Stable Angina Pectoris(Management of)
Stable Angina Pectoris(Management of)
Stable Angina Pectoris(Management of)
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
2<br />
sarCevi<br />
1. Sesavali ....................................................................................3<br />
1. diagnozi da gamokvleva ..................................................5<br />
simptomebi da damaxasiaTebeli niSnebi .....................11<br />
laboratoruli testebi ....................................................14<br />
gulmkerdis rentgenoskopia .............................................15<br />
mosvenebis eleqtrokardiograma (ekg) ....................... 16<br />
fizikuri datvirTvis ekg sinji .................................... 16<br />
stres-testi warmosaxviT meTodebTan erTad .......19<br />
mosvenebis eqokardiografia ............................................. 23<br />
2. mkurnaloba ........................................................................... 28<br />
daavadebis marTvis zogadi principebi<br />
mkurnalobis ara-farmakologiuri<br />
meTodebis CaTvliT ............................................................... 28<br />
medikamenturi mkurnaloba prognozis<br />
gaumjobesebis mizniT ........................................................... 30<br />
iSemiuri gamovlinebebisa da klinikuri<br />
simptomebis farmakoTerapia ............................................. 34<br />
aorto-koronaruli Suntirebis (akS) operacia .... 40<br />
transkutanuri koronaruli angioplastika<br />
(tka) ................................................................................................41<br />
angioplastikisa da aorto-koronaruli<br />
Suntirebis urTierTSedareba. ........................................ 42<br />
gansakuTrebuli SemTxvevebi ............................................ 43<br />
revaskularizaciisa da medikamenturi<br />
mkurnalobis urTierTSedareba ...................................... 45<br />
gansakuTrebuli diagnostikuri SemTxvevebi:<br />
stenokardia “normaluri” koronaruli<br />
arteriebis fonze ..................................................................49<br />
X sindromi ................................................................................. 50<br />
vazospastiuri/variantuli stenokardia ..................51<br />
stabiluri stenokardiis gaidlainSi<br />
gamoyenebuli SemoklebaTa sia ........................................53
Sesavali<br />
winamdebare tipis gaidlainebi umTavresad<br />
mocemuli daavadebis marTvisaTvis<br />
Sesaferisi, sadReisod xelmisawvdom yvela<br />
mniSvnelovan mtkicebulebebze damyarebuli<br />
rekomendaciebis warmosaCenadaa Sedgenili,<br />
raTa maTi gaTvaliswinebiT eqimebma<br />
konkretuli pacientis mkurnalobis<br />
saukeTeso meTodi SearCion. yoveli<br />
konkretuli proceduris, an mkurnalobis<br />
meTodis vargisianoba Sefasebulia<br />
rekomendaciaTa klasebisa da mtkicebulebaTa<br />
donis winaswar gansazRvruli Skalis<br />
mixedviT, romelic qvemoTaa moyvanili.<br />
miuxedavad amisa, saboloo gadawyvetileba<br />
individualur pacientze zrunvis<br />
Sesaxeb mkurnali eqimis mier unda iqnes<br />
miRebuli sakuTar pr<strong>of</strong>esionalizmsa da<br />
gamocdilebaze dayrdnobiT.<br />
rekomendaciis klasebi<br />
klasi I mtkicebuleba, an/da saerTo<br />
SeTanxmeba, rom mocemuli<br />
diagnostikuri procedura/<br />
mkurnalobis meTodi saWiro,<br />
sargebliani da efeqturia;<br />
klasi II urTierTsawinaaRmdego<br />
mtkicebulebebi da/an in azrTa<br />
sxvadasxvaoba mocemuli<br />
proceduris/mkurnalobis meTodis<br />
3
sargeblianobis/Sesaxeb:<br />
klasi IIa mtkicebulebebi/mosazrebebi<br />
aRniSnuli proceduris/<br />
mkurnalobis meTodis<br />
sasargeblod ixrebian;<br />
klasi IIb proceduris/mkurnalobis meTodis<br />
sargeblianobis/efeqturobis<br />
Sesaxeb SedarebiT naklebi<br />
mtkicebulebebia:<br />
klasi III mtkicebuleba, an saerTo<br />
SeTanxmeba, rom mkurnalobis<br />
meTodi/procedura ar aris<br />
sasargeblo/efeqturi da zog<br />
SemTxvevaSi SeiZleba sazianoc<br />
iyos<br />
mtkicebulebaTa done<br />
4<br />
mtkicebulebaTa done<br />
A<br />
mtkicebulebaTa done<br />
B<br />
mtkicebulebaTa done<br />
C<br />
monacemebi miRebulia<br />
mravlobiTi randomizebuli<br />
kvlevebis, Sedegebis, an metaanalizis<br />
mixedviT;<br />
monacemebi miRebulia erTi<br />
randomizebuli kvlevis, an<br />
farTo ararandomizebul<br />
kvlevaTa Sedegebis mixedviT;<br />
urTierTSeTanxmebuli<br />
mosazreba, an/da mcirericxovani,<br />
an retrospeqtruli kvlevebis,<br />
an sxvadasxva samedicino<br />
dokumentaciis monacemebis<br />
mixedviT
1. diagnozi da gamokvleva<br />
1. diagnozi da gamokvleva<br />
stabiluri stenokardia klinikuri sindromia,<br />
romlisTvisac damaxasiaTebelia diskomforti<br />
gulmkerdis areSi, ybaSi, zurgSi, an xelebSi,<br />
rac Cveulebriv, emociuri gadaZab vis, an<br />
fizikuri datvirTvis fonze gamovlindeba<br />
da mosvenebisas, an nitroglicerinis miRebiT<br />
ixsneba. SedarebiT iSviaTad, diskomforti<br />
SeiZleba epigastriumSi aRmocendes. es<br />
termini ixmareba umTavresad im SemTxvevaSi, Tu<br />
aRniSnuli sindromi miokardis iSemiis mqone<br />
pacientebSi viTardeba.<br />
stenokardiis diagnozi da gamokvleva<br />
moicavs klinikur (fizikalur) gamokvlevas,<br />
laboratoriul testebsa da specifiuri<br />
kardiologiuri gamokvlevis meTodebs.<br />
gamokvlevis ZiriTadi miznebi SeiZleba<br />
Semdegnairad CamovayaloboT:<br />
1. savaraudod stabiluri stenokardiis<br />
mqone pacientebSi iSemiis arsebobis<br />
dasabuTeba.<br />
2. Tanmxlebi paTologiis, an gamomwvevii<br />
mizezis arsebobis dadastureba, an<br />
gamoricxva.<br />
3. riskis stratifikacia.<br />
4. mkurnalobis sqemis SemuSaveba.<br />
5. mkurnalobis efeqtianobis Sefaseba.<br />
stenokardiis arsebobaze mimaniSnebeli<br />
klinikuri simptomebis mqone pacientTa<br />
sawyisi<br />
gamokvlevis algoriTmi #1 sqemazea<br />
gamosaxuli, xolo gamokvlevebis ufro<br />
sruli CamonaTvali #1 cxrilSia mocemuli.<br />
5
sqema 1. stenokardiis simptomebis mqone pacientebis sawyisi gamokvlevis algoriTmi<br />
6<br />
savaraudod filtvis<br />
daavadeba<br />
klinikuri gamokvleva<br />
anamnezi, fizikaluri<br />
gasinjva; ekg;<br />
laboratoriuli testebi<br />
mks marTvis<br />
algoriTmi<br />
gulmkerdis<br />
RO” grafia<br />
savaraudod gu, gadatanili<br />
mi, fizikaluri gasinjvisas,<br />
an ekg-ze paTologiuri<br />
cvlilebebi, hipertenzia,<br />
an dkm<br />
iSemiis Sefaseba<br />
arastabiluri<br />
sindromi<br />
kvlav darwmundiT, rom<br />
simptomebi namdvilad<br />
iSemiuri genezisaa<br />
eqokardiografia<br />
(an amr) struqturuli, an<br />
funqciuri darRvevebis<br />
gamosavlenad<br />
daarwmuneT<br />
pacienti.<br />
urCieT sxva<br />
saxis gamokvlevebi,<br />
an/da<br />
mkurnaloba,<br />
Tu SesaZlebelia<br />
SeafaseT prognozi klinikuri gamokvlevisa da<br />
arainvaziuri gamokvlevebis safuZvelze<br />
Tu kad diagnozi ueWvelia, mag ram parkuWis<br />
funqcia jer ar gamok vleula I klasis Cve ne biT,<br />
am SemTxvevaSi aR niS nu li gamokvleva mocemul<br />
etap ze CaatareT<br />
araviTari<br />
mtkicebuleba,<br />
rom simptomebi<br />
kardiuli genezisaa
maRali riski<br />
wliuri gs<br />
sikvdiloba >2%<br />
saSualo riski<br />
wliuri gs<br />
sikvdiloba 1-2%<br />
dabali riski<br />
wliuri gs<br />
sikvdiloba
cxrili #1 rekomendaciebi stabiluri stenokardiis<br />
rutinuli arainvaziuri gamokvlevebis Casatareblad<br />
8<br />
gamokvlevebis<br />
dasaxeleba<br />
diagnostikuri<br />
TvalsazrisiT<br />
daniSvnisrekomendaciis<br />
klasi<br />
mtkicebulebaTa<br />
done<br />
prognozuli<br />
TvalsazrisiT<br />
daniSvnisrekomendaciis<br />
klasi<br />
mtkicebulebaTa<br />
done<br />
1<br />
laboratoruli<br />
gamokvlevebi<br />
2 3 4 5<br />
sisxlis saerTo<br />
analizi, kreatinini<br />
