1 B GIO DC V O TO B Y T TRNG I HC Y H NI *** T TH HUYN TRANG Giá trị tiên l-ợng nồng độ lactate máu động mạch lúc nhập viện bệnh nhân nhồi máu tim cấp Chuyờn ngnh : Tim mch Mó s : 60720140 LUN VN THC S Y HC Ngi hng dn khoa hc: TS NGUYN NGC QUANG H NI 2015 LI CM N Nhõn dp hon thnh lun tt nghip thc s, tụi xin trõn trng cm n ng u, Ban giỏm hiu, phũng o to sau i hc, B mụn Tim mch Trng i hc Y H Ni, Ban giỏm c Bnh vin Bch Mai v Vin Tim mch Vit Nam ó giỳp , to mi iu kin thun li cho tụi quỏ trỡnh hc v nghiờn cu khoa hc Vi lũng kớnh trng v bit n sõu sc, tụi xin trõn trng cm n GS.TS Nguyn Lõn Vit, nguyờn Vin trng Vin Tim mch Vit Nam, Ch nhim B mụn Tim mch trng i hc Y H Ni, GS.TS Doón Li, vin trng Vin Tim mch Vit Nam, ch nhim B mụn Tim mch trng i hc Y H Ni, nhng ngi Thy ó ht lũng dy bo, to mi iu kin thun li cho tụi quỏ trỡnh hc v hon thnh lun ny Tụi xin c by t lũng kớnh trng v bit n sõu sc ti TS Nguyn Ngc Quang, ngi Thy luụn tn tỡnh ging dy, giỳp tụi thc hnh lõm sng, cng nh hc v nghiờn cu khoa hc, ó ginh nhiu thi gian v tõm huyt trc tip hng dn tụi thc hin v hon thnh lun Tụi xin trõn trng cm n PGS.TS inh Th Thu Hng, PGS.TS Trng Thanh Hng, PGS.TS Nguyn Quang Tun, PGS.TS Nguyn Lõn Hiu, Ths Nguyn Tun Hi, Ths Phan ỡnh Phong, Ths inh Hunh Linh, Ths Phan Tun t, Ths Nguyn Th Minh Lý v cỏc thy cụ B mụn Tim mch ó luụn tn tỡnh ging dy, to iu kin thun li cho tụi quỏ trỡnh hc v lm lun Tụi xin trõn trng cm n PGS.TS Nguyn Th Bch Yn, TS Phm Quc Khỏnh, PGS.TS Phm Th Hng Thi Phú Vin trng Vin Tim mch Vit Nam ó luụn to cho tụi nhng iu kin thun li quỏ trỡnh hc v lm lun ti Vin Tim mch Tụi xin chõn thnh cm n th cỏc bỏc s, iu dng, nhõn viờn Vin Tim mch Vit Nam ó giỳp v to mi iu kin thun li cho tụi quỏ trỡnh hc v thc hin ti Cui cựng tụi xin by t lũng bit n sõu sc ti gia ỡnh tụi ó luụn ng viờn, chia s cựng tụi nhng lỳc khú khn nht, dnh cho tụi nhng tỡnh cm m ỏp nht, l ng lc giỳp tụi hc v vt qua khú khn Xin cm n cỏc anh, ch, em, bn bố v ng nghip ó luụn c v, giỳp tụi quỏ hc v lm lun Mt ln na tụi xin trõn trng cm n! H Ni, ngy 24 thỏng 11 nm 2015 T Th Huyn Trang LI CAM OAN Tụi l T Th Huyn Trang, hc viờn cao hc khúa XXII, chuyờn ngnh Tim mch, Trng i hc Y H Ni xin cam oan: õy l nghiờn cu ca tụi, thc hin di s hng dn khoa hc ca TS Nguyn Ngc Quang Cỏc s liu v thụng tin nghiờn cu l hon ton trung thc v khỏch quan, tụi thu thp v thc hin ti Bnh vin Bch Mai mt cỏch khoa hc v chớnh xỏc Kt qu nghiờn cu ca lun ny