miokardiumis infarqti ST-segmentis elevaciis gareSe /arastabiluri ...
miokardiumis infarqti ST-segmentis elevaciis gareSe /arastabiluri ...
miokardiumis infarqti ST-segmentis elevaciis gareSe /arastabiluri ...
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<strong>miokardiumis</strong> <strong>infarqti</strong> <strong>ST</strong>-<strong>segmentis</strong><br />
<strong>elevaciis</strong> <strong>gareSe</strong> /<strong>arastabiluri</strong><br />
stenokardia<br />
klinikuri praqtikis erovnuli rekomendacia<br />
(gaidlaini)<br />
1
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) `<strong>miokardiumis</strong><br />
<strong>infarqti</strong> <strong>ST</strong>-<strong>segmentis</strong> <strong>elevaciis</strong> <strong>gareSe</strong> /<strong>arastabiluri</strong> stenokardia”<br />
miRebulia klinikuri praqtikis erovnuli rekomendaciebis (gaidlainebi)<br />
da daavadebaTa marTvis saxelmwifo standartebis (protokolebi)<br />
SemuSavebis, Sefasebis da danergvis erovnuli sabWos 2006 wlis 21 #2<br />
noembris sxdomaze da damtkicebulia saqarTvelos Sromis,<br />
janmrTelobisa da socialuri dacvis ministris 2007 wlis 21 dekembris<br />
# 360/o brZanebiT.<br />
2
<strong>miokardiumis</strong> <strong>infarqti</strong> <strong>ST</strong>-<strong>segmentis</strong> <strong>elevaciis</strong> <strong>gareSe</strong><br />
/<strong>arastabiluri</strong> stenokardia<br />
gamoyenebuli Semoklebebi<br />
ABC = kardiopulmonaruli reanimaciis 3 etapi: sasunTqi gzebi A, sunTqva B,<br />
sisxlis mimoqceva C.<br />
ACE = angiotenzin gardamqmneli fermenti<br />
ACS = mwvave koronaruli sindromi<br />
AHA/ACC = amerikis gulis asociacia/amerikis kardiologiuri koleji<br />
AF = winagulTa fibrilacia<br />
aPTT = aqtivirebuli Tromboplastinis dro<br />
ARB = angiotenzin II –is blokerebi<br />
ASA = aspirini<br />
BMI = sxeulis masis indeqsi = wona (kg-Si) / simaRleze 2 (metr.)<br />
BNP = B tipis natriurezuli peptidia<br />
BUN = sisxlis Sardovana nitrogeni<br />
CABG = kororonarul arteriuli baipas grafti. (aorto koronaruli Suntireba)<br />
CBC = sisxlis saerTo analizi<br />
CCS = kanadis kardiologiuri asociacia<br />
CHD = gulis koronaruli daavadeba<br />
CHF = gulis SegubebiTi ukmarisoba<br />
CK-MB = kreatinfosfokinaza MB izofermenti<br />
CPR = kardiopulmonaruli resustiqcia<br />
CPR = kardiopulmonaruli resustiqcia (reanimacia)<br />
cTnI = kardiotroponini I<br />
cTnT = kardiotroponini T<br />
CT = kompiuteruli tomografia<br />
Cx = Semomxvevi toti<br />
D5W = deqstroza 5 %-iani<br />
EPS = eleqtrofiziologiuri kvleva<br />
ECG = e.k.g.<br />
GI = gastrointerstinuli<br />
GU = genitourinaluri (Sardasasqeso)<br />
GP = glukoproteini<br />
HDL-C = maRali simkvrivis lipoprotein qolesteroli<br />
HF = gulis ukmarisoba<br />
HIT = hepariniT inducirebuli Trombocitopenia<br />
HR = gulis SekumSvaTa sixSire<br />
IABP = intraaortuli balonuri kontrpulsacia<br />
ICD =kardioverter defibrilatori<br />
INR = saerTaSoriso normalizaciis Sefardeba<br />
IV = intravenuri<br />
LAD = marcxena wina daswvrivi toti<br />
LBBB = hisis konis marcxena fexis blokada<br />
LDL-C = dabali simkvrivis lipoprotein qolesteroli<br />
LMWH = dabalmolekuluri wonis heparini<br />
LOE = mtkicebulebis xarisxi<br />
LV = marcxena parkuWi<br />
3
MET = metaboluri eqvivalenti<br />
MI = <strong>miokardiumis</strong> <strong>infarqti</strong><br />
NCEP = riskis daTvlis programa: http://www.nhlbi.nih.gov/about/ncep/ (kiTxvari romelSiac<br />
SegaqvT Semdegi monacemebi: saerTo qolesterini, HDL, sistoluri wneva, sqesi, asaki,<br />
eweviT Tu ara da igi gaZlevT gulis gulis daavadebebiT 10 wliani sikvdilianobis<br />
risks)<br />
non-HDL-C = saerTo qolesterins gamoklebuli HDL<br />
NSVT = aramdgradi (xanmokle) ventrikuluri taqikardia<br />
NTG = nitroglicerini<br />
PCI = perkutaneuli koronaruli intervencia<br />
PTCA = perkutaneuli transluminaruli koronaruli angioplastika<br />
RC = marjvena koronari<br />
RBBB = hisis konis marjvena fexis blokada<br />
RV = marjvena parkuWi<br />
<strong>ST</strong>EMI = <strong>miokardiumis</strong> <strong>infarqti</strong> <strong>ST</strong> elevaciiT am jgufSi ganixileba pacientebi<br />
<strong>miokardiumis</strong> <strong>infarqti</strong>T, romelTac e.k.g-ze aqvT persistentuli > (20-30wT) <strong>ST</strong><br />
<strong>segmentis</strong> elevacia<br />
TG = trigliceridebi<br />
UA = <strong>arastabiluri</strong> stenokardia<br />
UFH = arafraqcionirebuli heparini<br />
VF =ventrikuluri fibrilacia<br />
VO2 = moxmarebuli Jangbadi drois garkveul monakveTSi<br />
VSR = parkuWTa Sua Zgidis rubtura<br />
VT =ventrikuluri taqikardia<br />
WPW = volf-parkinson-uaitis sindromi<br />
flail leaflet = “mofarfate” qorda<br />
preexitation = naadrevi aRgzneba<br />
niacini = vitamini B-3<br />
s.d.b. = saswrafo daxmarebis brigada<br />
Imaging Modality = gamosaxulebiTi kvleva<br />
Preexitation = delta talRa, naadrevi agzneba<br />
Electronically paced ventricular rhythm = parkuWSi riTmis xelovnuri wamyvani<br />
Escape Beat = gamomxtari eqstrasistola<br />
Advanced AV Block = Sorswasuli blokada<br />
Capture = CaWera (miokardis depolarizacia peismekeris impulsis mier)<br />
4
definicia<br />
termini - mwvave koronaruli sindromi aerTianebs Semdeg klinikur sindromebs:<br />
arastabilur stenokardias, M<strong>miokardiumis</strong> infarqts <strong>ST</strong>-<strong>segmentis</strong> <strong>elevaciis</strong> <strong>gareSe</strong><br />
da <strong>miokardiumis</strong> infarqts <strong>ST</strong>-<strong>segmentis</strong> elevaciiT. pacientebi <strong>arastabiluri</strong><br />
stenokardiiT da <strong>miokardiumis</strong> <strong>infarqti</strong>T <strong>ST</strong>-<strong>segmentis</strong> <strong>elevaciis</strong> <strong>gareSe</strong><br />
miekuTvnebian erT jgufs, xolo pacientebi <strong>ST</strong>-<strong>segmentis</strong> elevaciiT mimdinare<br />
<strong>miokardiumis</strong> <strong>infarqti</strong>T miekuTvnebian meore jgufs. termini – <strong>arastabiluri</strong><br />
stenokardia asaxavs sindroms, romelsac Sualeduri mdgomareoba ukavia qronikul<br />
stabilur stenokardiasa da <strong>miokardiumis</strong> infarqts Soris. Ppacientebs <strong>ST</strong>-<strong>segmentis</strong><br />
<strong>elevaciis</strong> <strong>gareSe</strong> mimdinare mwvave koronaruli sindromiT aqvT an <strong>arastabiluri</strong><br />
stenokardia an <strong>ST</strong>-<strong>segmentis</strong> <strong>elevaciis</strong> <strong>gareSe</strong> mimdinare <strong>miokardiumis</strong> <strong>infarqti</strong>.<br />
sisxlSiM<strong>miokardiumis</strong> enzimebis donis (CK-MB an Troponins) matebis SemTxvevaSi<br />
diagnostirdeba <strong>miokardiumis</strong> <strong>infarqti</strong> <strong>ST</strong>-<strong>segmentis</strong> <strong>elevaciis</strong> <strong>gareSe</strong> da<br />
normaluri donis SemTxvevaSi - <strong>arastabiluri</strong> stenokardia. mwvave koronaruli<br />
sindromi <strong>ST</strong>-<strong>segmentis</strong> elevaciT uxSiresad sruldeba <strong>miokardiumis</strong> Q kbilovani<br />
<strong>infarqti</strong>T da iSviaTad ara Q kbilovani <strong>infarqti</strong>T. <strong>ST</strong>-<strong>segmentis</strong> elevacis <strong>gareSe</strong><br />
<strong>miokardiumis</strong> <strong>infarqti</strong> uxSiresad sruldeba ara Q kbilovani <strong>miokardiumis</strong><br />
<strong>infarqti</strong>T da iSviaTad Q kbilovani <strong>miokardiumis</strong> <strong>infarqti</strong>T (ix sqema #1).<br />
mniSvnelovnad gamoxatuli gulis koronaruli daavadeba (CHD) - ganisazRvreba<br />
angiografiulad erT-erTi didi epikardiuli arteriis sanaTuris 70% an meti<br />
SeviwroebiT an marcxena koronaruli arteriis ZiriTadi Reros (Left Main) 50% an<br />
meti stenoziT. ufro naklebad gamoxatulma stenozmac SesaZloa gamoiwvios<br />
stenokardia, Tumca maT prognozulad naklebi mniSvneloba eniWeba.<br />
mwvave koronaruli sindromis marTvisas umniSvnelovanesia diagnozis swrafad<br />
