
c. Cc triu chng thc th ca suy tim tri v suy
tim phi (tnh mch c ni, gan to, c chng,
ph chi di) xut hin khi bnh tin trin nng.
A. Nguyn nhn gy ra HoHL
1. Bnh l l van:
a. Di chng thp tim: x ho, dy, vi, co rt l van.
b. Thoi ho nhy: lm di ng qu mc l van.
254
c. Vim ni tm mc nhim khun (VNTMNK) gy

thng l van, co rt l van khi lnh bnh.
d. Phnh l van do dng h van MC (do
VNTMNK) tc ng ln van hai l.
e. Bm sinh:
X (nt) van hai l: n thun hoc phi hp
(thng sn nh tht).
Van hai l c hai l van.
f. Bnh c tim ph i: van hai l di ng ra trc
trong k tm thu.
2. Bnh l vng van hai l:
a. Gin vng van:
Gin tht tri do bnh c tim gin, bnh
tim
ed
thiu mu cc b, tng huyt p. eserv
r
ts vn
b. Vi ho vng van:
h
g
i om.
l ry
l
Thoi ho ngi gi, thc
.c do tng huyt
v. A ahoo
e
p, i ng, suy nthn.
o
i l 20@y
Fthp,
.
Do bnh tim do
0 hi chng Marfan, hi
8
00 ity2
2
chng Hurler.
t oc
gh Pot
ichng:
3. Bnh l dy
r
opy
C
a. Thoi ho nhy gy t dy chng.
b. Di chng thp tim: dy, dnh, vi ho dy chng.
4. Bnh l ct c:
a. Nhi mu c tim gy t ct c nh.
b. Ri lon hot ng c nh:
Thiu mu c tim: cm c nh trc c cp
mu t nhnh m v nhnh lin tht trc,
cm c nh sau t nhnh xung sau (PDA).
Bnh l thm nhim c tim: amyloid, sarcoid.
c. Bm sinh: d dng, van hnh d...
B. C ch bnh sinh
1. HoHL cp tnh: gy tng th tch cui tm trng tht
tri (v thm mt lng mu do HoHL t nh tri
255
v), tng di si c (tin gnh) v tng co bp c

tim theo nh lut Frank-Starling d hu qu l tng
p lc y tht tri v gy huyt phi. Hu
gnh gim do mu thot v nh tri v th cng lm
tht tri bp khe, tng ng tuy th tch tng mu
vn gim. Nu dung np c, bnh nhn s tin
trin thnh HoHL mn tnh.
2. Trong trng hp HoHL mn tnh, tht tri gin v
ph i lch tm. Sc p ln thnh c tim s tr li
bnh thng do ph i c tim, ng thi mc
gim hu gnh do thot mu v nh tri khng cn
nhiu nh trong pha cp. Tin gnh vn mc cao
lm nh tri gin. Tht tri khng co bp tng ng
nh trong pha cp song vn ngng bnhvethng
d
r
e
s
cao. Ri lon chc nng tht tri s tin
re trin m
ts vn c rt t
h
thm trong nhiu nm d khng rc
hoc
g
i om.
l
l
c
.thng
triu chng. Nhng thng s truyn
nh gi
v. A ahoo
e
o
l
y
co bp c tim (nh phn
s
tng
mu)
s
vn
Fin020@
.
8
ngng bnh thng 0trong
thi gian di do tng tin
0 ity2
2thng
c
gnh v gim/bnh
ho
hu gnh. Lu dn ri
o
ht Pot
g
i
r
lon chc pnng
km vi gin tin trin bung tht tri
oy
v tng Csc p ln thnh tim cng lm HoHL tng
ln, thnh mt vng xon tip tc gy gim chc
nng tht tri, gy mt b. Khi cc triu chng c
nng r th c khi ri lon chc nng tht tri
khng hi phc, lm tng nguy c suy tim, tng t l
bin chng v t vong d phu thut gii quyt
bnh van hai l.
III. Cc xt nghim chn on
A. in tim: cc biu hin khng c hiu nh dy nh
tri, dy tht tri, rung nh u c th gp bt k giai
on no ca HoHL.
B. Xquang ngc: thng c gin tht tri v nh tri nu
HoHL mn tnh. Hnh nh ph khong k v ph ph
nang gp khi HoHL cp hoc khi suy tht tri nng.
256
C. Siu m Doppler tim: (qua thnh ngc v qua thc

qun) ng vai tr rt quan trng, c s dng rng ri
chn on xc nh v nh gi mc h van hai l.
Mc h hai l trn siu m Doppler tim thng chia
lm 4 (t 1/4 n 4/4) hoc cc mc : nh (1+), va
(2+), nhiu (3+) v rt nhiu (4+).
1. Siu m Doppler mu: chn on HoHL bng hnh
nh dng mu pht ngc v nh tri. HoHL c
th c tnh da vo s lan ca dng mu pht ngc
trong nh tri. Lng gi mc h hai l: da vo
cc thng s nh:
d
rve
e
s
re
ts vn
h
.
g
l ri .com
l
A o
ev. yaho
o
l
Fin 0@
8. 202
0
20 ocity
t ca
Hnh 13-1. Dng gmu
h
Pot HoHL trn siu m Doppler.
ri
y
p
Co
Hnh 13-2. Sa van hai l v ba l trn siu m 2D.

a. di ti a ca dng mu (h) pht ngc
trong nh tri hoc % din tch dng h so vi
din tch nh tri. Rt ng tin cy nu HoHL
kiu trung tm, song thng nh gi thp mc
h van nu dng h lch tm. Vi nhng dng
257
h lch tm ln, HoHL c c tnh tng thm 1

. Hng ca dng h cho php nh gi
nguyn nhn gy HoHL.
Bng 13-1. Lng gi mc h van hai l.
Din tch dng
Chiu di ti a ca
h so vi din
HoHL dng h (cm) pht
tch nh tri (%)
ngc vo nh tri
1
< 1,5
< 20
2
1,5 2,9
20 40
3
3,0 4,4
4
> 4,4
> 40
Cn ch : vi phng php ny, khi dng
siu m qua thc qun nh gi HoHL, nu
d
dng an thn (gim hu gnh) s lm gim
rve mc
e
s
HoHL so vi bnh thng. Tng t,snu
re nh gi
t vn
h
g
HoHL ngay trong m, h thay
i. nhiu ph
l ri .com
l
A
thuc vo tin gnh v hu
gnhoc tim. Do vy,
ev. yaho
o
l
ngi ta thng phi
in hp
0@ thm nhiu phng
. F 2mc
02 HoHL.
8gi
php khc nh
0
20 ocity
t h
b. rng dng
h
Pot (ch hp nht) khi qua l h
ig
r
y
(venaocontracta):
l mt ch s ng tin cy. Nu
p
C
rng > 0,5 cm l bng chng ca HoHL nng.
Tuy nhin phng php ny i hi my siu m
phi c phn gii cao v phi phng hnh to,
nn d c xu hng nh gi qu mc h.
c. Din tch l h hiu dng (ERO) tnh theo
phng php PISA (Proximal Isovelocity Surface
Area): da trn hin tng dng chy qua l hp
hnh phu: khi ti gn l h, vn tc ca dng h
gia tng hi t c dng bn cu, ti phn ra vng
hi t vn tc dng chy chm, dng cu ln
trong khi ti vng st l h vn tc dng chy
nhanh, dng cu nh. C th o chnh xc vn tc
dng chy v ng knh vng cu ti im u
tin c hin tng aliasing ca ph Doppler (tn
258
s gii hn Nyquist), t tnh din tch l h

hiu dng (ERO = 2r2V/Vmr) v th tch dng
h (RV = ERO VTImr) trong r l chiu di
t b ngoi vng cu hi t n mt phng van
hai l, V l vn tc ti vng aliasing, Vmr l vn
tc ti a dng h xc nh bng Doppler lin
tc, VTImr l tch phn vn tc thi gian ca
dng h. Din tch l h hiu dng (ERO) l
thng s nh gi chnh xc h: nh (ERO: 010 mm2), va (10-25 mm2), nng (25-50 mm2),
rt nng (> 50 mm2). Tuy nhin thc t li c mt
vi sai s khi chn vng hi t dng cu dt, xc
nh mt phng l h, khi dng h li khng
ng nht, lch tm... v lm tng gi to
h.
ed
v
r
e
D vy hin tng PISA thng bo hiu
es mc
sr n
tDoppler
h hai l va nht l khi s dng
xung
h
ig om.v
r
l
(PRF).
l .c
v. A ahoo
e
o
2. Siu m Doppler xung: c
y nh gi mc
@gip
inl th
20
. F 20nhng
h van hai l, nht l08trong
trng hp HoHL
0 ity
2
tdng
nng, c th dat vo
oc chy tnh mch phi. Hin
Po thu ca dng chy tnh mch
igh tm
tng gimyrph
p
phi khiCochc nng tht tri bnh thng bo hiu
HoHL nng, tuy nhin khng chnh xc nu rung nh
hoc ri lon chc nng tht tri nng. Hin tng
o ngc ph tm thu dng chy tnh mch phi bo
hiu HoHL rt nng.
D. Thng tim
1. Sng v trn ng cong p lc nh tri (tng ng
giai on y nh tri t cc tnh mch phi trong
thi k tm thu) cho php c lng mc HoHL,
c bit l HoHL cp tnh. Bin sng v gp 2-3 ln
p lc trung bnh nh tri gi HoHL nng. Tuy
nhin nu HoHL mn tnh hoc khi gim hu gnh,
c th khng thy bt thng sng v. Khng c sng
v cng khng th loi tr HoHL nng. Mt khc sng
259
v cao cng c th gp trong nhng trng hp nh ri

lon chc nng tht tri m nh tri km gin, thng
lin tht sau nhi mu c tim hoc nhng tnh trng
tng lu lng phi.
2. Chp bung tht tri: cho php c lng mc
HoHL theo phn ca Seller:
1/4: Ch c vt cn quang m vo nh tri,
khng vin r hnh nh tri.
2/4: Cn quang trn khp nh tri nhng m
khng bng tht tri, mt i nhanh chng
sau 2-3 nht bp.
3/4: m cn quang nh tri v tht tri
bng nhau.
4/4: Cn quang nh tri m hn rtht
ved tri,
e
s
xut hin c cn quang tnh mch
re phi.
ts vn
h
.
g
3. Thng tim cng dng kho st
om thi bnh
l ri ng
l
c
.
o
. A ahonhn
ng mch vnh khi HoHL:evbnh
nam tui
o
l
y
n
@
40, n tui 50 d khng
c
triu
chng
hoc
yu t
i
. F 2020
8
0
nguy c ca bnh20mchty vnh cng nn chp ng
tCh
oci nh thng tim gm:
t m.
mch vnh trc
h
o
P
g
ri
a. Khi Ckhng
opy tng xng gia triu chng lm sng
v kt qu thm d khng chy mu,
b. Khi d nh phu thut nhng bnh nhn cn
nghi ng v mc nng ca h van hai l hoc
bnh mch vnh,
c. Bnh nhn h van hai l c nguy c mc bnh
mch vnh hoc nghi ng bnh mch vnh l cn
nguyn gy h van hai l.
IV. iu tr
Nm bt c ch sinh bnh l vic rt cn thit la chn
bin php iu tr ph hp.
A. H van hai l cp tnh
1. iu tr ni khoa: nu huyt p trung bnh ng
mch vn trong gii hn bnh thng, s dng cc
260
thuc h hu gnh c th lm n nh tnh trng

HoHL cp. Truyn tnh mch Nitroprusside v
Nitroglycerin lm gim p lc mch phi v tng
cng th tch tng mu. Nu cha cn phu thut
ngay, c th chuyn sang dng thuc ung, phi hp
thuc c ch men chuyn v Hydralazin. Trong
nhng trng hp HoHL nng, cp (m tht tri cha
kp gin, ph i nh HoHL do t ct c nh sau
nhi mu c tim) nu xut hin triu chng ph phi,
sc tim th nn t bng trong ng mch ch n
nh tnh trng huyt ng trc khi gi i m.
2. iu tr ngoi khoa: a s bnh nhn HoHL nng,
cp tnh u phi m cp cu.
d
B. H van hai l mn tnh
rve
e
s
re
tstrvph
1. Chn phng php v thi im iu
n hp:
h
g
i om.
r
l
l o.c nu c triu
a. Bnh nhn HoHL t va n
o
. A ahnng
v
e
o
chng th c ch nh m.
l
y
in 0@
. F 202khng
b. Bnh nhn HoHL08nng
c hoc c rt t
0 ity
c
2 ch
triu chnghtth
nh
phc
tp hn. Vn
o
ot
P
g
i
r
mu cht
l xc nh c thi im can thip
opy
trcC khi chc nng tht tri gim n mc khng
hi phc. Nu ch theo di st ti khi xut hin
triu chng th vn c nguy c b qua ri lon
nng chc nng tht tri v tin lng s km i
hn. u th ca sa van i vi tnh trng suy tim
v t l t vong sau m khin cho ngy cng c
khuynh hng ch nh m sa van hai l sm
hn nu thng tn gii phu cho php.
c. Rt nhiu phng tin v thng s c xut
d bo tin trin ca ri lon chc nng tht
tri, suy tim v t vong sau m bnh nhn
HoHL nng. Song la chn thi im v bin
php iu tr cn phi hp tu tng c nhn:
261
Triu chng lm sng: bnh nhn tui trn 75,

c km bnh l mch vnh hoc ri lon chc
nng thn c tin lng km hn sau m v
th nn gi i m trc khi biu hin r triu
chng cc bnh km theo. Rung nh cng l
mt l do cn nhc ch nh m sm.
Thng s o bng siu m tim: rt c ch
nh gi xem bnh nhn cn gi i m hay
cha. Thng thng phn s tng mu (EF)
trn ngng bnh thng. V th EF < 50%
cho thy tnh trng ri lon chc nng tht
tri nng nn gi i m sm cho d cha c
triu chng. Ngay c khi EF t 50-60% cng
lm tng nguy c suy tim v t l td vong
rve
sau m. Cc thng s d bo nguy
ese c khc
r
ts vn tht tri
bao gm: ng knh cui tm
.
gh mthu
i
r
(LVESD, Ds) 45 mm, A
phn
ll osut
co co ngn si
.
. aho
evthay
c tht tri FS 31%,
i p lc tht tri
o
l
n 0@y
i
F
2
theo thi gian dp/dt
. < 1343.
08 ty20
0sng
2
(a) Khi lm
i v siu m tim khng l r,
t otoc
h
P
g
nn
ri lm siu m tim gng sc: gim p
py
Co ng vi gng sc, EF tht tri khng tng
khi gng sc, ch s th tch cui tm thu
tht tri (LVESVI) 25 cm3/m2 l nhng
ch s gi cn ch nh m sm.
(b) Bnh nhn c sa l van hai l gy HoHL
nng nn ch nh m sm d khng c
hoc c rt t triu chng.
Thng s o bng thng tim:
(a) p lc trung bnh ng mch phi 20
mmHg, ch s tim (CI) < 2 l/pht, p lc
cui tm trng tht tri 12 mmHg l
cc du hiu d bo tin lng ti sau m.
(b) Cung lng tim khng tng hoc p lc
mao mch phi bt tng khi gng sc l
262
du hiu cho bit c ri lon chc nng

tht tri n.
(c) gin (elastance) tht tri (ng cong
tng quan gia th tch v p lc) l
thng s nh gi chc nng co bp tht
tri tt nht song t c ng dng rng
ri v phi dng cc thit b c bit.
2. iu tr ni khoa:
a. HoHL do ri lon chc nng tht tri (c gin
vng van) c iu tr bng cc thuc cha suy
tim nh :
Cc thuc gim hu gnh, c bit l c ch
men chuyn, lm gim th tch dng h v
d
tng th tch tng mu. Nhm ny cng
rve c tc
e
s
dng vi bnh nhn HoHL do bnh
re l van tim
ts vn
h
g
c triu chng ang ch m.ri m.
o
l
Al hoo.cc tc dng tt
Thuc li tiu v nhmv.Nitrate
oe ya
trong iu tr huyt
inl 2phi.
0@
F
. 20iu
8c
Rung nh phi
tr kim sot tn s
0
20 ocity
tht bng
ht ccot thuc chng lon nhp, nht l
rig vPthuc chn giao cm.
Digitalis
y
op
b. Vai Ctr ca thuc vi bnh nhn HoHL mn tnh
do bnh van tim, cha c triu chng, ni chung
cn cn nhiu th nghim chng minh nht l v
kh nng lm chm tin trin ca HoHL hoc
phng ri lon chc nng tht tri. iu tr cc
thuc gim hu gnh qu tch cc c th che bt
cc triu chng, t a ra cc quyt nh sai
lm v thi im v bin php can thip.
c. Phi d phng vim ni tm mc nhim khun
cho tt c trng hp HoHL do bnh van tim
ngoi tr h do gin tht tri m cc van tim bnh
thng.
3. iu tr phu thut:
263
a. Kinh in l ct b b my van hai l ri thay

bng van hai l nhn to. Tuy nhin, sau m
thng c gim chc nng tht tri v suy tim
huyt. Cc k thut mi c xu hng bo tn t
chc di van nhm gim th tch tht tri v sc
p trn c tim sau m (tht tri cng c dng elp
th cng ci thin EF sau m).
b. K thut sa van lm gim ng k t l t vong
v bin chng: t l sng cn sau 5 nm > 85%
v ch c 10% bnh nhn phi m li trong 5
nm. Cc k thut bc l ti thiu cng lm gim
hn na t l bin chng v t vong. Tuy cha c
th nghim no so snh m sa v thay van song
cc nghin cu u cho thy u th ca m
d sa
rve
e
van (phn no do s la chn bnh nhn):
s
re
hts so
T vong ca m sa van l ig2%
.vnvi 5-8%
r
m
o
l
l .c
ca thay van.
v. A ahoo
e
o
l @m
Phn s tng muinsau
y thng cao hn
0
Fsa02c
.
nhm bnh nhn
van.
8
00 ity2
2
c bnh nhn sa van thp
mch
Nguy ct tc
h Poto
hny(5%
5-10 nm so vi 10-35% nu
rig trong
p
o
C
thay van). Nguy c vim ni tm mc cng
gim hn (0,4% so vi 2,2%). Sau m sa van
khng cn dng thuc chng ng ko di
(ch 3 thng) nn gim nguy c khi dng
thuc chng ng.
T l phi m li tng t gia hai nhm
bnh nhn m sa v thay van.
Mt s bnh nhn ri lon chc nng tht tri
nng hoc h van hai l th pht c th p
dng th thut Batista (ti cu trc tht tri
kt hp vi m sa van) cho kt qu sm rt
tt trong khi khng th m thay van.
Tuy nhin ch nh m sm (nht l sa van)
nhng bnh nhn HoHL nng m cha c triu
chng cn gy nhiu tranh ci.
264
c. Kh nng sa van thng ph thuc vo nguyn

nhn gy HoHL, d nh gi trc m bng siu
m tim qua thnh ngc hoc qua thc qun.
Thnh cng v cc bin chng ca m sa
van/thay van c th nh gi bng siu m tim
ngay trong m. HoHL tn d l bin chng hay
gp nht sau khi ngng my tim phi nhn to.
Nu HoHL cn 2/4 nn chy li tim phi nhn
to sa tip hoc thay van hai l. Chy my
tim phi nhn to ln th hai khng tng thm t
l t vong ti vin.
d. Cn loi tr mt bin chng sau m l hp ng
ra tht tri do tha m l van sau (> 1,5 cm) y
vng ng hai l van ra trc di chuyn
d vo
rve Bin
e
ng ra tht tri trong thi k tm
thu.
s
re
tsnhn
n
h
chng ny rt hay gp nhng bnh
g
i om.v c tha
r
l
l o.cng. K thut
m l van v tht tri nh v
o
. Atng
v
e
ah dng hn ch
o
s bt m l van sau nc
p
l
y
Fi 020@nu c cn tr ng
bin chng ny, 0tuy
8. nhin
2
0 ityth
2nhiu
ra tht tri qu
nn m thay van hai l.
c
o
t
gh Pot
i
r
4. Theo di sau
py m:
Co
Siu m tim sau m 4-6 tun c dng lm mc
theo di. HoHL ti pht do sa khng tt hoc do
nguyn nhn gy bnh tip tc tin trin. Bnh nhn
nn c theo di lm sng v siu m tim (nh gi
kt qu m sa van, c ch v mc h van, chc
nng tht tri, huyt khi hay vim ni tm mc) t
nht 1 nm/1 ln.
Ti liu tham kho
1.
2.
Alpert JS, Sabik J, Cosgrove DM III. Mitral valve disease. In: Topol
EJ, ed. Textbook of cardiovascular medicine. Philadelphia:
Bach DS, Boiling SF. Improvement following correction of
secondary mitral regurgitation in end-stage cardiomyopathy with
mitral annuloplasty. Am J Cardiol 1996;78:966-969.
265
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Braunwald E. Valvular heart disease. In: Braunwald E, sd. Heart

disease: a textbook of cardiovascular medicine, 5th ed. Philadelphia:
WB Saunders, 1997:1007-1076.
Carabello B, Grossman W. Calculation of stenotic valve orifice area.
In: Baim DS, Grossman W, eds. Cardiac catheterization,
angiography and intervention, 5th ed. Baltimore: Williams &
Wilkins, 1996:151-166.
Carabello BA, Crawford FA. Valvular heart disease. N Engl J Med
1997;337:32-41
Cohn LH, Couper OS, Aranki SF. Long-term results of mitral valve
reconstruction for regurgitation of the myxomatous mitral valve. J
Thorac Cardiovasc Surg 1994;107:1453-151
Enriquez-Sarano M, Schaff HV, Orszulak TA, et al. Valve repair
improves the outcome of surgery for mitral regurgitation: a
multivariate analysis. Circulation 1995;91: 1022-1028.
Griffin BP, Stewart WJ. Echocardiography in patient selection,
operative planning, and intra operative evaluation of mitral valve
repair. In: Otto CM, ed. The practice of clinical echocardiography.
d DS,
Grossman W. Profiles in valvular heart disease. In: Baim
rve and
e
Grossman W, eds. Cardiac catheterization, angiography
s
re
intervention, 5th ed. Baltimore: Williams & Wilkins,
ts1996:735-756.
h
.vn
g
Hall SA, Brickner E, Willett DL, Irani WN, Mridi
PA.
i oI,mGrayburn
r
l
l Doppler
.c color flow of
Assessment of mitral regurgitation severity
by
A
o
o
.
the vena contracta. Circulation 1997;95:636-642.
oev yah
inl 2Cosgrove
Leung DY, Griffin BP, Stewart FWJ,
DM, Thomas JD,
0@
8. 20 after valve repair for chronic
Marwick TH. Left ventricular0function
y
0
mitral regurgitation: predictive
2 tocitvalue preoperative assessment of
t
h
o
contractile reserve by
exercise
P echocardiography. Am Coll Cardiol
rig
1996;28:1195-1205.
y
p
Co BP, Stewart WJ, et al. Left ventricular function
Leung DY, Griffin
after valve repair for chronic mitral regurgitation: predictive value of
preoperative assessment of contractile reserve by exercise
echocardiography. J Am Coll Cardiol 1996;28:1195-1205.
Mpert JS, Sabik J, Cosgrove DM III. Mitral valve disease. In: Topol
EJ, ed. Textbook of Cardiovascular Medicine. Philadelphia:
Stewart WJ. Choosing the golden moment for mitral valve repair. J
Am Coll Cardiol 1994;24: 1544-1546.
Stewart WJ: Intraoperative echocardiography. In Topol EJ, ed.
Textbook of cardiovascular medicine. Philadelphia: LippincottRaven, 1998: 1492-1525.
Thamilarasan M. Mitral valve disease. In: Marso SP, Griffin BP,
Thomas JD. How leaky is that mitral valve? simplified Doppler
methods to measure regurgitant orifice area. Circulation
1997;95:545-550.
Zuppiroli A, Rinaldi M, Kramer-Fox R. Natural history of mitral
valve prolapse. Am J Cardiol 1995;75:10281032.
266
H van ng mch ch
H van ng mch ch (HoC) c th chia thnh 2 loi: cp

tnh v mn tnh. HoC mn thng do van ng khng kn v b
ca l van b dy ln v cun li, do gin vng van-gc ng
mch ch (MC) hoc c hai. HoC cp thng do chn thng
ngc, vim ni tm mc, tch thnh ng mch ch gy thng,
sa l van hoc gin cp tnh vng van v gn nh lun phi m
cp cu.
I. Triu chng lm sng
A. Triu chng c nng
d
rvekhun,
1. Nu HoC cp do vim ni tm mc nhim
e
s
re th tin
mc h ban u c th khng ln, song
ts vc
h
. n
g
i v
r
m
trin rt nhanh chng v mc HoC
suy
tim, cn
o
l
Al hoo.c
.
v
theo di st.
a
oe
inl 20@y
F
. 0
2. HoC mn tnh thng
biu hin g trong
08 ty2khng
0
2
i
nhiu nm. Triut chng
oc c nng khi xut hin thng
Pot phi nh kh th khi gng sc,
ighhuyt
lin quan n
r
py
Co dn xut hin kh th khi nm, cn kh
sau dn
th kch pht v m, cui cng l cc du hiu ca
suy tim ton b.
3. au tht ngc xut hin nhng bnh nhn HoC
nng (do gim ti mu mch vnh trong thi k tm
trng v gim chnh p qua li mch vnh khi
tng p lc cui tm trng tht tri v suy tim).
B. Triu chng thc th
1. HoC cp, mc nng thng c bnh cnh cp
tnh. Cn ngh ti tch thnh ng mch ch bnh
nhn HoC cp c km au ngc. Cng cn xc nh
bnh s v cc yu t nguy c ca vim ni tm mc
nhim khun. Triu chng suy tim huyt (ph
phi...) bo hiu tin lng xu trong bnh HoC cp.
267
2. HoC mn tnh thng khng biu hin triu chng

g trong mt thi gian di ngoi mt ting thi tm
trng b tri xng c. Cn tm biu hin HoC
nhng bnh nhn c hi chng Marfan hoc phnh
gin ng mch ch ln.
3. Cc triu chng bn ngoi c th gp trong HoC mn
tnh l:
a. Kiu hnh Marfan: thng ngi tr, c d tt
nhiu c quan: nt rui son, bn chn - tay v cc
ngn di nh chn tay nhn, ngc hnh phu...
b. C th km triu chng ca vim ni tm mc
nhim khun.
c. Nhn thy vng p rng trc tim hoc mm tim
d
lch tri do tht tri gin.
rve
e
s
re
ts vnHoC nh.
d. S o huyt p vn bnh thng hnu
.
g
ri comcon
l gin,
Khi HoC nng, bung tht tri
s huyt
l
.
A hoo
.
v
p tm thu tng cao, huyt
a tm trng gim
oe yp
@ s o huyt p ln.
inl 20v
F
nhiu, to ra chnh
lch
. 20
08 tytun
0ng
Tnh trng tng
hon ny c th gy ra
2
i
t otoc
h
P
g
mt lot rcc
du
hiu
nh:
i
py
Du
Co hiu Musset: u gt g theo nhp p
ca tim.
Du hiu Mller: li g p theo nhp tim.
Du hiu Hill: huyt p chn ln hn cnh
tay > 60 mmHg.
Mch Corrigan: mch p ny nhanh mnh,
chm su.
Mch Quincke: hin tng nhp nhy ca
li mao mch mng tay, mi.
Du hiu Duroziez: ting thi i ng
mch i khi p ng nghe vo.
Du hiu Trobe: ting tm thu v tm trng
ni bt ng mch i
Khi suy tim tin trin, co mch ngoi vi s lm
tng con s huyt p ti thiu, huyt p ti a
268
gim do ri lon chc nng tht tri. Trng hp

tch thnh ng mch ch km trn dch mng
tim, c th gp hin tng mch nghch thng.
4. S: mm tim thng p mnh, tng ng, lch tri,
khoang lin sn V ngoi ng gia n, do tht
tri gin. Thng c rung miu tm trng khoang
lin sn II tri, i khi c c rung miu tm thu (do
tng lu lng qua van MC). ny v thi gian
khi bt mch quay, mch i c th xc nh c
mc HoC. Kinh in l mch Corrigan (ny
nhanh, mnh, chm xung nhanh). C th gp mch
hai nh ny trong trng hp hp phi hp h van
ng mch ch. Nhp tim vn nm trong gii hn
bnh thng cho ti giai on mun ca bnh,
d nhp
rve mu
e
s
tim thng tng ln b tr cho th tch
tng
re
ts vn
h
khi gim qu mc.
.
g
l ri .com
l
A o
5. Nghe tim:
ev. yaho
o
l
@ nh mc HoC:
a. Ting tim c th dng
Fin 0xc
8. 202
0
0 ityHoC nng v ri lon chc
Ting T1 m
2 tkhi
oc
t
h
nng tht
Po do hin tng ng sm van hai
ig tri
r
py
l
Cocng nh gim lc gy ng van.
Thnh phn ch ca ting T2 thng m do
cc l van MC ng khng kn, thnh phn
phi ca T2 cng hay b ting thi tm trng
ln p. T2 tch i st nhau hoc tch i
nghch thng (trn tm thanh c ng ,
thnh phn ch i sau thnh phn phi) do
thi gian tng mu tht tri b ko di v th
tch tng mu tng.
Ting T3 nghe c khi gim nng chc nng
tm thu tht tri. T4 hay c, do nh tri phi
bp mu xung bung tht tri gim
gin.
b. Thi tm trng kiu pht ngc, bt u ngay
sau ting T2, cng gim dn, nghe r nht
269
b tri xng c khi bnh nhn ngi nghing

ngi v pha trc v th ra ht sc. Mc
HoC lin quan cht vi di hn l cng
ca ting thi: giai on u, ting thi thng
ngn, n khi bnh tin trin, ting thi tr thnh
ton tm trng, tuy vy khi suy tim nng, giai
on cui, ting thi thng ngn li do p lc
cui tm trng tht tri tng dn ln. Vn c tnh
(bp cht tay...), ngi xm, dng thuc tng co c
tim s lm tng ting thi trong khi ang ngi
xm ng thng dy, nghim php Valsalva hoc
ht Amyl Nitrite li lm gim ting thi ny.
c. Thi tm thu y tim lan ln cc ng mch
cnh do tng lu lng tng mu qua vaned ng
rv
mch ch.
ese
r
tsnghe
d. Rung tm trng Austin Flint:
.vn thy
gh m
i
r
o
l
l .cnng: do dng
mm tim trong trng hp. AHoC
v ahoo
e
o
l l ytrc van hai l hoc
HoC pht ngc gy rung
Fin020@
.
dng HoC lm ng
2 van hai l v to dng
08 tysm
20 ol
i gy rung. Khi , cn phn
c
xoy qua van

hai
ht Pot
rig tm
bit vipyrung
trng do hp hai l phi hp.
Co
A. Nguyn nhn gy ra HoC
1. Bnh l gc ng mch ch lm ng van khng
kn gy h:
a. H van ng mch ch cp tnh:
Phnh tch thnh ng mch ch.
Tch thnh ng mch ch do chn thng
ngc.
b. H van ng mch ch mn tnh:
Hi chng Marfan.
Gin phnh ng mch ch.
Gin vng van ng mch ch.
270
Vim thnh ng mch ch do bnh giang

mai.
Lupus ban h thng.
Lon sn xng.
Hi chng Ehlers-Danlos.
Lng ng mucopolysacharide.
Vim ct sng dnh khp.
Hi chng Reiter.
Vim ng mch t bo khng l.
Hi chng Takayashu.
2. Bnh l ti l van ng mch ch:
a. H van ng mch ch cp tnh:
d
Sa l van do chn thng.
rve
e
s
b. H van ng mch ch mn tnh: ts re
n
h
Di chng van tim do thp. l rig om.v
l o.c
o
Thoi ho vi hoc thoi
v. Aho
e
ah nhy.
o
l
y
Phnh gin xoangFValsalva.
in @
. 2020
8
0
Van ng mch
ty hai l, bn l hoc mt l
20 ich
van. ght Potoc
ri
iu
py tr thuc methysergide.
Co
B. C ch bnh sinh
1. HoC mn tnh lm tng gnh th tch tht tri, gy
ph i lch tm, gin v tng th tch cui tm
trng ca tht tri. Nu chc nng tht tri cn b,
th tch tng mu ni chung s tng ln ng k, th
tch tng mu thc s vn cn bnh thng, tht tri
c th chu c th tch mu pht ngc m khng
tng qu p lc cui tm trng tht tri. Bnh nhn
s khng thy r cc biu hin triu chng lm sng.
2. Dn dn ri lon chc nng tht tri pht trin, gin
tht tri tng dn, ri lon qu trnh tng mu tht
tri, lm gim phn s tng mu, tng th tch v p
lc cui tm trng tht tri, gim th tch tng mu.
Qu trnh tng gnh c th tch v p lc gy ph i
271
tht tri lch tm phi hp ng tm. Thi im ny

cng l lc xut hin cc triu chng lm sng.
3. HoC cp tnh gy tng th tch cui tm trng tht
tri nhanh chng, trong khi c tht tri cha th ph
i dung np, nn d dng vt qu p lc nh tri
to ra tnh trng ph phi cp. ng thi p lc cui
tm trng tht tri tng nhanh, c th gy ng sm
van ng mch ch, gim th tch tng mu, gim
cung lng tim a n tnh trng sc tim.
III. Din bin t nhin
1. Bnh nhn HoC mn tnh khi xut hin triu
chng s c khuynh hng tin trin bnh kh nhanh.
Cc yu t tin lng xu bnh nhn HoCd mn
rve
gm:
ese
r
tscon
a. Triu chng c nng (NYHA >II),
.vns huyt
gh m
i
r
o
l
l .c
p ng mch chnh lch ln.
v. A ahoo
e
o
l tht
y tri: phn s tng
b. Ch s nh gi chc inng
F n020@
.
mu < 50-55%,0phn
08 ty2sut co ngn si c < 25ci tm thu > 55 mm, ng
2 tocui
30%, nghtknh
o
P
g
ritm trng > 75-80 mm.
knh cui
opy
C
c. Gim phn s tng mu khi gng sc.
d. in tim c ri lon ti cc, ST chnh xung >
0,1 mV khi gng sc.
e. Rung nh.
Ni chung phn s tng mu tht tri l thng
s quan trng nht xc nh t l sng cn nhng
bnh nhn c HoC. Khi ri lon chc nng tht
tri, triu chng s xut hin trong vng 2-3 nm,
trung bnh > 25%/nm.
Bnh nhn HoC mc nh-va c t l sng
sau 10 nm t 85-95%. Bnh nhn HoC va-nng
iu tr ni khoa c t l sng sau 5 nm l 75% v
sau 10 nm l 50%. Nu c au ngc, iu tr ni
khoa cng ch ko di thi gian sng khong 5 nm.
272
i vi nhm bnh nhn HoC nng cha c triu

chng, nhng nghin cu gn y cho thy t l bin
c (t t, xut hin triu chng phi phu thut, ri
lon co bp tht tri) khong 6,2%/nm, t l xut
hin triu chng khong 10%/nm. T l t vong
tng tuyn tnh hng nm: vi bnh nhn c triu
chng khong 9,4% cn vi bnh nhn cha c triu
chng l 2,8%. Din bin t nhin ca HoC nng
mn tnh khng h tt nh trc y m t. ng ch
ch triu chng c nng tin trin khng tng
ng vi bt k ch s chc nng tht tri no.
t t c th xy ra bnh nhn HoC nng
c triu chng, thng do cc ri lon nhp tht lin
quan n ph i v ri lon chc nng tht tri
d hoc
rve
e
s
th pht do thiu mu c tim.
re
ts vn
h
. cc thuc
g
2. T l sng cn s tng nu iu tr rtch
cc
l i .com
l
A c ch
o men chuyn,
gin mch nh Nifedipine, thuc
ev. yaho
o
l
Hydralazine, ch nh sm
@ im phu thut v
Fin0thi
20
8. d
ci tin k thut m.00Mc
thuc
ci thin phn no
2
2 ocity
tin lng snghtnhng

tc dng chnh ch l ko di
Pot
g
rim.
thi gian och
y
p
C
A. in tm : Hnh nh in hnh l dy tht tri, T cao
v ri lon nhp nh. Dng ri lon nhp nh hay gp nht
l rung nh, nht l khi c bnh van hai l phi hp. Bloc
dn truyn cc mc c th gp khi p xe vng van
MC.
B. Xquang tim phi: bnh nhn HoC mn c hnh nh
tim to. C th gp hnh nh gin nh tri hoc gin ng
mch ch ln.
C. Siu m tim: siu m 2D cho php xc nh nguyn
nhn HoC cp, kho st c gc MC, kch thc v
chc nng ca tht tri. Siu m Doppler tim cho php
chn on xc nh HoC v lng gi mc HoC (bng
273
nhiu phng php s dng Doppler mu, Doppler xung

v Doppler lin tc).
1. Xc nh dng pht ngc ca HoC da trn mt ct
dc cnh c v mt ct 5 bung t mm. ng thi
phi hp cc mt ct khc nh gi hnh dng van
MC (cnh c trc ngn), phn gc MC v MC
ln (trn 1 khoang lin sn so vi mt ct cnh c
trc di), quai MC v MC xung (trn hm c v
di mi c) cng nh nh gi c ch, nguyn nhn
gy h, chc nng tht tri, mc HoC nh hng
n cc bung tim v tn thng van phi hp. Du
hiu rung cnh van hai l, ng sm van hai l (trn
siu m tim kiu TM) c gi tr chn on cao.
d
rve
e
s
re
ts vn
h
.
g
l ri .com
l
A o
ev. yaho
o
l
Fin 0@
8. 202
0
20 ity
t otoc
h
P
rig
A Copy
B
Hnh 14-1: Dng pht ngc ca h van MC trn

Doppler mu. (A: Mt ct dc cnh c tri. B: Mt ct ngang
qua gc MC. C: Mt ct 5 bung tim t mm. D: Hnh nh
siu m TM mu ca mt trng hp h van MC).
274
2. nh gi mc HoC c rt nhiu phng php

da vo siu m Doppler song khng phng php
no c chp nhn lm tiu chun chung. Mt khc,
nhiu yu t c th nh hng ti vic dng siu m
Doppler o: thay i tu theo gin n ca tht
tri, ca MC v sc cn i tun hon. Ci chnh l
c lng mc nng ca HoC da trn c s tng
hp ca nhiu thng s trn siu m. Song cn ch :
cc thng s tng i thng nht nu mc HoC
nh hoc nng nhng thng khc nhau nhiu nu
HoC mc va, do cn phi hp thm cc triu
chng lm sng. Mt s thng s sau thng c s
dng nh gi mc h van MC:
a. Da vo siu m Doppler mu:
ng knh dng HoC/ng knh ng
ra
ved
r
tht tri (RTT).
e
es
s r n ra tht
Din tch dng HoC/din tchhtng
.v
g
tri.
l ri .com
l
oo t MC ln:
. A ahhi
Hin tng dng chy
evgn
o
l
y
@ 4+.
tng ng vi HoC
0hay
Fin3+
02 dng HoC pht ngc
8. 2tch
Chiu di v00din
2 ocity
vo trong
tri: tuy nhin kt qu tnh giao
t tht
h
Pot ph thuc vo tnh trng ti
g nhiu,
rirt
ng
y
p
Co c tim v hng ca dng h. Dng HoC
ca
thng b trn vi dng chy qua van hai l
v lm cho vic c lng mc h ch b
qu ln.
b. Da vo siu m Doppler lin tc:
Tng quan tn hiu gia ph Doppler lin tc
ca dng h MC so vi dng tng mu t
tht tri vo ng mch ch.
Dc gim p v thi gian bn gim p lc[PHT] (thi gian chnh p gia ng mch
ch v tht tri gim cn mt na so vi gi
tr ban u): dc gim p cng dc, PHT cng
ngn th HoC cng nng.
Dng chy ngc trong thi k tm trng
on u ng mch ch xung: tng ng
vi HoC nng.
275
T s gia tch phn vn tc theo thi gian

ca dng chy tm trng (VTId) trn tch
phn vn tc theo thi gian ca dng chy
tm thu (VTIs):
VTId / VTIs > 50% tng ng vi HoC nng.
c. Da vo huyt ng: tnh phn s h (RF) da
trn hiu s dng chy qua van ng mch phi
so vi dng chy qua van MC nu khng c
lung thng trong tim.
Qa Qp
RF =
/ 100
Qa
Trong : Qa = LVOTvti
0,785 Da v
Qp = RVOTvti 0,785 Dp
Da l ng knh ng ra tht tri (LVOT) o
mc van MC; Dp l ng knh ng ra tht
phi (RVOT) o mc ngang van ng
edmch
rvgian
e
phi; vti l tch phn vn tc theo thi
ti
s
re
ts vn
LVOT hoc RVOT.
h
rig com.
lHoC
l
d. Cc thng s siu m tim ca
. mn tnh mc
v. A ahoo
e
nng:
o
nl 0@y
FiHoC
ng knh dng
.
8 202 / ng knh ng ra
0
0
tht tri 65%.
2 ocity
t
h
Din rtch
Pot HoC / din tch bung tht tri
ig dng
y
p
Co60%.
Dc gim tc trn ph Doppler lin tc dng
HoC 3m/giy.
PHT 300 ms.
C dng chy ngc ton tm trng on
u ng mch ch xung.
Hin tng dng chy gn hi t trn siu m
Doppler mu.
Mt tn hiu Doppler lin tc dng h
MC ging dng tng mu ln MC.
Ph dng chy qua van hai l c dng hn
ch.
Phn s h > 50%.
Th tch h > 60 ml.
ng knh cui tm trng tht tri > 65
mm.
276
Bng 14-1. Cc phng php nh gi mc HoC.

Mc HoC
Phng php
ng knh HoC
/ ng ra tht
tri (%)
Din tch HoC /
Din tch tht tri
(%)
PHT (ms)
Nh (1+)
Va (2+)
25-45
Vanng (3+)
46-64
Nhiu
(4+)
65
< 25
4-25
25-59
60
400
300-400
300-400
300
400170
37070
25080 14030
Dc gim tc
2
2-3
2-3
3
nht,
nht t
cng
Mt ph ca nht,
d
hon ton hn,
mt
dng h so vi khng
rve
e
s
hon ton
mt ph dng hon ton
re
ts vn
h
.
tng mu ln
g
l ri .com
l
A o
MC
ev. yaho
o
l
Chiu di dng ngay
khng
ti tn
ti tn
Fin020@
.
HoC pht ngc di cc008 qu
vng cc mm
21/2
2 ociltytrc
v tht tri
l van
c nh
tim
t
gh Pot
i
r
MC
van hai l
opy
C
8-12 mm
12-16
>16
ng knh dng < 8 mm
mm
mm
HoC trn siu m
mu kiu TM
0%
1-10%
11-20%
>20Vn tc dng
25%
chy cui tm
trng/vn tc ti
a dng chy tm
thu
Vn tc dng
< 0,1
0,1-0,2
0,2-0,4
> 0,4
chy cui tm
trng (o ti eo
MC) (m/s)
277
D. Siu m tim qua thc qun: rt c gi tr bnh

nhn vim ni tm mc nhim khun pht hin cc si
hoc p xe vng van MC. Nu HoC n thun, si in
hnh thng mt nhn v pha tm tht ca l van. Vim
ni tm mc nhim khun d lm tn thng c l van
(thng) v cc cu trc ca gc MC gy tnh trng HoC
cp, tin trin nhanh. Siu m qua thc qun cng cho
php nh gi nguyn nhn gy HoC, xc nh cc tn
thng bm sinh v loi tr phnh tch MC.
E. Siu m gng sc: nh gi p ng ca tht tri vi
gng sc. Phn s tng mu tht tri bnh thng khi
ngh nhng khng tng khi gng sc chnh l du hiu
ri lon tim n chc nng tht tri v c ch nh m.
F. Chp x hnh kiu nhiu cng (MUGA): nh gi
chc nng tht tri, tnh phn s v th tch h. erved
res
ts nh
G. Thng tim v thm d huyt ng: ch
n khi:
h
ig om.v
r
l
1. Bnh nhn nam tui 40 v .n
Al tui
o.c 50 nn chp
hong
vbnh
e
a
o
ng mch vnh loi ntr
mch vnh
l @y
i
0
F
2
trc khi thc hin bt8k
. can
0 thip no.
00 ity2
2
2. Chp ng mch
oc nh gi mc HoC (t
t ch
Pot u vi ng thng trn l van
igh chch
th nghingyrtri
op Cn cn thn khi li ng thng (do quai
MC 1 Ccm).
ng mch ch thng gin, nht l trong hi chng
Marfan) trnh gy sang chn. Cng cn ch
bnh l hp l vo ng mch vnh phi hoc tri.
Bng 14-2. Mc h van MC khi chp MC.
Mc HoC
Mt cn quang
Tc cn
tht tri
quang nht
dn
Nh (1+)
Nht, khng vin hon
Nhanh
ton
Va (2+)
Nht, vin hon ton
Nhanh
Va-nhiu
Bng cn quang
Va
(3+)
MC
Nhiu
m hn cn quang
Chm
(4+)
MC
278
3. Huyt ng: bnh nhn HoC mn tnh cn b s c

tng p lc tm thu v gim p lc tm trng MC
trong khi p lc cc bung tim bn phi bnh thng.
Bnh nhn HoC nng s c tng p lc cui tm
trng tht tri, tng p lc mao mch phi bt, tng
p lc ng mch phi tu theo mc suy tim v
cc tnh trng bnh l van tim phi hp khc. Cng
nn c gng o chnh p qua van ng mch ch
nh gi mc hp van MC phi hp (nu c).
V. iu tr
A. La chn phng hng iu tr: ch yu l phi
xc nh nguyn nhn, n nh tnh trng huyt ng,
d
xc nh nhu cu v thi im phu thut tu thuc
rve vo
e
s
re hoc mt
bnh cnh HoC cp tnh, HoC mn tnh, cn
ts b
h
.vn
g
i bnh
r
m
b. Phu thut l iu tr tt yu cho
nhn HoC
o
l
Al hoo.c
.
v
nng cho d nguyn nhn g, nht
a suy tim.
oe l khi
inl 20@y
F
1. Ch nh m gm: 08. 20
0 ity
2 tocch
t mch
a. H van ng
nng, cp tnh.
h
Po
rig
y
p
b. BnhCoMC:
khi ng knh gc MC 50 mm
d h van mc no.
c. H van ng mch ch mn tnh c km theo:
Triu chng suy tim huyt (NYHA 2)
hoc c au ngc.
Phn s tng mu tht tri EF 50%.
ng knh tht tri cui tm thu 55 mm.
ng knh tht tri cui tm trng 75mm.
Phn s tng mu gim khi gng sc.
B. iu tr ni khoa
1. HoC mn tnh: bao gm:
a. Phi iu tr d phng vim ni tm mc nhim
khun nht l HoC nng.
279
b. C th duy tr hot ng th lc bnh thng

(gng sc nh, chi th thao) song nn trnh dng
gng sc tnh nu chc nng tht tri bnh thng
v cha biu hin triu chng. Nn lm nghim
php gng sc nh gi kh nng hoc mc
dung np gng sc vi yu cu hot ng c th.
c. Cc thuc gin mch nh Nitroprusside,
Hydralazine, Nifedipine tc dng chm v thuc
c ch men chuyn: c tc dng gim th tch h
v tng th tch tng mu, gim ti, gip ti cu
trc tht tri, gim th tch cui tm thu v tng
phn s tng mu. Thuc gin mch c ch
nh bnh nhn HoC c:
d
rve
e
s
Tng huyt p ng mch.
e
sr n
tnng
h
v tht tri
Suy tim v/hoc ri lon chc
.
g
l ri .com
l
A o
nhng chng ch nh m.
ev. yaho
o
l
Ci thin tnh trng
lm
sng v huyt ng
Fin020@
.
2 ri lon chc nng tht
trc m bnh
08 nhn
20 ocity
t xutt hin triu chng c nng v

tri cha
igh Po
r
y
bnh
p nhn c triu chng lm sng nhng
Co
chc nng tht tri cn tt hoc bt u gim.
Khng nn iu tr lu di thuc gin mch
nu c ch nh m v nhm bnh nhn ny
nn c m ngay, khng tr hon.
HoC nng, cha c triu chng, tht tri gin
(ng knh cui tm trng > 60-65 mm) vi
mc ch ci thin tin lng v tr hon thi
im phi m. Tuy nhin, khi:
(a) HoC mc nh-va: nu cha c triu
chng khng cn iu tr.
(b) HoC nng: nu cha c triu chng, chc
nng tm thu tht tri bnh thng, tht
tri khng to hoc gin nh (ng knh
280
cui tm trng < 60 mm) th cha phi

m, nn cng khng cn iu tr thuc.
d. Thuc c ch men chuyn cn c ch nh
bnh nhn c ri lon chc nng tm thu tht tri
ko di sau m thay van. Nifedipine (so vi
Digoxin) chng t li ch r rt, gim t l
xut hin triu chng, bo tn chc nng tm thu
tht tri sau m song hin cha y thng tin
v cc tc dng ca cc thuc khc nh
Hydralazine v c ch men chuyn. Khng nn
dng ko di Digoxin, Nitrate, thuc li tiu hoc
cc thuc tng co bp c tim nhm bnh nhn
khng c triu chng. Liu dng thuc phid c
rve
iu chnh lm gim huyt p ng
ese mch.
r
ts vnmn tnh
e. Nhng bnh nhn h van MC
.
ghnng
i
r
l .com
l
A onhm pht hin
cn phi theo di thng vxuyn
e . yaho
o
l
s xut hin ca cc itriu
chng
v s thay i
F n020@
.
8 2chc nng tht tri ch
kch thc cng00nh
2 ocity
t MC.
t
nh thay gvan
Khong thi gian gia cc
i h Po
r
y
ln theo
p di s tu thuc vo bnh cnh v chc
Co
nng ca tht tri.
Hnh 14-2.Theo di bnh nhn HoC cha c triu chng.
Bnh cnh
Ch nh
Xut hin triu chng c nng
Phu thut
Chc nng tht tri gim (EF < 50%) Phu thut
Chc nng tht tri bnh thng,
Theo di & Siu m
v khng c triu chng c nng
lm sng
tim
Ds < 45mm hoc Dd < 60mm (*)

12 thng
12 thng
Ds: 45-50mm hoc Dd: 60-70mm(*) 6 thng 6-12 thng
Ds: 50-55mm hoc Dd: 70-75mm(*) 3 thng
3-6 thng
Ds > 55mm hoc Dd > 75mm
Phu thut
281
(*)
Khi mi o ln u tin hoc khi cc gi tr cha n nh

(chng hn khi gi tr o ln trc thp hn), cn phi o li nh
k 3 thng/ln.
i vi bnh nhn HoC khng nng, phn s tng
mu tht tri bnh thng, bung tim khng gin
hoc gin rt t, ch cn lm siu m kim tra nh k
2-3 nm mt ln. Nhng bnh nhn HoC nng nn
c kim tra siu m nhiu hn, ti thiu 1 ln/nm.
Siu m Doppler tim nn c kim tra li 2-3 thng
sau ln khm u tin m bo tin trin ca bnh
khng qu nhanh. Khi ng knh tht tri thay
i so vi ln o trc, nn lp k hoch khm lm
sng v siu m tim 3 thng mt ln. Nu hnh
nh
ved
r
e
siu m tim khng r, nn theo di bng
es chp x
sr n
t
h
hnh bung tht. Chp x hnh bung
.vcng c
ig tht
ll r otri
comtrn siu m
.
ch nh nu phn s tng mu. Atht
v aho
loe @
y m tt, khng cn
mc ranh gii. Nu hnhinnh
siu
F 020
.
tin hnh chp x hnh
2 Siu m cng c ch
08 thm.
20 ocity
t nh
nh theo di h
gi kch thc gc MC
Pot
ig
rnhn
y
nhng bnh
c
gin
gc MC. Mt khi cc du
p
Co
hiu ca tnh trng ri lon chc nng tm thu tht
tri xut hin, cn xem xt kh nng phu thut ngay
c khi bnh nhn cha c triu chng. Bnh nhn sau
m thay van hoc sa van th chm sc v theo di
nh quy trnh bnh thng.
2. HoC cp tnh:
a. Trng hp HoC cp do phnh tch ng mch
ch, nu tnh trng huyt ng cn n nh, cn
iu tr tch cc bng thuc chn giao cm
kim sot c huyt p trc khi khi dng thuc
gin mch.
b. Cn nhc ch nh m ngay nu chn on HoC
cp do phnh tch ng mch ch hoc do chn
282
thng. Mc ch ca iu tr ni khoa ch l
tng ti a th tch tng mu v hn ch ti a
tin trin lan ca phnh tch MC. Dng ng
tnh mch cc thuc gin mch v chn giao
cm nu bnh cnh c tnh cht cp tnh. Nu n
nh, c th dng thuc ung nh Nifedipine, c
ch men chuyn, Hydralazine lm gim tin
gnh, ci thin th tch tng mu v cung lng
tim.
c. HoC cp lin quan n vim ni tm mc nhim
khun, cn iu tr thuc khng sinh ngay (sau
khi cy mu). Nu tnh trng huyt ng km,
vn c th phu thut thay van MC nhnedto d
v
mi ch dng khng sinh. (Khi vanreMC
ser ng
ts
loi/t thn thng c a chung).
gh m.vn
i
r
ll o.co
Anh
3. iu tr can thip: chng ch
.
v
e yaho t bng trong
o
l
@ t va-nhiu. Bnh
ng mch ch (IABP) Fkhi
in HoC
. 2020
8
0
nhn phi hp h 2v0 hp
tyvan MC khng nn nong
ocido khuynh hng tng nhiu
t oda
t
h
van bng bng
qua
P
rig
y
p
mc CHoC
cp
sau
nong.
o
4. Phu thut:
a. Thi im phu thut ph thuc vo nhiu yu
t bao gm triu chng c nng, kch thc v
chc nng tht tri. C th l:
Vi HoC cp, phu thut vn c li cho d
chc nng tht tri ra sao.
HoC khng c triu chng:
(a) Bnh nhn khng c triu chng nhng
ri lon chc nng tht tri khi ngh s d
c nguy c cao xut hin cc triu chng
suy tim trong vng 2-3 nm, do nn
c m c chun b.
283
(b) Bnh nhn khng c triu chng, chc

nng tht tri bnh thng, kh nng dung
np gng sc bnh thng (t mc 8
MET theo quy trnh chun) th ch nn
theo di st v c th dng cc thuc gin
mch.
(c) Bnh nhn khng c triu chng v bt
thng dung np gng sc hoc tng
ng knh cui tm thu tht tri (>
55mm) s nhanh chng c ri lon chc
nng tht tri, do nn c xt m c
chun b.
Thay van MC phi c tin hnhd ngay
rve
trc thi im m nu tip tc tr hon
ese c th
r
tsmvn(ch yu
dn ti kt cc khng tt sau
.
gh m
i
r
o
l .cchc
l
lin quan vi mc ri
lon
nng tht
v. A ahoo
e
o
tri). Thi im iphu
nhng bnh
l @thut
y
0
F n02c
.
nhn khng c
hoc
rt
t
triu chng v
8
00 ity2
2
chc nng
t thtoctri trong gii hn bnh thng
gh Pot
i
r
vnpycn nhiu bn ci. Chc nng tm thu tht
Co thng s c ci thin ng k sau m
tri
nu ch mi ri lon trong vng 18 thng.
Chc nng tm thu v kch thc cui tm thu
tht tri l nhng yu t d bo quan trng
nht i vi thi gian sng, tin lng v chc
nng tht tri sau phu thut nn thng c
cc thy thuc dng theo di v quyt nh
thi im m trn lm sng.
b. Cc kh nng phu thut cng tng t nh hp
van ng mch ch. Nhiu bnh nhn c sa l
van MC hoc vim ni tm mc nhim khun
gy h ch th c th xem xt kh nng m sa
van MC nu thng tn ph hp.
284
Ti liu tham kho

