miokardiumis infarqti st elevaciit stemi - gfma.ge · gulis daavadebebi 6-e gamocema 2001w da brain...
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miokardiumis infarqti ST elevaciiT STEMI
gaidlaini;
momzadebulia saqarTvelos kardiologTa kolejis da
saqarTvelos kardiologTa sazogadoebis mier mier 2006 w.
saqarTvelos kardiologTa kolejis da saqarTvelos kardiologTa
sazogadoebis gaerTianebuli komitetis eqspertTa samuSao jgufi: giorgi
kaWarava jo-enis saxelobis samedicino centri; aCiko CuxrukiZe gadaudebeli
kardiologiis centri; levan yuraSvili jo-enis saxelobis samedicino
centri; vaxtang WumburiZe profesori, Terapiis erovnuli centri, zaza
mgalobliSvili jo-enis saxelobis samedicino centri; nata gonjilaSvili
jo-enis saxelobis samedicino centri;, naTia axalaZe jo-enis saxelobis
samedicino centri; giorgi papiaSvili jo-enis saxelobis samedicino centri;
1
ABC = kardiopulmonaruli reanimaciis 3 etapi: sasunTqi gzebi A, sunTqva B, sisxlis
mimoqceva C. ACE = angiotenzin gardamqmneli fermenti ACS = mwvave koronaruli sindromi
AHA/ACC = amerikis gulis asociacia/amerikis kardiologiuri koleji
AF = winagulTa fibrilacia
aPTT = aqtivirebuli Tromboplastinis dro
ARB = angiotenzin II –is blokerebi
ASA = aspirini BMI = sxeulis masis indeqsi = wona (kg-Si) / simaRleze 2 (metr.)
BNP = B tipis natriurezuli peptidia
BUN = sisxlis Sardovana nitrogeni
CABG = kororonarul arteriuli baipas grafti. (aorto koronaruli Suntireba)
CBC = sisxlis saerTo analizi
CCS = kanadis kardiologiuri asociacia
CCU = intensiuri/koronaruli movlis ganyofileba
CHD = gulis koronaruli daavadeba
CHF = gulis SegubebiTi ukmarisoba
CK-MB = kreatinfosfokinaza MB izofermenti CPR = kardiopulmonaruli
CPR = kardiopulmonaruli resuscitacia (reanimacia) cTnI = kardiotroponini I cTnT = kardiotroponini T CT = kompiuteruli tomografia Cx = Semomxvevi toti D5W = deqstroza 5 %-iani
DVT = Rrma venebis Trombozi
EPS = eleqtrofiziologiuri kvleva
ECG = e.k.g.
GI = gastrointerstinuli
GU = genitourinaluri (Sardasasqeso)
GP = glukoproteini
HDL-C = maRali simkvrivis lipoprotein qolesteroli
HF = gulis ukmarisoba
HIT = hepariniT inducirebuli Trombocitopenia
HR = gulis SekumSvaTa sixSire IABP = intraaortuli balonuri kontrpulsacia ICD =kardioverter defibrilatori INR = saerTaSoriso normalizaciis Sefardeba
IV = intravenuri
LAD = marcxena wina daswvrivi toti LBBB = hisis konis marcxena fexis blokada
LDL-C = dabali simkvrivis lipoprotein qolesteroli
LMWH = dabalmolekuluri wonis heparini
LOE = mtkicebulebis xarisxi LV = marcxena parkuWi MET = metaboluri eqvivalenti
MI = miokardiumis infarqti NCEP = riskis daTvlis programa: http://heart.healthcentersonline.com/tools/calc_hd_results.cfm
(kiTxvari romelSiac SegaqvT Semdegi monacemebi: saerTo qolesterini, HDL, sistoluri
wneva, sqesi, asaki, eweviT Tu ara da igi gaZlevT gulis gulis daavadebebiT 10 wliani
sikvdilianobis risks)
non-HDL-C = saerTo qolesterins gamoklebuli HDL NSVT = aramdgradi (xanmokle) ventrikuluri taqikardia
NTG = nitroglicerini
PCI = perkutaneuli koronaruli intervencia
PTCA = perkutaneuli transluminaruli koronaruli angioplastika
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PE = pulmonaruli embolia
RC = marjvena koronari
RBBB = hisis konis marjvena fexis blokada
RV = marjvena parkuWi
STEMI = miokardiumis infarqti ST elevaciiT am jgufSi ganixileba pacientebi miokardiumis
infarqtiT, romelTac e.k.g-ze aqvT persistentuli > (20-30wT) ST segmentis elevacia
TG = trigliceridebi UA = arastabiluri stenokardia
UFH = arafraqcionirebuli heparini
VF =ventrikuluri fibrilacia
VO2 = moxmarebuli Jangbadi drois garkveul monakveTSi
VSR = parkuWTa Sua Zgidis rubtura
VT =ventrikuluri taqikardia
WPW = volf-parkinson-uaitis sindromi
flail leaflet = “mofarfate” qorda preexitation = naadrevi aRgzneba Imaging Modality = gamosaxulebiTi kvleva
Preexitation = naadrevi agzneba (delta talRa),
Electronically paced ventricular rhythm = parkuWSi riTmis xelovnuri wamyvani
Advanced AV Block = Sorswasuli blokada
niacini = vitamini B-3 s.d.b. = saswrafo daxmarebis brigada
PM I Sesavali: ............................................................................................................................................6
a. samuSao jgufis ganmarteba: ................................................................................................6 b) cxrili 1. gaidlainSi gamoyenebuli rekomendaciebis da mtkicebulebebis
xarisxi. Sedgenilia AHA/ACC-is rekomendaciebis mixedviT mocemuli
cxrili saSualebas gvaZlevs ganvsazRvroT TiToeuli samedicino midgomis
roli pacientis mkurnalobisas. mtkicebulebebis xarisxi (LOE)-gamoyenebuli iqneba sxvadasxva samkurnalo meTodis Tu diagnostikis
rolis gansazRvrisas..................................................................................................................7 g. mwvave miokardiumis infarqtis definicia ...................................................................8 d. mwvave miokardiumis infarqtis paTogenezi: ................................................................8 v. mwvave koronaruli sindromis ganmarteba da klinikuri mimdinareoba: ........9 sqema: 1 ................................................................................................................................................9
II STEMI-s ganviTarebamde mkurnaloba................................................................................10 a. rekomendaciebi STEMI-s risk faqtorebis mqone pacientebis gamovlenisTvis.............................................................................................................................10 b. rekomendaciebi STEMI-s niSnebis naadrevi gamovlenisa da CarevisaTvis,
pacientebis ganaTleba: .............................................................................................................11 III STEMI-s Setevis dawyeba da prehospitaluri qmedeba ..............................................12
a. STEMI-T pacientebis transportireba da pirveladi reperfuziuli
mkurnalobis SerCeva .................................................................................................................12 IV. pirveladi amocnoba da marTva gadaudebeli daxmarebis departamentSi....15
a. sqema. 3 gadaudebeli daxmarebis algoriTmi/protokoli pacientSi
STEMI–s simptomebiT an niSnebiT ........................................................................................15 b. damateba: ekg-s interpretacia: .........................................................................................16 g. cxrili 3. STEMI-is diferencialuri diagnostika ................................................17 d. STEMI-s diagnoziT miRebul pacientSi rutinuli testebi ..............................18 e. reperfuziis meTodis aucileblobis da SesaZleblobis gansazRvra
pacientebSi STEMI-T ................................................................................................................20 v. reperfuziis saxis SerCeva pacientebSi STEMI-T .....................................................21
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z. fibrinolizis Cvenebebi: .....................................................................................................22 T. STEMI-s dros fibrinolizis ukuCveneba da safrTxeebi ....................................23 cxrili 6. ........................................................................................................................................23 i. diagnostikuri koronaruli angiografia ..................................................................23 k. pirveladi PCI-s rekomendaciebi.......................................................................................24 l. pirveladi PCI-s rekomendaciebi pacientebSi romlebic ver Rebuloben
Tromboliziss raimis gamo; (Seuferebelia TrombolizisisaTvis) ....................25 m. pirveladi PCI-s rekomendaciebi klinikebisaTvis romelTac ara aqvT
kardioqirurgiuli ganyofileba .........................................................................................26 n. damxmare PCI ..............................................................................................................................26 o. gadamrCeni PCI: ........................................................................................................................26 p. PCI fibrinolizisis Semdeg:...............................................................................................27 r. mwvave qirurgiuli reperfuzia:......................................................................................28 s. zogadad urgentuli da gadaudebeli qirurgiuli revaskularizaciis
Cveneba STEMI-s dros aris Semdegi .....................................................................................28 V hospitaluri mkurnaloba.......................................................................................................29
a...CCU intensiuri/koronaruli movlis ganyofileba: ...............................................29 b. CCU-is Semdgomi mkurnaloba: ............................................................................................30 g. pacientebis gaaqtiveba:.........................................................................................................31 d. dieta:...........................................................................................................................................31 e. analgetikebi/aRgznebis sawinaaRmdego preparatebi: ..............................................31 v. antiagregantebi: ......................................................................................................................31 z. reperfuziisas damatebiTi antiTrombozuli farmakologiuri daxmareba32 T. renin-angiotenzin-aldosteronis sistemaze moqmedi preparatebi STEMI-s dros: .................................................................................................................................................35 i. glukozis kontroli STEMI-s dros:.............................................................................36 k. eleqtrolitebis balansi:..................................................................................................36 l. kalciumis arxebis blokatorebi: .................................................................................37 m. beta-blokatorebi: .................................................................................................................37 n. nitroglicerini:.....................................................................................................................38 i. sqema 4. garTulebuli STEMI. gadaudebeli mdgomareobebis marTvis
protokoli.....................................................................................................................................39 VI hemodinamikuri darRvevebi................................................................................................41 a. hemodinamikuri gazomvebi: ...................................................................................................41 b. hipotenzia: .................................................................................................................................42 g. dabali wuTmoculobiTi mdgomareoba: ........................................................................42 d. pulmonaruli Segubeba: ......................................................................................................42 e kardiogenuri Soki: ................................................................................................................43 v. marjvena parkuWis infarqti: .............................................................................................44 VII gulis ukmarisobis meqanikuri mizezebi/dabali wuTmoculobis sindromi
.............................................................................................................................................................45 a. mitraluri sarqvlis ukmarisoba:...................................................................................45 b. parkuWis Zgidis rubtura: ..................................................................................................45 g. marcxena parkuWis Tavisufali kedlis rubtura ...................................................45 d. marcxena parkuWis anevrizma:............................................................................................45 e. intraaortuli balonuri kontrpulsacia: IABP:.....................................................46 VIII ariTmiebis marTva STEMI-is Semdgom .........................................................................48 a. VF: parkuWovani fibrilacia: ............................................................................................48 b. VT: parkuWovani taqikardia ...............................................................................................48
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g parkuWovani eqstraistolia: ..............................................................................................49 d. aCqarebuli idiventrikuluri an kvanZovani riTmiv. marjvena parkuWis
infarqti: .........................................................................................................................................49 g. supraventrikuluri ariTmia/AF.......................................................................................49
IX. bradiariTmiebi: .........................................................................................................................50 a. sinusis kvanZis disfunqcia STEMI-s Semdgom: ............................................................50 b. gamtareblobis moSla: .........................................................................................................50 d. mudmivi peisingis Cveneba bradiaritmiis da/an gamtareblobis darRvevisas
romelic asocirdeba STEMI-Tan:...........................................................................................53 e. mudmivi peisingis modelis SerCeva Cveneba bradiaritmiis da/an
gamtareblobis darRvevisas romelic asocirdeba STEMI-Tan: ..............................54 v. ganmeorebiTi tkivili STEMI-s Semdgom........................................................................54 T. STEMI-s Semdgomi aorto koronaruli Suntirebis Cvenebebi mocemuli
iqneba zogadad CABG-is gaidlainSi. .................................................................................56 X meoradi prevencia da xangZlivi marTva:.......................................................................56
a. riskis Sefaseba stacionaridan gaweris Semdgom: ..................................................56 b. cxrili 10 meoradi prevencia STEMI-s dros:.............................................................58 g. ST elevaciiT mimdinare miokardimis infarqtis ( STEMI) stacionaridan gaweris Semdgomi antiTrombozuli mkurnaloba .........................................................62 d. rekomendaciebi gaweris Semdgomi vizitebis da zogadad daavadebis
marTvis Sesaxeb: ...........................................................................................................................63 e. cxrili 11 medikamentebi romlebic gamoyeneba STEMI-s mkurnalobisas .......64
GXI gamoyenebuli masala: ............................................................................................................68
5
I Sesavali:
a. samuSao jgufis ganmarteba:
gaidlaini eyrdnoba amerikis kardiologTa kolejis, amerikis gulis
asociaciis da evropis kardiologTa asociaciis masalebs. aseve
gamoyenebulia monacemebi Semdegi literaturidan braunvaldi, zaips libbi,
gulis daavadebebi 6-e gamocema 2001w da brain p. grifini erik j. topoli
kardiovaskularuli medicinis saxelmZRvanelo, 2-e gamocema 2004w. samuSao
jgufma moaxdina teqstis adaptireba, rac ZiriTadSi rCeba zemoT aRniSnuli
gaidlainebis farglebSi da Seesabameba maT rekomendaciebs. amasTan erTad
Cven davamateT ramodenime ganmarteba da cxrili CamoTvlili literaturidan
romelic Cvenis azriT daexmareba mkiTxvels mkurnalobis sqemebis swor
interpretaciaSi.
es moxseneba warmoadgens ST elevaciiT mimdinare miokardiumis infarqtis
mkurnalobis ZiriTad principebs. cxadia igi ver iqneba sakmarisi
kardiologisaTvis daavadebirulyofili marTvisTvis. mocemul versiaSi
ganxilulia mxolod mkurnalobis ZiriTadi etapebi, aseve garTulebebi da
maTi marTva. miuxedavad zogadi xasiaTisa warmodgenili versia saSualebas
gvaZlevs swrafad gadavxedoT mkurnalobis ZiriTad principebs da igi
daexmareba rogorc kardiologebs aseve zogadi praqtikis/ojaxis da
saswrafo daxmarebis eqimebs, romelTaTvisac siswrafes da masalis
kompaqturobas didi mniSvneloba aqvs.
samuSao jgufi acnobierebs moTxovnilebas moxdes Cveni jan-dacvis sistemis
harmonizacia evropisa da amerikis samedicino sistemebis maRal samedicino
standartebTan da miiCnevs, rom am procesSi gaidlainebs, ufro zustad ki
maT implementacias aqvs udidesi mniSvneloba. swored es gaxda imis mizezi
rom Cven aRar davucadeT sruli teqstis damTavrebas da gadavwyviteT mokle
versiis gamoqveyneba. vfiqrobT teqstis TandaTan Sevsebas, rac xels ar
SeuSlis mis danergvas, vinaidan mudmivi ganaxleba gaidlainebiT muSaobis
Tanmxlebi da ganuyofeli procesia. Cveni jgufia Riaa msjelobisaTvis iseT
Temebze rogoricaa: Tu ramdenad realuria saqarTveloSi am sqemebiT
muSaoba, Tu ramdenad zustad Seesabameba Cvens mier adaptirebuli
rekomendaciebi evropis da a.S.S/-s Sesabamis rekomendaciebs da xom ar
ewinaaRmdegebian isini maT ZiriTad suliskveTebas. problematuria agreTve
rigi enobrivi sakiTxebisa. Cven gadavwyviteT abreviaturebis inglisuri
SriftiT xmareba. Cvenis azriT am MmeTodis ZiriTadi mizania 1) teqstis
Semokleba. 2) ganmeorebebis meti saSualeba da 3) yuradRebis miqceva swrafi
kiTxvisas. vinaidan qarTulSi ar arsebobs didi asoebi am SemoklebebiT
yuradRebis miqceva efeqturi ver aris. amasTan erTad zogi abreviatura
imdenad damkvidrebulia rom maTi Secvla iqneboda xelovnuri da uxerxuli
saxmarad. amgvarad Tuki am princips ar gavavrcelebdiT yvela Semoklebaze
maSin teqstSi xan iqneboda inglisuri xan qarTuli abreviatura, rac aseve
gaugebari da mouxerxeli iqneboda. sayuradReboa is faqtic rom mkurnalobis
Tu diagnostikis zogierTi meTodi saqarTveloSi ver tardeba teqnikuri Tu
finansuri mizezebidan gamomdinare. aseT SemTxvevebSi Cveni jgufi
rekomendacias iZleva, rom pacientis istoriaSi, Tu ambulatoriul baraTSi
dafiqsirdes am gamokvlevaze, Tu mkurnalobaze uaris Tqmis mizezi, raTa
naTeli gaxdes, rom mkurnali eqimi flobs daavadebis Tanamedrove midgomebs,
6
magram gamodis konkretuli realiebidan. Cvenis mxriv mzada varT farTo
diskusiisaTvis aRniSnul Temebze mizanSewonilia gaviTvaliswinoT rogorc
enis specialistebis aseve sazogadoebis da sxvadasxva dargis eqspertebis
azri. mTavari CvenTvis am etapze Tavad gaidlainiT muSaobis praqtikis
damkvidrebaa saqarTvelos samedicino sistemaSi, rac vfiqrobT etapuri iqneba
saqrTveloSi medicinis ganviTarebisaTvis.
b) cxrili 1. gaidlainSi gamoyenebuli rekomendaciebis da
mtkicebulebebis xarisxi. Sedgenilia AHA/ACC-is rekomendaciebis mixedviT
mocemuli cxrili saSualebas gvaZlevs ganvsazRvroT TiToeuli samedicino midgomis roli
pacientis mkurnalobisas. mtkicebulebebis xarisxi (LOE)-gamoyenebuli iqneba sxvadasxva
samkurnalo meTodis Tu diagnostikis rolis gansazRvrisas.
