{"id":100565,"date":"2024-09-20T14:45:00","date_gmt":"2024-09-20T07:45:00","guid":{"rendered":"https:\/\/vnras.com\/drug\/?p=100565"},"modified":"2024-09-21T09:42:31","modified_gmt":"2024-09-21T02:42:31","slug":"thuoc-chong-dong-mau","status":"publish","type":"post","link":"https:\/\/vnras.com\/drug\/thuoc-chong-dong-mau\/","title":{"rendered":"T\u00ccM HI\u1ec2U V\u1ec0 C\u00c1C NH\u00d3M THU\u1ed0C CH\u1ed0NG \u0110\u00d4NG M\u00c1U HI\u1ec6N NAY"},"content":{"rendered":"

C\u00c1C THU\u1ed0C CH\u1ed0NG HUY\u1ebeT KH\u1ed0I<\/span><\/h2>\n
L\u00ea B\u1ea3o Trung<\/span><\/p>\n
Drugs for the heart<\/span><\/p>\n
Applied therapeutics- the clinical use of drug 11th 2018<\/span><\/p>\n
I. Qu\u00e1 tr\u00ecnh h\u00ecnh th\u00e0nh huy\u1ebft kh\u1ed1i v\u00e0 s\u1ef1 thuy\u00ean t\u1eafc<\/span><\/h3>\n
1. Qu\u00e1 tr\u00ecnh h\u00ecnh th\u00e0nh huy\u1ebft kh\u1ed1i<\/span><\/h4>\n
Th\u00f4ng th\u01b0\u1eddng, c\u00e1c m\u00e0ng n\u1ed9i m\u00f4 m\u1ea1ch m\u00e1u nguy\u00ean v\u1eb9n s\u1ebd \u0111\u1ea9y l\u00f9i ti\u1ec3u c\u1ea7u v\u00e0 \u1ee9c ch\u1ebf h\u00ecnh th\u00e0nh huy\u1ebft kh\u1ed1i b\u1eb1ng c\u00e1ch ti\u1ebft ra c\u00e1c ch\u1ea5t g\u00e2y \u1ee9c ch\u1ebf qu\u00e1 tr\u00ecnh n\u00e0y. Khi m\u00e0ng n\u1ed9i m\u00f4 b\u1ecb t\u1ed5n th\u01b0\u01a1ng (v\u00ed d\u1ee5 nh\u01b0 s\u1ef1 bong m\u1ea3ng x\u01a1 v\u1eefa ch\u1eb3ng h\u1ea1n) l\u00e0m cho c\u00e1c ch\u1ea5t d\u01b0\u1edbi n\u1ed9i m\u00f4 ti\u1ebfp x\u00fac v\u1edbi m\u00e1u v\u00e0 t\u1eeb \u0111\u00f3 k\u00edch ho\u1ea1t qu\u00e1 tr\u00ecnh h\u00ecnh th\u00e0nh c\u1ee5c m\u00e1u \u0111\u00f4ng ngay t\u1ea1i v\u1ecb tr\u00ed t\u1ed5n th\u01b0\u01a1ng.<\/span><\/p>\n
Ngay khi c\u00f3 s\u1ef1 t\u1ed5n th\u01b0\u01a1ng n\u1ed9i m\u00f4 m\u1ea1ch m\u00e1u, c\u00e1c collagen d\u01b0\u1edbi n\u1ed9i m\u00f4, phospholipid ti\u1ebfp x\u00fac v\u1edbi m\u00e1u v\u00e0 g\u00e2y k\u1ebft d\u00ednh ti\u1ec3u c\u1ea7u l\u00ean b\u1ec1 m\u1eb7t t\u1ed5n th\u01b0\u01a1ng. Y\u1ebfu t\u1ed1 Von Willebrand (vWF) \u0111\u00f3ng vai tr\u00f2 nh\u01b0 m\u1ed9t c\u1ea7u n\u1ed1i g\u00e2y k\u1ebft d\u00ednh ti\u1ec3u c\u1ea7u l\u1ea1i v\u1edbi nhau th\u00f4ng qua Glycoprotein I (GLP I) tr\u00ean b\u1ec1 m\u1eb7t ti\u1ec3u c\u1ea7u. Nh\u1eefng ti\u1ec3u c\u1ea7u b\u1ecb k\u1ebft d\u00ednh tr\u1edf n\u00ean ho\u1ea1t h\u00f3a, thay \u0111\u1ed5i k\u00edch th\u01b0\u1edbc, ti\u1ebft ra nhi\u1ec1u ch\u1ea5t nh\u01b0 adenosine diphosphate v\u00e0 thromboxan A2. Nh\u1eefng ch\u1ea5t n\u00e0y l\u1ea1i k\u00edch th\u00edch s\u1ef1 k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u.<\/span><\/p>\n
\u0110\u1ed3ng th\u1eddi v\u1edbi s\u1ef1 k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u, t\u1ed5n th\u01b0\u01a1ng n\u1ed9i m\u00f4 c\u00f2n g\u00e2y k\u00edch ho\u1ea1t qu\u00e1 tr\u00ecnh \u0111\u00f4ng m\u00e1u theo con \u0111\u01b0\u1eddng ngo\u1ea1i sinh b\u1eb1ng c\u00e1ch ti\u1ebft ra y\u1ebfu t\u1ed1 m\u00f4 (TF- Tissua Factor). C\u1ee5 th\u1ec3 con \u0111\u01b0\u1eddng ti\u1ebfp theo \u0111\u01b0\u1ee3c m\u00f4 t\u1ea3 trong h\u00ecnh 1.2 m\u00e0 k\u1ebft qu\u1ea3 cu\u1ed1i c\u00f9ng l\u00e0 \u0111\u01b0a t\u1edbi s\u1ef1 h\u00ecnh th\u00e0nh thrombin. Trong khi \u0111\u00f3, con \u0111\u01b0\u1eddng \u0111\u00f4ng m\u00e1u n\u1ed9i sinh c\u0169ng \u0111\u01b0\u1ee3c ho\u1ea1t h\u00f3a b\u1edfi y\u1ebfu t\u1ed1 XII ti\u1ebfp x\u00fac v\u1edbi c\u00e1c th\u00e0nh ph\u1ea7n n\u1ed9i m\u00f4 c\u1ee7a m\u1ea1ch m\u00e1u t\u1ed5n th\u01b0\u01a1ng. Qu\u00e1 tr\u00ecnh n\u00e0y ti\u1ebfp di\u1ec5n b\u1edfi s\u1ef1 k\u00edch ho\u1ea1t m\u1ed9t lo\u1ea1t c\u00e1c y\u1ebfu t\u1ed1 v\u00e0 cu\u1ed1i c\u00f9ng \u0111\u01b0a \u0111\u1ebfn s\u1ef1 h\u00ecnh th\u00e0nh thrombin.<\/span><\/p>\n
Hai con \u0111\u01b0\u1eddng \u0111\u00f4ng m\u00e1u: n\u1ed9i sinh v\u00e0 ngo\u1ea1i sinh giao nhau \u1edf v\u1ecb tr\u00ed ho\u1ea1t h\u00f3a y\u1ebfu t\u1ed1 X th\u00e0nh Xa. Y\u1ebfu t\u1ed1 Xa chuy\u1ec3n y\u1ebfu t\u1ed1 II (prothombin th\u00e0nh thrombin). Thrombin chuy\u1ec3n Fibrinogen th\u00e0nh Fibrin. Fibrin \u0111\u00f3ng vai tr\u00f2 l\u00e0m cho c\u1ee5c m\u00e1u \u0111\u00f4ng tr\u1edf n\u00ean v\u1eefng ch\u1eafc h\u01a1n so v\u1edbi kh\u1ed1i k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u \u0111\u01a1n thu\u1ea7n.<\/span><\/p>\n
$\"H\u00ecnh$ <\/a>
H\u00ecnh 1.1 T\u1eeb s\u1ef1 bong m\u1ea3ng x\u01a1 v\u1eefa t\u1edbi huy\u1ebft kh\u1ed1i<\/figcaption><\/figure>\n
$\"H\u00ecnh$ <\/a>
H\u00ecnh 1.2 Con \u0111\u01b0\u1eddng \u0111\u00f4ng m\u00e1u n\u1ed9i sinh v\u00e0 ngo\u1ea1i sinh<\/figcaption><\/figure>\n
Ta c\u00f3 th\u1ec3 th\u1ea5y 2 con \u0111\u01b0\u1eddng n\u00e0y g\u1eb7p nhau t\u1ea1i v\u1ecb tr\u00ed chuy\u1ec3n y\u1ebfu t\u1ed1 X th\u00e0nh Xa. Nh\u1eefng v\u1ecb tr\u00ed \u0111\u00e1nh d\u1ea5u * l\u00e0 n\u01a1i c\u00e1c thu\u1ed1c kh\u00e1ng vitamin K t\u00e1c \u0111\u1ed9ng v\u00e0o. Nguy\u00ean nh\u00e2n s\u1ebd \u0111\u01b0\u1ee3c n\u00eau k\u0129 h\u01a1n trong ph\u1ea7n n\u00f3i v\u1ec1 thu\u1ed1c kh\u00e1ng Vitamin K. T\u01b0\u01a1ng t\u1ef1 l\u00e0 c\u00e1c d\u1ea5u hi\u1ec7u kh\u00e1c \u0111\u00e1nh d\u1ea5u c\u00e1c v\u1ecb tr\u00ed t\u00e1c \u0111\u1ed9ng c\u1ee7a c\u00e1c lo\u1ea1i thu\u1ed1c l\u00ean con \u0111\u01b0\u1eddng \u0111\u00f4ng m\u00e1u.<\/span><\/em><\/p>\n
Huy\u1ebft kh\u1ed1i th\u01b0\u1eddng \u0111\u01b0\u1ee3c ph\u00e2n lo\u1ea1i d\u1ef1a v\u00e0o v\u1ecb tr\u00ed v\u00e0 th\u00e0nh ph\u1ea7n c\u1ee7a n\u00f3. Huy\u1ebft kh\u1ed1i \u0111\u1ed9ng m\u1ea1ch th\u01b0\u1eddng ch\u1ee9a th\u00e0nh ph\u1ea7n ch\u1ee7 y\u1ebfu l\u00e0 ti\u1ec3u c\u1ea7u, m\u1eb7c d\u00f9 ch\u00fang c\u0169ng c\u00f3 th\u00e0nh ph\u1ea7n fibrin v\u00e0 leukocyte n\u1eefa. Huy\u1ebft kh\u1ed1i \u0111\u1ed9ng m\u1ea1ch h\u00ecnh th\u00e0nh trong \u0111i\u1ec1u ki\u1ec7n m\u00e1u ch\u1ea3y nhanh v\u00e0 h\u00ecnh th\u00e0nh ch\u1ee7 y\u1ebfu t\u1eeb s\u1ef1 bong m\u1ea3ng x\u01a1 v\u1eefa. Trong khi huy\u1ebft kh\u1ed1i t\u0129nh m\u1ea1ch ch\u1ee7 y\u1ebfu \u0111\u01b0\u1ee3c t\u00ecm th\u1ea5y trong tu\u1ea7n ho\u00e0n t\u0129nh m\u1ea1ch l\u1ea1i ch\u1ee9a th\u00e0nh ph\u1ea7n ch\u1ee7 y\u1ebfu l\u00e0 h\u1ed3ng c\u1ea7u v\u00e0 fibrin. Huy\u1ebft kh\u1ed1i t\u0129nh m\u1ea1ch c\u00f3 ph\u1ea7n \u0111\u1ea7u nh\u1ecf l\u00e0 kh\u1ed1i ti\u1ec3u c\u1ea7u h\u00ecnh th\u00e0nh khi c\u00f3 s\u1ef1 t\u1ed5n th\u01b0\u01a1ng th\u00e0nh t\u0129nh m\u1ea1ch sau ph\u1eabu thu\u1eadt ho\u1eb7c ch\u1ea5n th\u01b0\u01a1ng. C\u00e1c khu v\u1ef1c \u1ee9 \u0111\u1ecdng, ch\u1ea3y ch\u1eadm ng\u0103n ch\u1eb7n s\u1ef1 pha lo\u00e3ng c\u00e1c y\u1ebfu t\u1ed1 \u0111\u00f4ng m\u00e1u \u0111\u01b0\u1ee3c k\u00edch ho\u1ea1t n\u00ean k\u00e9o theo l\u00e0 \u0111u\u00f4i huy\u1ebft kh\u1ed1i g\u1ed3m fibrin v\u00e0 h\u1ed3ng c\u1ea7u. Hi\u1ec3u \u0111\u01b0\u1ee3c s\u1ef1 kh\u00e1c bi\u1ec7t trong t\u00ednh ch\u1ea5t c\u1ee7a huy\u1ebft kh\u1ed1i d\u1eabn t\u1edbi t\u1eebng t\u00ecnh tr\u1ea1ng thuy\u00ean t\u1eafc c\u1ee5 th\u1ec3 s\u1ebd gi\u00fap b\u00e1c s\u0129 l\u00e2m s\u00e0ng \u0111\u01b0a ra ch\u1ec9 \u0111\u1ecbnh lo\u1ea1i thu\u1ed1c ch\u1ed1ng huy\u1ebft kh\u1ed1i c\u00f3 hi\u1ec7u qu\u1ea3 cho b\u1ec7nh nh\u00e2n (ch\u1eb3ng h\u1ea1n nh\u01b0 d\u1ef1a v\u00e0o t\u00ednh ch\u1ea5t huy\u1ebft kh\u1ed1i t\u0129nh m\u1ea1ch, ta hi\u1ec3u r\u1eb1ng aspirin va c\u00e1c thu\u1ed1c ch\u1ed1ng k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u kh\u00e1c s\u1ebd cho \u00edt hi\u1ec7u qu\u1ea3 l\u00ean lo\u1ea1i huy\u1ebft kh\u1ed1i ch\u1ec9 ch\u1ee9a h\u1ea7u nh\u01b0 fibrin v\u00e0 h\u1ed3ng c\u1ea7u n\u00e0y).<\/span><\/p>\n
2. S\u1ef1 thuy\u00ean t\u1eafc<\/span><\/h4>\n
B\u00ecnh th\u01b0\u1eddng, c\u1ee5c huy\u1ebft kh\u1ed1i s\u1ebd kh\u00f4ng tr\u00f4i n\u1ed5i t\u1ef1 do trong m\u1ea1ch m\u00e1u m\u00e0 g\u1eafn v\u1edbi th\u00e0nh m\u1ea1ch \u1edf v\u1ecb tr\u00ed t\u1ed5n th\u01b0\u01a1ng. Lu\u00f4n c\u00f3 c\u00e1c y\u1ebfu t\u1ed1 \u1ee9c ch\u1ebf s\u1ef1 h\u00ecnh th\u00e0nh c\u1ee5c m\u00e1u \u0111\u00f4ng trong m\u00e1u \u0111\u1ec3 khu tr\u00fa huy\u1ebft kh\u1ed1i ch\u1ec9 n\u1eb1m t\u1ea1i v\u1ecb tr\u00ed t\u1ed5n th\u01b0\u01a1ng. Nh\u1eefng y\u1ebfu t\u1ed1 n\u00e0y \u0111\u01b0\u1ee3c li\u1ec7t k\u00ea trong b\u1ea3ng 1.1. C\u1ed9ng v\u1edbi s\u1ef1 tham gia c\u1ee7a h\u1ec7 th\u1ed1ng ti\u00eau s\u1ee3i huy\u1ebft c\u1ee7a c\u01a1 th\u1ec3, hai qu\u00e1 tr\u00ecnh n\u00e0y ng\u0103n c\u1ea3n s\u1ef1 \u0111\u00f4ng m\u00e1u qu\u00e1 m\u1ee9c. Tuy v\u1eady, c\u00f3 nh\u1eefng y\u1ebfu t\u1ed1 b\u1ea5t l\u1ee3i ch\u1eb3ng h\u1ea1n nh\u01b0 s\u1ef1 thay \u0111\u1ed5i \u00e1p l\u1ef1c d\u00f2ng m\u00e1u (vd: huy\u1ebft \u00e1p t\u00e2m thu, t\u00e2m tr\u01b0\u01a1ng ch\u00eanh cao) c\u00f3 th\u1ec3 g\u00e2y ra s\u1ef1 \u0111\u1ee9t g\u00e3y trong c\u1ea5u tr\u00fac huy\u1ebft kh\u1ed1i. C\u00e1c ph\u1ea7n \u0111\u1ee9t g\u00e3y t\u1ef1 do trong m\u00e1u theo d\u00f2ng ch\u1ea3y v\u00e0 k\u1eb9t l\u1ea1i \u1edf n\u01a1i c\u00e1c m\u1ea1ch m\u00e1u c\u00f3 \u0111\u01b0\u1eddng k\u00ednh nh\u1ecf m\u00e0 h\u1ec7 qu\u1ea3 l\u00e0 s\u1ef1 t\u1eafc m\u1ea1ch.<\/span><\/p>\n\n\n\n\n\n\n\n\n\n
Y\u1ebfu t\u1ed1 \u1ee9c ch\u1ebf h\u00ecnh th\u00e0nh huy\u1ebft kh\u1ed1i<\/td>\n M\u1ee5c ti\u00eau<\/td>\n<\/tr>\n
Antithrombin<\/td>\n \u1ee8c ch\u1ebf IIa, IXa, Xa<\/td>\n<\/tr>\n
Protein S<\/td>\n Cofactor nh\u1eb1m ho\u1ea1t h\u00f3a protein C<\/td>\n<\/tr>\n
Protein C<\/td>\n B\u1ea5t ho\u1ea1t Va v\u00e0 VIIIa<\/td>\n<\/tr>\n
Ch\u1ea5t \u1ee9c ch\u1ebf con \u0111\u01b0\u1eddng y\u1ebfu t\u1ed1 m\u00f4 (TF)<\/td>\n \u1ee8c ch\u1ebf ho\u1ea1t h\u00f3a VIIa<\/td>\n<\/tr>\n
Plasminogen<\/td>\n Chuy\u1ec3n h\u00f3a th\u00e0nh plasmin<\/td>\n<\/tr>\n
Plasmin<\/td>\n Ly gi\u1ea3i huy\u1ebft kh\u1ed1i<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n
B\u1ea3ng 1.1 C\u01a1 ch\u1ebf ho\u1ea1t \u0111\u1ed9ng c\u1ee7a c\u00e1c y\u1ebfu t\u1ed1 \u1ee9c ch\u1ebf h\u00ecnh th\u00e0nh huy\u1ebft kh\u1ed1i<\/span><\/p>\n
II. C\u00e1c thu\u1ed1c ch\u1ed1ng huy\u1ebft kh\u1ed1i<\/span><\/h3>\n
D\u1ef1a v\u00e0o c\u01a1 ch\u1ebf c\u1ee7a c\u00e1c qu\u00e1 tr\u00ecnh tham gia v\u00e0o s\u1ef1 h\u00ecnh th\u00e0nh huy\u1ebft kh\u1ed1i tr\u00ean. Ng\u01b0\u1eddi ta \u0111i\u1ec1u ch\u1ebf ra c\u00e1c lo\u1ea1i thu\u1ed1c \u0111\u00e1nh v\u00e0o c\u00e1c v\u1ecb tr\u00ed kh\u00e1c nhau c\u1ee7a qu\u00e1 tr\u00ecnh n\u00e0y. D\u01b0\u1edbi \u0111\u00e2y tr\u00ecnh b\u00e0y v\u1ec1 c\u01a1 ch\u1ebf t\u00e1c d\u1ee5ng v\u00e0 ch\u1ec9 \u0111\u1ecbnh c\u1ee7a m\u1ed9t s\u1ed1 nh\u00f3m thu\u1ed1c th\u01b0\u1eddng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng nh\u1ea5t.<\/span><\/p>\n
THU\u1ed0C CH\u1ed0NG K\u1ebeT T\u1eacP TI\u1ec2U C\u1ea6U<\/span><\/h2>\n
I. Vai tr\u00f2 c\u1ee7a ti\u1ec3u c\u1ea7u trong c\u00e1c b\u1ec7nh l\u00fd tim m\u1ea1ch<\/span><\/h3>\n
Ti\u1ec3u c\u1ea7u \u0111\u00f3ng m\u1ed9t vai tr\u00f2 then ch\u1ed1t trong sinh l\u00fd b\u1ec7nh h\u1ecdc c\u1ee7a AMI n\u00f3i chung v\u00e0 c\u00e1c b\u1ec7nh tim m\u1ea1ch n\u00f3i ri\u00eang. Ch\u00fang ta bi\u1ebft r\u1eb1ng theo thuy\u1ebft h\u00ecnh th\u00e0nh huy\u1ebft kh\u1ed1i, khi m\u1ea3ng x\u01a1 v\u1eefa b\u1ecb bong ra, c\u00e1c y\u1ebfu t\u1ed1 m\u00f4 (TF) s\u1ebd ti\u1ebfp x\u00fac tr\u1ef1c ti\u1ebfp v\u1edbi m\u00e1u d\u1eabn t\u1edbi k\u00edch ho\u1ea1t y\u1ebfu t\u1ed1 \u0111\u00f4ng m\u00e1u m\u00e0 k\u1ebft qu\u1ea3 l\u00e0 t\u1ea1o ra thrombin. Thrombin k\u00edch ho\u1ea1t, l\u00e0m thay \u0111\u1ed5i h\u00ecnh d\u1ea1ng, t\u0103ng t\u1eadp trung, t\u0103ng k\u1ebft d\u00ednh ti\u1ec3u c\u1ea7u t\u1ea1i v\u1ecb tr\u00ed t\u1ed5n th\u01b0\u01a1ng \u0111\u1ed3ng th\u1eddi chuy\u1ec3n fibrinogen th\u00e0nh fibrin. S\u1ef1 k\u1ebft h\u1ee3p gi\u1eefa kh\u1ed1i ti\u1ec3u c\u1ea7u k\u1ebft d\u00ednh v\u00e0 c\u00e1c s\u1ee3i fibrin bao ph\u1ee7 l\u00ean v\u1ecb tr\u00ed t\u1ed5n th\u01b0\u01a1ng tr\u1edf th\u00e0nh ph\u1ea7n \u201c\u0111\u1ea7u\u201d c\u1ee7a huy\u1ebft kh\u1ed1i, trong khi ph\u1ea7n \u201c\u0111u\u00f4i\u201d tr\u00f4i n\u1ed5i trong m\u1ea1ch m\u00e1u v\u1edbi th\u00e0nh ph\u1ea7n l\u00e0 c\u00e1c s\u1ee3i fibrin v\u00e0 h\u1ed3ng c\u1ea7u. ngo\u00e0i ra ti\u1ec3u c\u1ea7u khi ho\u1ea1t h\u00f3a c\u00f2n ti\u1ebft ra ch\u1ea5t \u1ee9c ch\u1ebf y\u1ebfu t\u1ed1 ho\u1ea1t h\u00f3a plasminogen\u2013I (PAI) g\u00e2y \u0111\u1ec1 kh\u00e1ng v\u1edbi thu\u1ed1c ti\u00eau s\u1ee3i huy\u1ebft, ti\u1ebft Thromboxan A2(TXA2) g\u00e2y co m\u1ea1ch. Tr\u00ean ti\u1ec3u c\u1ea7u c\u00f3 r\u1ea5t nhi\u1ec1u lo\u1ea1i recepter v\u00e0 t\u1eeb \u0111\u00f3 c\u00f3 th\u1ec3 b\u1ecb k\u00edch ho\u1ea1t, ch\u1eb3ng h\u1ea1n nh\u01b0 recepter g\u1eafn v\u1edbi Thromboxan A2(TXA2), th\u1ee5 th\u1ec3 P2Y12 g\u1eafn v\u1edbi Adenosine diphosphate (ADP), recepter GpIIb\/IIIa… T\u1eeb \u0111\u00e2y ch\u00fang ta \u0111\u00e3 ph\u00e1t tri\u1ec3n nhi\u1ec1u lo\u1ea1i thu\u1ed1c ch\u1ed1ng k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u \u0111\u00e1nh v\u00e0o kh\u1ea3 n\u0103ng ho\u1ea1t h\u00f3a ti\u1ec3u c\u1ea7u th\u00f4ng qua c\u00e1c recepter n\u00e0y (h\u00ecnh 1.3)<\/span><\/p>\n
II. Aspirin<\/span><\/h3>\n
1. T\u00e1c d\u1ee5ng c\u1ee7a Aspirin<\/span><\/h4>\n