1.
Borer JS, Hochreiter C, Herrold EM, et al. Prediction of indications

for valve replacement among asymptomatic or minimally
symptomatic patients with chronic aortic regurgitation and normal
left ventricular performance. Circulation 1998;97:525-534.
2. Brener SJ, Dufly CI, Thomas JD, Stewert WJ. Progression of aortic
stenosis in 394 patients: relation to changes in myocardial and mitral
valve dysfunction. J Am Coll Cardiol 1995;25:305-310.
3. Carabello BA, Crawford FA. Valvular heart disease. N Engl J Med
1997;337:32-41.
4. Carabello BA, Stewart WJ, Crawford FA. Aortic valve disease. In:
Topol EJ, ed. Comprehensive cardiovascular medicine.
Philadelphia: Lippincott-Raven, 1998: 563-585.
ed
rvstenosis:
e
s
5. Carabello BA. Timing of valve replacement in aortic
re
ts 1997;95:2241n
h
moving closer to perfection [Editorial]. Circulation
g
i om.v
r
l
l .c
2243.
v. A ahoo
e
o
l
y Griffin BP, Topol EJ,
6. Deedy M. Aortic valve disease. In:in
Marso
SP,
F 020@
.
2
eds. Manual of Cardiovascular
Philadelphia: Lippincott08 Medicine.
20 ocity
t
t
Raven, 2000.
igh Po
r
y
7. Gaasch WH, Sundaram
M, Meyer TE. Managing asymptomatic
p
Co
patients with chronic aortic regurgitation. Chest 1997;111:17021709.
8. Kelly TA, Rothbart RM, Cooper CM, Kaiser DL, Smucker ML,
Gibson RS. Comparison of outcome of asymptomatic to
symptomatic patients older than 20 years of age with valvular aortic
stenosis. Am J Cardiol 1988;61:123-130.
9. Otto CM, Burwash IG, Legget ME, et al. Prospective study of
asymptomatic valvular aortic stenosis: clinical, echocardiographic,
and exercise predictors of outcome. Circulation 1997;95:2262-2270.
10. Otto M. Aortic stenosis: echocardiographic evaluation of disease
severity, disease progression, and the role of echocardiography in
clinical decision making. In: Otto CM, ed. The practice of clinical
echocardiography. Philadelphia: WB Saunders, 1997:405-32.
285
11. Pellikka PA, Nishimura RA, Bailey KR, Tajik AJ. The natural
history of adults with asymptomatic, hemodynamically significant
aortic stenosis. J Am Coll Cardiol 1990;15:1012-1017.
12. Weyman AE, Griffin BP. Left ventricular outflow tract: the aortic
valve, aorta, and subvalvular outflow tract. In: Weyman AE, ed.
Principles and practice of echocardiography, 2nd ed. Philadelphia:
Lea & Febiger, 1994:498-574.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
286
Hp van ng mch ch
Hp van ng mch ch (HC) l nguyn nhn thng gp

nht gy tc nghn ng tng mu ca tht tri. Cc nguyn
nhn khc bao gm hp di van ng mch ch do mng x,
hp di van ng mch ch do c tim ph i v hp trn van
ng mch ch.
I. Triu chng lm sng
Nn ngh n chn on HC trc bt k bnh nhn no c
ting thi tm thu tng mu b phi pha trn xng c, lan ln
ng mch cnh. Phn ln bnh nhn khi i khm cha c triu
d
chng c nng tuy nhin buc phi hi k pht hin
rvetin s
e
s
re ca suy
au ngc, chong vng, ngt hoc cc du hiu tskhc
n
h
.vhai
g
tim. Tin s hp eo MC gi bnh van MC
l van,
i oc
r
m
l
l o.c
A
ngc li nu bnh nhn c chn on
van
MC
c
hai l
o
.
ev yah
o
l
van, phi o huyt p ng mch tFchi
in 2
0@loi tr hp eo MC.
0 l di chng thp tim.
8. HC
2
Tin s thp tim gi nguyn nhn
0
y
0
2 tocit
t
h
o
A. Triu chng c
nng:
thng ch gp khi hp van
P
rig
y
p
MC mc
nng.
Co
1. au ngc do tng tiu th xy c tim trong khi cung
cp xy cho c tim b gim hoc do x va mch
vnh. 25% s bnh nhn khng au ngc c bnh
mch vnh, trong khi 40-80% s bnh nhn HC
au ngc c km bnh mch vnh.
2. Chong vng, ngt: do tc nghn c nh ng
tng mu tht tri v gim kh nng tng cung lng
tim, bnh nhn HC c th tt huyt p nng trong cc
tnh hung gim sc cn ngoi vi dn n chong
vng hoc ngt.
3. Biu hin ca suy tim: do ri lon chc nng tm
thu hoc chc nng tm trng. Theo tin trin ca
bnh, x ho c tim s dn ti gim co bp. Cc c
287
ch b tr nhm lm tng th tch trong lng mch s

lm tng p lc tht tri cui tm trng, tng p lc
mao mch phi bt gy huyt phi. Cc tnh trng
gy ri lon y tht tri nh rung nh hoc tim
nhanh n thun c th gy biu hin suy tim.
B. Triu chng thc th
1. Bt mch: triu chng ni bt ca HC l mch cnh
ny yu v tr (pulsus parvus et tardus), l du hiu
tt nht cho php c lng mc HC ti ging.
Mt s bnh nhn ln tui bt mch li vn thy gn
ging bnh thng do gim chun gin ca thnh
mch, nn gy c lng thp mc HC. Bt mch
ngoi vi u gim khi c HC nng. i khi s thy
d
rung miu tm thu dc theo ng mch cnh
rve bnh
e
s
re
nhn HC kht. C th s thy rung miu
ts vtm
n thu
h
.
g
i
khoang lin sn II bn phi bnh
nhn
HC.
r
om
l
Al hoo.c
.
v
2. S thy mm tim p rng,loelanyta
a nu tht tri ph
n 0@
ii
F
i nhng cha ln hn.
vi
mt s trng hp,
2
8. 20
0
y
0
s thy mm tim p
2 p,
it tng ng vi sng a hay
t otoc
h
P
g
ting T4 do tht
tri
gin
n km.
ri
y
p
Co cc ting bnh l chnh bao gm:
3. Nghe tim:
a. Thi tm thu tng mu pha trn bn phi
xng c, lan ln c, t cng cao nht vo
u-gia tm thu. Mc HC cng nng, ting
thi cng di hn, mnh hn v t cc i chm
hn (cui k tm thu). Tuy nhin cng ting
thi khng lin quan cht vi mc hp do
cng ting thi c th gim nh i nu cung
lng tim gim nhiu hoc chc nng tht tri
gim nng. Trng hp van MC c hai l van,
cn di ng, c th nghe c ting m van MC
trc ting thi tm thu.
b. Ting T1 ni chung khng thay i khi HC, tuy
nhin nu chc nng tm thu tht tri ri lon
288
nng v tng p lc cui tm trng tht tri, m

sc T1 gim do hin tng ng sm v gim lc
tc ng ng van hai l. Thnh phn ch ca
ting T2 gim i khi HC kht, T2 tr nn nh v
gn (n c) do ch nghe thy thnh phn phi
ca ting T2. Mt s bnh nhn HC nng c ting
T2 tch i nghch thng do ko di thi gian
tng mu tht tri qua l van hp kht. T2 tch i
nghch thng cng gp trong cc tc nghn
ng tng mu tht tri khc v trong bloc
nhnh tri. Ting T3 l du hiu chc nng tm
thu tht tri km. Ting T4 xut hin do nh tri
co bp tng mu vo bung tht tri c gin
km khi hp van MC kht.
d
rveh van
e
c. Ngoi ra, c th gp cc ting thi rca
s
e
hts .Hin
MC do hp thng i km higvan.
vn tng
r
m
o
l
l o.trng
c
Gallevardin xy ra trong mt
hp hp
o
. A as
h
v
e
o
van MC nng, vi ho:
nl 0thnh
@y phn m sc cao
Fixung
2
.
ca ting thi li0lan
mm tim, d ln vi
0
8 2
y
0
t
2
i
ting thi cat h tvan
c hai l km theo.
h Po o
g
i
r
d. Nhp tim
nhanh lc ngh bnh nhn HC nng l
opy
mt Ctrong nhng du hiu u tin ca tnh trng
cung lng tim gim thp.
A. Cc nguyn nhn gy hp van ng mch ch
1. Hp van MC bm sinh: dng hp van MC hay
gp nht ngi ln l bnh van MC c hai l van,
chim 1-2% dn s, ch yu nam gii. Van MC
thng thoi ho v vi sm. Mt s dng HC khc
nh dnh l van, van mt cnh...
2. Hp van MC mc phi:
a. Hp do thoi ho v vi ho l dng bnh thng
gp nht, ni tri tui 70-80. Qu trnh ri lon
chuyn ho canxi trong bnh Paget, bnh thn
289
giai on cui lm tng qu trnh vi ho. Cc

yu t nguy c ca bnh mch vnh thc y
nhanh qu trnh vi ho cc l van b thoi ho.
b. Hp van MC do thp tim t khi n thun m
khng km bnh van hai l. Thp tim gy x ho,
vi ho, dnh cc l van v mp van MC, dy l
van nht l ti b.
d
rve
e
s
re
ts vn
h
.
g
l ri .com
l
A o
ev. yaho
o
l
Fin 0@
8. 202
0
20 ocity vi ho.
Hnh 15-1. Van
t oMC
h
Pt
rig
y
B. Sinh l bnh
p
Co
1. Hp van MC c trng bi qu trnh hp dn l van
MC gy tng dn hu gnh cho tht tri. duy tr
cung lng tim, tht tri phi bp vi sc bp tm thu
cao hn, lm tng p lc ln thnh tim, dn n ph
i ng tm, nh bnh thng ho sc p ln
thnh tim (theo nh lut Laplace: sc p ln thnh
tim = p lc ng knh + 2 dy tim), song li
lm gim gin n ca tht tri.
2. Tht tri gin km s lm gim qu trnh y tht
tri th ng trong giai on u ca thi k tm
trng. Tin gnh tht tri ph thuc rt nhiu vo co
bp nh tri. Tht tri cng dy, lc bp cng gia
tng, thi gian tm thu ko di, cng lm tng mc
tiu th xy c tim. Khi suy tim, p lc cui tm
290
trng tht tri tng lm gim p lc ti mu ng

mch vnh, gy p cc ng mch nh trong c
tim hoc pha di ni tm mc, do cng lm
gim hn na cung cp xy cho c tim, gy biu hin
au ngc...
C. Din bin t nhin ca bnh
1. Tin trin ca hp van MC c trng bi mt giai
on ko di khng biu hin triu chng c nng
cho ti khi din tch l van MC < 1,0 cm2. Ni
chung, chnh p trung bnh qua van MC tng
khong 7 mmHg/nm v din tch l van gim
khong 0,12-0,19 cm2/nm. Do tc tin trin rt
khc nhau, tt c bnh nhn HC cn c tuyn
d
truyn k v cc triu chng bo hiu tin etrin
rve ca
s
re
bnh. T l sng cn gn nh bnh thng
ts vkhi
n khng
h
.
g
i
c triu chng c nng. Nguy c
t
t
<
r
ll o.com 2%/nm
A
o
.
ngay c bnh nhn hp van
ev MC
ah nng m khng
o
l
y
c triu chng c nng.. Fin 20@
0
08 ty2triu
0trin
2. Nhng khi pht
chng c nng, t l
2
i
t otoc
h
P
g
sng cn gim
xung
nhanh
chng
nu khng m:
ri
y
p
o
a. Khi Cbnh
nhn c au ngc th t l sng cn
ch t 50% sau 5 nm,
b. Khi c ngt th t l sng cn ch t 50% sau
3 nm,
c. Khi c suy tim th thi gian sng trung bnh <
2 nm.
d. t t c th xy ra nhng bnh nhn HC c
triu chng c nng do cc ri lon nhp tht trn
bnh nhn ph i v ri lon chc nng tht tri
hoc ri lon nhp th pht do thiu mu c tim.
A. in tm : thng c dy nh tri (80%) v ph i
tht tri (85%). Ri lon nhp t khi xy ra, ch yu giai
on cui v a s l rung nh, nht l khi c km bnh
291
van hai l. Bloc nh tht c th gp khi c pxe vng van

bin chng ca vim ni tm mc.
B. Xquang ngc: t c gi tr chn on do hnh nh c
th hon ton bnh thng. Bng tim ging hnh chic
ng nu ph i tht tri ng tm. Hnh tim thng to
nu c ri lon chc nng tht tri hoc c HoC phi
hp. Mt vi hnh nh khc c th bt gp l hnh nh vi
ho van MC ngi ln tui (phim nghing) hoc gin
on MC ln sau hp.
C. Siu m Doppler tim: siu m Doppler tim l phng
php c la chn chn on xc nh v nh gi
mc nng ca hp ch. Cc mt ct cnh c (2D hoc
TM) l nhng v tr tt nht nh gi c ch, nguyn
d
nhn HC v o c kch thc bung tim, thnh etim.
rve
s
re
ts vn gy hp
1. nh gi v tnh trng van, nguyn
nhn
h
g
i om.
l rtim:
van v nh hng n cc bung
l
.c
v. A ahoo
e
o
a. Cc l van dy, m dng
@y trong thi k tm
inl 20vm
. F 20sinh
thu gp trong HC08bm
v do thp tim, phn
0 ity
2
dyc ca l van (mt ct trc di
bit bng kiu
ht Poto
cnh cytri):
do thp thng dy khu tr b
rig HC
p
o
C
t do nhiu hn so vi thn l van, rt hay c
HHL km theo. Ngc li, HC do thoi ho th
qu trnh vi ho thng tin trin t thn cho ti
b mp van, lm gim dn di ng l van n
gn nh c nh. C th s b nh gi mc
HC da vo bin m van trn siu m TM
(bnh thng l 16-22 mm):
HC nh: bin m van MC t 13-15 mm.
HC va: bin m van MC t 8-12 mm.
HC nng: bin m van MC < 8 mm.
Tuy nhin gi tr ny c tnh cht gi , ch
khng hon ton chnh xc, v ch nh gi c
khong cch gia 2 trong s 3 l van MC. K
thut o v v tr mt ct c th lm sai lc kt
qu o. Cung lng tim gim nhiu cng lm
292
gim bin m ca van MC d khng c HC

thc s.
b. S lng mp van, ng ng van v hnh dng
l van (mt ct trc ngn cnh c tri) cho php
chn on cc loi HC bm sinh: van MC c
hai l van, van MC dng mt l-mt mp hoc
dng mt l-khng c mp van... Tuy nhin, khi
van MC vi ho nng th vic xc nh
nguyn nhn HC tr nn rt kh khn.
c. Ph i v gin tht tri, gin nh tri trn mt ct
trc di cnh c tri nhng nu hp van MC n
thun, tht tri thng nh tuy c ph i. Mt ct
bn bung hoc nm bung t mm cho php
nh gi chung chc nng co bp v vn
d ng
rve
e
s
thnh tht. Cc mt ct ny cng cho
re php xc
tsbng
n
h
nh mc h van MC km rtheo
g
i om.v siu m
l
l .c
Doppler mu.
v. A ahoo
e
o
l
y
2. nh gi v huyt ng:
Fin020@
.
08 ty2 MC: thng o bng
a. Chnh p qua
20 ovan
i
t tcotsc dng mt ct nm bung t

h
Doppler lin
P
g
ri
py mt s mt ct khc nh: khoang lin
mmCov
sn II b phi xng c, trn hm c... da trn
cng thc Bernoulli sa i (P = 4 V2) xc
nh chnh p trung bnh v chnh p ti a (tc
thi nh-nh) gia MC v tht tri. Mc
HC c phn loi da vo chnh p qua van
MC:
HC nh: chnh p ti a < 40 mmHg hoc
chnh p trung bnh < 20 mmHg.
HC va: chnh p ti a: 40-70 mmHg hoc
chnh p trung bnh: 20-40 mmHg.
HC nng: chnh p ti a > 70 mmHg hoc
chnh p trung bnh > 40 mmHg.
Mt s yu t lm tng gi to chnh p qua van
MC nh: c km h van MC, mng ngn di
293
van MC, tnh trng tng cung lng tim, o sau

nht ngoi tm thu, ly nht bp khng i din
(khi rung nh) hoc ln vi ph ca h van hai l.
Hnh 15-2. Ph Doppler lin tc ca hp van MC.

d
rve
e
s
b. Din tch l van MC: o theo nguyn
l ca
re
ts vn
h
.
g
phng trnh lin tc:
l ri .com
2 Al
oo
.
Din tch van MC = erv VTI
ah TT / VTIMC
o
l
y
@ phn vn tc theo
Trong : VTI
Finl 0tch
8. TT202
0
thi gian ca dng
ty tm thu ti v tr bung
20 ocichy
t
t
h
o
tng murigca tht
P tri (Doppler xung vi ca s
y
p
Doppler
cch
van
MC 1 cm ti mt ct 5 bung
Co
tim); VTIMC l tch phn vn tc theo thi gian
ca dng chy qua v tr van MC b hp; r l
bn knh ca bung tng mu tht tri (mt ct
trc di, ngay st vng van MC).
Mc hp van MC c phn loi da vo
din tch l van nh sau:
HC nh: din tch l van > 1,5 cm2.
HC va: din tch l van t 1-1,5 cm2.
HC nng: din tch l van < 1 cm2, khi din
tch < 0,75 cm2 (< 0,5 cm2/m2 din tch da) th
c coi l hp van MC rt kht.
c. Ch s VTITT/VTIMC: khi < 0,3 tng ng vi
hp van MC nng, khi < 0,25 tng ng vi HC
kht. Ch s ny khng ph thuc vo lu lng
294
tim v trnh c cc sai st khi o ng knh

bung tng mu tht tri, c ch trong trng hp
hp van MC kht v ri lon chc nng tht tri
nng. Tuy nhin, cn lu ch s ny c t l sai
st cao khi ng knh bung tng mu tht tri
rng > 2,2 cm hoc hp < 1,8cm.
3. Siu m tim qua thc qun: c th o trc tip din
tch l van (2D), nhng kh ly c ph Doppler
ca dng chy qua van b hp hn. Cng c ny rt
c ch nh gi hnh thi van MC trong bnh hp
van MC bm sinh.
4. Siu m gng sc: nhm phn bit nhng trng hp
hp van MC thc s c ri lon chc nng tm thu
d
tht tri nng (nn chnh p qua van thp) vi
rve nhng
e
s
re c tim t
trng hp gi hp (bnh l nh hngtsn
h
.vn ri lon
g
trc, c km hp van MC nh,l rnn
i ocng
m
.c thp qua van
Al hoop
chc nng tm thu tht tri vev.chnh
a
o
l @khng
y
MC) bi trng hp gi
h c ci thin
0
Finhp
2
.
0
8 2
sau khi c m. Dobutamine
truyn
vi liu tng
0
20 ocity
dn t 5 n g20
tng dn cung lng
ht g/kg/pht
Pot
ri siu
y
tim, sau
dng
m
tim
kim tra tng bc din
op
C
tch l van v chnh p qua van MC. Cn ngng
ngay nghim php khi bnh nhn tt p, au ngc
hoc xut hin ri lon nhp tim.
D. Thng tim: trc y thng tim l tiu chun vng
chn on v lng gi hp van ng mch ch. Tuy
nhin ngy nay, siu m tim dn dn c chp nhn
rng ri nh mt phng tin chn on v nh gi
HC thay th cho thng tim.
1. Thng tim c ch nh khi c nghi ng v mc
hp van trn siu m tim hoc chp ng mch
vnh cho bnh nhn nam tui > 40 v n tui > 50
trc khi m thay van.
2. Cn cn nhc gia cc li ch ca thng tim v nguy
c bin chng nht l bnh nhn HC kht. Nguy c
295
t vong sau thng tim bnh nhn hp kht van MC

l 0,2%. Bnh nhn HC nng nn dng thuc cn
quang loi trng lng phn t thp, khng ionic
hn ch bt cc nguy c tt huyt p do gin mch
ngoi vi, ri lon nhp chm, ri lon chc nng c
tim thong qua, hn ch tc dng li tiu thm thu,
nh gim bt nguy c ca th thut. i vi bnh
nhn hp kht van MC, nn trnh chp bung tht
tri.
3. Gi tr chnh p trung bnh qua van MC o bng
thng tim rt ging vi siu m trong khi gi tr
chnh p ti a nh nh o qua thng tim thng
thp hn so vi siu m. C th lm th nghim kch
thch bng truyn Nitroprusside tnh mch
d nh
rve
e
s
gi s thay i v chnh p qua van v rdin
tch l
e
ts nhm
n
h
v
van mi khi c thay i cung lng
tim
phn
.
g
ri com
l
l
.
bit cc trng hp hp van MC
A thc
o s vi nhng
ev. yaho
o
l
trng hp gi hp.
in @
. F 2020
8
0
4. Khi HC khng kht20th phn
ty s tng mu, cung lng
cc
oci bung tim bn phi v p lc
tlc
t
tim khi ngh, p
h
o
rig btPu bnh thng. p lc cui tm
y
mao mch
phi
p
Co
trng tht tri thng tng do tht tri ph i
gim gin. Sng a trn ng cong p lc nh tri,
p lc mao mch phi bt thng ni r. Khi mc
HC tng ln, p lc cui tm trng tht tri, p lc
cc bung tim phi v ng mch phi cng tng ln.
Phn s tng mu v cung lng tim s gim khi
bnh tin trin n giai on cui. Trng hp HC
kht, chc nng tht tri gim nng th chnh p qua
van MC s gim. Khng bao gi nh gi mc
hp van MC ch da trn gi tr chnh p qua van
n thun m phi ch n chc nng tht tri v
mc h van hai l km theo.
296
IV. iu tr
A. La chn bin php iu tr: ct li ca iu tr hp
van MC nng l phu thut thay van MC. Ni chung
phu thut u tin cho nhng bnh nhn c triu
chng c nng, do thay van MC c nguy c bin chng
kh cao v t l sng cn ch thc s ci thin r rt khi
bnh nhn bc l triu chng c nng. Ngy cng c
nhiu bng chng cho thy khi hp van MC ti mc
nng, th xu hng s xut hin triu chng v phi m
thay van ch trong vng 3 nm. i vi bnh nhn ln
tui hp kht van MC, vic m khi cha c triu
chng xem ra c li hn so vi vic i n khi xut hin
triu chng c nng. M sm cng c li i vi nhng
d
bnh nhn tr m chnh p qua van MC rt cao
rvev hn
e
s
e
ch c nguy c cao xut hin t t. Tng
s r n t, bnh
2t
h
v theo hp
.
g
nhn c din tch l van MC 1,0 cm
km
l ri .com
l
Acu oni ch-vnh th
ng k ng mch vnh v cn lm
ev. yaho
o
l
nn tnh c n vic m thayFvan
in MC.
0@
8. 202
0
B. iu tr ni khoa 20 city
ht Ptr
oto khng sinh d phng vim ni
igiu
1. Bt buc phi
r
py khun.
tm mcConhim
2. Vi bnh nhn cha c triu chng c nng (din
tch l van MC > 1,0 cm2) th iu tr c mc ch
phng tin pht bnh l ng mch vnh, duy tr nhp
xoang v khng ch huyt p. Tt c bnh nhn phi
c hng dn v cc du hiu v triu chng ca
au tht ngc, ngt hoc suy tim i khm li ngay
v xt m nu xut hin cc triu chng c nng ny,
v khi nguy c phu thut thp hn cc nguy c
ca vic tip tc iu tr ni khoa.
3. iu tr suy tim nhm vo vic kim sot cn bng
dch gim huyt phi, thng bng thuc li
tiu. Tuy nhin, cung lng tim bnh nhn HC
nng ph thuc nhiu vo tin gnh, nn cn rt thn
297
trng khi dng li tiu trnh dng liu qu cao,

gy tt huyt p (do gim cung lng tim) v gim
ti mu ngoi vi. Trnh dng cc thuc nhm
Nitrates bnh nhn suy tim do HC nng v thuc
lm gim tin gnh ng k, c th gy gim ti
mu no v ngt. Digoxin thng ch c ch nh
cho bnh nhn HC suy tim nht l khi rung nh. iu
tr HC c suy tim bng thuc khng h ci thin tin
lng sng lu di ca bnh nhn. Hn na, iu tr
ni khoa bnh nhn hp van MC nng v ri lon
chc nng tht tri qu tch cc khng h c li m
cn nguy him.
4. Trnh dng cc thuc gin mch cho bnh nhn
hp ch n thun.
d
rve
e
s
re
a. Trong mt s bnh cnh hp h van
HC
ts vMC,
n
h
.
g
phi hp h van hai l, HC phi
i hp bnh mch
ll r o.com
A
vnh th c th cn nhc vic
dng
o
.
ev yah cc thuc gin
o
l
mch song nn ht Fsc
in 2thn
0@ trng, i khi phi
0 bnh nhn ti phng hi
8. cho
2
theo di huyt ng
0
0 ty
2 tocibnh
tthuyt,
sc. Trn l
nhn h van nhiu s c
h
Po
ig
yr thuc gin mch; bnh nhn c bnh
li khiopdng
C vnh cng c li v gim hu gnh s lm
mch
gim nhu cu xy c tim. D vy, thuc gin
mch ch l bin php iu tr tm thi trc
khi m lm cu ni ch vnh.
b. Liu khi u nn dng rt thp ti phng hi sc
(tt nht l nitroprusside d chnh liu), sau
khi n nh liu gin mch s chuyn dn sang
thuc ung (c ch men chuyn, Hydralazine).
5. Bnh nhn hp van MC nng chu ng rt km
tnh trng rung nh (v tin gnh tht tri ph thuc
rt nhiu vo co bp nh), nhanh chng-d dng gy
gim cung lng tim v huyt phi, ng thi tng
nhu cu xy (do nhp nhanh). Bi vy, cn iu tr
298
tch cc rung nh ngay t lc mi khi pht bnh

nhn HC nng nhm chuyn v nhp xoang.
6. i vi bnh nhn hp van MC nng v chc
nng tht tri ri lon nng, c chnh p qua van
MC thp: phu thut ch ci thin triu chng
khong 50%, 50% cn li khng h ci thin triu
chng v cht trong giai on hu phu m khng t
trong s l cc trng hp gi hp ch (ri lon
chc nng c tim nng t trc km theo gi hp van
MC do cung lng tim thp). Tuy cn nhiu im
cha thng nht song trc khi i n vic la chn
bnh nhn ph hp v quyt nh m, th:
a. Nn lm siu m tim gng sc hoc nghim php
kch thch khi thng tim nh girvednhng
e
res ri lon
trng hp hp van MC thc stsgy
vn tch l
.din
chc nng tht tri nng bng cch
ighoo
r
m
l
c
Al hoo.khi
van v chnh p qua vanev.MC
cung lng
a
o
l
y
tim tng. Nu cung Flng
in @tim tng ng k m
. 2020
khng gy thay0i
p th l gi hp,
08 tychnh
2 oci
t cung
ngc li nu
t lng tim tng gy tng chnh
igh Po
yr th l hp tht.
p quaopvan
C
b. Nn th nong van bng bng qua da: nu triu
chng suy tim v cung lng tim ci thin sau
can thip th kh nng hi phc sau m thay van
MC s ln hn.
C. iu tr can thip
1. t bng trong ng mch ch (IABP): nhm n
nh tm thi tnh trng huyt ng bnh nhn hp
van ng mch ch nng, suy tim mt b chun b
m. Hiu qu ca t bng trong ng mch ch l
nh tng ti mu mch vnh trong k tm trng,
lm gim tnh trng thiu mu ca ton th c tim khi
hp van MC kht, suy tim mt b.
299
2. Nong van ng mch ch bng bng qua da: c

vai tr r rt i vi hp van MC bm sinh tr em
tuy khng c p dng tuyt i bnh hp van
MC mc phi. Mc d k thut ny c nhiu ha
hn nhng so vi m th vn cha hiu qu bng: sau
th thut, din tch l van tng ln 50% song sau 6
thng c ti 50% ti pht. V th nong van MC
bng bng ch c ch nh trong mt s trng hp
nht nh nh: hp van MC bm sinh tr em, bnh
nhn khng th m do tui cao hay c bnh phi hp,
iu tr tm thi trc khi m c chun b, iu tr
th bnh nhn c ri lon chc nng tht tri nng
(xem liu bnh nhn c ci thin sau m hay khng).
T l t vong ca th thut ny khong 2-5%. d
rve
ese
D. iu tr ngoi khoa
r
hts n
1. Ch nh m thay van MC: ll rig com.v
.
. Anng:
hoo
vc
a. Bnh nhn c triu chng
e
a
o
l
y
Fin020@
au ngc.
.
08 2
Ngt.
20 ocity
ht Pot
Suy tim.
rig
y
p
b. BnhConhn
khng c triu chng c nng:
Tui tr v chnh p qua van MC > 100
mmHg.
Cn lm th thut/phu thut ln, c nguy c
cao.
C ch nh bc cu ni ch vnh.
Ri lon chc nng tm thu tht tri.
2. Cc loi phu thut thay van ng mch ch: thay
van ng mch ch c a chung hn m sa van
v sau khi gt mng v ly vi l van, cc l van
hay co rt, gy h van ngay sau phu thut v dn
dn mc h s tng ln. Tuy nhin, vi hp van
MC bm sinh m van cha vi th vn c th sa
van tu theo tng trng hp c th. M thay van
MC n thun khng km bnh mch vnh hoc
300
cc bnh nng khc th t l t vong quanh phu

thut khong 2-3%. T l sng cn sau m thay van
MC vo khong 85% sau 10 nm. S la chn loi
van thay ph thuc vo rt nhiu yu t nh tui,
nguy c dng/khng dng thuc chng ng, c
im gii phu, chc nng tht tri, mc hot
ng th lc, d tnh m li... Ni chung, bao gm
cc loi nh:
a. Phu thut Ross (ghp van t thn): van v thn
ng mch phi c ct lun c khi ri thay
vo v tr ca van ng mch ch ng thi cm
li hai ng mch vnh. Ch van ng mch phi
b ct s c thay th bng mt van ng mch
phi ng loi. Van ghp t thn kiu nyedrt tt
rv
v huyt ng, khng cn dng thuc
ese chng
r
ts vnhc khc,
ng, t vi ho hn so vi cc van
.
ghsinh
i
r
om th, c c
lca.cc
l
c th ln ln theo pht trin
A hoo
ev. cao
a nn rt ph hp
o
l
tnh chng nhim trng
rt
in 20@y
F
lm tr nh 0hoc
8. 0 bnh nhn vim ni tm
0 ity2
2
csong i hi k thut cao v
mc nhim khun
ht Poto
igko
thi gian
di,
d gy ra nhiu ri lon sau
r
py
o
C
m. Tin lng lu di ph thuc vo mc h
van ng mch ch, bnh l van ng mch phi
(h, hp) hay cc ri lon chc nng tht phi
(th pht sau bnh van MP).
b. Thay van MC ng loi: c dng rng ri
cc bnh nhn tr tui do c im huyt ng
tt v khng cn dng thuc chng ng. Tuy
nhin theo thi gian, cc van loi ny khng h
ln ln, s b thoi ho, vi v gy h. Bn thn
k thut thay van loi ny cng kh phc tp v
thng phi hp vi vic to hnh mt phn gc
ng mch ch v cm li ng mch vnh, cho
d vn n gin hn so vi phu thut Ross. Tui
th trung bnh ca van l 15 nm. Phu thut ny
c t l nhim trng rt t khi ang c vim ni
301
tm mc v y l thay van ng loi c ch

nh khi vim ni tm mc nhim khun trn van
nhn to.
c. Thay van sinh hc (d loi): thng c ch nh
cho bnh nhn tui > 70. Trong vng 10 nm, 8090% van thoi ho gy h hoc hp do thng l
van, gim vn ng, r quanh chn van. Khng
cn dng chng ng lu di sau thay van v nguy
c huyt khi thp. Phn ln u c chnh p qua
van ngay sau m (v b vng van, khung cn
tr mt phn), mc nhiu hn so vi van c
hc v th khi thay, cn chn loi van c kch
thc ln nht c th c gim bt chnh p
qua van.
d
rve
e
s
d. Thay van c hc: cc loi van thngredng l St.
ts vn
Jude Medical, Metronic-Hall rv
gh Carbomedics.
i
m.
o
l
l
c
.
Bnh nhn sau thay van loi
oophi ung thuc
. Any
evc
ah huyt khi van
o
l
y
chng ng gim nguy
to
in 20@
. F mch
0 khc. bn ca loi
v cc bin chng08tc
0 ity2
2
c nu duy tr c iu tr
tnht
van ny lhtcao
oo
P
g
i
r
chng py
ng v d phng khng sinh cn thn
o
trongC nhiu nm.
3. Bin chng: nhng bin chng tim tng sau m
thay van MC l h hng cu trc van, ri lon hot
ng (huyt ng) van, huyt khi kt van, tc mch,
chy mu do dng thuc chng ng, vim ni tm
mc nhim khun van MC nhn to, huyt tn v
bloc nh tht. Phi dng thuc chng ng cn thn
(i vi bnh nhn no c ch nh) v phi dng ko
di sut thi gian tn ti van nhn to (n c i).
Bnh nhn hot ng th lc mc thp s t nh
hng hn n huyt ng ca van v do tc
thoi ho van cng s chm hn.
302
E. Theo di
1. Bnh nhn hp van ng mch ch nng cha c
triu chng c nng nn c theo di st v hng
dn ti khm ngay khi c bt k triu chng c
nng no.
2. Siu m Doppler tim 1-6 tun sau m thay van
MC nh gi hot ng ca van v chnh p qua
van nhn to lm mc theo di. Sau bnh nhn
c kim tra siu m nh k 1-2 ln/nm.
3. Kim tra hiu qu chng ng mu (t l
prothrombin, INR) nh k iu chnh liu ph
hp bnh nhn c ch nh dng thuc chng ng.
Ti liu tham kho
1.
2.
3.
4.
5.
6.
7.
8.
rve
Borer JS, Hochreiter C, Herrold EM, et al. Predictionrof

eseindications
s
t or n minimally
for valve replacement among asymptomatic
ighom.v and normal
r
symptomatic patients with chronic aortic regurgitation
l
l
c
. A ahoo.
left ventricular performance. Circulationev1998;97:525-534.
o
y Progression of aortic
Brener SJ, Dufly CI, Thomas JD, Stewert
nl 0@WJ.
Fichanges
2
.
0
stenosis in 394 patients: relation
to
in myocardial and mitral
08 ty2
0Cardiol
2
i
valve dysfunction. J Am Coll
1995;25:305-310.
oc
t otValvular
Carabello BA, Crawford
heart disease. N Engl J Med
P
igh FA.
r
1997;337:32-41.opy
Carabello BA,CStewart WJ, Crawford FA. Aortic valve disease. In:
Topol EJ, ed. Comprehensive cardiovascular medicine.
Philadelphia: Lippincott-Raven, 1998: 563-585.
Carabello BA. Timing of valve replacement in aortic stenosis:
moving closer to perfection [Editorial]. Circulation 1997;95:22412243.
Deedy M. Aortic valve disease. In: Marso SP, Griffin BP, Topol EJ,
eds. Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven, 2000.
Gaasch WH, Sundaram M, Meyer TE. Managing asymptomatic
patients with chronic aortic regurgitation. Chest 1997;111:17021709.
Kelly TA, Rothbart RM, Cooper CM, Kaiser DL, Smucker ML,
Gibson RS. Comparison of outcome of asymptomatic to
symptomatic patients older than 20 years of age with valvular aortic
stenosis. Am J Cardiol 1988;61:123-130.
303
9.
Otto CM, Burwash IG, Legget ME, et al. Prospective study of

asymptomatic valvular aortic stenosis: clinical, echocardiographic,
and exercise predictors of outcome. Circulation 1997;95:2262-2270.
10. Otto M. Aortic stenosis: echocardiographic evaluation of disease
severity, disease progression, and the role of echocardiography in
clinical decision making. In: Otto CM, ed. The practice of clinical
echocardiography. Philadelphia: WB Saunders, 1997:405-32.
11. Pellikka PA, Nishimura RA, Bailey KR, Tajik AJ. The natural
history of adults with asymptomatic, hemodynamically significant
aortic stenosis. J Am Coll Cardiol 1990;15:1012-1017.
12. Weyman AE, Griffin BP. Left ventricular outflow tract: the aortic
valve, aorta, and subvalvular outflow tract. In: Weyman AE, ed.
Principles and practice of echocardiography, 2nd ed. Philadelphia:
Lea & Febiger, 1994:498-574.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
304
vim ni tm mc nhim khun
Vim ni tm mc nhim khun (VNTMNK) l tnh trng

bnh l do vim nhim vi thng tn ch yu lp ni mc ca
tim. Biu hin i th thng gp l nhng tn thng lot v si
cc van tim. y l bnh rt nng, nu khng c pht hin
v iu tr sm bnh thng dn n t vong. Ngy nay d c
nhiu tin b trong cc khng sinh iu tr cng nh phu thut
nhng t l t vong ca bnh vn cn kh cao.
I. Nguy c mc VNTMNK
A. Nguy c cao
d
1. Van nhn to.
rve
e
s
re
2. Tin s b VNTMNK.
ts vn
h
.
g
l ri .com
3. Tim bm sinh c tm.
l
A hoo
ev. hoc
a hp van MC.
4. Bnh h van ng mch ch
v/
o
l
in 20@y
F
5. H van hai l.
8. 0
00 ity2
2
6. Hp van hai l km
t h
tocvan hai l.
igh Po
r
7. Cn ng ng
py mch.
Co
8. Thng lin tht.
9. Hp eo ng mch ch.
10. Cc phu thut tim m vn tn ti tnh trng huyt
ng bt n sau m.
B. Nguy c va
1. Sa van hai l c gy h van hai l.
2. Hp hai l n thun.
3. Bnh l van ba l.
4. Hp ng mch phi.
5. Bnh c tim ph i lch tm.
6. Bnh van MC c hai l van hoc vi ho van ng
mch ch m cha nh hng nhiu n huyt ng.
7. Bnh thoi ho van ngi gi.
305
8. Cc phu thut tim m tnh trng huyt ng sau m

t bin ng (trong thi gian 6 thng sau m).
C. Nguy c thp
1. Sa van hai l khng gy h hai l.
2. H ba l trn siu m tim m khng km theo bt
thng van.
3. Thng lin nh l th hai n thun.
4. Mng x m ng mch.
5. Bnh ng mch vnh.
6. Cy my to nhp.
7. Cc phu thut tim m tnh trng huyt ng sau m
khng bin ng, thi gian > 6 thng sau m.
d
II. Nguyn nhn
rve
e
s
re
ts nhin:
A. Vim ni tm mc bnh nhn vanht
hay
n
g
i om.v
r
l
gp nht l lin cu khun (viridansAStreptococcus
v
cc
l o.c
o
.
h
v
phn nhm khc) chim khong
a Staphylococcus
oe 60%,
@y
inlHACEK
0
F
25%, Enterococcus, nhm
(Haemophilus,
2
8. 20
0
y
0
Actinobacillus, Cardiobacterium,
Eikenella, v Kingella)
2 it
t otoc
h
P
g
khong 3%.
ri
opy
C
B. Vim ni tm mc bnh nhn dng ma tu
ng tnh mch: thng hay b tn thng van tim
bn phi v hay gp nht l t cu vng (S. aureus), ngoi
ra i khi c th gp nm.
C. Vim ni tm mc bnh nhn van nhn to: c
th xy ra sm hoc mun. Thng hay xy ra trong 6
thng u sau thay van. Thng hay gp t cu vng (S.
aureus), vi khun gram m, c th do nm lm tin lng
bnh thm phn nng.
D. Vim ni tm mc c cy mu m tnh (10-30%):
thng gp bnh nhn dng khng sinh trc ,
cng cn ch nhm c vi khun gy bnh mc mun:
do nm, nhm HACEK, Legionella, Chlamydia psittaci,
Coxiella, Brucella, Bartonella...
306
E. Vim ni tm mc do nm: thng gp Candida v

Aspergillus, hay gp bnh nhn van tim nhn to, c
thit b c hc ci ghp trong tim, suy gim min dch,
dng thuc ma tu ng tnh mch. Bnh cnh phc tp
v tin lng rt nng.
III. Triu chng lm sng v xt nghim chn on
L biu hin bi 3 hi chng: (Bng 16-1)
1. Nhim trng h thng.
2. Tn thng ni mc mch.
3. Phn ng h min dch vi nhim trng.
Ni tm li: trc mt bnh nhn vi tam chng kinh in nh:
st, thiu mu, ting thi tim cn ngh ti kh nng VNTMNK.
ved
rtrng
e
Vn cy mu: l mt xt nghim cc k quan
s
re
ts vnthc hin
chn on bnh cng nh nh hng iu tr.ghPhi
.
om3 mu mu
ltrinht
sm ngay khi c chn on lm sng. Ly
l
c
.
A hoo
ev. mch
a khc nhau, mi
ring bit trong 24 gi, nhng v tr tnh
o
l
n 0@y
i
F
2
ln nn ly 2 ng nghim i kh8.v k0 kh ring. V VNTMNK
00 itc
ty2 trong mu nn khng cn
2lin
l hin tng c mt vi khun
c
o
ht ot
phi ch lc st nh cao
rigmi Ply mu cho d cy mu khi bnh
y
p
nhn ang st th t
Co l dng tnh s cao hn. Cn lu l khi
cy mu gi l m tnh trong nhng ngy u th phi tip tc
cy tip v mt s vi khun nh ni trn mc rt mun.
IV. Tiu chun chn on VNTMNK
Ngy nay, hu ht cc tc gi dng tiu chun Duke ci
tin v c nhy v c hiu cao nht (Bng 16-2a v16-2b).
Tiu chun bao gm: VNTMNK chc chn (v gii phu bnh
v v lm sng), VNTMNK c th v loi tr VNTMNK.
i vi VNTMNK chc chn trn gii phu bnh th ch
cn 1 trong 2 tiu chun l .
i vi VNTMNK chc chn trn lm sng th cn c 2
tiu chun chnh, hoc 1 tiu chun chnh v 3 tiu chun ph,
hoc c 5 tiu chun ph.
307
VNTMNK c th khi khng tiu chun ni trn nhng

cng khng tiu chun loi tr.
Loi tr VNTMNK khi cc du hiu lm sng c gii
quyt sau 4 ngy dng khng sinh, hoc khng c bng chng
gii phu bnh sau 4 ngy dng khng sinh.
d
rve
e
s
re
ts vn
h
.
g
A
l riB.com
l
A hoophi (A); Si
Hnh 16-1. Si ni mc thn ng
ev.mch
a
o
l
in 20@y
van ng mch phi (B).
F
8. 0
00 ity2
2
t toc
igh Po
r
py
Co
C
D
Hnh 16-2. Si van ng mch ch (C) gy h van ng
mch ch nng (D). LA: nh tri, MV: van hai l, V: si, AV:
van ng mch ch, Ao: ng mch ch, RV: tht phi, LV:
tht tri, AR: h van ng mch ch.
308
Bng 16-1. Cc biu hin lm sng v cn lm sng ca VNTMNK.

Biu hin
Triu chng c nng
Thm khm
Nhim trng St ko di, rt run, v m St.
h thng.
hi, kh chu, yu c, ng Xanh ti.
lm, m sng, au u, mt St cn.
ng, st cn, au lng, au Suy nhc.
khp, au c... C th khai Lch to.
thc thy ng vo: mi Thiu mu.
hng, rng ming, ngoi
da, tit niu, tim chch...
Tn thng Kh th, au ngc, lit khu Ting thi mi tim.
ni mc tim tr, tai bin mch no, au Suy tim.
m xut huyt di da, mt,
bng, au v lnh u chi.
mch.
c.
Nt Roth.
Nt Osler.
Tn thng Janeway.
m xut huyt.
Tai bin mch no.
Phnh vi mch no.
Thiu mu hoc tc mch chi.
Co
i mu vi th.
Chp tim phi.
Siu m tim.
Chp mch mu.
CT scan s no.
309
Cc thm d
Tnh trng thiu mu.
Tng bch cu mu.
Tng tc lng mu.
Cy mu dng tnh.
Bt thng dch no tu.
ved
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.
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rig

Bng 16-1. Cc biu hin lm sng v cn lm sng ca VNTMNK (tip theo).

Protein niu,
Phn
ng au khp, au c, vim Vim khp.
Hng cu niu, tr niu,
min dch.
bao gn.
Cc du hiu tng ur mu.
Tng ur mu,
Mng tay khum
Nhim toan mu.
Tng gramma globulin.
Thy c yu t dng thp,
gim b th v phc hp
min dch trong mu.
Tm khng th khng t
cu trong mu.
Co
py
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310
Bng 16-2a. Tiu chun Duke chn on chc chn VNTMNK trn gii phu bnh.
Tm thy vi khun (nm) bng nui cy hoc soi t bo :
Cc si trong tim.
Cc si bn i gy tc mch.
p xe trong tim.
Hnh nh tn thng gii phu bnh:
Thy cc si hoc pxe trong tim c hnh nh t bo hc ca vim ni tm mc ang tin
trin.
ved
ved
Co
py
er
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311
Tiu chun chnh:

Cy mu dng tnh c trng cho VNTMNK:
Loi vi khun in hnh ( t nht 2 mu mu): viridant Streptococcus; S. bovis; nhm HACEK;
S. aureus hoc Enterococcus.
Cy mu dng tnh bn vng:
Tn ti loi vi khun hai mu mu khc nhau t nht 12 gi, hoc
Tn ti loi vi khun c 3 mu mu, hoc phn ln trong 4 hoc hn cc mu mu cch bit
m thi im ca mu u v mu cui cch nhau t nht 1 gi.
Bng chng tn thng ni tm mc: Bng chng siu m tim:
Khi si di ng lc lc trong tim, dnh vi van tim hoc cc cu trc trong tim, hoc cc cu
trc nhn to (van) m khng gii thch c v hnh dng gii phu thng thng ca tim, hoc
Hnh nh pxe, hoc
Hnh nh t tch mi mt phn van nhn to, hoc
Hnh nh h van tim mi xy ra.
Tiu chun ph:
1. Tin s:
C bnh van tim t trc.
Tim chch ma tu
Bng 16-2b. Tiu chun Duke trn lm sng.
Co

312
2. St trn 38oC.
3. Tn thng mch mu:
Tc mch ln.
Nhi mu phi nhim khun.
Phnh mch hnh nm.
Xut huyt ni s.
Xut huyt m lin kt.
Tn thng Janeway.
4. Hin tng min dch:
Vim cu thn.
Nt Osler.
Chm Roth.
Yu t dng thp.
5. Bng chng vi khun:
Cy mu dng tnh nhng khng tiu chun chnh.
Xt nghim huyt thanh vi cc tc nhn gy VNTMNK c bng chng ang hot ng.
6. Siu m tim nghi ng hnh nh ca VNTMNK nhng khng bng chng quy nh trong tiu
chun chnh
Bng 16-2b. Tiu chun Duke trn lm sng (tip theo).
ved
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V. iu tr
A. Nguyn tc iu tr
1. Khng sinh cn c cho sm ngay sau khi cy mu
kt thc. Trong lc ch kt qu cy mu th cho
khng sinh theo quy c: thng dng quy c l
Ampicilin 2g tim tnh mch (TM) mi 4 gi kt hp
vi Gentamycin 1,0 mg/kg cn nng TM mi 8 gi.
C th thay th bng Nafcillin 1,5 g tim TM mi 4
gi hoc Vancomycin 1 g tim TM mi 12 gi.
2. Khi c khng sinh cn iu chnh khng sinh theo
ch chun (trnh by k phn sau).
3. Ch kim tra v theo di cc chc nng thn, gan...
d
chn khng sinh v liu thch hp.
rve
e
s
re
4. Khng nn dng chng ng ngnhnga
ts vntc mch
.
g
trong VNTMNK.
l ri .com
l
A o
ev. yahophi kt hp iu
5. iu tr VNTMNK do nm
thng
o
l
Fin 0@
tr ni ngoi khoa.
8. 202
0
20 ocitykhoa can thip thng kh
6. Ch nh iu htr
t ngoi
Pot
ig rt
rcng
khn nhng
cn thit trong nhng hon cnh
y
p
Co
nht nh.
7. Vic phng nga VNTMNK nhng bnh nhn c
nguy c l vic ht sc cn c ch n.
B. iu tr c th
1. iu tr ni khoa:
a. Ch dng khng sinh cho cc loi cu khun
(Bng 16-3).
b. Ch dng khng sinh cho Trc khun m xanh
(Pseudomonas aeruginosa) v cc vi khun gram
m khc.
Nn dng loi Penicillin c ph rng
(Penicillin mi): Ticarcillin hoc Piperacillin),
hoc Cephalosporin th h 3, hoc Imipenem
Phi hp vi Aminoglycoside.
313
Co

314
Bng 16-3. La chn khng sinh cho cc loi cu khun.

Loi vi
Ch
Thi
khun
gian
Lin cu 1. Penicillin G 4 triu v tim TM mi 6 2 tun
gi, kt hp vi Gentamycin 1 mg/kg
viridant,
mi 12 gi TM, hoc
bovis
2. Penicillin G 4 triu v tim TM mi 6 4 tun
gi kt hp Gentamycin 1 mg/kg TM
mi 12 gi (ch cho 2 tun u), hoc
3. Penicillin G 4 triu v tim TM mi 6 4 tun
gi, hoc
4. Ceftriaxone 2 g tim TM hoc TB 1 4 tun
ln trong ngy, hoc
5. Vancomycine 10 mg/kg tim TM mi 4 tun
12 gi.
Enterococ 1. Ampicillin 2g tim TM mi 4 gi kt 4-6
hp vi Gentamycin 1 mg/kg TM mi tun
-cus
v
8 gi, hoc
cc
cu
2. Vancomycine 15 mg/kg, tim TM mi 4-6
khun
12 gi kt hp vi Gentamycin 1 tun
khng
mg/kg tim TM mi 8 gi
Penicillin
Cho cc trng hp d ng vi
Penicillin.
Cho bnh nhn b d ng vi

Penicillin.
Cho bnh nhn b d ng vi nhm
Lactamine.
4 tun thng cho cc trng hp
c triu chng < 3 thng.
Cho bnh nhn > 65 tui, c suy thn.
Ch chun, cho bnh nhn < 65

tui, khng c suy thn, khng c bin
chng.
Cho bnh nhn c bin chng hoc
lin cu khng Penicillin mc va.
Lu
ved
py
er
res
s
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l .c
v. A ahoo
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.
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Co
py
er
res
s
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v. A ahoo
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315
Bng 16-3. La chn khng sinh cho cc loi cu khun (tip theo).
Ch chun.
T
cu 1. Nafcillin 1,5 g, tim TM mi 4 gi, 4-6
tun
hoc
vng (S.
Cho bnh nhn nhim t cu nng.
2. Nh trn kt hp vi Gentamycin 1 4-6
aureus)
mg/kg tim TM mi 8 gi trong 3-5 tun
ngy, hoc
D ng vi Penicillin.
3. Cefazolin 2 g tim TM mi 8 gi, hoc 4-6
tun
D
ng
vi
Penicillin
v
4. Vancomycin 15 mg/kg tim TM mi 4-6
Cephalosporins; cho loi t cu khng
tun
12 gi
vi Methicillin.
Lin cu 1. Penicillin G, 2 triu v tim TM mi 6 2-4
tun
gi, hoc
nhm A,
2-4
Lin cu 2. Cefazolin, 1 g tim TM mi 8 gi.
tun
pneumon
-iae
Nhm
1. Ampicillin 2 g, tim TM mi 4 gi kt 4 tun Gentamycin c th ngng nu vi
khun nhy cm vi Ampicillin.
HACEK
hp vi Gentamycin 1 mg/kg TM mi
12 gi, hoc
Cho bnh nhn b d ng vi
2. Ceftriaxone 1-2 g tim TM hoc tim
4 tun Penicillin.
bp 1 ln trong ngy.
c. iu tr VNTM do nm.
Thng dng Amphotericin B, c th kt hp
vi Flucytosine.
(a) Amphotericin B: ho trong Dextro 5%
truyn TM trong 2-4 gi vi liu 0,5
mg/kg/ngy.
(b) Thuc c c tnh nhiu n thn.
(c) Flucytosine c c tnh lm c ch tu
xng, cn theo di cng thc mu khi
iu tr thuc ny.
Sau khi dng thuc 1-2 tun nn tnh n vic
phu thut thay van.
Mt s thuc dng ung nh Fluconazole
hoc Itraconazole c th dng phi hp.ed
rv
2. iu tr ngoi khoa:
ese
r
hts .vnkhoa cho
gngoi
a. Mc ch c bn ca iu tr
i
r
l .com
Al hoosi
VNTMNK l ly i nhng
mnh
hoc hoi t
.
v
e ya
o
l
m khng th iu tr
c, sa li van
@
inni khoa
. F 2020
hoc thay van b0tn
08 tthng.
y
2 toci
b. Ch nh igiu
ht Ptr
o ngoi khoa cho VNTMNK l
r
mt quyt
py nh kh khn nhng rt cn thit
Co
trong mt s hon cnh. Khi ch nh phi cn
nhc nhiu yu t v phi ch ti thi im can
thip (bng 16-4).
c. Suy tim tin trin l mt trong nhng ch nh
chnh, v c ti 90 % cht v suy tim nu khng
c can thip kp thi.
d. VNTMNK van nhn to thng i hi kt hp
iu tr ni v ngoi khoa.
e. Thi khong dng khng sinh sau khi m bnh
nhn VNTMNK cn cha thng nht. Cc tc gi
cho rng, nu mnh si (hoc p xe ly ra trong
m cy c vi khun th thi gian iu tr sau m
phi di bng mt liu trnh y cho iu tr
VNTMNK.
316
Bng 16-4. Ch nh phu thut khi VNTMNK.

Ch nh r rng:
Suy tim khng khng ch c do tn thng
van.
Van nhn to khng n nh.
Khng khng ch c hoc khng th khng ch
c nhim khun (v d do nm hoc
Enterocuccus khng thuc khng sinh).
Tc mch ti pht.
Ch nh tng i:
Tn thng lan rng quanh van (d, pxe).
Tn thng van t nhin sau khi iu tr ti u.
VNTMNK m cy mu m tnh c st dai dng
khng gii thch c.
ed
rvcao.
e
s
Mnh si to (>10mm) vi nguy c tc mch
re
ts vn
h
.
g
VI. Phng nga VNTMNK
l ri .com
l
A hoo
y l cng tc c bit quan trng
hi tt c cc thy
ev.i
o
l
ya
n
@
i
0 c trnh by
thuc thc hnh cn nm r. V .nguy
c
F
8 202
0nhn
y
0
bng 16-5, trong nhng bnh
c
nguy c cao v va cn
2 tocit
t
h
o
phi c phng nga ng
mc
P khi lm cc th thut.
rig
y
p
o thut c nguy c VNTMNK cao v va.
Bng 16-5. CTh
Cc th thut rng ming, hng:
Cc th thut rng ming c th gy chy mu.
Ct amidan hoc no VA.
Soi thanh qun bng ng soi cng.
Cc th thut tiu ho:
Cc phu thut lin quan n nim mc rut.
Th thut gy x trong gin tnh mch thc qun.
Phu thut ng mt.
Ni soi ng mt.
Cc th thut ng tit niu:
Soi bng quang.
Nong niu o.
Phu thut tin lit tuyn.
Cc th thut khc: Chch, dn lu cc nhim trng.
317
Co

318
Bng 16-6. Ch khng sinh phng nga VNTMNK trong mt s th thut.

Bnh cnh
Loi khng sinh
Liu dng
A. Ch cho cc th thut rng,ming, ng h hp, thc qun
Ch phng chun.
Amoxicillin
2g, ung 1 gi trc khi lm th thut.
Trng hp khng Ampicillin
2g, tim TM hoc TB 30 pht trc
ung c khng sinh.
th thut.
Trng hp d ng vi Clindamycin hoc
600mg, ung 1 gi trc th thut.
Penicillin.
2g, ung 1 gi trc th thut.
Cephalexin hoc
500 mg, 1 gi trc th thut.
Azithromycin.
B. Cho cc th thut ng sinh dc tit niu, d dy rut
2g, tim TM hoc tim bp.
bnh nhn nguy c Ampicillin kt hp vi
Gentamicin (30 pht trc th thut) 1,5mg/kg, tim TM hoc tim bp.
cao.
1g, tim TM hoc tim bp.
tip theo dng Ampicillin
1g, ung.
hoc Amoxicillin (6 gi sau).
1g, truyn TM trong vng 1-2 gi.
nhng bnh nhn Vancomycin kt hp vi
Gentamycin
(trong
vng
30
pht
1,5mg/kg tim TM hoc TB
nguy c cao, d ng vi
trc th thut).
Penicillin.
2g, ung 1 gi trc th thut.
bnh nhn nguy c Amoxicillin hoc
Ampicillin.
2g, tim TM hoc tim bp trong vng
va.
30 pht trc th thut.
Bnh nhn nguy c va, Vancomycin.
1g, truyn TM trong 1-2 gi v kt
d ng vi Penicillin.
thc 30 pht trc khi lm th thut.
ved
py
er
res
s
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ighom.v
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.
08 2
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Ti liu tham kho

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Baue A, Geha AS, Hammond GL, Laks H, Naunheim KS, eds.

Glenn's thoracic and cardiovascular surgery, 6th ed. Norwalk, CT:
Appleton & Lange, 1996:1915-1930.
Braunwald E, ed. Heart disease: a textbook of cardiovascular
medicine, 5th ed. Philadelphia: WB Saunders, 1997:1077-1104.
Child JS, ed. Diagnosis and management of infective endocarditis.
Cardiol Clin North Am 1996;14.
Dajani AS, Taubert KA, Wilson W, et at. Prevention of bacterial
endocarditis: recommendations by the American Heart Association.
Circulation 1997;96:358-366.
Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of
d
infective endocarditis: utilisation of specific echocardiographic
rve
e
s
findings. Am J Med 1994;96:200-209.
re
ts vn
h
g
Durack DT. Prevention of infective endocarditis.
N. Engl J Med
l ri .com
l
A o
1995;332:38-44.
ev. yaho
o
l
n Opin
@ Cardiol 1997;12:123Farmer JA, Torre G. Endocarditis.FiCurr
. 2020
8
0
130.
y
0
2 tocit
t
h
o
Fauci AS, ed. Harrison's
principles
of internal medicine, 14th ed.
P
rig
y
p
New York: McGraw-Hill,
1998:785-791.
Co
Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of
infectious diseases, 4th ed. New York: Churchill-Livingstone,
1995:740-799.
Mexander RW, Schlant RC, Fuster V, eds. Hurst's the heart. New
York: McGraw-Hill, 1998:2205-2239.
Murphy M. Infective endocarditis. In: Marso SP, Griffin BP, Topol
EJ, eds. Manual of Cardiovascular Medicine. Philadelphia:
Lippincott-Raven, 2000.
Otto C. The practice of clinical echocardiography. Philadelphia: WB
Saunders, 1997:389-403.
Topol EJ, ed. Textbook of cardiovascular medicine. Philadelphia:
Lippincott-Raven Publishers, 1998:607-637.
319
14. Von Reyn CF, Levy BS, Arheit RD, Friedland G, Crumpacker CS.
Infective endocarditis: an analysis based on strict case definitions.
Ann Intern Med 1981;94: 505-518.
15. Wilson WR, Karchmer AW, Dajani AS, et al. Antibiotic treatment
of adults with infective endocarditis due to streptococci, enterococci,
staphylococci, and HACEK microorganisms. JAMA 1995;274:
1706-1713.
ved
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320
Van tim nhn to
I. Cc loi van tim nhn to

Cc loi van tim nhn to c chia thnh 2 nhm ln: van
c hc v van sinh hc. Mi loi van li c bn, nguy c to
huyt khi, v c im huyt ng khc nhau.
Bng 17-1. c im ca cc loi van tim nhn to.
Nguy
Din tch l van hiu
2
c
dng (cm )
Loi van
bn
V tr van V tr van huyt
khi
MC
hai l
d
Van bi
++++
1,2-1,6
1,4-3,1 erve++++
s
re
(Starr-Edwards)
ts vn
h
g
ri com.
+++/
1,5-2,1
+++
Van a mt cnh
l1,9-3,2
l
A hoo.
.
++++
(Bjrk-Shiley,
v
a
oe
inl 20@y
Medtronic-Hall,
F
8. 0
Omnicarbon)
00 ity2
2
t toc
++++
2,8-3,4
++
Van a hai cnh
igh Po 2,4-3,2
r
(St. Jude Medical,Copy
Carbomedics)
++
1,0-1,7
1,3-2,7
+/++
Van sinh hc d
loi (IonescuShiley, Hancock,
CarpentierEdwards)
Van sinh hc
+++
3,0-4,0
+
ng loi
A. Van c hc
1. Van a mt cnh: (van Bjrk-Shiley, MedtronicHall v Omnicarbon) c cu to gm mt vng van
bng kim loi gn vi mt cnh a bng pyrolytic
carbon di ng t do mt gc 60-85o xung quanh mt
trc, to thnh hai l ln mu lu thng.
321
ved
er
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v. A ahoo
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.
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py
Co
Hnh 17-1a. Cu trc mt s loi van tim c hc.

