ACS - sibi syndrome senhliziyo

IV Samorodskaya,

UProfesa, Doctor of Medical Sciences

yenhliziyo acute
syndrome

ithimba multidisciplinary enquma

Ukusebenzisa izindlela zanamuhla eliphambili lokwelapha sibi syndrome senhliziyo (ACS)
- a term elisho Nobe nguliphi licembu izimpawu emtholampilo noma izimpawu
ngokuvumela esolwa acute isilethikusebenza (MI) noma ingazinzi
angina, unikeza ithemba ukuncipha okukhulu esibhedlela
lokufa futhi ngcono Izibikezelo esikhathini eside.

Eminyakeni ethile edlule, ucwaningo ngamazwe Amathrendi kukhona
esifingqa Zonke-Russian Scientific Society of nezenhliziyo e izincomo Russian ku uphethwe
futhi nokwelashwa kweziguli isilethikusebenza ne-ST ingxenye kokuphakama (2007), ngaphandle ST kokuphakama futhi angina engazinzile (2006). Ngo-2010, enyatheliswa yi-izincomo European
Society of nezenhliziyo (ESC) kukhethwa izindlela revascularization esivimba amanzi, imihlahlandlela kazwelonke lokuphathwa kweziguli ACS e-Australia
Britain, imiphumela ngamazwe
kuvunyelwane ukuphathwa kweziguli ACS. Ngo 2013
i-American Heart
Umphakathi (ACCF / AHA) ibuyekeze
izincomo ukuphathwa kweziguli ACS
ST ingxenye ephakeme.  

Isinqumo amaqhinga
ukuphathwa nibekezele ACS njengoba ephakeme kanjalo ngaphandle-ST ingxenye kokuphakama akuyona kuphela elula njalo, ngokuvamile kudinga iqhaza multidisciplinary
iqembu ongoti okusekelwe imihlahlandlela yomtholampilo, Yiqiniso lesi sifo, ubudala isiguli, izimo
anakekele. Ngesikhathi esifanayo yonke iziguli ezine esolwa ACS
Kumele wenze i-electrocardiogram (ngokungabi bikho
izinguquko noma idatha ezingabazekayo ebezidinga okuphindaphindiwe ukuqoshwa ngezikhawu 15
imizuzu -30, kuye ngesimo zokwelapha isiguli), futhi amazinga kunokwenzeka yokutadisha
I-enzyme inhliziyo, ukusetshenziswa esiyisibopho aspirin kubhekwa. e
Zonke izincomo ezwakala amasu endovascular
revascularization esivimba amanzi ebukhoneni i kwabasebenzi abaqeqeshiwe abanolwazi.
ukwelashwa Fibrinolytic (njengoba isinyathelo sokuqala ekunakekela iziguli ACS ne-ST ingxenye kokuphakama) uhlala efanele kulabo izimo,
lapho akunakwenzeka ukwenza stenting
imizuzu 120 ngemva
elivela kuzo ubuhlungu (ngokungabi bikho contraindications uma kusukela ubuhlungu Kwakungekhona ngaphezu
amahora angu-12). Lapho ACS ngaphandle oqeda ST fibrinolytic ingxenye
yokwelapha is hhayi iqondiswa.

Uma ingozi yokuhlaselwa isifo senhliziyo kanye / noma yayo
yezinkinga okusezingeni eliphezulu

