ACS - chenjera coronary urwere

IV Samorodskaya,

Professor, Doctor Kurapwa Sciences

chenjera coronary
urwere

chikwata Multidisciplinary afunga

Kushandisa nzira ano pakurapa chakasimba coronary syndrome (ACS)
- shoko kureva chero boka kunotoda kurapwa zviratidzo kana zviratidzo
kubvumira vanofungidzirwa chenjera myocardial infarction (MI) kana isina
angina, anopa tariro inokosha zvinoderedza muchipatara
hunofa kuvandudza fungidziro munguva-nguva yakareba.

Makore akawanda apfuura, kutsvakurudza uye dzakawanda dzinoitwa vari
ipfupiso All-Russian Scientific Society of Cardiology mu vanorumbidza Russian ari kuongorora chirwere
uye mabatiro varwere myocardial infarction pamwe ST-chidimbu kukwirira (2007), pasina ST pakakwirira uye kusagadzikana angina (2006). Muna 2010, rakabudiswa European rutsigiro
Society of Cardiology (ESC) pamusoro pakusarudza nzira myocardial revascularization, yenyika mirayiridzo kuti kurapa varwere ACS mu Australia
Britain, migumisiro international
nekubvirana pasi kurapa varwere ACS. In 2013
American Heart
Society (ACCF / Hekani) akaita yoku-
kurumbidza nokuti basa varwere ACS
ST chidimbu kukwidza.  

Chisarudzo pamusoro nzira
tsungirirai utariri muna ACS sezvo pakakwirira saka pasina ST-chidimbu kukwirira hakusi nguva dzose oga nyore, kazhinji zvinoda multidisciplinary Kupinda
chikwata vanachiremba kwakavakirwa kurapwa mirayiridzo, kosi yacho chirwere, zera murwere, zvinhu
hanya. Panguva iyoyo pavarwere vose vanofungidzirwa ACS
anofanira kuita unonzi, electrocardiograph (pasina
kuchinja kana mubvunzo Data zvinodiwa akadzokorora yakarekodwa zvikamu 15
maminitsi -30, zvichienderana navanachiremba ezvinhu omurwere), uye zvingangoitika kwevari kudzidza
nokuti cardiac makemikari, kushandisa mutemo unoti pamusoro asipurini anonzi. mu
mazano ose vaifarira endovascular unyanzvi
myocardial revascularization pamberi vanonyatsokwanisa tsvimbo ane ruzivo.
Fibrinolytic kurapa (sezvo danho rokutanga kutarisira varwere vane ACS pamwe ST-chidimbu elevation) inoramba kuhupenyu avo ezvinhu,
kana hazvibviri kuita stenting
kwemaminitsi 120 pashure
panowanikwa marwadzo (pasina contraindications uye kana kubva kurwadziwa haana kupfuura
maawa 12). Apo ACS pasina vachisimudza fibrinolytic ST chidimbu
kurapa haina chinotarisirwa.

