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Thuoc dieu tri suy tim o nguoi lon tuoi

Suy tim man tinh la mot van de rat thuong gap o nguoi lon tuoi va co the gay ra do nhieu nhom nguyen nhan khac nhau. Trong nhung nam gan day, tan xuat va do luu hanh cua suy tim o nguoi lon tuoi y hoc da gia tang dang ke, mot phan la nho nhung tien bo vuot bac da dat duoc trong cong tac phat hien va chan doan benh.

Cac buong tim cua benh nhan suy tim man tinh bi gian rong.

Theo mot so nghien cuu gan day, toi 10% nguoi lon tuoi co roi loan chuc nang tam thu that trai va 30% co roi loan chuc nang tam truong. Tang huyet ap, benh van tim, rung nhi, benh co tim, benh mach than va thieu mau man tinh la cac nguyen nhan hoac yeu lam nang benh thuong gap nhat doi voi suy tim o nguoi lon. Mac du cac truong hop suy tim co roi loan chuc nang tam thu thuong nang hon va co tien luong xau hon nhung nhung truong hop suy tim co chuc nang tam thu binh thuong cung co ty le tu vong sau 5 nam len toi 40%.

Dieu tri: Ke hoach dieu tri suy tim o nguoi lon tuoi can can cu vao trieu chung cu the cua tinh trang suy tim cung nhu nhung benh ma nguoi benh mac dong thoi. Can luu y giam thieu so luong thuoc su dung va nguy co tuong tac thuoc. Cac nhom thuoc chu yeu duoc dung trong dieu tri suy tim o nguoi lon tuoi la thuoc loi tieu, uc che men chuyen, khang angiotensin, chen beta giao cam va digoxin. 

Thuoc loi tieu: Hien nay, loi tieu van la mot trong nhung nhom thuoc can ban trong dieu tri suy tim o nguoi lon tuoi, nhat voi cac trieu chung gay ra do tinh trang giu nuoc giu muoi nhu phu, tieu it. Cac nghien cuu cho thay, viec dung cac thuoc loi tieu quai nhu furosemide co the giup giam ganh cho tim trai, nho do cai thien cung luong tim. Mot van de can dac biet luu y khi dung thuoc loi tieu o nguoi lon tuoi la phai dieu chinh lieu loi tieu dua vao trieu chung cua suy tim, theo doi can nang, huyet ap tu the dung va dien giai do cua nguoi benh. Lieu cua cac thuoc loi tieu quai nen duoc giam xuong thap nhat ngay khi tinh trang u tre nuoc va muoi duoc giai quyet. Mot so truong hop co the gay kho khan cho viec dung loi tieu o nguoi lon tuoi la khi nguoi benh co roi loan thang bang nuoc dien giai hoac co phi dai tien liet tuyen gay kho di tieu hoac tieu khong tu chu. Trong nhung truong hop nay, nen phoi hop them cac thuoc khac de co the giam duoc lieu loi tieu. Khi nhung benh nhan lon tuoi phai dung loi tieu keo dai, nen duy tri o lieu thap nhat co the va uu tien dung duong uong, duong tiem chi su dung trong nhung truong hop co thua dich nhieu hoac co doa phu phoi. Nhung truong hop phu keo dai khong dap ung voi loi tieu thong thuong, neu loai tru duoc nhung nguyen nhan khac gay phu (nhu giam albumin mau), co the su dung mot dot ngan ngay nhung thuoc loi tieu khac manh hon nhu metolazone. Cac thuoc loi tieu giu kali nhu spironolactone khi dung phoi hop voi dieu tri chuan co the giup giam ty le tu vong va cai thien trieu chung cua suy tim. Nhung benh nhan lon tuoi dung spironolactone can duoc theo doi chat che chuc nang than va nong do kali trong mau.

Thuoc uc che men chuyen: Hien nay co nhieu bang chung y hoc khang dinh loi ich cua cac thuoc uc che men chuyen (nhu captopril, enalapril...) trong dieu tri suy tim co giam chuc nang tam thu that trai o nguoi lon tuoi. O mot lieu phu hop va khi khong co chong chi dinh, cac thuoc nay giup cai thien trieu chung lam sang va giam ty le tu vong o nhung benh nhan co suy giam chuc nang tam thu that trai. O nhung benh nhan lon tuoi, can lua chon lieu khoi dau mot cach than trong de tranh hien tuong tut huyet ap tu the dung. Mot tac dung phu cung can duoc luu y cua nhom thuoc nay la gay ho, xay ra o khoang 1/3 so nguoi dung thuoc.

Nhom thuoc chen beta giao cam:  Cho den giua nhung nam 1990, hieu qua cua cac thuoc chen beta giao cam trong dieu tri suy tim van la mot van de con nhieu tranh cai do cac thuoc nay co kha nang lam giam suc co bop co tim. Tuy nhien, cac nghien cuu voi quy mo rat lon gan day da chung minh hieu qua ro ret cua mot so dan xuat chen beta giao cam nhu metoprolol, carvedilol va bisoprolol trong dieu tri suy tim man tinh, giup giam khoang 1/3 ty le tu vong. Dang luu y la hau het cac dan xuat khac cua nhom chen beta giao cam da khong chung minh duoc hieu qua ro ret nhu 3 thuoc tren, co the do co che tac dung cua cac thuoc nay doi voi tinh trang suy tim la khong giong nhau. Mac du co mot so bang chung cho thay cac thuoc chen beta giao cam co the hieu qua ca trong cac truong hop suy tim nang tien trien, nhung nhom thuoc nay chi nen duoc su dung trong dieu tri cac truong hop suy tim man tinh on dinh.

Thuoc khang angiotensin: Khi nguoi benh co chong chi dinh voi cac thuoc uc che men chuyen (nhu ho sau dung thuoc, suy than nang), co the can nhac dieu tri thay the bang cac thuoc khang angiotensin nhu candesartan. Mot so nghien cuu lon da chung minh duoc hieu qua va tinh an toan cua cac nhom thuoc nay (dac biet la candesartan) trong dieu tri cac truong hop suy tim man tinh khong dung nap voi thuoc uc che men chuyen.

Digoxin: Digoxin la mot trong nhung thuoc can ban trong dieu tri suy tim voi  tac dung tang suc co bop co tim va lam cham nhip tim. Chi dinh tot nhat cua thuoc la cac truong hop suy tim co kem theo rung nhi, thuoc co vai tro khong lon trong nhung truong hop suy tim voi nhip xoang. Dang luu y la o nhung benh nhan lon tuoi, rung nhi kem theo suy tim thuong co nguy co mat bu rat lon. Do viec ha kali mau lam tang nguy co nhiem doc digoxin nen khi dung digoxin o nguoi lon tuoi, can theo doi chat che nong do kali mau va chuc nang than, dac biet neu benh nhan co dung thuoc loi tieu. Trong nhung truong hop suy tim co kem theo rung nhi, cac thuoc chong dong nen duoc dung phoi hop voi digoxin.

BS. Nguyen Huu Truong (Benh vien Bach Mai)