Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011

TRl/ONG DAI HOC Y HA NOI

CAC BO MON NOI

BAI GIANG

BENH HOC NOI KHOA
TAP II

(Tdi ban Ian thit mitdi co sita chiia vd bo sung)

NHA XUAT BAN Y HOC
HA NOI-2011


Tham gia bien soan:
GS.TS. TRAN NGOC AN

PGS.TS. PHAM THI THU HO
TS. PHAM MANH HUNG
GS. PHAM KHUE

PGS.TS. NGUYEN THI NGOC LAN

TS. NGUYEN VlNH NGOC
GS.TS. NGUYEN KHANH TRACH
GS.TS. NGUYEN LAN VIET

Thtfky bien soan:
GS.TS. TRAN NGOC AN

PGS.TS. PHAM THI THU HO


LOTI NOI OAU

Bai gidng benh hoc noi khoa do can bo gidng day cdc bo
mon noi thuoc Trtfbng Dai hoc Y Ha Noi bien soan nham

cung cap mot so tdi lieu de sinh vien cdc Idp Y3 - Y6 theo

chtfOng trinh cdi each mdi dung de hoc tap vd tham khao khi
hoc ly thuyet cung nhu khi thUc hanh d benh vien.

Noi khoa la mot trong nhiCng mon hoc chinh cua cdc

TrUdng Dai hoc Y. Noi dung can duac sita doi bo sung cho
phii hap vdi sU tien bo khong ngitng cua y hoc.

Ldn tdi ban nay hdu het cdc chuang da duac viet lai vd
bo sung de cap nhdt cdc kien thiCc mdi cua y hoc.

Tuy nhien trong dieu kien so can bo con it di, thdi gian
han che cudn sdch khong trdnh khdi thieu sot nhdt dinh,
mong ban doc gop y de ldn tdi ban sau cudn sdch dUOc hodn
thien hdn.

Xin trdn trong cam On

TRirdNG DAI HOC Y HA NOI
Cac bo mon noi

Chtftfng 5

TIM MACH
SUY TIM
GS. TS. Nguyin Ldn Viet
TS. Pham Manh Hung

Suy tim la mot hoi cluing benh iy thu'dng gap trong nhieu benh ve tim mach
nhu* cac benh van tim, benh cd tim, benh mach vanh, benh tim bam sinh va mot

so'benh khac co anh hu'dng nhieu den tim.
Binh thu'dng khi chiing ta can lam mot hoat clong gang siic nao do (lao dong,
chay nhay...) thi lap trie tim se tang tan so'va tang siic co bop de dtfa d\10c nhieu
mau (tiic la du"a diio'c nhieu oxy) den cho cac mo ciia cd the. Nhifng khi tim bi suy,
thi tim khong con kha nang cung cap mau theo nhu cau ciia cd the nufa. Vi vay
ngiidi ta co the dinh nghia: Suy tim Id trang thai benh ly trong do cung IvCdng tim
khong du dap iCng vdi nhu cau cua cd the ve mat oxy trong moi tinh huong sinh
hoat cua benh nhdn.

Suy tim la mot tinh trang benh ly rat thu'dng gap tren lam sang. To chiic Y
te The gi6i \idc tinh co khoang 5 trieu ngUdi mdi mac suy tim hang nam tren toan
the gi6i. Theo nghien cu*u Framingham thi co khoang 2,3 trieu ngUdi My bi suy
tim (1981) va cung d My moi nam co khoang 400.000 benh nhan m6i mac suy tim
(thong ke nam 1983).

Can day, tren cd sd nhufng hieu biet sau sac hdn ve cd che benh sinh ciia suy
tim, ve tinh nang va tac dung ciia mot so' loai thuoc m6i trong dieu tri suy tim,
ngLfdi ta da thu dUdc nhi3ng ket qua kha quan trong viec dieu tri hoi chiing nay.

I. SINH LYBENH

Cung lifting tim thu'dng bi giam trong suy tim. Khi cung lUdng tim bi giam
xuong thi cd the phan ling lai bang cac cd che bu trii ciia tim va ciia cac he thong
ngoai tim, de co duy tri cung lUOng nay. NhUng khi cac cd che bu trii nay bi vu"dt
qua se xay ra suy tim vdi nhieu hau qua ciia no.
1. Cac yeu to anh hirong den cung lu'cfng tim

Cung liidng tim phu thuoc vao 4 yeu to' chinh: tien ganh, hau ganh, siic co
bop ciia cd tim va tan so' tim.


Siic co bop cO tim

Tien ganh

1

• Cung lifting tim A

Hau ganh

.!.

Tan so tim

1.1. Tien ganh (Preload)

Tien ganh diiPc danh gia bang the tich hoac ap liic cuoi tarn triidng ciia tarn
that. Tien ganh la yeu to' quyet dinh miic do keo dai spi cd tim trong thdi ky tam

trifting, triidc liic tam that co bop. Tien ganh phu thuoc vao:

- Ap liic do day that, tiic la liidng mau tinh mach trd ve tam that.
- Dp gian ciia tam that, nhiing d miic dp it quan trpng hdn.
1.2. Sue co bop cua cotim

Triidc day bang thiic nghiem noi tieng cua minh, Starling da cho ta hieu ro
diidc moi tiidng quan giiia ap liic hoac the tich cuoi tam triidng trong tam that v6i
the tich nhat bop. Cu the la:

Khi ap liic hoac the tich cuoi tam triidng trong tam that tang, thi se lam
tang siic co bop ciia cd tim va the tich nhat bop se tang len.

Nhiing den mot miic nao do, thi du ap liic hoac the tich cuo'i tam tru"dng ciia
tam that co tiep tuc tang len di nufa, thi the tich nhat bop se khong tang ttfdng
ling ma tham chi con bi giam di.

Qua day ta co the hieu dWdc mot van de quan trong trong suy tim la: ap liic
hoac the tich cuo'i tam triidng trong tam that tang do cac nguyen nhan khac nhau,
se lam the tich nhat bop tang, nhiing sau mot thdi gian se dan den suy tim vi siic
co bop cua cd tim kem dan va khi do the tich nhat bop se giam di. Tim cang suy
thi the tich*nhat bop cang giam.

1.3. Hau ganh (Afterload)

Hau ganh la siic can cua cac dpng mach do'i vdi su" co bop ciia tam that. Siic
can cang cao thi sii co bop cua tam that cang phai ldn. Neu siic can thap qua cd
the se lam giam su" co bdp ciia tam that, nhiing neu siic can tang cao se lam tang
cong ciia tim cung nhii tang miic tieu thu oxy ciia cd tim, tu* do se lam giam siic co
bdp ciia cd tim va lam giam lifu lifting tim.

1.4. Tan so tim

Trong suy tim, liic dau nhip tim tang len, se cd tac dung bu trii tot cho tinh
trang giam the tich nhat bdp va qua do se duy tri dUdc cung lu:dng tim. Nhiing neu


nhip tim tang qua nhieu thi nhu cau oxy ciia cd tim se lai tang len, cong ciia cd tim
cung phai tang cao va hau qua la tim se cang bi suy yeu di mot each nhanh chdng.
2. Cac cd che bu trCr trpng suy tim
2.1. Ca chebu trCt tai tim

Gian tam that: gian tam that chinh la cd che thich ling dau tien de tranh
qua tang ap liic cuoi tam triftmg ciia tam that. Khi tam that gian ra, se lam keo

dai cac spi cd tim va thed luat Starling, se lam tang siic cd bdp ciia cac sdi cd tim
neu dii trii co cd van con.

Phi dai tam that: tim cung cd the thich ling bang each tang be day cac
thanh tim, nhat la trong triftmg hdp tang ap liic d cac buong tim. Viec tang be day
cua cac thanh tim chii yeu la de ddi phd vdi tinh trang tang hau ganh. Ta bie't
rang khi hau ganh tang se lam giam the tich td'ng mau, do do de bu lai cd tim
phai tang be day len.