2. Van a hai cnh: (van St. Jude Medical,
Carbomedics) gm hai cnh a bn nguyt di ng
t do mt gc 75-90o hai bn, to thnh mt din
ch nht v hai l ln hai bn cho mu lu thng khi
van m. Van c thit k c mt dng h nh
trong van nhm gim hnh thnh huyt khi trn a.
322
Hin l loi c dng ph bin do nhiu u im v

huyt ng.
3. Van bi (lng) (van Starr-Edwards): gm mt vin bi
bng silicon di ng t do trong lng chp kim loi,
mu s i xung quanh vin bi. Loi ny hin gn nh
khng cn s dng do nhiu nhc im v huyt
ng.
d
rve
e
s
re
Hnh 17-1b. Cu trc mt s loi van bi (lng).
ts vn
h
g
m. song v
B. Van sinh hc: mc d rt ging van
l rit.conhin
l
oo
v. Ado
huyt ng vn cha phi tiloeu
ahkch thc van b
y
Fin020@ van lm nh i.
cc thnh phn vng van, phn
8. 2chng
0
20 ocityph ln mt gi v mt
1. Van d loi: bng
t cch
h
ot
vng van kim
rigloi Pmng tim b hoc van tim ln
y
p
Co nh van Carpentier-Edwards. Cc loi van
qua x l
mi nh Hancock II hoc Medtronic Freestyle, St.
Jude-Medical c ci tin huyt ng do cch gn van
trc tip vi MC hoc t van ngi trn vng van...
2. Van ng loi: ch yu v tr van MC bng cch
ly van t ngi hin tng, c th km thm mt
on MC, bo qun lnh trong ngn hng m. Vic
pht trin cn gp nhiu kh khn v hn ch.
II. La chn loi van thay
1. Sa van:
Cn phi xem xt kh nng van cn sa c hay
khng trc khi quyt nh thay van, do sa van c
u th hn hn nh: bo tn c chc nng tht tri
323
v gi c cc t chc di van, t l t vong chu

phu thp, khng cn dng thuc chng ng, t l
sng cn lu di tt. Hin nay, ch yu mi p dng
rng ri cc k thut sa van hai l, cn i vi van
MC th kh sa hn rt nhiu, ch nn lm hn ch
trong mt s trng hp khng do thp tim nh van
MC hai l bm sinh gy HoC do sa van, van khng
vi, khng hp
Bng 17-2. So snh gia m thay van v sa van.
Nn thay van
Nn sa van
1. Di chng do thp 1. Bnh sa van hai l.
2. HoHL do bnh tim thiu
tim.
2. Vim ni tm mc. mu.
3. Tn thng van hai 4. Gin vng VHL, l edvan
rv
l phc tp (x, vi bnh thng.
ese
r
ts vn l sau
nhiu, co rt l van, 5. Tn thng ch
.
gh myu
i
r
t chc di van van HL. All o.co
o
ev. yl
ah van hai l qu
6. Di lng
thng tn nng...).
o
Fin 0@
4. Phu thut vin t mc.
8. 202
0
y MC hai l bm sinh,
kinh nghim.
20 7.itVan
t otosac van gy h.
h
P
rig
y
p
2. Van sinh
Co hc d loi: ch nh thay cho bnh nhn
khng th dng thuc chng ng ko di, bnh nhn
tui cao (> 70), cng nn cn nhc thay van sinh hc
cho nhng bnh nhn n cn mun c thai. Cn ch
nguy c thoi ho van phi m thay van li (t l
m li 40% nu tui bnh nhn < 40, 20-30% nu
tui 40-60, v 10% nu tui > 70).
3. Van ng loi (sinh hc): c bn cao hn, chnh
p qua van thp nht so vi cc loi van sinh hc
khc nhng sau 20 nm ch 10% van hot ng cn
tt. Van MC ng loi c la chn cho bnh
nhn tui < 50, ph n cn mun c thai, bnh nhn
khng th dng thuc chng ng ko di, bnh nhn
cn thay c van v on MC v c bit l bnh
324
nhn vim ni tm mc nhim khun ti van MC c

bin chng (pxe, d...).
4. Van c hc: ch nh cho bnh nhn tui < 60 (do
bn cao, t cn m li), bnh nhn phi dng thuc
chng ng (do ri lon nhp hoc t qu). Bnh
nhn cn thay c van hai l v ng mch ch nn
thay van c hc v van hai l sinh hc nhanh thoi
ho. Do cu trc gn nn bnh nhn c kch thc
tht nh nn thay van c hc. Quyt nh la chn
tng loi van c th cn ph thuc vo cu to v c
im huyt ng tng loi van: van St. Jude Medical
v Metronic-Hall c a chung nht do u th v
huyt ng, bn cao v t l bin chng thp...
d
III. Theo di sau m thay van
rve
e
s
e
s r ht
tl
Vic theo di sau m thay van tim nhn to
n sc cn
h
.
g
i om v
r
l
thit, gm theo di triu chng lm sng vAxt
d bnh
l nghim,
o.c
hosiu
v. qu
e
a
nhn khng c triu chng c nng. Kt
m
Doppler
o
y
inl 2c
0@ dng lm mc
Fm
tim trong vng 1-6 tun ngay sau
.
0
08 ty2
20nn
theo di v sau. Thng thng
i kim tra nh k siu m tim
t otoc
h
P
g
1 nm mt ln hoc mauri hn nu c triu chng c nng, nht l
py
giai on 5 nm sau
Co m tr i. Tuyn truyn cho bnh nhn v
nguy c v s cn thit phi iu tr d phng vim ni tm mc.
Ring vi bnh nhn c van c hc, cn theo di nh k
hiu qu ca thuc chng ng bng xt nghim t l
Prothrombin v INR.
1. Dng thuc chng ng sau m thay van:
a. i vi van c hc:
Ngay sau m thay van c rt nhiu cch dng
thuc chng ng. Dng sm qu s lm tng
nguy c trn mu mng tim, p tim hoc chy
mu sau m. Mt s ni ch bt u dng
thuc chng ng ng ung 3-4 ngy sau
m thay van. Mt s khc dng Heparin tnh
mch liu thp ( aPTT t ngng bnh
325
thng cao) ngay t 6-12 gi sau m, tng

Heparin ln liu sau rt dn lu ngc, bt
u ung thuc chng ng t 24-48 gi sau
m. D sao nn xt k nguy c huyt khi
ca tng bnh nhn v v tr van (van hai l
cao hn van MC).
V lu di: ung thuc chng ng (thuc
khng vitamin K) duy tr gi tr INR trong
ngng tc dng.
Bng 17-3. Ngng tc dng chng ng cho cc loi
van tim nhn to.
Loi van
INR
Nguy c
Phi hp
tc mch
Thp
* Van c hc:
ved
4,0-5,0 reser- Van bi
ts
- Van a 1 cnh 3,0-4,0
gh m.vn i
r
o
l
- Van a 2 cnh 2,5-3,0
Al hoo.c
.
v
e
a
3,0-4,5
- Nhiu van
o
nl 0@y
i
F
2
* Van sinh 8hc:
. 0
00 ity2
- ng 2loi
oc
t
Aspirin
2,0-3,0
-riD
ghloiPot
py
325
Co
mg/ngy
3,0-4,5
Aspirin
Cao (km rung - Van c hc
80-160
nh, tin s tc
mg/ngy
mch,
huyt
2,0-3,0
khi nh, ri - Van sinh hc
lon chc nng
tht tri nng)
Dng thuc chng ng lu di c nguy c
chy mu nh (2-4%/nm), chy mu nng
(1-2%/nm), t vong 0,2-0,5%/nm. Nguy c
chy mu tng tui gi (5-6% bnh nhn
> 70 tui). Nguy c xy ra tc mch cho d
vn dng thuc chng ng l 1%/nm.
326
b. i vi van sinh hc: vic dng thuc chng

ng sau m thay van sinh hc cn nhiu bn ci.
Nguy c tc mch cao nht sau m v gim dn
trong 3 thng sau m, t l huyt khi v tr van
hai l (7%) cao hn so vi v tr van MC (3%).
V th cn dng thuc chng ng ng ung
sau m thay van sinh hc trong 3 thng u sau
m, ri chuyn sang Aspirin 325 mg/ngy.
Nhng bnh nhn c tin s tc mch, rung
nh, ri lon chc nng tht tri nn ung thuc
chng ng sut i.
2. iu chnh liu chng ng khi lm cc th thut
khng phi tim mch:
d
a. i vi cc th thut ln, mt mu nhiu,
rve nn
e
s
dng thuc chng ng ng ung
re t nht 3
ts vn
h
g
ngy trc khi lm th thut
INR . 1,6. Cn
l ri .com
l
A tnh
o mch bnh
iu tr gi bng Heparin vtim
e . yaho
o
l
nhn c van bi, rungFinh
khi nh tri, ri
n , 0huyt
@
2
8.tri20nng,
lon chc nng tht
tin
s tc mch.
0
20 ocity
t th
t thut nh (nh nh rng...),
b. i vi nhng
igh Po
r
y
nguy oc
p chy mu t, c th vn duy tr tip liu
C
chng ng ang dng.
c. Sau m, dng li Heparin ngay khi c th, sau
gi tip bng thuc chng ng ng ung
duy tr lu di.
3. iu chnh qu liu chng ng:
a. Liu thuc chng ng khi u nn l 5 mg
Warfarin (tng ng 1 mg Acenocoumaron
(Sintrom) hay 5 mg Fluindione (Previscan).
Phi gim bt liu ngi gi, ngi c bnh gan
mt phi hp hoc c nguy c chy mu cao.
b. Nu INR vt ngng iu tr v < 5,0 th nn h
bt liu iu tr hoc tm dng mt ngy v ung
vi liu h thp hn.
327
c. Nu INR > 5,0 v < 9,0 m khng chy mu ng

k, tm ngng thuc chng ng mt hoc hai
ngy, theo di thng xuyn INR, ung li thuc
vi liu thp hn khi INR v ngng iu tr
hoc tm dng mt ngy thuc, ung 1-2,5 mg
vitamin K1 nht l khi nguy c chy mu cao.
d. Nu cn nhanh hn (chng hn cn m cp) th
ung 2-4 mg vitamin K1 (INR s gim ng k
sau 24h). Nu INR vn cn cao th ch ung thm
1-2mg vitamin K1 m thi.
e. Nu INR > 9,0 m khng chy mu ng k, th
dng ngay thuc chng ng, phi hp ung 35mg vitamin K1 (INR s gim ng k sau 2448h), lp li nu cn, theo di st v dng
d li
rve
e
s
thuc chng ng vi liu thp khi INR
re nm
ts vn
h
trong ngng iu tr.
.
g
l ri .com
l
A
f. Nu INR > 20 c km chy
mu onng, dng ngay
ev. yaho
o
l
thuc chng ng, truyn
@ mch chm 10 mg
Fin020tnh
8. vi
vitamin K1, phi00hp
truyn
huyt tng ti
2
2 ocity
hoc ta prothrombin
tu trng hp, c th lp
ht Pot
rig
li 12h/ln.
y
p
Co
4. Thuc chng ng v thai nghn: t l bin chng
tc mch do huyt khi tng ln khi c thai. Tuy
nhin do tc dng gy d tt bm sinh, nn ngng
thuc chng ng ng ung (khng vitamin K)
trong ba thng u sau khi c thai, thay bng Heparin
tim di da 15.000 n v 2 ln/ngy nhm duy tr
thi gian aPTT gp 1,5-2,0 ln so vi chng (ly xt
nghim sau tim 6 gi) t nht cho n 3 thng gia,
khi c th quay li ung thuc chng ng tip
cho ti gia 3 thng cui. n lc , chuyn li tim
di da Heparin 5.000 n v 2 ln/ngy cho ti lc
chuyn d. C th phi hp vi Aspirin liu thp.
IV. Triu chng lm sng v xt nghim bnh nhn
c van tim nhn to
328
A. Triu chng lm sng: biu hin ca ri lon hot

ng van nhn to tng i phc tp (xem thm phn
bin chng van nhn to).
1. Tin s v bnh s: nn hi k hoc kim tra h s
ra vin v cc vn lin quan n van nhn to nh:
ch nh thay van; v tr van nhn to; loi v kch
thc van; thi gian k t khi thay; cc bin chng
lin quan n dng thuc chng ng, bin chng tc
mch, vim ni tm mc, st hoc thay i m sc
ting p ca van.
2. Khm thc th: pht hin cc ting thi mi, m
nght hoc cc biu hin huyt khi kt van. Bn
thn van nhn to lm thay i ting bnh thng
do di chuyn cnh van hoc do thay i tnhercht
ved ca
s
re van nhn
dng chy qua van. Cc ting, m sctsca
n
h
g
i om.v Mt khc
to che lp nhng ting tim bnhl rthng.
l o.c
o i cho d
nhng m sc ny c th khng
hahthay
v. A
e
o
l
y
n van.
@ Tuy nhin nu
ri lon nng hot ngFica
. 2020
8
0
quen vi cc ting 2van
0 tim
ty nhn to th nghe tim cng
oci vic chn on bnh l ca
t otcho
gip ch cgnhiu
h
P
i
yr trc khi s dng cc bin php chn
van nhnopto
C
on hnh nh khc.
B. Cc xt nghim chn on: xc nh ri lon hot
ng van nhn to ch yu da trn hnh nh siu m
Doppler tim, cho php nh gi sm trc khi biu l ra
triu chng lm sng.
1. Siu m Doppler tim: cn nh gi y cu trc
ca van, cc thnh phn ca b my van nhn to,
chnh p trung bnh v ti a qua van, dng h trong
van hoc quanh van. Siu m tim qua thc qun c
ch nh cho nhng trng hp nghi ng hoc c
triu chng ca vim ni tm mc nhim khun. Ni
chung, k thut lm siu m khng khc g so vi cc
van t nhin, song kh hn do van nhn to gy ra
cc bng cn m.
329
a. Ri lon hot ng ca van thng biu hin

ch cc l van ng khng kn (do huyt khi, do
vi ho van sinh hc hay do ni mc tng sinh
qu mc), di ng qu mc vng van (biu hin
ca long van, c th km theo cc tn thng
xung quanh nh pxe, d, gi phnh cnh vng
van gy ra do vim ni tm mc van nhn to).
b. Siu m Doppler mu cung cp cc kt qu o
c gin tip nhng ng tin cy v hot ng
ca van nhn to: nh chnh p qua van (t
c tnh din tch l van hiu dng), dng h
trong van hoc quanh van, c ch gy h van...
c. nh gi h van nhn to:
d sinh
i vi van c hc, dng h c coivel
r
e
2
s
e dng h
l nu din tch h < 2 cm v s rdi
t vn
h
.
< 2,5 cm v tr van hai l hoc
din
tch h <
g
l ri .com
2
l
A< 1,5o cm v tr van
1 cm v di dng h
ev. yaho
o
l
ng mch ch. Phn
ln
cc van sinh hc
Fin020@
.
8 nh
u c dng00h
2 (sinh l) ngay sau khi
2 ocity
thay van.
t
gh Pot
rih
Dng
van bnh l thng rng v di hn
y
p
Co
nhiu,
c th c nhiu dng h, thng lin
quan n hin tng vi, so ho vng van,
h hi cu trc van, p xe vng van, t chc
ln cn... Siu m tim qua thc qun s gip
lng gi kh chnh xc mc h van c
bit l trong trng hp h chn (quanh) van.
HoHL c coi l nng khi vn tc ti a u
tm trng 2,5 m/giy hoc PHT dng chy
qua van hai l 150 miligiy.
HoC c coi l nng khi PHT dng chy qua
van MC 250 miligiy hoc c dng chy
ngc trong ng mch ch xung.
d. nh gi hp van nhn to:
Chnh p qua van:
330
van. Chnh p qua van tnh

trn siu m Doppler lin tc sau m vi
tun c coi l gi tr tham chiu theo
di sau ny.
(b) Chnh p qua van cao khng nhng do
hp van m cn do tnh trng tng cung
lng, thiu mu, nhp nhanh, h van
nhn to nhiu hoc hin tng phc hi
p lc (rt hay gp van c hc hai cnh
v tr van MC, c hin tng p lc
tng th pht sau khi dng chy i qua l
hp, lm tng chnh p thc s qua van
ln khong 1/3 song nu hp van
, th
ed
v
r
e
hin tng ny gim i).
res
ts lin
Din tch l van: Phng trnh
n tc cho
h
ig om.v
r
l
php c tnh din tch lAvan
l chc
c nng:
. ahoo.
v
2
e
o
Din tchvan MC = n(
l ng
y knh vng van)
@
i
20MC
. F 20van
0,785 VTIRTT
08 /VTI
y
0
t
2HLto=ci(ng
knh RTT)2 0,785
Din tch
tvan
h
o
P
g
ri
VTI
py RTT / VTIvan HL
Co Trong RTT l ng ra tht tri,
VTI l tch phn vn tc theo thi gian dng
chy tnh bng siu m Doppler lin tc.
Thi gian bn gim p lc (PHT): c ch
nh gi din tch l van hai l nhn to
(=220/PHT), ng thi cho php phn bit
nguyn nhn gy tng VTI dng chy qua van
hai l (nu PHT cng tng, nguyn nhn l
hp van), nu PHT khng ko di, th nguyn
nhn ch l tng dng chy qua van. Tuy
nhin din tch l van tnh theo PHT i khi
s ln hn gi tr thc.
Ch s t sut gia vn tc dng chy ng
ra tht tri v van MC nhn to cho php
331

nh gi c hp van hay khng nht l khi

khng bit r ng knh vng van. Ch s
VRTT/Vvan MC ny cng ln th din tch l van
cng ln, nu < 0,23 th hp van ng k.
Bng 17-4. Mt s thng s bnh thng ca cc loi van
tim nhn to khi o bng siu m Doppler tim.
Loi van nhn to
Vn tc
Chnh p
ti a
trung bnh
(m/s)
(mmHg)
V tr van MC
24 0,4
3,1 0,5
Starr-Edwards
2,5
0,6
14 5
Bjrk-Shiley
3,0 0,8
11 6
St. Jude
2,6 0,3
12 d3
Medtronic-Hall
rve
2,4 0,4
Hancock
e7se 3
r
Carpentier-Edwards
2,4 0,5 ghts .1vn
12
i om
r
Van ng loi
l
l .c 14 6
0,8 A0,4
v. ahoo
e
V tr van hai l
o
l @y0,4
52
Fin01,8
20
Starr-Edwards
.
8 2 1,6
0
0,3
52
20 ity
Bjrk-Shiley
t otoc
h
1,6 0,3
52
P
St. Jude rig
y
p
1,7
0,3
31
Medtronic-Hall
Co
1,5 0,3
42
Hancock
Carpentier-Edwards
1,8 0,2
72
2. Soi di mn tng sng: ch c ch trong trng hp
cc van c hc. Nu chnh chm tia X i song
song vi mt phng ca van th hnh nh ng m
cc cnh van l r nht. Di ng cnh van gim l
du hiu ca tc nghn van, ngc li di ng vng
van qu ln (> 7o i vi van MC v > 11o i vi
van hai l) l du hiu ca long (hng) van mt phn.
3. Thng tim tri vo tht tri c th tin hnh an
ton bnh nhn c van MC sinh hc o chnh
p qua van, nhng i vi van MC c hc (chng
ch nh a ng thng qua) th phi xuyn vch lin
nh ri a ng thng xung tht tri. i vi van hai
332
l cng phi lm tng t o c chnh p.

Chng ch nh a ng thng qua cc van c hc
(lng bi, lng a, mt hay hai cnh).
4. Chp cng hng t (MRI): cho php xc nh h
van, r quanh van, hoc pxe vng van nu c chng
ch nh lm siu m qua thc qun. Chp ct lp
theo t trng (CT) khng c gi tr trong vic nh
gi hot ng van nhn to.
C. Ri lon hot ng ca van nhn to v cc
bin chng lin quan
1. Rung nh: c ti mt na s bnh nhn thay/sa van
xut hin rung nh sau m. iu tr loi rung nh ny
khng khc g so vi iu tr rung nh ni chung.
d
rvenh th
e
a. i vi bnh nhn cha c tin s rung
s
re
tsnu
n
h
thng t tr v nhp xoang. Nhng
g
i om.v rung nh
r
l
l cn
c
dai dng, ko di > 24 gi,. Ath
oo. xem xt iu
h
v
e
a
o
tr thuc chng ng v
y nhp bng thuc
nl chuyn
0@
Fisc
2
.
chng lon nhp hoc
in.
0
8
00 ty2
2 tocitrc
b. iu tr dhtphng
m bng thuc chn
o
P
g
i
r
giao cm
hoc Amiodarone c tc dng r rt
opy
lm Cgim t l rung nh sau m tim.
2. Ri lon dn truyn: bloc nh tht phi t my to
nhp chim khong 2-3% sau m thay van v khong
8% sau m li van. Nguyn nhn thng do sang
chn b His trong m hoc ph n t chc quanh van
sau m. Cc yu t nh vi ho vng van MC hoc
hai l, ri lon dn truyn trc m, tui cao, vim
ni tm mc nhim khun, phu thut van ba l lm
tng nguy c ri lon dn truyn sau m, c th dn
ti phi t my to nhp vnh vin.
3. Vim ni tm mc nhim khun (VNTMNK): T
l VNTMNK bnh nhn thay van nhn to xp x
3-6%, vi c im cc si rt ln (do vi khun gy
333
bnh c tr trn van, nn c th trnh khi cc c ch

bo v ca c th). Thng chia lm 2 loi:
a. VNTMNK trn van tim nhn to sm: trong vng
60 ngy sau m: ch yu do t cu da (S.
epidermidis), din bin rt nng, d dng a n
t vong (20-70%).
b. VNTMNK trn van tim nhn to mun: thng
xy ra bnh nhn c nhiu van nhn to hoc
v tr van MC. Lm sng ni chung ging
VNTMNK trn van t nhin. Tc nhn hay gp
nht l lin cu, sau l vi khun Gram m, t
cu rut v S. epidermis.
c. Chn on xc nh da vo siu m tim qua thc
d
qun do nhy v c hiu cao (90-95%);
rve ng
e
s
re xe vng
thi xc nh cc bin chng khc nh
ts vp
n
h
. siu
g
van, long van, r van..; cng nh
m
i dng
r
m
o
l
l
c
theo di hiu qu iu tr.ev. A hoo.
lo @ya
inkhng
d. iu tr: nu ch dng
F
. 2020 sinh n thun, t l
8
0
t vong ln ti 261%
y vi 38% nu thay van) do
0 it(so
oc rt thp (ct st) vi cc tc
t cng
t
kh nng ithnh
h
o
P
rg
nhn onh
py t cu, vi khun gram m hoc nm,
C
cn vi lin cu p ng cng ch khong 50%.
e. Bnh nhn VNTMNK van tim nhn to vn nn
dng thuc chng ng. Nu khng dng thuc
chng ng, nguy c t qu khi c thm
VNTMNK tng ln ti 50% trong khi nu dng
chng ng th t l tc mch ch l 10%. Hin
cha c kt lun chc chn no v vic tng nguy
c xut huyt no bnh nhn VNTMNK van
nhn to c dng thuc chng ng.
f. Ch nh m thay li van tim nhn to khi:
Tip tc nhim khun huyt d iu tr
khng sinh rt tch cc.
VNTMNK n thng cc t chc xung quanh
hoc to ng d.
334
Cc tc gy nghn mch ti pht.

VNTMNK do nm.
Long van hoc tc van nhn to.
Tc nghn ng dn truyn mi hoc ri
lon dn truyn nng hn.
Suy tim huyt tin trin hoc ri lon huyt
ng nng.
4. Tan mu: gp rt nhiu bnh nhn thay van c hc
nhng him khi biu hin ra triu chng lm sng.
a. T l thiu mu do tan mu gp 6-15% bnh
nhn thay van bi, song him gp hn van a
hoc van sinh hc. Thiu mu do tan mu thng
gp bnh nhn c nhiu van nhn to, van nhn
d van
to c nh, h quanh van v VNTMNK trn
rve
e
s
nhn to... vi c ch lin quan n
re dng mu
ts vn
h
. kim loi.
xoy c p lc cao p vo cc t
chc
g
l ri .com
l
b. Chn on xc nh khi ec
oomen LDH, tng
v. Atng
ah
o
l
y
hng cu li, Ftng
in 20@bilirubin gin tip,
0
8. xut
haptoglobin niu00v
y2 hin cc mnh v hng
t
2
i
tocSiu m tim thng pht hin
t mu.
cu trn lam
igh Po
r
thy c
opyhin tng va p ca dng mu c tc
C
cao (dng h lch tm hoc quanh van) va vo
cc t chc van nhn to.
c. Thiu mu tan mu nh c th iu tr b sung
vi st, acid folic v truyn mu. Dng thuc
chn bta giao cm v kim sot tt huyt p c
th lm gim mc nng ca tn huyt.
d. M li sa h quanh van hoc thay van c
ch nh cho nhng bnh nhn thiu mu tan mu
nng cn phi truyn mu nhiu ln hoc c suy
tim huyt.
5. Huyt khi: t l huyt khi ti van chim khong
0,2-1,8%/nm, hay gp nht v tr van ba l, sau
l v tr van hai l v cui cng l v tr van MC.
335
a. Nn ngh ti huyt khi kt van bnh nhn c

triu chng khi pht t ngt, c tin s tc
mch hoc dng thuc chng ng khng .
Siu m tim qua thc qun l bin php thng
dng nht chn on huyt khi ti van, tuy c
th pht hin hnh nh hn ch vn ng ca van
nhn to khi soi trn mn chiu Xquang. Hnh
nh trn siu m gi huyt khi l mt khi di
ng, mt mm, khng ng u.
b. iu tr: cch thc x tr ph thuc vo v tr
huyt khi ca van ch khng ph thuc vo loi
van hay thi gian gi nh hnh thnh huyt khi.
Trc khi iu tr:
(a) Heparin c dng sm ngay t khi
d ngh
rve chng
e
s
ti v kho st bnh. Tip tc rdng
e
hts .vn vitamine
ng ng ung (thucigkhng
m
ll r oli
.co r.
K) tr phi c ch nh
m
A
o
.
h
v
a
oe yqun
(b) Siu m tim qua
hoc t nht l
@
inl thc
0
F
2
. 2tng
0
soi di 0m8n
sng nn lm trong
0 ity
2 gi
vngt24
oc k t khi khi pht v lp li
h
Pot
ig xuyn
thng
nu cn huyt khi.
r
py
o
C
c. iu tr ni khoa:
Ch nh dng thuc tiu si huyt cho huyt
khi van nhn to tim phi do hu qu t
nghim trng nu huyt khi bn i xa khi so
vi bn tim tri. T l thnh cng ln ti 82%,
t l bin chng tc mch khong 12% v
bin chng chy mu nng khong 5%.
Cc thuc hay dng nht l: Streptokinase
(250.000 n v tim trc tip tnh mch/30
pht, sau truyn tnh mch 100.000 n
v/gi) hoc Urokinase (4.400 n v/kg/gi).
Thi gian dng thuc tiu si huyt thng t
2 n 120 gi, song nn dng nu khng ci
thin v huyt ng sau 24 n 72 gi.
336
Sau khi dng thuc tiu si huyt thnh cng,

cn theo di st hiu qu iu tr chng ng
ng ung cng nh siu m Doppler tim li
nhiu ln.
Chng ng bng Heparin v Wafarin ni
chung c khuyn dng cho cc huyt khi
nh ( 5mm): s dng Heparin tim tnh
mch, sau tim di da 17.000 n v 2
ln/ngy kt hp ung thuc khng vitamin K
(duy tr INR t 2,5-3,5) trong vng 3 thng.
d. Phu thut: t l t vong quanh phu thut thp
nht cng l 5% v th cn cn nhc nguy c ca
tng bnh nhn so vi kh nng v iu kin ca
tng trung tm. Ch nh thay van v ly bedhuyt
ervto tim
khi cho trng hp huyt khi van nh
esn
r
ts n m do
tri tr phi huyt khi nh hoc khng
gh m.vth
i
r
l .co ch nh m
nguy c phu thut qu cao.
Al Cng
.
hoo thnh cng,
v
e yakhng
nu iu tr tiu huyt
khi
o
l
in 0@
. F 202thuc
m sau khi ngng 8truyn
24 gi.
0
0 ity
2
toc vng van nhn to c th gp
6. Hng hc c hc:
ht Pbong
o
g
i
r
ngay trongpygiai on sm sau phu thut do k thut
Co vng van qu vi ho, bnh nhn dng
m km,
steroid lu di, m van qu mn (c bit nu m li)
hoc nhim trng. Hin tng bong van cng c th
xy ra mun do nhim trng. Hnh nh van ung a
(lc l) trn siu m tim hay khi soi di mn tng
sng l mt ch nh m li cp cu.
7. Mt tng xng gia kch thc van nhn to so
vi bnh nhn:
a. Tt c cc loi van nhn to tr van t thn MC
(khng c vng kim loi) u c din tch l van
hiu dng thp hn hn do vi van t nhin. V
th lun lun c hin tng chnh p qua van
nhn to v hp van tng i. Nu thay vo mt
van nhn to c ng knh qu nh th s gy ra
337
tnh trng gim ng k cung lng tim, gy ra

cc triu chng lm sng. Hin tng ny hay gp
nht khi thay van ng mch ch bnh nhn
hp van ng mch ch.
b. V vy, nu bnh nhn c vng van nh, nn
dng van ng loi hoc van a v tr van MC
do cc u th v huyt ng. Van MC nhn to
c ng knh 21mm cng khng nn thay cho
bnh nhn cao ln hoc hot ng th lc nhiu.
Nguyn l chung l nn c gng thay van bng
mt van nhn to c ng knh ln hn, nu cn
th phi hp vi to hnh (m rng) vng van.
8. Pannus (hin tng tng sinh ni mc qu mc
d khi
ph trm ln van): thng phi hp vi huyt
rve
e
s
gy tc van (t l c th ti 5% vis van
re c hc).
t vn
h
.c th lin
C ch hnh thnh pannus cn cha
r,
g
l ri .com
l
quan vi hin tng tng sinh
bo si do
hoo
v. A nguyn
loe @
yavan nhn to) hoc
phn ng min dch vi dinvt
(l
0
. F 202nh
phi hp vi cc tc
dng thuc chng
08 nhn
y
0
2 vim
it ni tm mc nhim khun,
c
o
ng khng hliu,
t ot
rigdngP mu xoy qua van hai l... Ni
tc ng c
a
y
p
Co lm siu m tim qua thc qun xc
chung, phi
nh v kho st cn nguyn gy tc van nhn to.
9. t qu do cc mu ng bnh nhn c van tim
nhn to:
a. Nguy c t qu ti pht khong 1%/ngy trong
2 tun u. Nu chp phim CT trong vng 24 v
48 gi m khng c chy mu no hoc nhn no
din ln th nn dng Heparin ng tnh mch.
Duy tr ung thuc chng ng s lm gim nguy
c ti pht t qu xung mt phn ba song li
tng t 8-24% nguy c chuyn dng nhn no
thnh xut huyt no nht l trong vng 48 gi
u tin. B sung Aspirin hoc Clopidogrel nu
338
ti pht t qu d dng liu thuc chng

ng.
b. Vi bnh nhn c nhn no ln, nn tm dng
thuc chng ng trong vng 5-7 ngy ng thi
cng nn ngng thuc chng ng 1-2 tun nu
c chuyn dng nhn no thnh xut huyt.
Ti liu tham kho
1.
Acar J, Iung B, Boissel JP, et al. Multicenter randomized comparison

of low-dose versus standard-dose anticoagulation in patients with
mechanical prosthetic heart valves. Circulation 1996;94:2107-2112.
2. Akins CW. Results with mechanical cardiac valvular prosthesis. Ann
Thorac Surg 1995;60:1836-1844.
3. Cannegieter SC, Rosendaal FR, Wintzen AR, et al. Optimal oral
anticoagulant therapy in patients with mechanical heartervalves.
ved N
s
re
Engl J Med 1995;333:11-17.
ts vn
h
.
g
4. Davis EA, Greene PS, Cameron DE, et al.l riBioprosthetic
versus
om
l
c
.
A
o
o
.
mechanical prosthesis for aortic valveevreplacement
in the elderly.
h
lo ya
Circulation 1996;94:II-121-125. Fin 20@
8. 0
5. Garcia MJ. Principles of 2Imaging.
00 ity2 In: Topol EJ. Comprehensive
t toc
Cardiovascular Medicine.
igh PoPhiladelphia: Lippincott-Raven, 1998:
r
609-35.
py
Co
6. Green CE, Glass-Royal M, Bream PR, et al. Cinefluoroscopic
evaluation of periprosthetic cardiac valve regurgitation. Am J Radiol
1988;151:455-459.
7. Israel DR, Sharma SK, Fuster V. Anti-thrombotic therapy in
prosthetic heart valve replacement. Am Heart J 1994;127:400-411.
8. Jaeger FJ, Trohman RO, Brener S, et al. Permanent pacing following
repeat cardiac valve surgery. Am J Cardiol 1994;74:505-507.
9. Lengyal M, Fuster V, Keitni M, et al. Guidelines for management of
left-sided prosthetic valve thrombosis: a role for thrombolytic
therapy. J Am Coll Cardiol 1997;30:1521-1526.
10. Lin S, Wong J. Prosthetic heart valves. In: Marso SP, Griffin BP,
339
11. Rahimtoola SH. Prosthetic heart valve performance: long-term

follow-up. Curr Probl Cardiol 1992:33406.
12. Shaff IW. Prosthetic Valves. In: Giuliani ER, Oersh BJ, McOoon
MD, et al., eds. Mayo Clinic Practice of Cardiology, 3rd ed. St.
Louis: Mosby, 1996:1484-1495.
13. Vogel W, Stoll HP, Bay W, et al. Cineradiography for determination
of normal and abnormal function in mechanical heart valves. Am J
Cardiol 1993;71:225-232.
14. Vongratanasin W, Hillis LD, et al. Prosthetic heart valves. N Engl J
Med 1996;335: 407-416.
15. Zabalgoitia M. Echocardiographic assessment of prosthetic heart
valves. Curr Probl Cardiol 1992:270-325.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
340
suy tim
Suy tim l mt hi chng bnh l thng gp trong nhiu

bnh v tim mch nh cc bnh van tim, bnh c tim, bnh mch
vnh, bnh tim bm sinh v mt s bnh khc c nh hng
nhiu n tim.
Bnh thng khi chng ta cn lm mt hot ng gng sc
no (lao ng, chy nhy...) th lp tc tim s tng tn s v
tng sc co bp a c nhiu mu (tc l a c nhiu
xy) n cho cc m ca c th. Nhng khi tim b suy, th tim
khng cn kh nng cung cp mu theo nhu cu ca c th na.
V vy ngi ta c th nh ngha: Suy tim l trng thi bnh
ed l
v
r
e
trong cung lng tim khng p ng vi nhurecu
s ca c
ts bnh
n nhn.
th v mt xy trong mi tnh hung sinh hot gca
h
i om.v
r
l
l .c gp trn lm
Suy tim l mt tnh trng bnh l rt
thng
v. A ahoo
e
o
l th c
y khong 2,3 triu
sng. Theo nghin cu Framingham
Fin020@
.
8 2 M mi nm c khong
ngi M b suy tim (1981) v 0cng
20 otim
ity
400.000 bnh nhn mi mc

suy
t ot c (thng k nm 1983).
h
P
rignhng
y
Gn y, trn c
s
hiu bit su sc hn v c ch
p
o
C
bnh sinh ca suy tim, v tnh nng v tc dng ca mt s loi
thuc mi trong iu tr suy tim, ngi ta thu c nhng kt
qu kh quan trong vic iu tr hi chng ny.
I. Sinh l bnh
Chng ta bit trong suy tim thng l cung lng tim b
gim xung. Khi cung lng tim b gim xung th c th phn
ng li bng cc c ch b tr ca tim v ca cc h thng ngoi
tim, c duy tr cung lng ny. Nhng khi cc c ch b tr
ny b vt qu s xy ra suy tim vi nhiu hu qu ca n.
341
A. Cc yu t nh hng n cung lng tim: Qua

nghin cu, ngi ta hiu r c cung lng tim ph
thuc vo 4 yu t: Tin gnh, hu gnh, sc co bp ca
c tim v tn s tim.
Sc co bp c tim
Tin gnh
Cung lng tim
Hu gnh
Tn s tim
1. Tin gnh: (Preload)
a. Tin gnh c nh gi bng th tch hoc
p
ved
r
e
lc cui tm trng ca tm tht.
es
sr n
t
h
b. Tin gnh l yu t quyt nhigmc .v ko di
ll r o.com
si c tim trong thi k tm. Atrng,
trc lc tm
v aho
e
o
l thuc
y vo:
tht co bp. Tin gnhinph
F 020@
.
8 tht, tc l lng mu tnh
p lc y
00 ity2
c
2tm
mch trhtv
o
ot tht.
P
g
i
r
pygin ca tm tht, nhng mc t quan
Co hn.
trng
2. Sc co bp ca c tim:
a. Trc y bng thc nghim ni ting ca mnh,
Starling cho ta hiu r c mi tng quan
gia p lc hoc th tch cui tm trng trong
tm tht vi th tch nht bp. C th l:
Khi p lc hoc th tch cui tm trng trong
tm tht tng, th s lm tng sc co bp ca
c tim v th tch nht bp s tng ln.
Nhng n mt mc no , th d p lc
hoc th tch cui tm trng ca tm tht c
tip tc tng ln i na, th th tch nht bp
s khng tng tng ng m thm ch cn b
gim i.
342
b. Qua y ta c th hiu c mt vn quan

trng trong suy tim l: p lc hoc th tch cui
tm trng trong tm tht tng do cc nguyn
nhn khc nhau, s lm th tch nht bp tng,
nhng sau mt thi gian s dn n suy tim v sc
co bp ca c tim km dn v khi th tch nht
bp s gim i. Tim cng suy th th tch nht
bp cng gim.
3. Hu gnh (Afterload): Hu gnh l sc cn ca cc
ng mch i vi s co bp ca tm tht. Sc cn
cng cao th s co bp ca tm tht cng phi ln.
Nu sc cn thp qu c th s lm gim s co bp
ca tm tht, nhng nu sc cn tng cao s lm tng
cng ca tim cng nh tng mc tiu th xy eca
c
vd
ser v lm
tim, t s lm gim sc co bp ca cretim
ts
gim lu lng tim.
gh m.vn
i
r
ll o.co
4. Tn s tim: Trong suy tim, evlc
. A au
ho nhp tim tng
o
l
y
ln, s c tc dng b tr
@ tnh trng gim th
intt cho
. F 2020
8
tch nht bp v qua
s
duy
tr c cung lng
0
20 ocity
tim. Nhng nu
htnhp
Pot tim tng qu nhiu th nhu cu
rig s li
y
xy ca c
tim
tng ln, cng ca c tim cng
op
C
phi tng cao v hu qu l tim s cng b suy yu i
mt cch nhanh chng.
B. Cc c ch b tr trong suy tim
1. C ch b tr ti tim:
a. Gin tm tht: Gin tm tht chnh l c ch
thch ng u tin trnh qu tng p lc cui
tm trng ca tm tht. Khi tm tht gin ra, s
lm ko di cc si c tim v theo lut Starling,
s lm tng sc co bp ca cc si c tim nu d
tr co c vn cn.
b. Ph i tm tht: Tim cng c th thch ng
bng cch tng b dy cc thnh tim, nht l
trong trng hp tng p lc cc bung tim.
343
Vic tng b dy ca cc thnh tim ch yu l

i ph vi tnh trng tng hu gnh. Ta bit rng
khi hu gnh tng s lm gim th tch tng mu,
do b li c tim phi tng b dy ln.
c. H thn kinh giao cm c kch thch: Khi c
suy tim, h thn kinh giao cm c kch thch,
lng Catecholamin t u tn cng ca cc si
giao cm hu hch c tit ra nhiu lm tng sc
co bp ca c tim v tng tn s tim.
2. Bng ba c ch thch ng ny, cung lng tim s
c iu chnh li gn vi mc bnh thng. Tuy
nhin cc c ch ny cng ch c th gii quyt trong
mt chng mc no m thi. Thc vy, nu tm
tht gin n mc ti a v d tr co c vbed gim
r
ese tng
th lut Starling s tr nn rt t hiu lc.s rCng
t vn
. tng cng
t nh vy, ph i cc thnh tim rs
ighlm
om
l
l
c
.
A kch
ca tim. H thn kinh giao cm
oo thch lu ngy
v. b
ahth bta trong cc
loe cm
y
cng s dn n gim mtin
0@
. F 2ng
02 vi Catecholamin.
8p
si c tim v gim dn
0
20 city
t ototim:
3. C ch b tr
ngoi
Trong suy tim, i ph
h
P
ig
r
y
vi vic gim
p cung lng tim, h thng mch mu
Co
ngoi vi c co li tng cng th tch tun hon
hu ch. C th c ba h thng co mch ngoi vi
c huy ng:
a. H thng thn kinh giao cm: Cng giao cm
s lm co mch ngoi vi da, thn v v sau
khu vc cc tng trong bng v cc c.
b. H Renin-Angiotensin-Aldosteron: Vic tng
cng hot ha h thn kinh giao cm v gim
ti mu thn (do co mch) s lm tng nng
Renin trong mu. Renin s hot ha
Angiotensinogen v cc phn ng tip theo
tng tng hp Angiotensin II. Chnh Angiotensin
II l mt cht gy co mch rt mnh, ng thi n
li tham gia vo kch thch sinh tng hp v gii
344
phng Nor-adrenalin u tn cng cc si thn

kinh giao cm hu hch v Adrenalin t ty
thng thn. Cng chnh Angiotensin II cn kch
thch v thng thn tit ra Aldosteron, t lm
tng ti hp thu Natri v nc ng thn.
c. H Arginin-Vasopressin: Trong suy tim giai
on mun hn, vng di i - tuyn yn c
kch thch tit ra Arginin - Vasopressin, lm
tng thm tc dng co mch ngoi vi ca
Angiotensin II, ng thi lm tng ti hp thu
nc ng thn.
d. C 3 h thng co mch ny u nhm mc ch
duy tr cung lng tim, nhng lu ngy chng li
lm tng tin gnh v hu gnh, tng vnc
d v
r e
e
s
Natri, tng cng v mc tiu th xyreca c tim,
ts vv
to nn mt "vng lun qun" bnh
. n lm cho
gh l
i
r
m
o
l
suy tim ngy mt nng hn.. Al oo.c
ah
oev ygng
4. Ngoi ra, trong suy tim, Fnhm
b p li vic
@
inl 20c
. 20
8ton
co mch khu tr hay
b
ni
trn,
cc h thng
0
20 ocity
t ot
gin mch vighBradykinin,
cc Prostaglandin (PGI2 ,
P
i
yr t nh lm tng o thi Natri (Atrial
PGE2) vopYu
C Peptid) vit tt l APN, cng c huy
Natriuretic
ng song hiu qu thng khng nhiu.
C. Hu qu ca suy tim: Khi cc c ch b tr (c ch
thch ng) ni trn b vt qua th s xy ra suy tim vi
cc hu qu nh sau:
1. Gim cung lng tim: cung lng tim gim s gy:
a. Gim vn chuyn xy trong mu v gim cung
cp xy cho cc t chc ngoi vi.
b. C s phn phi li lu lng mu n cc c
quan trong c th: lu lng mu gim bt da,
cc c, thn v cui cng mt s tng khc
u tin mu cho no v ng mch vnh.
345
c. Nu cung lng tim rt thp th lu lng nc

tiu c lc ra khi ng thn cng s rt t.
2. Tng p lc tnh mch ngoi vi:
a. Suy tim phi: Tng p lc cui tm trng tht
phi s lm tng p lc nh phi ri t lm
tng p lc cc tnh mch ngoi vi v lm cho
tnh mch c ni, gan to, ph, tm ti...
b. Suy tim tri: Tng p lc cui tm trng tht
tri s lm tng p lc nh tri, ri tip n lm
tng p lc tnh mch phi v mao mch phi.
Khi mu cng cc mao mch phi s lm th
tch kh cc ph nang b gim xung, s trao i
xy phi s km i lm bnh nhn kh th. c
d
bit khi p lc mao mch phi tng nemt
rve mc
s
re
no s ph v hng ro ph nang
mch
ts - vmao
h
. n cc ph
g
phi v huyt tng s c thl ritrnomvo
l o.c
o
nang, gy ra hin tng ph
phi.
v. A
e
ah
o
l
y
II. Phn loi v nguyn nhn8. Fin020@
0 ty2
20 oth
i
A. Phn loi suy tim:

C
t ot c c nhiu cch phn loi suy
h
P
g
ri trn c s:
tim khc nhau,pyda
Co
1. Hnh thi nh khu: Suy tim phi, suy tim tri v suy
tim ton b.
2. Tnh trng tin trin: Suy tim cp v suy tim mn
tnh.
3. Lu lng tim: Suy tim gim lu lng v suy tim
tng lu lng.
4. Suy tim do tng tin gnh v suy tim do tng hu
gnh.
5. Tuy nhin, trn lm sng ngi ta thng hay chia ra
ba loi: suy tim tri, suy tim phi v suy tim ton b.
B. Nguyn nhn suy tim
1. Suy tim tri:
346
a. Tng huyt p ng mch: l nguyn nhn

thng gp nht gy ra suy tim tri. Chnh tng
huyt p lm cn tr s tng mu ca tht tri
tc l lm tng hu gnh.
b. Mt s bnh van tim:
H hay hp van ng mch ch n thun
hoc phi hp vi nhau.
H van hai l.
c. Cc tn thng c tim:
Nhi mu c tim.
Vim c tim do thp tim, nhim c hay
nhim khun.
Cc bnh c tim.
d. Mt s ri lon nhp tim: c ba loi rri
ved lon
e
s
nhp tim ch yu c th a n bnh
re cnh ca
ts vn
h
.
g
suy tim tri:
l ri .com
l
o tht, nht l
Cn nhp nhanh kchevpht
. A ahotrn
o
l
y
cn rung nh hayFcn
in 2cung
0@ ng nh.
0
8. tht.
2
Cn nhp nhanh
0
20 ocity
t- tht
Bloc nh
h
Pot hon ton.
ig
r
y
e. Mt s
p bnh tim bm sinh:
Co
Hp eo ng mch ch.
Cn ng ng mch.
ng nh - tht chung...
f. Ch : Trng hp hp van hai l, do tng cao p
lc trong nh tri v mao mch phi nn dn n
nhng triu chng ging nh suy tim tri. Nhng
s thc th hp hai l n thun khng gy c
suy tim tri theo ng ngha ca n v hp hai l
to nn mt s cn tr dng mu i ti tht
tri, lm cho p lc (hay th tch) cui tm trng
ca tht tri li b gim hn bnh thng; tm tht
tri khng b tng gnh nn khng suy c.
2. Suy tim phi:
347
a. Cc nguyn nhn v phi v d dng lng

ngc, ct sng:
Cc bnh phi mn tnh : Hen ph qun, vim
ph qun mn, gin ph nang, gin ph qun,
x phi, bnh bi phi... dn dn a n
bnh cnh ca tm ph mn.
Nhi mu phi gy ra bnh cnh tm ph cp.
Tng p lc ng mch phi tin pht.
G vo ct sng, cc d dng lng ngc khc.
b. Cc nguyn nhn tim mch:
Hp van hai l l nguyn nhn thng gp
nht.
Mt s bnh tim bm sinh: hp ng mch
phi, tam chng Fallot. Mt s bnh tim
d bm
rve(thng
e
s
sinh khc c lung shunt triphi
e
sr n
tn
h
lin nh, thng lin tht vv...)
giai on
.
g
ri com v
lca
l
.
mun s c bin chng
tng
p ng
v. A ahoo
e
o
mch phi v gy isuy
yphi.
nl tim
0@
Fmc
2
.
0
Vim ni tm
nhim
khun gy tn
8
00 ity2
2
c ba l.
van
thng nng
ht Poto
Mtys
nhn t gp: u nhy nh tri, v
rignguyn
p
o
C
ti phnh xoang Valsalva vo cc bung tim
bn phi, tng p lc ng mch phi tin
pht v
v...
c. Ch : Trng hp trn dch mng ngoi tim
hoc vim mng ngoi tim co tht s c biu hin
ging nh suy tim phi, nhng thc cht ch l
nhng trng hp thiu nng tm trng ch
khng phi suy tim phi theo ng ngha ca n.
3. Suy tim ton b:
a. Thng gp nht l cc trng hp suy tim tri
tin trin thnh suy tim ton b.
b. Cc bnh c tim gin.
348
c. Vim tim ton b do thp tim, vim c tim.

d. Cui cng cn phi nhc n mt s nguyn nhn
c bit gy suy tim ton b vi "lu lng tng":
Cng gip trng.
Thiu Vitamin B1.
Thiu mu nng.
D ng - tnh mch.
III. Triu chng
A. Suy tim tri
1. Triu chng c nng:
a. Kh th: L triu chng hay gp nht. Lc u
ch kh th khi gng sc, v sau kh th xy ra
d nn
thng xuyn, bnh nhn nm cng kh vth
r e
e
s
thng phi ngi dy th. Din bin
re v mc
hts kh
.vn th mt
kh th cng rt khc nhau: crigkhi
m
o
l
l n
.c
cch dn dn, nhng nhiu
hoo t ngt, d
v. Akhi
e
a
o
l hay
y ph phi cp.
di nh trong cn henin
tim
F 020@
.
2 m hoc khi bnh nhn
b. Ho: Hay xy ra 0vo
08 ban
2 ocity
gng sc. gThng

ht ot l ho khan nhng cng c khi
ri ln tP mu.
y
ho ra om
p
C
a. Khm tim: Nhn, s thy mm tim p hi lch
sang tri. Nghe tim: Ngoi cc triu chng c th
gp ca mt vi bnh van tim gy nn suy tht
tri, ta thng thy c ba du hiu:
Nhp tim nhanh.
C th nghe thy ting nga phi.
Cng thng nghe thy mt ting thi tm thu
nh mm, du hiu ca h van hai l c
nng v bung tht tri gin to.
b. Khm phi:
Thng thy ran m ri rc hai bn y phi.
Trong trng hp cn hen tim c th nghe
c nhiu ran rt v ran m hai phi, cn
349
trong trng hp ph phi cp s nghe thy

rt nhiu ran m to, nh ht dng nhanh t hai
y phi ln khp hai ph trng nh "thy
triu dng".
Trong a s cc trng hp, huyt p ng
mch ti a thng gim, huyt p ti thiu
li bnh thng nn s huyt p chnh lch
thng nh i.
a. Xquang:
Tim to ra nht l cc bung tim bn tri. Trn
phim thng: tm tht tri gin biu hin bng
cung di bn tri phng v ko di ra.
C hai phi m nht l vng rn phi.rvi
ed khi
e
s
c th bt gp ng Kerley s(do
re ph cc
t vn
h
. ca phi)
g
khong k ca h thng bch
huyt
l ri .com
l
A okinh in hai
hoc hnh nh "cnh vbm"
e . yaho
o
l
rn phi trong trng
0@ c ph phi.
Fin02hp
8. ch
2
b. in tm : Thng
thy
du hiu tng gnh
0
20 ocity
cc bunggtim
ht bn
Pot tri: Trc tri, dy nh tri, dy
ri
y
tht tri.
p
Co
c. Siu m tim: Thng thy kch thc cc bung
tim tri (nh tri, tht tri) gin to. Ngoi ra siu
m cn gip ta bit c s co bp ca cc vch
tim cng nh nh gi c chnh xc chc nng
tm thu ca tht tri. Trong nhiu trng hp siu
m tim cn gip cho ta khng nh mt s
nguyn nhn gy ra suy tim tri.
d. Thm d huyt ng cho php:
nh gi mc suy tim tri thng qua vic
o ch s tim (bnh thng t 2-3,5 l/pht/m2)
v o p lc cui tm trng ca tht tri.
nh gi chnh xc mc nng nh ca mt
s bnh van tim.
350
B. Suy tim phi

1. Triu chng c nng:
a. Kh th: t hoc nhiu, nhng kh th thng
xuyn, ngy mt nng dn v khng c cc cn
kch pht nh trong suy tim tri.
b. Ngoi ra, bnh nhn hay c cm gic au tc
vng h sn phi (do gan to v au).
a. Ch yu l nhng du hiu mu ngoi bin:
Gan to u, mt nhn, b t, au mt cch t
pht hoc khi s vo gan th au. Lc u gan
nh i khi c iu tr v gan to li trong t
suy tim sau, nn cn gi l gan "n xp".
ed V
erv
sau, do mu lu ngy nn ganreskhng
th
s
t
n
h
nh li c na v tr nn cng.
rig com.v
ldu
l
Tnh mch c ni to v
. A ahoo. hiu phn hi
v
e
o
gan-tnh mch cnldng
y tnh. p lc tnh
0@ lc tnh mch ngoi
Fiv02p
.
mch trung ng
8
00 y2
bin tngt cao.
2 tocit
h Po
Tmyda
mc: Tm l do mu b tr
rig v nim
p
o
C
ngoi bin, nn lng Hemoglobin kh tng
ln trong mu. Ty mc suy tim m tm
nhiu hay t. Nu suy tim nh th ch thy tm
t mi v u chi. Cn nu suy tim nng th
c th thy tm r ton thn.
Ph: Ph mm, lc u ch khu tr hai chi
di, v sau nu suy tim nng th c th thy
ph ton thn, thm ch c th c thm trn
dch cc mng (trn dch mng phi, c
chng...). Bnh nhn thng i t (khong
200 - 500ml/ngy). Nc tiu sm mu.
b. Khm tim:
S: c th thy du hiu Hartzer (tm tht
phi p vng mi c), nhng khng phi
bnh nhn no cng c du hiu ny.
351
Nghe: ngoi cc triu chng ca bnh gy

ra suy tim phi ta cn c th thy:
(a) Nhp tim thng nhanh, i khi c ting
nga phi phi.
(b) Cng c khi nghe thy ting thi tm thu
nh trong mm hoc vng mi c do
h van ba l c nng. Khi ht vo su,
ting thi ny thng r hn (du hiu
Rivero-Carvalho).
(c) Huyt p ng mch ti a bnh thng,
nhng huyt p ti thiu thng tng ln.
3. Cc xt nghim chn on: tr trng hp suy tim
phi do hp ng mch phi c nhng c im ring
ca n, cn trong a s cc trng hp khc ta ethy:
d
rv
e
s
a. X quang:
re
ts vn
h
g
Trn phim tim phi thng: ri m.
o
ll phi)
Anh
o.c gin.
(a) Cung di phi (tm
o
.
h
v
a
oe yhn
(b) Mm tim nng
pha trn vm
@
inl 2cao
0
F
. tm
0 tht phi gin.
8do
honh tri,
2
0
0 ity
2 tocmch
(c) Cung
phi cng gin to.
t ng
h
o
rig mP nhiu do mu phi.
(d)
Phi
y
p
Co phim nghing tri: Tht phi to lm cho
Trn
khong sng sau xng c b hp li.
b. in tm : Thng thy cc du hiu ca trc
phi, dy nh phi, dy tht phi.
c. Siu m tim: ch yu thy kch thc tht phi
gin to. Trong nhiu trng hp c th thy cc
du hiu ca tng p ng mch phi.
d. Thm d huyt ng: c th thy:
p lc cui tm trng ca tht phi tng
(thng l trn 12 mmHg).
p lc ng mch phi cng thng tng.
C. Suy tim ton b: Thng l bnh cnh ca suy tim
phi mc nng:
1. Bnh nhn kh th thng xuyn, ph ton thn.
352
2. Tnh mch c ni to, p lc tnh mch tng rt cao.

3. Gan to nhiu..
4. Thng c thm trn dch mng phi, mng tim hay
c chng.
5. Huyt p ti a h, huyt p ti thiu tng, lm cho
huyt p tr nn kt.
6. X quang: Tim to ton b.
7. in tm : C th c biu hin dy hai tht.
IV. nh gi mc suy tim
C nhiu cch nh gi mc suy tim, nhng trn y
vn th gii ngi ta thng hay dng cch phn loi mc
suy tim theo Hi Tim mch hc New York (New YorkedHeart
rv
Association) vit tt l NYHA, da trn s nh gi mc
ese hot
r
ts vn
ng th lc v cc triu chng c nng ca bnh
.
ghnhn.
i
r
l .com
l
ANYHA
o
A. Phn loi mc suy tim theo
ev. yaho
o
l
@ theo NYHA.
Bng 18-1. Phn loi mc .
Finsuy0tim
8 202
0
Biu
ty
20 ihin
t otoc
h
I
Bnh nhn c bnh
rig timPnhng khng c triu chng c
y
p
nng no, vn
Co sinh hot v hot ng th lc gn nh
bnh thng.
II
Cc triu chng c nng ch xut hin khi gng sc
nhiu. Bnh nhn b gim nh cc hot ng v th lc.
III Cc triu chng c nng xut hin k c khi gng sc
rt t, lm hn ch nhiu cc hot ng th lc.
IV Cc triu chng c nng tn ti mt cch thng xuyn,
k c lc bnh nhn ngh ngi khng lm g c.
Trong thc t lm sng, cch phn loi ny rt tt i vi
suy tim tri, nhng khng tht thch hp lm i vi cc bnh
nhn suy tim phi.
B. Phn loi mc suy tim trn lm sng
nc ta, s lng cc bnh nhn suy tim phi thng
chim mt t l kh ln trong s cc bnh nhn b suy tim. V
353
vy, s b trn lm sng cc thy thuc thng qui c mc

suy tim theo khuyn co ca Hi Ni khoa Vit nam nh sau:
Bng 18-2. Phn loi mc suy tim trn lm sng.
Biu hin
I
Bnh nhn c kh th nh nhng gan cha s thy.
II
Bnh nhn kh th va, gan to di b sn vi cm.
III Bnh nhn kh th nhiu, gan to gn st rn nhng khi
c iu tr gan c th nh li.
IV Bnh nhn kh th thng xuyn, gan lun to nhiu
mc d c iu tr.
V. iu tr
iu tr suy tim bao gm:
Nhng bin php iu tr chung cho tt c cc
d loi
rve hon
e
s
nguyn nhn gy ra suy tim, nhm gim tr
tun
re
ts vn
h
v tng cng kh nng co bp ca c tim.
.
g
l ri .com
l
A po dng cho tng
Nhng bin php iu tr c bit
ev. yaho
o
l
trng hp c th ty theo nguyn
nhn ca suy tim.
Fin 0@
8. 202
0
A. Nhng bin php iu
20 tr
ity chung
t otoc
h
P dng thuc:
1. Cc bin php
rig khng
y
p
a. ChCo ngh ngi: Ngh ngi l mt vic kh
quan trng v n gp phn lm gim cng ca
tim. Ni chung bnh nhn cn gim hoc b hn
cc hot ng gng sc. Trong trng hp suy
tim nng th phi ngh ti ging theo t th na
nm na ngi. Tuy nhin, trong trng hp suy
tim m bnh nhn phi nm iu tr lu ngy th
khi hon cnh cho php, nn khuyn khch bnh
nhn xoa bp, lc u l th ng, sau l ch
ng cc chi, nht l hai chi di lm cho
mu tnh mch tr v tim c d dng hn, gim
bt cc nguy c huyt khi tnh mch thng hay
gp nhng bnh nhn ny.
b. Ch n gim mui:
354
Ch n gim mui l cn thit, v mui n

(NaCl) lm tng p lc thm thu trong mu,
do lm tng khi lng tun hon, t
gy tng gnh nng cho tim.
Mt ngi bnh thng hp thu khong 6 18g mui NaCl/ ngy, tc l 2,4 - 7,2g (100 300mmol) Na+ / ngy. i vi bnh nhn suy
tim, ty tng trng hp c th m p dng
ch n gim mui hoc ch n gn nh
nht hon ton.
Ch n gim mui: Bnh nhn ch c
dng < 3g mui NaCl /ngy, tc l < 1,2g (50
mmol) Na+ /ngy.
Ch n gn nh nht hon ton: Bnhd nhn
ve
ch c n < 1,2g mui NaCl /ngy
ser tc l <
e
r
0,48g (20mmol) Na+ /ngy. ghts .vn
i om
ll r odng
c. Hn ch lng nc v dch
cho bnh
.c
A
o
.
v ah
e
nhn:
o
l @y
0
Fin02nc
.
Cn hn ch 0lng
v dch dng cho
8 2
y
0
t
2
i
bnh nhn
oc ngy nhm gim bt khi
t hng
Pot v gim gnh nng vi tim.
gh hon
itun
lng
r
py
Co chung ch nn dng cho bnh nhn
Ni
khong 500 - 1000ml lng dch a vo c
th mi ngy.
d. Th xy: l bin php cn thit trong nhiu
trng hp suy tim v n tng cung cp thm xy
cho cc m, gim bt mc kh th ca bnh
nhn, ng thi lm hn ch s co mch phi
thng gp nhng bnh nhn thiu xy.
e. Loi b cc yu t nguy c khc:
B ru, thuc l, c ph...
Gim cn nng nhng bnh nhn bo ph.
Trnh cc xc cm mnh (stress).
Ngng nhng thuc lm gim sc bp ca c
tim nu ang dng, v d: cc thuc chn bta
355
giao cm hoc Verapamil hay Disopyramide,

Flecainide...
iu tr nhng yu t lm nng thm tnh
trng suy tim nh nhim trng, ri lon nhp
tim...
B. Cc thuc trong iu tr suy tim
1. GLUCOSID tr tim:
a. Cc dng Glucosid tr tim c dng trn lm
sng l:
Digitalis vi cc dng Digitalin hay Digitoxin
ly t Digitalis Purpurea; Digoxin v Isolanid
ly t Digitalis Lanata.
Strophanthus vi cc dng G Strophantin (tc
d
Uabain) ly t Strophantus Kombe. serve
re
Trong thc hnh lm sng
nay
ts vhin
n
h
.
g
i
r
m tiu biu
DIGOXIN l loi thucll tr.cotim
A hoo
.
v
thng c cc thy
thuc
hay
s dng
loe @ya
n
i
0
nhiu nht.
F
8. 202
0
y
0
b. C ch tc dng:
2 it
t otoc
h
P tng sc co bp ca c tim gin
g
Digoxin
lm
ri
y
p
tip
Co thng qua vic c ch men Natri - Kali Adenosine Triphosphatase (Na+-K+-ATPase)
ca bm ion mng t bo c tim, t cn
tr vic ion Na+ thot ra ngoi mng t bo.
Do s c ch ny lm cho nng Na+ trong
t bo tng cao, v vy s vn chuyn Na+ Ca++ qua mng t bo cng b ri lon, lm
tng nng Ca++ trong t bo c tim, t
thc y cc si c tim tng cng co bp.
Mt khc Digoxin cn tc ng trn h thng
thn kinh t ng ca tim, lm gim nhp tim
v gim tc dn truyn nh - tht.
Ngoi ra Digoxin cn lm tng trng lc h
ph giao cm v lm gim hot tnh ca h
giao cm.
356
c. Dc ng hc:
Digoxin thng c dng di dng ung
(vin nn, vin nang, dng cn) hoc tim.
dng ung, phn ln Digoxin c hp thu
rut non sau s c phn b tip ti mt
s m. Nng Digoxin thng c tp
trung ch yu thn, tim, gan, tuyn thng
thn, ng tiu ha...
Digoxin c chuyn ha ch yu ti gan.
Phn ln Digoxin c thi tr qua ng
nc tiu, ch c mt phn nh (khong 25%)
c thi tr qua ng phn.
ngi ln, vi chc nng gan, thn bnh
thng th thi gian bn hy trung bnh
ed ca
v
r
e
Digoxin (theo ng ung) l 36 gi.
res
ts l
n nng
Mt s nghin cu cho thy
h
ig om.v
r
l
l o.ca
c Digoxin c
trung bnh trong huyt tng
ho khong t 0,5
v. Atrong
e
a
tc dng iu tr thng
o
inl @y
. F 2020 Tuy nhin khong
hoc 0,8 n 82,0ng/ml.
0 y
20 ocit
cch gia
nng
iu tr v nng ng
t ot
h
P
g
cyl
ri rt hp. C bnh nhn phi dng trn
p
2,0
Co ng/ml mi c tc dng iu tr, ngc li
mt s bnh nhn khc nng 0,8 - 1,5
ng/ml c triu chng ca ng c Digoxin.
d. Liu lng v cch dng:
Trc y ngi ta hay dng bt u bng
liu tn cng sau chuyn sang liu duy tr.
Liu tn cng thng l 0,25 - 0,5mg, ri c
sau 6 gi c th cho thm 0,25mg t tng
liu l 1 - 1,5 mg/ngy.
Khi t c hiu qu, thng chuyn sang
liu duy tr t 0,125 - 0,375mg/ngy.
Ngy nay ngi ta thng khng cn dng
liu tn cng vi mt lng thuc ln trong
mt thi gian ngn nh trn v cch ny rt d
gy nguy him cho bnh nhn. Trong a s
357
cc trng hp, cc thy thuc thng bt u

ngay bng liu duy tr nh trnh by trn
t dn ti liu c hiu lc iu tr.
Vic theo di nng Digoxin trong huyt
tng s gip ta iu chnh c ti liu iu
tr ti u. Nng Digoxin huyt tng trong
khong t 1,8 - 2 ng/ml c coi l nng
c hiu lc iu tr, qu nng th d b
nhim c Digoxin.
e. Tng tc thuc:
Mt s thuc c th lm gim vic hp thu
Digoxin nh: Cholestyramine, Cholestipol,
Kaolin-pectin, Sulfasalazine, Neomycine v.v...
Ngc li, mt s thuc c th lm tng
d vic
rve hoc
e
hp thu Digoxin nh Tetracycline
s
re
n th lm
hts .vc
Erythromycine. Mt s thucigkhc
r
m
o
l
c
gim ng k thanh .thi
do c
Al hDigoxin,
oo.
v
e
a
o
th lm tng nng n
l ca
y Digoxin trong mu
0@
FiVerapamil,
2
.
nh: Quinidine,
Spironolactone,
0
08 ty2
0
2
i
Amiodarone...
c
ht Poto
Cnyc
ch khng bao gi c dng
rig bit
p
Co hp Digoxin vi cc mui Canxi (ng
phi
tnh mch) v s phi hp ny c th gy nn
nhng ri lon nhp tim nng n, thm ch c
th gy t vong.
f. Ch nh:
Suy tim vi cung lng tim thp, c bit khi
c rung nh nhanh.
Cc ri lon nhp trn tht, c bit trong
rung nh hay cung ng nh.
Ch : Nhng trng hp suy tim vi cung
lng tim cao (thiu mu nng, nhim c
gip, d ng - tnh mch, bnh thiu vitamin
B1...) hoc suy tim c lin quan n mt tc
nghn c hc hay suy tim trong tm ph mn
khng phi l nhng ch nh ca Digoxin.
358
g. Chng ch nh:
Nhp tim chm.
Bloc nh - tht cp II, cp III cha c t
my to nhp.
Ngoi tm thu tht.
Nhp nhanh tht v rung tht.
Hi chng Wolff - Parkinson - White.
Bnh c tim tc nghn.
Cn thn trng trong trng hp: Nhi mu
c tim cp (v Digoxin lm tng nhu cu xy
ca c tim) v cc ri lon in gii, c bit
l h K+ mu v / hoc h Mg ++ mu.
h. Nhim c Digoxin: mt s thng k cho thy
s bnh nhn dng Digoxin b nhim c chim
khong 5 - 15% tng s bnh nhn dng thuc.
d
rve l :
e
s
Yu t thun li cho nhim c Digoxin
e
s r n h Mg++
(a) Ri lon in gii: h Kig+ htmu,
v
.
mu, tng Ca++ mu.All r o.com
ho nhy cm vi
ev. ya
(b) Tui cao: lm lotng
in 0@lc ca thn, t d
Digoxin do8gim
. F 202
0
0 ity
lm ng
2 tocthuc.
t
h
o
(c) Nhim
chuyn ha.
Pkim
rig
y
(d)
Gim
xy
mu.
p
Co
(e) Suy thn, suy gan...
Biu hin lm sng ca nhim c Digoxin:
khi bnh nhn ang dng Digoxin, t nhin
thy mt s biu hin sau :
(a) Ri lon tiu ha: chn n, bun nn, nn
ma, a chy.
(b) Ri lon thn kinh: c th ch l au u,
chng mt nhng c th nng hn nh o
gic, mt phng hng, m sng...
(c) Ri lon tim mch: do tng tnh kch
thch, tng tnh t ng v gim tnh dn
truyn ca t bo c tim:
i. Ngoi tm thu nh v tht, hay gp l
ngoi tm thu tht nhp i, ngoi tm
thu tht a dng hoc tng chm.
359
ii. Nhp nhanh b ni, nhp nhanh tht.

