ACS - hlobaetsang gogoga syndrome,

IV Samorodskaya,

Professor, Doctor of Sciences Medical

hlobaetsang gogoga
lefu

Multidisciplinary sehlopha etsa qeto

Ho sebelisa mekhoa ea kajeno ea phekolo bakeng sa lefu hlobaetsang gogoga (ACS)
- e leng lentsoe le bolelang sehlopha leha e le efe ea lipontšo tsa tleleniki kapa matšoao a
lumella belaela hlobaetsang myocardial infarction (MI) kapa a sa tsitsang
angina, o fana ka tšepo bakeng sa phokotso bohlokoa sepetlele
shoang le ho ntlafatsa itse'ng ka nako ea nako e telele.

lilemo tse 'maloa tse fetileng, ho etsa lipatlisiso le tsa machaba mekhoa di
akaretsa All-Russia Scientific Society ea Cardiology ka dikgothaletso Russia ka fumanoe
le kalafo ea bakuli le myocardial infarction le ST-karolo bophahamo (2007), ba hlokang ST bophahamo le sa tsitsang angina (2006). Ka 2010, e hatisitsoeng ke dikgothaletso European
Mokhatlo oa Cardiology (esc lena) ka le ho khetha mekhoa ea revascularization myocardial, ditataiso ea sechaba bakeng sa taolo ya bakuli ba ACS Australia
Brithani, sephetho sa machaba
dumellana ka taolo ya bakuli ba ACS. ka 2013
American Heart
Society (ACCF / Eke) e ntlafalitsoeng
likhothaletso bakeng sa taolo ya bakuli ba ACS
ST karolo bophahamo.  

Qeto ea ka maqiti
taolo ya le mamello ka ACS ka bophahamo e joalo ntle ho ST-karolo bophahamo hase kamehla ho ikhethang ka tsela e itekanetseng, 'me hangata e hloka ho ba le seabo multidisciplinary
sehlopha sa litsebi e thehiloeng melao e tataisang ea tleleniki, tsela ea lefu lena, ea lilemo li ba le mamello, maemo a
tsotelle. Ka nako e tšoanang ka bakuli bohle ba ka belaela ACS
lokela ho phetha e electrocardiogram (ka ho ba sieo ha
liphetoho kapa ya data belaetsang hlokahala hore ka makhetlo-khetlo ho rekota dikgao 15
metsotso -30, ho itšetlehile ka boemo ba ea tleleniki ea mokuli), le maemo khoneha ho ithuta
bakeng sa enzyme cardiac, tšebeliso e tlamang ea aspirini ho nkoa. ka
likhothaletso tsohle di ratang dithekeniki endovascular
myocardial revascularization ka ho ba teng ha e badirimmogong ba nang le phihlelo ba tšoanelehang.
Fibrinolytic phekolo (ka mohato oa pele oa ho fana ka tlhokomelo ho bakuli ba ACS le ST-karolo bophahamo) ntse ama maemo ao,
ha ho ke ke ha khoneha ho etsa stenting
bakeng sa metsotso e 120 ka mor'a
ketsahalo e bohloko (ka ho ba sieo ha contraindications le haeba ho tloha bohloko e ne e se fetang
lihora tse 12). Ha ACS ntle le ho phahamisa fibrinolytic ST karolo
phekolo e sa tsamaisoa.