He than kinh giao cam dtftfc kich thich: khi cd suy tim, he than kinh giao
cam du'dc kich thich, lifting catecholamin tii dau tan ciing ciia cac spi giap cam hau
hach du'dc tiet ra nhieu lam tang siic co bdp ciia cd tim va tang tan so'tim.

Bang ba cd che thich ling nay, cung liidng tim se du'dc dieu chinh lai gan vdi
miic binh thu'dng. Tuy nhien cac cd che nay cung chi cd the giai quye't trong mpt
chiing miic nap do ma thdi. Thiic vay, neu tam that da gian den miic td'i da va dii

truf co cd bi giam thi luat Starling se trd nen rat it hieu liic. Cung tiidng tii nhii
vay, phi dai cac thanh tim se lam tang cdng ciia tim. He than kinh giao cam bi
kich thich lau ngay cung se dan den giam mat dp cam thu beta trpng cac sdi cd
tim va giam dan dap ling vdi catecholamin.
2.2. Cache bu trit ngoai tim

Trong suy tim, de dd'i phd vdi viec giam cung lifting tim, he thong mach mau
d ngoai vi du'dc co lai de tang ciidng the tich tuan hoan hiiu ich. Cu the cd ba he
thong co mach ngoai vi du'dc huy dpng:

He thong than kinh giao cam: ciidng giao cam se lam co mach ngoai vi d
da, than va ve sau d khu viic cac tang trong o bung va d cac cd.
He Renin-Angiotensin-Aldosteron: viec tang ciidng hoat hda he than
kinh giao cam va giam tiidi mau than (do co mach) se lam tang nong dp renin
trong mau. Renin se hoat hda angiotensinogen va cac phan ling tiep theo de tang

td'ng hdp angiotensin II. Chinh agiotensin II la mot chat gay co mach rat manh,
ddng thdi no lai tham gia vao kich thich sinh tong hop va giai phdng nor-adrenalin b
dau tan cung cac sdi than kinh giao cam hau hach va adrenalin tCi tiiy thu'dng
than. Cung chinh angiotensin II con kich thich vo thu'dng than tiet ra aldosteron,
tii do lam tang tai hap thu natri va niidc d d'ng than.

He Arginin-Vasopressin: trong suy tim d giai doan mupn hpn, viing diidi
dpi - tuyen yen diidc kich thich de tiet ra arginin - vasopressin, lam tang them tac


dung co mach ngoai vi ciia angiotensin II, dong thdi lam tang tai hap thu niidc d
d'ng than.

Ca ba he thong co mach nay deu nham muc dich duy tri cung lifting tim.

nhiing lau ngay chiing lai lam tang tien ganh va hau ganh, tang ti niidc va natri.
tang cong va miic tieu thu oxy ciia cd tim, tao nen mot "vdng luan quan" benh ly
va lam cho suy tim ngay mot nang hdn.
2.3. Cac yeu to khac

Ngoai ra, trong suy tim, nham cd'gang bu dap lai viec co mach khu trii hay
toan bp ndi tren, cac he thd'ng gian mach vdi bradykmin, cac prostaglandin (PGI,.
PGEv) va yeu to peptid tang dao thai natri (Natriuretic Peptid, viet tat la cac NP).
Cac yeu to nay dong vai trd khiem ton trong qua trinh suy tim. Trong so cac
peptid tang thai natri cd hai loai quan trpng du'dc biet den trpng lam sang do la
ANP (yeu to thai natri cd nguon gd'c tu' nhi) va BNP (yeu to tang thai natri cd
nguon gd'c tii nao). Thiic te la BNP lai chii yeu diidc tiet ra tii tam that ciia tim va
xua't hien kha sdm khi tim bi suy. Hien nay, xet nghiem danh gia BNP va cac dan
xua't ciia no cd gia tri quan trpng trong sang lpc benh nhan suy tim cung nhii tien
lifting benh va theo doi ket qua dieu tri.
3. Hau qua cua suy tim

Khi cac cd che bu tru (cd che thich ling) noi tren bi viip't qua thi se xay ra suy
tim vdi cac hau qua nhu' sau:

3.1. Giam cung luong tim
Cung lifting tim giam se gay

- Giam van chuyen oxy trong mau va giam cung cap oxy cho cac to chute
ngoai vi.

- Cd su" phan phoi lai hiu lifting mau den cac cd quan trong cd the: lu'u
liidng mau giam bdt 6* da. d cac cd, d than va cuoi cung d mot so tang khac de u'u
tien mau cho nao va dpng mach vanh

- Neu cung liidng tim rat thap thi lu'u liidng nude tieu du'dc lpc ra khoi ong
than cung se rat it.

3.2. Tang ap luc tinh mach ngoai vi

- Suy tim phai: tang ap liic cuo'i tam triidng d that phai se jam tang ap hie
d nhi phai roi tii do lam tang ap luc d cac tinh mach ngoai vi va lam cho tinh mach
cd ndi, gan to. phii, tim tai...

- Suy tim trai: tang ap liic cuoi tam tn.idng d thai trui se lam tang ap liic
nhi trai, roi tiep den lam tang ap liic d tinh mach phoi va mao mach phoi. Khi mau
li cang d cac mao mach phoi se lam the tich khi d cac phe nang bi giam xuong. su"
trao doi oxy d phdi se kem di lam benh nhan khd thd. Dae biet khi ap liic mao mach
ph6i tang den mot miic nao do se pha vd hang rao phe nang - mao mach phoi va

buyet tiidng se cd the tran vao cac phe nang, gay ra hien tiidng phii phdi.


II. PHAN LOAI VA NGUYEN NHAN

1. Phan loai suy tim

Co the co nhieu each phan loai suy tim khac nhau, dvta tren cd sd:
- Hinh thai dinh khu: suy tim phai, suy tim trai va suy tim toan bp.
- Tinh trang tien trien: suy tim cap va suy tim man tinh.

- Lu'u liidng tim: suy tim giam lu'u liidng va suy tim tang lu'u liidng.
-

Suy tim tam thu va suy tim tam triidng.

Tuy nhien, tren lam sang ngiidi ta thiidng hay chia suy tim lam ba loai: su.
tim trai, suy tim phai va suy tim toan bp.
2. Nguyen nhan suy tim
2.1. Suy tim trai

a. Tang huyet dp dong mach: la nguyen nhan thiidng gap nhat gay ra suy
tim trai. Chinh tang huyet ap da lam can trd su" td'ng mau ciia that trai tiic la lam
tang hau ganh.
b. Mot so benh van tim

Hd hay hep van dpng mach chii ddn thuan hoac phoi hdp vdi nhau.
Hd van hai la.

c. Cdc ton thu'dng cd tim
Nhdi mau cd tim

- Viem cd tim do thap tim, nhiem ddc hay nhiem khuan.
-

Cac benh cd tim

d. Mot so roi loan nhip tim

~ Cd ba loai rd'i loan nhip tim chii yeu cd the diia den benh canh ciia suy
tim trai:

+ Cdn nhip nhanh kich phat tren that, nhat la cdn rung nhi hay cdn cuong
dong nhi.

+ Cdn nhip nhanh that.
+

Bloc nhi - that hoan toan.

e. Mot so'benh tim bam sinh:

•- Hep eo dpng mach chii.
-

Cdn ong dpng mach.

-

Ong nhi - that chung...

Chii y: triidng hdp hep van hai la, do tang cao ap liic trong nhi trai va mao

mach phdi nen dan den nhiing trieu chiing giong nhu' suy tim trai. Nhiing su" thtfc


thi hep hai la ddn thuan khong gay du'dc suy tim trai theo diing nghia ciia no vi
hep hai la da tao nen mot sii can trd dong mau di tdi that trai, lam cho ap liic (hay

the tich) cuo'i tam triidng ciia that trai lai bi giam hdn binh thu'dng; tam that trai
khong bi tang ganh nen khong suy du'dc.
2.2. Suy tim phai

a. Suy tim trdi lau ngay

Suy tim trai lau ngay se dan den suy tim phai, day cd le la nguyen nhan kha
thu'dng gap.

b. Cdc nguyen nhan ve phoi vd di dang long ngitc, cot song
Cac benh phdi man tinh: hen phe quan, viem phe quan man, gian phe nang,

gian phe quan, xd phdi, benh bui phoi... dan dan diia den benh canh ciia tam phe
man.