abahlanganyeli
ukudala iseluleko lochwepheshe e-Europe, i-United States ukholelwa ukuthi ukuqaliswa
angiography yenhliziyo ngaphakathi 2 amahora kusukela okwamanje yokwemukela
Kunconywa uma isiguli ngokuhlasela angina ku ngezokwelapha
ngokuphatha ziphikelela noma ziyabuya
angina waphawula ashukumisayo ST ingxenye izinguquko, okuyela yentuthuko umonakalo
noma isilethikusebenza; hemodynamic
kokuntengantenga kwezomnotho, abalulekile ventricular arrhythmias. Buciko angiography (nge okwalandela
revascularization) amahora angu-24 emva yokwemukelwa lesiguli esibhedlela nge ACS Kunconywa uma ephezulu
ingozi isilethikusebenza, okuyisimo esisongela ukuphila
yezinkinga ukufa. isikhathi okufanayo angiography yenhliziyo Kunconywa
Lapho kudingeka khona uphethwe umehluko ACS nabanye
izimo esiphuthumayo (embolism yamaphaphu, sokuhlaziya
useshonile yomthambo i-aorta). Ezimweni sibi syndrome senhliziyo ngaphandle ingxenye ST lift engozini eliphansi esisongela ukuphila
yezinkinga ukufa ngesikhathi uhlala khona esibhedlela
ukwelashwa, kodwa ophikelelayo izimpawu of angina kanye / noma ischemia eyenga
phakathi novivinyo umthwalo, angiography yenhliziyo kulandele revascularization ngesikhathi
kunesidingo futhi kungenzeka kungcono ukuba afeze esikhathini esinikeziwe
esibhedlela emahoreni angama-72 emva yokwemukelwa. Esikhathini
uma isiguli ungeniswe isikhungo sokwelapha, lapho akwenzeki
ukwenza angiography yenhliziyo, it is idluliselwe esibhedlela efanele (isib
Regional Umhlinzi Centre).

ezivamile
kubhekwa stenting qhinga (stent engazweli camera
noma uncoated) ne infarct ezihlobene Umthambo tromboekstratsiey (at
kunesidingo), kuyilapho ACS c lift
ST ingxenye
kungakhathaliseki ukuqaliswa kanye nomphumela yokwelapha fibrinolytic (ngokuvumelana
Izincomo kusukela 2013 ACC emva kokwelashwa fibrinolytic Kunconywa ukwenza
FCT futhi stenting lungekho ngaphambi
amahora 2-3). Uma-c ingxenye kokuphakama acute yenhliziyo syndrome ST, ngaphandle infarct Umthambo, kukhona sina
stenoses kwezinye lemithambo yabo stenting eziphuthumayo wenziwa kuphela
kulabo nge ezinzima inhliziyo ukwehluleka kanye / noma ukushaqeka cardiogenic. Ngamanye
Ezimweni stenting imisiwe wenziwa - isidingo futhi isikhathi
isinqumo ngemva ukucindezeleka ihlola ngaphambi ukuchithela isiguli kusukela
esibhedlela. Ngokusho izincomo ochwepheshe abavela e-United States 2013, ngaphandle stents
I enamathela is okungcono esetshenziswa ezimweni lapho isiguli
izifo kanye nezimo nge ingozi eliphezulu ukopha, awokuthi,
ukuthi isiguli alihambisani ungakapheli unyaka ezimbili antiplatelet lwemithi
ukwelashwa, futhi kungenzeka ukuhlinza okwalandela
imisebenzi. Ngaphezu kwalokho, izincomo wabonisa ukuthi-c ingxenye kokuphakama ACS ST stenting ngemva kwamahora angu-24 kusuka ngesikhathi salo
Ukuthuthukiswa lingakhonjiswa amacala 1-2 izilonda semithambo ngokungabi bikho
izimpawu kulondolozwe ischemia esivimba amanzi. Ezimweni ezingavamile (ngaphansi ezithile
izimo) wenziwa angioplasty.

Isinqumo mayelana indlela revascularization in iziguli sibi syndrome senhliziyo ngaphandle ingxenye ST kuyanda, futhi ACS c ST ingxenye ukuphakama, kodwa ngenxa yokuntuleka kwezinhlelo ezibanzi
yenhliziyo ukuvaleka endawo nemithambo yegazi yenhliziyo, nakanjani "benecala" e
ACS noma ine isifo multivessel, lapho ukuqaliswa
Stenting ngokomthetho engenakwenzeka noma ingozi ukuthi idlula nomthamo
inzuzo sitholwa ngochwepheshe eziningana (kukadokotela ohlinza imithambo yenhliziyo,
wenhliziyo, onguchwepheshe emkhakheni
Imiphumela yaloku kuhlola okungenhla Endovascular nokwelashwa) ne
zokwelapha, angiographic kokuhlaziywa idatha ukugeleza fractional reserve,
elindelwe Izibikezelo eside.

ukwesekwa imithi
ngempela

Lapho ACS nge ST ingxenye kokuphakama ochwepheshe abaningi bakholelwa ukuthi amacebo samanje iziguli
It kuncike kakhulu ohlelweni lwezempilo wezwe
(Region) ukwenza endovascular eyinhloko kokungenela (ngaphandle
thrombolysis) amahora ama-2 on ukuthuthukisa izimpawu zokwelashwa e isiguli.