I klasi:
sargebloba > > > riskze.
procedura/mkurnaloba
unda
Catardes/dainiSnos
II-A klasi: sargebloba > > riskze
saWiroebs damatebiT
gamokvlevebs.
gonivrulia
Catardes/dainiSnos
Sesabamisi
procedura/mkurnaloba
II-B klasi:
sargebloba ≥ riskze saWiroebs damatebiT
gamokvlevebs.
procedura/mkurnaloba
SesaZlebelia gvqondes
mxedvelobaSi
III klasi: damatebiTi
gamokvlevebi aRaraa
saWiro.
procedura/mkurnaloba
ar unda
dainiSnos/Catardes
vinaidan igi
usargebloa da
SesaZloa iyos saSiSi
A-done: mravali (3-5) sxvadasxva
populaciuri
jgufebia
Sefasebuli.
efeqti da
mimarTuleba
myaria.
rekomendacia imis
Sesaxeb rom igi aris
sasargeblo/efeqturi.
monacemebis miRebulia
mravali
randomizebuli
kvleviT da meta-
analiziT.
rekomendacia
procedura/mkurnalobis
Catareba/daniSvnis
sasargeblodaa
aris zogierTi
urTierTsawinaaRmdego
monacemi mravali
randomizebuli kvlevis
da meta-analizisagan
rekomendaciis
sargebloba/efeqturoba
nakleb kargadaa
Seswavlili
urTierTsawinaaRmdego
monacemebi ufro metia
mravali
randomizebuli
kvlevis da meta-
analizisagan
rekomendacia rom
procedura/mkurnaloba
araa
sakmarisi monacemebia
mravali
randomizebuli da
metaanalizisagan
B-done: SezRuduali
(2-3) populaciuri
jgufebia
Safasebuli
rekomendacia imis
Sesaxeb rom igi aris
sasargeblo/efeqturi.
SezRuduli
monacemebia miRebulia
erTi randomizebuli
da
ararandomizirebuli
kvlevebisagan
rekomendacia
procedura/mkurnalobis
Catareba/dniSvnis
sasargeblodaa.
aris zogierTi
urTierTsawinaaRmdego
monacemi erTi
randomizirebuli da
ararandomizebuli
kvlevebisagan
rekomendaciis
sargebloba/efeqturoba
nakleb kargadaa
Seswavlili
ufro meti
urTierTsawinaaRmdego
monacemia erTi
randomizirebuli da
ararandomizebuli
kvlevebisagan
sasargeblo/efeqturi
da SesaZloa iyos
saziano.
SezRuduli
monacemebia erTi
randomizirebulia da
ararandomizebuli
kvlevebisagan.
C-done: Zalian
SezRuduali
(1-2) populaciuri
jgufebia
Safasebuli
rekomendacia imis
Sesaxeb rom igi aris
sasargeblo/efeqturi.
arsebobs mxolod
eqspertebis azri,
SemTxvevaTa
aRwera(case report)
rekomendacia
procedura/mkurnalobis
Catareba/dniSvnis
sasargeblodaa
eyrdnoba eqspertebis
azrs da SemTxvevaTa
aRweras
rekomendaciis
sargebloba/efeqturoba
nakleb kargadaa
Seswavlili
eyrdnoba eqspertebis
azrs da SemTxvevaTa
aRweras
sasargeblo/efeqturi
da SesaZloa iyos
saziano.
arsebobs mxolod
eqspertebis azri,
SemTxvevaTa
aRwera(case report)
7
g. mwvave miokardiumis infarqtis definicia
amerikis kardiologTa koleji da evropis kariologTa asociaciis
gaerTianebuli komiteti mwvave miokardiumis infarqts (acute, evolving or recent MI) gansazRvravs Semdegnairad: miokardiumis nekrozis bioqimiuri markerebis,
kerZod troponinis tipiuri zrda da TandaTanobiTi vardna an CK-MB-is ufro swrafi zrda da vardna, romelsac Tan axlavs erT-erTi
CamoTvlilTagani: iSemiuri simptomebi, e.k.g-ze paT. Q kbilis gaCena da/an
cvlilebebi romlebic miokardiumis iSemiaze miuTiTeben, koronaruli
intervencia an MI-s paTologiuri gamovlinebani (findings).
d. mwvave miokardiumis infarqtis paTogenezi:
dRevandeli gagebiT miokardiumis infarqti iyofa 2 ZiriTad jgufad I
mimdinare ST elevaciiT STEMI da II mimdinare ST-elevaciis gareSe NSTEMI. termini - mwvave koronaruli sindromi TavisTavSi aerTianebs Semdeg
klinikur sindromebs: arastabilur stenokardias, Mmiokardiumis infarqts ST -segmentis elevaciis gareSe da miokardiumis infarqts ST- segmentis elevaciiT, sadac pacientebi arastabiluri stenokardiiT da miokardiumis
infarqtiT. ST- segmentis elevaciis gareSe miekuTvnebian erT jgufs, xolo
pacientebi ST- segmentis elevaciiT mimdinare miokardiumis infarqtiT
miekuTvnebian meore jgufs. termini – arastabiluri stenokardia asaxavs
sindroms , romelsac Sualeduri mdgomareoba ukavia qronikul stabilur
stenokardiasa da miokardiumis infarqts Soris. pacientebs ST- segmentis elevaciis gareSe mimdinare mwvave koronaruli sindromiT, aqvT an
arastabiluri stenokardia an ST-segmentis elevaciis gareSe mimdinare
miokardiumis infarqti. Mmwvave koronaruli sindromi ST- segmentis elevaciT uxSiresad sruldeba miokardiumis Q kbilovani infarqtiT da
iSviaTad ara Q kbilovani infarqtiT. ST– segmentis elevacis gareSe
miokardiumis infarqti uxSiresad sruldeba ara Q kbilovani miokardiumis
infarqtiT da iSviaTad Q kbilovani miokardiumis infarqtiT. ( ix. mwvave
koronaruli sindromis (ACS) ganmarteba. cxrili 1.) NSTEMI-s paTogenezi
ganxilulia Sesabamis gaidlainSi. Cven aq mokled SevCerdebiT ST-elevaciiT
mimdinare miokardiumis infarqtis paTogenezze.
STEMI-s dros prevalirebs maokluzirebeli Trombozi. daaxlobiT 2/3 dan 3/4
-mde SemTxvevebSi Trombis warmoqmnas win uswrebs folaqis fibrozuli
garsis rubtura an misi erozia, romelic ufro xSirad ar iwvevs
obstruqcias, Tumca warmoadgens substancias romelic aZlierebs
Trombocitebis aqtivacias, agregacias, adhezias da Trombinis generacias,
rasac Tavis mxriv mohyveba ukve Trombis warmoqmna da sanaTuris daxSoba.
nela ganviTarebuli okluziisas SesaZloa ar gvqondes MI . savaraudod imis gamo, rom ganviTarebas aswrebs kolateraluri qseli, rac nawilobriv
akmayofilebs miokardiumis moTxovnilebas. procesi xSirad dinamiuria, anu:
Trombozi, spontanuri Trombolizisi, vazospazmi SeiZleba erTdroulad
aRiniSnos da mogvces koronaruli nakadis gardamavali Sewyveta da
distaluri embolizacia. (es ukanaskneli iwvevs mikrovaskularul
obstruqcias, rac xels uSlis srulyofil revaskularizacias miuxedavad
epikardiuli koronaris gaxsnisa.)
8
e. mwvave miokardiumis infarqtis gavrceleba/epidemiologia:
saqarTveloSi bolo 20 wlis ganmavlobaSi raime saxis seriozuli
statistikuri kvleva, romelic am daavadebis gavrcelebas Seiswavlida ar
Catarebula. aqedan gamomdinare Cven veyrdnobiT Aa.S.S-s da evropul
monacemebs.
maTi mixedviTac a.S.S-Si yovelwliuri sikvdilianoba gulis koronaruli daavadebebiT aris
500,000-ze meti. 1,680,000 pacientis hospitalizaciis mizezi aris ACS. amis garda 200,000 dan 300,000-mde kaci kvdeba MI-T savadmyofoSi gadayvanamde. anu mwvave koronaruli sindromi
TiTqmis 2,000,000 mde adamians emarTeba yovelwliurad. aqedan STEMI aqvs daaxloebiT 500,000
adamians. evropuli monacemebiT am ukanasknelis sikvdilianoba 1 TveSi Seadgens 30-50%-s
romelTagan TiTqmis naxevari pirvel 2-sT-Si xdeba. unda aRiniSnos rom bolo xanebSi
miokardiumis infarqtis sixSires aqvs Semcirebis xolo arastabiluri stenokardiis
sixSires zrdis tendencia. igive SeiZleba iTqvas STEMI-s Sesaxeb, romlis SemTxvevebi
mcirdeba NSTEMI-s sasargeblod. zogadad SesaZloa iTqvas, rom amerikaSi yovel 29 wm-Si
romelime adamians emarTeba mwvave MI xolo am daavadebiT pacienti kvdeba yovel 1 wT-Si.
Tuki saqrTvelos mosaxleobas aviRebT 4,000,000-mde, xolo statistikas igives
davtovebT rac evropasa da a.S.S-Sia, maSin SesaZloa iTqvas, rom CvenTan
yovelwliurad gulis koronaruli daavadebebiT kvdeba daaxloebi 6600
pacienti. ACS yovelwliurad emarTeba 26,000 adamians. aqedan STEMI yovelwliurad emarTeba daaxloebiT 6600 adamians ( romelTa 30%-50% kvdeba
pirvel 1-TveSi), xolo danarCens aqvs UA/NSTEMI ( daaxloebiT 18,000-19,000). saqarTveloSi yovel 40 wT-Si romelime adamians emarTeba MI, xolo am
daavadebiT kvdeba pacienti yovel 80 wT-Si.
v. mwvave koronaruli sindromis ganmarteba da klinikuri
mimdinareoba:
sqema: 1
mwvave koronaruli sindromi ACS
ST elevaciiT ST elevaciis gareSe
ara Q kbilovani miokardiumis
infarqti Q kbilovani
miokardiumis infarqti
arastabiluri
stenokardia UA
ST elevaciis gareSeE mimdinare mwvave koronaruli sindromi ( ACS ). ufro xSirad mTavrdeba UA an ara Q-kbilovani miokardiumis infarqtiT. naklebi sixSiriT man SeiZleba gamoiwvios Q -kbilovani MI. ST elevaciiT mimdinare ACS ufro xSirad mTavrdeba Q-kbilovani MI-T da naklebad xSirad ara Q
kbilovani MI-T an UA-iT
9
tkivils miokardiumis dros klasikuri mimdinareobisas aqvs substernaluri,
moWeriTi, xasiaTi xSiri iradiaciiT marcxena xelSi, tkivili msgavsia
stenokardiuli tkivilis, oRond grZeldeba > 20wT-ze. gansxvavebiT PE-s da aortis diseqciisa tkivilis piki araa myisieri. tkivili SeiZleba
gadaecemodes kiserSi, ybaSi, mxrebSi, marjvena mklavSi, epigastriumSi. es
tkivilebi SeiZleba iyos izolirebulic, gulmkerdis tkiilis gareSec da es
ufro xSirad gvxvdeba moxucebSi da maTSi visac aqvs diabeti.
a. Tu tkivili iradirebs zurgSi da aris xanjlis CacemasaviT eWvi unda
gvqondes aortis diseqciaze. am dros mizanSewonilia CT an transezofaguri eqoskopia. b. perikarditisas tkivili Zlierdeba zurgze wolisas, da
umjobesdeba jdomisas da win gadmoxrisas. ST elevaciis difuzuri xasiaTi
erT-erTi mniSvnelovani ganmasxvavebeli niSania MI-sgan, Tumca msgavsi suraTi
SesaZloa am ukanasknelisTvisac iyos damaxasiaTebeli. Pperikarditisas ST segmentis elevacias aqvs Cazneqili xasiaTi infarqtisagan gansxvavebiT. aseve
perikarditisaTvis araa damaxasiaTebeli reciprokuli cvlilebebi. aVR-is da V1 –is garda eqokardiografiisas MI-s dros gveqneba regionaluri
kumSvadobis moSla rac erT-erTi sadiferenciacio niSania.
g. miokarditi: eqokardiografia am SemTxvaSi ver gvexmareba. diferencireba
xdeba anamnezis safuZvelze, rac miokarditisas xSirad ukavSirdeba virusul
infeqcias.
d. PE xSirad sunTqvis gaZnelebasTan erTadaa, axasiaTebs plevraluri
tkivili, am SemTxvevaSi eqokardiografias aqvs didi roli diferencialuri
diagnozis gatarebaSi.
e. ezofagialuri daavadebebi: gastroezofaguri refluqss, ezofaguri
hiperalgezias SeuZlia mogvces MI-s msgavsi diskomforti. xSirad igi gvxvdeba pacientebSic romelTac aqvT CHD, riTac diagnostireba rTuldeba.
am SemTxvevaSi mniSvneloba aqvs igi ukavSirdeba Tu ara kvebas, mcirdeba Tu
ara antacidebis xmarebisas, ramdenad axasiaTebs radiacia. v. mwvave
qolecistiti: man SeiZleba mogvces msgavsi xasiaTis tkivili da e.k.g.
cvlilebebi, rac xSirad damaxasiaTebeli qveda kedlis miokardiumis
infarqtisTvis. muclis marjvena zeda kvadratis mgrZnobeloba da
daWimuloba, cxeleba leikocitozi laparakobs qolecistitis sasargeblod.
unda aRiniSnos, rom es gansxvavebebi araa absolituri da daavadeba xSirad
SesaZloa mimdinareobdes atipiurad an romelime sxva daavadebis msgavsi
klinikiT. aqedan gamomdinare SeiZleba iTqvas rom MI-s diagnozi moiTxovs
misi diagnostikisadmi kompleqsur midgomas, romelic iTvaliswinebs
sxvadasxva faqtorebs.
II STEMI-s ganviTarebamde mkurnaloba
a. rekomendaciebi STEMI-s risk faqtorebis mqone pacientebis gamovlenisTvis
riskis gansazRvra: CHD-s ZiriTadi/mTavari risk faqtorebia: moweva, ojaxuri
istoria, lipiduri speqtris gauareseba, maRali arteriuli wneva. pacientebs
diabetiT da periferiuli arteriebis daavadebebiT aqvT STEMI-s ganviTarebis
igive riski rac daavadebulebs gulis koronaruli daavadebiT.