dasma, razec Tavis mxriv damokidebulia mkurnalobis strategia. magaliTad <strong>ST</strong><strong>segmentis</strong><br />
elevaciiT mimdinare <strong>miokardiumis</strong> <strong>infarqti</strong>s dros gadaudeblad unda<br />
daiwyos reperfuziuli Terapia (Trombolizisi an PCI). <strong>arastabiluri</strong> stenokardiis<br />
da <strong>ST</strong>-<strong>segmentis</strong> <strong>elevaciis</strong> <strong>gareSe</strong> mimdinare <strong>miokardiumis</strong> <strong>infarqti</strong>s dros, erTis<br />
mxriv, mkurnalobis msgavsi midgoma ar gamoiyeneba, meores mxriv _ daavadebis<br />
dawyebis pirvel saaTebSi SeuZlebelia maTi garCeva erTmaneTisgan, radgan sisxlSi<br />
<strong>miokardiumis</strong> enzimebis donis mateba iwyeba ramdenime saaTSi, amitomac moxda am ori<br />
sindromis gaerTianeba erT jgufSi.<br />
<strong>ST</strong> <strong>elevaciis</strong> <strong>gareSe</strong><br />
<strong>arastabiluri</strong><br />
stenokardia UA<br />
mwvave koronaruli sindromi ACS<br />
ara Q kbilovani<br />
<strong>miokardiumis</strong> <strong>infarqti</strong><br />
<strong>ST</strong> elevaciiT<br />
Q kbilovani<br />
<strong>miokardiumis</strong> <strong>infarqti</strong><br />
sqema #1<br />
5
epidemiologia<br />
saqarTveloSi bolo 20 wlis ganmavlobaSi raime saxis seriozuli statistikuri<br />
kvleva, romelic am daavadebis gavrcelebas Seiswavlida ar Catarebula. aqedan<br />
gamomdinare Cven veyrdnobiT AaSS-s da evropul monacemebs.<br />
gulis koronaruli daavadeba (CHD) warmoadgens sikvdilianobis wamyvan mizezs<br />
amerikis SeerTebul StatebSi. am daavadebis xSiri gamovlinebaa <strong>arastabiluri</strong><br />
stenokardia (UA) da masTan dakavSirebuli <strong>miokardiumis</strong> <strong>infarqti</strong> <strong>ST</strong>-<strong>segmentis</strong><br />
<strong>elevaciis</strong> <strong>gareSe</strong> (N<strong>ST</strong>EMI). aSS-Si yovelwliuri sikvdilianoba gulis koronaruli<br />
daavadebebiT aris 500,000-ze meti. xolo yovelwliurad 1,680,000 pacientis<br />
hospitalizaciis mizezi aris ACS. amis garda 200,000-dan 300,000-mde kaci kvdeba MI-T<br />
savadmyofoSi gadayvanamde. anu mwvave koronaruli sindromi TiTqmis 2,000,000 mde<br />
adamians emarTeba yovelwliurad. aqedan <strong>ST</strong>EMI aqvs daaxloebiT 500,000 adamians.<br />
evropuli monacemebiT <strong>ST</strong>EMI-iT daavadebulTa sikvdilianoba 1 TveSi Seadgens 30-<br />
50%-s, romelTagan TiTqmis naxevari pirvel 2-sT-Si kvdeba. unda aRiniSnos, rom<br />
bolo xanebSi <strong>miokardiumis</strong> <strong>infarqti</strong>s sixSires aqvs Semcirebis, xolo<br />
<strong>arastabiluri</strong> stenokardiis sixSires zrdis tendencia. igive SeiZleba iTqvas <strong>ST</strong>EMIs<br />
Sesaxeb, romlis SemTxvevebi mcirdeba N<strong>ST</strong>EMI-s sasargeblod. zogadad SesaZloa<br />
iTqvas, rom amerikaSi yovel 29 wm-Si romelime adamians emarTeba mwvave MI, xolo am<br />
daavadebiT pacienti kvdeba yovel 1 wT-Si.<br />
Tuki saqrTvelos mosaxleobas aviRebT 4,000,000-mde, xolo statistikas igives<br />
davtovebT rac evropasa da aSS-Sia, maSin SesaZloa iTqvas, rom CvenTan<br />
yovelwliurad gulis koronaruli daavadebebiT kvdeba daaxloebi 6600 pacienti.<br />
ACS yovelwliurad emarTeba 25,000 adamians. <strong>ST</strong>EMI yovelwliurad emarTeba<br />
daaxloebiT 6600 adamians (romelTa 30%-50% kvdeba pirvel 1-TveSi), xolo danarCens<br />
aqvs UA/N<strong>ST</strong>EMI ( daaxloebiT 18,000-19,000). saqarTveloSi yovel 40 wT-Si romelime<br />
adamians emarTeba MI, xolo am daavadebiT kvdeba 1 pacienti yovel 80 wT-Si.<br />
etiopaTogenezi<br />
UA da N<strong>ST</strong>EMI miekuTvnebian mwvave koronarul sindroms, romelic xasiaTdeba<br />
<strong>miokardiumis</strong> JangbadiT momaragebasa da moTxovnilebas Soris balansis darRveviT.<br />
cnobilia am mdgomareobis gamomwvevi 5 mizezi:<br />
1) yvelaze xSiri mizezia koronaruli arteriis Seviwroeba aramaokluzirebeli<br />
Trombis gamo, romelic ganviTarebulia dazianebul aTerosklerozul<br />
folaqze da rogorc wesi ar iwvevs srul okluzias.<br />
2) SedarebiT iSviaTi – koronaruli arteriis dinamiuri obstruqcia gamowveuli<br />
fokaluri spazmiT, romelic SeiZleba gamowveuli iyos sisxlZarRvis gluvi<br />
kunTebis hiperqontraqtilurobiT da/an endoTeluri disfunqciiT.<br />
3) koronaruli arteriis Seviwroeba, romelsac ar iwvevs spazmi an Trombozi.<br />
mizezi am Seviwroebis aris progresirebadi aTerosklerozi an Semdgomi<br />
restenozi.<br />
4) arteriis anTebiT gamowveuli sanaTuris Seviwroeba, folaqis destabilizacia,<br />
ruptura da Trombogenezi. anTeba SeiZleba gamowveul iyos infeqciiTac.<br />
5) mizezebi, romlebic qronikuli stabiluri stenokardiiT daavadebul pirebSi,<br />
iwveven 1) Jangbadze moTxovnilebis gazrdas (cxleba, taqikardia,<br />
Tireotoqsikozi); 2) hipotenzia, romelic iwvevs koronaruli sisxlis<br />
6
mimoqcevis gauaresebas; 3) anemia an hipoqsemia, romlebic amcireben<br />
<strong>miokardiumis</strong> JangbadiT momaragebas.@<br />
aucileblad aRsaniSnavia, rom zogierT pacients SeiZleba aReniSnebodes<br />
erTdroulad ramdenime mizeziT gamowveuli mwvave koronaruli sindromi.<br />
klinikuri simptomatika<br />
<strong>arastabiluri</strong> stenokardia _ aris klinikuri sindromi, romelic SeiZleba<br />
gamovlindes sami ZiriTadi formiT: 1) mosvenebis stenokardia, rogorc wesi<br />
gaxangrZlivebuli >20 wuTze; 2) axlad aRmocenebuli stenokardia, rogorc minimum<br />
III funqciuri klasi (kanadis kardiologTa sazogadoebis klasifikaciis mixedviT);<br />
3) stenokardiis mateba, rac gamoixateba ufro xSir, ufro xangrZliv an ufro<br />
dabal datvirTvis zRurblze aRmocenebul stenokardiaSi. stenokardia<br />
xasiaTdeba diskomfortiT gulmkerdis areSi retrosternalurad, SesaZlebelia<br />
iradiaciiT qveda ybaSi, mxarSi, zurgSi, epigastriumSi an xelSi. Zlierdeba<br />
datvirTvisas an emociuri daZabvisas da msubuqdeba (gadis) nitroglicerinis<br />
miRebis Semdeg. mizezi: gulis koronaruli arteriebis daavadeba (erTi an meti<br />
epikardiuli koronaruli arteriis). stenokardia aseve gvxvdeba gulis sarqvlovani<br />
daavadebisas, hipertrofiuli kardiomiopaTiisas, arakontrolirebuli<br />
hipertenziisas. normaluri koronarebis SemTxvevaSi stenokardia SesaZloa<br />
gamowveuli iyos koronarebis spazmiT an endoTeluri disfunqciiT. msgavsi<br />
simptomebi SeiZleba gamowveuli iyos sxva arakardiuli mizeziTac, mag. -<br />
saylapavis, gulmkerdis an filtvis daavadebiT.<br />
sawyisi Sefaseba da mkurnaloba<br />
pacientebSi, romlebSic saeWvoa mwvave koronarul sindromi unda Sefasdnen Zalian<br />
swrafad. amas aqvs didi klinikuri da ekonomikuri mniSvneloba. maTi Sefasebisas<br />
pasuxi unda gaeces or mTavar kiTxvas: 1) aris Tu ara aRwerili simptomebi<br />
gamowveuli mwvave koronaruli sindromiT? 2) Tu ki, rogoria prognozi? Aam or<br />
kiTxvaze pasuxis gasacemad pirvel rigSi unda gadawydes, Tu sad unda moxdes<br />
pacientis Sefaseba, raSic gvexmareba Semdegi rekomendaciebi:<br />
rekomendaciebi sawyisi etapisaTvis<br />
klasi I<br />
1. pacientebi, savaraudo ACS-iT ar unda iqnen Sefasebulni mxolod<br />
distanciurad (telefoniT), aramed unda gaigzavnon ganyofilebaSi, sadac<br />
SesaZlebelia eqimis konsultacia da 12-ganxriani eleqtrokardiogramis<br />
Cawera;<br />
2. pacientebi, saeWvo ACS-iT da gulmkerdis areSi diskomfortiT 20 wuTze meti<br />
xnis ganmavlobaSi, hemodinamikuri arastabilurobiT, sinkopeTi an<br />
presinkopeTi aucileblad gadayvanil unda iqnen gadaudebeli Terapiis an<br />
gulmkerdis areSi tkivilis specializirebul ganyofilebaSi.<br />
amis Semdeg unda gairkves, ramdenadaa warmodgenili simptomebi gamowveuli mwvave<br />
koronaruli sindromiT. am kiTxvaze pasuxis gasacemad gvexmareba anamnezi,<br />
fizikaluri gamokvlevebi, ekg, <strong>miokardiumis</strong> dazianebis biomarkerebi da Semdegi<br />
cxrili:<br />
7
gulmkerdSi tkivilis dros CHD-is albaTobis Sefaseba<br />
asaki sqesi tipiuri/garkveuli<br />
anginuri tkivili<br />
30-39<br />
40-49<br />
50-59<br />
60-69<br />
kaci<br />
qali<br />
kaci<br />
qali<br />
kaci<br />
qali<br />
kaci<br />
qali<br />
saSualo<br />