I C I B<br />
uzmoze sisxlSi<br />
glukozis done<br />
lipiduri speqtri<br />
uzmoze<br />
C-rc, homocisteini, Lp(a),<br />
apoA, apoB<br />
I B I B<br />
I B I B<br />
I B I B<br />
eleqtrokardiograma<br />
sawyisi gamokvlevisas I B I C<br />
tkivili epizodis dros I B<br />
rutinuli ekg eqimTan<br />
rigiTi vizitisas<br />
IIb C IIb C<br />
ambulatoruli ekg<br />
monitorireba<br />
ariTmiis savaraudo<br />
arsebobisas<br />
vazospastiuri stenokardiis<br />
savarudo arsebobisas<br />
I B<br />
IIa C
cxrili #1 gagrZeleba<br />
1 2 3 4 5<br />
stenokardiis savaraudo<br />
arsebobisas normaluri<br />
stres-testis fonze<br />
IIa C<br />
gulmkerdis R’’<br />
grafia<br />
savaraudod gu, an<br />
auskultaciiT gulis<br />
paTologiuri tonebi<br />
savaraudod filtvis<br />
seriozuli daavadeba<br />
eqokardiografia<br />
savaraudod gu, gulis<br />
paTologiuri tonebi,<br />
ekg paTologiuri<br />
cvlilebebi, Q-kbili,<br />
hisis konis blokada, ST<br />
segmentis gamoxatuli<br />
cvlilebebi<br />
I B I B<br />
I B<br />
I B I B<br />
gadatanili mi I B<br />
hipertenzia, an Saqriani<br />
diabeti<br />
I C I B/C<br />
saSualo, an dabali<br />
riskis pacienti,<br />
romelsac ar SeuZlia mp<br />
funqciis alternatiuli<br />
gamokvlevis Catareba<br />
datvirTvis ekg sinji<br />
pirveli rigis sawyisi<br />
gamokvleva, gamonaklisia,<br />
Tu ar SeuZlia<br />
fizikuri datvirTva<br />
/jer araa gadaRebuli<br />
ekg<br />
IIa C<br />
I B I B<br />
9
cxrili #1 gagrZeleba<br />
1 2 3 4 5<br />
dadasturebuli kad<br />
mqone pacientebi<br />
gamoxatuli simptomebiT<br />
I B<br />
rutinulad Catarebuli<br />
sinji, Tu stenokardiis<br />
mimdinareoba<br />
kontrolirebadia<br />
datvirTvis sinji<br />
warmosaxviTi<br />
saSualebebiT<br />
(eqoskopiuri, an<br />
radionukliduri<br />
meTodi)<br />
pacientis sawyisi<br />
gamokvleva, roca ekg<br />
monacemebi gaurkvevelia<br />
datvirTvis sinji<br />
saeWvoa (magram<br />
Sromisunarianoba<br />
damakmay<strong>of</strong>ilebelia)<br />
revaskularizaciis<br />
Semdgomi stenokardia<br />
iSemiis ubnis<br />
lokalizacia<br />
revaskularizaciis<br />
mizniT<br />
arteriografiiT<br />
gamovlenili saSualo<br />
xarisxis dazianebis<br />
funqciuri Sefaseba<br />
farmakologiuri<br />
datvirTvis sinji<br />
warmosaxviTi<br />
saSualebebiT<br />
10<br />
IIb C IIb C<br />
I B I B<br />
I B I B<br />
IIa B IIa B<br />
IIa B<br />
IIa C
cxrili #1 gagrZeleba<br />
datvirTvis uunaro<br />
pacientebi<br />
dabali<br />
Sromisunarianobisa<br />
da datvirTvis saeWvo<br />
sinjis mqone pacientebi<br />
miokardis<br />
sicocxlisunarianobis<br />
Sefaseba<br />
sxva mizezebi (lokaluri<br />
laboratoria farmakologiur<br />
stresstests<br />
amjobinebs da a.S.)<br />
arainvaziuri<br />
kompiuterul-tomografiuli<br />
arteriografia<br />
roca klinikurad<br />
stenokardia saeWvoa da<br />
datvirTvis sinji saeWvo,<br />
an dadebiTia<br />
I B I B<br />
I B I B<br />
IIa B<br />
IIa B IIa B<br />
IIb C<br />
simptomebi da damaxasiaTebeli niSnebi<br />
daavadebis anamnezi stabiluri stenokardiis<br />
diagnostikis qvakuTxeds warmoadgens.<br />
miokardis iSemiis (stenokardiis) fonze<br />
ganviTarebuli diskomforti SeiZleba<br />
metnaklebad gamoxatuli oTxi sxvadasxva<br />
damaxasiaTebeli niSnis mixedviT SevafasoT:<br />
lokalizacia, xasiaTi, xangrZlioba da<br />
kavSiri fizikur datvirTvasTan. aqve<br />
SesaZloa, sxva maprovocirebeli, an<br />
Svebis momtani faqtorebis arsebobac<br />
11
gaviTvaliswinoT.<br />
mniSvnelovania, droze gamovavlinoT<br />
arastabiluri stenokardiis mqone pacientebi,<br />
romelTac SeiZleba axasiaTebdeT:<br />
12<br />
(I) mosvenebis stenokardia<br />
(II) (swrafad progresirebadi. an<br />
`kreSCendo~ tipis stenokardia, anu<br />
adre stabiluri stenokardia, romlis<br />
mimdinareobac swrafad, progresulad<br />
damZimda.<br />
(II) axlad aRmocenebuli stenokardia, anu<br />
cota xnis win ganviTarebuli mZime<br />
stenokardia, romelic gamovlenidan<br />
2 Tvis ganmavlobaSi Cveuli aqtiobis<br />
mkveTrad SezRudvas iwvevs.<br />
stabiluri stenokardiis dros ufro<br />
mosaxerxebelia pacientTa day<strong>of</strong>a daavadebis<br />
simptomebis simZimis mixedviT, rogorc<br />
es kanadis gulsisxlZarRvTa asociaciis<br />
(kga) klasifikaciis (cxrili #2), diukis<br />
specifiuri aqtiurobis indeqsis, an sietlis<br />
stenokardiis kiTxvaris mixedviT xdeba.<br />
riskis stratifikaciisaTvis aucilebeli<br />
anamnezuri monacemebia sigaretis mwevloba,<br />
xandazmuli asaki, adre gadatanili<br />
miokardis infarqti (mi), gulis ukmarisobis<br />
(gu) niSnebi, sakuTriv stenokardiis<br />
mimdinareoba (axlad aRmocenebuli, Tu
cxrili #2. kanadis gulsisxlZarRvTa sazogadoebis<br />
mier mowodebuli stenokardiis simZimis klasifikacia<br />
klasi simptomebis simZime<br />
klasi I “Cveuli datvirTva ar iwvevs anginur tkivils”.<br />
stenokardiuli tkivili mxolod swrafi, intensiuri,<br />
an xangrZlivi datvirTvisas viTardeba<br />
klasi II “Cveuli aqtiobis msubuqi SezRudva”<br />
stenokardiuli tkivili viTardeba swrafi siarulis,<br />
an kibeebze swrafi asvlisas, aRmarTze<br />
moZraobisas, Wamis Semdeg datvirTvis dros, civ<br />
amindSi, emociuri gadatvirTvisas, an gaRviZebidan<br />
mxolod pirveli ramdenime saaTis ganmavlobaSi<br />
klasi III “Cveuli aqtiobis gamoxatuli SezRudva”<br />
stenokardiuli Seteva viTardeba vakeze erTi, an<br />
ori kvartlis (100-200 m) erT tempSi gavlisas, an<br />
kibeebze naxevar sarTulze Cveulebrivi nabijiT<br />
asvlisas<br />
klasi IV “nebismieri fizikuri datvirTvisas diskomfortis<br />
aRmoceneba”, an “mosvenebis stenokardia”.<br />
progresirebadi) da simZime, gansakuTrebiT,<br />
Tu mkurnalobas ar eqvemdebareba.<br />
stenokardiis mimdinareoba, Setevebis sixSire<br />
da mosvenebis eleqtrokardiogramaze (ekg)<br />
darRvevebi sikvdilobis da mi ganviTarebis<br />
damoukidebeli gamsazRvrelebi arian,<br />
gansakuTrebiT gamokvlevis Semdgomi erTi<br />
wlis ganmavlobaSi.<br />
pacientis fizikaluri gasinjva<br />
stenokardiis (savaraudod) arsebobisas<br />
unda iTvaliswinebdes gamomwvevi mizezis,<br />
Tanmxlebi, an maprovocirebeli paTologiis<br />
gamovlenasa, Tu gamoricxvas da riskis<br />
13
stratifikacias. umTavresi faqtorebi,<br />
romelTa gamovlenasac yuradReba unda<br />
mieqces:<br />
� gulis sarqvlovani paTologiis,<br />
an obstruqciuli hipertr<strong>of</strong>iuli<br />
kardiomiopaTiis niSnebi.<br />
� hipertenzia<br />
� arakoronaruli sisxlZarRvovani<br />
daavadebis simptomebi<br />
� gulis ukmarisobis niSnebi<br />
� sxeulis masis indeqsisa da welis<br />
garSemowerilobis Sefaseba metaboluri<br />
sindromis arsebobis dasadastureblad/<br />
gamosaricxad<br />
laboratoruli testebi<br />
laboratoruli testebi<br />
uzmoze plazmaSi glukozis Semcveloba da<br />
uzmozeve gazomili lipiduri speqtri saer-<br />
To qolesterolis (sq), maRali simkvrivis<br />
lipoproteidebis (msl), dabali simkvrivis<br />
lipoproteidebis (dsl) qolesterolisa<br />
da trigliceridebis (tg) CaTvliT,<br />
stabiluri steokardiis yvela SemTxvevis<br />
dros unda iqnes gamokvleuli, raTa<br />
pacientis riskis pr<strong>of</strong>ili dadgindes da<br />
konkretuli mkurnalobis aucilebloba<br />
iqnas dadasturebuli. sisxlSi tg, dsl da<br />
glukozis donis momatebas prognozuli<br />
mniSvnelobac aqvs. glikemiisa da lipiduri<br />
pr<strong>of</strong>ilis ganmeorebiTi gasinjva periodulad<br />
14
unda moxdes mkurnalobis efeqturobis<br />
Sesafaseblad da axlad gamovlinebuli<br />
Saqriani diabetis gamosavlenad. sisxlis<br />
saerTo analizi da plazmaSi kreatininis<br />
Semcveloba aseve yvela pacientisaTvis unda<br />
ganisazRvros.<br />
sxva laboratoruli testebi, maT Soris<br />
glukozis peroraluri datvirTvis testi, sisxlSi<br />
qolesterolis subfraqciebis (apoA, apoB),<br />
homocisteinis, lipoproteini (a), N-terminuli<br />