cha c ng ti trờn bt k mt hay mt cụng trỡnh khoa hc no Tỏc gi lun T Th Huyn Trang CC CH VIT TT TRONG LUN VN ACC : Trng mụn Tim mch Hoa K : (American College of Cardiology) AHA : Hip hi Tim mch Hoa K BN : Bnh nhõn COPD : Bnh phi tc nghn mn tớnh CTMV : Can thip mch vnh MV : ng mch vnh T : ỏi thỏo ng ESC : Hip hi Tim mch Chõu u NMCT : Nhi mỏu c tim PCI :Can thip ng mch vnh qua da thỡ u RLMM : Ri lon m mỏu TBMN : Tai bin mch nóo THA : Tng huyt ỏp CNTTTTr : Chc nng tõm thu tht trỏi MC LC T VN Chng 1: TNG QUAN 13 1.1 TNG QUAN CC NGHIấN CU V LACTATE V THIU MU C TIM 13 1.1.1 Tng quan v lactate mỏu v hi chng vnh cp 13 1.1.2 Lactate mỏu v sc tim 16 1.1.3 Lactate mỏu v phu thut tim 18 1.1.4 Thanh thi lactate bnh nhõn tim mch 18 1.2 SINH Lí BNH V NHI MU C TIM V CHUYN HểA LACTATE TRONG NHI MU C TIM CP 22 1.2.1 Tng quan v lactate mỏu 22 1.2.2 C ch sinh lý bnh ca NMCT v chuyn húa lactate ca t bo c tim 28 1.3 TNG QUAN V CC YU T TIấN LNG TRONG NHI MU C TIM CP 33 1.3.1 Cỏc yu t tiờn lng NMCT cp 33 1.3.2 Cỏc bng im tiờn lng nguy c t vong 36 Chng 2: I TNG V PHNG PHP NGHIấN CU 40 2.1 I TNG NGHIấN CU 40 2.1.1 Tiờu chun la chn bnh nhõn 40 2.1.2 Tiờu chun loi tr 40 2.1.3 Phng phỏp chn c mu nghiờn cu 41 2.2 PHNG PHP NGHIấN CU 42 2.2.1 a im, thi gian nghiờn cu 42 2.2.2 Thit k nghiờn cu 42 2.2.3 Cụng c thu thp s liu 42 2.2.4 Cỏc bc tin hnh nghiờn cu 42 2.2.5 Cac bin sụ nghiờn cu 43 2.2.6 Qui trỡnh o nng lactate mỏu ng mch qua mỏy phõn tớch khớ mỏu GEM 3000 46 2.2.7 X lý thng kờ s liu nghiờn cu 48 2.2.8 o c nghiờn cu 48 Chng 3: KT QU NGHIấN CU 50 3.1 C IM CHUNG CA I TNG NGHIấN CU 50 3.2 KT QU V NNG LACTATE MU NG MCH LC NHP VIN NHểM I TNG NGHIấN CU 52 3.2.1 Kt qu chung v nng lactate mỏu ng mch lỳc nhp vin ca nhúm i tng nghiờn cu 52 3.2.2 Kt qu phõn b nng lactate theo gi NMCT 53 3.2.3 Nng lactate mỏu ng mch mt s nhúm bnh nhõn 55 3.2.4 Mi liờn quan gia lactate mỏu ng mch lỳc nhp vin vi mt s thụng s lõm sng v cn lõm sng 61 3.3 KT QU V MI LIấN QUAN GIA NNG LACTAE MU LC NHP VIN V BIN C TIM MCH 64 3.3.1 Cỏc bin c tim mch chớnh nhúm bnh nhõn nghiờn cu 64 3.3.2 S khỏc bit nng lactate mỏu ng mch cỏc nhúm bin c tim mch chớnh bnh nhõn NMCT cp 65 3.3.3 Kt qu dựng lactate mỏu ng mch lỳc nhp vin chn oỏn sc tim 66 3.3.4 Phõn tớch a bin mi liờn quan cỏc bin c tim mch chớnh v nng lactate mỏu ng mch 68 Chng 4: BN LUN 75 4.1 C IM CHUNG CA NHểM I TNG NGHIấN CU 75 4.1.1 Bn v c im lõm sng ca nhúm i tng nghiờn