10
klasi I
1. yvela pacientSi regularuli intervaliT ( 3 – 5 weli ) Sefasebul unda
iqnes CHD-is ZiriTadi/mTavari risk faqtorebi ( AHA/ACC-is ganmartebiT
esenia: ojaxuri istoria, moweva, gauaresebuli lipiduri profili, maRali
arteriuli wneva, diabeti) da maTi kontrolis xarisxi. LOE : C
2. simptomuri CHD ganviTarebis 10 wliani riski unda iqnes gaTvlili yvela
pacientSi visac aqvs 2 an meti didi risk faqtori ( gaTvla warmoebs
amerikis NCEP-is programis safuZvelze ) LOE : B
3. pacientebi CHD-iT, identificirebulni unda iqnan meoradi prevenciisTvis.
pacientebi CHD-is ekvivalenti riskiT ( diabeti, Tirkmlis qr. daavadeba an 10
wliani riski > 20% gamovlenili framingemis kvleviT: ganxilul unda iqnen,
ise rogorc klinikurad gamovlenili CHD. LOE : A
10-wliani sikvdilianobis riski.
http://heart.healthcentersonline.com/tools/calc_hd_results.cfm SegiZliaT gansazRvroT
mocemuli veb gverdze ganTavsebuli formuliT.
damateba: im pacientebSi romelTac NCEP-s mixedviT aqvT 10 wliani sikvdilianobis
riski > 6%-ze, SeiZleba ganvixiloT aspirinis miReba 75-162 mg dReSi.
b. rekomendaciebi STEMI-s niSnebis naadrevi gamovlenisa da
CarevisaTvis, pacientebis ganaTleba:
klasi I
1. pacientebi STEMI-T (diskomforti an tkivili gulmkerdSi iradiaciis
gareSe, an iradiaciiT mklavSi, zurgSi, epigastriumSi, ybaSi, nikapSi, haeris
ukmarisoba, sisuste, oflianoba, gulisrevis SegrZneba Tavbrusxveva)
umjobesia klinikaSi gadayvanil iqnan saswrafo daxmarebis brigadis mier,
vidre TviTdinebiT an axloblebis mier. LOE : B 2. mkurnalma eqimma pacients da misi axloblebs unda auxsnas:
a. gulis Setevis riski LOE : C b. rogor unda amovicnoT STEMI-s simptomebi LOE : C g. saswrafo daxmarebis brigadis gamoZaxebis aucilebloba, Tu simptomebi
ar qreba an uaresdeba 5 wuTis Semdeg, miuxedavad gaurkvevlobis da eqimebis
“ tyuilad Sewuxebis” SiSisa. LOE : C d. pacientma da misma axloblebma unda icodnen moqmedebis gegma aseT
SemTxvevebisas (s.d.b-s telefonis nomrebis CarTviT) LOE : C 3. pacientebs, visTvisac nitroglicerini ukunaCvenebi ar aris, erTi abi unda
mieces enis qveS gulmkerdis areSi tkivilis an diskomfortis dros. Tu
gulmkerdSi tkivili/diskomforti ar Semcirda an gauaresda 5 wuTSi,
rekomendirebulia dauyovnebliv darekil iqnas saswrafo daxmarebis
samsaxurSi. ( LOE : C)
damateba: pacientebs unda aexsnaT, rom Tuki simptomebi ar qreba an uaresdeba, saswrafo
daxmarebis sadgurSi darekvis Semdgom pacients SiZleba erCios aspirinis miReba s.d.b-s
mosvlamde.
11
damateba: yuradReba unda mieqces imas rom zogierT pacientSi MI mimdinareobs gulmkerdSi
diskomfortis gareSe. am mxriv gansakuTrebiT sayuradReboa qalebi, diabetiT daavadebulebi,
moxucebulebi, pacientebi gulis ukmarisobiT. agreTve sayuradReboa is pacientebi
romlebsac aqvT permanentuli peismekeri da tkivili gulmkerdSi, vinaidan maTSi e.k.g.
interpretacia Zalian garTulebulia.
III STEMI-s Setevis dawyeba da prehospitaluri qmedeba
a. STEMI-T pacientebis transportireba da pirveladi
reperfuziuli mkurnalobis SerCeva
sqema 2 A hospitaluri fibrinolizisi: unda Sesruldes
stacionarSi Semosvlidan 30 wT-Si
paneli A paciemier
reperfuzia ST(fibrinoliziT
pacientebis tr
transportireb
SenarCunebuli
saswrafo daxm
aReniSneba uku
daxmarebis bri
ara aqvs fibri
aris PCI-s saSufibrinolizi (
brigadas ara a
romelsac aqvs
Si unda Cautar
SeiZleba ganvixiloT
drois grafiki
s.d.b-s
gamgz
1-wT-S
oqros dro = 60
STEMI-s simptomebis
dawyeba
s.d.b.:
• iRebs 12 ganxrian e.k.g-s
• Tuki SesaZloa (igulisxmeba
saswrafos
gamoZaxeba
da
gamogzavna
klinikaSi PCI - SesaZlebelia ix. sqema 2B
inter hospitaluri
gadayvana
avreba
i
prehospital.
Trombolizisi.
s.d.b-s mosvlidan
30 wT-Si (Tuki
SesaZloa)
pacientis transportireba s.d.b-s mier. misi mosvlidan 90-
wT-Si baloni (igulisxmeba balonis gaberva PCI-s dros)
Tuki pacient TviTdinebiT midis stacionarSi hospitalSi
moxvedridan 90-wT-Si baloni.
kvalifikacia da teqnikuri
aRWurviloba) mosvlidan
30 wT-Si Trombolizisi
gegma
s.d.b-Si
darekva
simpt.
dwyebid.
5 wT-Si
ntebi hospitalSi transportirdebian saswrafo daxmar
EMI-an pacientebSi SesaZloa ganxorcielebul iqnas f
) an kaTeterizaciiT (PCI). arCeviToba am strategiebs
ansportirebis saxes da mimRebi klinikis SesaZleblo
is dro cvalebadia yvela SemTxvevaSi, magram iSemiis
unda iyos 120 wT-s farglebSi. arsebobs 3 SesaZlebl
arebis brigadas aqvs fibrinolizis SesaZlebloba da
Cveneba, prehospitaluri fibrinolizi dawyebul unda
gadis misvlidan 30 wT-Si. (klasi I LOE: B). 2. Tu saswr
nolizis saSualeba da pacienti transportirdeba kli
aleba, pacients klinikaSi Sesvlidan 30 wT-Si unda d
karidan-nemsamde dro 30 wT klasi I LOE: B). 3. Tu sasw
qvs fibrinolizis saSualeba da pacienti transporti
kaTeterizaciis PCI saSualeba, pacients klinikaSi Se
des PCI. (karidan-balonamde dro 90 wT(klasi I LOE: B)
wT-s mTlianobaSi iSemiis dro ≤ 120 wT-is
mimReb klinikaSi
PCI - SeuZlebelia ix. sqema 2B
ebis brigadis
armakologiurad
Soris emyareba
bebs.
dro
oba: 1. Tu
pacients ar
iqnes saswrafo
afo daxmarebas
nikaSi, sadac ar
aewyos
rafo daxmarebis
rdeba klinikaSi,
svlidan 90 wT-
. (an
12
Tromblizisi romlis warumateblobis SemTxvevaSi SeiZleba gakeTdes gadamrCeni PCI. unda aRiniSnos rom PCI-s SesaZleblobebiT aRWurvil klinikebs aqvT saSualeba
ufro mSvidad da swrafad ganaxorcielon aRnisnuli mkurnalobis TiToeuli etapi,
rac Tavis mxriv aZlevs maT saSualebas SeimuSaon maT klinikaSi saukeTeso
reperfuziuli strategiia mocemuli pacientisaTvis.
intrahospitaluri gadayvana agreTve aRsaniSnavia pacientebis intrahospitaluri
gadayvana PCI-iT uzrunvelyofil klinikaSi Tu: 1. aRiniSneba fibrinolizis
ukuCveneba; 2. PCI SesaZlebelia gakeTdes ufro swrafad (pacientis sawyis mimReb
klinikaSi Semosvlidan 90 wT-Si an fibrinolizis dawyebis SesaZleblobidan 60 wT-
Si ) 3. fibrinolizi warumatebelia (e.i. keTdeba gadamrCeni PCI ). meoradi, arasaswrafo interhospitaluri gadayvana SesaZlebelia ganxilul iqnes
ganmeorebiTi iSemiis dros.
pacientis TviTdineba: pacientis gadayvana TviTdinebiT riskTan aris dakavSirebuli.
Tu pacienti miva klinikaSi sadac PCI SeuZlebelia, karebidan-nemsamde dro unda
iyos 30 wT. Tu pacienti Seva PCI-iT aRWurvil klinikaSi karebidan-balonamde dro
unda iyos 90 wT. mkurnalobis SerCeva da drois rekomendaciebi klinikaSi Sesvlis
Semdeg aris igive.
13
sqema 2 B .
panel
rekom
saWir
gaiar
damat
pacien
cxril
gansaz
asaki ≥
asaki 6
diabeti
hiperte
angina
sistol
gulis
> 100
gulis
wona <
wina ke
dro re
riskis
arainvaziuri
Sefaseba
fibrinolizisi
mimRebi hospitali
sadac PCI araa SesaZlebeli
pirveladi PCI
PCI an CABG
gadamrCeni an
iSemiis
niSnebisda
mixedviT
intrahospitaluri
mkurnaloba da
meoradi prevencia
mimRebi hospitali
sadac PCI SesaZlebelia
i B pacientebisTvis, visac Cautarda fibrinolizi, riskis stratifikaciisTvis
endirebulia arainvaziuri Sefaseba gadamrCeni an iSemiiT ganpirobebuli PCI –s oebis dasadgenad. reperfuziuli Terapiis meTodis miuxedavad yvela pacientma unda
os STEMI-s meoradi prevencia. eba: unda aRiniSnos rom STEMI-s dros prehospitalur etapze rekomendirebulia
tis gadayvanamde 162-325 mg aspirinis micema Lklasi I LOE: C
i 1. STEMI-s dros maRali riskis prediqtorebi ( TIMI kvleva STEMI-s riskis RvrisaTvis ) damoukidebeli 30 dRiani sikvdilianobis risk faqtorebi
riskis
qulebi
jamuri
qula
saSualo
maCvenebeli
30 dRiani
sikvdiliano
bis %
min da maqs
maCvenebeli
75
3
0
0,1
0,1—0,2
5-75
2
1
0,3
0,2—0,30
1
2
0,4
0,3—0,5
nzia anamnezSi
1
3
0,7
0,6—0,9
anamnezSi
1
4
1,2
1,0—1,5
uri wneva < 100
3
5
2,2
1,9—2,6
SekumSvaTa sixSire
2
6
3,0
2,5—3,6
ukmar. kilipi II--IV
2
7
4,8
3,8—6,1
67 kg
1
8
5,8
4,2—7,8
deli an LBBB
1
> 8
8,8
6,3--12
perfuziamde > 4-sT
1
14
damateba: zogadad SeiZleba iTqvas rom cudi prognozis prediqtorebi STEMI-s dros arian asaki, gulis SekumSvaTa sixSire, arteriuli wneva, filtvebis SeSupeba da S3 toni
IV. pirveladi amocnoba da marTva gadaudebeli
daxmarebis departamentSi
a. sqema. 3 gadaudebeli daxmarebis algoriTmi/protokoli
pacientSi STEMI–s simptomebiT an niSnebiT
STEMI-s simptomebis
dawyeba
saswrafo daxmareba
miiyvans pacients
gadaudebeli daxmarebis
ganyofilebaSi
pacienti Semodis
gadaudebeli daxmarebis
ganyofilebaSi
triada romelic mniSvnelovnia stacionarSi miRebisas:
• STEMI-s simptomebis da niSnebis Sefaseba (Cvenebis klasi I LOE: C) • 12-ganxriani e.k.g (Semosvidan 10 wT-Si unda iyos gadaRebuli Tuki ara gvaqvs STEMI-s niSnebi da pacienti kvlav simptomuria seriuli e.k.g yovel 10-wT-Si. (Cveneba klasi I LOE:C) • Tuki pacients aqvs qveda kedlis MI unda gadaviRoT marjvena mxrivi ganxrebic marjvena parkuWis
infarqtis dasadgenad Cvenebis klasi I LOE: B)
gadaudebel saeqTno daxmarebas: kardiomonitoringi,
O2-is miwodeba Tuki SaO2 < 90% klasi I LOE B O2-is miwodeba yvela Semosul pacients STEMI-T miuxedavad
SaO2>90%. 6-sT-is ganmavlobaSi 2-3l Cveneba klasi II-A LOE C IV- D5W, sisxlis analizi ( cxrili 7) nitroglicerini † aspirini ††
† - ar miceT
naklebi, anN
parkuWis in
†† - Tumca z
aspirins, uf
daReWvisas
††† - oralu
klasi. LOE ATu aris ta
gaurkvevlo
konsultant
pacients aReniS
STEMI ? diax
Sefaseba:
• dro simptomebis dawyebidan
• STEMI-s riski ( ix. 1 gamosaxuleba damatebebSi )
• fibrinolizis riski
• dro romelic esaWiroeba PCI-iT aRWurvil
klinikamde
reperfuziuli Terapiis SerCeva da
uzrunvelyofa (cxr. 5 sqema 2 )
sxva Terapiis SerCeva:
• morfini
• aspirini ††
• antiTrombozuli mkurnaloba(heparini)
• nitrati (saWiroebisamebr gulmkerdis
areSi tkivilis an diskomfortis
SemTxvevaSi) †
• beta-blokerebi †††
gadaudebeli daxmarebis eqimi afasebs pacients:
anamnezi/istoria (Cvenebis klasi I LOE: C) fizikuri gamokvleva (2 cxrili) (Cvenebis
klasi I LOE: C) ekg interpretacia (Cvenebis klasi I LOE: C)
Tuki sistoluri wneva < 90 mmhg an bazalurze 30-iT
Tuki P > 100 an < 50 an Tuki eWvi gvaqvs marjvena
farqtze
ogierTi xmarobs nawlavuri garsiT dafarul
ro swrafi Sedegia garsis gareSe aspirinis
ri B-blokerebi pacientebSi ukuCvenebis gareSe ( I
) IV B-blokerebi Tuki araa ukuCveneba gansakuTrebiT
qikardia da hipertenzia. ( IIa klasi LOE: B).
bis SemTxvevaSi gamoiZaxeT
i
neba
ara
ix. suraTi ACC/AHA UA/NSTEMI pacientebis marTvis gaidlaini
15
damateba: STEMI-s e.k.g. niSnad fasdeba: ST elevacia ≥ 0,2 mV (2mm) V1-V4 ganxraSi da ≥0,1 mV(1mm) sxva gulmkerdis ganxrebSi, mwvaved g ST depresia V1—V4 ganxrebSi rasac axlavs maRali R marj dial ganxrebSi da pozitiuri T kbilebi, rac aris maCvenebeli WeSmariti posterior MI-s ( miuTiTebs rom procesSi Semomxvevi
totia CarTuli)
b. damateba: ekg-s interpretacia:
e.k.g-s mixedviT infarqtis gamomwvevi sisx
gamosaxuleba 4.
sqema romliTac sargebloben jo-enis
miRebulia 2 sqemis kombinirebis Sedegad: romelic Tavis mxriv aRebulia
Pproqsimalur
perforatoris
proqsimaluradaa
T ↑ V1— 6 I, aVL and
ar or bundle branch
irveli septaluri
Distal LAD or Diagonal distaluri LAD an TviTon diagonali
i
istaluradaa an
V1—4 or I, aVL, V5 V6
oderate to large inferior (poetrior, lateral, right ventricular) saSualo an didi qveda
kedeli ( ukana,
lateraluri, marjvena
parkuWovani)
ST ↑ II, III, aVF and any of the following:
a. V1 V3R, V4R b. V5—6 c. R >S in V1—V2
istalur nawilSi
III, aVF only
anviTarebuli LBBB, gamoxatuli
vena prekor
lZarRvis verificireba:
saxelobis samedicino centrSi, igi
Topol EJ. Van de Werf FJ Acute myocardial infarction: early diagnosis and menegment. In: Topol EJ. ed.Textbook of cardiovascular medicine. vinaidan am sqemidan Semomxvev totsa da marjvena koronars Soris Wirda diferencireba igi Sevsebuli iqna:
Braunwald Zipes Libby Heart sesease A Textbook of Cardiovascular Medicine 2001 6 edition
roximal LAD i LAD
Proximal to first septal perforator stenozi
Sfasicul
pirveli septaluri block
Mid LAD Sua LAD
Proximal to large diagonal but distal to eirst septal perforator stenozi didi
diagonalis
proqsimaluradaa
magram distalurad
ST ↑ V1— 6 I, aVL
p
perforatorisagan
Distal to large Diagonal or diagonal itself stenozidi diagonalis
d
d
Tavad diagonalSia Proximal R
T ↑ S
—
M
C or Left circumflex stenozi marjvena
koronaris
proqsimaluradaa an
SemomxvevSia
ST ↑ II,
Small inferior cire zomis qveda m
kedeli
Distal RCA or left circumflex branch stenozi aris
arjvena koronaris m
d
an Semomxvevis
totSia
ST ↑ V4R= proximal RC ST isoelect. V4R = Distal RC ST ↓ V4R = CX
diafragmuli
kedlis
infarqtis
fonze marjvena
ganxrebis
mixedviT
SesaZloa
uli
is
vimsjeloT
daintereseb
isxlZarRvs
lokalizaciaze
16
amosaxulg eba 5. e.k.g. kriteriumebi m.m.i.-s diagnostikisTvis LBBB-is fonze: am sqemaSi 3 qulas da mets aqvs 90%-ian specifiuroba da 88%-ini albaToba
irebulia Sgarbosa EB, Prinski SL iographic ing acut farction ft bundle brunch block. N
ed 1996; 334: 481
kriteriumebi qulebi
ST ↑ ≥1mm konkordantul 5
ST ↑ ≥ 1mm ganxrebSi V1,V 3
↑ ≥ 5mm diskordantuli QRS -is 2
k.g. kriteriumebi m.m.i.-is diagnostikisaTvis RBBB-is fonze: cvlad T kbilisa QRS-isgan diskordantulad gveqneba QRS
gadi meTvalyureoba
ugularuli) venebis daWimulobis arseboba/ararseboba
lenad
li gulze an gal is riTmi)
Slis arseboba a ararseboba
. pulsaciis arseboba an ararseboba
bovaneba,
ubtura
iT ( boerhavas ( borhaava)
laruli da
i
atipiuri angina
adreuli repolarizacia
rmad invertirebuli T kbilebi
ri nervuli
stemis dazianebis an
iopaTiis
axva
ia
brugdas sindromi
miokarditi
sis konis totebis blokada
zospastikuri angina
stroezofagaluri refluqsi
i
liaruli an pankreatuli
lebi diski an
igi adapt
diagnoses o, Barbagelata A, et al. Electrocard
f evolvEngl J M
e mypcardial in in the resence of le- 487
i QRS-is 2 or V3
ST e.
