Tối ưu điều trị thuyên tắc phổi cấp bệnh nhân có tiền sử nhồi máu tim Bs Nguyễn Ngô Thanh Phương BS Đinh Đức Huy Bv Tim Tâm Đức Trường hợp lâm sàng • • • • • • Bệnh nhân C J, 50 tuổi BMI 28 (CC 183cm, CN 96kg) Hút thuốc lá(+) Rối loạn mỡ máu (+) THA (-), ĐTĐ (-) Tiền NMCT ST chênh lên (2011)  can thiệp stent không phủ thuốc vào đoạn đầu LAD • Điều trị : Aspirin, Bisoprolol, Losartan, Rosuvastatin • BN không triệu chứng Trường hợp lâm sàng • • • • • • • • • • tháng trước, bệnh nhân bay từ HCM-London Khó thở gắng sức ngày tăng Đau chân bên phải Nhập viện khó thở Tỉnh táo, không dấu thần kinh khu trú, không sốt TST 88 bpm HA 135/80 mmHg TS thở 16 bpm SpO2 96% (room air) Tim đều, không âm thổi Phổi Chân bên phải lớn chân bên trái Xét nghiệm • • • • • BC 9.7k/uL, HGB 15 g/dL, TC 200K/uL Creatinin 101 mmol/L, eGFR:78ml/ph/1.73m2 Hs-CRP 70mg/L AST 26 U/L ALT 28 U/L Cholesterol 2.1 HDL-C 0.5 LDL-C 1.5 TG: 1.2 mmol/L • NT proBNP 1692pg/ml • Hs-TnT 21-22 pg/ml • D-Dimer 5990 ng/mL ECG Sinus rythm, 85 bpm, normal QRS axis and PR interval Cận lâm sàng Siêu âm tim • EF 62%, không RLVĐ vùng • Không bệnh lý van tim • Không tăng áp phổi (PAPs =20mmHg) • Không huyết khối • Lớn thất phải, TAPSE 19 Siêu âm mạch máu • Tắc hoàn toàn tĩnh mạch đùi nông bên phải • Huyết khối lan tỏa đến tĩnh mạch khoeo bên phải CTR: 0.55 Tuần hoàn phổi bên phải giảm Chẩn đoán Thuyên tắc phổi/ Nhồi máu tim đặt stent Xác định MSCT phổi Xử trí Ngày 1-2: Enoxaparin 0.9ml TDD /12 Acenocoumarol 1mg / ngày ASA 81mg /ngày Bisoprolol 2.5mg /ngày Losartan 25mg /ngày Rosuvastatin 10mg /ngày Ngày 3: Bệnh nhân từ chối kiểm tra INR ngày VTE treatment with VKAs • • • • VKAs = standard treatment for VTE (PE & DVT) Highly prevent recurrent VTE (RRR 85% vs placebo) Recurrence risk of 3% with patient on treatment Limitations of VKA treatment      need frequent INR monitoring major bleeding of 2.1% during the first months of treatment case-fatality rate 11% intracranial bleeding 8.7% of major bleeds with mortality risk of 46% most major bleeds occur during the first weeks of VKA treatment N Engl J Med 2012;366:1287-97 Cumulative event rate (%) EINSTEIN PE: principal safety outcome – major or non-major clinically relevant bleeding Enoxaparin/VKA N=2405 15 14 13 12 11 10 Rivaroxaban N=2412 30 60 90 120 150 Rivaroxaban n/N (%) Enoxaparin/VKA n/N (%) HR (95% CI) p-value 249/2412 (10.3) 274/2405 (11.4) 0.90 (0.76–1.07) p=0.23 180 210 240 270 300 330 360 Time to event (days) Number of patients at risk Rivaroxaban 2412 2183 2133 2024 1953 1913 1211 696 671 632 600 588 313 Enoxaparin/VKA 2405 2184 2115 1990 1923 1887 1092 687 660 620 589 574 251 Safety population Cumulative event rate (%) EINSTEIN PE: major bleeding 3.0 Rivaroxaban n/N (%) Enoxaparin/VKA n/N (%) HR (95% CI) p-value 2.5 26/2412 (1.1) 52/2405 (2.2) 0.49 (0.31–0.79) p=0.0032 Enoxaparin/VKA N=2405 2.0 1.5 1.0 Rivaroxaban N=2412 0.5 0.0 30 60 90 120 150 180 210 240 270 300 330 360 Time to event (days) Number of patients at risk Rivaroxaban 2412 2281 2248 2156 2091 2063 1317 761 735 700 669 659 350 Enoxaparin/VKA 2405 2270 2224 2116 2063 2036 1176 746 719 680 658 642 278 Safety population EINSTEIN PE: conclusions In patients