T\u00e1c d\u1ee5ng c\u1ee7a Aspirin l\u00e0 \u1ee9c ch\u1ebf Cyclooxygenase (COX) (t\u1eeb \u0111\u00f3 \u1ee9c ch\u1ebf s\u1ea3n xu\u1ea5t TXA2 c\u1ee7a ti\u1ec3u c\u1ea7u). TXA2 nh\u01b0 \u0111\u00e3 bi\u1ebft g\u00e2y k\u00edch ho\u1ea1t c\u00e1c ti\u1ec3u c\u1ea7u kh\u00e1c \u0111\u1ed3ng th\u1eddi g\u00e2y co m\u1ea1ch. T\u00e1c d\u1ee5ng \u1ee9c ch\u1ebf COX tr\u00ean ti\u1ec3u c\u1ea7u n\u00e0y l\u00e0 V\u0128NH VI\u1ec4N v\u00e0 KH\u00d4NG TH\u1ec2 T\u00c1I L\u1eacP L\u1ea0I cho t\u1edbi khi th\u1ebf h\u1ec7 ti\u1ec3u c\u1ea7u m\u1edbi \u0111\u01b0\u1ee3c sinh ra m\u00e0 kh\u00f4ng ch\u1ecbu t\u00e1c \u0111\u1ed9ng c\u1ee7a aspirin, k\u00e9o d\u00e0i kho\u1ea3ng 8-10 ng\u00e0y. C\u0169ng ph\u1ea3i l\u01b0u \u00fd r\u1eb1ng COX n\u00e0y l\u00e0 COX-1, n\u00ean n\u00f3 \u1ee9c ch\u1ebf lu\u00f4n c\u1ea3 s\u1ea3n xu\u1ea5t PGI-2 (y\u1ebfu t\u1ed1 bao v\u1ec7 d\u1ea1 d\u00e0y). V\u00ec th\u1ebf aspirin v\u1eeba c\u00f3 l\u1ee3i \u00edch v\u1ec1 tim m\u1ea1ch v\u1eeba c\u00f3 t\u00e1c d\u1ee5ng c\u00f3 h\u1ea1i l\u00ean d\u1ea1 d\u00e0y. Ngo\u00e0i ra, aspirin t\u00e1c d\u1ee5ng r\u1ea5t y\u1ebfu l\u00ean COX-2 n\u00ean khi s\u1eed d\u1ee5ng li\u1ec1u th\u1ea5p, aspirin v\u1eeba c\u00f3 t\u00e1c d\u1ee5ng \u1ee9c ch\u1ebf TXA2 m\u00e0 v\u1eabn cho ph\u00e9p ti\u1ebft prostacyclin. Aspirin c\u0169ng c\u00f3 nh\u1eefng t\u00e1c d\u1ee5ng ngo\u00e0i ti\u1ec3u c\u1ea7u. N\u00f3 \u1ee9c ch\u1ebf ho\u1ea1t h\u00f3a COX \u1edf n\u1ed9i m\u00f4 m\u1ea1ch m\u00e1u, t\u1eeb \u0111\u00f3 l\u00e0m gi\u1ea3m s\u1ef1 h\u00ecnh th\u00e0nh c\u1ee7a TXA2 v\u00e0 ch\u1ea5t \u1ee9c ch\u1ebf k\u1ebft t\u1eadp prostacyclin.<\/span><\/p>\n
L\u01b0u \u00fd r\u1eb1ng, kh\u00e1c v\u1edbi tr\u00ean ti\u1ec3u c\u1ea7u, COX \u1edf m\u1ea1ch m\u00e1u s\u1ebd \u0111\u01b0\u1ee3c t\u00e1i t\u1ed5ng h\u1ee3p sau v\u00e0i ti\u1ebfng \u0111\u1ed3ng h\u1ed3. Xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a cao xu\u1ea5t hi\u1ec7n \u1edf 2\/1000 b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb aspirin m\u1ed7i n\u0103m, \u0111\u1ed3ng th\u1eddi c\u00f3 t\u0103ng nh\u1eb9 nguy c\u01a1 xu\u1ea5t huy\u1ebft n\u00e3o. Tuy nhi\u00ean, trong d\u1ef1 ph\u00f2ng th\u1ee9 ph\u00e1t MI, aspirin c\u00f3 hi\u1ec7u qu\u1ea3 g\u1ea5p 100 l\u1ea7n trong d\u1ef1 ph\u00f2ng c\u00e1c bi\u1ebfn c\u1ed1 tim m\u1ea1ch khi so v\u1edbi nh\u1eefng nguy c\u01a1 ch\u1ea3y m\u00e1u (m\u1eb7c d\u00f9 s\u1ef1 \u0111\u1ec1 kh\u00e1ng aspirin c\u00f3 th\u1ec3 gi\u1edbi h\u1ea1n con s\u1ed1 n\u00e0y). Nguy c\u01a1 ch\u1ea3y m\u00e1u c\u1ee7a aspirin li\u00ean quan t\u1edbi li\u1ec1u d\u00f9ng c\u1ee7a n\u00f3. Nguy c\u01a1 ch\u1ea3y m\u00e1u t\u0103ng g\u1ea5p \u0111\u00f4i khi so s\u00e1nh gi\u1eefa li\u1ec1u <100mg\/ng\u00e0y v\u00e0 <200mg\/ng\u00e0y.<\/span><\/p>\n
$\"Qu\u00e1$ <\/a>
Qu\u00e1 tr\u00ecnh ho\u1ea1t h\u00f3a ti\u1ec3u c\u1ea7u v\u00e0 c\u00e1c th\u1ee5 th\u1ec3<\/figcaption><\/figure>\n
2. S\u1ef1 thi\u1ebfu \u0111\u00e1p \u1ee9ng (\u0111\u1ec1 kh\u00e1ng) v\u1edbi Aspirin<\/span><\/h4>\n
Thu\u1eadt ng\u1eef \u201c\u0111\u1ec1 kh\u00e1ng\u201d th\u01b0\u1eddng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng nh\u01b0ng \u0111\u1ecbnh ngh\u0129a c\u00f2n l\u1ecfng l\u1ebbo v\u00e0 c\u00f2n g\u00e2y tranh c\u00e3i. \u1ede nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 huy\u1ebft kh\u1ed1i \u0111\u1ed9ng m\u1ea1ch, kho\u1ea3ng 5% \u0111\u1ebfn 20% ho\u1eb7c h\u01a1n c\u00f3 s\u1ef1 t\u00e1i ph\u00e1t c\u00e1c b\u1ec7nh l\u00fd m\u1ea1ch m\u00e1u khi theo d\u00f5i th\u1eddi gian d\u00e0i m\u1eb7c d\u00f9 \u0111\u00e3 \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb aspirin v\u1edbi li\u1ec1u \u0111\u1ea7y \u0111\u1ee7. \u201cs\u1ef1 \u0111\u1ec1 kh\u00e1ng\u201d aspirin xu\u1ea5t hi\u1ec7n \u1edf kho\u1ea3ng 16% b\u1ec7nh nh\u00e2n prio-MI v\u00e0 li\u00ean quan t\u1edbi t\u1ef7 l\u1ec7 t\u1eed vong, t\u00e1i nh\u1ed3i m\u00e1u ho\u1eb7c t\u00e1i nh\u1eadp vi\u1ec7n g\u1ea5p 4 l\u1ea7n trong v\u00f2ng 12 th\u00e1ng. S\u1ef1 \u0111\u00e1p \u1ee9ng thu\u1ed1c n\u00e0y kh\u00f4ng ph\u1ea3i ki\u1ec3u \u201ct\u1ea5t c\u1ea3 ho\u1eb7c kh\u00f4ng g\u00ec c\u1ea3\u201d. Khi \u0111\u1ecbnh ngh\u0129a \u0111\u1ec1 kh\u00e1ng aspirin l\u00e0 s\u1ef1 th\u1ea5t b\u1ea1i trong vi\u1ec7c \u1ee9c ch\u1ebf s\u1ea3n xu\u1ea5t thromboxan b\u1eb1ng ch\u1ee9ng l\u00e0 c\u00f3 n\u1ed3ng \u0111\u1ed9 cao c\u00e1c s\u1ea3n ph\u1ea9m chuy\u1ec3n h\u00f3a c\u1ee7a TXA2 trong n\u01b0\u1edbc ti\u1ec3u, khi n\u00e0y, nguy c\u01a1 MI t\u0103ng g\u1ea5p \u0111\u00f4i. N\u1ebfu \u0111\u1ecbnh ngh\u0129a d\u1ef1a v\u00e0o test ch\u1ee9c n\u0103ng ti\u1ec3u c\u1ea7u v\u00e0 khi ch\u1ee9ng minh \u0111\u01b0\u1ee3c s\u1ef1 thi\u1ebfu \u0111\u00e1p \u1ee9ng aspirin th\u00ec nguy c\u01a1 t\u1eed vong, \u0111\u1ed9t qu\u1ef5, MI t\u0103ng g\u1ea5p 3 l\u1ea7n.<\/span><\/p>\n
C\u00f3 r\u1ea5t nhi\u1ec1u l\u00fd do d\u1eabn t\u1edbi s\u1ef1 thi\u1ebfu \u0111\u00e1p \u1ee9ng n\u00e0y, ch\u1eb3ng h\u1ea1n nh\u01b0 s\u1ef1 s\u1ea3n xu\u1ea5t TXA2 theo con \u0111\u01b0\u1eddng kh\u00e1c m\u00e0 kh\u00f4ng c\u1ea7n COX, COX kh\u00f4ng \u0111\u01b0\u1ee3c \u1ee9c ch\u1ebf ho\u00e0n to\u00e0n b\u1edfi aspirin, nh\u1eefng con \u0111\u01b0\u1eddng ho\u1ea1t h\u00f3a ti\u1ec3u c\u1ea7u kh\u00e1c m\u00e0 kh\u00f4ng c\u1ea7n TXA2. Clopidogerl c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c xem l\u00e0 m\u1ed9t thu\u1ed1c thay th\u1ebf ho\u1eb7c l\u00e0 th\u00eam v\u00e0o, tuy nhi\u00ean nh\u1eefng b\u1ec7nh nh\u00e2n \u0111\u1ec1 kh\u00e1ng v\u1edbi aspirin c\u0169ng c\u00f3 th\u1ec3 gi\u1ea3m \u0111\u00e1p \u1ee9ng v\u1edbi clopidogrel.<\/span><\/p>\n
3. S\u1eed d\u1ee5ng Aspirin tr\u00ean l\u00e2m s\u00e0ng<\/span><\/h4>\n
B\u1edfi ti\u1ec3u c\u1ea7u \u0111\u00f3ng m\u1ed9t vai tr\u00f2 v\u00f4 c\u00f9ng quan tr\u1ecdng trong c\u00e1c b\u1ec7nh l\u00fd m\u1ea1ch m\u00e1u n\u00ean c\u00f3 r\u1ea5t nhi\u1ec1u ch\u1ec9 \u0111\u1ecbnh l\u00e2m s\u00e0ng cho aspirin. M\u1ed9t ph\u00e2n t\u00edch tr\u00ean 135.000 b\u1ec7nh nh\u00e2n tr\u00ean 287 nghi\u00ean c\u1ee9u \u0111\u00e3 x\u00e1c nh\u1eadn t\u00e1c d\u1ee5ng d\u1ef1 ph\u00f2ng c\u1ee7a aspirin tr\u00ean b\u1ec7nh nh\u00e2n \u0111\u00e3 c\u00f3 MI tr\u01b0\u1edbc \u0111\u00f3, trong \u0111au ng\u1ef1c do g\u1eafng s\u1ee9c hay \u0111au ng\u1ef1c kh\u00f4ng \u1ed5n \u0111\u1ecbnh, sau \u0111\u1ed9t qu\u1ef5, ho\u1eb7c sau c\u00e1c ph\u1eabu thu\u1eadt b\u1eafc c\u1ea7u \u0111\u1ed9ng m\u1ea1ch v\u00e0nh. C\u00e1c nghi\u00ean c\u1ee9u c\u0169ng cho th\u1ea5y t\u00e1c d\u1ee5ng t\u01b0\u01a1ng \u0111\u01b0\u01a1ng \u1edf c\u1ea3 nam v\u00e0 n\u1eef.<\/span><\/p>\n
V\u1ea5n \u0111\u1ec1 quan tr\u1ecdng l\u00e0 ph\u1ea3i c\u00e2n b\u1eb1ng \u0111\u01b0\u1ee3c c\u00e1c y\u1ebfu t\u1ed1 l\u1ee3i \u00edch v\u00e0 nguy c\u01a1. Khi s\u1eed d\u1ee5ng aspirin trong d\u1ef1 ph\u00f2ng th\u1ee9 ph\u00e1t, s\u1ef1 c\u00e2n b\u1eb1ng nghi\u00eang m\u1ea1nh v\u1ec1 l\u1ee3i \u00edch trong khi d\u00f9ng v\u1edbi m\u1ee5c \u0111\u00edch d\u1ef1 ph\u00f2ng ti\u00ean ph\u00e1t th\u00ec c\u1ea7n c\u00f3 s\u1ef1 \u0111\u00e1nh gi\u00e1 c\u1ea9n th\u1eadn. <\/span><\/p>\n
D\u1ef1 ph\u00f2ng th\u1ee9 ph\u00e1t.<\/strong> T\u1ea5t c\u1ea3 nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 b\u1ec7nh l\u00fd tim m\u1ea1ch \u0111\u1ea7u ti\u00ean n\u00ean \u0111\u01b0\u1ee3c xem x\u00e9t s\u1eed d\u1ee5ng aspirin, nh\u1eb1m gi\u1ea3m t\u1edbi 1\u20444 nguy c\u01a1 xu\u1ea5t hi\u1ec7n tr\u1edf l\u1ea1i c\u00e1c bi\u1ebfn c\u1ed1 tim m\u1ea1ch sau \u0111\u00f3. \u1ede b\u1ec7nh nh\u00e2n \u0111au th\u1eaft ng\u1ef1c \u1ed5n \u0111\u1ecbnh \u0111ang d\u00f9ng ch\u1eb9n beta, aspirin 75mg\/ng\u00e0y l\u00e0m gi\u1ea3m t\u1ef7 l\u1ec7 AMI ho\u1eb7c \u0111\u1ed9t t\u1eed t\u1edbi 34% khi so v\u1edbi gi\u1ea3 d\u01b0\u1ee3c, 46% v\u1edbi \u0111au th\u1eaft ng\u1ef1c kh\u00f4ng \u1ed5n \u0111\u1ecbnh, 53% v\u1edbi b\u1ec7nh nh\u00e2n nong m\u1ea1ch v\u00e0nh, 25% v\u1edbi b\u1ec7nh nh\u00e2n prior MI, 22% \u1edf b\u1ec7nh nh\u00e2n TIA ho\u1eb7c prior stroke, 23% \u1edf b\u1ec7nh nh\u00e2n c\u00f3 b\u1ec7nh \u0111\u1ed9ng m\u1ea1ch ngo\u1ea1i bi\u00ean.<\/span><\/p>\n
D\u1ef1 ph\u00f2ng ti\u00ean ph\u00e1t.<\/strong> V\u1edbi nh\u1eefng khuy\u1ebfn c\u00e1o tr\u01b0\u1edbc \u0111\u00e2y \u0111\u01b0\u1ee3c h\u1ed7 tr\u1ee3 b\u1edfi ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p tr\u00ean 30.000 \u0111\u1ed1i t\u01b0\u1ee3ng m\u00e0 ch\u1ec9 \u0111\u1ecbnh aspirin ch\u1ec9 \u1edf tr\u00ean nh\u00f3m c\u00f3 nguy c\u01a1 cao. Trong m\u1ed9t th\u1eed nghi\u1ec7m nh\u1ecf nh\u01b0ng \u0111\u01b0\u1ee3c thi\u1ebft k\u1ebf r\u1ea5t t\u1ed1t tr\u00ean 1276 b\u1ec7nh nh\u00e2n \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng c\u00f3 b\u1ec7nh m\u1ea1ch m\u00e1u ngo\u1ea1i bi\u00ean \u0111\u01b0\u1ee3c theo d\u00f5i trong 8 n\u0103m cho th\u1ea5y aspirin th\u1ea5t b\u1ea1i trong vi\u1ec7c d\u1ef1 ph\u00f2ng c\u00e1c bi\u1ebfn c\u1ed1 tim m\u1ea1ch bao g\u1ed3m t\u1eed vong do b\u1ec7nh tim v\u00e0 \u0111\u1ed9t qu\u1ef5. Nghi\u00ean c\u1ee9u l\u1edbn nh\u1ea5t v\u1ec1 aspirin li\u1ec1u th\u1ea5p (\u2264300mg) tr\u00ean 186.425 b\u1ec7nh nh\u00e2n t\u1eeb 2003-2008 v\u1edbi m\u1ed9t nh\u00f3m kh\u00f4ng d\u00f9ng li\u1ec1u th\u1ea5p aspirin. Sau th\u1eddi gian theo d\u00f5i trung b\u00ecnh l\u00e0 5.7 n\u0103m, v\u1edbi 1,6 tri\u1ec7u ng\u01b0\u1eddi \u0111\u01b0\u1ee3c quan s\u00e1t. Nh\u00f3m s\u1eed d\u1ee5ng aspirin c\u00f3 t\u1ec9 l\u1ec7 xu\u1ea5t huy\u1ebft n\u00e3o l\u00e0 5.58\/1000 trong khi nh\u00f3m kh\u00f4ng d\u00f9ng aspirin l\u00e0 3.6\/1000. Ch\u00fa \u00fd, vi\u1ec7c t\u0103ng s\u1eed d\u1ee5ng PPIs l\u00e0m gi\u1ea3m nguy c\u01a1 ch\u1ea3y m\u00e1u. V\u1ea5n \u0111\u1ec1 ch\u00ednh c\u1ee7a nghi\u00ean c\u1ee9u tr\u00ean \u0111\u00f3 l\u00e0 \u201cli\u1ec1u th\u1ea5p\u201d trong nghi\u00ean c\u1ee9u l\u00ean t\u1eadn 300mg trong khi ch\u00fang t\u00f4i khuy\u1ebfn c\u00e1o th\u1ea5p h\u01a1n nhi\u1ec1u. C\u00e1c guideline m\u1edbi hi\u1ec7n nay kh\u00f4ng khuy\u1ebfn c\u00e1o s\u1eed d\u1ee5ng aspirin nh\u01b0 m\u1ed9t thu\u1ed1c d\u1ef1 ph\u00f2ng nguy c\u01a1 tim m\u1ea1ch tr\u00ean nh\u1eefng b\u1ec7nh nh\u00e2n kh\u00f4ng c\u00f3 b\u1ec7nh tim m\u1ea1ch tr\u01b0\u1edbc \u0111\u00f3 do hi\u1ec7u qu\u1ea3 kh\u00f4ng r\u00f5 r\u00e0ng m\u00e0 l\u1ea1i l\u00e0m t\u0103ng nguy c\u01a1 ch\u1ea3y m\u00e1u, nh\u1ea5t l\u00e0 \u1edf b\u1ec7nh nh\u00e2n gi\u00e0 ngo\u1ea1i tr\u1eeb d\u1ef1 ph\u00f2ng huy\u1ebft kh\u1ed1i \u1edf nh\u1eefng b\u00eanh nh\u00e2n rung nh\u0129 c\u00f3 nguy c\u01a1 th\u1ea5p (theo thang \u0111i\u1ec3m CHA2DS2-VASc).<\/span><\/p>\n
Aspirin d\u1ef1 ph\u00f2ng ung th\u01b0<\/strong>. Ch\u00fang t\u00f4i thay \u0111\u1ed5i quan \u0111i\u1ec3m c\u1ee7a m\u00ecnh tr\u01b0\u1edbc \u0111\u00e2y r\u1eb1ng vi\u1ec7c d\u00f9ng aspirin d\u1ef1 ph\u00f2ng \u1edf ng\u01b0\u1eddi kh\u1ecfe m\u1ea1nh l\u00e0 kh\u00f4ng c\u1ea7n thi\u1ebft. V\u1edbi nh\u1eefng nghi\u00ean c\u1ee9u hi\u1ec7n t\u1ea1i, ch\u00fang t\u00f4i \u0111\u00e3 t\u00ednh to\u00e1n \u0111\u01b0\u1ee3c c\u00f3 m\u1ed9t \u01b0u th\u1ebf v\u01b0\u1ee3t tr\u1ed9i trong ph\u00f2ng ng\u1eeba ung th\u01b0 \u0111\u01b0\u1eddng ti\u00eau h\u00f3a khi so v\u1edbi nguy c\u01a1 xu\u1ea5t huy\u1ebft \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 nguy c\u01a1 tim m\u1ea1ch th\u1ea5p. V\u1edbi anh s\u00e1ng t\u1eeb ph\u00e2n t\u00edch Rothwell g\u1ea7n \u0111\u00e2y tr\u00ean 51 th\u1eed nghi\u1ec7m, ch\u00fang t\u00f4i \u0111\u1ed3ng \u00fd v\u1edbi t\u00e1c gi\u1ea3 c\u1ee7a Lancet<\/em> r\u1eb1ng vi\u1ec7c s\u1eed d\u1ee5ng aspirin \u0111\u1ec3 d\u1ef1 ph\u00f2ng ung th\u01b0 l\u00e0 r\u1ea5t \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o, l\u1ee3i \u00edch cao h\u01a1n nhi\u1ec1u so v\u1edbi nguy c\u01a1. Khi ch\u01b0a c\u00f3 m\u1ed9t ph\u00e1c \u0111\u1ed3 r\u00f5 r\u00e0ng n\u00e0o \u0111\u1ec3 s\u1eed d\u1ee5ng, ta c\u00f3 th\u1ec3 d\u00f9ng li\u1ec1u th\u1ea5p 75mg c\u00f3 l\u1ebd l\u00e0 tr\u00ean nh\u1eefng b\u00ean nh\u00e2n sinh tr\u01b0\u1edbc nh\u1eefng n\u0103m 50 cho ph\u00e9p c\u1ea3 l\u1ee3i \u00edch ch\u1ed1ng v\u00e0 tr\u00ec ho\u00e3n ung th\u01b0. Ch\u00fang t\u00f4i v\u1eabn lo ng\u1ea1i v\u1ec1 vi\u1ec7c s\u1eed d\u1ee5ng aspirin \u1edf b\u1ec7nh nh\u00e2n gi\u00e0 v\u1edbi ch\u1ee9c n\u0103ng th\u1eadn gi\u1ea3m, tuy nhi\u00ean hi\u1ec7n ch\u01b0a c\u00f3 d\u1eef li\u1ec7u g\u00ec v\u1ec1 vi\u1ec7c d\u00f9ng aspirin \u1edf c\u00e1c m\u1ee9c \u0111\u1ed9 kh\u00e1c nhau c\u1ee7a CKD. Tr\u00ean th\u1ef1c h\u00e0nh l\u00e2m s\u00e0ng, aspirin li\u1ec1u d\u01b0\u1edbi 100mg v\u1eabn \u0111\u01b0\u1ee3c k\u00ea \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 CKD n\u1eb7ng.<\/span><\/p>\n