na -is
konkordantuli T kbili V1,V2 an V3 ganxrebSi (fsevdonormalizacia).
cxrili 2 swrafi fizikuri gasinjva gadaudebel departamentSi
1. sasunTqi gzebi, sunTqva, cirkulacia (ABC) 2. sasicocxlo niSnebi, zo
3. sauRle (i
4. auskultacia filtvebSi Segubebis niSnebis gamosav
5. gulis auskultacia (Sui op
6. T/t sisxlis mimoqcevis mo n
7
8. sistemuri hipoperfuziis arseboba an ararseboba (kanis sicive, sifermkrTale, weaWreleba)
g. cxrili 3. STEMI-is diferencialuri diagnostika
sicocxlisaTvis saSiSi
aortis diseqcia
daWimuli pnevmoToraqsi
pulmonaruli embolia ezofagealuri r
mediastinit
perforirebuli wyluli
sindromi
sxva
kardiovasku
ra iSemiur
perikarditi
marcxena parkuWis hipertrof
a
WPW sindromi
hiperkaliemia
R
rogorc centralu
si
hipertrofiuli kardiom
as
hi
va
hipertrofiuli kardiomiopaTia
sxva arakardialuri
ga
(CERD) da spazmi
gulmkerdis kedlis tkivil
bi
wyluli
xerxemlis ma
17
plevraluri tkivili
vralgia
maturi an fsiqogenuri tkivili
STEMI-s diagnoziT miRebul pacientSi rutinuli testebi
1. Sratis biomarkerebi gulis dazianebis Sesafaseblad :
kardiospecif daucad
strategiis Se : C damateba : tro onini upiratesi markeria mio
diagnostireb azomvisas SeiZl ba gamogvrCes mcire
zomis ifarqti. rogorc wesi iReben orives. vinaidan troponini
momatebuli rCeba 1-kviridan 10-14 dRemde, stacionarSi am periodSi
ganviTarebuli gulmkerdSi tkivilis Sesafaseblad gamoiyeneba CK-MB. vinaidan igi sabaziso dones ubrundeba procesis damTavrebidan 2-
2. sisxlis saerTo analizi (CBC); klasi I LOE: C
4. 5. OE: C 6. 7. 8. 9. ( es ukanaskneli
da
yof
dis rentgenogra tatul atiT adgilze, unda
uziuli Terapia(Tuki
otenciur garTulebaze rogoricaa aortis
OE: C atiT), transTorakaluri
ioskopia, sCT an MRI aortis diseqciis asi I LOE: B is dasazusteblad da riskis
par
ro
peptiuri wyluli
panikuri SiSi
ne
so
d.
iuri troponinebi ( ar o reperfuziul
degebs) klasi I LOEp kardiumis infarqtis
isas. CK-MB-s g e
3 dReSi. iq sadac ver keTdeba troponini SeiZleba visargebloT CK-MB-iT.
3. INR; klasi I LOE: C
aPTT klasi I LOE: C eleqtrolitebi da magniumi; klasi I LBUN; klasi I LOE: C kreatinini; klasi I LOE: C glukoza; klasi I LOE: C Sratis lipidebi; klasi I LOE: C
ar aris aucilebeli gakeTdes dauyovnebliv da
velodoT mis pasuxs, mkurnaloba iwyeba statiniT da stacionarSi
nis periodSi keTdeba analizi. damateba samuSao jgufis mier)
gulmker10. fia: por i apar
gvaxsovdes rom aman ar unda daayovnos reperf
ar aris eWvi iseT p
diseqcia). klasi I L11. gulmkerdis rentgenografia(portatuli apar
da/an
transTorakaluri eqokard
sadiferenciaciod STEMI-sagan. kl12. eqokardiografia SREMI-s diagnoz
Sesafaseblad
pacientebSi vinc moxvdeba gadaudebeli daxmarebis departamentSi
aRniSnuli
diagnoziT, gansakuTrebiT maSin roca saqme gvaqvs LBBB-sTan an
kuWovan
kardiostimulaciasTan, an eWvia ukana kedlis (posterior) STEMI-zemelic
18
mimdinareobs wina ganxrebSi ST segmentis depresiiT klasi II-A LOE: B gamosaxuleba 3.
STEMI-s gaidlainis sruli
gulis biomarkerebi STEMI-s dros. mowodebulia AHA/ACC teqstidan
uwyveti wiTeli aris gulis troponini, romelic matebas iwyebs 6-sT-Si da piks 36-sT-Si
aRwevs. (reperfuziis dros wiTeli wyvetili xazi piki ufro adrea 20-24 sT-Si). CK-MB aseve matebas iwyebs 6-sT-Si da piks 20-24-sT-Si aRwevs. uwyveti mwvane. (reperfuziisas igi
piks 16-18-sT-Si aRwevs). unda AaRiniSnos rom cTnI momatebuli rCeba 7-10 dRe xolo cTnT 10-14 dRe reperfuziis gareSe CK-MB reperfuziis gareSe normas 2 dReSi ubrundeba
Mmarkerebi MI-s gamosavlenad
markeri sawyisi Sefaseba Eelevaciis saSualo sabaziso monacemebTan dabrunebis
MI-s Semdgom piki MI-s Semdgom dro
Myoglobin 1 - 4 sT 6 sT 18 - 24 sT
CK-MB 3 - 12 sT 10 - 24 sT 48 - 72 sT
MB-isoforms
1 - 6 sT 4 - 12 sT 38 sT
cTnI 3 - 12 sT 10 - 24 sT 5 - 10 dRe
cTnT 3 - 12 sT 12 - 24 sT 5 - 14 dRe
Suggested testing schedule for cardiac markers
markeri < 6 sT 6 - 12 sT 12 - 24 sT 24 - 48 sT > 48 sT
Myoglobin +++ + - - - Troponin I + ++ +++ +++ +++ Troponin T + ++ +++ +++ +++ CK-MB + ++ +++ - - MB- isoforms ++
19
e. reperfuzi T uc ob esaZleb s
Rvra pacientebSi STEMI T
4
is me odis a ilebl is da S lobi
gansaz -
cxrili
I safexuri: Aaris Tu ara 15 wT-ze meti da 12 sT-ze naklebi xangrZlivobis tkivili an diskomforti gulmkerdis
ar
eSi ?
diax ara SeCerdi
II safexuri: aRiniSneba Tu ara fibrinolizis ukuCveneba7
Tu romelime qvemoTCamoTvlilze aRiniSneba pasuxi diax fibrinolizi SeiZleba iyos ukunaCvenebi
stoluri a.w. 180 mm Hg-ze metia diax ara
a
vaoba sistolur a.w. Soris marcxena da marjvena xelze 15 mm Hg-ze meti diax ara
ruqturuli cns daavadeba anamnezSi diax ara
lo 3 Tvis manZilze Tavis qalas/saxis daxuruli trvma diax ara
ali (bolo 6 kviris ) didi travma, qirurgiuli Careva (maT Soris Tvalis lazeruli
GI/GU
a
riozuli organuli daavadebebi(Sorswasuli simsivne an terminaluri stadia, RviZli da
si
diastoluri a.w. 110 -ze metia diax armm Hg
sx
st
bo
ax
operacia Tvalze) sisxldena
diax ra
sisxldenis an Trombis warmoqmnis problemebi an sisxlis gaTxeleba diax ara
lmonaluri resuscitacia ( CPR) 10 wT-ze metia diax ara kardiopu
orsuloba diax ara
se
Tirkmlis mZime daavadebebi )
diax ara
20
III safexuri
stemuri hipoperfuzia diax ara
.5
fi olizis riski
dro, romelic saWiroa PCI-iT uzrunvelyofil laboratoriaSi gadasayvanad.
safexuri: fibrinolizis Tu invaziuri strategia? upiratesobis gansazRvra?
naklebia da invaziuri strategiis dro
sazRvrul farglebSi arc erTi strategias
vs.
fibrin
) ( ix. qvemoT)
laboratoria Seesabameba standarts
• karebidan balonamde dro < 90 wT
arebidan balonamde dros
igulisxmeba Trombolizisis dawyebis
saZlebloba) dro < 1 sT-ze
eba
• kaTeterizaciis laboratoria
dakavebulia
• sisxlZarRvovani midgoma
garTulebulia
PCI laboratories unar-Cvevebi ar
EMI maRali riskiT
kardiogenuri Soki (am SemTxvevaSi
8-sT
75w-ze >
asi II-A LOE B
enebis klasi II-A E B
iltvebis Segubeba (Sua wilebze zemoT) diax ara f
aReniSneba Tu ara pacients gamoxatuli gulis ukmarisobaan kardiogenuri Soki, iseTi
rom PCI iyos upiratesi TrombolizisTan SedarebiT ?
si
v. reperfuziis saxis SerCeva pacientebSi STEMI-T
cxrili
I safexuri: drois da riskis Sefaseba:
dro simptomebis dawyebidan
STEMI iski .-s r
brin
II
Tu pacientis Semosvlis dro 3 sT-ze
SesaZloa iyos gaidlainiT gan
upiratesoba ar aq
olizi upiratesia Tuki:
P
invaziuri strategia upiratesia Tuki:
stacionarSi adreuli moxvedrisas (
PCI≤ 3-sT-ze simptomebis dawyebidan da
im SemTxvevaSi Tuki invaziuri
strategia gviandeba
† da aqvs qirurgiuli uzrunvelyofa
• k
gamoklebuli karebidan nemsamde (
Se
invaziuri strategia ar ganixil
rogorc arCevani Tuki:
• Seesabameba
standarts †
ST
•
nacvlad 12 sT-isa aRebulia 1
infarqtis dawyebidan da 75w asakis
qvemoT pacientebisaTvis klasi I LOE:A xolo maTTvis visasac aski >
kl
• kilipis klasi ≥ 3. CvLO
21
fibrinolizisze ukuCveneba
igulisxmeba sisxl
invaziuri Carevis dayovneba:
a xangZlivdeba
alonamde dro > 90wT-
karebidan balonamde dros
moklebuli karebidan nemsamde (
awyebis SesaZlebloba) dro > 1
denis da
trakranialuri hemoragiis gazrdili
lasi I LOE: B
me-11
rilSi
stacionarSi Semosvlis dagvianeba > 3
sT-ze simptomebis dawyebidan
Tuki infarqtis diagnozi saeWvoa da/an
pirveladi PCI-s rekomendaciebSi gaTvaliswinebuli SemTxvevebi
† P ri ze
weli b weliwadSi )
z fibrinolizis Cvenebebi:
I klasi:
1. ukuCvenebebis ar arsebobisas, fibr niSneba
TEMI-s dros Tuki simptomebis dawyebidan gasulia ≤ 12-sT da ST elevacia
2. ukuCvenebebis ar arsebobisas aRniSnuli mkurnaloba tardeba STEMI-s d n gasulia ≤ 12 sT da pacients aqvs axali
savaraudod axali LBBB LOE: A
aqvs
riti ukana kedlis infarqti LOE: C -s
a da ST elevacia aris meti 0,1 mV sul
cota 2 mimdebare prekordiul ganxraSi an or mimdebare kidurebis
i LOE: B
• transportireb
• karebidan b
ze
•
ga
igulisxmeba Trombolizisis
d
sT-ze
in
riskebi
k
Trombolizisis dozebi aris
cxrilSi
ukuCvenebebi mocemuli me-6 cx
CI-s standartebSi igulisxmeba operato s gamcdileba ( pirveladi PCI > 75 SemTxveva
rveladi PCI > 36 SemTxevazeadSi) da gunduri muSaobis gamocdile a ( pi
.
inolizisuri mkurnaloba i
Saris meti 0,1 mV sul cota or mimdebare prekordiul ganxraSi an or
mdebare kidurebis ganxraSi LOE: A mi
ros Tuki simptomebis dawyebida
an
II A klasi:
1. ukuCvenebebis ar arsebobisas aRniSnuli mkurnaloba tardeba STEMI-s dros Tuki simptomebis dawyebidan gasulia ≤ 12 sT da pacients
12 ganxriani e.k.g-s mixedviT WeSma
2. ukuCvenebebis ar arsebobisas aRniSnuli mkurnaloba tardeba STEMIdros, Tuki simptomebis dawyebidan gasulia 12-dan 24 sT-mde Tuki
iSemiis simptomebi grZeldeb
ganxraS
22
III 1.fibrroml
2. F r
ganxr
gamok
damate efeqturoba naklebia im pacientTa jgufSi romelsac
edlis infarqti, Tuki mas Tan ar axlavs RV infarqti an ST-segmentis obaze
bi
cxrili 6.
i), 3. cnobili avTvisebiani intrakranialuri
eoplazma(pirveladi an metastazuri), 4. iSemiuri insulti bolo 3 Tvis
m i
a a) 7.
s an saxis daxuruli travma
edarebiTi ukuCveneba 1. anamnezSi qr., mkacri, Znelad kontrolirebadi
s
amnezSi 3 Tveze
ebadi
a
i
T Tuki maT aqvT revaskularizaciis Cveneba
3. qirurgiuli koregireba ventrikuluri zgidis rubturisas/mkacri
s
pacientebSi persistentuli hemodinamikuri da/an eleqtruli
lurobisas. LOE: C
klasi:
inolizisuri Terapia ar iniSneba asimptomatur pacientebSi
ebSiac STEMI-s simptomebi daiwyo 24-sT-iT adre. LOE: C ib inolizisuri Terapia ar iniSneba pacientebSi romlebSiac 12
ian e.k.g.-ze mxolod ST segmentis depresiaa im SemTxvevebis
lebiT roca ara gvaqvs WeSmariti marcxena parkuWis infarqti. LOE: A
ba: Trombolizisis
aqvs qveda k
depresia prekordialur ganxrebSi, rac miuTiTebs rom didi ubanis arseb
riskis qveS.
T. STEMI-s dros fibrinolizis ukuCveneba da safrTxee
absoluturi ukuCveneba: 1. raime adreuli intrakranialuri hemoragia, 2.
cnobili cerebrovaskularuli dazianeba (mag: arteriovenozuri
paTologieb
n
anZilze garda mwvave iSemiuri Setevisa bolo 3 sT-s manZilze 5. eWv
ortis diseqciaze 6. sisxldena an sisxlmdeni diaTezi (menzesis gard
bolo 3 Tvis manZilze, Tavis qali
S
hipertenzia 2. mkacri ukontrolo hipertenzia (sistoluri 180 mmHG-ze
meti, 3. diastoluri 110 mmHG-ze meti) es ukuCveneba SesaZloa iyo
absolituri ukuCveneba dabali riskis STEMI-s dros 4. anadrindeli iSemiuri Seteva, demencia, an intrakranialuri paTologia,
romelic ar ifareba absolituri ukuCvenebebiT 5. travmuli an
gaxangrZlivebuli (10 wT-ze meti) CPR an didi operacia(3 kviraze nakleb
droSi ) 6. axali (2-4 kviris) Sinagani sisxldena 7. arakompresir
vaskularuli punqcia 8. streptokinaza/antistrptaza adrindeli gamoyeneb
(5 dReze adre) an alergiuli reaqcia am agentze 9. orsuloba 10. aqtiur
peptiuri wyluli 11. antikoagulantis miReba anamnezSi: rac maRalia INRmiT maRalia sisxldenis riski
i. diagnostikuri koronaruli angiografia
klasi I
1. irveladi PCI-s kandidatebi LOE: A 2. pacientebi kardiogenuri Soki
OE: A L
arqvlis naklovanebisas LOE: B 4.
arastabi
klasi III
23
1. koronaruli angiografia ar unda Catardes pacientebSi Tanmxlebi mZime
asi I zogadi ganxilva
1. Tu dauyovnebliv SesaZlebelia, pirveladi PCI Catarebul unda iqnes
pacientebSi STEMI-T (WeSmaritad ukana kedlis m.i.-s CaTvliT) an
axali an savaraudod axali hisis konis marcxena fexis blokadisas,
simptomebis dawyebidan 12 sT-Si. Tuki Careva tardeba dadgenil droSi
svlidan) gamocdili eqimis mier
(romelic akeTebs 75 pirveladi PCI proceduras weliwadSi).