Kana njodzi mwoyo kurwisa uye / kana ayo
yakakwirira yematambudziko

vatori
mukusika zano nyanzvi Europe, United States anotenda kuti Implementation pamusoro
coronary angiography mukati 2 maawa kubva nguva rubvumo
Zvinokurudzirwa kana murwere ane kurwisa angina pamusoro yezvokurapa kumashure
ichitarisira zviratidzo zvikaramba kana recur
angina vakachengeta simba ST chidimbu kuchinja, anoratidza kukuvara kukura
kana myocardial infarction; hemodynamic
Kusagadzikana, zvinokosha ventricular arrhythmias. Achiita angiography (pamwe tevera
revascularization) kwemaawa 24 pashure murwere kubvuma kuchipatara pamwe ACS inokurudzirwa kana mukuru
mukana myocardial infarction, upenyu pamutanhiko
matambudziko uye rufu. Similar riini coronary angiography inokurudzirwa mu
Where zvaida differential chirwere kubva ACS nevamwe
zvokukurumidzira ezvinhu (pulmonary embolism, nokupatsanura
kutsemuka aneurysm). Muzviitiko chakasimba coronary chirwere pasina chidimbu ST vachasimudza yakaderera panjodzi chinouraya
yematambudziko uye rufu panguva chipatara mutsigiri
kurapwa, asi kuramba zviratidzo angina uye / kana ischemia Kutemeswa
munguva mutoro bvunzo, coronary angiography zvichiteverwa revascularization pa
zvakakodzera uye zvinogoneka zvinokurudzirwa kutakura kubuda munguva
muchipatara mumaawa 72 pashure rubvumo. munguva
kana murwere vakabvuma kuti vezvokurapa nzvimbo, apo hazvibviri
uite coronary angiography, zviri akatamisira kuchipatara rakakodzera (semuenzaniso
Regional Vascular Center).

zvakajairika
vaiona Zano stenting (stent zvinodhaka-zvemapuranga
kana uncoated) pamwe infarct chokuita tsinga tromboekstratsiey (pa
zvakakodzera), apo ACS C chikwidzo
ST chidimbu
pasinei Implementation uye mugumisiro fibrinolytic mishonga (zvichienderana
Zvinotarisirwa kubva 2013 ACC pashure fibrinolytic kurapa inokurudzirwa kuita
FCT uye stenting haasi yapfuura pane
maawa 2-3). Kana munenge-chidimbu kukwirira chakasimba coronary chirwere ST, kunze infarct tsinga, pane zvakakomba
stenoses dzimwe arteries, avo nechimbichimbi stenting rinoitwa chete
vaya vane zvikuru mwoyo nokukundikana uye / kana cardiogenic kuvhunduka. nemamwe
Muzviitiko kunonoka stenting rinoitwa - kudiwa uye riini
yakasarudza pashure kunetseka anoedza asati tiite murwere kubva
chipatara. Maererano kunenge nenyanzvi vokuUnited States 2013, pasina stents
The bemhapemha iri iya inoshandiswa zviitiko apo murwere ane
zvirwere uye mamiriro rurefu pangozi ropa, mukuru mukana,
kuti murwere haadi kuteerera mukati gore Dual antiplatelet zvaiitwa
mushonga, uye zvichida kuita tevera kuvhiyiwa
kushandiswa. Uyezve, kunenge akaratidza kuti munenge-chidimbu kukwirira ACS ST stenting pashure maawa 24 kubva nguva yaro
Development kwete kuratidzwa mune nyaya 1-2 vascular maronda pasina
zviratidzo ndichengetedze myocardial ischemia. Mune zvisingawanzoitiki Muzviitiko (pasi vamwe
mamiriro ezvinhu) akaita angioplasty.

Chisarudzo pamusoro nzira revascularization pavarwere vane chakasimba coronary chirwere pasina chidimbu ST simukai, uye muna ACS C ST chidimbu pakukwirira kwaro, asi pasina
coronary omunharaunda aienda pamusoro coronary arteries, zvachose "mhosva" mu
ACS kana ane multivessel chirwere, umo Implementation pamusoro
Stenting iri pamutemo zvisingaiti kana ngozi kuti akapfuudza anokwanisa
kubatsira chichigamuchirwa nenyanzvi dzakawanda (zvemwoyo chiremba,
cardiologist, nyanzvi mune
Endovascular chirwere uye kurapwa) pamwe
kurapwa, angiographic mashoko kuongorora fractional aibuda chengetedza,
akatarisirwa-refu fungidziro.

mishonga rutsigiro
hazvo

Apo ACS pamwe ST chidimbu kukwidza Nyanzvi dzakawanda dzinofunga kuti mamiriro zvidobi varwere vari
It hunoenderana nyika utano maitiro
(Region) kuita chikuru endovascular kupindira (pasina risati
thrombolysis) nokuti 2 kwemaawa pamusoro pokumuka kurapwa zviratidzo mune murwere.