iii. Bloc xoang - nh.
iv. Bloc nh - tht cc loi.
v. Xon nh, rung tht.
X tr nhim c Digoxin:
(a) Ngng ngay vic iu tr bng Digoxin.
(b) Theo di cht ch nhng din bin trn
in tm .
(c) iu chnh kp thi cc ri lon v in
gii v thng bng toan kim, trong
cn c bit lu c tnh trng h K+ mu
khng? Nu c h K+ mu cn cho bnh
nhn ung khong 20 - 50 ml dung dch
Kalichlorua 10%. Trng hp cn thit c
th truyn nh git Kalichlorua vo
tnh
ved dung
r
mch sau khi pha thuc trong
e
es
s r niu kin
dch ng trng, nhng htvi
.v
ig omkhng
c
m K+ truyn tnhll rmch
c
.
A hoo
.
vt qu 13 - 15mmol/gi.
v
a
oe
(d) C th dngFAtropin
inl 20@y tim tnh mch vi
8. 20 khi c nhp chm xoang
liu t 0,5
00 - i1mg
ty
2
tchm
oc
hochtnhp
do Bloc nh - tht.
o
rig ccP loi ri lon nhp tht, c bit l
(e)pyVi
Co ngoi tm thu tht, ta c th iu tr bng
cch truyn Lidocaine vi m
2mg/pht.
(f) Gn y ngi ta cn dng mt phng
php kh mi na iu tr nhng
trng hp nhim c Digoxin. l
dng khng th c hiu ca Digoxin
(Fab fragments, Digibind) v thng c
vit tt l Fab. Thng Fab c dng
theo ng truyn tnh mch.
i. C ch: Phc hp Digoxin kt hp vi
Fab s c o thi qua thn, lm
mt tc dng ca Digoxin. Mt ng
Fab 40mg trung ha 0,6mg Digoxin.
360
ii. Vi ng c mn Digoxin: S ng Fab

cn dng = [nng Digoxin mu
(ng/ml) cn nng c th (kg)] / 100.
iii. Vi ng c cp Digoxin: S ng Fab
cn dng = [liu lng Digoxin dng
cho bnh nhn (mg) 0,8] / 0,6.
2. Thuc li tiu:
a. Thuc li tiu lm tng o thi nc tiu, qua
lm gim khi lng nc trong c th, gim
khi lng mu lu hnh, lm bt lng mu tr
v tim v lm gim th tch cng nh p lc cui
tm trng ca tm tht, lm gim tin gnh, to
iu kin cho c tim b suy yu hot ng
c tt hn.
d tiu
b. Bin chng c th gp khi dng cc thucrveli
e
+
+
s
l h K mu, h Na mu, lm gim
reth tch v
hts .bin
vn chng
kim ha mu. H K+ mu lrigmt
m
o
l
l omng
c
quan trng, c th e do. Atnh
ca bnh
o.
h
v
e
a
o
nhn, nht l khi dngnlcng
yvi Digoxin. Do
0@
Fi 0li
2
.
khi iu tr bng 0thuc
tiu,
cn phi theo di
8 2
20 ocmu.
ity Vic b mui Kali hoc
cht ch in gii
t
t
gh liPotiu
phi hprivi
gi Kali l vn lun lun
y
p
o n.
phiCnh
c. Nhm thuc li tiu Thiazide (Chlorothiazide,
Hydrochlothiazide, Metolazone, Indapamide):
Thng c dng mt cch kh ph bin
trong iu tr suy tim nhng bnh nhn m
chc nng thn cn bnh thng.
V tr tc ng ca thuc l ng ln xa
(ring Metolazone cn tc ng trn c ng
ln gn), vi c ch lm tng bi tit mui,
do s lm tng thi nc.
Hydrochlothiazide cn c dng nhiu v gi
kh r.
Bin chng c th gp khi dng Thiazide l
h K+, Na+, Ca++ mu. Thuc cng c th lm
tng ur, creatimin mu, c khi gy vim ty,
vim mch. Gn y ngi ta cp n tc
361
d. Nhm thuc li tiu tc dng ln quai Henle

(Furosemid, Bumetanide, Acid Ethacrynic...):
V tr tc ng ch yu ca thuc l nhnh
ln ca quai Henle. Li tiu nhm ny lm
tng thi Natri ln n 25%, ngoi ra chng
cn c tc dng lm tng dng mu n thn
do lm tng hot ha Prostaglandin PGE c
tc dng gin mch thn. V c tc dng li
tiu mnh v khng lm gim chc nng thn
nn li tiu nhm ny c ch nh bnh
nhn suy tim m i hi phi gim th
ed tch
v
r
e
tun hon nhanh hoc bnh nhn esuy
thn.
rs
ts vn
Furosemide ngoi kh nng hlm
gim
tin
.
ig om
r
gnh nhanh, khi dng tim
tnh
mch
n
cn
l
Al hoo.c
.
v
c tc dng gy gin
mch
trc
tip.
V
vy,
loe @ya
Furosemide c. bit
Fin0c
20 hiu qu trong iu tr
2
08tim
bnh nhn suy
nng
hoc b ph phi cp.
y
0
t
2 tociny
t nhm
Li tiu
c
th gy h K+, Na+,
h
o
++ rig ++ P
Caopy, Mg mu. Ngoi ra mt s bnh nhn
C khi c th c biu hin ni ban, vim
i
mch...
e. Nhm thuc li tiu gi Kali (Spironolactone,
Triamterene, Amiloride):
Li tiu nhm ny tc ng trn on cui
ca ng ln xa. Spironolactone tc ng
thng qua vng nhy cm aldosterone;
Triamterene v Amiloride cng tc ng
vng cui ca ng ln xa nhng khng chu
s kim sot ca aldosterone.
Tc dng li tiu ca cc thuc thuc nhm
ny yu nu ch dng mt mnh. Nhng v li
ch gi Kali nn chng thng c phi hp
vi li tiu Thiazide hoc li tiu quai Henle.
Li tiu gi Kali thng tc dng chm v
362
ko di. Ni chung vi loi li tiu gi Kali

ny, khi dng cng phi theo di Kali mu,
c bit ch khi dng cng vi thuc c ch
men chuyn, hoc thuc gim vim khng
Steroide. Ngoi ra nhm li tiu gi Kali ny
cng i khi cng c th gy ra tng ur mu,
si thn (vi Triamterene) hoc chng v to
nam gii (vi Spironolactone).
Bng 18-3. Mt s thuc li tiu dng trong suy tim.
Tc
Thuc
ng Liu TB Bt u
dng
dng ngy (mg)
tc
ko di
dng
Thiazide
Chlorothiazide
U
250
2h
6 - 12h
d
500
rve
e
s
e
TM
500
15ph hts r 1h
vn
.
g
Hydrochlothiazi U
25 100 2hll ri .com 12h
A o
-de
ev. yaho
o
l
Metolazone
U
2,5 - 20,0
1h
24 - 48h
Fin 0@
8. 202
0
y
0
Indapamide
U
2,5
5,0
2h
24h
2 it
t otoc
h
Li tiu quai
P
g
ri
y
p
Furosemide
U
20
80
1h
6 - 8h
Co
TM,
10 80
5ph
2 - 4h
TB
Ethacrynic
U
25 100 30ph
6 - 8h
acide
TM
50
5ph
2 - 4h
Bumetanide
U
0,5 - 2,0
30ph
2h
TM,
0,5 - 2,0
5ph
30ph
TB
Torsenide
U
5 - 10
2h
8 - 12h
TM
5 - 10
5ph
6 - 8h
Nhm gi kali
Spironolactone
U
50 - 200
1 - 2ng
2 - 3 ng
Triamterene
U
100 - 200 2 - 4 ng 7 - 9 ng
Amiloride
U
5 - 10
2h
24h
363
OLX: ng ln xa, OLG: ng ln gn, QH: Quai Henle, U: ng

ung, TM: tim tnh mch, TB: tim bp, h: gi, ph: pht, ng: ngy.
3. Cc thuc gin mch trong iu tr suy tim:

a. Nh chng ta r, c ch b tr bnh nhn
suy tim bao gm c s co tht h ng mch v
tnh mch. S co tht h ng mch lm tng hu
gnh v s co h tnh mch lm tng tin gnh.
Hn na trong suy tim, s co tht h mch phi
cn l hu qu ca thiu xy mu, hoc s p
ng lu di vi vic tng dng mu qua phi (v
d khi c Shunt tri phi trong tim) hoc p
ng lu di vi vic tng p lc nh tri (V d:
Hp hai l, suy tim tri...).
d
b. Cc thuc gin mch c th u tin tc dng
rve gim
e
s
re
hu gnh, tin gnh hoc c hai. tsNhng
thuc
h
vngim tin
.
g
i
lm gin tnh mch nhiu hn
s
lm
r
l .com
AlCn
o
.
gnh v p lc y tht.
v
e yaho cc thuc lm
o
l
in 2gim
gin ng mch s. Flm
0@ hu gnh. V vy,
0
8
2
0
ni chung cc 2thuc
0 itygin mch s ci thin c
oc p lc y tim v gim
t ogim
cung lng
tim,
h
Pt
ig
r
y thnh tim. nhng bnh nhn h van
sc popln
C
tim, suy tim nng hoc c tng tr khng mch,
hoc suy tim c tng huyt p th dng cc thuc
gin ng mch rt c hiu qu.
c. Tc dng ph ni chung ca cc thuc gin mch
trong iu tr suy tim thng l: H huyt p
(nht l h huyt p trong t th ng), tng nh
ur mu... Dng thuc gin mch cn ht sc
thn trng nhng bnh nhn c hn ch cung
lng tim (V d: Hp van ng mch ch, bnh
c tim ph i tc nghn) hoc nhng bnh nhn
c ri lon chc nng tm trng (Bnh c tim
hn ch).
d. Thuc c ch men chuyn dng angiotensin:
364
Cc thuc thuc nhm ny c tc dng c ch

men c nhim v chuyn t Angiotensin I
thnh Angiotensin II t c ch s tng hp
Angiotensin II, l mt cht gy co mch,
ng thi li lm tng Bradykinin, l mt cht
gy gin mch. Kt qu chung l cc thuc c
ch men chuyn ny s lm gin mch nhiu,
lm gim hu gnh, t gp phn ci thin
tnh trng suy tim. Trong nhng nm gn y,
vai tr ca thuc c ch men chuyn trong
iu tr suy tim ngy cng c nhn mnh
nht l trong nhng trng hp suy tim tr
vi nhng bin php iu tr kinh in.
Chng ch nh dng khi: Hp ng dmch
rve
thn hai bn, ph n c thai.
ese
r
Nhng tc dng ph c thggp
n ho, ni
hts .vl:
i
r
m
o
l
ban, tt huyt p, lon v
lgic,c tng creatinin
. A oo.
mu, tng kali mu loev yah
Fin020@ thuc c ch men
Thn trng khi
8. dng
2
0
20 ovi
chuyn cng
ityloi li tiu gi kali hoc
c
t ot
dngrthuc
bnh nhn c huyt p thp.
igh Pcho
y
p
Bng 18-4. Mt
Co s thuc c ch men chuyn thng dng.
Thuc
Liu u Trung bnh
(mg/ngy) (mg/ngy)
Benazepril (Cibace, Cibacen,
5 - 10
10 - 40
Lotensin)
Captopril (Capoten, Lopril, 12,5 - 25
12,5 - 100
Lopiril, Captopril)
Enalapril (Innovace, Pres,
2,5 - 5
2,5- 40
Renitec, Renivace, Vasotec)
Fosinapril (Monopril, Staril)
10
10 - 40
Lisinopril (Prinivil, Zestril)
10
5 - 40
Quinapril (Accupril, Acuitel)
10
5 - 80
Ramipril
(Altace,
Delix, 1,25 - 2,5
1,25 - 20
Ramace, Triatec, Tritace)
365
e. Nhm thuc c ch trc tip th th AT1 ca

angiotensin II:
Cc thuc nhm ny kh mi v c ch l c
ch trc tip th th AT1. Khc vi thuc c
ch men chuyn, cc thuc c ch th th
AT2 khng lm tng bradykinin nn c th
khng gy ra cc triu chng ph nh l ho
khan (mt tc dng ph rt ph bin khi dng
CMC v l hn ch ng k ca CMC).
Cc thuc ny c dng ch yu iu tr
bnh nhn THA nhng cc nghin cu mi
y cng chng minh vai tr tt trong iu tr
suy tim v l thuc thay th cho CMC khi
khng dung np c.
d
rve ca
e
Bng 18-5. Mt s thuc c ch th th
AT1
s
re
ts vn
h
angiotensin II trong iu tr suy tim.
g
ri com.
l
l
. trung bnh
Thuc
Liu ban u
Liu
v. A ahoo
e
o
l
y
Candesartan
8-16in
mg
2-32 mg
F 020@
.
8
Eprosartan
200-400
400-800 mg
00 ity2 mg
275-150
c
o
Irbersartan
mg
75-300mg
t
gh Pot
i
r
Losartan
25 mg
25-100 mg
py
Co
Telmisartan
20-40 mg
40 80 mg
Valsartan
80 mg
80-320 mg
f. Nhm Nitrates:
Nhm Nitrat ch yu lm gin h tnh mch,
t lm gim tin gnh. Nhm ny cn lm
gim bt tnh trng thiu mu c tim do lm
gim p lc y tim, ngoi ra chng cn
lm gin trc tip ng mch vnh.
Bng 18-6. Mt s Nitrat thng dng.
Ko di
Dng thuc
Liu
Bt
(mg)
u
(pht)
Nitroglycerin (ngm)
0,3 - 0,6 2 - 5
10-30ph
Dinitrat Isosorbide (ngm)
2,5 - 10 10- 30 1 - 2 h
366
Dinitrat Isosorbide (ung)

5 - 20
30- 60 4 - 8 h
Mononitrat Isosorbide (ung) 10 - 20
30- 60 6 - 8h
Nitroglycerin (cao dn)
5 - 15
> 30
12 - 14h
Tc dng ph c th gp ca thuc l: nhc
u, h huyt p, ni ban
Nitrat c th c dng di dng ung, m
bi da, cao dn, ngm di li hoc tim
truyn tnh mch.
g. Hydralazine:
Lm gin h ng mch do tc dng lm gin
trc tip c trn ca thnh mch mu, t
lm gim hu gnh. V vy, Hydralazine rt
c ch trong iu tr suy tim do h van tim.
Ch : thuc c th gy tng nhp tim
phn
ved
rau
e
s
x, au u, nn, lm xut hin cn
tht
e
sr n
t
h
ngc. Liu dng trung bnh
20 v
ig olm.ung
l rtrong
l
c
.
100mg, chia thnh 2 - 3. ln
ngy.
v A hoo
loe @yadng ng tim
h. Mt s thuc gin inmch
20
. F 20thng
truyn: Cc thuc
c ch nh cho
08ny
y
0
t
2
i
tocsuy tim nng hoc bnh nhn
nhng bnhhtnhn
Po
g khng
im
r
suy tim
th ung c thuc. Khi
y
p
o
C
dng, cn bt u bng liu nh v theo di cht
din bin v huyt ng. Khi ngng thuc, cn
gim liu dn dn trnh cc phn x co mch
t ngt.
Nitroglycerin: lm gin h thng tnh mch
v c tc dng gin trc tip mch vnh.
(a) Nitroglycerin c ngh trong iu tr
suy tim nhng bnh nhn b nhi mu
c tim cp hoc bnh nhn au ngc
khng n nh.
(b) Thi gian bt u tc dng ca thuc rt
nhanh; bn hy thng t 1 - 3 pht.
(c) Liu dng ban u thng l 10g/pht
(dng bm tim in). Bin chng nguy
him c th gp l tt huyt p.
367
Natri Nitroprusside: gy gin trc tip ng

mch lm gim hu gnh, cn tc dng gin
h tnh mch thng khng nhiu.
(a) Thuc c ch nh nhng bnh nhn
suy tim cp, nng do tng huyt p hoc
h van tim nng.
(b) Liu ban u thng l 10 g/pht (ti a
300 - 400 g/pht). Thi gian bn hy ca
thuc l 1-3 pht.
(c) Tt huyt p cng l bin chng quan
trng cn theo di. V thuc c chuyn
ha di dng Cyanide, nn c th gy
ng c vi nng Thiocyanate trn 10
ng/dl, do cn thn trng bnhd nhn
rve
suy thn.
ese
r
ts
Enalaprilat:
gh m.vn
i
r
o Enalapril
l .cca
(a) L dng hot ha mtAleste
o
o
.
h
v
e
aThi gian bt u
dng tim tnh lmch.
n o 0@y
i
F
2
tc dng nhanh,
8. 20thi gian bn hy ngn.
00uitythng
2
(b) Liu ban
l 1,25mg tim tnh
t otoc
h
P
g
mch
ri cho mi 6 gi. nhng bnh nhn
py
Co c dng km li tiu hoc suy thn nn
gim liu (0,025mg tim TM/6gi).
4. Thuc chn bta giao cm:
a. Trong nhng nm gn y, vai tr ca thuc chn
bta giao cm trong iu tr suy tim ngy cng
c nhn mnh. C ch l ngn chn tc dng
kch thch thi qu ca h thn kinh giao cm
trong suy tim huyt mn tnh.
b. Cc thuc chn bta giao cm c ch nh trong
iu tr suy tim mn, nng khi dng y
cc thuc khc, nhng cng khng nn dng khi
suy tim qu nng mt b.
c. Hin nay mi ch c 3 loi thuc chn bta giao
cm c chng minh l c th dng trong
368
iu tr suy tim l: Carvedilol (Dilatrend);

Metoprolol (Betaloc) v Bisoprolol (Concor).
d. Khi dng thuc chn bta giao cm trong iu tr
suy tim nn bt u bng liu rt thp, theo di
cht ch v tng dn liu chm. Li ch thc t
ca khi dng chn bta giao cm ch xut hin
chm v lu di.
5. Cc thuc chn knh canxi:
a. Tuy l cc thuc gin mch nhng cc thuc chn
knh canxi khng c dng iu tr suy tim
v n c th nh hng sc co c tim, nht l cc
thuc th h th nht.
b. Mt s thuc th h th hai (Amlodipine) khng
d
nh hng n sc co c tim nhng cng
rve khng
e
s
re
ci thin c suy tim.
ts vn
h
.
g
i om
6. Cc thuc lm tng sc co bpAc
khc:
ll rtim
c
.
. ahoo
oev y
a. Cc thuc ging giao ncm:
thng c dng
l
0@ suy tim nng m cc
Fi 0hp
2
.
iu tr trong cc 0trng
8 2
y
0
thuc thng t thng
2 tocit khng c hiu qu. Mt s
h
o
P thuc c th gp l: lm tng
g ca
tc dng
riph
y
p
thiuComu c tim, nhp tim nhanh, ri lon nhp
tht, co mch ngoi bin. Khi iu tr ta cn phi
theo di cht ch tnh trng huyt ng v in
tim ca bnh nhn.
Dopamine:
(a) Liu 1- 3 g/kg/pht c tc dng lm gin
mch thn v mc treo, thng qua kch
thch th th Dopamine, kt qu lm tng
dng mu n thn v s lng nc tiu.
(b) Liu 2-5g/kg/pht lm tng sc co bp
ca c tim do kch thch th th bta.
(c) Liu cao hn 5-10 g/mg/pht th thuc
s kch thch th th alpha giao cm gy
co mch ngoi bin, tng tr khng h
mch nh hng xu n cung lng tim.
369
(d) Dopamine rt c ngha khi ta dng cho

bnh nhn suy tim c h huyt p. Mt
nhc im ca thuc l hay lm cho nhp
tim nhanh nhiu.
Dobutamine:
(a) Ch yu kch thch chn lc 1-giao cm,
tc dng trn 2 v -giao cm yu hn
nhiu. Thuc c tc dng ci thin tnh
trng huyt ng, thng qua vic kch
thch trc tip tc dng co c tim v lm
gin h ng mch phn x, t lm
gim hu gnh v tng cng ci thin
cung lng tim. Khi dng thuc ny
thng huyt p v nhp tim thay
i
ed
v
r
e
khng qu nhiu. Tuy nhines nhp tim
s r n liu cao.
tdng
nhanh vn c th xy ra khi
h
v
g
m.
l ri .cong
(b) Liu dng ban u,Albng
truyn
oo
ev. ytah1-2
tnh mch hng lnh
g/kg/pht v
o
in 20@khi t c hiu qu
iu chnh 8cho
. F 2n
0
0
y thit.
0 cn
t
2
huyt ng
i
t otoc
P
(c) Nhng
nhn suy tim nng, mn tnh,
igh bnh
r
y
p
Co c th dng tng t Dobutamine trong
2-4 ngy, gim mt cch ng k cc
triu chng ca suy tim. Nhng bnh
nhn phi dng Dobutamine ko di, cn
theo di cht ch v khng nn vt qu
liu 10 g/kg/pht.
(d) Dobutamine khng c vai tr tt trong
iu tr suy tim nhng bnh nhn c ri
lon chc nng tm trng (v d: bnh c
tim ph i) hoc bnh nhn suy tim c
tng cung lng.
b. Cc thuc c ch men Phosphodiesterase: lm
tng sc co bp ca c tim v gin mch do lm
tng adenosin mono phosphate vng (AMPc).
370
Hai loi thuc c s dng trong lm

sng l Amrinone v Milrinone. Chng c
ch nh trong nhng t iu tr ngn ngy
bnh nhn suy tim dai dng, kh iu tr.
Amrinone c tc dng ci thin huyt ng
nh Dobutamin, nhng lm gin mch mnh
hn. V vy, h huyt p c th xy ra
nhng bnh nhn c dng thuc ny cng vi
mt thuc gin mch khc.
Liu lng :
(a) Amrinone tim tnh mch 750 g/kg
trong 2 - 3 pht sau truyn tnh mch
vi liu 2,5 - 10,0 g/kg/pht.
(b) Milrinone: liu ban u l 50 g/kg,d tim
ve TM
tnh mch trong 10 pht sau etruyn
ser
r
ts
vi liu 0,375-0,750 g/kg/pht.
gh m.vn
i
r
l .co c ch men
Tc dng ph ca ccAlthuc
.
hoo lon nhp nh
v
e thyagy
phosphodiesterse: c
o
l
@
in 20tc
hay tht v i8khi
mch.
. F 2gy
0
0
y dn xut ca Quinoline,
0 mt
t
2
i
c. Vesnarinone:
l
t otoc
P lm tng co bp c tim. Khi kt
igh dng
thuc c
tc
r
y
p
o Digoxin v thuc c ch men chuyn
hp Cvi
trong iu tr suy tim, thuc c th ci thin c
tt hn tnh trng suy tim. Liu trung bnh l
60mg/ngy, dng ko di. Tc dng ph c th
gp l gim bch cu ht.
7. Thuc chng ng:
a. Trong suy tim, mu thng li cc c quan
ngoi bin nn rt d to thnh cc cc mu ng
trong h thng tun hon v t gy ra nhng
tai bin tc nghn mch mu. V vy, ngi ta
phi dng thuc chng ng khng nhng trong
nhng trng hp cp tnh nh tc ng mch
phi, no, chi... m cn phi iu tr d phng
371
trong cc trng hp suy tim c tim to, nht l

trong cc trng hp c thm rung nh.
b. Bn cnh Heparin c s dng trong cc trng
hp tc mch cp, ngi ta cn s dng cc thuc
chng ng thuc nhm khng vitamin K.
C. iu tr nguyn nhn
Ngoi cc bin php iu tr chung (nh trnh by
trn), ta cn phi p dng mt s bin php iu tr c bit
ty theo tng nguyn nhn:
1. Suy tim do cng gip: Phi iu tr bng khng
gip trng tng hp hoc phng php phng x hay
phu thut.
2. Suy tim do thiu vitamin B1: cn dng vitamin
d B1
rve
e
s
liu cao.
re
ts vn
h
.
g
3. Suy tim do ri lon nhp tim ko
om th phi c
l ri .di
l
c
A htim
bin php iu tr cc ri lonev.nhp
oo mt cch hp
a
o
l
y
l: dng thuc, sc in Fhay
in t
0@my to nhp.
8. 202
0
y tim : ngi ta c th can
4. Suy tim do nhi mu
20 ocitc
t
t
h
o
thip trc tipigvo Pch tc ca ng mch vnh bng
r
py
thuc tiu
Co si huyt, nong v t Stent ng mch
vnh hoc m bc cu ni ch vnh...
5. Suy tim do mt s bnh van tim hoc d tt bm
sinh: nu c th, cn xem xt sm ch nh can thip
qua da (nong van bng bng) hoc phu thut...
D. Mt s bin php iu tr c bit khc
1. Bin php h tr tun hon c bit: c th c
p dng nhng bnh nhn suy tim m nhng bin
php iu tr khc tht bi hoc t hiu qu.
a. t bng trong ng mch ch: Bng phng
php thng tim, ngi ta a mt ng thng c
gn mt qu bng c bit, t ng mch i,
ng thng c y ln ti ng mch ch. Bng
s c t v tr trong lng ng mch ch
372
di ch phn nhnh ra ng mch di n tri.

Bng s c bm cng ra mt cch ng b vo
thi k tm trng ca chu chuyn tim. Kt qu
l n s lm tng lng mu n ti cho ng
mch vnh v lm gim nhu cu xy ca c tim.
Thm vo , n lm gim ng k tin gnh v
hu gnh, ci thin mt cch r rt cung lng
tim cho bnh nhn.
b. Thit b h tr tht: L thit b phi m cy
ghp gip cc bnh nhn suy tim qu nng ko
di thm thi gian ch thay tim.
2. Thay (ghp) tim:
a. L bin php hu hiu cui cng cho nhng bnh
d
nhn suy tim giai on cui, khng li
rvevi tt
e
s
re
c cc bin php iu tr ni, ngoi
thng
ts khoa
h
vn c tn
g
i om.hp
thng. thng l nhng ltrng
r
l o.c
o
thng c tim rt rng v enng
v. A ahn.
o
l
y
@ k t khi c thuc
b. Mt thng k gn y
Fincho0thy
8. 202
0
gim min dch20Cyclosporine,
t l sng st sau
y
tocit
t
h
o
mt nm igghp Ptim l 90% v sau 5 nm l 65r
py chung th chc nng v cht lng cuc
70%.CoNi
sng ca bnh nhn c ci thin ng k sau
ghp tim.
c. Cc thuc thng hay dng nht iu tr gim
min dch sau ghp tim l: Glucocorticoids,
Cyclosporine v Azathioprine. Mt s loi thuc
gim min dch mi khc cn ang trong giai
on th nghim.
d. Nhng bin chng c th gp sau ghp tim bao
gm: thi ghp sm, nhim trng do dng thuc
gim min dch. S pht trin ca bnh mch
vnh sau m cng l mt nguyn nhn quan trng
gy t vong sau nm u tin c ghp tim.
373
VI. Suy tim cp v ph phi cp do tim

A. Sinh l bnh
1. Ph phi cp xy ra khi p lc ca mao mch phi
tng qu ngng gy thot dch ra khi lng mch
vo trong khong k v ph nang. T gy ri lon
trm trng s trao i kh.
2. Vic tng p lc mao mch phi ny ch yu gy ra
l do tnh trng suy tim tri cp v mt s bnh l tc
nghn ng ra ca ca tnh mch phi c bit l
bnh hp van hai l.
B. Chn on
d
rvev t
a. Tnh trng kh th nhiu, i khi d sdi
e
re
ngt, pht trin nhanh chng.
ts vn
h
g
i om.
b. Km theo bnh nhn lo lng,Avt
ll r v,
c tm ti
. ahoo.
v
e
o
c. Mt s ho ra mu hocnlthm
ych tro bt hng ra
Fi 020@
.
ming.
08 ty2
20nhn
i
d. Khm thy hbnh

t otoc kh th nhanh, nng. Nghe
P
g
i thy ran rt, ran ngy v c bit l
rth
phi c
opy
C
ran m to nh ht hai bn ph trng (c th din
bin kiu nc thu triu dng t hai y phi).
2. Chp Xquang phi:
a. Hnh nh bng tim to, huyt qun phi tng m.
b. M hnh cnh bm lan to t hai rn phi.
c. i khi thy hnh nh ng Kerley B.
d. Tin trin theo tnh trng lm sng.
C. iu tr
1. Cc bin php h tr ban u:
a. Cung cp xy y .
b. t ni kh qun v thng kh nhn to nu cn.
c. bnh nhn t th na ngi.
374
d. C th tin hnh gar ba chi lun phin hoc

chch mu nu khng c iu kin thuc men tt.
2. Dng thuc:
a. Morphine sulphate l thuc rt quan trng v
lm gim lo lng cho bnh nhn v gin h tnh
mch phi, tnh mch h thng. Morphine c
dng bng ng tim tnh mch 2-5mg mi ln
v nhc li sau 10-25 pht nu cn cho n khi c
tc dng.
b. Furosemide lm gim gnh nng tun hon v c
hiu lc tc thi gin ng mch phi nhanh khi
tim tnh mch. Liu ban u t 20-40 mg tim
thng tnh mch sau c th tng liu v nhc
li sau vi pht cho n khi p ng uer.
ved Liu
s
c th tng n ti a l 2000mg. ts re
gh mh.vntnh mch
iyu
r
c. Nitroglycerin l thuc gin ch
o
l
Aldng
o.c hip ng vi
o
.
lm gim tin gnh v c
tc
h
v
oe ya
inl ng
Furosemide. Nn dng
0@ truyn tnh mch
F
8. 202
0
vi liu bt u
y g/pht v tng dn tu
0 l 10
2 tocit
t
h
o
theo p ng.
P
rig
y
p
d. Nitroprusside
rt c hiu qu iu tr ph phi
Co
cp bnh nhn tng huyt p hoc h van tim
cp. Khi dng thuc ny cn theo di cht ch
p ng ca bnh nhn da trn cc thng s
huyt ng. Liu khi u l 0,25 g/kg/pht.
e. Cc thuc tng co bp c tim c ch nh sau
khi dng cc bin php ban u trn v bnh
nhn b huyt p thp hoc sc tim.
3. Chy thn nhn to cp hoc siu lc mu c
ch nh nhng bnh nhn c bnh thn hoc khng
p ng vi li tiu.
4. Theo di huyt ng bng ng thng tim phi
(Swan-Ganz) c th c ch bnh nhn p ng km
vi iu tr. Theo di p lc ng mch phi v mao
375
mch phi bt cn gip phn bit c nguyn nhn

gy ph phi cp l do tim hay khng phi do tim.
5. Ch v gii quyt cc nguyn nhn nu c th.
Cc nguyn nhn gy ph phi cp huyt ng
thng gp l:
a. Tng huyt p.
b. NMCT cp hoc bnh mch vnh cp.
c. H van tim cp (do NMCT, vim ni tm mc...)
d. Cc bnh vim c tim, bnh c tim
e. Cc ri lon nhp tim mi xy ra hoc qu ti th
tch (truyn nhiu dch qu) bnh nhn c
ri lon chc nng tht tri.
d
Ti liu tham kho
rve
e
s
e
1. Bonow RO, Udelson JE. Left ventricular diastolic tdysfunction
as a
sr n
h
v
.
g
i
cause of congestive heart failure. Ann Intern
Med
1992;117:502r
om
l
Al hoo.c
.
510.
v
oe ya
@ et al. for the MOCHA
2. Bristow MR, Gilbert EM, Abraham
inl 2WR
F
. 20 0
8
0
Investigators. Carvedilol produces
20 ocitydose-related improvements in left
t survival
ventricular function gand
in subjects with chronic heart
h
Pot
i
r
y
failure. Circulation
p 1996; 94:2807-2816.
Co
3.
4.
5.
6.
Cairns JA, Connolly SJ, Roberts RS, Gent M. Canadian Amiodarone

Myocardial Infarction Arrhythmia Trial (CAMIAT): rationale and
protocol. Am J Cardiol 1993;72:87F-94F.
CAST Investigators. Preliminary report: effect of encainide and
flecainide on mortality in a randomized trial of arrhythmia
suppression after myocardial infarction. N Engl J Med 1989;321:
406-412.
Chatterjee K. Heart failure therapy in evolution. Circulation
1996;94:2689-2693.
CIBIS Investigators and Committees. A randomized trial of beta
blockade in heart failure: the Cardiac Insufficiency Bisoprolol Study
(CIBIS). Circulation 1994;90:1765-1773.
376
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Cohen GI, Pietrolungo JF, Thomas JD, Klein AL. A practical guide
to the assessment of ventricular diastolic dysfunction using Doppler
echocardiography. J Am Coll Cardiol 1996;27:1753-1760.
Cohn 'IN. The management of chronic heart failure. N Engl J Med
1996;335:490-498.
Doval HC, Nul DR, Grancelli HO, et al., For Gruppo de Estudio de
la Insuficiencia Cardiaca en Argentina. Randomized trial of low dose
amiodarone in severe congestive heart failure (GESICA). Lancet
1994;344:493-498.
Hosenpud JD, Greenberg BR. In: Hosenpud J, ed. Congestive heart
failure. New York: Springer-Verlag, 1994.
Lenihan DJ5 Gerson MC, Hoit BD, Walsh, RA. Mechanisms,
diagnosis, and treatment of diastolic heart failure. Am Heart J
1995;130:153-166.
d
rve
e
s
re
Medicine. Philadelphia: Lippincott-Raven, 2000. hts .vn
g
ri com Automatic
Moss AJ, Hall AJ, Cannom DS, et al. for the
llMulticenter
A
oo.
.
v ah(MADIT).
e
Defibrillator Implantation Trial Investigators
Improved
o
nl 0@y
i
F
2
survival with an implanted defibrillator
in patients with coronary
.
08 20
20 ocity arrhythmias. N Engl J Med
disease at high risk for ventricular
ht Pot
1996;335:1933-1940.
rig
y
p
Nishimura RA,
Co Tajik AJ, Evaluation of diastolic dysfunction in
health and disease: Doppler echocardiography is the clinician's
Rosetta stone. J Am Coll Cardiol 1997; 30:8-18.
Packer M, Bristow MR, Cohn JN, et al. for the U.S. Carvedilol Heart
Failure Study Group. The effect of carvedilol on morbidity and
mortality in patients with chronic heart failure. N Engl J Med
1996;334:1349-1355.
Packer M, Gheorghiade M, Young JB, et al. for the RADIENCE
Study. Withdrawal of digoxin from patients with chronic heart
failure treated with angiotensin-converting-enzyme inhibitors. N
Engl J Med 1993;329:1-7.
Packer M, O'Conner CM, Ghali JK, et al. for the Prospective
Randomized Amlodipme Survival Evaluation Study Group
(PRAISE). Effect of amlodipine on morbidity and mortality in severe
chronic heart failure. N Engl J Med 1996;335: 1107-1114.
377
18. Pitt B, Segal H, Martinez FA, et al. Randomized trial of losartan

versus captopril in patients over 65 with heart failure (Evaluation of
Losartan in the Elderly Study, ELITE). Lancet 1997;349:747-752.
19. Poole-Wilson PA, Massie BM, Yamani MR. In: Poole-Wilson P, ed.
Heart failure. New York: Churchill Livingstone, 1997.
20. Siugh SN, Fletcher RD, Gross Fischer S, et al. for the Survival Trial
ofAntiarrhythmic Therapy in Congestive Heart Failure. Veterans
Mfairs Anti-arrhythmia in Heart Failure Trial. N Engl J Med
1995;333:77-82.
21. SOLVD Investigators. Effect of enalapril on survival in patients with
reduced left ventricular ejection fractions and congestive heart
failure. N Engl J Med 1991;325:293-302.
22. The Antiarrhythmics versus Implantable Defibrillators (AVID)
Investigators. A comparison of antiarrhythmic drug therapy
with
ed
v
r
e
implantable defibrillators in patients resuscitated from
near-fatal
res
ts vn
ventricular arrhythmias. N Engl J Med 1997;337:1576-1583.
h
ig om.
23. Uretsky BF, Young JR, Shahidi FE, YellenALG,
MC, Jolly
ll r oHarrison
.c
ho digoxin withdrawal
v. aof
MK. Randomized study assessing theloeeffect
in 20@y heart failure: results of
Fcongestive
in patients with mild to moderate
.
8 20
y
00 itInvestigative
2
the PROVED trial. PROVED
Group. J Am Coll
t otoc
h
P
g
Cardiol 1993;22:955-962.
ri
py
24. Young JB, Haas
Co GA, Rodkey SR. In: Topol E, ed. Textbook of
cardiovascular medicine. Philadelphia: Lippincott-Raven, 1997.
25. Young JB. Contemporary management of patients with heart failure.
Med Clin North Am 1995;79:1171-1191.
378
Bnh c tim gin

Bnh c tim gin khng r nguyn nhn l bnh cha r
bnh nguyn gy ra hu qu lm mt dn chc nng co bp ca
c tim. Chn on xc nh khi c du hiu suy gim chc nng
tm thu v gin bung tht tri m khng tm thy cc nguyn
nhn thng thng nh bnh ng mch vnh, bnh tim bm
sinh, bnh van tim, tng huyt p hoc bnh mng ngoi tim.
Trong mt vi trng hp bnh c tim gin thy c cc yu t
thun li trn lm sng nh nghin ru, thai sn hoc tin s
gia nh c mc bnh c tim. Tuy nhin ngi ta cha tm ra mt
nguyn nhn c mi lin quan chc chn no dn n bnh c
ved mi
tim gin. Gii khoa hc vn ang tip tc nghin cuercc
s
re t min,
lin quan n bnh c tim gin ca h thng totskeo,
n
h
.vnhm
g
i ha
r
thn kinh c, cc qu trnh vim, hay chuyn
gp
m
o
l
l o.c
A
o
.
phn l gii bnh sinh phc tp ca bnhoevny.ah
l
y
Fin020@
I. Gii phu bnh
.
8
00 ity2
c cc trng hp bnh c tim
2 tht
A. Gii phu bnh cahthu
o
o
P
g
i
r
gin sau khi bnh
py nhn t vong u cho thy cc bung
Co Tng nhiu trng lng ton b, khi c,
tim gin nhiu.
v th tch t bo c tim trong bnh c tim gin, tuy
nhin dy ca thnh tht tri khng tng thm ch cn
mng v dt xung.
B. Huyt khi trong bung tim v huyt khi bm thnh
ni mc ca tim thng thy trong hn 50% cc trng
hp bnh c tim gin.
C. Tn thng vi th trong bnh c tim gin thng thy t
bo c tim ph i v kch thc ln, c hnh bu dc rt
k l.
D. Cu to bn trong ca t bo c tim cng rt bt thng,
c th thy bin i gin phn, ng ch T gin, v c cc
ht lipid bn trong. Trng hp nhng bnh tim khc
thng khng c cc du hiu ny. S tng si ha
379
thng xuyn thy trong bnh c tim gin, tuy nhin cc

tiu ng mch xuyn thnh v cc mao mch li c cu
trc bnh thng trong bnh c tim gin.
II. Sinh l bnh
A. C ch sinh bnh hng u ca bnh c tim gin l gim
kh nng co bp ca t bo c tim. Hu qu l lm gim
phn s tng mu v tng th tch cui tm trng tht
tri, nh tt c cc nguyn nhn khc dn n hu qu
cui cng l suy tim. Tuy nhin do qu trnh ny din ra
t t lm bnh nhn thch ng tt, v vy c rt nhiu
trng hp tuy chc nng tm thu tht tri gim nhiu
nhng bnh nhn vn c rt t triu chng lm sng.
B. Thay i ng k nht c nhn thy trong bnh c
tim
ed
v
r
e
gin khng r nguyn nhn l phc hp
th th
res
ts vTrong
adrenergic G protein adenylate ca cgtim.
cc
n
h
i om.
r
l
bnh nhn suy tim nng thy c gim
l 60
.c n 70% th
hoo1 mRNA.
v. Abta
a
th bta 1 adrenergic v tng thloeth
y
Fin020@
.
III. Triu chng lm sng 008 y2
2 cit
ht Poto
A. Triu chng cignng
r
py
1. Tt c cc
Co la tui u c th gp bnh c tim gin,
tuy nhin la tui thng gp nht l tui trung nin.
Cc du hiu thng din ra rt t t v bnh nhn
thng c mt giai on di t vi thng n vi nm
hon ton khng c triu chng. Mt vi trng hp
bnh khi pht t ngt nh cc bnh nhn sau mt
thi k tng nhu cu hot ng ca tim nh sau phu
thut hay nhim trng. i vi cc bnh nhn tr tui
nhiu khi b chn on nhm vi cc bnh phi thng
thng nh vim phi, vim ph qun...
2. Dn dn sau bnh nhn thng c cc biu hin
ca suy tim tri nh kh th khi gng sc, kh th
khi nm v kh th v m.
380
3. Giai on nng ln ca bnh s thy cc du hiu ca

suy tim phi nh ph ngoi bin, nn, cng tc bng
do gan to, i tiu m v c chng. Cc du hiu
khc c th gp l biu hin ca hi chng cung
lng tim thp nh mt mi v suy nhc c th. au
ngc cng c th gp mc d h thng ng mch
vnh hon ton bnh thng. Cc du hiu ngt v xu
thng c ngun gc do ri lon nhp hoc do dng
thuc gy h huyt p t th ng.
B. Triu chng thc th
1. Khm lm sng thng khng c du hiu c hiu
v thng ch lin quan n mc suy tim ca bnh
nhn. Huyt p bnh nhn thng bnh thng nhng
d
nu tnh trng ri lon chc nng tht tri etin
rve trin
s
re
c th dn n h huyt p, mch nh v
ts yu.
n
h
g
i om.vi khi c
r
l
2. Khm tim thng thy nhp tim
nhanh,
l o.c
o
. A ahting
vthy
e
ting nga phi. Thng nghe
thi tm thu
o
l
y
@ gin cc bung tim.
in
0
F
ca h van hai l v 8ba
l
do
2
. 20
00 idu
ty hiu bung tim gin vi
Ngoi ra cn thy 2cc
t otoc
h
P v sang tri (gin tht tri) hay
mm tim xung
rig thp
y
p
gin v pha
Co mi c ca tht phi.
3. Khm phi trong trng hp tr tun hon nhiu
c th thy xut hin cc ran m, bnh nhn kh th
kiu nhanh nng, th kh kh v thng c trn dch
mng phi phi hp.
4. Khm bng nhm pht hin cc du hiu ca suy
tim phi vi gan to. Trong cc trng hp nng c th
dn n x gan tim vi bng c chng trn lm
sng. Phn hi gan tnh mch c dng tnh, nhng
a phn cc bnh nhn c tnh mch phi ni t
nhin.
5. Khm ngoi bin pht hin ph chi di sau c
th dn n ph ton thn. Hay gp du hiu gim
ti mu ngoi bin vi chi lnh, ti hay tm. y
381
chnh l nhng bng chng th hin mc cung

lng tim gim cc bnh nhn bnh c tim gin
khng r nguyn nhn.
Khng c mt xt nghim no c coi l tiu chun
vng chn on xc nh bnh c tim gin. Vic chn
on cn phi kt hp gia lm sng v cc xt nghim cn
lm sng.
1. in tm (T): Khng c du hiu T in
hnh cho bnh c tim gin. Chng ta c th thy du
hiu nhp xoang nhanh nhng cng c th gp cc ri
lon nhp nh v tht phc tp. Ri lon dn truyn
trong tht hay gp m in hnh l bloc nhnh,d on
rve
ST v sng T cng rt hay bin i. Mt
esevi bnh
r
ts chuyn o
nhn li c sng r nh v Q su cc
gh m.vn
i
r
o
l trng
trc tim lm ta d nhm ln viAlcc
hp nhi
o.c
o
.
h
v
mu c tim c. Du hiu ldy
a tri v trc tri
oe tht
in 20@y
F
cung hay gp.
8. 0
00 ity2
2
ctim to, vi ch s tim ngc ln.
2. Chp tim phi:t Bng

h Poto
Ph phi lydu
c th thy trn phim do tng p
rig hiu
p
Co mch phi. Tnh mch ch trn v tnh
h tnh
mch n (azygos) gin do tng p h tnh mch ch.
C th gp trn dch mng phi.
3. Siu m tim: L phng php hu hiu nht chn
on v theo di tin trin ca bnh c tim gin cng
nh loi tr cc nguyn nhn c th dn n gin cc
bung tim nh bnh tim bm sinh, bnh van tim,
bnh mch vnh...
a. Siu m hai chiu: cho thy cc bung tim gin
nht ct 4 bung tim t mm v cnh c tri.
dy ca vch lin tht v tht tri vn trong gii
hn bnh thng, nhng bin di ng ca ton
b cc vch tim thuc tht tri u gim. C th
thy dch mng ngoi tim trong mt s cc trng
382
b. Siu m Doppler: gip nh gi dng h van hai

l, ba l v c tnh p lc ng mch phi.
4. Thng tim v chp bung tim:
a. Hnh nh chp bung tht tri thy tht tri gin
v gim vn ng ton b.
b. V mt huyt ng, thy c suy tht tri hay suy
c hai tht vi tng p lc cui tm trng ca
tht tri trong khi p lc tm thu li gim nhiu.
c. H thng ng mch vnh bnh thng hay hp
khng ng k (hp di 50%).
5. Sinh thit c tim: xc nh nhng nguyn
ed nhn
v
r
e
dn n suy tim d nhm vi bnh c timregin
s khng
ts vsarcoidose,
n
r nguyn nhn nh vim c tim,
h
ig om.
r
l
l .c
hemosiderosis...
v. A ahoo
e
o
l
y
V. Din bin t nhin v tin lng
Fin020@
.
2
08 tbnh
1. Din bin t nhin
20ca
i y s dn n suy tim tng
c
o
t totvong trong bnh cnh suy tim
hb
dn v c th
P
rig
y
p
nng hay
ri
lon
nhp.
Co
2. T l t vong trong vng 5 nm l 40 n 80%.
Trong i a s cc nghin cu cho thy t l t vong
trong vng 1 nm l 25% v 2 nm l 35 n 40%.
Tuy nhin cc tc gi cng ch ra rng cc bnh nhn
sng qu 2 hoc 3 nm u c tin lng lu di tt
hn rt nhiu. Tnh trng n nh s gp trong
khong 20 n 50% cc trng hp nhng chc nng
tht tri tr v bnh thng rt him gp trong thc t.
3. Tin lng da vo cc yu t sau: triu chng ca
bnh nhn, phn s tng mu ca tht tri, ch s tim,
ri lon dn truyn nh tht, ngoi tm thu tht a ,
h natri mu v tng yu t ANF (atrial natriuretic
factor). Ngoi ra cc yu t khc cng c th nh
hng n tin lng nh nghin ru, tin s gia
383
nh b bnh c tim, kch thc bung tht tri gin

nhiu, p lc nh tri tng, rung nh, tng hm lng
norepinephrine mu. Cc yu t sau y khng c
lin quan n tin lng l tui, thi gian mc bnh,
tin s nhim virus, ngoi tm thu tht n gin.
VI. iu tr
A. iu tr ni khoa
Nhm mc ch n nh tnh trng suy tim. Vic iu
tr bao gm ch n hn ch mui v nc, gim hot ng
ca tim bng gim tin gnh, hu gnh v nhp tim, tng sc
co bp ca c tim.
1. Thuc li tiu khi cho phi cn c vo chc nng
thn v th tch dch trong c th. Ch nh ttedtrong
erv bin
trng hp tng p MP, tr ti phi vresngoi
ts vn gii v
r rng. Qu liu li tiu s lm ri ilon
.
gh min
r
l .co tim. Li tiu
l
ur mu t lm gim cung
lng
A hoo
ev. yquai
a nh Furosemid,
o
l
c la chn l cc loi li
tiu
in 20@
F
Torsemid hay Bumetanide.
8. 0 Cn Thiazid thng
00 ity2
2
khng c khuyn
t dng
toc do hiu qu km.
igh Po
r
2. Thuc gin
opy mch lm gim gnh cho tim nh c ch
C
men chuyn dng Angiotensin, Nitrat v Hydralazin
trong c ch men chuyn dng Angiotensin l
thuc nn c la chn hng u. Cn ch tc
dng h huyt p t th ca thuc gin mch.
3. Digitalis l thuc c la chn trong cc trng hp
rung nh c tn s tht cao. Hn na cc nghin cu
cn ch ra rng n c tc dng ci thin phn s tng
mu, ci thin kh nng gng sc ca bnh nhn v
triu chng lm sng ngay c i vi cc bnh nhn
c nhp xoang. Tuy nhin trong nghin cu mi y
(nghin cu DIG) Digoxin khng lm thay i t l
t vong cc bnh nhn suy tim khi so snh vi gi
dc. Do cc trng hp nhp xoang ch nn
dng Digitalis khi bnh nhn c tim to, ri lon chc
nng tht tri nhiu v khng p ng vi iu tr li
384
tiu cng nh thuc c ch men chuyn dng

Angiotensin.
4. Thuc khng vitamin K cn c s dng khi bnh
nhn c huyt khi trong bung tim, c rung nh hay
c tin s tc mch.
5. iu tr ri lon nhp trong bnh c tim gin thng
gp nhiu kh khn. Trong s cc loi thuc chng
lon nhp th Amiodaron l thuc dng nh c hiu
qu v t tc dng ph nht. Ti cc nc pht trin
vic s dng my ph rung t ng cho kt qu tng
i kh quan i vi cc ri lon nhp phc tp.
6. Thuc chn bta giao cm. Hin ti duy nht ch c
Carvedilol l thuc c chp nhn dng iu tr
suy tim ti Hoa K. Tuy nhin, cc nghin cu
d mi
rve
e
s
y cng ch ra rng cc thuc khc nhre Bisoprolol
tsgim
hay Metoprolol cng c hiu qu rlm
.vn t l t
gh m
i
o
l
l khi
.c u cn rt
vong cc bnh nhn suy tim.. Liu
v A ahoo
e
o
l nng
y liu iu tr.
thp v ht sc thn trngin
khi
F 020@
.
B. iu tr phu thut ghp
2
08 tim
20 ocity
t trng
t hp NYHA 3 hoc 4 khng
Ch nh trong gcc
i h Po
r
y
p ng vi iuotr
p ni khoa ( bao gm c chn bta). Tuy
C
nhin, phu thut ny tn km v mi ch c thc hin ti
mt s trung tm y hc ln.
Ti liu tham kho
1.
2.
3.
4.
5.

medicine, 5th ed. Philadelphia: WB Saunders, 1997:1077-1104.
Fauci AS, ed. Harrison's principles of internal medicine, 14th ed.
New York: McGraw-Hill, 1998:785-791.
Kopecky SL, Gersh BJ. Dilated cardiomyopathy and myocarditis:
natural history, etiology, clinical manifestations, and management.
Curr Probl Cardiol 1987;12:573 647.
Medicine. Philadelphia: Lippincott-Raven, 2000.
Alexander RW, Schlant RC, Fuster V, eds. Hurst's the heart. New
York: McGraw-Hill, 1998:2205-2239.
385
6.
7.
Otto C. The practice of clinical echocardiography. Philadelphia:

WB Saunders, 1997:389-403.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
386
Bnh c tim ph i
Bnh c tim ph i l bnh cha r bnh nguyn gy ra

hu qu lm ph i c tim m khng c s gin cc bung tim.
Chc nng tm thu tht tri thng trong gii hn bnh thng
nhng cc thnh tim co bp mnh. y l nguyn nhn hng u
gy t t cc bnh nhn tr di 35 tui.
I. Nguyn nhn
Thng mang tnh cht gia nh, hin ti ngi ta tm thy 6
gen c lin quan n bnh c tim ph i. Trong s gen
bta myosin trn nhim sc th 14q1 chim tn sut gp cao
d
nht (35 n 45%).
rve
e
s
re
II. Gii phu bnh
ts vn
h
.
g
om c tim ph
l ri bnh
l
c
Gii phu bnh ca hu ht cc trng
hp
.
A o
ev. yaho
o
i thy cc du hiu:
l
Fin020@
8. 2ca
1. Ph i khng ng00tm
tm tht tri vi vch
2 ohn
ity thnh t do ca tht tri.
c
lin tht ph ihnhiu

t ot
P
ig
r
y
2. Bung tht
tri
nh
hoc c kch thc bnh thng.
p
Co
3. X ha thnh ni mc ca tim t vch lin tht trn
ng ra tht tri cho n l trc ca van hai l.
4. Van hai l rng v gin ra, c th dy hoc khng
dy th pht.
5. Gin bung nh.
6. Bt thng lng ng mch vnh vi s dy ln ca
thnh mch v hp lng mch.
7. X ha cc m k v ri lon cu trc ca tht tri.
A. Triu chng c nng
1. Triu chng suy tim: bao gm kh th khi gng sc
hay xut hin v m, mt mi, nguyn nhn thng
387
do tng p lc cui tm trng ca tht tri v gim

kh nng gin ca tm tht.
2. Thiu mu c tim vi biu hin au ngc: C th
gp trong c cc trng hp bnh c tim ph i tc
nghn hay khng. C ch chnh xc ca hin tng
ny cn cha r nhng ngi ta cho rng cc yu t
sau c th nh hng n du hiu au ngc ca
bnh nhn:
a. H thng mch vnh kch thc nh, gim kh
nng gin ra khi nhu cu xy c tim tng.
b. Tng p lc ca thnh tim do hu qu ca thi
gian gin tm trng tht tri chm v do cn tr
ng tng mu ca tim.
d
c. Gim t l gia h mao mch v m tim.
rve
e
s
re
ts vnh.
d. Gim p lc ti mu ca ng mch
n
h
g
i om.v
r
l
3. Ngt v xu: Nguyn nhn do. gim
.c mu no v
Al hooti
v
e
a
o
cung lng tim thp hay lin
l quan
y vi ri lon nhp
0@ nhn tr tui khng
Fin0bnh
2
.
tim hoc gng sc. Ngt
8 2
y
00 itlng
nht thit l yut t
nguy him cc bnh
c
2 tin
o
t
h
o
P ph i. Ngc li tr em v
igc tim
nhn c bnh
r
py
Co y l yu t lm tng nguy c t t.
thiu nin
4. t t hay nhng ri lon nhp nng c th gp trong
khong 1 n 6% cc trng hp.
B. Triu chng thc th
i vi cc bnh nhn c chnh p qua ng ra tht
tri, khm lm sng c th pht hin thy cc du hiu:
1. Ting thi tm thu pha thp dc theo b tri
xng c, cng gim khi bnh nhn ngi xm v
nm cht tay, cng tng ln khi bnh nhn lm
nghim php Valsalva, ng ln v sau cc ngoi tm
thu tht.
388
2. Du hiu mch ngoi bin ny mnh vi dng hai

pha, pha th nht nhanh mnh v pha th hai ko di
nh nc thy triu.
3. Mm tim p hai v tr, thng thy nht bp tin
tm thu mnh hn, du hiu ny lin quan n ting
th ba nghe c trn lm sng.
1. in tm (T): T bt thng trong khong
90 n 95% cc trng hp. Tuy nhin khng c du
hiu T c hiu cho bnh c tim ph i. Dy tht
tri vi tng bin ca phc b QRS v bin i bt
thng on ST, T l cc du hiu thng gp. Cng
hay gp bloc phn nhnh tri trc v sng Qdsu
rve
cc chuyn o pha sau, sng T o ngc,
ese dy nh
r
tsbin
tri v du hiu gi nhi mu vi gim
.vn sng
gh m
i
r
o
l
R cc chuyn o trc tim bn
lphi..c
v. A ahoo
e
o
l viych s tim ngc ln.
2. Chp tim phi: Bng timinto
F 020@
.
8 th thy trn phim do tng p
Ph phi l du hiu 0c
0 ity2
2 tocGin
h tnh mchhtphi.
bung nh tri cng hay
o
P
g
i
r
gp. Tuy pnhin
bng tim to t c gi tr trong vic
oy
nh giC s tin trin ca bnh, ngi ta thng s
dng siu m Doppler tim nh gi vn ny.
on v theo di tin trin ca bnh c tim ph i
cng nh loi tr cc nguyn nhn khc nh hp van
MC, hp trn van MC...
a. Siu m hai chiu: nh gi mc ph i ca
thnh tim. Thng c s ph i khng ng tm
ca thnh tht tri, vi u th vt tri ca vch
lin tht so vi thnh sau tht tri. Tht tri
thng khng gin v khng c cc bnh l khc
c th dn n tng dy ca thnh tim. Thnh
tim c th dy khu tr tng phn tuy nhin thng
thng c s dy lan ta ca tt c cc thnh tim,
389
nht l ca vch lin tht. S di ng ra trc

trong th tm thu ca van hai l thng gp c
gi tt l du hiu SAM. Du hiu ny lin
quan n s cn tr ng ra tht tri v thng
i km vi vic ng sm van ng mch ch.
Hnh 20-1. Du hiu SAM (mi tn) trn siu m TM.

