Medportal.ge
miokardiumis infarqti ST elevaciiT (STEMI)
gaidlaini
momzadebulia saqarTvelos kardiologTa kolejis da saqarTvelos kardiologTa sazogadoebis mier mier
2006 w.
saqarTvelos kardiologTa kolejis da saqarTvelos kardiologTa sazogadoebis gaerTianebuli komitetis eqspertTa samuSao jgufi: giorgi kaWarava jo-enis saxelobis samedicino centri; aCiko CuxrukiZe gadaudebeli kardiologiis centri; levan yuraSvili jo-enis saxelobis samedicino centri; vaxtang WumburiZe profesori, Terapiis erovnuli centri, zaza mgalobliSvili jo-enis saxelobis samedicino centri; nata gonjilaSvili jo-enis saxelobis samedicino centri;, naTia axalaZe jo-enis saxelobis samedicino centri; giorgi papiaSvili jo-enis saxelobis samedicino centri;
ABC = kardiopulmonaruli reanimaciis 3 etapi: sasunTqi gzebi A, sunTqva B, sisxlis mimoqceva C.
ACE = angiotenzin gardamqmneli fermenti
ACS = mwvave koronaruli sindromi
AHA/ACC = amerikis gulis asociacia/amerikis kardiologiuri koleji
AF = winagulTa fibrilacia
aPTT = aqtivirebuli Tromboplastinis dro
ARB = angiotenzin II –is blokerebi
ASA = aspirini
BMI = sxeulis masis indeqsi = wona (kg-Si) / simaRleze 2 (metr.)
BNP = B tipis natriurezuli peptidia
BUN = sisxlis Sardovana nitrogeni
CABG = kororonarul arteriuli baipas grafti. (aorto koronaruli Suntireba)
CBC = sisxlis saerTo analizi
CCS = kanadis kardiologiuri asociacia
CCU = intensiuri/koronaruli movlis ganyofileba
CHD = gulis koronaruli daavadeba
CHF = gulis SegubebiTi ukmarisoba
CK-MB = kreatinfosfokinaza MB izofermenti
CPR = kardiopulmonaruli
CPR = kardiopulmonaruli resuscitacia (reanimacia)
cTnI = kardiotroponini I
cTnT = kardiotroponini T
CT = kompiuteruli tomografia
Cx = Semomxvevi toti
D5W = deqstroza 5 %-iani
DVT = Rrma venebis Trombozi
EPS = eleqtrofiziologiuri kvleva
ECG = e.k.g.
GI = gastrointerstinuli
GU = genitourinaluri (Sardasasqeso)
GP = glukoproteini
HDL-C = maRali simkvrivis lipoprotein qolesteroli
HF = gulis ukmarisoba
HIT = hepariniT inducirebuli Trombocitopenia
HR = gulis SekumSvaTa sixSire
IABP = intraaortuli balonuri kontrpulsacia
ICD =kardioverter defibrilatori
INR = saerTaSoriso normalizaciis Sefardeba
IV = intravenuri
LAD = marcxena wina daswvrivi toti
LBBB = hisis konis marcxena fexis blokada
LDL-C = dabali simkvrivis lipoprotein qolesteroli
LMWH = dabalmolekuluri wonis heparini
LOE = mtkicebulebis xarisxi
LV = marcxena parkuWi
MET = metaboluri eqvivalenti
MI = miokardiumis infarqti
NCEP = riskis daTvlis programa: (kiTxvari romelSiac SegaqvT Semdegi monacemebi: saerTo qolesterini, HDL, sistoluri wneva, sqesi, asaki, eweviT Tu ara da igi gaZlevT gulis gulis daavadebebiT 10 wliani sikvdilianobis risks)
non-HDL-C = saerTo qolesterins gamoklebuli HDL
NSVT = aramdgradi (xanmokle) ventrikuluri taqikardia
NTG = nitroglicerini
PCI = perkutaneuli koronaruli intervencia
PTCA = perkutaneuli transluminaruli koronaruli angioplastika
PE = pulmonaruli embolia
RC = marjvena koronari
RBBB = hisis konis marjvena fexis blokada
RV = marjvena parkuWi
STEMI = miokardiumis infarqti ST elevaciiT am jgufSi ganixileba pacientebi miokardiumis infarqtiT, romelTac e.k.g-ze aqvT persistentuli > (20-30wT) ST segmentis elevacia
TG = trigliceridebi
UA = arastabiluri stenokardia
UFH = arafraqcionirebuli heparini
VF =ventrikuluri fibrilacia
VO2 = moxmarebuli Jangbadi drois garkveul monakveTSi
VSR = parkuWTa Sua Zgidis rubtura
VT =ventrikuluri taqikardia
WPW = volf-parkinson-uaitis sindromi
flail leaflet = “mofarfate” qorda
preexitation = naadrevi aRgzneba
Imaging Modality = gamosaxulebiTi kvleva
Preexitation = naadrevi agzneba (delta talRa),
Electronically paced ventricular rhythm = parkuWSi riTmis xelovnuri wamyvani
Advanced AV Block = Sorswasuli blokada
niacini = vitamini B-3
s.d.b. = saswrafo daxmarebis brigada
PM
I Sesavali: 5
a. samuSao jgufis ganmarteba: 5
b) cxrili 1. gaidlainSi gamoyenebuli rekomendaciebis da mtkicebulebebis xarisxi. Sedgenilia AHA/ACC-is rekomendaciebis mixedviT mocemuli cxrili saSualebas gvaZlevs ganvsazRvroT TiToeuli samedicino midgomis roli pacientis mkurnalobisas. mtkicebulebebis xarisxi (LOE)-gamoyenebuli iqneba sxvadasxva samkurnalo meTodis Tu diagnostikis rolis gansazRvrisas. 6
g. mwvave miokardiumis infarqtis definicia 7
d. mwvave miokardiumis infarqtis paTogenezi: 7
v. mwvave koronaruli sindromis ganmarteba da klinikuri mimdinareoba: 8
sqema: 1 8
II STEMI-s ganviTarebamde mkurnaloba 9
a. rekomendaciebi STEMI-s risk faqtorebis mqone pacientebis gamovlenisTvis 9
b. rekomendaciebi STEMI-s niSnebis naadrevi gamovlenisa da CarevisaTvis, pacientebis ganaTleba: 10
III STEMI-s Setevis dawyeba da prehospitaluri qmedeba 11
a. STEMI-T pacientebis transportireba da pirveladi reperfuziuli mkurnalobis SerCeva 11
IV. pirveladi amocnoba da marTva gadaudebeli daxmarebis departamentSi 14
a. sqema. 3 gadaudebeli daxmarebis algoriTmi/protokoli pacientSi STEMI–s simptomebiT an niSnebiT 14
b. damateba: ekg-s interpretacia: 15
g. cxrili 3. STEMI-is diferencialuri diagnostika 16
d. STEMI-s diagnoziT miRebul pacientSi rutinuli testebi 16
e. reperfuziis meTodis aucileblobis da SesaZleblobis gansazRvra pacientebSi STEMI-T 18
v. reperfuziis saxis SerCeva pacientebSi STEMI-T 20
z. fibrinolizis Cvenebebi: 21
T. STEMI-s dros fibrinolizis ukuCveneba da safrTxeebi 22
cxrili 6. 22
i. diagnostikuri koronaruli angiografia 22
k. pirveladi PCI-s rekomendaciebi 22
l. pirveladi PCI-s rekomendaciebi pacientebSi romlebic ver Rebuloben Tromboliziss raimis gamo; (Seuferebelia TrombolizisisaTvis) 24
m. pirveladi PCI-s rekomendaciebi klinikebisaTvis romelTac ara aqvT kardioqirurgiuli ganyofileba 24
n. damxmare PCI 25
o. gadamrCeni PCI: 25
p. PCI fibrinolizisis Semdeg: 25
r. mwvave qirurgiuli reperfuzia: 26
s. zogadad urgentuli da gadaudebeli qirurgiuli revaskularizaciis Cveneba STEMI-s dros aris Semdegi 27
V hospitaluri mkurnaloba 28
a...CCU intensiuri/koronaruli movlis ganyofileba: 28
b. CCU-is Semdgomi mkurnaloba: 28
g. pacientebis gaaqtiveba: 29
d. dieta: 29
e. analgetikebi/aRgznebis sawinaaRmdego preparatebi: 29
v. antiagregantebi: 29
z. reperfuziisas damatebiTi antiTrombozuli farmakologiuri daxmareba 30
T. renin-angiotenzin-aldosteronis sistemaze moqmedi preparatebi STEMI-s dros: 33
i. glukozis kontroli STEMI-s dros: 34
k. eleqtrolitebis balansi: 34
l. kalciumis arxebis blokatorebi: 35
m. beta-blokatorebi: 35
n. nitroglicerini: 35
i. sqema 4. garTulebuli STEMI. gadaudebeli mdgomareobebis marTvis protokoli 37
VI hemodinamikuri darRvevebi 39
a. hemodinamikuri gazomvebi: 39
b. hipotenzia: 39
g. dabali wuTmoculobiTi mdgomareoba: 40
d. pulmonaruli Segubeba: 40
e kardiogenuri Soki: 41
v. marjvena parkuWis infarqti: 42
VII gulis ukmarisobis meqanikuri mizezebi/dabali wuTmoculobis sindromi 42
a. mitraluri sarqvlis ukmarisoba: 42
b. parkuWis Zgidis rubtura: 42
g. marcxena parkuWis Tavisufali kedlis rubtura 43
d. marcxena parkuWis anevrizma: 43
e. intraaortuli balonuri kontrpulsacia: IABP: 43
VIII ariTmiebis marTva STEMI-is Semdgom 45
a. VF: parkuWovani fibrilacia: 45
b. VT: parkuWovani taqikardia 45
g parkuWovani eqstraistolia: 46
d. aCqarebuli idiventrikuluri an kvanZovani riTmiv. marjvena parkuWis infarqti: 46
g. supraventrikuluri ariTmia/AF 46
IX. bradiariTmiebi: 47
a. sinusis kvanZis disfunqcia STEMI-s Semdgom: 47
d. mudmivi peisingis Cveneba bradiaritmiis da/an gamtareblobis darRvevisas romelic asocirdeba STEMI-Tan: 49
e. mudmivi peisingis modelis SerCeva Cveneba bradiaritmiis da/an gamtareblobis darRvevisas romelic asocirdeba STEMI-Tan: 50
v. ganmeorebiTi tkivili STEMI-s Semdgom 50
T. STEMI-s Semdgomi aorto koronaruli Suntirebis Cvenebebi mocemuli iqneba zogadad CABG-is gaidlainSi. 52
X meoradi prevencia da xangZlivi marTva: 52
a. riskis Sefaseba stacionaridan gaweris Semdgom: 52
b. cxrili 10 meoradi prevencia STEMI-s dros: 54
g. ST elevaciiT mimdinare miokardimis infarqtis ( STEMI) stacionaridan gaweris Semdgomi antiTrombozuli mkurnaloba 56
d. rekomendaciebi gaweris Semdgomi vizitebis da zogadad daavadebis marTvis Sesaxeb: 58
e. cxrili 11 medikamentebi romlebic gamoyeneba STEMI-s mkurnalobisas 59
GXI gamoyenebuli masala: 62
I Sesavali:
a. samuSao jgufis ganmarteba:
gaidlaini eyrdnoba amerikis kardiologTa kolejis, amerikis gulis asociaciis da evropis kardiologTa asociaciis masalebs. aseve gamoyenebulia monacemebi Semdegi literaturidan braunvaldi, zaips libbi, gulis daavadebebi 6-e gamocema 2001w da brain p. grifini erik j. topoli kardiovaskularuli medicinis saxelmZRvanelo, 2-e gamocema 2004w. samuSao jgufma moaxdina teqstis adaptireba, rac ZiriTadSi rCeba zemoT aRniSnuli gaidlainebis farglebSi da Seesabameba maT rekomendaciebs. amasTan erTad Cven davamateT ramodenime ganmarteba da cxrili CamoTvlili literaturidan romelic Cvenis azriT daexmareba mkiTxvels mkurnalobis sqemebis swor interpretaciaSi.
es moxseneba warmoadgens ST elevaciiT mimdinare miokardiumis infarqtis mkurnalobis ZiriTad principebs. cxadia igi ver iqneba sakmarisi kardiologisaTvis daavadebirulyofili marTvisTvis. mocemul versiaSi ganxilulia mxolod mkurnalobis ZiriTadi etapebi, aseve garTulebebi da maTi marTva. miuxedavad zogadi xasiaTisa warmodgenili versia saSualebas gvaZlevs swrafad gadavxedoT mkurnalobis ZiriTad principebs da igi daexmareba rogorc kardiologebs aseve zogadi praqtikis/ojaxis da saswrafo daxmarebis eqimebs, romelTaTvisac siswrafes da masalis kompaqturobas didi mniSvneloba aqvs.
samuSao jgufi acnobierebs moTxovnilebas moxdes Cveni jan-dacvis sistemis harmonizacia evropisa da amerikis samedicino sistemebis maRal samedicino standartebTan da miiCnevs, rom am procesSi gaidlainebs, ufro zustad ki maT implementacias aqvs udidesi mniSvneloba. swored es gaxda imis mizezi rom Cven aRar davucadeT sruli teqstis damTavrebas da gadavwyviteT mokle versiis gamoqveyneba. vfiqrobT teqstis TandaTan Sevsebas, rac xels ar SeuSlis mis danergvas, vinaidan mudmivi ganaxleba gaidlainebiT muSaobis Tanmxlebi da ganuyofeli procesia. Cveni jgufia Riaa msjelobisaTvis iseT Temebze rogoricaa: Tu ramdenad realuria saqarTveloSi am sqemebiT muSaoba, Tu ramdenad zustad Seesabameba Cvens mier adaptirebuli rekomendaciebi evropis da a.S.S/-s Sesabamis rekomendaciebs da xom ar ewinaaRmdegebian isini maT ZiriTad suliskveTebas. problematuria agreTve rigi enobrivi sakiTxebisa. Cven gadavwyviteT abreviaturebis inglisuri SriftiT xmareba. Cvenis azriT am MmeTodis ZiriTadi mizania 1) teqstis Semokleba. 2) ganmeorebebis meti saSualeba da 3) yuradRebis miqceva swrafi kiTxvisas. vinaidan qarTulSi ar arsebobs didi asoebi am SemoklebebiT yuradRebis miqceva efeqturi ver aris. amasTan erTad zogi abreviatura imdenad damkvidrebulia rom maTi Secvla iqneboda xelovnuri da uxerxuli saxmarad. amgvarad Tuki am princips ar gavavrcelebdiT yvela Semoklebaze maSin teqstSi xan iqneboda inglisuri xan qarTuli abreviatura, rac aseve gaugebari da mouxerxeli iqneboda. sayuradReboa is faqtic rom mkurnalobis Tu diagnostikis zogierTi meTodi saqarTveloSi ver tardeba teqnikuri Tu finansuri mizezebidan gamomdinare. aseT SemTxvevebSi Cveni jgufi rekomendacias iZleva, rom pacientis istoriaSi, Tu ambulatoriul baraTSi dafiqsirdes am gamokvlevaze, Tu mkurnalobaze uaris Tqmis mizezi, raTa naTeli gaxdes, rom mkurnali eqimi flobs daavadebis Tanamedrove midgomebs, magram gamodis konkretuli realiebidan. Cvenis mxriv mzada varT farTo diskusiisaTvis aRniSnul Temebze mizanSewonilia gaviTvaliswinoT rogorc enis specialistebis aseve sazogadoebis da sxvadasxva dargis eqspertebis azri. mTavari CvenTvis am etapze Tavad gaidlainiT muSaobis praqtikis damkvidrebaa saqarTvelos samedicino sistemaSi, rac vfiqrobT etapuri iqneba saqrTveloSi medicinis ganviTarebisaTvis.
b) cxrili 1. gaidlainSi gamoyenebuli rekomendaciebis da mtkicebulebebis xarisxi. Sedgenilia AHA/ACC-is rekomendaciebis mixedviT mocemuli cxrili saSualebas gvaZlevs ganvsazRvroT TiToeuli samedicino midgomis roli pacientis mkurnalobisas. mtkicebulebebis xarisxi (LOE)-gamoyenebuli iqneba sxvadasxva samkurnalo meTodis Tu diagnostikis rolis gansazRvrisas.
| | | | | |
| |I klasi: |II-A klasi: sargebloba > > |II-B klasi: |III klasi: |
| |sargebloba > > > riskze. |riskze saWiroebs damatebiT |sargebloba ≥ riskze saWiroebs |damatebiTi gamokvlevebi aRaraa |
| |procedura/mkurnaloba unda |gamokvlevebs. gonivrulia |damatebiT gamokvlevebs. |saWiro. procedura/mkurnaloba ar|
| |Catardes/dainiSnos |Catardes/dainiSnos Sesabamisi |procedura/mkurnaloba |unda dainiSnos/Catardes |
| | |procedura/mkurnaloba |SesaZlebelia gvqondes |vinaidan igi usargebloa da |
| | | |mxedvelobaSi |SesaZloa iyos saSiSi |
| | | | | |
|A-done: mravali (3-5)|rekomendacia imis Sesaxeb rom |rekomendacia |rekomendaciis |rekomendacia rom |
|sxvadasxva |igi aris sasargeblo/efeqturi. |procedura/mkurnalobis |sargebloba/efeqturoba nakleb |procedura/mkurnaloba araa |
|populaciuri jgufebia| |Catareba/daniSvnis sasargeblodaa|kargadaa Seswavlili | |
|Sefasebuli. |monacemebis miRebulia mravali | | | |
| |randomizebuli kvleviT da |aris zogierTi |urTierTsawinaaRmdego monacemebi |sakmarisi monacemebia mravali |
|efeqti da mimarTuleba|meta-analiziT. |urTierTsawinaaRmdego monacemi |ufro metia mravali randomizebuli|randomizebuli da |
|myaria. | |mravali randomizebuli kvlevis da|kvlevis da meta-analizisagan |metaanalizisagan |
| | |meta-analizisagan | | |
| | | | |sasargeblo/efeqturi da SesaZloa|
|B-done: SezRuduali |rekomendacia imis Sesaxeb rom |rekomendacia |rekomendaciis |iyos saziano. |
|(2-3) populaciuri |igi aris sasargeblo/efeqturi. |procedura/mkurnalobis |sargebloba/efeqturoba nakleb | |
|jgufebia Safasebuli | |Catareba/dniSvnis sasargeblodaa.|kargadaa Seswavlili | |
| |SezRuduli monacemebia miRebulia| | | |
| |erTi randomizebuli da |aris zogierTi |ufro meti urTierTsawinaaRmdego |SezRuduli monacemebia erTi |
| |ararandomizirebuli |urTierTsawinaaRmdego monacemi |monacemia erTi randomizirebuli |randomizirebulia da |
| |kvlevebisagan |erTi randomizirebuli da |da ararandomizebuli |ararandomizebuli kvlevebisagan.|
| | |ararandomizebuli kvlevebisagan |kvlevebisagan | |
| | | | | |
| | | | | |
|C-done: |rekomendacia imis Sesaxeb rom |rekomendacia |rekomendaciis |sasargeblo/efeqturi da SesaZloa|
|Zalian SezRuduali |igi aris sasargeblo/efeqturi. |procedura/mkurnalobis |sargebloba/efeqturoba nakleb |iyos saziano. |
|(1-2) populaciuri | |Catareba/dniSvnis sasargeblodaa |kargadaa Seswavlili | |
|jgufebia Safasebuli |arsebobs mxolod eqspertebis | | | |
| |azri, SemTxvevaTa aRwera(case |eyrdnoba eqspertebis azrs da |eyrdnoba eqspertebis azrs da |arsebobs mxolod eqspertebis |
| |report) |SemTxvevaTa aRweras |SemTxvevaTa aRweras |azri, SemTxvevaTa aRwera(case |
| | | | |report) |
| | | | | |
g. mwvave miokardiumis infarqtis definicia
amerikis kardiologTa koleji da evropis kariologTa asociaciis gaerTianebuli komiteti mwvave miokardiumis infarqts (acute, evolving or recent MI) gansazRvravs Semdegnairad: miokardiumis nekrozis bioqimiuri markerebis, kerZod troponinis tipiuri zrda da TandaTanobiTi vardna an CK-MB-is ufro swrafi zrda da vardna, romelsac Tan axlavs erT-erTi CamoTvlilTagani: iSemiuri simptomebi, e.k.g-ze paT. Q kbilis gaCena da/an cvlilebebi romlebic miokardiumis iSemiaze miuTiTeben, koronaruli intervencia an MI-s paTologiuri gamovlinebani (findings).
d. mwvave miokardiumis infarqtis paTogenezi:
dRevandeli gagebiT miokardiumis infarqti iyofa 2 ZiriTad jgufad I mimdinare ST elevaciiT STEMI da II mimdinare ST-elevaciis gareSe NSTEMI. termini - mwvave koronaruli sindromi TavisTavSi aerTianebs Semdeg klinikur sindromebs: arastabilur stenokardias, Mmiokardiumis infarqts ST -segmentis elevaciis gareSe da miokardiumis infarqts ST- segmentis elevaciiT, sadac pacientebi arastabiluri stenokardiiT da miokardiumis infarqtiT. ST- segmentis elevaciis gareSe miekuTvnebian erT jgufs, xolo pacientebi ST- segmentis elevaciiT mimdinare miokardiumis infarqtiT miekuTvnebian meore jgufs. termini – arastabiluri stenokardia asaxavs sindroms , romelsac Sualeduri mdgomareoba ukavia qronikul stabilur stenokardiasa da miokardiumis infarqts Soris. pacientebs ST- segmentis elevaciis gareSe mimdinare mwvave koronaruli sindromiT, aqvT an arastabiluri stenokardia an ST-segmentis elevaciis gareSe mimdinare miokardiumis infarqti. Mmwvave koronaruli sindromi ST- segmentis elevaciT uxSiresad sruldeba miokardiumis Q kbilovani infarqtiT da iSviaTad ara Q kbilovani infarqtiT. ST– segmentis elevacis gareSe miokardiumis infarqti uxSiresad sruldeba ara Q kbilovani miokardiumis infarqtiT da iSviaTad Q kbilovani miokardiumis infarqtiT. ( ix. mwvave koronaruli sindromis (ACS) ganmarteba. cxrili 1.) NSTEMI-s paTogenezi ganxilulia Sesabamis gaidlainSi. Cven aq mokled SevCerdebiT ST-elevaciiT mimdinare miokardiumis infarqtis paTogenezze.