Nhoi mau phoi gay ra benh canh tam phe cap.

Tang ap liicddng mach phoi tien phat.

Gii veo cot sd'ng, cac di dang long ngiic khac.
c. Cdc nguyen nhan tim mach

Hep van hai la la nguyen nhan thu'dng gap nhat d cac niidc dang phat trien.

Mot so' benh tim bam sinh: hep dpng mach php'i, tam chiing Fallot. Mot sd'
benh tim bam sinh khac cd luong shunt trai ->phai (thong lien nhi, thong lien
that vv...) den giai doan mudn se cd bien chiing ciia tang ap dpng mach phoi va
gay suy tim phai.

Viem ndi tam mac nhiem khuan gay ton thu'dng nang d van ba la.
Mot sd nguyen nhan it gap: u nhay nhi trai, vd tiii phinh xoang Valsalva vao
cac buong tim ben phai, tang ap liic dpng mach phoi tien phat v.v...

Chii y: triidng hop tran dich mang ngoai tim hoac viem mang ngoai tim co
that se cd bieu hien gid'ng nhii suy tim phai, nhiing thiic chat do chi la nhiing
triidng hdp thieu nang tam triidng chii khong phai suy tim phai theo diing nghia

ciia no.

2.3. Suy tim toan bo

a. Thu'dng gap nhdt la cdc trUdng hdp suy tim trdi tien trien thanh suy tim
toan bo.

b. Cdc benh cd tim, gian.

c. Viem tim toan bo do thap tim, viem cd tim.

d. Cuoi cung cdn phai nhdc den mot sd nguyen nhan dac biet gay suy tim
toan bo vdi "lu'u lUdng tang":

10

-

Ciidng giap trang.

-

Thieu vitamin B^


- Thieu mau nang.
-

Rd dpng - tinh mach...

III. TRIEU CHLTNG

1. Suy tim trai

1.1. Trieu chiing carnang

a. Khd thd: la trieu chiing hay gap nhat. Liic dau chi khd thd khi gang siic,
ve sau khd thd xay ra thiidng xuyen, benh nhan nam cung khd thd nen thu'dng
phai ngoi day de thd. Dien bien va miic dp khd thd cung rat khac nhau: cd khi khd

thd mot each dan dan, nhiing nhieu khi den dot ngot, duE dpi nhu" trong cdn hen
tim hay phii phoi cap.

b. Ho: hay xay ra vao ban dem hoac khi benh nhan gang siic. Thu'dng la ho
khan nhiing cung cd khi ho ra ddm Ian it mau.
1.2. Trieu chung thut the
a. Khdm tim

Nhin, sd tha'y mom tim dap hdi lech sang trai. Nghe tim: ngoai cac trieu
chiing cd the gap ciia mot vai benh van tim da gay nen suy that trai, ta thiidng
tha'y cd ba dau hieu:
-

Nhip tim nhanh.

- Cd the nghe tha'y tie'ng ngiia phi.

- Cung thiidng nghe tha'y mot tie'ng thdi tam thu nhe d mom, dau hieu ciia
hd van hai la cd nang vi buong that trai gian to.

b. Khdm phdi
Thu'dng tha'y ran am rai rac hai ben day phoi. Trong triidng hdp cdn hen tim
cd the nghe du'dc nhieu ran rit va ran am d hai phoi, cdn trong triidng hdp phu
phoi cap se nghe tha'y rat nhieu ran am to, nhd hat dang nhanh tii hai day phoi
len khap hai phe triidng nhii "thiiy trieu dang".

c. Do huyet dp: trong da so' cac triidng hdp, tmyet ap dpng mach td'i da
thu'dng giam, huyet ap td'i thieu lai binh thu'dng nen so' huyet ap chenh lech
thu'dng nhd di.
1.3. Cac xet nghiem chan do an
a. Cdc xet nghiem mau

- Cac xet nghiem mau cd ban: giiip cho danh gia tinh trang chung ciia benh
nhan va cac roi loan, benh ly lien quan.

- Xet nghiem BNP va cac dan xua't: trong thuc te, khi suy tim, se tiet ra pro BNP va chuyen hda ra NT-proBNP va BNP. Xet nghiem ca hai chat BNP hoac NT-

pro BNP deu cd gia tri trong suy tim. Tuy vay, NT-proBNP cd dp ben viing hdn

11


BNP. Trong suy tim, cac dean xua't nay xua't hien kha sdm. ddi khi triidc ca trieu

chiing lam sang va kha nhay. Gia tri ciia BNP thay doi theo tudi, neu BNP > 100
pg/ml; NT-proBNP > 125 pg/ml d benh nhan nhd hdn 75 tudi va > 140 pg/ml d benh
nhan ldn hdn 75 tudi thi coi la tang. Vai trd ciia xet nghiem cac NP ngay cang
diidc de cap den va cd nhieu ting dung trong lam sang:

+ Sang lpc benh nhan suy tim: cd gia tri sang lpc sdm benh nhan cd ton

thu'dng tim nhiing chiia ro trieu chting (vi du d benh nhan sau NMCT, THA...).
+ Chan doan loai trti nguyen nhan khd thd cap: thu'dng gap d khoa cap ctiu
can loai trti nhanh khd thd la do nguyen nhan suy tim hay do benh phdi. Xet

nghiem BNP cd gia tri chan doan loai trti, gia tri du" bao am tinh ciia no tren 90%.

Tuy nhien. BNP cd the chiia tang ro d benh nhan phti phdi cap huyet dpng trong
mot vai gid dau.

+ Theo doi dieu tri suy tim: nong dp cac NP nay se giam tiiPng ting vdi mtic
cai thien trieu chting va choc nang d benh nhan suy tim. Cac bien ddi NP thu'dng
xua't hien sdm va cd gia tri dii bao ket qua dieu tri.
+ Gia tri tien liidng benh: d nhiing benh nhan suy tim hoac cac benh tim mach,
nong dp cac NP huyet thanh cd lien quan den ty le tii vong va bien chting ve sau.
-

Cac xet nghiem mau khac gitip danh gia cac nguyen nhan suy tim:

hormone tuyen giap; thieu mau...

- Cac xet nghiem cd ban de theo ddi dieu tri: dien giai do; choc nang than;
chtic nang gan

- Cac xet nghiem danh gia cac yeu to' nguy cd chinh ciia benh tim mach:
lipid mau. cholesterol, du'dng huyet

b. Xquang

- Tim to ra nhat la cac buong tim ben trai. Tren phim thang: tam that trai
gian bieu hien bang cung diidi ben trai phdng va keo dai ra.

- Ca hai phdi md nhat la vung rd'n phoi. D di khi cd the bat gap du'dng
Kerley (do phti cac khoang ke ciia he thd'ng bach huyet ciia phoi) hoac hinh anh
"canh biidm" kinh dien d hai rd'n phdi trong triidng hdp cd phti phdi.
c. Dien tam do: Thiidng chi tha'y dau hieu tang ganh cac buong tim ben trai:
True trai. day nhi trai, day that trai.

d. Sieu dm tim: Thiidng tha'y kich thudc cac buong tim trai (nhi trai. that
trai) gian to. Ngoai ra sieu am con gitip ta biet du'dc sii co bdp ciia cac vaeh tim
cung nhii danh gia diidc chinh xac chtic nang tam thu ciia that trai. Trong nhieu
triidng hd]) sieu am tim cdn gitip cho ta khang dinh mot so'nguyen nhan da gay ra
suy tim trai (benh van tim, benh tim bam sinh).

e. Thdm do huyet dong

- Tbam do huyet dpng chi dinh trong cac triidng hop dieu tri tich ciic cac
tinh trang suy tim cap va nang (sd'c tim) can dieu tri cac thudc du'dng truyen lien

12


tuc. Thong thu'dng dting dng thong loai Swan Ganz cd bdng d dau de diia len dpng
mach phdi. Thong tim cdn thu'dng du'dc tien hanh khi benh nhan diidc lam cac thu
thuat tim mach can thiep (dpng mach vanh, van tim).
-

Tham do huyet dpng chp phep danh gia miic dp suy tim trai thdng qua viec

do cung liidng tim (CO) va chi so' tim (CI: binh thu'dng tti 2-3,5 1/phut/m2) va do ap
liic cuo'i tam triidng ciia that trai (tang trong suy tim trai. binh thu'dng < 5 mmHg).