saSualo<br />
maRali<br />
saSualo<br />
maRali<br />
saSualo<br />
maRali<br />
maRali<br />
atipiuri/SesaZlo<br />
anginuri tkivili<br />
saSualo<br />
Zalian dabali<br />
saSualo<br />
dabali<br />
saSualo<br />
saSualo<br />
saSualo<br />
saSualo<br />
im SemTxvevaSi, Tu eWvia mwvave koronarul sindromze<br />
klasi I<br />
araanginuri<br />
tkivili<br />
gulmkerdSi<br />
dabali<br />
Zalian dabali<br />
saSualo<br />
Zalian dabali<br />
saSualo<br />
dabali<br />
saSualo<br />
saSualo<br />
asimptomuri<br />
Zalian<br />
dabali<br />
Zalian<br />
dabali<br />
dabali<br />
Zalian<br />
dabali<br />
dabali<br />
Zalian<br />
dabali<br />
dabali<br />
dabali<br />
1. pacientebSi, romelTac aqvT diskomforti gulmkerdis areSi, aucileblad<br />
unda moxdes riskis adreuli gansazRvra (cxrili 1 da 2.), romelic<br />
fokusirdeba anginalur simptomebze, fizikalur monacemebze, ekg monacemebze<br />
da kardialuri dazianebis biomarkerebze;<br />
2. 12-ganxriani ECG-is gadaReba unda moxdes dauyonebliv, gulmkerdis areSi<br />
diskomfortis periodSi;<br />
3. kardialuri dazianebis biomarkerebi unda ganisazRvros yvela pacientSi<br />
gulmkerdis areSi diskomfortiT, romelic gvafiqrebinebs ACS-ze. kardialurspecifiuri<br />
troponini, warmoadgens upirates markers da Tu SesaZlebeli<br />
iqneba, is unda iqnas gamokvleuli yvela aseT pacientSi. aseve misaRebia<br />
kreatin-fosfokinaza _ MB izoenzimis (CK – MB) gansazRvra. pacientebSi,<br />
romelTac aqvT uaryofiTi kardialuri markerebi tkivilis dawyebidan 6-12<br />
saaTSi isini ganmeorebiT unda ganisazRvros.<br />
8
klasi: II A<br />
1. yvela pacientSi simptomebis dawyebidan 6-sT-Si unda ganisazRvros CK-MB<br />
troponinebis garda<br />
klasi II B<br />
1. unda ganisazRvros C-reaqtiuli cila (CRP) da anTebadi procesis sxva<br />
markerebi.<br />
klasi III<br />
1. miokardialuri dazianebis aRmosaCenad unda ganisazRvros: saerTo CK (MB<br />
fraqciis <strong>gareSe</strong>), aspartataminotransferaza (A<strong>ST</strong>), Sratis glutaminuri<br />
oqsaloacetatis transaminaza (SGOT), beta-hidroqsibutiratis dehidrogenaza<br />
da/an laqtat-dehidrogenaza.<br />
pacientebSi <strong>arastabiluri</strong> stenokardiiT da <strong>ST</strong>-<strong>segmentis</strong> <strong>elevaciis</strong> <strong>gareSe</strong> mimdinare<br />
<strong>miokardiumis</strong> <strong>infarqti</strong>T uaRresad mniSvnelovania moxdes riskis stratifikacia,<br />
radgan swored amazea damokidebuli mkurnalobis strategia. riskis stratifikacia<br />
emsaxureba erTaderT mizans: ganisazRvros sikvdilianobis da <strong>miokardiumis</strong> axali<br />
<strong>infarqti</strong>s ganviTarebis romel risk-jgufSia pacienti – maRalSi, saSualoSi Tu<br />
dabalSi. pacientebi dabali riskiT SeiZleba adreulad gaeweron binaze<br />
ambulatoriuli meTvalyureobis qveS. PpacientebSi saSualo riskiT mkurnalobis<br />
strategiad SesaZlebelia arCeul iqnas rogorc invaziuri, iseve arainvaziuri –<br />
medikamenturi mkurnalobis gza. maRali riskis mqone PpacientebSi mkurnalobis<br />
strategiaa mxolod invaziuri – adreuli angiografia da revaskularizacia (Tu es<br />
SesaZlebelia). rogor ganvsazRvroT romel risk jgufs miekuTvneba pacienti?<br />
amisaTvis mowodebulia yvelaze farTod gamoyenebuli Semdegi ori cxrili:<br />
9
cxrili 1<br />
sikvdilianobis moklevadiani riski an arafataluri <strong>miokardiumis</strong> <strong>infarqti</strong><br />
pacientebSi <strong>arastabiluri</strong> stenokardiiT<br />
maxasiaTeblebi<br />
anamnezi<br />
tkivilis<br />
xasiaTi<br />
klinikuri<br />
monacemebi<br />
maRali riski<br />
CamoTvlili<br />
maxasiaTeblebidan sul<br />
mcire erTi mainc aris<br />
warmodgenili<br />
iSemiuri simptomebis<br />
aqseleracia bolo 48<br />
saaTSi<br />
gaxangrZlivebuli<br />
mimdinare tkivili<br />
(>20wT) mosvenebis<br />
mdgomareobaSi<br />
filtvis SeSupeba<br />
dakavSirebuli,<br />
iSemiasTan. axlad<br />
aRmocenebuli an<br />
gauaresebuli MR<br />
Suili S3 an axali/<br />
gauaresebuli xixini<br />
filtvebSi, hipotenzia,<br />
bradikardia,<br />
taqikardia, asaki<br />
>75welze<br />
ekg monacemebi mosvenebis stenokardia<br />
<strong>ST</strong> <strong>segmentis</strong> tranzitoruli<br />
cvalebadobiT<br />
>0,05 mV, hisis konis<br />
blokada, axali an<br />
savaraudod axali<br />
myari(gaxangZlivebuli)<br />
parku-Wovani<br />
kardialuri<br />
markerebi<br />
taqikardia<br />
momatebuli (mag. TnT an<br />
TnI >0,1 ng/mL) †<br />
saSualo riski<br />
warmodgenili unda iyos<br />
CamoTvlili<br />
maxasiaTeblebidan 1<br />
(ara-maRali riskis)<br />
gadatanili MI,<br />
periferiuli an<br />
cerebrovaskularuli<br />
daavadeba, an CABG;<br />
anamnezSi aspirinis<br />
gamoyeneba<br />
gaxangrZlivebuli<br />
(>20wT) stenokardia<br />
mosvenebis mdgomareobaSi,<br />
amJamad moxsnili.<br />
saSualo an didi<br />
msgavsebiT CHD-sTan,<br />
stenokardia mosvenebis<br />
mdgomare-obaSi (70welze<br />
T-kbilis inversia > 0,2<br />
mV, paTologiuri Q<br />
kbili<br />
msubuqad momatebuli<br />
(mag. TnT>0.01, magram<br />
0,4 ng/ml-Si. 0,1 dan 0,4 mde igi iTvleba rogorc saSualo riskis markeri.<br />
cTnT ganisazRvreba iseve rogorc mocemul cxrilSi.<br />
10
qula<br />
0 / 1<br />
2<br />
3<br />
4<br />
5<br />
6 / 7<br />
riskis Sefasebis erT-erTi popularuli sqema (T IMI)<br />
sikvdilianoba, axali an ganmeorebiTi<br />
<strong>infarqti</strong>, ganmeorebiTi iSemia da/an<br />
revaskularizacia<br />
4,7 %<br />
8,3 %<br />
13,2 %<br />
19,9 %<br />
26,2 %<br />
40,9 %<br />
1 qula _ roca aris risk faqtori da 0 qula _ roca ar aris:<br />
asaki > 65w.<br />
≥3 gulis koronaruli daavadebis risk-faqtori<br />
koronaruli stenozi ≥ 50%-ze<br />
<strong>ST</strong> <strong>segmentis</strong> deviacia e.k.g-ze miRebisas<br />
≥2 anginuri epizodisa bolo 24-sT-Si<br />
aspirinis miReba bolo 7 dRis ganmavlobaSi<br />
momatebuli gulis biomarkerebi<br />
cxrili 2<br />
aris aseve mravali sxvadasxva sqema riskis SefasebisTvis AU/N<strong>ST</strong>EMI-s dros, magram<br />
Cvens mier amorCeulia maT Soris 2 yvelaze popularuli<br />
am cxrilebidan naTlad Cans, rom riskis stratifikaciisTvis aucilebelia:<br />
1) eleqtrokardiografia, 2) sisxlSi <strong>miokardiumis</strong> enzimebis donis gansazRvra.<br />
eleqtrokardiografia<br />
12-ganxriani ekg asrulebs centralur rols iSemiuri diskomfortis Sefasebisa da<br />
mkurnalobis saqmeSi. misi Cawera gansakuTrebiT Rirebulia simptomTa arsebobis<br />
dros. ra tipis cvlilebia mosalodneli ekg–ze? <strong>ST</strong>-<strong>segmentis</strong> tranzitoruli<br />
depresia > 0,5 mm-ze (iSviaTad <strong>ST</strong>-<strong>segmentis</strong> tranzitoruli elevacia). standartul<br />
12-ganxrian ekg-ze <strong>ST</strong>-<strong>segmentis</strong> depresia yovelTvis gamoricxavs <strong>miokardiumis</strong><br />
infarqts <strong>ST</strong>-<strong>segmentis</strong> elevaciiT, garda izolirebuli ukana kedlis <strong>infarqti</strong>sa,<br />
roca <strong>ST</strong>-<strong>segmentis</strong> depresiaa V1-3 ganxrebSi da/an <strong>ST</strong>-<strong>segmentis</strong> elevaciaa gulmkerdis<br />
ukana ganxrebSi. T kbilis simetriuli inversia > 0.2 mv-ze prekordialur ganxrebSi<br />
mkacrad miuTiTebs mwvave iSemiaze. paTologiuri Q kbilebi > 0.04 sek.-ze miuTiTebs<br />
11
gadatanil <strong>miokardiumis</strong> infarqtze da Sesabamisad gvexmareba diagnozis dasmaSi.<br />
izolirebuli QQ kbili III ganxraSi, rogorc wesi, gvxvdeba normaSic, gansakuTrebiT<br />
Tu mas ar axlavs repolarizaciis darRveva romelime qvemo ganxraSi. Aaucileblad<br />
aRsaniSnavia, romNnormaluri ekg ar gamoricxavs <strong>arastabiluri</strong> stenokardiis<br />
diagnozs.<br />
sisxlSi <strong>miokardiumis</strong> enzimebi<br />
<strong>miokardiumis</strong> enzimebis dones sisxlSi aqvs didi mniSvneloba rogorc diagnozis<br />
dasasmelad, aseve prognozis Sesafaseblad. gamoiyeneba Semdegi markerebi:<br />
troponinebi, kreatinkinazas - MB fraqcia, mioglobini.<br />
troponinebi _ M<strong>miokardiumis</strong> troponinebi arian miocitebis nekrozis specifiuri da<br />