with acute symptomatic PE with or without DVT, rivaroxaban showed: Non-inferiority to LMWH/VKA for efficacy HR=1.12 (0.75–1.69); pnon-inferiority =0.0026 for non-inferiority margin of 2.0 Similar findings for principal safety outcome HR=0.90 (0.76–1.07); p=0.23 Superiority for major bleeding HR=0.49 (0.31–0.79) p=0.0032 Consistent efficacy and safety results irrespective of age, body weight, gender, kidney function and cancer No evidence for liver toxicity Clinical trials of NOACs for PE acute phase Systemic review and meta-analysis Introduction: Meta-analysis to determine the efficacy and safety of NOACs as compared with those of VKAs in patients with acute VTE Methods: MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews and the Clinical Trials Registry up to October 2013 Eligible studies included phase trials comparing NOACs with VKAs in patients with acute VTE RRs, absolute risk differences and NNTs to prevent one event were calculated for recurrent VTE, fatal PE, overall mortality, major bleeding, and other bleeding complications, with randomeffects models Study outcomes & Definitions Efficacy outcomes Recurrent VTE, fatal PE, and overall mortality Safety outcomes Major bleeding, non-fatal major bleeding at a critical site, clinically relevant non-major bleeding, non-fatal intracranial bleeding, major gastrointestinal bleeding, and fatal bleeding during anticoagulant treatment Definition of major bleeding Overt and associated with a decrease in the Hb level of ≥2g/dL, requiring transfusion of at least units of blood, occurring in a critical site (intracranial, intraspinal, intraocular, pericardial, intra-articular intramuscular with compartment syndrome, retroperitoneal), or contributing to death Study selection Study characteristics Main findings Five studies were included, NOACs (rivaroxaban, dabigatran, apixaban, edoxaban) in 24 455 patients with acute VTE RR for recurrent VTE 0.88 (95% CI 0.74–1.05) fatal PE 1.02 (95% CI 0.39–5.96) overall mortality 0.97 (95% CI 0.83–1.14) major bleeding 0.60 (95% CI 0.41–0.88) fatal bleeding 0.36 (95% CI 0.15–0.87) NNT to prevent one major bleed 149 one fatal bleed 1111 No significant differences between individual NOACs and rivaroxaban (Fixed-effect network analysis ) Efficacy outcomes Recurrent VTE Fatal PE Mortality 241/12 151 patients (2.0%) vs 9/12 151 patients (0.07%) vs 290 /12 197 patients (2.4%) vs 273 /12 153 patients (2.2%) 9/12 153 patients (0.07%) 298 /12 193 patients (2.4%) Safety outcomes Meta analysis conclusions NOACs show comparable efficacy to VKAs in patients with acute VTE Greater practical simplicity More favorable bleeding profile Absolute benefit was limited with high NNT 2014 ESC Guidelines Recommendations for Acute phase treatment Class I B for NOACs as an alternative to the combination of parental anticoagulation with a VKA www.escardio.org/guidelines Điều trị bệnh nhân Rivaroxaban 15mg lần/ngày x tuần Duy trì thuốc khác: aspirin, losartan, bisoprolol, rosuvastatin Rivaroxaban 20mg /ngày đến tháng Ngưng kháng đông hệ 08/ 2015, không biến chứng chảy máu Tiếp tục điều trị nội khoa mạch vành sau can thiệp Sử dụng vớ áp lực Thank you for your attention!