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miokardiumis infarqti ST elevaciiT STEMI
protokolebi
momzadebulia saqarTvelos kardiologTa kolejis da
saqarTvelos kardiologTa sazogadoebis 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;
1
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: http://heart.healthcentersonline.com/tools/calc_hd_results.cfm (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
2
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
I. gaidlainSi gamoyenebuli rekomendaciebis da mtkicebulebebis xarisxi..........5 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..................................................................................................................................5 II. mwvave miokardiumis infarqtis definicia .......................................................................5 III. mwvave koronaruli sindromis ganmarteba da klinikuri mimdinareoba: ..........6 IV STEMI-s ganviTarebamde mkurnaloba ................................................................................7
a. rekomendaciebi STEMI-s risk faqtorebis mqone pacientebis gamovlenisTvis...............................................................................................................................7 b. rekomendaciebi STEMI-s niSnebis naadrevi gamovlenisa da CarevisaTvis,
pacientebis ganaTleba: ...............................................................................................................8 V STEMI-s Setevis dawyeba da prehospitaluri qmedeba .................................................9
a. STEMI-T pacientebis transportireba da pirveladi reperfuziuli
mkurnalobis SerCeva ...................................................................................................................9 VI. pirveladi amocnoba da marTva gadaudebeli daxmarebis departamentSi....12
a. sqema. 3 gadaudebeli daxmarebis algoriTmi/protokoli pacientSi
STEMI–s simptomebiT an niSnebiT ........................................................................................12 b. cxrili 3. STEMI-is diferencialuri diagnostika ..............................................13 g. STEMI-s diagnoziT miRebul pacientSi rutinuli testebi...............................13 d. reperfuziis meTodis aucileblobis da SesaZleblobis gansazRvra
pacientebSi STEMI-T..................................................................................................................16 e. reperfuziis saxis SerCeva pacientebSi STEMI-T ....................................................17 v. fibrinolizis Cvenebebi: ......................................................................................................18 z. STEMI-s dros fibrinolizis ukuCveneba da safrTxeebi ....................................19 T. diagnostikuri koronaruli angiografia .................................................................19
3
i. pirveladi PCI-s rekomendaciebi......................................................................................20 VI hospitaluri mkurnaloba .....................................................................................................21
a. miRebis wesi pacientisTvis STEMI-T:.............................................................................21 b. sqema 4. garTulebuli STEMI. gadaudebeli mdgomareobebis marTvis
protokoli.....................................................................................................................................23 g. cxrili 9. parkuWTa Soris Zgidis rubtura, Tavisufali kedlis
rubtura, papilaruli kunTis rubtura ...........................................................................24 e. ST elevaciiT mimdinare miokardimis infarqtis ( STEMI) stacionaridan gaweris Semdgomi antiTrombozuli mkurnaloba .........................................................27 v. cxrili 10 meoradi prevencia STEMI-s dros: ............................................................28
VII gaweris Semdgomi vizitebis rekomendacia:..................................................................30 VIII gamoyenebuli masala:............................................................................................................36
4
I. 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:
sargebloba > > > riskze.
procedura/mkurnaloba
unda
Catardes/dainiSnos
II-A klasi: sargebloba > > riskze
saWiroebs damatebiT
gamokvlevebs.
gonivrulia
Catardes/dainiSnos
Sesabamisi
procedura/mkurnaloba
II-B klasi:
sargebloba ≥ riskze saWiroebs damatebiT
gamokvlevebs.
procedura/mkurnaloba
SesaZlebelia gvqondes
mxedvelobaSi
III klasi: damatebiTi
gamokvlevebi aRaraa
saWiro.
procedura/mkurnaloba
ar unda
dainiSnos/Catardes
vinaidan igi
usargebloa da
SesaZloa iyos saSiSi
A-done: mravali (3-5) sxvadasxva
populaciuri
jgufebia
Sefasebuli.
efeqti da
mimarTuleba
myaria.
rekomendacia imis
Sesaxeb rom igi aris
sasargeblo/efeqturi.
monacemebis miRebulia
mravali
randomizebuli
kvleviT da meta-
analiziT.
rekomendacia
procedura/mkurnalobis
Catareba/daniSvnis
sasargeblodaa
aris zogierTi
urTierTsawinaaRmdego
monacemi mravali
randomizebuli kvlevis
da meta-analizisagan
rekomendaciis
sargebloba/efeqturoba
nakleb kargadaa
Seswavlili
urTierTsawinaaRmdego
monacemebi ufro metia
mravali
randomizebuli
kvlevis da meta-
analizisagan
rekomendacia rom
procedura/mkurnaloba
araa
sakmarisi monacemebia
mravali
randomizebuli da
metaanalizisagan
B-done: SezRuduali
(2-3) populaciuri
jgufebia
Safasebuli
rekomendacia imis
Sesaxeb rom igi aris
sasargeblo/efeqturi.