sensitiuri markerebi. troponinebi gamoiyeneba ara mxolod diagnostikuri mizniT,<br />
aramed prognozuli mizniTac. Aam mizniT gamoyenebuli troponini I iTvleba maRali<br />
riskis markerad, maSin roca igi > 0,4 ng/ml-Si. 0,1-dan 0,4-mde igi iTvleba, rogorc<br />
saSualo riskis markeri. Ddiagnostikuri Rirebuleba troponini T-Tvis aris >0.01<br />
ng/ml-Si. Aaucilebelia troponinebis sisxlSi gamoTavisuflebis dinamikis codna.<br />
magaliTad, Tu pacienti Semodis klinikaSi simptomebis dawyebidan 6 saaTze nakleb<br />
droSi, mas SeiZleba hqondes troponinebis normaluri done sisxlSi, miuxedavad<br />
imisa, rom is maRali risk-jgufis pacientia. sisxlSi troponini matebas iwyebs<br />
miocitebis nekrozidan 6-sT-Si da piks aRwevs 36-sT-Si. aucilebelia troponinis<br />
pirveli analizi gakeTdes pacientis miRebisTanave da ganmeorebiTi analizi 6-12<br />
saaTis Semdeg.<br />
kreatinkinaza _ kreatinkinazas mb fraqcia gamoiyeneba rogorc miocitebis nekrozis<br />
markeri. CK-MB–is specifiuroba SedarebiT dabalia, misi elevacia SeiZleba<br />
gamoiwvios ConCxis kunTebis seriozulma dazianebamac. rogorc cnobilia,<br />
troponini momatebulia sisxlSi <strong>miokardiumis</strong> dazianebidan 2 kviris Semdegac,<br />
xolo CK-MB normas ubrundeba <strong>infarqti</strong>dan daaxloebiT 2 dReSi, Sesabamisad misi<br />
diagnostikuri Rirebuleba mkveTrad izrdeba re<strong>infarqti</strong>s diagnostirebisTvis.<br />
mioglobini _ is aRmoCenilia rogorc miokardiumSi, ise ConCxis kunTebSi,<br />
Sesabamisad mioglobini ar aris <strong>miokardiumis</strong> specifiuri cila. <strong>miokardiumis</strong><br />
nekrozidan daaxloebiT 2 saaTSi iwyeba misi gamoTavisufleba sisxlSi anu sanam<br />
troponini da CK-MB daiwyebs matebas. <strong>miokardiumis</strong> <strong>infarqti</strong>s diagnozis<br />
dasasmelad mioglobinis izolirebuli mateba ar aris sakmarisi, is unda<br />
ganvixiloT, rogorc damatebiTi diagnostikuri saSualeba. Tumca, tkivilis<br />
epizodidan 4-8 saaTSi sisxlSi dabali mioglobini sakamarisia <strong>miokardiumis</strong><br />
<strong>infarqti</strong>s gamosaricxad - misi maRali sensitiurobis gamo.<br />
12
damateba 1. aRebulia <strong>miokardiumis</strong> <strong>infarqti</strong>s <strong>ST</strong> elevaciiT gaidlainis sruli teqstidan<br />
uwyveti wiTeli aris gulis troponini, romelic matebas iwyebs 6-sT-Si da piks 36-sT-Si aRwevs.<br />
(reperfuziis dros wiTeli wyvetili xazi piki ufro adrea 20-24 sT-Si). CK-MB aseve matebas iwyebs 6sT-Si<br />
da piks 20-24-sT-Si aRwevs. uwyveti mwvane. (reperfuziisas igi piks 16-18-sT-Si aRwevs). unda<br />
aRiniSnos, rom cTnI momatebuli rCeba 7-10 dRe xolo cTnT 10-14 dRe reperfuziis <strong>gareSe</strong> CK-MB<br />
reperfuziis <strong>gareSe</strong> normas 2 dReSi ubrundeba<br />
Mmarkerebi MI-s gamosavlenad<br />
markeri sawyisi Sefaseba<br />
MI-s Semdgom<br />
E<strong>elevaciis</strong> saSualo<br />
piki MI-s Semdgom<br />
sabaziso monacemebTan<br />
dabrunebis dro<br />
Myoglobin 1 - 4 sT 6 sT 18 - 24 sT<br />
CK-MB 3 - 12 sT 10 - 24 sT 48 - 72 sT<br />
MBisoforms<br />
1 - 6 sT 4 - 12 sT 38 sT<br />
cTnI 3 - 12 sT 10 - 24 sT 5 - 10 dRe<br />
cTnT 3 - 12 sT 12 - 24 sT 5 - 14 dRe<br />
testebi kardialuri markerebisaTvis<br />
markeri < 6 sT 6 - 12 sT 12 - 24 sT 24 - 48 sT > 48 sT<br />
Myoglobin +++ + - - -<br />
Troponin I + ++ +++ +++ +++<br />
Troponin T + ++ +++ +++ +++<br />
CK-MB + ++ +++ - -<br />
MB- isoforms ++<br />
qvemoT moyvanil cxrilSi naCvenebia TiToeuli enzimis nakli da upiratesoba<br />
meoresTan SedarebiT (cxrili #3)<br />
13
cxrili 3<br />
bioqimiuri kardialuri markerebi savaraudod ACS-is mqone 12-ganxrian ekg-ze <strong>ST</strong><strong>segmentis</strong><br />
<strong>elevaciis</strong> <strong>gareSe</strong> pacientebis Sefasebisa da mkurnalobisaTvis<br />
markeri<br />
kardialuri<br />
troponinebi<br />
CK-MB<br />
mioglobini<br />
testirebis<br />
SesaZlebloba<br />
diax<br />
diax<br />
upiratesoba<br />
diax 1. riskis gansazRvris<br />
Zlieri<br />
saSualeba<br />
2. CK-MB-ze<br />
mgrZnobiare da<br />
specifikuri<br />
3. MI-is asaxva<br />
2 kviris<br />
ganmavlobaSi<br />
1. swrafi, xelmisawvdomi<br />
fasiT, zusti<br />
kvleva<br />
2. dreuli<br />
reinfarqtebis<br />
aRmoCenis<br />
SesaZlebloba<br />
1. maRali<br />
mgrZnobeloba<br />
2.MI-is adreul<br />
periodSi<br />
amosacnobad<br />
3. reperfuziis<br />
amocnoba<br />
4. ufro<br />
Rirebulia MIis<br />
gamosaricxad<br />
nakli<br />
1. dabali<br />
mgrZnobeloba<br />
MI-is Zalian adreul<br />
fazaSi (
ekomendaciebi iSemiur simptomTa eqscerebraciis arakardialuri mizezebis<br />
dasadgenad<br />
sawyisi gamokvlevis erT-erT mizans warmoadgens <strong>miokardiumis</strong> iSemiis potenciuri<br />
damaCqarebeli mizezebis gansazRvra (mag. arakontrolirebadi hipertenzia an<br />
Tireotoqsikozi), sxva kardialuri daavadebebis arseboba (mag. aortuli stenozi an<br />
hipertrofiuli kardiomiopaTia) da Tanmxlebi paTologiuri mdgomareobebis dadgena<br />
(mag. pulmonaruli daavadebebi) da maTi gavlenis dadgena iSemiis dinamikaze.<br />
klasi I<br />
1. savaraudo ACS-is mqone pacientebis Sefaseba unda moicavdes arakoronaruli<br />
mizezebis Ziebas, romliTac SesaZlebelia simptomTa eqscerebraciis axsna.<br />
damateba: 2 <strong>arastabiluri</strong> stenokardiis klasifikacia braunvaldis mixedviT<br />
klasi<br />
I<br />
II<br />
III<br />
A<br />
B<br />
C<br />
maxasiaTeblebi<br />
datvirTvis angina/stenokardia: 1. axlad dawyebuli, mkacri 2. romelic<br />
dawyebulia < 2-Tveze. 3. romelic xSirdeba. 4. romelic iwyeba nakleb<br />
fizikur datvirTvaze. 4. ar aRiniSneba mosvenebisas<br />
mosvenebis angina/stenokardia, qvemwvave: mosvenebis stenokardia bolo Tvis<br />
ganmavlobasi magram ara bolo 48-sT-is ganmavlobaSi<br />
mosvenebis angina/stenokardia, mwvave: mosvenebis stenokardia bolo 48-sT-is<br />
ganmavlobaSi<br />
meoradi <strong>arastabiluri</strong> stenokardia/angina: gamowveulia arakardiogenuri<br />
mizezebiT, rogoricaa: anemia, infeqcia, Tireotoqsikozi, hipoqsemia.<br />
pirveladi <strong>arastabiluri</strong> stenokardia/angina<br />
postinfarqtuli <strong>arastabiluri</strong> stenokardia/angina<br />
15
gadaudebeli mkurnaloba (sqema #2)<br />
rekomendaciebi:<br />
klasi<br />
1. anamnezi, fizikaluri gamokvleva, 12 arxiani ekg da kardialuri markerebis<br />
testebi unda iyos Sefasebuli mkerdis areSi tkivilis mqone pacientebSi.<br />
mdgomareoba fasdeba Semdegi 4 kategoriiT: arakardialuri diagnozi,<br />
qronikuli stabiluri stenokardia, savaraudo AACS da dadgenili ACS.<br />
2. pacientebi dadgenili an savaraudo ACS-iT, romelTa 12-ganxriani ekg da<br />
kardialuri markerebis done normaluria unda imyofebodnen kardialuri<br />
monitoringis qveS da ekg da kardialur markerTa gansazRvra unda CautardeT<br />
ganmeorebiT 6-12 saaTze simptomTa ganviTarebidan.<br />
3. pacientebSi, gulis iSemiuri daavadebiT an eWviT masze, Tu 12-ganxriani ekg da<br />
kardialuri markerebis ganzomilebebi normaSia, unda Catardes iSemiis<br />
provokaciuli stres-testi (fizikuri an farmakologiuri datvirTva). dabali<br />
riskis mqone pacientebs, uaryofiTi stres-testiT, SesaZloa mkurnaloba<br />
CautardeT ambulatoriulad.<br />
4. pacientebi dadgenili ACS-iT da mimdinare tkivilebiT, dadebiTi kardialuri<br />
markerebiT, axlad aRmocenebuli <strong>ST</strong>-segmenturi deviaciebiT, axlad<br />
ganviTarebuli T-kbilebiT, hemodinamikuri darRvevebiT an dadebiTi strestestiT<br />
unda moTavsdnen stacionarSi.<br />
5. pacientebs, savaraudo ACS-iT da uaryofiTi kardialuri markerebiT,<br />
romlebsac ar SeuZliaT fizikuri datvirTva an aqvT paTologiuri ekg<br />
cvlilebebi unda CautardeT farmakologiuri stres testi.<br />
6. pacientebSi aSkara ACS-iT da <strong>ST</strong> <strong>segmentis</strong> elevaciiT unda daisvas sakiTxi<br />
gadaudebeli reperfuziuli Terapiis Sesaxeb. L<br />
16
ACS Sefasebis da mkurnalobis algoriTmi<br />
arakardiologi<br />
uri diagnozi<br />
umkurnaleT<br />
Sesabamisad<br />
alternatuli<br />
diagnoziT<br />