tvinis natriurezuli faqtoris (NT-BNP),<br />
anTebis markerebis, mag., maRali mgrZnobelobis<br />
C-reaqtiuli cilis (hs CRP) Semcvelobisa da<br />
hemostazuri darRvevebis gansazRvra SesaZloa,<br />
zog SemTxvevaSi saWiro gaxdes.<br />
miokardis dazianebis markerebis, magaliTad,<br />
troponinebis gansazRvra saWiroa, Tu<br />
gamokvlevisas daavadebis arastabiluri<br />
mimdinareoba, an mwvave koronaruli sindromis<br />
arseboba gamovlinda. fariseburi jirkvlis<br />
funqcia unda Sefasdes im SemTxvevaSi,<br />
Tu klinikuri monacemebis mixedviT mis<br />
disfunqciaze iqna eWvi mitanili.<br />
gulmkerdis rentgenoskopia<br />
gulmkerdis rentgenoskopia<br />
gulmkerdis rentgenoskopiis saWiroeba<br />
mxolod maSin dgeba, Tu saeWvoa gulis<br />
ukmarisobis, gulis sarqvlovani paTologiebisa,<br />
15
Tu filtvismieri daavadebebis arseboba.<br />
kardiomegaliis, filtvebSi SegubebiTi<br />
cvlilebebis, winagulis gadidebisa da<br />
gulSi kalcifikaciuri ubnebis gamovlenas<br />
prognozuli mniSvneloba aqvs.<br />
mosvenebis eleqtrokardiograma (ekg)<br />
stenokardiis arsebobaze eWvis mitanisas<br />
yvela pacients mosvenebul mdgomareobaSi<br />
standartuli 12-ganxriani ekg unda gadaeRos,<br />
Tumca aRsaniSnavia, rom normaluri<br />
mosvenebis ekg arc Tu iSviaTia mZime<br />
stenokardiis mqone pacientebSic ki da<br />
iSemiis diagnozis gamosaricxad ver<br />
gamodgeba. cvlilebebi mosvenebis ekgze,<br />
mag. ST-segmentis depresia, Q kbilebi,<br />
wina marcxena hemibloki da hisi konis<br />
marcxena totis sruli bloki, stabiluri<br />
stenokardiis dros arakeTilsaimedo<br />
prognozuli maCveneblebia.<br />
fizikuri datvirTvis ekg sinji<br />
pacientTa umravlesobaSi datvirTvis ekg<br />
testi koronaruli arteriebis daavadebis<br />
dadgenisa da riskis stratifikaciisaTvis<br />
pirveli SerCevis diagnostikuri meTodia.<br />
koronaruli arteriebis daavadebis (kad)<br />
diagnostireba<br />
datvirTvisas ST-segmentis depresia testis<br />
16
dadebiTad Sefasebis kriteriumia. aRniSnuli<br />
meTodiT gamoxatuli koronaruli daavadebis<br />
gamovlenis mgrZnobeloba da specifi-uroba<br />
Sesabamisad 68% da 77%-ia. datvirTvis ekg<br />
testireba diagnostikur mniSvnelobas<br />
kargavs hisis konis marcxena totis<br />
sruli blokadis, peismekeriT moxveuli<br />
riTmisa da volf-parkinson-uaitis (WPW)<br />
sindromis dros. amasTan, Sedegebi naklebad<br />
damajerebelia mosvenebis ekg cvlilebebTan<br />
erTad marcxena parkuWis hipertr<strong>of</strong>iis,<br />
eleqtrolituri disbalansis, parkuWSorisi<br />
gamtareblobis darRvevis gamovlenisa<br />
da sagule glikozidebiT mkurnalobis<br />
fonze. mosvenebis ekg-ze cvlilebis mqone<br />
pacientebSi diagnostikuri da prognozuli<br />
TvalsazrisiT alternatiuli datvirTvis<br />
testis Catarebaa saWiro. datvirTvis<br />
ekg testireba naklebad specifiuri da<br />
mgrZnobiarea qalebSi.<br />
riskis stratifikacia<br />
saeWvo, an ukve diagnoscirebuli koronaruli<br />
daavadebis mqone simptomur pacientebSi<br />
datvirTvis ekg testi riskis SefasebisaTvis<br />
friad mniSvnelovani faqtoria. prognozuli<br />
mniSvnelobisaa datvirTvis moculoba da<br />
datvirTviT gamowveuli klinikurad da<br />
eleqtrokardiografiulad gamovlinebuli<br />
iSemiuri cvlilebebi. maqsimaluri<br />
17
Sromisunarianoba myari prognozuli markeria<br />
da datvirTvis maqsimaluri xangrZlivobiT,<br />
maqsimaluri MET 1 miRweuli monacemebiT,<br />
uatebiT gamoxatuli datvirTvis maqsimaluri<br />
simZlavriT, guliscemis maqsimaluri sixSiriTa<br />
da ormagi warmoebulis meSveobiT fasdeba.<br />
datvirTvis unarianobis gamsazRvreli<br />
TiToeuli sidide damoukideblad<br />
naklebmniSvnelovania, Tu gamokvlevis saerTo<br />
sqemidan gancalkevebulad ganvixilavT.<br />
datvirTvis testis klinikuri mniSvneloba<br />
mniSvnelovnad gaizarda kvlevis sqemaSi<br />
zogierTi parametris, kerZod, datvirTvis<br />
pikze guliscemis sixSiris, ST-segmentis<br />
depresiis, testis dros stenokardiuli<br />
Setevis arsebobis, an ararsebobis, datvirTvis<br />
maqsimaluri moculobisa da ST-segmentis<br />
daxrilobis kuTxis CarTvisa da maTi<br />
multivariantuli analizis meTodiT<br />
Sefasebis danergvis Semdeg. datvirTvis<br />
testisa da klinikuri monacemebis kombinacia<br />
qulebiT Sefasebis sxvadasxva sistemis<br />
(mag., tredmil-testis qulebiT Sefasebis<br />
diukis sistemis) gamoyenebiT, Tu mis gareSe,<br />
pacientTa maRali da dabali riskis<br />
jgufebis diferenciaciis efeqturi meTodia.<br />
1 MET metaboluri erTeulia, 1 MET Seesabameba Jangbadis<br />
moxmarebis dones 3,5 ml/kg/wT<br />
18
stres-testi warmosaxviT meTodebTan erTad<br />
stres-testi warmosaxviT meTodebTan erTad<br />
stres-testebTan erTad gamoyenebuli<br />
warmosaxviTi meTodebidan yvelaze ufro<br />
farTod eqokardiografia da miokardis<br />
perfuziuli scintigrafiaa danergili. orive<br />
maTganis gamoyeneba SesaZlebelia rogorc<br />
fizikuri, ise medikamenturi datvirTvis<br />
sinjis dros da maTi prognozuli da<br />
diagnostikuri mniSvneloba mraval kvlevaSi<br />
iqna Seswavlili.<br />
stres-warmosaxviTi meTodebs xSirad<br />
eZleva upiratesoba transkutanuri<br />
intrakoronaruli Carevis (tiC), an aortokoronaruli<br />
Suntirebis (akS) Semdeg iSemiis<br />
lokalizaciis ukeTesi gamovlenis gamo.<br />
Tanamedrove stres-warmosaxviTi teqnologia<br />
stres-birTvul-magnituri rezonansiT (sbr)<br />
gamdidrda. stress-warmosaxviTi meTodebis<br />
upiratesoba rutinuli fizikuri datvirTvis<br />
ekg sinjTan:<br />
1. ukeTesi diagnostikuri da prognozuli<br />
SesaZleblobebi.<br />
2. iSemiuri zonis lokalizacia da raodenobrivi<br />
Sefaseba.<br />
3. diagnostikuri informaciis warmodgena<br />
mosvenebis ekg-ze gamovlenili paTologiuri<br />
cvlilebebis arsebobisas, an roca<br />
pacients datvirTva ar SeuZlia.<br />
19
fizikuri datvirTvis sinji eqokardiografiis<br />
TanxlebiT<br />
koronaruli daavadebis gamosavlineblad<br />
fizikuri datvirTvis sinjTan erTad Catarebuli<br />
eqokardiografia (stres-eqokg) ufro<br />
mgrZnobiare da specifiuri meTodia, vidre<br />
rutinuli stres-testi. teqnologiuri progresis<br />
gamoxatulebaa aseve kontrastuli<br />
nivTierebis gamoyeneba endokardis sazRvris<br />
ufro zustad dasadgenad, an saineqcio radiaqtiuli<br />
nivTierebis saSualebiT miokardis<br />
perfuziis vizualizacia da iSemiis ukeTesad<br />
gamovlena qsovilovani doplerografiiTa da<br />
deformaciis siswrafis gazomviT.<br />
stres-eqokardiografia aseve warmatebiT<br />
gamoiyeneba avadmy<strong>of</strong>Ta riskis stratifikaciisaTvis.<br />
momavalSi mosalodneli garTulebebis<br />
ganviTarebaze gavlenas Semdegi monacemebi<br />
axdenen:<br />
� mosvenebul mdgomareobaSi parkuWis kedlis<br />
regionaluri moZraobis paTologiuri ubnebis<br />
raodenoba<br />
� stres-eqokardiografiis dros inducirebuli<br />
parkuWis kedlis moZraobis paTologiuri<br />
ubnebis raodenoba.<br />
fizikuri datvirTvis sinji miokardis<br />
perfuziuli scintigrafiis TanxlebiT<br />
fotonuri emisiis meTodiT Catarebuli<br />
20
kompiuteruli tomografia SeiZleba simptomlimitirebuli<br />
fizikuri datvirTvis sinjTan,<br />
an farmakologiur strestestTan erTad<br />
CavataroT, raTa radiaqtiuri izotopebis<br />
miokardSi “CarTvis” vizualuri warmoCinebiT<br />
datvirTvis fonze miokardis regionaluri<br />
sisxliT momarageba SevafasoT. miRebuli<br />
suraTi SeiZleba, mosvenebul mdgomareobaSi<br />
miRebul monacemebs SevadaroT. yvelaze<br />
xSirad gamoyenebuli izotopebi Talium-201<br />
da teqnecium-99-ia.<br />
fotonuri emisiis meTodiT Catarebuli<br />
kompiuteruli tomografia koronaruli<br />
arteriebis daavadebis ufro specifiuri da<br />
mgrZnobiare meTodia rutinul ekg-s strestestTan<br />
SedarebiT da ufro mgrZnobiare,<br />
magram naklebad specifiuri, vidre streseqokardiografia.<br />
datvirTvis perfuziuli<br />
