616.1 T116H PGS.TS.BS. NGUYEN QUANGTU TANG HUYET AP TRONG THirCHANH LAM SANG NHA XUAT BAN Y HOC

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1 616.1 T116H PGS.TS.BS. NGUYEN QUANGTU TANG HUYET AP TRONG THirCHANH LAM SANG NHA XUAT BAN Y HOC

2 PGS.TS.BS. NGUYEN QUANG TUAN TRONG THlTC HANH LAM SANG (Tai ban Ian thir ba c6 bo sung va sira chcra) NHA XUAT BAN Y HOC HA NOI

3 LOI CAM ON u6n sdch nay ra mat ban doc cho toi c6 dip duac bay to long kinh trong vd tri dn sdu sac den GS.TS. Phgm Gia Khdi, nguyen Vien truang Vien Tim mach Quoc gia Viet Nam, Chu tich Hoi Tim mach hoc Quoc gia Viet Nam, nguyen Chu tich Hoi Tim mach ASEAN; GS.TS. Nguyin Ldn Viet, Vien truang Vien Tim mach Quoc gia Viet Nam, Chu nhiem Bo mon Tim mach - Truang Dai hoc Y Hd Noi, Pho Chu tich Hoi Tim mach hoc Quoc gia Viet Nam, Gidm doc Ban Qudn ly du dn/hoat dong Phong, chong benh tang huyet dp thuoc Chuang trinh muc tieu Quoc gia Y te giai doan , nhimg nguai thdy da danh nhieu thai gian vd tdm huyet true tiep giup da toi thuc hien vd hodn thdnh cuon sdch ndy. Toi Cling xin chdn thdnh cam an tdt cd cdc benh nhdn da tin tuang, giao pho tinh mang cho toi dieu tri. Nhitng trdi nghiem c6 duac trong qud trinh dieu tri nguai benh khong chi Id nguon dong vien md con Id nhung trdn tra thuc giuc toi luon phdi cd gang nhieu han nua trong hoc tap, Idm viec vd nghien cini khoa hoc. Day ciing chinh Id dong luc de toi hodn thdnh cuon sdch ndy. Mot ldn nua toi xin trdn trong cdm an! Ha Noi, thang 08 nam 2012 PGS.TS.BS. Nguyen Quang Tuan

4 LOl GIOI THIEU Tang huyet dp la mpt b?nh ly dang c6 khuynh hudng tang len rd r$t trong cgng dong. Theo dieu tra gdn day nhat cua Vi$n Tim mach QuSc gia Vi$t Nam tai 8 tlnh ud thanh pho cua nude ta thl ty le tang huyet dp cua nhqng ngudi ti^ 25 tudi trd len da la 25,1%, nghia la CLJ[4 ngudi Idn c61 ngudi bi tdng huyet dp. Tang huyet dp cung la yeu to nguy cd quan trong nhat trong cdc yeu to nguy cd ue tim mach ul tinh pho bien cua no trong cgng dong vd nhat la ai no c6 the gay nen rat nhieu bien chdng nguy hiem dtim, than, mdt, ndo, uu... Tuy nhien, trong thuc te lam sang, nhieu ngudi bi tdng huyet dp thuc su oan khong ducfc chdn dodn kip thdi do hg khong thay c6 tri?u chdng cd ndng gi dqc bi$t nen van tudng la minh binh thadng. Mot so b$nh nhdn thi tuy da dudc chdn dodn la tdng huyet dp nhung van khong di dieu tri ngay, hodc la dieu tri khong lien tuc, hodc la c6 dieu tri roi nhung udn chua dgt dudc mdc huyet dp muc tieu. Vi oqy, de cong cugc phbng chong tdng huyet dp thu dudc nho^ng hi^u qua thitc su, thi phia ngudi b?nh rat can dupc nang cao SLtnhgn thctc cung nhu nhqng hieu biet cdbdn oe b$nh ly nay de c6 the phoi hdp odi cdc thay thuoc trong oi?c dieu chinh loi song cdng nha tuan thu cdc phdc do dieu tri ma cdc thay thuoc da hudng dan. Phia cdc thay thuoc Igi rat can phdi c6 dudc nhqng kien thdc cap nhat nhat, oi?c hoi b?nh oa khdm xet can ti mi, todn di$n; nhqng su ta van oa phdc do dieu tri phdi cu the, tsi Uu nhat cho ngudi b$nh de hg CO the hieu oa tudn thu dung theo nhqng hudng dan nay. TQ thtfc te Idm sang, chung toi thay da so ngudi b?nh ludn c6 nguy$n ogng dugfc thay thuoc gidi thich, tu oan them cho hg oe

