Các bệnh tim mạch có thể tiến triển từ một người chưa có triệu chứng đến NMCT hoặc

những bệnh lý cấp tính và dẫn đến cái chết. Do đó, cần phải nhận diện được những nguy
cơ của bệnh nhân trước khi kịp tiến triển đến biến chứng
Vd: bệnh nhân NMCT thường có tiền sử xơ vữa mạch máu, hoặc bệnh cơ tim phì đại
thường có những âm thổi ở tim trước đó. Ngược lại bệnh nhân bị bệnh tim giãn nở vô
căn (idiopathic dilated cardiomyopathy) hoặc bệnh van tim thường có dấu hiệu như khó
thở tiến triển từ từ, kéo dài

- Ischemia, which is caused by an imbalance between the heart’s oxygen supply and
demand, is manifest most frequently as chest discomfort
- reduction of the pumping ability of the heart commonly leads to fatigue and
elevated intravascular pressure upstream of the failing ventricle  peripheral
edema (Chap. 37) or pulmonary congestion and dyspnea
- Obstruction to blood flow, as occurs in valvular stenosis, can cause symptoms
resembling those of myocardial failure
- Cardiac arrhythmias often develop suddenly, and the resulting symptoms and
signs—palpitations (hồi hộp, đánh trống ngực), dyspnea, hypotension, and
syncope, occur abruptly and may disappear as rapidly

- dyspnea is observed in disorders as diverse as pulmonary disease, marked obesity,

and anxiety

- chest discomfort may result from a variety of noncardiac and cardiac causes other
than myocardial ischemia (Chap. 11)

- Edema, an important finding in untreated or inadequately treated heart failure,

also may occur with primary renal disease and in hepatic cirrhosis

- Ý nghĩa vì sao lại hỏi tình trạng gắng sức bệnh nhân: Myocardial or coronary
function that may be adequate at rest may be insufficient during exertion. Thus,
dyspnea and/or chest discomfort that appear during activity are characteristic of
patients with heart disease, whereas the opposite pattern, that is, the appearance
of these symptoms at rest and their remission during exertion, is rarely observed
in such patients. It is important, therefore, to question the patient carefully about
the relation of symptoms to exertion. Tuy vậy nếu tình trạng gắng sức ok vẫn ko
loại trừ được!!
o Vì: Many patients with cardiovascular disease may be asymptomatic both
at rest and during exertion but may present with an abnormal physical
finding such as a heart murmur, elevated arterial pressure, or an
 abnormality of the electrocardiogram (ECG) or imaging test. It is important
to assess the global risk of CAD in asymptomatic individuals, using a
combination of clinical assessment and measurement of cholesterol and its
fractions, as well as other biomarkers, such as C-reactive protein, in some
patients. Since the first clinical manifestation of CAD may be catastrophic—
sudden cardiac death, acute myocardial infarction, or stroke in previous
asymptomatic persons—it is mandatory to identify those at high risk of
such events and institute further testing and preventive measures.
Để chẩn đoán bệnh tim mạch thì phải trả lời 4 câu hỏi sau: (theo NYHA)
- The underlying etiology. Is the disease congenital, hypertensive, ischemic, or
inflammatory in origin?
- The anatomic abnormalities. Which chambers are involved? Are they
hypertrophied, dilated, or both? Which valves are affected? Are they regurgitant
and/or stenotic? Is there pericardial involvement? Has there been a myocardial
infarction?
- The physiologic disturbances. Is an arrhythmia present? Is there evidence of
congestive heart failure or myocardial ischemia?
- Functional disability. How strenuous is the physical activity required to elicit
symptoms? The classification provided by the NYHA has been found to be useful
in describing functional disability

o
Vì sao 4 câu hỏi đó quan trọng. đây là ví dụ chứng minh
In a patient who presents with exertional chest discomfort, the identification of
myocardial ischemia as the etiology is of great clinical importance
- However, the simple recognition of ischemia is insufficient to formulate a
therapeutic strategy or prognosis until the underlying anatomic abnormalities
responsible for the myocardial ischemia, for example, coronary atherosclerosis or
aortic stenosis, are identified and a judgment is made about whether other
physiologic disturbances that cause an imbalance between myocardial oxygen
supply and demand, such as severe anemia, thyrotoxicosis, or supraventricular
tachycardia, play contributory roles
Do đó, việc thăm khám đúng tim mạch là điều cần thiết
The establishment of a correct and complete cardiac diagnosis usually commences with
the history and physical examination (Chap. 234)