Kana Zvinotarisirwa kuti nguva kubva kuonana murwere
navanachiremba asati kuita coronary angiography achava anopfuura 2
maawa, varwere
(Pasina contraindications) vanofanira kuita thrombolysis pamwe
tevera wakurukura kukiriniki nokuita angiography uye revascularisation
infarction mumaawa 3-24. Muzviitiko, kana pakanyorwa thrombolysis
ST chidimbu kukwidza zvabatwa anopfuura 50% of pakutanga chechetere uye / kana retrosternal
marwadzo, murwere rinoratidza zvashata coronary angiography. Kana vabudirira,
thrombolysis coronary angiography uye revascularization (kana akaratidza) gona
kuitwa mumaawa 24. Kunenge waiti
revascularization anogona kunatsiridza fungidziro uye ayo Implementation kuburikidza 24-60
maawa pashure kutanga kurapwa zviratidzo, asi chete muzviitiko iwayo apo
Kune idzokororo angina uye / kana myocardial ischemia dzakaonekwa panguva
paku zveBhaibheri.

panze
Zvichienderana mufananidzo ACS uye revascularization nzira iri rokumanikidzirwa
mushonga rutsigiro, izvo zvinosanganisira antiplatelet,
antiplatelet kurapa, Beta-blockers kurapa, FIs ose angiotensin rokutendeutsa
enzayemu, statins. Drug ARV nomumwe kugadziridzwa
Zvichienderana pezvakaita ACS zvakaoma kwazvo, kuvapo soputsvuyuschie zvokurwara. The
Bhuku rino ichanyanya chete antiplatelet kurapa,
munyaya nzira myocardial revascularization.

Chidimbu kukwidza ACS pasina S T

The
nyaya dzakadaro endovascular revascularization nzira
akagadza "kaviri 'antiplatelet kurapa kunosanganisira nomumukanwa
acetylsalicylic asidhi (Asa) uye clopidogrel (kana prasugrel kana
ticagrelor). Asa basa yokutanga kugamuchira 150-300 MG (250-500 MG kana dziri
mu / mu bolus) anoteverwa chipimo chemushonga pamusoro 75-100 MG / zuva vachizvitakudza dose
MG 600 clopidogrel (sezvo mangwanani sezvinobvira) kunoteverwa kwokubatsira 75
MG / zuva 9-12 mwedzi prasugrel - 60 MG vachizvitakudza dose, zvichiteverwa
achitora 10 MG / zuva, kana ticagrelor - 180 MG vachizvitakudza dose, zvichiteverwa
achitora 90 MG 2 kanomwe pazuva. Zvairatidza kuti zvishandiswezve
GPIIb-IIIa FIs vanoonekwa kuti panguva yakakwirira mukana intracoronary thrombosis pavarwere achirapwa angioplasty uye / kana stenting
coronary arteries.

The
mazano Nice (UK) anoti
Varwere panguva mukuru mukana zvemwoyo zviitiko (projected 6 mwedzi
kufa pane 3%) uye pasi coronary angiography uye revascularization
mukati maawa 96 kubva panguva iyo kubvuma purogiramu akaratidzwa
kugadzwa eptifibatide kana tirofiban. Abciximab anogadzwa kuva kurapa,
munyaya endovascular revascularization kana pasina
Kukwanisa kupa zvimwe FIs pamusoro GPIIb-IIIa. Zvinofanira kucherechedzwa kuti
Kusiyana Nice nhungamiro (UK) audzwa
European Society of Cardiology "zvinodiwa" anopiwa abciximab (Grade
zvairatidza I), panguva imwe chete, nokuti eptifibatide
kana tirofiban Set Class IIa.

