NGHIM PHP GNG SC

IN TM

Ths. Vin Hong Long

i cng
Gng sc: (Exercise) l mt phng php
thm d khng chy mu thng dng pht
hin nhng bt thng tim mch khng biu
hin lc ngh v gip nh gi chc nng tim

Cc loi NPGS

in tm gng sc
Siu m tim gng sc
X hnh c tim gng sc
Chp cng hng t gng sc

Lch s
- Feil v Siegel ghi nhn thay i ca ST-T sau
gng sc (1928)
- Master v Oppenheimer a ra qui trnh gng
sc chun (1929)
- Voldobel s dng xe p lc k (1954)
- Bruce a ra qui trnh lm NPGS bng thm
chy (1956)

Cc phng php gng sc T

Cc phng php gng sc T

C ch sinh l khi gng sc

Tng trng lc giao cm
Gim trng lc giao cm
Co mch (tr cc c hot ng, mch no v
mch vnh)
Tng tit Norepinephrine v renin
Tng HA, tng nhp tim, tng sc co bp
c tim

C ch sinh l khi gng sc

Khi gng sc:
Tng tiu th oxy ca c tim
-> Tng cung lng tim
-> Gin mch vnh

Lu lng ti mu mch vnh khng so

vi nhu cu tiu th oxy ca c tim -> tnh
trng thiu mu c tim -> chn on sm
bnh mch vnh

CH NH (1)
Chn on bnh mch vnh
Chn on cc nguyn nhn ca cc triu
chng c th lin quan n tim mch nh:
au ngc, kh th, au u nh
Xc nh mc an ton ca gng sc
nh ga hiu qu ca vic ti ti mu ng
mch vnh VD: sau t Stent, CABG
D bo cc nguy c c th xy ra bin c tim
mch: VD: au tht ngc, t qu

CH NH (2)
Chn on cc ri lon nhp lin quan n gng sc
nh gi kh nng hot ng bnh nhn mc tim
bm sinh hoc bnh van tim
nh gi chc nng ca MTN vnh vin c p ng tn
s
Nam gii > 40 tui, khng c TC nhng c ngh nghip
c bit (phi cng, phi hnh gia, th ln)
Bnh nhn > 40 tui, khng c TC v c 2 YTNC tim
mch hoc c k hoc tham gia chng trnh hot
ng th lc mc nng
nh gi hiu qu iu tr BN THA trc khi tham gia
hot ng th lc mc nhiu

CH NH NGOI TIM MCH

Bnh phi:
nh gi s dung np vi gng sc
Chn on HPQ sau gng sc
nh gi mc SHH v tin lng
nh gi trc m

Trong th thao:
o V02 max.
Sng lc cc ri lon nhp

CHNG CH NH
CC tuyt i:
NMCT cp trong 2 ngy
NK nhng cha c iu tr n nh
Cc ri lon nhp khng kim sot c gy ra triu
chng hoc nh hng n huyt ng
Hp MC nng c triu chng
Suy tim c triu chng cha kim sot c
Nhi mu phi hoc tc MP cp
Vim c tim hoc vim mng ngoi tim cp
Tch MC cp

CHNG CH NH
CC tng i:

Hp thn chung MV
Hp van tim mc va
Ri lon in gii
THA (HATT> 200mmHg v/hoc HATTr>110 mmHg)
Nhp qu nhanh hoc qu chm
Bnh c tim ph i v cc trng hp c tc nghn
ng ra ca tht
Ri lon tm thn v thc tn gy nh hng n vic
thc hin gng sc
BAV mc cao

Chun b bnh nhn

Hi tin s: Cc bnh tim trc (chn on
bnh van tim, bnh mch vnh) hoc cc
bnh khng phi bnh tim mch (bnh ni
tit, h hp) -> xem bnh nhn c nm trong
ch nh hoc chng ch nh khng.

 Thm khm thc th: cc biu hin bnh tim

mch, cc bnh khc
Ngng cc thuc lm chm nhp tim v gim
HA khi lm gng sc (chn beta giao cm,
diltiazem, verapamil) hoc Nitrates (lm cc
bin i in tim khi gng sc gim i) trong
khong 5 ln thi gian bn hu ca thuc.