warmosaxviTi meTodebi prognozuli<br />
TvalsazrisiTac farTod gamoiyeneba.<br />
maRali riskis maCveneblebia:<br />
� Rrma, gavrcelebuli iSemia.<br />
� gardamavali iSemiuri dilatacia.<br />
� izotopebis filtvis qsovilSi CarTva.<br />
farmakologiuri stres-testi warmosaxviTi<br />
meTodebis gamoyenebiT<br />
fizikuri datvirTvis testis Catareba<br />
warmosaxviTi meTodebis gamoyenebiT<br />
21
SeZlebisamebr yvelgan unda tardebodes,<br />
radganac maTi saSualebiT iSemiis gamowveva<br />
ufro fiziologiurad xdeba da, Sesabamisad,<br />
simptomebic ufro damajereblad fasdeba.<br />
roca fizikuri datvirTvis sinjis Catareba<br />
SeuZlebelia, maSin farmakologiuri<br />
datvirTvis sinjis gamoyenebaa<br />
rekomendebuli. unda avirCioT:<br />
1. xanmokle moqmedebis simpatomimeturi<br />
preparati (dobutamini)<br />
2. koronaruli vazodilatorebi (mag.<br />
adenozini da dipiridamoli).<br />
datvirTvis sinjTan eqoskopiuri, Tu<br />
perfuziuli scintigrafiis meTodis<br />
gamoyenebas absoluturad erTnairi<br />
daniSnuleba aqvs da arCevanis gakeTeba<br />
adgilobrivi samkurnalo dawesebulebis<br />
SesaZleblobebzea damokidebuli.<br />
warmosaxviTi stres-meTodebi friad<br />
mniSvnelovania kad arsebobis dabali<br />
albaTobis mqone pacientebis gamokvlevisas<br />
(gansakuTrebiT qalebSi, sadac fizikuri<br />
datvirTvis ekg sinji xSirad saeWvo Sedegebs<br />
iZleva), revaskularizaciis saWiroebis<br />
gansazRvrisaTvis, sisxlZarRvis dazianebis<br />
gamosavlenad da iSemiis Sesafaseblad<br />
revaskularizaciis Semdeg.<br />
22
stres-testi birTvul magnituri rezonansis<br />
gamoyenebiT<br />
dobutaminiT stres-testis dros birTvulmagnituri<br />
rezonansis meSveobiT SesaZlebelia<br />
parkuWis kedlebis moZraobis iSemiiT<br />
gamowveuli paTologiuri cvlilebebi, an<br />
miokardis darRveuli perfuziis ubnebi gamovavlinoT,<br />
magram aRniSnuli meTodi am mizniT<br />
farTod ar gamoiyeneba.<br />
mosvenebis eqokardiografia<br />
mosvenebis eqokardiografia stabiluri<br />
stenokardiis dros gamoiyeneba gulis<br />
sarqvlovani paTologiis, an hipertr<strong>of</strong>iuli<br />
kardiomiopaTiis gamosavlenad, an<br />
gamosaricxad (roca gulmkerdSi tkivilis<br />
mizezis dadgenaa saWiro) da parkuWis<br />
funqciis Sesafaseblad.<br />
wminda diagnostikuri mizniT<br />
eqokardiografia gamosadegia iseTi<br />
pacientebis gamokvlevisas, visac gulze<br />
auskultaciiT Suilebi aReniSnebaT, roca<br />
anamneziT, an ekg monacemebiT safiqrebelia<br />
hipertr<strong>of</strong>iuli kardiomiopaTiis, an<br />
gadatanili mi arseboba, an gulis<br />
ukmarisobis klinikuri simptomebi<br />
aReniSnebaT. amasTan, eqokardiografiiT<br />
SeiZleba sakmaod sasargeblo prognozuli<br />
informacia movipovoT.<br />
23
stabiluri stenokardiis dros sikvdilobis<br />
yvelaze sarwmuno prediqtori marcxena<br />
parkuWis funqciaa, romlis daqveiTebis<br />
drosac sikvdiloba mniSvnelovnad<br />
imatebs. aseve mniSvnelovani prognozuli<br />
maCvenebelia marcx ena parkuWis hipertr<strong>of</strong>ia.<br />
eqokardiografiiT marcxena parkuWis<br />
funqciis Sefaseba SeiZleba im SemTxvevaSic,<br />
Tu sxva meTodiT aRniSnuli gamokvleva ar<br />
Catarebula.<br />
birTvul-magnituri rezonansiT gulis<br />
gamokvlevisas SesaZlebelia, miokardis<br />
struqturuli paTologia gamovlindes da<br />
parkuWis funqcia Sefasdes, magram am meTodis<br />
naklebad xelmisawvdomobis gamo misi<br />
rutinulad gamoyeneba ar xdeba.<br />
kompiuteruli tomografia<br />
eleqtronuli emisiiT Catarebuli<br />
mravalSriani kompiuteruli tomografiis<br />
(kt) saSualebiT koronarul sisxlZarRvTa<br />
kalcifikaciisa da am ubnebis gavrcelebis<br />
dadgena metad warmatebulad xdeba. kt<br />
koronaruli arteriografia intravenurad<br />
rentgenokontrastuli nivTierebis SeyvaniTac<br />
SeiZleba Catardes. multideteqtoruli<br />
kt meSveobiT Catarebuli angiografia<br />
gamoxatuli uary<strong>of</strong>iTi sarwmunoobiT<br />
gamoirCeva. dResdReobiT<br />
24
kt koronaroarteriografia gamoiyeneba im<br />
pacientebSi, vinc kad ganviTarebis dabali<br />
albaTobiT gamoirCevian da Tanac datvirTvis<br />
funqciuri sinjis (datvirTvis ekg testi,<br />
an stres-testi warmosaxviTi meTodebis<br />
gamoyenebiT) Sedegebi saeWvoa.<br />
arteriografia atomur-magnituri rezonansis<br />
gamoyenebiT.<br />
atomur-magnituri rezonansis teqnologiur<br />
gaumjobesebasTan erTad am meTodis<br />
gamoyenebiT SesaZlebeli gaxda koronaruli<br />
arteriografiis Catareba, magram sxvadasxva<br />
mizezis gamo igi jer-jerobiT ufro<br />
mecnierul kvlevebSi gamoiyeneba, vidre<br />
rutinul klinikur praqtikaSi.<br />
riskis stratifikacia kvlevis arainvaziuri<br />
meTodebiT<br />
rogorc aRniSnuli gaidlainis srul<br />
versiaSia aRniSnuli, Tu stabiluri<br />
stenokardiis mqone pacients riskis winaswar<br />
Sefasebis sarwmunod dadgenili modelis<br />
monacemebiT wliuri sikvdilobis 2%ze<br />
didi riski gaaCnia, igi maRali riskis<br />
jgufs miekuTvneba, Tu mosalodneli wliuri<br />
sikvdilobis riski 1-2%-ia – saSualo riskis<br />
jgufs, xolo roca wliuri sikvdilobis<br />
riski
koronaruli arteriografia<br />
arainvaziuri gamokvlevis meTodebis<br />
saSualebiT SesaZlebelia koronarebis<br />
obstruqciuli daavadebis arseboba<br />
garkveuli sarwmunoobiT dadgindes da<br />
riskis damajereblad Sefasebis Semdeg<br />
SesaZloa, misi SedegebiT koronaruli<br />
arteriografiis saWiroeba ganvsazRvroT.<br />
miuxedavad amisa, koronaruli<br />
arteriografias stabiluri stenokardiis<br />
mqone pacientebis gamokvlevaSi wamyvani<br />
pozicia uWiravs, radganac misi saSualebiT<br />
SesaZlebelia sarwmuno anatomiuri<br />
informaciis miReba koronaruli<br />
arteriebis sanaTuris Seviwroebis xarisxis<br />
Sesaxeb, mkurnalobis meTodis SemuSaveba<br />
(konservatiuli mkurnaloba, Tu miokardis<br />
revaskularizacia) da prognozis gansazRvra.<br />
ori, an sami koronaruli sisxlZarRvis<br />
dazianebisas bevrad ufro arakeTilsaimedo<br />
prognozia mosalodneli, vidre erTi<br />
sisxlZarRvis daavadebis dros. anatomiurad<br />
maRali riskis daavadeba moicavs an marcxena<br />
mTavari koronaruli arteriis dazianebas, an<br />
mravalsisxlZarRvovan daavadebas marcxena<br />
wina daswvrivi koronaruli arteriis<br />
dazianebis CaTvliT.<br />
Tu daniSnulebisamebr CavatarebT,<br />
arainvaziuri testebi mosalodneli<br />
garTulebebis ganviTarebas misaRebi<br />
26
damajereblobiT winaswarmetyveleben. roca<br />
mosalodneli wliuri gulsisxlZarRvovani<br />
sikvdiloba ≤1%, prognozis gaumjobesebis<br />
mizniT koronaroangiografiuli<br />
gamokvlevis Catareba miuRebelia. amis<br />
sapirispirod, aRniSnuli kvlevis meTodis<br />
gamoyeneba misaRebia, Tu pacientis wliuri<br />
kardiovaskuluri sikvdilobis riski >2%.<br />
proceduris saWiroebis Sesaxeb<br />
gadawyvetileba Sualeduri riskis jgufSi,<br />
sadac wliuri gulsisxlZarRvovani<br />
sikvdiloba 1-2%-ia, sxvadasxva garemoebebis<br />
gaTvaliswinebiT miiReba. aseTebia klinikuri<br />
simptomebi, funqciuri mdgomareoba, cxovrebis<br />
wesi, pr<strong>of</strong>esia. Tanmxlebi daavadebebi da<br />
sawyisi medikamenturi mkurnalobis Sedegi.<br />
koronaroarteriografia sasurvelia,<br />
aucileblad Catardes:<br />
� gamoxatuli parkuWovani ariTmiis<br />
arsebobisas, an gulis gaCerebis Semdeg (Tu<br />
misi ganviTareba dadgenili arakardiuli<br />
mizeziT ar moxda);<br />
� revaskularizaciis Semdgom periodSi<br />
zomierad, an mZimed gamoxatuli<br />
stenokardiuli simptomebis swrafadve<br />
ganaxlebisas.<br />
� Tu daavadebis simptomebis mixedviT<br />
mxedvelobaSi unda viqonioT<br />
27
28<br />
revaskularizaciis saWiroeba.<br />
2. mkurnaloba<br />
mkurnalobis miznebi<br />
1) miokardis infarqtisa da sikvdilobis<br />
SemTxvevebis Tavidan acilebiT daavadebis<br />
prognozis gaumjobeseba.<br />
2) klinikuri simptomebis maqsimalurad<br />
Semcireba, an gaqroba<br />
