19 (2).benh dm ngoi bien

8/4/2019 19 (2).BENH DM NGOI BIEN

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Bnh ng mch ngoi bint cc yu t nguy c

n chn on v iu tr

Ban M Thut, 5-6/08/2010


2/27

0% 5% 10% 15% 20% 25% 30% 35%

29%

11.7%

19.8%

19.1%

14.5%

4.3%

T l hin hnhbnh ng mch ngoi bin (BMNB)

PARTNERS5Aged >70 years, or 5069 years with a history diabetes orsmoking

San Diego2Mean age 66 years

Diehm4Aged 65 years

Rotterdam3Aged >55 years

NHANES1Aged 70 years

NHANES1Aged >40years

NHANES=National Health and Nutrition Examination Study;PARTNERS=PAD Awareness, Risk, and Treatment: New Resources for Survival [program].

1. Selvin E, Erlinger TP. Circulation. 2004;110:738-743.2. Criqui MH, et al. Circulation. 1985;71:510-515.3. Diehm C, et al. Atherosclerosis. 2004;172:95-105.4. Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192.5. Hirsch AT, et al. JAMA. 2001;286:1317-1324.

dn s chm scban u xc nh tuiv cc yu t nguy cph bin, t l caBMNB xp x 1/3 sbnh nhn


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1. Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192.2. Criqui MH, et al. Circulation. 1985;71:510-515.

Rotterdam Study (ABI


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T l c tnh ca BMNB trn bnh nhni tho ng tp 2 chu trn 50 tui

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

0

Trngh

p/100

,0

00

Korea Indonesia Thailand Taiwan China Philippines Hong Kong

NamNam NN Tng s

Sang Youl Rhee et al, Diabetes Research and Clinical Practice (2006)


5/27

Yu t nguy c

Ht thuc

i tho ng

Tng huyt p

Tng cholesterol trong mu

Tng homocystein trong mu

Tng C-Reactive Protein

Hirsch AT, et al. Circulation. 2006;113:e463-e465.


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Ht thuc

Price JF, Mowbray PI, Lee AJ, et al. Relationship between smoking and cardiovascular risk factors in the development of peripheral arterial disease andcoronary artery disease: Edinburgh Artery Study.Eur Heart J. 1999;20:344-353.

Ht thuc trung bnh: < 25 gi nm (s nm x s gi trung bnh ht mi ngy)Ht thuc nhiu: > 25 gi nm.

N = 1592Theo di 5nm

Tlph

tsinh(%)


7/27

Tng huyt p

Tlpht

sinh

(%)

Elizabeth Selvin and Thomas P. Erlinger, Circulation 2004;110;738-743


8/27

Tng cholesterol mu

Tlpht

sinh

(%)

Elizabeth Selvin and Thomas P. Erlinger, Circulation 2004;110;738-743


9/27

Tiu ng tng nguy c b BMNB

22.4*

19.9*

12.5

0

5

10

15

20

25

Dung np glucosebnh thng

Impaired glucose tolerance was defined as oral glucose tolerance test value 140 mg/dL but


10/27

CRP l yu t tin on ca BMNB

hs-CRP

(m

g/d

L)

Ridker, et al. Circulation.1998;97:425-28.

0.2

Bnh thng au cch hi

0.1

0.0

0.1

0.13

0.17

CRP = C-reactive protein; hs-CRP = high-sensitivity C-reactive protein

Phu thut ng mchngoi bin


11/27

Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

T l tng i

Ht thuc

i tho ng

Tng huyt pTng cholesterol mu

Tng homocystein mu

C-Reactive Protein

Gim Tng

Cc yu t nguy c ca BMNB

1 2 3 4 5 60


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Tui < 50 c bnh tiu ng, v mt yu t nguy ckm theo (v d ht thuc, ri lon m mu, tng huytp hay tng homocystein mu)