cu 75 4.1.2 Bn v c im cn lõm sng ca nhúm i tng nghiờn cu 77 4.2 NNG LACTATE MU NG MCH LC NHP VIN V MI LIấN QUAN VI MT S THễNG S LM SNG V CN LM SNG 77 4.2.1 Nng lactate mỏu ng mch nhúm bnh nhõn nghiờn cu 77 4.2.2 Nng lactate mỏu ng mch mt s nhúm bnh nhõn nghiờn cu 78 4.2.3 Mi liờn quan gia nng lactate mỏu ng mch vi mt s thụng s lõm sng 81 4.2.4 Mi liờn quan gia nng lactate mỏu ng mch vi mt s thụng s cn lõm sng 83 4.3 MI LIấN QUAN GIA NNG LACTATE MU NG MCH LC NHP VIN V MT S BIN C TIM MCH 84 4.3.1 S phõn b cỏc bin c nhúm bnh nhõn nghiờn cu 84 4.3.2 Mi liờn quan gia nng lactate mỏu ng mch lỳc nhp vin v sc tim bnh nhõn NMCT cp 85 4.3.3 Mi liờn quan gia nng lactate mỏu ng mch v t vong vũng 30 ngy nhúm bnh nhõn nghiờn cu 87 4.3.4 Mi liờn quan gia nng lactate mỏu ng mch lỳc nhp vin v bin c cng gp nhúm bnh nhõn nghiờn cu 89 KT LUN 91 TI LIU THAM KHO PH LC DANH MC BNG Bng 1.1: Phõn Killip 36 Bng 1.2: Bng im TIMI 37 Bng 1.3: T vong bnh vin v sau thỏng theo im GRACE 38 Bng 3.1: c im chung ca i tng nghiờn cu 50 Bng 3.2: S khỏc bit nng lactate mỏu ng mch lỳc nhp vin mt s nhúm bnh nhõn 55 Bng 3.3: Nng lactate mỏu trung bỡnh theo v trớ nhi mỏu 59 Bng 3.4: Mi liờn quan gia lactate mỏu ng mch lỳc nhp vin vi mt s thụng s lõm sng, cn lõm sng 61 Bng 3.5: Phõn tớch hi quy tuyn tớnh a bin v mi liờn quan gia nng lactate mỏu ng mch lỳc nhp vin vi mt s thụng s lõm sng v cn lõm sng 63 Bng 3.6: Cỏc bin c tim mch nhúm bnh nhõn nghiờn cu 64 Bng 3.7: S khỏc bit nng lactate mỏu ng mch cỏc nhúm bin c tim mch chớnh bnh nhõn NMCT cp 65 Bng 3.8: Cỏc giỏ tr cut off ca lactate mỏu, nhy, c hiu v din tớch di ng cong AUC tng ng dựng lactate chn oỏn sc tim 67 Bng 3.9: Mi liờn quan gia sc tim vi lactate v mt s yu t tiờn lng khỏc 68 Bng 3.10: Mi liờn quan gia t vong vi lactate mỏu v mt s yu t tiờn lng khỏc 69 Bng 3.11: Mi liờn quan gia bin c gp vi lactate mỏu v mt s yu t tiờn lng khỏc 72 10 DANH MC BIU Biu 3.1: Phõn b nng lactate mỏu ng mch lỳc nhp vin 52 Biu 3.2: Nng lactate trung bỡnh theo gi NMCT 53 Biu 3.3: Nng lactate mỏu trung bỡnh theo gi NMCT 54 Biu 3.4: Nng lactate mỏu trung bỡnh lỳc nhp vin theo tn s tim 56 Biu 3.5: Nng lactate mỏu trung bỡnh lỳc nhp vin theo Killip 57 Biu 3.6: Nng lactate mỏu trung bỡnh lỳc nhp vin theo nhúm Killip 58 Biu 3.7: Nng lactate mỏu trung bỡnh cỏc nhúm bnh nhõn cú chc nng tõm thu tht trỏi khỏc 59 Biu 3.8: Nng lactate mỏu trung bỡnh theo v trớ nhi mỏu 60 Biu 3.9: Nng