5 nguyen nhan gay b$nh, cdc bien chiing c6 de dieu chinh loi song, cdch svt dung thusc CO the gap cua thusc, ov... Day Id nhuing ng chinh ddng cua ngixcfi b$nh, nhung rat dec qud ban nen cdc thay thusc thixdng khong ud trd Idi day du cho nhqng cdu hoi cua ngu Chinh ui hieu rd dugfc thuc te nay nen Tuan, Gidng oien chinh Bo mon Tim mach Ha Ngi da rat tarn huyet bien sogn cusn trong thixc hanh lam sang". Day la m dixdc nhieu kinh nghi$m trong thixc te la nhqng kien thqc mdi nhdt trong ITnh vqc huyet dp. Vdi nhqng ngi dung rat da dang od ph tang huyet dp nhqng, tdc gid da kheo sd de pho bien nhdt cd lien quan den b?nh odn rd rang, sdng sua, odi nhqng ngi d ti'nh chat cap nhdt nen cusn sdch da th nhqng odn de gdn gui nhdt odi thqc tien l Hy ogng rang cusn sdch ndy se khong thong tin od sq tq odn can thiet nhdt cho n huyet dp md con la mgt tdi li?u tham khd

6 VE TAC GIA PGS.TS.BS. Nguyen Quang Tudn sink ra va Ian len tgi Hd Noi, hien Id gidng vien chinh Bo mon Tim mgch Trucmg Dgi hoc Y Hd Noi, Gidm doc Vien Tim Hd Noi. Tong thu ky Hoi Tim mgch hoc can thiep Viet Nam; Chu tich \^ Hoi Tim mgch Hd Noi; Uy vien Ban Qudn ly ^'"^^^l*^ ^^-^ dn/hogt dong Phong, chong benh tang huyet dp thuoc Chuomg trinh muc tieu Quoc A gia Y te giai dogn ; Thanh vien Trtcang mon Tim mgch hoc Dong Nam A ' " (FSACC); Thdnh vien Ban c6 van Hoi Tim mack hoc can thiep ChduA - Thdi Blnh Duomg (FAPSIC); Thdnh vien Hoi Tim mgch hoc can thiep Hoa Ky (FSCAI); Thdnh vien Trudng mon Tim mgch hoc Hoa Ky (FACC). Sou khi tot nghiep Dgi hoc YHd Noi nam 1994, tiep tuc hoc bdc si noi tru chuyen ngdnh Tim mgch. Tit nam , di tu nghiep ve Tim mgch can thiep tgi Phdp vd Id mot trong nhimg bdc st Viet Nam dan tien duac ddo tgo bdi ban nhdt ve linh vuc ndy. Nam 2005, bdo ve thdnh cong lugn dn Tien si Y khoa tgi Dgi hoc Y Hd Noi vd^ndm 2009 duac phong hdm Pho gido sir. PGS.TS.BS. Nguyen Quang Tudn da tham gia bien sogn, xudt ban nhieu sdch vd c6 nhieu nghien cini trong itnh vuc chuyen ngdnh tim mgch. Vai mong musn giup da nhung tre em ngheo bi tim bam sinh cd diiu kien duac chita tri, PGS.TS.BS. Nguyen Quang Tudn se ddnh tat cd so tien c6 duac tic cuon sdch ndy gin tang quy "Vi mot trdi tim kitde" cua Benh vien Tim Hd Noi. Rat mong cuon sdch duac nhieu ban doc vd nguai benh don nhgn.

7 MUC LUC LQI CAM ON LCJI GICJI THIEU VE TAC GIA LQI NOI DAU PHAN 1. TONG QUAN VE TANG HUYET AP 17 Chuong 1. DAI CUONG VE TANG HUYET A? 18 I Dinh nghia tang huyet ap Phan loai tang huyet ap theo muc do, ^ 21 3 Phan loai tang huyet ap theo nguyen nhan 29 4 Phan loai theo tuoi 35 Chuong 2. TY LE MAC TANG HUYET AP 38 5 Ty le mac tang huyet ap a Viet Nam 39 6 Ty le mac tang huyet ap tai cac nuoc trong khu virc va tren the gioi 41 Chuong 3. SU" LIEN QUAN GILTA TRI SO HUYET AP VA NGUY CO TIM MACH 46 7 Cach do huyet ap nao c6 lien quan ghn vai nguy ca nh4t 47 8 Huyet ap hieu dung c6 dir doan nguy ca tot hon huyet ap tarn thu khong 49 9 Tang huyet ap tarn truang hay tarn thu c6 gia tri tien doan bien chung tim mach manh han HuyIt ap tam truang thsp CO gay hai khong 52 II Vai tro cua huyet ap trung binh Huyet ap trung tam so vai huyet ap ngoai bien 55 Chuong 4. BIEN CHlTNG VA LOI ICH CUA VIEC DIEU TRI TANG HUYET AP Benh dong mach vanh Suy tim 61