STEMI-s dros prevalirebs maokluzirebeli Trombozi. daaxlobiT 2/3 dan 3/4 -mde SemTxvevebSi Trombis warmoqmnas win uswrebs folaqis fibrozuli garsis rubtura an misi erozia, romelic ufro xSirad ar iwvevs obstruqcias, Tumca warmoadgens substancias romelic aZlierebs Trombocitebis aqtivacias, agregacias, adhezias da Trombinis generacias, rasac Tavis mxriv mohyveba ukve Trombis warmoqmna da sanaTuris daxSoba. nela ganviTarebuli okluziisas SesaZloa ar gvqondes MI . savaraudod imis gamo, rom ganviTarebas aswrebs kolateraluri qseli, rac nawilobriv akmayofilebs miokardiumis moTxovnilebas. procesi xSirad dinamiuria, anu: Trombozi, spontanuri Trombolizisi, vazospazmi SeiZleba erTdroulad aRiniSnos da mogvces koronaruli nakadis gardamavali Sewyveta da distaluri embolizacia. (es ukanaskneli iwvevs mikrovaskularul obstruqcias, rac xels uSlis srulyofil revaskularizacias miuxedavad epikardiuli koronaris gaxsnisa.)
e. mwvave miokardiumis infarqtis gavrceleba/epidemiologia:
saqarTveloSi bolo 20 wlis ganmavlobaSi raime saxis seriozuli statistikuri kvleva, romelic am daavadebis gavrcelebas Seiswavlida ar Catarebula. aqedan gamomdinare Cven veyrdnobiT Aa.S.S-s da evropul monacemebs.
maTi mixedviTac a.S.S-Si yovelwliuri sikvdilianoba gulis koronaruli daavadebebiT aris 500,000-ze meti. 1,680,000 pacientis hospitalizaciis mizezi aris ACS. amis garda 200,000 dan 300,000-mde kaci kvdeba MI-T savadmyofoSi gadayvanamde. anu mwvave koronaruli sindromi TiTqmis 2,000,000 mde adamians emarTeba yovelwliurad. aqedan STEMI aqvs daaxloebiT 500,000 adamians. evropuli monacemebiT am ukanasknelis sikvdilianoba 1 TveSi Seadgens 30-50%-s romelTagan TiTqmis naxevari pirvel 2-sT-Si xdeba. unda aRiniSnos rom bolo xanebSi miokardiumis infarqtis sixSires aqvs Semcirebis xolo arastabiluri stenokardiis sixSires zrdis tendencia. igive SeiZleba iTqvas STEMI-s Sesaxeb, romlis SemTxvevebi mcirdeba NSTEMI-s sasargeblod. zogadad SesaZloa iTqvas, rom amerikaSi yovel 29 wm-Si romelime adamians emarTeba mwvave MI xolo am daavadebiT pacienti kvdeba yovel 1 wT-Si.
Tuki saqrTvelos mosaxleobas aviRebT 4,000,000-mde, xolo statistikas igives davtovebT rac evropasa da a.S.S-Sia, maSin SesaZloa iTqvas, rom CvenTan yovelwliurad gulis koronaruli daavadebebiT kvdeba daaxloebi 6600 pacienti. ACS yovelwliurad emarTeba 26,000 adamians. aqedan STEMI yovelwliurad emarTeba daaxloebiT 6600 adamians ( romelTa 30%-50% kvdeba pirvel 1-TveSi), xolo danarCens aqvs UA/NSTEMI ( daaxloebiT 18,000-19,000).
saqarTveloSi yovel 40 wT-Si romelime adamians emarTeba MI, xolo am daavadebiT kvdeba pacienti yovel 80 wT-Si.
v. mwvave koronaruli sindromis ganmarteba da klinikuri mimdinareoba:
sqema: 1
[pic]
tkivils miokardiumis dros klasikuri mimdinareobisas aqvs substernaluri, moWeriTi, xasiaTi xSiri iradiaciiT marcxena xelSi, tkivili msgavsia stenokardiuli tkivilis, oRond grZeldeba > 20wT-ze. gansxvavebiT PE-s da aortis diseqciisa tkivilis piki araa myisieri. tkivili SeiZleba gadaecemodes kiserSi, ybaSi, mxrebSi, marjvena mklavSi, epigastriumSi. es tkivilebi SeiZleba iyos izolirebulic, gulmkerdis tkiilis gareSec da es ufro xSirad gvxvdeba moxucebSi da maTSi visac aqvs diabeti.
a. Tu tkivili iradirebs zurgSi da aris xanjlis CacemasaviT eWvi unda gvqondes aortis diseqciaze. am dros mizanSewonilia CT an transezofaguri eqoskopia. b. perikarditisas tkivili Zlierdeba zurgze wolisas, da umjobesdeba jdomisas da win gadmoxrisas. ST elevaciis difuzuri xasiaTi erT-erTi mniSvnelovani ganmasxvavebeli niSania MI-sgan, Tumca msgavsi suraTi SesaZloa am ukanasknelisTvisac iyos damaxasiaTebeli. Pperikarditisas ST segmentis elevacias aqvs Cazneqili xasiaTi infarqtisagan gansxvavebiT. aseve perikarditisaTvis araa damaxasiaTebeli reciprokuli cvlilebebi. aVR-is da V1 –is garda eqokardiografiisas MI-s dros gveqneba regionaluri kumSvadobis moSla rac erT-erTi sadiferenciacio niSania.
g. miokarditi: eqokardiografia am SemTxvaSi ver gvexmareba. diferencireba xdeba anamnezis safuZvelze, rac miokarditisas xSirad ukavSirdeba virusul infeqcias.
d. PE xSirad sunTqvis gaZnelebasTan erTadaa, axasiaTebs plevraluri tkivili, am SemTxvevaSi eqokardiografias aqvs didi roli diferencialuri diagnozis gatarebaSi.
e. ezofagialuri daavadebebi: gastroezofaguri refluqss, ezofaguri hiperalgezias SeuZlia mogvces MI-s msgavsi diskomforti. xSirad igi gvxvdeba pacientebSic romelTac aqvT CHD, riTac diagnostireba rTuldeba. am SemTxvevaSi mniSvneloba aqvs igi ukavSirdeba Tu ara kvebas, mcirdeba Tu ara antacidebis xmarebisas, ramdenad axasiaTebs radiacia. v. mwvave qolecistiti: man SeiZleba mogvces msgavsi xasiaTis tkivili da e.k.g. cvlilebebi, rac xSirad damaxasiaTebeli qveda kedlis miokardiumis infarqtisTvis. muclis marjvena zeda kvadratis mgrZnobeloba da daWimuloba, cxeleba leikocitozi laparakobs qolecistitis sasargeblod. unda aRiniSnos, rom es gansxvavebebi araa absolituri da daavadeba xSirad SesaZloa mimdinareobdes atipiurad an romelime sxva daavadebis msgavsi klinikiT. aqedan gamomdinare SeiZleba iTqvas rom MI-s diagnozi moiTxovs misi diagnostikisadmi kompleqsur midgomas, romelic iTvaliswinebs sxvadasxva faqtorebs.
II STEMI-s ganviTarebamde mkurnaloba
a. rekomendaciebi STEMI-s risk faqtorebis mqone pacientebis gamovlenisTvis
riskis gansazRvra: CHD-s ZiriTadi/mTavari risk faqtorebia: moweva, ojaxuri istoria, lipiduri speqtris gauareseba, maRali arteriuli wneva. pacientebs diabetiT da periferiuli arteriebis daavadebebiT aqvT STEMI-s ganviTarebis igive riski rac daavadebulebs gulis koronaruli daavadebiT.
klasi I
1. yvela pacientSi regularuli intervaliT ( 3 – 5 weli ) Sefasebul unda iqnes CHD-is ZiriTadi/mTavari risk faqtorebi ( AHA/ACC-is ganmartebiT esenia: ojaxuri istoria, moweva, gauaresebuli lipiduri profili, maRali arteriuli wneva, diabeti) da maTi kontrolis xarisxi. LOE : C
2. simptomuri CHD ganviTarebis 10 wliani riski unda iqnes gaTvlili yvela pacientSi visac aqvs 2 an meti didi risk faqtori ( gaTvla warmoebs amerikis NCEP-is programis safuZvelze ) LOE : B
3. pacientebi CHD-iT, identificirebulni unda iqnan meoradi prevenciisTvis. pacientebi CHD-is ekvivalenti riskiT ( diabeti, Tirkmlis qr. daavadeba an 10 wliani riski > 20% gamovlenili framingemis kvleviT: ganxilul unda iqnen, ise rogorc klinikurad gamovlenili CHD. LOE : A
10-wliani sikvdilianobis riski. SegiZliaT gansazRvroT mocemuli veb gverdze ganTavsebuli formuliT.
damateba: im pacientebSi romelTac NCEP-s mixedviT aqvT 10 wliani sikvdilianobis riski > 6%-ze, SeiZleba ganvixiloT aspirinis miReba 75-162 mg dReSi.
b. rekomendaciebi STEMI-s niSnebis naadrevi gamovlenisa da CarevisaTvis, pacientebis ganaTleba:
klasi I
1. pacientebi STEMI-T (diskomforti an tkivili gulmkerdSi iradiaciis gareSe, an iradiaciiT mklavSi, zurgSi, epigastriumSi, ybaSi, nikapSi, haeris ukmarisoba, sisuste, oflianoba, gulisrevis SegrZneba Tavbrusxveva) umjobesia klinikaSi gadayvanil iqnan saswrafo daxmarebis brigadis mier, vidre TviTdinebiT an axloblebis mier. LOE : B
2. mkurnalma eqimma pacients da misi axloblebs unda auxsnas:
a. gulis Setevis riski LOE : C
b. rogor unda amovicnoT STEMI-s simptomebi LOE : C
g. saswrafo daxmarebis brigadis gamoZaxebis aucilebloba, Tu simptomebi ar qreba an uaresdeba 5 wuTis Semdeg, miuxedavad gaurkvevlobis da eqimebis “ tyuilad Sewuxebis” SiSisa. LOE : C
d. pacientma da misma axloblebma unda icodnen moqmedebis gegma aseT SemTxvevebisas (s.d.b-s telefonis nomrebis CarTviT) LOE : C
3. pacientebs, visTvisac nitroglicerini ukunaCvenebi ar aris, erTi abi unda mieces enis qveS gulmkerdis areSi tkivilis an diskomfortis dros. Tu gulmkerdSi tkivili/diskomforti ar Semcirda an gauaresda 5 wuTSi, rekomendirebulia dauyovnebliv darekil iqnas saswrafo daxmarebis samsaxurSi. ( LOE : C)
damateba: pacientebs unda aexsnaT, rom Tuki simptomebi ar qreba an uaresdeba, saswrafo daxmarebis sadgurSi darekvis Semdgom pacients SiZleba erCios aspirinis miReba s.d.b-s mosvlamde.
damateba: yuradReba unda mieqces imas rom zogierT pacientSi MI mimdinareobs gulmkerdSi diskomfortis gareSe. am mxriv gansakuTrebiT sayuradReboa qalebi, diabetiT daavadebulebi, moxucebulebi, pacientebi gulis ukmarisobiT. agreTve sayuradReboa is pacientebi romlebsac aqvT permanentuli peismekeri da tkivili gulmkerdSi, vinaidan maTSi e.k.g. interpretacia Zalian garTulebulia.
III STEMI-s Setevis dawyeba da prehospitaluri qmedeba
a. STEMI-T pacientebis transportireba da pirveladi reperfuziuli mkurnalobis SerCeva
sqema 2 A hospitaluri fibrinolizisi: unda Sesruldes
stacionarSi Semosvlidan 30 wT-Si
[pic]
paneli A pacientebi hospitalSi transportirdebian saswrafo daxmarebis brigadis mier
reperfuzia STEMI-an pacientebSi SesaZloa ganxorcielebul iqnas farmakologiurad (fibrinoliziT ) an kaTeterizaciiT (PCI). arCeviToba am strategiebs Soris emyareba pacientebis transportirebis saxes da mimRebi klinikis SesaZleblobebs. transportirebis dro cvalebadia yvela SemTxvevaSi, magram iSemiis dro SenarCunebuli unda iyos 120 wT-s farglebSi. arsebobs 3 SesaZlebloba: 1. Tu saswrafo daxmarebis brigadas aqvs fibrinolizis SesaZlebloba da pacients ar aReniSneba ukuCveneba, prehospitaluri fibrinolizi dawyebul unda iqnes saswrafo daxmarebis brigadis misvlidan 30 wT-Si. (klasi I LOE: B). 2. Tu saswrafo daxmarebas ara aqvs fibrinolizis saSualeba da pacienti transportirdeba klinikaSi, sadac ar aris PCI-s saSualeba, pacients klinikaSi Sesvlidan 30 wT-Si unda daewyos fibrinolizi (karidan-nemsamde dro 30 wT klasi I LOE: B). 3. Tu saswrafo daxmarebis brigadas ara aqvs fibrinolizis saSualeba da pacienti transportirdeba klinikaSi, romelsac aqvs kaTeterizaciis PCI saSualeba, pacients klinikaSi Sesvlidan 90 wT-Si unda Cautardes PCI. (karidan-balonamde dro 90 wT(klasi I LOE: B). (an Tromblizisi romlis warumateblobis SemTxvevaSi SeiZleba gakeTdes gadamrCeni PCI. unda aRiniSnos rom PCI-s SesaZleblobebiT aRWurvil klinikebs aqvT saSualeba ufro mSvidad da swrafad ganaxorcielon aRnisnuli mkurnalobis TiToeuli etapi, rac Tavis mxriv aZlevs maT saSualebas SeimuSaon maT klinikaSi saukeTeso reperfuziuli strategiia mocemuli pacientisaTvis.
intrahospitaluri gadayvana agreTve aRsaniSnavia pacientebis intrahospitaluri gadayvana PCI-iT uzrunvelyofil klinikaSi Tu: 1. aRiniSneba fibrinolizis ukuCveneba; 2. PCI SesaZlebelia gakeTdes ufro swrafad (pacientis sawyis mimReb klinikaSi Semosvlidan 90 wT-Si an fibrinolizis dawyebis SesaZleblobidan 60 wT-Si ) 3. fibrinolizi warumatebelia (e.i. keTdeba gadamrCeni PCI ). meoradi, arasaswrafo interhospitaluri gadayvana SesaZlebelia ganxilul iqnes ganmeorebiTi iSemiis dros.
pacientis TviTdineba: pacientis gadayvana TviTdinebiT riskTan aris dakavSirebuli. Tu pacienti miva klinikaSi sadac PCI SeuZlebelia, karebidan-nemsamde dro unda iyos 30 wT. Tu pacienti Seva PCI-iT aRWurvil klinikaSi karebidan-balonamde dro unda iyos 90 wT. mkurnalobis SerCeva da drois rekomendaciebi klinikaSi Sesvlis Semdeg aris igive.
sqema 2 B
.
[pic]paneli B pacientebisTvis, visac Cautarda fibrinolizi, riskis stratifikaciisTvis rekomendirebulia arainvaziuri Sefaseba gadamrCeni an iSemiiT ganpirobebuli PCI –s saWiroebis dasadgenad. reperfuziuli Terapiis meTodis miuxedavad yvela pacientma unda gaiaros STEMI-s meoradi prevencia.
damateba: unda aRiniSnos rom STEMI-s dros prehospitalur etapze rekomendirebulia pacientis gadayvanamde 162-325 mg aspirinis micema Lklasi I LOE: C
cxrili 1. STEMI-s dros maRali riskis prediqtorebi ( TIMI kvleva STEMI-s riskis gansazRvrisaTvis ) damoukidebeli 30 dRiani sikvdilianobis risk faqtorebi
| |riskis | |jamuri qula |saSualo |min da maqs |
| |qulebi | | |maCvenebeli 30 |maCvenebeli |
| | | | |dRiani | |
| | | | |sikvdilianobis % | |
| | | | | | |
|asaki ≥ 75 |3 | |0 |0,1 |0,1—0,2 |
| | | | | | |
|asaki 65-75 |2 | |1 |0,3 |0,2—0,30 |
| | | | | | |
|diabeti |1 | |2 |0,4 |0,3—0,5 |
| | | | | | |
|hipertenzia anamnezSi |1 | |3 |0,7 |0,6—0,9 |
| | | | | | |
|angina anamnezSi |1 | |4 |1,2 |1,0—1,5 |
| | | | | | |
|sistoluri wneva < 100 |3 | |5 |2,2 |1,9—2,6 |
| | | | | | |
|gulis SekumSvaTa sixSire > 100 |2 | |6 |3,0 |2,5—3,6 |
| | | | | | |
|gulis ukmar. kilipi II--IV |2 | |7 |4,8 |3,8—6,1 |
| | | | | | |
|wona < 67 kg |1 | |8 |5,8 |4,2—7,8 |
| | | | | | |
|wina kedeli an LBBB |1 | |> 8 |8,8 |6,3--12 |
| | | | | | |
|dro reperfuziamde > 4-sT |1 | | | | |
damateba: zogadad SeiZleba iTqvas rom cudi prognozis prediqtorebi STEMI-s dros arian asaki, gulis SekumSvaTa sixSire, arteriuli wneva, filtvebis SeSupeba da S3 toni
IV. pirveladi amocnoba da marTva gadaudebeli daxmarebis departamentSi
a. sqema. 3 gadaudebeli daxmarebis algoriTmi/protokoli pacientSi STEMI–s simptomebiT an niSnebiT
[pic]
[pic]
damateba: STEMI-s e.k.g. niSnad fasdeba: ST elevacia ≥ 0,2 mV (2mm) V1-V4 ganxraSi da ≥0,1 mV(1mm) sxva gulmkerdis ganxrebSi, mwvaved ganviTarebuli LBBB, gamoxatuli ST depresia V1—V4 ganxrebSi rasac axlavs maRali R marjvena prekordial ganxrebSi da pozitiuri T kbilebi, rac aris maCvenebeli WeSmariti posterior MI-s ( miuTiTebs rom procesSi Semomxvevi totia CarTuli)
b. damateba: ekg-s interpretacia:
e.k.g-s mixedviT infarqtis gamomwvevi sisxlZarRvis verificireba:
gamosaxuleba 4.
sqema romliTac sargebloben jo-enis saxelobis samedicino centrSi, igi miRebulia 2 sqemis kombinirebis Sedegad: romelic Tavis mxriv aRebulia Topol EJ. Van de Werf FJ Acute myocardial infarction: early diagnosis and menegment. In: Topol EJ. ed.Textbook of cardiovascular medicine. vinaidan am sqemidan Semomxvev totsa da marjvena koronars Soris Wirda diferencireba igi Sevsebuli iqna: Braunwald Zipes Libby Heart sesease A Textbook of Cardiovascular Medicine 2001 6 edition
| | | |
|Proximal LAD |Proximal to first septal |ST ↑ V1— 6 I, aVL and fasicular or |
|proqsimaluri LAD |perforator stenozi pirveli |bundle branch block |
| |septaluri perforatoris | |
| |proqsimaluradaa | |
| | | |
|Mid LAD |Proximal to large diagonal but | |
|Sua LAD |distal to eirst septal |ST ↑ V1— 6 I, aVL |
| |perforator | |
| |stenozi didi diagonalis | |
| |proqsimaluradaa magram | |
| |distalurad pirveli septaluri | |
| |perforatorisagan | |
| | | |
|Distal LAD or Diagonal |Distal to large Diagonal or |ST ↑ V1—4 or I, aVL, V5 —V6 |
|distaluri LAD an TviTon diagonali |diagonal itself stenozi didi | |
| |diagonalis distaluradaa an | |
| |Tavad diagonalSia | |
| | | |
|Moderate to large inferior (poetrior, |Proximal RC or Left circumflex |ST ↑ II, III, aVF and any of the |
|lateral, right ventricular) |stenozi marjvena koronaris |following: |
|saSualo an didi qveda kedeli ( ukana, |proqsimaluradaa an SemomxvevSia|V1 V3R, V4R |
|lateraluri, marjvena parkuWovani) | |V5—6 |
| | |R >S in V1—V2 |
| | | |
| | | |
| | | |
| | | |
|Small inferior |Distal RCA or left circumflex |ST ↑ II, III, aVF only |
|mcire zomis qveda kedeli |branch | |
| |stenozi aris marjvena koronaris| |
| |distalur nawilSi an Semomxvevis| |
| |totSia | |
| | | |
| | | |
gamosaxuleba 5. e.k.g. kriteriumebi m.m.i.-s diagnostikisTvis LBBB-is fonze: am sqemaSi 3 qulas da mets aqvs 90%-ian specifiuroba da 88%-ini albaToba igi adaptirebulia Sgarbosa EB, Prinski SL, Barbagelata A, et al. Electrocardiographic diagnoses of evolving acute mypcardial infarction in the resence of left bundle brunch block. N Engl J Med 1996; 334: 481- 487
|kriteriumebi |qulebi |
|ST ↑ ≥1mm konkordantuli QRS-is |5 |
|ST ↑ ≥ 1mm ganxrebSi V1,V2 or V3 |3 |
|ST ↑ ≥ 5mm diskordantuli QRS -is |2 |
e.k.g. kriteriumebi m.m.i.-is diagnostikisaTvis RBBB-is fonze:
nacvlad T kbilisa QRS-isgan diskordantulad gveqneba QRS-is konkordantuli T kbili V1,V2 an V3 ganxrebSi (fsevdonormalizacia).