ambulatoriuli<br />
meTvalyureoba<br />
qronikuli<br />
stab. angina<br />
naxeT AHA/ACC<br />
gaidi qr.<br />
stabiluri<br />
anginisaTvis<br />
SesaZlo mwvave<br />
kor. sindromi<br />
ganmeorebiTi angina araa.<br />
Semdgomi kvlevebi negatiuria<br />
stress gamokvleva (SeafaseT LV funqcia, testi gaweris win an Semdeg)<br />
negatiuri: potenciuri<br />
diagnozebia: araiSemiuri<br />
da dabali riskis ACS<br />
pozit. diagnozi<br />
dadasturda<br />
aSkara ACS<br />
<strong>ST</strong> elevacia ara gvaqvs <strong>ST</strong> elevacia<br />
aris<br />
aradiagnosti<br />
kuri e.k.g.<br />
normaluri<br />
sawyisi<br />
Sratis<br />
gulis<br />
markerebi<br />
daakvirdi<br />
Semdgomi 4-8<br />
sT. gadaiRe:<br />
e.kg. Seamowme<br />
gulis<br />
markerebi<br />
ganmeorebiTi angina an pozit<br />
gamokvlevebi: diagnoz dadasturda<br />
<strong>ST</strong>/T talRis<br />
cvlilebebi,<br />
mimdinare anginuri<br />
tkivili, pozitiuri<br />
gulis markerebi<br />
hemodinamikuri<br />
arastabiluroba<br />
moaTavseT hospitalSi umkurnaleT<br />
rogorc UA/N<strong>ST</strong>EMI-s<br />
SeafaseT<br />
reperfuziul<br />
iTerapiisaTv<br />
is<br />
naxeT <strong>ST</strong>EMIs<br />
gaidlaini<br />
AHA/ACC<br />
sqema #2<br />
17
stacionaruli mkurnaloba<br />
a) antiiSemiuri Terapia<br />
<strong>arastabiluri</strong> stenokardiis da <strong>ST</strong>-<strong>segmentis</strong> <strong>elevaciis</strong> <strong>gareSe</strong> mimdinare<br />
<strong>miokardiumis</strong> <strong>infarqti</strong>s samkurnalod gamoiyeneba Semdegi jgufis medikamentebi:<br />
1) nitratebi; 2) morfinis sulfati; 3) beta blokerebi; 4) kalciumis<br />
antagonistebi; 5) antiagregantebi; 6) antikoagulantebi.<br />
nitratebi<br />
nitroglicerini iwvevs venodilatacias, Sesabamisad amcirebs predatvirTvasa da<br />
parkuWis kedlis daWimulobas. rac iwvevs Jangbadze moTxovnilebis Semcirebas.<br />
aseve iwvevs arteriolebis dilatacias, amcirebs postdatvirTvas da amiT<br />
mciredeba moTxovnileba Jangbadze. nitroglicerini iwvevs rogorc normaluri<br />
ise aTeroskleroziT dazianebuli koronarebis dilatacias da amiT zrdis<br />
Jangbadis miwodebas. stenokardiis mosaxsnelad dauyonebliv unda iqnes micemuli<br />
nitroglicerini sublingvalurad tabletis an spreis saxiT. Tu simptomebi ar<br />
moixsna 3 tableti 0.4 mg. nitroglicerinis an spreis Semdeg (intervali<br />
tabletebs Soris 5 wuTi) unda daiwyos nitroglicerinis intravenuri infuzia,<br />
sawyisi siCqare 10 mkg/wuTSi, momateba SeiZleba yovel 5 wuTSi 10mkg-iani<br />
inkrementebiT sanam ar gaivlis tkivili an ar ganviTardeba gverdiTi efeqtebi:<br />
Tavis tkivili an hipotonia. stabilur pacientebSi sasurvelia 24 saaTSi i/v<br />
nitroglicerini Seicvalos peroraluri formiT. Nnitroglicerinis gadasxmis<br />
siCqaris kleba unda moxdes TandaTanobiT.<br />
morfinis sulfati<br />
aris efeqturi saSualeba stenokardiuli tkivilis mosaxsnelad. Ggamoiyeneba<br />
nitroglicerinis samjeradi uefeqto xmarebis Semdeg doziT 1-5 mg intravenurad.<br />
gameoreba SeiZleba yovel 5-30 wuTSi tkivilis moxsnamde. GgverdiTi efeqtebidan<br />
aRsaniSnavia gulisreva, pirRebineba, hipotenzia; romelTa marTvisTvis<br />
aucilebelia pacientis gadayvana trendelnburgis poziciaSi, intravenurad<br />
fiziologiuri xsnaris gadasxma da/an atropinis i/v Seyvana. gverdiTi<br />
efeqtebidan Zalzed iSviaTia sunTqvis depresia, romlis samkurnalodac SeiZleba<br />
saWiro gaxdes meqanikuri ventilacia da/an naloqsonis i/v Seyvana.<br />
beta-blokerebi<br />
iwveven beta-receptorebis blokadas gulSi da amcireben gulis SekumSvaTa<br />
sixSires, arteriul wnevas, kumSvadobas, riTac amcireben Jangbadze <strong>miokardiumis</strong><br />
moTxovnilebas.<br />
maRali riskis pacientebSi beta-blokerebi unda dawyebul iqnas intravenurad da<br />
gagrZeldes peroralurad. amisaTvis mowodebulia Semdegi sqemebi: intravenurad<br />
metoprololis Seyvana iwyeba 5 mg pirveli doza 1-2 wuTis ganmavlobaSi, 5 wuTSi<br />
isev 5 mg da ase Semdeg totalur gajerebis dozamde - 15 mg-mde. Bbolo<br />
dozidan 15 wuTSi iwyeba oraluri Terapia metoprololiT doza 25-50 mg yovel 6<br />
saaTSi (48 saaTis ganmavlobaSi), Semdeg mkurnaloba grZeldeba doziT 100 mg<br />
orjer dReSi. intravenuri propranololisTvis mowodebulia Semdegi sqema:<br />
sawyisi intravenuri dozaa 0,5 -1 mg, romelic 1-2 saaTis Semdeg grZeldeba<br />
peroralurad 40 - 80 mg yovel 6 – 8 saaTSi. Ddabali da saSualo riskis<br />
pacientebSi beta-blokerebis dawyeba SeiZleba peroralurad.<br />
18
eta-blokerebis xmarebis ukuCvenebebia: pirveli (>24ms), II-III xarisxis<br />
atrioventrikuluri blokada, asTma, mZime marcxena parkuWovani ukmarisoba,<br />
sinusuri bradikardia ( < 50 ze) , hipotenzia (sistoluri wneva < 90 ze).<br />
kalciumis arxebis antagonistebi<br />
arian koronarebis dilatatorebi, maTi erTi nawili upiratesad moqmedebs<br />
periferiul sisxlZarRvebze da iwvevs maT dilatacias (dihidropiridinebi).<br />
meore nawili moqmedebs gulze da amcirebs gulis SekumSvaTa sixSires, zrdis<br />
atrioventrikuluri gatarebis dros (verapamili, dilTiazemi). kvlevebis mixedviT<br />
ar iqna nanaxi am jgufis preparatebis sasikeTo gavlena daavadebis gamosavalze,<br />
piriqiT dihidropiridinebi zrdian garTulebebs Tu gamoiyenebian betablokerebis<br />
<strong>gareSe</strong>. am jgufis preparatebis gamoyenebis Cvenebebi mocemulia<br />
qvemoT.<br />
rekomendaciebi<br />
klasi I<br />
1. woliTi reJimi pacientebSi, romelTac aReniSnebaT mosvenebis stenokardia.<br />
iSemiisa da ariTmiis aRmosaCenad saWiroa uwyveti ekg monitoringi;<br />
2. sublingvaluri da SemdgomSi intravenuri NTG-i iSemiis da masTan<br />
dakavSirebuli simptomebis swrafi moxsnisaTvis;<br />
3. Jangbadis micema pacientTaTvis cianoziT an respiratoruli distresiT.<br />
TiTis puls-oqsimetri, raTa ganisazRvros adeqvaturia Tu ara<br />
oqsigenizacia (SO2 > 90%-ze.) da Jangbadis miwodebis gagrZelebis saWiroeba;<br />
4. intravenurad morfinis sulfati, rodesac simptomebi ar ixsneba NTG-iT an<br />
saxezea mwvave pulmonaruli Segubeba;<br />
5. beta-blokerebi, mimdinare tkivilis dros pirveli doza intravenurad,<br />
xolo Semdgomi peroralurad, ukuCvenebebis ararsebobisas;<br />
6. aradihidropiridinis jgufis kalciumis antagonisti (mag. verapamili an<br />
dilTiazemi) marcxena parkuWis mZime disfunqciis an sxva ukuCvenebebis<br />
ararsebobisas pacientebSi, mimdinare da xSirad morecidive iSemiiT,<br />
rodesac beta-blokerebi ukunaCvenebia;<br />
7. ACE inhibitorebi, rodesac hipertenzia persistirebs miuxedavad NTG-iT da<br />
beta-blokebiT mkurnalobisa pacientebSi: LV sistoluri disfunqciiT an<br />
CHF-iT da ACS-s dros pacientebSi, romlebsac aqvT diabeti.<br />
klasi II A<br />
1. peroraluri gaxangrZlivebuli moqmedebis kalciumis antagonistebi<br />
recidiuli iSemiis dros, ukuCvenebaTa ararsebobisas da rodesac betablokerebi<br />
da nitratebi sruladaa gamoyenebuli;<br />
2. ACE inhibitorebi yvela pacientebSi ACS-s Semdgom.<br />
19
klasi II B<br />
1. gaxangrZlivebuli moqmedebis aradihidropiridinis jgufis kalciumis<br />
antagonistebi, (gaxangZlivebuli moqmedebis verapamili an diltiazemi)<br />
nacvlad beta-blokerebisa.<br />
2. swrafi moqmedebis dihidropiridinis jgufis kalciumis antagonistebi<br />
(nifedipini) beta-blokerebTan erTad.<br />
klasi III<br />
1. NTG an sxva nitratis 24 saaTiani gamoyeneba;<br />
2. swrafi moqmedebis dihidropiridinis jgufis kalciumis antagonistebi (mag:<br />
nifedipini) beta-blokerebis <strong>gareSe</strong>.<br />
b) antiTrombocitaruli da antiTrombozuli Terapia<br />
antiTrombocitaruli da antiTrombozuli Terapia mniSvnelovania daavadebis<br />
procesis modificirebisTvis da <strong>miokardiumis</strong> <strong>infarqti</strong>s, ganmeorebiTi <strong>infarqti</strong>s da<br />
sikvdilianobis Tavidan asacileblad. kombinireba aspirinis (ASA), klopidogrelis<br />
da UFH an LMWH warmoadgens yvelaze efeqtur Terapias. Trombocitebis<br />
glikoproteini GPIIb/IIIa receptoris antagonisti gamoyenebul unda iqnas pacientebSi<br />
maSin, roca iSemia grZeldeba an pacientebSi maRali risk-faqtorebiT, romlebSic<br />
