ACS - pachimake inatsekeratu syndrome

IV Samorodskaya,

Professor, Doctor wa Sciences Medical

pachimake inatsekeratu
syndrome

Multidisciplinary gulu laganiza

Kugwiritsa ntchito njira yamakono ya mankhwala syndrome pachimake inatsekeratu (ACS)
- liwu kutanthauza gulu zizindikiro matenda kapena zizindikiro
kulola amaganiziridwa pachimake m'mnyewa wamtima infarction (MI) kapena kusokonekera
angina, amapereka chiyembekezo kwa kuchepetsa kwambiri kuchipatala
pamatenda ndi kusintha madokotala ananena zawo mu nthawi yaitali.

Zaka zingapo zapitazo, kufufuza ndi mayiko mumaganiza ndi
mwachidule Onse-Russian Scientific Society of Cardiology mu ayamikira Russian matenda
Ndi chithandizo cha odwala m'mnyewa wamtima infarction ndi cha ku Switzerland-gawo kukwezedwa (2007), popanda cha ku Switzerland kukwezedwa ndi wosakhazikika angina (2006). Mu 2010, lofalitsidwa ndi umboni European
Society of Cardiology (Esc) pa kusankha njira revascularization m'mnyewa wamtima, malangizo dziko la kasamalidwe ka odwala ACS ku Australia
Britain, zotsatira za mayiko
kugwirizana pa kasamalidwe ka odwala ndi ACS. mu 2013
American Heart
Society (ACCF / Eya) yasinthidwa
malangizo kasamalidwe ka odwala ndi ACS
Cha ku Switzerland gawo okwera.  

chisankho pa machenjerero
kasamalidwe moleza ACS monga okwera popanda cha ku Switzerland-gawo okwera si nthawi zonse mwapadera yosavuta, amafunika nawo multidisciplinary
gulu la akatswiri zochokera malangizo kuchipatala, njira ya matenda, m'badwo wa mtima, zinthu
kusamalira. Pa nthawi yomweyo odwala onse ndi amaganiziridwa ACS
ayenera kuchita ndi electrocardiogram (pakalibe
kusintha kapena deta zokayikitsa chofunika mobwerezabwereza kujambula intervals 15
Mphindi -30, malingana ndi chikhalidwe matenda a mtima), ndi milingo zotheka kuphunzira
kwa michere mtima, ntchito kuvomerezedwa ndi aspirin imatengedwa. mu
ayamikira onse adalipo njira endovascular
m'mnyewa wamtima revascularization mu pamaso pa ndodo odziwa oyenerera.
Fibrinolytic mankhwala (monga chinthu choyamba cha kusamalira odwala ACS ndi cha ku Switzerland-gawo okwera) amakhalabe zogwirizana zochitika,
pamene n'zosatheka kuchita stenting
kwa mphindi 120 pambuyo
yatsoka ululu (pakalibe contraindications ndi ngati kuyambira ululu anali osapitirira
maola 12). Pamene ACS popanda kutukula fibrinolytic cha ku Switzerland gawo
mankhwala si kutumikiridwa.

