ACS - m jijiyoyin zuciya ciwo

IV Samorodskaya,

Farfesa, Doctor of Medical Sciences

m jijiyoyin zuciya
ciwo

Ansu} ungiyoyi yanke shawarar

Amfani da hanyoyin zamani na jiyya ga m jijiyoyin zuciya ciwo (ACS)
- wani lokaci a samansu da wani rukuni na asibiti ãyõyi, ko da bayyanar cututtuka
kyale ake zargin m tsokar zuciya infarction (MI) ko m
angina, ya ba da bege ga wani gagarumin raguwa a asibiti
mace-mace da kuma inganta hangen nesa a cikin dogon lokacin da zamani.

Shekaru da dama da suka wuce, bincike da kuma na kasa da kasa yayi ne
takaita All-Russian Scientific Society of Cardiology a Rasha shawarwari a kan ganewar asali
da kuma lura da marasa lafiya da tsokar zuciya infarction da ST-kashi tadawa (2007), ba tare da ST tadawa kuma m angina (2006). A 2010, aka buga da Turai shawarwarin
Society of Cardiology (QShortcut) a kan ya zabi na hanyoyi na tsokar revascularization, na kasa jagororin ga management na marasa lafiya da ACS a Australia
Birtaniya, sakamakon na kasa da kasa
yarjejeniya a kan gudanar da marasa lafiya da ACS. a 2013
American Zuciya
Society (ACCF / AHA) ya sabunta
shawarwari ga management na marasa lafiya da ACS
ST kashi tadawa.  

The yanke shawara a kan dabara
haƙuri management a ACS matsayin tadawa haka ba tare da ST-kashi tadawa ba ko da yaushe uniquely sauki, sau da yawa na bukatar zantawar} ungiyoyin sa hannu
wata tawagar kwararru dangane da asibiti jagororin, Hakika na cuta, shekaru na haƙuri, yanayi
kula. A lokaci guda a duk marasa lafiya da ake zargin ACS
dole yi wani electrocardiogram (in babu
canje-canje ko m data bukata maimaita rikodi jinkiri 15
-30 minti, dangane da asibiti yanayin haƙuri), da kuma zai yiwu matakan nazari
domin cardiac enzymes, m yin amfani da asfirin an dauke. a
All shawarwari aka fĩfĩta endovascular dabaru
tsokar revascularization a gaban wani gogaggen m sandarka.
Fibrinolytic far (a matsayin mataki na farko na bayar da kula ga marasa lafiya da ACS da ST-kashi tadawa) ya zauna dacewa ga waɗanda yanayi,
a lokacin da ba shi yiwuwa a yi stenting
ga 120 minti bayan
abin da ya faru na zafi (in babu contraindications kuma idan tun zafi ba fiye da
12 hours). Lokacin da ACS ba tare da dagawa fibrinolytic ST kashi
far ba gudanar.

Idan hadarin ciwon zuciya da kuma / ko ta
high rikitarwa

mahalarta
samar da masu sana'a shawara a Turai, Amurka ta yi imanin cewa da aiwatar da
jijiyoyin zuciya angiography cikin 2 hours daga lokacin da na shiga
bada shawarar idan wani haƙuri da wani hari na angina a kan likita bango
zalunta da cututtuka nace ko recur
angina lura tsauri ST kashi canje-canje, suggestive lalacewa ci gaba
ko tsokar zuciya infarction. hemodynamic
rashin zaman lafiya, da muhimmanci na ramin zuciya arrhythmias. Yin angiography (tare da m
revascularization) for 24 hours bayan haƙuri da kudin shiga ga wani asibiti tare da ACS bada shawarar idan akwai high
hadarin tsokar zuciya infarction, rai barazana
rikitarwa da kuma mutuwa. Similar lokaci na jijiyoyin zuciya angiography bada shawarar a
Inda ake bukata bambanci ganewar asali ACS tare da sauran
gaggawa yanayi (na huhu embolism, dissecting
aortic aneurysm). A lokuta da m jijiyoyin zuciya ciwo ba tare da kashi ST daga at low hadarin rai barazana
rikitarwa da kuma mutuwa a lokacin asibiti Yawara
magani, amma m bayyanar cututtuka na angina da / ko ischemia jawo
a lokacin da load gwajin, jijiyoyin zuciya angiography bi ta revascularization a
dole kuma zai yiwu shi ne bu mai kyau zuwa ga gudanar da wani a cikin wani da aka ba lokacin
arin cikin sa'o'i 72 bayan m. a
idan haƙuri aka shigar da shi wani likita makaman, inda ba shi yiwuwa
yi a jijiyoyin zuciya angiography, shi da aka canjawa wuri zuwa dace asibiti (msl.
Regional jijiyoyin bugun gini Center).