d
rve
e
s
re
ts vn
h
.
g
l ri .com
l
A o
ev. yaho
o
l
Fin 0@
8. 202
0
20 ity
t otoc
h
P
rig
y
p
Co
Hnh 20-2. Mt ct dc trn siu m 2D c ph i ton
b cc thnh tht tri (LV) trong th tm trng (A), tm thu (B).
b. Siu m Doppler: cho php nh gi mc
chnh p ng ra tht tri, dng h van hai l,
ba l v p lc ng mch phi, t nh gi
mc tin trin ca bnh.
4. Thng tim: Ch nh trong cc trng hp chun b
phu thut, t my to nhp, gy tc nhnh vch th
nht ca ng mch lin tht trc hay cc trng
hp kh khn cn chn on phn bit.
a. Chp bung tht tri s gip nh gi kch thc
tht tri v sc co bp ca tht tri.
390
b. V mt huyt ng thy c chnh p trong bung

tht tri v do c cn tr ng ra tht tri nn c
c chnh p gia tht tri v ng mch ch. Nu
chnh p ny khng r rng th c th lm cc
nghim php lm tng chnh p trong bnh c
tim ph i nh nghim php Valsalva, truyn
Isoproterenol hay ngi Amyl Nitrite, gy ngoi
tm thu tht.
c. H thng ng mch vnh thng bnh thng
hay hp khng ng k (hp di 50%). Cn ch
quan st nhnh vch th nht ca ng mch
lin tht trc.
d. Khng c ch nh sinh thit mt cch c h
thng tt c cc trng hp bnh c tim ph
di.
rve
e
s
re mc
5. Holter in tim: Cn tin hnh nh
ts gi
h
.vntht. y
g
v s xut hin ca cc cn nhp
inhanh
r
m
o
l
l o.c
chnh l yu t nh gi mcev
o c t t trong
. Anguy
ah
o
l
y
bnh c tim ph i.
Fin 0@
8. 202
0
V. Din bin t nhin v tin
20 lng
ity
t otoc
h
P
1. y l mtytrong
bnh tim din bin ht sc
rig nhng
p
o
C
phc tp. N l mt nguyn nhn hng u dn n
t t cc bnh nhn tr tui. Tuy nhin nhiu
trng hp bnh nhn vn c th chung sng ha
bnh vi bnh m khng cn i hi cc phng php
iu tr c bit.
2. t t: c th gp cc bnh nhn tr (t 12 n 35
tui). Cc du hiu suy tim c th din bin tng dn
sau tui 35 n 40 tui. Cng c mt nhm bnh
nhn hon ton khng c triu chng c nng. Cc
bnh nhn ln tui c th c biu hin suy tim nng
sau mt giai on hon ton khng c triu chng
lm sng. Cn ch t t c th gp c cc bnh
nhn bnh c tim ph i c hay khng c tc nghn
ng ra tht tri. Mt s t cc bnh nhn tr tui
391
3. Rung nh lm mt s co bp hiu qu ca tm nh c
th l nguyn nhn ca suy tim nng trn lm sng v
tc mch. Vim ni tm mc nhim khun c th gp
cc bnh nhn c h hai l. Qu trnh thai sn c
th vn c din bin tt, ngay c khi cho bnh nhn
thng.
VI. Chn on phn bit
1. Ting thi tm thu trn lm sng cn phn bit vi
hp van MC, thng lin tht, hay h hai l. Mt vi
bnh nhn tr em b bnh c tim ph i c hn ch
ng ra tht phi cn c phn bit vi hp
van
ed
v
r
e
ng mch phi.
es
sr n
t
h
2. au ngc trong bnh c tim ph i
.v rt in
rig cc
mth
o
l
l
.
hnh nh cn au tht ngc v i
khi ngay trn T
v. A ahoo
evi
o
l
y
cng c hnh nh ca NMCT
sng
Q hoi t.
Fin020@
.
08 2
VII. iu tr
20 ocity
ht Pc
ot triu chng: c th khng
A. Bnh nhn khng
rig
y
op c hiu nhng cng c th iu tr d
cn iu tr Cthuc
phng bng chn bta giao cm hoc Verapamil nhm
mc ch gim s tin trin ca bnh.
B. Bnh nhn c triu chng kh th v au ngc
1. Cn iu tr bng chn bta giao cm. Thuc chn
knh canxi nh Verapamil c th lm gim triu
chng v tng kh nng gng sc ca cc bnh nhn
khng p ng vi thuc chn bta giao cm. Mt vi
trung tm ang th s dng Disopyramid ci thin
cc triu chng lm sng.
2. Thuc chng ng cn ch nh trong cc bnh nhn
c rung nh hoc c ri lon nhp trn lm sng.
Khng sinh dng trong cc trng hp cn d phng
vim ni tm mc nhim khun.
392
3. Thuc gin mch khng nn s dng m ch nn s

dng li tiu nu cn cc bnh nhn c hn ch
ng ra tht tri.
4. Digitalis c th lm tng chnh p ng ra tht tri,
do chng ch nh dng cc thuc ny cc bnh
nhn bnh c tim ph i c hp mg ra tht tri.
5. Cc bnh nhn c nguy c t t cao (tin s ngng
tun hon, tin s gia nh c t t, c nhp nhanh
tht trn lm sng) cn d phng bng Amiodarone
v my ph rung t ng nu c iu kin.
C. Phu thut v cc can thip xm ln khc
1. Phu thut Morrow (ct b phn c ph i ca
vch lin tht): c ch nh cc bnh nhn
c
ved
ser tht tri
triu chng nng n vi chnh p ngrera
ts vn
trn 50mmHg khng p ng vi iu
Phu
.
ghtrmthuc.
i
r
o nhng khng
l sng
l
c
.
thut ci thin tt cht lng cuc
A hoo
ev. yaca
o
l
loi tr hon ton s tin
trin
bnh (ti pht
in 20@
. Fca
0
bnh) v nguy c t08t
bnh
nhn.
Trong phu
0 ity2
2
l cnng c th thay bng van hai
thut nu c h thai
h Poto
l c hc. yrig
p
Co to nhp hai bung loi DDD c th ch
2. t my
nh trong cc trng hp nhp chm, bloc nh tht v
gip cho ci thin triu chng lm sng v chnh p
qua ng ra tht tri.
3. Gy tc nhnh vch th nht ca ng mch lin
tht trc bng cch bm cn chn lc vo nhnh
ng mch ny. y l phng php c thc hin
trong phng thng tim sau khi chp MV. Cc
nghin cu gn y thy rng phng php ny
cho cc kt qu ht sc ng khch l trong vic lm
gim chnh p ng ra cc bnh nhn c bnh c
tim ph i.
393
Ti liu tham kho

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Alessandri N, Pannarale G, Del Monte F, et al. Hypertrophic

obstructive cardiomy-opathy and infective endocarditis: a report of
seven cases and a review of the literature. Eur Heart J 1990;11:
1041-1048.
Almendral JM, Ormastre J, Martinez-Abby JD, et al. Treatment of
ventricular
arrhythmias
in
patients
with
hypertrophic
cardiomyopathy. Eur Heart J 1993;14:71-72.
medicine, 5th ed. Philadelphia: WB Saunders, 1997, 1414-1426.
Fananapazir L, Epstein ND. Prevalence of hypertrophic
cardiomyopathy and limitations of screening methods. Circulation
1995;92:700-704.
Lakkis N, Kiemman N, Killip D, et al. Hypertrophic obstructive
cardiomyopathy: alternative therapeutic options. Clin Cardiol
1997;20:417-418.
Maron JM, Cerchi F, McKenna WS, et al. Risk factors and
stratification for sudden death in patients with hypertrophic
cardiomyopathy. Br Heart J 1994;72 (Suppl):S13-Sl8.
d
rve
Maron JM, Gardin JM, Flack JM, et al. Prevalence of shypertrophic
e
re
cardiomyopathy in a general population of young adults.
ts vnCirculation
h
1995;92:785-789.
g
i om.
Maron JM, Isner JM, et al. Task AForce
Hypertrophic
ll r o.c3:
. aho
cardiomyopathy, myocarditis, and otherevmyopericardial
diseases and
lo 1994;24:
y
mitral valve prolapse. J Am Coll Cardiol
880-885
n
@
i
0
Maron JM, Pelliccia A, Spirito8.P.F Cardiac
02 disease in young trained
2
0 distinguishing
y
athletes: insights methods20for
athlete's heart from
cit
oparticular
t with
t
structural heart disease,
emphasis on hypertrophic
h
o
P 1995;91:15961601.
rig
cardiomyopathy. Circulation
y
p
Morten ET. Hypertrophic
obstructive cardiomyopathy: problems in
Co
management. Chest 1997;112:262-264.
Posma JL, van de Wall EE, Blauksma P. New diagnostic options in
hypertrophic cardiomyopathy. Am Heart J 1996;132:1031~1041.
Robbins M. Hypertropic cardiomyopathy. In: Marso SP, Griffin BP,
Schlant RC, Alexander RW, eds. Hurst's The Heart, 8th ed. New
York: McGraw-Hill, 1621-1635.
Smolders W, Redemakers F, Conraads V, et al. Apical hypertrophic
cardiomyopathy. Acta Cardiol 1993;48: 369-383.
Spirito P, Seidman CE, McKenna WS, et al. The management of
hypertrophic cardiomyopathy. N Engl J Med 1997;336:775-784.
Watkins H. Multiple disease genes cause hypertrophic
cardiomyopathy. Br Heart J 1994;72:54-59.
Wigle D, Rakowski H, Kimball B. Hypertrophic cardiomyopathy:
clinical spectrum and treatment. Circulation 1995;92: 1680-1692.
394
Bnh c tim Hn ch
Bnh c tim hn ch l bnh c t l gp rt thp nhng l

mt nhm bnh quan trng trong suy tim tm trng. N c
nh ngha l bnh c tim tin pht hay th pht gy ra ri lon
chc nng tm trng tht tri nhng khng phi l vim mng
ngoi tim co tht. Cc bung tht khng gin hay ph i, tng
p ng v tnh mch phi, p lc cui tm trng tht tri tng.
Tuy nhin tm nh c th gin nhiu, i khi rt to a n hnh
nh tim to trn phim chp Xquang. Chc nng tm thu tht tri
thng bnh thng.
I. Nguyn nhn
d
rve
e
s
re
Mt vi trng hp khng r nguyn nhn (v
nhng
ts cn),
n
h
v
.
g
nhiu trng hp thng do nhim amyloid.
i Hemochroatosis
ll r o.com
A
l nguyn nhn hay gp gy bnh c
tim
o
.
ev yah gin nhng li t
o
l
n @
gp hn trong bnh c tim hnFich.
Cc nguyn nhn gy
. 2020
8tim,
bnh khc c th l vim c
sau
ghp tim, sarcoidose,
0
20 ocity
Loffler, x ha ni mc,
ht bnh
Pot Gaucher tr em
rig
y
p
II. Triu chng lm
Co sng
Du hiu ch yu l tr ngoi bin nh gin tnh mch c,
huyt phi v gan to, c chng.
1. in tm (T): Hu nh lun c T bt
thng. Bloc nhnh tri v dy nh l cc du hiu
hay gp. Trong nhim amyloid hay c du hiu gim
bin cc sng ngoi bin i ngc vi hnh nh
dy cc thnh tim trn siu m tim. Ri lon nhp tim
nht l rung nh rt hay gp, c bit l trong nhim
amyloid.
2. Chp tim phi: Bng tim thng khng to tr khi c
gin rng hai nh, huyt phi thng nng.
395
3. Siu m tim: Tm tht thng c kch thc bnh

thng vi chc nng tm thu trong gii hn bnh
thng. Trn dch mng tim i khi gp. Khng thy
cc bt thng cu trc tim khc, c bit l khng
thy cc tn thng van tim. ng knh tht tri
tng trong th tin tm trng tuy nhin khng tng
ln na trong thi k gia v cui tm trng. Dng
chy trong tm tht c trng bi sng E rt u th
do ko di thi gian gim tc.
d
rve
e
s
re
ts vn
h
.
g
l ri .com
l
A o
ev. yaho
o
l
Fin 0@
8. 202
0
20 city
t otoca
Hnh 21-1. Ph Doppler
dng chy qua van hai l
h
righn Pch do amyloidosis (A) v ngi
y
ngi mc bnh c otim
p
C
bnh thng (B). T l E/A (A) cao hn (B).
4. Chp ct lp t trng (CT) v cng hng t
trng ht nhn (MRI): Cho hnh nh gip phn
bit vi bnh vim mng ngoi tim co tht nh du
hiu dy mng ngoi tim.
5. Thng tim: Ch nh trong cc trng hp cn chn
on phn bit vi vim co tht mng ngoi tim v
cng phc v cho mc ch sinh thit c tim chn
on nguyn nhn bnh c tim hn ch. ng cong
p lc ca tm nh ging ht nh trong bnh vim
mng ngoi tim co tht, p lc cui tm trng ca
tm tht cng c dng cao nguyn. Tuy nhin nu
dng cao nguyn tht tri cao v r rng hn so vi
tht phi th lc ny ngh nhiu n bnh c tim hn
396
ch hn l vim mng ngoi tim co tht. Phim chp

bung tht tri thy tht tri kch thc v sc co bp
ca tht tri trong gii hn bnh thng v khng c
vng ri lon vn ng khu tr ca thnh tim.
6. Sinh thit ni mc c tim cho php chn on xc
nh v c th hng n chn on nguyn nhn.
IV. Chn on phn bit: ch yu l phn bit vi vim
mng ngoi tim co tht.
1. Nu c tin s lao, chn thng, vim mng ngoi
tim cp, bnh h thng, sau chy tia x, sau phu
thut... thng ngh n vim co tht mng ngoi tim.
Nu c tin s ghp tim, nhim amyloid,
hemochromatosis... th thng ngh n bnh c
tim
ed
v
r
e
hn ch.
es
sr n
t
h
v
2. Tc dng chy qua van hai l s
rigtng
m. khi ht vo
o
l
l
c
.
su bnh nhn vim mng ngoi
. A ahootim co tht, cn
evth
o
l
y hin tng ny s
trong bnh c tim hn ich
F n020@
.
khng thay i theo h
2
08 hp.
20 ocity
t obng
3. Chn on xcghnh
sinh thit ni mc c tim.
Pt
ri
y
p
V. iu tr
Co
A. Khi bnh nhn c tng p cui tm trng tht
tri nhiu: c th iu tr bng li tiu. Cc loi thuc
tng co bp c tim thng khng c hiu qu. Cc thuc
gin mch cn s dng ht sc thn trng. Thuc chn
knh Canxi c th tng sc gin n cui tm trng ca
tm tht nhng cha c khng nh trn lm sng v
hiu qu iu tr.
B. iu tr bnh nguyn
1. Nhim amyloid hay gp cc nc khng thuc
vng nhit i. C th ch nh hng n tim nhng
cng c th c nh hng n cc h thng khc.
Hay gp ri lon nhp km theo, tin lng khng tt,
hu nh ch c cch iu tr hiu qu l ghp tim.
397
2. Trng hp hemochromatosis th hay gp bnh c

tim gin hn l bnh c tim hn ch.
Ti liu tham kho
1.
Aroney C, Bett N, Radford D. Familial restrictive cardiomyopathy.

Aust N Z J Med 1988;18:877-8.
2. Buxbaum J. The amyloidoses. Mt Sinai J Med 1996;63:16-23.
3. Cetta F, OLeary PW, Seward JB, Driscoll DJ. Idiopathic restrictive
cardiomyopathy in childhood: diagnostic features and clinical
course. Mayo Clin Proc 1995;70:634-40.
4. Goodwin JF. Cardiomyopathies and specific heart muscle diseases:
definitions, terminology, classifications and new and old approaches.
Postgrad Med J 1992;68:Suppl 1:S3-S6.
5. Hirota Y, Shimizu G, Kita Y, et al. Spectrum of restrictive
cardiomyopathy: report of the national survey in Japan. Am Heart J
1990;120:188-94.
6. Katritsis D, Wilmshurst PT, Wendon JA, Davies MJ, Webb-Peploe
ved
MM. Primary restrictive cardiomyopathy: clinical andserpathologic
characteristics. J Am Coll Cardiol 1991;18:1230-5. ts re
h .vn
7. Kushwaha SS, Fallon JT, Fuster V. Restrictive
N
igcardiomyopathy.
r
l
l o.com
Engl J Med 1997;336:267-276.
A
o
.
v ah
8. Lewis AB. Clinical profile and
of restrictive
loe @outcome
y
n
i
F 02J 01992;123:1589-93.
cardiomyopathy in children. Am .Heart
08 2
9. Pellikka PA, Tajik AJ, Khandheria
20 ocity BK, et al. Carcinoid heart
t ot
disease: clinical and hechocardiographic
spectrum in 74 patients.
P
rig
Circulation 1993;87:1188-96.
y
op
10. Richardson P,CMcKenna
W, Bristow M, et al. Report of the 1995
World Health Organization/International Society and Federation of
Cardiology Task Force on the Definition and Classification of
Cardiomyopathies. Circulation 1996;93:841-2.
398
Vim mng ngoi tim cp
Vim mng ngoi tim l mt tnh trng bnh l c ngun

gc do phn ng vim ca mng ngoi tim vi cc triu chng
chnh l au ngc, ting c mng ngoi tim v cc bin i in
tm . Bnh hay gp nam gii hn so vi n gii.
Cc th bnh v nguyn nhn gy bnh ca vim mng
ngoi tim cp rt a dng. Nguyn nhn hay gp nht l: vim
mng ngoi tim cp v cn, do virus, do vi khun (nht l vi
khun lao), tng ur mu, sau nhi mu c tim, ung th v chn
thng.
d
I. Vim mng ngoi tim cp khng r cn nguyn
rve
e
s
re
C kh nhiu cc trng hp vim mng hngoi
ts vn tim cp
.
g
khng tm thy nguyn nhn gy bnh, ngi
omcho rng i
l ri .cta
l
oo
a s cc trng hp ny c ngunoegc
v. A do
ah virus. Tuy nhin
l
y
@ bnh hin cn gp
in 0gy
vic phn lp tm ra chnh xc. Fvirus
8 202
0
nhiu kh khn v mt k 2thut.
0 ity
t otoc
h
P
A. Triu chng lm
rig sng
y
p
Co c nng:
1. Triu chng
a. au ngc do vim mng ngoi tim thng au
sau xng c, au but, c th mc nng d
di nhng cng c th m ko di sut ngy,
au thng lan ln c v ra sau lng. Kinh in
au thng tng ln khi ho v khi ht vo su.
b. Thng km theo st v du hiu au mi c nh
cc trng hp nhim virus thng thng.
c. Kh th i khi c th gp nhng thng thng
xut hin sau giai on au ngc khi vim mng
ngoi tim cp din bin thnh trn dch mng
ngoi tim.
d. Bnh nhn thng cm gic cng thng, bun b
v kh chu.
399

a. Nghe tim l du hiu ch yu chn on. Nghe
thy c ting c mng ngoi tim. Ting c thng
th, rp, rt, c m cao. N c th thay i
theo thi gian v t th bnh nhn hoc khi bnh
nhn ht vo su. Kinh in ting c s c ba thi
k tng ng vi tm nh co, tm tht co v tin
tm trng. Tuy nhin, thng thng chng ta
ch nghe thy ting c trong thi k tm nh v
tm tht co, thm ch ch nghe thy trong mt
thi k nht nh m thi.
b. V tr tt nht nghe thy ting c mng ngoi
tim l pha thp ca b tri xng c, khi bnh
d nn
nhn ngi hi ci ra trc v ht su voveri
r
e
s
th.
re
ts vn
h
.
g
l ri .com
l
hoo s din bin
v. A aT
1. in tm (T): Kinhloein
y
in nghim
0@
qua 4 giai on. y l. Fxt
rt c gi tr
8 202
0
chn on xc nh,
chn
on
phn
bit
v nh gi
y
0
2 ocit
t otngoi
giai on vim
mng
tim
cp.
h
P
rig
y
p
a. GiaiCon
u
thng xut hin vi gi sau cn
o
au ngc u tin. y l giai on rt kh phn
bit vi du hiu ti cc sm hay nhi mu c tim
cp trn in tm . Kinh in giai on 1 s
gm cc du hiu on ST chnh ln ng hng
vi sng T dng cc chuyn o trc tim.
b. Giai on th hai xut hin vi ngy sau vi on
ST tr v ng ng in, sng T dt xung.
c. Giai on ba l giai on sng T m o ngc.
d. Sau vi ngy n vi tun sng T s dng tr li,
y l giai on cui cng ca bnh.
e. Nu vim mng ngoi tim cp c trn dch mng
tim, T c th c du hiu in th gim (nht
l cc chuyn o ngoi vi) v du hiu lun
phin in hc.
400
d
rve on
Hnh 22-1. Tin trin trn in tim tesegiai
r
ts cp
VMNT cp (trn) chuyn sang giai on gbn
n (di).
h
i om.v
r
l
l .cch thy trong
2. Chp tim phi: hnh tim to .thng
v A ahoo
e
o
cc trng hp c trn dch
l mng
y ngoi tim phi hp
0@
Finl02du
.
v y cng khng 0phi
hiu c hiu gip
8
0 ity2
2
chn on.
t toc
igh Po
r
3. Cy mu,opy
cy m v dch ht d dy c kh nng
C
gip chn on mt s cc trng hp vim mng
ngoi tim phc tp nh do lao (sau 1 tun), nhim
khun huyt hay vim ni tm mc nhim khun.
4. Xt nghim mu: thng c tng bch cu, mu
lng tng v tng men creatine phosphokinase MB.
5. Siu m tim:
a. Siu m tim thng c ch nh trong cc
trng hp giai on sau ca bnh (vi tun sau
du hiu lm sng u tin xut hin) hay khi c
bin i huyt ng tuy nhin cng c th thc
hin thng quy trong tt c cc trng hp
chn on loi tr. Du hiu c th gp trn siu
m l khong trng siu m do dch mng ngoi
tim gy ra (8 n 15% cc trng hp vim mng
401
ngoi tim cp). Him gp hn c th c du hiu

mng ngoi tim dy hn so vi bnh thng.
b. Mt khc trong cc trng hp bnh nhn mi
phu thut tim hay nghi ng c trn dch mng
tim, lc ny siu m tim tr thnh xt nghim kh
quan trng, cn thc hin nhiu ln nh gi
s tin trin ca bnh.
6. Cc xt nghim khc nh siu m tim qua thc
qun, chp ct lp vi tnh, cng hng t ht nhn c
th p dng trong mt vi trng hp c bit
nghin cu k hn v mng ngoi tim.
C. Chn on phn bit
1. au ngc do tch thnh ng mch ch, nhid mu
rve
phi, vim phi hay nhi mu c tim.
ese
r
ts vn do thiu
2. Bin i T cn phn bit vi ccribin
.
gh mi
o
l
l
c
.
mu c tim cc b gy ra. Din
bin ca on ST v
v. A ahoo
loe @yi
sng T cho php phn bitintrong
a s cc trng
F 020
.
8
hp. Tuy nhin cc0trng
hp ST chnh ln lan ta
0 ity2
c siu m chn on loi
2 tlm
cc chuyn ohtcn
o
g timPo(tm ri lon vn ng vng trn
ric
tr nhi mu
y
op
siu m Ctim).
D. iu tr
1. Nguyn l chung: i a s cc trng hp vim
mng ngoi tim cp khng c bin chng, bnh s t
khi v p ng tt vi iu tr ni khoa.
a. Thuc iu tr ch yu l thuc khng vim
khng steroid.
b. iu tr vim mng ngoi tim c bin chng trn
dch mng ngoi tim hay vim mng ngoi tim co
tht s c bn lun nhng bi sau.
2. iu tr ni khoa:
402
a. Ibuprofen 600 n 800mg ung chia 3 ln trong

ngy, trong 3 tun hay Indomethacin 25 n
50mg ung chia 3 ln trong ngy, trong 3 tun.
b. Trong cc trng hp bnh nhn khng p ng
vi khng vim khng steroid hay trong trng
hp ti pht vim mng ngoi tim c th s dng
prednisone ung trong 3 tun, cng c th dng
ng tim tnh mch vi Methylprednisone
trong cc trng hp nng. Colchicine 1mg trong
ngy cng c mt vi nghin cu ch ra tnh
hiu qu trong iu tr vim mng ngoi tim cp.
3. iu tr chc dn lu dch mng ngoi tim qua da
(trn dch mng tim c p tim): Ch p dng trong
d dch
cc trng hp vim mng ngoi tim c trn
rve
e
s
nhiu, c nh hng n huyt ng hays trong
trng
re
t vn
h
.
hp cn chc d chn on bnh
nguyn.
Chc
g
l ri .com
l
o lu trong cc
dn lu vi gy t ti ch c th
hodn
v. At
loe @lin
ya tc.
trng hp dch nhiu, tiinpht
. F 20
08 ty20
4. Phu thut:
0
2 i
t otoc ngoi tim di xng c
a. M dn rilu
P
gh mng
y
p
thng
Co ch p dng trong cc trng hp vim
mng ngoi tim do ung th.
b. Phu thut ct mng ngoi tim thng p dng
trong trn dch ti pht nhiu hay vim co tht
mng ngoi tim.
II. Vim mng ngoi tim do virus
Nguyn nhn ch yu do Coxackie virus nhm B v
Echovirus gy ra. Chn on da vo du hiu nhim virus
ng h hp, au ngc xut hin sau vi bin i T
v cui cng l cc xt nghim huyt thanh chn on. i
a s cc trng hp bnh t khi. i khi c th dn n
cc bin chng nh vim c tim, ti pht vim mng ngoi
tim, trn dch mng tim, p tim v vim mng ngoi tim co
403
tht. Du hiu lm sng v iu tr nh trong cc trng hp

vim mng ngoi tim khng r nguyn nhn.
III. Vim mng ngoi tim do lao
A. Triu chng lm sng
Tt c cc trng hp vim mng ngoi tim c st lai dai,
nht l v chiu th trc ht cn phi ngh n vim
mng ngoi tim do lao.
1. Du hiu lm sng in hnh thng n mun, i
a s cc bnh nhn ch c biu hin kh th, st, n
lnh v ra m hi v chiu ti.
2. Du hiu tr ngoi bin trn lm sng hay gp hn
du hiu au ngc v ting c mng ngoi tim.
ed
rvnguyn
B. Nguyn nhn: Vim mng ngoi tim do laosl
e
re co tht.
nhn hng u dn n vim mng ngoi
ts tim
h
.vn
g
ri 1comn
Vim mng ngoi tim gp khongll t
2% cc
A hoo.
.
v
trng hp lao phi.
a
oe
inl 20@y
F
C. Cc xt nghim chn0on
8. 0
0 ity2
2
oc chnh ln kinh in thng
t otST
1. in tm :ghon
P
i
r
khng thy
pytrong vim mng ngoi tim do lao.
Co
2. Chp tim phi: thy du hiu ca lao phi mi hoc
c trong mt s cc trng hp v du hiu bng tim
to ra do c dch mng ngoi tim.
3. Cy tm vi khun lao BK (AFB): l xt nghim c
hiu cho chn on. Dch cy c th ly t cc dch
tit ca c th (m, dch d dy, dch mng phi...)
hay t chnh dch chc ht ca mng ngoi tim.
4. Xt nghim mu: thng tng bch cu a nhn giai
on sm v bch cu lympho giai on mun hn,
mu lng thng tng trong a s cc trng hp.
5. Siu m tim: Thy du hiu c dch khoang mng
tim vi nhiu si fibrin, ng thi c th c du hiu
mng ngoi tim dy hn so vi bnh thng.
404
D. iu tr
1. Rifampicin 600mg/ngy, Isoniazid 300mg/ngy,
Pyridoxine 50mmg/ngy phi hp vi Streptomycin
1g/ngy hoc Ethambutol 15mg/kg/ngy trong 6 n
9 thng.
2. Cn sm phu thut ct mng ngoi tim trong cc
trng hp trn dch ti pht gy p tim nhiu ln hay
mng ngoi tim dy nhiu dn n vim mng ngoi
tim co tht.
IV. Vim mng ngoi tim sau nhi mu c tim
Do vim mng ngoi tim phi hp vi hoi t c tim
nn bnh nhn c nguy c suy tim huyt v t l t vong
trong vng mt nm cao. Trong nhm cc bnh nhn
d nhi
rve
e
s
mu c tim cp c ti ti mu (tiu si huyt
re hay nong
ts thp
n hn
h
ng mch vnh), t l vim mng ngoi
tim
g
i om.v
r
l
l .c
nhm iu tr bo tn.
v. A ahoo
e
o
l @trong
y
Vim mng ngoi tim hay
cc trng hp
0
Fingp
2
.
0
8 rng
2
nhi mu c tim thnh trc
ko
di
vi
gi n vi
0
20 ocity
ngy sau nhi mu. ght Pot

ri
py
A. Triu chng
Co lm sng
Tt c cc trng hp sau nhi mu c tim cp m
thy bnh nhn c ti pht au ngc v nghe tim c ting
c mng ngoi tim th cn phi ngh n vim mng
ngoi tim sau nhi mu c tim.
in tm cho thy sng T c th dng cao hn
trong hai ngy hoc sng T o ngc trc tr nn
dng. Tuy nhin, cc du hiu T in hnh cho vim
mng ngoi tim thng khng thy r.
C. iu tr
1. Aspirin l la chn iu tr hng u.
405
2. Chng ch nh cc thuc khng vim khng steroid

do c th gy co tht ng mch vnh, cn cc thuc
steroid th li c th gy thng tim trong vim mng
ngoi tim sau nhi mu co tim cp.
V. Hi chng Dressler
Xut hin vi tun cho n vi thng sau nhi mu c
tim vi t l gp khong 1%. Sinh bnh hc cn cha r
rng tuy nhin ngi ta ngh nhiu n nguyn nhn do c
ch t min. Bnh nhn thng c biu hin st, trn dch
mng phi, ting c mng tim, mng phi, xu v au ngc
nhiu. iu tr bng Aspirin v thuc chng vim khng
steroid, ngh ngi ti ging. Nu dng thuc chng ng
c th d gy ra trn mu mng ngoi tim tuy nhin tin
lng ca hi chng ny thng rt tt. Hn hu cc etrng
d
erv dng
hp khng khng ch c phn ng vim miesphi
r
ts vn
steroid iu tr.
h
.
g
l ri .com
l
VI. Hi chng sau m mng ngoi tim
A o
ev. yaho
o
l
Hi chng ny cng gnFin
ging
@ hi chng Dressler,
20 l gp khong 10 n
8. 20T
xut hin mt tun sau phu
thut.
0
20 ocity t khi song i khi ko
40% cc trng hp. Bnh
t othng
h
P t Aspirin, chng vim khng
rigtr bng
di vi tun. iu
y
p
Co ch dng trong cc trng hp khng p
steroid, Corticoid
ng vi iu tr. Bin chng c th gp l p tim v him gp
hn l vim mng ngoi tim co tht.
VII. Vim mng ngoi tim do tng ur mu
A. Triu chng lm sng
1. Hay gp cc bnh nhn va bt u lc mu, rt
hay nghe thy ting c mng tim trn lm sng.
2. Thng gp trn dch mng ngoi tim s lng nhiu
sau giai on vim cp.
406
B. Sinh bnh hc: Cn cha tht r rng c ch sinh

bnh hc ca bnh v khng thy mi lin h vi nng
ur mu cng nh ng c vi s xut hin ca vim
mng ngoi tim.
C. iu tr
1. iu tr ni khoa: Hn ch s dng chng vim
khng steroid; steroid nhiu khi t hiu qu tt.
2. iu tr dn lu dch mng ngoi tim qua da: Lc
mu l la chn hng u cho cc bnh nhn vim
mng ngoi tim do tng ur mu nu c triu chng.
Nu khng c triu chng ca hi chng ur mu cao
th lc mu khng phi l bt buc. Nu trn dch
mng tim s lng nhiu vi tng bch cu, st hay
c p tim th vic chc dn lu dch mng tim dl cn
rve
thit.
ese
r
ts di
3. iu tr ngoi khoa. M mng ngoi
.vn xng
ghtim
i
r
m
o
l
c, ct mng ngoi tim ti thiu
l c
.c ch nh cho
. A hoc
hoo khng ht dn
vln
e
cc trng hp ti pht nhiu
a
o
l
y
lu dch qua da c. 8. Fin020@
2
00 ung
2do
ity th
VIII. Vim mng ngoi tim
c
o
ht ot
righp Pl do di cn n mng ngoi tim
i a s cc trng
y
op
(ung th phi, Cung th v, Hodgkin v khng Hodgkin, lx-mi...). Ung th nguyn pht mng ngoi tim him gp c
th do sarcome, mesothelioma, teratoma hay fibroma.
A. Triu chng lm sng
1. Bnh nhn thng khng c triu chng lm sng g
c bit, ngoi cc triu chng ca bnh l ung th.
Vim mng ngoi tim thng pht hin kh mun.
2. C th gp du hiu c nng l kh th, trn dch
mng phi v i khi bnh nhn n vin v p tim.
3. Cn sm pht hin p tim cc bnh nhn ung th
khi t ngt xut hin kh th, mt mi hoc ph.
1. in tm (T): Cc du hiu T in hnh
cho vim mng ngoi tim thng khng thy r. Bin
407
i on ST-T khng c hiu, i khi c th thy

du hiu lun phin in hc.
2. Xt nghim gii phu bnh vi th: tm t bo ung
th trong dch chc ht mng ngoi tim hoc cc dch
tit khc ca c th. T l gp t bo c tnh cao
trong dch mng ngoi tim cc bnh nhn ung th
phi, ung th v nhng t l ny thp cc bnh
nhn ung th mu v cc ung th khc.
3. Siu m tim: gip nh gi mc trn dch mng
tim, huyt ng v theo di s din bin ca bnh.
C. iu tr
1. iu tr dn lu dch mng ngoi tim qua da:
a. Chc dn lu dch mng tim: Rt tt nu c s
d
hng dn ca siu m, ch nh cho cc
rve bnh
e
s
nhn c triu chng lm sng ca trn
redch mng
ts vn
h
ngoi tim m s lng kh nhiu.
.
g
l ri .com
l
b. Dng bng nong mng ngoi
hool k thut nguy
v. Atim
loe @ya cc bnh nhn ti
him hn, ch nn pindng
. F 2020tim nhiu ln.
pht trn dch mng
08 tngoi
0
2 oci ydng mt vi th thut sau
2. Phu thut: c
t thotp
h
Php cn thit:
ig
rtrng
trong nhng
y
p
o
a. M C
mng ngoi tim di xng c.
b. Lm cng mng ngoi tim bng Tetracycline vi
nc mui sinh l. Bin chng c th gp ca th
thut ny l au nhiu trong th thut, ri lon
nhp v st.
c. Ct mng ngoi tim. Phu thut ny khng l la
chn hng u cho cc bnh nhn trn dch mng
ngoi tim do ung th.
IX. Theo di cc trng hp vim mng ngoi tim
Cc bnh nhn vim mng ngoi tim do virus hay
khng r nguyn nhn cn c theo di trong vng mt
thng k t sau khi ht cc triu chng lm sng khng
nh khng c ti pht bnh v khng c vim mng ngoi
tim co tht.
408
Cc bnh nhn c trn dch mng ngoi tim cn phi

theo di nh k bng siu m khng nh khng c ti
pht hay tng mc dch trong khoang mng tim.
X. Bin chng
A. Ti pht vim mng ngoi tim
Thng gp vi t l 20 n 30% cc trng hp, hay
gp trong vim mng ngoi tim khng r nguyn nhn,
sau phu thut tim h, chn thng, hi chng Dressler.
iu tr nu khng p ng vi khng vim khng
steroid c th dng Prednisone 40-60mg/ngy t 1 n 3
tun. Phu thut c ch nh trong cc trng hp ti
pht nhiu ln vim mng ngoi tim c au ngc nhiu
m khng p ng vi iu tr ni khoa. Phng nga
ti
ed
v
r
e
pht c th s dng Colchicine 1mg/ngy trong
mt thi
res
ts vnhn. Tuy
gian vi vic gim dn liu trc khigdng
h
i m.
nhin cn cn c thm mt s cc Anghin
lm sng
ll r o.cocu
v. aho
e
khng nh vn ny.
o
l
y
Fin020@
.
B. p tim: chim khong 15%
2 trng hp.
08 cc
20 ocity
t
t
C. Vim mng ngoi
igh Potim co tht: khong 9% cc
r
y
trng hp vim
p mng ngoi tim s b vim dnh mng
Co
ngoi tim mc t trung bnh tr ln.
Ti liu tham kho
1. Adler Y, Finkelstein Y, Guindo J, et al. Colchicine treatment for
recurrent pen-carditis. Circulation 1998;97:2183-2185.
2. Alexander RW, Schiant H, Fuster V. Hurst's the heart, 9th ed. New
York: McGraw-Hill, 1998.
3. Braunwald E, ed. Heart disease: a textbook of cardiovascular

medicine, 5th ed. Philadelphia: WB Saunders, 1997.
4. Fowler NO. Tuberculous pericarditis. JAMA 1991;266:99-103.

5. Kirkland LL, Taylor RW. Pericardiocentesis. Crit Care Clin
1992;8:669-711.
6. Shabetai R. Diseases
1990;8(4):579-716.
of
the
pericardium.
Cardiol
Clin
409
7. Spodick DH. Pericarditis, pericardial effusion, cardiac tamponade,

and constriction. Crit Care Clin 1989;5:455~75.
8. Topol EJ, ed. Textbook of cardiovascular medicine. Philadelphia
Lippincott-Raven Publishers, 1998.
9. Wu J. Acute pericarditis. In: Marso SP, Griffin BP, Topol EJ, eds.
Manual of Cardiovascular Medicine. Philadelphia: Lippincott-Raven, 2000.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
410
Trn dch mng ngoi tim
Trn dch mng ngoi tim l mt tnh trng bnh l kh

thng gp trn lm sng. Bnh c th hon ton thm lng,
khng c triu chng nhng cng c th nguy kch n tnh
mng bnh nhn trong bnh cnh p tim. Biu hin lm sng ty
thuc vo s lng dch cng nh bn cht ca dch.
I. Trn dch mng ngoi tim khng c du p tim
Khoang mng ngoi tim cha ng t 15 n 30 ml dch
gip cho hai l thnh v l tng khng c st vo nhau. Kh
nng cha ti a ca khoang mng ngoi tim l t 80 n
200ml dch, vi s lng dch ny trn lm sng rhu
ved nh
e
s
re
khng nhn thy cc bin i v huyt ng. Cc
nhn
ts vbnh
n
h
.
g
vim mng ngoi tim cp p lc tnh mch
i trung tm tng
ll r o.com
A
lm gim s tr v ca h tnh mch
do
o
.
ev yah kh nng cha
o
l
dch ca khoang mng tim s tng
in ln.@ Vi s tng dn ca
. F 2020
8khoang
lng dch nhiu trng hp
mng tim c th cha
0
20 ocity
t oc
n 2 lt dch m vnghcha
t bin i huyt ng trn lm
ring Phay gp trong cc trng hp dch
y
sng. Chn p huyt
op
qu nhiu hay Ctng qu nhanh hoc trong cc trng hp
dch c nhiu si fibrin, trn dch mng tim do ung th.
A. Triu chng lm sng
1. Triu chng c nng:
a. Dch mng tim tng dn khng lm bin i p
lc trong bung tim thng khng c biu hin
triu chng lm sng.
b. i khi bnh nhn c biu hin au m , p
nng ngc.
c. C th c cc biu hin do dch mng tim p
vo cc c quan ln cn. Kh nut do chn p vo
thc qun, kh th do chn p phi v xp phi,
411
nc do chn p vo dy thn kinh honh, nn v

cng bng do chn p cc tng trong bng.
a. Dch mng tim s lng t thng kh thy cc
du hiu trn khm thc th.
b. Dch mng tim s lng nhiu c th thy cc
du hiu ting tim m, du hiu ca Edwart (g
c, ting thi ca ph qun) v ran phi do
chn p th pht.
B. Nguyn nhn
Cc nguyn nhn hay gp gy trn dch mng ngoi tim
nhiu l vim mng ngoi tim khng r nguyn nhn,
tng ur mu, hi chng thn h, vim mng ngoi
d tim
rve gip,
e
do ung th hay u nhy, suy tim huyt, x gan,
suy
s
re
ts vn
h
sau phu thut tim v do thuc.
g
ri com.
l
l
. mng tim
Bng 23-1. Cc nguyn nhn gy trn
dch
v. A ahoo
e
o
l
y
1. V cn
Fin020@
.
08 2
2. Nhi mu c tim cp
20 ocity
ht ot
3. Cc hi chng
rig sauPtn thng c tim-mng tim: hi
y
p
Co
chng Dressler;
sau m mng tim
4. Nguyn nhn chuyn ho: hi chng ur mu cao,
ph nim, gim albumin mu
5. Do tia x
6. Phnh tch ng mch ch ngc
7. Chn thng: ng dp, do dng c, th thut..)
8. Do virus: Coxsackie cc tp A, B5, B6; Echovirus;
Adenovirus, virus cm, quai b, thu u, vim gan
B, HIV
9. Do vi khun: t cu, ph cu, lin cu, H. influenzae,
no m cu, lu cu, lao, thng hn, vi khun gy
st m, st vt, L. hemophilia, vim ni tm mc
nhim khun
412
10. Do nm su, nm ph tng: Histoplasmosis,

Aspergillosis, Blastomycosis, Coccidiodomycosis
11. Cc loi nhim trng khc: amp, Echinococcus, st
Lyme, M. pneumonia, Rickettsia
12. U tin pht (mesothelioma, teratoma, fibroma,
leiomyofibroma, sarcoma, lipoma, angioma...) v di
cn (ung th v, ph qun, l-x-mi, u lympho...)
13. Cc bnh min dch (thp tim, lupus ban h
thng, vim ct sng dnh khp, vim khp dng
thp, vim mch, vim nt quanh ng mch, x
cng b, vim da v c, bnh Whipple, Behcet,
Reiter, st a Trung Hi, vim ng mch thi
dng, amyloidosis
d
rve
e
s
14. Do thuc: Procainamide, Hydralazine,re Heparin,
ts vn
Warfarin, Phenytoin, Phenylbutazone,
.
gh mDantrolene,
i
r
o
l
l
c
.
Methysergide, Doxorubicin, Penicillin,
Minoxidil,
A o
ev. yaho
o
l
Interleukin
in @
. F 2020
8
0
C. Cc xt nghim chn
20 on
ity
t otoc
h
P
1. in tm
Kinh in s thy du hiu
rig (T):
y
p
in thCothp lan ta. Du hiu lun phin in hc
hay gp trong cc trng hp dch mng tim nhiu.
2. Phim chp tim phi: bng tim khng thay i khi
dch mng tim ch dy 1 n 2mm, tim to thng ch
thy trong cc trng hp c trn dch mng ngoi
tim s lng nhiu hn 250ml. Tim to vi du hiu
gin rng cung ca tnh mch ch trn, tnh mch
n (azygous) v gim ti mu phi gi cho chn
on trn dch mng ngoi tim.
on v theo di trn dch mng ngoi tim. Ngoi gi
tr chc chn trong chn on, siu m cn gip cho
vic t dn lu mng tim v nh gi s lng dch
cn li trong khoang mng tim. Tuy nhin siu m t
413
c gi tr chn on sinh bnh hc ca cc loi

dch mng tim khc nhau.
a. Siu m hai bnh din cn tm cc du hiu sau:
Khong trng siu m gia l thnh v l tng
ca mng ngoi tim.
Hnh 23-1. Khong trng siu m khi c TDMT.

d
Tng vn ng ca cc thnh tim
rve
e
s
re du hiu
Khi dch mng tim nhiu c th sthy
t vn
h
. tim. y
g
qu tim lc lc trong khoang
mng
l ri .com
l
A tng
o
chnh l c ch ca vhin
lun phin
e . yaho
o
l
in hc thy c
0@in tm .
Fintrn
02mng ngoi tim c th
8. dch
2
0
b. Kch c ca lng
20 ocity
t qua
xc nh thng
h
Pot khong cch gia hai l ca
rig tim
y
khoang
mng
( dy ca lng dch) v kiu
op
C
lan ta ca dch mng tim.
Lng dch t (di 100ml) tp trung ch yu
pha sau v dy thng di 1 cm.
Lng dch trung bnh (t 100 ti 500ml).
Lng dch thng bc xung quanh tim
nhng dy vn di 1 cm hoc ch c t
xung quanh cc mch mu ln.
Lng dch nhiu (hn 500ml) qu tim b y
ra sau vi lng dch bc xung quanh lan ln
ti c cc mch mu ln, c bn, mm v
pha trc ca tim. dy ca lng dch ln
hn 1cm mi v tr.
4. Cc xt nghim khc nh siu m qua thc qun,
chp ct lp vi tnh, cng hng t trng ht nhn
414
c th p dng trong mt vi trng hp c bit

nghin cu k hn v mng ngoi tim.
5. Xt nghim dch mng tim nhng trng hp dch
nhiu c chc ht dn lu. Cc xt nghim cn lm l
tm trc khun lao, sinh ha, vi khun v t bo hc.
a. Xt nghim dch s cho php xc nh mt s cc
nguyn nhn gy bnh gip ch rt nhiu cho vic
iu tr. Dch mng tim l mu thng gi c
chy mu mi vo trong khoang mng tim, tuy
nhin nu dch mu mu c th gp trong cc
trng hp bnh ung th, nhim khun hay vim
nhim. Nu dch c rt nhiu mu, cn gi mu
mu lm xt nghim kh mu. Nu c dy c
d
mu cc r rng th rt c th chc vo
rve mch
e
s
re
mu hay bung tim. Dch m nguyn
l do
ts vnhn
n
h
.
g
vi khun nhim trng. Dch dng
chp thng
i
ll r com
do tn thng hay tc ngevngc.
. A ahoo.
o y
@
inltrong
b. Cy dch c ch nh
F
. 2020 cc trng hp nghi
8
0
ng c ngun 2gc
0 igy
ty bnh l do nhim trng,
t otocvirus v nhim nm.
bao gm c
nhim
h
P
rig
y
p
D. iu tr Co
1. Nguyn l chung: iu tr bao gm iu tr bnh
nguyn, iu tr cc bin ng v huyt ng do dch
mng tim gy ra.
2. iu tr chc dn lu dch mng ngoi tim qua
da:
a. Ch nh trong cc trng hp ung th, nhim
khun vi khun, nm.
b. Trong cc trng hp trn dch mng ngoi tim
s lng dch nhiu, d triu chng lm sng
khng in hnh cng vn c th ch nh chc
dn lu mng ngoi tim.
c. Chc dch mng ngoi tim khng nn ch nh
cc trng hp dch mng tim t.
415
3. iu tr thuc chng ng: cn hn ch s dng

thuc chng ng trong tuyt i a s cc trng
hp trn dch mng ngoi tim.
II. Trn dch mng ngoi tim c du hiu p tim
Khi dch mng tim s lng nhiu s dn n hin tng
tng p lc trong khoang mng ngoi tim v t s dn
n hn ch tm trng ca tim, qu trnh p tim bt u
xy ra. Bnh cnh p tim c xc nh bng cc triu
chng ca tng p lc trong cc bung tim, hn ch s gin
ra ca tm tht trong thi k tm trng v lm gim cung
lng tim.
A. Triu chng lm sng
1. Triu chng c nng:
d
rve
e
s
re
Biu hin trn lm sng l bnh cnh ca
lng
ts cung
h
.vn l m
g
i omthch,
tim thp: bn chn, lo lng hocl rkch
l o.c
. A atch
ng g, c th xu i; gimevth
ho nc tiu; c
o
l
y
n gic
@ chn p ngc; suy
bit l biu hin kh th;Ficm
. 2020
8
0
sp, chn n v gy
0 st
ty trong cc trng hp trn
2 tmn
oci tnh.
t tim
dch mng ngoi
h
o
P
rig
y
p
2. Triu chng
thc
th:
Co
a. Tng p lc ca tnh mch trung tm, th nhanh;
nhp tim nhanh; ting c mng ngoi tim; ting
tim m.
b. Cc triu chng ging nh suy tim phi: gan to,
tnh mch c ni, c th c trn dch mng phi
phi hp...
c. Tt huyt p v du hiu mch o c xc nh
l huyt p gim thp hn 10mmHg khi bnh
nhn ht vo su. C ch ca hin tng ny l
khi ht vo su s lm tng lng mu tnh mch
tr v tht phi, do xung quanh tim l dch p
khng cho tim n ra nn tht phi phi n v pha
tht tri lm gim s y ca tht tri, hu qu
cui cng l gim s tng mu ngoi bin gy
416
gim huyt p. Mch o khng c hiu trong

p tim, n c th gp trong bnh phi tc nghn,
nhi mu tht phi, nhi mu phi hoc hen ph
qun. S khng thy c mch o trn bnh nhn
c p tim nhng chc nng tht tri gim nhiu
v c tng p lc tm trng hoc trong thng
lin nh, h ch hay p tng vng tim.
1. Siu m tim qua thnh ngc: l phng php bt
buc phi thc hin khi nghi ng c p tim trn lm
sng. N s gip khng nh chn on khi thy c
nhiu dch trong khoang mng tim.
a. Siu m hai bnh din cn phn bit cc trng
d
hp c tng p lc tnh mch trung stm
rve v h
e
e
s r n vim co
huyt p nh nhi mu c tim ththtphi,
v
.
g
tht mng ngoi tim.
l ri .com
l
A hoo
ev. y
b. Cc du hiu ca p timlobao
gm:
a
n 0@
i
F
2
C dch trong8. khoang
mng ngoi tim (biu
0 ty20
20 okhong
hin bng cc
trng
v siu m tim).
i
t ot c
h
P
g
Du rhiu
p nh phi th tm trng thng
i
py
bt
Co u t cui tm trng v thy r nht
mt ct cnh c tri trc ngang, di sn v
4 bung t mm. y l du hiu c nhy
cao tuy nhin c hiu ch l 82% vi gi
tr d bo dng tnh l 50%.
A
B
Hnh 23-2. Du hiu p tht phi (A) v p nh phi (B).
417
Du hiu p tht phi thng quan st thy ti

thnh trc tht phi v vng phu trong t
th nm nga. Trc ngang v trc dc cnh c
tri l hai mt ct thun li nht quan st
du hiu ny. Cn s dng siu m TM
khng nh du hiu ny. Du hiu p tht
phi n c trn siu m c th c trc biu
hin p tim trn lm sng.
Du hiu p nh tri.
Tng kch thc tht phi v gim kch thc
tht tri mt cch bt thng khi bnh nhn
ht vo su.
Thay i theo nhp th ca cc dng chy qua
van nh tht, tng bt thng dng chy qua
van ba l v gim bt thng dng chy
d qua
rve Bnh
van hai l khi bnh nhn ht vo ssu.
e
e
s r nvan ba l
thng khi ht vo dng chyhtqua
v
.
g
m qua van
khng tng qu 7%, cn ldng
l ri .cochy
A hooNu khi ht vo,
hai l khng gim qu
ev.10%.
o
l
ya hn 25% th rt
@gim
sng E qua van Fhai
in l
0
2
0
8. p
gi c biu00hin
y2 tim trn siu m.
t
2
i
t toc
igh Po
r
py
Co
Hnh 23-3. Thay i theo h hp th ht vo (INSP) v

th ra (EXP) ca ph Doppler xung dng chy qua van
hai l (pha trn) v van ba l (pha di) bnh nhn
TDMT p tim.
418
Gin tnh mch ch di. Tnh mch ch di

gin hn 50% khi bnh nhn ht vo su l
du hiu rt nhy (97%) nhng c hiu
ch l 40% trong chn on p tim.
Tht tri gi ph i.
2. Thng tim phi: quan trng cho chn on v ra
hng iu tr. N khng nh chn on p tim,
nh gi s cn tr huyt ng v xc nh cung
lng tim, theo di s tin trin ca huyt ng sau
khi c chc dn lu dch mng ngoi tim.
a. Cc du hiu huyt ng cn xc nh l p lc
nh phi, p lc mao mch phi bt, p lc tm
trng ca ng mch phi, p lc gia
d tm
rve
e
s
trng ca tht phi, vi ch s bnhsthng
t 10
re
t vn
.
gh lc
n 30mmHg. Trong khi th rarip
mao
mch
l .com
Al hlc
o
phi bt tng nh so vi
p
.
v
e ya o trong khoang
o
l
mng tim do hot ng
in n@ ra ca tht tri. Khi
. F 2020
8
0
bnh nhn ht 2vo
0 ip
ty lc mao mch phi bt s
oc p rt thp, thm ch l m
t chnh
t
h
o
tng dn in
P
rg
y
p
giaCh
thng
tnh
mch phi v tht tri.
o
b. Khi chc ht dn lu mng ngoi tim cn xc
nh s gim ca hu ht cc p lc trong thng
tim (nh phi, tht phi tm trng, khoang mng
tim, p lc mao mch phi bt v p lc cui tm
trng ca tht tri).
C. iu tr
1. Nguyn l chung. Khi c chn on p tim th u
tin hng u l cn phi ht dn lu dch mng
ngoi tim. Phng php c th thc hin l chc ht
qua da vi gy t ti ch, phu thut dn lu (m
khoang mng tim di xng c, m ca s mng
tim v ct mng tim gn ton b), nong mng ngoi
tim qua da bng bng. Trong cc trng hp trn
419
dch mng ngoi tim sau m, phu thut dn lu

mng ngoi tim hay c ch nh; cc trng hp
khc vic chc ht qua da l phng php u tin
c la chn vi bc s c kinh nghim, theo di
huyt ng lin tc v c siu m kim tra. Soi lng
ngc di mn tng sng s gip hn ch ti a cc
bin chng ca th thut.
2. iu tr ni khoa: Bao gm bi ph dch, thuc
nng huyt p nu c tt p nh Norepinephrine,
Dobutamine, trnh dng cc thuc gin mch nh
Nitroglycerine, Nitroprusside...
3. iu tr chc dn lu qua da: C th thc hin
ed hn
nhanh chng trong iu kin cp cu, t xmrvln
e
s
re
cc phng php khc v ch cn stschun
b ti
n
h
v
.
g
i om tim v cc
thiu. Bin chng c th gp l chc
ll r o.cvo
A
o
.
mch mu ln, chc vo phi,
h ng cng ph
v phn
loe @ya
n
i
v... C th t dn lu .lin
F tc0 nhng nn trnh trong
8 202
00 idch
cc trng hp b 2dy
ty t hn 1cm, dch khu tr
t otoc
h
hay c nhiurisi
P dnh cht.
g fibrin
y
p
Co ngoi tim bng bng qua da: Ch nn
4. Nong mng
p dng khi c nhiu kinh nghim v cc bnh
nhn ung th gy trn dch mng ngoi tim. Bng
nong c th s dng l bng ngoi bin nh
Mansfield kch c t 18 n 30mm hay bng Inoue.
Sau khi nong c th t dn lu mt thi gian
hon ton ht dch trong khoang mng ngoi tim.
5. Phu thut: Trong cc trng hp trn dch phc
tp, sau m hay ti pht dch th c th ch nh phu
thut dn lu dch mng ngoi tim.
a. M dn lu mng ngoi tim di xng c. C
th thc hin bng gy t ti ch. K thut thc
hin bng cch m mt ng rch nh di
420
xng c nhn thy mng ngoi tim trc tip,

sau s a ng dn lu vo khoang mng tim.
b. M ca s mng ngoi tim. Nhm mc ch to
ra s thng thng gia khoang mng tim v
mng phi tri. Kt qu ngay lp tc l lm gim
bt p lc trong khoang mng tim, hn na do
lm tng din tip xc nn s lm tng s hp thu
dch, t trnh c hin tng ti pht trn
dch mng tim. ng rch thng v tr ca
ngc tri.
c. Ct mng ngoi tim ton b hay gn ton b.
Phu tch mng ngoi tim v tr st tnh mch
ch di gn c honh cho n cc mch
ed mu
erv
ln. Phu thut ny c la chnrestrong
cc
ts vn
h
trng hp trn dch khu tr hay
g trn. dch phi
l ri .com
l
A o
hp vi co tht mng ngoiv.tim.
e yaho
o
l
Fin 0@
8. 202
0
20 ity
Ti liu tham kho
t otoc
h
P
rig effusion.
y
1. Chetcuti S. Pericardial
In: Marso SP, Griffin BP, Topol EJ,
p
Co
2.
3.
4.
5.
eds. Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven, 2000.

Feigenbaum H. Pericardial disease. In:Feigenbaum H, ed.
Echocardiography, 5th ed. Baltimore: Williams & Wilkins, 1994.
Lorell BH, Grossman W. Profiles in constrictive pericarditis,
restrictive cardiomyopathy and cardiac tamponade in cardiac
catheterization. In: Bairn DS, Grossman W, eds. Angiography and
intervention, 5th ed. Baltimore: Williams & Wilkins, 1996:801-822.
Lorell BH. Pericardial diseases. In: Braunwald E, ed. Heart disease:
a textbook of cardiovascular medicine. 5th ed. Philadelphia: WB
Saunders, 1997:1478-1534.
Pericardial heart disease. Curr Probl Cardiol 1988 (Aug);22.
421
6.
7.
Riem A, Scalia G. The pericardium, restrictive cardiomyopathy, and

diastolic flinction. In: Topol EJ, ed. Textbook of cardiovascular
medicine. Philadenphia: LippincottRaven Publishers, 1998:639-707.
SanFillpo AJ, Weyman AE. Pericardial disease. In: Weyman AE, ed.
Principles and practice ofechocardiography, 2nd ed. Philadelphia:
Lea & Febiger, 1994:1102-1134.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
422
vim mng ngoi tim co tht
Vim mng ngoi tim co tht l hu qu ca qu trnh x

ho lm dy ln v dnh ca mng ngoi tim, l hu qu th pht
ca qu trnh vim mn tnh do nhiu nguyn nhn gy ra. Lc
ny qu tim c mt mng ngoi tim c nh cng nhc bao
bc, lm hn ch tim gin ra trong th tm trng, tng cc p
lc trong bung tim v lm mt tng ng gia p lc trong cc
bung tim v p lc ca lng ngc. S tng p lc trong bung
tim v gim s gin th tm trng ca tim lm hn ch s v
ca mu tnh mch ch v phi, gy ra du hiu ca suy tim
huyt ca c tim bn phi v bn tri. Rt nhiu cc trng hp
d
rve c
b b st chn on vim mng ngoi tim co tht v khng
e
s
e
sr n
ngh n nn dn ti hu qu nng n cho bnhhtnhn.
v
.
g
l ri .com
l
I. Nguyn nhn
A o
ev. yaho
o
l
Cc nguyn nhn hay gp gy vim
ngoi tim co tht
@
Fin 0mng
8. 202
c lit k bng di y:
0
y
0
2 tocit
t
h
o
1. Khng r nguyn
nhn
P (idiopathy).
rig
y
p
o
2. Nhim C
trng:
lao, vi khun, virus, nm v k sinh
trng. Trong s lao vn l nguyn nhn hng u
dn n vim mng ngoi tim co tht.
3. Chn thng (bao gm c phu thut tim) trong
cc trng hp phu thut tim c trn mu mng tim
l yu t thun li dn n vim mng ngoi tim co
tht sau ny.
4. Sau chy tia x iu tr. y l bin chng mun ca
x tr liu dn n vim co tht mng ngoi tim,
nhiu khi vi nm sau.
5. Vim nhim/ri lon min dch: thp tim, lupus ban
, sarcoidose.
6. Bnh ung th: v, phi, hch lympho, u sc t, u
trung biu m.
423
II. Triu chng lm sng

A. Triu chng c nng
1. Cc du hiu sm ca vim mng ngoi tim co tht
thng rt khng c hiu nh xu, mt, v gim kh
nng gng sc.
2. Dn dn sau bnh nhn thng c cc biu hin
ca suy tim tri nh kh th khi gng sc v kh th
v m.
3. Giai on nng ln ca bnh s thy cc du hiu
ging nh ca suy tim phi nh ph ngoi bin, cng
tc bng v c chng.
B. Triu chng thc th
d
rvedng
1. Tnh mch c ni, phn hi gan tnh mch
c
e
s
re
ts vnRt nhiu
tnh gp gn nh tt c cc bnh nhn.
h
g
ri coca
m. Kussmaul
l o
cc trng hp c du hiu mch
l
.
. A ahotoo ca tnh mch
evcng
(ht su vo li lm gim
o
l
@y nhng c hiu
in 20cao
Fnhy
c). Du hiu ny c
.
0
8 2
00 itrong
ty
thp do n c th 2gp
cc trng hp ph i
o
t ot c
h
P
g
tht phi v rnhi
mu
c
tim
tht
phi. Nguyn nhn
i
y
p
ca tt c
Co cc hin tng ny l do s gin nhanh ca
tm tht trong thi k u tm trng.
2. Khm tim: thng thy ting tim m do mng ngoi
tim dy. Ting ng van hai l v ba l gn nh xut
hin cui th tm trng, gy ra ting T1 rt nh.
i khi c th nghe ting g ca mng ngoi tim
ngay u tm trng (60 n 120 ms sau ting T2).
Ting ny c ngun gc do s gin ra t ngt ca
tm tht sau mt giai on b mng tim cng hn ch
gin. Cn phn bit ting ny vi cc ting tm
trng sm khc nh ting T3, ting m van hai l.
Thng thng ting g mng ngoi tim c m sc cao
hn v n sm hn ting T3 v ting m van hai l
lun lun i km vi ting rung tm trng.
424
3. Khm phi thng thy gim r ro ph nang hai

y phi, nguyn nhn l do xung huyt phi hay
trn dch nh y mng phi hai bn. Trong trng
hp tr nhiu, c th thy ph phi vi cc ran m
xut hin.
4. Khm bng nhm pht hin cc du hiu ging nh
suy tim phi vi gan to. Trong cc trng hp nng
c th dn n x gan tim vi bng c chng r.
5. Khm ngoi bin pht hin ph hai chi di, sau
c th dn n ph ton thn.
khng nh chn on vim mng ngoi tim co tht th
vn khng c mt xt nghim no c coi l tiuvedchun
er cc xt
vng c. V vy, cn phi kt hp gia lm sngresv
s
t n
nghim cn lm sng.
ighom.v
r
l
l o.c
1. in tm : Kinh in thy
c hdu
o hiu in th
v. A
e
a
o
l
y
thp lan ta. Sng T thng
@ c th thy du hiu
in dt,
. F 2020
dy nh tri v cng 0hay
rung
nh phi hp.
08 tgp
2 oci y
ht Pot
2. Chp tim phi:
rig
y
p
a. Mng
Co ngoi tim canxi ho l du hiu hay gp
trn lm sng. du hiu ny thng thy trn
phim chp nghing v hay thy v tr ca tht
phi v rnh nh tht.
b. Trn dch mng phi cng l du hiu hay gp.
c. Gin nh phi v nh tri c th thy r rng trn
phim chp Xquang.
d. Ph phi l du hiu him thy trn phim.
on v theo di trn dch mng ngoi tim. Ngoi gi
tr chc chn trong chn on, siu m cn gip cho
vic t dn lu mng tim v nh gi s lng dch
cn li trong khoang mng tim. Tuy nhin siu m
425
tim t c gi tr chn on nguyn nhn ca cc

loi dch mng tim khc nhau.
a. Siu m TM cn tm cc du hiu sau:
Thnh t do tht tri dt.
dy ca mng ngoi tim thng tng ln
v c th thy c du hiu vi ho ca mng
ngoi tim (mng ngoi tim dy v sng hn so
vi bnh thng). Tuy nhin vic o b dy
mng ngoi tim mt cch tht chnh xc bng
siu m TM nhiu khi cng gp kh khn.
Lc ny cc phng php chn on hnh nh
khc c nhiu u im hn nh CT Scanner,
MRI, siu m thc qun.
Van ng mch phi m sm. Do tng
dp lc
rve
e
s
cui tm trng ca tht phi dn
re n nh
ts vn
h
hng ti p lc ng mchrphi.
g
i om.
l
l
Vn ng nghch thng
ca.c vch lin nh
v. A ahoo
e
o
trong th tm thu. inl @y
0
. F 2th
02 thy thm mt s du
b. Siu m 2D: cn
08c
y
0
2 it
hiu khc nh:
t otoc
h
P
g
rilin tht
Vch
ny ln trong th tm trng:
y
p
o
C
thy mt ct 4 bung tim t mm.
Gin tnh mch ch di.
Gim gc hp gia nh tri v tht tri. Gc
ny b nhn hn so vi bnh thng do s vn
ng bt thng ca tm tht v tm nh.
c. Siu m Doppler: Siu m TM v 2D cho php
gi vim mng ngoi tim co tht. Tuy nhin cc
du hiu va nu ch c nhy v c hiu
thp. Trong khi siu m Doppler l phng
php cho php nh gi tt nht chc nng tm
trng ca tm tht. C th l:
S thay i theo h hp ca dng chy qua
van hai l v van ba l. Khi bnh nhn ht vo
su, p lc trong lng ngc gim, p lc ny
426
ko theo p lc trong tnh mch phi gim

nhng khng lm thay i p lc tht tri.
Chnh do nguyn nhn ny nn trong giai
on ht vo, tc dng chy qua van hai l
tng ln cn tc dng chy qua van ba l
gim i: Tc sng E qua van hai l tng
ln khong 33%, cn tc qua van ba l li
gim i.
Dng chy trong tnh mch phi gim trong
giai on th ra.
C s thay i theo h hp ca dng chy
trong tnh mch gan.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht APot
rig
opy3
Hnh 24-1. Thay i theo h hp ca dng chy qua van hai l (A),
qua van ba l (B), trong tnh mch phi (C), trong tnh mch trn gan
(D): lc ngng th (trn), khi ht vo (gia) v khi th ra (di),
ngi bnh thng (1), bnh nhn VMNT co tht (2) v bnh c tim
hn ch (3).
427
4. Thng tim: y l phng php quan trng chn

on phn bit vim co tht mng ngoi tim v bnh
c tim hn ch.
a. p lc tm nh: sng nh s c dng ch W, do
sng a chim u th.
b. p lc tm tht:
p lc tht c biu hin b nho-cao
nguyn (dip-plateau), l mt du hiu kinh
in ca vim mng ngoi tim co tht.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
Hnh 24-2. Du hiu b nho cao nguyn biu hin r

hn sau mt nht bp ngoi tm thu.
p lc cui tm trng ca hai tm tht
khng ch tng cao m cn cn bng gia tht
tri v tht phi, chnh p cui tm trng
gia hai tht nh hn 5mmHg vi p lc cui
tm trng tht phi ln hn 1/3 p lc tm
428
thu ca tht phi. y chnh l du hiu kinh

in chn on phn bit gia vim mng
ngoi tim co tht v bnh c tim hn ch.
IV. iu tr
A. iu tr ni khoa
Cc bnh nhn giai on u vi mc kh th
NYHA 1 c th iu tr ni khoa bo tn bng li tiu v
ch n hn ch mui. Ngoi ra iu tr ni khoa cng
c ch nh cc bnh nhn qu nng khng cn ch
nh m hay khng chp nhn nguy c ca cuc m.
B. iu tr phu thut
1. Phu thut ct mng ngoi tim l phu thut c
ed k
la chn. Hn 90% c ci thin triu chngrvng
e
s
re
sau phu thut.
ts vn
h
.
g
2. T l t vong trong v ngay sau m
om i cao (5
l ri tng
l
c
.
A hoo
n 20%) l mt yu t cn
trng cn nhc.
ev. thn
o
l
ya
n
@
i
0 cc phu thut vin
Cng chnh v nguyn .nhn
F 02ny
2 cho cc bnh nhn ch
08 tsm
y
0
thng quyt nh
m
2 oci
t th
h
khng i n
khi
Pot trng bnh nhn b suy sp
g
ri
y
do bnhCdin
op bin ko di.
Ti liu tham kho
1.
2.
3.
4.
5.
Brockington GM, Zebede J, Pandian NG. Constrictive pericarditis.