il unda iqnes gamocdili personalis mier
Sesatyvis laboratoriaSi (yovel wels laboratories mier
speci
mkurn
a. pi
konta
b. T
karid sxvaoba
aris:
upiratesia fibrinolizuri Terapia. (LOE B ) g. Tu simptomebis xangrZlivoba 3 sT-ze metia, pirveladi PCI upiratesia
dan-
vaskularizaciisTvis Sesaferi (Carevis teqnikuri SesaZlebloba
s a igi
S
e.
daavadebebiT sadac revaskularizaciis riski ufro metia vidre
sargebloba. LOE: C
k. pirveladi PCI-s rekomendaciebi
kl
(balonuri inflacia 90 wT-Si Semo
procedura mxardaWer
gakeTebuli unda iyos 200 PCI aqedan 36 mainc pirveladi PCI STEMI-s dros da unda qondes qirurgiuli uzrunvelyofa). (LOE A )
fiuri sakiTxebi: rac exmareba eqims gadawyvetilebis miRebaSi airCios
alobis meTodi;
rveladi PCI unda Catardes rac SeiZleba swrafad, samedicino
qtidan-balonamde an karidan-balonamde dro 90 wT. (LOE A )
u simptomebis xangrZlivoba aris 3 sT-s farglebSi da mosalodneli
an balonamde drois da mosalodneli karidan-nemsamde drois
• 1 sT-s farglebSi _ upiratesoba eZleva PCI (LOE B ) • metia 1 sT-ze
da unda gakeTdes rac SeiZleba xanmokle droSi samedicino kontaqti
balonamde an karidan-balonamde 90 wT-is farglebSi (LOE B ) d. pirveladi PCI unda Catardes pacients 75 wlis qvemoT ST-elevaciiT an
LBBB-T, romelTac ganuviTardaT Soki MI-dan 36 sT-Si da arian
re
isxlZarRvis antomiuri da dazianebisTaviseburebebis gamo.) d
eiZleba Catardes Sokis ganviTarebidan 18 sT-Si Tu Semdgomi
mkurnalobis gagrZeleba araa azrs moklebuli pacientis survilis.
ukuCvenebebis an imis gamo rom invaziuri CarevisaTvis mdgomareoba
Seuferebelia (igulisxmeba Carevis teqnikuri SeuZlebloba
sisxlZarRvis anatomiuri Taviseburebebis da dazianebis
Taviseburebebis gamo. (LOE A )
pirveladi PCI unda Cautardes pacientebs mkacri SegubebiTi gulis
ukmarisobiT, da/an filtvebis SeSupebiT (kilipi III) simptomebis
24
dawyebidan 12 sT-is ganmavlobaSi. samedicino kontaqtidan balonamde
karidan-balonamde dro unda iyos rac SeiZleba mokle, 90 wT-is
farglebSi. ( LOE B )
si II A
an
kla
I_T an
sTvis,
tares Sokidan 18 sT-Si. pacientebi romelTac
manamde hqondaT kargi funqciuri statusi, mdgomareoba Sesaferisia
ularizaciisTvis da pacieti Tanaxmaa invaziur Carevaze,
SesaZloa arCeul iqnan invaziuri strategiisTvis. . ( LOE B )
kla
1 p ba STEMI-an pacientebSi romlebic
fibrinolizisisaTvis Sesaferisni arian, ar aris kargad
5
)
1. eriaze
OE C ) 2. -
hemodinamikurad da eleqtrofiziologiurad stabilurebi. ( LOE C )
l. r
Rebul
Tr b
klasi
1. pirveladi PCI sruldeba STEMI-s dros pirvel 12 sT-Si Tuki
klasi II-
rombolizisisaTvis,. simptomebis dawyebida 12-24
sT-Si Tu saxezea romelime CamoTvlilTagan:
mkacri CHF ( LOE C )
1. pirveladi PCI 75 wlis an mis zeviT asakis pacientebSi STEMLBBB-T, visac ganuviTarda Soki infarqtidan 36 sT-Si da
Sesaferisia (anatomiurad da teqnikurad) revaskularizacii
rac SesaZloa Cau
revask
2. pirveladi PCI SesaZloa Cautardes pacientebs visac simptomebi
daewyo 12-dan 24 sT-is ganmavlobaSi da aReniSneba erTi an ramdenime
qvemoTCamoTvlilTagani:
a) mkacri SegubebiTi gulis ukmarisoba. ( LOE C ) b) hemodinamikuri an eleqtrlituri arastabiluroba ( LOE C ) g) persistentuli iSemiuri simptomebi ( LOE C )
si II B
irveladi PCI-is sargeblo
gansazRvruli, rodesac PCI-is atarebs operatori, romelsag aqvs 7
PCI proceduraze naklebi Catarebuli weliwadSi. ( LOE C
klasi III
pirveladi PCI ar unda Cautardes arainfarqtul art
pacientebSi hemodinamikuri arastabilurobis gareSe. ( L pirveladi PCI ar unda Cautardes asimptomur pacientebs Tuki STEMIs dawyebidan gasulia 12 sT-ze meti da Tu isini arian
pi veladi PCI-s rekomendaciebi pacientebSi romlebic ver
oben Tromboliziss raimis gamo; (Seuferebelia
om olizisisaTvis)
I
pacienti Seuferebelia TrombolizisisaTvis ( LOE C ) A
1. gonivrulia gavakeToT pirveladi PCI pacientebSi STEMI-T, Tuki isini
Seuferebeli arian T
•
• hemodinamikuri an eleqtruli arastabiloba ( LOE C ) • iSemiuri simptomebi persistirebs ( LOE C )
25
m. p r
ara a
kl
asi II-B 1. pirveladi i romelsac ara aqvs
li/SeTanxmebuli gegma
Sesaferisi hemodinamikuri daxmarebis fonze. am SemTxvevaSic
ba pacientebiT romelTac aqvT STEMI an MI axali
an savaraudod axali LBBB-iT e.k.g-ze da SesaZlebelia maTSi Careva
lad Sesruldes ( balonis gaberva 90-wT-Si) operatoris mier
klasi
aqvs
qirur
uaxlo
gaday
PCI
uri
m
am ukanasknelis da Trombolizisis kombinaciis Semdgom.
damxmare PCI SesaZloa Sesruldes rogorc reperfuziuli strategiis
wili maRali riskis pacientebSi roca PCI ver sruldeba gadaudeblad da
oca sisxldenis riski aris dabali LOE: B
Ceni PCI:
romelTa asaki < 75w. aqvT
TEMI an LBBB da romelTac MI ganuviTardaT 36 sT-is farglebSi da
isxlZarRvebi Sesaferisia (anatomiurad da teqnikurad)
i veladi PCI-s rekomendaciebi klinikebisaTvis romelTac
qvT kardioqirurgiuli ganyofileba
asi I da II-A ara aqvs
kl
PCI SeiZleba Sesruldes hospitalS
kardioqirurgia im SemTxvevaSi, Tuki arsebobs kardioqirurgiul
saoperacio oTaxSi gadayvanis dadasturebu
procedura izRude
drou
romelic weliwadSi asrulebs sul cota 75 PCI-s. aqedan 36 pirveladi PCI (( LOE C ) III
1. pirveladi PCI ar unda Catardes hospitalSi romelsac ara
giuli ganyofileba da ara aqvs damtkicebuli/SeTanxmebuli gegma
s stacionarSi kadioqirurgiuli ganyofilebis saoperacioSi
vanisTvis, Sesaferisi hemodinamikuri uzrunvelyofiT. ( LOE C )
n. damxmare
ganmarteba: damxmare PCI-Si igulisxmeba dagegmili PCI sawyisi farmakologi
Carevis Semdgom, rogoricaa fibrinolizisi sruli doziT, naxevari doza
b/IIIa-is inhibitoris gadasxmis Semdgofibrinolizisis Semdgom, glukoprotein II
an
klasi I da II-A ara aqvs
klasi II-B 1.na
r
o. gadamr
I klasi:
1. gadamrCeni PCI unda Sesruldes pacientebSi
Ss
26
r s, xolo PCI SeiZleba Sesruldes Sokis dawyebidan
-sT-Si. Tuki es Careva araa amao imis gamo rom pacients es ar surs, an
nvaziuri mkurnalobaze aris ukuCvenebebi/SeuTavseblobi. LOE: B
E B
sT-
(anatomiurad/teqnikurad) revaskularizaciisaTvis, xolo PCI SeiZleba Sesruldes Sokis dawyebidan 18-sT-Si. es exebaT pacientebs
ac aqvT kargi funqcionaluri statusi da Tanaxmani arian
2.
p.
kl
aferisia), PCI tardeba, roca aris obieqturi monacemebi romlebic adastureben ganmeorebiT
(recurent) infarqts LOE: C PCI unda Catardes
saSualo an mkacri, spontanuri an provocirebadi miokardiumis
miisas STEMI is Semdgom aRdgenis fazaSi LOE: B
klasi
1. i romelTa
vani
2. s PCI Tuki aris dokumentirebuli klinikuri
gulis ukmarisobis mwvave epizodi, miuxedavad imisa rom Semdgomi
sebisas SesaZloa LVgandevnis fraqcia iyos ≥ 40%-ze LOE: C
klasi
1. saZloa ganvixiloT rogorc invaziuri strategiis
evaskularizaciisaTvi
18
Semdgomi i
2. gadamrCeni PCI unda Cautardes pacientebs mkacri SegubebiTi gulis
ukmarisobiT, (kilipi) III. simptomebis dawyebidan gasulia ≤ 12 sT-ze( LO)
II-A klasi:
1. PCI mizanSewonilia Sesruldes seleqtiur pacientebSi ≥ 75w. romelTac aqvT STEMI an LBBB da romelTac MI ganuviTardaT 36
is farglebSi da romelTa sisxlZarRvebi Sesaferisia
romelT
invaziur Carevaze. LOE: B mizanSewonilia Sesruldes gadamrCeni PCI Tuki aris erTerTi
CvenebaTagani:
• hemodinamikuri an eleqtruli arastabiluroba LOE: C • persistentuli iSemiuri simptomebi LOE: C
PCI fibrinolizisis Semdeg:
asi I
1. pacientebSi (Tuki sisxlZarRvTa anatomia Ses
2. pacientebSi romelTa anatomia Sesaferisia,
iSe
3. pacientebSi romeTa anatomia Sesaferisia, PCI unda Catardes kardiogenuri Sokis an hemodinamikuri arastabiluriobisas
(ixgadamrCeni PCI) LOE: B
IIA mizanSewonilia Catardes PCI rutinulad pacientebS
gandevnis fraqcia ≤ 40%-ze, aqvT CHF an seriozuli parkuWo
ariTmia. LOE: C mizanSewonilia Catarde
Sefa
IIB rutinuli PCI Senawili fibrinolizisuri Terapiis Semdgom. LOE: B
27
ganmarteba:
• warmat luria da aris
veneba rac zrdis
afrTxoebas (garda im zemoTCamoTvlili SemTxvevebisa rac aCqarebs invaziur
revas)
.warumatebeli Trombolizisis SemTxvevaSi moqmedebs gadamrCeni Trombolizisis
beli Trombolizis niSnebia: simptomebis moxsna,(SeiZleba
avSirdebodes analgezias an nawilobri inervacias, rac gvxvdeba zogierT
izisi iTvleba warumateblad da tardeba gadamrCeni (es gansakuTrebiT
ni daavadeba
parkuWis infarqti, romelic ZiriTadSi
g ba. vinaidan am dros Wirs pacientis
xsna xelovnuri sisxlis mimoqcevidan.
audebeli qirurgiuli
vaskularizaciis Cveneba STEMI-s dros aris Semdegi
I klasi
1. warumatebeli PCI persistentuli tkivilis da arastabiluri
hemodinamikisas pacientebSi romelTac aqvT Sesaferisi anatomia
q
2. ia
medikamentur mkurnalobaze, isi
atomia qirurgiuli CarevisaTvis, miokardiumis mnisvnelovani areali
eS da ar arian kandidatebi Trombolizisis an PCI-s LOE: B o
STEMI LBBB-iT an
ents es
ebuli Trombolizisis Semdgom Tuki mdgomareoba stabi
PCI-s igi umjobesia Sesruldes dReeebis an kvireebis Semdgom, C
us
Ca
•
sqema. warmate
uk
pacientebSi), aCqarebuli idioventrikuluri riTmi, hemodinamikis stabilizacia STsegmentis elevaciis 50-70%-iT Semcireba Trombolizisis dawyebidan 90-wT-Si. Tuki
Trombolizisis dawyebidan 90 wT-Si ara gvaqvs reperfuziis aSkara niSnebi
Trombol PCIexeba wina kedlis infarqts). gansakuTrebiT unda aRiniSnos, rom kardiogenuri
Sokis ganviTarebisas ra Tqma unda ar velodebiT 90-wT-is gasvlas.
r. mwvave qirurgiuli reperfuzia:
zogadad gadaudebeli qirurgiuli reperfuzia unda Sesruldes STEMI-s dros Tuki gvinda
am dros pirdapiri an gadamrCeni PCI-s Catareba magram pacients aReniSneba marcxena mTavari/ZiriTadi koronaris kritikuli stenozi an mkacri 3 sisxlZarRvova
omelic miudgomelia PCI-sTvis. r
gansakuTrebul SemTxvevas warmoadgens marjvena
vevlineba rogorc gadaudebeli CABG-s ukuCvene
mo
s. zogadad urgentuli da gad
re
irurgiuli CarevisaTvis. LOE: B persistentuli an ganmeorebiTi iSemia romelic refraqterul
pacientebSi romelTac aqvT Sesafer
an
riskis qv
3. postinfarqtuli VSR da mitraluri sarqvlis naklovanebis gam
operaciisas LOE: B 4. kardiogenuri Soki 75w naklebi asakis pacientebSi -T an
ukana kedlis MI-s gamo romelTac Soki unviTardebaT infarqtidan 36-sT-Si
da aqvT marcxena mTavari/ZiriTadi totis mkacri stenozi, mkacri
multisisxlZarRvovani daavadeba da arian revaskularizaciisaTvis
Sesaferisi kandidatebi, rac Tavis mxriv SesaZloa Catardes Sokis
ganviTarebidan 18-sT-Si. Tuki es Careva araa amao imis gamo rom paci
28
ar surs, an Semdgomi invaziuri mkurnalobaze ukuCvenebebis/SeuTavseblobis
arsebobis gamo. LOE: A 5. sicocxlisaTvis saSiSi parkuWvani ariTmiebi marcxena mTavari/Zi
koronaris stenozisas romelic ≥ 50%-ze. an/da 3 sisxlZarRvovani
daavadebisas LOE: B IIA klasi:
1. gadaudebeli CAB
riTadi
G SesaZloa iyos rogorc pirveladi reperfuziuli
an
T. gansakuTrebiT maSin Tu saxezea mkacri stenozi marcxena mTavari/ZiriTadi koronaris an multi sisxlZarRvovani
deba. LOE: B
I-s
s
atebi rac Tavis mxriv SesaZloa Catardes Sokis
III kl
1.
2. atebuli epikardiuli
reperfuziisas magram warumatebeli mikrovaskularuli
fuziisas LOE: C
hospitaluri mkurnaloba
..CCU intensiuri/koronaruli movlis ganyofileba:
r garemos sadac pacients unda
grZeldebodes e.k.g. monitoringi da puls oqsimetria da sadac unda iyos
saSualeba hemodinamikuri monitoringisTvis da defibrilaciis. LOE: C 2 re,
gina(stenokardia), wneva, gulis ukmarisoba. da Semowmdes adeqvaturia Tu
nare mkurnaloba. LOE: A
strategia pacientebisaTvis Sesaferisi anatomiiT, romlebic ara
arian PCI-s an Trombolizisis kandidatebi da STEMI-s dawyebdgasulia 6-12 s
daava
2. gadaudebeli CABG SeiZleba iyos efeqturi pacientebSi romelTa
asaki ≥ 75w da aReniSnebaT STEMI-T an LBBB-iT an ukana kedlis Mgamo, romelTac Soki unviTardebaT infarqtidan 36-sT-Si da aqvT
marcxena mTavari/ZiriTadi totis mkacri stenozi, mkacri
multisisxlZarRvovani daavadeba da arian revaskularizaciisaTvi
Sesaferisi kandid
ganviTarebidan 18-sT-Si. Tuki es Careva araa amao imis gamo rom
pacients es ar surs, an Semdgomi invaziuri mkurnaloba
ukuCvenebebia/SeuTavsebelia LOE: B
asi
gadaudebeli CABG ar tardeba roca gvaqvs persistentuli angina
magram miokardiumis mcire zonaa riskis qveS da pacienti
hemodinamikurad stabiluria. LOE: C gadaudebeli CABG ar tardeba warm
reper
V
a.
I klasi:
1. CCU unda warmoadgendes mSvid da wynau
. unda ganisazRvros kontrolirebulia Tu ara riTmis sixSi
an
ara mimdi
29
3. unda ganisazRvros Jangbadis micemis saWiroeba: (stabilur pacientSi 6
sT-is semdgom sadac SO2 > 90%-e mxedvelobaSi unda gvqondes misi moxsna.