Aspirin ch\u1ec9 \u0111\u1ecbnh cho b\u1ec7nh l\u00fd tim m\u1ea1ch.<\/strong> Khi x\u1ea3y ra s\u1ef1 ti\u00eau fibrin, k\u1ec3 c\u1ea3 do thu\u1ed1c ti\u00eau s\u1ee3i huy\u1ebft hay do h\u1ec7 th\u1ed1ng ch\u1ed1ng \u0111\u00f4ng c\u1ee7a c\u01a1 th\u1ec3, c\u00f3 m\u1ed9t ngh\u1ecbch l\u00fd l\u00e0 c\u00f3 s\u1ef1 t\u0103ng thrombin t\u1ea1i ch\u1ed7 v\u00e0 t\u0103ng k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u v\u00e0 c\u00f3 th\u1ec3 g\u00e2y t\u00e1i nh\u1ed3i m\u00e1u. V\u00ec v\u1eady, trong h\u1ed9i ch\u1ee9ng v\u00e0nh c\u1ea5p, bao g\u1ed3m c\u1ea3 AMI \u0111\u00e3 d\u00f9ng ti\u00eau s\u1ee3i huy\u1ebft hay PCI ti\u00ean ph\u00e1t, \u0111au th\u1eaft ng\u1ef1c kh\u00f4ng \u1ed5n \u0111\u1ecbnh, aspirin n\u00ean \u0111\u01b0\u1ee3c d\u00f9ng c\u1ea3 trong pha c\u1ea5p l\u1eabn sau \u0111\u00f3, v\u00e0 n\u00f3 l\u00e0 m\u1ed9t ph\u1ea7n c\u1ee7a c\u1ee7a li\u1ec7u ph\u00e1p 3 thu\u1ed1c ch\u1ed1ng k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u. Li\u1ec1u n\u1ea1p c\u1ee7a Aspirin l\u00e0 162-325mg\/ng\u00e0y v\u00e0 81-325 mg\/ng\u00e0y trong c\u00e1c ng\u00e0y sau \u0111\u00f3. C\u00e1c nghi\u00ean c\u1ee9u r\u1ed9ng so s\u00e1nh li\u1ec1u h\u00e0ng ng\u00e0y 300-325mg\/ng\u00e0y v\u1edbi 75- 100mg\/ng\u00e0y cho th\u1ea5y kh\u00f4ng c\u00f3 s\u1ef1 kh\u00e1c bi\u1ec7t tr\u00ean nguy c\u01a1 ch\u1ea3y m\u00e1u v\u00e0 k\u1ebft c\u1ee5c. Aspirin v\u1edbi t\u00e1c d\u1ee5ng ch\u1ed1ng vi\u00eam. M\u1eb7c d\u00f9 thang \u0111i\u1ec3m Framingham l\u00e0 m\u1ed9t h\u01b0\u1edbng d\u1eabn r\u1ea5t t\u1ed1t nh\u01b0ng n\u00f3 l\u1ea1i kh\u00f4ng xem y\u1ebfu t\u1ed1 vi\u00eam c\u00f3 vai tr\u00f2 trong th\u00fac \u0111\u1ea9y b\u1ec7nh m\u1ea1ch m\u00e1u. Ch\u00fang ta c\u00f3 th\u1ec3 xem x\u00e9t s\u1eed d\u1ee5ng aspirin \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 C-reactive protein cao \u0111\u1ec3 d\u1ef1 ph\u00f2ng ti\u00ean ph\u00e1t. Tuy nhi\u00ean, l\u1ee3i \u00edch c\u1ee7a vi\u1ec7c n\u00e0y v\u1eabn c\u1ea7n \u0111\u01b0\u1ee3c ch\u1ee9ng minh th\u00eam.<\/span><\/p>\n
Nh\u1eefng ch\u1ec9 \u0111\u1ecbnh kh\u00e1c.<\/strong><\/p>\n
(1) B\u1ec7nh \u0111\u1ed9ng m\u1ea1ch ngo\u1ea1i bi\u00ean (PAD). C\u00e1c nghi\u00ean c\u1ee9u hi\u1ec7n t\u1ea1i \u0111\u00e3 ch\u1ee9ng minh hi\u1ec7u qu\u1ea3 gi\u1ea3m t\u1ec9 l\u1ec7 b\u1ec7nh t\u1eadt v\u00e0 t\u1eed vong c\u1ee7a aspirin tr\u00ean b\u1ec7nh nh\u00e2n PAD. M\u1eb7c d\u00f9 aspirin kh\u00f4ng \u0111\u1ea9y l\u00f9i t\u00ecnh tr\u1ea1ng x\u01a1 v\u1eefa nh\u01b0ng l\u1ea1i c\u00f3 vai tr\u00f2 \u1ee9c ch\u1ebf ti\u1ec3u c\u1ea7u nh\u1eb1m h\u1ea1n ch\u1ebf huy\u1ebft kh\u1ed1i g\u00e2y ra t\u1eeb s\u1ef1 bong m\u1ea3ng x\u01a1 v\u1eefa. Aspirin \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o v\u1edbi li\u1ec1u 75-162 mg\/ng\u00e0y \u1edf b\u1ec7nh nh\u00e2n PAD.<\/span><\/p>\n
(2)Sau ph\u1eabu thu\u1eadt b\u1eafc c\u1ea7u \u0111\u1ed9ng m\u1ea1ch v\u00e0nh, aspirin n\u00ean \u0111\u01b0\u1ee3c d\u00f9ng trong v\u00f2ng 48 gi\u1edd sau ph\u1eabu thu\u1eadt, gi\u00fap gi\u1ea3m t\u1ef7 l\u1ec7 t\u1eed vong xu\u1ed1ng 2\/3 v\u00e0 ti\u1ebfp t\u1ee5c d\u00f9ng v\u00f4 th\u1eddi h\u1ea1n.<\/span><\/p>\n
(3) D\u1ef1 ph\u00f2ng \u0111\u1ed9t qu\u1ef5 n\u00e3o \u1edf b\u1ec7nh nh\u00e2n rung nh\u0129, khi wafarin ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh ho\u1eb7c \u0111i\u1ec3m CHADS-VASc nh\u1ecf h\u01a1n 2.<\/span><\/p>\n
(4) v\u1edbi b\u1ec7nh nh\u00e2n c\u00f3 shunt \u0111\u1ed9ng t\u0129nh m\u1ea1ch, aspirin l\u00e0m gi\u1ea3m nguy c\u01a1 huy\u1ebft kh\u1ed1i.<\/span><\/p>\n
(5) d\u1ef1 ph\u00f2ng \u0111\u1ed9t qu\u1ef5 \u1edf b\u1ec7nh nh\u00e2n h\u1eb9p \u0111\u1ed9ng m\u1ea1ch n\u00e3o, li\u1ec1u cao aspirin (325-1300mg\/ng\u00e0y) t\u1ed1t h\u01a1n wafarin.<\/span><\/p>\n
(6) Trong pha c\u1ea5p \u0111i\u1ec1u tr\u1ecb TIAs ho\u1eb7c \u0111\u1ed9t qu\u1ef5 nh\u1ecf, aspirin l\u00e0 m\u1ed9t ph\u1ea7n c\u1ee7a li\u1ec7u ph\u00e1p to\u00e0n di\u1ec7n (v\u1edbi clopidogel, statin, h\u1ea1 \u00e1p, ch\u1ed1ng \u0111\u00f4ng n\u1ebfu c\u00f3 ch\u1ec9 \u0111\u1ecbnh). <\/span><\/p>\n
Aspirin li\u1ec1u th\u1ea5p v\u00e0 hi\u1ec7u qu\u1ea3 c\u1ee7a n\u00f3.<\/strong> V\u1ec1 m\u1eb7t l\u00fd thuy\u1ebft, li\u1ec7u ph\u00e1p n\u00e0y c\u00f3 th\u1ec3 \u0111\u1ea3m b\u1ea3o t\u00e1c d\u1ee5ng \u0111\u1ed3ng th\u1eddi gi\u1ea3m nguy c\u01a1 xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a. C\u00e1c nghi\u00ean c\u1ee9u g\u1ee3i \u00fd kho\u1ea3ng li\u1ec1u l\u00e0 75-150mg\/ng\u00e0y. C\u00e1c nghi\u00ean c\u1ee9u tr\u00ean non-STEMI cho th\u1ea5y li\u1ec1u t\u1ed1i \u01b0u l\u00e0 75-100mg. Li\u1ec1u 80mg\/ng\u00e0y \u0111\u00e3 \u0111\u1ee7 \u0111\u1ec3 \u1ee9c ch\u1ebf ho\u00e0n to\u00e0n t\u00e1c d\u1ee5ng c\u1ee7a COX. Li\u1ec1u 30mg\/ng\u00e0y cho th\u1ea5y c\u00f3 hi\u1ec7u qu\u1ea3 d\u1ef1 ph\u00f2ng TIAs t\u1ed1t h\u01a1n so v\u1edbi li\u1ec1u cao h\u01a1n nh\u01b0ng nh\u1eefng enpoint kh\u00e1c th\u00ec ch\u01b0a \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1. C\u1ea7n s\u1eed d\u1ee5ng aspirin v\u1edbi li\u1ec1u cao h\u01a1n (160mg) ngay khi kh\u1edfi ph\u00e1t AMI hay \u0111au th\u1eaft ng\u1ef1c kh\u00f4ng \u1ed5n \u0111\u1ecbnh. <\/span><\/p>\n
Ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh c\u1ee7a aspirin.<\/strong> Kh\u00f4ng d\u1ee5ng n\u1ea1p, xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a, lo\u00e9t d\u1ea1 d\u00e0y, ho\u1eb7c c\u00e1c nguy c\u01a1 ch\u1ea3y m\u00e1u kh\u00e1c t\u1edbi t\u1eeb \u0111\u01b0\u1eddng ti\u00eau h\u00f3a ho\u1eb7c \u0111\u01b0\u1eddng ti\u1ebft ni\u1ec7u- sinh d\u1ee5c. Hemophilia kh\u00f4ng c\u00f3 ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh tuy\u1ec7t \u0111\u1ed1i. C\u1ea7n theo d\u00f5i uric acid, creatinin (do aspirin l\u00e0m ch\u1eadm \u0111\u00e0o th\u1ea3i). Nh\u1eefng ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh kh\u00e1c: gout, thi\u1ebfu m\u00e1u thi\u1ebfu s\u1eaft, t\u00e1o b\u00f3n, xung quanh ph\u1eabu thu\u1eadt. L\u01b0u \u00fd, Aspirin c\u00f9ng v\u1edbi nh\u1eefng lo\u1ea1i thu\u1ed1c NSAIDs kh\u00e1c c\u00f3 th\u1ec3 g\u00e2y kh\u1edfi ph\u00e1t c\u01a1n hen c\u1ea5p tr\u00ean b\u1ec7nh nh\u00e2n ti\u1ec1n c\u0103n hen ph\u1ebf qu\u1ea3n.<\/span><\/p>\n
T\u01b0\u01a1ng t\u00e1c thu\u1ed1c.<\/strong> K\u1ebft h\u1ee3p v\u1edbi wafarin l\u00e0m t\u0103ng nguy c\u01a1 ch\u1ea3y m\u00e1u, \u0111\u1eb7c bi\u1ec7t v\u1edbi aspirin li\u1ec1u cao. Nh\u1eefng thu\u1ed1c t\u00e1c d\u1ee5ng l\u00ean COX-1 khi d\u00f9ng k\u00e8m l\u00e0m gi\u1ea3m t\u00e1c d\u1ee5ng tim m\u1ea1ch c\u1ee7a aspirin. Aspirin v\u00e0 ACEi c\u00f3 th\u1ec3 c\u00f3 t\u00e1c d\u1ee5ng \u0111\u1ed1i ng\u01b0\u1ee3c l\u00ean huy\u1ebft \u0111\u1ed9ng h\u1ecdc \u1edf th\u1eadn, do aspirin th\u00ec \u1ee9c ch\u1ebf c\u00f2n ACEi l\u1ea1i th\u00fac \u0111\u1ea9y s\u1ea3n xu\u1ea5t c\u00e1c PGs gi\u00e3n m\u1ea1ch. Tuy v\u1eady khi s\u1eed d\u1ee5ng ACEi k\u00e9o d\u00e0i \u1edf b\u1ec7nh nh\u00e2n suy tim, sau nh\u1ed3i m\u00e1u c\u01a1 tim, ho\u1eb7c d\u1ef1 ph\u00f2ng nguy c\u01a1 cao th\u00ec n\u00f3 v\u1eabn gi\u1eef l\u1ee3i \u00edch khi d\u00f9ng k\u00e8m aspirin. <\/span><\/p>\n
\u0110i\u1ec1u tr\u1ecb xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a do aspirin.<\/strong> \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 lo\u00e9t \u0111\u00e3 l\u00e0nh, aspirin + PPI l\u00e0m gi\u1ea3m nguy c\u01a1 t\u00e1i xu\u1ea5t huy\u1ebft h\u01a1n l\u00e0 \u0111\u1ed5i sang clopidogrel. C\u00f3 th\u1ec3 d\u00f9ng clopidogrel t\u1eeb \u0111\u1ea7u \u0111\u1ec3 tr\u00e1nh ho\u1eb7c gi\u1ea3m b\u1edbt t\u1ec9 l\u1ec7 xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a do aspirin hay kh\u00f4ng? C\u00e1c b\u1eb1ng ch\u1ee9ng kh\u00f4ng tr\u1ef1c ti\u1ebfp cho th\u1ea5y r\u1eb1ng g\u1ea7n 1000 b\u1ec7nh nh\u00e2n ph\u1ea3i \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb trong 1 n\u0103m v\u1edbi clopidogrel thay cho aspirin \u0111\u1ec3 tr\u00e1nh nguy c\u01a1 ch\u1ea3y m\u00e1u th\u00ec s\u1ed1 ti\u1ec1n ph\u1ea3i b\u1ecf ra th\u00eam l\u00e0 1 tri\u1ec7u \u0111\u00f4 la.<\/span><\/p>\n
III. Clopidogel<\/span><\/h3>\n
Clopidogrel l\u00e0 m\u1ed9t thu\u1ed1c \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh r\u1ed9ng r\u00e3i v\u1edbi vai tr\u00f2 ch\u1ed1ng k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u nh\u1edd kh\u1ea3 n\u0103ng \u1ee9c ch\u1ebf receptor P2Y12 (m\u1ed9t th\u1ee5 th\u1ec3 kh\u00e1c tr\u00ean b\u1ec1 m\u1eb7t ti\u1ec3u c\u1ea7u) (h\u00ecnh 1.2). Clopidogrel an to\u00e0n h\u01a1n \u0111\u00e1ng k\u1ec3 khi so v\u1edbi Ticagrelor v\u1edbi t\u1ef7 l\u1ec7 \u0111\u1ed9c v\u1edbi t\u1ee7y x\u01b0\u01a1ng th\u1ea5p (0.8%). Kh\u00f4ng c\u00f3 nghi\u00ean c\u1ee9u n\u00e0o \u0111\u00e1nh gi\u00e1 nguy c\u01a1 xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a c\u1ee7a clopidogrel nh\u01b0ng n\u00f3 \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ee9ng minh l\u00e0 th\u1ea5p h\u01a1n so v\u1edbi aspirin. Clopidogrel l\u00e0m gi\u1ea3m nguy c\u01a1 bi\u1ebfn c\u1ed1 tim m\u1ea1ch \u0111\u1ed3ng th\u1eddi l\u1ea1i c\u00f3 kh\u1ea3 n\u0103ng dung n\u1ea1p cao h\u01a1n Ticagrelor (\u00cdt ch\u1ea3y m\u00e1u \u0111\u01b0\u1eddng ti\u00eau h\u00f3a v\u00e0 \u00edt t\u00e1c d\u1ee5ng ph\u1ee5 h\u01a1n). C\u0169ng nh\u01b0 aspirin, c\u00f3 s\u1ef1 \u0111\u1ec1 kh\u00e1ng v\u1edbi clopidogrel.<\/span><\/p>\n
1. T\u00ednh ch\u1ea5t d\u01b0\u1ee3c l\u00fd<\/span><\/h4>\n
Clopidogrel l\u00e0 d\u1ea1ng thu\u1ed1c ti\u1ec1n ch\u1ea5t v\u00e0 \u0111\u00f2i h\u1ecfi ph\u1ea3i \u0111\u01b0\u1ee3c oxy h\u00f3a \u1edf gan ho\u1eb7c b\u1edfi isoenzymes cytochrome CYP3A4 and 2C19 \u0111\u01b0\u1eddng ti\u00eau h\u00f3a. Clopidogrel kh\u1edfi ph\u00e1t t\u00e1c d\u1ee5ng l\u00ean ti\u1ec3u c\u1ea7u ch\u1ec9 sau v\u00e0i gi\u1edd v\u1edbi li\u1ec1u duy nh\u1ea5t nh\u01b0ng c\u1ea7n 3-7 ng\u00e0y \u0111\u1ec3 \u0111\u1ea1t kh\u1ea3 n\u0103ng \u1ee9c ch\u1ebf \u1ed5n \u0111\u1ecbnh. Tr\u01b0\u1edbc khi th\u1ef1c hi\u1ec7n PCI, s\u1eed d\u1ee5ng clopidogrel li\u1ec1u n\u1ea1p 600mg \u0111\u01b0\u1eddng u\u1ed1ng nh\u1eb1m \u0111\u1ea1t kh\u1ea3 n\u0103ng \u1ee9c ch\u1ebf ti\u1ec3u c\u1ea7u ch\u1ec9 sau 2 gi\u1edd khi so v\u1edbi 24-48 gi\u1edd khi d\u00f9ng li\u1ec1u 300mg. C\u1ea3 2 li\u1ec1u \u0111\u1ec1u \u0111\u1ea1t kh\u1ea3 n\u0103ng \u1ee9c ch\u1ebf ti\u1ec3u c\u1ea7u cao h\u01a1n Ticlopidine.<\/span><\/p>\n
D\u01b0\u1ee3c \u0111\u1ed9ng h\u1ecdc Clopidogrel kh\u00f4ng tuy\u1ebfn t\u00ednh v\u00e0 thay \u0111\u1ed5i nhi\u1ec1u, c\u00f3 s\u1ef1 gi\u1ea3m thanh th\u1ea3i \u0111\u00e1ng k\u1ec3 khi s\u1eed d\u1ee5ng li\u1ec1u l\u1eb7p l\u1ea1i.<\/span><\/p>\n
Khi ng\u1eebng thu\u1ed1c, c\u1ea7n kho\u1ea3ng 5 ng\u00e0y \u0111\u1ec3 th\u1ebf h\u1ec7 ti\u1ec3u c\u1ea7u m\u1edbi sinh ra v\u00e0 l\u00e0m gi\u1ea3m s\u1ef1 ch\u1ea3y m\u00e1u. V\u00ec th\u1ebf, t\u1ea1m ng\u1eebng 5 ng\u00e0y \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o tr\u01b0\u1edbc ph\u1eabu thu\u1eadt b\u1eafc c\u1ea7u \u0111\u1ed9ng m\u1ea1ch v\u00e0nh.Kh\u00f4ng c\u1ea7n ch\u1ec9nh li\u1ec1u \u1edf ng\u01b0\u1eddi gi\u00e0 v\u00e0 b\u1ec7nh nh\u00e2n r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng th\u1eadn.<\/span><\/p>\n
2. T\u00e1c d\u1ee5ng ph\u1ee5<\/span><\/h4>\n
Gi\u1ea3m b\u1ea1ch c\u1ea7u trung t\u00ednh (0.02% so v\u1edbi 2.4% c\u1ee7a ticlopidine). L\u00e0m t\u0103ng nguy c\u01a1 ch\u1ea3y m\u00e1u nh\u01b0ng kh\u00f4ng l\u00e0m t\u0103ng nguy c\u01a1 xu\u1ea5t huy\u1ebft n\u00e3o. Ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh khi c\u00f3 ch\u1ea3y m\u00e1u \u0111ang ti\u1ebfn tri\u1ec3n.<\/span><\/p>\n
3. Test gene<\/span><\/h4>\n
Clopidogrel l\u00e0 m\u1ed9t ti\u1ec1n ch\u1ea5t \u0111\u00f2i h\u1ecfi ph\u1ea3i k\u00edch ho\u1ea1t chuy\u1ec3n h\u00f3a b\u1eb1ng cytochrome P450 gan. C\u00e1c alen CYP2C19 * 2 l\u00e0 m\u1ed9t bi\u1ebfn th\u1ec3 di truy\u1ec1n ph\u1ed5 bi\u1ebfn v\u00e0 c\u00f3 li\u00ean quan t\u1edbi s\u1ef1 t\u0103ng t\u1ef7 l\u1ec7 c\u00e1c bi\u1ebfn c\u1ed1 thi\u1ebfu m\u00e1u c\u1ee5c b\u1ed9 v\u00e0 huy\u1ebft kh\u1ed1i stent sau PCI. C\u00e1c bi\u1ebfn th\u1ec3 di truy\u1ec1n n\u00e0y v\u00e0 m\u1ed9t s\u1ed1 kh\u00e1c \u0111\u01b0\u1ee3c ph\u00e1t hi\u1ec7n trong g\u1ea7n 30% s\u1ed1 c\u00e1 th\u1ec3 T\u00e2y\u00a0 u v\u00e0 kho\u1ea3ng 40% c\u1ee7a nh\u1eefng ng\u01b0\u1eddi ch\u00e2u \u00c1 v\u00e0 ng\u01b0\u1eddi da \u0111en. Prasugrel ho\u1eb7c Ticargrelor c\u00f3 th\u1ec3 d\u00f9ng \u0111\u1ec3 thay th\u1ebf trong tr\u01b0\u1eddng h\u1ee3p n\u00e0y.<\/span><\/p>\n
4. T\u01b0\u01a1ng t\u00e1c thu\u1ed1c<\/span><\/h4>\n
M\u1eb7c d\u00f9 c\u00f3 nh\u1eefng lo ng\u1ea1i kh\u1ea3 n\u0103ng c\u1ea1nh tranh l\u00e0m gi\u1ea3m t\u00e1c d\u1ee5ng c\u1ee7a clopidogrel b\u1edfi omeprazole hay atorvastatin nh\u01b0ng ch\u01b0a c\u00f3 nghi\u00ean c\u1ee9u l\u00e2m s\u00e0ng n\u00e0o so s\u00e1nh v\u1edbi gi\u1ea3 d\u01b0\u1ee3c \u0111\u1ec3 \u0111\u00e1nh gi\u00e1.<\/span><\/p>\n
5. Nh\u1eefng thu\u1ed1c \u1ee9c ch\u1ebf P2Y12 kh\u00e1c so v\u1edbi clopidogrel<\/span><\/h4>\n