cxrili 2 swrafi fizikuri gasinjva gadaudebel departamentSi
1. sasunTqi gzebi, sunTqva, cirkulacia (ABC)
2. sasicocxlo niSnebi, zogadi meTvalyureoba
3. sauRle (iugularuli) venebis daWimulobis arseboba/ararseboba
4. auskultacia filtvebSi Segubebis niSnebis gamosavlenad
5. gulis auskultacia (Suili gulze an galopis riTmi)
6. T/t sisxlis mimoqcevis moSlis arseboba an ararseboba
7. pulsaciis arseboba an ararseboba
8. sistemuri hipoperfuziis arseboba an ararseboba (kanis sicive, sifermkrTale, webovaneba, aWreleba)
g. cxrili 3. STEMI-is diferencialuri diagnostika
| | | |
|sicocxlisaTvis saSiSi |aortis diseqcia |daWimuli pnevmoToraqsi |
| | | |
| |pulmonaruli embolia |ezofagealuri rubtura mediastinitiT ( boerhavas ( |
| | |borhaava) sindromi |
| |perforirebuli wyluli | |
| | | |
|sxva kardiovaskularuli da ara |perikarditi |marcxena parkuWis hipertrofia |
|iSemiuri | | |
| |atipiuri angina |brugdas sindromi |
| | | |
| |adreuli repolarizacia |miokarditi |
| | | |
| |WPW sindromi |hiperkaliemia |
| | | |
| |Rrmad invertirebuli T kbilebi rogorc centraluri nervuli|hisis konis totebis blokada |
| |sistemis dazianebis an hipertrofiuli kardiomiopaTiis | |
| |asaxva |vazospastikuri angina |
| | | |
| | |hipertrofiuli kardiomiopaTia |
| | | |
|sxva arakardialuri |gastroezofagaluri refluqsi (CERD) da spazmi |biliaruli an pankreatuli wyluli |
| | | |
| |gulmkerdis kedlis tkivili |xerxemlis malebi diski an nevralgia |
| | | |
| |plevraluri tkivili |somaturi an fsiqogenuri tkivili |
| | | |
| |peptiuri wyluli | |
| | | |
| |panikuri SiSi | |
d. STEMI-s diagnoziT miRebul pacientSi rutinuli testebi
1. Sratis biomarkerebi gulis dazianebis Sesafaseblad : kardiospecifiuri troponinebi ( ar daucado reperfuziul strategiis Sedegebs) klasi I LOE: C
damateba : troponini upiratesi markeria miokardiumis infarqtis diagnostirebisas. CK-MB-s gazomvisas SeiZleba gamogvrCes mcire zomis ifarqti. rogorc wesi iReben orives. vinaidan troponini momatebuli rCeba 1-kviridan 10-14 dRemde, stacionarSi am periodSi ganviTarebuli gulmkerdSi tkivilis Sesafaseblad gamoiyeneba CK-MB. vinaidan igi sabaziso dones ubrundeba procesis damTavrebidan 2-3 dReSi. iq sadac ver keTdeba troponini SeiZleba visargebloT CK-MB-iT.
2. sisxlis saerTo analizi (CBC); klasi I LOE: C
3. INR; klasi I LOE: C
4. aPTT klasi I LOE: C
5. eleqtrolitebi da magniumi; klasi I LOE: C
6. BUN; klasi I LOE: C
7. kreatinini; klasi I LOE: C
8. glukoza; klasi I LOE: C
9. Sratis lipidebi; klasi I LOE: C
( es ukanaskneli ar aris aucilebeli gakeTdes dauyovnebliv da davelodoT mis pasuxs, mkurnaloba iwyeba statiniT da stacionarSi yofnis periodSi keTdeba analizi. damateba samuSao jgufis mier)
10. gulmkerdis rentgenografia: portatuli aparatiT adgilze, unda gvaxsovdes rom aman ar unda daayovnos reperfuziuli Terapia(Tuki ar aris eWvi iseT potenciur garTulebaze rogoricaa aortis diseqcia). klasi I LOE: C
11. gulmkerdis rentgenografia(portatuli aparatiT), transTorakaluri da/an
transTorakaluri eqokardioskopia, sCT an MRI aortis diseqciis
sadiferenciaciod STEMI-sagan. klasi I LOE: B
12. eqokardiografia SREMI-s diagnozis dasazusteblad da riskis Sesafaseblad
pacientebSi vinc moxvdeba gadaudebeli daxmarebis departamentSi aRniSnuli
diagnoziT, gansakuTrebiT maSin roca saqme gvaqvs LBBB-sTan an parkuWovan
kardiostimulaciasTan, an eWvia ukana kedlis (posterior) STEMI-ze romelic
mimdinareobs wina ganxrebSi ST segmentis depresiiT klasi II-A LOE: B gamosaxuleba 3. gulis biomarkerebi STEMI-s dros. mowodebulia AHA/ACC STEMI-s gaidlainis sruli teqstidan
[pic]
uwyveti wiTeli aris gulis troponini, romelic matebas iwyebs 6-sT-Si da piks 36-sT-Si aRwevs. (reperfuziis dros wiTeli wyvetili xazi piki ufro adrea 20-24 sT-Si). CK-MB aseve matebas iwyebs 6-sT-Si da piks 20-24-sT-Si aRwevs. uwyveti mwvane. (reperfuziisas igi piks 16-18-sT-Si aRwevs). unda AaRiniSnos rom cTnI momatebuli rCeba 7-10 dRe xolo cTnT 10-14 dRe reperfuziis gareSe CK-MB reperfuziis gareSe normas 2 dReSi ubrundeba
| |
|Mmarkerebi MI-s gamosavlenad |
|markeri |sawyisi Sefaseba MI-s |Eelevaciis saSualo piki MI-s |sabaziso monacemebTan dabrunebis dro |
| |Semdgom |Semdgom | |
|Myoglobin |1 - 4 sT |6 sT |18 - 24 sT |
|CK-MB |3 - 12 sT |10 - 24 sT |48 - 72 sT |
|MB-isoforms |1 - 6 sT |4 - 12 sT |38 sT |
|cTnI |3 - 12 sT |10 - 24 sT |5 - 10 dRe |
|cTnT |3 - 12 sT |12 - 24 sT |5 - 14 dRe |
|Suggested testing schedule for cardiac markers |
|markeri |< 6 sT |6 - 12 sT |12 - 24 sT |24 - 48 sT |> 48 sT |
|Myoglobin |+++ |+ |- |- |- |
|Troponin I |+ |++ |+++ |+++ |+++ |
|Troponin T |+ |++ |+++ |+++ |+++ |
|CK-MB |+ |++ |+++ |- |- |
|MB- isoforms |++ | | | | |
e. reperfuziis meTodis aucileblobis da SesaZleblobis gansazRvra pacientebSi STEMI-T
cxrili 4
[pic]
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|sistoluri a.w. 180 mm Hg-ze metia ο diax ο ara |
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|diastoluri a.w. 110 mm Hg-ze metia ο diax ο ara |
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|sxvaoba sistolur a.w. Soris marcxena da marjvena xelze 15 mm Hg-ze meti ο diax ο ara |
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|struqturuli cns daavadeba anamnezSi ο diax ο ara |
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|bolo 3 Tvis manZilze Tavis qalas/saxis daxuruli trvma ο diax ο ara |
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|axali (bolo 6 kviris ) didi travma, qirurgiuli Careva (maT Soris Tvalis lazeruli operacia Tvalze) GI/GU sisxldena |
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|ο diax ο ara |
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|sisxldenis an Trombis warmoqmnis problemebi an sisxlis gaTxeleba ο diax ο ara |
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|kardiopulmonaluri resuscitacia ( CPR) 10 wT-ze metia ο diax ο ara |
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|orsuloba ο diax ο ara |
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|seriozuli organuli daavadebebi(Sorswasuli simsivne an terminaluri stadia, RviZli da Tirkmlis mZime daavadebebi ) |
|ο diax ο ara |
III safexuri
filtvebis Segubeba (Sua wilebze zemoT) ο diax ο ara
sistemuri hipoperfuzia ο diax ο ara
v. reperfuziis saxis SerCeva pacientebSi STEMI-T
cxrili .5
I safexuri: drois da riskis Sefaseba:
λ dro simptomebis dawyebidan
λ STEMI.-s riski
λ fibrinolizis riski
λ dro, romelic saWiroa PCI-iT uzrunvelyofil laboratoriaSi gadasayvanad.
II safexuri: fibrinolizis Tu invaziuri strategia? upiratesobis gansazRvra?
Tu pacientis Semosvlis dro 3 sT-ze naklebia da invaziuri strategiis dro SesaZloa iyos gaidlainiT gansazRvrul farglebSi arc erTi strategias upiratesoba ar aqvs.
| |P |
|fibrinolizi upiratesia Tuki: |invaziuri strategia upiratesia Tuki: |
| | |
|stacionarSi adreuli moxvedrisas ( ≤ 3-sT-ze simptomebis |PCI laboratoria Seesabameba standarts † da aqvs qirurgiuli uzrunvelyofa |
|dawyebidan da im SemTxvevaSi Tuki invaziuri strategia gviandeba) | |
|( ix. qvemoT) |• karebidan balonamde dro < 90 wT |
| | |
| |• karebidan balonamde dros gamoklebuli karebidan nemsamde ( igulisxmeba |
| |Trombolizisis dawyebis SesaZlebloba) dro < 1 sT-ze |
| | |
|invaziuri strategia ar ganixileba rogorc arCevani Tuki: |STEMI maRali riskiT |
| | |
|• kaTeterizaciis laboratoria dakavebulia |• kardiogenuri Soki (am SemTxvevaSi nacvlad 12 sT-isa aRebulia 18-sT |
| |infarqtis dawyebidan da 75w asakis qvemoT pacientebisaTvis klasi I |
|• sisxlZarRvovani midgoma garTulebulia |LOE: A xolo maTTvis visasac aski > 75w-ze > klasi II-A LOE B |
|• PCI laboratories unar-Cvevebi ar Seesabameba | |
|standarts † |• kilipis klasi ≥ 3. Cvenebis klasi II-A LOE B |
| | |
| | |
|invaziuri Carevis dayovneba: |fibrinolizisze ukuCveneba |
| | |
|• transportireba xangZlivdeba |igulisxmeba sisxldenis da intrakranialuri hemoragiis gazrdili riskebi |
| | |
|• karebidan balonamde dro > 90wT-ze |klasi I LOE: B |
| | |
|• karebidan balonamde dros gamoklebuli karebidan nemsamde ( | |
|igulisxmeba Trombolizisis dawyebis SesaZlebloba) dro > 1 sT-ze | |
| | |
| | |
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|Trombolizisis dozebi aris me-11 cxrilSi |stacionarSi Semosvlis dagvianeba > 3 sT-ze simptomebis dawyebidan |
|ukuCvenebebi mocemuli me-6 cxrilSi | |
| | |
| |Tuki infarqtis diagnozi saeWvoa da/an |
| |pirveladi PCI-s rekomendaciebSi gaTvaliswinebuli SemTxvevebi |
† PCI-s standartebSi igulisxmeba operatoris gamcdileba ( pirveladi PCI > 75 SemTxvevaze weliadSi) da gunduri muSaobis gamocdileba ( pirveladi PCI > 36 SemTxevaze weliwadSi )
z. fibrinolizis Cvenebebi:
I klasi:
1. ukuCvenebebis ar arsebobisas, fibrinolizisuri mkurnaloba iniSneba STEMI-s dros Tuki simptomebis dawyebidan gasulia ≤ 12-sT da ST elevacia aris meti 0,1 mV sul cota or mimdebare prekordiul ganxraSi an or mimdebare kidurebis ganxraSi LOE: A
2. ukuCvenebebis ar arsebobisas aRniSnuli mkurnaloba tardeba STEMI-s dros Tuki simptomebis dawyebidan gasulia ≤ 12 sT da pacients aqvs axali an savaraudod axali LBBB LOE: A
II A klasi:
1. ukuCvenebebis ar arsebobisas aRniSnuli mkurnaloba tardeba STEMI-s dros Tuki simptomebis dawyebidan gasulia ≤ 12 sT da pacients aqvs 12 ganxriani e.k.g-s mixedviT WeSmariti ukana kedlis infarqti LOE: C
2. ukuCvenebebis ar arsebobisas aRniSnuli mkurnaloba tardeba STEMI-s dros, Tuki simptomebis dawyebidan gasulia 12-dan 24 sT-mde Tuki iSemiis simptomebi grZeldeba da ST elevacia aris meti 0,1 mV sul cota 2 mimdebare prekordiul ganxraSi an or mimdebare kidurebis ganxraSi LOE: B
III klasi:
1.fibrinolizisuri Terapia ar iniSneba asimptomatur pacientebSi romlebSiac STEMI-s simptomebi daiwyo 24-sT-iT adre. LOE: C
2. Fibrinolizisuri Terapia ar iniSneba pacientebSi romlebSiac 12 ganxrian e.k.g.-ze mxolod ST segmentis depresiaa im SemTxvevebis gamoklebiT roca ara gvaqvs WeSmariti marcxena parkuWis infarqti. LOE: A
damateba: Trombolizisis efeqturoba naklebia im pacientTa jgufSi romelsac aqvs qveda kedlis infarqti, Tuki mas Tan ar axlavs RV infarqti an ST-segmentis depresia prekordialur ganxrebSi, rac miuTiTebs rom didi ubanis arsebobaze riskis qveS.
T. STEMI-s dros fibrinolizis ukuCveneba da safrTxeebi
cxrili 6.
absoluturi ukuCveneba: 1. raime adreuli intrakranialuri hemoragia, 2. cnobili cerebrovaskularuli dazianeba (mag: arteriovenozuri paTologiebi), 3. cnobili avTvisebiani intrakranialuri neoplazma(pirveladi an metastazuri), 4. iSemiuri insulti bolo 3 Tvis manZilze garda mwvave iSemiuri Setevisa bolo 3 sT-s manZilze 5. eWvi aortis diseqciaze 6. sisxldena an sisxlmdeni diaTezi (menzesis garda) 7. bolo 3 Tvis manZilze, Tavis qalis an saxis daxuruli travma
SedarebiTi ukuCveneba 1. anamnezSi qr., mkacri, Znelad kontrolirebadi hipertenzia 2. mkacri ukontrolo hipertenzia (sistoluri 180 mmHG-ze meti, 3. diastoluri 110 mmHG-ze meti) es ukuCveneba SesaZloa iyos absolituri ukuCveneba dabali riskis STEMI-s dros 4. anamnezSi 3 Tveze adrindeli iSemiuri Seteva, demencia, an intrakranialuri paTologia, romelic ar ifareba absolituri ukuCvenebebiT 5. travmuli an gaxangrZlivebuli (10 wT-ze meti) CPR an didi operacia(3 kviraze nakleb droSi ) 6. axali (2-4 kviris) Sinagani sisxldena 7. arakompresirebadi vaskularuli punqcia 8. streptokinaza/antistrptaza adrindeli gamoyeneba (5 dReze adre) an alergiuli reaqcia am agentze 9. orsuloba 10. aqtiuri peptiuri wyluli 11. antikoagulantis miReba anamnezSi: rac maRalia INR miT maRalia sisxldenis riski
i. diagnostikuri koronaruli angiografia
klasi I
1. irveladi PCI-s kandidatebi LOE: A
2. pacientebi kardiogenuri SokiT Tuki maT aqvT revaskularizaciis Cveneba LOE: A
3. qirurgiuli koregireba ventrikuluri zgidis rubturisas/mkacri sarqvlis naklovanebisas LOE: B
4. pacientebSi persistentuli hemodinamikuri da/an eleqtruli arastabilurobisas. LOE: C
klasi III
1. koronaruli angiografia ar unda Catardes pacientebSi Tanmxlebi mZime daavadebebiT sadac revaskularizaciis riski ufro metia vidre sargebloba. LOE: C
k. pirveladi PCI-s rekomendaciebi
klasi I zogadi ganxilva
1. Tu dauyovnebliv SesaZlebelia, pirveladi PCI Catarebul unda iqnes pacientebSi STEMI-T (WeSmaritad ukana kedlis m.i.-s CaTvliT) an axali an savaraudod axali hisis konis marcxena fexis blokadisas, simptomebis dawyebidan 12 sT-Si. Tuki Careva tardeba dadgenil droSi (balonuri inflacia 90 wT-Si Semosvlidan) gamocdili eqimis mier (romelic akeTebs 75 pirveladi PCI proceduras weliwadSi). procedura mxardaWeril unda iqnes gamocdili personalis mier Sesatyvis laboratoriaSi (yovel wels laboratories mier gakeTebuli unda iyos 200 PCI aqedan 36 mainc pirveladi PCI STEMI-s dros da unda qondes qirurgiuli uzrunvelyofa). (LOE A )
specifiuri sakiTxebi: rac exmareba eqims gadawyvetilebis miRebaSi airCios mkurnalobis meTodi;
a. pirveladi PCI unda Catardes rac SeiZleba swrafad, samedicino kontaqtidan-balonamde an karidan-balonamde dro 90 wT. (LOE A )
b. Tu simptomebis xangrZlivoba aris 3 sT-s farglebSi da mosalodneli karidan balonamde drois da mosalodneli karidan-nemsamde drois sxvaoba aris:
• 1 sT-s farglebSi _ upiratesoba eZleva PCI (LOE B )
• metia 1 sT-ze upiratesia fibrinolizuri Terapia. (LOE B )
g. Tu simptomebis xangrZlivoba 3 sT-ze metia, pirveladi PCI upiratesia da unda gakeTdes rac SeiZleba xanmokle droSi samedicino kontaqtidan-balonamde an karidan-balonamde 90 wT-is farglebSi (LOE B )
a. pirveladi PCI unda Catardes pacients 75 wlis qvemoT ST-elevaciiT an LBBB-T, romelTac ganuviTardaT Soki MI-dan 36 sT-Si da arian revaskularizaciisTvis Sesaferi (Carevis teqnikuri SesaZlebloba sisxlZarRvis antomiuri da dazianebisTaviseburebebis gamo.) da igi SeiZleba Catardes Sokis ganviTarebidan 18 sT-Si Tu Semdgomi mkurnalobis gagrZeleba araa azrs moklebuli pacientis survilis. ukuCvenebebis an imis gamo rom invaziuri CarevisaTvis mdgomareoba Seuferebelia (igulisxmeba Carevis teqnikuri SeuZlebloba sisxlZarRvis anatomiuri Taviseburebebis da dazianebis Taviseburebebis gamo. (LOE A )
b. pirveladi PCI unda Cautardes pacientebs mkacri SegubebiTi gulis ukmarisobiT, da/an filtvebis SeSupebiT (kilipi III) simptomebis dawyebidan 12 sT-is ganmavlobaSi. samedicino kontaqtidan balonamde an karidan-balonamde dro unda iyos rac SeiZleba mokle, 90 wT-is farglebSi. ( LOE B )
klasi II A
1. pirveladi PCI 75 wlis an mis zeviT asakis pacientebSi STEMI_T an LBBB-T, visac ganuviTarda Soki infarqtidan 36 sT-Si da Sesaferisia (anatomiurad da teqnikurad) revaskularizaciisTvis, rac SesaZloa Cautares Sokidan 18 sT-Si. pacientebi romelTac manamde hqondaT kargi funqciuri statusi, mdgomareoba Sesaferisia revaskularizaciisTvis da pacieti Tanaxmaa invaziur Carevaze, SesaZloa arCeul iqnan invaziuri strategiisTvis. . ( LOE B )
2. pirveladi PCI SesaZloa Cautardes pacientebs visac simptomebi daewyo 12-dan 24 sT-is ganmavlobaSi da aReniSneba erTi an ramdenime qvemoTCamoTvlilTagani:
a) mkacri SegubebiTi gulis ukmarisoba. ( LOE C )
b) hemodinamikuri an eleqtrlituri arastabiluroba ( LOE C )
g) persistentuli iSemiuri simptomebi ( LOE C )
klasi II B
1. pirveladi PCI-is sargebloba STEMI-an pacientebSi romlebic fibrinolizisisaTvis Sesaferisni arian, ar aris kargad gansazRvruli, rodesac PCI-is atarebs operatori, romelsag aqvs 75 PCI proceduraze naklebi Catarebuli weliwadSi. ( LOE C )
klasi III
1. pirveladi PCI ar unda Cautardes arainfarqtul arteriaze pacientebSi hemodinamikuri arastabilurobis gareSe. ( LOE C )
2. pirveladi PCI ar unda Cautardes asimptomur pacientebs Tuki STEMI-s dawyebidan gasulia 12 sT-ze meti da Tu isini arian hemodinamikurad da eleqtrofiziologiurad stabilurebi. ( LOE C )
l. pirveladi PCI-s rekomendaciebi pacientebSi romlebic ver Rebuloben Tromboliziss raimis gamo; (Seuferebelia TrombolizisisaTvis)
klasi I
1. pirveladi PCI sruldeba STEMI-s dros pirvel 12 sT-Si Tuki pacienti Seuferebelia TrombolizisisaTvis ( LOE C )
klasi II-A
1. gonivrulia gavakeToT pirveladi PCI pacientebSi STEMI-T, Tuki isini Seuferebeli arian TrombolizisisaTvis,. simptomebis dawyebida 12-24 sT-Si Tu saxezea romelime CamoTvlilTagan:
• mkacri CHF ( LOE C )
• hemodinamikuri an eleqtruli arastabiloba ( LOE C )
• iSemiuri simptomebi persistirebs ( LOE C )
m. pirveladi PCI-s rekomendaciebi klinikebisaTvis romelTac ara aqvT kardioqirurgiuli ganyofileba
klasi I da II-A ara aqvs
klasi II-B
1. pirveladi PCI SeiZleba Sesruldes hospitalSi romelsac ara aqvs kardioqirurgia im SemTxvevaSi, Tuki arsebobs kardioqirurgiul saoperacio oTaxSi gadayvanis dadasturebuli/SeTanxmebuli gegma Sesaferisi hemodinamikuri daxmarebis fonze. am SemTxvevaSic procedura izRudeba pacientebiT romelTac aqvT STEMI an MI axali an savaraudod axali LBBB-iT e.k.g-ze da SesaZlebelia maTSi Careva droulad Sesruldes ( balonis gaberva 90-wT-Si) operatoris mier romelic weliwadSi asrulebs sul cota 75 PCI-s. aqedan 36 pirveladi PCI (( LOE C )
klasi III
1. pirveladi PCI ar unda Catardes hospitalSi romelsac ara aqvs qirurgiuli ganyofileba da ara aqvs damtkicebuli/SeTanxmebuli gegma uaxlos stacionarSi kadioqirurgiuli ganyofilebis saoperacioSi gadayvanisTvis, Sesaferisi hemodinamikuri uzrunvelyofiT. ( LOE C )
n. damxmare PCI
ganmarteba: damxmare PCI-Si igulisxmeba dagegmili PCI sawyisi farmakologiuri Carevis Semdgom, rogoricaa fibrinolizisi sruli doziT, naxevari doza fibrinolizisis Semdgom, glukoprotein IIb/IIIa-is inhibitoris gadasxmis Semdgom an am ukanasknelis da Trombolizisis kombinaciis Semdgom.