Uma-ke kulindeleke ukuthi isikhathi kusuka Ungowokuqala okuxhunyanwa naye isiguli
izisebenzi zezokwelapha ngaphambi kokwenza angiography yenhliziyo kuyoba ngaphezu 2
amahora, iziguli
(In the ukungabikho Izimo) enze thrombolysis nge
ukulethwa okwalandela emtholampilo angiography enza futhi revascularisation
infarction kungakapheli amahora 3-24. Kulezo zimo, uma isizinda thrombolysis
ST ingxenye kokuphakama agcinwayo ezingaphezu kuka-50% izinga sokuqala kanye / noma retrosternal
ubuhlungu, isiguli libonisa eziphuthumayo angiography yenhliziyo. Uma uphumelele,
thrombolysis angiography yenhliziyo futhi revascularization (uma kuboniswe) may
kwenziwe emahoreni angu-24. Izincomo wawuthi
revascularization angathuthukisa onalesi sifo kanye nokuqaliswa kwalo ngokusebenzisa 24-60
amahora lapho kuqala izimpawu zokwelashwa, kodwa kuphela lokhu ikakhulukazi ezimweni lapho
Kukhona angina yansukuzonke kanye / noma ischemia esivimba amanzi itholwe ngenkathi
izifundo wezinsimbi.

ukuphuma
Kuye uhlobo ACS futhi revascularization indlela kuphoqelelwe
ukwesekwa izidakamizwa, okubandakanya antiplatelet,
yokwelapha antiplatelet, beta-blocker yokwelapha, inhibitor ka angiotensin ukuguqulela
enzyme, statin. yokwelapha izidakamizwa is ngamunye kushintshwe
Kuye ukuma ACS kanzima khona soputsvuyuschie egunjini lokuhlolwa kwezifo. I
Le ncwadi izogxila kuphela yokwelapha antiplatelet,
izindlela esihambisana revascularization esivimba amanzi.

Ingxenye kokuphakama ACS ngaphandle S T

I
Ezimweni ezinjalo izindlela revascularization endovascular
ubeke "kabili 'yokwelapha antiplatelet ebandakanya ngomlomo
acetylsalicylic acid (ASA), kanye clopidogrel (noma prasugrel noma
ticagrelor). ASA inikezwe lokuqala ethola 150-300 mg (250-500 mg noma ngesimo
e / e bolus) kulandelwa umthamo ukulayisha 75-100 mg / usuku umthamo
600 mg clopidogrel (kusenesikhathi) kulandele nokuphathwa 75
mg / ngosuku izinyanga 9-12 prasugrel - ukulayisha 60 mg umthamo, kulandele
ukuthatha 10 mg / ngosuku, noma ticagrelor - 180 mg ukulayisha umthamo, kulandele
ukuthatha 90 mg 2 izikhathi ngosuku. Izinkomba ukusetshenziswa eminye
GPIIb-IIIa inhibitor abhekwa zisengozini enkulu yokuba lesi thrombosis intracoronary ezigulini othola angioplasty kanye / noma stenting
nemithambo yegazi yenhliziyo.

I
izincomo NICE (UK) uphawula ukuthi
Iziguli zisengozini enkulu yokuba lesi izenzakalo zenhliziyo (afakwa sezinyanga ezingu-6
ngokwempilo yangenyama kuka-3%) futhi equliswa angiography yenhliziyo futhi revascularization
engakapheli amahora angu-96 kusukela ngesikhathi isimiso yokuvuma aboniswe
Ukuqokwa komgwamanda eptifibatide noma tirofiban. Abciximab esemisiwe njengenceku yokwelapha,
elikulesi sihloko revascularization endovascular uma kungekho
Amandla wokunika abanye inhibitor ka GPIIb-IIIa. Kufanele kuqashelwe ukuthi
Ngokungafani isiqondiso NICE (UK) izincomo
European Society of nezenhliziyo "izintandokazi" kunikezwa abciximab (Ibanga
izinkomba I), ngesikhathi esifanayo i-eptifibatide
noma tirofiban Setha Class IIa.