SezRuduli
monacemebia miRebulia
erTi randomizebuli
da
ararandomizirebuli
kvlevebisagan
rekomendacia
procedura/mkurnalobis
Catareba/dniSvnis
sasargeblodaa.
aris zogierTi
urTierTsawinaaRmdego
monacemi erTi
randomizirebuli da
ararandomizebuli
kvlevebisagan
rekomendaciis
sargebloba/efeqturoba
nakleb kargadaa
Seswavlili
ufro meti
urTierTsawinaaRmdego
monacemia erTi
randomizirebuli da
ararandomizebuli
kvlevebisagan
sasargeblo/efeqturi
da SesaZloa iyos
saziano.
SezRuduli
monacemebia erTi
randomizirebulia da
ararandomizebuli
kvlevebisagan.
C-done: Zalian
SezRuduali
(1-2) populaciuri
jgufebia
Safasebuli
rekomendacia imis
Sesaxeb rom igi aris
sasargeblo/efeqturi.
arsebobs mxolod
eqspertebis azri,
SemTxvevaTa
aRwera(case report)
rekomendacia
procedura/mkurnalobis
Catareba/dniSvnis
sasargeblodaa
eyrdnoba eqspertebis
azrs da SemTxvevaTa
aRweras
rekomendaciis
sargebloba/efeqturoba
nakleb kargadaa
Seswavlili
eyrdnoba eqspertebis
azrs da SemTxvevaTa
aRweras
sasargeblo/efeqturi
da SesaZloa iyos
saziano.
arsebobs mxolod
eqspertebis azri,
SemTxvevaTa
aRwera(case report)
II. mwvave miokardiumis infarqtis definicia
amerikis kardiologTa koleji da evropis kariologTa asociaciis
gaerTianebuli komiteti mwvave miokardiumis infarqts (acute, evolving or recent MI)
5
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).
III. mwvave koronaruli sindromis ganmarteba da klinikuri
mimdinareoba:
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.)
mwvave koronaruli sindromi ACS
ST elevaciiT ST elevaciis gareSe
ara Q kbilovani miokardiumis
infarqti Q kbilovani
miokardiumis infarqti
arastabiluri
stenokardia UA
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
6
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.
IV 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
7
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.
http://heart.healthcentersonline.com/tools/calc_hd_results.cfm 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.
8
V 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
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 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
mimReb klinikaSi
PCI - SeuZlebelia ix. sqema 2BSTEMI-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
gegma
s.d.b-Si
darekva
simpt.
dwyebid.
5 wT-Si
9
10
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 .
11
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
damateba: zogadad SeiZleba iTqvas rom cudi prognozis prediqtorebi STEMI-s dros arian asaki, gulis SekumSvaTa sixSire, arteriuli wneva, filtvebis SeSupeba da S3 toni .
cxrili 1. STEMI-s dros maRali riskis prediqtorebi ( TIMI kvleva STEMI-s riskis gansazRvrisaTvis ) damoukidebeli 30 dRiani sikvdilianobis risk faqtorebi
riskis
qulebi
jamuri
qula
saSualo
maCvenebeli
30 dRiani
sikvdiliano
bis %
min da maqs
maCvenebeli
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
pirveladi PCI
riskis
arainvaziuri
Sefaseba
PCI an CABG
gadamrCeni an
iSemiis
niSnebisda
mixedviT
intrahospitaluri
mkurnaloba da
meoradi prevencia
mimRebi hospitali
sadac PCI SesaZlebelia
mimRebi hospitali
sadac PCI araa SesaZlebeli
fibrinolizisi
VI. pirveladi amocnoba da marTva gadaudebeli
daxmarebis departamentSi
a. sqema. 3 gadaudebeli daxmarebis algoriTmi/protokoli
pacientSi STEMI–s simptomebiT an niSnebiT
STEMI-s simptomebis
dawyeba
saswrafo daxmareba
miiyvans pacients
gadaudebeli daxmarebis
ganyofilebaSi
pacienti Semodis
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)
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 ††
gaurkvevlo
konsultant
† - ar miceT
naklebi, anN
parkuWis inf
†† - Tumca z
aspirins, uf
daReWvisas
††† - oralu
klasi. LOE ATu aris taq
pacients aReniSn
STEMI ? diax
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 †††
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)
bis SemTxveva
i
Tuki sisto
Tuki P > 10arqtze
ogierTi xma
ro swrafi S
ri B-blokere
) IV B-blok
ikardia da h
eba
ara
ix. suraTi ACC/AHA UA/NSTEMI pacientebis marTvis gaidlaini
12
Si gamoiZaxeT
luri wneva < 90 mmhg an bazalurze 30-iT
0 an < 50 an Tuki eWvi gvaqvs marjvena
robs nawlavuri garsiT dafarul
edegia garsis gareSe aspirinis
bi pacientebSi ukuCvenebis gareSe ( I
erebi Tuki araa ukuCveneba gansakuTrebiT
ipertenzia. ( IIa klasi LOE: B).