klasi I da II-A ara aqvs
klasi II-B
1. damxmare PCI SesaZloa Sesruldes rogorc reperfuziuli strategiis nawili maRali riskis pacientebSi roca PCI ver sruldeba gadaudeblad da roca sisxldenis riski aris dabali LOE: B
o. gadamrCeni PCI:
I klasi:
1. gadamrCeni PCI unda Sesruldes pacientebSi romelTa asaki < 75w. aqvT STEMI an LBBB da romelTac MI ganuviTardaT 36 sT-is farglebSi da sisxlZarRvebi Sesaferisia (anatomiurad da teqnikurad) revaskularizaciisaTvis, xolo PCI SeiZleba Sesruldes Sokis dawyebidan 18-sT-Si. Tuki es Careva araa amao imis gamo rom pacients es ar surs, an Semdgomi invaziuri mkurnalobaze aris ukuCvenebebi/SeuTavseblobi. LOE: B
2. gadamrCeni PCI unda Cautardes pacientebs mkacri SegubebiTi gulis ukmarisobiT, (kilipi) III. simptomebis dawyebidan gasulia ≤ 12 sT-ze( LOE B )
II-A klasi:
1. PCI mizanSewonilia Sesruldes seleqtiur pacientebSi ≥ 75w. romelTac aqvT STEMI an LBBB da romelTac MI ganuviTardaT 36 sT-is farglebSi da romelTa sisxlZarRvebi Sesaferisia (anatomiurad/teqnikurad) revaskularizaciisaTvis, xolo PCI SeiZleba Sesruldes Sokis dawyebidan 18-sT-Si. es exebaT pacientebs romelTac aqvT kargi funqcionaluri statusi da Tanaxmani arian invaziur Carevaze. LOE: B
2. mizanSewonilia Sesruldes gadamrCeni PCI Tuki aris erTerTi CvenebaTagani:
• hemodinamikuri an eleqtruli arastabiluroba LOE: C
• persistentuli iSemiuri simptomebi LOE: C
p. PCI fibrinolizisis Semdeg:
klasi I
1. pacientebSi (Tuki sisxlZarRvTa anatomia Sesaferisia), PCI tardeba, roca aris obieqturi monacemebi romlebic adastureben ganmeorebiT (recurent) infarqts LOE: C
2. pacientebSi romelTa anatomia Sesaferisia, PCI unda Catardes saSualo an mkacri, spontanuri an provocirebadi miokardiumis iSemiisas STEMI is Semdgom aRdgenis fazaSi LOE: B
3. pacientebSi romeTa anatomia Sesaferisia, PCI unda Catardes kardiogenuri Sokis an hemodinamikuri arastabiluriobisas (ixgadamrCeni PCI) LOE: B
klasi IIA
1. mizanSewonilia Catardes PCI rutinulad pacientebSi romelTa gandevnis fraqcia ≤ 40%-ze, aqvT CHF an seriozuli parkuWovani ariTmia. LOE: C
2. mizanSewonilia Catardes PCI Tuki aris dokumentirebuli klinikuri gulis ukmarisobis mwvave epizodi, miuxedavad imisa rom Semdgomi Sefasebisas SesaZloa LVgandevnis fraqcia iyos ≥ 40%-ze LOE: C
klasi IIB
1. rutinuli PCI SesaZloa ganvixiloT rogorc invaziuri strategiis nawili fibrinolizisuri Terapiis Semdgom. LOE: B
ganmarteba:
• warmatebuli Trombolizisis Semdgom Tuki mdgomareoba stabiluria da aris Cveneba PCI-s igi umjobesia Sesruldes dReeebis an kvireebis Semdgom, rac zrdis usafrTxoebas (garda im zemoTCamoTvlili SemTxvevebisa rac aCqarebs invaziur Carevas)
• .warumatebeli Trombolizisis SemTxvevaSi moqmedebs gadamrCeni Trombolizisis sqema. warmatebeli Trombolizis niSnebia: simptomebis moxsna,(SeiZleba ukavSirdebodes analgezias an nawilobri inervacias, rac gvxvdeba zogierT pacientebSi), aCqarebuli idioventrikuluri riTmi, hemodinamikis stabilizacia ST segmentis elevaciis 50-70%-iT Semcireba Trombolizisis dawyebidan 90-wT-Si. Tuki Trombolizisis dawyebidan 90 wT-Si ara gvaqvs reperfuziis aSkara niSnebi Trombolizisi iTvleba warumateblad da tardeba gadamrCeni PCI(es gansakuTrebiT exeba wina kedlis infarqts). gansakuTrebiT unda aRiniSnos, rom kardiogenuri Sokis ganviTarebisas ra Tqma unda ar velodebiT 90-wT-is gasvlas.
r. mwvave qirurgiuli reperfuzia:
zogadad gadaudebeli qirurgiuli reperfuzia unda Sesruldes STEMI-s dros Tuki gvinda am dros pirdapiri an gadamrCeni PCI-s Catareba magram pacients aReniSneba marcxena mTavari/ZiriTadi koronaris kritikuli stenozi an mkacri 3 sisxlZarRvovani daavadeba romelic miudgomelia PCI-sTvis.
gansakuTrebul SemTxvevas warmoadgens marjvena parkuWis infarqti, romelic ZiriTadSi gvevlineba rogorc gadaudebeli CABG-s ukuCveneba. vinaidan am dros Wirs pacientis moxsna xelovnuri sisxlis mimoqcevidan.
s. zogadad urgentuli da gadaudebeli qirurgiuli revaskularizaciis Cveneba STEMI-s dros aris Semdegi
I klasi
1. warumatebeli PCI persistentuli tkivilis da arastabiluri hemodinamikisas pacientebSi romelTac aqvT Sesaferisi anatomia qirurgiuli CarevisaTvis. LOE: B
2. persistentuli an ganmeorebiTi iSemia romelic refraqterulia medikamentur mkurnalobaze, pacientebSi romelTac aqvT Sesaferisi anatomia qirurgiuli CarevisaTvis, miokardiumis mnisvnelovani areali riskis qveS da ar arian kandidatebi Trombolizisis an PCI-s LOE: B
3. postinfarqtuli VSR da mitraluri sarqvlis naklovanebis gamo operaciisas LOE: B
4. kardiogenuri Soki 75w naklebi asakis pacientebSi STEMI-T an LBBB-iT an ukana kedlis MI-s gamo romelTac Soki unviTardebaT infarqtidan 36-sT-Si da aqvT marcxena mTavari/ZiriTadi totis mkacri stenozi, mkacri multisisxlZarRvovani daavadeba da arian revaskularizaciisaTvis Sesaferisi kandidatebi, rac Tavis mxriv SesaZloa Catardes Sokis ganviTarebidan 18-sT-Si. Tuki es Careva araa amao imis gamo rom pacients es ar surs, an Semdgomi invaziuri mkurnalobaze ukuCvenebebis/SeuTavseblobis arsebobis gamo. LOE: A
5. sicocxlisaTvis saSiSi parkuWvani ariTmiebi marcxena mTavari/ZiriTadi koronaris stenozisas romelic ≥ 50%-ze. an/da 3 sisxlZarRvovani daavadebisas LOE: B
IIA klasi:
1. gadaudebeli CABG SesaZloa iyos rogorc pirveladi reperfuziuli strategia pacientebisaTvis Sesaferisi anatomiiT, romlebic ara arian PCI-s an Trombolizisis kandidatebi da STEMI-s dawyebdan gasulia 6-12 sT. gansakuTrebiT maSin Tu saxezea mkacri stenozi marcxena mTavari/ZiriTadi koronaris an multi sisxlZarRvovani daavadeba. LOE: B
2. gadaudebeli CABG SeiZleba iyos efeqturi pacientebSi romelTa asaki ≥ 75w da aReniSnebaT STEMI-T an LBBB-iT an ukana kedlis MI-s gamo, romelTac Soki unviTardebaT infarqtidan 36-sT-Si da aqvT marcxena mTavari/ZiriTadi totis mkacri stenozi, mkacri multisisxlZarRvovani daavadeba da arian revaskularizaciisaTvis Sesaferisi kandidatebi rac Tavis mxriv SesaZloa Catardes Sokis ganviTarebidan 18-sT-Si. Tuki es Careva araa amao imis gamo rom pacients es ar surs, an Semdgomi invaziuri mkurnaloba ukuCvenebebia/SeuTavsebelia LOE: B
III klasi
1. gadaudebeli CABG ar tardeba roca gvaqvs persistentuli angina magram miokardiumis mcire zonaa riskis qveS da pacienti hemodinamikurad stabiluria. LOE: C
2. gadaudebeli CABG ar tardeba warmatebuli epikardiuli reperfuziisas magram warumatebeli mikrovaskularuli reperfuziisas LOE: C
V hospitaluri mkurnaloba
a...CCU intensiuri/koronaruli movlis ganyofileba:
I klasi:
1. CCU unda warmoadgendes mSvid da wynar garemos sadac pacients unda ugrZeldebodes e.k.g. monitoringi da puls oqsimetria da sadac unda iyos saSualeba hemodinamikuri monitoringisTvis da defibrilaciis. LOE: C
2. unda ganisazRvros kontrolirebulia Tu ara riTmis sixSire, angina(stenokardia), wneva, gulis ukmarisoba. da Semowmdes adeqvaturia Tu ara mimdinare mkurnaloba. LOE: A
3. unda ganisazRvros Jangbadis micemis saWiroeba: (stabilur pacientSi 6-sT-is semdgom sadac SO2 > 90%-e mxedvelobaSi unda gvqondes misi moxsna. LOE: C
4. am ganyofilebaSi pacientebTan unda muSaobdnen eqTnebi romelTac aqvT Sesabamisi kvalifikacia da ician movlis zogadi principebi, aseve gadaudebeli mdgomareobebisas SeuZliaT daxmarebis aRmoCena da utardebaT regularuli trainingebi. LOE: C
5. ganyofilebis muSaoba unda eyrdnobodes Sesabamis protokolebs. LOE: C
6. monitorze e.kg. gamosaxuleba unda iyos optimizirebuli. raTa ar gamogvrCes ST segmentis deviacia an riTmis moSla LOE: C
III klasi:
1. mizanSewonili araa CCU-is gamoyeneba terminaluri pacientebis misaRebad, romelTac emarTebaT STEMI da “sadac resuscitacia ar tardeba”(igulisxmeba pacientebi, sadac winaswar cnobilia rom mas aqvs zogadad raime cxva daavadebis gamo terminaluri mdgomareoba). LOE: C
b. CCU-is Semdgomi mkurnaloba:
I klasi:
1. pacientebi dabali riskis STEMI-T romelTac CautardaT warmatebuli reperfuzia PCI-T SesaZlebelia gadavidnen ganyofilebaSi CCU-is gavlis gareSe. LOE C
2. pacientebi STEMI-T Tuki 12-24-sT is ganmavlobaSi arian klinikurad stabilurni, (ara aqvT ganmeorebiTi iSemia, gulis ukmarisoba, hemodinamikuri darRveva an ariTmia romelic iwvevs am moSlilobas) unda gadavidnen CCU-dan ganyofilebaSi. LOE C
II A klasi:
1. mizanSewonilia pacientebi STEMI-s Semdgom romelTac darCaT kinikurad gamoxatuli gulis ukmarisoba gadavidnen CCU-dan ganyofilebaSi im pirobiT, rom saWiroebisas SesaZlebeli iqneba e.k.g. monitoringi da oqsimetria. LOE C
2. mizanSewonilia pacientebi STEMI-s Semdgom romelTac aqvT ariTmia romelic ar arRvevs hemodinamikas (AF kontrolirebulin sixSiriT, aramyari VT-s paroqsizmebi 30-wm-ze naklebi xangZlivobiT) gadadian CCU-dan ganyofilebaSi im pirobiT, rom saWiroebisas SesaZlebeli iqneba e.k.g. monitoringi, defibrilatori da kvalificiuri eqTanis momsaxureba LOE C
II B klasi
1. mizanSewonilia pacientebi STEMI-s Semdgom romelTac aqvT klinikurad mniSvnelovani pulmonaruli daavadeba da saWiroeben Jangbadis did nakads an arainvaziur maskiT ventilacias gadadian CCU-dan ganyofilebaSi im pirobiT, rom SesaZlebeli iqneba puls oqsimetria da Sesabamisi kvalifikaciis eqTnis momsaxureba LOE C
g. pacientebis gaaqtiveba:
II A
1. pacientebSi hemodinamikuri arastabilurobiT an maTSi visac iSemiuri tkivilebi umeordeboda, stabulizaciis 12-24 sT-is Semdeg SesaZlebelia wamojdomis nebis micema da sawolSi gaaqtiveba rasac moyveba aqtivobis donis TandaTanobiTi zrda. LOE C
III klasi:
1. pacientebs STEMI-T romlebSiac araa ganmeorebiTi iSemiis epzodebi, gulis ukmarisobis simptomebi, an seriozuli riTmis darRvevebi ar unda gaugrZeldeT woliTi reJimi 12-24 sT-is Semdgom.
LOE C
d. dieta:
I klasi:
1. daiwyeT dieta yvela pacientSi. ( saerTo kaloraJSi gajerebuli cximi < 7%-ze da qolesteroli < 2000 mg/dReSi.) urCieT wonis kontroli da fizikuri aqtivoba. urCieT omega-3 cximovani mJavis xmarebis gazrda. LOE C
e. analgetikebi/aRgznebis sawinaaRmdego preparatebi:
II A klasi:
1. mizanSewonilia gamoviyenoT damamSvideblebi pacientebSi STEMI-T romelTac aqvT aRgzneba an Secvlili qceva rac ukavSirdeba hospitalizacias LOE C
2. mizanSewonilia Sefasdes pacientis qceva da aRgznebis done da saWiroebisas Cautardes specialistis konsultacia. LOE C
v. antiagregantebi:
(maTi gamoyeneba ufro dawvrilebiT iqneba axsnili srul teqstSi da PCI-s gaidlainSi romelic dasruldeba 2007 welSi).
aspirini:
I klasi:
1. STEMI-s dros sawyisi doza 162-325 mg per.os. da Semdeg SemnarCunebeli doza 75-162 mg ganusazRvreli vadiT yvela pacientSi visac ara aqvs alergia masze. LOE: A
†† - Tumca zogierTi xmarobs nawlavuri garsiT dafarul aspirins, ufro swrafi Sedegia garsis gareSe aspirinis daReWvisas
Tienopiridinebi
I klasi:
1. klopidrogeli iniSneba pacientebSi vinc ver iRebs aspirins hipermgrZnobelobis an mniSvnelovani gastrointersticiuli garTulebebis gamo. LOE: C
2. klopidrogelis miReba grZeldeba stentirebis Semdgom sul cota 1 Tve bare metal stentis implantaciis Semdgom da ramodenime Tve drug-eluting stentis Semdgom( 3-Tve sirolimus da 6 Tve paclitaxe-is Semdgom) da grZeldeba 12 Tve pacientebSi romelTac ara aqvT sisxldenis maRali riski. . LOE: B
Ddamateba: Tuki tardeba STEMI-s dros reperfuzia PCI-T, maSin klopidrogels aZleven 400 mg-s xolo Semdeg agrZeleben 75 mg dRiurad
glukoprotein IIb/IIIa inhibitorebi
IIA klasi: iwyeben rac SeiZleba adre STEMI-s dros Tuki igegmeba pirveladi PCI (stentiT an stentis gareSe). LOE: B
(AHA/ACC gaidlainiT absqsimabi IIa jgufSia, xolo tirofibani eptifibatidi IIb-Si)
z. reperfuziisas damatebiTi antiTrombozuli farmakologiuri daxmareba
zogadi rekomendacia heparnisTvis: mwvane koronaruli sindromis dros (ACS ) igi ixmareba 2-3 dRidan 7-8 dRemde
arafraqcionirebuli heparini UFH
im SemTxvevebSi roca reperfuziuli Terapia ar tardeba:
I klasi:
1. i/v UFH ( bolusi 60 U/kg da max 4000 U da Semdeg 12 U/kg/sT max 1000 U) unda gamoviyenoT pacientebSi STEMI-s Semdgom, romlebic arian sistemuri emboliebis maRali riskis jgufSi, (didi zomis an wina kedlis MI, AF, anamnezSi emboliuri epizodi, LV Trombi an kardiogenuri Soki). LOE: C
IIa klasi:
1. mizanSewonilia, rom pacientebSi STEMI-T visac ar gadautania reperfuziuli Terapia da romelTac ara aqvT raime ukuCveneba antikoagulaciis mimarT UFH dainiSnos intravenurad an kanqveSa ineqciebis saxiT sul cota 48-sT. im pacientebSi romelTa mdgomareoba moiTxovs xangZliv woliT reJims da/an aqtiobis donis minimumamde dayvanas mizanSewonilia igi gagrZeldes gaweramde (igulisxmeba gaaqtiveba) LOE: C
damateba: am SemTxvevaSi UFH-s i/v dozaa: 60-70 U/kg bolusi (magram maqsimaluri dozaa 4000 erT) da Semdeg 12-15U/kg/sT (maqsim. dozaa 1000 erT/kg-ze.) da aPTT narCundeba 50-70-is farglebSi. kanqveSa ineqciebis dros sxvadasxva kvlevebSi gamoyenebuli dozebia 7500 U 2-jer an 5000 U 3-jer an 12,500 U 2-jer.
dReisaTvis arsebuli praqtika rac gamoixateba pacientis adreuli gaaqtivebaSi moiTxovs am monacemebis gadaxedvas da kiTxvis qves ayenebs UFH –is am reJimebiT xmarebas.
arafraqcionirebuli heparini UFH im SemTxvevebSi roca reperfuziuli Terapia tardeba TrombolizisiT:
I klasi:
1. UFH unda dainiSnos i/v im pacientebSi STEMI-T romelTac reperfuzia CautardaT alteplaziT, teneqteplaziT an reteplaziT. doza: bolusi 60 U/kg(maqs. 4000U) da Semdeg 12U/kg/sT(maqs. 1000 U/sT) aPTT unda SenarCundes 1,5-2 iT meti sakontroloze (daaxloebiT 50-70 wm) LOE: C
2. UFH iniSneba intravenurad pacientebSi Trombolizisis mere, romelic Catarebulia araseleqtiuri fibrinolitikebiT (mag: streptokinaza) romlebsac aqvT sistemuri emboliebis ganviTarebis maRali riski (miokardiumis wina kedlis an didi zomis infarqti, AF, gadatanili Trromboemboliuri epizodi, an LV-is Trombi. LOE: B
3. Trombocitebi mowmdeba yoveldRiurad pacientebSi romlebic Rebuloben UFH-s. LOE: C
IIB klasi:
1. mizanSewonilia davniSnoT UFH intravenurad pacientebSi streptokinziT reperfuziis Semdgom LOE: C
damateba: kanqveSa ineqciebis dros sxvadasxva kvlevebSi gamoyenebuli dozebia 7500 U 2-jer an 5000 U 3-jer an 12,500 U 2-jer. dReisaTvis arsebuli praqtika, rac gamoixateba reperfuziul Terapiasa da pacientis adreuli gaaqtivebaSi moiTxovs am monacemebis gadaxedvas da kiTxvis qveS ayenebs UFH –is am reJimiT xmarebas.