Ukukhetha kanye umthamo
anticoagulants ukwenza angiography
revascularization iziguli ngaphandle ACS
ST ephakamisa ingxenye kunqunywa esekelwe
Babhekane nezinga elikhulu lobungozi yezinkinga thrombotic, ischemic futhi oluhambisana. Isengozini enkulu kakhulu
izenzakalo ischemic (ngokwesibonelo, lapho ukuntengantenga hemodynamic refractory ezisongela ukuphila arrhythmias) nesineke
zilethwe ngqo-X-ray kanye kunikezelwe
heparin unfractionated (UFH) njengoba / in a bolus 60 U / kg okwalandela
ukumnika ngesikhathi revascularization ihambisana double
ukwelashwa antiplatelet. Basengozini enkulu ebangela ukopha kungenziwa kusetshenziswa
monotherapy bivalirudin bolus ka 0.75 mg / kg kulandele nekufakwa 1.75
mg / kg / ihora. Ezigulini ezine-ingozi isilinganiso izenzakalo ischemic (isibonelo,
hemodynamics esethembisayo, kodwa a troponin test omuhle, ekubhemeni
angina, izinguquko ashukumisayo e ST ingxenye), okuyinto ihlelelwe izinqubo koda 24-48
amahora ezilandelayo zokwelapha ezikhona ngaphambi angiography yenhliziyo
kuhlelwe endovascular revascularization esivimba amanzi:

• Ezigulini
  

heparin Unfractionated 60 U / kg ngesimo ku / e bolus,
ke ukumnika ngaphansi ukulawula isebenze ngokwengxenye thromboplastin isikhathi
(APTT) noma enoxaparin 1 mg / kg S.C. x 2 ngosuku noma Fondaparinux 2.5 mg / usuku
Bivalirudin phansi kwesikhumba noma 0.1 mg / kg njengoba / in a bolus kulandele ukumnika
0.25 mg / kg / ihora

• Iminyaka iziguli ≥75

heparin Unfractionated 60 U / kg ngesimo ku / e bolus,
ke ukumnika ngaphansi kolawulo APTT

Noma enoxaparin 0.75 mg / kg x 2
Fondaparinux usuku noma 2.5 mg / usuku phansi kwesikhumba noma Bivalirudin 0.1 mg / kg njengendlela
Mina / bolus kulandele nekufakwa 0.25 mg / kg / ihora.

Ngo
iziguli nge obuncane imicimbi zenhliziyo (ngaphandle okwandisa
troponin futhi ST ingxenye izinguquko), olandelanayo ngaphezulu kuhlelwe
ukwelashwa kanye fondaparinux babelwe (2.5 mg / usuku phansi kwesikhumba) noma enoxaparin (1
mg / kg S.C., izikhathi 2 ngosuku iziguli iminyaka ≥75 - 0.75 mg) kanye heparin unfractionated (60 U / kg
njengasezulwini / bolus, kulandele ukumnika ngaphansi kolawulo aPTT).

ACS nge ST ingxenye kokuphakama  

kulesi
isimo emitholampilo inikezwa "kabili" Ukwelapha Ack antiplatelet (150-300 mg ngomlomo noma
250-500 mg njengoba / in a bolus kulandele nokuphathwa 75-100 mg / ngosuku) kanye prasugrel
(60 mg ukulayisha umthamo kulandele nokuphathwa 10 mg / ngosuku), noma ticagrelor (iyalayisha umthamo 180 mg
kulandele nokuphathwa 90 mg izikhathi 2 ngosuku) noma clopidogrel (iyalayisha umthamo 600
kulandele ekuphathweni
75 mg / ngosuku). I Izincomo European Society of nezenhliziyo uthi
prasugrel futhi ticagrelor clopidogrel ngempumelelo ngaphezulu ngokuya ekunciphiseni
imvamisa kuhlanganiswe Endpoints ischemic futhi stent thrombosis ezigulini
MI kokuphakama ST, futhi akusho kwandisa ingozi
ukopha ezinzima. Ngokusho izincomo nezembongolo 2013 akuyona prasugrel
It Kunconywa iziguli
umlando unhlangothi noma TIA. Uma kwenzeka ukuthi ngaphambi kokungena
isikhungo sezokwelapha ukwenza angiography yenhliziyo kanye nesineke stenting
fibrinolysis kwenziwe futhi kwaba emahora langaphasi kulangu-24 futhi ngesikhathi esifanayo ayengasetshenziswa
clopidogrel (prasugrel), khona-ke clopidogrel ukulayisha umthamo kuyinto 300 mg,
Prasugrel kuyinto 60 mg.