Trong c\u00e1c thu\u1ed1c ch\u1eb9n P2Y12, ticagrelor c\u00f3 m\u1ed9t s\u1ed1 \u01b0u \u0111i\u1ec3m so v\u1edbi prasugrel (\u0111\u00f2i h\u1ecfi ph\u1ea3i ho\u1ea1t h\u00f3a \u1edf gan, do \u0111\u00f3 ticagrelor tr\u00e1nh \u0111\u01b0\u1ee3c v\u1ea5n \u0111\u1ec1 \u1ea3nh h\u01b0\u1edfng c\u1ee7a c\u00e1c bi\u1ebfn th\u1ec3 di truy\u1ec1n gan kh\u00f4ng ph\u00e1t sinh) (h\u00ecnh 1.3). Trong tr\u01b0\u1eddng h\u1ee3p ch\u1ea3y m\u00e1u qu\u00e1 m\u1ee9c, ticagrelor c\u00f3 th\u1ec3 d\u1ec5 d\u00e0ng \u0111\u1ea3o ng\u01b0\u1ee3c h\u01a1n v\u1edbi th\u1eddi gian t\u00e1c d\u1ee5ng ng\u1eafn h\u01a1n (3-4 ng\u00e0y) so v\u1edbi (5-10 ng\u00e0y) \u0111\u1ed1i v\u1edbi prasugrel. H\u01a1n n\u1eefa, ticagrelor c\u00f3 d\u1eef li\u1ec7u th\u1eed nghi\u1ec7m m\u1ea1nh v\u1edbi kh\u1ea3 n\u0103ng gi\u1ea3m t\u1ec9 l\u1ec7 t\u1eed vong trong ACS trong th\u01b0 nghi\u1ec7m PLATO. Prasugrel cho ph\u00e9p \u1ee9c ch\u1ebf ti\u1ec3u c\u1ea7u hi\u1ec7u qu\u1ea3 h\u01a1n so v\u1edbi clopidogrel \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 ti\u1ec3u c\u1ea7u c\u00f2n l\u1ea1i ph\u1ea3n \u1ee9ng cao, nh\u01b0ng kh\u00f4ng c\u00f3 thay \u0111\u1ed5i g\u00ec v\u1ec1 k\u1ebft c\u1ee5c.<\/span><\/p>\n
6. Ch\u1ec9 \u0111\u1ecbnh, li\u1ec1u v\u00e0 c\u00e1ch d\u00f9ng<\/span><\/h4>\n
Clopidogrel \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh trong:<\/span><\/p>\n
(1) Gi\u1ea3m c\u00e1c bi\u1ebfn c\u1ed1 tim m\u1ea1ch do x\u01a1 v\u1eefa \u1edf b\u1ec7nh nh\u00e2n c\u00f3 ti\u1ec1n s\u1eed \u0111\u1ed9t qu\u1ef5 m\u1edbi, MI m\u1edbi, b\u1ec7nh \u0111\u1ed9ng m\u1ea1ch ngo\u1ea1i bi\u00ean.<\/span><\/p>\n
(2) ACS d\u00f9 PCI hay kh\u00f4ng ho\u1eb7c ph\u1eabu thu\u1eadt b\u1eafc c\u1ea7u \u0111\u1ed9ng m\u1ea1ch v\u00e0nh. Li\u1ec1u<\/span><\/p>\n
n\u1ea1p 600mg l\u00e0 \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o h\u01a1n c\u1ea3. C\u00f3 th\u1ec3 d\u00f9ng li\u1ec1u n\u1ea1p 300mg \u1edf b\u1ec7nh nh\u00e2n d\u00f9ng ti\u00eau s\u1ee3i huy\u1ebft (ho\u1eb7c \u1edf b\u1ec7nh nh\u00e2n PCI sau khi d\u00f9ng ti\u00eau s\u1ee3i huy\u1ebft m\u00e0 nh\u1ecf h\u01a1n 24 gi\u1edd). xem x\u00e9t kh\u00f4ng d\u00f9ng li\u1ec1u n\u1ea1p \u1edf ng\u01b0\u1eddi gi\u00e0 tr\u00ean 75 tu\u1ed5i. Li\u1ec1u duy tr\u00ec l\u00e0 75mg\/ng\u00e0y trong \u00edt nh\u1ea5t 12 th\u00e1ng \u0111\u1ec3 d\u1ef1 ph\u00f2ng huy\u1ebft kh\u1ed1i do stent v\u00e0nh ph\u1ee7 thu\u1ed1c (DES), t\u1ea5t nhi\u00ean l\u00e0 d\u00f9ng c\u00f9ng v\u1edbi aspirin.<\/span><\/p>\n
N\u00ean duy tr\u00ec bao l\u00e2u sau PCI? C\u00e1c ti\u00eau chu\u1ea9n hi\u1ec7n t\u1ea1i khuy\u1ebfn c\u00e1o duy tr\u00ec \u00edt nh\u1ea5t 1 n\u0103m cho DES v\u00e0 1 th\u00e1ng cho lo\u1ea1i kh\u00f4ng ph\u1ee7 thu\u1ed1c. M\u1ed9t nghi\u00ean c\u1ee9u quan s\u00e1t th\u1ea5y r\u1eb1ng c\u00f3 s\u1ef1 t\u0103ng c\u00e1c bi\u1ebfn c\u1ed1 tim m\u1ea1ch b\u1ea5t l\u1ee3i sau trung b\u00ecnh 278 ng\u00e0y d\u1eebng thu\u1ed1c.<\/span><\/p>\n
(3) Clopidogrel th\u01b0\u1eddng \u0111\u01b0\u1ee3c d\u00f9ng thay th\u1ebf aspirin \u1edf PAD b\u1edfi t\u00ednh an to\u00e0n c\u1ee7a n\u00f3. Tuy nhi\u00ean hi\u1ec7u qu\u1ea3 c\u1ee7a n\u00f3 tr\u00ean b\u1ec7nh nh\u00e2n PAD th\u00ec v\u1eabn ch\u01b0a \u0111\u01b0\u1ee3c nghi\u00ean c\u1ee9u. trong m\u1ed9t nghi\u00ean c\u1ee9u so s\u00e1nh v\u1edbi aspirin. Clopidogrel li\u1ec1u 75 mg\/ng\u00e0y cho th\u1ea5y l\u00e0m gi\u1ea3m nguy c\u01a1 tim m\u1ea1ch 25% so v\u1edbi aspirin. N\u00f3 cho hi\u1ec7u qu\u1ea3 r\u00f5 r\u00e0ng nh\u1ea5t \u1edf nh\u00f3m bn c\u00f3 PAD. V\u00ec v\u1eady c\u00f3 th\u1ec3 clopidogrel th\u1ef1c s\u1ef1 th\u00edch h\u1ee3p cho b\u1ec7nh nh\u00e2n PAD m\u1eb7c d\u00f9 v\u1eabn c\u1ea7n th\u00eam c\u00e1c nghi\u00ean c\u1ee9u m\u1edbi trong t\u01b0\u01a1ng lai.<\/span><\/p>\n
$\"H\u00ecnh$ <\/a>
H\u00ecnh 1.3 S\u01a1 \u0111\u1ed3 ho\u1ea1t h\u00f3a c\u1ee7a c\u00e1c lo\u1ea1i thu\u1ed1c \u1ee9c ch\u1ebf recepter P2Y12<\/figcaption><\/figure>\n
IV. Li\u1ec7u ph\u00e1p ch\u1ed1ng k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u k\u00e9p<\/span><\/h3>\n
1. Aspirin-Clopidogrel.<\/span><\/h4>\n
C\u00f3 th\u1ec3 th\u1ea5y aspirin v\u00e0 clopidogrel t\u00e1c \u0111\u1ed9ng v\u00e0o c\u00e1c v\u1ecb tr\u00ed kh\u00e1c nhau tr\u00ean ti\u1ec3u c\u1ea7u, v\u00ec th\u1ebf li\u1ec7u ph\u00e1p k\u1ebft h\u1ee3p c\u00f3 th\u1ec3 cho hi\u1ec7u qu\u1ea3 cao h\u01a1n tr\u00ean b\u1ec7nh nh\u00e2n nguy c\u01a1 cao. C\u00e1c d\u1eef li\u1ec7u nghi\u00ean c\u1ee9u cho th\u1ea5y l\u1ee3i \u00edch c\u1ee7a li\u1ec7u ph\u00e1p kh\u00e1ng ti\u1ec3u c\u1ea7u k\u00e9p trong t\u00ecnh tr\u1ea1ng t\u1ed5n th\u01b0\u01a1ng m\u1ea1ch v\u00e0nh c\u1ea5p t\u00ednh, khi th\u1ef1c hi\u1ec7n c\u00e1c quy tr\u00ecnh can thi\u1ec7p v\u00e0nh, \u0111\u1eb7t stent.<\/span><\/p>\n
Trong m\u1ed9t th\u1eed nghi\u1ec7m OASIS-7 tr\u00ean 17.263 b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c can thi\u1ec7p PCI \u0111\u01b0\u1ee3c d\u00f9ng li\u1ec7u ph\u00e1p kh\u00e1ng k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u k\u00e9p v\u1edbi li\u1ec1u Clopidogrel g\u1ea5p \u0111\u00f4i trong 7 ng\u00e0y (600mg li\u1ec1u n\u1ea1p v\u00e0 150mg\/ng\u00e0y) l\u00e0m gi\u1ea3m bi\u1ebfn c\u1ed1 tim m\u1ea1ch v\u00e0 huy\u1ebft kh\u1ed1i stent sau 30 ng\u00e0y so v\u1edbi nh\u00f3m d\u00f9ng li\u1ec1u clopidogrel th\u1ea5p ( n\u1ea1p 300mg v\u00e0 duy tr\u00ec 75mg\/ng\u00e0y).Li\u1ec7u ph\u00e1p kh\u00e1ng k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u k\u00e9p l\u00e0m gi\u1ea3m 27% nguy c\u01a1 t\u1eed vong, MI v\u00e0 \u0111\u1ed9t qu\u1ef5 sau 1 n\u0103m.<\/span><\/p>\n
Li\u1ec7u ph\u00e1p ch\u1ed1ng k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u k\u00e9p ko cho th\u1ea5y hi\u1ec7u qu\u1ea3 g\u00ec h\u01a1n so vs aspirin \u0111\u01a1n \u0111\u1ed9c \u1edf b\u1ec7nh nh\u00e2n PAD n\u00ean hi\u1ec7n t\u1ea1i clopidogel ch\u1ec9 \u0111\u01b0\u1ee3c xem nh\u01b0 l\u00e0 1 thu\u1ed1c thay th\u1ebf aspirin ch\u1ee9 ko khuy\u00ean d\u00f9ng k\u1ebft h\u1ee3p.<\/span><\/p>\n
2.S\u1eed d\u1ee5ng trong rung nh\u0129 c\u00f3 nguy c\u01a1 \u0111\u1ed9t qu\u1ef5 cao <\/span><\/h4>\n
Hi\u1ec7n nay t\u1ed1i \u01b0u nh\u1ea5t v\u1eabn l\u00e0 nh\u1eefng thu\u1ed1c \u1ee9c ch\u1ebf thrombin tr\u1ef1c ti\u1ebfp m\u1edbi ho\u1eb7c c\u00e1c thu\u1ed1c \u1ee9c ch\u1ebf y\u1ebfu t\u1ed1 Xa. V\u1edbi nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 TIAs tr\u01b0\u1edbc \u0111\u00f3 ho\u1eb7c \u0111\u1ed9t qu\u1ef5 nh\u1ecf, th\u1eed nghi\u1ec7m cho th\u1ea5y li\u1ec7u ph\u00e1p kh\u00e1ng k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u k\u00e9p l\u00e0m t\u0103ng nguy c\u01a1 ch\u1ea3y m\u00e1u m\u00e0 kh\u00f4ng cho th\u1ea5y s\u1ef1 c\u1ea3i thi\u1ec7n k\u1ebft c\u1ee5c. V\u00ec th\u1ebf \u1edf nh\u1eefng tr\u01b0\u1eddng h\u1ee3p n\u00e0y n\u1ebfu c\u1ea7n ch\u1ec9 n\u00ean d\u00f9ng 1 lo\u1ea1i kh\u00e1ng k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u (aspirin l\u00e0 \u01b0u ti\u00ean).<\/span><\/p>\n
V. C\u00e1c lo\u1ea1i thu\u1ed1c ch\u1ed1ng k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u m\u1edbi: Prasugrel, <\/span>Ticagrelor<\/span><\/h3>\n
Prasugrel<\/span><\/h4>\n
Prasugel l\u00e0 lo\u1ea1i thu\u1ed1c m\u1edbi thu\u1ed9c nh\u00f3m thienopyridine (th\u1ebf h\u1ec7 \u0111\u1ea7u ti\u00ean l\u00e0 ticlopidine, th\u1ebf h\u1ec7 th\u1ee9 2 l\u00e0 clopidogrel) v\u1edbi t\u00e1c d\u1ee5ng \u1ee9c ch\u1ebf kh\u00f4ng h\u1ed3i ph\u1ee5c v\u00e0 kh\u00f4ng c\u1ea1nh tranh th\u1ee5 th\u1ec3 P2Y12 t\u1ea1i c\u00f9ng v\u1ecb tr\u00ed v\u1edbi clopidogrel. Prasugrel l\u00e0 ti\u1ec1n ch\u1ea5t v\u00e0 kh\u00f4ng th\u1ec3 ph\u00e1t hi\u1ec7n trong huy\u1ebft t\u01b0\u01a1ng n\u1ebfu d\u00f9ng \u0111\u01b0\u1eddng u\u1ed1ng. N\u00f3 nhanh ch\u00f3ng \u0111\u01b0\u1ee3c oxy h\u00f3a \u1edf ru\u1ed9t v\u00e0 chuy\u1ec3n h\u00f3a \u1edf gan th\u00e0nh d\u1ea1ng ho\u1ea1t \u0111\u1ed9ng. Prasugel c\u00f3 kh\u1ea3 n\u0103ng \u1ee9c ch\u1ebf k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u m\u1ea1nh g\u1ea5p 9 l\u1ea7n so v\u1edbi clopidogrel 600mg v\u1edbi th\u1eddi gian kh\u1edfi ph\u00e1t t\u00e1c d\u1ee5ng trong v\u00f2ng 1 gi\u1edd.<\/p>\n
M\u1ed9t th\u1eed nghi\u1ec7m so s\u00e1nh Prasugrel (60mg li\u1ec1u n\u1ea1p v\u00e0 10mg\/ng\u00e0y li\u1ec1u duy tr\u00ec) v\u00e0 clopidogel (300mg n\u1ea1p v\u00e0 75mg\/ng\u00e0y duy tr\u00ec) \u1edf b\u1ec7nh nh\u00e2n PCI sau 6-15 th\u00e1ng cho th\u1ea5y prasugrel l\u00e0m gi\u1ea3m k\u1ebft c\u1ee5c t\u1eed vong do tim m\u1ea1ch, MI, \u0111\u1ed9t qu\u1ef5 t\u1eeb 12% xu\u1ed1ng 9%, gi\u1ea3m t\u1ec9 l\u1ec7 huy\u1ebft kh\u1ed1i stent t\u1eeb 2.4%-1.1%.<\/p>\n
FDA \u0111\u00e3 c\u1ea3nh b\u00e1o t\u00e1c d\u1ee5ng ph\u1ee5 g\u00e2y ch\u1ea3y m\u00e1u nghi\u00eam tr\u1ecdng c\u1ee7a prasugrel. \u0110i\u1ec1u n\u00e0y c\u00f3 th\u1ec3 kh\u1eafc ph\u1ee5c b\u1eb1ng c\u00e1ch d\u1eebng s\u1eed d\u1ee5ng prasugrel v\u00e0 thay th\u1ebf n\u00f3 b\u1eb1ng m\u1ed9t lo\u1ea1i kh\u00e1c, \u0111\u1eb7c bi\u1ec7t l\u00e0 trong m\u1ed9t v\u00e0i tu\u1ea7n \u0111\u1ea7u ti\u00ean sau STEMI. \u0110\u00e3 c\u00f3 b\u1eb1ng ch\u1ee9ng cho th\u1ea5y vi\u1ec7c chuy\u1ec3n sang clopidogrel (trong li\u1ec7u ph\u00e1p kh\u00e1ng k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u k\u00e9p v\u1edbi aspirin) sau 7 ng\u00e0y \u0111\u1ea7u d\u00f9ng prasugrel v\u1eabn gi\u1eef \u0111\u01b0\u1ee3c hi\u1ec7u qu\u1ea3 ch\u1ed1ng huy\u1ebft kh\u1ed1i m\u00e0 l\u1ea1i gi\u1ea3m nguy c\u01a1 xu\u1ea5t huy\u1ebft so v\u1edbi nh\u00f3m ch\u1ee9ng d\u00f9ng c\u1ed1 \u0111\u1ecbnh prasugrel. B\u1ec7nh nh\u00e2n d\u01b0\u1edbi 60kg, hay c\u00f3 ti\u1ec1n s\u1eed \u0111\u1ed9t qu\u1ef5, TIAs th\u00ec n\u00ean tr\u00e1nh s\u1eed d\u1ee5ng prasugrel.<\/p>\n
Ticagrelor<\/span><\/h4>\n
Ticagrelor thu\u1ed9c v\u1ec1 m\u1ed9t ph\u00e2n nh\u00f3m m\u1edbi, cyclopentyl- triazolopyrimidine. N\u00f3 c\u00f3 t\u00e1c d\u1ee5ng \u1ee9c ch\u1ebf kh\u00f4ng c\u1ea1nh tranh recepter P2Y12 v\u1edbi th\u1eddi gian b\u00e1n th\u1ea3i kho\u1ea3ng 12 gi\u1edd. Gi\u1ed1ng Prasugrel, Ticagrelor c\u00f3 th\u1eddi gian kh\u1edfi ph\u00e1t v\u00e0 t\u00e1c d\u1ee5ng k\u00e9o d\u00e0i h\u01a1n clopidogrel nh\u01b0ng khi ng\u1eebng thu\u1ed1c th\u00ec th\u1eddi gian \u0111\u1ec3 ti\u1ec3u c\u1ea7u h\u1ed3i ph\u1ee5c l\u1ea1i nhanh h\u01a1n. Ngo\u00e0i ra, n\u00f3 kh\u00f4ng c\u1ea7n ho\u1ea1t h\u00f3a \u1edf gan.<\/p>\n
Ticagrelor c\u0169ng cho th\u1ea5y hi\u1ec7u qu\u1ea3 trong c\u00e1c th\u1eed nghi\u1ec7m tr\u00ean b\u1ec7nh nh\u00e2n STEMI \u0111\u01b0\u1ee3c PCI ti\u00ean ph\u00e1t v\u1edbi li\u1ec1u n\u1ea1p 180 mg v\u00e0 90mg\/ng\u00e0y li\u1ec1u duy tr\u00ec khi so s\u00e1nh v\u1edbi clopidogrel. Khuy\u1ebfn c\u00e1o xu\u1ed1ng thang xu\u1ed1ng clopidogrel t\u01b0\u01a1ng t\u1ef1 prasugrel \u1edf b\u1ec7nh nh\u00e2n c\u00f3 nguy c\u01a1 ch\u1ea3y m\u00e1u cao.<\/p>\n
T\u00e1c d\u1ee5ng ph\u1ee5 c\u1ee7a Ticagrelor l\u00e0 t\u0103ng t\u1ef7 l\u1ec7 ch\u1ea3y m\u00e1u kh\u00f4ng li\u00ean quan t\u1edbi b\u1eafc c\u1ea7u \u0111\u1ed9ng m\u1ea1ch v\u00e0nh t\u0103ng acid uric kh\u00f4ng tri\u1ec7u ch\u1ee9ng, ng\u01b0ng th\u1ea5t (kho\u1ea3ng 3 gi\u00e2y ho\u1eb7c h\u01a1n t\u0103ng l\u00ean, ng\u1eebng n\u00fat xoang c\u0169ng c\u00f3 th\u1ec3 g\u1eb7p, v\u00ec th\u1ebf ph\u1ea3i c\u1ea9n th\u1eadn \u1edf b\u1ec7nh nh\u00e2n b\u1ec7nh l\u00fd n\u00fat xoang ti\u1ebfn tri\u1ec3n, block AV 2-3), kh\u00f3 th\u1edf (kh\u00f3 th\u1edf kh\u00e1 ph\u1ed5 bi\u1ebfn, l\u00ean t\u1edbi 14% \u1edf giai \u0111o\u1ea1n b\u1eaft \u0111\u1ea7u \u0111i\u1ec1u tr\u1ecb nh\u01b0ng th\u01b0\u1eddng ch\u1ec9 l\u00e0 t\u1ea1m th\u1eddi v\u00e0 kh\u00f4ng \u0111\u00e1ng ng\u1ea1i t\u1edbi m\u1ee9c ph\u1ea3i d\u1eebng \u0111i\u1ec1u tr\u1ecb). C\u01a1 ch\u1ebf c\u1ee7a kh\u00f3 th\u1edf v\u00e0 ng\u1eebng th\u1ea5t ch\u01b0a \u0111\u01b0\u1ee3c hi\u1ec3u r\u00f5.<\/p>\n
Kh\u00f4ng s\u1eed d\u1ee5ng ticagrelor li\u1ec1u tr\u00ean 100mg\/ng\u00e0y khi k\u1ebft h\u1ee3p v\u1edbi Aspirin do l\u00e0m gi\u1ea3m t\u00e1c d\u1ee5ng c\u1ee7a li\u1ec7u ph\u00e1p (th\u1eed nghi\u1ec7m ch\u1ec9 tr\u00ean ng\u01b0\u1eddi Nam M\u0129).<\/p>\n
Hi\u1ec7n t\u1ea1i c\u00e1c khuy\u1ebfn c\u00e1o ko d\u00f9ng tircagrelor cho nh\u00f3m bn PAD \u0111\u1ec3 l\u00e0m gi\u1ea3m bi\u1ebfn c\u1ed1 tim m\u1ea1ch k\u1ec3 c\u1ea3 \u0111\u01a1n \u0111\u1ed9c hay k\u1ebft h\u1ee3p v\u00ec ch\u01b0a cho th\u1ea5y hi\u1ec7u qu\u1ea3 n\u00e0o t\u1eeb nh\u00f3m n\u00e0y (aspirin l\u00e0 \u01b0u ti\u00ean).<\/p>\n
WARFARIN<\/span><\/h2>\n
Warfarin (Coumarin, Coumadin, Panwarfin) l\u00e0 lo\u1ea1i thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng \u0111\u01b0\u1eddng u\u1ed1ng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng ph\u1ed5 bi\u1ebfn nh\u1ea5t. Warfarin c\u0169ng c\u00f3 \u00edt t\u00e1c d\u1ee5ng ph\u1ee5 ngo\u1ea1i tr\u1eeb bi\u1ebfn ch\u1ee9ng do ch\u1ed1ng \u0111\u00f4ng qu\u00e1 m\u1ee9c l\u00e0 ch\u1ea3y m\u00e1u, c\u00f3 th\u1ec3 g\u00e2y xu\u1ea5t huy\u1ebft n\u00e3o nghi\u00eam tr\u1ecdng. S\u1ef1 chuy\u1ec3n h\u00f3a c\u1ee7a warfarin c\u0169ng b\u1ecb \u1ea3nh h\u01b0\u1edfng b\u1edfi nhi\u1ec1u lo\u1ea1i thu\u1ed1c kh\u00e1c.<\/p>\n
I. C\u01a1 ch\u1ebf t\u00e1c d\u1ee5ng<\/span><\/h3>\n
