ACS - elibukhali semithambo syndrome

IV Samorodskaya,

Unjingalwazi, Doctor of Sciences Medical

ivaleke yayiyazi
syndrome

iqela discipline isigqibo

Ukusebenzisa iindlela zale mihla sokuphathwa acute coronary syndrome (ACS)
- igama elibhekisela naliphi iqela iimpawu zonyango okanye iimpawu
ngokuvumela okusolwayo etsolo iposi engabalulekanga (MI) okanye ingahlali
angina, inika ithemba sokuncitshiswa ebalulekileyo esibhedlele
ukufa nokuphucula ALS kwixesha elide.

Kwiminyaka emininzi eyadlulayo, uphando kunye ngamazwe kwenzeka izinto
lushwankathela All-Russian Scientific Society of Cardiology iziphakamiso Russian kwi isifo
kunye nonyango kwezigulane iposi engabalulekanga kunye ST-ingxenye umphakamo (2007), ngaphandle ST ukuphakama angina ezingazinzanga (2006). Ngo-2010, epapashwe yi ngengcebiso European
Society of Cardiology (PrintPro) kwi ukhetho kwiindlela revascularization engabalulekanga, isikhokelo sikazwelonke ukulungiselela ulawulo izigulane ACS e Australia
Britain, iziphumo ze-international
kuvunyelwane nolawulo izigulane kunye ACS. ngo-2013
American Heart
Society (ACCF / Tshotsho) iye yahlaziywa
izincomo ulawulo izigulane ACS
ST ingxenye ephakeme.  

Isigqibo on amaqhinga
ulawulo nomonde ACS njenge ephakamileyo ukuze ngaphandle ST-ingxenye umphakamo akusoloko ngokukhethekileyo elula, kudinga inxaxheba ezahlukeneyo
iqela leengcaphephe osekeke kwizikhokelo zonyango, indlela yesi sifo, ubudala isigulane, iimeko
ukunakekela. Ngelo xesha nye kuzo zonke izigulane kuyakrokreleka ACS
kufuneka enze i electrocardiogram (engekho
utshintsho okanye data oluthandabuzekayo kufunekayo ngokuphindaphindiweyo lokurekhoda amathuba 15
imizuzu -30, kuxhomekeke imeko bezonyango isigulana), kunye namanqanaba ufundisiso kunokwenzeka
ngokuba enzyme kwentliziyo, ukusetyenziswa olusisinyanzelo aspirin uthathwa. ngo
Zonke iziphakamiso ekhethwa ubuchule endovascular
revascularization engabalulekanga phambi kukho abasebenzi abaqeqeshiweyo nabanamava.
therapy Fibrinolytic (njengenyathelo lokuqala yokubonelela ezinonophela izigulana ACS kunye ST-ingxenye umphakamo) kuhlala ezifanelekileyo kwezo meko,
xa kunzima ukwenza stenting
imizuzu 120 emva
isahlakalo buhlungu (kungekho Izimo kwaye ukuba ngenxa yokuba iintlungu hayi ngaphezulu kwe
iiyure ezili-12). Xa ACS ngaphandle kokuphakamisa fibrinolytic ST ingxenye
uthomalaliso akukho iphethwe.