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)
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. cxrili 3. STEMI-is diferencialuri diagnostika
sicocxlisaTvis saSiSi
aortis diseqcia
pulmonaruli embolia
perforirebuli wyluli
daWimuli pnevmoToraqsi
ezofagealuri rubtura
mediastinitiT ( boerhavas ( borhaava) sindromi
sxva
kardiovaskularuli da
ara iSemiuri
perikarditi
atipiuri angina
adreuli repolarizacia
WPW sindromi
Rrmad invertirebuli T kbilebi
rogorc centraluri nervuli
sistemis dazianebis an
hipertrofiuli kardiomiopaTiis
asaxva
marcxena parkuWis hipertrofia
brugdas sindromi
miokarditi
hiperkaliemia
hisis konis totebis blokada
vazospastikuri angina
hipertrofiuli kardiomiopaTia
sxva arakardialuri
gastroezofagaluri refluqsi
(CERD) da spazmi
gulmkerdis kedlis tkivili
plevraluri tkivili
peptiuri wyluli
panikuri SiSi
biliaruli an pankreatuli
wyluli
xerxemlis malebi diski an
nevralgia
somaturi an fsiqogenuri tkivili
g. STEMI-s diagnoziT miRebul pacientSi rutinuli testebi
1. Sratis biomarkerebi gulis dazianebis Sesafaseblad :
kardiospecifiuri troponinebi ( ar daucado reperfuziul
strategiis Sedegebs) klasi I LOE: C 13
14
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
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 Semdgom
Eelevaciis saSualo
piki MI-s Semdgom sabaziso monacemebTan dabrunebis
dro
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 ++
15
d. reperfuziis meTodis aucileblobis da SesaZleblobis
gansazRvra pacientebSi STEMI-T
cxrili 4
I safexuri: Aaris Tu ara 15 wT-ze meti da 12 sT-ze naklebi xangrZlivobis tkivili an diskomforti gulmkerdis
areSi ?
diax SeCerdi ara
II safexuri: aRiniSneba Tu ara fibrinolizis ukuCveneba7
Tu romelime qvemoTCamoTvlilze aRiniSneba pasuxi diax fibrinolizi SeiZleba iyos ukunaCvenebi
16
sistoluri a.w. 180 mm Hg-ze metia diax ara
diastoluri a.w. 110 mm Hg-ze metia diax ara
sxvaoba sistoluri wnvebis marcxena da marjvena xelze 15 mm Hg-ze meti diax ara
struqturuli cns daavadeba anamnezSi diax ara
bolo 3 Tvis manZilze Tavis qalas/saxis daxuruli trvma diax ara
axali (bolo 6 kviris ) didi travma, qirurgiuli Careva (maT Soris Tvalis lazeruli
operacia Tvalze) GI/GU sisxldena
diax ara
sisxldenis an Trombis warmoqmnis problemebi an sisxlis gaTxeleba diax ara
kardiopulmonaluri resuscitacia ( CPR) 10 wT-ze metia diax ara
orsuloba diax ara
seriozuli organuli daavadebebi(Sorswasuli simsivne an terminaluri stadia, RviZli da
Tirkmlis mZime daavadebebi )
diax ara
III safexuri
aReniSneba Tu ara pacients gamoxatuli gulis ukmarisoba an kardiogenuri Soki, iseTi
rom PCI iyos upiratesi TrombolizisTan SedarebiT ?
filtvebis Segubeba (Sua wilebze zemoT) diax ara
sistemuri hipoperfuzia diax ara
e. reperfuziis saxis SerCeva pacientebSi STEMI-T
cxrili .5
I safexuri: drois da riskis Sefaseba:
dro simptomebis dawyebidan
STEMI.-s riski fibrinolizis riski
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.
fibrinolizi upiratesia Tuki:
P
invaziuri strategia upiratesia Tuki:
stacionarSi adreuli moxvedrisas (
≤ 3-sT-ze simptomebis dawyebidan da
im SemTxvevaSi Tuki invaziuri
strategia gviandeba) ( ix. qvemoT)
PCI laboratoria Seesabameba standarts
† da aqvs qirurgiuli uzrunvelyofa
• 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:
• kaTeterizaciis laboratoria
dakavebulia
• sisxlZarRvovani midgoma
garTulebulia
• PCI laboratories unar-Cvevebi ar
Seesabameba
standarts †
STEMI maRali riskiT
• kardiogenuri Soki (am SemTxvevaSi
nacvlad 12 sT-isa aRebulia 18-sT
infarqtis dawyebidan da 75w asakis
qvemoT pacientebisaTvis klasi I LOE: A xolo maTTvis visasac aski > 75w-ze >
klasi II-A LOE B
• kilipis klasi ≥ 3. Cvenebis klasi II-A LOE B
17
18
invaziuri Carevis dayovneba:
• transportireba xangZlivdeba
• karebidan balonamde dro > 90wT-
ze
• karebidan balonamde dros
gamoklebuli karebidan nemsamde (
igulisxmeba Trombolizisis
dawyebis SesaZlebloba) dro > 1
sT-ze
fibrinolizisze ukuCveneba
igulisxmeba sisxldenis da
intrakranialuri hemoragiis gazrdili
riskebi
klasi I LOE: B
Trombolizisis dozebi aris me-11
cxrilSi
ukuCvenebebi mocemuli me-6 cxrilSi
stacionarSi Semosvlis dagvianeba > 3
sT-ze simptomebis dawyebidan
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 )
v. 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
19
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.