lactate mỏu trung bỡnh theo phõn loi cú ST chờnh lờn v khụng cú ST chờnh lờn 60 Biu 3.10: Mi liờn quan gia lactate mỏu ng mch lỳc nhp vin vi tn s tim 62 Biu 3.11: ng cong ROC (receiver operating characteristic) chn oỏn sc tim bng lactate 66 Biu 3.12: ng cong Kaplan Meier v t l t vong nhúm lactate 2mmol/l v lactate < 2mmol/l 70 Biu 3.13: Phõn tớch hi quy Cox mi tng quan gia t vong v nng lactate mỏu 71 Biu 3.14: ng cong Kaplan Meier v t l bin c gp sau 30 ngy nhúm lactate 2mmol/l v lactate < mmol/l 73 Biu 3.15: Phõn tớch hi quy Cox v mi tng quan gia bin c gp v nng lactate 74 91 KT LUN Qua nghiờn cu 422 bnh nhõn nhi mỏu c tim cp vo Vin Tim mch t thỏng 1/2014 n thỏng 8/2015 Cỏc bnh nhõn c theo dừi vũng 30 ngy Kt qu chỳng tụi thu c nh sau: Nghiờn cu nng lactate mỏu ng mch lỳc nhp vin v mi tng quan vi mt s thụng s lõm sng v cn lõm sng - Nng lactate mỏu ng mh trung bỡnh lỳc nhp vin ca qun th nghiờn cu l 1.98 1.28mmol/l - Nng lactate mỏu ng mch lỳc nhp vin cú tng quan vi tn s tim lỳc nhp vin, Killip, tỡnh trng tt huyt ỏp tõm thu v chc nng tõm thu tht trỏi, ng mỏu lỳc nhp vin vi h s r ln lt l 0.5; 0.2; 0.1; 0.22; 0.4 - Nng lactate mỏu ng mch lỳc nhp vin nhúm bnh nhõn vo vin trc 12 gi (tớnh t lỳc phỏt triu chng au ngc) cao hn so vi nhúm vo vin sau 12 gi (s khỏc bit cú ý ngha thng kờ) - Khụng thy cú mi tng quan gia nng lactate mỏu ng mch lỳc nhp vin vi pro BNP, troponin v CK MB Mi liờn quan gia nng lactate mỏu ng mch lỳc nhp vin v mt s bin c tim mch chớnh sau 30 ngy - Nng lactate mỏu ng mch lỳc nhp vin cú mi tng quan cht vi sc tim (OR = 3.73; 95%CI = 2.2 6.4) v cú ý ngha thng kờ vi p < 0.05 - Dựng lactate chn oỏn sc tim cú nhy v c hiu cao Vi giỏ tr cut off ca lactate bng 2mmol/l thỡ cú nhy l 100%, c hiu l 66.6% v din tớch di ng cong AUC l 0.5876 92 - Lactate l yu t tiờn lng c lp v mnh 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LACTATE V THIU MU C TIM 13 1.1.1 Tng quan v lactate mỏu v hi chng vnh cp 13 1.1.2 Lactate mỏu v sc tim 16 1.1.3 Lactate mỏu v phu thut tim 18 1.1.4 Thanh thi lactate. .. ST khụng chờnh Killip Lactate lỳc nhp Lactate vin > 2mmol/l Killip Sc tim 22 1.2 SINH Lí BNH V NHI MU C TIM V CHUYN HểA LACTATE TRONG NHI MU C TIM CP 1.2.1 Tng quan v lactate mỏu 1.2.1.1 Ngun... bnh nhõn tim mch 18 1.2 SINH Lí BNH V NHI MU C TIM V CHUYN HểA LACTATE TRONG NHI MU C TIM CP 22 1.2.1 Tng quan v lactate mỏu 22 1.2.2 C ch sinh lý bnh ca NMCT v chuyn húa lactate