Ukuba ingozi yesifo sentliziyo kunye / okanye yayo
iingxaki eliphezulu

nxaxheba
ekudaleni ingcebiso kwingcali eYurophu, eUnited States ikholelwa ukuba ukuqaliswa
angiography coronary kwiiyure-2 ukusuka ngomzuzu wokwamkelwa
Kucetyiswa ukuba isigulane kunye kokuhlaselwa angina kwi yangasemva zonyango
ngokuphatha ziqhubeka okanye ziphinde zenzeke
angina waphawula utshintsho ceke ST onamandla, lidiza lophuhliso umonakalo
okanye iposi engabalulekanga; hemodynamic
Ukungazinzi, arrhythmias ventricular ebalulekileyo. Ukwenza angiography (kunye elandelayo
revascularization) iiyure ezingama-24 emva kokuba yokwamkelwa yesigulane kwisibhedlele kunye ACS kucetyiswa kwimeko phezulu
ingozi iposi engabalulekanga, ezisongela ubomi
iingxaki kunye nokufa. ixesha efanayo angiography coronary kucetyiswa ku
Apho kufuneka diagnosis mahluko of ACS kunye namanye
iimeko ezingxamisekileyo (Embolism pulmonary, sokuhlaziya
kwemithambo aortic). Kwiimeko ahlekise coronary syndrome ngaphandle kwicandelo ST lift emngciphekweni aphantsi ezisongela ubomi
iingxaki kunye nokufa ebudeni bokuhlala esibhedlele
unyango, kodwa gqolo iimpawu angina kunye / okanye ischemia eyenga
ngexesha test umthwalo, angiography coronary kulandele revascularization kwi
kuyimfuneko yaye kunokwenzeka, kucetyiswa ukuba bazenze yothuba elithile
esibhedlela kwisithuba seeyure ezingama-72 emva kokwamkelwa kwabafundi. in the
ukuba isigulane amkelwe kwindawo yonyango, apho akunakwenzeka
enze angiography coronary, loo nto idluliselwa kwisibhedlele efanelekileyo (umzk
Regional anxulumene nemithambo Centre).

eqhelekileyo
ingqalelo stenting qhinga (stent-camera iziyobisi
okanye uncoated) kunye enxulumene infarct kwemithambo tromboekstratsiey (at
kuyimfuneko), lo gama ACS c lift
ST ingxenye
kungakhathaliseki ukuba ukuphunyezwa kunye nefuthe unyango fibrinolytic (ngokwendlela
Iingcebiso ezivela ACC 2013 emva konyango fibrinolytic Kucetyiswa ukuba enze
Fct kunye stenting lungekho ngaphambi
iiyure 2-3). Ukuba c-ingxenye umphakamo etsolo coronary syndrome ST, ngaphandle infarct kwemithambo, kukho kakhulu
stenoses kwezinye imithambo, stenting yabo zikaxakeka lwenziwa kuphela
ngokuba abo sisifo sentliziyo kakhulu kunye / okanye kukothuka cardiogenic. ngamanye
amatyala stenting imisiwe kwenziwa - imfuno kunye nexesha
isigqibo emva kokuba uxinezeleko kuvavanya phambi ukuze kulahlwe amanzi isigulane ukusuka
esibhedlele. Ngokutsho izindululo leengcali ezivela eUnited States 2013, ngaphandle stents
Ukutyabeka ke bhetele ezisetyenziswa kwiimeko apho ogulayo
kwezifo kunye neemeko kunye nengozi ephezulu nokopha, kungenzeka phezulu,
ukuba isigulana lungahambelani kwisithuba sonyaka irejimeni antiplatelet ezimbini
unyango, kwaye kungenzeka ukwenza utyando elandelayo
imisebenzi. Ngapha koko, iingcebiso yabonisa ukuba c-kwicandelo umphakamo ACS ST stenting emva kweeyure ezingama-24 ukususela ngexesha layo
Development aluboniswa kwezi meko 1-2 amanxeba nemithambo engekho
Iimpawu ukugcinwa ischemia engabalulekanga. Kwiimeko ezinqabe kakhulu (phantsi ezithile
iimeko) wenza angioplasty.

Isigqibo malunga indlela revascularization kwizigulane kunye acute coronary syndrome ngaphandle ceke ST Vuka, yaye ACS c ST ingxenye ephezulu, kodwa kungekho
coronary ukuvala lendawo nemithambo yenhliziyo, ngokuqinisekileyo "unetyala" ku
ACS okanye onesifo multivessel, apho ukuphunyezwa
Stenting senziwe ngendlela engenakwenzeka okanye umngcipheko engaphezu amandla
inzuzo ifunyanwa ziingcali ezininzi (ugqirha sentliziyo,
cardiologist, oyingcali kwicandelo
isifo Endovascular kunye unyango) kunye
lwezonyango, angiographic uvavanyo data flow fraction Reserve,
ukuba abantu abane ixesha elide kulindeleke.

inkxaso imithi
ngokuyimfuneko

Xa ACS ne ST ingxenye umphakamo iingcali abaninzi bakholelwa ukuba amaqhinga ngoku izigulane
Oku kuxhomekeke kakhulu kwinkqubo yezempilo yelizwe
(Ummandla) ukwenza ungenelelo endovascular ephambili (ngaphandle kokuba
thrombolysis) iiyure ezi-2 kuphuhliso iimpawu kwezonyango umguli.