z. STEMI-s dros fibrinolizis ukuCveneba da safrTxeebi
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
T. diagnostikuri koronaruli angiografia
klasi I
1. pirveladi 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
20
i. 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
21
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 )
VI hospitaluri mkurnaloba
a. miRebis wesi pacientisTvis STEMI-T:
1. IV fiziologiuri an D5W imisaTvis rom SevinarCunoT venuri
midgoma
2. SeamowmeT sasicocxlo funqciebi yovel 1,5-sT-Si. eqTanma unda
seatyobinos eqims Tuki P< 60-ze an > 100-ze. Wneva Tuki
sistoluri > 150 an < 100-ze. sunTqvis sixSire Tuki > 22-ze an <
8-ze.
3. ek.g. monitoringi ariTmiis da ST-cvlilebebis gamosavlenad
4. dieta: dasawyisSi kvebas ar vaZlebT, mxolod wyali. Semdeg
dieta: marilis SezRudva, dabal qolesteriniani sakvebi.
5. stabilizaciis Semdgom wamojdoma da Semdeg msubuqad
gaaqtiveba.
6. O2 2/l wT-Si 6-sT-is stabilizaciis Semdgom Tuki SO2>.90%-ze
moxseniT
medikamentebi:
1. nitroglicerini: sublingvalurad 0,4 mg tkivilis an
diskomfortis moxsnamde misi IV infuzia hipertenziis an
persistentuli tkivilisas romelic pasuxobs nitroglicerins.
22
2. aspirini: 162-325 mg dasaReWad.(umjobesia nawlavuri garsis
gareSe). SemnarCunebeli doza 75-162 mg. SesaZklebelia nawlavuri
garsiT dafarulic.
3. beta-blokeri: ukuCvenebebis ar arsebobisas. Wnevis da P-is kontroliT
4. ACE inhibitori: per. Os. wina kedlis infarqtis, Segubebisas
mcire wreSi,
an Tuki EF < 40 % -ze.
5. angitenzin receptorebis blokerebi: ARB: daiwyeT Tuki
intolerantobaa ACE-s mimarT.
6. IV morfini: 2-4mg 2-8 mg inkrementebiT 5-15 wuTiani intervalebiT
7. SfoTvis momxsneli saSualebebo
8. yabzobis sawinaaRmdego preparatebi
b. sqema 4. garTulebuli STEMI. gadaudebeli mdgomareobebis marTvis protokoli
klinikuri niSnebi: Soki, hipoperfuzia, gulis SegubebiTi ukmarisoba, pulmonaruli edema. ZiriTadi klinikuri suraTi:
23
mwvave pulmonaruli edema hipovolemia kardiogenuri Soki
dabali wuT.moc.
brad taq.
naxeT ariTmiis marTva
STEMI-s Semdgom.
ariTmia
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 So s niSnebi
araa
siTxeebi
sisxlis transfuzia
mizezis gamosworeba
gaiTvaliswineT
vazopresorebi
SeinarCune si .wneva
> 100 mmhg da a
naklebi 30-isa sabazo
wnevasTan SedarebiT
sist. wneva > 100
mmhg
sist eva 70-100 mmhg
Sok niSnebis gareSe
sist.wneva 70-100 Sokis
niSnebiT
sist.wneva < 70 mmhg
Sokis niSnebiT
ACE inhibitorebi umjobesia xanmokle
moqmedebis rogoricaa
kaptoprili 6,25 mg
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
Semdgomi/damatebiTi diagnostikur/ :
diagnostikuri: pulmonaruli arter ografia, angiografia miokardiumis farqti/iSemiisTvis, damatebiTi diagnostikuri RonisZiebebi.
Terapiuli: 1) intraaortuli balon reperfuzia/revaskularizacia, 3) S leba gamoviyenoT dobutamin, dofaminis kombinacia.
ki
st
ar
Terapiuli RonisZiebebi
ies kaTeteri, eqokardi
uri kontrpulsacia, 2)
in
eiZ
.wn
is
24
g. cxrili 9. parkuWTa Soris Zgidis rubtura, Tavisufali kedlis rubtura, papilaruli kunTis rubtura
parkuWTaSua Zgidis rubtura parkuWis Tavisufali kedlis
rubtura
papilaruli kunTis rubtura
sixSire/gavrcel
eba
1-3% pacientebSi romelTac ar
CatarebiT reperfuziuli Terapia
0,2-0,34% pacientebSi visac
Cautarda Trombolizisi
3,9% Sokiani pacientebisa
0,8-6,2% Trombolizisi ar amcirebs
risks; pirveladi PTCA savaraudod
amcirebs.