In: Shabetaj R, ed. Diseases of the pericardium. Cardiol Clin
1990;8(4):6454561.
Fewler N. Constrictive pericarditis: its history and current status.
Clin Cardiol 1995;18:841-B50.
Klein AL, et at. Differentiation of constrictive pericarditis from
restrictive
cardiomyopathy
by
Doppler
transesophageal
echocardiographic measurements of respiratory variations in
pulmonary venous flows. J Am Coll Cardiol 1993;22:1935-1943.
Klein AL, Cohen GI. Doppler echocardiographic assessment of
constrictive pericarditis, cardiac amyloidosis, and cardiac
tamponade. Cleveland Clin J Med 1992;59:27&290.
Oh J, et at. Diagnostic role of Doppler echocardiography in
constrictive pericarditis. J Am Coll Cardiol 1994;23:154-162.
429
6.
Braunwald E, Lorell BH. Pericardial diseases. In: Braunwald E, ed.

Heart disease: a textbook of cardiovascular medicine, 5th ed.
Philadelphia: WBSaunders, 1997:1496-1505.
7. Feigenbaum H. Pericardial disease-constrictive pericarditis. In:
Feigenbaum H, ed. Echocardiography. Baltimore: Williams &
Wilkins, 1994:577-583.
8. Grossman W, Lorell BH. Profiles in constrictive pericarditis,
restrictive cardiomyopathy, and cardiac tamponade. In: Balm DS,
Grossman W, eds. Cardiac catheterization, angiography, and
intervention. Baltimore: Williams & Wilkins, 1996:801-821.
9. Topol EJ, Klein AL, Scalia GM. Diseases of the pericardium,
restrictive cardiomyopathy, and diastolic dysfunction. In: Topol EJ,
ed. Comprehensive cardiovascular medicine. Philadelphia:
10. Reginelli JP, Grady TA. Constrictive pericarditis. In: Marso SP,
Philadelphia: Lippincott-Raven, 2000.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
430
Tm ph mn
Tm ph mn (chronic cor pulmonale) l mt thut ng
m t cc nh hng ca ri lon chc nng phi ln tim phi.
Tng p ng mch phi (TAMP) l cu ni gia ri lon chc
nng phi v tim phi trong tm ph mn (TPM). Do cc ri lon
chc nng phi dn n TAMP nn TPM l mt dng bnh tim
th pht, nh l mt biu hin mun ca nhiu bnh phi v
trong tng trng hp bnh c th th tng hu gnh tht phi l
biu hin chung nht. Tu theo mc v thi gian b m
TAMP s dn n gin tht phi v c hoc khng c ph i
tht phi. Suy tim phi khng phi l yu t cn thit chn
on TPM, nhng suy tim phi l biu hin ph bin ca bnh.
d
rve tim,
Cc du hiu lm sng ca TPM thay i theo cung slng
e
re
cn bng nc in gii v trong hu ht cc trng
ts vnhp l s
h
.
g
thay i trao i kh phi.
l ri .com
l
A hoo
ev. ysau
a suy tim tri, cc
Ri lon chc nng tim phi th
pht
o
l
in 20@
F
bnh l van tim, bnh tim bm sinh
0 khng nm trong nh
8. 2u
y nghn hp l mt nguyn
00 ib
t
2
ngha ca TPM. Tnh mch
phi
toc
ht Pophi
igmch
nhn ca TPM. Bnh tnh
tc nghn thng c xem
r
py
l nm trong bnh cnh
Co TAMP nguyn pht.
I. Nguyn nhn
Gin ph nang v vim ph qun mn tnh l nguyn nhn
ca hn 50% cc trng hp tm ph mn Hoa K. Tn xut
ca TPM rt kh xc nh v TPM khng phi xy ra tt c cc
trng hp b bnh phi mn tnh. Hn na, cc thm khm thc
th v xt nghim thng qui th thng kh xc nh c
TAMP. Tn xut bnh phi tc nghn mn tnh Hoa K
khong 15 triu ngi, l nguyn nhn trc tip ca 70.000 ca t
vong mi nm v gp phn gy t vong 160.000 trng hp
khc. TPM chim t 5-10% bnh tim thc tn. Trong mt
nghin cu ngi ta thy TPM l nguyn nhn ca 20 n 30%
cc trng hp nhp vin.
431
TPM thng gp nht nhng ngi n ng ht thuc l,

tuy nhin t l ny ph n cng ang tng ln, do ph n ht
thuc ngy cng nhiu.
Bng 25-1. Cc nguyn nhn ca TPM phn loi theo c
ch tng p ng mch phi.
1. Co mch do gim xy mu:
a. Vim ph qun mn v kh ph thng, x nang phi.
b. Gim thng kh phi mn.
Bo ph.
Kh th khi ng.
Bnh thn kinh c.
Ri lon chc nng thnh ngc.
c. Bnh m yu mn tnh vng ni (bnh Monge).
d
2. Tc nghn h thng mch mu phi:
rve
e
s
a. Thuyn tc ng mch phi, nhim trng k sinh
re trng,
ts vn
h
tc nghn mch mu phi do u.
g
ri com.
l
l
.
b. Tng p ng mch phi nguyn pht.
v. A ahoo
e
o
l mch
y phi.
c. Bnh tc tnh mch phi / Gin imao
F n020@
.
8 nghn
d. Bnh hng cu hnh lim /00Tc
tu.
2
2 trung
itytht.
c
e. Vim trung tht x ho,

u
o
ht ot
rig do Pbnh h thng:
f. Vim mch mupphi
y
Co mch.
Bnh collagen
Bnh phi do thuc.
Vim hoi t v nt ng mch.
3. Bnh nhu m phi c mt din tch ti mu:
a. Trn kh hnh bng, bnh thiu anpha1 antiproteinase.
b. Gin ph qun lan to, x nang phi.
c. Bnh m k lan to.
Bnh bi phi.
Sarcoid, bnh x phi t pht, chng m bo huyt X.
Lao phi, nhim trng nm mn tnh.
Hi chng suy gim h hp ngi ln.
Bnh collagen mch mu (bnh phi t min).
Vim phi qu mn cm.
432
T nm 1950 - 1964 ti khoa ni bnh vin Bch Mai c

200 trng hp tm ph mn (ng Vn Chung). Bnh TPM
chim 7% bnh phi ti khoa h hp bnh vin Bch Mai (Chu
Vn - 1986).
A. Bnh phi tc nghn mn tnh (COPD)
1. Cc bnh phi tc nghn mn tnh (BPTNMT) gy ra
TPM qua mt vi c ch c tc ng qua li bao
gm: gim thng kh phi, gim xy mu do t l
thng kh/ti mu (V/Q) khng tng ng nhau, v
gim din tch b mt c ti mu.
a. Bnh nhn vi gim xy mu v gim thng kh
ph nang l chnh thng c chng a hng cu,
ph, v sm c biu hin TPM, TPM xanh.
ed
rvth
b. Bnh nhn vi triu chng chnh l kh
khi
e
s
re
s
gng sc thng c gim thnghtkh.vnt hn v
ig vy
om thng c
l rv
gim xy mu lc ngh t hn
l
A hoo.c
.
v
biu hin TPM mun hn,
a hng.
oe TPM
inl 20@y
F
2. Mt vi s khc bit 0gia
8. TPM
20 xanh v TPM hng c
y
0
t
2
i
th lin quan n
c thc thng kh phi. Bnh
t cch
oto
ighkh Pphi
nhn c thng
thp c v thch ng vi loi
r
py
o
C
TPM xanh, trong khi loi TPM hng vn gi c pH
v nng kh mu ng mch bnh thng. Mt gi
thit khc l nhng ngi b TPM xanh thng do
vim ph qun v nhm TPM hng thng do gin
ph nang n thun hn.
3. Khm thc th tt c cc th BPTNMT u thy
tng ng knh lng ngc, c honh h thp, g
vang, r ro ph nang gim vi m th kh kh th
th ra, ting tim nghe m, tnh mch c ni trong th
th ra v gan to. Gan to v ph chn l du hiu
ng dch v suy tim phi.
4. Xquang lng ngc c th thy cc c im ca kh
ph thng nh hai trng phi sng, tng ng knh
trc sau ca lng ngc v cc c honh nm phng
433
5. Thm d chc nng phi cho thy tng th tch cn

(RV) v dung tch phi ton phn (TLC); gim mnh
dung tch sng (VC) v kh gim cc t l lu lng
th ra (FEV1, FEF).
6. Xt nghim v kh mu ng mch thng l bnh
thng nhng trng hp bnh nh v i vi
nhng trng hp nng th PaO2 gim, PaCO2 tng v
pH gim. Cc bnh nhn TPM thng c PaO2 thp
di 55 mmHg. T l V/Q khng tng xng v
gim thng kh ph nang, c hai gp phn lm gim
xy mu. PaO2 lc ngh khong 45 mmHgerchng
ved t
s
re
gim thng kh ph nang r.
ts vn
h
.
g
i omkhi
7. Hen l mt dng BPTNMT nhng
dn n
l rhim
l
c
.
A hoo
.
v
TPM, c l do hen thng
loe chyal bnh tc nghn
ng h hp tng lc.8. Fin020@
0 ty2
20 oc
i
8. TPM trong BPTNMT
t ot c lin quan n mc nng

h
P
g
i
ca ri lonyrchc
nng phi v TAMP l biu hin
p
o
C
ca bnh. Hn ch kh nng gng sc trong
BPTNMT thng do hn ch kh nng thng kh phi
m khng lin quan n d tr tim mc d cc bnh
nhn ngi nhiu l t th lm gim kh nng gng
sc. Khng c mt thm d n c no v phi nh
o cc dung tch v th tch chc nng ca phi, kh
nng khuych tn CO (DL CO), cc nng kh mu
hay Xquang phi l c gi tr d bo nhiu v TPM v
nhng bt thng nh gim din tch b mt trao i
kh v co mch do gim xy t chc xy ra c lp
vi p lc ng mch phi.
B. Bnh m k phi lan to
1. Bnh nhn thng kh th, th nhanh, khng c kh
nng gng sc v i khi c ngn tay, chn hnh di
434
2.
3.
4.
5.
trng. Nghe phi thng c ran m, ran n v c th

nghe thy c trong th ht vo.
Phim Xquang phi thng c cc tn thng nh
mng ph huyt qun m, tn thng dng li-nt
hoc x ho lan to. Cc du hiu ny khng phi lc
no cng c m s xut hin lin quan cht ch vi
cc tn thng sinh l phi. Trong mt s bnh nh
vim phi k bc vy, chng ta c th thy hnh ph
nang y cng vi hnh ph qun y kh.
Sinh thit phi l cn thit xc nh nguyn nhn
chnh xc ca bnh, nhng khng phi lc no sinh
thit cng em li kt qu ng. Sinh thit phi qua
ph qun c th chn on c mt s bnh m k
ed c
phi nh bnh sacoide v ra ph qun phervnang
s
re
th a ra chn on trong nhiu trngtshp.
h
vn
g
ri cthy
m. tnh trng
Cc xt nghim chc nng phillcho
o
oo. gim n
. A ahphi,
vtch
tc nghn phi vi gim dung
e
o
l @y
Fin020khuych
hi phi v gim kh8. nng
tn kh cc
2
0
y
0
ng th khng tc
Dung tch sng gim, v
t
2 nghn.
oci
ht ra
t l th tchrigth
Potti a trong mt giy vi dung
py
tch sng
Co ti a thng di 80%. Lc u, PaO2
gim khi gng sc nhng vn gi c mc bnh
thng lc ngh bng cch tng thng kh. Khi bnh
tin trin nng hn, PaO2 s thp trong c lc ngh.
Tin trin v tin lng bnh m k phi ph thuc
vo cn nguyn bnh v nhiu yu t khc ca bnh.
Biu hin ca TPM trong cc bnh m k phi
thng l cc ri lon chc nng phi mc nng
hn, c l c lin quan n mch mu (nh lupus ban
h thng) v TPM cng c th khng xy ra ngay
c khi bnh giai on cui.
435
C. Cc hi chng gim thng kh

1. Mt s d tt (nh g vo ct sng) c th lm suy
gim v hn ch thng kh phi dn n gim thng
kh chung ca ph nang v gim xy ph nang.
2. Bo ph nhiu c th c thng kh phi km, tm, a
hng cu v bun ng (khng c s tht nght phi)
thng c gi l Hi chng Pickwick. Bnh nhn
bun ng ngy, au u vo bui sng, ri lon v
nhn cch c nhn v c nhng giai on kh th
trong khi ng kt hp vi mt ng, ngy to, gim xy
mu v tng CO2 mu do tc nghn ng h hp
trn (do li, a-mi-an to hoc sp thnh kh qun).
3. Mt s bt thng v no nh bt thng Arnold d
rvehp v
Chiari cng c th lm suy gim trung tmsh
e
re
gim thng kh phi nguyn pht. Cchbnh
ts vnthn kinh
.
g
c nh hi chng sau vim tu
om hi chng
l rixm,
l
c
.
A hoo
Guillain-Barre mn tnh cloth
ev. dn
a n TPM v suy
in 20@y
F
tim phi.
.
08 ty20
0
2
i
4. Chn on gimt thng
toc kh c xc nh qua phn
h
o
P
g
tch kh mu,
rip ng thng kh gim sau th nghim
py
o
C
ht CO2, cc thm d v gim thng kh phi hoc cc
thm d v gic ng. Ri lon thng kh trong khi
ng l mt biu hin kh thng gp nhiu hi
chng gim thng kh.
5. Trong tt c cc trng hp gim thng kh, nguyn
nhn chnh lm tng p lc ng mch phi l co
mch do gim xy t chc, mt p ng ca cc tiu
ng mch phi i vi gim xy ph nang. Tnh
trng toan h hp, i km vi gim thng kh, c th
lm tng p ng co mch i vi gim xy t chc.
D. Cc bnh mch mu phi
1. Tm ph mn l hu qu ca mt vi bnh mch mu
phi. Tng p ng mch phi tin pht v thuyn tc
ng mch phi l nhng bnh cnh hay gp.
436
2. Bnh t bo hnh lim, do c hemoglobin SS hoc SC,

c th gy ra tm ph mn sau mt thi gian di b
nhi mu phi nh, khu tr v thuyn tc ng mch
phi do m hay huyt khi.
3. Tc tnh mch phi l bnh him gp, thng c tng
p ng mch phi v thm nhim phi nhiu ni,
p ng tt vi iu tr bng thuc gim min dch.
4. X gan thng c km vi gin cc mch mu phi.
5. Nhim HIV cng l nguyn nhn gy bnh mch
mu phi, ging vi TAMP tin pht.
6. Bnh collagen mch mu c th dn n TPM do
vim mch tin pht cng nh do x ho t chc k
lan to. Bnh x cng b, lupus ban h thng v
vim khp dng thp l cc bnh collagen mch mu
thng gy ra vim tiu ng mch phi nht. Bnh
d khp
nhn b lupus ban h thng hoc b vim
rve
e
s
dng thp thng c bnh phi k tin pht.
re
ts vn
h
.
g
II. Sinh l bnh
l ri .com
l
oo
. A lc
ng mch phi c lu lng cao,
evp
ah dng chy thp,
o
l
y
in 20@ cp mu cho trao i
sc cn mch mu thp vi chc nng
. F 2cung
0
8
0
kh v c 3 c im: (1) thnh
y vi trng lc c lc ngh
0 mng
t
2
i
oc s iu chnh nh vn mch
t otc
thp, (2) ngi ln, lcghngh
P
i
r
phi nh h thng othn
py kinh t ng, (3) c nhiu tiu ng
C
mch v mao mch ph nang khng tham gia vn chuyn mu
lc ngh v c th hot ng li khi cn thit m rng mng
li mao mch phi v nh vy lm gim sc cn mch mu
phi. Bnh thng, p lc ng mch phi trung bnh khong 12
- 17 mmHg, khi p lc ng mch phi lc ngh ln hn 20
mmHg th cn phi ngh ti c tng p ng mch phi. Sc cn
ca h mch mu phi tng v TAMP l nhng c ch bnh
sinh chnh trong tt c cc trng hp TPM.
A. C ch tng p ng mch phi
1. Suy h hp tng phn gy thiu xy mu, thiu xy
t chc, lm co tht cc tiu ng mch phi v t
dn n tng p lc ng mch phi. Nguyn nhn
quan trng nht gy co cc tiu ng mch phi l
thiu xy cc ph nang. C ch co mch do thiu
xy t chc cn cha c r. Ngi ta cho l c th
437
2. Mc co mch do gim xy t chc ph thuc ch

yu vo PaO2 ph nang v khi PaO2 ph nang < 55
mmHg th p lc ng mch phi tng rt nhanh. Khi
p lc ng mch phi ln hn 40 mmHg th bo
ho xy ng mch c th thp hn 75%.
3. Suy h hp ton b s lm tr CO2 v gy toan h
hp. Toan mu lm co tht cc tnh mch phi v
phi hp vi co tht tiu ng mch phi do thiu
xy t chc s lm tng p lc ng mch phi.
d
rve
e
s
re
ts vn
h
.
g
Suy h hp
Suy h hp tng phn
om phn
l ri .ctng
l
A o
ev. yaho
o
l
Fin 0@
8. 202
0
Thiu xy mu
Tng CO2
20 ity
t otoc
h
P
g
ri
py
Co
Suy h hp
Thiu xy t chc
Toan mu
Co tht tiu ng mch phi
Co tht tiu tnh mch phi
Tng p ng mch phi
Ph i tht phi
Suy tim phi
Hnh 25-1. S v c ch tng p lc ng mch phi v suy

tim phi trong TPM.
438
4. Mt s c ch khc lm tng p lc ng mch phi

nh tng lu lng tim do tng chuyn ho, hot
ng gng sc, nhim khun phi cp tnh...; Tng
qunh ca mu: a hng cu th pht; Nhp tim
nhanh do thiu xy hoc do suy tim...
B. C ch gy suy tim: Tng p lc ng mch phi l
tr lc chnh lm tng cng ca tim phi. Tnh trng
thiu xy, tng th tch, tng cung lng tim cng gp
phn lm tng cng ca tim. Tng cng ca tim ko di
lm ph i tht phi, sau gin tht phi v cui cng
l suy tim phi.
A. Triu chng c nng
d
rve
e
s
1. Biu hin lm sng ca tm ph mn thng
b che
re
ts vn
h
.
g
du bi cc triu chng ca bnh phi
i othc
m th c
ll r mc
.c nng ca
A
o
sn. Cn phi xc nh loi bnh
v
o
.
ah
oev yxt
lxem
cc bnh phi sau mi
bnh nhn c b
n
@
i
F 20
tm ph mn khng.008. y20
2 cit
ht Pcotonhng t ph chn, au ngc
2. Bnh nhn cigth
r
py
khng in
Co hnh, kh th khi gng sc, tm ngoi vi
lin quan n gng sc.
a. au ngc c th do lng ngc b cng phng (au
c xng) hoc c th lin quan n thiu mu c
tim tht phi.
b. Ho v cm gic d b mt mi l cc triu chng
ph bin.
c. Mt s bnh nhn c biu hin gim thng kh
ban m, kh th khi ng v c th c thay i
nhn cch c nhn, tng huyt p nh v au u.
d. Th ngn l triu chng lun c cc bnh nhn
tm ph mn. Cn phi xem xt mc hot
ng no lm cho bnh nhn kh th v bnh
nhn thng gim hot ng trnh kh th.
439
e. i khi c au tc vng bng do mu gan.

B. Triu chng thc th
1. Hai phi cng phng c tnh cht mn tnh nn lng
ngc thng bin dng hnh thng v g vng
ngc hai bn u thy rt vang. Ting tim thng hi
m do hin tng gin ph nang ca phi.
2. Cc du hiu sm nht l cc du hiu c lin quan
n tng p lc ng mch phi ko di.
a. Du hiu nhy nht ca tng p ng mch phi
l thnh phn phi ca ting T2 vang mnh, c th
nghe c v tr van ng mch phi v
vng tht phi trn xng c.
b. Khi p lc ng mch phi tng rt cao, cedth c
rv
ting thi tm trng van ng mch
ese phi v
r
ts vphi
ting thi tm thu van ba l ido
. n v h
gh h
r
m
o
l
lth .nghe
c
van ba l, ng thi cng c
thy ting
v. A ahoo
e
o
l nga
tng mu tm thu v ting
y phi T3 tht phi.
Fin020@
.
3. Khi c suy tim phi
2 nhn thng c tim to,
08 bnh
20 ocity
tnh mch c ni,

ht Pgan
ot to v ph ngoi bin. Du
rig c ni
hiu tnh omch
c trong th ht vo v th ra l
y
p
C
du hiu ch im chc chn c suy tim phi. Trong
cc trng hp suy tim phi nng, bnh nhn c th
c ph ton thn v trn dch c mng phi, mng
tim, c chng
4. Cc u chi c th m do gin mch ngoi bin v
tng CO2 mu; hoc cng c th tm do lu lng
mu thp hoc gim xy mu.
5. Nhng bnh nhn c TPM lu c th b tm en nh
ngi en, mt li v do tng sinh ca cc mch
mu mng tip hp trng nh mt ch v thng c
ngn tay, ngn chn di trng.
A. in tm
440
1. in tm ca bnh nhn TPM b nh hng bi

nhiu yu t nh p lc ng mch phi, s quay v
thay i v tr ca tim do hai phi cng phng, thay
i kh mu ng mch, thiu mu c tim v cc ri
lon chuyn ho. V vy gi tr ca in tm trong
chn on bnh tm ph mn cn ph thuc vo bnh
phi nn v cc bin chng ca n.
2. Hnh thi ph i tht phi thng gp nhng
trng hp c tc hp h mch mu phi. Hai phn
ba bnh nhn b bnh phi tc nghn mn tnh c ph
i tht phi khi m t thi nhng trn in tm li
khng c hnh nh ca tht phi ph i. Khi khng
c hnh nh ph i tht phi in hnh th vic chn
on phi da vo mt lot cc du hiu invetm
d
r
e
s
nh rS V5, V6; qR aVR; v P ph.reSng P cao
hts .Bloc
vn nhnh
nhn DII v aVF chng t dy nhrigphi.
m
o
l
l .c
phi gp 15% bnh nhn TPM.
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
y
p
Co
Hnh 25-2. in tm ca mt bnh nhn b TPM.

3. Ri lon nhp khng phi lun c bnh nhn TPM
khng bin chng, nhng khi c ri lon nhp th hu
441
nh l ri lon nhp trn tht v chng t c bt

thng v kh mu, h kali mu hoc dng qu liu
cc thuc nh Digitalis, Theophyllin v cc thuc
kch thch giao cm. Cn tim nhanh nh a
thng gp bnh nhn b bnh phi tc nghn mn
tnh v iu tr tt nht l kim sot bnh phi nn
hn l dng cc thuc chng lon nhp. Bnh nhn
TPM khi ri lon nhp tht thng c tin lng
xu v t l t vong cao.
B. Xquang tim phi
1. Phn ln cc bnh gy ra TPM u c hnh nh hai
trng phi sng hn bnh thng trn phim Xquang
lng ngc v v vy vic chn on tng p ng
mch phi trn phim s gp kh khn hn. erved
res
tsvi
2. Tht phi gin c th kh xc nh c
h
.vnbng tim
ig okh
r
m
l
trn phim thng nm thng ng
do
ph thng
Al hoo.c
.
v
e th
v so snh vi cc phim cloc
a gip ch cho vic
n 0@y
inhn
F
chn on. Hu ht bnh
TPM
u c tht phi
2
8. 20
0
y
0
v ng mch phi
2ginitto, nhng tng p ng mch
t otoc
h
P gin tht phi.
g
phi thng rc
trc
i
y
p
o
3. Mt chCim
v tng p ng mch phi l o ng
knh ca ng mch phi phi v tri. ng mch
phi phi gin khi c ng knh ngang > 16mm v
i vi ng mch phi tri l > 18mm. Du hiu ny
gp 43 - 46% bnh nhn bit c tng p ng
mch phi, nhng nhy v c hiu tht s ca
php o ny vn cha c xc nh.
C. Siu m tim: rt hu ch bnh nhn b TPM.
1. Siu m tim kiu TM cho php xc nh tht phi
gin v cng c th xc nh c tng p ng mch
phi qua hnh thi vn ng ca van ng mch phi
(mt sng a).
2. Siu m tim 2 bnh din c th nhn thy c ton
b bung tht phi, o c dy thnh tht cng
442
nh xc nh c nhng thay i ca vch lin tht

do ph i tht phi. V tht phi c hnh dng khng
i xng nn vic o th tch tht phi rt kh. Tng
gnh p lc tht phi thng c xc nh bng ph
i thnh trc tht phi v bung tht phi gin.
Trng hp TPM nng c th thy ph i vch lin
tht v di ng nghch thng ca vch vo tht tri.
Tng gnh th tch tht phi thng lm gin bung
tht v c vch lin tht di ng nghch thng.
3. Siu m Doppler tim: l phng php thm d
huyt ng khng chy mu tin dng xc nh
tng p ng mch phi v cung lng tim. Phng
php ny kh chun xc khi p lc ng mch phi >
30mmHg v km chun xc hn i vi p lc
d ng
rve
e
s
mch phi thp hn mc ny. Siu m Doppler
cng
re
ts mt
n tr liu
h
v
hu ch theo di hiu qu lu di
ca
.
g
i
ll r o.com
bng thuc.
A
o
.
h
v
loe @ya
n
i
D. Thng tim phi
0
F
8. 202
0
y
0
1. Thng tim phi ch
2 c
it gi tr xc nh p lc
t otoc
h
P
g
ng mch phi,
p
lc
ng mch phi bt v cung
ri
y
p
lng tim.
Co Bnh nhn TPM c p lc ng mch phi
trung bnh cao hn nhiu so vi p lc ng mch
phi bt, khng ging vi suy tim tri hay hp van hai
l ch c s chnh lch nh gia p lc ng mch
phi trung bnh v p lc phi bt.
2. p lc ng mch phi trung bnh rt cao trong
cc trng hp bnh mch mu phi tc nghn nhng
ch tng nh cc bnh m phi k. Trong giai on
u ca bnh TPM, p lc ng mch phi ch t 25 30mmHg v khi c suy tim phi thng tng trn
40mmHg.
E. Kh mu ng mch
1. Giai on u: suy h hp tng phn, p sut xy
mu ng mch (PaO2) thng gim, nht l khi
443
2. Giai on suy h hp ton b: PaO2 gim nhiu <

70mmHg; PaCO2 tng cao 50 - 80mmHg; SaO2 gim
<75%; pH gim di 7,2.
F. Cng thc mu: thng thy biu hin ca a hng
cu v tng hematocrit.
V. Chn on
A. Chn on xc nh TPM da vo:
1. Tin s mc bnh phi mn tnh hoc bnh ca h
d
thng c xng lng ngc.
rve
e
s
re
ts vn
2. Hi chng suy tim phi.
h
g
ri com.
l
l
. tng gnh tht
3. in tm : P ph, dy tht. Aphi,
v ahoo
e
o
l
y
phi.
Fin020@
.
08 ty2 bng tim to, cung ng
4. Phim Xquang lng
20 ngc:
i
t ng
toc mch phi phi, tri gin.
mch phi ni,ghcc
o
P
ri
py
5. Thm d
Co huyt ng (siu m tim hoc thng tim
phi): p lc ng mch phi tng.
B. Chn on phn bit
1. Suy tim ton b do bnh van tim mc phi (hp van
hai l), bnh tim bm sinh, bnh c tim.
2. Suy tim do suy vnh, nhi mu c tim : cn au tht
ngc in hnh, bin i on ST -T v cc men tim
tng.
3. Hi chng Pick: Vim mng ngoi tim co tht.
4. Tim ngi gi: ngi ln tui, khng c tin s b
bnh phi mn tnh.
444
C. Chn on giai on
1. Giai on sm: Ch c bnh phi mn tnh vi
nhng t suy h hp kch pht, cha c tng p
ng mch phi, cn pht hin sm phng.
2. Giai on tng p ng mch phi: Thng lm
sng khng th pht hin c, thm d bng thng
tim phi hoc siu m Doppler tim th c tng p
ng mch phi, c th iu tr tt v tr v n nh.
3. Giai on suy tim phi cn hi phc: c biu hin
tng p ng mch phi v suy tim phi, iu tr c
kt qu.
4. Giai on suy tim phi khng hi phc: iu tr
khng c kt qu.
d
rve
e
s
re
VI. Tin trin v tin lng
ts vn
h
.
g
Bnh phi mn tnh tin trin t t, chm
om dn lm
l ri .cchp,
l
oo n suy gim
v. A ahdn
tn thng n chc nng h hp caloephi
y
@ nng phi ton b
Fin020chc
chc nng phi tng phn, ri suy
8. gim
2
0
v cui cng l tng p ng mch
ty ri suy tim phi.
20 iphi,
t otoc
h
P thuc vo ngi bnh c c
S tin trin caybnh
rig ph
p
pht hin bnh sm,
Coc iu tr v theo di thng xuyn hay
khng. Nhn chung, nhng bnh phi mn tnh gy suy tim phi
c tin trin nhanh nu nhng t kch pht xy ra nhiu ln.
Ngc li, khi bnh nhn c theo di v iu tr tt th c th
n nh c t 5 n 20 nm v hn na.
Tin lng bnh ph thuc ch yu vo vic kim sot
bnh phi nn hn l iu tr tng p ng mch phi. Trong
nhm bnh phi tc nghn, vim ph qun mn tnh tin trin
nhanh hn, bnh hen ph qun tin trin chm hn nht l th
hen d ng. Trong nhm bnh phi hn ch c bit l cc bnh
c lin quan n tnh cht c hc ca h hp nh g vo, d dng
lng ngc nu khng b bi nhim phi th c th sng lu m
khng c biu hin TPM. Bnh tc mch mu phi tin lng
xu hn.
445
VII. iu tr
A. xy liu php
1. Rt quan trng, c th cho th xy bng ng thng
qua mi, bng xy, th xy trong vng kn. xy nn
dn qua bnh nc lm m, khng cho th xy
100% trong trng hp suy h hp ton b c tng
CO2 v nh vy d c ch trung tm h hp. S tng
p lc xy trong mu ci thin tnh trng thiu xy t
chc s lm gim p lc ng mch phi.
2. Cc nghin cu ln ti Anh v Hoa K u cho thy
dng xy liu php liu thp (1 -2 lt/pht), ko di
(12 - 24 gi/ngy, trong vi thng n nhiu nm)
lm ci thin r t l sng cn bnh nhn tm
ph
ed
v
r
e
mn. c bit dng xy liu php lin tcesc th lm
r
ts vn
gim t l t vong r hn dng xyghliu
php ngt
i om.
r
l
qung vo ban m.
l .c
v. A ahoo
e
o
l thiny chc nng tm thn
3. xy liu php cng lm ci
Fin020@
.
8 v s ci thin ny thng
kinh ca bnh nhn TPM
00 ity2
2 tocdng
c c sau mthtthng
xy.
Po
ig
r
4. V sao xy
py liu php lm ci thin tnh trng sng
Co
cn ca bnh nhn TPM n nay vn cha c r.
C hai gi thit chnh: (1) xy lm gim tnh trng
co mch phi, gim sc cn mch mu phi v vy
chc nng tht phi c ci thin v th tch tng
mu tht phi tng; (2) xy liu php lm ci thin
nng xy mu ng mch nn cung cp tt xy
cho cc c quan sng cn nh no, tim, gan, thn...
5. Liu php xy ko di c khuyn co cc bnh
nhn TPM c PaO2 lc ngh di 55mmHg v
c iu tr n nh trong 3 tun vi cc thuc nh
thuc gin ph qun, khng sinh, li tiu... Bnh nhn
c PaO2 lc ngh ln hn 55mmHg th cn phi xem
xt cn nhc khi dng xy liu php ko di v ch
dng khi bnh nhn c a hng cu hoc c cc du
446
6. xy liu php ko di ban m c vai tr quan trng

cc bnh nhn c ri lon bo ho xy mu khi
ng. Bnh nhn gim bo ho xy khi gng sc
ch cn cung cp b sung xy khi gng sc v hiu
qu ca liu php xy ko di cha c chng minh
trong trng hp ny.
B. Thuc li tiu v tr tim
1. Thuc li tiu loi c ch men anhydrase carbonic
nh Diamox, hoc li tiu nh Aldacton t ra dc ch
rve
bnh nhn TPM, liu 10 mg/kg cn nng
ese cho tng
r
ts tiu khi pH
t 3-4 ngy. Khng nn dng thuc hli
g m.vn
i
r
o
l
mu < 7,30.
Al hoo.c
.
v
a
oe
2. Thuc tr tim nhm Digitalis:
inl 20@y Tc dng ca cc
F
0 phi rt phc tp. Cc
thuc ny ln chc nng
8. tht
00 ity2
2
thuc Digitalis lm
oc kh nng co bp ca c tim
t otng
P t cng lm tng co tht mch
igh thi
phi nhngyrng
p
Co lm gim s tr v ca mu tnh mch
mu phi,
ngoi bin do lm tng th tch d tr ca tnh mch
v v vy c th nh hng n cung lng tim.
a. Ch nn dng tr tim nhm Digitalis bnh nhn
TPM khi c suy tim tri ng thi. Mathur v
cng s theo di tc dng ca Digoxin liu
0,25mg/ ngy cc bnh nhn TPM trong 8 tun
th nhn thy Digoxin khng lm ci thin phn
s tng mu tht phi khi phn s tng mu tht
tri bnh thng; ch cc bnh nhn c phn s
tng mu tht tri gim t u th Digoxin c lm
ci thin phn s tng mu tht phi. S dng
thuc tr tim phi rt thn trng, Digitalis c th
gy ri lon nhp tim, ch nn s dng khi suy tim
cn b tr v liu nh.
447
b. Khng dng khi suy tim mt b. Thuc li tiu v

Digitalis trong trng hp ny khng quan trng
bng cc bin php ci thin thng kh ph nang
nh xy liu php. Mc d cc thuc tr tim
nhm Digitalis khng phi l thuc iu tr thng
thng ca bnh tm ph mn, nhng mt nghin
cu cho thy dng Digoxin ng tnh mch
trong nhng t suy h hp cp bnh nhn TPM
c th lm tng sc cng ca c honh v tng
cung lng tim.
3. Cc thuc gin ph qun:
a. Theophylline: y l thuc c tc dng lm gin
ph qun c s dng nhiu nht. Tuy nhin,
Theophylline c tc dng lm gim khrvth
ed ch
e
s
yu nhng bnh nhn b bnh ng
re th tc
ts vn
h
. mch c
g
nghn. Aminophylline dng ng
tnh
l ri .com
l
Ang
o mch phi v
th lm gim nhanh p lc
ev. yaho
o
l
lm tng phn s tng
0@ ca c tht phi v
Fin mu
8. 202 ko di bnh nhn
tht tri. Ung Theophylline
0
20 ocity
TPM cng hc
dng tt ln chc nng tht
t tc
Pot
g
ringhin
phi. oC
cu
cho thy bnh nhn dng
y
p
C
Theophylline trong 4 thng lm ci thin r
phn s tng mu tht phi. Phn s tng mu
tht tri cng tng ln r. Cc nghin cu in vivo
cho thy Theophylline v Aminophylline u lm
gim hu gnh (do lm gim sc cn mch mu
phi v mch mu h thng) v lm tng sc co
c tim, v vy, mt tr liu Theophylline ko di
c th lm tng r chc nng bm mu ca hai
tht. Tuy nhin, Theophylline khng lm gim
hin tng co mch mu phi do thiu xy t
chc.
b. Cc thuc kch thch th th -adrenergic nh
Salbutamol, Terbutaline, Pirbuterol c s dng
nh thuc lm gin ph qun v c tc dng tt
448
4. Cc thuc gin mch:

a. Rt kh khn khi nh gi tc dng ca cc thuc
gin mch trong iu tr TPM v nhng rthay
ved i
e
s
huyt ng trong iu tr rt phc tp.
re Mc ch
ts vn
h
g
ca vic dng cc thuc gin mch
l. lm gim
l ri .com
l
A tng
o
p lc ng mch phi vang
cao bnh
e . yaho
o
l
nhn TPM. Gin mch
0@ gim sc cn ca
Fin lm
8. li20l2 cung lng tim tng v
mch mu nhng00b
ty
2 lc
oci ng mch phi khng thay
cui cng l
t p
t
h
o
P
rig gin
i. C
th
mch l tc dng c li (v lm
y
p
o
C
tng s vn chuyn xy) mc d tng p ng
mch phi khng h bt. Cc thuc lm gim s
tr v ca mu tnh mch (nhm Nitrate) hoc
cc thuc lm gim chc nng tht phi
(Nifedipine) c th lm gim bt tng p ng
mch phi do lm gim cung lng tim. Cc
nghin cu theo di ko di cho thy cn thit
phi nh gi cc p ng v mt huyt ng khi
dng cc thuc gin mch v cn nh gi tc
dng ln t l sng cn ca tng loi thuc khc
nhau.
b. Dng cc thuc gin mch c th c tc dng ph
nh h huyt p v gim bo ho xy mu
ng mch. Phn ln cc thuc gin mch c tc
449
dng mnh ln mch mu h thng hn l mch

mu phi. cc bnh nhn c tng p ng mch
phi nhiu v cung lng tim bn phi gim th
co mch h thng nh l mt c ch bo v chnh
duy tr huyt p ng mch h thng. cc
bnh nhn ny, gin mch mu h thng chn lc
c th lm gim huyt p v khi u cho vng
xon bnh l ca suy tht phi (do gim lu
lng mch vnh phi) v tru mch. Cc thuc
gin mch cng c th lm gim xy mu ng
mch do trng lc mch mu phi b ph v lm
mt cn bng thng kh - ti mu ca phi.
c. Kt qu nghin cu iu tr TPM vi cc thuc
gin mch ny u khng c kt lun r rng
v
ved
khng c mt thuc no trong ccrethuc
trn
ser
ts vtrong
c khuyn co s dng thng
thc
. n
ghquy
i
r
m
o
l
l
c
hnh lm sng. Cc nitrate. c
v
c
tc
dng
tt
.
A hoo
v
e
a
o
nhng thc cht u khng
l @yc vai tr r rng v
0 ng mch v lm
Fin02mu
.
lm gim nng
xy
08 ty2
0
2 oci
gim c ch s
t tim.
h
Pot cc thuc gin mch cn phi
g
i
rTPM
d. iu tr
vi
y
op
xemCxt v cn nhc k v ch dng khi cc iu
tr thng quy v xy liu php khng lm ci
thin tnh trng suy tim phi v tng p ng
mch phi. V cc thuc ny c nhiu tc dng
ph nn hiu qu ca chng v mt huyt ng v
vn chuyn xy cn c nh gi cn thn,
thng sau 4 - 5 thng iu tr v tt nht l nh
gi qua thng tim phi.
5. Khng sinh: Vai tr khng sinh trong iu tr t bi
nhim rt quan trng. Thuc khng sinh nn dng
loi c ph khng khun rng, dng ko di v liu
lng cao trong 2-3 tun (tim, ung, kh dung).
Nhiu tc gi ch trng dng khng sinh ngoi t
bi nhim phng nht l cho ung khng sinh
450
vo nhng thng ma lnh (mi t ung 10 ngy

trong 3 thng).
6. Corticoid: C hiu qu trong iu tr t cp: dng
Prednisolon ung, Hydrocortison kh dung,
Depersolon hay Solu-Medron tim tnh mch.
Corticoid va c tc dng chng vim, chng d ng
v lm gim tit dch.
7. Chch mu: t dng, ch nh khi hematocrit ln hn
65%. Ly khong 300ml mu mi ln. Sau chch
mu, p lc ng mch phi trung bnh v sc cn
mch mu phi thng gim, cung lng tim thay
i khng ng k, s vn chuyn xy gim nhiu v
s tiu th xy lc ngh c th tng nh hoc khng
ed kh
thay i. Chch mu c tc dng r rt iervvi
s
e
nng gng sc ca bnh nhn TPM. tNhiu
s r n nghin
h
v
.
g
cu cho thy kh nng gng sc, lthi
ri cogian
m gng sc
l
.
A hotng
o
v mc tiu th xy ti a
ln ng k
ev. u
a
o
l
y
@
sau khi chch mu ccFbnh
TPM c a huyt
in 20nhn
. 20
08 tgim
cu. Chch mu 20lm
hematocrit cn khong
iy
ocv
t tt
t
50% c tc dng
mt
huyt ng trong thi
h
o
P
ig
r
y
gian ngn,
p nht l khi c gng sc. Tuy nhin, tc
Co
dng lu di ca vic chch mu lp li nhiu ln vn
cha c xc nh.
8. Ch d n ung v ngh ngi: Nhng ngi b bnh
phi mn tnh khi xut hin kh th th nn lm
vic nh, khng phi gng sc. Khi c du hiu
suy tim phi th phi ngh vic hon ton. n t mui.
9. Khng dng cc thuc sau: Morphin, gardenal v
cc thuc an thn khc khng c dng cho cc
bnh nhn TPM v s gy suy trung tm h hp.
10. Tp th: Rt quan trng, lm tng gin n ca
phi v lng ngc, tng thng kh ph nang, nht l
tp th bng c honh.
11. Loi b cc yu t kch thch: Thuc lo, thuc l...
451
C. iu tr tm ph mn mt s th c bit
1. Tm ph mn bnh nhn hen ph qun: cho
Hemisucinat Hydrocortison, Depersolon tim tnh
mch.
2. Bnh nhn x phi thng khng c tr CO2, nn
ch cn cho th xy rng ri v cho corticoid.
3. Ngi bo bu: cho n ch lm gim cn.
4. Ngi g vo ct sng d dng lng ngc: tp th,
chng bi nhim phi l rt quan trng, c th cho
iu tr chnh hnh t sm.
5. Do tc mch phi: ngh ngi tuyt i, n ch
khng mui, dng thuc chng ng, tr tim
digitalis, th xy. Phu thut ly cc mu rng
ved tc
e
s
ng mch phi ln.
re
ts vn
h
.
g
Ti liu tham kho
l ri .com
l
. A ahoo of Cardiovascular
1. Marso SP, Griffin BP, Topol EJ, eds.
evManual
o
l
y
Medicine. Philadelphia: Lippincott-Raven,
Fin020@2000.
.
2. Topol E, ed. Textbook of 0cardiovascular
medicine. Philadelphia:
08 ty2
Lippincott-Raven, 1997.t 2 toci
h Po pulmonary hypertension. New York:
3. Rubin LJ, Rich S, eds.
rig Primary
y
p
Marcel Dekker;
Co1997.
4.
5.
6.
7.
8.
9.
Jaffe CC, Weltin G. Echocardiography of the right side of the heart.

Cardiol Clin 1992; 10:4157.
Shure D. Chronic thromboembolic pulmonary hypertension:
Diagnosis and treatment. Semin Respir Crit Care Med 1996; 17:7.
Braunwald E. Heart disease: a textbook of cardiovascular medicine,
5th ed. Philadelphia: WB Saunders; 1997.
Feigenbaum H. Echocardiography, 5th ed. 1994. Baltimore:
Williams & WilkinB.
Reynolds T. The echocardiographer's pocket reference. Arizona
Heart Institution Foundation, 1993.
Weyman AE. Principles and practice of echocardiography, 2nd ad.
Philadelphia: l,ea & Febiger, 1994.
452
Nhi mu phi
Tc ng mch phi hay thng gi l nhi mu phi

(NMP) l mt bnh l ht sc nng n, thng dn n t vong
nu khng c pht hin v x tr kp thi. Mc d c nhiu
bin php iu tr kh tch cc hin nay, nhng t l t vong
chung (ti Hoa k) bnh nhn NMP vn khong 20-30%. Tc
mch phi l mt bnh l kh thng gp, bnh cnh lm sng
d do
a dng, d b b st hoc chn on nhm, t vong thng
rve
e
s
e
ri lon huyt ng khi tc mch phi din rng. tNn
s r ncoi huyt
h
v
.
g
khi tnh mch su v tc mch phi l cng lmt
ri cqu
om trnh bnh
l
.
oo
. A ahhuyt
l. Tin lng sm ty vo cc loi rievlon
ng. Chn
o
l
y
n
@
on v x tr tc mch phi i theo
hai
hng
khc
nhau ty
i
. F 2020
8
0
theo s n nh huyt ng trn
y sng. Chp ct lp vi tnh
20 lm
cit can thip qua ng ng
t otov
xon c, thuc tiu sighhuyt
P
ri tin
y
thng... l nhng bin
php
tin c th lm thay i hn din
p
Co
bin v tin lng khi x tr tc ng mch phi.
I. Sinh l bnh
Vic tc t ngt mt mch ca phi dn n tng t
ngt tr khng ca mt vng h mao mch phi, tng gnh cho
tim phi, tht phi gin v suy cp, lm gim cung lng tim v
h huyt p ng mch. Thm vo c hin tng gim xy
mu ng mch v s mt tng xng gia thng kh v ti
mu cng lm bnh thm trm trng.
Tc mch phi biu hin lm sng rt a dng, c th
khng h c triu chng lm sng nhng cng c th c suy
huyt ng nhanh chng dn n t vong.
Hai biu hin bnh l chnh khi tc mch phi l ri lon
chc nng tht phi v ri lon trao i kh. Tc mch phi lm
453
tng sc cn mch phi, tng hu gnh tht phi, tng p lc v

sc p ln thnh tim ca bung tht phi, tng nhu cu xy c
tim... a n thiu mu c tim v ri lon chc nng tht phi,
gim th tch tng mu tht phi. Tht phi gin gy y vch
lin tht sang tri lm gim y v tin gnh tht tri (cn do
gim th tch tng mu tht phi), t cung lng tim, huyt
p ng mch ch, p lc ti mu mch vnh u gim. Nhp
tim nhanh, nhu cu xy tng, bung tim qu gin, ti mu vnh
gim... l nhng yu t lm nng thm ri lon chc nng tht
phi v to vng xon bnh l dn n cung lng tim gim
sc tim. Ri lon trao i kh bnh nhn tc mch phi rt
phc tp, lin quan n kch thc v tnh cht ca cc nghn,
mc lan rng, thi gian tc cng nh tnh trng bnh tim phi
trc . Gim xy mu thng do tng khong cht phdnang,
rve
lung thng t phi sang tri, bt tng hp gia thng
ese kh vi
r
ti mu (V/Q) v bo ha xy mch trn (MvOg2h)tsthp
n(ch yu
i om.v
r
l
l hai c ch cui). T l thng kh/ti mu
.cdo ti phn b
Al thp
hoo mch, tng qu
ev. yatc
dng mu phi (gim lng mu nlovng
@
Fin020do
mc lng mu n vng phi lnh)
xp phi khng hi
8. 2v
0
y cn do mt lp surfactant,
t
20 ophi
phc sau khi ly gii cc tc. Xp
i
t
tc
xut huyt ph nang hoc
ightnhPotrng gim CO2 ph nang, do co
r
py
tht ph qun, tt c
Cou c s tham gia ca cc yu t th dch
do tiu cu trong li cc huyt khi gy ra. PaO2 c th gim
hn na sau dng thuc vn mch do tng lung thng sinh l
khi tng dng mu qua vng phi c t l V/Q thp. Cc hin
tng khc cng c nhc n nh: ph phi sau tc mch phi
do p lc nh phi tng v hu qu ca lung thng t phi sang
tri qua l bu dc hoc l thng lin nh gy tc mch nghch
thng hoc gy gim nng PaO2.
Tc mch phi nh khi din tc mch 20% hoc p lc
mch phi (ALMP) trung bnh < 20 mmHg. Tc mch phi
din rng c nh ngha khi din tc mch 50% hoc tc 2
ng mch ca hai thy phi.
454
II. Chn on
Chn on nhi mu phi va d b st va d chn on
nhm. Rt d b st chn on bnh nhn c bnh tim phi t
trc, ngi gi, hoc khi ch c duy nht triu chng kh th.
10% trng hp t vong ti vin l do tc mch phi cp, a s
ch c chn on khi m t thi. Mt khc, cng d chn on
nhm. Ngay c cc nc tin tin, chn on xc nh bng
chp ng mch phi ch chim xp x mt phn ba s bnh
nhn nghi ng.
A. Triu chng lm sng
Bng 26-1. c lng kh nng tc mch phi
- Kh th t ngt, th nhanh (> 20 ln/pht) hoc
Cao
> 85% au ngc (kiu mng phi hoc sau xng c) ekhng
d
erv nhng
gii thch c, km theo t nht 2 trongress
ts
biu hin sau:
gh m.vn
i
r
o
l
- C yu t nguy c (khng vn ng,
Al hoo.c tr tun hon,
.
v
e ma xng khp hoc
tin s vim tc tnh mch, lsau
n o 0@y
i
F
2
tiu khung, sau chn thng,
8. 0 khi u c tnh, suy tim,
00 ity2
2
dng thuc trnhtthai...).
toc
- Thu km theo
igh duPohiu tng gnh tht phi mi c
r
opy
trn inCtim.
- Triu chng vim tc tnh mch su (sng, nng, ,
au mt chn).
- Phim Xquang c du hiu nhi mu phi, bu
vng rn phi hoc vng gim ti mu.
Trung C cc biu hin nm gia hai nhm thp v cao.
bnh
Thp
- Khng c kh th t ngt, th nhanh (> 20
< 15% ln/pht) hoc au ngc.
- Kh th t ngt, th nhanh hoc au ngc nhng
do l do khc.
- Khng c yu t nguy c.
- Bt thng trn phim Xquang do nguyn nhn khc.
- INR > 2 hoc aPTT > 1.5 ln chng trong vng 1
tun trc .
455
Hu ht bnh nhn c biu hin m h vi rt nhiu mc

khc nhau, nn rt cn c cc thm d thm loi tr hay
khng nh chn on. Nhiu nghin cu cho thy phi hp cc
triu chng lm sng, yu t nguy c, vi thm d n gin cho
php phn loi kh tin cy kh nng tc mch phi, t s la
chn nhanh chng, chnh xc, t tn km cc bin php chn
on khc. Xc nh kh nng tc mch phi trn lm sng c
bit c ch khi phi hp nh gi kt qu x hnh phi-mt
phng tin chn on c in.
Ngoi tr bnh l tng ALMP do thuyn tc mn tnh,
tc mch phi c th chia thnh ba loi chnh:
1. Tc MP nh, cp tnh:
Nu din tc nghn mch t hn 50% mch phi,
th thng khng c triu chng. Triu chng ced nng
rv
hay gp nht l kh th ngay c khi gng sc rnh.
ese Mt s
ts vn
khc xut hin biu hin ca nhi mu phi
ngay
.
gh m(NMP)
i
r
o
l bnh):
l
c
.
t u (khi tc nhnh MP c .trung
au
chi
A hoo
v
e
a
o
ngc, c th km ho khan hoc
l ho
yra mu. T l NMP
0@
Fin02nhn
.
ch chim khong 10% s
bnh
khng c bnh tim
8
00 ity2
2
phi t trc, trong tkhi
t
tocl ny c th n 30% nu c
igh Pong h hp. Triu chng thc
bnh tim triyrhoc
p
Co NMP: kh th nhanh, nng do au ngc
th ch c khi
song cha tm, hi chng ng c ln vi trn dch
mng phi, c th c c mng phi. Thng st nh v
nhp tim nhanh (do au+st). p lc MP t khi > 25
mmHg, cung lng tim khng gim, khng tt huyt p,
ting tim v p lc tnh mch hon ton bnh thng.
2. Tc MP din rng cp tnh:
Nu tc cp tnh trn 50% din mch phi th biu
hin ch yu l hi chng tm ph cp kt hp vi try
mch, tt huyt p. Thng gp nht l du hiu kh th
t ngt, nhp tim nhanh (> 100 chu k/pht) v triu
chng suy tht phi (TM c ni cng, tht phi p
mnh, nhp nga phi b tri xng c, T2 tch i rng
hoc mnh ln, thi tm thu do h van ba l, gan to).
456
Nng hn na l biu hin try mch: mch nhanh nh,

trng ngc, tt huyt p, v m hi, u chi lnh, tm ti,
ngt/thu hoc l ln... Gn 22% s bnh nhn tc mch
phi din rng c au ngc tri ging NMCT. Tht
phi gin cng, p lc tht phi v ALMP tm thu tng,
song t khi >55 mmHg; p lc nh phi v cui tm
trng tht phi tng (15-20mmHg), ch s tim v huyt
p ng mch gim, sc cn ngoi vi tng. Mt s trng
hp p lc mao mch phi bt bnh thng, nht l khi
th tch bung tht tri nh (do mt tng quan gia p
lc v th tch tht tri khi vch lin tht b y sang
tri). Triu chng s y nu biu hin 24 gi k t
khi khi pht, song t khi y nu xut hin sau 24
gi.
ved
ser tm thu
Try mch, tt huyt p (sc) khi huytrep
n
hts .vthuc
ng mch 90 mmHg v/hoc phiigdng
vn
r
m
o
l
l
c
.
mch. Sc bnh nhn tc mch phi
cp
tnh
(mt
cn
v. A ahoo
e
o
bng gia cc c ch b tr duy
huyt
p v/hoc ti
y
inl 2tr
0@
Fqu
.
0
mu m ca c th) l hu
ca
tc
mch
phi din
8
00 ity2
2
c tin s bnh phi tc nghn
rng bnh nhn khng

c
ht Poto
ighoc
mn tnh (COPD)
tc
din nh hn bnh nhn c
r
py
o
C
tin s COPD. T l t vong tng thm 3 n 7 ln nu
c sc tim (22-40%), a phn t vong ngay trong gi
u. Tuy nhin a s (97%) trng hp tc mch phi
din rng li khng c sc trn lm sng. Nu khng c
sc th t l t vong tng ng gia tc mch phi din
rng v din nh hn (0-8%). Cc ri lon huyt ng
khc bao gm tt huyt p khng cn dng vn mch;
thu/ngt (do phi hp gia gim xy mu v tt huyt
p, chim ti 13%), ri lon nhp v dn truyn, ngng
tim (ch yu do phn ly in c) hoc t vong. Cc ri
lon ny chim khong 10% (thm ch cao hn) tng s
trng hp tc mch phi ni chung, trong khi t l ny
tng cao nhm nng c suy tim phi cp hoc tng p
lc ng mch phi: t l ngng tim chim ti 18-29%,
457
sc phi dng vn mch l 10% (theo cc nghin cu