arafraqcionirebuli heparini UFH, im SemTxvevebSi, roca reperfuzia tardeba PCI-T:
I klasi:
1. pacientebi romlebsac utardebaT PCI an qirurgiuli revaskularizacia unda miiRon UFH. LOE: C
ganmarteba: roca reperfuzia xdeba PCI-T UFH-is i/v bolusis dozaa 70-100 U/kg
am dros aqtiuri Sededebis dro procedurisas HemoTec-iT sul cota 250-300 da Hemochron-iT 300-350 da Semdgom aPTT narCundeba 1,5-2,0-iT meti sakontroloze (50-70wm). Tuki gamoiyeneba glukoprotein IIb/IIIa antagonistebi bolusis doza mcirdeba 50-70 U/kg-mde da procedurisas aqtiuri Sededebis dro 200 orive meTodiT, xolo Semdgom aPTT-i igive reJimiT.
dabal-molekuluri wonis heparini heparini LMWH
LMWH im SemTxvevebSi roca reperfuziuli Terapia ar tardeba:
I klasi:
1.. LMWH (samkurnalo doziT) unda gamoviyenoT pacientebSi STEMI-s Semdgom, romlebic arian sistemuri emboliebis maRali riskis jgufSi, (didi zomis an wina kedlis MI, AF, anamnezSi emboliuri epizodi, LV Trombi an kardiogenuri Soki). LOE: C
LMWH im SemTxvevebSi reperfuziuli Terapia tardeba TrombolizisiT:
IIB klasi:
1. reperfuziuli Terapiis damatebiTi farmakologiuri daxmarebis TvalsazrisiT LMWH SeiZleba ganvixiloT rogorc UFH-is alternativa, pacientebSi 75 wlis qvemoT romlebic Rebuloben Trombolizisur Terapias.( Tuki Sratis kreatinini araa > 2,5 mg/dl-ze kacebSi da 2,0 mg/dl-ze meti qalebSi) enoqseparinis 30 mg i/v boluss moyveba 1 mg/kg ze kanqveS ineqcia 12-sT-Si erTxel saavadmyofodan gaweramde. es kombinacia teneqteplaziT Trombolizisis dros srulyofiladaa Seswavlili. LOE: B
III klasi:
1. LMWH ar gamoiyeneba zemoT aRniSnul situaciebSi, rogorc UFH-is alternativa Tuki pacientis asaki ≥ 75 w. LOE: B
2. LMWH ar gamoiyeneba zemoT aRniSnul situaciebSi, rogorc UFH-is alternativa Tundac maSin roca pacientis asaki < 75 welze, Tuki Sratis kreatinini > 2,5 mg/dl-ze kacebSi da 2,0 mg/dl-ze meti qalebSi) LOE: B
LMWH im SemTxvevebSi reperfuzia tardeba PCI-T:
miuxedavad imisa rom arsebobs pozitiuri informacia rom LMWH aris UFH-is kargi alternativa, monacemebi jer araa sakmarisi garkveuli rekomendaciebis Camosayalibeblad.
pirdapiri antiTrombini:
IIA klasi:
1. pacientebSi hepariniT gamowveuli TrombocitopeniiT HIT SeiZleba mxedvelobaSi gvqondes bivalirudini rogorc heparinis alternativa streptokinazis Semdeg. HERO 2 is kvlevaSi gamoyenebuli dozebia: i/v bolusi 0,25 mg/kg da Semdgom 0,5 mg/kg/sT-S 12-sT-s manZilze xolo Semdeg 0,25mg/kg-ze 36-sT. doza mcirdeba Tuki aPTT> 75-ze pirvel 12-sT-Si. LOE: B
T. renin-angiotenzin-aldosteronis sistemaze moqmedi preparatebi STEMI-s dros:
I klasi:
1. ACE inhibitorebi unda dainiSnos per.os pirvel 24-sT-Si STEMI-s dawyebidan, pacientebSi wina kedlis infarqtiT, pulmonaruli SegubebiT, Lmarcxena parkuWis EF-iT < 40%-ze, Tuki ar aRiniSneba hipotenzia (sisit. wneva < 100 mmhg an sabaziso wnevaze 30%-iT naklebi) da ukuCvenebebi am medikamentis mimarT. LOE: A
2. ARB iniSneba STEMI-s dros pacientebSi romelTac aqvT wina paragrafSi gansazRvruli Cveneba da autanloba ACE inhibitorebis mimarT. LOE: C
IIa klasi:
1. ACE inhibitorebis daniSvna pirvel 24-sT-Si STEMI-s dawyebidan SeiZleba iyos sasargeblo pacientebSi romelTac ar aqvT wina kedlis infarqti, pulmonaruli Segubeba da marcxena parkuWis gandevnis fraqcia < 40%-ze, Tuki araa arteriuli hipotenzia (sist. wneva < 100 mmhg an sabaziso wnevaze 30%-iT naklebi) da ukuCvenebebi am medikamentis mimarT ( Tumca am pacientebSi sargebloba naklebia vidre I klasSi moxvedril pacientebis jgufSi) LOE: B
III klasi:
1. i/v ACE inhibitorebi ar eZleva pirvel 24-sT-Si STEMI-s dawyebidan hipotenziis riskis gamo(gamonaklisi SeiZleba iyos refraqteruli hipertenzia)
ACE inhibitorebis swrafi titraciis sqema hopspitalizebul pacientebSi (sqema SesaZloa gamoyenebuli iqnas pacientebSi tendenciiT hipotoniisken da gulis SegubebiTi ukmarisobiT. am dros saWiroa saWiroa gulis wuTmoculobis swrafi gazrda, vinaidan winaaRmdeg SemTxvevaSi SesaZloa Seuqcevadi cvlilebebis ganviTareba. am mdgomareobas Sokis wina periodi, preSoki ewodeba.(“nearly shock”)
kaptoprili:
sawyisi doza 12,5 mg peroralurad (6,25 mg pacientebSi hiponatremiiT, azotemiiT, siTxis danakargiT, orTostatikuri hipotenziiT).
2 sT-Si gavzardoT doza 25 mg-mde
6sT-Si gavzardoT doza 50 mg-mde 3 -jer dReSi
saboloo mizani 150 mg dReSi.
Sardmdeni SegviZlia mivceT 1 sT-iT adre an erTi saaTis Semdeg ACE inhibitoris miRebidan.
enelaprili:
sawyisi doza 5 mg peroralurad (2,5 mg pacientebSi hiponatremiiT, azotemiiT, siTxis danakargiT, orTostatikuri hipotenziiT)
6 sT-Si gavzardoT doza 10 mg-mde.
12sT-Si gavzardoT doza 10 mg-mde 2- jer dReSi.
saboloo mizani 20 mg dReSi.
Sardmdeni SegviZlia mivceT 1 sT-iT adre an erTi saaTis Semdeg pirveli dozis miRebidan.
sqema mowodebulia: kardiovaskularuli medicinis saxelmZRvanelodan. erik j. topoli II gamocema 2002w.
i. glukozis kontroli STEMI-s dros:
I klasi:
1. insulinis i/v infuzia sisxlis glukozis normalizaciisaTvis rekomendirebulia pacientebisaTvis STEMI-T da garTulebuli mimdinareobiT. LOE B
IIa klasi:
1. STEMI-s mwvave fazis dros (pirvel 24-48-sT-Si) pacientebs romelTac aqvT hiperglikemia mizanSewonilia daeniSnoT insulinis i/v infuzia glukozis normalizaciisaTvis, maSinac ki roca daavadeba gaurTuleblad mimdinareobs. LOE B
2. STEMI-s mwvave fazis Semdgom mizanSewonilia moaxdinon diabetis mkurnalobis individualizacia insuliniT, insulinis analogebiT, oraluri hipoglikemiuri saSualebebis kombinirebis gziT. LOE C
saqrTvelos kardiologTa koleji rekomendacias iZleva STEMI-s dros Saqris cifrebis normalizaciad CaiTvalos glukoza < 150 mg/dl-is farglebSi
k. eleqtrolitebis balansi:
I klasi:
1. maTi deficiti unda gamoswordes. siswrafe damokidebulia sisxlSi maT doneze da Tanmxleb klinikur movlenebze. LOE: C
II A klasi:
1.. mizanSewonilia magniumis deficitis gasworeba, gansakuTrebiT pacientebSi STEMI-T romlebic iRebdnen diuretikebs infarqtamde LOE: C
2. VT “torsade depoint” Tan asocirebuli QT-intervalis gaxangZlivebiT namkurnalebi unda iqnes i/v Mg ( bolusi 5 wT-is ganmavlonbaSi) LOE: C
III klasi:
1. dokumentirebuli eleqtrolituri deficitis an torsade depoint” Tan asocirebuli VT-is gareSe ar SeiZleba Mg rutinulad gadasxma riskis donis miuxedavad. LOE: A
l. kalciumis arxebis blokatorebi:
IIa klasi:
1. miznSewonilia mivceT verapamili an diltiazemi pacientebs romlebSiac beta-blkerebi uefeqtoa da/an ukunaCvenebia. iSemiis sakontrolod an paekuWovani riTmis sixSiris Sesamcireblad Tuki STEMI-s dros pacients emarTeba AF an winagulTa TrTola da ara aqvs CHF da LV disfunqcia an AV bloki. LOE: A
III klasi:
1. verapamili an diltiazemi ukunaCvenebia pacientebSi SYEMI-T da adocirebuli CHF da LV disfunqciiT. LOE: C
2. nifedipinis (swrafad xsnadi forma) ukunaCvenebia STEMI-s samkurnalod, vinaidan axasiaTebs refleqsuri simpaTikuri aqtvaciis gamo taqikardia da hipotenzia. LOE: B
m. beta-blokatorebi:
I klasi:
1. oraluri beta-blokerebi unda dainiSnos STEMI-s dawyebidan rac SeiZleba adre Tuki araa raime ukuCveneba maT mimarT. miuxedavad imisa tardeba Tu ara reperfuzia (Trombolizisi an/daPCI-i) LOE: A
2. Tuki beta-blokeri ver iniSneba STEMI-s dawebidan 24-sT-Si imis gamo, rom raime ukuCvenebaa, am periodis gavlis Semdgom maTi daniSvnis SesaZlebloba Tavidan unda Sefasdes. LOE: C
3. pacientebi romlebic Rebuloben beta-blokerebs pirvel 24 sT-Si STEMI-s dawyebidan da ara aqvT gverdiTi movlenebi agrZeleben maT miRebas adreuli aRdgenis fazaSi. xolo isini visTanac betablokerebi ar iqna dawyebuli pirvel 24-sT-Si da visTanac araa ukuCvenebebi maTi miReba iwyeba adreul aRgenis fazaSi. LOE: A
IIa klasi:
1. mizanSewonilia beta-blokerebis i/v daniSvna STEMI-s dawyebidan rac SeiZleba adre, Tuki araa raime ukuCveneba, gansakuTrebiT maSin Tuki gvaqvs taqiariTmia an hipertenzia. LOE: A
gnmarteba: pacientebSi (Tuki araa raime ukuCveneba) beta-blokerebi grZeldeba minimum 6-Tve. gamonakliss warmoadgenen pacientebi romelTac koronarografiisas gamouvlindaT mxolod 1 sisxlZarRvis stenozi/okluzia romlis reperfuziac warmatebiT ganxorcielda. maTSi beta blokerebi iniSneba 5-28 dRe. (samuSao jgufis ganmarteba)
n. nitroglicerini:
I klasi:
1. pacients mimdinare tkiviliT aZleven sublingvalur nitroglicerins (0,4mg) 5 wT-iani intrevalebiT ris Semdgomac dRis wesrigSi SesaZloa dadges i/v infuziis sakiTxi. LOE: C i/v nitroglicerinis infuzia naCvenebia STEMI-s dawyebidan 48-sT-is manZilze pacientebSi persistentuli iSemiiT, CHF-iT, hipertenziiT. nitroglicerinis i/v infuziis gamo Tavidan ar unda aviridoT sxva medikamentebis daniSvna (rogoricaa beta-blokerebi an ACE-inhibitorebi.) romlebic dadasturebulad amcireben sikvdilianobas. LOE: A
2. nitratebi sasargebloa STEMI-s dawyebidan 48-sT-is Semgomac, pacientebSi persistentuli iSemiiT, CHF-iT, hipertenziiT da im SemTxvevaSi Tuki maTi miReba xels ar uSlis im medikamentebis daniSvnas (rogoricaa beta-blokerebi an ACE-inhibitorebi.) romlebic dadasturebulad amcireben letalobas. LOE: B
II-Bklasi:
1. nitratebis xmareba STEMI-s dawyebidan pirveli 24-48-sT-is Semdgom persistentuli iSemiis an CHF-is ar arsebobisas SeiZleba iyos sasargeblo Tumca es sargebloba savaraudod mcirea da kargad araa Seswavlili. LOE: B
III klasi:
1. nitratebi ar iniSneba pacientebSi Tuki sistoluri wneva < 100 mmhg an art. wneva 30%-iT naklebia pacientis sabaziso wnevaze an gvaqvs bradikardia ( P < 50-ze wT-Si) an taqikardia ( P > 100-ze wT-Si ) an marjvena parkuWis infarqti. LOE: C aseve im pacientebSi romlebsac wina 24-sT-is ganmavlobaSi miRebulia aqvT fspodiesTerazas inhibitorebi (sindenafili. xolo 48-sT tadafil-is SemTxvevaSi) LOE: B
i. sqema 4. garTulebuli STEMI. gadaudebeli mdgomareobebis marTvis protokoli
|klinikuri niSnebi: Soki, hipoperfuzia, gulis SegubebiTi ukmarisoba, pulmonaruli edema. ZiriTadi klinikuri suraTi: |
cxrili 9. parkuWTa Soris Zgidis rubtura, Tavisufali kedlis rubtura, papilaruli kunTis rubtura
| | parkuWTaSua Zgidis rubtura |parkuWis Tavisufali kedlis rubtura |papilaruli kunTis rubtura |
| |1-3% pacientebSi romelTac ar CatarebiT reperfuziuli |0,8-6,2% Trombolizisi ar amcirebs risks; pirveladi PTCA |1% posteromedialuri ufro xSirad gvxvdeba vidre |
| |Terapia |savaraudod amcirebs. |anterolateraluri. |
|sixSire/gavrceleba |0,2-0,34% pacientebSi visac Cautarda Trombolizisi | | |
| |3,9% Sokiani pacientebisa | | |
| |aqvs 2 piki 24 sT-Si da Semdeg 3-5 dReSi jamSi |aqvs 2 piki 24 sT-Si da Semdeg 3-5 dReSi jamSi viTardeba 1-14|aqvs 2 piki 24 sT-Si da Semdeg 3-5 dReSi jamSi |
| |viTardeba 1-14 dReSi |dReSi |viTardeba 1-14 dReSi |
|dro | | | |
| | | | |
| |tkivili gulmkerdSi, sunTqvis gaZneleba, hipotenzia |anginuri, plevraluri, an perikardiuli tkivili gul-mkerdSi, |sunTqvis gaZnelebis uecari dawyeba da pulm. SeSupeba. |
|klinikuri manifestacia | |sinkope, hipotenzia, ariTmiebi, gulisreva, mousvenroba, |hipotenzia. |
| | |hipotenzia, uecari sikvdili. | |
| |uxeSi holosistoluri Suili, gaZlierebuli S3 da 2 gulis |iugularuli venebis dilatacia(pacientebis 29%) paradoqsuli |nazi Suili, marjvena parkWis gadatvirTvis cvalebadi |
| |toni, pulmonaruli edema, RV da LV ukmarisoba, |pulsi(47%) eleqtromeqanikuri dissociacia, kardiogenuri Soki. |niSnebi, mkacri pulmonaruli Segubeba, kardiogenuri Soki|
|fizikuri niSnebi |kardiogenuri Soki | | |
| | | | |
| |parkuWTaSua Zgidis defeqti, marcxnidan marjvniv Sunti, |5 mm-ze meti [perikardiuli siTxe romelic yovelTvis ar |LV –s hiperkontraqtiloba, gawyvetili papilar. kunTi, |
|eqokardiografiuli niSnebi |marjvena nawilebis gadatvirTva |vizualizdeba, Sreobrivi,maRal akustikuri eqo signali |flail qorda, mkacri mitraluri naklovaneba. |
| | |perikardiumis Signdan(Trombuli masa) Semavali karis | |
| | |vizualizacia, tamponadis niSnebi | |
| |gazrdili Jangbadis saturacia gulis marjvena nawilebSi, |ventrikulografii mgrZnobeloba dabalia, tamponadis klasikuri |gulis marjvena nawilebSi Jangbadis saturacia ar |
|marjvena gulis kaTeterizacia |giganturi V-talRebi. |niSnebi xSirad araa(diastoluri wnevebis gaTanabreba gulis |matulobs., giganturi V talRebi, Zalian maRali PCWP |
| | |marcxena da marjvena nawilebs Soris) | |
VI hemodinamikuri darRvevebi
a. hemodinamikuri gazomvebi:
I klasi:
1. pulmonaruli arteriis kaTeteriT monitoringi saWiroa Semdeg SemTxvevebSi:
a. Tuki hipotenzia progresirebs, miuxedavad siTxeebis infuziisa an Tuki es RonisZieba ukunaCvenebia LOE: C
b. Tuki gvaqvs eWvi meqanikur garTulebaze (VSR, papilaruli kunTis an Tavisufali kedlis rubtura) LOE: C
2. intraarteriuli wnevis monitoringi saWiroa Tuki:
a. saxezea wnevis mkveTrad vardna (sist. art. wneva < 80 mmhg) LOE: C.
b. kardiogenuli Soki. LOE: C
g. Tuki pacientebs utardebaT vazopresorebit/inotropebiT mkurnaoba. LOE: C
II A klasi:
1. pulmonaruli arteriis kaTeteriT monitoringi SeiZleba saWiro iyos Semdeg SemTxvevebSi:
a Tuki hipotenzia mimdinareobs pulmonaruli Segubebis gareSe da igi ver swordeba siTxeebis gadasxmaze. LOE C
b. kardiogenuli Soki
g. mkacri an progresirebadi CHF an pulmonaruli SeSepeba romelic swrafad ar swordeba TerapiiT LOE C
d. persistentuli hipoperfuziis niSnebi rodesac ara gvaqvs filtvebSi Segubeba LOE C
g. pacientebi romelTac mkurnaloba utardebaT vazopresorebit/inotropebiT. LOE C.