Basengozini enkulu
thrombosis intracoronary, kanye ezimbili ukwelashwa antiplatelet
It uncoma ukusebenzisa GPIIb-IIIa inhibitor (abciximab / v bolus ka 0.25 mg / kg kulandele nekufakwa 0,125 mg / kg / amaminithi
ezingeni obungu-10 mg / imiz amahora 12.). Okwamanje akekho
nekutsi uphetsa ngalokufanele yini ubufakazi ngekhono elingcono GPIIb-IIIa inhibitor lapho kusetshenziswa
prehospital noma ngaphambi catheterization.

njengoba
UFH yokwelapha anticoagulation isetshenziswa (e / e bolus 60 U / kg lihambisana inhibitor GPIIb-IIIa noma / bolus 100 U / kg ngaphandle
GPIIb-IIIa) inhibitor. Bivalirudin njengoba monotherapy esikhundleni UFH lihambisana i inhibitor ka GPIIb-IIIa njengoba batusa ACC 2013
It Kunconywa iziguli engozini eliphezulu ezinkulu ukopha (bolus ka 0.75 mg / kg kulandele nekufakwa 1.75
mg / kg / ihora); Ngesikhathi esifanayo, fondaparinux is hhayi Kunconywa ngenxa ingozi eliphezulu
ipayipi thrombosis.

Ngokusho isitatimende kulandela kusukela
esibhedlela ezimbili ukwelashwa antiplatelet isetshenziswa izinyanga okungenani 12.

Ngokukhethekile kufanele kukhokhelwe inhlanganisela
clopidogrel futhi proton futha inhibitor, ebisetshenziswa nokuvimbela
ukopha emathunjini. Ngokwe ukuvumelana wesiqhema esisebenzako nokuvimbela thrombotic
kanye nezinkinga oluhambisana ICSI kuhlanganiswe ukusetshenziswa kwezidakamizwa iziguli
ingozi eliphansi GI ukopha ayiboniswa, ukusetshenziswa kwazo ngesikhathi esifanayo kufanele abathile ngesisekelo
ikhumbula izinzuzo nezingozi. kuphela
PPI imithi kusukela iqembu - pantoprazole - hhayi "esincintisana" klopidoglelya
I-isoenzyme CYP2C19. Ngakolunye uhlangothi
kungekho eliphezulu zokwelapha ahlola umphumela joint
isicelo pantoprazole futhi clopidogrel
ukunciphisa ingozi senhliziyo nemithambo yegazi ngesikhathi esifanayo futhi oluhambisana
izinkinga. Kungenjalo PPI kungase H2 yokwamukela blocker - famotidine, ranitidine.

imithi isimiso
Ukwelapha

Beta-blocker babelwa angu-24 zokuqala kusukela esikhathini zonke iziguli ezine-ACS
ngokungabi bikho senhliziyo nge ongaphakeme okukhipha syndrome,
ukushaqeka cardiogenic kanye contraindications ejwayelekile ukusetshenziswa leli qembu izidakamizwa.
Ukwamukelwa beta blocker kwaqhubeka phakathi nayo yonke inkathi esibhedlela nangemva
izitatimende.
ACE inhibitor aqokwa
Zonke iziguli ezine-anterior isilethikusebenza, ejection ingxenyenamba ngaphansi kuka-40% ku engekho
Izimo. Uma kukhona Izimo for ACE inhibitor asetshenziswa blocker
angiotensin II yokwamukela. abamelene
aldosterone wabonisa in iziguli lingaze senhliziyo
kanye / noma ukuba khona sikashukela. ukusetshenziswa isikhathi eside wonke statin eboniswe
iziguli ezine-ACS (akukho Izimo).