- Tham do huyet dpng chp phep danh gia chinh xac mtic dp nang nhe ciia
mpt so'benh van tim.
2. Suy tim phai

2.1. Trieu chung ca nang

a. Khd thd: it heac nhieu, nhiing khd thd thu'dng xuyen, ngay mpt nang dan
va khdng cd cac cdn kich phat nhii trong suy tim trai.

b. Ngoai ra, benh nhan hay co cam gidc dau titc viing ha su'dn phdi (do gan
to vd dau).

2.2. Trieu chung thuc the

a. Chii yeu la nhiCng dau hieu it mau ngoai bien
- Gan to deu, mat nhan, bd tti, dau mpt each tii phat hoac khi sd vao gan
thi dau. Liic dau gan nhd di khi du'dc dieu tri va gan to lai trong ddt suy tim sau,

nen cdn gpi la gan "dan xep". Ve sau, do ti mau lau ngay nen gan khdng the nho
lai du'dc ntia va trd nen cting.

- Tinh mach cd noi to va dau hieu phan hoi gan - tinh mach cd du'dng tinh.
Ap liic tinh mach trung lidng va ap liic tinh mach ngoai bien tang cao.

- Tim da va niem mac: tim la do mau bi ti tre d ngoai bien, nen liidng
hemoglobin khti tang len trong mau. Tiiy mtic dp suy tim ma tim nhieu hay it.
Neu suy tim nhe thi chi tha'y tim it d mdi va dau chi. Cdn neu suy tim nang thi cd
the tha'y tim rd d toan than.

- Phti: phti mem, luc dau chi khu trti d hai chi dtidi, ve sau neu suy tim

nang thi cd the tha'y phii toan than, tham chi cd the cd them tran dich cac mang
(tran dich mang phoi, co triidng...). Benh nhan thu'dng dai it (khdang 200 500ml/ngay). Niidc tieu sara mau.
b. Khdm tun

- Sd: cd the tha'y dau hieu Hartzer (tam that phai dap d vting mui tic),
nhiing khdng phai benh nhan nao cung cd dau hieu nay.

- Nghe: ngoai cac trieu chting ciia benh da gay ra suy tim phai ta cdn cd
the tha'y:

+ Nhip tim thu'dng nhanh, ddi khi cd tie'ng ngiia phi phai.

13


+ Cung cd khi nghe tha'y tie'ng thdi tam thu nhe d trong mom hoac d viing
mui tic do hd van ba la cd nang. Khi hit vao sau, tie'ng thdi nay thiidng ro hdn
(dau hieu Rivero-Carvalho).

+ Huyet ap dpng mach td'i da binh thu'dng, nhiing huyet ap td'i thieu thu'dng
tang len.

2.3. Cac xet nghiem chan doan

Trti triidng hdp suy tim phai dd hep dpng mach phdi cd nhiing dac diem

rieng ciia no, cdn trong da so'cac triidng hdp khac ta tha'y:
a. Cdc xet nghiem mau: nhii da neu trong suy tim trai. Lu'u y la khi suy tim
phai don thuan do cac nguyen nhan hd hap thi nong dp cac NP chi tang khiem ton.
b. X quang

-

Tren phim tim phdi thang:

+ Cung diidi phai (tam nhi phai) gian.
+ Mom tim nang cao hdn phia tren vdm hoanh trai, do tam that phai gian.

+ Cung dpng mach phdi cung gian to.
+ Phdi md nhieu do ti mau d phdi.
- Tren phim nghieng trai: that phai to lam cho khoang sang sau xiidng tic
bi hep lai.

c. Dien tam do: thu'dng tha'y cac dau hieu ciia true phai, day nhi phai, day
that phai.

d. Sieu am tim: chii yeu tha'y kich thiidc that phai gian to. Trong nhieu
triidng hdp cd the tha'y cac dau hieu ciia tang ap dpng mach phdi.
e. Tham do huyet dong

Cd the tha'y:

- Ap lift cuo'i tam triidng ciia that phai tang (thu'dng la tren 12 mmHg).
-

Ap liic dpng mach phdi cung thu'dng tang.

3. Suy tim toan bo

- Thu'dng la benh canh ciia suy tim phai d mtic dp nang:

- Benh nhan khd thd thu'dng xuyen, phti toan than.
-

Tinh mach cd ndi to, ap liic tinh mach tang rat cao.

-

Gan to nhieu..

-

Thu'dng cd them tran dich mang phdi, mang tim hay cd triidng.

- Huyet ap td'i da ha, huyet ap td'i thieu tang, lam cho huyet ap trd nen ket.

14


-

X quang: tim to toan bp.

-

Dien tam dp: cd the cd bieu hien day hai that.

IV. CHAN DOAN XAC OjNH SUY TIM
De chan doan xac dinh suy tim, cd mpt so' tieu chuan du'dc dat ra, trong do
cac yeu to' quan trpng nhii hoi benh va tham kham ky lam sang, cac xet nghiem
can lam sang (dac biet la xet nghiem BNP hoac NT-Pro BNP cd gia tri), dien tam

dd, X quang tim phdi thang, sieu am tim... gitip chan doan xac dinh suy tim.

Trong thiic te, hai tieu chuan thu'dng du'dc dting tren lam sang de chan doan
suy tim la: tieu chuan Framingham (bang 5) va Tieu chuan ciia Hpi Tim mach

chau Au. Trong do, tieu chuan ciia Hpi Tim mach chau Au (bang 6) chp phep tiep
can ddn gian hdn trong chan doan suy tim.
Bang 1. Tieu chuan Framingham
- Tieu chuan chinh:

Cdn khd thd kich phat ve derm hoac khd thd pha ngoi

Phong TM co9
Ran
Tim to

Phu phoi cap
T3

Ap life TM he thong > 16 cm H20
Thdi gian tuan hoan > 25 giay

Phan hoi gan TM cd? du'dng tinh
- Tieu

chuan phu
Phu co' chan
Ho ve dem

Khd thd gang stic

Gan to

Tran dich mang phdi
Dung tich song giam 1/3 so vdi td'i da
- Tieu

Tim nhanh (> 120/phut)
chuan chinh hay phu
Giam 4,5 kg/5 ngay dieu tri suy tim

- Chan doan xac dinh suy tim:
2 tieu chuan chinh hoac 1 tieu chuan ch 'nh kem 2 tieu chuan

phu

Bang 2. Cac tieu chuan xac dinh suy tim theo Hoi Tim mach chau Au
(Cac tieu chuan 1 va 2 can co trong moi triidng hop)
1. Cd trieu chting cd nang suy tim (luc nghi hay trong khi gang siic) va

2 Chiing cd khach quan ciia rd'i loan chiic nang tim (tren tham kham va cac tham dd) (luc
nghi) va
3. Dap ling vdi dieu tri suy tim (trong triidng hdp cd nghi ngd chan doan)

15


V. DANH GIA ML/C 00 SUY TIM

Co nhieu each de danh gia mtic dp suy tim, nhiing trong thiic te lam sang,

each phan loai mtic dp suy tim theo Hoi Tim mach hoc New York (New York
Heart Association) viet tat la NYHA, diia tren sii danh gia mtic dp hoat dpng the
luc va cac trieu chting cd nang ciia benh nhan la diidc chap nhan va ting dung
rdng rai.