Ngati chiopsezo mtima ndi / kapena ake
zosokonezeka mkulu

gulu
kulenga malangizo akatswiri ku Ulaya, United States akukhulupirira kuti kukhazikitsa
inatsekeratu angiography pasanathe maola 2 kuchokera pamene chikuonetseratu
tikulimbikitsidwa ngati wodwala ndi kuukira kwa angina pa maziko zachipatala
kuchitira zizindikiro amapitirirabe kapena anawathetsa akuyambiranso
angina anati zazikulu cha ku Switzerland gawo kusintha, likunena za chitukuko kuwonongeka
kapena m'mnyewa wamtima infarction; hemodynamic
Kusakhazikika, chidwi yamitsempha yamagazi arrhythmias. Kuchita angiography (ndi wotsatira
revascularization) kwa mawola 24 kuvomereza wodwala ku chipatala ndi ACS bwino mu nkhani ya mkulu
chiopsezo infarction m'mnyewa wamtima, akayakaya
mavuto ndi imfa. Similar nthawi angiography inatsekeratu bwino mu
Kodi chofunika masiyanidwe matenda a ACS ndi zina
zinthu mwamsanga (embolism m'mapapo mwanga, kugaŵa
kung'ambika aneurysm). Nthawi ya syndrome pachimake inatsekeratu popanda gawo cha ku Switzerland Nyamulani pa ngozi yochepa ya moyo pachiswe
mavuto ndi kufa pa m'chipatala
mankhwala, koma kulimbikira zizindikiro za angina ndi / kapena ischemia anachititsa
pa mayeso katundu, inatsekeratu angiography akutsatiridwa ndi revascularization pa
koyenera ndi zotheka kuti m'pofunika kuchita mu nthawi anapatsidwa
hospitalization mkati mawola 72 chikuonetseratu. mu
ngati wodwalayo ali anavomereza kuti malo zachipatala, kumene kuli kosatheka
kuchita angiography inatsekeratu, ndi kunditumiza ku chipatala yoyenera (e.g.
Regional mtima Center).

wamba
tikambirana njira stenting (mankhwala TACHIMATA stent
kapena uncoated) ndi infarct zokhudzana mtsempha wamagazi tromboekstratsiey (pa
zofunika), pamene ACS Nyamulani m'ma
cha ku Switzerland gawo
kaya kukhazikitsa ndi zotsatira za mankhwala fibrinolytic (monga
Ayamikira kuchokera 2013 ACC pambuyo mankhwala fibrinolytic tikulimbikitsidwa kuchita
FCT ndi stenting si kale kuposa
maola 2-3). Ngati C-gawo okwera pachimake inatsekeratu syndrome cha ku Switzerland, kupatula mtsempha wamagazi infarct, pali lalikulu
stenoses mu mitsempha zina, stenting awo mwadzidzidzi imagwiridwa okha
anthu ndi kulephera aakulu mtima ndi / kapena cardiogenic mantha. mu zina
Nthawi anachedwa stenting imagwiridwa - kufunika ndi nthawi
anaganiza pambuyo nkhawa likuyesetsa isanafike zimatulutsa a wodwalayo
kuchipatala. Malinga ndi malangizo a akatswiri ku United States 2013, popanda stents
❖ kuyanika ali makamaka ntchito pa nthawi imene wodwalayo
matenda ndi zikhalidwe ndi chiopsezo cha magazi, mkulu Mwina,
kuti wodwalayo sizili mu chaka cha wapawiri antiplatelet kamwedwe
mankhwala, ndipo zikuoneka kuti madokotala wotsatira
ntchito. Komanso, ayamikira anasonyeza kuti c-gawo okwera ACS cha ku Switzerland stenting pambuyo maola 24 pa mphindi yake
Development osati tikuonera milandu 1-2 zotupa mtima, pakalibe
Zizindikiro kuteteza ischemia m'mnyewa wamtima. Nthawi zina (pansi ena
zinthu) anachita angioplasty.

kusankha njira revascularization odwala ndi matenda pachimake inatsekeratu popanda gawo cha ku Switzerland uka, mu ACS m'ma cha ku Switzerland gawo okwera, koma pakalibe
inatsekeratu m'dera kuchepetsa wa mitsempha inatsekeratu, ndithudi "olakwa" mu
ACS kapena matenda multivessel, imene kukhazikitsa
Stenting ndi mwaukadaulo n'zosatheka chiopsezo choposa mphamvu
phindu ndi analandira mwa akatswiri angapo (dokotala mtima,
cardiologist, katswiri mu munda wa
Endovascular matenda ndi chithandizo) zochokera
matenda, angiographic deta kuwunika fractional otaya malo,
kuyembekezera nthawi yaitali madokotala ananena zawo.

mankhwala chithandizo
kwenikweni

Pamene ACS ndi cha ku Switzerland gawo okwera Akatswiri ambiri amakhulupirira kuti machenjerero panopa odwala mu
Iwo kumadalira dongosolo thanzi dziko
(Region) kuchita yaikulu endovascular alowererepo (popanda isanafike
thrombolysis) kwa maola 2 pa chitukuko cha zizindikiro matenda wodwalayo.