Vitamin K \u0111\u00f3ng vai tr\u00f2 l\u00e0 cofactor c\u1ea7n thi\u1ebft cho s\u1ef1 x\u00fac t\u00e1c chuy\u1ec3n c\u00e1c y\u1ebfu t\u1ed1 \u0111\u00f4ng m\u00e1u II, VII, IX, X \u1edf d\u1ea1ng ti\u1ec1n ch\u1ea5t th\u00e0nh d\u1ea1ng ho\u1ea1t \u0111\u1ed9ng \u1edf gan. Vitamin K sau khi tham gia v\u00e0o qu\u00e1 tr\u00ecnh chuy\u1ec3n \u0111\u1ed5i c\u1ee7a c\u00e1c y\u1ebfu t\u1ed1 \u0111\u00f4ng m\u00e1u th\u00ec tr\u1edf th\u00e0nh d\u1ea1ng vitamin K epoxide (kh\u00f4ng ho\u1ea1t \u0111\u1ed9ng). \u1ede ng\u01b0\u1eddi b\u00ecnh th\u01b0\u1eddng, vitamin K epoxide c\u00f3 th\u1ec3 chuy\u1ec3n v\u1ec1 d\u1ea1ng vitamin K d\u1ea1ng ho\u1ea1t \u0111\u1ed9ng. Warfarin t\u00e1c d\u1ee5ng b\u1eb1ng c\u00e1ch ng\u0103n c\u1ea3n vitamin K \u1edf d\u1ea1ng kh\u00f4ng ho\u1ea1t \u0111\u1ed9ng th\u00e0nh d\u1ea1ng ho\u1ea1t \u0111\u1ed9ng nh\u1edd \u0111\u00f3 l\u00e0m gi\u1ea3m l\u01b0\u1ee3ng c\u00e1c ch\u1ea5t ch\u1ed1ng \u0111\u00f4ng ph\u1ee5 thu\u1ed9c vitamin K. B\u1edfi c\u00e1c y\u1ebfu t\u1ed1 \u0111\u00f4ng m\u00e1u c\u00f2n l\u1ea1i c\u00f3 th\u1eddi gian b\u00e1n th\u1ea3i l\u00e0 8-60 gi\u1edd n\u00ean ph\u1ea3i sau th\u1eddi gian n\u00e0y, warfarin m\u1edbi c\u00f3 t\u00e1c d\u1ee5ng m\u1ea1nh nh\u1ea5t (kho\u1ea3ng 2- 7 ng\u00e0y). \u0110\u1ed3ng th\u1eddi c\u0169ng ph\u1ea3i m\u1ea5t m\u1ed9t th\u1eddi gian sau khi ng\u1eebng thu\u1ed1c hay ti\u00eam vitamin K th\u00ec kh\u1ea3 n\u0103ng \u0111\u00f4ng m\u00e1u m\u1edbi tr\u1edf l\u1ea1i do ph\u1ea3i m\u1ea5t th\u1eddi gian t\u1ed5ng h\u1ee3p y\u1ebfu t\u1ed1 \u0111\u00f4ng m\u00e1u m\u1edbi.<\/p>\n
$\"H\u00ecnh$ <\/a>
H\u00ecnh 1.4 V\u1ecb tr\u00ed t\u00e1c d\u1ee5ng c\u1ee7a warfarin, c\u00e1c thu\u1ed1c \u1ee9c ch\u1ebf y\u1ebfu t\u1ed1 Xa, thu\u1ed1c \u1ee9c ch\u1ebf tr\u1ef1c ti\u1ebfp thrombin tr\u00ean con \u0111\u01b0\u1eddng \u0111\u00f4ng m\u00e1u.<\/figcaption><\/figure>\n
$\"H\u00ecnh$ <\/a>
H\u00ecnh 1.5 vai tr\u00f2 c\u1ee7a vitamin K trong \u0111\u00f4ng m\u00e1u<\/figcaption><\/figure>\n
II. D\u01b0\u1ee3c \u0111\u1ed9ng h\u1ecdc<\/span><\/h3>\n
Warfarin \u0111\u01b0\u1ee3c h\u1ea5p thu r\u1ea5t nhanh v\u00e0 ho\u00e0n to\u00e0n \u1edf \u0111\u01b0\u1eddng ti\u00eau h\u00f3a tr\u00ean nh\u1edd c\u01a1 ch\u1ebf khu\u1ebfch t\u00e1n th\u1ee5 \u0111\u1ed9ng. Sinh kh\u1ea3 d\u1ee5ng g\u1ea7n 100%. 99% warfarin \u0111\u01b0\u1eddng u\u1ed1ng g\u1eafn v\u1edbi protein trong huy\u1ebft t\u01b0\u01a1ng v\u1edbi th\u1eddi gian b\u00e1n th\u1ea3i l\u00e0 37 gi\u1edd. Th\u1ec3 t\u00edch ph\u00e2n ph\u1ed1i c\u1ee7a warfarin l\u00e0 kho\u1ea3ng 12.5% tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3. L\u01b0\u1ee3ng ph\u00e2n ph\u1ed1i nh\u1ecf n\u00e0y ph\u00f9 h\u1ee3p v\u1edbi s\u1ef1 g\u1eafn k\u1ebft r\u1ed9ng r\u00e3i c\u1ee7a warfarin v\u1edbi albumin. Warfarin b\u1ecb chuy\u1ec3n h\u00f3a \u1edf gan th\u00e0nh d\u1ea1ng kh\u00f4ng ho\u1ea1t \u0111\u1ed9ng r\u1ed3i \u0111\u00e0o th\u1ea3i qua ph\u00e2n v\u00e0 n\u01b0\u1edbc ti\u1ec3u.<\/p>\n
III. V\u1ea5n \u0111\u1ec1 gi\u00e1 th\u00e0nh<\/span><\/h3>\n
Do t\u1ea7m quan tr\u1ecdng c\u1ee7a c\u00e2u h\u1ecfi: \u201ckhi n\u00e0o th\u00ec s\u1eed d\u1ee5ng warfarin hay c\u00e1c thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng th\u1ebf h\u1ec7 m\u1edbi \u1edf b\u1ec7nh nh\u00e2n rung nh\u0129 kh\u00f4ng c\u00f3 van nh\u00e2n t\u1ea1o?\u201d M\u1ed9t trong nh\u1eefng y\u1ebfu t\u1ed1 quy\u1ebft \u0111\u1ecbnh \u0111\u00f3 l\u00e0 gi\u00e1 th\u00e0nh c\u1ee7a ch\u00fang. Dabigatran (m\u1ed9t NOAC) gi\u00fap n\u00e2ng cao ch\u1ea5t l\u01b0\u1ee3ng s\u1ed1ng trung b\u00ecnh 4.7 n\u0103m so v\u1edbi 3.9 n\u0103m c\u1ee7a warfarin. Dabigatran n\u00e2ng cao ch\u1ea5t l\u01b0\u1ee3ng s\u1ed1ng th\u00eam 0.36 n\u0103m so v\u1edbi warfarin v\u1edbi gi\u00e1 9000 \u0111\u00f4 la. N\u00e2ng t\u1ed5ng chi ph\u00ed l\u00ean kho\u1ea3ng 25000 \u0111\u00f4 la.<\/p>\n
IV. Li\u1ec1u d\u00f9ng<\/span><\/h3>\n
Quy tr\u00ecnh kh\u1edfi \u0111\u1ea7u chu\u1ea9n l\u00e0 d\u00f9ng warfarin 5mg\/ng\u00e0y trong v\u00f2ng 5 ng\u00e0y \u0111\u1ea7u, check INR h\u00e0ng ng\u00e0y cho t\u1edbi khi \u0111\u1ea1t ng\u01b0\u1eddng m\u1ee5c ti\u00eau. Sau \u0111\u00f3 check l\u1ea1i m\u1ed7i 3 l\u1ea7n m\u1ed7i tu\u1ea7n. Li\u1ec1u kh\u1edfi \u0111\u1ea7u th\u1ea5p h\u01a1n n\u00ean \u0111\u01b0\u1ee3c \u00e1p d\u1ee5ng cho b\u1ec7nh nh\u00e2n gi\u00e0 v\u00e0 nh\u1eefng ng\u01b0\u1eddi c\u00f3 nguy c\u01a1 cao xu\u1ea5t huy\u1ebft (bao g\u1ed3m c\u1ea3 s\u1eed d\u1ee5ng aspirin tr\u01b0\u1edbc \u0111\u00f3). Y\u1ebfu t\u1ed1 gen kh\u00e1c bi\u1ec7t l\u00e0 l\u00fd do m\u00e0 ng\u01b0\u1eddi ch\u00e2u \u00c1 c\u1ea7n m\u1ed9t li\u1ec1u th\u1ea5p h\u01a1n v\u00e0 li\u1ec1u cao h\u01a1n \u1edf ng\u01b0\u1eddi da \u0111en. Trong v\u1ea5n \u0111\u1ec1 chuy\u1ec3n lo\u1ea1i thu\u1ed1c, Warfarin n\u00ean \u0111\u01b0\u1ee3c d\u00f9ng \u00edt nh\u1ea5t 4 ng\u00e0y tr\u01b0\u1edbc khi ng\u1eebng heparin. Do warfarin c\u1ea7n th\u1eddi gian \u0111\u1ec3 ch\u1ec9nh li\u1ec1u v\u00e0 \u0111\u1ea1t t\u00e1c d\u1ee5ng, c\u1ea7n ph\u1ea3i g\u1ed1i heparin tr\u01b0\u1edbc \u0111\u1ec3 \u0111\u1ea3m b\u1ea3o ch\u1ed1ng huy\u1ebft kh\u1ed1i. C\u00f3 th\u1ec3 ng\u1eebng heparin sau khi \u0111\u00e3 \u0111\u1ea1t m\u1ee5c ti\u00eau INR 2 ng\u00e0y. Kh\u00f4ng s\u1eed d\u1ee5ng m\u1ed9t li\u1ec1u cao ban \u0111\u1ea7u v\u00ec c\u00f3 th\u1ec3 g\u00e2y t\u0103ng INR cao qu\u00e1 m\u1ee9c. B\u1ec7nh nh\u00e2n c\u00f3 b\u1ec7nh l\u00fd gan ho\u1eb7c suy tim c\u1ea7n \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng v\u1edbi li\u1ec1u th\u1ea5p h\u01a1n. Li\u1ec1u d\u00f9ng duy tr\u00ec thay \u0111\u1ed5i t\u1eeb 1-5mg\/ng\u00e0y, th\u1eadm ch\u00ed l\u00ean \u0111\u1ebfn 20mg\/ng\u00e0y. S\u1ef1 kh\u00e1ng warfarin ch\u1ee7 y\u1ebfu l\u00e0 do y\u1ebfu t\u1ed1 di truy\u1ec1n. \u0110\u00f3 l\u00e0 l\u00fd do ph\u1ea3i ch\u1ec9nh li\u1ec1u tr\u00ean t\u1eebng c\u00e1 th\u1ec3 theo INRs.<\/p>\n
V. M\u1ee5c ti\u00eau<\/span><\/h3>\n
Hi\u1ec7u qu\u1ea3 c\u1ee7a warfarin \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 b\u1edfi PT. PT k\u00e9o d\u00e0i g\u00e2y ra b\u1edfi s\u1ef1 thi\u1ebfu h\u1ee5t y\u1ebfu t\u1ed1 II, V, VII, X, c\u0169ng nh\u01b0 n\u1ed3ng \u0111\u1ed9 th\u1ea5p fibrinogen v\u00e0 n\u1ed3ng \u0111\u1ed9 cao heparin. N\u00f3 ph\u1ea3n \u00e1nh hi\u1ec7u qu\u1ea3 c\u1ee7a con \u0111\u01b0\u1eddng \u0111\u00f4ng m\u00e1u ngo\u1ea1i sinh v\u00e0 con \u0111\u01b0\u1eddng \u0111\u00f4ng m\u00e1u chung nh\u01b0ng kh\u00f4ng \u0111\u00e1nh gi\u00e1 \u0111\u01b0\u1ee3c con \u0111\u01b0\u1eddng \u0111\u00f4ng m\u00e1u n\u1ed9i sinh. PT \u0111o l\u01b0\u1eddng b\u1eb1ng c\u00e1ch th\u00eam canxi v\u00e0 thromboplastin v\u00e0o m\u1eabu huy\u1ebft t\u01b0\u01a1ng \u0111\u00e3 lo\u1ea1i b\u1ecf ti\u1ec3u c\u1ea7u. th\u1eddi gian c\u1ee5c m\u00e1u \u0111\u00f4ng h\u00ecnh th\u00e0nh \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbn b\u1eb1ng thi\u1ebft b\u1ecb t\u1ef1 \u0111\u1ed9ng \u0111\u1ec3 \u0111\u00e1nh gi\u00e1. PT b\u00ecnh th\u01b0\u1eddng l\u00e0 kho\u1ea3ng 12 gi\u00e2y. Tuy v\u1eady thromboplastin s\u1eed d\u1ee5ng trong \u0111o l\u01b0\u1eddng PT \u0111\u01b0\u1ee3c tr\u00edch xu\u1ea5t t\u1eeb c\u00e1c ngu\u1ed3n kh\u00e1c nhau v\u00e0 d\u1eabn t\u1edbi k\u1ebft qu\u1ea3 PT kh\u00f4ng \u0111\u01b0\u1ee3c chu\u1ea9n h\u00f3a. \u0110\u1ec3 \u0111\u1ea3m b\u1ea3o t\u00ednh chu\u1ea9n h\u00f3a, ng\u01b0\u1eddi ta \u0111\u01b0a ra m\u1ed9t lo\u1ea1i thromboplastin tham chi\u1ebfu \u0111\u1ec3 l\u00e0m ti\u00eau chu\u1ea9n cho lo\u1ea1i thromboplastin \u0111ang \u0111\u01b0\u1ee3c d\u00f9ng trong ph\u00f2ng x\u00e9t nghi\u1ec7m (ng\u01b0\u1eddi ta s\u1ebd ghi r\u00f5 \u0111\u1ed9 nh\u1ea1y ISI c\u1ee7a lo\u1ea1i thromboplastin \u0111\u00f3). Gi\u00e1 tr\u1ecb ISI n\u00e0y s\u1ebd \u0111\u01b0\u1ee3c d\u00f9ng \u0111\u1ec3 chuy\u1ec3n \u0111\u1ed5i PT \u0111o \u0111\u01b0\u1ee3c th\u00e0nh ch\u1ec9 s\u1ed1 INR \u0111\u01b0\u1ee3c chu\u1ea9n h\u00f3a qu\u1ed1c t\u1ebf theo c\u00f4ng th\u1ee9c d\u01b0\u1edbi:<\/p>\n
INR = (PT b\u1ec7nh nh\u00e2n\/PT trung b\u00ecnh b\u00ecnh th\u01b0\u1eddng)ISI<\/p>\n
INR hi\u1ec7n nay \u0111\u01b0\u1ee3c xem l\u00e0 ti\u00eau chu\u1ea9n \u0111\u1ec3 theo d\u00f5i b\u1ec7nh nh\u00e2n d\u00f9ng warfarin. Trong th\u1ef1c h\u00e0nh l\u00e2m s\u00e0ng n\u00f3i chung, m\u1ee5c ti\u00eau INR th\u01b0\u1eddng l\u00e0 2-3, \u0111\u00e2y l\u00e0 ng\u01b0\u1ee1ng ph\u00f9 h\u1ee3p cho h\u1ea7u h\u1ebft c\u00e1c b\u1ec7nh l\u00fd \u0111\u00f2i h\u1ecfi d\u1ef1 ph\u00f2ng\/\u0111i\u1ec1u tr\u1ecb huy\u1ebft kh\u1ed1i. Li\u1ec7u ph\u00e1p c\u01b0\u1eddng \u0111\u1ed9 cao v\u1edbi m\u1ee5c ti\u00eau INR 2.5-3.5 c\u00f3 th\u1ec3 c\u1ea7n thi\u1ebft \u1edf b\u1ec7nh nh\u00e2n rung nh\u0129 c\u00f3 van nh\u00e2n t\u1ea1o c\u01a1 h\u1ecdc v\u00e0 m\u1ed9t s\u1ed1 t\u00ecnh tr\u1ea1ng thuy\u00ean t\u1eafc nh\u1ea5t \u0111\u1ecbnh. \u1ede ng\u01b0\u1eddi ch\u00e2u \u00c1, c\u00f3 t\u1ec9 l\u1ec7 cao h\u01a1n m\u1eafc xu\u1ea5t huy\u1ebft n\u00e3o, ng\u01b0\u1eddng INR th\u1ea5p h\u01a1n c\u00f3 th\u1ec3 c\u1ea7n thi\u1ebft.<\/p>\n
M\u1ed9t khi \u0111\u00e3 thi\u1ebft l\u1eadp vi\u1ec7c d\u00f9ng warfarin \u1ed5n \u0111\u1ecbnh. C\u1ea7n theo d\u00f5i INR m\u1ed7i 4-6 tu\u1ea7n. Quan tr\u1ecdng l\u00e0, s\u1ef1 \u0111\u00e1p \u1ee9ng v\u1edbi warfarin d\u1ec5 b\u1ecb thay \u0111\u1ed5i do ch\u1ebf \u0111\u1ed9 \u0103n u\u1ed1ng, s\u1eed d\u1ee5ng r\u01b0\u1ee3u v\u00e0 t\u01b0\u01a1ng t\u00e1c v\u1edbi c\u00e1c lo\u1ea1i thu\u1ed1c kh\u00e1c.<\/p>\n
V\u1ea5n \u0111\u1ec1 gi\u1ea3m li\u1ec1u.<\/strong> Li\u1ec1u warfarin c\u00f3 th\u1ec3 ph\u1ea3i gi\u1ea3m xu\u1ed1ng khi c\u00f3 s\u1ef1 xu\u1ea5t hi\u1ec7n suy tim sung huy\u1ebft, t\u1ed5n th\u01b0\u01a1ng gan do b\u1ea5t k\u00ec ngu\u1ed3n n\u00e0o, bao g\u1ed3m u\u1ed1ng r\u01b0\u1ee3u, r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng th\u1eadn (l\u00e0m t\u0103ng ph\u00e2n s\u1ed1 thu\u1ed1c t\u1ef1 do trong m\u00e1u), ch\u1ebf \u0111\u1ed9 \u0103n (l\u00e0m thi\u1ebfu h\u1ee5t vitamin K). Ng\u1ed9 \u0111\u1ed9c gi\u00e1p l\u00e0m t\u0103ng d\u1ecb h\u00f3a vitamin K, v\u00ec v\u1eady c\u1ea7n gi\u1ea3m li\u1ec1u warfarin, trong khi b\u1ec7nh ph\u00f9 ni\u00eam l\u1ea1i c\u00f3 t\u00e1c d\u1ee5ng ng\u01b0\u1ee3c l\u1ea1i. C\u0169ng n\u00ean gi\u1ea3m li\u1ec1u \u1edf ng\u01b0\u1eddi gi\u00e0 do c\u00f3 s\u1ef1 t\u0103ng \u0111\u00e1p \u1ee9ng v\u1edbi warfarin theo tu\u1ed5i. \u1edf ng\u01b0\u1eddi c\u00f3 ch\u1ebf \u0111\u1ed9 \u0103n gi\u00e0u vitamin K (vd \u0103n nhi\u1ec1u rau xanh nh\u01b0 s\u00fap l\u01a1 xanh) l\u00e0m gi\u1ea3m hi\u1ec7u qu\u1ea3 warfarin. M\u1ed9t s\u1ed1 ch\u1ebf \u0111\u1ed9 \u0103n kh\u00e1c c\u0169ng g\u00e2y \u1ea3nh h\u01b0\u1edfng t\u1edbi s\u1ef1 kh\u00f3 kh\u0103n trong ki\u1ec3m so\u00e1t INR.<\/p>\n
VI. T\u01b0\u01a1ng t\u00e1c thu\u1ed1c<\/span><\/h3>\n
Warfarin t\u01b0\u01a1ng t\u00e1c v\u1edbi g\u1ea7n 80 lo\u1ea1i thu\u1ed1c. N\u00f3 b\u1ecb \u1ee9c ch\u1ebf b\u1edfi barbiturates hay phenyltoin. Allopurinol, aminodarone, cephalosporins c\u00f3 ti\u1ec1m n\u0103ng g\u00e2y \u1ee9c ch\u1ebf vitamin K. Nhi\u1ec1u lo\u1ea1i kh\u00e1ng sinh nh\u01b0 metronidazol hay co-trimoxazole l\u00e0m gi\u1ea3m s\u1ef1 tho\u00e1i gi\u00e1ng warfarin \u1edf gan \u0111\u1ed3ng th\u1eddi t\u0103ng t\u00e1c d\u1ee5ng ch\u1ed1ng \u0111\u00f4ng c\u1ee7a n\u00f3.<\/p>\n
Thu\u1ed1c ch\u1ed1ng ng\u01b0ng t\u1eadp ti\u1ec3u c\u1ea7u nh\u01b0 aspirin, clopidogrel, NSAIDs c\u00f3 th\u1ec3 l\u00e0m t\u0103ng nguy c\u01a1 ch\u1ea3y m\u00e1u.<\/p>\n
Nguy\u00ean t\u1eafc l\u00e0 kh\u00f4ng \u0111\u1ec3 b\u1ec7nh nh\u00e2n s\u1eed d\u1ee5ng b\u1ea5t k\u00ec m\u1ed9t thu\u1ed1c n\u00e0o khi \u0111ang d\u00f9ng warfarin m\u00e0 kh\u00f4ng tham kh\u1ea3o \u00fd ki\u1ebfn b\u00e1c s\u0129. Khi nghi ng\u1edd c\u1ea7n ph\u1ea3i ki\u1ec3m tra INR th\u01b0\u1eddng xuy\u00ean h\u01a1n.<\/p>\n
VII. Ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh<\/span><\/h3>\n
Ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh b\u00e0o g\u1ed3m: 3 th\u00e1ng \u0111\u1ea7u thai k\u00ec, \u0111\u1ed9t qu\u1ef5 m\u1edbi, t\u0103ng huy\u1ebft \u00e1p kh\u00f4ng ki\u1ec3m so\u00e1t, x\u01a1 gan, c\u00f3 \u0111i\u1ec3m ch\u1ea3y m\u00e1u \u0111\u01b0\u1eddng ti\u00eau h\u00f3a ho\u1eb7c sinh d\u1ee5c, lo\u00e9t d\u1ea1 d\u00e0y- t\u00e1 tr\u00e0ng, vi\u00eam d\u1ea1 d\u00e0y, tr\u00e0o ng\u01b0\u1ee3c d\u1ea1 d\u00e0y th\u1ef1c qu\u1ea3n, vi\u00eam \u0111\u1ea1i-tr\u1ef1c tr\u00e0ng, vi\u00eam b\u00e0ng quang. N\u1ebfu ch\u1ed1ng \u0111\u00f4ng l\u00e0 c\u1ef1c k\u00ec c\u1ea7n thi\u1ebft, c\u1ea7n ph\u1ea3i \u0111\u00e1nh gi\u00e1 c\u1ea9n th\u1eadn l\u1ee3i \u00edch v\u00e0 nguy c\u01a1. Tu\u1ed5i gi\u00e0 kh\u00f4ng ph\u1ea3i l\u00e0 ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh m\u1eb7c d\u00f9 ng\u01b0\u1eddi gi\u00e0 d\u1ec5 ch\u1ea3y m\u00e1u.<\/p>\n
VIII. Warfarin v\u1edbi b\u1ec7nh nh\u00e2n suy th\u1eadn<\/span><\/h3>\n
Theo d\u00f5i c\u1ea9n th\u1eadn v\u00e0 ch\u1ec9nh li\u1ec1u (trong m\u1ed9t nghi\u00ean c\u1ee9u nh\u1ecf, c\u1ea7n gi\u1ea3m kho\u1ea3ng 25% khi creatinin c\u00f2n 47 mL\/min).<\/p>\n
IX. Warfarin v\u1edbi ph\u1ee5 n\u1eef mang thai<\/span><\/h3>\n