Tui t 50 n 69 tui c tin s ht thuc hoc bnhtiu ng

Tui trn 70 Triu chng chn khi gng sc (gi au cch hi)

hoc au khi ngh do thiu mu

Khm mch chi di c bt thng Bnh l x va bit ng mch vnh, ng mch

cnh, ng mch thn

Da trn cc chng c dch t hc dn s c nguy c vi BMNB c th

c xc nh l: :

Nhng i tng c nguy c mc BMNB



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Chn on bnh ng mch ngoi bin

Yu t nguy c

Triu chng lm sng

Ch s c chn-cnh tay (ABI)

Cc k thut chn on hnh nh

Siu m mch mu Dupplex

MSCT ng mch

Cng hng t ng mch

DSA ng mch


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Triu chng lm sng

Khng triu chng thng gp ngi tiu ng, ln tui, di chngthn kinh lm cho vn ng i li t nn khng bc l c triu chng.

Khp khing cch hi in hnh (au bp chn khi i li v gim khi

ngh), khp khing cch hi khng in hnh (au bp chn khi i li

nhng khng gim khi ngh).

au do thiu mu chi di nng (au c khi ngh, vt thng lu lnh

hoc hoi th).

au do thiu mu chi cp 5P: au (pain), v mch (pulselessness), tmti (palor), t (paresthesia), yu lit chi (paralysis).


15/27

Ch s c chn - cnh tay (ABI)

L ch s nh gi lm sng n gin v gi tr

Phng php ny c nhy cm l 79-95% v chiu 95 - 100%

Nhng gii hn ca phng php ny l tr s o s khngchnh xc khi ng mch chy b vi ho, khng xpc v khi c hp nh ng mch di n

Ga tr ca ABI: 1.00 - 1.29: Bnh thng

0,91 - 0,99: Gii hn 0,41 - 0,90: Bnh ng mch ngoi bin nh-va

0,40: Bnh ng mch ngoi bin nng

1,30: ng mch cng


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Cc k thut chn on hnh nh

Siu m mch mu Dupplex: Hin nay s dng m t tnhtrng gii phu, huyt ng v hnh thi tn thng.

MSCT ng mch: Vi s tin b ca k thut CT scan a lt ct, nhy cm v c hiu ca k thut ny l kh cao (94 - 100%v 98 - 100%) trong chn on bnh mch mu ngoi bin.

Cng hng t ng mch: nhy cm v c hiu ca kthut ny kh cao (93 - 100% v 96 - 100%) trong vic xc nhmc hp ca cc ng mch chu, i.

DSA ng mch: c s dng khi c ch nh can thip, sau

cc xt nghim khng xm nhp.


17/27

iu tr

iu tr, kim sot cc yu t nguy c

iu tr triu chng v ci thin chc nng

iu tr ti thng: can thip mch mu v phu

thut mch mu


18/27

iu chnh cc yu t nguy c

Ngng ht thuc l

Vic ngng thuc l cho thy gim t l t vong

10 nm t 54% cn 18% ngi 65-75 c

BMNB. Ngoi ra, vic ngng thuc l cng

gip lm gim triu chng bnh.

Burns P, Gough S, Bradbury AW. Management of peripheral arterial disease in primary care BMJ 2003, Mar15:326 (7389): 584-8.


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iu tr tng lipid mu

iu tr vi thuc c ch HMG-CoA Reductase (statin)

c ch nh cho tt c bnh nhn BMNB t mc

tiu LDL < 100 mg/dl.

iu tr vi thuc c ch HMG-CoA Reductase (statin)

c ch nh t mc tiu LDL < 70 mg/dl choBMCD c nguy c cao cc bin c thiu mu.