1% posteromedialuri ufro
xSirad gvxvdeba vidre
anterolateraluri.
dro
aqvs 2 piki 24 sT-Si da Semdeg 3-5
dReSi jamSi viTardeba 1-14 dReSi
aqvs 2 piki 24 sT-Si da Semdeg 3-5
dReSi jamSi viTardeba 1-14 dReSi
aqvs 2 piki 24 sT-Si da Semdeg 3-5
dReSi jamSi viTardeba 1-14 dReSi
klinikuri
manifestacia
tkivili gulmkerdSi, sunTqvis
gaZneleba, hipotenzia
anginuri, plevraluri, an
perikardiuli tkivili gul-mkerdSi,
sinkope, hipotenzia, ariTmiebi,
gulisreva, mousvenroba, hipotenzia,
uecari sikvdili.
sunTqvis gaZnelebis uecari
dawyeba da pulm. SeSupeba.
hipotenzia.
fizikuri
niSnebi
uxeSi holosistoluri Suili,
gaZlierebuli S3 da 2 gulis
toni, pulmonaruli edema, RV da LV ukmarisoba, kardiogenuri
Soki
iugularuli venebis
dilatacia(pacientebis 29%)
paradoqsuli pulsi(47%)
eleqtromeqanikuri dissociacia,
kardiogenuri Soki.
nazi Suili, marjvena parkWis
gadatvirTvis cvalebadi niSnebi,
mkacri pulmonaruli Segubeba,
kardiogenuri Soki
eqokardiografi
uli niSnebi
parkuWTaSua Zgidis defeqti,
marcxnidan marjvniv Sunti,
marjvena nawilebis gadatvirTva
5 mm-ze meti [perikardiuli siTxe
romelic yovelTvis ar
vizualizdeba, Sreobrivi,maRal
akustikuri eqo signali
perikardiumis Signdan(Trombuli
masa) Semavali karis vizualizacia,
tamponadis niSnebi
LV –s hiperkontraqtiloba,
gawyvetili papilar. kunTi, flail qorda, mkacri mitraluri
naklovaneba.
marjvena gulis
kaTeterizacia
gazrdili Jangbadis saturacia
gulis marjvena nawilebSi,
giganturi V-talRebi.
ventrikulografii mgrZnobeloba
dabalia, tamponadis klasikuri
niSnebi xSirad araa(diastoluri
wnevebis gaTanabreba gulis marcxena
da marjvena nawilebs Soris)
gulis marjvena nawilebSi
Jangbadis saturacia ar
matulobs., giganturi V talRebi,
Zalian maRali PCWP
sqema 5 ICD-is Cveneba pacientisaTvis STEMI_T da dabali EF -iT sqema 6. ganmeorebiTi iSemiis/infarqtis marTva STEMI-s Semdgom
25
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.
arastabilur
oba? mag:
NSVT
ICD EPS + - ICD ara
ganmeorebiTi iSemiuri tkivili an diskomforti STEMI-s SEmdgom
medik. mkurnalobias
optimizacia
12-ganxriani
e.k.g.
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
revaskulari
zaciis
kandidati ?
ara
diax
iSemia
kontroldeba
medik.
optimizaciiT ?
diax
ganix.
ganmeorebiTi
Trombolizi
si
gegmiuri
kaTeterizacia
urgentuli
kaTeterizacia
gaiTvaliswine
IABP
ara
SesaZleb
elia
swrafi
kaTeteri
zacia ?
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
ara
diax
klasi
II-B LOE: B
d. sqema 7. kaTeterizaciis da revaskularizaciis Cveneba STEMI-s Semdgom adreuli
invaziuri strategia fibrinolizisi arareperfuziuli strategia
26
EF > 40 % EF < 40 %
maRali riskis
gareSe †
maRali riskiT
†
kaTeterizaci
a Cvenebis
mixedviT
funqciuri
Sefaseba
EF < 40 % EF > 40 % Semdg.
kaTeterizaciiT
Semd. kaTeteriz.
gareSe
maRali riski † maRali riskis
gareSe †
e.k.g
interpretire
badia
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.)
farmakologiuri stres testi
adenozini an
dipiridamoli
dobutamin eqo.