2. intraarteriuli wnevis monitoringi SeiZleba saWiro iyos pacientebSi, romlebic Rebuloben i/v natriumis nitroprusids an sxva vazodilatatorebs. LOE C
II B klasi:
1. intraarteriuli wnevis monitoringi SeiZleba saWiro iyos pacientebSi, romlebic Rebuloben i/v inotropebs LOE C
III klasi:
1. pulmonaruli arteriis kaTeteriT monitoringi rekomendirebuli araa pacientebSi STEMI-T Tuki maT ara aqvT hemodinamikuri an respiratoruli darRvevebi. LOE C
2. intraarteriuli wnevis monitoringi araa rekomendirebuli pacientebSi STEMI-T romelTac ara aqvs pulmonaruli Segubeba da aqvT adeqvaturi qsovilTa perfuzia meqanikuri kardiocirkulatoruli daxmarebis gareSe. LOE C
b. hipotenzia:
I klasi:
1. Tuki pacients ar aReniSneba moculobiTi gadatvirTvis niSnebi, rekomendirebulia siTxeebis i/v infuzia. LOE: C
2. ariTmia Tuki igi iwvevs hemodinamikur darRvevebs unda gamoswordes. LOE: C
3. IABP ixmareba im SemTxvevaSi Tuki sxva CareviT pacientis mdgomareoba ar umjobesdeba, da Tuki Semdgomi invaziuri mkurnaloba araa azrs moklebuli pacientis survilis, ukuCvenebebis/Seusabamobis arsebobis gamo. LOE: B
4. vazopresorebi iniSneba im semTxvevaSi Tukis hipotenzia ar gamoswordeba siTxeebis infuziiT. LOE: C
5. Tuki invaziuri gazomvebi araa Catarebulia, saWiroa eqoskopiuri gamokvleva raTa Sefasdes meqanikuri garTulebebis arseboba. LOE: C
g. dabali wuTmoculobiTi mdgomareoba:
I klasi:
1. unda Sefasdes marcxena parkuWis funcia da SesaZlo meqanikuri garTulebebis SesaZlebloba unda ganisazRvros eqokardiografiulad, Tuki manmade ar iyo Sefasebuli invaziurad. LOE: C
2. rekomendirebuli mkurnaloba dabali wuTmoculobiTi mdgomareobisaTvis moicavs:
a. inotropul daxmarebas LOE: C
b. IABP-s LOE: B
g. meqanikuri reperfuzias PCI-T an CABG-T LOE: B
d. meqanikuri garTulebebis qirurgiuli koregireba. LOE: B
III klasi:
1. beta blokerebi da kalciumis antagonistebi ar iniSneba pacientebSi dabali wuTmoculobiT stadiaSi, rodesac igi ganpirobebulia gulis rogorc tumbos funqciis daqveiTebiT. LOE: C
saubaria STEMI-is fonze mimdinare garTulebaze, romelic wamoadgens pre-Sokur mdgomareobas
d. pulmonaruli Segubeba:
I klasi:
1. Jangbadis micema mizanSewonilia arteriuli saturaciis SesanarCuneblad > 90%-ze pacientebSi pulmonaruli SegubebiT. LOE C
2. morfinis sulfati eZleva pacients pulmonaruli SegubebiT. LOE C
3. aseT SemTxvevebSi iwyeba ACE inhibitorebis titracia. 1-6,25mg kaptoprili eZleva pacients pulmonaruli SegubebiT, Tuki sistoluri wneva naklebi araa 100 mmhg an 30 mmhg-Ti naklebi sabaziso wnevaze. pacientebi dabali wneviT da pulmonaruli SegubebiT xSirad saWiroeben inotropebs da vazopresobs da/an IABP-s adeqvaturi perfuziis SenarCunebis mizniT. LOE: A
4. nitratebi iniSneba Tuki sistoluri wneva naklebi araa 100 mmhg an 30 mmhg-Ti naklebi sabaziso wnevaze. pacientebi dabali wneviT da pulmonaruli SegubebiT xSirad saWiroeben inotropebs da vazopresobs da/an IABP-s adeqvaturi perfuziis SenarCunebis mizniT. LOE: C
5. diuretikebi saS. an mcire dozebiT(furosemidi, torsemidi, bumetanidi) iniSneba pacientebSi pulmonaruli SegubebiT Tuli mas Tan axlavs hipervolemiuri mdgomareoba. winaaRmdeg semTxvevaSi saWiroa sifrTxile diuretikenbis xmarebisas. LOE: C
6. beta blokerebi iniSneba aseT pacientebSi gaweris win, meoradi prevenciisTvis, maT visac am droisaTvis aReniSnebaT gulis ukmarisobis niSnebi am medikamentis titracia iwyeba dabali dozebiT. LOE: B
7. xangZlivi aldosteronis blokada iniSneba post-STEMI pacientebSi gaweris win, Tuki aseT pacientebs ara aqvT renaluri disfunqcia(kreatinini ≥ 2,5 mg/dl kacebSi da 2,0 mg/dl qalebSi} an hiperkaliemia(kaliumi ≥ 5,0 mEq/L} da rolebic ukve iReben ACE inhibitorebs, LVEF ≤ 40% da aqvT romelime diabeti an simptomaturi gulis ukmarisoba. LOE: C
8. eqokardiografia unda DSesruldes urgentulad raTa Sefasdes RV da LV funqcia da gamoiricxos meqanikuri garTulebebi. LOE: C
II B klasi:
1. pacientebSi, romelTac aReniSnebaT refraqteruli pulmonaruli Segubeba SeiZleba mizansewonili iyos IABP-s xmareba. LOE: C
III klasi:
1. beta blokerebi da kalciumis antagonistebi ar iniSneba mwvaved pacientebSi STEMI-T romelTac aqvT aSkara monacemebi pulmonaruli Segubebis an dabali-wuTmoculobis niSnebi. LOE: B
e kardiogenuri Soki:
I klasi:
1. IABP rekomendirebulia pacientebSi STEMI-T da kardiogenuli SokiT Tuki igi swrafad ver swordeba farmakologiuri CareviT. am SemxvevaSi IABP aris mastabilizirebeli faqtori koronarografiis da revaskularizaciisaTvis. LOE: B
2. pacientebSi STEMI-T da kardiogenuli SokiT rekomendirebulia hemodinamikis intraarteriuli monitoringi. LOE: C
3. adreuli revaskularizacia PCI an CABG rekomendirebulia pacientebSi, romelTa asaki < 75w-ze da romlebsac aqvT STEMI, Tuki kardiogenuli Soki ganuviTardaT infarqtis dawyebidan 36-sT-ze adre, xolo invaziuri Careva SesaZlebelia Sokis dawyebidan 18-sT-ze adre da Tuki Semdgomi invaziuri mkurnaloba azrs araa moklebuli pacientis survilis da ukuCvenebebis/Seusabamobis arsebobis gamo. LOE: A
4. pacientebSi STEMI-T da kardiogenuli SokiT romlrbSiac ver xerxdeba invaziuri Careva tardeba fibrinolizisi ukuCvenebebis ar arsebobisas. LOE: B
5. eqokardiografia tardeba aseT pacientebSi meqnikuri garTulebebis Sesafaseblad, Tuki am mizniT ar gamoiyeneba invaziuri RonisZiebebi. LOE: B
II A klasi:
1. pacientebSi kardiogenuli SokiT pulmonaruli arteriis kaTeteriT monitoringi SeiZleba iyos sasargeblo. LOE: C
2. adreuli revaskularizacia PCI an CABG rekomendirebulia pacientebSi, romelTa asaki > 75w-ze da romlebsac aqvT STEMI, Tuki kardiogenuli Soki ganuviTardaT infarqtis dawyebidan 36-sT-ze adre, xolo invaziuri Careva SesaZlebelia Sokis dawyebidan 18-sT-ze adre da Tuki Semdgomi invaziuri mkurnaloba azrs araa moklebuli pacientis survilis da ukuCvenebebis/Seusabamobis arsebobis gamo LOE: A
v. marjvena parkuWis infarqti:
I klasi:
1. pacientebs qveda kedlis STEMI-T da hemodinamikuri darRvevebiT unda gadaeRoT marjvena prekordiuli ganxrebi (V4R) ST-segmentis elevaciis gamosavlenad da CautardeT eqokardiografiuli meTvalyureoba, marjvena parkuWis ukmarisobis gamovlenis mizniT. LOE: B
2. marjvena parkuWis STEMI-s dros Semdegi principebi gamoiyeneba:
a. miRweuli unda iqnes adreuli reperfuzia Tuki es Sesazlebelia. LOE: C
b. uzrunvelyofili unda iqnes winagulebis da parkuWebis sinqronizacia da bradikardia unda gamoswordes. LOE: C
g. uzrunvelyofili unda iqnas marjvena parkuWis optimaluri predatvirTva, rac saWiroebs siTxeebis infuzias hemodinamikurad arastabilur pacientebSi romlebSic sauRle venebis wneva dabali an normaluria. LOE: C
d. marjvena parkuWis postdatvirTva unda iqnes optimizirebuli rac moiTxovs Tanmxlebi marcxena parkuWis disfunqciis mkurnalobas. LOE: C
e. inotropebi gamoiyeneba hemodinamikuri arastabilurobisas rac ar swordeba siTxeebis gadasxmaze. LOE: C
IIA klasi:
1. marjvena parkuWis klinikurad mniSvnelovani infarqtis dros, Tuki igi CABG-is gakeTeba yovndeba 4 kvira raTa marjvena parkuWma aRidginos kontraqtiloba. LOE: C
VII gulis ukmarisobis meqanikuri mizezebi/dabali wuTmoculobis sindromi
a. mitraluri sarqvlis ukmarisoba:
I klasi:
1. pacientebSi STEMI-T, romelsac axlavs papilaruli kunTis rubtura, mizanSewonilia urgentuli kardioqirurgiuli Careva, Tuki Semdgomi invaziuri mkurnalobis gagrZeleba azrs araa moklebuli pacienti survilis, ukuCvenebebis/Seusabamobis arsebobis gamo. LOE: B
2. CABG keTdeba mitraluri sarqvlis ukmarisobis gamo Catarebul operaciasTan erTad. LOE: B
b. parkuWis Zgidis rubtura:
I klasi:
1. pacientebSi STEMI-T romelic garTulebulia VSR-iT mizanSewonilia urgentuli kardioqirurgiuli Careva, Tuki Semdgomi invaziuri mkurnalobis gagrZeleba azrs araaa moklebuli pacienti survilis, ukuCvenebebis/Seusabamobis arsebobis gamo. LOE: B
2. CABG keTdeba marcxena parkuWis VSR-is gamo Catarebuli operaciasTan erTad LOE: B
g. marcxena parkuWis Tavisufali kedlis rubtura
I klasi:
1. aseT pacientebSi mizanSewonilia urgentuli kardioqirurgiuli Careva. Tuki Semdgomi invaziuri mkurnalobis gagrZeleba azrs araaa moklebuli pacienti survilis, ukuCvenebebis/Seusabamobis arsebobis gamo. LOE: B
2. CABG keTdeba marcxena parkuWis Tavisufali kedlis rubturs qirurgiul SekeTebasTan erTad LOE: B
d. marcxena parkuWis anevrizma:
II A klasi
1. pacientebSi STEMI-T romelTac ganuviTardebaT parkuWovani ariTmia, rac asocirdeba parkuWovan taqiariTmiebTan, romelTa kontroli Wirs da/an gulis rogorc tumbos ukmarisobasTan, romelis rezistentulia mkurnalobis mimarT mizanSewonilia Catardes anevrizmeqtomia da CABG qirurgia LOE: B
e. intraaortuli balonuri kontrpulsacia: IABP:
I klasi:
1. IABP gamoyenebuli unda iqnes pacientebSi STEMI-T romelTac aReniSnebaT hipotenzia (sist. art. wneva < 90 mmhg an 30 mmhg-iT naklebi sabaziso saSualo arteriul wnevaze, da romelic ar swordeba sxva Carevaze/mkurnalobaze da Tuki Semdgomi invaziuri mkurnalobis gagrZeleba azrs araa moklebuli pacienti survilis, ukuCvenebebis/Seusabamobis arsebobis gamo.. LOE: B
2. IABP rekomendirebulia STEMI-s dros Tuki mas axlavs dabali wuTmoculobiTi stadia. LOE: B ix. sqema 4
3. kardiogenuri Sokisas roca igi ver swordeba swrafad farmakologiur TerapiiT. igi aris mastabilizirebeli RonisZieba aseT pacientebSi angiografiis win. LOE: B ix. sqema 4
4. IABP unda gamoviyenoT rogorc damatebiTi RonisZieba medikamentozur mkurnalobaze STEMI-an pacientSi Tuki mas aReniSneba rekurentuli iSemiuri xasiaTis diskomforti gulmkerdSi an hemodinamikuri arastabiluroba, dabali gandevnis fraqcia an didi zomis miokardiumi riskis qveS, aseT pacientebi saWiroeben urgentul gulis kaTeterizacias da revaskularizacia saWiroebisamebr. LOE: C
II-A klasi:
1. IABP gamoiyeneba pacientebSi STEMI-T romelTac aReniSnebaT polimorfuli VT miokardiumis iSemiis Semcirebis mizniT. LOE: C
II-B
1. IABP-is gamoyeneba SeiZleba iyos mizanSewonili pacientebSi STEMI-T refraqteruli pulmonaruli Segubebis mkurnalobis mizniT LOE: C
sqema 5 ICD-is Cveneba pacientisaTvis STEMI_T da dabali EF -iT sqema 6. ganmeorebiTi iSemiis/infarqtis marTva STEMI-s
Semdgom
[pic]
VIII ariTmiebis marTva STEMI-is Semdgom
a. VF: parkuWovani fibrilacia:
klasi I :
1. parkuWovani fibrilacia an VT pulsis gareSe saWiroebs asinqronul eleqtrul soks monofazurs swyisi energia 200 J. ganmeorebiTi ganmuxtva 200-300 da warumateblobisas 360 J. LOE B.
klasi IIA:
2. Tuki parkuWovani fibrilacia an VT pulsis gareSe refraqterulia eleqtrikul Sokze mizansewonilia daviwyoT amiodaroni(300mg bolusi intravenurad da Semdeg gavimeorebT asinqronul ganmuxtvas LOE B
3. mizanSewonilia gamovasworoT eleqtruli da mJava tutovani wonasworoba ( K SevinarCunoT > 4 mEq/L da Mg > 2 mg/dl raTa Tavidan aviciloT VF-is ganmeoreba LOE C
klasi IIB :
1. el SokisTvis refraqteruli VT an VF-is mkurnaloba prokainamidis i/v infuziiT. Tumca amas aqvs SezRuduli Rirebuleba, vinaidan medikamentis infuzia saWiroebs SedarebiT xangZliv dros. LOE C
klasi III:
1. rutinuli gamoyeneba antiaritmuli preparatebis fibrinolizisur mkurnalobasTan erTad naCvenebi araa. LOE B.
b. VT: parkuWovani taqikardia
klasi I :
1. myari ( > 30 wm-ze an hemodinamikuri kolafsis gamomwvevi) polimorfuli VT –s dros asinqronuli monofazuri eleqtruli Soki 200 J ganmeorebiTi ganmuxtva 200-300 da warumateblobisas 360 J. LOE B.
2. myari VT-s epizodebi rasac axlavs angina, filtvebis SeSupeba, hipotenzia(sist. art. wneva < 90 mmhg-ze) saWiroebs sinqronizirebul el. Soks 100 j monfazurs. warumateblobisas TandaTanobiT zrdian energias. sasurvelia anesTezia Tuki hemodinamoka gvaZlevs saSualebas. LOE B.
3. myari ( > 30 wm-ze an hemodinamikuri kolafsis gamomwvevi) monomorfuli VT –s dros romelic ar asocirdeba anginasTan, filtvebis SeSupebasTan, hipotenziasTan saWiroebs:
a. amiodarons 150 mg i/v infuzia 10-wT-Si (alternatiuli dozaa 5mg/kg-ze) gaimeoreT igive doza yovel 10-15wT-Si saWiroebisas. alternatiuli dozaa 360 mg 6-sT-si Semdeg 540 mg Semdgom 18 –sT-Si. jamurma dozam ar unda gadaaWarbos 2,2 g 24-sT-Si. LOE B.
klasi IIA:
1. mizanSewonilia refraqteruli polimorfuli VT-s mkurnaloba:
a. iSemiisa da adrenaluri stimulaciis Semcirebis mizniT,Terapiul saSualebebTan erTad mxedvelobasi qona iseTi saSualebebis rogoricaa: IABP, PCI an CABG LOE B
b. eleqtrolitebis Semdgomi normebi; K > 4 mEq/l da magneziumi > 2 mg/dl LOE C.
g. Tuki pacients aqvs bradikardia < 60-ze wT-Si an QTc gaxangZlvebulia droebiTi peisingi maRali sixSiriT. LOE C.
klasi IIB:
1. monomorfuli VT romelic ar asocirdeba anginasTan, filtvebis SeSupebasTan, hipotenziasTan saWiroebs prokainamidis boluss da infuzias. LOE B.
klasi III:
1. lidokainis profilaqtikuri mizniT rutinuli gamoyeneba araa rekomendirebuli izolirebuli parkuWovani eqstrasistolebis kupletebis, garbenebi acqarebuli idioventrikuluri riTmis an NSVT-is samkurnalod. LOE B.
2. rutinuli gamoyeneba antiaritmuli preparatebis fibrinolizisur mkurnalobasTan erTad naCvenebi araa. LOE B.
g parkuWovani eqstraistolia:
klasi III:
1. izolirebuli parkuWovani eqstraistoliis, kupletebis, NSVT-s mkurnaloba mizanSewonili araa Tuki ar axlavs hemodinamikuri darRvevebi. LOE B
d. aCqarebuli idiventrikuluri an kvanZovani riTmiv. marjvena parkuWis infarqti:
III klasi:
1. antiariTmuli Terapia araa naCvenebi LOE B
g. supraventrikuluri ariTmia/AF
klasi: I
1. myari AF an winagulebis TrTola Tuki axlavs hemodinamikuri darRvevebi saWiroebs Semdgom mkurnalobas:
a. sinqronizebuli kardiversia. sawyisi monofazuri Soki 200 J AF-s dros da 50 J winagulTa TrTolisas. zogadi anesTeziiT an sedaciiT Tuki es SesaZlebelia LOE C
b. Tuki ariTmia grZeldeba an meordeba moxsnis Semdgom. gamoiyeneba Semdegi medikamentebi: i/v amiodaroni LOE C, i/v digoqsini riTmis sixSiris Sesamcireblad ( gansakuTrebiT maSin Tuki gvaqvs gulis marcxena parkuWis ukmarisoba LOE C.
2. myari AF an winagulebis TrTola hemodinamikuri darRvevebis gareSe magram mimdinare iSemiiT:
a. beta-blokatorebi Tuki araa ukuCveneba LOE C
b. i/v diltiazemi an verapamili LOE C
g. sinqronuli kardioversia. sawyisi monofazuri energia 200 J AF-s dros da 50 J winagulTa TrTolisas. zogadi anesTeziiT an sedaciiT Tuki es Sesazlebelia LOE C
3. myari AF an winagulebis TrTolisas hemodinamikuri darRvevebis an iSemiis gareSe rekomendirebulia riTmis sixSiris kontroli. mxedvelobaSi unda gvqondes antikoagulaciuri Terapia. pacientebSi visac STEMI-s dawyebamde ar hqondaT ariTmia SeiZleba vifiqroT sinusuri riTmis aRdgenaze. LOE C
4. re-entri paroqsizmuli SVT saWiroebs Semdgom mkurnalobas:
a. karotiduli sinusis masaJi LOE C
b. i/v adenozini(6 mg swrafi bolusit 1-2 wm-Si. warumateblobisas 12 mg, romlis gameorebac Sesazlebelia) LOE C
g. i/v beta-blokerebi LOE C
d. i/v diltiazemi ( 20 mg an 0,25 mg/kg-ze 2-wT-Si da Semdgomi infuzia 10 mg-sT-Si). LOE C
e. i/v digoqsini( unda vicodeT rom Sedegi iqneba daaxloebiT 1-sT-Si. 0,6 dan 1 mg-mde 70 kg-ian pacientSi.(8-15 mkg/kg-ze.) LOE C
klasi III:
1. winagulovani eqstrasistolebis mkurnaloba saWiro araa. LOE C
IX. bradiariTmiebi:
a. sinusis kvanZis disfunqcia STEMI-s Semdgom:
Iklasi:
1. simptomuri sinusuri bradikardia, sinusuri pauza > 3 wm-ze, an sinusuri bradikardia < 40-ze asocirebuli hipotenziasTan, an sistemri hemodinamikuri darRvevebTan namkurnalevi unda iqnen: i/v atropiniT 0,6-1 mg. bolusi ( maqs. doza: 2 mg ) Tu bradikardia persistirebs gamoiyeneba transkutaneuri an transvenozuri ( umjobesia winagulovani) droebiTi peisingi. LOE: C
b. gamtareblobis moSla: warmodgenilia cxrilis saxiT
es cxrili efuZneba winagulovan_parkuWovani ( vertikaluri grafa ) da parkuWSida ( horizontaluri grafa ) gamtari sistemais darRvevas, romelic SeiZleba Camoyalibdes wina kedlis mwvave infarqtis da ara ST segmentis elevaciiT mimdinare infarqtis dros. agreTve mocemulia TiToeuli situaciis mkurnalobis Cveneba.
A = atropini, AV = atrioventrikularuli, TC = kanzeda/garegani peisingi, TV = droebiT transvenuri peisingi, LAFB = hisis konis marcxena wina fexis bloki, LPFB = hisis konis marcxena ukana fexis bloki.
moqmedeba
CamoTvlili bradiariTmiebis da gamtareblobis darRveveis samkurnalod miCneulia 4 Terapiuli punqti
1. dakvirveba: mudmivi e.k.g-s monitoringi, aranairi Semdegi qmedeba.
2. A da A*: atropinis Seyvana intravenurad 0.6_1.0 mg-idan 5 wuTis intervaliT maqs.. 0.04mg/kg-e. zogadad vinaidan atropins SeuZlia gamoiwvalos mkveTri taqikardia rac araa sasurveli maqsimalurad cdiloben Tavidan airidon am preparatis xmareba Tuki ar gveqneba simptomuri sinusuri an Mmobitc I AV bloki.
3. TC: kanze safenebis moTavseba, mzad yofna garegani peisingisaTvis.
4. TV: droebiT venuri peisingi.
rogor unda ixelmZRvanelo cxriliT
magaliTi: 54 wlis mamakaci wina kedlis ST segmentis elevaciiT mimdinare infarqtiT da viwro QRS kompleqsebiT. pirvel dRes ganuviTarda hisis konis marjvena fexis sruli bloki da PR intervali am dros iyo 0.28 wm.
1. hisis konis marjvena fexis sruli bloki gamoxatavs gamtareblobis darRvevas, cxrilSi yoradReba miaqcie “hisis konis axal bloks”.
2. ipove vertikalur grafaSi “pirveli xarisxia AV bloki”.
3. ipove “moqmedeba” da “klasi”.