igegmeba invaziuri midgoma. iq, sadac ukunaCvenebia ASA, unda moxdes klopidogrelis<br />
gamoyeneba. sisxldenis maRali riskis ararsebobis SemTxvevaSi, aspirinis da<br />
klopidogrelis miReba unda moxdes PCI-mde da igi unda gagrZeldes sul mcire<br />
erTi Tve stentirebis Semdeg. (sasurvelia zog SemTxvevebSi ufro xangZlivadac,<br />
rasac Semdgom gaidlainebSi ganvixilavT) aspirinis gagrZeleba xdeba<br />
ganusazRvreli periodis ganmavlobaSi.<br />
aspirini<br />
cxrili 4<br />
antiTrombocituli da antiTrombozuli mkurnalobis klinikuri gamoyeneba<br />
klopidrogeli<br />
sawyisi dozaa 162-325 mg aranawlavuri formis ASA da SemdgomSi 75-165<br />
mg/dReSi nawlavuri an ara nawlavuri konfiguraciiT damzadebuli<br />
4-8 abi dartymiTi doza (300-600mg) roca gvinda miviRoT swrafi efeqti<br />
tiklopidini 250 mg 2-jer dReSi. dartymiTi dozaa 500 mg<br />
enoqseparini<br />
heparini UFH<br />
absiqsimabi<br />
1 mg/kg-ze kanqveS 12-sT-Si erTxel pirveli dozas SeiZleba win uswrebdes<br />
30 mg I/V bolusiT<br />
bolusi IV 60-70 U/kg (maqsimum 5000U) da 12-15 U/kg sT-Si (maqsimaluri doza<br />
1000 U/sT) aPTT-is kontroliT (1,5-2,5-iT meti sakontrolosTan SedarebiT)<br />
0,25 mg/kg IV bolusiT da Semdeg infuzia 0,125 mkg/kg/wT-Si ( maqs. 10 mkg/wT-<br />
Si) 12-24 sT-is ganmavlobaSi<br />
eptifibatidi 180 mkg bolusi da Semdeg 2 mkg/kg/wT-Si 72-96-sT.<br />
tirifibani<br />
0,4 mkg/kg/wT-Si 30 wT-i da 0,1 mkg/kg/wT 48-96-sT<br />
20
heparini (UFH an dabal molekuluri wonis heparini (LMWH)) warmoadgens sakvanZo<br />
komponents UA/N<strong>ST</strong>EMI–is antiTrombozuli mkurnalobisaTvis. UFH-is dozis<br />
titrireba unda moxdes aPTT-is mixedviT (1,5-2,5-jer meti sakontroloze). LMWH-is<br />
upiratesobas warmoadgens misi xmarebis simartive da monitoringis saWiroebis<br />
ararseboba. aseve, LMWH ufro naklebad astimulirebs Trombocitebs, vidre UFH da<br />
naklebad aris asocirebuli hepariniT gamowveul TrombocitopeniasTan (HIT).<br />
miuxedavad amisa, mas xSirad ukavSirdeba mniSvnelovnad gamoxatuli mcire (magram<br />
ara didi) sisxldenebi. rodesac Trombocitebi aqtiurdebian, GP IIb/IIIa receptori<br />
gadis konfiguraciis cvlilebas, rac iwvevs receptoris mier fibronogenis<br />
SeboWvas da Trombocitebis agregacias. GP IIb/IIIa antagonistebis efeqturoba PCI-s<br />
dros damtkicda mravali kvlevebiT, romelTagan umravlesoba moicavda srulad an<br />
didi nawiliT UA-s mqone pacientebs. kvlevebSi tirofibaniT da erT kvlevaSi<br />
eftifibatidiT naCvenebi iyo maTi efeqturoba UA/N<strong>ST</strong>EMI–is mqone pacientebSi,<br />
maTgan mxolod ramodenimem gaiara kanqveSa intervenciuli Careva. PCI kvlevebSi,<br />
abisiqsimabis sistematiurma gamoyenebam aCvena MI–is da urgentuli<br />
revaskularizaciis Semcireba.<br />
GP IIb/IIIa blokirebiT mkurnaloba zrdis sisxldenis risks, romelic tipiurad<br />
mukokutaneuria an moicavs vaskularuli intervenciis midgomis adgils. unda moxdes<br />
sisxlSi hemoglobinis da Trombocitebis raodenobis monitoringi da pacientebSi<br />
sisxldenis ararseboba unda dadgindes yoveldRiurad GP IIb/IIIa blokirebis<br />
gadasxmis ganmavlobaSi.<br />
rekomendaciebi:<br />
zogadad SeiZleba iTqvas rom mwvane koronaruli sindromis dros (ACS ) heparini<br />
ixmareba saSualod 2-3 dRidan 7-8 dRemde. UFH-is-i/v infuziisas aPTT narCundeba 50-70is<br />
farglebSi.<br />
klasi I<br />
1. antiTrombocituli mkurnaloba unda daiwyos dauyonebliv. ASA eZleva rac<br />
SeiZleba adre simptomebis gamovlinebidan da grZeldeba ganusazRvreli<br />
vadiT.<br />
2. klopidogreli unda dainiSnos im hospitalizirebul pacientebSi, romlebsac<br />
ar SeuZliaT ASA-s miReba momatebuli hipermgrZnobelobis an mZime (didi)<br />
gastrointestinuli garTulebebis gamo.<br />
3. hospitalizebul pacientebSi, romlebTanac adreuli araintervenciuli<br />
midgomaa (miuxedavad maRali riskis niSnebisa invaziuri Careva ar<br />
xorcieldeba raime mizezis gamo), klopidogreli unda daematos ASA-s, rac<br />
SeiZleba male stacionarSi moxvedrisas da gagrZeldes sul mcire 1 Tve,<br />
(sasurvelia 9 Tvis ganmavlobaSi).<br />
4. pacientebSi, romelTanac igegmeba PCI, klopidogreli unda iyos dawyebuli da<br />
grZeldeba sul mcire 1 Tve, da sasurvelia 9 Tvis ganmavlobaSi im<br />
pacientebSi, romelTac ar aqvT sisxldenis maRali riski.<br />
5. pacientebSi, romlebic iReben klopidogrels da unda CautardeT CABG, Tu<br />
SesaZlebelia preparati unda moixsnas sul mcire 5 dRiT (umjobesia 7-iT)<br />
adre.<br />
21
6. antikoagulacia kanqveSa LMWH-iT an intravenuri arafraqciuli hepariniT<br />
(UFH) unda daematos ASA-Ti da /an klopidogreliT antiTrombocitarul<br />
mkurnalobas.<br />
7. Trombocitis GP IIb/IIIa antagonisti unda iqnas damatebuli ASA da heparinTan<br />
erTad pacientebSi, romelTanac dagegmilia kaTeterizacia da PCI. GP IIb/IIIa<br />
antagonisti aseve SesaZloa Seyvanili iyos uSualod PCI-is win.<br />
klasi II A<br />
1. enoqsaparini umjobesia UFH-ze, rogorc antikoagulanti Tirkmlis ukmarisobis<br />
ararsebobis SemTxvevaSi da Tu CABG ar igegmeba 24 saaTis ganmavlobaSi.<br />
klasi III<br />
1. intravenuri fibrinolizuri Terapia pacientebSi mwvave <strong>ST</strong> <strong>segmentis</strong><br />
<strong>elevaciis</strong>, WeSmariti ukana kedlis MI-is an savaraudod axali LBBB-is <strong>gareSe</strong>.<br />
2. absiqsimabis miReba pacientebSi, romlebSic PCI ar igegmeba.<br />
g) riskis gansazRvra<br />
ACS-is mqone pacientTa mkurnaloba moiTxovs periodulad riskis Sefasebas.<br />
arainvaziuri testirebis mizans warmoadgens CHD-is dadastureba an uaryofa<br />
pacientebSi CHD-is arsebobis dabali riskiT da maTSi prognozis Sefaseba.<br />
standartulia datvirTvis ekg stres-testi: simartivis, dabali fasis, farTod<br />
gavrcelebulobis gamo pacientebSi, romelTa mosvenebis kardiograma saSualebas<br />
gvaZlevs movaxdinoT misi Sedareba datvirTvis ekg-sTan da SeuZliaT fizikuri<br />
datvirTvis atana, xolo misi SeuZleblobis dros tardeba farmakologiuri<br />
gamosaxulebiTi stres-testi.<br />
rekomendaciebi:<br />
klasi I<br />
1. arainvaziuri stres-testireba dabali riskis mqone pacientebSi (cxrili 1),<br />
romelTac ara aReniSnebaT iSemia mosvenebis an mcire fizikuri aqtivobisas an<br />
Tu CHF ar aris gamoxatuli 12-24 saaTis ganmavlobaSi.<br />
2. arainvaziuri stres-testireba saSualo riskis mqone pacientebSi (cxrili 1),<br />
romelTac ara aqvT iSemia mosvenebis an mcire fizikuri aqtivobisas an Ty CHF<br />
ar aris gamoxatuli minimum 2-3 dReSi.<br />
3. stres-testis arCeva dafuZnebulia mosvenebis ekg-ze, datvirTvis unarze,<br />
lokalur gamocdilebasa da teqnologiur SesaZleblobaze.<br />
4. swrafi angiografia arainvaziuri riskis gansazRvris <strong>gareSe</strong>, intensiuri<br />
TerapiiT stabilizaciis SeuZleblobisas.<br />
22
klasi IIA<br />
1. arainvaziuri testi (eqokardiograma an radionukliduri angiograma) marcxena<br />
parkuWis funqciis Sesafaseblad pacientebSi, dadgenili ACS-iT,<br />
romelebSiac araa dagegmili koronaruli angiografia da marcxena<br />
ventrikulografia.<br />
d) adreuli konservatiuli mkurnaloba invaziuri strategiis nacvlad<br />
pacientebSi UA/N<strong>ST</strong>EMI–iT miRebulia 2 sxvadasxva samkurnalo strategia ,,adreuli<br />
konservatiuli” da ,,adreuli invaziuri”. ,,adreuli konservatiuli” strategiis<br />
dros koronaluri angiografia pacientebSi rCeba Cvenebad recidiuli iSemiis dros<br />
(stenokardia an <strong>ST</strong>-<strong>segmentis</strong> cvalebadoba mosvenebis an mcire aqtivobis<br />
mdgomareobaSi) an miuxedavad sruli mkurnalobisa, Tuki stres-testisas<br />
gamovlindeba maRali riskis niSnebi. adreuli invaziuri strategiis dros,<br />
pacientebs, romlebsac ara aqvT koronaruli revaskularizaciis klinikurad<br />
gamoxatuli ukuCvenebebi, rutinulad ewevaT rekomendacia Caitaron adreuli<br />
koronaruli angiografia da revaskularizacia.<br />
pacientebSi UA/N<strong>ST</strong>EMI-iT recidiuli iSemiis <strong>gareSe</strong> pirveli 24 saaTis<br />
ganmavlobaSi, adreuli angiografia mosaxerxebeli midgomaa riskis<br />