UPET, UPSET, ICOPER, PIOPED, MAPPET).
3. Tc MP din rng bn cp:
Thng do nhiu cc tc kch thc nh hoc trung
bnh din ra trong vi tun, do c qu trnh thch nghi
ca tht phi. Triu chng ch yu l kh th tng ln v
gim dung np vi gng sc, thng km theo ho khan,
c th c tm kiu trung ng. Mc kh th khng
tng xng vi cc triu chng thc th. Mch v huyt
p vn trong gii hn bnh thng. Khm thng thy
tnh mch c ni, ting T3 phn di mi c tng ln
khi ht vo, thnh phn phi ca ting T2 mnh. Tin s
c nhiu t NMP xen k, cui cng tin trin nng dn
d
dn n suy tim phi v gim cung lng tim ging
rve bnh
e
s
e
cnh cp tnh. p lc tht phi v p lc ttm
s r nthu MP
h
v
.
g
cao hn trong khi p lc nh phi thp
om so vi tc
l ri .chn
l
A o
MP din rng cp tnh.
ev. yaho
o
l
Fin 0@
8. 202
0
20 ocity c bnh tim phi t trc,
1. in tm : D
t khng
h
Potch gp trong 6% tc mch phi
in tim bnh
rigthng
y
op v 23% tc mch phi bn cp. Nu tc
ln cp Ctnh
mch phi nh, huyt ng n nh thng ch gp
nhp nhanh xoang. Cc ri lon nhp nh bloc nh
tht cc cp hoc ri lon nhp tht rt t gp, t l
rung/cung nh ch chim 0-5%. Du hiu thng
gp nht ( 50%) l thay i khng c hiu on ST
v T, thng thong qua, cc thay i giai on kh
cc tr li bnh thng sm hn so vi ti cc, mc
thoi trin sng T lin quan cht vi hiu qu iu
tr ca thuc tiu si huyt. Hnh nh tm ph cp
(trc QRS quay phi, bloc nhnh phi, P ph,
SIQIIITIII-S su rng DI, Q su DIII, T m o chiu
DIII) ch chim khong mt phn ba cc trng hp
tc mch phi din rng. in tm ch yu loi
tr cc chn on khc nh NMCT hoc vim mng
458
Tc mch phi thng nng hn nu: xut hin

sm ( 24 gi) o ngc sng T V1-V4, ri lon
dn truyn v ti cc ca tht phi, dng SISIISIII. Tuy
nhin biu hin trn in tim vn c th tn ti nhiu
ngy sau khi bnh thoi trin.
2. Xquang tim phi: Hnh nh phim chp Xquang phi
bnh thng c th gp trong tt c cc dng tc
mch phi (16-34%) nn khng th dng bin php
ny xc nh hoc loi tr tc mch phi ln. D
khng c hiu, chp Xquang phi cng gip chn
on tc mch phi ln nh loi tr cc bnh ging
d
tc mch phi (vim phi, trn kh mng phi,
rve suy
e
s
re
tim tri, u, gy xng sn, trn dch
phi
ts mng
n
h
v
.
g
nhiu, xp phi thy), xc nh l nhng
tn thng
i
l r o.com
nghi ng cn thm d tip vevcho
c
lng
o
. A aphp
h
o
l
y
nng ca bnh ng thi
@ cn c phim chp
in cng
. F 2020
Xquang nh gi0y
phim chp x hnh phi.
08 ty
2 toci
t xp
h
Hnh nh
Po phi, trn dch mng phi s
g
ri
y
p honh nng cao l nhng du hiu c
lng t,Coc
nhy thp. Du bu ca Hamptons (nt m ngoi vi
hnh ch V hoc bn nguyt, nm dc cnh mng
phi, hng v rn phi, hay gc sn honh), du
Westermark (vng phi b gim ti mu khu tr)
hoc phng on gn MP hay gp bnh nhn tc
mch phi din rng.
3. Cc xt nghim mu:
Men LDH tng, bilirubin gin tip tng v
SGOT bnh thng l b ba xt nghim gp trong
trng hp tc mch phi, tuy khng nhy song kh
c hiu, thng gp nht l tng LDH. Bch cu
tng nh (12.000-13.000/ml) trong khi hematocrit
gim nh (30-35%). Tiu cu cng gim nh
459
(100.000-200.000/ml) c khi khng c bin chng do

dng heparin.
Sn phm lin kt cho thoi ging ca fibrin
c cha D-dimer (c trng cho qu trnh tiu hy
fibrin ni sinh) tng > 500 ng/ml trong > 90% bnh
nhn tc mch phi. Tuy D-dimer tng c khi c
huyt khi tnh mch, ng mu ni qun ri rc
(DIC), sau chn thng, phu thut hay c khi u c
tnh... song c nhy cao (nht l khi nh lng
bng k thut ELISA) nn c th dng lm xt
nghim sng lc loi tr tc mch phi, c bit l
nhm c biu hin trn lm sng v/hoc hnh nh c
nguy c thp-va.
4. Kh mu ng mch: Bin i c trngrvled PaO2
se thng
gim v PaCO2 bnh thng hoc gim do
retng
s
t vn
. xy ra
kh. PaCO2 gim v kim chuyn rha
vn
ighom
l
l
c
.
A .o Tc mch phi
bnh nhn c ng CO2 trc
ev. yaho
o
l
din rng c th gy c Ftoan
in 2h
0@ hp (do tng khong
. 2c
0 h hp) v toan chuyn
8mt
cht sinh l VD/VT v
0
20 ocity
ha (do gim ti
m khi sc). 14-38% nhng
t mu
h
Pot
rig mch
trng hp
tc
phi
vn c kt qu kh mu
y
op
C
bnh thng (PaO2 80 mmHg, PaCO2 35 mmHg,
chnh lch gia phn p xy ph nang v ng mch
phi P(A-a)O2 bnh thng). PaO2 khng bao gi
bnh thng bnh nhn tc mch phi ln nhng
vn bnh thng nu tc mch nh do tng thng kh,
khi P(A-a)O2 > 20 mmHg l du hiu nhy hn.
Song PaO2 gim v P(A-a)O2 tng thng do nhiu
nguyn nhn, nn kt qu kh mu ng mch khng
mnh loi tr hoc xc nh tc ng mch
phi.
McIntyre v Sasahara ghi nhn tng quan
tuyn tnh gia mc nng ca tc mch phi (o
bng ch s tc mch khi chp mch, p lc MP
trung bnh, ch s tim) v gi tr PaO2 bnh nhn
460
khng c tin s COPD. Ngoi ra cc tc gi ny cn

thy tng quan cht gia P(A-a)O2 vi ALMP
trung bnh v s thng tn trn phim chp mch.
Thng kh khong cht sinh l (VD/VT) tng (o
gin tip qua th tch v p lc ring phn ca CO2
ton phn hoc cui k th ra ETCO2) l mt ch s
rt nhy v c hiu chn on tc mch phi, lin
quan cht vi mc tc v tin trin bnh.
5. Siu m tim: Siu m tim (qua thnh ngc hoc thc
qun) dng nh gi tnh trng tng gnh tht
phi, tm huyt khi bung tim v loi tr nhng
bnh l khc (phnh tch ng mch ch, bnh mng
ngoi tim, sc gim th tch, ri lon chc nng/nhi
mu c tim, h van tim - trong 2 bnhrvl
ed cui
e
s
chim gn mt na s bnh nhn nghi sng
re tc mch
t vn
h
g
phi c lm siu m). Siu m tim
ch. nn coi l
l ri .com
l
A o tin chn on
phng tin ph tr hn l phng
ev. yaho
o
l
chnh, xc nh tc mchFiphi.
n @
. 2020
8
0
Nhng du hiu
y tng gnh tht phi do
0 ca
2 tocit
t
h
o
tc mch phiigtrn Psiu m gm: gin/gim vn ng
r
py TP hay gp nht: 50-100%), tng t l
tht phiCo(gin
ng knh TP/TT, di ng nghch thng vch lin
tht, h van ba l... Nhng du hiu ny t khi gp
nu tc mch phi din nh. Gin tht phi cn c
th gp trong cc nguyn nhn khc: NMCT tht
phi, bnh c tim, tm ph mn hay TALMP, song
c th ngh n tc mch phi cp nu c km cc
du hiu nh: tht phi khng ph i ( dy 57mm) km khng xp TMC di khi ht su, di ng
vch lin tht nghch thng, vn tc ti a dng
chy ca h van ba l mc trung bnh (>2,5-2,8 m/s
v <3,5-3,7m/s), hoc ri lon vn ng vng c
bit ca tht phi (mt vn ng vng gia thnh t
do, vn ng bnh thng vng mm: do tng co bp
b ca tht tri).
461
Siu m tim qua ng thc qun c th thy

huyt khi thn hoc on gn ch chia ng mch
phi (chim 50-90% cc trng hp gin tht phi)
vi chnh xc cao ( nhy: 80-96,7%, c
hiu: 84-100%), tuy nhin nhy gim vi nhng
huyt khi nhnh nh ca MP, hoc on gia
v xa ca MP tri. Siu m tim cho php xc nh
tnh trng huyt khi ang di chuyn (emboli-intransit) tim phi, chim ti 17% s bnh nhn tc
mch phi cp, vi hai tp A v B khc nhau v hnh
thi v tin lng (theo phn loi ca European
Cooperative Study). Tp A (gp trong 18% tc mch
phi ln c sc) l cc huyt khi di (2-10cm), rt di
ng, ngun gc t h tnh mch su ngoi vi, thng
d
rvec cao
e
thy nh phi (84%) th vo tht phi, nguy
s
re
ts lvnt vong
(mt phn ba cht trong vng 24 gi,ght
m. thng l
oy
l riv
40% k c khi dng tiu si huyt),
l
c
.
A hoo
ev. tuyt
a i m cp cu
nhng trng hp c ch nh
o
l
n 0@y
i
F
2
ly huyt khi (t l t
0 cn 15-25%). Tp B l
8. vong
y2 hn, hnh trn/van, t di
00 inh
t
2
cc huyt khi thng
t otoc
P phi, lin quan n cc ri lon
ng, nm trong
igh tht
r
y
p
tng ng
Co trong tht phi (suy tim huyt, in cc
to nhp vnh vin, d vt...), thng tin lng tt (d
gy tc mch phi trong 40% cc trng hp). Tuy
nhin Kinney v Wright li khng thy s khc bit
r v t l t vong gia cc loi huyt khi.
Siu m cng xc nh nhm bnh nhn c
nguy c cao nh: cn l bu dc (tng t l t vong,
tc mch no v cc bin chng gn khc). Ri lon
chc nng tht phi l yu t nguy c ng ch
khc: d bo tin lng xu, c bit bnh nhn
huyt ng khng n nh. 10% bnh nhn huyt
ng n nh c ri lon chc nng tht phi s tin
trin thnh sc tim, vi t l t vong vt qu 50% do
tc mch phi ti pht, nht l bnh nhn tui cao,
mi sau phu thut xng hoc chn thng, huyt
462
p thp. Tuy cn phi nghin cu thm na, song

dng nh thuc tiu si huyt gp phn lm gim
t l t vong nhm tc mch phi huyt ng n
nh c ri lon chc nng tht phi (MAPPET).
6. X hnh phi (scintigraphy): X hnh phi l
phng tin chn on gin tip v khng th pht
hin c bn thn huyt khi m ch pht hin hu
qu l cc vng khuyt v ti mu. Hnh nh x
hnh ti mu phi bnh thng cho php loi tr
chn on tc mch phi. Kh nng chn on tc
mch phi ca hnh nh vng khuyt ti mu c th
chia thnh 3 loi: cao, trung bnh v thp. Hnh nh
c kh nng cao cho php chn on ng ti 85%.
Tuy nhin phn ln (60%) bnh nhn nghi tcedmch
rv
phi trn lm sng ch c nhng hnh rnh
ese c kh
ts vnl bnh
nng chn on thp hoc trung bnh
.
ghnht
i
r
om mch phi
l .ctc
l
nhn c tin s COPD, m trong
v. A ahoo
ed
o
l
thc s ch chim 25%. Mc
kt hp vi kh nng
y
0@
Finda
2
.
0
chn on tc mch 0phi
vo
lm sng s nng
8
0 ity2
2
cao chnh xc
t osong
toc cng ch chn on ng
gh Pba
iphn
khong mt
s bnh nhn. Ngc li, d
r
py
o
C
hnh nh x c kh nng thp cng khng loi tr
c chn on v c ti 40% l tc mch phi nu
kh nng tc mch trn lm sng cao.
D vy, x hnh phi vn rt c ch quyt
nh hng x tr: hnh nh x hnh ph hp vi lm
sng c kh nng thp cho php loi tr tc mch
phi, hnh nh x hnh ph hp vi lm sng c kh
nng ng cao ng ngha vi vic phi iu tr.
Nhng phng tin khc nh siu m tm huyt khi
tnh mch su, chp ng mch phi hay phim CT s
dng la chn phng php iu tr cho hai nhm
trn cng nh gip cho chn on khi khng ph hp
kh nng chn on gia lm sng v nh x hnh
phi, ch khng nn ch da vo lm sng...
463
7. Chp ct lp t trng vi tnh (CT thng, CT

xon c, CT chm in t): Chp CT xon c c
dng thuc cn quang hoc chp CT chm in t
(electron beam CT) l bin php chn on khng
xm ln c nhiu u th, b sung hoc thay th cho
ghi hnh phng x phi kinh in. CT xon c c
nhiu ni coi l bin php u tay chn on do
k thut chp nhanh (ch trong mt ln nn th),
phc tp v t ph thuc hn, pht hin c gin tht
phi so vi phng php chp mch phi truyn
thng; hnh nh r nt v y hn (c nhu m v
mch mu) so vi ghi hnh phng x.
Biu hin ca tc mch phi trn phim CT r
rng trong a s (90%) trng hp: cc hnhvekhuyt
d
r
e
s
mt phn hay hon ton trong lng mch,
re hay du
hts .vnkhi bp
hiu ng ray (dng chy giarighuyt
l .comi vi tc
bnh trong lng mch v thnh
Almch).
oo
.
v
ehoc
ahphn thy phi th
o
l
y
thn MP, tc MP ti thy
Fin020@
8. 85%
chp CT c chnh0xc
( nhy v c hiu
2
20 o100%
ity nhm bnh nhn nng
c
u 94%, thm
ch
ht ot
riggnhP tht phi). Hnh nh dng tnh
hoc c tng
y
p
Co do hch rn phi to gy xp phi, m trung
gi c th
tht, ph quanh mch (suy tim huyt), bm thuc
cn quang chm... Hnh nh m tnh gi c th gp
khi nh gi cc ng mch nh ca h phn thy
phi, hoc nhng vng MP xut pht khng theo
chiu dc, hoc khi c tc TMC trn, c lung thng
trong tim, trong phi gy gim cn quang cc MP.
chnh xc ca chp CT ch gim nhm bnh
nhn tc mch phi nh (di h phn thy), l nhm
chim t l t (6% cc trng hp tc mch phi) v
tin trin vn tt d khng dng thuc chng ng.
Sau khi chp CT phi c bm thuc, lng cn quang
trong h tnh mch vn nh gi tip huyt
khi trong tnh mch su vng chn, vng bng,
khung chu v TMC di m khng tn thm thi
464
gian (5 pht), rt cn nu bnh nhn c ch nh t

dng c lc trong TMC di.
8. Chp cng hng t ht nhn (MRI): Chp cng
hng t ht nhn cng l mt bin php chn on
khng xm ln, cho php nh gi v hnh thi gii
phu-chc nng ca ti mu phi cng nh chc
nng tht phi. So vi chp CT hay chp mch phi,
MRI cn c cc u im nh: trnh ng c thn do
thuc cn quang, chp h tnh mch ngay trong mt
th, nhy v c hiu rt cao pht hin huyt
khi tnh mch su v huyt khi MP. Tuy nhin
thi gian chp ko di (15-30 pht) gy nhiu bt li
nht l nhm bnh nhn c huyt ng khng n
nh. Do , MRI cng t c ng dng trong
d chn
rve
e
s
on tc mach phi.
re
ts vn
h
.
g
9. Chp ng mch phi: Chp chn
om ng mch
l ri .lc
l
c
phi c th coi l tiu chunevvng
oo chn on xc
. A ah
o
l
y
nh hoc loi tr tc mch
@ Nn ch nh khi
in phi.
. F 2020
8mch
c tt huyt p, try
hoc
khng chn on
0
20 ocity
c bng phng
ht tin
ot khc. Tuy nhin khng phi
rigthcPhin c v lun c nguy c t
y
ch no cng
op
vong dCnh (< 0,3%) khi chp, nht l nhm nng
c p lc cui tm trng tht tri cao hoc tng p
ng mch phi. Chng ch nh tng i bnh
nhn c thai, nguy c chy mu cao, suy thn v c
huyt khi trong tim phi. C th chp bng ng
thng i qua tnh mch i (khng th nu bnh nhn
t li lc TMC di, c nguy c lm bong huyt
khi vng chu i hoc TMC di v d chy mu
nu dng thuc tiu si huyt), ng TM cnh tay
(kh li ng thng, d co tht TM nht l khi sc
hoc dng thuc vn mch liu cao) hoc TM cnh
trong v TM di n (chng ch nh nu dng
chng ng liu). Trc khi chp nn thng tim
nh gi cung lng tim, shunt, mc ri lon
465
huyt ng v nguy him phng nga, chn loi

v lng thuc cn quang... Nhng thay i huyt
ng ty vo mc tc (bn nh lng trn phim
chp) bao gm: tng p ng mch phi (th pht do
tc mch ln), p lc nh phi v cui tm trng tht
phi tng, p lc cui tm trng tht tri v cung
lng tim gim. Huyt khi th hin qua hnh nh ct
ct hoc khuyt trn trong lng mch km theo gim
ti mu vng phi chi phi.
Nhiu tc gi t du hi v s cn thit
phi chp ng mch phi trc khi can thip tch
cc nh dng thuc tiu si huyt thm ch phu
thut ly huyt khi do nguy c chy mu, bin
chng v lm chm tr chn on trong khi cvednhng
ser nhin,
bin php khng xm ln chnh xc khc.reTuy
s
ht p
chp ng mch phi s l bt bucrignu
.vndng cc
m
o
l
l huyt
.c
bin php ly huyt khi hoc. nong
khi theo
v A ahoo
e
o
l
y
ng ng thng.
Fin020@
8. tnh
2
10. Pht hin huyt khi
mch su: a phn
0
20 ocity
t
huyt khi tnh
mch
t chi di (HKTMCD) khng c
igh Po
rr
y
triu chng
rng
m
vic pht hin phi da vo:
op
C
siu m Doppler mu mch mu, MRI hay chp cn
quang h tnh mch. Chp cn quang h tnh mch
hin rt t c s dng, MRI li qu phc tp, nn
siu m Doppler mu mch mu l phng tin l
tng pht hin huyt khi tnh mch su, cho d
t tin cy nhm khng biu hin triu chng hoc
khi nh gi huyt khi TMC di. 40% bnh nhn
huyt khi TM su c tc mch phi khi lm x hnh
d khng c triu chng lm sng. Cho d cc bin
php trn khng th chn on xc nh tc mch
phi, song vic pht hin huyt khi TM su rt quan
trng quyt nh hng x tr. Bn thn vic tn
ti huyt khi TM on gn c ch nh iu tr
thuc chng ng d lm sng khng biu hin tc
466
mch phi, ngc li nu khng c huyt khi TM

gc chi, bn, chu..., khng cn nguy c tc mch
thm th d c tc mch phi nh vn c th b
qua thuc chng ng. Tt nhin phi rt thn trng
khi kt lun nhm bnh nhn c chc nng tim
phi hn ch, t hot ng hoc huyt khi hnh
thnh t ni khc (nh phi, TMC...). Mt khc siu
m mch c th lm li nhiu ln nu vn nghi ng.
C. Chn on phn bit
1. Nhi mu c tim cp.
2. Vim phi thu.
3. Suy tim tri cp.
d
4. Tng p ng mch phi tin pht.
rve
e
s
re
5. Cn hen ph qun.
ts vn
h
.
g
l ri .com
l
6. Vim mng ngoi tim.
A o
ev. yaho
o
l
7. Trn kh mng phi.
in @
. F 2020
8
0
8. Gy xng sn. 20 ity
t otoc
P
9. Vim khp sn
ighsn.
r
y
p
o thn kinh lin sn.
10. au c,Cau
III. iu tr
Bnh nhn tc ng mch phi c nguy c t vong, huyt
khi ti pht hoc bin chng mn tnh. T l t vong c th ln
ti 30% nu khng iu tr.
Ngay khi nghi ng tc mch phi nn tim trc tip tnh
mch ngay 5.000-10.000 n v Heparin nu khng c chng ch
nh, ri tip tc chn on xc nh. Nu loi tr tc mch
phi th dng Heparin, nu c chn on xc nh th la chn
iu tr ph thuc vo tnh trng huyt ng ca bnh nhn. Khi
huyt ng suy sp nng gy tt huyt p hoc sc, cn nhanh
chng m thng ch tc mch phi bng thuc tiu huyt khi
v/hoc th thut can thip iu tr huyt khi. Nu tht bi hoc
chng ch nh, nn tin hnh phu thut cp cu ly huyt khi.
467
Nu thnh cng, tip tc duy tr bng Heparin v thuc khng

vitamin K. Bnh nhn tc mch nh hoc thm ch tc mch din
rng nhng huyt ng n nh c iu tr bng Heparin gi
vi thuc chng ng ng ung. Tc mch phi ti pht hoc
chng ch nh dng khng vitamin K, th nn xem xt t dng
c lc (filter) tnh mch ch di phng huyt khi.
A. Cc bin php hi sc cho NMP din rng
1. Bnh nhn nghi ng tc mch phi din rng thng
phi hi sc tch cc n nh huyt ng ngay c
trong lc chn on.
2. Nu au ngc nhiu c th dng thuc gim au.
3. Nu xy mu gim nng, t p ng vi th xy qua
mt n p vo mi, cn t ng ni kh qun vedthng
rv
kh nhn to. t ni kh qun v thng kh
ese nhn to
r
hts .huyt
c th lm nng thm tnh trng suyigsp
ng
vn
r
m
o
l
l ng
c
do: (1) thuc gy ng dng khi. At
ni
kh
qun
.
oo
h
v
e
a
o
hoc th my s gy gin
mch ng thi lm
inl 20@y
Fcatecholamine,
.
gim/tr tc dng ca
(2) th my
0
08 ty2
0
2
i
lm gim lng tmu
tTM
oc tr v v tng sc cn mch
Po nhc thn trng gia li ch v
igh cn
phi. Do
cn
r
opy bn thn vic t ni kh qun, k thut
nguy cCca
tin hnh v cc thuc h tr. Etomidate l thuc
gim au gy ng l tng v t nh hng n huyt
ng. Th my p lc dng lm ci thin tt xy
mu do tc mch phi hay c xp phi.
4. Thng thng, truyn 1-2 lt dch mui s nng c
huyt p bnh nhn sc khng r nguyn nhn.
Cung lng tim s tng ln bnh nhn tc mch
phi din rng khi cha tt huyt p nu truyn
500ml Dextran. Tuy nhin, bnh nhn tt huyt p
c ri lon chc nng tht phi nng, th tch v p
lc bung tht phi cao lm tng sc p ln thnh tim
v/hoc gy thiu mu tht phi, y lch vch lin
tht qu mc sang tri gy ri lon kh nng gin
v/hoc y tht tri. Khi truyn dch qu mc
468
cng lm nng thm tnh trng trn cng nh ri lon

chc nng tht phi nhiu hn, v th nu p lc
bung tim phi cao hoc c biu hin suy tim phi th
vic truyn dch cn phi rt thn trng v nn dng
thuc vn mch sm.
5. T l sng ca bnh nhn tc mch phi din rng
ph thuc vo vic duy tr p lc ng mch ch
cp mu mch vnh nui dng cho tht phi ang
suy. Noradrenaline thng qua th th (gy co ng
mch-tng p lc ti mu mch vnh v gy co tnh
mch-tng lng mu tnh mch tr v tim) ng thi
thng qua th th 1 (tng co bp c tim hn na)
cho php ci thin r rt chc nng tht phi.
Dobutamine tuy tng cung lng tim v kh nng
d vn
rve
e
s
chuyn xy song li thay i t l thng kh/ti
mu
e
sr n
ttc
h
v
(V/Q) v lm gim PaO2 bnh nhn
mch
phi
.
g
i om
ll r ogin
.c mch ngoi
din rng c sc, hn na thuc. Agy
o
v ah
e
o
l thy nu tc mch phi
vi thng qua th th 2. inV
F 020@
.
8 2
din rng, nn chn 0Dobutamine
nu h huyt p t20 onu
ity sc nng, tuy nhin khi
c
va v Noradrenaline
ht Pot
rig
nng catecholamine
ni sinh t n mc rt
y
op
cao nnCp ng vi cc thuc vn mch s km, c
khi khng c tc dng m cn gy ri lon nhp.
B. Heparin
Bng 26-2. Liu Heparin trong HKTMCD v NMP
Chn on
Liu heparin
HKTMCD - Tim thng TM 5000 v tip theo truyn TM
khng km 1000 v/gi, kim tra thi gian throboplastin bn
theo NMP phn (aPTT) iu chnh liu Heparin sao cho
hoc NMP aPTT trong khong 1,5 - 2,5 ln thi gian chng.
nh
- C th thay bng dng Heparin trng lng
phn t thp liu 1 mg/kg tim di da x 2
ln/ngy.
- Dng khng vitamin K, gi t ngy th 3-4,
ngng Heparin sau 7-10 ngy.
469
NMP ln - 7000 -10 000 v tim thng TM, sau truyn

(din rng) tc 1000 - 2000 v/gi, kim tra thi gian
aPTT iu chnh liu Heparin sao cho aPTT
trong khong 1,5 - 2,5 ln thi gian chng.
- Dng khng vitamin K, gi t ngy th 3-4,
ngng heparin sau 7-10 ngy (khi n nh).
Cc thuc khng vitamin K (Warfarin, Cumadin...) cn
c dng gi vo t ngy th 3-4 sau khi dng Heparin v
thi gian c tc dng ca cc thuc ny mun. Cn iu
chnh liu sao cho INR trong khong 2,0 n 3,0. Warfarin
nn dng bt u bng liu 5 mg/ngy. Thi gian dng thuc
ny t 3-6 thng sau khi bnh nhn ra vin. Nu bnh nhn
cn c nhng tnh trng tng ng ( ni trn) th vn nn
tip tc ko di.
d
rve
e
C. Thuc tiu huyt khi
s
re
ts vn
h
. khi gy
1. Tc dng nhanh chng lm tan cc
huyt
g
l ri .com
l
A tnh
o trng suy tim
nghn MP, gim ti v hi phc
ev. yaho
o
l
phi cp. Thuc tiu huyt
khi
so
vi Heparin lm
Fin020@
.
gim ng k t l 0t
2 sau 30 ngy (4,7 so vi
08 vong
2 cocti
ity pht nghn mch phi (7,7
11,1%), gim nguy

ht ot
rig v Pgim nguy c pht trin bnh l
so vi 18,7%)
y
op
tng p C
ng mch phi do thuyn tc mn tnh.
2. iu tr tiu huyt khi c ch nh cho bnh nhn
suy sp huyt ng: tt huyt p, thiu niu, gim
xy mu nng. Mt s tc gi cn ch nh cho
nhng trng hp ri lon chc nng tht phi trn
siu m.
3. Cc thuc tiu si huyt dng nh u c hiu qu
v an ton nh nhau nu s dng vi liu tng
ng (Bng 26-3). Nu dng Streptokinase hoc
APSAC (Anistreplase hay Antisoylated Plasminogen
Streptokinase Activator Complex) th nn phi hp
100 mg Hydrocortisone gim cc tc dng ph.
4. Chng ch nh bao gm: cc bnh l ni s, ni
ty, chy mu trong, mi phu thut ln hoc chn
470
thng nng (< 10 ngy), tng huyt p khng kim

sot c, tin s d ng hoc mi dng thuc (ring
vi Streptokinase hoc APSAC). Ngc vi NMCT,
tiu huyt khi vn c tc dng iu tr trong vng
10-14 ngy cho cc bnh nhn nhi mu phi k t
khi khi pht. Hiu qu l tng ng d dng
ng tnh mch ngoi vi hay trc tip qua ng thng
vo MP. Ngng Heparin trc v sau khi dng
thuc tiu si huyt, o aPTT v fibrinogen mu
quyt nh thi im dng tip Heparin. Nu aPTT
vn gp i chng hoc fibrinogen < 1g/l th lm xt
nghim ny 4gi/ln cho ti khi c th dng li an
ton Heparin, sau gi vi khng vitamin K t nht
trong nm ngy. Bin chng chnh khi dng dthuc
rve
tiu si huyt l chy mu nng (12%, tng
ese ng
r
ts vxut
gia cc thuc tiu si huyt), trong
. n huyt
gh
i
r
m
o
l
ni s khong 0,5-2,1%. Streptokinase
l
c hoc APSAC
. A ahoo.
vbng,
e
c th gy d ng nh nng
ni
ban, st (5o
nl 0@y
i
F
2
7%), p ng tt vi corticoid
8. 20 v khng histamine d
00khiity
2
sc phn v rt him
xy ra (<0,5%).
t otoc
h
P
g
Bng 26-3. Liu
rithuc tiu si huyt cho NMP.
opy
C
Streptokinase Liu np 250.000-500.000 n v/15 pht,
duy tr 100.000 n v/gi 24 gi
Urokinase
Liu np 4.400 n v/kg/10 pht,
duy tr 4.400 n v/kg/gi 12 gi
rt-PA
Liu np 10mg, sau truyn lin tc 90
mg/2 gi
APSAC
30mg/5 pht
Reteplase
2 mi tim trc tip 10 n v cch nhau 30
pht
D. Can thip qua da v phu thut
1. t dng c lc tnh mch ch di xuyn qua
da ngn nga nguy c tc thm MP khi bnh
nhn c biu hin ca HKTMCD. Ngy nay ngi ta
thng dng loi lc (Green Field) t ngay tnh
mch ch di, di ch vo ca hai tnh mch
471
thn. C th i bng ng tnh mch i bn khng

b tc hoc i t ng tnh mch nn.
Hin nay ngi ta ang th nghim dng dng
c c bit (Angio - Jet) ht cc mu ng qua
ng thng tim (catheter), phng php ny bc u
t ra c trin vng.
2. Phu thut ly cc mu ng trong ng mch
phi l phu thut nng vi t l t vong rt cao, kh
thc hin cc trung tm y t nh. Phu thut ch
c ch nh khi bnh nhn c tnh trng rt nng
vi suy tht phi nhiu, huyt p tt v chp mch
phi hoc cng hng t chng minh c cc tc
mch ln (thn ng mch phi hoc nhnh ln).
E. Ngn nga nguy c v iu tr HKTMCD
V HKTMCD l mt trong nhng nguyned nhn
rv
hng u gy NMP, nn vic ngn nga v iu
ese tr kp
r
thi HKTMCD cng l ngn nga NMP. hts n
.v
g
1. Yu t nguy c ca HKTMCD: ll ri .com
hoo
v. A amch,
a. Tnh trng bnh l hloetnh
tn thng
y
n 0ng
@
itng
mch, hoc tnh trng
th
pht:
F
2
8. 20 (c bit l cc phu
Cc phu thut
y
00 itnng
2
c
odi,
t chi
t
thut vng
tiu khung).
h
o
P
g
rithng
Chn
(c
bit
l gy xng i, chn
y
p
Co
thng
s no, v tu sng).
Suy tim huyt, gim cung lng tim.
Cc bnh c tnh.
Ph n c thai.
Dng thuc trnh thai ko di.
Bo ph.
Gin tnh mch chi di.
Bnh vim i trc trng.
Tui gi.
Hi chng thn h.
Nhim trng.
b. Tnh trng tng ng tin pht:
Thiu ht yu t Antithrombin III.
Thiu ht Protein C.
Thiu ht Protein S.
Ri lon Plasminogen v s hot ho.
Bnh i ra hemoglobin kch pht v m.
472
Bnh gim tiu cu gy ra bi Heparin.

Khng th khng lupus (anticoagulant hoc
anticardiolipin).
Ri lon tng sinh tu xng.
Bnh a hng cu.
2. Chn on HKTMCD
a. Lm sng thng l xut hin sng, au, cng
mt chi. Mt s trng hp triu chng lm sng
khng r rng m ch n khi xut hin NMP mi
pht hin ra c HKTMCD.
b. Chn on xc nh da vo chp h tnh mch,
tuy nhin y l thm d chy mu v gy kh
chu cho bnh nhn.
c. Siu m Doppler tnh mch l xt nghim rt hu
ch, cho php chn on tt.
d
3. iu tr HKTMCD
rve
e
s
e
a. Heparin tim TM 5.000 n v sau t
TM
s r truyn
h
vn ngy.
.
g
i
tc 1.000 v / gi lin tc trong
7
10
r
ll o.com
o
b. Heparin trng lng phnev.tA thp
ah (LMWH) hin
o
l
y
c coi l thuc tt
iu
tr
thay cho Heparin
0@
Finhuyt
2
.
0
thng trong iu
tr
khi
tnh mch chi
08 ty2
0ny
2
i
di. Cc thuc
c
nhiu
u
im
hn l tc
toc
ht khng
Po
dng korigdi,
phi theo di bng cc xt
py
nghim
Co khi dng, ngoi tc dng chng yu t Xa
cn c tc dng chng yu t II tiu cu.
Bng 26-3. Heparin trng lng phn t thp trong iu
tr huyt khi tnh mch.
LMWH
Xa/IIa
iu tr
D phng
Adreparin
1.9
130 U/kg/12h
50 U/kg/12h
(Normiflo)
Certoparin
8000 U/12h
3.000 U/24h
(MonoEmbolex)
Dalteparin
2.7
120 U/kg/12h
2.500200 U/kg/24h
5.000 U/24h
(Fragmin)
Enoxaparin
3.8
100 U/kg/12h
2.000-4.000
U/24h
(Lovenox)
Nadroparin
3.6
<55kg:4.000 U/12h
3.100 U/24h
55-80kg:6.000 U/12h 40-60U/kg/24h
(Fraxiparin)
473
>80kg: 8.000 U/12h
Reviparin
3.5
<60kg: 4.200 U/12h
1750 U/24h
>60kg:6.300 U/12h
(Clivarin)
Tinzaparin
1.9
175 U/kg/24h
3.500 U/24h
50 U/kg/24h
(Innohep)
c. Dng gi t ngy th 3-4 mt loi khng vitamin
K (Warfarin, Sintrom) v ko di vi thng.
d. Hin nay mt s tc gi a dng cc thuc tiu
si huyt (Streptokinase, Urokinase, rt-TPA...),
tuy nhin kt qu cha vt tri hn phng thc
iu tr thng thng v rt t tin.
e. Can thip t dng c lc (phin lc) tnh mch
ch di ngn nga cc mu ng bn ln
d
ng mch phi gy NMP.
rve
e
s
re
Ti liu tham kho
ts vn
h
g
i om. Opinions
1. ACCP Consensus Commitee on pulmonary
l rembolism.
l
.c
regarding the diagnosis and management
hoo thromboembolic
v.ofAvenous
e
a
o
disease. Chest, 1996;109:233-7. inl 0@y
.F 2
2. Britist Thoracic Society, Standards
08 ty20of Care Commitee. Suspected
0
2 i a practical approach. Thorax,
acute pulmonary embolism:
t otoc
h
1997;52(suppl 4):S1-24.
P
g
ri
3. Fitzmaurice D,opy
Hobbs FDR, McManus R. Thromboembolism.
C
Clinical Evidence, 2001;5:158-68.
Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous
thromboembolism. Chest, 2001;119:132S-175S.
5. Goldhaber SZ. Pulmonary embolism. N Eng J Med, 1998;339:93104.
6. Hyers TM, Agnelli G, Hull RD, et al. Antithrombotic therapy for
venous thrombo-embolic disease. Chest, 2001;119:176S193S.
7. Layish DT, Tapson VF. Pharmacologic hemodynamic support in
massive pulmonaryembolism. Chest, 1997;111:218-24.
8. Mercat A, Diehl JL, Meyer G, et al. Hemodynamic effects of fluid
loading in acute massive pulmonary embolism. Crit Care Med,
1999; 27:540-4.
9. Riedel M. Emergency diagnosis of pulmonary embolism. Heart,
2001;85:607-9.
10. Riedel M. Venous thromboembolic disease. Acute pulmonary
embolism 1: pathophysiology, clinical presentation, and diagnosis.
Heart, 2001;85:229-40.
4.
474
11. Riedel M. Venous thromboembolic disease. Acute pulmonary

embolism 2: treatment. Heart, 2001;85:351-60.
12. Wood KE. Major pulmonary embolism: Review of a
pathophysiologic approach to the golden hour of hemodynamically
significant pulmonary embolism. Chest, 2002;121:877-905.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
475
Thng lin nh
Thng lin nh (TLN) chim khong t 5% n 10% cc

trng hp tim bm sinh. Cng vi bnh van ng mch ch hai
l van v sa van hai l, TLN l bnh tim bm sinh cn hay gp
nht ngi ln. Bnh ch yu gp n gii: t l gp n so
vi nam l 2 so vi 1.
i a s cc bnh nhn TLN khng c triu chng c
nng m ch c cc triu chng lm sng rt kn o do
thng b b st chn on cho n tui trng thnh.
i vi cc trng hp TLN khng c iu tr trit ,
cc bnh nhn s dn dn c cc triu chng lm sng. vLu
d di
r e
e
s
cc bnh nhn s biu hin cc du hiu ca s qu
re ti bung
htstheo
tim phi nh ri lon nhp nh (tng dn nguyrigc
.vn tui ca
m
o
l
l sc .ccn mch phi,
bnh nhn), tng p ng mch phi v tng
v. A ahoo
e
o
lsuy tim
y xung huyt. Vic
cui cng hu qu tt yu l dn n
Fin020@
.
8 yu
tn ti l thng lin nh cng l 0mt
2 t thun li dn n tc
20 ocity
mch nghch thng.

t
t
igh Po
r
y
I. Gii phu bnh:
p c bn dng thng lin nh thng thng:
Co
TLN kiu l th hai, TLN kiu l th nht, TLN kiu xoang
tnh mch v TLN th xoang vnh.
A. TLN kiu l th hai hay TLN th pht (l bu dc)
l tn thng hay gp nht chim khong t 60% n
70% cc trng hp. L thng nm v tr gn l oval,
trung tm vch lin nh (VLN). C th gp phi hp vi
sa van hai l, c bit ph n (t l 2:1 so snh gia n
v nam gii).
B. TLN kiu l th nht hay TLN tin pht chim
15% n 20% cc trng hp. L thng nm thp, gc
hp bi vch lin nh v mt phng ca vch ngn nh
tht (mt phng van nh tht). Chnh v v tr thp nn
loi ny hay i km vi khuyt tt ca van nh tht v
vch lin tht. Khi c TLN l th nht th rt thng gp
475
h van hai l i km do c k h ca l trc van hai l.

Lc , bnh l ny c phn loi trong nhm c bit
gi l thng sn nh tht (ng nh tht chung), c c ch
sinh l bnh, din bin lm sng v phng hng iu
tr khc.
C. TLN th xoang tnh mch l loi TLN t gp, chim
khong t 5% n 10% cc trng hp. L thng nm
cao v ra sau ca VLN, n nm ngay st vi tnh mch
(TM) ch trn do vy rt hay gp hin tng tnh mch
phi (TMP) qua l thng vo nh phi (TMP lc
ch). Ngoi ra c th gp cc th rt him ca TLN nh:
TLN nm rt thp pha di st vi TM ch di (pha
sau v di ca VLN).
vedthng
D. TLN th xoang vnh l th him gp nht,erl
s
re dng
nm ngay st pha trn xoang TM vnh,
ts do
h
.vn
g
shunt t nh tri s trc tip vo l''cu
om ny. Tn
l ri .ctrc''
A htt
oo
thng ny hay phi hp vi cc
ev. d
a bm sinh khc
o
l
y
in 0@
nh ng nh tht chung, tnh. Fmch
ch trn lc ch.
8 202
0
y
0
2 it
t otoc
h
P
g
ri
y
p
Co
Hnh 27-1. V tr gii phu ca cc dng TLN.

II. Sinh l bnh
A. TLN thng dn n dng shunt t nh tri sang nh phi,
lu lng shunt ph thuc vo ng knh l thng v
ph thuc gin tip vo gin n ca tht tri v tht
476
phi. Lung thng c th ngay lp tc (di 1 nm) hoc

dn dn (nhiu nm) dn n s tng gnh ca bung tim
phi lm ph i tht phi, tng ti mu phi v cui
cng s dn n tng p lc ng mch phi (MP).
cc bnh nhn ngi ln hoc do p lc bung tim phi
tng ln hoc/v kh nng co bp ca tim tri gim
xung (c tim b nh hng do tng cng hay do bnh
ng mch vnh, tng huyt p... phi hp), lc ny dng
shunt thng s gim xung dn dn v c th dn n
shunt hai chiu hay o chiu dng shunt (him gp).
B. Nguy c chnh ca vic khng ng l thng lin nh l
s gy suy tim th pht do tng gnh mn tnh, tng p
MP, ri lon nhp nh v tc mch.
d
rve
e
s
re
tsi
n
h
A. Triu chng c nng: thng kn o,
g
i om.v khi bnh
r
l
l o.cvim ph qun
nhn n khm v kh th khi gng
o
. A sc,
v
e
ah t cc trng hp
o
phi nhiu ln hoc chm ln.nlMt
s
y
Fi 20@ tri sang phi nhiu
vi l TLN ln c th dn
8.n20shunt
0
y sm khong t 6 n 12
20 ocitrt
v tr c du hiu c
t nng
t
h
o
thng, cn li i
riga sP cc trng hp bnh thng pht
y
p
o thm khm thng k. Cc trng hp
hin mun Cnh
bnh din bin lu di c th c cc biu hin ca ri
lon nhp nh rung nh hay cung nh, tng p ng
mch phi nng v suy tim xung huyt.
B. Khm lm sng: Nghe tim c ting thi tm thu cng
nh van MP do tng lu lng mu qua van
MP. Ngoi ra cn nghe thy ting T2 tch i do s
ng mun ca ba l van MP; ting T1 mnh v rung
tm trng do tng lu lng van ba l c th gp
trong cc trng hp dng shunt ln lm tng nhiu s
y v tht phi.
A. in tm (T)
477
1. TLN l th hai: in tm thng c dng:

a. RSR hay rSR V1.
b. QRS ln hn 0,11 giy.
c. Trc phi.
d. i khi c th km theo PR ko di (khong 20%
cc trng hp, hay gp cc bnh nhn TLN
mang tnh cht gia nh).
e. Dy nh phi trong khong 50% cc trng hp.
2. TLN l th nht: in tm c dng
a. RSR V1.
b. Trc tri.
c. Bloc nh tht cp I.
d
d. C th thy dy c 2 tht.
rve
e
s
e
s r n vi gin
B. Chp Xquang tim phi: Tim to vahtphi
v
.
g
m phi ca
odi
l rib
cung MP. i khi thy du hiu gin
l
c
.
. A amu
hoo phi hay gp.
evti
tim do gin bung nh phi. Tng
o
l
y
Fin020@
8. 2php
C. Siu m tim: y l phng
ch yu v chnh xc
0
20 olin
itynh. i vi cc bnh nhn
c
nht chn on hthng

t ot
rig cnPdng siu m qua thnh ngc cn
nh tui c th
ch
y
op
i vi cc Cbnh nhn ln tui, thnh ngc dy, i khi
cn lm siu m qua thc qun.
1. Siu m qua thnh ngc: Mt ct siu m in hnh
quan st l TLN l trc ngn cnh c tri, bn
bung t mm v nht l mt ct di sn.
a. Hnh nh gin tip s thy du hiu gin bung
tht phi v nh phi. Mc gin bung tim phi
ph thuc vo mc dng shunt tri phi hay
kch thc l TLN.
b. Thy hnh nh trc tip ca l TLN trn siu m
2D: bn bung t mm, 4 bung di mi c,
hay trc ngn cnh c tri. Hnh nh TLN th
xoang tnh mch kh thy hn, c bit ngi
ln tui.
478
c. Tm kim s bt thng ca TM phi v TM ch:

TM ch trn tri vo nh phi khng c thn
TM v danh; TM phi lc ch vo TM ch
trn, TM v danh, TM ch di hay nh phi... l
cc bt thng bm sinh c th gp phi hp vi
TLN. Cn quan st bng siu m 2D v c bit
l siu m Doppler mu.
d. nh gi mc ca dng shunt: gin tip thng
qua kch thc tht phi so vi tht tri.
Nu thy t l kch thc tht phi/tht tri t
1/2 n 2/3: TLN l nh.
Nu t l ny t 2/3 n 1: TLN l trung bnh.
Nu t l ny trn 1: TLN l rng.
e. Nn tin hnh o cung lng phi, so snh
d vi
rve
e
s
cung lng ch. Nu tng cung lngrephi nhiu:
ts
TLN c dng shunt tri phi rln.
gh m.vn
i
l .co
Aldng
o chy qua van
f. nh gi p lc MP: bng
.
v
e yaho
o
l
ba l v dng chy qua
in van@ MP (trong TLN p
. F 2020 i mun).
lc MP thng0tng
08 tytng
2 i
t otoc
h
P
g
ri
y
p
Co
Hnh 27-2. Hnh nh thng lin nh trn siu m 2D.

2. Siu m qua thc qun: c p dng vi cc
trng hp thng lin nh m siu m qua thnh ngc
cn cha r. Siu m qua thc qun rt hu ch trong
vic o chnh xc kch thc l thng lin nh cng
nh kch thc cc ra pha trn v pha di ca l
thng chun b bt cc l thng bng dng c.
Siu m qua thc qun cng cn c p dng i
479
vi cc th TLN him gp c bit l TLN th xoang

tnh mch vi bt thng s v ca tnh mch
phi.
3. Siu m cn m: Siu m vi tim cht cn m c
bit rt hu ch cho vic chn on xc nh v loi
tr cc bt thng bm sinh phi hp khc.
d
rve
e
s
e phi.
Hnh 27-3. Hnh nh ra bt cn m trongs rnh
t vn
h
.
g
i
D. Thng tim
ll r o.com
A
o
.
1. Mc ch ca thng tim: loev yah
Fin020@ch yu da vo siu
a. Chn on xc nh
8. TLN
2
0
20 o2D,
ity Doppler, siu m cn m,
m tim (siut m
c
Pot qun). Thng tim c th gip
igh thc
siu myrqua
p
Co vic nh gi mc shunt, ngoi ra cn
ch cho
xc nh chnh xc p lc ng mch phi, o
cung lng ng mch phi, cung lng ng
mch ch...
b. Vit nam do c rt nhiu cc trng hp n
mun nn vic thng tim xc nh chnh xc mc
shunt, p lc MP, t l cung lng QP/QS v
c bit l sc cn mch phi c vai tr quyt
nh xem bnh nhn c cn ch nh phu thut
hay khng. Vi cc bin php th xy, thuc gin
MP lm gim p MP s l nhng nghim php
cui cng quyt nh chn on bnh nhn c
tng p lc ng mch phi c nh (hi chng
Eisenmenger) hay khng ?
480
c. Ngoi ra trong nhng nm gn y, thng tim cn

nhm mc ch ng l TLN bng dng c
qua da (Amplatzer, CardioSeal...).
2. Chp bung tim:
a. Nu l thng thy r trn siu m, c th khng
cn thc hin chp bung tim.
b. Khi c du hiu ca TM phi lc ch, c th
chp MP cho hnh nh r rng v xc nh
lung thng ( th thuc ''chm'' khi mu v TM
phi). L thng lin nh s thy r gc chp
nghing tri 20 n 450 nghing u 250, ng
thng bm thuc cn quang nm tnh mch
phi phi.
ved gi
c. Chp bung tht tri c th thc hin ernh
s
re l. Nu
co bp tht tri v mc h van
ts hai
h
.vn nh tht
g
iccomvan
r
nghi ng thng lin tht v h
l
l o.c
o tri t th
phi hp th cn chp obung
v. A ahtht
e
l
y
thng mt v nghing
0@60 70o, chch u
Fintri
2
.
0
8
khong 250. 200 ity2
c
o
t otbnh
d. Cui cng
nhn c tui (nam hn 40,
P
igh cc
r
y
p
n hn
Co 45), cn chp MV mt cch h thng
xc nh c bnh ng mch vnh phi hp hay
khng.
V. Ch nh iu tr v tin trin
A. ng l TLN c th thc hin bng phu thut tim h vi
tun hon ngoi c th (ng m dc xng c, di
sn hoc sau bn lng). y l phng php iu tr
kinh in c p dng t lu. Hin nay ngi ta c
th ng qua da cc l TLN th pht m cn c g
xung quanh l thng bng cc loi dng c c bit.
B. Ch nh iu tr
1. i vi cc l thng b: ting thi nh, ting T2 tch
i, ng knh tht phi/ tht tri nh hn 2/3 th
cn theo di nh k thng xuyn.
481
2. Vi cc l thng kch thc trung bnh: khng c du

hiu c nng, bloc nhnh phi khng hon ton, t l
ng knh tht phi/tht tri t 2/3 n 1, c tng
ti mu phi trn phim chp Xquang: nu l n gii
th nn phu thut khong nm 15 tui (phu thut
ng ngang di v); nu l nam gii th nn phu
thut lc 5 tui. Nu c kh nng ng qua da bng
dng c (Amplatzer, CardioSeal...) th nn thc hin
ngay khi c th cc l thng loi ny.
3. Vi cc l thng ln: ting T1 mnh, rung tm trng
do tng lu lng, t l ng knh tht phi/tht tri
ln hn: nu c tng p MP cn ng l thng ny
cng sm cng tt. Nu khng tng p MP, ng l
thng mt cch h thng lc tr 5 tui. ved
er
res cn lm
4. TLN nghi ng c tng p MP c tnh:
s
h .vn
igkhi
thng tim chn on. Ch phu thut
cha c tng
r
l
l o.com
A
o
.
p MP c nh, lu lng mch
phi vn tng hn
oev yah
@
lu lng i tun hon F(vn
shunt
tri phi l
inl 2cn
. 20 0
8
0
ch yu) v sc cn20mch
typhi vn cn trong gii hn
oci phc hp Eisenmenger).
t thnh
t
cho php (cha
tr
h
o
P
rig
y
p
5. Tin trin
Co ca TLN thng dung np tt v vy i
khi pht hin bnh rt mun tui trng thnh.
Tng p MP c nh (khng cn ch nh phu
thut) c th gp tui 20 n 30. Suy tim v ri lon
nhp tim c th bt u xy ra tui 30 n 40. Nu
l thng lin nh c ng kn (bng phu thut hay
bng dng c qua da) th c th coi nh bnh nhn
c cha khi hon ton. Ri lon nhp cc bnh
nhn ny l hn hu.
482
C. Phu thut ng TLN vi tun hon ngoi c th t rt

lu tr thnh mt phu thut kinh in. Ty theo kch
thc v v tr ca l TLN m phu thut vin c th
khu trc tip hoc lm ming v bng mng ngoi tim
ng kn hon ton l TLN.
1. Nguy c phu thut lin quan n c a bnh nhn
nh tui, rung nh, p lc ng mch phi v sc cn
mch phi tng cao.
2. Sau m, bnh nhn cn c th b nguy c mc hi
chng sau m mng ngoi tim (hay gp hn cc phu
thut tim bm sinh khc). Ri lon nhp nh c th
vn ko di mt thi gian sau cho n khi kch
thc ca nh v tht phi tr v kch thc bnh
d
thng. Ti mt vi trung tm, thuc chn ebta
rve giao
s
re phng
cm c s dng t 3 n 6 thng sautsm
n
h
g
i om.v
nga cc ri lon nhp nh.
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
y
p
Co
Hnh 27-4. Trc (A) v sau (E) ng l TLN bng Amplatzer.

D. ng l TLN qua da bng dng c l th thut ngy
cng c p dng nhiu nc trn th gii. Ti Vit
Nam phng php ny hin nay c tin hnh
thng quy ti Vin Tim mch Vit Nam. Tt c cc
trng hp TLN l th hai c kch thc khng qu ln
v g xung quanh l ln (hn 5mm) u c kh nng
ng bng dng c qua da di mn tng sng. Phng
483
php ny ngy cng chng minh c tnh hiu qu nh

thi gian nm vin ngn, t au, khng c so m, t bin
chng ngay c nhm bnh nhn c nguy c cao.
Ti liu tham kho
1.
Brecker S,ID. Atrial septal defect. In: Redington A, Shore D,

Oldershaw P, eds. Congenital heart disease in adults: a practical
guide. London: WB Saunders, 1994:103-110.
2. Connelly MS, Webb GD, Sommerville J, et al. Canadian Consensus
Conference on Adult Congenital Heart Disease 1996. Can J Cardiol
l998;14:395-452.
3. Gatzoulis MA, Redington AN, Somerville J, Shore DF. Should atrial
septal defects in adults be closed? Ann Thorac Surg 1996;61:657659.
4. Latson LA. Per-catheter ASD Closure. Pediatr Cardiol 1998;19:86d
93.
rve
e
s
5. Mahoney LT. Acyanotic congenital heart disease:
re atrial and
ts patent
n ductus
ventricular septal defects, atrioventricular canal,
h
g
i om.v
r
l
arteriosus, pulmonic stenosis. Cardiol Clin 1993;11:603-616.
l o.c
o
. ALong-term
6. Mandelik J, Moodie DS, Sterba R, eteval.
follow-up ef
ah
o
l
y
n
@
children after repair of atrial septal
defects.
Cleveland
Clin J Med
i
0
F
8. 202
1994;61:29-33.
0
0 ity defect. In: Marso SP, Griffin
7. Moore JD, Moodie DS.t Atrial
2 tocseptal
h
Po
BP, Topol EJ, reds.
of Cardiovascular Medicine.
ig Manual
y
p
Philadelphia: LippincottRaven,
2000.
Co
8. Perloff JK. Survival patterns without cardiac surgery or
interventional catheterization: a narrowing base. In: Perloff JK,
Child JS, eds. Congenital heart disease in Adults, 2nd ed.
9. Snider AR, Serwer GA, Ritter SB. Defects in cardiac septation. In:
Snider AR, Serwer GA, Ritter SB, eds. Echocardiography in
pediatric heart disease, 2nd ed. St. Louis: Mosby, 1997:235-246.
10. Vick GW. Defects of the atrial septum including atrioventricular
septal defects. In: Garson A, Bricker JT, Fisher DJ, Neish SR, eds.
The science and practice of pediatric cardiology, 2nd ed. Baltimore:
Williams & Wilkins, 1998:1141-1179.
484
Thng lin tht
Ngoi tr bnh van ng mch ch (MC) ch c hai l

van th thng lin tht (TLT) l bnh tim bm sinh hay gp nht,
n chim khong 25% cc bnh tim bm sinh.
Do cc triu chng lm sng c hiu (ting thi tm thu
to vng gia tim) v cc bin chng sm ca n nn thng lin
tht hay c chn on sm t khi bnh nhn cn nh. Chn
on TLT t khi cn trong thai nhi c th thc hin c bng
siu m tim bi cc bc s c kinh nghim.
TLT l nh rt hay gp v thng dung np rt tt. Do
n c th gp ngi trng thnh v c kh nng t ng.
d T
rve
e
s
l t ng li ca cc trng hp TLT l nh trrem
e ln n
ts vn
h
75%. Ngc li TLT l ln s nh hng nhanh
n
.
g
ri com h hp v
l
l
.
p lc ng mch phi (MP) c th tng. Amtoocch
c nh rt
v ah
e
o
l
y
sm t 6 n 9 thng. i vi cc trng
hp
sc
cn
mch phi
Fin020@
.
tng c nh (hi chng Eisenmenger)
08 2 bnh nhn him khi sng
20 ocityhay gp nhm bnh nhn
c qu tui 40. Cc bin

chng
ht ot
rigvimP ni tm mc, p xe no, ri lon
ny l chy mu phi,
y
p
Co chng ca a hng cu. Tin lng s rt
nhp tht v cc bin
km cc bnh nhn c cc biu hin ngt, suy tim xung huyt
v ho ra mu.
Ngi ta nhn thy ngoi nguyn nhn do m b cm trong
ba thng u, TLT hay gp trong cc hi chng bnh l, c bit
l hi chng c ba nhim sc th 21, hi chng do m nghin
ru khi mang thai...
I. Gii phu bnh
A. Phn loi: C rt nhiu cch phn loi gii phu bnh
v TLT khc nhau c t ra nhng nhn chung li c 4
loi TLT chnh v gii phu bnh l: TLT phn quanh
mng, TLT phn c, TLT phn bung nhn v TLT phn
phu (TLT pha trn ca ca Wolff).
485
1. TLT phn quanh mng l loi TLT hay gp nht,

chim khong 70-80% cc trng hp, nm cao
thuc phn mng ca vch lin tht (VLT), ch ni
gia van 3 l v van MC. Tuy nhin n c th dch
chuyn ra sau, ra trc hay xung di mt cht ty
tng trng hp. Tn thng thng phi hp to
thnh mt ti nh di van 3 l hay xung quanh b
van (thng cng c gi l ti phnh phn mng
vch lin tht). N c th gy h van MC v hp
phn thp ca ng ra tht phi. y l loi TLT c
kh nng t ng cao.
2. TLT phn c hay TLT gn mm tim. N c th
bt c v tr no ca phn thp VLT cho n mm
tim. Th bnh ny chim khong 5 n 20%
d cc
rve
e
s
trng hp TLT v cng c kh nng t ng
e cao tr
sr
cc trng hp c nhiu l TLT. right m.vn
o
l
Al hoo.c
.
v
a
oe
inl 20@y
F
8. 0
Hnh 28-1. V tr
00 ity2
2
c
o
gii phu cc loi
t
t
igh Po
r
thng lin tht.
py
Co
3. TLT phn bung nhn hay TLT kiu ng nh tht

chung chim khong t 5 n 8% cc trng hp.
TLT loi ny thng v tr cao ca VLT, rng, t
kh nng t ng v hay i km tn thng ca cc
van nh tht. Hay gp phnh vch lin tht v tr ny.
486
4. TLT phn phu hay TLT di van MC hoc

di van MP: him gp hn (5 n 7%), l loi
TLT m l thng nm phn rt cao ca vch lin
tht ni c tip gip vi van MC v van MP (nn
cn c gi l thng lin tht kiu ''di cc i
ng mch''). im c bit quan trng ca loi TLT
ny l l thng thng phi hp vi tn thng l van
MC v c h ch i km (hi chng Laubry-Pezzy).
B. Cc tn thng khc phi hp c th gp: hp van MP,
hp trn van MP, h 3 l, thng trc tip t tht tri
sang nh phi, mng ngn di MC
II. Sinh l bnh
A. Lung thng ca shunt c lu lng ph thuc vo
kch
ved
thc l TLT v sc cn h MP cng nhrep
ser lc tht
n tri v
hts .vnh
phi. Lung shunt s gy ra qu ti igphi,
r
m
o
l
l .c
tht tri.
v. A ahoo
e
o
y
B. Din bin xu dn s l tngFp
inlMP
0@ gy suy tim phi v
2
.
0
2 Eisenmenger (tng sc
v sau s chuyn thnh 0hi
08 chng
2 ocity
tdo bnh
cn ca mch phi
l MP tc nghn c nh
t
igh Po
rshunt
y
lm gim dng
tri
phi, lm tng dng shunt

op
C
phi tri).
A. Triu chng c nng: hay gp nht bnh nhn ln
tui l kh th, mt kh nng gng sc. Cc triu chng
thng lin quan n mc ca lung thng tri
phi, p lc v sc cn ca ng mch phi.
B. Triu chng thc th: Nghe tim l du hiu ch yu
chn on. Thng nghe thy c ting thi ton tm
thu, cng mnh cnh c tri, tng i thp v lan
ra tt c xung quanh. Ting thi ny c th nh hn
nhng c m sc cao hn trong cc trng hp l thng
nh phn c v c th ch lan ra mm hay sang tri nu
l TLT mm tim. Nu l TLT qu ln, c th nghe thy
487
C. Chn on phn bit trn lm sng vi h van ba l,

t chng Fallot khng tm (Fallot trng), hp di van
ng mch phi n thun v bnh c tim ph i.
A. in tm (T): thy hnh nh tng gnh bung
tim tri vi dy tht tri, dy nh tri. Trc tri hay gp
trong cc trng hp TLT phn bung nhn hoc ng
ed nh
erv
tht chung. Dy tht phi v trc phi gprestrong
cc
s
t
n
h
trng hp tng gnh bung tim phi vi
.v p ng
g tng
l ri .com
l
mch phi.
A o
ev. yaho
o
l
B. Chp Xquang tim phi Fin 0@
. 202
08htymch
0
1. Hnh tim khng to
v
phi bnh thng hay
2 toci
t
h
o
thy cc trng
hp
P TLT l nh khng gy tng p
rig
y
p
ng mch
phi.
Co
2. Tim to va phi vi gin cung di tri. i khi thy
du hiu gin cung MP. Tng ti mu phi hay
gp cc bnh nhn c lung thng tri phi ln.
3. Bng tim khng to nhng c du hiu huyt phi
nhiu thng gp trong cc trng hp TLT l rng
c tng sc cn mch phi c nh (hi chng
Eisenmenger).
C. Siu m tim
1. Hnh nh gin tip: Kch thc bung tim tri v
thn MP u gin.
2. Hnh nh trc tip ca l TLT trn siu m 2D:
mt ct trc di cnh c tri (TLT phn phu); mt
ct qua cc gc ng mch (TLT quanh mng, phu);
488
mt ct di c, bn bung t mm (TLT phn c,

quanh mng v bung nhn).
Hnh 28-2. TLT phn quanh mng: mt ct cnh c trc

ngn (hnh tri) v mt ct 5 bung tim t mm (hnh phi).
3. nh gi mc ca dng shunt: dng shunt
ed tri
v
r
e
phi ln khi gin bung nh tri, tht tri
res v MP.
tspvnlc MP
o chnh p qua l TLT nh gi
h
ig om.
ll r ophi)
c
(nu khng c cn tr ng raAtht
v mc
o.
v. aht
e
bnh. Nu chnh p cn ln
chng
l
thng
nh v
o
inl 20@y
F
khng c qu ti tim phi.
0 nh o huyt p ng
8. 2Cn
y
00 Doppler
t
2
i
mch khi lm siu
m
tim.
t otoc
h
P
g
ri hp p lc MP tng c nh: thnh
4. Trong trng
opy
C
tht phi dy, dng chy qua l TLT yu hoc hai
chiu, p lc MP tng nhiu gn bng hay vt p
lc i tun hon.
5. Siu m Doppler tim cn cn phi loi tr cc tn
thng phi hp nh thng lin nh, cn ng ng
mch, h ch, cn tr ng ra tht phi v tht tri.
D. Thng tim
1. Ch nh:
a. Cc trng hp TLT vi cc du hiu qu ti ca
tht tri (tim to, thi tm trng mm tim, suy
tim huyt) hoc tng p MP m cn phi c
cc bng chng khng nh mc lung shunt,
489
b. Cc trng hp TLT vi nghi ng c cc tn

thng khc phi hp nh h ch, hp ng ra
tht phi, hp di van MC... cng l cc trng
hp c th ch nh thng tim.
c. Thng tim ng l TLT bng dng c
(Amplatzer, Coil, Buttoned device...).
2. Chp bung tim:
a. Chp bung tht tri s gip xc nh chnh xc
v tr, kch thc ca l thng lin tht v c bit
gip cho chn on thng lin tht c nhiu l.
T th chp hay dng nht l nghing tri 45 vedthng
700, nghing u 250. Tuy nhin ty loierl
s
re
c th thay i cht t. TLT kiuhtsquanh
mng:
vn
.
0 ig
r
thy r nghing tri 60-45ll. TLT
omphn c, ra
A 45
o0..cTLT kiu di
o
.
pha trc chp nghing
tri
h
v
loe @ya
cc gc ng mch. ln
0 t th nghing 900
Fin0chp
2
08 2
v nghing phi.
20 ocity
ht ot
b. Chp MC
rig Pxc nh c h ch phi hp hay
y
p
khng?
Co c bit trong cc th TLT kiu di cc
gc ng mch, hi chng Laubry - Pezzy.
c. Chp bung tht phi xc nh xem c hp ng
ra tht phi khng, c h van ba l khng v xem
c phi ch vo ca dng shunt trc tip vo
tht phi hay khng.
V. Ch nh iu tr v tin trin
A. iu tr ni khoa
1. TLT vi tng p MP nhiu tr nh cn c iu
tr bng li tiu, tr tim v gim tin gnh trc khi
phu thut.
2. Sau phu thut v cc trng hp cha phu thut
(hoc khng cn phu thut) cn phng bin chng
490
vim ni tm mc nhim khun (rt d xy ra vi cc

trng hp TLT).
B. ng l thng qua da bng dng c
Hin nay c th ch nh cc trng hp TLT l nh
phn c, mm hoc sau NMCT c bin chng. Tng
lai nhiu loi dng c ang c nghin cu ng
TLT phn quanh mng-bnh bm sinh c tn sut gp
cao nht.
C. iu tr ngoi khoa
ng l TLT c th thc hin bng phu thut tim h vi
tun hon ngoi c th (ng m dc xng c). Cn
lu c mt t l kh ln l TLT c th t ng rli.
ved
e
s
e
s r MP
1. i vi cc l thng b, shunt nh, phtlc
bnh
vn
.
g
i
r
l .com hng nm,
thng cn theo di nh k thng
Al hoxuyn
o
.
v
e ynhim
a
o
phng chng vim ni tm
mc
khun. Nguy
l
in 20@
F
. 0 h ch (TLT phn phu)
c gp nhm ny l08Osler,
0 ity2
2
v hp phn phu
t MP
toc (TLT phn quanh mng).
igh Po
r
py lin tht ln s nh hng r n ton
2. Khi l thng
Co
trng tr di 6 thng: iu tr ni khoa vi li tiu,
tr tim, c ch men chuyn. Nu khng p ng vi
iu tr ni th cn ng l TLT.
3. Khi l TLT ln, nh hng r n ton trng tr
trn 6 thng th cn phu thut ng l TLT.
4. Khi l thng ln, c tng p MP trn 50mmHg tr
hn 6 thng: phu thut ng l TLT.
5. Khi l TLT phi hp vi h van MC va hoc hp
ng k ng ra tht phi th cn phu thut ng l
TLT.
491
6. Nu TLT c nhiu l, c nh hng n ton trng

th cn lm phu thut nh ai (banding) MP cc
tr nh di 6 thng v sau phu thut sa cha
ton b.
Tin trin ca TLT nu c ng kn (bng phu
thut hay ng l thng qua da) c th coi nh bnh
nhn c cha khi hon ton. Ri lon nhp cc
bnh nhn ny l hn hu nh bloc nh tht sau phu
thut.
7. Cc trng hp TLT nghi ng c tng p MP c
nh: cn thng tim vi nghim php th xy v
thuc gin mch, chp mao mch phi, o sc
d cn
rve
e
s
mch phi v cui cng c th sinh thitre phi. Nu
n
hts .vth
sc cn mch phi khng tng crignh
c th
m
o
l
l o.c
A
o
.
phu thut, nu tng c nh
v thh l mt chng
loe @ya
n
i
0 trng hp nghi ng
ch nh ca phu thut.
F Trong
8. 202
0
y
0
t MP v lm li cc thm
c th phu thut nh
2 iai
t otoc
h
P
g
d sau virinm. i vi cc trng hp khng cn
opy na th thng din bin c th nng ln
ch nhCm
bng cc du hiu suy tim phi, hn ch gng sc, a
hng cu vi biu hin tm nhiu da v nim mc.
Cc bin chng c th gp l chy mu phi, pxe
no v t t. Gii php iu tr ch ng duy nht
trong trng hp ny l phu thut ghp c tim v
phi cho ngi bnh.
Ti liu tham kho
1.
Brecker SJD. Ventricular septal defect. In: Redington A, Shore D,

492
2.
Bridges ND, Perry SB, Keane JF, et at. Preoperative transcatheter

closure ofcongenital muscular ventricular septal defects. N Engl J
Med 1991;324:1312-1317.
3.
Connelly MS, Webb GD, Sommerville J, et at. Canadian Consensus

1998;14:395-452.
4.
Ellis JH, Moodie DS, Sterba R, Gill CC. Ventricular septal defect in
the adult: natural and unnatural history. Am Heart J 1987;114:115120.
5.
Folkert M, Szatmari A, Utens E, et at. Long-term follow-up after

surgical closure of ventricular septal defect in infancy and
childhood. J Am Coll Cardiol 1994;24:1358-1364.
6.
ed
rv
Gumbiner CH, Takao A. Ventricular septal defect. In:seGarson
A,
re
g
ri com.
lWilliams
l
pediatric cardiology; 2nd ed. Baltimore:
& Wilkins,
.
v. A ahoo
e
o
l
y
1998:1119-1140.
Fin020@
.
7. Lock JE, Block PC, McKay
08RG, 2et at. Transcatheter closure of
20 ocity
ventricular septal defects.