5 test nên làm trong tim mạch

- ECG (Chap. 235)
- noninvasive imaging examinations (chest roentgenogram, echocardiogram,
radionuclide imaging, computed tomographic imaging, positron emission
tomography, and magnetic resonance imaging) (Chap. 236)
- blood tests to assess risk (e.g., lipid determinations, C-reactive protein) or cardiac
function (e.g., brain natriuretic peptide [BNP] [Chap. 252])
- occasionally specialized invasive examinations (i.e., cardiac catheterization and
coronary arteriography [Chap. 237])
- genetic tests to identify monogenic cardiac diseases (e.g., hypertrophic
cardiomyopathy [Chap. 254]

Tiền sử gia đình  liên quan yếu tố về gen

- Marfan’s syndrome (Chap. 406), and sudden death associated with a prolonged
QT syndrome (Chap. 247)
- Premature coronary disease and essential hypertension, type 2 diabetes mellitus,
and hyperlipidemia (the most important risk factors for CAD) are usually
polygenic disorders

Khi nào chỉ định siêu âm tim ở bn có âm thổi

- The majority of heart murmurs are midsystolic and soft (grades I–II/VI). When
such a murmur occurs in an asymptomatic child or young adult without other
evidence of heart disease on clinical examination, it is usually benign and
echocardiography generally is not required. By contrast, two-dimensional and
Doppler echocardiography (Chap. 236) are indicated in patients with loud systolic
murmurs (grades ≥III/VI), especially those that are holosystolic or late systolic, and
in most patients with diastolic or continuous murmurs
 o

Nguyên tắc phòng ngừa và kiểm soát bệnh tim mạch

Phòng ngừa bệnh tim mạch, đặc biệt là bệnh mạch vành (CAD) là nhiệm vụ quan trọng
nhất của nhân viên y tế. Phòng ngừa đầu tiên là việc đánh giá yếu tố nguy cơ về lối sống
(cân nặng lý tưởng, vận động thể dục, ngừng hút thuốc lá, và sau đó là các yếu tố nguy
cơ về bệnh: hypertension, hyperlipidemia, and diabetes mellitus (Chap. 396).
- Nếu ko có bằng chứng bệnh tim  bn nên được giải thích cặn kẽ về việc đánh giá
yếu tố nguy cơ vừa làm và không cần phải trở lại theo dõi. Vì sao phải giải thích?
Vì khi ko tìm ra bằng chứng bệnh tim, bệnh nhân vẫn sẽ lo lắng về việc mình có
mắc bệnh hay ko dẫn đến lo lắng thái quá
- Nếu ko có bằng chứng bệnh tim + bn vẫn có yếu tố nguy cơ phát triển thành bệnh
tim thiếu máu cục bộ  phải có kế hoạch đẩy lùi YTNC đó + tái khám sau 1 thời
gian để kiểm tra sự đáp ứng với kế hoạch điều trị YTNC
- Bệnh van tim nặng (về mặt giải phẫu) + triệu chứng nhẹ hoặc không triệu chứng
 tái khám mỗi 6 – 12 tháng. Những triệu chứng thực thể sớm báo hiệu sự hủy
hoại dần chức năng thất  cần cân nhắc phẫu thuật sớm để tránh bệnh tiến triển
suy chức năng thất nặng, tổn thương cơ tim không phục hồi hoặc nguy cơ cao cho
việc phẫu thuật sau này
 - Bệnh mạch vành  làm theo Guidline

Phân loại Chest discomfort

- myocardial ischemia
- other cardiopulmonary causes (pericardial disease, aortic emergencies, and
pulmonary conditions);
- non-cardiopulmonary causes
Thái độ tiếp nhận bệnh nhân đau ngực:

Khi tiếp cận bệnh nhân đau ngực cần hỏi những tính chất sau
Tính chất “Pivotal point”
cơn đau Cảm giác bóp nghẹt hoặc đè ép  nghĩ tới thiếu máu cục bộ cơ tim
(ngoài ra còn có khó thở hoặc lo lắng mơ hồ). Lưu ý từ “nhói” “đau như
dao đâm” thường được bn sử dụng để nói về cường độ đau hơn là tính
chất
Lưu ý đau kiểu xoắn vặn, đè ép, bóp nghẹt cũng có ở đau dạ dày-thực
quản co thắt