1. Phan loai mure do suy tim theo NYHA

Bang 3. Phan loai mtic do suy tim theo NYHA
Bieu hien

06

Benh nhan cd benh tim nhiing khdng cd trieu chiing cd nang nao, van sinh hoat va
hoat dpng the liic gan nhu" binh thu'dng.

Cac trieu chiing cd nang chi xua't hien khi gang siic nhieu. Benh nhan bi giam nhe
cac hoat dpng ve the luc.

Cac trieu chiing cd nang xua't hien ke ca khi gang siic rat it, lam han che nhieu cac
hoat dpng the liic.
IV

Cac trieu chiing cd nang ton tai mpt each thu'dng xuyen, ke ca liic benh nhan nghi
ngdi khdng lam gi ca.

Trong thiic te lam sang, each phan loai nay rat td't dd'i vdi suy tim trai.
nhiing khdng that thich hdp lam dd'i vdi cac benh nhan suy tim phai.
2. Phan loai mure do suy tim tren lam sang theo Hoi Noi Khoa Viet Nam
0 niidc ta. so liidng cac benh nhan suy tim phai thu'dng chiem mpt ty le kha
ldn trong so' cac benh nhan bi suy tim. Vi vay, sd bp tren lam sang cac thay

thud'c thiidng quv lidc mtic dp suy tim theo khuyen cao ciia Hpi Ndi khoa Viet
Nam nhii sau:

Bang 4. Phan loai mtic do suy tim tren lam sang
0?

Bieu hien

I

Benh nhan cd khd thd nhe nhiing gan chiia sd tha'y.

II

Benh nhan khd thd viia, gan to diidi bd stidn vai cm.

III

Benh nhan khd thd nhieu, gan to gan sat rd'n nhiing khi du'dc dieu tri gan cd the nhd
lai.

IV

Benh nhan khd thd thudng xuyen, gan ludn to nhieu mac du da dUdc dieu tri.


3. Phan loai suy tim theo giai doan cua cac Hoi Tim mach hoc Hoa ky (AHA/ACC)
2005

Cach phan loai nay nhan manh den sii tien trien va cac giai dean ciia suy tim.

Bang 5. Phan loai giai doan suy tim theo AHA/ACC
Giai doan
A

Oac diem

Benh nhan cd cac nguy cd cao ciia suy tim nhiing chiia cd cac benh ly ton
thu'dng cau true tim

Benh nhan da cd cac benh ly anh hiidng cau true tim nhiing chiia cd trieu
chiing va bieu hien ciia suy tim
Benh nhan cd benh tim va cd trieu chiing ciia suy tim; cd anh hiidng den cau
true ciia tim
D

Benh nhan suy tim giai doan cuoi can Gdi bi6n phap JJeu tri d,fic biet T

OfUHOCVOTRWHGTOfiN
VI. DIEU TR!
Dieu tri suy tim bao gdm:
•

•

i

- Nhiing bien phap dieu tri chung cho tat ca cac loai nguyen nhan gay ra
suy tim, nham giam ti tre tuan hoan va tang ciidng kha nang co bdp ciia cd tim.

- Nhiing bien phap dieu tri dac biet ap dung cho tting triidng hdp cu the

tuy theo nguyen nhan ciia suy tim.

1. Nhting bien phap dieu trj chung

1.1. Cac bien phap khong dung thudc
a. Che do nghi ngdi: nghi ngdi la mpt viec kha quan trpng vi no gdp phan
lam giam cong ciia tim. Ndi chung benh nhan can giam hoac bd han cac hoat dpng
gang stic. Trong triidng hdp suy tim nang thi phai nghi tai giiidng theo tii the niia
nam niia ngdi. Tuy nhien, trong triidng hdp suy tim ma benh nhan phai nam dieu
tri lau ngay thi khi hoan canh cho phep, nen khuyen khich benh nhan xoa bdp,
liic dau la thu dpng, sau dd la chii dpng d cac chi, nhat la hai chi diidi de lam cho
mau tinh mach trd ve tim du'dc de dang hdn, giam bdt cac nguy cd huyet khd'i tinh
mach thiidng hay gap d nhting benh nhan nay.

b. Che do an giam mudi

- Che dp an giam mudi la can thie't, vi mudi an (NaCT) lam tang ap liic
tham thau trong mau, do dd lam tang khd'i liidng tuan hoan, tti do gay tang ganh
nang cho tim.

- Mpt ngiidi binh thu'dng hap thu khoang 6 - 18g mudi NaCl/ngay, tiic la 2,4 7,2g (100 - -SOOmmol) Na+/ngay. Dd'i vdi benh nhan suy tim, tuy tting triidng hdp cu
the ma ap dung che dp an giam mudi hoac che' dp an gan nhii nhat hoan toan.

17


+ Che dp an giam mud'i: benh nhan chi diidc dting < 3g mud! NaCl/ngay, ttic
la < l,2g (50 mmol) Na+/ngay.

+ Che dp an gan nhu nhat hoan toan: benh nhan chi du'dc an < l,2g mud'i

NaCl /ngay ttic la < 0,48g (20mmol) Na+/ngay.
c. Han che liidng niidc va dich diing cho benh nhan

- Can han che liidng niidc va dich dting cho benh nhan hang ngay nham
giam bdt khd'i liidng tuan hoan va giam ganh nang vdi tim.

- Ndi chung chi nen dting cho benh nhan khoang 500 - 1000ml liidng dich
diia vao cd the mdi ngay.

d. Thd oxy: la bien phap can thiet trong nhieu triidng hdp suy tim vi no tang

cung cap them oxy cho cac mo, giam bdt mtic dp khd thd ciia benh nhan. dong thdi
lam han che sii co mach phdi thu'dng gap d nhting benh nhan thieu oxy.
e. Loai bo cdc yeu to nguy cd khac
-

Bo ru'du, thud'c la, ca phe...

-

Giam can nang 0 nhting benh nhan beo phi.

-

Tranh cac xtic cam manh (stress).

- Ngting nhting thud'c lam giam siic bdp ciia cd tim neu dang dung, vi du:
cac thud'c chen beta giao cam hoac verapamil hay disopyramid, Flecainid...
- Dieu tri nhting yeu to lam nang them tinh trang suy tim nhii nhiem
truing, rdi loan nhip tim...

1.2. Cac thuoc trong dieu tri suy tim
a. Glucosid trd tim

-

Cac dang glucosid trd tim du'dc dting tren lam sang la:

+ Digitalis vdi cac dang digitalin hay digitoxin lay tti digitalis purpurea:
Digoxin va isolanid lay tti digitalis Lanata.

+ Strophantus vdi cac dang G Strophantin (ttic Uabain) lay tti strophantus
Kombe.

Trong thuc hanh lam sang hien nay digoxin la loai thud'c trd tim tieu bieu
thu'dng du'dc cac thay thud'c hay sii dung nhieu nhat.
-

Cd che tac dung:

+ Digoxin lam tang stic co bdp ciia cd tim gian tiep thong qua viec tic che
men natri - kali - adenosine triphosphatase (Na+-K+-ATPase) ciia bdm ion d mang
te bao cd tim, tti do can trd viec ion Na+ thoat ra ngoai mang te bao. Do sii tic che

nay lam cho nong dp Na+ trong te bao tang cao, vi vay sii van chuyen Na+ - Ca++
qua mang tebao cung bi rd'i loan, lam tang nong dp Ca++ trong te bao cd tim, tti do
thuc day cac sdi cd tim tang ciidng co bdp.

18

+ Mat khac digoxin cdn tac dpng tren he thd'ng than kinh tii dpng ciia tim,
lam giam nhip tim va giam td'c dp din truyen nhi - that.

+ Ngoai ra digoxin cdn lam tang triidng liic he phd giao cam va lam giam
hoat tinh ciia he giao cam.
-

Du'dc dpng hoc:

+ Digoxin thu'dng du'dc dting diidi dang ud'ng (vien nen, vien nang, dang
con) hoac tiem.