LOE: C
-
ac aqvT
uZliaT daxmarebis aRmoCena da utardebaT
orze e.kg. gamosaxuleba unda iyos optimizirebuli. raTa ar
CU-is gamoyeneba terminaluri pacientebis
lia
amo terminaluri
mdgomareoba). LOE: C
b. CCU-is Se
I klasi:
pacientebi dabali riskis T romelTac CautardaT warmatebuli
eperfuzia PCI-T SesaZlebelia gadavidnen ganyofilebaSi CCU-is gavlis
g
2 ganmavlobaSi arian klinikurad
abilurni, (ara aqvT ganmeorebiTi iSemia, gulis ukmarisoba, kuri darRveva an ariTmia romelic iwvevs am moSlilobas) unda
CCU-dan ganyofilebaSi im
irobiT, rom saWiroebisas SesaZlebeli iqneba e.k.g. monitoringi da
qsimetria. LOE C . mizanSewonilia pacientebi STEMI-s Semdgom romelTac aqvT ariTmia
arRvevs hemodinamikas (AF kontrolirebulin sixSiriT,
.
urad
valifikaciis eqTnis momsaxureba LOE C
4. am ganyofilebaSi pacientebTan unda muSaobdnen eqTnebi romelT
Sesabamisi kvalifikacia da ician movlis zogadi principebi, aseve
gadaudebeli mdgomareobebisas Se
regularuli trainingebi. LOE: C 5. ganyofilebis muSaoba unda eyrdnobodes Sesabamis protokolebs. LOE: C 6. monitgamogvrCes ST segmentis deviacia an riTmis moSla LOE: C III klasi:
1. mizanSewonili araa CmisaRebad, romelTac emarTebaT STEMI da “sadac resuscitaciaar tardeba”(igulisxmeba pacientebi, sadac winaswar cnobi
rom mas aqvs zogadad raime cxva daavadebis g
mdgomi mkurnaloba:
STEMI-1.
r
areSe. LOE C . pacientebi STEMI-T Tuki 12-24-sT is
st
hemodinami
gadavidnen CCU-dan ganyofilebaSi. LOE C II A klasi: 1. mizanSewonilia pacientebi STEMI-s Semdgom romelTac darCaT kinikurad
gamoxatuli gulis ukmarisoba gadavidnen
p
o
2romelic ar
aramyari VT-s paroqsizmebi 30-wm-ze naklebi xangZlivobiT) gadadian CCU-dan
ganyofilebaSi im pirobiT, rom saWiroebisas SesaZlebeli iqneba e.k.g
monitoringi, defibrilatori da kvalificiuri eqTanis momsaxureba LOE C II B klasi 1. mizanSewonilia pacientebi STEMI-s Semdgom romelTac aqvT klinik
mniSvnelovani pulmonaruli daavadeba da saWiroeben Jangbadis did nakads
an arainvaziur maskiT ventilacias gadadian CCU-dan ganyofilebaSi im
pirobiT, rom SesaZlebeli iqneba puls oqsimetria da Sesabamisi
k
30
g. pacientebis gaaqtiveba:
II A 1. pacientebSi hemodinamikuri arastabiluro
meordeboda, stabulizaciis 12-24 sT-is Semdeg
biT an maTSi visac iSemiuri tkivilebi
SesaZlebelia wamojdomis nebis
sawolSi gaaqtiveba rasac moyveba aqtivobis donis TandaTanobiTi zrda.
LOE C
I i: cientebs STEMI-T romlebSiac araa ganmeorebiTi iSemiis epzodebi, gulis
diet :
( saerTo kaloraJSi gajerebuli cximi <
qolesteroli < 2000 mg/dReSi.) urCieT wonis kontroli da
fizikuri aqtivoba. urCieT omega-3 cximovani mJavis xmarebis gazrda. LOE C
omelTac aqvT aRgzneba an Secvlili qceva rac ukavSirdeba
hospitalizacias LOE C 2 da
aWiroebisas Cautardes specialistis konsultacia. LOE C
vrilebiT iqneba axsnili srul teqstSi da PCI-s
aspirini:
klasi:
i
acientSi visac ara aqvs
lergia masze. LOE: A
u
micema da
II klas
1. paukmarisobis simptomebi, an seriozuli riTmis darRvevebi ar unda gaugrZeldeT
woliTi reJimi 12-24 sT-is Semdgom.
LOE C
d. a
I klasi:
1. daiwyeT dieta yvela pacientSi.
7%-ze da
e. analgetikebi/aRgznebis sawinaaRmdego preparatebi:
II A klasi:
mizanSewonilia gamoviyenoT damamSvideblebi pacientebSi STEMI-T 1.
r
. mizanSewonilia Sefasdes pacientis qceva da aRgznebis done
s
v. antiagregantebi:
(maTi gamoyeneba ufro daw
gaidlainSi romelic dasruldeba 2007 welSi).
I
1. STEMI-s dros sawyisi doza 162-325 mg per.os. da Semdeg SemnarCunebeldoza 75-162 mg ganusazRvreli vadiT yvela p
a
†† - Tumca zogierTi xmarobs nawlavuri garsiT dafarul aspirins, ufro
swrafi Sedegia garsis gareSe aspirinis daReWvisas
31
Tienopiridinebi
I klasi:
klopidrogeli iniSneba pacientebSi vinc ver iRebs aspirins
permgrZnobelobis an mniSvnelovani gastrointersticiuli garTulebebis
mo. LOE: C miReba grZeldeba stentirebis Semdgom sul cota 1 Tve
re metal stentis implantaciis Semdgom da ramodenime Tve drug-eluting mdgom( 3-Tve sirolimus da 6 Tve paclitaxe-is Semdgom) da grZeldeba
i. . LOE: B
ki tardeba STEMI-s dros reperfuzia PCI-T, maSin
A klasi: iwyeben rac SeiZleba adre STEMI-s dros Tuki igegmeba pirveladi
ptifibatidi IIb-Si)
ogiuri
ogadi rekomendacia heparnisTvis: mwvane koronaruli sindromis dros (ACS ) igi mareba 2-3 dRidan 7-8 dRemde
afraqcionirebuli heparini UFH
SemTxvevebSi roca reperfuziuli Terapia ar tardeba:
klasi:
i/v UFH ( bolusi 60 U/kg da max 4000 U da Semdeg 12 U/kg/sT max 1000 U) unda moviyenoT pacientebSi STEMI-s Semdgom, romlebic arian sistemuri
didi zomis an wina kedlis MI, AF, namnezSi emboliuri epizodi, LV Trombi an kardiogenuri Soki). LOE: C
nilia, ie -T visa da
iebis
ilia igi gagrZeldes gaweramde (igulisxmeba gaaqtiveba) LOE: C
1.
hi
ga
2. klopidrogelis
bastentis Se
12 Tve pacientebSi romelTac ara aqvT sisxldenis maRali risk
Ddamateba: Tu
klopidrogels aZleven 400 mg-s xolo Semdeg agrZeleben 75 mg dRiurad glukoprotein IIb/IIIa inhibitorebi
II
PCI (stentiT an stentis gareSe). LOE: B (AHA/ACC gaidlainiT absqsimabi IIa jgufSia, xolo tirofibani
e
z. reperfuziisas damatebiTi antiTrombozuli farmakol
daxmareba
z
ix
ar
im
I
1.
ga
emboliebis maRali riskis jgufSi, (a
IIa klasi:
1. mizanSewo rom pac ntebSi STEMI c ar ga utania
reperfuziuli Terapia da romelTac ara aqvT raime ukuCveneba
antikoagulaciis mimarT UFH dainiSnos intravenurad an kanqveSa ineqc
saxiT sul cota 48-sT. im pacientebSi romelTa mdgomareoba moiTxovs
xangZliv woliT reJims da/an aqtiobis donis minimumamde dayvanas
mizanSewon
32
damateba: am SemTxvevaSi UFH-s i/v dozaa: 60-70 U/kg bolusi (magr
maqsimaluri dozaa 4000 erT) da Semdeg 12-15U/kg/sT (maqsim. dozaa 1000
erT/kg-ze.) da aPTT narCundeba 50-70-is farglebSi. kanqveSa ineqciebis dr
sxvadasxva kvlevebSi gamoyenebuli dozebia 7500 U 2-jer an 5000 U 3
12,500 U 2-jer.
am
os
-jer an
T:
klasi:
UFH unda dainiSnos i/v im pacientebSi STEMI-T romelTac reperfuzia
utardaT alteplaziT, teneqteplaziT an reteplaziT. doza: bolusi 60
,5-2
T 50-70 wm) LOE: C UFH iniSneba intravenurad pacientebSi Trombolizisis mere, romelic
ia araseleqtiuri fibrinolitikebiT (mag: streptokinaza)
en
cientebSi
streptokinziT reperfuziis Semdgom LOE: C
veSa ineqciebis dros sxvadasxva kvlevebSi gamoyenebuli
ozebia 7500 U 2-jer an 5000 U 3-jer an 12,500 U 2-jer. dReisaTvis arsebuli
ac gamoixateba reperfuziul Terapiasa da pacientis adreuli
gaa
UFH –
klasi:
1. pacientebi romlebsac utardebaT PCI an qirurgiuli revaskularizacia
nda miiRon UFH. LOE: C
dReisaTvis arsebuli praqtika rac gamoixateba pacientis adreuli
gaaqtivebaSi moiTxovs am monacemebis gadaxedvas da kiTxvis qves ayenebs
UFH –is am reJimebiT xmarebas.
arafraqcionirebuli heparini UFH im SemTxvevebSi roca reperfuziuli
Terapia tardeba Trombolizisi
I 1.
Ca
U/kg(maqs. 4000U) da Semdeg 12U/kg/sT(maqs. 1000 U/sT) aPTT unda SenarCundes 1iT meti sakontroloze (daaxloebi
2.Catarebul
romlebsac aqvT sistemuri emboliebis ganviTarebis maRali riski
(miokardiumis wina kedlis an didi zomis infarqti, AF, gadatanili
Trromboemboliuri epizodi, an LV-is Trombi. LOE: B 3. Trombocitebi mowmdeba yoveldRiurad pacientebSi romlebic Rebulob
UFH-s. LOE: C IIB klasi:
1. mizanSewonilia davniSnoT UFH intravenurad pa
damateba: kanqd
praqtika, r
qtivebaSi moiTxovs am monacemebis gadaxedvas da kiTxvis qveS ayenebs
is am reJimiT xmarebas.
arafraqcionirebuli heparini UFH, im SemTxvevebSi, roca reperfuzia
tardeba PCI-T:
I
u
33
ganmarteba: roca reperfuzia xdeba PCI-T UFH-is i/v bolusis dozaa
U/kg
70-100
dros aqtiuri Sededebis dro procedurisas HemoTec-iT sul cota 250-300
ron-iT 300-350 da Semdgom aPTT narCundeba 1,5-2,0-iT meti
oza mcirdeba 50-70 U/kg-mde da procedurisas
tiuri Sededebis dro 200 orive meTodiT, xolo Semdgom aPTT-i igive
:
.. LMWH (samkurnalo doziT) unda gamoviyenoT pacientebSi STEMI-s ali riskis jgufSi,
MI, AF, anamnezSi emboliuri epizodi, LV Trombi
IB klasi:
reperfuziuli Terapiis damatebiTi farmakologiuri daxmarebis
valsazrisiT LMWH SeiZleba ganvixiloT rogorc UFH-is alternativa,
cientebSi 75 wlis qvemoT romlebic Rebuloben Trombolizisur
erapias.( Tuki Sratis kreatinini araa > 2,5 mg/dl-ze kacebSi da 2,0 mg/dl-
neqcia 12-sT-Si erTxel saavadmyofodan gaweramde. es kombinacia
iT Trombolizisis dros srulyofiladaa Seswavlili. LOE: B
ti
LMWH
miuxed H-
is kar
rekomendaciebis Camosayalibeblad.
am
da Hemochsakontroloze (50-70wm). Tuki gamoiyeneba glukoprotein IIb/IIIa antagonistebi bolusis d
aq
reJimiT.
dabal-molekuluri wonis heparini heparini LMWH LMWH im SemTxvevebSi roca reperfuziuli Terapia ar tardeba
I klasi:
1
Semdgom, romlebic arian sistemuri emboliebis maR
(didi zomis an wina kedlis
an kardiogenuri Soki). LOE: C
LMWH im SemTxvevebSi reperfuziuli Terapia tardeba TrombolizisiT:
I1.
T
pa
T
ze meti qalebSi) enoqseparinis 30 mg i/v boluss moyveba 1 mg/kg ze kanqveS
i
teneqteplaz
III klasi: 1. LMWH ar gamoiyeneba zemoT aRniSnul situaciebSi, rogorc UFH-is
alternativa Tuki pacientis asaki ≥ 75 w. LOE: B 2. LMWH ar gamoiyeneba zemoT aRniSnul situaciebSi, rogorc UFH-is
alternativa Tundac maSin roca pacientis asaki < 75 welze, Tuki
Sratis kreatinini > 2,5 mg/dl-ze kacebSi da 2,0 mg/dl-ze me
qalebSi) LOE: B
im SemTxvevebSi reperfuzia tardeba PCI-T:
avad imisa rom arsebobs pozitiuri informacia rom LMWH aris UFgi alternativa, monacemebi jer araa sakmarisi garkveuli
34
pirdapiri antiTrombini:
i TrombocitopeniiT HIT SeiZleba
mxedvelobaSi gvqondes bivalirudini rogorc heparinis alternativa
streptokinazis Semdeg. HERO 2 is kvlevaSi gamoyenebuli dozebia: i/v
bolusi 0,25 mg/kg da Semdgom 0,5 mg/kg/sT-S 12-sT-s manZilze xolo
-sT. doza mcirdeba Tuki aPTT> 75-ze pirvel 12-
sT-Si. LOE: B
T. re
dros:
I kla
1. ACE unda dainiSnos per.os pirvel 24-sT-Si STEMI-s awyebidan, pacientebSi wina kedlis infarqtiT, pulmonaruli SegubebiT,
Lmarcxena parkuWis EF-iT < 40%-ze, Tuki ar aRiniSneba hipotenzia (sisit.
LOE: A
ARB iniSneba STEMI-s dros pacientebSi romelTac aqvT wina paragrafSi
uli Cveneba da autanloba ACE LOE: C
,
enzia (sist. wneva < 100 mmhg an sabaziso
is
: B
CE inhibitorebis swrafi titraciis sqema hopspitalizebul pacientebSi
loa gamoyenebuli iqnas pacientebSi tendenciiT hipotoniisken
aZloa
vlilebebis ganviTareba. am mdgomareobas Sokis wina periodi,
reSoki ewodeba.(“nearly shock”)
IIA klasi:
1. pacientebSi hepariniT gamowveul
Semdeg 0,25mg/kg-ze 36
nin-angiotenzin-aldosteronis sistemaze moqmedi preparatebi STEMI-s
si:
inhibitorebid
wneva < 100 mmhg an sabaziso wnevaze 30%-iT naklebi) da ukuCvenebebi am
medikamentis mimarT.
2.
gansazRvr inhibitorebis mimarT.
IIa klasi:
1. ACE inhibitorebis daniSvna pirvel 24-sT-Si STEMI-s dawyebidan SeiZleba
iyos sasargeblo pacientebSi romelTac ar aqvT wina kedlis infarqti,
pulmonaruli Segubeba da marcxena parkuWis gandevnis fraqcia < 40%-ze
Tuki araa arteriuli hipot
wnevaze 30%-iT naklebi) da ukuCvenebebi am medikamentis mimarT ( Tumca am
pacientebSi sargebloba naklebia vidre I klasSi moxvedril pacienteb
jgufSi) LOE
III klasi: 1. i/v ACE inhibitorebi ar eZleva pirvel 24-sT-Si STEMI-s dawyebidan hipotenziis riskis gamo(gamonaklisi SeiZleba iyos refraqteruli
hipertenzia) A(sqema SesaZ
da gulis SegubebiTi ukmarisobiT. am dros saWiroa saWiroa gulis
wuTmoculobis swrafi gazrda, vinaidan winaaRmdeg SemTxvevaSi Ses
Seuqcevadi c
p
kaptoprili:
sawyisi doza 12,5 mg peroralurad (6,25 mg pacientebSi hiponatremiiT,
azotemiiT, siTxis danakargiT, orTostatikuri hipotenziiT).