8 15 Benh mach mau nao 16 Benh than man tinh 17 Benh mach mau ngoai bien 18 Lai ich cua dieu tri tang huyet ap Chuang 5. NHAN THlTC VA KIEM SOAT TAN 19 Nhan thuc ve tang huyet ap 20 Kilm scat huylt ap 21 Cac yeu to lien quan din viec kiem sca PHAN II. CO CHE BENH SINH VA SINH CUA TANG HUYET AP Chuang 1. PHAN LOAI TANG HUYET AP NGU 22 Dinh nghia tang huyet ap nguyen phat 23 Phan loai tang huylt ap nguyen phat Chuang 2. CAC YEU TO CO BAN DIEU HOA T 24 Cung lugng tim va su dieu hoa don 25 Cac nguyen ly ca ban cua viec dihu hoa 26 Dieu hoa ngugc than-the dich la ca chs dieu hoa huyet ap lau dai Chuang 3. CAC CO CHE TANG HUYET AP DO 27 Tang huyet ap gay ra bai tang toan bo than ^ 28 Tang huyet ap do tang dan thuin sue can

9 34 Giam phan ung cua he renin-angiotensin gay tang huyet ; ap nhay cam muoi Tang huyet ap nhay cam voi mu6i c6 thi lam tang t6n thuong cac co quan dich 129 Chuong 5. CAC CO CHE THAN KINH THE DICH CUA TANG HUYET AP He thong than kinh giao cam He thong Renin-angiotensin Aldosterone He thong noi mac Nitric oxide Stress oxyhoa Eicosanoids 'i' Peptid Igi nieu nhi 162 Chuong 6. CAC NGUYEN NHAN GAY TANG HUYET AP THlT PHAT Tang huylt ap do benh mach than Tang huyet ap do v6 thuong than U tuy thuong than Tiksangiat 179 Chuong 7. CAC NGUYEN NHAN DI TRUYEN CUA TANG HUYET AP Su bien doi gen va tang huyet ap nguyen phat d nguoi Bat thuong don gen gay tang huyet ap 186 Chuong 8. SINH LY BENH CUA TANG HUYET AP TIEN PHAT Beo phi la nguyen nhan chu yeu cua tang huyet ap nguyen phat Vai tro cua hoi chung chuysn hoa, dh khang insulin trong tang huyet ap nguyen phat An man 206 n

10 PHANIII. CHAN DOAN VA DIEU TRI TA HUYET AP Chuang 1. THAM KHAM BENH NHAN TANG H 54 Do huyet ap tai phong kham 55 Do huyet ap luu dong (holter huyet ap) 56 Theo doi huyet ap tai nha 57 Khai thac tien su va tham kham lam sang Chuang 2. CHAN DOAN TANG HUYET AP THU 58 Phan loai tang huyet ap thii phat 59 Hep dong mach than 60 Ngung tha khi ngu 61 Tang Aldosterone nguyen phat 62 Hoi chung Gushing. 63 U tuy thugng than * Chuang 3. DIEU TRI TANG HUYET AP NGUYE 64 T6ng quan diku tri tang huyet ap 65 Bang chung ve Igi ich cua dieu tri tang thu6c 66 Cac yeu t6 anh huang tien lugng 67 Khi nao nen bat dau dieu tri thuoc? 68 Muc tieu dieu tri tang huyet ap 69 Vai tro cua thay doi loi song 70 Dieu tri tang huyet ap bang thuoc 71 Cat day than kinh than bang nang luotig qua 6ng thong

11 79 RungnhT Benh than khong do dai thao duang Nguai ion tu6i Tang huyet ap a phu nu Tang huyet ap a tre em va nguai tre Tang huyet ap khang tri Ccm tang huyet ap: tang huyet ap cap cuu va tang huyet ap khan cap 366 Chuang 5. DIEU TRI BENH NHAN TANG HUYET AP TRONG CAC TINH TRANG DAC BIET Phi dai that trai Benh dong mach ngoai bien Tang huyet ap sau ghep tang dac ^ Nguai da den Tang huyet ap va roi loan chuc nang cuang duang Chuc nang nhan thuc va mat tri nha Tac nghen duang tieu Ngung tha khi ngu do tsc nghen duang tha Tang huyet ap a benh nhan phau thuat Tang huyet ap va cac thii thuat lien quan den rang Tang huyet ap va benh ve mst Ha huyet ap tu the dung ^1 Chuang 6. DIEU TRI CAC YEU TO NGUY CO DI KEM Dieu tri roi loan lipid mau Dieu tri thuoc uc che ket tap tieu cau Kiem soat duang mau 407 Chuang 7. THUOC VA CAC CHAT CO ANH HU'CJNG DEN HUYET AP Cac chat va thu6c c6 anh huofng din huylt ap Rugu Thuoc chong viem, giam dau khong steroid 413 Chuang 8. CAC TRC) NGAI KHI itng DUNG KET QUA NGHIEN ciru VAO THirc HANH LAM SANG Cac "van de" ve thu nghiem lam sang