Ukuba kulindeleke ukuba ixesha ukususela yomfowunelwa wokuqala isigulane
abasebenzi bezonyango phambi kokwenza angiography coronary iya kuba ngaphezu kwe-2
iiyure, iziguli
(Xa kungekho Izimo) kufuneka enze thrombolysis nge
yokusiwa kwee ukuya eklinikhi angiography obudlalwayo revascularisation
iqhosha kwisithuba seeyure 3-24. Kwezo meko, ukuba yangasemva thrombolysis
ST ingxenye ephezulu ukugcina ngaphezu kwama-50% yenqanaba lokuqala kunye / okanye retrosternal
iintlungu, isigulana ubonisa likaxakeka angiography sentliziyo. Ukuba uphumelele,
thrombolysis angiography coronary kunye revascularization (ukuba kuboniswe) unokuthi
yenziwe kwisithuba seeyure ezingama-24. Iziphakamiso yathi
revascularization unako ukuphucula ALS kunye nokuphunyezwa kwayo ngokusebenzisa 24-60
iiyure emva kokuqala iimpawu zonyango, kodwa kuphela kwiimeko apho
Kukho angina nezolo kunye / okanye ischemia engabalulekanga zafunyanwa ngexesha
izifundo instrumental.

ngaphandle
Ngokuxhomekeka kuhlobo ACS kunye indlela revascularization kunyanzelekile
inkxaso kweziyobisi, nto leyo ibandakanya antiplatelet,
unyango antiplatelet, beta-blocker zonyango, inhibitors of angiotensin ukuguqulela
enzyme, statins. Unyango ngamachiza ke ngabanye ayilungiswanga
Kuxhomekeka imilo ACS elihlabayo, ubukho soputsvuyuschie ngezifo. the
Le ncwadi iza kugxininisa kuphela unyango antiplatelet,
iindlela ezihambisana of revascularization engabalulekanga.

Ingxenye ephezulu ACS ngaphandle S T

the
Kwiimeko ezinjalo iindlela revascularization endovascular
wamisela "double 'unyango antiplatelet equka yomlomo
acetylsalicylic acid (ASA) kunye clopidogrel (okanye prasugrel okanye
ticagrelor). ASA yabelwa kuqala ezifumana 150-300 mg (250-500 mg okanye ngohlobo
ngo / kwi bolus) elandelwa umthamo 75-100 mg / imini ukulayisha idosi
600 mg of clopidogrel (kwangoko kangangoko kunokwenzeka) kulandele ukuqhutywa 75
mg / ngosuku iinyanga 9-12 prasugrel - 60 mg ukulayisha idosi, ilandelwe yi
ukuthatha 10 mg / imini, okanye ticagrelor - 180 mg ukulayisha idosi, ilandelwe yi
ukuthatha amaxesha 90 mg 2 ngosuku. Ubungqina obubonakalayo buxela ukuba ziphinde
GPIIb-IIIa inhibitors zithathwa basengozini enkulu yokuba thrombosis intracoronary kwi iziguli angioplasty kunye / okanye stenting
nemithambo yenhliziyo.

the
izincomo Nice (UK) uphawula ukuba
Izigulane basengozini enkulu yokuba iziganeko sentliziyo (eqikelelweyo ngenyanga 6
ukufa kwe-3%), ize ke inyanzeleke ukuba angiography semithambo kunye revascularization
kwisithuba seeyure 96 ukususela kwixesha le yesiqhelo yokwamkelwa kwabafundi eboniswe
Ukuqeshwa eptifibatide okanye tirofiban. Abciximab emiselwe kwanonyango,
revascularization ehamba endovascular ukuba akukho
Ukubanako ukwabela abanye inhibitors of GPIIb-IIIa. Kufuneka kuqatshelwe ukuba ngazo
Ngokungafaniyo isikhokelo Nice (UK) izindululo
European Society of Cardiology "okukhethwayo" unikwa abciximab (Grade
ukwalatha I), ngelo xesha ukuba eptifibatide
okanye tirofiban Misela Class IIA.