1985;78:361-368.
ht Circulation
Pot
rig
y
p
8. Mahoney LT. oAcyanotic
congenital heart disease: a trial and
C
Bricker JT, Fisher DJ, Neish SR, eds. The science
htsandvnpractice of
ventricular septal defects, atrioventricular canal, patent ductus

9.
Moore JD, Moodie DS. Ventricular septal defect. In: Marso SP,
10. O'Fallon MW, Weidman WH, eds. Long-term follow-up of

congenital aortic stenosis, pulmonary stenosis, and ventricular septal
defect. Report from the Second Joint Study on the Natural History of
Congenital Heart Defects (NHS-2). Circulation 1993;87[Suppl II]:II1-II-126.
11. O'Laughlin MP, Mullins CE. Transcatheter closure of ventricular
septal defect. Catheter Cardiovasc Diagn 1989;17:175-179.
493
12. Perloff
JK.
Survival
patterns
without
cardiac
surgery
or

Child JS, eds. Congenital heart disease in adults, 2nd ed.
pediatric heart disease, 2nd ed. St. Louis:Mosby, 1997:246-265.
14. Somerville J. How to manage the Elsenmenger syndrome. Int J
Cardiol 1995;63:1-8.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
494
Cn ng ng mch
Cn ng ng mch (COM) (TBS) chim khong 10%

cc bnh tim bm sinh (1 trong 2000 n 5000 tr s sinh).
Dng shunt thng nh v t triu chng lm sng, tr khi c
bin chng.
Din bin t nhin ca bnh ph thuc vo kch thc ca
ng ng mch v mc dng shunt triphi. Nu khng
c iu tr c th dn n suy tim huyt do qu ti bung
tim tri. Trong thc t rt t gp ng ng mch t ng sau khi
tr ra i (tr cc trng hp rt sm) m thng phi ng ng
bng phu thut hay ng qua da bng dng c. Nu ng
ed ng
v
r
e
mch qu mun m cha c can thip nh ngi
es trng
sr n
tnh
thnh th c th gp cc ri lon nhp nh cung
hoc rung
h
ig om.v
r
l
l cn
nh, vim ni tm mc nhim khun, tng sc
.c mch phi c
v. A ahoo
e
nh (hi chng Eisenmenger).
o
l
y
Fin020@
.
I. Gii phu bnh
08 2
20 ocity
t ot mch s t ng t gi th 15
hng
A. Thng thng ng
P
rig
y
p sau khi sinh. Cc yu t thc y vic
n gi thCo16
ng ng ng mch l p lc ring phn ca xy trong
mao mch phi tng, gim nng prostaglandine lu
hnh trong mu do tng chuyn ha tun hon phi v
do cc hiu ng nhau thai gy ra. Cc yu t ny c th
ko di tc dng n ngy th 21 sau khi sinh nhng nu
cn thy tn ti ng ng mch sau 3 thng tui th gn
nh chc chn ng ng mch khng th t ng, tr
mt s rt him cc trng hp t ng ng ng mch
do phnh ng bnh nhn c tui v thng sau vim ni
tm mc nhim khun.
B. V gii phu, ng ng mch nm quai MC ngay ch
chia ra ca ng mch di n tri v c vo thn
hoc MP tri. ng ng mch thng c chiu di thay
i v c th phi hp vi gin MC khi MC quay
495
phi, ng ng mch c th xut pht t pha trc ni

hnh nh soi gng ca thn ng mch khng tn tri
hoc t pha sau ng mch di n tri bt thng
hoc him gp hn l t quai MC bn tri.
II. Sinh l bnh
A. Lung thng ca ng ng mch thng nh, nhng i
khi lung thng ln c th gy qu ti phi v tng gnh
nh tri, tht tri. Cui cng c th dn n huyt phi
v suy tim huyt, tng p MP, hi chng
Eisenmenger.
B. Rt hay gp hin tng huyt phi, d dn n vim
phi v c th gy Osler bt k loi ng ng mch
no. N cn lm gim p lc tm trng ca ngedmch
rv
ch do hiu ng ca dng pht ngc tm trng.
ese
r
hts .vn
gMC
C. Tn thng phi hp hay gp l: Hp
bm sinh,
i
r
ll o.com
A
hp eo MC. Nu c TLT phi hp:
c
th
che
lp ting
o
.
ev yah
o
l
tm trng ca ting thi lin
in tc@ do thi tm thu ca
. F 2020
8MC
TLT qu to. Khi hp eo
phi hp hp MP: hi
0
20 ocity
chng Rubella. ght Pot

ri
py
III. Triu chng lm
Co sng
A. Triu chng c nng: Cng nh cc bnh tim bm
sinh khng tm khc, ng ng mch rt t cc triu
chng c nng c hiu. Cc du hiu c th gp l gim
kh nng gng sc, kh th...
B. Triu chng thc th
1. Nghe tim l du hiu ch yu chn on:
a. Nghe thy c ting thi lin tc cng ln
di xng n bn tri. Ting thi ny c th
ch c trong th tm thu, hi ko di ra trong th
tm trng trong cc trng hp ng ln v c
tng p MP nhiu. Ngoi ra c th nghe thy
ting thi nh trong cc trng hp ng nh.
496
tr s sinh, ting thi thng v tr thp v

thng ch c th tm thu.
b. C th nghe thy ting rung tm trng do tng
lu lng mu qua van hai l.
c. Nu lung shunt ln gy tng p MP th c th
thy ting thi nh i, khng ko di v c ting
th hai mnh ln.
2. Mch ngoi bin ny mnh v chm su, hay gp
du hiu ny khi dng shunt tri phi ln.
3. Mm tim xung thp v sang tri do gin bung tim
tri. Nu bnh nhn c tng p MP, tht phi s
gin vi mm tim sang phi.
C. Chn on phn bit: vi d ng-tnh mched phi,
rv
d ng mch vnh vo cc bung tim bn phi,
ese d ng
r
hts .vn thng
tnh mch h thng, v ti phnh xoangigValsalva,
r
om tun hon
ll o.chp,
lin tht vi h van ng mch ch
Aphi
o
.
h
v
athng lin tht vi
oe
bng h ch-phi cc bnhnlnhn
i 20@y
F
thiu sn van ng mch0phi...
8. 0
0 ity2
2
t on
IV. Cc xt nghim chn
toc
igh Po
r
opy (T): thng khng c hiu, c th
A. in tm C
thy hnh nh tng gnh bung tim tri vi trc tri v
dy tht tri. Ph i tht phi c th thy giai on
mun vi tng p MP nhiu.
B. Chp Xquang tim phi: tim to va phi vi gin cung
di tri. i khi thy du hiu gin cung MP. C th
thy gin nh tri vi hnh nh hai b. Hnh nh tng ti
mu phi cng hay gp. Phim Xquang c th cho ta thy
s b mc nh hng n huyt ng ca bnh.
C. Siu m Doppler tim
1. Hnh nh trc tip ca ng ng mch trn siu m
2D thy c mt ct trn c v qua cc gc ng
mch ln. o ng knh v nh gi hnh thi ca
ng. Siu m Doppler mu xc nh chnh xc v tr
497
vo MP ca ng ng mch. nh gi chnh p
qua ng ng mch bng siu m Doppler, t xc
nh mt cch gin tip p lc ng mch phi (cn
o huyt p ng mch khi lm siu m tim). Quan
st quai MC tm cc tn thng phi hp.
2. Hnh nh gin tip: Gin bung tim tri v MP c
th gp trng hp ng ng mch c shunt ln.
d
rve
e
s
re cnh c
Hnh 29-1. Hnh nh ng ng mch: mt
ts ct
h
.vn
g
i phi).
trc ngn (hnh tri) v mt ct hm trn c (hnh
r
m
o
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
Hnh 29-2. Dng
t ot
h
P
g
chy qua ng ng
ri
py
mch trn siu m
Co
Doppler mu.
3. nh gi mc ca dng shunt: dng shunt

tri phi ln khi thy gin bung nh tri, tht tri
v thn MP. Cn nh gi p lc MP tng c
nh cha, dy ca thnh tht phi, dng chy qua
ng ng mch yu hoc hai chiu, p lc MP tng
nhiu gn bng hay vt p lc i tun hon.
498
D. Thng tim
1. Ch nh thng tim: Khi khng thy ng ng mch
trn siu m tim mt bnh nhn c ting thi lin
tc hoc cn ng ng mch nhng p lc MP tng
nhiu trn siu m Doppler tim. Ngoi ra thng tim
cn ng ng ng mch qua da bng dng c
(Coil, Amplatzer...).
2. Cc bc tin hnh thng tim:
a. Thng tim phi theo cc phng php kinh in
(nh trong thng lin nh): ng thng ln MP
thng d dng qua ng ng mch xung MC
xung (nu thng tim theo ng TM di n
phi s thy hnh ch kinh in). Nu gp kh
ed ly
khn c th dng dy dn iu khin.
rvKhi
e
s
re
mu mu cn phi ly on xa hca
ts vcc
n nhnh
.
g
i
r
MP do dng shunt thngllchy
lch, nn
om
A hoo.c
.
v
bo ho xy thn v on
gn
ca
MP khng
loe @ya
n
i
0 c nh ca MP.
phn nh ng bo. Fho02xy
08 ty2nhiu c th s dng cch
0
Nu c tng p
MP
2 toci
ht Pmch
o
ng ngigng
tm thi bng bng v theo
r
y
p
di p
lc
MP
trong
khi bm bng, nu p lc
Co
h xung tt th c th ch nh ng ng ng
mch.
b. Thm d huyt ng:
Thy c bc nhy xy MP. o QP/QS vi
bo ho xy on xa ca MP. a s
cc trng hp ALMP thng bnh thng,
i khi ng ng mch ln c th dn n
tng ALMP. Trng hp p lc qu cao c
th lm nghim php ng ng tm thi bng
bng c l bn (ng thng u c gn bng,
on gn u c l bn theo di p lc).
Trong hi chng Eisenmenger c s o
chiu dng shunt t phi tri, bo ho
499
xy MC xung s thp hn MC ln,

lc ny khng cn ch nh ng ng.
c. Chp bung tim: bng cch bm trc tip thuc
cn quang vo ng ng mch t th ngang 900.
Nu nghi ng hp eo MC cng chp MC t
th ny. ng ng ng mch cng dng t th
ny nhng bm thuc t MC sang MP.
V. Ch nh iu tr
1. Ch nh ng ng ng mch l bt buc nu cn
dng shunt tri phi.
2. ng bng thuc: s dng prostaglandine trong cc
d
trng hp tr s sinh (bit dc l Indocid 0,2mg/kg
rve
e
s
re
c th tim nhc li sau 8 gi). Cn ch
ts vn l thuc
h
.
g
i rut.
cng c th gy suy thn hoc hoi
om
l rt
l
c
.
. A ahoo
oev C
3. ng qua da bng dngnlc:
th dng coil hay
i 20@y
F
. mi
0 khc nh: Amplatzer,
cc loi dng c th08h
0 ity2
2
Buttoned Device,
Coil thng c ch
t CardioSeal...
toc
igh Po
r
nh trong
cc trng hp ng ng mch kch thc
py
Co
b trn phim chp (di 4mm). Cn cc dng c
khc dc bit l Amplatzer th rt tt cho cc trng
hp ng ln, ngn.
Hnh 29-3. ng ng ng mch bng Amplatzer.

4. ng ng ng mch bng phu thut theo ng
bn sau ca lng ngc. Hin nay ti Vit Nam vn l
phng php iu tr ch yu nhng trong tng lai
500
gn y th ch l phng php c la chn th hai

sau khi khng ng c ng qua da hoc khi c cc
d tt bm sinh khc phi hp cn phu thut.
5. Phng vim ni tm mc nhim khun cn ko di
6 thng sau khi ng ng bng phu thut hay bng
dng c qua ng ng thng.
Ti liu tham kho
1.
Burke RP, Wernovaky G, van der Velde M, et al. Video-assisted

thoracoscopy surgery for congenital heart disease. J Thorac
Cardiovasc Surg 1995;109:499-505.
2.
Connelly MS, Webb GD, Sommerville J, et al. Canadian Consensus
d
Conference on Adult Congenital Heart Disease 1996. CanrvJeCardiol
e
res
s
t
gh m.vn
3. Fisher RG, Moodie DS, Sterba R, Gill CC. lPatent
arteriosus
l ri .coductus
A hoo
.
v
a
in adults: long-term follow-up-nonsurgical
versus surgical
oe
inl 20@y
F
management. J Am Coll Cardiol
0
8.1986;8:280284.
00 ity2
2
4. Harrison DA, Benson LN,
oc C, et al. Percutaneous catheter
t Lazzam
gh Pot
i
r
closure of the persistently
patent ductus arteilosus in the adult. Am J
opy
C
Cardiol 1996;77:1084-1097.
1998;14:395-452.
5.
Ing FF, Mullins CE, Rose M, et al. Transcatheter closure of the

patent ductus arteriosus in adults using the Gianturco coil. Clin
Cardiol 1996;19:875-879.
6.
Mahoney LT. Acyanotic congenital heart disease: atrial and

ventricular septal defeczs, atrioventricular canal, patent ductus
7.
Moore JD, Moodie DS. Patent ductus arteriosus. In: Marso SP,
8.
Mullins CE, Pagotto L. Patent ductus arteriosus. In: Garson A,

Bricker JT, Fisher DJ, Neish SR, eds. The science and practice of
501
pediatric cardiology, 2nd ed. Baltimore: Williams & Wilkins,

1998:1181-1197.
9.
Perloff
JK.
Survival
patterns
without
cardiac
surgery
or

10. Schenk MH, 0 Laughlin MP, Rokey R, et at. Transcatheter occlusion
of patent ductus arteriosus in adult patients. Am J Cardiol
1993;72:591-595.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
502
Bnh van ng mch phi
Van ng mch phi l van t chim ngn cch ng mch

phi vi tht phi. Ri lon hot ng van ng mch phi s
gy tc ng c hi ln chc nng ca tht phi. Bnh thng, t
l h van ng mch phi pht hin bng siu m Doppler tim
ngi bnh thng kh cao, song ch c mt s t bnh l van
ng mch phi (h hoc hp) thc s gy nh hng n tnh
trng huyt ng ca tim phi v gy ri lon chc nng tht
phi.
I. Hp van ng mch phi n thun (HP)
d
A. Triu chng lm sng
rve
e
s
re gng sc
1. Cc triu chng suy tim phi v kh th
tskhi
h
.vn
g
i omkhng
r
thng xut hin tui 30-40 nu
bnh
c
l
Al hoo.c
.
v
pht hin v iu tr t trc.
a
oe
inl 20@y
F
. 20 thi tm thu tng mu
2. Triu chng in hnh
08ltyting
0
2
khoang lin sn
oci tri, gim cng khi ht
t ot3-4
h
P
g
vo (do gim
ri chnh p qua van ng mch phi)
py
o
C
ng thi gim cng hoc mt hn ting T2.
3. Triu chng suy tim phi biu hin giai on mun.
B. in tm
1. Hnh nh in tim bnh thng nu HP nh.
2. Trc phi, dy tht phi khi HP mc t va-nng.
Mc dy tht phi trn in tim c lin quan kh
cht vi mc nng ca HP. Trng hp hp kht
van MP, c th gp hnh nh dy nh phi.
C. Chp tim phi: bng tim khng to, cung ng mch
phi phng r (gin MP sau hp), mu ln phi t. Bng
tim s to khi c suy tim.
D. Nguyn nhn
503
1. Hp van ng mch phi bm sinh l dng bnh l

hay gp nht (chim t l 10% trong s cc bnh tim
bm sinh).
2. Di chng thp tim: dnh mp van gy hp van. Cn
lu rng van ng mch phi l van t b nh hng
nht do bnh thp tim.
3. Hp th pht do hi chng u carcinoid gy thm
nhim l van MP.
4. Gi hp van ng mch phi trong trng hp tc
nghn ng tng mu tht phi do u trong tim hoc
ti phnh xoang Valsalva.
E. Chn on:
d
1. Siu m Doppler tim rt c gi tr chn on
rve xc
e
s
re phi.
nh v lng gi mc hp van ngtsmch
h
.vn ct trc
g
ri commt
a. Van ng mch phi thy r llnht
.
ngn cnh c tri hoc di
hoo Nu hnh nh
v. Asn.
e
a
o
l @y
qua thnh ngc c .cht
km, c th dng
0
Fin02lng
2
08 tyqun.
siu m tim qua20thc
oci
t ottim
h
b. Siu m Doppler
cho php nh gi tnh trng
P
g
ri
y
p
o
van Cng
mch phi (van dy, vi, hn ch vn
ng ngi ln; l van khng vi, m dng vm
tr con) v tht phi (bnh thng hoc ph i
ph thuc vo mc hp van ng mch phi
v thi gian b bnh).
2. Mc hp van ng mch phi c phn loi da
trn chnh p ti a nh-nh qua van ng mch
phi o bng ph Doppler lin tc (tnh theo cng
thc ca Bernoulli). Hin ti, siu m Doppler tim
c xem nh mt phng php chun nh gi
mc hp van (tng quan rt cht so vi tiu
chun vng l thng tim). Hp van MP chia thnh
cc mc nh sau:
a. Hp nh: khi chnh p ti a qua van MP < 40
mmHg
504
b. Hp va: khi chnh p ti a t 40 n 80 mmHg

c. Hp kht (nng): khi chnh p ti a 80 mmHg.
F. iu tr
1. Hp van ng mch phi mc t nh n va c
tin lng rt tt v rt t khi cn can thip.
2. Hp van ng mch phi nng hoc suy tim phi th
pht thng biu hin sau tui 40 hoc 50 d c
nhiu dng bnh biu hin ngay t nh. Phng php
iu tr chnh l nong van ng mch phi bng bng
qua da, c kt qu kh quan, ni chung gim c
75% chnh p qua van. Tin lng lu di v t l
sng cn sau can thip hon ton ph thuc vo tnh
trng chc nng tht phi khi nong van.
d
rve
e
s
3. Hp van ng mch phi th pht dorehi chng
ts vnsng st
carcinoid c tin lng rt xu (thi
gh gian
i
r
m.
o
l
l
c
.
trung bnh sau khi chn on
A bnh
oo ch c 1,6
ev. yvi
ah nong van bng
o
l
nm), hu nh khng p
ng
Fin020@
8. thay
bng nn ni chung phi
2 van.
0
20 ocity
t ot(HoP)
II. H van ng mch
hphi
P
rig
y
p
A. Triu chng
Co lm sng
1. Thng c biu hin kh th khi gng sc v triu
chng ca suy tim phi.
2. Nghe tim:
a. Thi tm trng m sc thp, nghe r nht
khoang lin sn 3-4 tri km T2 tch i, tng
ln khi ht vo v nu c tng p ng mch phi
th T2 mnh.
b. Ting thi ca Graham Steell l ting thi tm
trng gim dn v cng , c m sc cao, xut
hin ngay sau ting T2, l ting thi in hnh khi
p lc ng mch phi vt qu 70 mmHg ng
thi c h van MP.
505
3. Ngoi ra c th pht hin c cc triu chng ca

suy tim phi.
B. Nguyn nhn
1. Khc vi hp van, h van ng mch phi rt t khi
do nguyn nhn bm sinh nh khng c l van, thiu
sn hay thng l van MP.
2. Thng gp l cc bnh tim mc phi gy h van
ng mch phi: hng u l hp van hai l, u nhy
nh tri gy tng p lc ng mch phi, sau l do
vim ni tm mc nhim khun. U carcinoid hoc
thp tim cng c th gy HoP song thng gy hp
van nhiu hn. Cn gp HoP th pht trong hi
d
chng Marfan do gin ng mch phi.
rve
e
s
re
ts tim.
n
C. Chn on: ch yu bng siu m Doppler
h
g
i om.v
r
l
.c
Al nht
1. Van ng mch phi nhn thy
hoo mt ct trc
v. r
e
a
o
l @y a s ngi bnh
ngn cnh c tri hoc di
0
Fin02sn.
.
08 ty2pht ngc nh do h van
thng u c mt20dng
i
nh.
t rt
toc Dng HoP ny ch c coi
ng mch phi
h
o
P
g
ri
l ng Ck
opykhi pht su vo tht phi 1-2 cm v ko
di 75% thi k tm trng. Doppler xung cng c
th dng thm d dng pht ngc trong thi k
tm trng.
2. Khng gim vn tc dng h trong thi k tm
trng l du hiu gi tng p lc ng mch phi
gy ra h van. Biu hin khc ca tng p lc ng
mch phi trn siu m tim l hin tng mt sng a
v s ng nh van MP gia tm thu trn siu m
TM cng nh trn ph Doppler dng chy qua van.
3. p lc MP tm thu c th c tnh da trn ph
Doppler ca dng h van ba l. p lc MP cui tm
trng (ALMPCTTr) c th tnh c khi ghi c
ph ca h van ng mch phi, da theo cng thc:
506
ALMPCTTr = 4(VPR-E)2 + ALTP

Trong ALTP l p lc tht phi v thng = 10
mmHg; VPR-E l vn tc dng HoP cui tm trng.
Tng t nh vy, ta cng c th tnh c p lc
trung bnh ca MP (ALMPTB) cn c vo vn tc
u tm trng ca dng h phi da theo cng thc
sau:
ALMPTB = 4(VPR-P)2 + ALTP
Trong ALTP l p lc tht phi v thng = 10
mmHg; VPR-P l vn tc dng HoP u tm trng.
4. Hin tng gim vn tc dng h phi k tm
trng thng gi c d dng ca van MP.
d
rve
e
s
D. iu tr
re
ts vn
h
g
1. H van ng mch phi tin pht
m. lng rt
l ric.cotin
l
A hootht phi.
tt, t khi cn x tr tr phi gy
ev.raysuy
a
o
l
in 20@
F
2. H van MP th pht:
. tin lng hon ton ph
08 ty20
0ca
2
i
thuc vo din bin
t otoc bnh chnh nh hp van hai
h
P
g
l kht, vim
rini tm mc nhim khun, u carcinoid,
py
o
C
tng p lc ng mch phi... iu tr ngoi khoa
bng thay van hoc sa vng van ng mch phi ch
c p dng trong mt s trng hp rt hn hu.
III. Ti liu tham kho
1.
2.
3.
4.
Braunwald E. Heart disease: a textbook of cardiovascular medicine,

5th ed. Philadelphia: WB Saunders; 1997.
Cheitlin MD, MacGregor JS. Acquired tricuspid and pulmonary
valve disease. In: Topol EJ, ad. Textbook of cardiovascular
medicine. Philadelphia: Lippincott-Raven Publishers, 1998:557-578.
Feigenbaum H. Echocardiography, 5th ed. 1994. Baltimore:
Williams & WilkinB.
Reynolds T. The echocardiographer's pocket reference. Arizona
Heart Institution Foundation, 1993:23-29.
507
5.
6.
Topol EJ, ad. Textbook of cardiovascular medicine. Philadelphia:

Weyman AE. Principles and practice of echocardiography, 2nd ad.
Philadelphia: l,ea & Febiger, 1994:chapter 26, 824-862.
ved
er
res
s
t n
ighom.v
r
l
l .c
v. A ahoo
e
o
l
y
Fin020@
.
08 2
20 ocity
ht Pot
rig
py
Co
508
T chng Fallot
T chng Fallot l bnh tim bm sinh c tm hay gp nht,

chim khong 10% cc bnh tim bm sinh. C th chn on
c bnh ny t trc khi sinh bng siu m tim thai.
Din bin t nhin ca bnh thng l tm ngy cng tng,
i khi c cn mt xu. Chn on lm sng hay da vo cc du
hiu tm da, ting thi cao ca hp ng mch phi, phi sng
v tng gnh tht phi. Siu m tim thng gip khng nh chn
on.
Phu thut sa ton b c kt qu tt tr t 6 n 9
thng. Phu thut sa ton b hoc lm cu ni cp cu
dtrong
rve
e
s
trng hp c cn xu, ngt do thiu oxy. T l t vong
re khi phu
ts vn
h
thut thp, tin lng tt.
.
g
l ri .com
l
T chng Fallot l bnh tim bm esinh
hoo i km vi cc
v. A ahay
o
l
y
n 0@n: hi chng nhim
tn thng ngoi tim. C th c linFiquan
8. 202 hi chng Cardiofacial,
c ru bo thai, hi chng Goldenhar,
0
0 ity
2 21
oc
tth
hi chng c 3 nhim sc
h
Pot (thng i cng vi ng nh
ig
r
y tnh cht gia nh.
tht chung) v c thopc
C
I. Gii phu bnh
A. T chng Fallot gm 4 chng
Hp ng ra ca ng mch phi (MP).
Thng lin tht (TLT).
ng mch ch (MC) lch sang phi v ci
nga ngay trn l thng lin tht.
Ph i tht phi.
1. Trong s cc chng ny th 2 "chng" quan trng
nht l hp ng ra ca MP v TLT. Hp ng ra
MP c rt nhiu th nhng bao gi cng c hp
phn phu MP. Hp c th di hay ngn, cao hoc
thp, kht hoc va. Ngoi ra c th hp ng ra
MP phi hp vi hp van MP, hp trn van v cc
509
nhnh MP. C th hp va hoc hoc rt kht, thm

ch thiu sn nhnh MP. L TLT trong Fallot 4
thng rt rng, b ca c, ngay pha di ca ca
Wolf (loi quanh mng chim khong 80% cc
trng hp).
2. Chnh do 2 thng tn hp MP v TLT ny s dn
n ph i tht phi, dng shunt t phi tri s c
xu hng ko ng mch ch lch sang phi v dn
dn "ci nga" trn l TLT. Mc lch phi ca
MC ph thuc vo 2 yu t: kch thc ca MC
v kch thc ca l thng lin tht (t l thun vi 2
thng s ny).
B. Cc thng tn phi hp
d
1. MC quay phi (25% cc trng hp).
rve
e
s
re
2. Hp MP (10 - 20%).
ts vn
h
.
g
ri combng
3. Thiu sn MP vi nhiu tunll hon
h (5.
A hoo
.
v
10%).
loe @ya
in10%).
F
4. TLT phn c phi hp8(5
20
.
0 ty20
0
5. Tun hon bng h
2ch i- phi (5- 10%).
t otoc
h
P (1 - 2%) trong hay gp l
g
6. Bt thng rMV
i
y
p
MVLTT
Co bt u t MV phi. y c th l mt
kh khn cho phu thut t chng Fallot.
II. Sinh l bnh
A. Hp MP ngn cn dng mu ln MP v gy ra ting
thi tm thu van MP. Tng gnh bung tim phi do
hp MP, tuy nhin tn thng ny c dung np tt
nh c l thng lin tht rng do mu s c "thot"
sang i tun hon (do p lc tm thu bung tim phi cn
bng vi p lc i tun hon).
B. Lung thng qua l TLT s lin quan n mc hp
MP v sc cn ca h mch i tun hon. Khi tc
nghn ca ng ra tht phi tng ln (theo thi gian s
pht trin ca c vng ph i tng) v sc cn ca h
mch i tun hon gim (v d khi gng sc) dng shunt
510

A. Bnh s: mc tm nhiu hay t thng ph thuc vo
mc hp ng mch phi. Tm thng i km vi
gim vn ng. Tm c c im l khng hng nh,
tng ln khi gng sc hoc khi lnh. Cn tm kch pht
km ngng th v ngt, c th dn n t vong, co git
v li triu chng thn kinh, nhng thng hi phc.
Du hiu ngi xm v du hiu ngn tay di trng cng
thng gp trn lm sng.
B. Khm lm sng
d
rve
e
s
e
1. Ting thi tm thu tng mu (do hps rng
mch
t vn
h
.
g
phi): cng t 3 n 5/6, thng
i omnghe thy
ll r xng
.c
A
khoang lin sn II - IV st b
tri
c. C th
o
.
v ah o
e
o
l
y
nghe c ting clc tng
@MC, ting T2 mnh
Finmu
20
8.i,20loi
duy nht. Nu T2 tch
tr chn on teo tt
0
20 ocity
van MP. i hkhi

th nghe c thi lin tc di
t c
Pot
rig cn
xng n
(do
ng
ng mch), hoc vng
y
op
C
lng (do tun hon bng h ch - phi).
2. Tm nhiu da v nim mc; ngn tay di trng rt
thng gp.
3. th khng tm: thi tm thu do TLT v hp phu,
c th nghe c dc b tri xng c v bnh nhn
khng tm (du hiu lm sng ca Fallot 4 khng tm
ging vi TLT shunt nh).
A. Xquang ngc
1. Bng tim bnh thng vi mm tim ln cao, cung
gia tri lm, ph trng sng.
2. 20% quai MC bn phi kh qun.
511
B. in tm : ph i tht phi n thun, ph i 2 tht

c th gp th khng tm.
d
rve
e
s
re
Hnh 31-1. Hnh phim Xquang tim phi thng.
ts vn
h
.
g
l ri .com
C. Siu m Doppler tim
l
A hoo
ev.quanh
a mng.
o
l
1. TLT rng, cao, thng l iphn
n 0@y
F
2
8. 20ci nga ln VLT.
2. MC gin rng c hnh
y
00 itnh
2
c
t otovan
3. Hp MP: hp
phu,
MP (phi o c ng
h
P
ig
r
y
knh vngopphu, vng van v 2 nhnh MP). Siu m
DopplerC khng nh mc hp ng mch phi
bng cch o chnh p qua phu v van MP (p lc
MP thng bnh thng).
Hnh 31-2. Mt ct trc dc vi hnh nh thng lin tht

cao (mi tn) v MC ci nga r.
512
4. Cn phi thm d trn siu m xem c hay khng cc

tn thng sau: hp cc nhnh MP, thng lin tht
nhiu l, thng lin nh, dng chy lin tc trong
MP chng t cn ng ng mch hoc tun hon
bng h ch phi.
5. Xc nh cc tn thng phi hp nh thng lin nh,
thng lin tht phn c...
D. Thng tim
1. Ch nh: Trc phu thut tt c bnh nhn t
chng Fallot nn c thng tim xc nh s tc
nghn ca ng ra tht phi, c hp MP on gn
hay cc nhnh ca n hay khng, v loi tr cc bt
thng v v tr xut pht v ng i bt thng
(nu
ved
r
c) ca ng mch vnh.
e
es
sr n
t
h
2. Cc thng s huyt ng:
.v
g
l ri .com
l
A thy
o dng shunt 2
a. o bo ho xy c th
ev. yaho
o
l
chiu qua l TLT vi
inbc@nhy xy tht phi
. F 020 tri cng nh MC.
v gim bo ho0xy
08 ty2tht
2 oci
t ottht
b. p lc tht
phi,
tri v MC bng nhau do
h
P
g
i
r
y
l thng
p lin tht rng.
Co
c. Hp ng mch phi thng mc va, vi p
lc MP t mc thp n bnh thng.
3. Chp bung tim:
a. Chp bung tht phi t th nghing phi 30o,
quay ln u 25 v t th nghing tri 60o
n 70o, chch u 250. T th nghing phi s
thy ng ra tht phi v MP, t th nghing
tri s thy l thng lin tht. Nu cha r, c th
chp t th nghing tri nh 30o v chch u
25o, t th ny thy r MP v ch phn i.
b. Chp bung tim tri (nghing phi v/hoc
nghing tri 60-75o chch u 25o) nh gi chc
nng tht tri v xc nh cc dng ca l TLT.
513
c. Chp MC t th nghing phi, nghing tri v

chp MV chn lc l cn thit v t l bt
thng ca n kh thng gp bnh nhn Fallot
4 (ch ng mch lin tht trc).
d. Nu c nghi ng shunt t MC - MP cn chp
MC xc nh cu trc ny (nh chp chn
on cn ng ng mch).
V. Tin trin t nhin
A. Tm ngy cng tng vi cc hu qu:
1. a hng cu, nguy c gy TBMN, nht l nhng
trng hp hng cu nh, s lng hng cu ln hn
7 triu/mm3. Tng hng cu lm thay i cc xt
nghim v ng mu v gim tc mu lng.ed
rv
ese
2. Thng c ngn tay di trng.
r
hts .vn
g
i
r
m tnh.
3. Hn ch hot ng th lc do thiu
l xyomn
Al hoo.c
.
v
e hua qu ca shunt phi
4. Bnh nhn rt d b p xe no,
nlo 0@y
i
F
2
sang tri.
8. 0
00 ity2
2
5. Thay i tun hon
t mao
toc mch phi.
igh Po
r
6. Bnh c otim
py th pht c th c sau nhiu nm tin
C
trin (10 - 20 nm).
7. Bnh nhn rt d b lao phi do gim tun hon phi.
B. Cn thiu xy: thng xut hin vo bui sng khi
ng dy hoc sau gng sc: khc, cu gin, kch thch
au, st... Cn thiu xy thng c lp vi mc tm
v c th dn n t vong hoc b TBMN. Cn thiu xy
thng bt u bng pha "cng" vi kch thch, khc,
tm tng ln v nhp tim nhanh. Sau l pha c ch":
da xm v nht, th nhanh v su do toan chuyn ho,
nhp tim nhanh vi gim hoc mt ting thi do hp ng
mch phi, gim trng lc c. Nu cn qua i, tr s
ng v bnh tnh li.
514
VI. iu tr t chng Fallot

A. iu tr d phng: pht hin v iu tr thiu mu
thiu st tng i, phng thiu mu hng cu nh ca
ph n mang thai.
B. iu tr cn thiu xy
1. a tr ln vai hoc cho tr ngi u gi vo
ngc.
2. Morphin sulfat 0,1 - 0,2 mg/kg tim di da hay tim
bp c ch trung tm h hp, ct cn kh th
nhanh, khng nn c gng tim tnh mch m nn s
dng ng tim di da.
3. iu tr nhim toan bng natri bicarbonate 1 mEq/kg
tnh mch, nhm lm gim kch thch trung tm h
hp do toan chuyn ho.
d
rve
e
s
4. Th xy cn hn ch v trong bnh l ny
re c gim
ts vncung cp
h
dng mu ln phi ch khng phi do
thiu
.
g
l ri .com
l
xy t ngoi vo.
A o
ev. yahophp trn, c th
o
l
5. Nu khng p ng vi cc
phng
Fin020@TM chm thng c
dng Ketamin 1-3 mg/kg
8. 2tim
0
ty i tun hon, an thn).
20 ocicn
kt qu (gy tng
t sc
t
h
o
P nh Phenylephrine. (Neo g
Thuc co rimch
y
p
synephrine)
Co 0,02 mg/, Propranolol: 0,01 - 0,25 mg/kg
tim TM chm thng lm gim tn s tim v c th
iu tr cn thiu xy.
6. Ung Propranolol 2-4mg/kg/ngy c th dng
phng cn thiu xy v tr hon thi gian m sa
cha ton b. Hot tnh c li ca Propranolol l lm
n nh phn ng ca mch ngoi vi.
C. Phng vim ni tm mc nhim khun: Nh trong
cc bnh tim bm sinh c tm khc.
D. iu tr ngoi khoa
1. Phu thut tm thi: c ch nh tng dng
mu ln phi tr tm nng v khng kim sot c
cn thiu xy nhng bnh nhn m phu thut sa
ton b kh thc hin an ton v tr nh hay phu
thut sa ton b gp kh khn v mt k thut.
515
a. Cu ni Blalock Taussig (ni gia ng mch

di n v mt nhnh MP) c th thc hin
tr nh.
b. Cu ni Gore - Tex: ng Gore - Tex gia ng
mch di n v mt nhnh MP.
c. Phng php Waterston: ni gia MC ln v
MP phi nhng phng php ny khng cn
thng dng na do c nhiu bin chng.
d. Phu thut Potts: ni gia MC xung v MP
cng him khi c s dng. Tt c cc phu
thut to cu ni ch phi u c m ngc theo
ng bn, thi gian nm vin t 8 - 10 ngy; t
l t vong rt thp, bin chng c th gp l trn
kh, trn dch v dng chp mng phi; xon vn
d gp.
nhnh ca MP l bin chng lu di c th
rve
e
s
re
2. Phu thut sa ton b: bao gm ng
ts lvnTLT bng
h
. vic ct
g
ming v, m rng ng ra tht phi
bng
l ri .com
l
t chc c phn phu, thng vt
oo ming patch
. A mt
e phi.
ah C th m rng
o
l
y
lm rng ng ra ca itht
F n 20@ nu cn thit. Phu
vng van MP bng 0ming
8. 20patch
20 ocity
thut c thc hin
2 nhnh MP v h lu pha
t otkhi
h
g btP thng MV.
ic
xa tt, khng
r
py
Co thut c thc hin vi tun hon ngoi
Phu
c th v ng m dc gia xng c. Thi gian
nm vin trung bnh t 12 - 15 ngy v t l t vong 1
- 5%. Bin chng c th gp l bloc nh tht cp III,
l TLT tn lu, nht l cn hp ng mch phi.
3. Nong van MP: ch p dng trong trng hp hp
van ng mch phi, c nguy c gy cn thiu xy
nng. Ch ginh k thut ny cho nhng trng hp
c chng ch nh phu thut.
E. Ch nh iu tr
1. T chng Fallot thng thng (MP tt, MV bnh
thng, 1 l TLT) c tm nhiu v hng cu hn 6
triu/mm3: phu thut sa ton b bt k tui no.
2. T chng Fallot thng thng (MP tt, MV bnh
thng, 1 l TLT) vi cn thiu xy: phu thut tm
516
thi vi cu ni Blalock-Taussig hoc sa ton b ty

theo kh nng ca tng bnh vin.
3. T chng Fallot thng thng: phu thut sa ton b
c thc hin mt cch h thng khi tr c t 6 9 thng tui.
4. T chng Fallot c bit (hp nhnh MP, TLT
nhiu l), bt thng MV v d tt khc): Nu trc
2 tui th c th lm phu thut tm thi (cu ni
Blalock). Nu sau 2 tui th ty tng trng hp v
kh nng ca bnh vin m quyt nh phng php
iu tr thch hp cho tng ngi bnh.
F. Sau khi phu thut
1. Nu kt qu phu thut tt thng a bnh nhn tr
v cuc sng bnh thng. Khi c hn ch kh
d nng
rve th c
e
s
gng sc th khng nn luyn tp th thao.
C
re
ts vngy tng
h van ng mch phi do m rng
phu
h
.
g
om nm bng
l ri .hng
gnh tm trng tht phi. TheoAldi
c
oo
ev.
siu m tim v Holter in ltim
ahc th thy s tin
o
y
Fin020@
trin ca hp ng mch
hoc xut hin cc ri
8. phi
0
y2 hoc nhp nhanh tht...
0 itthu
lon nhp: ngoi 2tm
c
ht Pcc
oto ri lon nhp nhng trng
Thng xut ighin
r
hp cn hp
py MP.
Co
2. Trong mt s trng hp, nht l nhng trng hp
MP m qu rng, suy tht phi do tng gnh tm
trng nhiu v trong vi trng hp do h van ng
mch phi nhiu.
3. Cc bc s tim mch s ngy cng gp nhiu cc bnh
nhn b Fallot 4 m, nhng vn cn tn ti hp
MP, cn l TLT, hoc h MP nng gy gin
bung tht phi, ri lon chc nng tht phi v h
van ba l (c nng hay thc th). Thng tim c th
c ch nh nu cc bt thng cn nng n c
ch nh m li. Ri lon nhp tht cng nh hng
nhiu n tin lng xa do cng c th c ch nh
thm d in sinh l cc bnh nhn Fallot 4 m
sa cha ton b.
517
Ti liu tham kho

1.
Connelly MS, Webb GD, Somerville J, et at. Canadian Consensus

1998;14:395-452.
2. Cullen S, Celermajer DS, Franklin RCG, et at. Prognostic
significance of ventricular arrhythmia after repair of tetralogy of
Fallot: a 12-year prospective study. J Am Coll Cardiol 1994;23:
1151-1155.
3. Harrison DA, Harris L, Siu SC, et at. Sustained ventricular
tachycardia in adult patients late after repair of tetralogy of Fallot. J
Am Coll Cardiol 1997;30:1368-1373.
4. Murphy JG, Gersh BJ, Mair DD, et at. Long-term outcome in
patients undergoing surgical repair of tetralogy of Fallot. N Engl J
Med 1993;329:593-599.
5. Nollert G, Fischlein T, Bouterwek 5, et at. Long-term survival in
patients with repair of tetralogy of Fallot: 36-year follow-up of 490
survivors of the first year after surgical repair. J Am Coll Cardiol
d
rve
1997;30:1374-1383.
e
s
re
6. Yemets IM, Williams WG, Webb GD, et at. Pulmonary
valve
ts vn
h
.
g
replacement late after repair of tetralogy of Fallot.
Ann
Thorac
Surg
i
r
ll o.com
1997;64:526-530.
A
o
.
h
v
7. Neches WH, Park S, Ettedgni JA. Tetralogy
loe @yaof Fallot and Tetralogy
n
i
of Fallot with pulmonary atresia.
A, Bricker JT, Fisher
20
. FIn:
0Garson
2
08and
DJ, Neish SR, eds. The science
practice
of
pediatric cardiology,
y
0
2 cit
t o&toWilkins,
2nd ed. Baltimore: Wmiams
1998:1383-1411.
h
P
rig patterns
8. Perloff JK. Survival
without cardiac surgery or
y
p
o
interventional Ccatheterization:
a narrowing base. In: Perloff JK,
9. Redington A, Shore D, Oldershaw P. In: Tetralogy of Fallot.
Redingion A, Shore D, Oldershaw P, eds. Congenital heart disease
in adults: a practical guide. London: Mm Saunders, 1994:57-67.
pediatric heart disease, 2nd ed. St. Louis: Mosby, 1997:235-246.
11. Moore JD, Moodie DS. Tetralogy of Fallot. In: Marso SP, Griffin
BP, Topol EJ, eds. Manual of Cardiovascular Medicine.
518
Hp eo ng mch ch
L bnh tim bm sinh (TBS) cng thng gp, chim

khong 8% cc bnh TBS. Cn pht hin sm tr s sinh hay
tr nh v l bnh nguy him c th dn n t vong. Chn on
lm sng thng da vo du hiu khng c hay yu ca mch
bn so vi mch cnh tay, ting thi tm thu thng kh in
hnh. Hp eo MC rt hay i km vi cc bnh TBS phc tp
khc m c bit hay gp trong hi chng Turner (20%), hi
chng Noonan.
Cc bin chng mun ca bnh c th gp l phnh mch
ti ch hp, tch thnh ng mch ch ln, gin phnh v ev
d cc
v
r
e
mch mu no, tng huyt p ng mch. Tng huyt
res p c th
ts b
n c bit
cn tn ti ngay c sau khi phu thut sa chagton
h
i om.v
r
l
l .c
cc bnh nhn can thip mun.
v. A ahoo
e
o
l
y
I. Gii phu bnh
Fin020@
.
08 ty2eo MC nm ngay trc
A. i a s cc trng hp
20 ohp
i
t ong
t c mch ngha l gn st vi
h
v tr xut pht ca
ng
P
g
ri
ch bt uCca
opy MC xung. Thng gp c s ph i,
co tht thnh sau ca MC gy hp lng mch MC
v tr ny. Cng c th gp s thiu sn ca eo MC vi
cc mc khc nhau. Bnh c th t ngt hoc t t
dn n suy tim huyt tr nh. ng mch di n
tri thng xut pht ngay gn ch hp ca eo MC.
Trong mt s him cc trng hp, v tr hp nm
MC ngc hay MC bng.
B. Tun hon bng h thng gp bnh nhn ln tui.
in hnh nht l xut pht t ng mch di n, ng
mch v trong, gian sn, ng mch gip trng xung,
ng mch ch xung sau ch hp eo ng mch ch.
C. Cc tn thng phi hp: a s l cc bt thng
ca bung tim tri; van MC c 2 l van chim khong
519
50% cc trng hp, hp di van MC, bt thng hnh

dng van 2 l (hi chng Shone), TLT, ng nh tht
chung, tm tht duy nht, bt thng ch xut pht ca
ng mch di n phi.
II. Sinh l bnh
Hp eo MC dn n tng huyt p vi s chnh lch
huyt p tm thu tay v chn. Tng hu gnh do dn n
ph i tht tri v cui cng dn n gin bung tim tri v suy
tim tri dn n suy tim ton b vi tng p MP. Hp eo MC
mn tnh s dn n hin tng pht trin tun hon bng h t
MC ln sang MC xung.
d
A. Du hiu c nng: Hp eo ng mch ch pht
rve hin
e
s
c ngi ln thng bi du hiu tng shuyt
re p, au
t vn
h
g
u hay l du hiu au cch hi. i rvi
cc. bnh nhn
l i .com
l
A suyotim huyt.
tr tui hay phi nhp vin v cc vt
e . yaho
o
l
B. Triu chng thc th . Fin020@
08 ty2
20mnh
i
1. Mch chi trn ny
t otoc hn nhiu so vi mch chi

h
P
g
di. Nhng
ritrng hp hp nng c th khng thy
py
mch bn.
Co Tuy nhin mt s trng hp m ng
mch di n tri xut pht t ngay ch hp ca eo
MC th mch quay tri cng khng c hoc yu nh
ng mch bn. Cn trng hp ng mch di n
phi qut ngc thc qun, mch cnh tay phi cng
nh v M cnh phi p rt mnh.
2. Huyt p chi trn thng tng t l thun vi mc
hp eo MC. Cn phi o huyt p tay bn phi,
thng thch ng tt khi huyt p tm thu cha vt
qu 150mmHg.
3. Ting thi tm thu thng nghe thy vng di
n bn tri, c th lan ra lng v tr cnh ct sng.
Ngoi ra c th nghe thy cc ting thi lin tc do
tun hon bng h gy ra. Trong cc trng hp phi
520
hp vi van ng mch ch c hai l van chng ta c

th nghe thy ting thi tm trng, thi tm thu do
h, hp van MC gy nn.
A. in tm : Thng c du hiu tng gnh tht tri.
Nu c du hiu tng gnh tht phi nhng bnh nhn
hn 2 tui th cn tm cc tn thng phi hp.
B. Xquang ngc: C th bnh thng hay bin i nh vi
cung di tri gin. Kinh in c th thy du hiu 3
cung ng mch ch, quan st thy t th thng mt.
Sau vi tui c th thy cc du hiu c hiu hn nh:
du n xng sn, ch s tim ngc tng r rt.
d
rve
e
s
re
ts vn
h
.
g
l ri .com
l
A o
ev. yaho
o
l
Fin 0@
8. 202
0
20 ity
t otoc
h
P
rig
y
p
Co
Hnh 32-1. Du n sn trn phim tim phi thng.
C. Nghim php gng sc: C th thy du hiu tng
huyt p tm thu cc bnh nhn hp eo MC.
D. Siu m Doppler tim: L xt nghim quyt nh chn
on tr nh, tuy nhin c th gp kh khn cc bnh
nhn ln tui.
1. Siu m TM xc nh dy ca cc vch tim, sc co
bp ca tm tht tri.
2. Siu m Doppler mu v siu m 2D cho php xc
nh v tr v hnh thi ca ch hp eo MC, c bit
521
l tr nh. Siu m Doppler khng nh chn on

v o mc chnh p qua eo MC.
3. Siu m cn gip loi tr hay pht hin ra cc tn
thng phi hp. c bit cn pht hin mt s bt
thng nh van ng mch ch c hai l van, hp van
hai l, tc nghn ng ra tht tri v thng lin tht
phi hp.
4. Cn ch quan st trn siu m pht hin cc tn
thng ca ng mch ch bng, cung ng mch
ch v cc mch mu vng u v c. Siu m cng
c th pht hin s tn ti ca ng ng mch cng
nh cc tun hon bng h nu c.
E. CT Scanner xon c, 3 chiu v cng hng
t
ed
vhu
r
trng ht nhn (MRI) l nhng thm d ert
ch
e
s
s r n cc tn
cho vic xc nh hnh thi ca ch hp eohtMC,
.v
rig ccc
om nhnh ca
lvi
thng phi hp, dng hp eo MC
l
.
A hoo
ev. yac
ng mch di n, c hay khng
tun hon bng
o
l
in 20@ta cn c th quan st
F
h. Vi cc th h my mi
chng
8. 20
00cng
hnh nh quay phim trn
2
ity hng t, y l cc hnh
t otoc
h
P chn on v ra phng php
nh rt hu ch cho
rig vic
y
p
iu tr.
Co
Hnh 32-2. Hp eo MC trn phim MRI v chp mch.

F. Thng tim v cc bc tin hnh thng tim
1. Thng tim v chp bung tim c ch nh khi:
522
a. Nghi ng c tn thng phi hp.

b. Cc thm d khng chy mu cha xc nh r
rng hoc khng thng nht v kt qu.
c. Xc nh mc tun hon bng h chun b
phu thut.
d. Can thip bng bng v Stent qua da.
2. K thut thng tim
a. Thng tim phi nu c tn thng phi hp ti
tim.
b. Thng tim tri qua ng ng mch i c th
gp kh khn khi qua ch hp eo nhng vi dy
dn mm thng vn c th thc hin c i
a s cc trng hp. Cn o chnh p qua
eo
ed
v
r
e
MC v chp MC.
res
s
t
n
h
c. Nu khng th qua ch hp ca
theo
.vMC
ig eo
r
m
o
l
l
c
ng ng mch i th .c
th
thng
tim
theo
.
A hoo
v
e
a
o
ng ng mch cnh
l tay@y chp ch hp eo
0
Fin02h.
.
MC v tun hon
bng
08 ty2
0
2 tv
d. bo hohtxy
oci cung lng tim cn c o
o
P
g
riphu thut.
trc khi
opy
C
3. Cc thng s huyt ng:
a. Hp eo MC c chn on khi c chnh p ln
hn hay bng 10mmHg gia MC ln v MC
xung.
b. Chnh p qua eo MC khng phi lun lun c
mi tng quan trc tip vi mc hp eo
MC, do c rt nhiu tun hon bng h pht
trin lm thay i thng s ny.
4. Chp ng mch:
a. ng thng ''ui ln'' c a n gn st ch
hp (pha trn). Chp t th nghing phi v
nghing tri.
b. Tun hon bng h cng hay thy c cc t
th ny.
523
c. Cc phim chp bung tim c th thc hin nu

nghi ng c bt thng bm sinh khc phi hp.
V. Tin trin t nhin
A. Suy tht tri c bit nhng trng hp hp nhiu c
th dn n din bin lm sng nng n ngay nhng
tun u tin ca tr (sau khi ng ng mch ng). Trn
lm sng thy du hiu suy tim tri vi ting nga phi
tri, ran phi; T, Xquang v siu m tim khng nh
du hiu qu ti bung tim tri. Din bin lm sng tip
theo thng rt nng n vi t l t vong cao. Vic iu
tr tch cc suy tim c th gip tr thot khi suy tim cp
nhng thng li hu qu trn tht tri v tng huyt
p ng mch (cnh tay) nng n. i vi cc trng hp
d
nhiu tui hn, suy tim tri thng din bin thm
rve lng
e
s
e
vi kh nng thch ng tt, do vic bhtst
on
s r chn
vn
.
g
i
r
m c tht
c th gp v bnh nhn thng nhpllvincokhi
A hoo.
.
tri gin nhiu.
v
a
oe
inl 20@y
F
B. Tng huyt p ng mch:
8. 20 Thng xut hin sau 15
y
00 ithuyt
2
ngy tui. Thng thng
p tm thu vn di
t otoc
h
P
g
150mmHg. Nu
rihuyt p tm thu t 150 n 200mmHg
py
th s c dy
Co tht tri nhiu trn T, Xquang v siu
m tim. Nu huyt p tm thu trn 200mmHg, c th
thy du hiu m mt. Khi t tui 15 tr ln, tng huyt
p ng mch thng s tr nn c nh, khng gim
xung c sau khi iu tr nguyn nhn.
C. Bin chng khc c th gp l Osler. Phnh ng mch
ch ch xut hin sau mt thi gian di tin trin bnh.
VI. iu tr
A. iu tr ni khoa l iu tr triu chng nhm bo tn
bnh nhn chun b can thip. iu tr suy tim tri l
vn quan trng nht. i vi tr s sinh,
Prostaglandine E1 gip m ng ng mch s ci thin
nhanh chng triu chng lm sng. Thuc li tiu,
Digoxin v thng kh nhn to l cc bin php phi hp
524
B. Ch nh phu thut: trong cc trng hp:

1. Tr s sinh m iu tr ni khoa t kt qu.
2. Tr nh nhi v tr nh: c du hiu suy tim tri trn
lm sng v cn lm sng.
3. Tr c huyt p ng mch tm thu ln hn
150mmHg.
4. i vi cc trng hp hp eo MC khc th phu
d
thut mt cch h thng khi tr t 6 n 9 thng
rve tui.
e
s
e
s r n in khi
5. Vi ngi ln th ch nh can thiphtkinh
v
.
g
ri c30mmHg.
chnh p qua eo MC ln hn 20lln
Tuy
om
.
A hoo
.
v
nhin cn phi hp vi cc du
hiu
khc
nh
suy
tim
loe @ya
n
i
0 huyt p kh khng
xung huyt, ph i tht. tri,
F 2tng
08 ty20
0
ch...
2 i
t otoc
h
g
i hpPeo ng mch ch sau khi can
6. Trng hpyrti
p
o nhiu trung tm ch nh nong bng bng
thip thCc
qua da c hay khng km vic t gi (Stent). Cc
nghin cu ngn hn ch ra kt qu kh tt, t bin
chng, tuy nhin vn cn phi c cc nghin cu lu
di hn khng nh vn ny.
C. Theo di
Tt c cc bnh nhn hp eo MC cn c theo
di lu di. Theo di bng lm sng (tnh trng suy tim
tri, tng huyt p, mch bn) v cn lm sng (S,
T) mi nm mt ln.
Ti liu tham kho
1.
Breelver SJD. Coarctation of the aorta. In: Redingion A, Shore D,

525
2.
3.
4.
5.
6.
7.
8.
9.
Connelly MS, Webb GD, Sommerville J, et al. Canadian Consensus

1998;14:395-452.
Ebeid MR, Prieto LR, Latson LA. Use of balloon expandable stents
for coarctation of the aorta: initial results and intermediate-term
follow-up. J Am Coll Cardiol 1997; 80:1847-1852.
Kaplan S. Natural history and postoperative history across age
groups. Cardiol Clin 1993;11:543-556.
Mathew P, Moodie D, Blechman C, Gill CC. Long-term follow-up of
aortic coarctation in infants, children and adults. Cardiol Young
1993;3:20-26.
Mendelsoha AM. Balloon angioplasty for native coarctation of the
aorta. J Intervent Cardiol 1995;8:487-508.
Moore JD, Moodie DS. Coarctation of the aorta. In: Marso SP,
Morriss MJH, McNamara DG. Coarctation of the aorta and
d Neish
interrupted aortic arch. In: Carson A, Bricker JT, Fisher DJ,
rve2nd
e
s
SR, eds. The science and practice ofpediatric cardiology,
ed.
re
Baltimore: Williams & Wilkins, 1998:1317-1346.ghts .vn
i om Transcatheter
Ovaett C, Benson LN, Nykanen, Freedom
ll r oRM.
.c
A
o
.
treatment of coarctation of the aorta:evoverview.
Pediatr Cardiol
h
a
o
1998;19:27-44.
inl 0@y
.F 2
08 ty20
0
2 i
t otoc
h
P
g
ri
py
Co
526

Thuc Hanh Benh Tim Mach

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