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Pgs. Ts. Ds. PH M Thành Suôl
Pgs. Ts. Ds. PH M Thành Suôl
Pgs. Ts. Ds. PH M Thành Suôl
B Y T
TRNG I HC Y DC CN TH
KHOA DC LIN B MN DC L DC LM SNG
Cn Th Nm 2016
T VN
HI CHNG VANH CP: T l t vong
Nc pht trin
nh gi cc yu t tin lng
Phn tng nguy c
ti: Nghin cu cc yu t tin lng nguy
c t vong v ti nhp vin bnh nhn hi chng vnh
cp sau xut vin ti bnh vin a khoa Trung ng Cn
Th v bnh vin a khoa Thnh ph Cn Th nm 2015
2
MC TIU NGHIN CU
1
c im hi chng vnh cp
au ngc
Nhp vin
Hi chng vnh cp
Chn on s b
in tm
ST chnh
ln dai dng
Sinh ha
Chn on
xc nh
NMCT cp
c ST
chnh ln
Bt thng
ST/T
ECG
bnh thng
Troponin
tng
Troponin
bnh thng
NMCT cp
khng ST
chnh ln
TNK
iu tr hi chng vnh cp
iu tr ti bnh vin
Mc tiu: Gim triu chng thiu mu cc b c tim
Phng nga bin chng ngn hn v di hn
Chng thiu mu
cc b
1. iu tr ni khoa
Chng kt tp
tiu cu
Khng ng
2. iu tr can thip
5
iu tr hi chng vnh cp
1. Dng thuc
Chn th th
Statin
Yu t tin lng
YTNC
HCVC
Tui
Gii tnh
C a
YTTL
Cn
lm
sng
Lm
sng
Thi gian
Nhp tim
Huyt p
Killip
Thang im GRACE
Tui
Ngng tim
Creatinin
Killip
GRACE
Nhp tim
Bin i ST
Huyt p
tm thu
i tng nghin cu
Tt c bnh nhn HCVC ti 2 bnh vin, xut vin
trong khong thi gian t 26/01/2015 26/10/2015
Tiu chun chn mu
Tt c BN ni tr khoa Tim
mch c chn on xut
vin:
1. Khng c n thuc
xut vin
1. TNK
2. NMCT cp khng ST
chnh ln
3. NMCT cp c ST chnh
ln
2. BN ti nhp vin
c tn trong nghin cu
3. Khng ng tham
gia hoc khng c ST
4. Khng thng tin
v yu t tin lng
9
N 1,96 x
2
p(1 p)
N: c mu nghin cu N = 247
trnh hao ht, tng c mu thm 30%
C mu cn thit l 322 BN
* Sangu PV (2012)
10
11
Nm vin
12
Yu t tin lng
T vong
Ti nhp
vin
14
15
tT l t vong
T l ti nhp
vin
Bin c
16
S chn mu
257 BN c theo di
sau 1 thng
206 BN khng ti
nhp vin v khng
t vong
37 BN ti
nhp vin
14 BN
t vong
86 BN ti
nhp
vin
29 BN
t vong
17
(N = 257)
T l
Trung bnh
(%)
( lch chun)
67 13
Tui
Nam gii
158
61,5
Tin s NMCT
74
28,8
11
4,3
Tin s t qu
15
5,8
18
S bnh nhn
(N = 257)
T l (%)
140
14
111
207
62
66
54,5
5,4
43,2
80,5
24,1
25,7
194
63
75,5
24,5
19
STT
Bin c do tt c
nguyn nhn
Tng s BN gp
bin c
N = 257; (%)
30
7
Trn Th Trc o: 16,8%
(15,5)
(11,1)
37
(14,4)
T vong 1 thng
14
(5,4)
67
19
20,1%
(34,5) Sangu VS:
(30,2)
86
(33,5)
T vong 6 thng
18
11
Fox KAA: 9,1%
(9,3)
(17,5)
29
(11,3)
20
Suy tim
Sng Q hoi t
Troponin T
Rung nh
Lon nhp tht
Hi quy n bin
Hi quy a bin
OR
(KTC 95%)
OR