Choice nokuba umthamo
anticoagulants ukwenza angiography
revascularization kwizigulane ngaphandle ACS
ephakamisa ST ingxenye sagqitywa ngokusekelwe
Ngokwezinga le ingozi kubunzima thrombotic, kobuchopho kunye ukopha. Basengozini enkulu kakhulu
iziganeko kobuchopho (umzekelo, xa ukungazinzi hemodynamic eliyinjubaqa ezisongela ubomi arrhythmias) nomonde
kusiwa ngqo X-reyi kwaye yabelwa
lweeHedfowuni unfractionated (UFH) njengoko / kwi bolus ka 60 U / kg kunye elandelayo
nokubandakanywa ngexesha revascularization ngokudibene ne kabini
therapy antiplatelet. Basengozini enkulu yokuba ukopha zingasetyenziswa
monotherapy bivalirudin bolus we 0.75 mg / kg kulandele ukumnika 1,75
mg / kg / hr. Izigulana ungcipheko avareji kweziganeko kobuchopho (umzekelo,
hemodynamics isitali, kodwa uvavanyo troponin positive, kulowo mkhuba
angina, utshintsho onamandla i ST isiqwempu), nto leyo eza kuba iinkqubo ezonakalisayo 24-48
iiyure ezilandelayo iindlela zonyango akhona phambi angiography semithambo
ezicwangcisiweyo revascularization endovascular engabalulekanga:

• Izigulane
  

lweeHedfowuni Unfractionated 60 U / kg ngohlobo kwi / ku bolus,
ngoko ke nokubandakanywa phantsi kolawulo ixesha iyasebenza thromboplastin Lahlani
(APTT) okanye enoxaparin 1 mg / kg s.c. x 2 ngosuku okanye Fondaparinux 2.5 mg / ngosuku
Bivalirudin kwesikhumba okanye 0.1 mg / kg njengoko / kwi bolus ilandelwa ngu nokubandakanywa
0.25 mg / kg / ngeyure

• Kuba iziguli ≥75 iminyaka

lweeHedfowuni Unfractionated 60 U / kg ngohlobo kwi / ku bolus,
ke nokubandakanywa phantsi kolawulo APTT

Okanye enoxaparin 0.75 mg / kg x 2
imini Fondaparinux okanye 2.5 mg / kwesikhumba imini okanye Bivalirudin 0.1 mg / kg njenge
Mna / bolus kulandele ukumnika 0.25 mg / kg / hr.

in
izigulane kunye nengozi ephantsi kweziganeko sentliziyo (ngaphandle ukwanda
troponin and ST utshintsho ceke), elondoloza ngaphezulu isicwangciso
unyango kunye fondaparinux eyabelwe (2.5 mg / imini kwesikhumba) okanye enoxaparin (1
mg / kg s.c., amaxesha 2 ngosuku izigulane kwiminyaka ≥75 - 0.75 mg) kunye lweeHedfowuni unfractionated (60 U / kg
njengokuba / bolus, kulandele nokubandakanywa phantsi kolawulo aPTT).

ACS ne ST ingxenye umphakamo  

kule
imeko yezonyango unikwe "double" eyo antiplatelet therapy (150-300 mg ngomlomo okanye
250-500 mg njengoko / kwi bolus kulandele ukuqhutywa 75-100 mg / ngosuku) kunye prasugrel
(60 mg ukulayisha yedosi kulandele ukuqhutywa-10 mg / ngosuku), okanye ticagrelor (ukulayisha ithamo 180 mg
kulandele ukuqhutywa 90 mg amaxesha 2 ngemini) okanye clopidogrel (ukulayisha isikalo 600
ilandelwe ngabaphethe
75 mg / ngosuku). Izindululo European Society of Cardiology uthi
prasugrel kunye ticagrelor clopidogrel kakuhle ngokwemiqathango yokunciphisa
frequency odityanisiweyo endpoints kobuchopho kwaye stent thrombosis kwizigulane
MI ephezulu ST, kwaye ayithethi kwandisa ingozi yokuba
ukopha kakhulu. Ngokutsho izindululo-ASS 2013 ayikho prasugrel
Kuyanconywa ukuba izigulane
imbali icala okanye TIA. Kwimeko apho ngaphambi kokuba lingene
iziko lonyango ukwenza angiography nemithambo kunye nomonde stenting
fibrinolysis lwenziwa kwaye yaba ngaphantsi kweeyure ezingama-24 kunye xesha ayizange isetyenziswe
clopidogrel (prasugrel), ngoko clopidogrel ukulayisha iidosi 300 mg,
Prasugrel i mg 60.