Warfarin ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh v\u1edbi 3 th\u00e1ng \u0111\u1ea7u thai k\u00ec do kh\u1ea3 n\u0103ng g\u00e2y qu\u00e1i thai v\u00e0 2 tu\u1ea7n tr\u01b0\u1edbc sinh b\u1edfi nguy c\u01a1 cao b\u0103ng huy\u1ebft. \u0111\u1ec3 thay th\u1ebf, s\u1eed d\u1ee5ng UHF (heparin kh\u00f4ng ph\u00e2n \u0111o\u1ea1n) (FDA kh\u00f4ng khuy\u1ebfn c\u00e1o LMWH-heparin tr\u1ecdng l\u01b0\u1ee3ng ph\u00e2n t\u1eed th\u1ea5p) tr\u00f2n 3 th\u00e1ng \u0111\u1ea7u thai k\u00ec, warfarin trong qu\u00fd th\u1ee9 2 cho \u0111\u1ebfn kho\u1ea3ng 38 tu\u1ea7n sau \u0111\u00f3 l\u1ea1i \u0111\u1ed5i sang heparin. Ng\u1eebng heparin 12 ti\u1ebfng tr\u01b0\u1edbc khi \u0111\u01b0a v\u00e0o ph\u00f2ng \u0111\u1ebb. T\u00e1i s\u1eed d\u1ee5ng l\u1ea1i heparin sau sinh c\u00f9ng v\u1edbi warfarin trong 4-5 ng\u00e0y. Heparin d\u00f9ng trong qu\u00fd th\u1ee9 3 c\u00f3 th\u1ec3 ph\u1ea3i t\u0103ng li\u1ec1u do t\u0103ng protein g\u1eafn v\u1edbi heparin.<\/p>\n
X. Bi\u1ebfn ch\u1ee9ng v\u00e0 nh\u1eefng l\u01b0u \u00fd<\/span><\/h3>\n
Bi\u1ebfn ch\u1ee9ng ph\u1ed5 bi\u1ebfn nh\u1ea5t l\u00e0 ch\u1ea3y m\u00e1u v\u1edbi t\u0103ng nguy c\u01a1 xu\u1ea5t huy\u1ebft n\u00e3o, \u0111\u1eb7c bi\u1ec7t l\u00e0 \u1edf ng\u01b0\u1eddi gi\u00e0. Ph\u00e1t hi\u1ec7n n\u00e0y \u0111\u00e3 \u0111\u1ea9y nhanh xu h\u01b0\u1edbng chuy\u1ec3n sang s\u1eed d\u1ee5ng c\u00e1c thu\u1ed1c \u1ee9c ch\u1ebf thrombin tr\u1ef1c ti\u1ebfp. Bi\u1ebfn ch\u1ee9ng ch\u1ea3y m\u00e1u c\u00f3 nguy c\u01a1 xu\u1ea5t hi\u1ec7n cao nh\u1ea5t trong 1-3 th\u00e1ng \u0111\u1ea7u ti\u00ean d\u00f9ng thu\u1ed1c, cao g\u1ea5p 10 l\u1ea7n th\u1eddi gian sau \u0111\u00f3. M\u1eb7c d\u00f9 hi\u1ebfm g\u1eb7p nh\u01b0ng bi\u1ebfn ch\u1ee9ng ho\u1ea1i t\u1eed da do warfarin kh\u00e1 nghi\u00eam tr\u1ecdng. Ho\u1ea1i t\u1eed da c\u00f3 th\u1ec3 xu\u1ea5t hi\u1ec7n v\u00e0o kho\u1ea3ng ng\u00e0y th\u1ee9 3-8 c\u1ee7a li\u1ec7u ph\u00e1p, nh\u1ea5t l\u00e0 khi d\u00f9ng li\u1ec1u cao sau khi l\u00e0m c\u1ea7u n\u1ed1i tim ph\u1ed5i. C\u00e1ch b\u1ea3o v\u1ec7 duy nh\u1ea5t l\u00e0 d\u00f9ng li\u1ec1u warfarin th\u1ea5p h\u01a1n k\u1ebft h\u1ee3p heparin v\u00e0 t\u0103ng li\u1ec1u tr\u1edf l\u1ea1i sau m\u1ed9t v\u00e0i tu\u1ea7n. Nguy\u00ean nh\u00e2n c\u1ee7a ho\u1ea1i t\u1eed da do warfarin l\u00e0 ch\u01b0a r\u00f5 r\u00e0ng. \u1ede nh\u1eefng b\u1ec7nh nh\u00e2n d\u00f9ng thu\u1ed1c k\u00e9o d\u00e0i c\u00f3 th\u1ec3 c\u00f3 bi\u1ebfn ch\u1ee9ng g\u00e3y x\u01b0\u01a1ng do lo\u00e3ng x\u01b0\u01a1ng, r\u00f5 r\u00e0ng h\u01a1n \u1edf nam gi\u1edbi.<\/p>\n
XI. Qu\u00e1 li\u1ec1u Warfarin<\/span><\/h3>\n
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N\u1ebfu cao nh\u01b0ng INR < 9 m\u00e0 kh\u00f4ng c\u00f3 ch\u1ea3y m\u00e1u c\u00f3 th\u1ec3 qu\u1ea3n l\u00fd b\u1eb1ng c\u00e1ch b\u1ecf qua m\u1ed9t li\u1ec1u v\u00e0 b\u1eaft \u0111\u1ea7u d\u00f9ng l\u1ea1i v\u1edbi li\u1ec1u th\u1ea5p.<\/li>\n
N\u1ebfu INR > 9 ho\u1eb7c <9 nh\u01b0ng c\u00f3 ch\u1ea3y m\u00e1u, d\u00f9ng 3-5g \u0111\u01b0\u1eddng u\u1ed1ng vitamin K c\u00f3 th\u1ec3 l\u00e0m gi\u1ea3m INR trong 24-48 gi\u1edd. S\u1eed d\u1ee5ng \u0111\u01b0\u1eddng ti\u00eam d\u01b0\u1edbi da cho hi\u1ec7u qu\u1ea3 kh\u00f3 d\u1ef1 \u0111o\u00e1n n\u00ean tr\u00e1nh d\u00f9ng. Thay v\u00e0o \u0111\u00f3 s\u1eed d\u1ee5ng \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch (5-10mg trong 30 ph\u00fat) cho tr\u01b0\u1eddng h\u1ee3p c\u1ea5p c\u1ee9u. \u1edf b\u1ec7nh nh\u00e2n c\u00f3 van nh\u00e2n t\u1ea1o, Vitamin K n\u00ean tr\u00e1nh d\u00f9ng do nguy c\u01a1 huy\u1ebft kh\u1ed1i van tim, cho d\u00f9 \u0111\u00f3 l\u00e0 xu\u1ea5t huy\u1ebft n\u00e3o nguy hi\u1ec3m t\u00ednh m\u1ea1ng. So s\u00e1nh gi\u1eefa huy\u1ebft t\u01b0\u01a1ng t\u01b0\u01a1i \u0111\u00f4ng l\u1ea1nh (FFP) v\u00e0 vitamin K \u1edf b\u1ec7nh nh\u00e2n van tim c\u01a1 h\u1ecdc c\u00f3 qu\u00e1 li\u1ec1u nh\u1eb9 \u0111\u1ebfn v\u1eeba cho th\u1ea5y FFP \u0111\u00e1p \u1ee9ng nhanh h\u01a1n (ch\u1ec9 trong 6 gi\u1edd). \u1ede b\u1ec7nh nh\u00e2n kh\u00f4ng \u0111\u00e1p \u1ee9ng v\u1edbi vitamin K ho\u1eb7c ch\u1ea3y m\u00e1u nguy hi\u1ec3m t\u00ednh m\u1ea1ng, c\u00f3 th\u1ec3 s\u1eed d\u1ee5ng (1) kh\u1ed1i y\u1ebfu t\u1ed1 \u0111\u00f4ng m\u00e1u nh\u00f3m prothombin g\u1ed3m y\u1ebfu t\u1ed1 II, IX, X ho\u1eb7c (2) FFP (15mL\/kg).<\/li>\n<\/ul>\n
\u0110\u1ea3o ng\u01b0\u1ee3c t\u00ecnh tr\u1ea1ng t\u0103ng INR ho\u1eb7c ch\u1ea3y m\u00e1u \u1edf b\u1ec7nh nh\u00e2n d\u00f9ng wafarin<\/p>\n\n\n\n\n\n\n\n
\u0110i\u1ec1u ki\u1ec7n<\/td>\n Can thi\u1ec7p<\/td>\n<\/tr>\n
M\u1ee5c ti\u00eau INR 5 Ch\u1ea3y m\u00e1u kh\u00f4ng \u0111\u00e1ng k\u1ebf ho\u1eb7c kh\u00f4ng c\u00f3 nguy c\u01a1 ch\u1ea3y m\u00e1u<\/td>\n Li\u1ec1u th\u1ea5p h\u01a1n ho\u1eb7c b\u1ecf qua li\u1ec1u ti\u1ebfp theo<\/td>\n<\/tr>\n
INR \u2265 5 ho\u1eb7c <9 V\u00c0 Ch\u1ea3y m\u00e1u kh\u00f4ng \u0111\u00e1ng k\u1ec3 ho\u1eb7c kh\u00f4ng c\u00f3 nguy c\u01a1 ch\u1ea3y m\u00e1u<\/td>\n \n
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\u01afu ti\u00ean: b\u1ecf qua 1-2 ti\u1ec3u k\u1ec3 ti\u1ebfp<\/li>\n
Ho\u1eb7c, b\u1ecf qua 1-2 li\u1ec5u v\u00e0 d\u00f9ng vitamin K (1-2,5 mg \u0111\u01b0\u1eddng u\u1ed1ng).<\/li>\n
\u0110\u1ed1i v\u1edbi nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 nguy c\u01a1 huy\u1ebft kh\u1ed1i cao (v\u00ed d\u1ee5 d\u00f9ng van nh\u00e2n t\u1ea1o), b\u1ecf qua 1-2 li\u1ec1u k\u1ebf ti\u1ebfp v\u00e0 s\u1eed d\u1ee5ng 2 \u0111\u01a1n v\u1ecb huy\u1ebft t\u01b0\u01a1ng t\u01b0\u01a1i \u0111\u00f4ng l\u1ea1nh \u2013 KH\u00d4NG D\u00d9NG<\/strong> Vitamin K<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
INR \u2265 9 Ch\u1ea3y m\u00e1u kh\u00f4ng \u0111\u00e1ng k\u00ea V\u00c0\/HO\u1eb6C Nguy c\u01a1 ch\u1ea3y m\u00e1u th\u1ea5p-trung b\u00ecnh<\/td>\n \n
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Ng\u1eebng li\u1ec7u ph\u00e1p warfarin<\/li>\n
D\u00f9ng 2 \u0111\u01a1n v\u1ecb huy\u1ebft t\u01b0\u01a1ng t\u01b0\u01a1i \u0111\u00f4ng l\u1ea1nh \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch<\/li>\n
Vitamin K (2,5-5mg \u0111\u01b0\u1eddng u\u1ed1ng)<\/li>\n
\u1ede nh\u1eefng b\u1ec7nh nh\u00e2n d\u00f9ng van tim nh\u00e2n t\u1ea1o, truy\u1ec1n 2 \u0111\u01a1n v\u1ecb HTT\u0110L v\u00e0 vitamin K li\u1ec1u th\u1ea5p h\u01a1n (1-2,5 mg \u0111\u01b0\u1eddng u\u1ed1ng)<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
Ch\u1ea3y m\u00e1u nghi\u00eam tr\u1ecdng v\u1edbi INR b\u1ea5t k\u1ef3 V\u00c0\/HO\u1eb6C Nguy c\u01a1 ch\u1ea3y m\u00e1u cao<\/td>\n \n
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HASHTI<\/li>\n
4 \u0111\u01a1n v\u1ecb HTT\u0110L \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch<\/li>\n
Truy\u1ec1n t\u0129nh m\u1ea1ch ch\u1eadm 10mg vitamin K<\/li>\n
C\u00f3 th\u1ec3 l\u1eb7p l\u1ea1i HTT\u0110L v\u00e0 vitamin K n\u1ebfu c\u1ea7n<\/li>\n
N\u1ebfu b\u1ec7nh nh\u00e2n d\u00f9ng van tim nh\u00e2n t\u1ea1o. HTT\u0110L \u0111\u01b0\u1ee3c \u01b0u ti\u00ean h\u01a1n vitamin K ch\u1ec9 s\u1eed d\u1ee5ng vitamin K li\u1ec5u r\u1ea5t th\u1ea5p( 1mg \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch ch\u1eadm)<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n
B\u1ea3ng 1.3. X\u1eed l\u00ed t\u00ecnh tr\u1ea1ng t\u0103ng INR khi d\u00f9ng warfarin<\/span><\/p>\n
XII. Ch\u1ec9 \u0111\u1ecbnh warfarin<\/span><\/h3>\n
1. Huy\u1ebft kh\u1ed1i t\u0129nh m\u1ea1ch (DVT)<\/span><\/h4>\n
V\u1edbi b\u1ec7nh nh\u00e2n DVT, c\u1ea7n s\u1eed d\u1ee5ng s\u1edbm warfarin k\u1ebft h\u1ee3p v\u1edbi heparin t\u0129nh m\u1ea1ch ho\u1eb7c LMWH. Sau \u0111\u00f3, ti\u1ebfp t\u1ee5c d\u00f9ng ch\u1ed1ng \u0111\u00f4ng \u0111\u01a1n \u0111\u1ed9c trong \u00edt nh\u1ea5t 3 th\u00e1ng ti\u1ebfp theo. Ng\u01b0\u1ee1ng INR 2-3 \u0111\u01b0\u1ee3c xem l\u00e0 an to\u00e0n h\u01a1n ng\u01b0\u1ee1ng cao h\u01a1n. Vi\u1ec7c duy tr\u00ec INR 1.5-2 d\u00e0i h\u1ea1n cho th\u1ea5y l\u00e0m gi\u1ea3m c\u00e1c bi\u1ebfn c\u1ed1 t\u00e1i ph\u00e1t. Vi\u1ec7c k\u00e9o d\u00e0i \u0111i\u1ec1u tr\u1ecb n\u00ean \u0111\u01b0\u1ee3c xem x\u00e9t \u1edf b\u1ec7nh nh\u00e2n c\u00f3 t\u00ecnh tr\u1ea1ng huy\u1ebft kh\u1ed1i t\u0129nh m\u1ea1ch t\u00e1i ph\u00e1t ho\u1eb7c c\u00f3 y\u1ebfu t\u1ed1 nguy c\u01a1 nh\u01b0 thi\u1ebfu antiprothombin- III, protein C, protein S, t\u0103ng dai d\u1eb3ng T\u1ef1 kh\u00e1ng th\u1ec3 antiphospholipid ho\u1eb7c b\u1ec7nh \u00e1c t\u00ednh. V\u1edbi thuy\u00ean t\u1eafc ph\u1ed5i, LMWH ho\u1eb7c UFH \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o, theo sau l\u00e0 warfarin \u0111\u01b0\u1ee3c u\u1ed1ng k\u00e9o d\u00e0i kho\u1ea3ng 6 th\u00e1ng n\u1ebfu kh\u00f4ng t\u00e1i ph\u00e1t. N\u1ebfu c\u00f3 t\u00e1i ph\u00e1t, c\u1ea7n xem x\u00e9t \u0111i\u1ec1u tr\u1ecb k\u00e9o d\u00e0i v\u00f4 th\u1eddi h\u1ea1n.<\/p>\n
2. Rung nh\u0129<\/span><\/h4>\n
Rung nh\u0129 v\u00e0 thuy\u00ean t\u1eafc do huy\u1ebft kh\u1ed1i c\u00f3 t\u1ef7 l\u1ec7 song h\u00e0nh cao v\u00e0 nguy c\u01a1 c\u00f2n cao h\u01a1n n\u1eefa tr\u00ean n\u1ec1n b\u1ec7nh nh\u00e2n suy tim sung huy\u1ebft, r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng th\u1ea5t tr\u00e1i (LV), t\u0103ng huy\u1ebft \u00e1p, tu\u1ed5i gi\u00e0, ti\u1ec3u \u0111\u01b0\u1eddng, TIA, c\u00f3 ti\u1ec1n s\u1eed thuy\u00ean t\u1eafc huy\u1ebft kh\u1ed1i tr\u01b0\u1edbc \u0111\u00f3, MI tr\u01b0\u1edbc \u0111\u00f3, b\u1ec7nh \u0111\u1ed9ng m\u1ea1ch ngo\u1ea1i bi\u00ean, x\u01a1 v\u1eefa \u0111\u1ed9ng m\u1ea1ch, v\u00e0 ti\u1ec1n s\u1eed \u0111\u1ed9t qu\u1ef5. Vi\u1ec7c \u0111i\u1ec1u tr\u1ecb c\u1ea7n ph\u1ea3i d\u1ef1a v\u00e0o thang \u0111i\u1ec3m CHA2DS-VASc. L\u1ee3i \u00edch c\u1ee7a warfarin l\u00e0 v\u01b0\u1ee3t xa so v\u1edbi nguy c\u01a1 ch\u1ea3y m\u00e1u. Nh\u1eefng ch\u1ec9 \u0111\u1ecbnh duy nh\u1ea5t kh\u00f4ng c\u1ea7n t\u1edbi warfarin l\u00e0: (1) b\u1ec7nh nh\u00e2n rung nh\u0129 tr\u1ebb tu\u1ed5i (<65 tu\u1ed5i) kh\u00f4ng c\u00f3 y\u1ebfu t\u1ed1 nguy c\u01a1; (2) b\u1ec7nh ch\u1ea3y m\u00e1u di truy\u1ec1n; v\u00e0 (3) b\u1ec7nh nh\u00e2n gi\u00e0 v\u1edbi nguy c\u01a1 ch\u1ea3y m\u00e1u cao, l\u00fac n\u00e0y c\u1ea7n ph\u1ea3i \u0111\u00e1nh gi\u00e1 qua thang \u0111i\u1ec3m nguy c\u01a1 ch\u1ea3y m\u00e1u HAS-BLED ho\u1eb7c ATRIA. Vi\u1ec7c kh\u1eed rung l\u00e0m t\u0103ng nguy c\u01a1 thuy\u00ean t\u1eafc khi th\u1ef1c hi\u1ec7n \u1edf b\u1ec7nh nh\u00e2n rung nh\u0129 sau 48 gi\u1edd kh\u1edfi ph\u00e1t, v\u00ec th\u1ebf c\u1ea7n s\u1eed d\u1ee5ng ch\u1ed1ng \u0111\u00f4ng 3 tu\u1ea7n tr\u01b0\u1edbc khi th\u1ef1c hi\u1ec7n kh\u1eed rung (khuy\u1ebfn c\u00e1o m\u1ea1nh). Si\u00eau \u00e2m qua th\u1ef1c qu\u1ea3n c\u00f3 th\u1ec3 d\u00f9ng \u0111\u1ec3 t\u00ecm v\u00e0 ph\u00e1t hi\u1ec7n huy\u1ebft kh\u1ed1i \u1edf nh\u0129, n\u1ebfu kh\u00f4ng c\u00f3 huy\u1ebft kh\u1ed1i th\u00ec \u0111\u01b0\u1ee3c ph\u00e9p kh\u1eed rung v\u00e0 kh\u00f4ng ch\u1eafc ch\u1eafn th\u1eddi \u0111i\u1ec3m kh\u1edfi ph\u00e1t. \u1ede h\u1ea7u h\u1ebft b\u1ec7nh nh\u00e2n, vi\u1ec7c s\u1eed d\u1ee5ng ch\u1ed1ng \u0111\u00f4ng khi tr\u1edf v\u1ec1 nh\u1ecbp xoang n\u00ean \u0111\u01b0\u1ee3c duy tr\u00ec k\u00e9o d\u00e0i. Nh\u1eefng b\u1ec7nh nh\u00e2n rung nh\u0129 k\u1ecbch ph\u00e1t s\u1ebd c\u00f3 nguy c\u01a1 cao \u0111\u1ed9t qu\u1ef5 t\u01b0\u01a1ng t\u1ef1 nh\u01b0 b\u1ec7nh nh\u00e2n AF dai d\u1eb3ng.<\/p>\n
Rung nh\u0129 k\u1ecbch ph\u00e1t<\/strong><\/p>\n
L\u1ef1a ch\u1ecdn \u0111i\u1ec1u tr\u1ecb c\u00f3 th\u1ec3 l\u00e0 kh\u00f4ng can thi\u1ec7p \u1edf b\u1ec7nh nh\u00e2n rung nh\u0129 \u0111\u01a1n \u0111\u1ed9c cho t\u1edbi warfarin \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n gi\u00e0 v\u1edbi nguy c\u01a1 \u0111\u1ed9t qu\u1ef5 cao. Trong t\u01b0\u01a1ng lai, c\u00e1c lo\u1ea1i thu\u1ed1c antithrombin m\u1edbi s\u1ebd \u0111\u01b0\u1ee3c \u01b0a d\u00f9ng h\u01a1n do l\u00e0m gi\u1ea3m nguy c\u01a1 \u0111\u1ed9t qu\u1ef5.<\/p>\n
Rung nh\u0129 c\u00f3 b\u1eb1ng ch\u1ee9ng c\u1ee7a nh\u1ed3i m\u00e1u n\u00e3o c\u1ea5p<\/strong><\/p>\n
M\u1eb7c d\u00f9 ch\u1ed1ng \u0111\u00f4ng l\u00e0 b\u1eaft bu\u1ed9c cho tr\u01b0\u1eddng h\u1ee3p n\u00e0y, c\u1ea7n ph\u1ea3i lo\u1ea1i tr\u1eeb xu\u1ea5t huy\u1ebft n\u00e3o tr\u00ean phim CT ho\u1eb7c MRI. \u1ede nh\u1eefng case nh\u1ed3i m\u00e1u n\u00e3o r\u1ed9ng, warfarin n\u00ean \u0111\u01b0\u1ee3c tr\u00ec ho\u00e3n kho\u1ea3ng 1 tu\u1ea7n \u0111\u1ec3 cho ph\u00e9p s\u1ef1 ti\u1ebfn tri\u1ec3n \u0111\u1ea7y \u0111\u1ee7 di\u1ec5n ra.<\/p>\n
Rung nh\u0129: \u0111\u1ec1 xu\u1ea5t<\/p>\n
C\u00f3 nh\u1eefng b\u1eb1ng ch\u1ee9ng m\u1ea1nh cho vi\u1ec7c s\u1eed d\u1ee5ng ch\u1ed1ng \u0111\u00f4ng v\u1edbi m\u1ee5c ti\u00eau INR 2-3 \u1edf b\u1ec7nh nh\u00e2n \u201cnguy c\u01a1 cao\u201d, nh\u1eefng b\u1ec7nh nh\u00e2n m\u00e0 warfarin s\u1ebd cho l\u1ee3i \u00edch cao h\u01a1n aspirin (CHADS2 > 1). Vi\u1ec7c kh\u00f4ng d\u00f9ng aspirin v\u00e0 ch\u1ed1ng \u0111\u00f4ng ch\u1ec9 n\u00ean xem x\u00e9t \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 nguy c\u01a1 th\u1ea5p (0 hay 1 \u0111i\u1ec3m).<\/p>\n
Rung nh\u0129 \u1edf b\u1ec7nh nh\u00e2n gi\u00e0<\/strong><\/p>\n
S\u1ef1 k\u1ebft h\u1ee3p th\u01b0\u1eddng g\u1eb7p v\u00e0 \u0111\u00f2i h\u1ecfi ph\u1ea3i \u0111\u00e1nh gi\u00e1 c\u1ea9n th\u1eadn c\u00e2n b\u1eb1ng gi\u1eefa l\u1ee3i \u00edch <\/span>v\u00e0 nguy c\u01a1.<\/span><\/p>\n
Table 2<\/em> Scoring systems for assessing the risk of stroke (CHA_{2<\/sub>DS_{2<\/sub>-VASc) and bleeding (HAS-BLED) In patients with atrial fibrillation^{5<\/sup><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\nCHA_{2<\/sub>DS_{2<\/sub>-VASc<\/td>\n}} Score<\/td>\n HAS-BLED<\/td>\n Score<\/td>\n<\/tr>\n