4. gaiTvaliswine, rom “dakvirveba” da “atropini” aris III klasi, anu ar aris naCvenebi; kanzeda peisingi (TC) aris I klasi; droebiTi venuri peisingi ki (TV) IIb klasi.
d. mudmivi peisingis Cveneba bradiaritmiis da/an gamtareblobis darRvevisas romelic asocirdeba STEMI-Tan:
I klasi:
1. permanentuli ventrikuluri peisingi naCvenebia persistentuli II xarisxis AV blokisas romelic erwymis bilateralur hisis konis fexis bloks an III xarisxis AV bloki his-purkinies sistemaSi an mis qvemoT rac viTardeba STEMI-s Semdgom. LOE: B
2. permanentuli ventrikuluri peisingi naCvenebia gardamavali Sorswasuli II an III xarisxis infranodaluri blokis da asocirebuli hisis konis fexis blokisas, Tuki blokis adgili gaurkvevelia mizanSewonilia eleqtrofiziologiuri kvleva. LOE: B
3. permanentuli ventrikuluri peisingi naCvenebia persistentuli da simptomuri II an III xarisxis AV blokisas. LOE: C
II B klasi:
1. permanentuli ventrikuluri peisingi SeiZleba gaviTvaliswinoT persistentuli II an III xarisxis AV blokisas AV kvanZis doneze. LOE: B
III klasi:
1. permanentuli ventrikuluri peisingi araa rekomendirebuli gardamavali AV blokisas, Tuki araa intraventrikuluri gamtareblobis defeqtebi. LOE: C
2. permanentuli ventrikuluri peisingi araa rekomendirebuli gardamavali AV blokisas izolirebuli marcxena wina fascikularuli blokisas LOE: B
3. permanentuli ventrikuluri peisingi araa rekomendirebuli SeZenili marcxena wina fascikularuli blokisas AV blokis ar arsebobisas LOE: B
4. permanentuli ventrikuluri peisingi araa rekomendirebuli persistentuli I xarisxis AV blokisas romelic Serwymulia Zvel(ara axal) hisis konis fexis blokTan. LOE: B
e. mudmivi peisingis modelis SerCeva Cveneba bradiaritmiis da/an gamtareblobis darRvevisas romelic asocirdeba STEMI-Tan:
I klasi
1. yvela pacienti visac aqvs mudmivi peismekeris Cadgmis Cveneba unda Sefasdes ICD-s Cvenebaze LOE: C
II A klasi
1. orkameriani peisingi pacientTaTvis romelTac aqvT sinusuri riTmi da erTkameriani Tuki pacients aqvs winagulTa TrTola an cimcimi LOE: C
2. yvela pacienti visac aqvs mudmivi peismekeris Cadgmis Cveneba unda Sefasdes biventrikuluri peisingis (gulis resinqronizaciuli Terapia) Cvenebaze LOE: C
v. ganmeorebiTi tkivili STEMI-s Semdgom
gamowveulia rogorc wesi perikarditiT an iSemiiT. pirvel Tormet saaTSi ufro mosalodnelia tkivili ukavSirdebodes iSemias. perikarditi nakleb mosalodnelia iZleodes mniCvnelovan diskomforts gul-mkerdSi pirvel 24-sT-Si.
I perikerditi:
I klasi:
1. aspirini 650 mg (nawlavuri garsiT dafaruli) 4-6 sT-Si LOE: B
2. antikoagulacia ixsneba Tukis gamoCndeba perikardiuli gamonadeni an zomaSi moimatebs. LOE: C
II A klasi:
1. Tuki aspiriniT mkurnalobaze mdgomareoba ar umjobesdeba iniSneba 1 a) kolxicini 0,6 mg oralurad yovel 12-sT-Si LOE: B an/da( 1 an orive) b) acetaminofeni 500 mg yovel 6-sT-Si oralurad LOE: B
II B klasi:
1. kortikosteroidebi rogorc ukanaskneli arCevani Tuki perikarditi refraqterulia, vinaidan isini zrdian rubturis risks. LOE: C
2. arasteroiduli anTebis sawinaaRmdego preparatebi xanmokle droiT vinaidan isini aseve zrdian rubturis, infarqtis eqspansiis da Trombocitebis disfunqciis risks. LOE: B
III klasi:
1. ibubrufeni ar iniSneba vinaidan igi amcirebs aspirinis antiagregantul Tvisebas, iwvevs infarqtis eqspansias da zrdis rubturis risks. LOE: B
II ganmeorebiTi infarqti/iSemia
I klasi:
1. Tuki pacientebs Catarebuli aqvT reperfuziuli Terapia STEMI-s gamo xdeba mkurnalobis optimizacia nitratebiT da beta-blokerebiT. SesaZlebelia daviwyoT i/v antikoagulacia. Tuki ukve ar utardeboda. LOE: B
2. zemoT aRniSnulis garda, Tuki iSemias Tan axlavs hemodinamikuri arastabiluroba, cudi marcxena parkuWis funqcia, da riskis qveSaa didi zomis miokardiumi pacientebs urgentulad utardebaT kaTeterizacia da saWiroebisas revaskularizacia mxedvelobaSi unda viqonioT kontrpulsacia. LOE C
3. Tuki pacienti ganmeorebiTi infarqti/iSemiiiT aris revaskularizaciis kandidati utardeba koronarografia da PCI an CABG koronaruli anatomiis da mixedviT. L LOE B O
II A klasi:
1. Tuki aseT pacientebSi koronarografia an/da PCI ver xerxdeba da gvaqvs ganmeorebiTi ST elevaciiT mimdinare infarqti fibrinplizisi SeiZleba gavimeoroT ( idelur SemTxvevaSi simptomebis dawyebidan 1-sT-Si). LOE C
III klasi: E
1.streptokinaza ar iniSneba ganmeorebiT Tuki maT manmde 5 dRiT adre Cautardat Trombolizisi am preparatiT.LOE C
z. sxva garTulebebi:
T/t sisxlis mimoqcevis moSla (iSemiuri)
I klasi :
1. nevropaTologis konsultacia pacientSi STEMI-T, Tuki pacients aReniSneba T/t sisxlis mimoqcevis moSla LOE C
2. pacientebis zemoaRniSnul jgufSi saWiroa Catardes eqokardiografia, nevrologiuri (CT, MRI...) da vaskularuli gamosaxulebiTi kvleva insultis mizezis gamovlenis mizniT. LOE C
3. pacientebis aRniSnul jgufSi persistentuli AF-iT iniSneba Terapia varfariniT (INR 2-3) mTeli sicocxlis manZilze LOE A
4. pacientebSi STEMI-T iSemiuri insultiT Tu mis gareSe, visac aqvs emboliis kardialuri wyaro (AF, Trombi intrakardialurad, didi zomis akinetiuri segmenti) unda dainiSnos Terapia varfariniT (INR 2-3) aspirinTan erTad. (sul cota 3 Tve intramuraluri Trombis da akinetiuri ubnis arsebobisas da mTeli cxovreba AF-s dros). varfariniT adeqvatur antikoagulaciamde pacientma unda miiRos UFH an LMWH. LOE B
II Aklasi:
1. mizanSewonilia Sefasdes pacientebSi STEMI-T iSemiuri insultis riski. LOE A
2. mizanSewonilia pacientebSi STEMI-T da ara fataluri iSemiuri insultiT Catardes Sesabamisi movla garTulebebis sixSiris Sesamcireblad da funqciuri gaumjobesebis mizniT. LOE C
II B klasi:
1. karotidebis angioplastika/stentireba, 4-6 kviraSi iSemiuri insultidan, Tuki pacientebs STEMI-T aqvT mwvave epizodi, rasac axlavs Sida karotidis stenozi > 50%-ze, da aqvT maRali qirurgiuli sikvdilianobis/avadobis riski STEMI-s Semdgom adreul periodSi LOE C
Rrma venebis Trombozi DVT da pulmonaruli embolia PE:
rogorc prevencia aseve mkurnaloba ganxiluli iqneba DVT da PE-s Sesabamis gaidlainebSi. aq ki avRniSnavT rom mkurnal eqims mxedvelobaSi unda hqondes es garTulebebi xangZlivi woliTi/jdomiTi rejimisas da iseT pacientebSi, romelTac amis gareSec aqvT aRniSnuli garTulebebis maRali riski.
T. STEMI-s Semdgomi aorto koronaruli Suntirebis Cvenebebi mocemuli iqneba zogadad CABG-is gaidlainSi.
X meoradi prevencia da xangZlivi marTva:
a. riskis Sefaseba stacionaridan gaweris Semdgom:
sqema 7. kaTeterizaciis da revaskularizaciis Cveneba STEMI-s Semdgom
adreuli
invaziuri strategia fibrinolizisi arareperfuziuli strategia
[pic]
b. cxrili 10 meoradi prevencia STEMI-s dros:
| | | | |
| |mizani |rekomendaciebi | |
| | | | |
| |moweva |pacienti da misi ojaxi mkacrad unda gafrTxildes mowevis sruli Sewyvetis| |
| |mizani: sruli Sewyveta |Sesaxeb ( Tavidan unda iqnes aridebuli misi TandraswebiT ojaxis | |
| | |wevrebis mier moweva) saWiroebisas SesaZloa farmakologiuri Terapiis | |
| | |daniSvnac ( nikotinis Canacvleba da “ Bupropion”-i) | |
| | | | |
| | |Tuki wneva ≥ 120/80 mmhg | |
| |sisxlis wnevis kontroli |• daiwyeT cxovrebis stilis modifikacia (wonis kontroli, fizikuri | |
| |mizani: < 140/90 mmhg an < 130/80 mmhg qronikuli Tirkmlis |aqtivoba, alkoholis Warbi gamoyenebis Tavidan arideba, marilis xmarebis| |
| |naklovanebis an diabetis dros |zomieri Semcireba, dietaSi xilis, bostneulis, dabal-cximiani | |
| | |produqtebis didi xvedriTi wili) | |
| | | | |
| | |Tuki wneva ≥ 140/90 mmhg an > 130/80 mmhg pacientebSi Tirkmlis | |
| | |qronikuli ukmarisobiT an diabetiT: | |
| | |• daamateT wnevis Sesamcirebeli medikamentebi | |
| | | | |
| | |daiwyeT dieta yvela pacientSi. ( saerTo kaloraJSi gajerebuli cximi < | |
| | |7%-ze da qolesteroli < 2000 mg/dReSi.) urCieT wonis kontroli da | |
| | |fizikuri aqtivoba. urCieT omega-3 cximovani mJavis xmarebis gazrda. | |
| | | | |
| | |gansazRvreT lipiduri speqtri da daiwyeT medikamenturi mkurnaloba | |
| | |Semdegi sqemis mixedviT: | |
| |lipiduri menejmenti ( Tuki TG < 200 mg/dl) | | |
| |mizani: LDL-C mniSvnelovnad < 100 mg/dl-ze) |LDL -C < 100 mg/dl ( sabaziso an mkurnalobis fonze) | |
| | |• gamoiyeneT/gaagrZeleT statinebi mizani misi Semcireba 70 mg/dl-is | |
| | |qvemoT statinebi | |
| | | | |
| | |LDL ≥ 100 mg/dl ( sabaziso an mkurnalobis fonze) | |
| | |• moaxdineT LDL-is Semamcirebeli medikamentozuri mkurnalobis | |
| | |intensifikacia. upiratesoba eniWeba statinebs. ) | |
| |lipiduri menejmenti ( TG ≥ 200 mg/dl | | |
| |mizani: ara HDL-C mniSvnelovnad naklebi 130 mg/dl-ze * |Tuki TG ≥ 150 mg/dl an HDL < 40 mg/dl : | |
| | |• xazi gausviT wonis kontrolis da mowevis Sewyvetis mniSvnelobas | |
| | |TG aris 200-499 mg/dl | |
| | |• LDL-C Semamcirebeli Terapiis ESmdgom, † mxedvelobaSi gqondes fibrati | |
| | |an niacini †† | |
| | | | |
| | |Tuki TG aris ≥ 500 mg/dl | |
| | |• mxedvelobaSi iqonie fibratis an niacinis dawyeba LDL is Semamcirebeli| |
| | |Terapiis win. † | |
| | |• mxedvelobaSi iqonie omega-3 mJavis dawyeba | |
| | | | |
| |fizikuri aqtivoba |gansazRvreT riski, upiratesad datvirTvis testiT. pacientebs urCieT | |
| |minimaluri mizani: 30 wT 3-4 dRe kviraSi; |30-60 wT-iani aqtivoba. umjobesia yovel dRe magram minimum 3-4 jer | |
| |optimaluria yovel dRe |kviraSi.(fexiT siaruli, sirbili, velosipedi, aerobika.) aseve urCieT | |
| | |dRis ganmavlobaSi ufro aqtiuri moZraoba: siaruli, saxlis samuSaoebi. | |
| | |gulis reabilitaciuri programebi pacientebisaTvis mravlobiTi risk | |
| | |faqtorebiT unda mimdinareobdes eqimis meTvalyureobiT. | |
| | | | |
| |wonis kontroli |gamoTvaleT BMI ( sasurvelia 18,5-24,9 kg/m2 da gazomeT welis | |
| |mizani: sxeulis masis indeqsi BMI = 18,5-24,9 kg/m2 |garSemoweriloba( 101-sm kacebSi da 89-sm qalebSi). periodulad | |
| |welis garSemoweriloba: qalebSi: 88,9 sm |gadaamowmeT. Tuki monacemebi aradaamkmayofilebelia pacients urCieT | |
| |kacebSi 101,6 sm |metad gaaqtiveba da cxovrebis wesis modificireba. | |
| | | | |
| | |
| | |
| | |
| | |
| | |
| | |
g. ST elevaciiT mimdinare miokardimis infarqtis ( STEMI) stacionaridan gaweris Semdgomi antiTrombozuli mkurnaloba
[pic]
* ara HDL qolesteroli = saerTo qolesterols minus HDL-i.
† mizania ara HDL-C < 130 mg/dl-ze
†† niacini unda gamoviyenoT mxolod eqimis monitoringiT
††† kreatinini ≤ 2,5 mg/dl kacSi da 2 mg/dl qalSi
†††† kaliumi ≤ 5 mEq/L
d. rekomendaciebi gaweris Semdgomi vizitebis da zogadad daavadebis marTvis Sesaxeb:
klasi I :
1. gaweris Semdgomi viziti unda asaxavdes kardiovaskularuli simptomebis dinamikas da funqcionalur klass. (LOE C)
2. unda moxdes mimdinare mkurnalobis gadafaseba da unda SeirCes titraciis gziT ACE inhibitorebis, B-blokerebis da statinebis optimaluri dozebi.
3. riskis gansazRvra da gegmiuri reabilitacia unda gadaixedos da gagrZeldes. es unda moicavdes marcxena parkuWis funqciis Sefasebas, SesaZloa holteris monitorings im pacientebSi romelTa post-STEMI EF iyo 31-40% an ufro dabali. vinaidan am pacientebSi mxedvelobaSi unda gvqondes ICD-is implantacia. (LOE C)
4. mkurnalma unda auxsnas pacients da misi ojaxis wevrebs meoradi prevenciis principebi. (LOE C)
5. pacientis fsiqologiuri statusi unda Sefasdes da yuradReba unda mieqces iseTi niSnebis arsebobas rac miuTiTebs depresiaze, aRgznebaze, Zilis moSlilobaze da socialuri qcevis Secvlaze. (LOE C)
6. Semdgomi vizitebisas mkurnalis mier unda ganisazRvros fizikuri aqtivobis done, samsaxurSi dabrunebis vada, seqsualuri aqtivoba, mgzavrobis da manqanis tarebis SesaZlebloba, aseve TviTmfrinaviT mgzavrobis sakiTxebi. fizikuri datvirTvis done gamoixateba metaboluri eqvivalentiT MET-Si. (damatebebSi gamosaxuleba 2) ( LOE C )
7. mkurnalma pacients da misi ojaxis wevrebs unda SesTavazos CPR-is ZiriTadi principebis axsna da maTi survilis SemTxvevaSi SesTavazos treiningis kursebze daswreba. ( LOE C )
8. mkurnlma pacientTan da maTi ojaxis wevrebTan erTad unda ganixilos Semdegi sakiTxebi:
a. pacientis gulis Setevis riski ( LOE C )
b. rogor gamovicnoT STEMI-s simptomebi. ( LOE C )
g. saswrafos gamoZaxebis aucilebloba Tuki simptomebi ar umjobesdeba an uaresdeba 5 wT-Si. Tundac rom ar iyvnen darwmunebuli mdgomareobis simZimeSi. ( LOE C )
d. amasTan unda aexsnaT potenciuri kardiologiuri incidentis gamocnobis da Semdgomi moqmedebis gegma. saswrafoSi darekvis CaTvliT. ( LOE C )
e. gulis reabilitaciis programebi rekomendirebulia pacientTaTvis gansakuTrebiT ki maTTvis vinc saWiroebs mravlobiTi risk faqtorebis modificirebas an/da is pacientebi, romelTac aqvT garTulebebis saSualo an maRali riski da romlebSiac varjiSi rekomendirebulia.
e. cxrili 11 medikamentebi romlebic gamoyeneba STEMI-s mkurnalobisas
| | | | |
|medikamenti |pirveli 24-sT |hospitalizaciis manZilze |gawerisas da xangZlivi |
| | | |mkurnalobisas |
| | | | |
|aspirini |dasaReWad ( umjobesia ara enteruli |75-162 mg dRiuri |75-162 mg dRiuri ganusazRv-reli|
| |garsiT dafaruli) 162-325 mg | |vadiT |
| | | | |
|fibrinolizisuri Terapia |streptokinaza 1,5 MU IV 30-60 wT-is | | |
|ixileT ukuCvenebebi da Cvenebebi me-6 |manZilze | | |
|cxrilidan | | | |
| |alteplaza IV bolusi 15 mg. infuzia 75 | | |
| |mg/kg-ze 30 wT-Si (maqsimumi 50 mg) | | |
| |Semdeg 50 mg/kg ( maqs. 35 mg) 60 wT-Si.| | |
| |jamSi maqsimaluri dozaa 100 mg | | |
| | | | |
| |reteplaze 10 U IV bolusi 2wT-Si Semdeg | | |
| |gaimeoreT 30 wT-Si 10 U IV bolusi 2 | | |
| |wT-Si | | |
| | | | |
| |teneqteplaza IV bolusi 10-15 wm-Si 30 mg| | |
| |Tuki wona < 60 mg. 35 mg Tuki wona aris | | |
| |60-69 kg. 40 mg 70-79kg-ze, 45 mg 80-89| | |
| |kg-ze da 50 mg > 90 kg-ze. | | |
| | | | |
| | | | |
| | | | |
| | | | |
|arafraqcionirebadi heparini UFH |60 U/kg ( maqs. 4000 U ) IV bolusi. |aPTT 1,5-2,0 normasTan SedarebiT (|ix. 8 sqema antiTrombozuli |
| |Semdeg infuzia 12 U/kg/sT-Si. max. 1000 |50-70-s Soris) 48 sT-is |mkurnalobis rekomendaciebisTvis|
| |U/sT-Si. aPTT 1,5-2,0 normasTan |ganmavlobaSi | |
| |SedarebiT ( 50-70-s Soris) | | |
| | | | |
|beta-blokeri |per-os |per-os |per-os ganusazRvreli vadiT |
| | | | |
| |ACE inhibitori yvela pacientSi wina | | |
| |kedlis infarqtiT, pulmonaruli SegubebiT,| | |
|ACE inhibitori |EF < 40 %-ze Tuki araa hipotenzia da |per-os |per-os ganusazRvreli vadiT |
| |sxva ukuCvenebebi, gatitreT wnevis da | | |
| |kreatininis kontroliT | | |
| | | | |
|angiotenzin II-is blokatori ARB |ARB unda dainiSnos pacientebSi visac |iseve rogorc pirvel 24-sT-Si |iseve rogorc pirvel 24-sT-Si |
| |aqvs ACE inhibitorebis autanloba da | | |
| |igive Cveneba rac am ukanasknelT | | |
| | | | |
| | |yvela pacientSi Tirkmlis mniSv. | |
| | |ukmarisobis gareSe ( kreatinini < | |
|aldosteronis blokada | |2,5 mg/dl kacSi ada 2 mg/dl |igive rac hospitalizaciisas. |
| | |qalebSi) an hiperkaliemiis gareSe | |
| | |K < 5mEq/l romlebic iReben ACE-s, | |
| | |EF < an toli 40% da romelTac aqvT | |
| | |gulis ukmarisoba an diabeti. | |
| | | | |
| |sublingvaluri NTG 0,4 mg yovel 5 wT-Si |oralurad Tuki iSemia grZeldeba an | |
| |Tuki rCeba tkivili an diskomforti |aris ukontrolo hipertenzia | |
|nitroglicerini |gulmkerdSi. | | |
| |IV NTG gulis ukmarisobis, hipertenziis,| | |
| |persistentuli iSemiisas rac pasuxobs | | |
| |nitratebs | | |
| | | | |
|statinebi | |daiwyeT lipiduri profiles gareSe |ganusazRvreli vadiT Tuki LDL-C |
| | | |aris 100 mg an meti. gazardeT |
| | | |manam sanam igi ar gaxdeba |
| | | |mniSvnelovnad naklebi zemoT |
| | | |aRniSnul doneze ( an toli 70 |
| | | |mg/dl) |
| | | | |
|morfin sulfati |IV 2-4 mg da zrda 2-8 mg-iT 5-15 | | |
| |wT-iani intervalebiT tkivilis | | |
| |kontrolisaTvis | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
|pacientis ganaTleba | | |pacientisTvis mniSvnelovania |
| | | |imis codna Tu rogor Secvalos |
| | | |cxovrebis stili STEMI-s |
| | | |Semdgom. informacias |
| | | |medikamenturi mkurnalobis |
| | | |Sesaxeb meoradi garTulebebis |
| | | |prevenciisTvis aseve didi |
| | | |mniSvneloba aqvs. iseve rogorc |
| | | |codnas Tu rogor gamoicnos gulis|
| | | |simptomebi da Tu rodis |
| | | |gamoiZaxos saswrafo daxmarebis |
| | | |brigada |
| | | | |
|dieta | |axsna saturirebuli cximebiT da |Sesabamisi dietis rekomendireba|
| | |qolesteroliT dabali dietis | |
| | |aucileblobis da mniSvnelobis | |
| | |Sesaxeb | |
| | | | |
|moweva |avukrZaloT moweva |avukrZaloT moweva |avukrZaloT moweva. saWiroebisas|
| | | |farmakologiuri Terapia. da |
| | | |CavrToT mowevis Sewyvetis |
| | | |programaSi |
| | | | |
| | | | |
|varjiSi |axsna-ganmarteba |siarulis dawyeba |rekomndacia varjiSis da |
| | | |aqtivobis donis Sesaxeb |
GXI gamoyenebuli masala:
teqsti eyrdnoba amerikis gulis asociaciis da amerikis kardiologTa kolejis 2004w ( sruli teqsti da jibis gaidlaini) aseve evropis kardiologTa asociaciis ( 2003w sruli teqsti) Sesabamis gaidlainebs.
damatebaSi gamoyenebulia masalebi: 1. ACC/AHA gaidlainis sruli teqstidan
2004w.