daavadebis marTvis zogadi principebi<br />
mkurnalobis ara-farmakologiuri meTodebis<br />
CaTvliT<br />
� pacientebi da maTi axloblebi unda<br />
informirebuli iyvnen daavadebis bunebis,<br />
SesaZlo garTulebebisa da mkurnalobis<br />
saWiro meTodebis Sesaxeb.<br />
� eqimis mier guldasmiT unda iqnes ganmartebuli<br />
mwvave anginuri Setevisas misaRebi<br />
zomebi, mag. datvirTvis dros aRmocenebuli<br />
tkivilis dros dasvenebisa (mcire<br />
xniT mainc) da enis qveS nitroglicerinis<br />
miRebis aucileblobis Sesaxeb.<br />
� pacienti saqmis kursSi unda iyos<br />
nitratebis SesaZlo gverdiTi movlenebisa<br />
da maTi pr<strong>of</strong>ilaqtikis mizniT Sesaferisad<br />
gamoyenebis sargeblianobis Sesaxeb.<br />
� pacientma unda icodes, rom dasvenebis, an/<br />
da nitroglicerinis uSedego miRebidan
anginuri Setevis 10-20wT-ze metad<br />
gaxangrZlivebisas igi gadaudebeli<br />
samedicino daxmarebas saWiroebs.<br />
� gansakuTrebuli yuradReba unda mieqces<br />
Tambaqos mowevis mavneblobis ganmartebas.<br />
� pacients unda vurCioT e.w. “xmelTaSua<br />
zRvispireTis” dieta umTavresad<br />
bostneulis, xilis, Tevzeulisa da Sinauri<br />
frinvelis xorcis gamoyenebiT. simsuqnis<br />
SemTxvevaSi pacients unda erCios wonis<br />
dakleba.<br />
� alkoholis zomierad moxmareba SeiZleba<br />
sasargebloc ki iyos, magram Warbi miReba<br />
namdvilad sazianoa.<br />
� Tevzeuli cximebis miReba omega-3 cximovani<br />
mJavis (n-3 poliujeri cximovani mJavebis)<br />
saxiT rekomendebulia kviraSi erTjer<br />
mainc.<br />
� pacients SesaZleblobis farglebSi<br />
fizikuri aqtiobis SenarCuneba unda vurCioT.<br />
� Tanmxlebi daavadebebi, rogoricaa Saqriani<br />
diabeti da hipertenzia, Sesaferisad unda<br />
iqnas namkurnalebi. Tu pacients Saqriani<br />
diabeti da/an Tirkmlis ukmarisoba<br />
aReniSneba, arteriuli wneva < 130/80 mm.vwy.<br />
sv unda iyos. diabetiani pacientebis<br />
mravalmxrivi mkurnaloba diabetis rogorc<br />
gulsisxlZarRvovani, ise sxva saxis<br />
garTulebebs amcirebs.<br />
� anemias, an hiperTireoidizms adeqvaturad<br />
29
unda vumkurnaloT.<br />
� seqsualurma aqtiurobam, SesaZloa,<br />
stenokardiis gamwvaveba gamoiwvios.<br />
amis Tavidan asacileblad pacients<br />
sqesobrivi aqtis win nitroglicerinis<br />
miReba unda vurCioT. koronaruli<br />
arteriebis daavadebis mqone pacientebSi<br />
fosfodiesTerazis inhibitorebi,<br />
rogorebicaa sidenafili, tadafili,<br />
an vardenafilis daniSvna usafrTxoa,<br />
magram aRniSnuli preparatebis gamoyeneba<br />
xangrZlivi moqmedebis nitratebTan erTad<br />
winaaRmdegnaCvenebia.<br />
medikamenturi mkurnaloba prognozis<br />
gaumjobesebis mizniT<br />
antiTrombuli preparatebi<br />
koronaruli Trombozis Tavidan asacileblad<br />
naCvenebia antiagregantuli preparatebis<br />
gamoyeneba, radganac isini stabiluri<br />
stenokardiis mqone pacientebSi riskze<br />
ufro metad gamoxatuli sargeblianobiT<br />
gamoirCevian. umetes SemTxvevaSi SerCevis<br />
preparati dabaldoziani (75-150 mg)<br />
aspirinia. Tienopiridinis jgufis preparati<br />
klopidogreli alternatiul medikamentad<br />
moiazreba aspirinisadmi alergiul pacientebSi,<br />
an gamoiyeneba aspirinTan erTad stentirebis<br />
Semdgom, an mwvave koronaruli sindromis mqone<br />
30
pacientebSi. anamnezSi gastro-intestinuri<br />
sisxldenis arsebobisas klopidogrelze ufro<br />
metad naCvenebia aspirinis gamoyeneba protonis<br />
tumbos inhibitorebTan erTad.<br />
antikoagulantebi (varfarini, an Trombinis<br />
inhibitorebi), romlebic aspirinTan erTad<br />
gamoiyenebian danamdvilebiT maRali riskis,<br />
magaliTad, gadatanili mi mqone pacientebSi,<br />
stabiluri stenokardiis rutinuli<br />
mkurnalobisaTvis ar arian rekomendebuli<br />
gansakuTrebuli SemTxvevebis, mag. Tanmxlebi<br />
winagulTa fibrilaciis, garda.<br />
antilipiduri preparatebi<br />
stabiluri stenokardiis mqone<br />
pacientebSi statinebiT mkurnaloba<br />
gulsisxlZarRvovan garTulebaTa risks<br />
daaxloebiT 30%-iT amcirebs. sxvadasxva<br />
kvlevebis monacemebiT, aRniSnuli jgufis<br />
preparatebi sargeblianobiT gamoirCevian<br />
sisxlZarRvovani paTologiebis mqone<br />
diabetian avadmy<strong>of</strong>ebSi da agreTve<br />
asakovan (>70 w) pacientebSi. garda amisa,<br />
statinebiT xangrZlivi mkurnalobisas<br />
fardobiTi sargeblianoba gamovlinda<br />
mkurnalobamde sisxlSi lipidebis<br />
sxvadasxva donis, maT Soris “normaluri”<br />
Semcvelobis mqone populaciaSic ki. amrigad,<br />
aRniSnuli preparatebiT mkurnalobisas<br />
31
unda vixelmZRvaneloT pacientTa<br />
gulsisxlZarRvovani riskis arsebobiT iseve,<br />
rogorc sisxlSi qolesterinis SemcvelobiT<br />
(lipidebis normaluri da zomierad<br />
momatebuli Semcvelobis drosac).<br />
statinoTerapia yovelTvis unda tardebodes<br />
koronaruli arteriebis stabiluri daavadebisa<br />
da stabiluri stenokardiis mqone<br />
pacientebSi. mkurnalobis mizania, Seamciros<br />
sisxlSi lipidebis Semcveloba iseT donemde,<br />
rodesac klinikuri kvlevebis monacemebiT,<br />
avadoba/sikvdiloba mcirdeba. sarwmunod dasabuTebuli<br />
kvlevebis monacemebiT sikvdilobis<br />
Semcireba dRiurad 40 mg simvastatinisa,<br />
an pravastatinis, an 10 mg atrovastatiniT<br />
mkurnalobis fonze xdeba. Tu es doza sakmarisi<br />
ar aris saerTo qolesterinisa da<br />
dsl samizne donemde Sesamcireblad, amtanobis<br />
mixedviT igi SeiZleba gaizardos saWiro<br />
Sedegebis miRebamde.<br />
bolo kvlevebis monacemebiT, atrovastatinis<br />
maRali doziT (80 mg) mkurnalobisas 10 mg<br />
dozirebasTan SedarebiT kardiovaskuluri<br />
riskis Semcireba aRiniSna, magram statinebis<br />
aseTi maRali dozebi mxolod maRali riskis<br />
pacientebSi unda gamoviyenoT.<br />
sxva antilipiduri preparatebis, magaliTad<br />
fibratebis, xangrZlivi moqmedebis nikotinis<br />
32
mJavisa da maTi statinebTan kombinaciiis,<br />
agreTve lipidebis damaqveiTebeli sxva<br />
saSualebebis saWiroeba SeiZleba Seiqnas<br />
gamoxatuli dislipidemiis, gansakuTrebiT<br />
trigliceridebis siWarbisa da mslqolesterinis<br />
dabali Semcvelobis dros<br />
lipiduri speqtris mosawesrigeblad.<br />
statinebTan erTad damatebiTi antilipiduri<br />
mkurnalobis saWiroeba individualurad<br />
unda ganisazRvros maRali riskis (savaraudo<br />
gulsisxlZarRvovani sikvdiloba >2%) da<br />
standartuli mkurnalobis miuxedavad<br />
gamoxatuli dislipidemiis mqone populaciaSi.<br />
age inhibitorebi<br />
hipertenziis, gulis ukmarisobisa (gu) da<br />
marcxena parkuWis disfunqciis angiotenzinis<br />
gardamqmneli enzimis (age) inhibitorebiT<br />
mkurnaloba sayovelTaod miRebulia. amasTan,<br />
ori farTo randomizebuli placebokontrolirebadi<br />
kvlevis monacemebiT<br />
ramipriliTa da perindopriliT<br />
mkurnalobisas gulis ukmarisobis armqone<br />
pacientebSi stabiluri stenokardiis fonze<br />
kardiovaskuluri avadobisa da sikvdilobis<br />
riskis Semcireba aRiniSna. mesame kvlevam age<br />
inhibitoris, trandolaprilis gamoyenebisas<br />
ver gamoavlina gulsisxlZarRvovani<br />
sikvdilobisa da miokardis infarqtis<br />
ganviTarebis sixSiris sarwmuno Semcireba.<br />
33
age-inhibitorebiT mkurnaloba naCvenebia, Tu<br />
stabiluri stenokardiis mqone pacients<br />
aReniSneba hipertenzia, Saqriani diabeti, gu,<br />
marcxena parkuWis asimptomuri disfunqcia,<br />
an gadatanili aqvs mi. CamoTvlili Tanmxlebi<br />
paTologiebis arqonisas stenokardiiT<br />
daavadebuli pacientis age-inhibitorebiT<br />
mkurnalobis gadawyvetileba unda moxdes<br />
mosalodneli Sedegianobisa da savaraudo<br />
gverdiTi movlenebis albaTobis, agreTve<br />
mkurnalobis xarjebis Sefasebis Semdeg<br />
da sasurvelia randomizebuli klinikuri<br />
kvlevebis monacemebiT dadebiTi Sedegis<br />
mqone preparatebis gamoyeneba.<br />
beta-blokerebi<br />
arsebuli mtkicebulebebis Tanaxmad<br />