Congestive heart failure<\/td>\n 1<\/td>\n Hypertension (systolic blood pressure >160 mm Hg)<\/td>\n 1<\/td>\n<\/tr>\n
Hypertension<\/td>\n 1<\/td>\n Abnormal renal and liver function (1 point each)<\/td>\n 1 or 2<\/td>\n<\/tr>\n
Age \u226575 years old<\/td>\n 2<\/td>\n Stroke<\/td>\n 1<\/td>\n<\/tr>\n
Diabetes mellitus<\/td>\n 1<\/td>\n Bleeding tendency\/predisposition<\/td>\n 1<\/td>\n<\/tr>\n
Stroke\/transient ischaemic attack\/thromboembolism<\/td>\n 2<\/td>\n Labile INRs (if on warfarin)<\/td>\n 1<\/td>\n<\/tr>\n
Vascular disease (prior myocardial infarction, peripheral artery<\/td>\n 1<\/td>\n Elderly (e.g. age >65 years old) disease, or aortic plaque)<\/td>\n 1<\/td>\n<\/tr>\n
Age 65-74 years old<\/td>\n 1<\/td>\n Drugs or alcohol (1 point each)<\/td>\n 1 or 2<\/td>\n<\/tr>\n
Sex category (i.e. female sex)<\/td>\n 1<\/td>\n <\/td>\n <\/td>\n<\/tr>\n
Maximum score<\/td>\n 9<\/td>\n Maximum score<\/td>\n 9<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\nB\u1ea3ng 1.3 thang \u0111i\u1ec3m CHA_{2<\/sub>DS-VASc v\u00e0 HAS-BLED<\/p>\n}
3. H\u1eb9p 2 l\u00e1 ho\u1eb7c tr\u00e0o ng\u01b0\u1ee3c van 2 l\u00e1<\/span><\/h4>\n\u1ede b\u1ec7nh nh\u00e2n c\u00f3 b\u1ec7nh l\u00fd van 2 l\u00e1, nguy c\u01a1 thuy\u00ean t\u1eafc huy\u1ebft kh\u1ed1i cao nh\u1ea5t khi c\u00f3 rung nh\u0129, \u0111\u1eb7c bi\u1ec7t kh\u00ed c\u00f3 nh\u0129 tr\u00e1i gi\u00e3n, ho\u1eb7c c\u00f3 ti\u1ec1n s\u1eed thuy\u00ean t\u1eafc tr\u01b0\u1edbc \u0111\u00f3. Ch\u1ed1ng \u0111\u00f4ng l\u00e0 m\u1ed9t ch\u1ec9 \u0111\u1ecbnh r\u1ea5t quan tr\u1ecdng \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u00e0y v\u1edbi b\u1ea5t k\u00ec t\u00ecnh tr\u1ea1ng n\u00e0o trong s\u1ed1 kia. Ng\u01b0\u1ee3c l\u1ea1i, ch\u1ed1ng \u0111\u00f4ng kh\u00f4ng ch\u1ec9 \u0111\u1ecbnh cho b\u1ec7nh nh\u00e2n h\u1eb9p van 2 l\u00e1 v\u1edbi nh\u1ecbp xoang. B\u00edt ti\u1ec3u nh\u0129 tr\u00e1i qua da c\u00f9ng thi\u1ebft b\u1ecb watchman l\u00e0 ph\u01b0\u01a1ng ph\u00e1p ti\u1ebfp c\u1eadn m\u1edbi. So v\u1edbi nh\u1eefng tr\u01b0\u1eddng h\u1ee3p th\u1ef1c hi\u1ec7n b\u00edt ti\u1ec3u nh\u0129 v\u00e0 tr\u01b0\u1eddng h\u1ee3p d\u00f9ng warfarin v\u1edbi CHADS2 1 \u0111i\u1ec3m ho\u1eb7c h\u01a1n, vi\u1ec7c th\u1ef1c hi\u1ec7n th\u1eed thu\u1eadt mang l\u1ea1i hi\u1ec7u qu\u1ea3 kh\u00f4ng k\u00e9m so v\u1edbi warfarin trong ph\u00f2ng ng\u1eeba \u0111\u1ed9t qu\u1ef5, thuy\u00ean t\u1eafc h\u1ec7 th\u1ed1ng v\u00e0 t\u1eed vong do tim m\u1ea1ch. Tuy v\u1eady n\u00f3 l\u1ea1i c\u00f3 nguy c\u01a1 bi\u1ebfn ch\u1ee9ng cao h\u01a1n \u0111\u00e1ng k\u1ec3, ch\u1ee7 y\u1ebfu l\u00e0 tr\u00e0n d\u1ecbch m\u00e0ng ngo\u00e0i tim v\u00e0 thuy\u00ean t\u1eafc kh\u00ed g\u00e2y \u0111\u1ed9t qu\u1ef5. Nh\u1eefng bi\u1ebfn ch\u1ee9ng c\u00f3 th\u1ec3 gi\u1ea3m b\u1edbi b\u1eb1ng c\u00e1ch th\u1ef1c hi\u1ec7n th\u1ee7 thu\u1eadt chu\u1ea9n ch\u1ec9 v\u00e0 kinh nghi\u1ec7m.<\/p>\n
4. B\u1ec7nh c\u01a1 tim gi\u00e3n<\/span><\/h4>\nB\u1ec7nh l\u00fd n\u00e0y c\u00f3 m\u1ed9t nguy c\u01a1 \u0111\u00e1ng k\u1ec3 g\u00e2y thuy\u00ean t\u1eafc h\u1ec7 th\u1ed1ng, \u0111\u1eb7c bi\u1ec7t n\u1ebfu c\u00f3 AF. M\u1eb7c d\u00f9 ch\u1ed1ng \u0111\u00f4ng c\u00f3 mang l\u1ea1i nh\u1eefng hi\u1ec7u qu\u1ea3 nh\u01b0ng v\u1ea5n \u0111\u1ec1 c\u00e2n b\u1eb1ng l\u1ee3i \u00edch-nguy c\u01a1 v\u1eabn c\u00f2n \u0111\u01b0\u1ee3c ti\u1ebfp t\u1ee5c th\u1eed nghi\u1ec7m th\u00eam. \u1ede b\u1ec7nh nh\u00e2n suy tim, aspirin c\u00f3 hi\u1ec7u qu\u1ea3 t\u01b0\u01a1ng \u0111\u01b0\u01a1ng warfarin. V\u00ec th\u1ebf ch\u00fang t\u00f4i kh\u00f4ng khuy\u1ebfn c\u00e1o d\u00f9ng ch\u1ed1ng \u0111\u00f4ng \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n kh\u00f4ng c\u00f3 nguy c\u01a1 huy\u1ebft kh\u1ed1i n\u00e0o th\u00eam ho\u1eb7c b\u1eb1ng ch\u1ee9ng c\u1ee7a huy\u1ebft kh\u1ed1i.<\/p>\n
5. H\u1ed9i ch\u1ee9ng nh\u1ecbp nhanh-nh\u1ecbp ch\u1eadm<\/span><\/h4>\nH\u1ed9i ch\u1ee9ng nh\u1ecbp nhanh nh\u1ecbp ch\u1eadm c\u00f3 th\u1ec3 l\u00e0 h\u1eadu qu\u1ea3 c\u1ee7a rung nh\u0129 v\u00e0 huy\u1ebft kh\u1ed1i. Ch\u1ed1ng \u0111\u00f4ng n\u00ean \u0111\u01b0\u1ee3c xem x\u00e9t, \u0111\u1eb7c bi\u1ec7t l\u00e0 n\u1ebfu c\u00f3 b\u1ec7nh tim th\u1ef1c th\u1ec3, ch\u1eb3ng h\u1ea1n nh\u01b0 b\u1ec7nh thi\u1ebfu m\u00e1u c\u01a1 tim c\u1ee5c b\u1ed9, t\u0103ng huy\u1ebft \u00e1p, b\u1ec7nh c\u01a1 tim.<\/p>\n
6. Khuy\u1ebft t\u1eadt v\u00e1ch li\u00ean nh\u0129<\/span><\/h4>\n\u1ede nh\u1eefng b\u1ec7nh nh\u00e2n gi\u00e0 v\u1edbi khuy\u1ebft t\u1eadt v\u00e1ch li\u00ean nh\u0129 v\u00e0 t\u0103ng \u00e1p ph\u1ed5i, ch\u1ed1ng \u0111\u00f4ng l\u00e0 m\u1ed9t khuy\u1ebfn c\u00e1o m\u1ea1nh nh\u01b0 m\u1ed9t ph\u01b0\u01a1ng ph\u00e1p d\u1ef1 ph\u00f2ng huy\u1ebft kh\u1ed1i \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i ho\u1eb7c, hi\u1ebfm h\u01a1n l\u00e0 t\u1eafc m\u1ea1ch ngh\u1ecbch th\u01b0\u1eddng.<\/p>\n
7. Warfarin v\u00e0 van tim nh\u00e2n t\u1ea1o<\/span><\/h4>\nWarfarin \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o \u1edf b\u1ec7nh nh\u00e2n d\u00f9ng van nh\u00e2n t\u1ea1o c\u01a1 h\u1ecdc, v\u1edbi m\u1ee5c ti\u00eau INR th\u01b0\u1eddng l\u00e0 2.5-3.5. tuy nhi\u00ean c\u00e1c ph\u00e2n t\u00edch \u0111\u00e3 \u0111\u1ec1 xu\u1ea5t ng\u01b0\u1ee1ng INR cao h\u01a1n (3-4.5) v\u1edbi van \u0111\u1ed9ng m\u1ea1ch ch\u1ee7 c\u01a1 h\u1ecdc \u1edf ng\u01b0\u1ee1ng d\u01b0\u1edbi v\u00e0 van 2 l\u00e1 \u1edf ng\u01b0\u1ee1ng cao h\u01a1n c\u1ee7a m\u1ee5c ti\u00eau INR. \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n van sinh h\u1ecdc, nguy c\u01a1 huy\u1ebft kh\u1ed1i cao nh\u1ea5t sau 6-12 tu\u1ea7n, \u0111\u00e2y l\u00e0 th\u1eddi \u0111i\u1ec3m b\u1eaft bu\u1ed9c d\u00f9ng warfarin. Sau \u0111\u00f3, aspirin c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng v\u00e0 ng\u1eebng li\u1ec7u ph\u00e1p ch\u1ed1ng \u0111\u00f4ng n\u1ebfu kh\u00f4ng c\u00f3 ch\u1ec9 \u0111\u1ecbnh kh\u00e1c. C\u00f3 b\u1eb1ng ch\u1ee9ng m\u1ea1nh \u1ee7ng h\u1ed9 vi\u1ec7c ti\u1ebfp t\u1ee5c d\u00f9ng warfarin khi van 2 l\u00e1 sinh h\u1ecdc c\u00f3 k\u00e8m theo rung nh\u0129, nh\u0129 tr\u00e1i l\u1edbn, ho\u1eb7c suy th\u1ea5t tr\u00e1i. \u1ede nh\u1eefng b\u1ec7nh nh\u00e2n v\u1edbi van \u0111\u1ed9ng m\u1ea1ch ch\u1ee7 sinh h\u1ecdc th\u00ec nguy c\u01a1 l\u00e0 th\u1ea5p h\u01a1n v\u00e0 aspirn d\u00f9ng trong 6-12 tu\u1ea7n l\u00e0 ph\u00f9 h\u1ee3p.<\/p>\n
8. Warfarin v\u00e0 b\u1ec7nh th\u1eadn m\u1ea1n (CKD) m\u1ee9c \u0111\u1ed9 trung b\u00ecnh: li\u00ean quan \u0111\u1ebfn b\u1ec7nh \u1ed1ng <\/span>th\u1eadn<\/span><\/h4>\nCKD li\u00ean quan \u0111\u1ebfn vi\u1ec7c duy tr\u00ec warfafin v\u1edbi li\u1ec1u th\u1ea5p h\u01a1n v\u00e0 gi\u1ea3m s\u1ef1 \u1ed5n \u0111\u1ecbnh c\u1ee7a thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng, \u0111\u00f2i h\u1ecfi ph\u1ea3i \u0111\u01b0\u1ee3c qu\u1ea3n l\u00fd ch\u1eb7t ch\u1ebd h\u01a1n. \u1ede nh\u1eefng b\u1ec7nh nh\u00e2n CKD giai \u0111o\u1ea1n 3 k\u00e8m rung nh\u0129 l\u00e0m t\u0103ng g\u1ea5p \u0111\u00f4i c\u00e1c bi\u1ebfn c\u1ed1 b\u1ea5t l\u1ee3i, bao g\u1ed3m c\u1ea3 t\u0103ng ch\u1ea3y m\u00e1u. Vi\u1ec7c ch\u1ec9nh li\u1ec1u warfarin so v\u1edbi aspirin v\u00e0 li\u1ec1u warfarin r\u1ea5t th\u1ea5p l\u00e0m gi\u1ea3m \u0111\u1ed9t qu\u1ef5 v\u00e0 thuy\u00ean t\u1eafc h\u1ec7 th\u1ed1ng t\u1edbi 76%, kh\u00f4ng l\u00e0m t\u0103ng nguy c\u01a1 ch\u1ea3y m\u00e1u. Tuy nhi\u00ean, l\u01b0u \u00fd r\u1eb1ng CKD giai \u0111o\u1ea1n 3 th\u00ec dabigatran ho\u1eb7c rivaroxaban c\u0169ng c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng. Apixaban c\u00f3 v\u1ebb an to\u00e0n h\u01a1n m\u1eb7c d\u00f9ng kh\u00f4ng c\u00f3 nghi\u00ean c\u1ee9u so s\u00e1nh r\u00f5 r\u00e0ng.<\/p>\n
B\u1ec7nh \u1ed1ng th\u1eadn li\u00ean quan t\u1edbi warfarin:<\/em> l\u00e0 m\u1ed9t m\u00f4 t\u1ea3 m\u1edbi \u1edf nh\u1eefng tr\u01b0\u1eddng hipwj t\u0103ng INR tr\u00ean 3 nhanh sau li\u1ec1u warfarin b\u1eaft \u0111\u1ea7u. \u0110i\u1ec1u n\u00e0y, n\u1ebfu \u0111\u01b0\u1ee3c x\u00e1c nh\u1eadn, \u0111\u1eb7c bi\u1ec7t tr\u00ean b\u1ec7nh nh\u00e2n CKD- nh\u1eefng b\u1ec7nh nh\u00e2n m\u00e0 th\u01b0\u1eddng c\u00f3 s\u1ef1 t\u0103ng creatinin m\u00e1u kh\u00f4ng r\u00f5 l\u00fd do v\u00e0 t\u0103ng t\u1ed1c \u0111\u1ed9 ti\u1ebfn tri\u1ec3n CKD. INR n\u00ean \u0111\u01b0\u1ee3c gi\u1eef d\u01b0\u1edbi 3 \u1edf t\u1ea5t c\u1ea3 b\u1ec7nh nh\u00e2n CKD sau khi d\u00f9ng warfarin.<\/p>\n
Thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng pha c\u1ea5p: Heparin<\/span><\/h2>\nHeparin \u0111\u01b0\u1ee3c xem l\u00e0 x\u01b0\u01a1ng s\u1ed1ng c\u1ee7a li\u1ec7u ph\u00e1p ch\u1ed1ng \u0111\u00f4ng, l\u00e0 m\u1ed9t mucopolysaccharide kh\u00f4ng \u0111\u1ed3ng nh\u1ea5t v\u1edbi c\u01a1 ch\u1ebf t\u00e1c d\u1ee5ng r\u1ea5t ph\u1ee9c t\u1ea1p l\u00ean qu\u00e1 tr\u00ecnh \u0111\u00f4ng m\u00e1u v\u00e0 m\u1ea1ch m\u00e1u. Trong c\u01a1 th\u1ec3, heparin c\u00f3 ngu\u1ed3n g\u1ed1c t\u1eeb t\u1ebf b\u00e0o mast (gan, ph\u1ed5i, th\u1eadn,tim). Heparin c\u00f3 t\u00ednh acid cao n\u00ean khi ng\u1ed9 \u0111\u1ed9c c\u00f3 th\u1ec3 s\u1eed d\u1ee5ng c\u00e1c ch\u1ea5t ki\u1ec1m mang \u0111i\u1ec7n t\u00edch d\u01b0\u01a1ng (nh\u01b0 protamin) \u0111\u1ec3 trung h\u00f2a. C\u00e1c ch\u1ebf ph\u1ea9m b\u00e1n tr\u00ean th\u1ecb tr\u01b0\u1eddng hi\u1ec7n nay \u0111\u01b0\u1ee3c chi\u1ebft xu\u1ea5t t\u1eeb ph\u1ed5i b\u00f2 ho\u1eb7c ni\u00eam m\u1ea1c ru\u1ed9t l\u1ee3n.<\/p>\n
I. C\u01a1 ch\u1ebf t\u00e1c d\u1ee5ng<\/span><\/h3>\nTrong ph\u1ea7n c\u01a1 ch\u1ebf \u0111\u00f4ng m\u00e1u, ch\u00fang ta \u0111\u00e3 nh\u1eafc t\u1edbi nh\u1eefng y\u1ebfu t\u1ed1 ch\u1ed1ng \u0111\u00f4ng c\u1ee7a c\u01a1 th\u1ec3, trong \u0111\u00f3 c\u00f3 antithrombin. Antithrombin t\u00e1c d\u1ee5ng b\u1eb1ng c\u00e1ch g\u1eafn b\u1ec1n ch\u1eb7t v\u00e0o c\u00e1c y\u1ebfu t\u1ed1 IIa, IXa, Xa, Xia, XIIa (nh\u1eefng y\u1ebfu t\u1ed1 c\u1ee7a con \u0111\u01b0\u1eddng \u0111\u00f4ng m\u00e1u n\u1ed9i sinh) v\u00e0 \u1ee9c ho\u1ea1t ch\u00fang. Ph\u1ea3n \u1ee9ng n\u00e0y di\u1ec5n ra m\u1ea1nh g\u1ea5p 1000 l\u1ea7n khi c\u00f3 m\u1eb7t heparin. Li\u1ec1u t\u00e1c d\u1ee5ng c\u1ee7a heparin r\u1ea5t kh\u00f3 \u0111\u1ec3 d\u1ef1 \u0111o\u00e1n b\u1edfi vi\u1ec7c chi\u1ebft xu\u1ea5t n\u00f3 tr\u1ea3i qua r\u1ea5t nhi\u1ec1u c\u00f4ng \u0111o\u1ea1n v\u00e0 \u0111\u1ed9 m\u1ea1nh c\u1ee7a n\u00f3 kh\u00e1c nhau theo t\u1eebng m\u1ebb s\u1ea3n ph\u1ea9m. \u0110\u00f3 l\u00e0 l\u00fd do r\u1ea5t kh\u00f3 ch\u1ec9nh li\u1ec1u heparin v\u00e0 \u0111\u00f2i h\u1ecfi ph\u1ea3i \u0111\u01b0\u1ee3c theo d\u00f5i c\u1ea9n th\u1eadn.<\/p>\n
II. Ph\u00e2n lo\u1ea1i<\/span><\/h3>\nKhi nh\u1eafc \u0111\u1ebfn heparin, th\u01b0\u1eddng th\u00ec \u0111\u00f3 l\u00e0 UFH (heparin kh\u00f4ng ph\u00e2n \u0111o\u1ea1n) c\u00f3 tr\u1ecdng l\u01b0\u1ee3ng 5000-30.000 KDA. C\u00f2n LMWH (heparin tr\u1ecdng l\u01b0\u1ee3ng ph\u00e2n t\u1eed th\u1ea5p) l\u00e0 nh\u1eefng UFH \u0111\u00e3 tr\u1ea3i qua th\u1ee7y ph\u00e2n v\u00e0 tr\u00f9ng h\u1ee3p \u0111\u1ec3 t\u1ea1o th\u00e0nh nh\u1eefng \u0111o\u1ea1n heparin ng\u1eafn v\u00e0 chuy\u00ean bi\u1ec7t h\u01a1n. LMWH c\u00f3 nh\u1eefng \u01b0u \u0111i\u1ec3m v\u00e0 nh\u01b0\u1ee3c \u0111i\u1ec3m so v\u1edbi UFH v\u00e0 chi ti\u1ebft v\u1ec1 n\u00f3 s\u1ebd \u0111\u01b0\u1ee3c n\u00f3i r\u00f5 h\u01a1n \u1edf ri\u00eang m\u1ed9t ph\u1ea7n sau.<\/p>\n
III. X\u00e9t nghi\u1ec7m \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 hi\u1ec7u qu\u1ea3 heparin<\/span><\/h3>\nC\u00f3 th\u1ec3 th\u1ea5y heparin t\u00e1c \u0111\u1ed9ng l\u00ean c\u00e1c y\u1ebfu t\u1ed1 \u0111\u00f4ng m\u00e1u n\u1ed9i sinh v\u00e0 thrombin. V\u00ec v\u1eady aPTT, m\u1ed9t x\u00e9t nghi\u1ec7m ph\u1ea3n \u00e1nh qu\u00e1 tr\u00ecnh \u0111\u00f4ng m\u00e1u n\u1ed9i sinh \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 theo d\u00f5i heparin v\u00e0 c\u00e1c thu\u1ed1c \u1ee9c ch\u1ebf thrombin tr\u1ef1c ti\u1ebfp \u0111\u01b0\u1eddng ti\u00eam. Test \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n b\u1eb1ng c\u00e1ch th\u00eam c\u00e1c y\u1ebfu t\u1ed1 ho\u1ea1t h\u00f3a b\u1ec1 m\u1eb7t (kaolin ho\u1eb7c micronized silica), m\u1ed9t ph\u1ea7n c\u1ee7a thu\u1ed1c th\u1eed thromboplastin (phospholipid; y\u1ebfu t\u1ed1 3 ti\u1ec3u c\u1ea7u thay th\u1ebf), v\u00e0 canxi v\u00e0o m\u1eabu huy\u1ebft t\u01b0\u01a1ng.<\/p>\n
Th\u00f4ng th\u01b0\u1eddng, k\u1ebft qu\u1ea3 s\u1ebd r\u01a1i v\u00e0o kho\u1ea3ng 24-36 gi\u00e2y.<\/p>\n