Ha kotsi ea pelo ea tlhaselo le / kapa lona
mathata a phahameng

barupeluoa ba
theha keletso litsebi tsa Europe, United States o lumela hore ho kenngwa tshebetsong ha
gogoga angiography ka hare ho lihora tse 2 ho tswa ho motsotso ya kenoa
buelloa ha mokuli ka tlhaselo ea angina ka semelo sa tsa bongaka
ho phekola matšoao a phehella kapa khutla
angina hlokometse matla ST karolo liphetoho, bontšang tsa ntshetsopeleng tshenyo
kapa myocardial infarction; hemodynamic
tsitse, bohlokoa ventricular arrhythmias. Ho phetha angiography (ka morago ga moo e
revascularization) bakeng sa lihora tse 24 ka mor'a kenoa ba mokuli sepetlele ka ACS buelloa tabeng ea phahameng
kotsi ea infarction myocardial, beha bophelo kotsing
mathata a le lefu. Tshwanang nako ea angiography gogoga buelloa ka
Moo hlokahala differential phumano ya ACS le tse ling
maemo e potlakileng (embolism methapo, dissecting
aortic aneurysm). Ka maemo a ho lefu hlobaetsang gogoga ntle karolo ST mphahamisetsa kotsing tlaase tsa beha bophelo kotsing
mathata a le lefu nakong sepetlele lula
kalafo, empa phehellang matšoao a angina le / kapa ischemia hlohlelletsoa
nakong ea teko mojaro, gogoga angiography lateloa ke revascularization ka
hlokahala le khoneha ke ke bohlale ho phetha ka nako ya fuoa
bookelong ka hare ho lihora tse 72 ka mor'a kenoa. ka
ha mamello e ile a lumela ho tla etsa hore mehaho ea bongaka, moo ke ke ha khoneha
etsa angiography gogoga, e isoa sepetlele loketseng ho tse (mohlala
Regional Vascular Center).

ho tloaelehile hore batho
nkoa leqheka stenting (lithethefatsi a tlotsitsoeng stent
kapa uncoated) le infarct amanang mothapo tromboekstratsiey (ka ho
hlokahala), ha a ntse a ACS mphahamisetsa ka c
ST karolo
ho sa tsotellehe hore ho kenngwa tshebetsong le phello ea phekolo fibrinolytic (ho latela
Dikgothaletso ho tloha 2013 ACC mor'a phekolo fibrinolytic buelloa ho phetha
FCT le stenting hase pejana ho
dihora tse 2-3). Ha a c-karolo bophahamo hlobaetsang gogoga lefu ST, haese mothapo infarct, ho na le a mang a tebile
stenoses ka methapo a mang, stenting bona tshohanyetso o etsoa feela
bakeng sa batho ba nang le ho hloleha haholo pelo le / kapa cardiogenic makala. ka tse ling
Maemong a lieha stenting o etsoa - hore ho hlokahala hore le nako ea
a etsa qeto ea ka mor'a khatello ea kelello e leka pele ho tebelwa mosebetsing ea mokuli
sepetlele. Ho ea ka ka dikgothaletso tsa litsebi ho tloha United States 2013, ntle ho stents
The barbotage e ka go tlhaolega sebelisoa maemong a moo mamello e na
mafu a le maemo a le kotsing e khōlō ea ho tsoa mali, phahameng kgonego,
hore mokuli ha latela pele selemo se fela ya kopanetsoe antiplatelet Melao
phekolo, 'me ho ka etsahala ho etsa opereishene latelang
tshebetso. Ho feta moo, ka dikgothaletso ho bontša hore c-karolo bophahamo ACS ST stenting mor'a lihora tse 24 ho tloha ka motsotso oa lona
Ntshetsopeleng sa kang a bontšoa maemong a sa 1-2 diso vascular ka ho ba sieo ha
matšoao pholosa ischemia myocardial. Maemong a sa tloaelehang (tlas'a itseng
maemo a) phethile angioplasty.

Qeto ea ka mokhoa oa ho revascularization ka bakuli ba lefu a hlobaetsang gogoga ntle karolo ST phahama, 'me ka ACS mdlody ST karolo bophahamo, empa ka ho ba sieo ha
gogoga ea moo narrowing tsa methapo gogoga, sebele "molato" ho
ACS kapa ea nang le lefu multivessel, eo ho eona ho kenngwa tshebetsong ha
Stenting ke ka botsebi khonehe kapa kotsi e feta bokgoni ba
molemo oo o fumanwe ke litsebi tse 'maloa (ngaka e buoang pelo le methapo,
cardiologist, setsebi lefapheng la
Endovascular tepelletse maikutlong le kalafo) le
tlelenike, angiographic ya data sekasekale palophatlo phallo pokello,
ho lebeletsoe nako e telele itse'ng.

meriana tšehetso
hakaalo

Ha ACS le ST karolo bophahamo litsebi tse ngata li lumela hore maqiti a morao-rao tsa bakuli ba ka
Ho itšetlehile haholo ka tsamaiso ea oona bophelo ba naha eo
(Region) ho phetha mathomo endovascular kenella (ntle le pele
thrombolysis) bakeng sa lihora tse 2 pele ntshetsopele ya le matšoao litleleniki tsa ka mamello.