stenokardiis mqone pacientebSi, romlebsac<br />
gadatanili mi, an gu aReniSnebaT, betablokerebis<br />
gamoyeneba prognozuli<br />
sargeblianobiT gamoirCeva, xolo am<br />
monacemebisagan damoukideblad, beta<br />
adrenoblokerebi winaaRmdegCvenebis<br />
ararsebobis SemTxvevaSi pirveli rigis<br />
antianginuri preparatebia.<br />
iSemiuri gamovlinebebisa da klinikuri<br />
simptomebis farmakoTerapia<br />
stenokardiis simptomebi da iSemiuri<br />
34
cvlilebebi (maT Soris munji iSemiuri<br />
cvlilebebic) SeiZleba im preparatebiT<br />
Semcirdes, romlebis miokardis Jangbadze<br />
moTxovnilebas amcireben da/an iSemiur ubanSi<br />
sisxliT momaragebas zrdian. sayovelTaod<br />
miRebuli antianginuri preparatebia betablokerebi,<br />
kalciumis antagonistebi<br />
da nitratebi (cxrili #3), amave mizniT<br />
gamoiyenebian kaliumis arxebis gamxsnelebic.<br />
axlaxan sinusis kvanZis inhibitorebi gaxda<br />
xelmisawvdomi, aseve SesaZlebelia metaboluri<br />
preparatebis gamoyenebac.<br />
medikamenturi mkurnalobis zogadi<br />
rekomendaciebi:<br />
� antianginuri mkurnaloba misadagebuli<br />
unda iyos individualuri pacientisadmi<br />
da igi mudmiv individualur dakvirvebas<br />
saWiroebs.<br />
� xanmokle moqmedebis nitratebis<br />
miReba daavadebis mwvave simptomebis<br />
kupirebisaTvis yvela pacientisaTvis<br />
aucilebelia, Tu maTi miReba asatania.<br />
� klinikur kvlevebSi SeiZleba sxvadasxva<br />
klasis preparatebis damatebiTi<br />
antianginuri Tviseba gamovlindes.<br />
� erTi preparatis dozis optimizacia meore<br />
preparatis damatebamde unda moxdes.<br />
� sami preparatiT mkurnalobis dawyebamde<br />
ori preparatis sxvadasxva kombinaciiT<br />
35
cxrili #3. preparatebi, romlebic amcireben iSemiur movlenebsa<br />
da daavadebis simptomebs (monoTerapiis Catarebisas)<br />
preparatebi moqmedeba komentari rekomen./<br />
mtkicebuleba<br />
1 2 3 4<br />
xanmokle<br />
moqmedebis<br />
nitratebi<br />
gaxangrZliebuli<br />
moqmedebis<br />
nitratebi<br />
betablokerebi<br />
kalciumis<br />
arxebis<br />
blokerebi<br />
36<br />
venodilatacia,<br />
↓diastoluri<br />
avseba-<br />
↓ Semcirebuli<br />
intrakardiuli<br />
wneva,<br />
↓ subendokardiuli<br />
perfuzia<br />
↓Jangbadis<br />
moTxovnileba<br />
guliscemis six-<br />
Siris↓ gamo<br />
↓kumSvadoba<br />
↓arteriuli wneva<br />
- heterogenuli<br />
klasi<br />
- sistemuri da<br />
koronaruli<br />
vazodilatacia<br />
L-tipis arxebiT<br />
kalciumis Sesvlis<br />
daTrgunviT.<br />
- verapamili da<br />
dilTiazemi miokardisSekumSvadobas<br />
aqveiTeben.<br />
- ↓ gs da AV gamtarobas<br />
- dihidropiridinis<br />
tipis<br />
kab(mag. nifedipini,<br />
amlodipini da<br />
felodipini)<br />
ufro vazo-seleqtiurebia<br />
- sublingualuri<br />
miReba<br />
- situaciuri pr<strong>of</strong>ilaqtika<br />
- peroraluri, an<br />
transdermuli forma<br />
- nitratebisgan<br />
Tavisufali periodi<br />
SevinarCunoT<br />
- seleqtiuri β 1 -blokerebi<br />
gverdiT movlenebs<br />
naklebad iwveven<br />
- doza gavtitroT simptomebis<br />
gamoxatulebisa<br />
da gs mixedviT<br />
- sarwmunod amcireben<br />
simtomebis gamovlinebis<br />
sixSiresa da aumjobeseben<br />
Sromisunarianobas<br />
- sarwmunod amcireben<br />
simtomebis gamovlinebis<br />
sixSiresa da<br />
aumjobeseben Sromisunarianobas<br />
- efeqturoba betablokerebis<br />
sadaria<br />
- gansakuTrebiT efeqturi<br />
arian vazospastiuri<br />
stenokardiis<br />
dros<br />
IC<br />
IA<br />
IA<br />
IA
cxrili #3 gagrZeleba<br />
1 2 3 4<br />
kaliumis<br />
arxebis gamxsnelebi<br />
sinusis<br />
kvanZis inhibitorebi<br />
metaboluri<br />
preparatebi<br />
- kaliumis<br />
arxebis aqtivacias<br />
iwveven<br />
- nitratebis<br />
msgavsi vazodilatoruli<br />
efeqti<br />
axasiaTebT<br />
- guliscemis<br />
sixSires amcirebs<br />
sinusis kvanZis If<br />
arxebze uSualo<br />
moqmedebiT<br />
-cximovani mJavebis<br />
moxmerebasTan SedarebiT<br />
glukozis<br />
utilizaCias<br />
zrdian<br />
- nikorandili sikvdilobas<br />
amcirebs<br />
- erTi randomizebuli,<br />
placebo-kontrolirebadi<br />
kvlevis<br />
monacemebiT ↓mi<br />
da stenokardiiT<br />
gamowveul hospitalizaciis<br />
sixSires sxva<br />
preparatebTan damatebiT<br />
gamoyenebisas<br />
- randomizebuli placebo-kontrolirebadi<br />
kvlevebis monacemebiT,<br />
simptomebis Semcirebisas<br />
ivabradini betablokerebis<br />
sadaria<br />
- SezRuduli hemodinamokuri<br />
efeqti<br />
- trimetazidini yvela<br />
qveyenaSi ar iSoveba<br />
- ranolazini evropaSi<br />
daregistrirebuli ar<br />
aris<br />
unda vcadoT Sedegis miRweva.<br />
� warumatebeli medikamenturi mkurnaloba<br />
sisxlZarRvovani rezervis seriozuli<br />
gauaresebis maCvenebelia<br />
� Tu pacientis ori preparatiT<br />
mkurnalobisas daavadebis simptomebis<br />
marTva arasakmarisad adeqvaturia,<br />
mxedvelobaSi revaskularizaciis Catareba<br />
unda viqonioT (Tu es ukve gadawyvetili ar<br />
aris).<br />
qvemoT aRwerili strategiuli midgoma<br />
(algoriTmi ix. #2 sqemaze) rekomendebulia<br />
IC<br />
IIaB<br />
IIbB<br />
37
sqema 2. stabiluri stenokardiis medikamenturi marTvis algoriTmi<br />
tkivilis meyseuli<br />
xanmokle moxsna<br />
38<br />
stabiluri stenokardiis medikamenturi mkurnaloba<br />
mkurnalobis prognozis<br />
gasaumjobeseblad<br />
mkurnaloba<br />
simptomebis<br />
moxsnis mizniT<br />
xanmokle moqmedebis nitrati enis qveS, an loyis-<br />
Sida aplikaciis saxiT, tkivilis mosaxsnelad<br />
aspirini 75-150 mg 1-jer dReSi<br />
xstatinebi<br />
+/- dozis titraciiT qolesterinis samizne<br />
dozis misaRwevad<br />
autanloba, an winaaRmdegCveneba<br />
age-inhibitori dadasturebuli kad SemTxvevaSi<br />
beta-blokerebi, Tu gadatanili mi, an gu aRiniSneba<br />
beta-blokerebi sxva SemTxvevaSi ar davniSnoT<br />
simptomebis kontroli ar xerxdeba dozis optimizaciiT<br />
davamatoT kalciumis antagonistebi, an xangrZlivi<br />
moqmedebis nitratebi<br />
simptomebis kontroli ar xerxdeba dozis optimizaciiT<br />
mxedvelobaSi iqonieT revaskularizacia
winaaRmdeg Cveneba<br />
(mag. alergia aspirinze)<br />
klopidogreli 75 mg 1-jer<br />
gamocvaleT statini, an gamoiyeneT<br />
ezetimibi statinis dabali doziT, an sxva<br />
lipiddamaqveiTebeli preparati<br />
autanloba (mag. advilad daRla), an winaaRmdegCveneba<br />
kalciumis antagonisti, an prolongirebuli<br />
nitrati, an K arxebis gamxsneli, an If inhibitori<br />
autanloba<br />
gamocvaleT an kalciu-mis<br />
antagonisti, an prolongirebuli<br />
nitrati<br />
mtkicebulebis done<br />
prognozuli simptomuri<br />
A<br />
B<br />
A<br />
B/C<br />
A/B<br />
A<br />
simptomebis kontroli ar<br />
erxdeba optimizaciiTac<br />
B<br />
nitratebisa da kalciumis<br />
antagonistebis, an<br />
K arxebis gamxsnelebis<br />
kombinacia<br />
simptomebis kontroli ar erxdeba optimizaciiTac<br />
B<br />
A<br />
A<br />
A/B<br />
B/C<br />
39
im pacientebisaTvis, romlebisTvisac riskis<br />
Sefasebisa da sawyisi gamokvlevis Semdeg medikamenturi<br />
Terapia iqna SerCeuli.<br />
aorto-koronaruli Suntirebis (akS)<br />
operacia<br />
arsebobs akS ori mTavari Cveneba:<br />
prognozuli da simptomuri. akS-s<br />
prognozuli sargeblianoba umTavresad<br />
kardiuli sikvdilobis SemcirebiT<br />
gamoixateba, rameTu miokardis infarqtis<br />
ganviTarebis sarwmuno Semcireba sadReisod<br />
arsebuli monacemebiT ar aRiniSneba.<br />
am meTodis upiratesi prognozuli<br />
sargeblianoba medikamentur mkurnalobasTan<br />
SedarebiT sikvdilobis zomieri da maRali<br />
riskis mqone pacientebSi gamovlinda.<br />
farmakoTerapiasTan SedarebiT qirurgiuli<br />
Carevisas ukeTesi prognozi koronaruli<br />
anatomiis Semdeg jgufebSi aRiniSna:<br />
1. marcxena mTavari Reros mniSvnelovani<br />
stenozi.<br />
2. sami ZiriTadi koronaruli arteriis<br />