C\u0169ng nh\u01b0 PT, aPTT c\u00f3 m\u1ed9t s\u1ef1 sai l\u1ec7ch t\u00f9y v\u00e0o lo\u1ea1i thu\u1ed1c th\u1eed thromboplastin. Tuy nhi\u00ean, h\u1ec7 th\u1ed1ng chu\u1ea9n h\u00f3a INR kh\u00f4ng \u0111\u01b0\u1ee3c ph\u00e1t tri\u1ec3n cho aPTT. M\u1ee5c ti\u00eau d\u00f9ng heaparin l\u00e0 \u0111\u01b0a aPTT l\u00ean cao g\u1ea5p 1.5 \u0111\u1ebfn 2 l\u1ea7n ng\u01b0\u1ee1ng b\u00ecnh th\u01b0\u1eddng. Tuy nhi\u00ean ti\u00eau chu\u1ea9n n\u00e0y s\u1ebd s\u1edbm b\u1ecb lo\u1ea1i b\u1ecf do t\u00ednh thi\u1ebfu th\u1ed1ng nh\u1ea5t c\u1ee7a k\u1ebft qu\u1ea3. Thay v\u00e0o \u0111\u00f3, aPTT ph\u1ea3i \u0111\u01b0\u1ee3c hi\u1ec7u ch\u1ec9nh theo t\u1eebng l\u00f4 thu\u1ed1c v\u00e0 t\u1eebng m\u00e1y \u0111o kh\u00e1c nhau, c\u00e1c l\u00f4 thu\u1ed1c th\u1eed n\u00e0y s\u1ebd \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh m\u1ee9c \u0111\u1ed9 t\u01b0\u01a1ng \u1ee9ng v\u1edbi li\u1ec1u heparin \u0111i\u1ec1u tr\u1ecb \u1edf 0.3-0.7 \u0111\u01a1n v\u1ecb qu\u1ed1c t\u1ebf\/mL b\u1edfi thu\u1ed1c \u1ee9c ch\u1ebf Xa. C\u00e1c thu\u1ed1c \u1ee9c ch\u1ebf thrombin tr\u1ef1c ti\u1ebfp c\u0169ng s\u1eed d\u1ee5ng m\u1ed1c aPTT t\u01b0\u01a1ng t\u1ef1.<\/p>\n
IV. Ch\u1ec9 \u0111\u1ecbnh c\u1ee7a UFH<\/span><\/h3>\n1. Trong nh\u1ed3i m\u00e1u c\u01a1 tim c\u1ea5p<\/span><\/h4>\nHeparin \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng c\u00f9ng thu\u1ed1c ti\u00eau s\u1ee3i huy\u1ebft ho\u1eb7c can thi\u1ec7p v\u00e0nh qua da ti\u00ean ph\u00e1t. Trong ACS, UFH l\u00e0 ti\u00eau chu\u1ea9n tham kh\u1ea3o, nh\u01b0ng b\u00e2y gi\u1edd ch\u1ee7 y\u1ebfu l\u00e0 s\u1eed d\u1ee5ng LMWH, fondaparinux v\u00e0 bivalirudin. T\u00e1i nh\u1ed3i m\u00e1u c\u00f3 th\u1ec3 xu\u1ea5t hi\u1ec7n sau khi ng\u1eebng heparin t\u0129nh m\u1ea1ch th\u01b0\u1eddng l\u00e0 h\u1eadu qu\u1ea3 c\u1ee7a t\u00e1c d\u1ee5ng n\u1ea3y ng\u01b0\u1ee3c (heparin rebound). Heparin n\u00ean \u0111\u01b0\u1ee3c d\u1eebng ngay sau c\u00e1c th\u1ee7 t\u1ee5c can thi\u1ec7p.<\/p>\n
Trong d\u1ef1 ph\u00f2ng v\u00e0 \u0111i\u1ec1u tr\u1ecb huy\u1ebft kh\u1ed1i t\u0129nh m\u1ea1ch s\u00e2u, heparin d\u01b0\u1edbi da \u0111\u00e3 b\u1ecb thay th\u1ebf b\u1eb1ng LMWH ho\u1eb7c fondaparinux.<\/p>\n
2. Ch\u1ed1ng \u0111\u00f4ng trong th\u1eddi k\u1ef3 thai ngh\u00e9n<\/span><\/h4>\nUFH c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng, tuy nhi\u00ean n\u00f3 c\u00f3 th\u1ec3 g\u00e2y lo\u00e3ng x\u01b0\u01a1ng n\u1ebfu d\u00f9ng li\u1ec1u cao h\u01a1n 20.000 IU\/ng\u00e0y trong nhi\u1ec1u h\u01a1n 5 th\u00e1ng. Thu\u1ed1c thay th\u1ebf l\u00e0 fondaparinux ho\u1eb7c LMWH.<\/p>\n
V. Ki\u1ec3m so\u00e1t li\u1ec1u heparin t\u0129nh m\u1ea1ch<\/span><\/h3>\nKhi heparin \u0111\u01b0\u1ee3c d\u00f9ng sau li\u1ec7u ph\u00e1p ti\u00eau s\u1ee3i huy\u1ebft \u1edf b\u1ec7nh nh\u00e2n ACS, c\u1ea7n ph\u1ea3i ki\u1ec3m so\u00e1t th\u1eadt c\u1ea9n th\u1eadn li\u1ec1u c\u1ee7a n\u00f3. Heparin c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c pha trong d\u1ecbch mu\u1ed1i \u0111\u1eb3ng tr\u01b0\u01a1ng ho\u1eb7c dextrose. Li\u1ec1u khuy\u1ebfn c\u00e1o l\u00e0 50-70 IU\/Kg, kh\u00f4ng qu\u00e1 5000 IU, sau \u0111\u00f3 l\u00e0 12-15 IU\/Kg\/gi\u1edd (t\u1ed1i \u0111a 1000 IU). Ch\u1ec9nh li\u1ec1u \u0111\u1ec3 \u0111\u1ea1t m\u1ee5c ti\u00eau aPTT 1.5-2.5 l\u1ea7n ng\u01b0\u1ee1ng tr\u00ean b\u00ecnh th\u01b0\u1eddng ho\u1eb7c 50- 75 gi\u00e2y v\u1edbi theo d\u00f5i \u1edfi 6,12, v\u00e0 24 gi\u1edd. AHA-ACC khuy\u1ebfn c\u00e1o m\u1ed9t li\u1ec1u c\u1ea9n tr\u1ecdng h\u01a1n l\u00e0 bolus 60 IU\/kg (kh\u00f4ng qu\u00e1 4000 IU) v\u00e0 li\u1ec1u truy\u1ec1n t\u0129nh m\u1ea1ch l\u00e0 12 IU\/kg\/gi\u1edd v\u1edbi m\u1ee5c ti\u00eau aPTT l\u00e0 60-80 gi\u00e2y.<\/p>\n
M\u1ee5c ti\u00eau aPTT cao h\u01a1n l\u00e0m t\u0103ng nguy c\u01a1 xu\u1ea5t huy\u1ebft n\u00e3o m\u00e0 kh\u00f4ng l\u00e0m t\u0103ng ti\u00ean l\u01b0\u1ee3ng s\u1ed1ng cho b\u1ec7nh nh\u00e2n m\u1ed9t ch\u00fat n\u00e0o. N\u1ebfu aPTT cao g\u1ea5p 3 l\u1ea7n ng\u01b0\u1ee1ng ki\u1ec3m so\u00e1t, li\u1ec1u truy\u1ec1n t\u0129nh m\u1ea1ch c\u00f3 th\u1ec3 gi\u1ea3m \u0111i m\u1ed9t n\u1eeda, n\u1ebfu l\u00e0 g\u1ea5p 2-3 l\u1ea7n ng\u01b0\u1ee1ng ki\u1ec3m so\u00e1t, n\u00ean gi\u1ea3m li\u1ec1u t\u0129nh m\u1ea1ch \u0111i 25%. N\u1ebfu g\u1ea5p 1.5 \u0111\u1ebfn 2 l\u1ea7n, c\u00f3 th\u1ec3 kh\u00f4ng c\u1ea7n ch\u1ec9nh li\u1ec1u. n\u1ebfu aPTT th\u1ea5p h\u01a1n 1.5 l\u1ea7n ng\u01b0\u1ee1ng ki\u1ec3m so\u00e1t, c\u00f3 th\u1ec3 t\u0103ng li\u1ec1u th\u00eam 25% v\u1edbi t\u1ed1i \u0111a l\u00e0 2500IU\/gi\u1edd. H\u1ea1n ch\u1ebf c\u1ee7a aPTT l\u00e0 n\u00f3 c\u00f3 th\u1ec3 kh\u00e1c nhau \u1edf c\u00e1c trung t\u00e2m kh\u00e1c nhau do s\u1ef1 thi\u1ebfu quy chu\u1ea9n c\u1ee7a thu\u1ed1c th\u1eed. ACT th\u00ec \u0111\u01b0\u1ee3c \u01b0u ti\u00ean d\u00f9ng \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 h\u01a1n n\u1ebfu \u0111\u1eb7t catheter.<\/p>\n
VI. T\u00e1c d\u1ee5ng ph\u1ee5 v\u00e0 nh\u1eefng th\u1ee9 c\u1ea7n l\u01b0u \u00fd<\/span><\/h2>\nHIT ( Gi\u1ea3m ti\u1ec3u c\u1ea7u do heparin) v\u00e0 h\u1ed9i ch\u1ee9ng huy\u1ebft kh\u1ed1i xu\u1ea5t hi\u1ec7n \u1edf kho\u1ea3ng 3-5% b\u1ec7nh nh\u00e2n sau khi d\u00f9ng UFH t\u1eeb 5 ng\u00e0y tr\u1edf l\u00ean. V\u1edbi LMWH th\u1ea5p h\u01a1n nhi\u1ec1u, \u00edt h\u01a1n 1%. M\u1ed9t h\u1ec7 th\u1ed1ng thang \u0111i\u1ec3m l\u00e2m s\u00e0ng d\u00f9ng \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 s\u1ef1 li\u00ean quan n\u00e0y: \u201cTi\u1ec3u c\u1ea7u gi\u1ea3m 50% ho\u1eb7c h\u01a1n (gi\u1ea3m ti\u1ec3u c\u1ea7u), 5-10 ng\u00e0y sau khi b\u1eaft \u0111\u1ea7u UFH, c\u00f3 huy\u1ebft kh\u1ed1i m\u1edbi xu\u1ea5t hi\u1ec7n, v\u00e0 c\u00e1c nguy\u00ean nh\u00e2n gi\u1ea3m ti\u1ec3u c\u1ea7u kh\u00e1c \u0111\u01b0\u1ee3c lo\u1ea1i tr\u1eeb\u201d. H\u1ea7u h\u1ebft HIT x\u1ea3y ra trong th\u1eddi gian \u0111ang d\u00f9ng heparin nh\u1eefng c\u00f3 kho\u1ea3ng 5% xu\u1ea5t hi\u1ec7n sau khi \u0111\u00e3 ng\u1eebng li\u1ec7u ph\u00e1p (HIT mu\u1ed9n).<\/p>\n
HIT l\u00e0 m\u1ed9t h\u1ed9i ch\u1ee9ng do mi\u1ec5n d\u1ecbch qua trung gian t\u1ebf b\u00e0o v\u00e0 c\u00f3 th\u1ec3 g\u00e2y ch\u1ebft ng\u01b0\u1eddi, trong \u0111\u00f3 ti\u1ec3u c\u1ea7u c\u1ea7u g\u1eafn v\u1edbi globulin mi\u1ec5n d\u1ecbch heparin g\u00e2y ra gi\u1ea3m ti\u1ec3u c\u1ea7u v\u00e0 huy\u1ebft kh\u1ed1i. N\u00ean ng\u1eebng ng\u00e0y heparin ho\u1eb7c LMWH n\u1ebfu nghi ng\u1edd. H\u00e3y thay th\u1ebf lo\u1ea1i ch\u1ed1ng \u0111\u00f4ng kh\u00e1c n\u1ebfu c\u1ea7n thi\u1ebft v\u00e0 h\u1ea7u h\u1ebft b\u1ec7nh nh\u00e2n s\u1ebd \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb v\u00f3i thu\u1ed1c \u1ee9c ch\u1ebf thrombin ho\u1eb7c heparinoid v\u00e0 sau \u0111\u00f3 l\u00e0 b\u1eaft \u0111\u1ea7u v\u1edbi warfarin khi ti\u1ec3u c\u1ea7u tr\u1edf v\u1ec1 b\u00ecnh th\u01b0\u1eddng.<\/p>\n
Li\u1ec7u ph\u00e1p HIT. \u1edf M\u0129, Nh\u1eefng b\u1ec7nh nh\u00e2n nghi ng\u1edd HIT ho\u1eb7c \u0111\u00e3 ch\u1ea9n \u0111o\u00e1n HIT m\u00e0 c\u1ea7n PCI, argatroban (thu\u1ed1c \u1ee9c ch\u1ebf thrombin tr\u1ef1c ti\u1ebfp, 240mcg\/kg bolus theo sau l\u00e0 20mcg\/kg\/ph\u00fat truy\u1ec1n t\u0129nh m\u1ea1ch) c\u00f3 th\u1ec3 cover can thi\u1ec7p, k\u1ec3 c\u1ea3 khi kh\u00f4ng d\u00f9ng th\u00eam thu\u1ed1c \u1ee9c ch\u1ebf GpIIb\/IIIa. M\u1ed9t s\u1ef1 thay th\u1ebf kh\u00e1c trong ACS l\u00e0 fondaparinux ho\u1eb7c bivalirudin. Heparinoid danaparoid c\u0169ng l\u00e0 m\u1ed9t l\u1ef1a ch\u1ecdn nh\u01b0ng n\u00f3 c\u00f3 s\u1ef1 ch\u1ed3ng ch\u00e9o v\u1edbi heparin.<\/p>\n
Hi\u1ec7p h\u1ed9i huy\u1ebft h\u1ecdc Anh khuy\u1ebfn c\u00e1o:<\/strong> T\u1ea5t c\u1ea3 nh\u1eefng b\u1ec7nh nh\u00e2n \u0111i\u1ec1u tr\u1ecb v\u1edbi b\u1ea5t k\u00ec lo\u1ea1i heparin n\u00e0o k\u00e9o d\u00e0i c\u1ea7n ph\u1ea3i \u0111\u1ecbnh l\u01b0\u1ee3ng ti\u1ec3u c\u1ea7u trong ng\u00e0y \u0111\u1ea7u ti\u00ean v\u00e0 m\u1ed7i 2-4 ng\u00e0y sau \u0111\u00f3.<\/em><\/p>\n
Ngo\u00e0i ra heparin c\u0169ng l\u00e0m t\u0103ng nguy c\u01a1 ch\u1ea3y m\u00e1u \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n vi\u00eam n\u1ed9i t\u00e2m m\u1ea1c nhi\u1ec5m khu\u1ea9n b\u00e1n c\u1ea5p ho\u1eb7c \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 r\u1ed1i lo\u1ea1n huy\u1ebft h\u1ecdc nh\u01b0 hemophilia, b\u1ec7nh gan, ho\u1eb7c lo\u00e9t \u0111\u01b0\u1eddng ti\u00eau h\u00f3a tr\u00ean, \u0111\u01b0\u1eddng sinh d\u1ee5c. Ch\u1ec9 c\u00f3 m\u1ed9t c\u1eeda s\u1ed5 h\u1eb9p cho vi\u1ec7c \u0111i\u1ec1u tr\u1ecb heparin k\u1ebft h\u1ee3p v\u1edbi li\u1ec7u ph\u00e1p ti\u00eau s\u1ee3i huy\u1ebft. M\u1ed9t s\u1ed1 b\u1ec7nh nh\u00e2n c\u00f3 s\u1ef1 \u0111\u1ec1 kh\u00e1ng heparin, v\u00e0 nh\u1eefng b\u1ec7nh nh\u00e2n \u0111\u00f3 \u0111\u00f2i h\u1ecfi m\u1ed9t li\u1ec1u heparin cao h\u01a1n \u0111\u1ed3ng th\u1eddi ph\u1ea3i \u0111\u01b0\u1ee3c theo d\u00f5i aPTT m\u1ed7i 4 ti\u1ebfng 1 l\u1ea7n.<\/p>\n
Qu\u00e1 li\u1ec1u heparin \u0111\u01b0\u1ee3c x\u1eed tr\u00ed b\u1eb1ng c\u00e1ch ng\u1eebng thu\u1ed1c v\u00e0 n\u1ebfu c\u1ea7n thi\u1ebft, ph\u1ea3i s\u1eed d\u1ee5ng protamine sulfat (check d\u1ecb \u1ee9ng tr\u01b0\u1edbc v\u1edbi c\u00e1 h\u1ed3i) v\u1edbi dung d\u1ecbch 1% li\u1ec1u truy\u1ec1n t\u0129nh m\u1ea1ch r\u1ea5t ch\u1eadm, kh\u00f4ng qu\u00e1 50mg trong b\u1ea5t k\u00ec kho\u1ea3ng 10 ph\u00fat n\u00e0o.<\/p>\n
Heparin tr\u1ecdng l\u01b0\u1ee3ng ph\u00e2n t\u1eed th\u1ea5p<\/span><\/h2>\nLMWHs c\u00f3 tr\u1ecdng l\u01b0\u1ee3ng kho\u1ea3ng 1\/3 tr\u1ecdng l\u01b0\u1ee3ng Heparin, v\u00e0 k\u00edch th\u01b0\u1edbc c\u1ee7a n\u00f3 c\u0169ng kh\u00f4ng \u0111\u1ed3ng nh\u1ea5t. LMWHs c\u00f3 sinh kh\u1ea3 d\u1ee5ng cao h\u01a1n v\u00e0 th\u1eddi gian b\u00e1n th\u1ea3i k\u00e9o d\u00e0i h\u01a1n so v\u1edbi heparin ti\u00eau chu\u1ea9n. LMWHs c\u0169ng \u1ee9c ch\u1ebf y\u1ebfu t\u1ed1 Xa tuy nhi\u00ean kh\u1ea3 n\u0103ng \u1ee9c ch\u1ebf thrombin c\u1ee7a n\u00f3 k\u00e9m h\u01a1n UFH. Nh\u1edd \u0111\u00f3 t\u00e1c d\u1ee5ng ph\u1ee5 g\u00e2y xu\u1ea5t huy\u1ebft c\u1ee7a LMWHs gi\u1ea3m \u0111i nh\u01b0ng kh\u00f4ng b\u1ecb \u0111\u1ea3o ng\u01b0\u1ee3c ho\u00e0n to\u00e0n b\u1edfi protamine (do v\u1eabn c\u00f2n t\u00e1c d\u1ee5ng l\u00ean y\u1ebfu t\u1ed1 Xa). LMWHs d\u00f9ng d\u01b0\u1edbi da v\u1edbi li\u1ec1u \u0111i\u1ec1u ch\u1ec9nh d\u1ec5 d\u00e0ng h\u01a1n nhi\u1ec1u so v\u1edbi UFH, nguy c\u01a1 HIT th\u1ea5p h\u01a1n, tuy nhi\u00ean v\u1eabn c\u1ea7n theo d\u00f5i l\u01b0\u1ee3ng ti\u1ec3u c\u1ea7u v\u00e0 n\u00ean ng\u1eebng n\u1ebfu ti\u1ec3u c\u1ea7u < 100.000\/mm2.<\/p>\n
LMWH trong h\u1ed9i ch\u1ee9ng v\u00e0nh c\u1ea5p<\/span><\/h3>\nEnoxaparin l\u00e0 m\u1ed9t LMWH r\u1ea5t ph\u1ed5 bi\u1ebfn. Nghi\u00ean c\u1ee9u cho th\u1ea5y enoxaparin li\u1ec1u 0.5-0.75 mg\/kg \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch \u1edf b\u1ec7nh nh\u00e2n PCI \u00edt g\u00e2y ch\u1ea3y m\u00e1u h\u01a1n UFH, v\u00e0 li\u1ec1u 0.75mg\/kg cho hi\u1ec7u qu\u1ea3 \u1ee9c ch\u1ebf y\u1ebfu t\u1ed1 Xa cao h\u01a1n m\u1ee9c li\u1ec1u th\u1ea5p h\u01a1n. Kh\u00f4ng c\u1ea7n thi\u1ebft ph\u1ea3i ch\u1ec9nh li\u1ec1u enoxaparin \u1edf b\u1ec7nh nh\u00e2n r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng th\u1eadn khi s\u1eed d\u1ee5ng li\u1ec1u bolus \u1edf b\u1ec7nh nh\u00e2n PCI. Nghi\u00ean c\u1ee9u c\u0169ng ch\u1ee9ng minh vi\u1ec7c chuy\u1ec3n \u0111\u1ed5i t\u1eeb UFH sang LMWH l\u00e0m t\u0103ng nguy c\u01a1 ch\u1ea3y m\u00e1u.<\/p>\n
L\u1ef1a ch\u1ecdn LMWHs hay UFH?<\/span><\/h3>\nLMWH th\u01b0\u1eddng \u0111\u01b0\u1ee3c \u01b0a d\u00f9ng h\u01a1n UFH b\u1edfi t\u00ednh ti\u1ec7n d\u1ee5ng, gi\u00e1 th\u01b0\u1eddng r\u1ebb h\u01a1n, kh\u00f4ng c\u1ea7n theo d\u00f5i aPTT qu\u00e1 c\u1ea9n th\u1eadn, tr\u00e1nh \u0111\u01b0\u1ee3c v\u1ea5n \u0111\u1ec1 nhi\u1ec5m tr\u00f9ng t\u1ea1i v\u1ecb tr\u00ed truy\u1ec1n t\u0129nh m\u1ea1ch, cho hi\u1ec7u qu\u1ea3 cao h\u01a1n. Vi\u1ec7c kh\u00f4ng c\u00f3 m\u1ed9t thu\u1ed1c gi\u1ea3i \u0111\u1ed9c ho\u00e0n to\u00e0n l\u00e0 m\u1ed9t nh\u01b0\u1ee3c \u0111i\u1ec3m ti\u1ec1m n\u0103ng, \u0111\u1eb7c bi\u1ec7t l\u00e0 trong b\u1ed1i c\u1ea3nh c\u1ea5p c\u1ee9u nh\u01b0 PCI cho m\u1ed9t tr\u01b0\u1eddng h\u1ee3p ACS c\u00f3 nguy c\u01a1 cao.<\/p>\n
<\/p>\n","protected":false},"excerpt":{"rendered":"
C\u00c1C THU\u1ed0C CH\u1ed0NG HUY\u1ebeT KH\u1ed0I L\u00ea B\u1ea3o Trung Drugs for the heart Applied therapeutics- the clinical use of drug 11th 2018 I. Qu\u00e1 tr\u00ecnh h\u00ecnh th\u00e0nh huy\u1ebft kh\u1ed1i v\u00e0 s\u1ef1 thuy\u00ean t\u1eafc 1. Qu\u00e1 tr\u00ecnh h\u00ecnh th\u00e0nh huy\u1ebft kh\u1ed1i Th\u00f4ng th\u01b0\u1eddng, c\u00e1c m\u00e0ng n\u1ed9i m\u00f4 m\u1ea1ch m\u00e1u nguy\u00ean v\u1eb9n s\u1ebd \u0111\u1ea9y l\u00f9i ti\u1ec3u c\u1ea7u v\u00e0 […]\n","protected":false},"author":1,"featured_media":100580,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-100565","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-y-te-suc-khoe"],"acf":[],"_links":{"self":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts\/100565","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/comments?post=100565"}],"version-history":[{"count":4,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts\/100565\/revisions"}],"predecessor-version":[{"id":100652,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts\/100565\/revisions\/100652"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/media\/100580"}],"wp:attachment":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/media?parent=100565"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/categories?post=100565"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/tags?post=100565"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}}}}