revaskul
arizacia
Cvenebis
mixedviT
e. ST elevaciiT mimdinare miokardimis infarqtis ( STEMI) stacionaridan gaweris Semdgomi antiTrombozuli mkurnaloba
27
pacienti gaweris win
stentireba
ar Cautarda
stentireba
Cautarda
aspirinze araa
alergiuli
aspirinze
alergia aqvs
araa
antikoagulaci
is Cveneba
aris
antikoagulaci
is Cveneba ††††
araa
antikoagulaci
is Cveneba
aris
antikoagulaci
is Cveneba ††††
aspirinze araa
alergiuli
aspirinze
alergia aqvs
araa
antikoagula
ciis Cveneba
aris
antikoagulaciis
Cveneba ††††
araa
antikoagula
ciis Cveneba
aris
antikoagulaci
is 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 + klopidroge
li (plaviqsi)
75 mg I klasi
LOE B. †
ASA 75-162 mg + klopidrogeli
(plaviqsi) 75
mgࠠ +
varfarini (INR 2,0-3,0) IIB klasi LOE C †††
klopidroge
li (plaviqsi)
75 mg +
varfarini (
INR 2,0-3,0) I klasi LOE C †††
varfarini
(INR 2,0-3,0) I klasi LOE B.
klopidroge
li (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.
v. cxrili 10 meoradi prevencia STEMI-s dros:
mizani
rekomendaciebi
moweva
mizani: sru Sewyv
pac misi oja mk a u
gafrTxildes mowevis sruli Sewyvetis Sesaxeb (
Tavidan unda iqnes aridebuli misi TandraswebiT
ojaxis wevrebis mier moweva) saWiro as
SesaZloa farmakologiuri Terapiis daniSvnac (
nik is Canacvleba a “ u n
sisxlis wnevis
kontroli
mizani: < 140/90 mmhg an <
130/80 mmhg qronikuli
Tirkmlis n lovane
an diabetis dros
Tuki wneva ≥ 120/80 m
• daiwyeT nis
ko l zikuri i o s Warbi
gamoyenebis Tavidan arideba, marilis xmarebis
zomieri Semcireba, dietaSi xilis, bostneulis,
da i produqtebis didi xv Ti wili)
Tuki wneva ≥ 140/90 mm mpacientebSi Tirkmlis qronikuli ukmarisobiT
an diabetiT:
• d m nevis Ses r tebi
lipiduri me ment
Tuki TG < 200 mg/dl)
mizani: LDmniSvnelov < 100
mg/dl-ze)
daiwyeT dieta yvela pacientSi. ( saerTo
kaloraJSi gajerebuli cximi < 7%-ze da
qolesteroli < 2000 mg/dRe onis
kontroli da fizikuri aqtivoba. urCieT omega-3
cximovani mJavis xmar
gansazRvreT lipiduri speqtri da daiwyeT
medikamenturi mkurnaloba Semdegi sqemis mixedviT:
LD 100 mg/ abaziso 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 Semamcirebeli
medikamentozuri mkurnalobis intensifikacia.
upi a eni statinebs. )
lipiduri m ejment
TG ≥ 200 mg/dl
mizani: ara L-C mniSvnelovnad naklebi
130 mg/dl-ze *
Tu 150 mg an HDL < 40 mg/dl :
• xazi gausviT wonis kontrolis da mowevis
Sewyvetis mniSvnelobas
TG is 200-499
• LDL-C Semamci erapi mdgom, †
ienti da xi
d
mhg
aqt
hg an > 130/80
amci
ebis
acr
B
voba,
ebel
Si.)
gazr
d
prop
al
i
u
da.
nd
io
k
med
rCi
a
ebis
”-i)
holi
edri
mhg
ikamen
eT w
li eta
otin
cxovrebis stilis modifikacia (wo
ro i, fi
l-cximian
nt
ba
bis ak
aa ateT w
nej
L-C nad
i (
L -C < dl ( s
-is
Weba
/dl
ratesob
ki TG ≥ i ( en
HD ar mg
re
/dl
beli T is ES
28
mxedvelobaSi gqondes fibrati an niacini ††
Tuki TG aris ≥ 500 mg/dl
mxedvelobaSi iqonie fibratis an niacinis
emamcirebeli Terapiis win. †
• mxedvelobaSi iqonie omega-3 mJavis dawyeba
minimaluri mizani: 30
wT 3-4 dRe kviraSi;
optimaluria yovel
dRe
i ufro
tiuri moZraoba: siaruli, saxlis samuSaoebi.
lis reabilitaciuri programebi
Ti risk faqtorebiT
,9
/m2
welis
garSemoweriloba:
qalebSi: 88,9 sm
kacebSi 101,6 sm
-sm qalebSi). periodulad gadaamowmeT. Tuki
s
.
diabetis kontroli:
mizani HbA1c < 7%-ze.