mniSvnelovani proqsimaluri stenozi:<br />
3. ori ZiriTadi koronaruli arteriis<br />
mniSvnelovani stenozi, maT Soris marcxena<br />
wina daswvrivi (mwd) koronaruli arteriis<br />
maRali xarisxis proqsimaluri stenozi.<br />
4. sami sisxlZarRvis dazianeba da marcxena<br />
parkuWis daqveiTebuli funqcia.<br />
40
kaS amasTanave efeqturad amcirebs<br />
stenokardiisa da iSemiis simptomebs<br />
koronaruli arteriebis daavadebis mqone<br />
pacientebSi.<br />
kaS saerTo operaciuli sikvdiloba 1-4%ia<br />
da amasTanave, calkeuli pacientisaTvis<br />
riskis individualuri stratifikaciis kargad<br />
Camoyalibebuli modelebi arsebobs. qirurgiuli<br />
Carevis riski Sedarebuli unda iqnes cxovrebis<br />
xarisxis gaumjobesebiT miRweul dadebiT<br />
Sedegebsa da zemoT CamoTvlili anatomiuri<br />
jgufebis pacientTa mosalodnel riskTan. Sida<br />
mamaruli arteriis gamoyeneba mwd koronarul<br />
arteriaze Suntis dasadebad sikvdilobas,<br />
miokardis dagvianebuli infarqtisa da Seqcevadi<br />
stenokardiis ganviTarebisa da Semdgomi<br />
intervenciuli Carevis sixSires amcirebs.<br />
sxva arteriuli Suntebis gamoyeneba aseve<br />
aumjobesebs sisxlZarRvTa gamavlobis Soreul<br />
monacemebs.<br />
transkutanuri koronaruli angioplastika (tka)<br />
stabiluri stenokardiisa da koronarebis<br />
Sesaferisi anatomiuri monacemebis mqone<br />
pacientebSi stentirebisa(axlo momavalSi<br />
wamliT gaJRenTili stentis gamoyenebiT)<br />
da adeqvaturi Tanmxlebi medikamenturi<br />
mkurnalobis fonze kompetenturi<br />
specialistis mier SesaZlebelia erT, an<br />
41
amdenime sisxlZarRvze angioplastikis<br />
warmatebuli Catareba riskis misaRebi donis<br />
gaTvaliswinebiT. rutinuli angioplastikis<br />
dros procedurasTan dakavSirebuli<br />
sikvdiloba daaxloebiT 0,3-1%-ia.<br />
simptomebis moxsnis mizniT Catarebuli<br />
tka nebismier SemTxvevaSi SeiZleba akSs<br />
alternatiul meTodad CaiTvalos.<br />
arsebuli monacemebis mixedviT stabiluri<br />
stenokardiis dros tka medikamentur<br />
mkurnalobasTan SedarebiT ukeTesi<br />
sargeblianobiT ar gamoirCeva, magram<br />
angioplastikis fonze ufro xSirad<br />
viTardeba iseTi cvlilebebi, romlebic<br />
cxovrebis xarisxs aumjobeseben<br />
(stenokardiuli Setevebis, qoSinis,<br />
rehospitalizaciis sixSiris Semcireba da<br />
datvirTvisadmi tolerantobis gazrda).<br />
intervenciuli teqnologiis gaumjobesebam<br />
transkutanuri revaskularizaciis axlo<br />
da Soreuli Sedegebis gaumjobeseba<br />
gamoiwvia, rac ufro dawvrilebiT Sesabamis<br />
gaidlainSia aRwerili.<br />
angioplastikisa da aorto-koronaruli<br />
Suntirebis urTierTSedareba.<br />
randomizebuli kvlevebis monacemebis<br />
mixedviT dadgenilia, rom maRali riskis<br />
42
mqone pacientebs garda, sadac qirurgiuli<br />
meTodi prognozuli sargeblianobiT<br />
gamoirCeva, rogorc angioplastika, ise<br />
aorto-koronaruli Suntireba erTnairad<br />
efeqturi meTodia daavadebis simptomebis<br />
mkurnalobisas.<br />
diabetis armqone pacientebSi, romelTac 1-2<br />
koronaruli arteriis dazianeba gamouvlindaT,<br />
magram ar aReniSnebaT mwd koronaruli<br />
arteriis maRali xarisxis stenozi da<br />
Tavidanve angioplastikis warmatebulobis<br />
maRali albaTobiT gamoirCevian, tka zogadad<br />
umjobes meTodad moiazreba, radganac<br />
mxedvelobaSi miiReba misi naklebinvaziuroba<br />
da procedurasTan dakavSirebuli ufro<br />
dabali riski. amasTan, mxedvelobaSi<br />
misaRebia isic, rom SedarebiT dabali riskis<br />
populaciaSi akS sikvdilobis sarwmuno<br />
SemcirebiT ar gamoirCeva. mkurnalobis<br />
strategiis SerCevisas individualuri<br />
garemoebebi da Tavad pacientis arCevani<br />
aucileblad gasaTvaliswinebelia.<br />
gansakuTrebuli SemTxvevebi<br />
pacientebi, romlebic gamoxatulad<br />
daqveiTebuli marcxena parkuWis funqciiTa<br />
da/an maRali qirurgiuli riskiT<br />
gamoirCevian, romlebsac marcxena ZiriTadi<br />
koronaris dazianeba aReniSnebaT, diabetis,<br />
43
mravali sisxlZarRvis dazianebis mqone<br />
pacientebi, an isini, visac axlad gadatanili<br />
aqvT akS operacia, revaskularizaciis<br />
meTodis SerCevisas garkveuli garemoebebis<br />
gaTvaliswinebas saWiroeben:<br />
� savaraudod maRali qirurgiuli riskis<br />
pacientebSi angioplastika SesaZloa,<br />
ufro sargebliani iyos, gansakuTrebiT,<br />
Tu samanipulacio sisxlZarRvebiT<br />
momaragebul daqveiTebuli funqciis<br />
mqone miokardis zonaSi narCeni<br />
sicocxlisunariani kunTis ubnebi<br />
gamovlinda.<br />
� marcxena mTavari koronaris dazianebisas<br />
angioplastikis Catareba misaRebia da<br />
wamliT gaJRenTili da SiSveli metalis<br />
stentebis Canergvis urTierTSedarebis<br />
samedicino dokumentaciis monacemebiT<br />
kargi Sedegebic aRiniSneba. miuxedavad<br />
amisa, qirurgiuli midgoma upirates<br />
midgomad CaiTvleba sakmarisi<br />
mtkicebulebebis dagrovebamde.<br />
� randomizebuli kvlevebis sxvadasxva<br />
qvejgufebSi miRebuli Sedegebis mixedviT<br />
mravali sisxlZarRvis dazianebis mqone<br />
diabetian pacientebSi Suntirebis operaciis<br />
fonze angioplastikasTan SedarebiT<br />
sikvdilobis Semcireba aRiniSna. am<br />
mniSvnelovani problemis ukeT Sesaswavlad<br />
44
andomizebuli kvlevebi amJamad<br />
momdinareobs, magram maTi monacemebis<br />
gamoqveynebamde tka aRniSnuli monacemebis<br />
mqone pacientebSi didi sifrTxiliT unda<br />
gamoviyenoT.<br />
� im pacientebSi, romelTac ukve Catarebuli<br />
aqvT akS, Semdgomi mkurnalobis umjobesi<br />
meTodis SesarCevi randomizebuli,<br />
placebo-kontrolirebadi kvlevebi ar<br />
Catarebula. simptomebis gamoxatulebis<br />
mixedviT(Sesaferisi anatomiuri monacemebis<br />
SemTxvevaSi) gameorebiTi qirurgiuli<br />
Careva SesaZloa, saWiro gaxdes. miuxedavad<br />
amisa, operaciuli riski maRalia. aseT<br />
SemTxvevaSi tka simptomebis moxsnis mizniT<br />
Catarebuli ganmeorebiTi qirurgiuli<br />
Carevis warmatebuli alternativaa.<br />
revaskularizaciisa da medikamenturi<br />
mkurnalobis urTierTSedareba<br />
Tu mxedvelobaSi ar miviRebT maRali riskis<br />
mqone populacias, sadac revaskularizaciis<br />
prognozuli sargeblianoba dadasturebulia,<br />
simptomebis mosaxsnelad Tavdapirvelad<br />
medikamenturi Terapia unda vcadoT.<br />
revaskularizaciis Catareba SeiZleba<br />
vurCioT pacientebs, romlebsac Sesaferisi<br />
koronaroanatomiuri monacemebi gaaCniaT<br />
da farmakoTerapia adeqvaturi SedegiT ar<br />
gamoirCeva, an iseT SemTxvevaSi, Tu pacients,<br />
45
miuxedavad asakisa, fizikuri aqtiobis<br />
garkveuli donis SenarCuneba unda(mag.<br />
regularulad varjiSobs).<br />
mkurnalobis Sedegianoba aucileblad<br />
pacientTan erTad unda iyos Sefasebuli.<br />
optimaluri medikamenturi meoradi prevencia,<br />
maT Soris antiagregantebi, +/- beta-blokerebi,<br />
+/- age-inhibitorebi, unda gagrZeldes<br />
revaskularizaciis Semdegac antianginuri<br />
Terapiis aucileblobis miuxedavad.<br />
revaskularizaciis rekomendaciebi<br />
mocemulia #4 cxrilSi.<br />
cxrili #4. stabiluri stenokardiis dros revaskularizaciis<br />
Catarebis rekomendaciebi<br />
46<br />
Cveneba prognozuli TvalsazrisiT<br />
rekomendaciis<br />
klasi<br />
mtkicebulebis<br />
done<br />
simptomuri gaumjobesebis<br />
mizniT<br />
rekomendaciis<br />
klasi<br />
mtkicebulebis<br />
done<br />
kvlevebi<br />
1 2 3 4 5 6<br />
tka (procedurisaTvis Sesaferisi anatomiuri monacemebis, riskis Sesaferisi<br />
stratifikaciiTa da pacientis arCevanis gaTvaliswinebiT)<br />
kgs klasifikaciiT<br />
I-IV klasis stenikardia<br />
miuxedavad<br />
farmakoTerapiisa,<br />
erTi sisxlZarRvis<br />
dazianebiT<br />
kgs klasifikaciiT<br />
I-IV klasis stenokardia<br />
miuxedavad<br />
farmakoTerapiisa,<br />
mravali<br />
sisxlZarRvis<br />
dazianebiT(diabetis<br />
armqone pacientebSi)<br />
I A ACME,<br />
MASS<br />
I A RITA 2,<br />
VA-<br />