Khng dng cc cht kch thch: ru, bia

NPGS c thc hin sau n t nht 2 gi
Mc qun o rng, thoi mi, giy
Gii thch cho bnh nhn v mc ch, hng
dn bnh nhn cc thc hin v cc triu
chng xut hin trong khi lm
K giy cam oan.

nh gi nguy c mc BMV

Tui
Gii
Cn au ngc
Tin s NMCT
T c sng Q
Khong ST-T khi ngh
i tho ng
Ri lon lipid mu
Ht thuc

nh gi nguy c mc BMV

Phc chn on BMV

Chun b dng c
Thm chy hoc xe p lc k
My o huyt p
My theo di nhp tim lin tc, ghi c in
tm 12 chuyn o
Cc dng c cp cu: My shock in, cc
dng c cp cu ngng tun hon, thuc cp
cu tim mch, ri lon nhp

Mc in cc

Mason- Likar
Modification

Quy trnh Bruce

1956
Stage

Time (min)

M/hr

Slope

1.7

10%

2.5

12%

3.4

14%

4.2

16%

12

5.0

18%

15

5.5

20%

18

6.0

22%

21

6.5

24%

24

7.0

26%

10

30

7.5

28%

Quy trnh Bruce ci tin (Modified Bruce)

1963
Giai on

Tc (Km/h)

dc (%)

Thi gian (pht)

2,72

2,72

2,72

10

4,00

12

5,44

14

6,72

16

8,00

18

8,60

20

Quy trnh cho xe p lc k Astrand

Tin hnh NPGS T

o huyt p nhp tim, ghi T t th nm ng
(lc ngh)
Tin hnh lm NPGS theo quy trnh Bruce ci tin
Theo di tnh trng bnh nhn trong qu trnh gng
sc
o HA nhp tim ghi T cui mi giai on gng
sc.
Theo di pht hin cc du hiu phi ngng gng sc
Sau khi ngng gng sc tip tc theo di HA nhp tim
T 3 pht/ ln cho n 12 pht sau.

Tiu chun ngng NPGS

1. Ch nh dng NPGS tuyt i (ngay lp tc)
- Du hiu NMCT
- au ngc mc va -> nng mi xut hin
- HATT tt > 10mmHg so vi trc gng sc cho d mc gng sc
tng ln, c bit nu km theo du hiu ca thiu mu c
tim
- Du hiu ca gim ti mu bao gm tm ti, nht hoc da
lnh, m
- Kh th nng hoc kh th mt cch bt thng
- Cc du hiu ca h thn kinh trung ng: hoa mt, chng mt,
chong vng
- Cc ri lon nhp nguy him: BAV 2,3, rung nh vi tn s p
ng tht nhanh hoc nhp nhanh tht
- Li k thut ca h thng theo di
- Bnh nhn yu cu

Tiu chun ngng NPGS

2.Tiu chun tng i (c th cn nhc)
- Mi trng hp au ngc tng ln
- Kh th hoc mt mi
- Mi chn hoc tnh trng khng p ng (chut rt)
- Tng HA qu cao (HATT > 260 mmHg, HATTr > 115 mmHg)
- Thay i T: ST chnh ln 1mm cc chuyn o khng c
sng Q trc y (tr V1 hoc aVR). ST chnh xung > 2mm, i
ngang hoc i dc xung, c bit nu km theo au ngc.
- Xut hin block nhnh do gng sc m khng phn bit c
vi cn tim nhanh tht
- Cc ri lon nhp tim t nguy him: CNNKPTT, NTT/T s lng
nhiu
- t c 85% tn s l thuyt ti a:

CT Astrand : TSLTT = 220 - Age

Bin chng
-

NMCT cp: 1/10.000 ca

Rung nh: 9/10.000 ca
Nhp nhanh tht: 6/10.000 ca
Rung tht: 0,6/10.000 ca
T vong: 1/25.000 ca

nh gi kt qu
1. T: on ST, sng T, sng U
2. Huyt p
3. Nhp tim: p ng nhp tim, nhp tim giai on
hi phc
4. Kh nng gng sc ti a
5. Mt s ch s gng sc khc: Duke,VO2 max,
METs
6. au ngc
7. Ri lon nhp

p ng bnh thng trn T vi NPGS

- Phc b QRS nh li
- PR, QRS, QT ngn li
- im J h thp, hu qu ca vic on ST chnh
xung
- on ST tr v bnh thng sau 80 ms. (i vi
trng hp tn s tim < 130 ck/p -> ST60)
- on PR c th chnh xung (Cc chuyn o trc
tim c th i ngang)
- Bin sng R c th gim khi tn s tim > 130
ck/pht
- Bin sng P tng
- Sng T gim

Cch xc nh s thay i on ST
trn T NPGS
- S thay i on ST phi xut hin trn 3 phc b
in tm lin tc
- on ST c nh gi da trn on ng in ni
gia P-Q
- Tm im J -> ST80
1. Bt thng:i ngang v chnh > 1 mm hoc chch
xung > 2 mm ca ST80 trn 3 phc b QRS lin nhau.
2. Ranh gii: i ngang v chnh 0,5-1 mm hoc chch
xung 1.5 -2 mm ca ST80 trn 3 phc b QRS lin nhau

Thay i ca in tm

Thay i ca in tm

Thay i ca in tm

Thay i ca in tm

V d 1
chuyn o V4, ST
chnh xung 3 mm
khi kt thc bi test.