Choice uye dose
anticoagulants kuita angiography
revascularization pavarwere pasina ACS
nokusimudza ST chidimbu akatara yakavakirwa
Stratification kuti njodzi thrombotic, ischemic uye Hemorrhagic matambudziko. Panguva yakakwirira zvikuru ngozi
ischemic zviitiko (somuenzaniso, apo hemodynamic kusagadzikana refractory arrhythmias zvinouraya) murwere
wakaisa zvakananga X-ray uye basa
unfractionated heparin (UFH) sezvo / vari bolus 60 U / makirogiramu pamwe tevera
aizomupa panguva revascularization pachiimbwa miviri
antiplatelet kurapa. At yakakwirira ngozi ropa zvinogona kushandiswa
monotherapy bivalirudin bolus pamusoro 0.75 MG / makirogiramu kunoteverwa aizomupa 1.75
MG / makirogiramu / hr. Varwere neavhareji mukana ischemic zviitiko (somuenzaniso,
akatsiga hemodynamics, asi yakanaka troponin bvunzo, watangazve
angina, guru kuchinja ST chidimbu), iyo yakarongwa invasive maitirwo ezvinhu 24-48
maawa anotevera marapirwo zviripo asati coronary angiography
akaronga endovascular myocardial revascularization:

• Varwere
  

Unfractionated heparin 60 U / makirogiramu muchimiro pamusoro / mu bolus,
ipapo aizomupa pasi kudzora kusashanda thromboplastin nguva isina kukwana
(APTT) kana enoxaparin 1 MG / makirogiramu s.c. X 2 pazuva kana Fondaparinux 2.5 MG / zuva
Bivalirudin subcutaneously kana 0.1 MG / makirogiramu sezvo / vari bolus zvichiteverwa aizomupa
0.25 MG / makirogiramu / awa

• Varwere ≥75 makore

Unfractionated heparin 60 U / makirogiramu muchimiro pamusoro / mu bolus,
ipapo aizomupa kudzora APTT

Kana enoxaparin 0.75 MG / makirogiramu X 2
Fondaparinux zuva kana 2.5 MG / zuva subcutaneously kana Bivalirudin 0.1 MG / makirogiramu somunhu
I / bolus kunoteverwa aizomupa 0.25 MG / makirogiramu / hr.

mu
varwere yakaderera mukana zvemwoyo zviitiko (pasina kuwedzera
troponin uye ST chidimbu kuchinja), zvikuru kuchinja akaronga
kurapwa uye basa fondaparinux (2,5 MG / zuva subcutaneously) kana enoxaparin (1
MG / makirogiramu s.c., 2 kanomwe pazuva pavarwere makore ≥75 - 0.75 MG) uye unfractionated heparin (60 U / makirogiramu
sezvakunoitwa / bolus, zvichiteverwa aizomupa kudzora aPTT).

ACS pamwe ST chidimbu kukwidza  

In ichi
navanachiremba mamiriro ezvinhu ari hurukuro "kaviri" ACK antiplatelet kurapa (150-300 MG nomuromo kana
250-500 MG sezvo / vari bolus kunoteverwa kwokubatsira 75-100 MG / zuva) uye prasugrel
(60 MG vachizvitakudza dose kunoteverwa kwokubatsira 10 MG / zuva), kana ticagrelor (vachizvitakudza dose kuti 180 MG
kunoteverwa kwokubatsira 90 MG 2 kanomwe pazuva) kana clopidogrel (vachizvitakudza dose 600
zvichiteverwa adhimini
75 MG / zuva). The Zvinotarisirwa of European Society of Cardiology rinoti
prasugrel uye ticagrelor clopidogrel zvikuru mashoko kuderedza
maitikiro vasanganiswa ischemic endpoints uye stent thrombosis pavarwere
MI kukwidza ST, uye haina kuwedzera ngozi
zvakakomba kubuda ropa. Maererano kunenge nembongoro 2013 haisi prasugrel
It pachii varwere
nhoroondo sitiroko kana Tia. Kuri kuti asati kupinda
sangano zvokurapa kuita coronary angiography uye stenting murwere
fibrinolysis kwakaitwa uye rakanga maawa asingasviki 24 uye nokuda chete nguva havana kushandiswa
clopidogrel (prasugrel), ipapo clopidogrel vachizvitakudza dose iri 300 MG,
Prasugrel ane 60 MG.