Vị trí đau mà có thể định vị được bằng 1 ngón tay  ít nghĩ đến MI

Đau sau xương ức  hoặc MI hoặc dạ dày thực quản

 - pain that occurs solely above the mandible or below the
epigastrium is rarely angina
- Severe pain radiating to the back, particularly between the
shoulder blades, may  acute aortic syndrome
- Radiation to the trapezius ridge is characteristic of pericardial
pain and does not usually occur with angina
Pattern - Myocardial ischemic discomfort usually builds over minutes and
is exacerbated by activity and mitigated by rest
- In contrast, pain that reaches its peak intensity immediately is
more suggestive of aortic dissection, pulmonary embolism, or
spontaneous pneumothorax
- Pain that is fleeting (lasting only a few seconds) is rarely ischemic
in origin
- Pain that is constant in intensity for a prolonged period (many
hours to days) is unlikely to represent myocardial ischemia if it
occurs in the absence of other clinical consequences, such as
abnormalities of the ECG, elevation of cardiac biomarkers, or
clinical sequelae (e.g., heart failure or hypotension)
- Both myocardial ischemia and acid reflux may have their onset in
the morning?
rovoking - Patients with myocardial ischemic pain usually prefer to rest, sit,
and or stop walking (nhưng vẫn ko được loại trừ)
Alleviating - Alterations in the intensity of pain with changes in position or
Factors movement of the upper extremities and neck are less likely with
myocardial ischemia and suggest a musculoskeletal etiology
- The pain of pericarditis, however, often is worse in the supine
position and relieved by sitting upright and leaning forward
- Gastroesophageal reflux may be exacerbated by alcohol, some
foods, or by a reclined position. Relief can occur with sitting
- Exacerbation by eating suggests a gastrointestinal etiology such
as peptic ulcer disease, cholecystitis, or pancreatitis. Peptic ulcer
disease tends to become symptomatic 60–90 min after meals.
However, in the setting of severe coronary atherosclerosis,
redistribution of blood flow to the splanchnic vasculature after
eating can trigger postprandial angina
- Relief of chest discomfort within minutes after administration of
nitroglycerin is suggestive of but not sufficiently sensitive or
specific for a definitive diagnosis of myocardial ischemia, do:
esophageal spasm may also be relieved promptly with
 nitroglycerin. A delay of >10 min before relief is obtained after
nitroglycerin suggests that the symptoms either are not caused by
ischemia or are caused by severe ischemia, such as during acute
MI
Associated Symptoms that accompany myocardial ischemia may include
Symptoms diaphoresis, dyspnea, nausea, fatigue, faintness, and eructations

Dyspnea may occur with multiple conditions considered in the

differential diagnosis of chest pain and thus is not discriminative, but
the presence of dyspnea is important because it suggests a
cardiopulmonary etiology. Sudden onset of significant respiratory
distress should lead to consideration of pulmonary embolism and
spontaneous pneumothorax

Hemoptysis may occur with pulmonary

embolism, or as blood-tinged frothy sputum in severe heart failure
but usually points toward a pulmonary parenchymal etiology of
chest symptoms

Presentation with syncope or pre-syncope should

prompt consideration of hemodynamically significant pulmonary
embolism or aortic dissection as well as ischemic arrhythmias

Although nausea and vomiting suggest a gastrointestinal disorder,

these symptoms may occur in the setting of MI (more commonly
inferior MI), presumably because of activation of the vagal reflex or
stimulation of left ventricular receptors as part of the Bezold-Jarisch
reflex.
Past risk factors for coronary atherosclerosis and
Medical venous thromboembolism as well as for conditions that
History may predispose the patient to specific disorders.
- For example, a history of connective tissue diseases such as
Marfan syndrome should heighten the clinician’s suspicion of an
acute aortic syndrome or spontaneous pneumothorax
CARDIAC BIOMARKERS
creatine kinase MB, cardiac troponin is the preferred biomarker for the diagnosis of MI
and should be measured in all patients with suspected ACS at presentation and
repeated in 3–6 h

Đặc hiệu 92%, nhạy 35% trong việc xem xem bệnh nhân có bị bệnh hay ko:
- Nếu KQ (+)  35 người bị bệnh  65 người ko chắc bị bệnh hay không và trong
65 người này sẽ có 92% x 65 = 60 người không bệnh  tổng người thực sự bệnh =
35 + 5 = 40
- Nếu KQ (-)  92 người không mắc bệnh  8 người ko chắc bị bệnh hay không
và trong 8 người này có 35% x 8 = 3 người mắc bệnh  tổng người không mắc
bệnh = 92 + 5 = 97