+ O dang ud'ng, phan ldn digoxin du'dc hap thu d rudt non sau do se du'dc

phan bd' tiep tai mpt sd' md. Ndng dp digpxin thu'dng du'dc tap trung chii yeu d
than, tim, gan, tuye'n thu'dng than, d'ng tieu hda...
+ Digoxin diidc chuyen hda chii yeu tai gan. Phan ldn digoxin du'dc thai trti
qua diidng niidc tieu, chi cd mpt phan nhd (khoang 25%) diidc thai trti qua diidng
phan.

+ 0 ngiidi ldn, vdi chtic nang gan, than binh thu'dng thi thdi gian ban huy
trung binh ciia digoxin (theo du'dng ud'ng) la 36 gid.

+ Mpt sd nghien ctiu da cho thay la nong dp trung binh trong huyet tiidng

ciia digoxin cd tac dung dieu tri thu'dng trong khoang tti 0,5 hoac 0,8 den
2,0ng/ml. Tuy nhien khoang each gitia nong dp dieu tri va nong dp ngd ddc la rat
hep. Cd benh nhan phai dting tren 2,0 ng/ml mdi cd tac dung dieu tri, ngiidc lai
mpt so benh nhan khac d nong dp 0,8 - 1,5 ng/ml da cd trieu chting ciia ngd ddc

digoxin.

-

Lieu liiOng va each dting:

+ Trade day ngiidi ta hay dting bat dau bang lieu tan cong sau ctd chuyen
sang lieu duy tri.

+ Lieu tan cong thu'dng la 0,25 - 0,5mg, roi cti sau 6 gid cd the cho them 0,
25mg de dat tong lieu la 1 - 1,5 mg/ngay.
+ Khi dat du'dc hieu qua, thu'dng chuyen sang lieu duy tri tti 0,125 0,375mg/ngay»

+ Ngay nay ngiidi ta thu'dng khdng cdn dung lieu tan cong vdi mpt liidng
thudc ldn trong mpt thdi gian ngan nhii tren vi each nay rat de gay nguy hiem cho
benh nhan. Trong da so cac triidng hdp, cac thay thud'c thu'dng bat dau ngay bang
lieu duy tri nhii da trinh bay d tren de dat dan tdi lieu cd hieu liic dieu tri.

+ Viec theo ddi ndng dp digoxin trong huyet tiidng se gitip ta dieu chinh
diidc tdi lieu dieu tri td'i ifu. Nong dp digoxin huyet tiiOng trong khoang tti 1,8 - 2
ng/ml du'dc coi la ndng dp cd hieu liic dieu tri, qua nong dp do thi di bi nhiem ddc
Digoxin.

-

TiiOng tac thudc:

+ Mpt sd thud'c cd the lam giam viec hap thu digoxin nhu": cholestyramin,
cholestipol, kaolin-pectin, sulfasalazin, neomycin v.v... Ngiidc lai, mpt so'thud'c cd

19


the lam tang viec hap thu digoxin nhii tetracyclm hoac erythromycin. Mpt sd
thudc khac cd the lam giam dang ke dp thanh thai Digoxm. do dd cd the lam tang
ndng dp cua digoxin trong mau nhii: quinidin. verapamil, spironolacton.
amiodaron...

+ Can dac biet chii y khdng bao gid diidc dung phdi hdp digoxin vdi cac mudi
calci (diidng tinh mach) vi sii phdi hop nay cd the gay nen nhting rdi loan nhip tim
nang tie, tham chi cd the gay tii vong.
-

Chi dinh:

+ Suy tim vdi cung liidng tim thap, dac biet khi cd rung nhi nhanh.
+ Cac rdi loan nhip tren that, dac biet trong rung nhi hay cuong dpng nhi.

+ Chti y: nhiing triidng hdp suy tim vdi cung liidng tim cao (thieu mau
nang. nhiem ddc giap. ro dpng - tinh mach. benh thieu vitamin 131...) hoac suy tim
cd lien quan den mpt tac nghen cd hoc hay suy tim trong tam phe man khdng phai
la nhiing chi dinh ciia digoxm.
-

Chd'ng chi dinh:

+ Nhip tim cham.

+ Bloc nhi - that cap II, cap III chiia du'dc dat may tao nhip.
+ Ngoai tam thu that.

+ Nhip nhanh that va rung that.

+ Hpi chting Wolff - Parkinson - White.
+ Benh c(J tim tac nghen.

+ Can than trpng trong triidng hdp: nhoi mau cd tim cap (vi digoxin lam
tang nhu cau oxy ciia cd tim) va cac roi loan dien giai. dac biet la ha K+ mau va /
hoac ha Mg ++ mau.
-

Nhiem ddc digoxin

+ Mpt so' thong ke da cho tha'y so' benh nhan dting digoxin bi nhiem ddc
chiem khoang 5 - 15% td'ng so'benh nhan dting thudc.
+ Yeu to' thuan ldi cho nhiem ddc digoxin la:

.

Rdi loan dien giai: ha K+ mau, ha Mg++ mau, tang Ca++ mau.

• Tudi cao: lam tang dp nhay cam vdi digoxin do giam dp lpc ciia than, tti
dd de lam ti dong thud'c.
•

Nhiem kiem chuyen hda.

•

Giam oxy mau.

•

Suy than, suy gan...

+ Bieu hien lam sang ciia nhiem ddc digoxin: khi benh nhan dang dung
digoxin, tii nhien tha'y mpt sd'bieu hien sau:

20


• Rdi loan tieu hda: chan an, buon ndn, ndn rniia, ia chay.

• Rd'i loan than kinh: cd the chi la dau dau. chdng mat nhiing cd the
nang hdn nhii ao giac, mat phiidng hiidng, me sang...

• Rdi loan tim mach: do tang tinh kich thich, tang tinh tii dpng va giam
tinh dan truyen ciia te bao cd tim

Ngoai tam thu nhi va that, hay gap la ngoai tam thu that nhip ddi, ngoai
tam thu that da dang hoac tting churn.

Nhip nhanh bp nd'i, nhip nhanh that.
Bloc xoang - nhi.
Bloc nhi - that cac loai.

Xoan dinh, rung that.
+ Xii tri nhiem ddc digoxin:

•

Ngting ngay viec dieu tri bang digoxin.

•

Theo ddi chat che nhting dien bien tren dien lam do.

• Dieu chinh kip thdi cac roi loan ve dien giai va thang bang toan kiem,
trong do can dac biet lu'u y cd tinh trang ha K+ mau khdng? Neu cd ha K+ mau can

cho benh nhan ud'ng khoang 20 - 50 ml dung dich kalichlorua 10%). Triidng hdp
can thiet cd the truyen nhd gipt kalichlprua vap tinh mach sau khi da pha thud'c
trong dung dich dang triidng, nhiing vdi dieu kien dam dp K+ truyen tinh mach
khdng du'dc viidt qua 13 - 15mmol/gid.

Cd the dting atropin tiem tinh mach vdi lieu tti 0,5 - lmg khi cd nhip cham
xoang hoac nhip cham do Bloc nhi - that.

Vdi cac loai rd'i loan nhip that, dac biet la ngoai tam thu that, ta cd the dieu
tri bang each truyen lidocain vdi dam dp 2mg/phut.

Cd the dting khang the dac hieu ciia digoxin (Fab fragments, digibind) va
thu'dng diidc viet tat la Fab. Thu'dng Fab du'dc dting theo diidng truyen tinh mach.

Cd che: phtic hdp digoxin ke't hdp vdi Fab se du'dc ctao thai qua than, lam
mat tac dung ciia digoxin. Mpt d'ng Fab 40mg trung hda 0,6mg digoxin.
Vdi ngd ddc man digoxin: So' d'ng Fab can dting = [nong dp digpxin mau
(ng/ml) x can nang cd the (kg)] / 100.