T
.
antiTrombocitebi/antik
oagulantebi
ogeli 75 mg an varfarini Tuki aspirini
iT )
renin-angiotenzin-
a is
b
lis MI, adre
ciiT Segubeba
afiuli
bis blokerebi
torebis autanlobisas, da
•
dawyeba LDL is S
fizikuri aqtivoba
gansazRvreT riski, upiratesad datvirTvis
testiT. pacientebs urCieT 30-60 wT-iani aqtivoba.
umjobesia yovel dRe magram minimum 3-4 jer
kviraSi.(fexiT siaruli, sirbili, velosipedi,
aerobika.) aseve urCieT dRis ganmavlobaS
aq
gu
pacientebisaTvis mravlobi
unda mimdinareobdes eqimis meTvalyureobiT.
gamoTvaleT BMI ( sasurvelia 18,5-24,9 kg/m2 da
gazomeT welis garSemoweriloba( 101-sm kacebSi da
wonis kontroli
mizani: sxeulis masis
indeqsi BMI = 18,5-24kg
89
monacemebi aradaamkmayofilebelia pacient
urCieT metad gaaqtiveba da cxovrebis wesis
modificireba
hipoglikemiuri dieta da Terapia raTa mivaRwio
normalurTan axlo Saqris
cifrebs uzmoze da HbA1c < 7%-ze
aspirini 75-162 mg Tuki araa ukuCveneba.
klopidr
ukunaCvenebia. (es ukanaskneli INR-is kontrol
ldosteron sistem
lokerebi
ACE inhibitorebi yvela pacientSi. daiwyeT adre
maRali riskis pacientebSi ( wina ked
gadatanili MI, kilipi II-ze meti gulis
ukmarisoba. (S3 galopi, auskulta
mcire wreSi, gulis ukmarisobis radiogr
niSnebi. EF ≤ 40%-ze.
angiotenzinis receptore
pacientebSi ACE-inhibiromelTac aqvT maTi daniSvnis Cveneba.
29
gom
jaxis eqimisaTvis)
aruli daavad
adaixedo
hibitorebis, beta-bloker bis, statinebis optimaluri dozebi. LOE: C unda gadafasdes riskebiefasebas da SesaZloa hol
is 31-40% an ufro dabal
pacients da mis axloble
OE: C mieqces p
lur
n unda visaubr
tivoba, samuSaoze dabru
mogzauroba(frena Tu saWesTan jdoma)
iSvnelovani renaluri ukmarisobis ††† an
romlebic iReben ACE aqvT
beta blokerebi
aiwyeT yvela pacientSi romelsac ara aqvs
oba
diabetis marTva
mowmdeba
varfarini si Cvenebebi aris qvemoT mocemul cxrilSi.
i
aldosteronis blokatorebi pacientebSi
mn
hiperkaliemiis gareSe ††††
inhibitorebs, aqvT EF < an toli 40 %-ze. da
diabeti an gulis ukmarisoba.
HF
d
ukuCveneba da SearCieT optimaluri doza.
gaagrZeleT monitoringi dozis optimizaciis
mizniT (monitorings gansakuTrebuli mniSvnel
aqvs pacientebSi gulis ukmarisobiT)
hipoglikemiuri Terapia. efeqturoba
HbA1C-iT romelic unda iyos 7%-ze naklebi.
mi
damatebiT SeiZleba aRiniSnos rom varfarini
SeiZleba mieces pacients STEMI-s Semdgom Tuki
aqvs LV disfunqcia da didi zomis regionalur
kumSvadobis moSla. LOE IIA
VII gaweris Semd i vizitebis rekomendacia
(o :
I klasi:
1. gaweris Semdgomi vizitebisas unda
rdiovaskul
Sefasdes aqvs Tu ara paciets
ebis simptomebi; LOE: C s misi daniSnuleba da SerCeuli unda iqnes ACE
ka
2. vizitisas unda g
in e
3. rac moicavs marcxena parkuWis funqciis
teris monitorings pacientebisTvis sadac EF
i mxedvelobaSi gvqondes ICD-is saWiroeba LOE: C bs unda aexsnaT pirveladi prevenciis roli
acientis fsiqologiur statuss, ( depresia,
LOE: C
S
ar
4.L5. yuradReba unda SfoTva, Zili da socia
6. pacientTa
i aqtivoba)
oY iseT sakiTxebze rogoricaa: fizikuri
nebis vadebi, seqsualuri aqtivoba
LOE: C aq
30
7. pacientis axloblebs un bis
Seswavla da praqtikuli t : C 8. pacientTan da mis axlob
sakiTxebze: a. gulis “ Setevis” riski LOE: C rogor gamovicnoT miok diumis infarqtis niSnebi LOE: C
vurCioT darekon saswra
matulobs 5 wuTis Semdgom d”
Sewuxeba. LOE: C d. pacientebma unda icodn axmarebis
brigadas. LOE: C ia reabi itaciis programaSi pacientis CarTva da
meoradi profilaqtika, ga
risk faqtorebi romelTa
saSualo an maRali risk faqtorebi ( maTTSi varjiSi eqimis
edamxedvelobiT (tredmil an veloergometri)
lia LOE: C cxrili 11 medikamentebi r
medikamenti
da vkiTxot surT Tu ara CPR-is safuZvle
reiningi saavadmyofodan gaweris Semdgom LOElebTan erTad unda vimsjeloT Semdeg
b. ar
g. fo daxmarebis sadgurSi Tuki simptomebi
( xandaxan pacientebs eridebaT vinmes “tyuila
en Tu rogr daukavSirdnen saswrafo d
e. rekomendirebul l
nsakuTrebiT maTTvis visac aqvs mravlobiTi
modificirebac SesaZlebelia an maTi visac aqvs
z i
mizanSewoni
omlebic gamoyeneba STEMI-s mkurnalobisas
pirveli 24-sT
hospitalizaciis
manZilze
gawerisas da
xangZlivi
mkurnalobisas
dasaReWad (
aspirini
umjobesia ara
enteruli
garsiT
dafaruli)
162-325 mg
75-162 mg dRiuri
75-162 mg dRiuri
ganusazRvreli
vadiT
streptokinaza
ibrinolf izisuri
1,5 MU IV 30-60
wT-is
Terapia
ixileT
ukuCvenebebi da
Cvenebebi me-6
rilidan
manZilze
alteplaza IV cx
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
31
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.