Ngati kuyembekezeredwa kuti nthawi kuchokera yoyamba ndi mtima
ogwira ntchito kuchipatala asanayambe kuchita inatsekeratu angiography adzakhala oposa 2
maola, odwala
(Popeza contraindications) ayenera kuchita thrombolysis ndi
yobereka wotsatira ku chipatala yochita angiography ndi revascularisation
infarction pasanathe maola 3-24. Nthawi imeneyo, ngati maziko a thrombolysis
Cha ku Switzerland gawo okwera anapitiriza oposa 50% mlingo woyamba ndi / kapena retrosternal
ululu, wodwalayo limasonyeza mwadzidzidzi inatsekeratu angiography. Ngati bwino,
thrombolysis inatsekeratu angiography ndi revascularization (ngati anasonyeza) mulole
kuchitidwa pasanathe maola 24. ayamikira ananena kuti
revascularization kusintha kuti madokotala ananena zawo ndi kukhazikitsa kudzera 24-60
Patapita maola chiyambire matendawa matenda, koma pokha pokha kumene
Pali angina kobwereza ndi / kapena m'mnyewa wamtima ischemia wapezeka pa
zoimbidwa maphunziro.

kunja
Malinga mtundu wa ACS ndi njira revascularization ndi mokakamizidwa
thandizo mankhwala, womwenso antiplatelet,
antiplatelet mankhwala beta-blockers mankhwala zoletsa wa angiotensin akatembenuka
enzyme, statins. mankhwala ali payekha zopanda
Malinga ndi mawonekedwe a ACS mwamphamvu, pamaso soputsvuyuschie kudwala. The
buku lino lidzakuthandizani kuyang'ana pa mankhwala antiplatelet,
njira pansiyi wa revascularization m'mnyewa wamtima.

Gawo okwera ACS popanda S T

The
Zikatero endovascular revascularization njira
anasankha "awiri 'antiplatelet mankhwala monga m'kamwa
acetylsalicylic asidi (ASA) ndi clopidogrel (kapena prasugrel kapena
ticagrelor). ASA amagwira ntchito woyamba kulandira 150-300 mg (250-500 mg kapena mu mawonekedwe a
mu / mu bolus) akutsatiridwa ndi mlingo wa 75-100 mg / tsiku Mumakonda mlingo
600 mg wa clopidogrel (mwamsanga) akutsatiridwa ndi utsogoleli wa 75
mg / tsiku kwa miyezi 9-12 prasugrel - 60 mg Mumakonda mlingo, kenako
kutenga 10 mg / tsiku, kapena ticagrelor - 180 mg wa Mumakonda mlingo, kenako
kutenga 90 mg wa 2 pa tsiku. Zikuonetsa ntchito zina
zoletsa GPIIb-IIIa amaonedwa kukhala pa chiopsezo thrombosis intracoronary odwala pansi angioplasty ndi / kapena stenting
inatsekeratu mitsempha.

The
ayamikira YABWINO (UK) limati
Odwala chiopsezo zochitika mtima (imene 6 mwezi
imfa kuposa 3%) ndi pansi angiography inatsekeratu ndi revascularization
pasanathe maola 96 kuyambira nthawi imene chikuonetseratu chizolowezi wasonyeza
Kusankhidwa kwa eptifibatide kapena tirofiban. Abciximab Amasankhidwa monga mankhwala ndi,
pansiyi endovascular revascularization ngati palibe
Luso perekani zoletsa zina GPIIb-IIIa. Tikumbukenso kuti
Mosiyana YABWINO chiongoko (UK) ayamikira
European Society of Cardiology "zokonda" wapatsidwa abciximab (kalasi
zikuonetsa I), nthawi yomweyo chifukwa eptifibatide
kapena tirofiban Khazikitsani Maphunziro IIa.