Vdi ngd ddc cap digoxin: so'dng Fab can dting = [lieu liidng digoxin da dting

cho benh nhan (mg) x 0,8] / 0,6.
b. Thudc Idi tieu

Thud'c ldi tieu lam tang dao thai niidc tieu, qua do lam giam khd'i liidng niidc
trong cd the, giam khd'i liidng mau lu'u hanh, lam bdt liidng mau trd ve tim va lam
giam the tich cung nhii ap liic cuoi tam triidng ciia tam that, lam giam tien ganh,
tao dieu kien cho cd tim da bi suy yeu hoat dpng du'dc tot hdn.

21


Bien chting cd the gap khi dting cac thud'c ldi tieu la ha K+ mau, ha Na+ mau,
lam giam the tich va kiem hda mau. Ha K+ mau la mpt bien chting quan trpng, cd
the de dpa tinh mang ciia benh nhan, nhat la khi dting cting vdi digoxin. Do do
khi dieu tri bang thud'c ldi tieu, can phai thee ddi chat che dien giai mau. Viec bu
mud'i kali hoac phoi hdp vdi ldi tieu giti kali la van de ludn ludn phai nhd den.
- Nhom thuoc M tieu thiazid (chlorothiazid, hydrochlothiazid, metolazpn
indapamid):

+ Thiidng du'dc dung mpt each kha phd' bien treng dieu tri suy tim d nhting
benh nhan ma chtic nang than cdn binh thu'dng.

+ Vi tri tac dpng ciia thud'c la d d'ng liidn xa (rieng metelazpn cdn tac dpng

tren ca d'ng liidn gan), vdi cd che lam tang bai tiet mud'i, de dd se lam tang thai
niidc. Hydrochlothiazid cdn diidc dting nhieu vi gia kha re.

+ Bien chting cd the gap khi dting thiazid la ha K+, Na+, Ca++ mau. Thud'c
cung cd the lam tang ure, creatimin mau, cd khi gay viem tuy, viem mach. Gan
day ngiidi ta de cap den tac dung phu lam tang LDL-cholesterol khi dting thiazid

dai ngay (trong nhdm nay Indapamide it anh hiidng den chuyen hda lipoprotein).
- Nhom thuoc lpfi tieu tac dung len quai Henle (furosemid, bumetanid,
acid ethacrynic...):

+ Vi tri tac dpng chii yeu ciia thud'c la d nhanh len ciia quai Henle. Ldi tieu
nhdm nay lam tang thai natri len den 25%, ngoai ra chting cdn cd tac dung lam
tang dong mau den than do lam tang hoat hda prostaglandin PGE cd tac dung
gian mach than. Vi cd tac dung ldi tieu manh va khdng lam giam chtic nang than
nen ldi tieu nhdm nay diidc chi dinh d benh nhan suy tim ma ddi hoi phai giam
the tich tuan hoan nhanh hoac d benh nhan suy than.

+ Furosemid ngoai kha nang lam giam tien ganh nhanh, khi dting tiem
tinh mach no cdn cd tac dung gay gian mach triic tiep. Vi vay, furosemid dac biet
cd hieu qua trong dieu tri benh nhan suy tim nang hoac bi phti phdi cap.

+ Ldi tieu nhdm nay cd the gay ha K+, Na+, Ca++, Mg++ mau. Ngoai ra mpt sd'
benh nhan ddi khi cd the cd bieu hien noi ban, viem mach...

-

Nhom thuoc lc/i tieu giuf kali (spironolacton, triamteren, amilorid):

+ Ldi tieu nhdm nay tac dpng tren dean cud'i cua d'ng liidn xa. Spironolacton
tac dpng thong qua viing nhay cam aldosteron; Triamteren va amilorid cung tac

dpng 0 vting cud'i cua d'ng liidn xa nhiing khdng chiu sii kiem soat ciia aldosteron.
+ Tac dung ldi tieu ciia cac thud'c thudc nhdm nay yeu neu chi dting mpt
minh. Nhiing vi ldi ich giti kali nen chting thu'dng du'dc phd'i hdp vdi ldi tieu
thiazid hoac ldi tieu quai Henle. Ldi tieu giti kali thu'dng tac dung cham va keo
dai. Ndi chung vdi loai ldi tieu giti kali nay, khi dung cung phai thee doi kali mau,

dac biet chti y khi dting cting vdi thud'c tic che' men chuyen, hoac thud'c giam viem
khdng steroid. Ngoai ra nhdm ldi tieu giti kali nay cung ddi khi cting cd the gay ra
tang ure mau, sdi than (vdi triamterene) hoac chting vti to d nam gidi (vdi
spironolacton).

22


+ Trong chien liidc dieu tri suy tim nang hien nay, vai trd ciia thud'c khang
aldosteron da du'dc chting minh ro. Thud'c khang aldosteron khdng chi cd tac dung
ldi tieu ma no dac biet cd ldi ich lam giam cac qua trinh bti trti thai qua ciia tang
aldosteron trong suy tim nang, do dd lam giam sii co mach, giti mud'i va niidc, sii
phi dai cd tim, suy than, rd'i loan chtic nang ndi mach. Do vay, thud'c ldi tieu
khang aldosteron da lam giam ty le tii vong va nhap vien d nhting benh nhan suy
tim nang.
Bang 6. Mot so thuoc ldi tieu dung trong suy tim.

Du'dng dung

Lieu TB ngay
(mg)

Bat dau

Tac dung

tac dung

keo dai

U

250 - 500

2h

6- 12h

TM

500

15ph

1h

Hydrochlothiazid

U

25- 100

2h

12h

Metolazon

U

2,5-20,0

1h

24 - 48h

Indapamid

U

2,5-5,0

2h

24h

U

20-80

1h

6-8h

TM.TB

10-80

5ph

2-4h

Thuoc
Thiazid
Chlorothiazid

Ldi tieu quai
Furosemid

Ethacrynic acid

U

25- 100

30ph

6-8h

TM

50

5ph

2-4h

U

0,5-2,0

30ph

2h

TM.TB

0,5-2,0

5ph

30ph

U

5- 10

2h

8- 12h

TM

5- 10

5ph

6-8h

Spironolacton

U

50 - 200

1-2ng

2-3ng

Triamteren

U

100-200

2-4ng

7-9ng

Amilorid

U

5- 10

2h

24h

Bumetanid

Torsenid

Nhdm giti kali

OLX: d'ng luan xa, OLG: ong luan gan, QH: Quai Henle, U: dudng uong, TM: tiem tinh mach,
TB: tiem bSp, h: gid, ph: phut, ng: ngay.

c. Cdc thudc gidn mach trong dieu tri suy tim
Nhii chting ta da ro, cP che bti trti d benh nhan suy tim bao gdm ca sii co
that d he ddng mach va tinh mach. Sii co that he ddng mach lam tang hau ganh
va sii co he tinh mach lam tang tien ganh. Hdn ntia trong suy tim, sii co that he
mach phdi cdn la hau qua ciia thieu oxy mau, hoac sii dap ting lau dai vdi viec
tang ddng mau qua phoi (vi du khi cd Shunt trai -> phai trong tim) hoac dap ting
lau dai vdi viec tang ap liic nhi trai (Vi du: hep hai la, suy tim trai...).
23


Cac thud'c gian mach cd the liu tien tac dung giam hau ganh. tien ganh hoac
ca hai. Nhting thud'c lam gian tinh mach nhieu hdn se lam giam tien ganh va ap
liic do day that. Cdn cac thud'c lam gian ddng mach se lam giam hau ganh. Vi vay.
ndi chung cac thud'c gian mach se cai thien du'dc cung liidng tim, giam ap liic do

day tim va giam siic ep len thanh tim. 6 nhting benh nhan hd van tim, suy tim
nang hoac cd tang trd khang mach, hoac suy tim cd tang huyet ap thi dting cac
thud'c gian ddng mach rat cd hieu qua.