Ha ho lebeletsoe hore nako eo ho tloha ka ikopanya le pele le mamello
basebetsi ya kalafi pele ho phetha gogoga angiography tla fetang 2
lihora, bakuli
(Ho ba sieo ha contraindications) lokela ho ho phetha thrombolysis le
pelehi morago ga moo e ho tleliniking bakeng sa ho phetha angiography le revascularisation
infarction ka hare ho lihora tse 3-24. Maemong ao, ha semelo sa thrombolysis
ST karolo bophahamo bolokoa ho feta 50% ya boemong ba ka lekhetlo la pele le / kapa retrosternal
bohloko, mokuli bontša tshohanyetso gogoga angiography. Ha atleha,
thrombolysis gogoga angiography le revascularization (haeba a bontša) ka
ho phethwa ka hare ho lihora tse 24. dikgothaletso e ile ea bolela hore
revascularization ka ntlafatsa itse'ng le tshebediso lona ka 24-60
lihora tse ka mor'a hore ho qala ho ea le matšoao litleleniki tsa, empa feela ka maemong tseo ho tsona
Ho na le angina iphetang le / kapa myocardial ischemia lemoha nakong
karaoke lithuto.

tsoa
Ho itšetlehile ka mofuta oa ACS le mokhoa revascularization e qobelloang
tšehetso ea lithethefatsi, e kenyeletsang antiplatelet,
antiplatelet phekolo, beta-blockers phekolo, inhibitors tsa angiotensin fetola
potlakisang tsebetso ea lik'hemik'hale, statins. phekolo ea lithethefatsi e le batho ka bomong a fetola
Ho itšetlehile ka sebopeho sa ACS tiea, ho ba teng soputsvuyuschie malwetse. The
Buka ena e tla tsepamisa kelello feela ka phekolo antiplatelet,
mekhoa tsamaeang ba revascularization myocardial.

Karolo bophahamo ACS ntle S T

The
Maemong a joalo endovascular revascularization mekhoa
khetha "habeli 'antiplatelet phekolo e akarelletsang ho nyanyana
acetylsalicylic acid e (Asa) le clopidogrel (kapa prasugrel kapa
ticagrelor). Asa o abetsoe ho ea pele fumana 150-300 mg, (250-500 mg, kapa ka mokgwa wa
ka / ka bolus) lateloa ke litekanyetso li behoa ea 75-100 mg, / ka letsatsi a play loading lethal dose
600 mg, ea clopidogrel (ka bo-ho khoneha) lateloa ke tsamaiso ea 75
mg, / ka letsatsi bakeng sa likhoeli tse 9-12 prasugrel - 60 mg, play loading lethal dose, lateloa ke
ho nka 10 mg, / ka letsatsi a, kapa ticagrelor - 180 mg, play loading lethal dose, lateloa ke
ho nka 90 mg, 2 ka letsatsi. Bontšang bakeng sa ho sebelisoa ka ho eketsehileng
inhibitors GPIIb-IIIa ba nkoa e le kotsing e khōlō ea tsa thrombosis intracoronary bakuli ntse angioplasty le / kapa stenting
gogoga methapo.

The
dikgothaletso e ntle (UK) e bolela hore
Bakuli ba kotsing e khōlō ea liketsahalo tsa pelo le methapo (thulametse 6 khoeli
shoa ha ho feta 3%) le tlas'a angiography gogoga le revascularization
ka hare ho lihora tse 96 ho tloha nakong eo ho kenoa kemiso bontšoa
kgethwa ha eptifibatide kapa tirofiban. Abciximab o behoa ka phekolo e,
tsamaeang endovascular revascularization ha se
Bokhoni ba ho abela inhibitors tse ling tsa GPIIb-IIIa. Re lokela ho hlokomela hore ka
Ho fapana le e ntle tataiso (UK) likhothaletso
European Society ea Cardiology "ratang" o fuoa abciximab (Kereiti
ho bonahala ke), ka nako e tšoanang bakeng sa eptifibatide
kapa tirofiban Behantsha Class IIa.