Basengozini enkulu
thrombosis intracoronary, kunye nonyango antiplatelet ezimbini
Lucebisa ukusetyenziswa inhibitors GPIIb-IIIa (abciximab / V bolus we 0.25 mg / kg kulandele ukumnika 0,125 mg / kg / min ku
inqanaba eliphezulu lika-10 mg / min iiyure ezili-12.). Okwangoku akukho
obupheleleyo ubungqina ngempumelelo enkulu GPIIb-IIIa inhibitors xa isetyenziswa
prehospital okanye ngaphambi catheterization.

njengendlela
UFH anticoagulation therapy isetyenziswa (ngo / kwi bolus 60 U / kg ezidityaniswe inhibitor GPIIb-IIIa okanye / bolus 100 U / kg ngaphandle
GPIIb-IIIa) inhibitor. Bivalirudin njengoko monotherapy endaweni UFH udibanise kunye inhibitor of GPIIb-IIIa njengoko isincomo yi ACC 2013
Kuyanconywa ukuba izigulana emngciphekweni omkhulu ezinkulu ukopha (bolus we 0.75 mg / kg kulandelwe ukumnika 1,75
mg / kg / ngeyure); Kwangaxeshanye, fondaparinux ayikhuthazwa ngenxa umngcipheko omkhulu
catheter thrombosis.

Ngokutsho mazwi lulandelayo
esibhedlele elikabini therapy antiplatelet sisetyenziselwa iinyanga ezili-12.

ingqalelo ekhethekileyo kufuneka ihlawulwe ukuhlanganiswa
clopidogrel kunye nempompo Proton inhibitors, ezisetyenziswa ngokuqhelekileyo yokuthintela
ukopha zesisu. Ngokutsho abavumelana yeqela elisebenzayo kuthintelo thrombotic
kunye sophele iingxaki ICSI odityanisiweyo ukusetyenziswa kweziyobisi kwizigulane
ingozi ephantsi GI ukopha ayiboniswanga, ukusetyenziswa kwazo ebandakanyekayo kufuneka ngamnye ngokusekelwe
kuthathelwa ingqalelo izibonelelo kunye neengozi. kuphela
PPI amayeza evela kwiqela - pantoprazole - hayi "okhuphisanayo" klopidoglelya
ngokuba isoenzyme CYP2C19. Kwelinye icala
akukho ezikumgangatho ophezulu yolingo lwezonyango nokuvavanya ifuthe welungu
isicelo pantoprazole kunye clopidogrel
ukunciphisa ingozi sentliziyo ebandakanyekayo kunye ukopha
iingxaki. Kungenjalo PPI ukuze h2 blocker receptor - famotidine, ranitidine.

amayeza njalo
therapy

Beta-blocker sabelwe khona seeyure ezingama-24 ukususela kwixesha zonke izigulane ACS
xa engekho ukusilela intliziyo eliphantsi imveliso syndrome,
mothuko cardiogenic kunye Izimo standard yokusetyenziswa kweli qela iziyobisi.
blocker Admission beta kwaqhubeka ngalo lonke ixesha esibhedlele nasemva
iingxelo.
ACE inhibitor bamiswa
Zonke izigulane kunye iqhosha akudala engabalulekanga, ejection iqhezu ngaphantsi kwe-40% xa engekho
Izimo. Ukuba kukho Izimo ukuze ACE inhibitors zisetyenziswa blocker
angiotensin II receptor. abamelene
aldosterone eboniswe izigulane ukusilela ngentliziyo lingaze
kunye / okanye ubukho seswekile. ukusetyenziswa elide zonke statins eboniswe
izigulane ACS (akukho Izimo).