Kusankha ndi mlingo
anticoagulants kuchita angiography
revascularization odwala popanda ACS
kukweza cha ku Switzerland gawo anatsimikiza ndi mtima wonse zochokera
Stratification pa choopsya mavuto thrombotic, ischemic ndi hemorrhagic. Pa chiopsezo kwambiri
zochitika ischemic (mwachitsanzo, pamene hemodynamic Kusakhazikika refractory moyo pachiswe arrhythmias) wodwala
anapulumutsa mwachindunji ndi X-ray ndipo anatumizidwa
unfractionated heparin (UFH) monga / mu bolus 60 U / kg ndi wotsatira
kulowetsedwa pa revascularization molumikizana ndi awiri
antiplatelet mankhwala. Pa chiopsezo magazi angagwiritsidwe ntchito
monotherapy bivalirudin bolus wa 0,75 mg / kg pa akutsatiridwa ndi kulowetsedwa wa 1,75
mg / kg pa / hr. Kwa odwala ndi chiopsezo pafupifupi zochitika ischemic (mwachitsanzo,
hemodynamics khola, koma chenichenicho troponin mayeso, maliseche
angina, kusintha wochitachita mu cha ku Switzerland gawo), amene inakonzedwa njira olanda 24-48
maola zotsatirazi chithandizo kulibe isanafike angiography inatsekeratu
anakonza endovascular m'mnyewa wamtima revascularization:

• Kwa odwala
  

Unfractionated heparin 60 U / kg mu mawonekedwe a pa / mu bolus,
ndiye kulowetsedwa pansi pa ulamuliro wa adamulowetsa tsankho thromboplastin nthawi
(APTT) kapena enoxaparin 1 mg / kg s.c. × 2 pa tsiku kapena Fondaparinux 2.5 mg / tsiku
Bivalirudin subcutaneously kapena 0.1 mg / kg pa monga / mu bolus ndi akutsatiridwa ndi kulowetsedwa
0,25 mg / kg pa / ola

• Kwa odwala ≥75 zaka

Unfractionated heparin 60 U / kg mu mawonekedwe a pa / mu bolus,
ndiye kulowetsedwa lolamulidwa APTT

Kapena enoxaparin 0,75 mg / kg pa × 2
Fondaparinux tsiku kapena 2.5 mg / tsiku subcutaneously kapena Bivalirudin 0.1 mg / kg pa ngati
Ine / bolus akutsatiridwa ndi kulowetsedwa wa 0,25 mg / kg pa / hr.

mu
odwala ndi ngozi yochepa ya zochitika mtima (popanda kuwonjezera
troponin ndi cha ku Switzerland gawo kusintha), zambiri ndiwofatsa anakonza
chithandizo ndipo apatsidwa fondaparinux (2.5 mg / tsiku subcutaneously) kapena enoxaparin (1
mg / kg pa s.c., 2 nthawi tsiku odwala zaka ≥75 - 0,75 mg) ndi unfractionated heparin (60 U / kg
monga / bolus, kenako kulowetsedwa lolamulidwa aPTT).

ACS ndi cha ku Switzerland gawo okwera  

mu ichi
zinthu matenda akapatsidwa ndi "awiri" ACK antiplatelet mankhwala (150-300 mg ndi kuwauza kapena
250-500 mg ndi monga / mu bolus akutsatiridwa ndi utsogoleli wa 75-100 mg / tsiku) ndi prasugrel
(Kutsegula mlingo wa 60 mg akutsatiridwa ndi 10 mg / tsiku), ndipo ticagrelor (Mumakonda mlingo wa 180 mg wa
otsatidwa ndi utsogoleli wa 90 mg wa nthawi 2 tsiku) kapena clopidogrel (Mumakonda mlingo 600
otsatidwa ndi makonzedwe
75 mg / tsiku). The Malangizo a Society Loona za Cardiology limati
prasugrel ndi ticagrelor clopidogrel aluso mu mawu a kuchepetsa
pafupipafupi ophatikizana ischemic endpoints ndi stent thrombosis odwala
MI okwera cha ku Switzerland, ndipo zilibe azitaya
amataya magazi. Malinga ndi malangizo a bulu 2013 si prasugrel
Iwo akulimbikitsidwa odwala ndi
mbiriyakale ya sitiroko kapena TIA. Kukachitika kuti asanaloŵe
bungwe zachipatala kuchita inatsekeratu angiography ndi stenting mtima
fibrinolysis inachitika ndipo zinali maola 24 ndipo kuti nthawi yomweyo sizinagwiritsidwe ntchito
clopidogrel (prasugrel), ndiye clopidogrel Mumakonda mlingo ndi 300 mg,
Prasugrel ndi 60 mg.