Choice le lethal dose
anticoagulants ho phetha angiography
revascularization bakuli ntle ACS
ho phahamisa ST karolo Ikemisetsa e thehiloeng
Stratification ba kotsing ea mathata a thrombotic, ischemic le hemorrhagic. Kotsing e khōlō haholo
liketsahalo ischemic (ka mohlala, ha hemodynamic tsitse refractory behang bophelo kotsing arrhythmias) le mamello
nehelanoa ka ho toba ka X-ray le e abetsoe
unfractionated heparin (UFH) e le / ka bolus 60 U / lik'hilograma le morago ga moo e
Infusion nakong ea revascularization hammoho le oa habeli
antiplatelet phekolo. Kotsing e khōlō ea mali e ka sebediswa
monotherapy bivalirudin bolus tsa 0,75 mg, / lik'hilograma lateloa ke Infusion ea 1,75
mg, / lik'hilograma / ka lebelo la. Bakeng sa bakuli ba le kotsi karolelano ea liketsahalo ischemic (ka mohlala,
hemodynamics tsitsitse, empa e ntle troponin teko, ua khutlela mokhoeng oo
angina, liphetoho tse matla ka ST karolo), e leng e lokiselitsoe mekgwa ya tshebetso itaolang 24-48
dihora tse latelang dikgetho kalafo teng pele ho angiography gogoga
rerile endovascular myocardial revascularization:

• Bakeng sa bakuli
  

Unfractionated heparin 60 U / lik'hilograma ka mokgwa wa ka / ka bolus,
joale e ntan'o ba Infusion tlas'a taolo ea butswe leeme thromboplastin nako
(APTT) kapa enoxaparin 1 mg, / lik'hilograma s.c. x, 2 ka letsatsi kapa Fondaparinux 2,5 mg, / ka letsatsi
Bivalirudin subcutaneously kapa 0,1 mg, / lik'hilograma ka / ka bolus e lateloa ke Infusion
0,25 mg, / lik'hilograma / hora

• Bakeng sa bakuli ≥75 lilemo

Unfractionated heparin 60 U / lik'hilograma ka mokgwa wa ka / ka bolus,
ebe Infusion tlas'a taolo APTT

Kapa enoxaparin 0,75 mg, / lik'hilograma x, 2
Fondaparinux letsatsi kapa 2,5 mg, / ka letsatsi a subcutaneously kapa Bivalirudin 0,1 mg, / lik'hilograma ka
Ke / bolus lateloa ke Infusion ea 0,25 mg, / lik'hilograma / ka lebelo la.

ka
bakuli ba nang le kotsi e tlaase ea liketsahalo pelo le methapo (ntle le e ntseng e eketseha
troponin le ST karolo liphetoho), ho feta mekhoa e tloaetsoeng rerile
kalafo le ho abeloa fondaparinux (2,5 mg, / ka letsatsi a subcutaneously) kapa enoxaparin (1
mg, / lik'hilograma s.c., makhetlo a 2 ka letsatsi bakuli lilemo ≥75 - 0,75 mg,) le unfractionated heparin (60 U / lik'hilograma
joalokaha e etsahala / bolus, lateloa ke Infusion tlas'a taolo aPTT).

ACS le ST karolo bophahamo  

ena
boemo bo ea tleleniki e abeloa "habeli" ACK antiplatelet phekolo (150-300 mg, ka molomo kapa
250-500 mg, ka / ka bolus lateloa ke tsamaiso ea 75-100 mg, / ka letsatsi a) le prasugrel
(60 mg, play loading lethal dose lateloa ke tsamaiso ea 10 mg, / ka letsatsi a), kapa ticagrelor (play loading lethal dose ea 180 mg,
lateloa ke tsamaiso ea 90 mg, makhetlo a 2 ka letsatsi) kapa clopidogrel (play loading lethal dose 600
lateloa ke tsamaiso
75 mg, / ka letsatsi a). The ka dikgothaletso tsa Society Europe la Cardiology e re
prasugrel le ticagrelor clopidogrel atlehang ka ho ya ka fokotsa
maqhubu a ho kopantswe ischemic endpoints le stent thrombosis bakuli
MI bophahamo ST, 'me ha ho eketsa kotsi ea ho
mali haholo. Ho ea ka ka dikgothaletso la esele 2013 ha prasugrel
Ho khothalletsoang hore bakuli ba
le histori ea setorouku kapa Tia. Ka ketsahalo eo pele ba kena
mokgatlo tsa bongaka hore ba etse gogoga angiography le stenting mamello
fibrinolysis ile a etsa 'me e ne lihora tse ka tlaase ho tse 24' me bakeng sa nako e tšoanang li ne li sa sebelisoe
clopidogrel (prasugrel), ka nako eo clopidogrel play loading lethal dose ke 300 mg,,
Prasugrel ke 60 mg,.