kowa
dauke tactic stenting (miyagun ƙwayoyi-mai rufi stent
ko uncoated) tare da infarct alaka jijiya tromboekstratsiey (a
dole), yayin da ACS c daga
ST kashi
ko da kuwa da aiwatar da sakamakon fibrinolytic far (bisa
Shawarwari daga 2013 ACC bayan fibrinolytic far bada shawarar a yi
FCT, kuma stenting ba a baya fiye da
2-3 hours). Idan c-kashi tadawa m jijiyoyin zuciya ciwo ST, fãce infarct jijiya, akwai tsanani
stenoses a wasu jijiyoyi, da gaggawa stenting aka yi kawai
ga waɗanda suke tãre da tsananin zuciya gazawar da kuma / ko cardiogenic buga. a wasu
lokuta jinkirta stenting aka yi - da bukatar da lokaci na
yanke shawarar bayan da danniya gwaje-gwaje kafin sallamar na haƙuri daga
asibiti. Bisa ga shawarwarin da masana daga kasar Amurka shekarar 2013, ba tare da stents
A shafi ne zai fi dacewa a yi amfani da lokuta inda haƙuri yana da
cututtuka da kuma yanayi da wani babban hadarin zub da jini, high yiwuwa,
cewa haƙuri ba cika a cikin shekara na dual antiplatelet regimen
far, kuma shi ne wata ila don yin m tiyata
yadda ake gudanar. Bugu da ƙari, cikin shawarwari nuna cewa c-kashi tadawa ACS ST stenting bayan 24 hours daga lokacin da ta
Development ba aka nuna a cikin lokuta 1-2 jijiyoyin bugun gini raunuka in babu
ãyõyi adana tsokar ischemia. A rare lokuta (a karkashin wasu
yanayi) yi angioplasty.

A yanke shawara game da hanyar da revascularization a marasa lafiya tare da m jijiyoyin zuciya ciwo ba tare da kashi ST Yunƙurin, kuma a ACS c ST kashi tadawa, amma in babu
jijiyoyin zuciya gida takaita da jijiyoyin zuciya arteries, shakka "m" a cikin
ACS ko yana multivessel cuta, a cikin abin da ta aiwatar da
Stenting ne a zahiri ba zai yiwu ba, ko hadarin da cewa ya wuce da damar
da amfani da aka samu da dama masana (zuciya da jijiyoyin jini likita,
likitan zuciyar, wani gwani a fagen
Endovascular ganewar asali da kuma lura) tare da
asibiti, angiographic data kimantawa fractional kwarara ajiye,
da sa ran dogon lokacin da hangen nesa.

magani support
dole

Lokacin da ACS da ST kashi tadawa kwararru da yawa imani da cewa yanzu dabara na marasa lafiya a cikin
Yana dogara sun fi mayar a kan tsarin lafiyar kasar
(Region) yin farko endovascular baki (ba tare da kafin
thrombolysis) domin 2 hours a kan ci gaban na asibiti cututtuka a haƙuri.

Idan ana sa ran cewa lokaci daga farko lamba tare da haƙuri
kiwon lafiya kafin yin jijiyoyin zuciya angiography zai zama fiye da 2
hours, da marasa lafiya
(A babu contraindications) dole yi thrombolysis tare da
m bayarwa ga asibitin domin yin angiography da revascularisation
infarction cikin 3-24 hours. A waɗannan lokuta, idan bango na thrombolysis
ST kashi tadawa riƙe fiye da 50% na farko matakin da / ko retrosternal
zafi, da mãsu haƙuri nuna gaggawa jijiyoyin zuciya angiography. Idan nasara,
thrombolysis jijiyoyin zuciya angiography da revascularization (idan ya nuna) may
za a yi cikin awoyi 24. The shawarwari ya bayyana cewa,
revascularization iya inganta hangen nesa da kuma ta aiwatar da ta 24-60
sa'o'i bayan da farko na asibiti bayyanar cututtuka, amma kawai a kuma waɗannan lokuta inda
Akwai maimaita angina da / ko tsokar ischemia gano a lokacin
instrumental karatu.

daga
Dangane da irin ACS da revascularization Hanyar ne wajibi
miyagun ƙwayoyi support, wanda ya hada da antiplatelet,
antiplatelet far, beta-blockers far, hanawa na angiotensin tana mayar
enzyme, statins. Drug far ne akayi daban-daban gyara
Dangane da siffar ACS mai tsanani, gaban soputsvuyuschie Pathology. A
Wannan littafin zai mayar da hankali ne kawai kan antiplatelet far,
rakiya da hanyoyin da tsokar revascularization.