2. ESC gaidlainis sruli teqstidan
2003w.
3. braunvaldi, zaips libbi, gulis
daavadebebi 6-e gamocema 2001w
4. brain p. grifini erik j. topoli
kardiovaskularuli medicinis
saxelmZRvanelo, 2-e gamocema 2004w.
-----------------------
ST elevaciiT
ST elevaciis gareSe
arastabiluri stenokardia UA
ara Q kbilovani miokardiumis infarqti
Q kbilovani miokardiumis infarqti
klinikaSi PCI - SesaZlebelia
ix. sqema 2B
SeiZleba ganvixiloT inter hospitaluri gadayvana
drois grafiki
s.d.b-s
gamgzavreba
1-wT-Si
prehospital. Trombolizisi. s.d.b-s mosvlidan 30 wT-Si (Tuki SesaZloa)
pacientis transportireba s.d.b-s mier. misi mosvlidan 90-wT-Si baloni (igulisxmeba balonis gaberva PCI-s dros)
Tuki pacient TviTdinebiT midis stacionarSi hospitalSi moxvedridan 90-wT-Si baloni.
oqros dro = 60 wT-s mTlianobaSi iSemiis dro ≤ 120 wT-is
gegma
pirveladi PCI
riskis arainvaziuri Sefaseba
PCI an CABG
gadamrCeni an iSemiis niSnebisda mixedviT
intrahospitaluri mkurnaloba da meoradi prevencia
fibrinolizisi
STEMI-s simptomebis dawyeba
pacienti Semodis gadaudebeli daxmarebis ganyofilebaSi
saswrafo daxmareba miiyvans pacients gadaudebeli daxmarebis ganyofilebaSi
triada romelic mniSvnelovnia stacionarSi miRebisas:
• STEMI-s simptomebis da niSnebis Sefaseba (Cvenebis klasi I LOE: C)
• 12-ganxriani e.k.g (Semosvidan 10 wT-Si unda iyos gadaRebuli Tuki ara gvaqvs STEMI-s niSnebi da pacienti kvlav simptomuria seriuli e.k.g yovel 10-wT-Si. (Cveneba klasi I LOE:C)
• Tuki pacients aqvs qveda kedlis MI unda gadaviRoT marjvena mxrivi ganxrebic marjvena parkuWis infarqtis dasadgenad Cvenebis klasi I LOE: B)
† - ar miceT Tuki sistoluri wneva < 90 mmhg an bazalurze 30-iT naklebi, anN Tuki P > 100 an < 50 an Tuki eWvi gvaqvs marjvena parkuWis infarqtze
†† - Tumca zogierTi xmarobs nawlavuri garsiT dafarul aspirins, ufro swrafi Sedegia garsis gareSe aspirinis daReWvisas
††† - oraluri B-blokerebi pacientebSi ukuCvenebis gareSe ( I klasi. LOE A ) IV B-blokerebi Tuki araa ukuCveneba gansakuTrebiT Tu aris taqikardia da hipertenzia. ( IIa klasi LOE: B).
gaurkvevlobis SemTxvevaSi gamoiZaxeT konsultanti
ara gvaqvs parkuWTa fibrilacia da myari ventrikuluri taqikardia STEMI-dan 48-sT-Si da gandevnis fraqcia gaizoma infarqtidan 1-Tvis Semdeg
EF ≤ 30%
EF=31- 40%
EF > 40%
gvaqvs eleqt. arastabiluroba? mag: NSVT
ICD
EPS
+
-
ICD ara
ganmeorebiTi iSemiuri tkivili an diskomforti STEMI-s SEmdgom
12-ganxriani
e.k.g.
medik. mkurnalobias optimizacia
antikoagulaciis dawyeba Tu manamade ar iyo
balonuri kontrpulsacia hemodinamikuri arastabilurobis, dabali kumSvadi funqciis, an Tuki miokardis didi ubania riskis qveS
iSemiis meoradi mizezebis gasworeba
ST elevacia
ara
diax
aris revaskularizaciis kandidati ?
ara
diax
iSemia kontroldeba medik. optimizaciiT ?
diax
ganix. ganmeorebiTiTrombolizisi
gegmiuri kaTeterizacia
urgentuli kaTeterizacia gaiTvaliswine IABP
ara
SesaZlebelia swrafi kaTeterizacia ?
ara
ganixile re-Trombolizisis SesaZlebloba streptkinazisaTvis 2 dRidan 5 wliwadSi ganmeorebiTi xmareba SedarebiTi ukuCvenebaa
diax
PCI an CABG
klasi II-A. LOE: B
klsi I LOE: B
klasi II-B
LOE: B
klasi III
LOE: B
klasi II-B
LOE: B
ara
diax
| | | I xarisxis AV bloki |mobic I meore xarisxis AV bloki |mobitc II meore xarisxis AV bloki |
| | |wina MI arawina MI |A wina MI arawina MI |wina MI arawina MI |
| |moqmedeba |klasi |moq.med |klasi |moq.med |klasi |moq.me |klasi |moqmed |klasi |moq.med |klasi |moqmed |klasi |
|normaluri |dakvirveba|I |dakvirv |I |dakvir. |I |dakvir. |II b |dakvir. |IIA |dakvir. |III |dakvir. |III |
| | | | | | | | | | | | | | | |
| |A |III |A |III |A |III |A * |III |A |III |A |III |A |III |
| | | | | | | | | | | | | | | |
| |TC |III |TC |II b |TC |II b |TC |I |TC |I |TC |I |TC |I |
| | | | | | | | | | | | | | | |
| |TV |III |TV |III |TV |III |TV |III |TV |III |TV |II a |TV |II a |
|axali an Zveli | | | | | | | |B | | | | | | |
|fascikul. bloki LAFB |dakvirveba|I |dakvir. |IIb |dakvir. |IIb |dakvir. |IIb |dakvir. |IIb |dakvir. |III |dakvir. |III |
|an PFB) | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | |
| |A |III |A |III |A |III |A * |III |A * |III |A |III |A |III |
| | | | | | | | | | | | | | | |
| |TC |IIb |TC |I |TC |IIa |TC |I |TC |I |TC |I |TC |I |
| | | | | | | | | | | | | | | |
| |TV |III |TV |III |TV |III |TV |III |TV |III |TV |IIa |TV |IIb |
| | | | | | | | | | | | | | | |
| |dakvirveba|I |dak |III |dak |III |dak |III |dak |III |dak |III |dak |III |
| | | | | | | | | | | | | | | |
|hisis konis Zveli | | | | | | | | | | | | | | |
|bloki | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | |
| |A |III |A |III |A |III |A * |III |A |III |A |III |A |III |
| | | | | | | | | | | | | | | |
| |TC |II b |TC |I |TC |I |TC |I |TC |I |TC |I |TC |I |
| | | | | | | | | | | | | | | |
| |TV |III |TV |II b |TV |II b |TV |II b |TV |II b |TV |II a |TV |II a |
| | | | | | | | | | | | | | | |
| |dakvirveba|III |dak |III |dak |III |dak |III |dak |III |dak |III |dak |III |
| | | | | | | | | | | | | | | |
|hisis konis axali | | | | | | | | | | | | | | |
|bloki | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | |
| |A |III |A |III |A |III |A* |III |A |III |A |III |A |III |
| | | | | | | | | | | | | | | |
| |TC |I |TC |I |TC |I |TC |I |TC |I |TC |IIb |TC |IIb |
| | | | | | | | | | | | | | | |
| |T |IIb |TV |IIa |TV |Ia |TV |IIa |TV |IIa |TV |I |TV |I |
| | | | | | | | | | | | | | | |
| |dak |III |dak |III |dak |III |dak |III |dak |III |dak |III |dak |III |
|fascikularuli bloki+ | | | | | | | | | | | | | | |
|RBBB | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | |
| |A |III |A |III |A |III |A* |III |A |III |A |III |A |III |
| | | | | | | | | | | | | | | |
| |TC |I |TC |I |TC |I |TC |I |TC |I |TC |II B |TC |II b |
| | | | | | | | | | | | | | | |
| |TV |IIb |TV |II a |TV |II a |TV |II a |TV |II a |TV |I |TV |I |
| | | | | | | | | | | | | | | |
|gardamavali |dakvirveba|III |dak |III |dak |III |dak |III |dak |III |dak |III |dak |III |
|marjvena da | | | | | | | | | | | | | | |
|marcxena hisis konis | | | | | | | | | | | | | | |
|bloki | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | |
| |A |III |A |III |A |III |A* |III |A |III |A |III |A |III |
| | | | | | | | | | | | | | | |
| |TC |II b |TC |II b |TC |II b |TC |II b |TC |II b |TC |II b |TC |II b |
| | | | | | | | | | | | | | | |
| |TV |I |TV |I |TV |I |TV |I |TV |I |TV |I |TV |I |
EF > 40 %
EF < 40 %
maRali riskis gareSe †
maRali riskiT †
kaTeterizacia Cvenebis mixedviT
funqciuri Sefaseba
EF < 40 %
EF > 40 %
maRali riski †
maRali riskis gareSe †
e.k.g interpretirebadia
e.k.g. interpretirebadi araa
fiz..datvir. testi ar SeuZlia
fiz. datvirT testi ar SeuZlia
datvirTvis stress eqo
nuklearuli datvirT.vis testi
SeuZlia fizik. datir. testi
submaqs. dat. testi gaweramde
maqsimaluri datvirTvis testi gaweris win an Semdgom
klinikurad mniSv. iSemia
klinik. mniSv. iSemia araa
medikament. mkurnaloba
kaTeterizacia da revaskularizacia Cvenebisda mixedviT
† maRal riskSi igulisxmeba STEMI-s riski (ix. gamosaxuleba 1 ) Semosvlisas. amasTan erTad mas emateba iseTi maRali riskis prediqtorebi rogoricaa: warumatebeli reperfuziis niSnebi( tkivilis ganmeoreba, ek.k.g-niSnebis persistireba. ) meqanikuri garTulebebi(gulis ukmarobis uecari ganviTareba, axali Suili, Soki.)
Semd. kaTeteriz. gareSe
Semdg. kaTeterizaciiT
farmakologiuri stres testi
adenozini an dipiridamoli
dobutamin eqo.
| | |
|diabetis kontroli: |hipoglikemiuri dieta da Terapia raTa mivaRwioT normalurTan axlo Saqris |
|mizani HbA1c < 7%-ze. |cifrebs uzmoze da HbA1c < 7%-ze. |
| | |
| | |
| | |
| | |
|antiTrombocitebi/antikoagulantebi |aspirini 75-162 mg Tuki araa ukuCveneba. klopidrogeli 75 mg an varfarini |
| |Tuki aspirini ukunaCvenebia. (es ukanaskneli INR-is kontroliT ) |
| | |
| |ACE inhibitorebi yvela pacientSi. daiwyeT adre maRali riskis pacientebSi |
| |( wina kedlis MI, adre gadatanili MI, kilipi II-ze meti gulis ukmarisoba.|
| |(S3 galopi, auskultaciiT Segubeba mcire wreSi, gulis ukmarisobis |
| |radiografiuli niSnebi. EF ≤ 40%-ze. |
| |angiotenzinis receptorebis blokerebi pacientebSi ACE-inhibitorebis |
|renin-angiotenzin-aldosteron sistemis blokerebi |autanlobisas, da romelTac aqvT maTi daniSvnis Cveneba. |
| |aldosteronis blokatorebi pacientebSi mniSvnelovani renaluri ukmarisobis |
| |††† an hiperkaliemiis gareSe †††† romlebic iReben ACE inhibitorebs, aqvT |
| |EF < an toli 40 %-ze. da aqvT diabeti an gulis ukmarisoba. |
| |HF |
| | |
|beta blokerebi |daiwyeT yvela pacientSi romelsac ara aqvs ukuCveneba da SearCieT |
| |optimaluri doza. gaagrZeleT monitoringi dozis optimizaciis mizniT |
| |(monitorings gansakuTrebuli mniSvneloba aqvs pacientebSi gulis |
| |ukmarisobiT) |
|diabetis marTva |hipoglikemiuri Terapia. efeqturoba mowmdeba HbA1C-iT romelic unda iyos |
| |7%-ze naklebi. |
|varfarini |misi Cvenebebi aris qvemoT mocemul cxrilSi. damatebiT SeiZleba aRiniSnos |
| |rom varfarini SeiZleba mieces pacients STEMI-s Semdgom Tuki aqvs LV |
| |disfunqcia da didi zomis regionaluri kumSvadobis moSla. LOE IIA |
pacienti gaweris win
stentireba ar Cautarda
stentireba Cautarda
aspirinze araa alergiuli
aspirinze alergia aqvs
araa antikoagulaciis Cveneba
aris antikoagulaciis Cveneba ††††
araa antikoagulaciis Cveneba
aris antikoagulaciis Cveneba ††††
aspirinze araa alergiuli
aspirinze alergia aqvs
araa antikoagulaciis Cveneba
aris antikoagulaciis Cveneba ††††
araa antikoagulaciis Cveneba
aris antikoagulaciis Cveneba ††††
ASA 75-162 mg
I klasi LOE A.
ASA 75-162 mg + varfarini (INR 2,0-3,0) ††† I klasi LOE B.
klopidrogeli (plaviqsi)* 75 mg I klasi LOE C
ASA 75-162 mg +
klopidrogeli (plaviqsi) 75 mg I klasi
LOE B. †
ASA 75-162 mg +
klopidrogeli (plaviqsi) 75 mg‡†† + varfarini (INR 2,0-3,0) IIB klasi LOE C †††
klopidrogeli (plaviqsi) 75 mg + varfarini ( INR 2,0-3,0) I klasi LOE C †††
varfarini (INR 2,0-3,0) I klasi LOE B.
klopidrogeli (plaviqsi) 75 mg I klasi
LOE B.
alternativaa
ASA 75-162 mg + varfarini (INR 2,0-3,0) II A klasi LOE B.
an varfarini ( INR-2,5-3,5) I klasi LOE B
alternativaa
varfarini (INR 2,5-3,5) I klasi LOE B
an varfarini ( INR-2,5-3,5) II A klasi LOE B.
* klopidrogels aqvs upiratesoba varfarinTan SedarebiT naklebi sisxldeniT garTulebebis gamo. amasTan erTad pacientebis umravlesoba arCevs mis miRebas.
† 12-Tvis ganmavlobaSi
†† klopidrogeli ixsneba 1-TveSi ( Tu gamoyenebulia bare metal stenti, grZeldeba ramodenime Tve Tu gamoyenebulia drug-diluting stentebi( 3 Tve sirolimus-is Semdeg 6-Tve paclitaxel-is Semdeg) ixsneba sisxldenebis potenciuri safrTxeebis Sesamcireblad.
grZeldeba aspirini varfarinTan erTad Cvenebis mixedviT (winagulTa fibrilacia, Trombuli masa gulis RruebSi, cerebraluri emboli, didi zomis regionaluri kumSvadobis moSla)
††† umjobesia INR-i iyos qveda zRvrisken. 75 wlis qvemoT am medikamentebis kombinacias aqvs naklebi sisxldenis garTulebebi
†††† STEMI-s Semdgom antikoagulaciis Cvenebaa wina kedlis didi zomis MI an LV-s Trombi eqokardiografiaze. am dros antikoagulacia grZeldeba 6 kvira ( ra Tqma unda antikoagulacias aqvs sxva Cvenebebi romlebic ar ukavSirdeba MI-s. mag winagulTa fibrilacia.
‡‡
mimRebi hospitali sadac PCI araa SesaZlebeli
mimRebi hospitali sadac PCI SesaZlebelia
ST elevaciis gareSeE mimdinare mwvave koronaruli sindromi ( ACS ). ufro xSirad mTavrdeba UA an ara Q-kbilovani miokardiumis infarqtiT. naklebi sixSiriT man SeiZleba gamoiwvios Q -kbilovani MI.
ST elevaciiT mimdinare ACS ufro xSirad mTavrdeba Q-kbilovani MI-T da naklebad xSirad ara Q kbilovani MI-T an UA-iT
gadaudebel saeqTno daxmarebas: kardiomonitoringi,
O2-is miwodeba Tuki SaO2 < 90% klasi I LOE B
O2-is miwodeba yvela Semosul pacients STEMI-T miuxedavad SaO2>90%. 6-sT-is ganmavlobaSi 2-3l Cveneba klasi II-A LOE C
IV- D5W, sisxlis analizi ( cxrili 7)
nitroglicerini † aspirini ††
gadaudebeli daxmarebis eqimi afasebs pacients:
anamnezi/istoria (Cvenebis klasi I LOE: C)
fizikuri gamokvleva (2 cxrili) (Cvenebis klasi I LOE: C)
ekg interpretacia (Cvenebis klasi I LOE: C)
I safexuri: Aaris Tu ara 15 wT-ze meti da 12 sT-ze naklebi xangrZlivobis tkivili an diskomforti gulmkerdis areSi ?
aReniSneba Tu ara pacients gamoxatuli gulis ukmarisobaan kardiogenuri Soki, iseTi rom PCI iyos upiratesi TrombolizisTan SedarebiT ?
diax
ara
SeCerdi
II safexuri: aRiniSneba Tu ara fibrinolizis ukuCveneba7
Tu romelime qvemoTCamoTvlilze aRiniSneba pasuxi diax fibrinolizi SeiZleba iyos ukunaCvenebi
pacients aReniSneba
STEMI ?
ST ↑ V4R= proximal RC
ST isoelect. V4R =
Distal RC
ST ↓ V4R = CX
diafragmuli kedlis infarqtis fonze marjvena ganxrebis mixedviT SesaZloa vimsjeloT dainteresebuli sisxlZarRvis lokalizaciaze
mwvave pulmonaruli edema
hipovolemia
kardiogenuri Soki dabali wuT.moc.
ariTmia
brad.da
taq.
furosemidi: IV 0,5-1,0 mg/kg 0,5 axlad ganviTarebuli mwv. pulm. edemaze. 1,0 mwvave an qr. moculobiT gadatvirTvaze, Tirkmlis ukmarobisas.
morfini: IV 2- 4 mg
Jangbadi/intubacia: saWiroebisas
nitroglicerini: Sl, Semdeg IV 10-20 mkg/wT Tuki sist.wneva >100 mmhg
dofamini: IV 5-15 mkg/kg/wT Tu sist.wneva 70-100 da Sokis niSnebia
dobutreqsi: IV 2-20 mkg/kg/wT Tu sist.wneva 70-100 da Sokis niSnebi araa
siTxeebi
sisxlis transfuzia
mizezis gamosworeba
gaiTvaliswineT vazopresorebi
naxeT ariTmiis marTva STEMI-s Semdgom.
sist. wneva > 100 mmhg
sist.wneva 70-100 mmhg Sokis niSnebis gareSe
sist.wneva 70-100 Sokis niSnebiT
sist.wneva < 70 mmhg Sokis niSnebiT
nitroglicerini 10-20 mkg/wT IV
dobutamini 2-20 mkg/kg/wT IV
dofamini 5-15 mkg/kg/wT IV
norepinefrini 0,5—30 mkg/wT IV
SeinarCune sist.wneva > 100 mmhg da ara naklebi 30-isa sabazo wnevasTan SedarebiT
ACE inhibitorebi umjobesia xanmokle moqmedebis rogoricaa kaptoprili 6,25 mg
Semdgomi/damatebiTi diagnostikur/Terapiuli RonisZiebebi:
diagnostikuri: pulmonaruli arteries kaTeteri, eqokardiografia, angiografia miokardiumis infarqti/iSemiisTvis, damatebiTi diagnostikuri RonisZiebebi.
Terapiuli: 1) intraaortuli balonuri kontrpulsacia, 2) reperfuzia/revaskularizacia, 3) SeiZleba gamoviyenoT dobutamin, dofaminis kombinacia.
revaskularizacia Cvenebis mixedviT
diax
ara
mwvave koronaruli sindromi ACS
STEMI-s simptomebis dawyeba
saswrafos gamoZaxeba da gamogzavna
s.d.b.:
• iRebs 12 ganxrian e.k.g-s
• Tuki SesaZloa (igulisxmeba
kvalifikacia da teqnikuri
aRWurviloba) mosvlidan
30 wT-Si Trombolizisi
s.d.b-Si
darekva
simpt. dwyebid.
5 wT-Si
mimReb klinikaSi PCI - SeuZlebelia
ix. sqema 2B
ix. suraTi ACC/AHA UA/NSTEMI pacientebis marTvis gaidlaini
Sefaseba:
• dro simptomebis dawyebidan
• STEMI-s riski ( ix. 1 gamosaxuleba damatebebSi )
• fibrinolizis riski
• dro romelic esaWiroeba PCI-iT aRWurvil klinikamde
reperfuziuli Terapiis SerCeva da uzrunvelyofa (cxr. 5 sqema 2 )
sxva Terapiis SerCeva:
• morfini
• aspirini ††
• antiTrombozuli mkurnaloba(heparini)
• nitrati (saWiroebisamebr gulmkerdis
areSi tkivilis an diskomfortis
SemTxvevaSi) †
• beta-blokerebi †††
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