-> Thiu mu c tim

V d 2
- Sng J thi im cui
bi test chnh xung
2.5mm, on ST80
chnh xung 1.6mm
- Du hiu thiu mu c
tim thy r sau thi gian
ngh vi s chnh xung
ca on ST.

V d 3
T lc trc gng sc

T lc gng sc mc 3

Cc trng hp nh hng n on ST
1. Digoxin:
- Xut hin trong khong 25-40% trng hp, lm ST bin i bt
thng -> dng tnh gi
2. Dy tht tri
- Lm gim c hiu, khng nh hng n nhy
- Vn l thm d c ch nh u tin, c th cn thm cc thm d
khc
3. Block nhnh tri hon ton:
- Lm tng mc chnh xung ca ST (khng lin quan n thiu mu
c tim) -> khng c mc chnh xc nh chn on.
4. Block nhnh phi hon ton:
- Khng lm gim nhy, c hiu cng nh gi tr tin lng.
5. Thuc Chn Beta giao cm:
- Khng cn dng cc thuc chn beta giao cm thng quy trc khi
lm test
- Vi cc bnh nhn ang dng -> c th lm gim kh nng chn on
v tin lng do cho p ng ca tn s tim khng chnh xc

Cc tiu chun in tm khc

- Sng U o ngcj khi gng sc ( nhy 21%,
c hiu 99%), c bit nu km au ngc -> tn
thng thn chung MV tri hoc LAD
- Tng bin sng R -> tn thng nhiu mch v
c ri lon chc nng tm tht ( Do chc nng
tm tht km -> gng sc tm tht gin ra nhiu
lm tng bin sng R)

p ng ca huyt p
1. Bnh thng: HA tng dn ln khi mc gng sc
tng (160-200 mmHg), t nht l tng 40 mmHg.
2. Bt thng khi:
- HATT tng < 120 mmHg
- HA gim > 10 mmHg
- HATT thp hn HA lc ngh

p ng ca nhp tim
1. Bnh thng: nhp tim tng dn ln khi mc gng
sc tng.
2. Nhp tim tng bt thng khi:
- Thiu mu
- Gim th tch
- Suy tim
3. Nhp tim tng khng tng xng:
- Suy nt xoang
- Dng thuc (Chn Beta giao cm)
- Thiu mu c tim (tin lng xu)

KT QU
Hay

Hi phc nhp tim (HRR)

- HRR bt thng khi nhp tim gim tng i chm
sau khi ngng gng sc
- Do trng lc TK ph giao cm tng t l t vong
- HRR bt thng khi mc gim < 12 ck/pht vi
t th ng v < 18 ck/pht vi t th nm

Duke treadmill score

Thang gng sc (5x ST chnh) (4x ch s au
ngc)
ST< 1mm c coi l 1, khng p dng cho BN 75
tui
Ch s au ngc- Treadmill Angina index
0 khng au ngc
1 au ngc in hnh khi gng sc
2 au ngc nhiu, phi ngng gng sc

Duke treadmill score

Kh nng gng sc ti a
- VO2 max:
- Nam: 14.8 (1.379 x T) + (0.451 x T2) (0.012 x
T3)
- N: 4.38 x T 3.9
* T= tng thi gian gng sc tnh theo pht

Kh nng gng sc ti a
- Metabolic Quivalen Term (MET)
- 1 MET = tc chuyn ho trong iu kin c bn
(ngh ngi) = 3,5 ml 02/kg/phut i vi nam gii
40 tui 70 kg.
Stage

METs

10

13

17

20

Kh nng gng sc ti a
< 5 METs: tin lng ti nu < 65 tui
1 MET = c bn, ngh ngi
2 METs = i b tc 2 dm/h
4 METs = i b tc 4 dm/h
10 METs = iu tr tt ngang vi CABG
13 METs = Tin lng rt tt
16 MET = ng cp vn ng vin
20 MET = Super athlete

Kt lun
NPGS in tm l mt thm d khng xm
ln rt c gi tr, r tin, gip chn on sm
mt s bnh l tim mch, c bit l bnh l
MV.
nh gi kh nng gng sc ca bnh nhn
BMV ni ring v bnh l tim mch ni chung

 nhy v c hiu