Kashi tadawa ACS ba tare da S T

A
irin haka endovascular revascularization hanyoyin
nada wani "biyu" antiplatelet far da ya hada da na baka
acetylsalicylic acid (ASA) da kuma clopidogrel (ko prasugrel ko
ticagrelor). ASA aka sanya wa na farko samun 150-300 MG (250-500 MG ko a cikin nau'i na
a / a bolus) bi ta wani sashi na 75-100 MG / rana loading kashi
600 MG na clopidogrel (as farkon yiwu) bi gwamnati na 75
MG / rana for 9-12 watanni prasugrel - 60 MG loading kashi, bi da
shan 10 MG / rana, ko ticagrelor - 180 MG loading kashi, bi da
shan 90 MG sau 2 a rana. Alamomi ga kara yin amfani da
GPIIb-IIIa hanawa an dauke su a babban hadarin da intracoronary thrombosis a marasa lafiya jurewa angioplasty da / ko stenting
jijiyoyin zuciya jijiyoyi.

A
shawarwari kyau (UK) Notes cewa
Marasa lafiya a babban hadarin da cututtuka na zuciya events (kimanta 6 ga watan
mace-mace fiye da 3%) kuma ya hõre su jijiyoyin zuciya angiography da revascularization
cikin 96 hours daga lokacin da m na yau da kullum da aka nuna
nada eptifibatide ko tirofiban. Abciximab aka nada a matsayin far,
rakiya endovascular revascularization idan babu
Ability don sanya wasu hanawa na GPIIb-IIIa. Ya kamata a lura cewa a
Ba kamar kyau shiriya (UK) shawarwari
Turai Society of Cardiology "son" da aka ba abciximab (Grade
alamomi na), a lokaci guda domin eptifibatide
ko tirofiban Saita Class IIa.

Choice da kuma kashi
anticoagulants yin angiography
revascularization a marasa lafiya ba tare da ACS
dagawa ST kashi m dogara ne a kan
Stratification na hadarin thrombotic, ischemic da hemorrhagic rikitarwa. A sosai high hadarin
ischemic events (misali, a lokacin da hemodynamic rashin zaman lafiya, mai tsaurin rai-barazanar arrhythmias) haƙuri
tsĩrar da kai tsaye tare da X-ray, kuma shi ake sa
unfractionated heparin (UFH) kamar yadda / a bolus na 60 U / kg tare da m
jiko a lokacin revascularization a tare da wani biyu
antiplatelet far. A babban hadarin da zub da jini za a iya amfani da
monotherapy bivalirudin bolus na 0.75 MG / kg bi ta jiko na 1,75
MG / kg / hr. Ga marasa lafiya da wani talakawan hadarin ischemic events (misali,
barga hemodynamics, amma a tabbatacce troponin gwajin, relapsed
angina, tsauri canje-canje a cikin ST kashi), wanda aka shirya domin cin zali hanyoyin 24-48
hours bin jiyya zabin zama kafin jijiyoyin zuciya angiography
shirya endovascular tsokar revascularization:

• Ga marasa lafiya <75 years

Unfractionated heparin 60 U / kg a cikin nau'i na a / a bolus,
sa'an nan jiko a karkashin iko na kunna m thromboplastin lokaci
(APTT) ko enoxaparin 1 MG / kg s.c. x 2 a kowace rana ko Fondaparinux 2.5 MG / rana
Bivalirudin subcutaneously ko 0.1 MG / kg kamar yadda / a bolus bi ta jiko
0.25 MG / kg / hour

• Ga marasa lafiya ≥75 shekaru

Unfractionated heparin 60 U / kg a cikin nau'i na a / a bolus,
sa'an nan jiko karkashin iko APTT

Ko enoxaparin 0.75 MG / kg x 2
Fondaparinux rana ko 2.5 MG / rana subcutaneously ko Bivalirudin 0.1 MG / kg a matsayin
I / bolus bi ta jiko na 0.25 MG / kg / hr.

a
marasa lafiya tare da wani low hadarin da cututtuka na zuciya events (ba tare da kara
troponin kuma ST kashi canje-canje), mafi ra'ayin mazan jiya shirya
magani da kuma sanya fondaparinux (2.5 MG / rana subcutaneously) ko enoxaparin (1
MG / kg s.c., sau 2 a rana a marasa lafiya ≥75 shekaru - 0.75 MG) da kuma unfractionated heparin (60 U / kg
kamar yadda a / bolus, bi da jiko karkashin iko aPTT).