gansazRvrisaTvis. mas SeuZlia gansazRvros pacientebi, mniSvnelovani koronaruli<br />
stenozis <strong>gareSe</strong> da isini, romelTac aqvT 3-sisxlZarRvovani paTologia marcxena<br />
parkuWis disfunqciiT an marcxena koronaris ZiriTadi totis paTologia. pirvel<br />
jgufs aqvs SesaniSnavi prognozi, xolo meore jgufis pacientebSi mizanSewonilia<br />
CABG qirurgia. adreuli PCI-is dros mcirdeba hospitalizaciis dro da<br />
mravlobiTi antianginaluri medikamentebis miRebis saWiroeba.<br />
rekomendaciebi:<br />
unda aRiniSnos, rom im SemTxvevebSi, rodesac virCevT adreul invaziur strategias<br />
Cveni samuSao jgufi rekomendacias aZlevs e.w. adreul magram dayovnebul (defered)<br />
PCI anu invaziuri Careva 12-48-sT-Si. es exeba im SemTxvevebs rodesac pacienti<br />
saWiroebs invaziur Carevas, magram mdgomareoba stabiluria. Tuki mdgomareoba<br />
<strong>arastabiluri</strong>a, miuxedavad sruli konservatuli mkurnalobisa, invaziuri Careva<br />
xdeba dauyovnebliv.<br />
klasi I<br />
1. adreuli invaziuri strategia rekomendebulia UA/N<strong>ST</strong>EMI-is mqone pacientebSi<br />
da nebismieri qvemoT CamoTvlili maRali riskis maCveneblis dros: LOE A<br />
recidiuli/ganmeorebiTi stenokardia/iSemia mosvenebis an dabali donis<br />
aqtivobis dros, miuxedavad intensiuri anti-iSemiuri Terapiisa;<br />
momatebuli TnT an TnI;<br />
axali an savaraudod axali <strong>ST</strong> <strong>segmentis</strong> depresia;<br />
recidiuli stenokardia/iSemia CHF-is simptomebiT, S3 galopi, pulmonaruli<br />
SeSupeba, gauaresebuli xixini, an axali an gauaresebuli mitraluri<br />
regulacia;<br />
23
maRali riskis monacemebi arainvaziuri stres-testirebisas;<br />
marcxena parkuWis daqveiTebuli funqcia ( EF< 40%-ze arainvaziuri kvlevis<br />
dros);<br />
hemodinamikuri<br />
hipotenziiT;<br />
arastabiluroba an mosvenebis stenokardia Tanmxlebi<br />
myari parkuWovani taqikardia;<br />
Catarebuli PCI 6 Tvis ganmavlobaSi;<br />
adre Catarebuli CABG<br />
zogadad unda aRiniSnos, rom saSualo riskis dros SesaZlebelia rogorc adreuli<br />
invaziuri, aseve adreuli konservatiuli strategiis gamoyeneba (samuSao jgufis<br />
ganmarteba).<br />
2. am monacemTa ararsebobis dros, rogorc adreuli konservatiuli, iseve<br />
adreuli invaziuri strategia SesaZlebelia hospitalizebul pacientebSi<br />
revaskularizaciis ukuCvenebis <strong>gareSe</strong>.<br />
klasi II A<br />
1. adreuli invaziuri strategia pacientebSi, romelTac miuxedavad Catarebuli<br />
mkurnalobisa aReniSnebaT ACS-i Tumca mas ara aqvs maRali riskis niSnebi da<br />
ar aris xangZlivi.<br />
klasi III<br />
1. koronaruli angiografia pacientebSi mZime TandarTuli daavadebebiT (mag.<br />
RviZlis an filtvis ukmarisoba, kibo), romelTa drosac revaskulaciis<br />
riski aRemateba sargebels.<br />
2. koronaruli angiografia pacientebSi mwvave tkivilebiT gulmkerdis areSi<br />
da ACS-is mcire albaToba.<br />
24
maRali riski<br />
PCI<br />
savaraudo UA/N<strong>ST</strong>EMI-is dros moqmedebis algoriTmi<br />
koronaruli revaskularizacia<br />
savaraudoa UA/N<strong>ST</strong>EMI klinikuri<br />
niSnebis mixedviT<br />
saSualo riski<br />
SesaZlebelia rogorc adreuli invaziuri<br />
aseve adreuli konservatiuli midgoma<br />
maRali saSualo<br />
dabali<br />
dabali riski<br />
vimeorebT<br />
troponins<br />
SesaZlebelia<br />
rogorc adreuli<br />
invaziuri aseve<br />
adreuli<br />
konservatiuli<br />
midgoma/ stres<br />
test- 2-3 dReSi<br />
sqema #3<br />
negatiuri/<br />
dabali<br />
stress testi<br />
SesaZlebelia<br />
gakeTdes 24sT-Si<br />
koronaruli revaskularizacia (PCI an CABG) tardeba prognozis<br />
gasaumjobeseblad, simptomTa Sesamsubuqeblad, iSemiis garTulebaTa<br />
profilaqtikisaTvis da funqcionaluri Sromisunarianobis gasaumjobeseblad.<br />
maRali riskis mqone koronaruli anatomiis mqone pacientebis mdgomareoba<br />
umjobesdeba revaskularizaciis Semdeg (igulisxmeba simptomebi da sicocxlis<br />
xangZlivoba). koronaruli revaskularizaciis Cveneba UA/N<strong>ST</strong>EMI-s dros msgavsia<br />
qronikuli stabiluri stenokardiisa. PCI–is umravlesoba amJamad moicavs<br />
balonur dilatacias koronaruli stentirebiT. stentireba, romelic xSirad Tan<br />
axlavs kaTeterul revaskularizacias, amcirebs sisxlZarRvTa mwvave daxSobis<br />
da gviani restenozis risks. PCI iZleva angiografiul gaumjobesebas pacientTa<br />
umetesobaSi UA/N<strong>ST</strong>EMI-iT. UA/N<strong>ST</strong>EMI-is mqone pacientebSi PCI-sTan erTad<br />
warmatebiT gamoiyeneba GPIIb/IIIa receptoris inhibitorebi. es damokidebulia<br />
imaze, rom Trombocitebi mniSvnelovan rols asrulebs iSemiuri garTulebebisas<br />
PCI-s dros. am proceduraTa usafrTxoeba izrdeba aspirinis, heparinis da<br />
antiiSemiuri preparatebis standartul reJimze intravenuri GPIIb/IIIa receptoris<br />
inhibitorebis damatebiT.<br />
25
a) UA/N<strong>ST</strong>EMI-is dros, PCI da CABG revaskularizacia<br />
klasi I<br />
1. CABG pacientebisaTvis marcxena koronaris ZiriTadi totis mniSvnelovani<br />
dazianebiT.<br />
2. CABG pacientebisaTvis 3-sisxlZarRvovani koronaruli dazianebiT.<br />
sargebloba ufro didia pacientebSi gauaresebuli LV funqciiT (EF< 50%ze)<br />
3. CABG pacientebisaTvis 2-sisxlZarRvovani koronaruli paTologiiT<br />
romelTagan erT-erTi aris marcxena wina daswvrivi totis proqsimaluri<br />
<strong>segmentis</strong> mniSvnelovani paTologia da aRiniSneba gauaresebuli LV<br />
funqcia (EF< 50%-ze) an gamoxatulia iSemia arainvaziuri testirebis dros.<br />
4. PCI da CABG pacientebisaTvis 1 an 2-sisxlZarRvovani koronaruli<br />
paTologiiT romelTac ara aqvT marcxena koronaris wina daswvrivi totis<br />
proqsimaluri <strong>segmentis</strong> dazianeba, magram iSemiuri Tumca moqmedi<br />
<strong>miokardiumis</strong> (viable) zona didia da arainvaziuri testirebisas gvaqvs<br />
maRali riskis kriteriumebi.<br />
5. .PCI pacientebisaTvis multi-sisxlZarRvovani koronaruli dazianebebiT,<br />
stentirebisTvis mosaxerxebeli koronaruli anatomiiT, normaluri LV<br />
funqciiT da diabetis <strong>gareSe</strong>.<br />
6. CABG SigniTa mamaruli arteriiT, pacientebSi multi-sisxlZarRvovani<br />
kornaruli dazianebebiT da namkurnalevi Saqriani diabetiT.<br />
7. intravenuri, GP IIb/IIIa inhibitorebi UA/N<strong>ST</strong>EMI-is mqone pirebSi PCI-is<br />
Catarebisas.<br />
klasi II A<br />
1. PCI an CABG, pacientebSi 1-sisxlZarRvovani koronaruli dazianebiT<br />
romelTagan erT-erTi aris marcxena koronaris wina daswvrivi totis<br />
proqsimaluri <strong>segmentis</strong> mniSvnelovani dazianeba.<br />
klasi II B<br />
1. PCI pacientebSi 2 an 3-sisxlZarRvovani mniSvnelovani koronaruli<br />
dazianebiT, romelTagan erT-erTi aris marcxena koronaris wina daswvrivi<br />
totis proqsimaluri segmenti, pacients aqvs namkurnalevi diabeti an<br />
gauaresebuli LV funqcia da kaTeterizaciisaTvis Sesaferisi anatomia.<br />
klasi III<br />
1. PCI da CABG, pacientebSi romelTac aqvT umniSvnelo koronaruli stenozi<br />
(≤ 50% diametri).<br />
2. PCI pacientebSi marcxena ZiriTadi koronaruli arteriis mniSvnelovani<br />
daavadebiT, romlebic arian CABG-is kandidatebi<br />
26
stacionaridan gawera da post-hospitaluri mkurnaloba<br />
UA/N<strong>ST</strong>EMI-is mwvave faza Cveulebriv mTavrdeba 2 Tveze adre. am periodSi MI<br />
infarqtamde progresiis an ganmeorebiTi MI-is an sikvdilis ganviTarebis riski<br />
yvelaze maRalia. am periodis Semdeg umetesoba pacientebisa warmogvidgeba<br />
stabiluri stenokardiis klinikuri kursiT.<br />
samedicino reJimi<br />
pacientis stacionaridan gawerisTvis mosamzadeblad xSirad saWiroa mTeli<br />
personalis CarTva (eqimebi, eqTnebi, dietologebi, farmacevtebi, reabilitaciis<br />
specialistebi da Terapevtebi). mniSvnelovania pacientis darigeba, romelic unda<br />
gamyardes da dasabuTdes xelnaweri instruqciebiT. Ggaweris Semdeg kardialuri<br />
reabilitaciis programaSi CarTvas SeuZlia gaaumjobesos pacientis ganaTleba da<br />
samedicino reJimisadmi damorCileba.<br />
rekomendaciebi stacionaridan gawerisSemdgomi TerapiisaTvis<br />
klasi I<br />