Pa chiopsezo
intracoronary thrombosis, pamodzi ndi antiplatelet mankhwala wapawiri
Iwo akuonetsa ntchito GPIIb-IIIa zoletsa (abciximab / vesi bolus wa 0,25 mg / kg pa akutsatiridwa ndi kulowetsedwa wa 0,125 mg / kg pa / mphindi kuti
mlingo pazipita 10 mg / Mph kwa maola 12.). Pakali pano palibe
wokwanira umboni waukulu Mwachangu GPIIb-IIIa zoletsa pamene ntchito
prehospital kapena pamaso catheterization.

monga
UFH anticoagulation mankhwala ntchito (mu / mu bolus 60 U / kg osakaniza ndi GPIIb-IIIa woletsa kapena / bolus 100 U / kg popanda
GPIIb-IIIa) woletsa. Bivalirudin monga monotherapy m'malo UFH osakaniza ndi woletsa wa GPIIb-IIIa monga analimbikitsa ndi ACC 2013
Iwo akulimbikitsidwa odwala ndi chiopsezo magazi lalikulu (bolus wa 0,75 mg / kg pa akutsatiridwa ndi kulowetsedwa wa 1,75
mg / kg pa / ola); Pa nthawi yomweyo, fondaparinux ali osavomerezeka chifukwa cha chiopsezo
catheter thrombosis.

Malinga ndi mawu motere kuchokera
kuchipatala wapawiri antiplatelet mankhwala ntchito kwa miyezi 12.

chidwi ziperekedwe kwa kuphatikiza
clopidogrel ndi pulotoni mpope zoletsa, chotchuka ntchito kupewa
m'mimba magazi. Malinga ndi ofanana wa gulu la ntchito za kupewa thrombotic
ndipo hemorrhagic mavuto ICSI ophatikizana ntchito mankhwala odwala
OKHUDZIDWA magazi GI sitingachisonyeze, ntchito zawo munthawi yomweyo ayenera payekha payekha pamaziko a
amaganizira ubwino ndi kuopsa. okha
PPI mankhwala ku gulu - pantoprazole - osati "mpikisano" klopidoglelya
chifukwa isoenzyme CYP2C19. Komano
palibe apamwamba mayesero matenda mumayesto zotsatira za olowa
kutsatira pantoprazole ndi clopidogrel
kuchepetsa chiopsezo cha mtima imodzi ndi hemorrhagic
zosokonezeka. Kapenanso PPI mwina H2 cholandilira blockers - famotidine, ranitidine.

mankhwala chizolowezi
mankhwala

Beta-blockers amapatsidwa choyamba maola 24 kuchokera nthawi odwala onse ndi ACS
pakalibe kulephera mtima ndi matenda otsika linanena bungwe,
cardiogenic mantha ndi contraindications muyezo kugwiritsa ntchito gulu la mankhwala.
Chikuonetseratu beta blockers anapitiriza mu nthawi ya m'chipatala ndipo pambuyo
mawu.
zoletsa Ace amaikidwa
odwala onse ndi zapambuyo MI, lv ejection kachigawo pansipa 40%, pakalibe
contraindications. Ngati pali contraindications kwa zoletsa Ace ntchito blockers
angiotensin II cholandilira. muzikangana
aldosterone anasonyeza odwala ndi kulephera symptomatic mtima
ndi / kapena pamaso pa matenda a shuga. Yaitali ntchito statins zonse asonyeza
odwala ACS (palibe contraindications).