Semdeg
infuzia 12 U/kg/sT-Si.
max. 1000 U/sT-
Si. aPTT 1,5-2,0 normasTan
SedarebiT (
50-70-s Soris)
aPTT 1,5-2,0 normasTan
SedarebiT ( 50-
70-s Soris) 48
sT-is
ganmavlobaSi
ix. 8 sqema
antiTrombozuli
mkurnalobis
rekomendaciebisTvis
keri
beta-blo
per-os
per-os
per-os ganusazRvreli
vadiT
ACE inhibitori
ACE inhibitori
yvela
pacientSi wina
kedlis
infarqtiT,
pulmonaruli
SegubebiT, EF
< 40 %-ze
Tuki araa
hipotenzia da
per-os
per-os ganusazRvreli
vadiT
32
sxva
ukuCvenebebi,
gatitreT
wnevis da
kreatininis
kontroliT
angiotenzin II-is
blokatori ARB
ARB unda dainiSnos
pacientebSi
visac aqvs ACE inhibitorebis autanloba da
igive Cveneba
rac am
ukanasknelT
iseve rogorc
pirvel 24-sT-Si
iseve rogorc
pirvel 24-sT-Si
aldosteronis
okada bl
yvela pacientSi
Tirkmlis mniSv.
ukmarisobis
gareSe (
kreatinini < 2,5
mg/dl kacSi ada
2 mg/dl
qalebSi) an
hiperkaliemiis
gareSe K <
5mEq/l
romlebic
iReben ACE-s, EF < an toli 40%
da romelTac
aqvT gulis
ukmarisoba an
diabeti.
igive rac
hospitalizaciisas.
33
nitroglicerini
sublingvaluri
NTG 0,4 mg
yovel 5 wT-Si
Tuki rCeba
tkivili an
diskomforti
gulmkerdSi.
IV s NTG guli
ukmarisobis,
hipertenziis,
persistentuli
iSemiisas rac
pasuxobs
nitratebs
oralurad Tuki
iSemia
grZeldeba an
aris
ukontrolo
hipertenzia
atinebi
st
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
cientis
naTleba
pacientisTvis
mniSvnelovania
imis codna Tu
rogor
Secvalos
cxovrebis
stili STEMI-s Semdgom.
informacias
medikamenturi
pa
ga
34
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
qolesteroliT
dabali dietis
aucileblobis
da mniSvnelobis
Sesaxeb
Sesabamisi
dietis
rekomendireba
moweva
avukrZaloT
moweva
avukrZaloT
moweva
avukrZaloT
moweva.
saWiroebisas
farmakologiuri
Terapia. da
CavrToT mowevis
Sewyvetis
programaSi
rjiSi
va
axsna-ganmarteba
siarulis
dawyeba
rekomndacia
varjiSis da
aqtivobis donis
Sesaxeb
35
VIII gamoyenebuli masala:
teqsti eyrdnoba amerikis gulis asociaciis da amerikis
kolejis 2004w ( sruli teqsti da jibis gaidlaini) asev
kardiologTa asociaciis ( 2003w sruli teqsti) Sesabam
damatebaSi gamoyenebulia masalebi: 1. ACC/AHA gaidlain
teqstidan
2004w.
2. ESC gaidlainis sruli teqstidan
2003w.
3. braunvaldi, zaips libbi, gulis
debebi 6-e gamocema 2001w
4 fini opoli
r
saxelmZRvanelo, 2-e gamocema 2004w.
kardiologTa
e evropis
is gaidlainebs.
is sruli
daava
. brain p. gri
kardiovaskula
erik j. t
uli medicinis
36
37