35
2 sT-Si gavzardoT doza 25 mg-mde
6sT-Si gavzardoT doza 50 mg-mde 3 -jer dReSi
aboloo mizani 150 mg dReSi.
viZlia mivceT 1 sT-iT adre an erTi saaTis Semdeg ACE hibitoris miRebidan.
i hiponatremiiT,
orTostatikuri hipotenziiT)
a 10 mg-mde 2- jer dReSi.
boloo mizani 20 mg dReSi.
iZlia mivceT 1 sT-iT adre an erTi saaTis Semdeg pirveli
ozis miRebidan.
nelodan. erik
klasi:
Tvis STEMI-T da garTulebuli
mdinareobiT. LOE B IIa klasi:
1.
perglikemia mizanSewonilia daeniSnoT insulinis i/v infuzia glukozis
ciisaTvis, maSinac ki roca daavadeba gaurTuleblad
etis
ualizacia insuliniT, insulinis analogebiT,
poglikemiuri saSualebebis kombinirebis gziT. LOE C
eleqtrolitebis balansi:
. maTi deficiti unda gamoswordes. siswrafe damokidebulia sisxlSi maT
oneze da Tanmxleb klinikur movlenebze. LOE: C
mizanSewonilia magniumis deficitis gasworeba, gansakuTrebiT
i STEMI-T romlebic iRebdnen diuretikebs infarqtamde LOE: C
s
Sardmdeni Seg
in
enelaprili:
sawyisi doza 5 mg peroralurad (2,5 mg pacientebS
azotemiiT, siTxis danakargiT,
6 sT-Si gavzardoT doza 10 mg-mde.
12sT-Si gavzardoT doz
sa
Sardmdeni Segv
d
sqema mowodebulia: kardiovaskularuli medicinis saxelmZRva
j. topoli II gamocema 2002w.
i. glukozis kontroli STEMI-s dros:
I
1. insulinis i/v infuzia sisxlis glukozis normalizaciisaTvis
rekomendirebulia pacientebisa
mi
STEMI-s mwvave fazis dros (pirvel 24-48-sT-Si) pacientebs romelTac aqvT
hi
normaliza
mimdinareobs. LOE B 2. STEMI-s mwvave fazis Semdgom mizanSewonilia moaxdinon diab
mkurnalobis individ
oraluri hi
saqrTvelos kardiologTa koleji rekomendacias iZleva STEMI-s dros Saqris cifrebis normalizaciad CaiTvalos glukoza < 150 mg/dl-isfarglebSi
k.
I klasi:
1
d
II A klasi:
1..
pacientebS
36
2. VT “torsade depoint” Tan asocirebuli QT-intervalis gaxangZlivebiT
I klasi:
n
. kalciumis arxebis blokatorebi:
apamili an diltiazemi pacientebs romlebSiac
eta-blkerebi uefeqtoa da/an ukunaCvenebia. iSemiis sakontrolod an
ekuWovani riTmis sixSiris Sesamcireblad Tuki STEMI-s dros pacients emarTeba AF an winagulTa TrTola da ara aqvs CHF da LV disfunqcia an AV
b
I klasi:
i an diltiazemi ukunaCvenebia pacientebSi SYEMI-T da
od,
okerebi unda dainiSnos STEMI-s dawyebidan rac eiZleba adre Tuki araa raime ukuCveneba maT mimarT. miuxedavad imisa
rdeba Tu ara reperfuzia (Trombolizisi an/daPCI-i) LOE: A 2. Tuki beta-blokeri ver iniSneba STEMI-s dawebidan 24-sT-Si imis gamo, rom
raime ukuCvenebaa, am periodis gavlis Semdgom maTi daniSvnis
esaZlebloba Tavidan unda Sefasdes. LOE: C ebi romlebic Rebuloben beta-blokerebs pirvel 24 sT-Si STEMI-s
miReba iwyeba
namkurnalebi unda iqnes i/v Mg ( bolusi 5 wT-is ganmavlonbaSi) LOE: C
II
1. dokumentirebuli eleqtrolituri deficitis an torsade depoint” Ta
asocirebuli VT-is gareSe ar SeiZleba Mg rutinulad gadasxma riskis
donis miuxedavad. LOE: A
l
IIa klasi:
1. miznSewonilia mivceT ver
b
pa
loki. LOE: A II
1. verapamil
adocirebuli CHF da LV disfunqciiT. LOE: C 2. nifedipinis (swrafad xsnadi forma) ukunaCvenebia STEMI-s samkurnalvinaidan axasiaTebs refleqsuri simpaTikuri aqtvaciis gamo taqikardia da
hipotenzia. LOE: B
m. beta-blokatorebi: I klasi: 1. oraluri beta-bl
S
ta
S
3. pacient
dawyebidan da ara aqvT gverdiTi movlenebi agrZeleben maT miRebas
adreuli aRdgenis fazaSi. xolo isini visTanac betablokerebi ar iqna
dawyebuli pirvel 24-sT-Si da visTanac araa ukuCvenebebi maTi
adreul aRgenis fazaSi. LOE: A
IIa klasi:
1. mizanSewonilia beta-blokerebis i/v daniSvna STEMI-s dawyebidan rac SeiZleba adre, Tuki araa raime ukuCveneba, gansakuTrebiT maSin Tuki gvaqvs
taqiariTmia an hipertenzia. LOE: A
37
38
marteba: pacientebSi (Tuki araa raime ukuCveneba) beta-blokerebi
rmoadgenen pacientebi romelTac
. nitroglicerini:
a naCvenebia
STEMI-s dawyebidan 48-sT-is manZilze pacientebSi persistentuli iSemiiT, CHF-
daniSvna (rogoricaa beta-blokerebi an ACE-ebi.) romlebic dadasturebulad amcireben sikvdilianobas. LOE: A
ntebSi Tuki sistoluri wneva < 100 mmhg . wneva 30%-iT naklebia pacientis sabaziso wnevaze an gvaqvs
an
inhibitorebi (sindenafili. xolo 48-sT tadafil-is SemTxvevaSi) LOE: B
gn
grZeldeba minimum 6-Tve. gamonakliss wa
koronarografiisas gamouvlindaT mxolod 1 sisxlZarRvis
stenozi/okluzia romlis reperfuziac warmatebiT ganxorcielda. maTSi
beta blokerebi iniSneba 5-28 dRe. (samuSao jgufis ganmarteba)
n
I klasi:
1. pacients mimdinare tkiviliT aZleven sublingvalur nitroglicerins
(0,4mg) 5 wT-iani intrevalebiT ris Semdgomac dRis wesrigSi SesaZloa
dadges i/v infuziis sakiTxi. LOE: C i/v nitroglicerinis infuzi
iT, hipertenziiT. nitroglicerinis i/v infuziis gamo Tavidan ar unda
aviridoT sxva medikamentebis
inhibitor
2. nitratebi sasargebloa STEMI-s dawyebidan 48-sT-is Semgomac, pacientebSi
persistentuli iSemiiT, CHF-iT, hipertenziiT da im SemTxvevaSi Tuki maTi
miReba xels ar uSlis im medikamentebis daniSvnas (rogoricaa beta-
blokerebi an ACE-inhibitorebi.) romlebic dadasturebulad amcireben
letalobas. LOE: B II-Bklasi:
1. nitratebis xmareba STEMI-s dawyebidan pirveli 24-48-sT-is Semdgom
persistentuli iSemiis an CHF-is ar arsebobisas SeiZleba iyos sasargeblo
Tumca es sargebloba savaraudod mcirea da kargad araa Seswavlili. LOE: B III klasi:
1. nitratebi ar iniSneba pacie
an art
bradikardia ( P < 50-ze wT-Si) an taqikardia ( P > 100-ze wT-Si )
marjvena parkuWis infarqti. LOE: C aseve im pacientebSi romlebsac wina 24-sT-is ganmavlobaSi miRebulia aqvT fspodiesTerazas
i. sqema 4. garTulebuli STEMI. gadaudebeli mdgomareobebis marTvis protokoli
klinikuri niSnebi: Soki, hipoperfuzia, gulis SegubebiTi ukmarisoba, pulmonaruli edema. ZiriTadi klinikuri suraTi:
39
mwvave pulmonaruli edema hipovolemia kardiogenuri Soki
dabali wuT.moc.
brad taq.
naxeT ariTmiis marTva
STEMI-s Semdgom.
ariTmia
furosemidi: IV 0,5-1,0 mg/kg 0,5
axlad ganviTarebuli mwv. pulm.
edemaze. 1,0 mwvave an qr.
moculobiT gadatvirTvaze,
Tirkmlis ukmarobisas.
morfini: IV 2- 4 mg
Jangbadi/intubacia: saWiroebisas
nitroglicerini: Sl, Semdeg IV 10-20 mkg/wT Tuki sist.wneva >100 mmhg
dofamini: IV 5-15 mkg/kg/wT Tu
sist.wneva 70-100 da Sokis niSnebia
dobutreqsi: IV 2-20 mkg/kg/wT Tu
sist.wneva 70-100 da Sokis niSnebi
araa
siTxeebi
sisxlis transfuzia
mizezis gamosworeba
gaiTvaliswineT
vazopresorebi
SeinarCune sist.wneva
> 100 mmhg da ara
naklebi 30-isa sabazo
wnevasTan SedarebiT
sist. wneva > 100
mmhg
sist.wneva 70-100 mmhg
Sokis niSnebis gareSe
sist.wneva 70-100 Sokis
niSnebiT
sist.wneva < 70 mmhg
Sokis niSnebiT
ACE inhibitorebi umjobesia xanmokle
moqmedebis rogoricaa
kaptoprili 6,25 mg
nitroglicerini 10-
20 mkg/wT IV
dobutamini 2-20 mkg/kg/wT IV
dofamini 5-15
mkg/kg/wT IV
norepinefrini 0,5—30
mkg/wT IV
Semdgomi/damatebiTi diagnostikur/Terapiuli RonisZiebebi:
diagnostikuri: pulmonaruli arteries kaTeteri, eqokardiografia, angiografia miokardiumis infarqti/iSemiisTvis, damatebiTi diagnostikuri RonisZiebebi.
Terapiuli: 1) intraaortuli balonuri kontrpulsacia, 2) reperfuzia/revaskularizacia, 3) SeiZleba gamoviyenoT dobutamin, dofaminis kombinacia.
40
parkuWTaSua Zgidis rubtura parkuWis Tavisufali kedlis
rubtura
papilaruli kunTis rubtura
sixSire/gavrcel
eba
1-3% pacientebSi romelTac ar
CatarebiT reperfuziuli Terapia
0,2-0,34% pacientebSi visac
Cautarda Trombolizisi
3,9% Sokiani pacientebisa
0,8-6,2% Trombolizisi ar amcirebs
risks; pirveladi PTCA savaraudod
amcirebs.
1% posteromedialuri ufro
xSirad gvxvdeba vidre
anterolateraluri.
dro
aqvs 2 piki 24 sT-Si da Semdeg 3-5
dReSi jamSi viTardeba 1-14 dReSi
aqvs 2 piki 24 sT-Si da Semdeg 3-5
dReSi jamSi viTardeba 1-14 dReSi
aqvs 2 piki 24 sT-Si da Semdeg 3-5
dReSi jamSi viTardeba 1-14 dReSi
klinikuri
manifestacia
tkivili gulmkerdSi, sunTqvis
gaZneleba, hipotenzia
anginuri, plevraluri, an
perikardiuli tkivili gul-mkerdSi,
sinkope, hipotenzia, ariTmiebi,
gulisreva, mousvenroba, hipotenzia,
uecari sikvdili.
sunTqvis gaZnelebis uecari
dawyeba da pulm. SeSupeba.
hipotenzia.
fizikuri
niSnebi
uxeSi holosistoluri Suili,
gaZlierebuli S3 da 2 gulis
toni, pulmonaruli edema, RV da LV ukmarisoba, kardiogenuri
Soki
iugularuli venebis
dilatacia(pacientebis 29%)
paradoqsuli pulsi(47%)
eleqtromeqanikuri dissociacia,
kardiogenuri Soki.
nazi Suili, marjvena parkWis
gadatvirTvis cvalebadi niSnebi,
mkacri pulmonaruli Segubeba,
kardiogenuri Soki
eqokardiografi
uli niSnebi
parkuWTaSua Zgidis defeqti,
marcxnidan marjvniv Sunti,
marjvena nawilebis gadatvirTva
5 mm-ze meti [perikardiuli siTxe
romelic yovelTvis ar
vizualizdeba, Sreobrivi,maRal
akustikuri eqo signali
perikardiumis Signdan(Trombuli
masa) Semavali karis vizualizacia,
tamponadis niSnebi
LV –s hiperkontraqtiloba,
gawyvetili papilar. kunTi, flail qorda, mkacri mitraluri
naklovaneba.
marjvena gulis
kaTeterizacia
gazrdili Jangbadis saturacia
gulis marjvena nawilebSi,
giganturi V-talRebi.
ventrikulografii mgrZnobeloba
dabalia, tamponadis klasikuri
niSnebi xSirad araa(diastoluri
wnevebis gaTanabreba gulis marcxena
da marjvena nawilebs Soris)
gulis marjvena nawilebSi
Jangbadis saturacia ar
matulobs., giganturi V talRebi,
Zalian maRali PCWP
cxrili 9. parkuWTa Soris Zgidis rubtura, Tavisufali kedlis rubtura, papilaruli kunTis rubtura
VI hemodinamikuri darRvevebi
a. hemodinamikuri gazomvebi:
I klasi:
1. pulmonaruli arteriis kaTeteriT monitoringi saWiroa Semdeg
SemTxvevebSi:
a. Tuki hipotenzia progresirebs, miuxedavad siTxeebis infuziisa an Tuki
es RonisZieba ukunaCvenebia LOE: C b. Tuki gvaqvs eWvi meqanikur garTulebaze (VSR, papilaruli kunTis an
Tavisufali kedlis rubtura) LOE: C 2. intraarteriuli wnevis monitoringi saWiroa Tuki:
a. saxezea wnevis mkveTrad vardna (sist. art. wneva < 80 mmhg) LOE: C. b. kardiogenuli Soki. LOE: C g. Tuki pacientebs utardebaT vazopresorebit/inotropebiT mkurnaoba.
LOE: C
II A klasi:
1. pulmonaruli arteriis kaTeteriT monitoringi SeiZleba saWiro iyos
Semdeg SemTxvevebSi:
a Tuki hipotenzia mimdinareobs pulmonaruli Segubebis gareSe da igi ver
swordeba siTxeebis gadasxmaze. LOE C b. kardiogenuli Soki
g. mkacri an progresirebadi CHF an pulmonaruli SeSepeba romelic
swrafad ar swordeba TerapiiT LOE C d. persistentuli hipoperfuziis niSnebi rodesac ara gvaqvs filtvebSi
Segubeba LOE C g. pacientebi romelTac mkurnaloba utardebaT
vazopresorebit/inotropebiT. LOE C. 2. intraarteriuli wnevis monitoringi SeiZleba saWiro iyos pacientebSi,
romlebic Rebuloben i/v natriumis nitroprusids an sxva
vazodilatatorebs. LOE C II B klasi:
1. intraarteriuli wnevis monitoringi SeiZleba saWiro iyos pacientebSi,
romlebic Rebuloben i/v inotropebs LOE C III klasi:
1. pulmonaruli arteriis kaTeteriT monitoringi rekomendirebuli araa
pacientebSi STEMI-T Tuki maT ara aqvT hemodinamikuri an respiratoruli
darRvevebi. LOE C 2. intraarteriuli wnevis monitoringi araa rekomendirebuli pacientebSi
STEMI-T romelTac ara aqvs pulmonaruli Segubeba da aqvT adeqvaturi
qsovilTa perfuzia meqanikuri kardiocirkulatoruli daxmarebis gareSe.