Tac dung phu ndi chung ciia cac thud'c gian mach trong dieu tri suy tim
thu'dng la: ha huyet ap (nhat la ha huyet ap trong tii the dting). tang nhe ure

mau... Dting thuoc gian mach can het stic than trpng d nhiing benh nhan cd han
che cung liidng tim (Vi du: hep van ddng mach chii, benh cd tim phi dai tac nghen)
hoac d nhting benh nhan cd rd'i loan chtic nang tam triidng (Benh cd tim han che).
- Thud'c tic che men chuyen dang angiotensin (UCMC)
+ Cac thudc thudc nhdm nay cd tac dung tic che men cd nhiem vu chuyen tti

angiotensin I thanh angiotensin II tti dd tic che sii tong hop angiotensin II. la mpt
chat gay co mach, ddng thdi lai lam tang bradykmin. la mpt chat gay gian mach.
Ket qua chung la cac thud'c tic che men chuyen nay se lam gian mach nhieu. gian
c;i tieu ddng mach va tinh mach, do vay lam giam ca hau ganh vn tien ganh, tti do
lam giam ganh nang cho tim va giam suy tim.

•+ Thudc itc che men chuyen diidc coi Id, lita chgn hang dau trong dieu tri suy
tim. Cac nghien ctiu da chting minh ro vai trd cua thudc UCMC trong dieu tri suy
tim, khdng chi lam giam trieu chting ma cdn cai thien dupe tien liidng benh rat
dang ke.

+ Chd'ng chi dinh: hep ddng mach than hai ben. phu nu cd thai.
+ Nhting tac dung phu cd the gap la: ho. ndi ban. tut huyet ap, loan vi giac.
tang creatinin mau. tang kali mau

+ Than trpng khi dting thud'c tic che men chuyen cung vdi loai ldi tieu giti
kali hoac dting thud'c cho benh nhan cd huyet ap thap.
Bang 7. Mot so thuoc tic che men chuyen thu'dng dung

(mg/ngay)

Trung binh
(mg/ngay)

5- 10

10 40

12,5-25

12,5 - 100

2,5-5

2,5-40

Fosinapril (Monopril, Stari!)

10

10-40

Lisinopril (Prinivil, Zestril)

10

5-40

'*•

Thuoc

Benazepril (Cibace, Cibacen, Lotensin)
Captopril (Capoten, Lopril, Lopiril, Captopril)

Enalapril (Innovace, Pres, Renitec, Renivace, Vasotec)

Perindopril (Coversyl)
Quinapril (Accupril, Acuitel)

Ramipril (Altace, Delix, Ramace, Triatec, Tritace)

2 1

Lieu dau

2-4

4-8

10

5-80

1,25- 2.5

1,25-20


- Nhdm thud'c tic che triic tiep thu the ATI ciia angiotensin II
+ Cac thudc nhdm nay kha mdi va cd che la tic che triic tiep thu the ATI ndi
ma angiotensin II gay ra tac dung tren cac to chtic dich (mach, than. tim). Khac

vdi thud'c tic che men chuyen. cac thud'c tic che thu the ATI ciia angiotensin II

khdng lam tang bradykinm nen cd the khdng gay ra cac trieu chting phu nhii la
ho khan (mpt tac dung phu rat phd bien khi dting UCMC va la han che dang ke
ciia UCMC).

+ Cac thudc nay diidc dting chii yeu de dieu tri benh nhan THA nhiing cac

nghien ctiu mdi day cung chting minh vai trd tot trong dieu tri suy tim va la thudc
cd the thay the hoac phdi hdp vdi UCMC.

Bang 8. Mot so thuoc tic che thu the AT1 cua angiotensin II trong dieu tri suy tim
Thuoc

Lieu ban dau

Lieu trung binh

8-16 mg

2-32 mg

Eprosartan

200-400 mg

400-800 mg

Irbersartan

75-150 mg

75-300mg

25 mg

25-100 mg

20-40 mg

40 - 80 mg

80 mg

80 - 320 mg

Candesartan

Losartan
Telmisartan
Valsartan

-

Nhdm nitrat

+ Nhdm nitrat chii yeu lam gian he tinh mach, tti dd lam giam tien ganh.
Nhdm nay cdn lam giam bdt tinh trang thieu mau cd tim do lam giam ap hie dd
day tim, ngoai ra chting cdn lam gian triic tiep ddng mach vanh.
Bang 9. Mot so nitrat thiidng dung
Lieu

Bat dau

(mg)

(phut)

Keo dai

Nitroglycerin (ngam)

0,3-0,6

2-5

10- 30ph

Dinitrat Isosorbid (ngam)

2,5- 10

10-30

1 -2h

Dinitrat Isosorbid (ud'ng)

5-20

30-60

4 -8h

Mononitrat Isosorbid (ud'ng)

10-20

30-60

6 -8h

Nitroglycerin (cao dan)

5 - 15

> 30

12 - 14h

Dang thuoc

+ Tac dung phu cd the gap ciia thud'c la: nhtic dau, ha huyet ap, ndi ban
Khdng du'dc dting cting vdi sinadefil.

+ Nitrat cd the diidc dting diidi dang ud'ng, md bdi da. cao dan, ngam diidi
hidi hoac tiem truyen tinh mach.

25


+ Nitrat chii yeu du'dc dting d benh nhan suy tim trong benh ddng mach

vanh, hoac khi khdng the dting cac thud'c gian mach nhdm tic che men chuyen
hoac chen thu the ATI.

-

Hydralazin:

+ Lam gian he ddng mach do tac dung lam gian triic tiep cd trdn ciia thanh
mach mau, tti do lam giam hau ganh. Vi vay, hydralazin rat cd ich trong dieu tri
suy tim va thu'dng phdi hdp vdi nitrat.

+ Chti y: thud'c cd the gay tang nhip tim phan xa, dau dau, ndn, lam xua't
hien cOn dau that ngiic. Lieu dting trung binh la ud'ng 20 - lOOmg, chia thanh 2 3 Ian trong ngay. Thudc nay khong phdi la lita chqn Wu tien trong dieu tri suy tim.
- Mpt sd' thud'c gian mach dting diidng tiem truyen:

Cac thud'c nay thiidng du'dc chi dinh cho nhting benh nhan cap ctiu, ddt cap
cua suy tim nang. Khi dting, can bat dau bang lieu nhd va theo ddi chat dien bien
ve huyet ddng. Khi ngting thud'c, can giam lieu dan dan de tranh cac phan xa co
mach dot ngpt.

+ Nitroglycerin: lam gian he thd'ng tinh mach va cd tac dung gian triic
tiep mach vanh.

. Nitroglycerin du'dc de nghi trong dieu tri suy tim d nhiing benh nhan
bi nhoi mau cd tim cap hoac benh nhan dau ngiic khdng on dinh.

. Thdi gian bat dau tac dung ciia thud'c rat nhanh: ban hiiy thu'dng tti 1 3 phut.

. Lieu dting ban dau thu'dng la lOug/phut (dting bdm tiem dien). Bien
chting nguy hiem cd the gap la tut huyet ap.

+ Natri nitroprussid: gay gian triic tiep ddng mach lam giam hau ganh.
cdn tac dung gian he tinh mach thu'dng khdng nhieu.

. Thud'c du'dc chi dinh d nhting benh nhan suy tim cap. nang do tang
huyet ap hoac hd van tim nang.

.

Lieu ban dau thiidng la 10 ug/phut (td'i da 300 - 400 ug/phut). Thdi

gian ban hiiy ciia thud'c la 1-3 phut.

. Tut huyet ap cting la bien chting quan trpng can theo doi. Vi thudc
diidc chuyen hda diidi dang cyanid, nen cd the gay ngd ddc vdi ndng dp thiocyanat
tren 10 ng /dl, do do can than trpng d benh nhan suy than.
+ Enalaprilat:

. La dang hoat hda mat este ciia enalapnl d dang tiem tinh mach. Thdi
gian bat dau tac dung nhanh, thdi gian ban hiiy ngan.

. Lieu ban dau thiidng la 1, 25mg tiem tinh mach cho mdi 6 gid. 0
nhting benh nhan cd dting kem ldi tieu hoac suy than nen giam lieu (0,025mg
tiemTM/6gid).

26