Kotsing e khōlō
intracoronary thrombosis, hammoho le antiplatelet phekolo kopanetsoe
Ho buella tšebeliso ea GPIIb-IIIa inhibitors (abciximab / v Le bolus tsa 0,25 mg, / lik'hilograma lateloa ke Infusion ea 0,125 mg, / lik'hilograma / mets ho
boemo palo e kahodimodimo ea 10 mg, / mets bakeng sa lihora tse 12.). Hona joale ho na le ho na
bopaki bo felletseng bo boholoanyane bokgoni GPIIb-IIIa inhibitors ha sebelisoa ka
prehospital kapa pele catheterization.

ka
UFH anticoagulation phekolo e sebediswa (ka / ka bolus 60 U / lik'hilograma hammoho le GPIIb-IIIa sesitisa kapa / bolus 100 U / lik'hilograma ntle
GPIIb-IIIa) sesitisa. Bivalirudin ka monotherapy ho fapana UFH hammoho le e sesitisa tsa GPIIb-IIIa ka kgothaletswa ke ACC 2013
Ho khothalletsoang hore bakuli ba kotsing e khōlō ea ho tsoa mali ka sehloohong (bolus tsa 0,75 mg, / lik'hilograma lateloa ke Infusion ea 1,75
mg, / lik'hilograma / hora); Ka nako e tšoanang, fondaparinux e sa kgothaletswa hobane ba kotsing e khōlō
catheter thrombosis.

Ho ea ka polelo e latelang ho tswa ho
sepetlele kopanetsoe antiplatelet phekolo e sebediswa bakeng sa bonyane likhoeli tse 12.

hloko ka ho khetheha ba lokela ho ho leshwa ho motsoako oa
clopidogrel le proton e pompa inhibitors, e atisa ho sebelisoa bakeng sa ho thibela
gastrointestinal mali. Ho ea ka tumellano tsa sehlopha ho sebetsa bakeng sa thibelo ea thrombotic
le hemorrhagic mathata ICSI kopantswe tšebeliso ea lithethefatsi bakuli
tlaase kotsi ea mali GI e sa bontša, ho sebelisa ha bona melato e lokela ho individualized motheong oa
e nahane ka melemo le likotsi. feela
PPI meriana ho tswa ho sehlopha - pantoprazole - se le "mohlodisani" klopidoglelya
bakeng sa isoenzyme CYP2C19. Ka lehlakoreng le leng
ha ho boleng bo phahameng le liteko tse litleleniki tsa hlahloba phello ea e kopanetsweng
ho sebelisa pantoprazole le clopidogrel
ho fokotsa menyetla ea pelo le methapo melato e le hemorrhagic
mathata. Ho seng jwalo PPI ka 'na h2 receptor blockers - famotidine, ranitidine.

meriana kemiso
phekolo

Beta-blockers ba abeloa ho ea pele lihora tse 24 ho tloha ka nako ea bakuli bohle ba nang le ACS
ka ho ba sieo ha ho hloleha pelo le lefu tlaase khumo,
cardiogenic makala le contraindications tekanyetso ho tšebeliso ea sehlopha sena sa lithethefatsi.
Kenoa tsa beta blockers a tsoela pele ho pholletsa le nako ea kamohelo sepetlele 'me ka mor'a
lipolelo tse.
inhibitors Ace khethoa
bakuli bohle le anterior myocardial infarction, ejection karoloana ka tlase ho 40% ka ho ba sieo ha
contraindications. Haeba ho na le contraindications ho inhibitors Ace sebelisoa blockers
angiotensin II receptor. ba khahlanong le lōna
aldosterone bontšitsoe bakuli ba ho hloleha bontshang matshwao pelo
le / kapa ho ba teng ha lefu la tsoekere. Ka nako e telele ho sebelisoa ha statins tsohle bontšoa
bakuli ba ACS (ha ho contraindications).