Pangozi yokuva
intracoronary thrombosis, pamwe Dual antiplatelet kurapa
It rinokurudzira Kushandisa GPIIb-IIIa FIs (abciximab / vs. bolus pamusoro 0.25 MG / makirogiramu kunoteverwa aizomupa 0,125 MG / makirogiramu / Maminitsi kuti
kufadza pamwero 10 MG / Maminitsi kwemaawa 12.). Parizvino hakuna
hunogutsa uchapupu hukuru kunyatsoshanda GPIIb-IIIa FIs kana kushandiswa
prehospital kana vasati catheterization.

somunhu
UFH anticoagulation kurapa inoshandiswa (mu / mu bolus aine GPIIb-IIIa inhibitor kana / bolus 100 U / makirogiramu pasina 60 U / makirogiramu yakasanganiswa
GPIIb-IIIa) inhibitor. Bivalirudin sezvo monotherapy pachinzvimbo UFH akabatana ane inhibitor pamusoro GPIIb-IIIa sezvo ndakarumbidzwa ACC 2013
It pachii varwere yakakwirira mukana mikuru ropa (bolus pamusoro 0.75 MG / KG kunoteverwa aizomupa 1.75
MG / makirogiramu / awa); Panguva iyoyowo, fondaparinux haina yakarumbidza nokuda mukuru ngozi
anobudisa mushonga zvishoma nezvishoma thrombosis.

Maererano mashoko anotevera kubva
chipatara Dual antiplatelet kurapa rinoshandiswa kwemwedzi dzinenge 12.

Cherechedzai inofanira kubhadharwa kuti wemishonga
clopidogrel uye hwepurotoni pombi FIs, inowanzoshandiswa nokuda kudzivirira
gastrointestinal kubuda ropa. Maererano vabvumirana rwekuita boka kuti kudzivirira thrombotic
uye Hemorrhagic yematambudziko ICSI kubatanidzwa Kushandisa zvinodhaka varwere
yakaderera ngozi GI ropa hakuratidzwi, kushandisa kwavo pamunhu yaizoshanda panguva zvinofanira munhu mumwechete maererano
kufungisisa zvikomborero uye ngozi. chete
PPI mushonga kubva boka - pantoprazole - kwete "mukwikwidzi" klopidoglelya
nokuti isoenzyme CYP2C19. Ukuwo
hapana yepamusoro miedzo zvekuchipatara vanoongorora kubata pejoinhi
nokushandisa pantoprazole uye clopidogrel
kuderedza ngozi pamunhu yaizoshanda panguva zvemwoyo uye Hemorrhagic
matambudziko. Nerumwe PPI anogona H2 Kanotokonya blockers - famotidine, ranitidine.

mishonga urongwa
kurapa

Beta-blockers tanzi maawa 24 okutanga kubva panguva varwere vose ACS
pasina mwoyo kukundikana pamwe yakaderera goho urwere,
cardiogenic kuvhunduka uye mureza contraindications pakushandisa boka iri zvinodhaka.
Rubvumo Beta blockers mberi yose nguva muchipatara uye pashure
mashoko.
ACE FIs vanogadzwa
Varwere zvose Anterior myocardial infarction, ejection chakapatsanurwa asingasviki 40% pasina
contraindications. Kana pane contraindications kuti ACE FIs anoshandiswa blockers
angiotensin II Kanotokonya. mhandu
aldosterone akaratidza varwere symptomatic mwoyo nokukundikana
uye / kana kuti kuvapo chirwere cheshuga. Refu kushandiswa statins zvose rakaratidzwa
varwere ACS (pasina contraindications).