1. stacionaridan gaweramde, pacienti da/an pasuxismgebeli momvleli piri unda<br />
iyos uzrunvelyofili advilad gasarkvevi instruqciebiT medikamentis tipis,<br />
miznis, dozis, miRebis sixSiris da Sesabamisi gverdiTi movlenebis Sesaxeb;<br />
2. medikamentebi, romelTac pacienti Rebulobda stacionarSi iSemiis<br />
sakontrolod, aseve unda gagrZeldes gaweris Semdegac (pacientebSi romelTac<br />
ar CautardaT koronaruli revaskularizacia). SesaZloa saWiro iyos<br />
dozirebis Secvla;<br />
3. stenokardiuli diskomforti, romelic grZeldeba 2-3 wuTze met xans niSnavs<br />
imas, rom pacientma Sewyvitos aqtivoba an Tavi moaridos stresul situacias.<br />
Tu tkivili ar moixsneba maSinve, pacientma rekomendebulia miiRos<br />
nitroglicerini. Tu tkivili grZeldeba 15-20 wuTze metxans an persistirebs,<br />
miuxedavad 3 abi nitroglicerinis miRebisa, pacienti eZaxis saswrafo<br />
daxmarebis brigadas da hospitalizirdeba uaxloesi klinikis gadaudebeli<br />
Terapiis ganyofilebaSi. (zogi gaidlaini gvirCevs 1 abi nitroglicerinis<br />
miRebis Semdgom 5 wuTian dakvirvebas da Tuki tkivili rCeba s.d.b-is<br />
gamoZaxebas);<br />
4. Tu pacientis stenokardiuli simptomebi icvleba (mag. tkivili, romelic ufro<br />
xSirad meordeba an mZimea, iwyeba ufro nakleb datvirTvaze an ukve adgili aqvs<br />
mosvenebis dros), pacienti unda daukavSirdes mis mkurnal eqims damatebiTi<br />
mkurnalobis an testirebis gansazRvrisaTvis;<br />
5. ASA 75-dan 325mg/dReSi ukuCvenebis ararsebobis SemTxvevaSi;<br />
6. klopidogreli 75mg dReSi (ukuCvenebis ararsebobis SemTxvevaSi), rodesac ASA<br />
ar aris dasaSvebi momatebuli mgrZnobelobis an gastrointestinaluri<br />
autanlobis SemTxvevaSi;<br />
7. ASA-s kombinireba klopidogrelTan 9 Tvis ganmavlobaSi UA/N<strong>ST</strong>EMI-dan;<br />
8. beta-blokerebi, ukuCvenebis ararsebobis SemTxvevaSi;<br />
9. lipidebis-damaqveiTebeli agentebi da dieta pacientebSi ACS-is Semdgom Tuki<br />
LDL qolesteroli > 130mg/dl, maT Soris revaskularizaciis Semdeg;<br />
27
10. lipidebis-damaqveiTebeli agentebi Tu, LLDL qolesterinis done dietis Semdeg<br />
metia 100 mg/dl-ze;<br />
11. ACE inhibitorebi pacientebSi CHF-T, LV disfunqciiT (EF100 mg/dl-ze<br />
dietis Semdeg;<br />
• fibrati an niacini, Tu HDL qolesterini aris < 40 mg/dl-ze, da igi<br />
aRiniSneba rogorc izolirebuli monacemi an kombinaciaSi sxva lipidur<br />
anomaliasTan;<br />
• hipertenziis kontroli sisxlis wnevis daqveiTebiT
gaidlainis miRebis xerxi/wyaro<br />
gaidlainis SemuSavebis meTodologia<br />
“gaidlainebis miRebis xerxi/wyaro” aris “sxvadasxva gaidlainebis Sejereba da<br />
adaptacia”.<br />
rekomendaciebis da mtkicebulebebis xarisxi AHA/ACC-is mixedviT<br />
A-done: mravali<br />
(3-5)<br />
sxvadasxva<br />
populaciuri<br />
jgufebia<br />
Sefasebuli.<br />
efeqti da<br />
mimarTuleba<br />
myaria.<br />
B-done:<br />
SezRuduali (2-3)<br />
populaciuri<br />
jgufebia<br />
Safasebuli<br />
C-done:<br />
Zalian<br />
SezRuduali (1-2)<br />
populaciuri<br />
jgufebia<br />
Safasebuli<br />
I klasi:<br />
sargebloba > > ><br />
riskze.<br />
procedura/mkurnaloba<br />
unda<br />
Catardes/dainiSnos<br />
rekomendacia imis<br />
Sesaxeb rom igi aris<br />
sasargeblo/efeqturi.<br />
monacemebis miRebulia<br />
mravali<br />
randomizebuli<br />
kvleviT da metaanaliziT.<br />
rekomendacia imis<br />
Sesaxeb rom igi aris<br />
sasargeblo/efeqturi.<br />
SezRuduli monacemebi<br />
miRebulia erTi<br />
randomizebuli da<br />
ararandomizirebuli<br />
kvlevebisagan<br />
rekomendacia imis<br />
Sesaxeb rom igi aris<br />
sasargeblo/efeqturi.<br />
arsebobs mxolod<br />
eqspertebis azri,<br />
SemTxvevaTa<br />
aRwera(case report)<br />
II-A klasi:<br />
sargebloba > > riskze<br />
saWiroebs damatebiT<br />
gamokvlevebs.<br />
gonivrulia<br />
Catardes/dainiSnos<br />
Sesabamisi<br />
procedura/mkurnaloba<br />
rekomendacia<br />
procedura/mkurnalobis<br />
Catareba/daniSvnis<br />
sasargeblodaa<br />
aris zogierTi<br />
urTierTsawinaaRmdego<br />
monacemi mravali<br />
randomizebuli kvlevis<br />
da meta-analizisagan<br />
rekomendacia<br />
procedura/mkurnalobis<br />
Catareba/dniSvnis<br />
sasargeblodaa.<br />
aris zogierTi<br />
urTierTsawinaaRmdego<br />
monacemi erTi<br />
randomizirebuli da<br />
ararandomizebuli<br />
kvlevebisagan<br />
rekomendacia<br />
procedura/mkurnalobis<br />
Catareba/dniSvnis<br />
sasargeblodaa<br />
eyrdnoba eqspertebis<br />
azrs da SemTxvevaTa<br />
aRweras<br />
II-B klasi:<br />
sargebloba ≥ riskze<br />
saWiroebs damatebiT<br />
gamokvlevebs.<br />
procedura/mkurnaloba<br />
SesaZlebelia gvqondes<br />
mxedvelobaSi<br />
rekomendaciis<br />
sargebloba/efeqturoba<br />
nakleb kargadaa<br />
Seswavlili<br />
urTierTsawinaaRmdego<br />
monacemebi ufro metia<br />
mravali<br />
randomizebuli<br />
kvlevis da metaanalizisagan<br />
rekomendaciis<br />
sargebloba/efeqturoba<br />
nakleb kargadaa<br />
Seswavlili<br />
ufro meti<br />
urTierTsawinaaRmdego<br />
monacemia erTi<br />
randomizirebuli da<br />
ararandomizebuli<br />
kvlevebisagan<br />
rekomendaciis<br />
sargebloba/efeqturoba<br />
nakleb kargadaa<br />
Seswavlili<br />
eyrdnoba eqspertebis<br />
azrs da SemTxvevaTa<br />
aRweras<br />
III klasi:<br />
damatebiTi<br />
gamokvlevebi aRaraa<br />
saWiro.<br />
procedura/mkurnaloba<br />
ar unda<br />
dainiSnos/Catardes<br />
vinaidan igi<br />
usargebloa da<br />
SesaZloa iyos saSiSi<br />
rekomendacia rom<br />
procedura/mkurnaloba<br />
araa<br />
sakmarisi monacemebia<br />
mravali<br />
randomizebuli da<br />
metaanalizisagan<br />
sasargeblo/efeqturi<br />
da SesaZloa iyos<br />
saziano.<br />
SezRuduli<br />
monacemebia erTi<br />
randomizirebulia da<br />
ararandomizebuli<br />
kvlevebisagan.<br />
sasargeblo/efeqturi<br />
da SesaZloa iyos<br />
saziano.<br />
arsebobs mxolod<br />
eqspertebis azri,<br />
SemTxvevaTa<br />
aRwera(case report)<br />
29
alternatiuli gaidlaini ar arsebobs<br />
gamoyenebuli literatura<br />
teqsti eyrdnoba amerikis gulis asociaciis da amerikis kardiologTa kolejis<br />
2002w (sruli teqsti da jibis gaidlaini) aseve evropis kardiologTa asociaciis<br />
(2003w) Sesabamis gaidlainebs.<br />
damatebaSi gamoyenebulia masalebi:<br />
1. ACC/AHA gaidlainis sruli teqstidan 2002w;<br />
2. aseve evropis kardiologTa asociaciis masalebi (2003w);<br />
3. braunvaldi, zaips libbi, gulis daavadebebi 6-e gamocema 2001w;<br />
4. brain p. grifini erik j. topoli kardiovaskularuli medicinis<br />
saxelmZRvanelo, 2-e gamocema 2004w.<br />
avtorTa jgufi<br />
saqarTvelos kardiologTa koleji da saqarTvelos kardiologTa sazogadoeba<br />
⇒ giorgi kaWarava _ jo enis saxelobis samedicino centri;<br />
⇒ aCiko CuxrukiZe _ gadaudebeli kardiologiis centri;<br />
⇒ levan yuraSvili _ jo enis saxelobis samedicino centri;<br />
⇒ vaxtang WumburiZe _ profesori, Terapiis erovnuli centri;<br />
⇒ zaza mgalobliSvili _ jo enis saxelobis samedicino centri.<br />
⇒ nata gonjilaSvili _ jo enis saxelobis samedicino centri;<br />
⇒ naTia axalaZe _ jo enis saxelobis samedicino centri;<br />
⇒ giorgi papiaSvili _ jo enis saxelobis samedicino centri.<br />
eqspertebi:<br />
⇒ saojaxo medicinis profesionalTa kavSiri _ irina qarosaniZe;<br />
⇒ saojaxo medicinis eqspertTa jgufi, romelic aerTianebs Tbilissa da<br />
mcxeTaSi moqmedi eqvsi saojaxo medicinis saswavlo centris<br />
warmomadgenlebs m.S. praqtikosi ojaxis eqimebs da dawesebulebis<br />
xelmZRvanelebs (saojaxo medicinis erovnuli saswavlo centri; Tbilisis<br />
saojaxo medicinis saswavlo centri; saojaxo medicinis centri /#28<br />
mozrdilTa poliklinika; saaqcio sazogadoeba `vere XXI~; q. Tbilisis #1<br />
samkurnalo-profilaqtikuri centri; mcxeTa-mTianeTis regionuli saswavlo<br />
centri);<br />
⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa da socialuri<br />
dacvis saministros janmrTelobis dacvis departamenti;<br />
⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da socialuri<br />
dacvis saministros janmrTelobis dacvis departamenti.<br />
30
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