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Tng huyt p

Thuc chng tng huyt p c s dng cho bnh

nhn tng huyt p c BMNB chi di t mc tiu

< 140/90 mmHg (khng T) hay


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Kim sot glucose huyt Chm sc bn chn ng cch bao gm s dng v ph hp,

thuc chm sc bn chn, quan st chn hng ngy, lm sch

da, v dng cht lm m, nn c khuyn khch v cc sang

thng da v lot nn c pht hin kp thi tt c bnh nhn

T c BMNB.

iu tr T c BMNB bng cc thuc h ng huyt gim

HbA1C < 7% c th hiu qu gim bin chng mch mu nh v

ci thin bnh tim mch.

Hirsch AT, et al. Circulation. 2006;113:e463-

e465.


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Thuc khng tiu cu Thuc khng tiu cu c ch nh gim nguy cnhi mu c tim, t qu v cht do mch mu bnhnhn BMNB (Level of Evidence: A).

Aspirin, liu hng ngy 75 n 325 mg, c nghnh liu php khng tiu cu hiu qu v an ton gim nguy c nhi mu c tim, t qu, v cht do mchmu bnh nhn BMNB (Level of Evidence: A).

Clopidogrel (75 mg/ngy) c ngh nh liu phpkhng tiu cu thay th hiu qu cho aspirin gimnguy c nhi mu c tim, t qu v cht do mch mu bnh nhn BMNB (Level of Evidence: B).

Hirsch AT, et al. Circulation. 2006;113:e463-

e465.


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iu tr ci thin chc nng

Mt chng trnh hun luyn tp luyn c gim st c ngh nh l mt phng thc iu tr u tin cho cc bnhnhn au cch hi (Level of Evidence: A).

Mt chng trnh hun luyn tp luyn c gim st nnc thc hin ti thiu 30 n 45 pht, trong mt chngtrnh t nht 3 ln/tun trong ti thiu 12 tun (Level ofEvidence: A).

S hiu qu ca chng trnh tp luyn khng c gim stth cha c tha nhn nh l mt phng thc iu tr utin hiu qu cho cc bnh nhn au cch hi (Level ofEvidence: B).

Hirsch AT, et al. Circulation. 2006;113:e463-e465.


24/27

iu tr triu chng au cch hi

Cilostazol

Cilostazol (100 mg ung ngy 2 ln) c ch nh nhl mt thuc hiu qu ci thin triu chng v giatng khong cch i li bnh nhn BMNB v aucch hi ( cc bnh nhn khng suy tim) (Level of

Evidence: A).Pentoxifyline

Pentoxifyline (400 mg 3 ln mt ngy) c th xem xtnh mt liu php thay th th 2 cho cilostazol ci

thin khong cch i li nhng bnh nhn au cchhi (Level of Evidence: A).

Khng c bng chng cho cc thuc sau

L-arginine, propionyl-L-carnitine, gingko biloba,

prostaglandins, vitamin E Hirsch AT, et al. Circulation. 2006;113:e463-e465.

i t ti th thi h


25/27

iu tr ti thng: can thip mch mu vphu thut mch mu

Theo AHA/ACC v TASC II, ti thng c xut chonhng trng hp sau:

Cn can thip sm vi nhng BN c thiu mu e dachi nh au khi ngh, lot chn do thiu mu, hoi th.

BN khng p ng vi tr liu phc hi chc nng gngsc v thuc.

BN b gii hn hot ng bi au khp khing cch hi.

La chn ti thng bng can thip ni mch hoc phuthut ph thuc vo tui, bnh km, dng tn thng(theo phn loi tn thng TASC).

i t ti th thi h


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iu tr ti thng: can thip mch mu vphu thut mch mu

Phu thut thng t ra nhng ngi c gii phu

ng mch chi m d t c kt qu lu di v nguy

c tim mch thp i vi phu thut.

Ni chung, ngi ta u nht tr rng can thip ni mch

nn l iu tr chn la cho phn loi tn thng A, B

ca TASC v phu thut mch mu l chn la cho

phn loi tn thng C, D ca TASC.


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Cm n s theo dica qu ng nghip!

19 (2).benh dm ngoi bien

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