12 105 Nhung nguyen nhan lam hieu qua dieu thucta ^ 106 NhiJng nguyen nhan lam hieu qua dieu vai thuc te 107 Giai phap cho "vin ds" vai cac thu ng 108 Cac "vdn dl" cua phan tich gop hoac b 109 Cac "van d6" cua khuysn cao Chuong 9. CAC YEU TO GIUP CAI THIEN VIE HUYET AP 110 Cac ysu to giup benh nhan gsn k t vai >' 111 Vai tro cua bac st dieu tri / 112 Tinh tri tre tren lam sang? 113 Vai tro cua cac nhan vien y ts khac 114 Cac yeu t6 cua nguai benh 115 Rao can va kinh tl ; ^: THAY CHO L6I KET ^ - TAI LIEU THAM KHAO PHU LUC. ' Phu luc 1. Danh muc mot so loai thuc pham muoi natri cao Phu luc 2. Ham lugng cholesterol trong loo Phu luc 3. Cac thuoc ha huyet ap su dung du V Phu luc 4. Cac thu6c kit hop trong tang huy Phu luc 5. Chi dinh va ch6ng chi dinh su du thuoc chii ylu Phu luc 6. Tuong tac thuoc dieu tri tang huy

13 LdlNOIDAU Han mot ty nguoi tren the gidi bi tang huyet ap va con so nay dang tiep tuc tang len. Tang huyet ap dugc menh danh la "Ke giit ngudi tham Igng" vai nhieu cai nhat: 1. Benh man tinh pho bien nhat d nuoc ta ciing nhu cac nuac idiac tren the gidi. 2. Nguyen nhan hang dau thuong gap d cac phong kham noi khoa va tim mach. 3. Thuoc dieu tri benh tang huyet ap dugc ke nhi^u nh^t. 4. Yeu to nguy ca chinh cua benh tim thieu mau cue bo va dot quy - la nguy en nhan hang dsu va thu hai gay tu vong tai nude ta theo thong ke cua T6 churc Y t6 Th6 gidi nam Yeu to nguy CO so mot gay tu vong tren toanthi gidi. Moi tuang quan thuan true tiep giua huyet ap va nguy ca mac benh tim mach, deu dugc quan sat th4y d ca nam va nu du mgi lua tuoi, chung toe, cac nhdm dan cu va cac quoc gia, ben canh cac yeu to nguy CO khac cua benh tim mach. Cac nghien cuu quan sat cho thay, tu vong do benh tim mach gia tang va tuang quan tuyin tinh, khi huyet ap tang tren 115 mmhg doi vdi huyet ap tam thu va 75 mmhg doi vdi huyet ap tam truang. Vdi moi muc huyet ap tam thu tang them 20 mmhg hoac 10 mmhg doi vdi huyet ap tam truang, ty le tu vong do thieu mau cue bg ca tim va dot quy tang len gap doi d tat ca cac nhdm tuoi tu 40 tdi 89. Cac nghien cuu cung cho thay, huyet ap cao han muc toi uu la yeu to nguy ca gay tu vong hang dau tren the gidi va xsp xi 7,1 trieu ca tu vong mdi nam dugc cho la do tang huyet ap khong dugc kiem soat. 15

14 Mac du chung ta da dat dugc nhieu tien b sinh ly benh cua tang huyet ap, cung nhu c6 n ha ap hieu qua vai phkn Ion cac truong hop, t tuc la yeu to nguy ca quan trong nhat cua be may min la c6 thi thay d6i dugc. V8 mat t chuyen khoa tim mach va dac biet la cac bac thiet ylu trong viec phat hien va di6u tri tan thich hop. Can cur vao tinh hinh dan so cua n nhu ty le mac benh tang huyet ap va tuoi tho cua ho tham chi con quan trong hon the. ' Trong cu6n sach nay, chung toi se trinh b huyet ap, cac each phan loai, cung vai tan su thuang gap ciia chung. Chung toi cung se thao sinh va sinh ly benh cua tang huy8t ap. Phan vao chan doan va dieu trj tang huyet ap, nhat cho cac doi tugng dac biet va benh nhan tan tinh trang dac biet. Chung toi xin chan thanh cam an nhung bau cho Ian tai ban nay, rat mong nhan dugc n va chi din cho Ian tai ban sau.