ACME
cxrili #4 gagrZeleba<br />
1 2 3 4 5 6<br />
minimaluri simptomebiT<br />
mimdinare stabiluri<br />
stenokardia(kgs<br />
klasiI) mkurnalobis<br />
fonze ori, an<br />
meti sisxlZarRvis<br />
dazianebiT, magram<br />
gamoxatuli iSemiis<br />
obieqturi monacemebis<br />
gareSe)<br />
IIb C ACIP<br />
akS (operaciuli CarevisaTvis Sesaferisi anatomiuri monacemebis, riskis<br />
Sesaferisi stratifikaciiTa da pacientis arCevanis gaTvaliswinebiT)<br />
stenokardia da marcxena<br />
koronaruli<br />
arteriis dazianeba<br />
stenokardia da sami<br />
sisxlZarRvis paTologia<br />
didi zomis<br />
iSemiuri dazianebis<br />
obieqturi niSnebiT<br />
stenokardia da<br />
sami sisxlZarRvis<br />
paTologia parkuWis<br />
daqveiTebuli<br />
funqciiT<br />
stenokardia orisami<br />
sisxlZarRvis<br />
dazianebiT, maT<br />
Soris mwd arteriis<br />
gamoxatuli proqsimaluri<br />
obstruqcia<br />
kgs I-IV klasis<br />
stenokardia mravali<br />
sisxlZarRvis<br />
dazianebiT (diabetiani<br />
pacientebi)<br />
kgs I-IV klasis<br />
stenokardia mravali<br />
sisxlZarRvis<br />
dazianebiT (diabetis<br />
armqone pacientebi)<br />
I A I A CASS,<br />
ECS<br />
kvl-<br />
I A I A<br />
eva,<br />
VAS,<br />
metaanalizi<br />
Yusef<br />
I A I A mier<br />
I A I A<br />
IIa B I B BARI,<br />
GABI,<br />
ERACH,<br />
SoS,<br />
ARTs,<br />
I A<br />
Yusef<br />
et al.,<br />
H<strong>of</strong>fman<br />
et<br />
al.<br />
47
cxrili #4 gagrZeleba<br />
kgs I-IV klasis stenokardia<br />
miuxedavad<br />
farmakoTerapiisa,<br />
erTi sisxlZarRvis<br />
dazianebiT (mwd<br />
arteriis proqsimaluri<br />
dazianebis<br />
CaTvliT)<br />
kgs I-IV klasis stenokardia<br />
miuxedavad<br />
farmakoTerapiisa,<br />
erTi sisxlZarRvis<br />
dazianebiT (mwd arteriis<br />
gamoxatuli<br />
dazianebis gareSe)<br />
minimaluri simptomebiT<br />
mimdinare<br />
stenokardia (kgs<br />
klasi I) mkurnalobis<br />
fonze, erTi, ori,<br />
an sami sisxl-<br />
ZarRvis dazianebiT,<br />
gavrcelebuli<br />
iSemiuri cvlilebebis<br />
obieqturi<br />
niSnebiT I<br />
48<br />
I b MASS<br />
IIb B<br />
IIb C ACIP<br />
revaskularizaciis meTodis SerCevisas unda<br />
gaviTvaliswinoT:<br />
1. periproceduruli avadoba da sikvdiloba.<br />
2. warmatebis albaToba, maT Soris dazianebis<br />
mkurnalobis samkurnalod angioplastikisa,<br />
Tu qirurgiuli meTodis teqnikuri<br />
Sesaferisoba.<br />
3. restenozisa, Tu Suntis okluziis riskis<br />
albaToba.<br />
4. srulfasovani revaskularizaciis<br />
aucilebloba.<br />
5. Saqriani diabetis arseboba.
6. adgilobrivi saavadmy<strong>of</strong>os personalis<br />
gamocdileba da kompetenturoba<br />
gulmkerdis qirurigiasa, Tu intervenciul<br />
kardiologiaSi.<br />
7. pacientis arCevani.<br />
gansakuTrebuli diagnostikuri SemTxvevebi:<br />
stenokardia “normaluri” koronaruli<br />
arteriebis fonze<br />
pacientTa sakmaod did raodenobas,<br />
gansakuTrebiT qalebs, romlebsac<br />
gulmkerdSi arsebuli tkivilebis gamo<br />
angiografia utardebaT, gamoxatuli<br />
koronaruli daavadeba ar aReniSnebaT.<br />
am SemTxvevaSi, sakuTriv tkivilis<br />
interpretaciis mixedviT, SeiZleba sami<br />
varianti viqonioT mxedvelobaSi:<br />
a) ara-kardiuli tkivili gulmkerdSi.<br />
b) atipiuri, maT Soris vazospastiuri<br />
stenokardia.<br />
g) X kardiuli sindromi<br />
didi mniSvneloba aqvs X sindromis,<br />
an vazospastiuri stenokardiis fonze<br />
ganviTarebuli tkivilis diferencirebas<br />
gulmkerdis arakardiuli tkivilisagan.<br />
Tu angiografiuli gamokvleviT<br />
koronarul sisxlZarRvebis normalur<br />
49
gamavlobaze ufro metad savaraudoa maTSi<br />
araobstruqciuli cvlilebebis arseboba,<br />
xolo warmosaxviTi stres-meTodiT iSemiis<br />
mozrdili ubanis arseboba vlindeba,<br />
SesaZloa intravaskulurma ultrabgeriTma<br />
gamokvlevam, koronaruli sisxlis<br />
mimoqcevis, an fraqciuli sisxlis mimoqcevis<br />
rezervis Sefasebam saSualebas mogvces,<br />
gamovavlinoT koronaroangiografiis<br />
dros gamorCenili obstruqciuli<br />
dazianeba, Tu angiogramebi vizualurad<br />
normaluria, koronaroangiografiis<br />
dros intrakoronarulad ergonovinisa,<br />
Tu acetilqolinis Seyvana SeiZleba<br />
endoTeliumiT ganpirobebuli koronaruli<br />
sisxlis mimoqcevis rezervis, an vazospazmis<br />
arsebobis Sesafaseblad.<br />
X sindromi<br />
klasikuri “X sindromis” diagnoscireba<br />
Semdegi triadis arsebobisas xdeba:<br />
1. datvirTviT gamowveuli tipiuri<br />
stenokardia(mosvenebis stenokardiisa, an<br />
qoSinis TanxlebiT, an mis gareSe).<br />
2. dadebiTi datvirTvis testi, an sxva<br />
nebismieri warmosaxviTi datvirTvis sinji.<br />
3. normaluri koronaroarteriograma.<br />
mosvenebis eqokardiografia unda<br />
50
Catardes, raTa Sefasdes marcxena parkuWis<br />
hipertr<strong>of</strong>iisa da/an diastoluri<br />
disfunqciis arseboba. Tumca X sindromis<br />
dros sikvdilobis prognozi keTilsaimedoa,<br />
avadobis xarisxi maRalia. X sindromis<br />
mkurnalobisas gansakuTrebuli yuradReba<br />
simptomebis moxsnas unda mieqces. iseTi<br />
risk-faqtorebis mkurnaloba, rogoricaa<br />
hipertenzia da hiperlipidemia, rac SeiZleba<br />
endoTeliumis disfunqcias iwvevdes da<br />
Sesabamisad, simptomebis gamovlenasTan<br />
iyos dakavSirebuli, aseve Sesaferisad unda<br />
xdebodes.<br />
vazospastiuri/variantuli stenokardia<br />
xSirad “princmetalis stenokardiis”<br />
saxeliT cnobili es paTologia tipiuri<br />
lokalizaciis tkiviliT gamoirCeva.<br />
tkivili ZiriTadad mosvenebisas viTardeba,<br />
magram iSviaTad, an arasodes warmoiSveba<br />
datvirTvisas da nitratebis fonze wuTebis<br />
ganmavlobaSi qreba. klasikurad, tkivils Tan<br />
axlavs ST segmentis elevacia.<br />
vazospastiuri stenokardia, SesaZloa,<br />
diagnoscirebuli sisxlZarRvovani<br />
dazianebiT gamowveuli tipiuri datvirTvis<br />
stenokardiasTan erTad arsebobdes.<br />
vazospazmis provocireba SeiZleba Tambaqos<br />
51
mowevam, eleqtroliturma (kaliumis, magniumis)<br />
disbalansma, kokainis xmarebam, sicivem,<br />
autoimunurma daavadebebma, hiperventilaciam,<br />
an insulinrezistentobam gamoiwvios.<br />
vazospastiuri stenokardiis prognozi<br />
Tanmxlebi koronaruli daavadebis simZimiTaa<br />
ganpirobebuli. ST segmentis ambulatoruli<br />
monitorireba SeiZleba saWiro gaxdes.<br />
variantuli stenokardiis mkurnaloba<br />
moicavs maprovocirebeli faqtorebis<br />
mocilebasa da nitratebiT, an kalciumis<br />
antagonistebiT mkurnalobas.<br />
52
stabiluri stenokardiis gaidlainSi<br />
gamoyenebuli SemoklebaTa sia<br />
akS – aorto-koronaruli Suntireba<br />
apoA – apolipoproteini A<br />
apoB – apolipoproteini B<br />
bmr – birTvul-magnituri rezonansi<br />
C- rc – C – reaqtiuli cila<br />
dkm – dilataciuri kardiomiopaTia<br />
dsl – dabali simkvrivis lipoproteidebi<br />
ekg _ eleqtrokardiograma<br />
gu – gulis ukmarisoba<br />
gs – guliscemaTa sixSire<br />
gs sikvdiloba – gulsisxlZarRvovani<br />
sikvdiloba<br />
hs CRP – maRali mgrZnobelobis C – reaqtiuli<br />
cila<br />
kab – kalciumis arxebis blokerebi<br />
kad – koronaruli arteriuebis dazianeba<br />
kgs _ kanadis gulsisxlZarRvTa sazogadoeba<br />
kt – kompiuteruli tomografia<br />
Lp(a) – lipoproteini (a)<br />
MET – metaboluri erTeuli, 1 MET Seesabameba<br />
Jangbadis moxmarebis dones 3,5 ml/kg/wT<br />
mks – mwvave koronaruli sindromi<br />
mi – miokardiumis infarqti<br />
mp – marcxena parkuWi<br />
msl – maRali simkvrivis lipoproteidebi<br />
mwd – marcxena wina daswvrivi<br />
NT- BNP – n-terminuli natriurezuli faqtori<br />
53
RO” – rentgenoskopia<br />
sq – saerTo qolesteroli<br />
stres-eqokg – stres-eqokardiografia<br />
tg – trigliceridebi<br />
tiC – transkutanuri intrakoronaruli<br />
Careva<br />
tka – transkutanuri angioplastika<br />
54
SeniSvnebi<br />
55
SeniSvnebi<br />
56
Change language