(KTC 95%)
8,96
(2,70 29,72)
<0,001
6,33
(1,68 23,89)
0,006
0,015
> 0,05
0,048
> 0,05
0,002
> 0,05
<0,001
9,80
(1,69 56,73)
0,011
3,59
(1,20 10,67)
0,78
(0,73 0,84)
7,09
(1,68 29,92)
12,98
(2,75 61,39)
21
Tui
Suy tim
Sng Q hoi t
Troponin T
Lon nhp tht
Rung nh
T vong 6 thng
Hi quy n bin
Hi quy a bin
OR
OR
p
p
(KTC 95%)
(KTC 95%)
2,93
0,014
> 0,05
(1,20 7,13)
6,66
3,52
<0,001
0,007
(2,94 15,08)
(1,40 8,81)
3,13
2,78
0,004
0,024
(1,41 6,96)
(1,14 6,78)
0,77
0,003
> 0,05
(0,72 0,82)
5,15
0,017
> 0,05
(1,16 22,79)
4,40
22
0,013
> 0,05
(1,24 15,66)
Hi quy n bin
OR
(KTC 95%)
p dng hng
dn iu tr
Chc nng thn
Sng Q hoi t
1,75
(1,04 2,96)
3,35
(1,64 6,86)
2,65
(1,27 5,52)
p
0,001
0,001
0,007
Hi quy a bin
OR
(KTC 95%)
2,75
(1,28 5,93)
2,89
(1,30 6,42)
2,23
(1,03 4,81)
p
0,010
0,009
0,041
23
Hi quy n bin
OR
(KTC 95%)
p dng hng
dn iu tr
Tin s NMCT
Chc nng thn
1,75
(1,04 2,96)
1,82
(1,04 3,18)
2,01
(1,17 3,44)
Hi quy a bin
OR
(KTC 95%)
0,035
> 0,05
0,035
> 0,05
0,010
> 0,05
24
Nhm nguy c
Nguy c cao
Nguy c thp - trung
bnh
Tng cng
T vong thc t
C
Khng
n (%)
n (%)
12
112
(6,8)
(63,3)
0
53
(0,0)
(29.9)
12
165
(6,8)
(93,2)
Tng
cng
p*
124
(70,1)
53
(29,9)
177
(100,0)
0,019
26
nhy
AUC: 0,685
p = 0,032
1 c hiu
27
Nhm nguy c
Nguy c cao
Nguy c thp - trung
bnh
Tng cng
T vong thc t
C
Khng
n (%)
n (%)
23
101
(13,0)
(57,1)
2
51
(1,1)
(28,8)
25
152
(14,1)
(85,9)
Tng
cng
p*
124
(70,1)
53
(29,9)
177
(100,0)
0,009
28
nhy
AUC: 0,628
p = 0,041
1 c hiu
29
KT LUN
1. c im bnh nhn: 30% BN b NMCT trc . 75% BN HCVC
khng ST chnh ln v 25% BN HCVC c ST chnh ln
2. T l t vong v ti nhp vin trong 1 v 6 thng sau xut vin
- 1 thng: 5,4% BN t vong v 14,4% BN ti nhp vin
- 6 thng: t l t vong tch ly 11,3% v ti nhp vin tch ly 33,5%
3. Yu t tin lng t vong v ti nhp vin trong 1 v 6 thng
- YTTL 1 thng: p dng HDT, chc nng thn, suy tim, sng Q hoi
t, troponin T, rung nh v lon nhp tht
- YTTL 6 thng: p dng HDT, tui, tin s NMCT, chc nng thn,
suy tim, sng Q hoi t, troponin T, rung nh v lon nhp tht
4. Gi tr tin lng v nguy c t vong ca thang im GRACE
Thang im GRACE tin lng tt cho nguy c t vong ngn hn v
di hn BN HCVC
30
KIN NGH
1. nh gi li cc yu t nh hng n bin c t vong, ti
nhp vin di hn qua cc mc 6 thng v 1 nm
2. nh gi gi tr tin lng nguy c t vong ngn hn v di
hn ca thang im GRACE mi gm 9 yu t c th p dng
cho BN c v khng c PCI
3. Ngi iu tr cn ch trong vic phn tng nguy c, da