ACS da ST kashi tadawa  

a wannan
asibiti halin da ake ciki da aka sanya a "biyu" ACK antiplatelet far (150-300 MG baki ko
250-500 MG kamar yadda / a bolus bi ta gwamnati na 75-100 MG / rana) da kuma prasugrel
(60 MG loading kashi biyar ta gwamnati na 10 MG / rana), ko ticagrelor (loading kashi na 180 MG
bi da gwamnati na 90 MG sau 2 a rana), ko clopidogrel (loading kashi 600
bi da gwamnati
75 MG / rana). A Yabo na Turai Society of Cardiology ce
prasugrel da ticagrelor clopidogrel mafi tasiri a cikin sharuddan na rage
mita hada ischemic endpoints da stent thrombosis a marasa lafiya
MI tadawa ST, kuma bã ya ƙãra hadarin
m zub da jini. Bisa ga shawarwari na jaki 2013 ne ba prasugrel
Yana bada shawarar ga marasa lafiya da
wani tarihi na bugun jini ko Tia. A cikin taron cewa kafin shigar da
likita ma'aikata yin jijiyoyin zuciya angiography da stenting haƙuri
fibrinolysis da aka yi, kuma shi ne kasa da sa'o'i 24 da kuma don daidai wannan lokacin da aka ba a amfani da
clopidogrel (prasugrel), sa'an nan clopidogrel loading kashi ne 300 MG,
Prasugrel ne 60 MG.

A babban hadarin
intracoronary thrombosis, tare da dual antiplatelet far
Yana bada shawarar amfani da GPIIb-IIIa hanawa (abciximab / v bolus na 0.25 MG / kg bi ta jiko na 0,125 MG / kg / min to
matsakaicin matakin na 10 MG / min for 12 hours.). A halin yanzu babu wani
isasshiya shaida mafi girma yadda ya dace GPIIb-IIIa hanawa idan amfani da
prehospital ko kafin catheterization.

a matsayin
UFH anticoagulation far da ake amfani (a / a bolus 60 U / kg a hade tare da wani GPIIb-IIIa hanawa ko / bolus 100 U / kg ba tare da
GPIIb-IIIa) hanawa. Bivalirudin kamar yadda monotherapy maimakon UFH a hade tare da wani hanawa na GPIIb-IIIa kamar yadda shawarar da ACC 2013
Yana bada shawarar ga marasa lafiya da babban hadarin da manyan zub da jini (bolus na 0.75 MG / kg bi ta jiko na 1,75
MG / kg / hour). A lokaci guda, fondaparinux ba da shawarar saboda babban hadarin
catheter thrombosis.

A cewar sanarwar haka daga
asibiti dual antiplatelet far da ake amfani da akalla watanni 12.

Musamman hankali ya kamata a biya su hade da
clopidogrel da proton famfo hanawa, amfani don rigakafin
gastrointestinal zub da jini. Bisa ga yarjejeniya da aiki kungiyar don rigakafin thrombotic
kuma hemorrhagic rikitarwa ICSI hade da yin amfani da magunguna ga marasa lafiya
low hadarin GI zub da jini ba a nuna, su lokaci guda amfani ya kamata a individualized kan
shan la'akari da amfani da kasada. kawai
PPI magani daga kungiyar - pantoprazole - ba wani "gasa" klopidoglelya
domin isoenzyme CYP2C19. A gefe guda
babu high quality-gwajinsu kimantawa da sakamako na hadin gwiwa
da ake ji pantoprazole da clopidogrel
to rage hadarin lokaci guda zuciya da jijiyoyin jini da kuma hemorrhagic
rikitarwa. A madadin PPI iya H2 tsoka mai amsa sigina blockers - famotidine, ranitidine.

na yau da kullum magani
far

Beta-blockers aka sanya a cikin ta farko 24 hours daga lokacin duk marasa lafiya da ACS
in babu zuciya rashin cin nasara tare da low fitarwa ciwo,
cardiogenic buga da kuma misali contraindications ga yin amfani da wannan kungiyar da kwayoyi.
Kudin shiga beta blockers ci gaba a ko'ina cikin lokaci na asibiti da kuma bayan
kalamai.
ACE hanawa ake nada
All marasa lafiya da agara tsokar zuciya infarction, ejection sulusi da murabba'i kasa da 40% a cikin rashi na
contraindications. Idan akwai contraindications for ACE hanawa ake amfani blockers
angiotensin II tsoka mai amsa sigina. antagonists
aldosterone nuna a marasa lafiya tare da symptomatic zuciya rashin cin nasara
da / ko gaban ciwon sukari. Tsawo amfani da duk statins nuna
marasa lafiya da ACS (babu contraindications).