LOE C
41
b. hipotenzia:
I klasi:
1. Tuki pacients ar aReniSneba moculobiTi gadatvirTvis niSnebi,
rekomendirebulia siTxeebis i/v infuzia. LOE: C 2. ariTmia Tuki igi iwvevs hemodinamikur darRvevebs unda gamoswordes. LOE: C 3. IABP ixmareba im SemTxvevaSi Tuki sxva CareviT pacientis mdgomareoba ar
umjobesdeba, da Tuki Semdgomi invaziuri mkurnaloba araa azrs
moklebuli pacientis survilis, ukuCvenebebis/Seusabamobis arsebobis gamo. LOE: B 4. vazopresorebi iniSneba im semTxvevaSi Tukis hipotenzia ar gamoswordeba
siTxeebis infuziiT. LOE: C 5. Tuki invaziuri gazomvebi araa Catarebulia, saWiroa eqoskopiuri
gamokvleva raTa Sefasdes meqanikuri garTulebebis arseboba. LOE: C
g. dabali wuTmoculobiTi mdgomareoba:
I klasi:
1. unda Sefasdes marcxena parkuWis funcia da SesaZlo meqanikuri
garTulebebis SesaZlebloba unda ganisazRvros eqokardiografiulad,
Tuki manmade ar iyo Sefasebuli invaziurad. LOE: C 2. rekomendirebuli mkurnaloba dabali wuTmoculobiTi mdgomareobisaTvis
moicavs:
a. inotropul daxmarebas LOE: C b. IABP-s LOE: B g. meqanikuri reperfuzias PCI-T an CABG-T LOE: B d. meqanikuri garTulebebis qirurgiuli koregireba. LOE: B III klasi:
1. beta blokerebi da kalciumis antagonistebi ar iniSneba pacientebSi
dabali wuTmoculobiT stadiaSi, rodesac igi ganpirobebulia gulis
rogorc tumbos funqciis daqveiTebiT. LOE: C
saubaria STEMI-is fonze mimdinare garTulebaze, romelic wamoadgens pre-
Sokur mdgomareobas
d. pulmonaruli Segubeba:
I klasi:
1. Jangbadis micema mizanSewonilia arteriuli saturaciis SesanarCuneblad
> 90%-ze pacientebSi pulmonaruli SegubebiT. LOE C 2. morfinis sulfati eZleva pacients pulmonaruli SegubebiT. LOE C 3. aseT SemTxvevebSi iwyeba ACE inhibitorebis titracia. 1-6,25mg kaptoprili
eZleva pacients pulmonaruli SegubebiT, Tuki sistoluri wneva naklebi
araa 100 mmhg an 30 mmhg-Ti naklebi sabaziso wnevaze. pacientebi dabali
42
wneviT da pulmonaruli SegubebiT xSirad saWiroeben inotropebs da
vazopresobs da/an IABP-s adeqvaturi perfuziis SenarCunebis mizniT. LOE: A
4. nitratebi iniSneba Tuki sistoluri wneva naklebi araa 100 mmhg an 30 mmhg-Ti naklebi sabaziso wnevaze. pacientebi dabali wneviT da
pulmonaruli SegubebiT xSirad saWiroeben inotropebs da vazopresobs
da/an IABP-s adeqvaturi perfuziis SenarCunebis mizniT. LOE: C 5. diuretikebi saS. an mcire dozebiT(furosemidi, torsemidi, bumetanidi)
iniSneba pacientebSi pulmonaruli SegubebiT Tuli mas Tan axlavs
hipervolemiuri mdgomareoba. winaaRmdeg semTxvevaSi saWiroa sifrTxile
diuretikenbis xmarebisas. LOE: C 6. beta blokerebi iniSneba aseT pacientebSi gaweris win, meoradi
prevenciisTvis, maT visac am droisaTvis aReniSnebaT gulis ukmarisobis
niSnebi am medikamentis titracia iwyeba dabali dozebiT. LOE: B 7. xangZlivi aldosteronis blokada iniSneba post-STEMI pacientebSi gaweris win, Tuki aseT pacientebs ara aqvT renaluri
disfunqcia(kreatinini ≥ 2,5 mg/dl kacebSi da 2,0 mg/dl qalebSi} an
hiperkaliemia(kaliumi ≥ 5,0 mEq/L} da rolebic ukve iReben ACE inhibitorebs, LVEF ≤ 40% da aqvT romelime diabeti an simptomaturi
gulis ukmarisoba. LOE: C 8. eqokardiografia unda DSesruldes urgentulad raTa Sefasdes RV da LV funqcia da gamoiricxos meqanikuri garTulebebi. LOE: C II B klasi: 1. pacientebSi, romelTac aReniSnebaT refraqteruli pulmonaruli
Segubeba SeiZleba mizansewonili iyos IABP-s xmareba. LOE: C
III klasi:
1. beta blokerebi da kalciumis antagonistebi ar iniSneba mwvaved
pacientebSi STEMI-T romelTac aqvT aSkara monacemebi pulmonaruli
Segubebis an dabali-wuTmoculobis niSnebi. LOE: B
e kardiogenuri Soki:
I klasi:
1. IABP rekomendirebulia pacientebSi STEMI-T da kardiogenuli SokiT Tuki
igi swrafad ver swordeba farmakologiuri CareviT. am SemxvevaSi IABP aris mastabilizirebeli faqtori koronarografiis da revaskularizaciisaTvis. LOE: B 2. pacientebSi STEMI-T da kardiogenuli SokiT rekomendirebulia
hemodinamikis intraarteriuli monitoringi. LOE: C 3. adreuli revaskularizacia PCI an CABG rekomendirebulia pacientebSi,
romelTa asaki < 75w-ze da romlebsac aqvT STEMI, Tuki kardiogenuli Soki
ganuviTardaT infarqtis dawyebidan 36-sT-ze adre, xolo invaziuri Careva SesaZlebelia Sokis dawyebidan 18-sT-ze adre da Tuki Semdgomi invaziuri
mkurnaloba azrs araa moklebuli pacientis survilis da
ukuCvenebebis/Seusabamobis arsebobis gamo. LOE: A
43
4. pacientebSi STEMI-T da kardiogenuli SokiT romlrbSiac ver xerxdeba
invaziuri Careva tardeba fibrinolizisi ukuCvenebebis ar arsebobisas.
LOE: B 5. eqokardiografia tardeba aseT pacientebSi meqnikuri garTulebebis
Sesafaseblad, Tuki am mizniT ar gamoiyeneba invaziuri RonisZiebebi. LOE: B II A klasi: 1. pacientebSi kardiogenuli SokiT pulmonaruli arteriis kaTeteriT
monitoringi SeiZleba iyos sasargeblo. LOE: C 2. adreuli revaskularizacia PCI an CABG rekomendirebulia pacientebSi,
romelTa asaki > 75w-ze da romlebsac aqvT STEMI, Tuki kardiogenuli Soki
ganuviTardaT infarqtis dawyebidan 36-sT-ze adre, xolo invaziuri Careva SesaZlebelia Sokis dawyebidan 18-sT-ze adre da Tuki Semdgomi invaziuri
mkurnaloba azrs araa moklebuli pacientis survilis da
ukuCvenebebis/Seusabamobis arsebobis gamo LOE: A
v. marjvena parkuWis infarqti:
I klasi:
1. pacientebs qveda kedlis STEMI-T da hemodinamikuri darRvevebiT unda
gadaeRoT marjvena prekordiuli ganxrebi (V4R) ST-segmentis elevaciis
gamosavlenad da CautardeT eqokardiografiuli meTvalyureoba, marjvena
parkuWis ukmarisobis gamovlenis mizniT. LOE: B 2. marjvena parkuWis STEMI-s dros Semdegi principebi gamoiyeneba: a. miRweuli unda iqnes adreuli reperfuzia Tuki es Sesazlebelia. LOE: C b. uzrunvelyofili unda iqnes winagulebis da parkuWebis sinqronizacia
da bradikardia unda gamoswordes. LOE: C g. uzrunvelyofili unda iqnas marjvena parkuWis optimaluri
predatvirTva, rac saWiroebs siTxeebis infuzias hemodinamikurad
arastabilur pacientebSi romlebSic sauRle venebis wneva dabali an
normaluria. LOE: C d. marjvena parkuWis postdatvirTva unda iqnes optimizirebuli rac
moiTxovs Tanmxlebi marcxena parkuWis disfunqciis mkurnalobas. LOE: C e. inotropebi gamoiyeneba hemodinamikuri arastabilurobisas rac ar
swordeba siTxeebis gadasxmaze. LOE: C IIA klasi: 1. marjvena parkuWis klinikurad mniSvnelovani infarqtis dros, Tuki igi
CABG-is gakeTeba yovndeba 4 kvira raTa marjvena parkuWma aRidginos
kontraqtiloba. LOE: C
44
VII gulis ukmarisobis meqanikuri mizezebi/dabali
wuTmoculobis sindromi
a. mitraluri sarqvlis ukmarisoba:
I klasi:
1. pacientebSi STEMI-T, romelsac axlavs papilaruli kunTis rubtura,
mizanSewonilia urgentuli kardioqirurgiuli Careva, Tuki Semdgomi
invaziuri mkurnalobis gagrZeleba azrs araa moklebuli pacienti
survilis, ukuCvenebebis/Seusabamobis arsebobis gamo. LOE: B 2. CABG keTdeba mitraluri sarqvlis ukmarisobis gamo Catarebul
operaciasTan erTad. LOE: B
b. parkuWis Zgidis rubtura:
I klasi:
1. pacientebSi STEMI-T romelic garTulebulia VSR-iT mizanSewonilia
urgentuli kardioqirurgiuli Careva, Tuki Semdgomi invaziuri
mkurnalobis gagrZeleba azrs araaa moklebuli pacienti survilis,
ukuCvenebebis/Seusabamobis arsebobis gamo. LOE: B 2. CABG keTdeba marcxena parkuWis VSR-is gamo Catarebuli operaciasTan
erTad LOE: B
g. marcxena parkuWis Tavisufali kedlis rubtura
I klasi:
1. aseT pacientebSi mizanSewonilia urgentuli kardioqirurgiuli Careva.
Tuki Semdgomi invaziuri mkurnalobis gagrZeleba azrs araaa moklebuli
pacienti survilis, ukuCvenebebis/Seusabamobis arsebobis gamo. LOE: B 2. CABG keTdeba marcxena parkuWis Tavisufali kedlis rubturs
qirurgiul SekeTebasTan erTad LOE: B
d. marcxena parkuWis anevrizma:
II A klasi
1. pacientebSi STEMI-T romelTac ganuviTardebaT parkuWovani ariTmia, rac
asocirdeba parkuWovan taqiariTmiebTan, romelTa kontroli Wirs da/an
gulis rogorc tumbos ukmarisobasTan, romelis rezistentulia
mkurnalobis mimarT mizanSewonilia Catardes anevrizmeqtomia da CABG
qirurgia LOE: B
45
46
e. intraaortuli balonuri kontrpulsacia: IABP:
I klasi:
1. IABP gamoyenebuli unda iqnes pacientebSi STEMI-T romelTac aReniSnebaT
hipotenzia (sist. art. wneva < 90 mmhg an 30 mmhg-iT naklebi sabaziso
saSualo arteriul wnevaze, da romelic ar swordeba sxva
Carevaze/mkurnalobaze da Tuki Semdgomi invaziuri mkurnalobis
gagrZeleba azrs araa moklebuli pacienti survilis,
ukuCvenebebis/Seusabamobis arsebobis gamo.. LOE: B 2. IABP rekomendirebulia STEMI-s dros Tuki mas axlavs dabali
wuTmoculobiTi stadia. LOE: B ix. sqema 4 3. kardiogenuri Sokisas roca igi ver swordeba swrafad farmakologiur
TerapiiT. igi aris mastabilizirebeli RonisZieba aseT pacientebSi
angiografiis win. LOE: B ix. sqema 4 4. IABP unda gamoviyenoT rogorc damatebiTi RonisZieba medikamentozur
mkurnalobaze STEMI-an pacientSi Tuki mas aReniSneba rekurentuli
iSemiuri xasiaTis diskomforti gulmkerdSi an hemodinamikuri
arastabiluroba, dabali gandevnis fraqcia an didi zomis miokardiumi
riskis qveS, aseT pacientebi saWiroeben urgentul gulis kaTeterizacias
da revaskularizacia saWiroebisamebr. LOE: C II-A klasi: 1. IABP gamoiyeneba pacientebSi STEMI-T romelTac aReniSnebaT
polimorfuli VT miokardiumis iSemiis Semcirebis mizniT. LOE: C II-B 1. IABP-is gamoyeneba SeiZleba iyos mizanSewonili pacientebSi STEMI-T
refraqteruli pulmonaruli Segubebis mkurnalobis mizniT LOE: C
47
sqema 5 ICD-is Cveneba pacientisaTvis STEMI_T da dabali EF -iT sqema 6. ganmeorebiTi iSemiis/infarqtis marTva STEMI-s
Semdgom
ara gvaqvs parkuWTa fibrilacia da myari ventrikuluri
taqikardia STEMI-dan 48-sT-Si da gandevnis fraqcia gaizoma
infarqtidan 1-Tvis Semdeg
EF ≤ 30% EF=31- 40% EF > 40%
gvaqvs eleqt.
arastabilur
oba? mag:
NSVT
ICD EPS + - ICD ara
ganmeorebiTi iSemiuri tkivili an diskomforti STEMI-s SEmdgom
12-ganxriani
e.k.g.
medik. mkurnalobias
optimizacia
antikoagulaciis dawyeba
Tu manamade ar iyo
balonuri kontrpulsacia
hemodinamikuri
arastabilurobis, dabali
kumSvadi funqciis, an
Tuki miokardis didi
ubania riskis qveS
iSemiis meoradi mizezebis
gasworeba
ST elevacia ara diax
aris
revaskulari
zaciis
kandidati ?
ara
diax
iSemia
kontroldeba
medik.
optimizaciiT ?
diax
ganix.
ganmeorebiTi
Trombolizi
si
gegmiuri
kaTeterizacia
urgentuli
kaTeterizacia
gaiTvaliswine
IABP
ara
SesaZleb
elia
swrafi
kaTeteri
zacia ?
ganixile re-Trombolizisis SesaZlebloba
streptkinazisaTvis 2 dRidan 5 wliwadSi
ganmeorebiTi xmareba SedarebiTi ukuCvenebaa
ara
PCI an CABG diax
klasi
III
LOE: B
klasi II-A.
LOE: B
klsi I
LOE: B
klasi
II-B LOE: B
klasi
II-B LOE: B
ara
diax
VIII ariTmiebis marTva STEMI-is Semdgom
a. VF: parkuWovani fibrilacia:
klasi I :
1. parkuWovani fibrilacia an VT pulsis gareSe saWiroebs asinqronul
eleqtrul soks monofazurs swyisi energia 200 J. ganmeorebiTi ganmuxtva
200-300 da warumateblobisas 360 J. LOE B. klasi IIA:
2. Tuki parkuWovani fibrilacia an VT pulsis gareSe
refraqterulia eleqtrikul Sokze mizansewonilia daviwyoT
amiodaroni(300mg bolusi intravenurad da Semdeg gavimeorebT
asinqronul ganmuxtvas LOE B 3. mizanSewonilia gamovasworoT eleqtruli da mJava tutovani
wonasworoba ( K SevinarCunoT > 4 mEq/L da Mg > 2 mg/dl raTa
Tavidan aviciloT VF-is ganmeoreba LOE C klasi IIB :
1. el SokisTvis refraqteruli VT an VF-is mkurnaloba prokainamidis i/v
infuziiT. Tumca amas aqvs SezRuduli Rirebuleba, vinaidan
medikamentis infuzia saWiroebs SedarebiT xangZliv dros. LOE C klasi III:
1. rutinuli gamoyeneba antiaritmuli preparatebis fibrinolizisur
mkurnalobasTan erTad naCvenebi araa. LOE B.
b. VT: parkuWovani taqikardia klasi I :
1. myari ( > 30 wm-ze an hemodinamikuri kolafsis gamomwvevi) polimorfuli VT –s dros asinqronuli monofazuri eleqtruli Soki 200 J ganmeorebiTi
ganmuxtva 200-300 da warumateblobisas 360 J. LOE B. 2. myari VT-s epizodebi rasac axlavs angina, filtvebis SeSupeba,
hipotenzia(sist. art. wneva < 90 mmhg-ze) saWiroebs sinqronizirebul el.
Soks 100 j monfazurs. warumateblobisas TandaTanobiT zrdian energias.
sasurvelia anesTezia Tuki hemodinamoka gvaZlevs saSualebas. LOE B. 3. myari ( > 30 wm-ze an hemodinamikuri kolafsis gamomwvevi) monomorfuli VT –s dros romelic ar asocirdeba anginasTan, filtvebis SeSupebasTan,
hipotenziasTan saWiroebs:
a. amiodarons 150 mg i/v infuzia 10-wT-Si (alternatiuli dozaa 5mg/kg-ze)
gaimeoreT igive doza yovel 10-15wT-Si saWiroebisas. alternatiuli dozaa
360 mg 6-sT-si Semdeg 540 mg Semdgom 18 –sT-Si. jamurma dozam ar unda
gadaaWarbos 2,2 g 24-sT-Si. LOE B. klasi IIA: 1. mizanSewonilia refraqteruli polimorfuli VT-s mkurnaloba:
a. iSemiisa da adrenaluri stimulaciis Semcirebis mizniT,Terapiul
saSualebebTan erTad mxedvelobasi qona iseTi saSualebebis rogoricaa: IABP, PCI an CABG LOE B b. eleqtrolitebis Semdgomi normebi; K > 4 mEq/l da magneziumi > 2 mg/dl LOE C.
48
g. Tuki pacients aqvs bradikardia < 60-ze wT-Si an QTc gaxangZlvebulia
droebiTi peisingi maRali sixSiriT. LOE C. klasi IIB: 1. monomorfuli VT romelic ar asocirdeba anginasTan, filtvebis
SeSupebasTan, hipotenziasTan saWiroebs prokainamidis boluss da infuzias. LOE B.
klasi III: 1. lidokainis profilaqtikuri mizniT rutinuli gamoyeneba araa
rekomendirebuli izolirebuli parkuWovani eqstrasistolebis kupletebis,
garbenebi acqarebuli idioventrikuluri riTmis an NSVT-is samkurnalod. LOE B. 2. rutinuli gamoyeneba antiaritmuli preparatebis fibrinolizisur
mkurnalobasTan erTad naCvenebi araa. LOE B.
g parkuWovani eqstraistolia:
klasi III:
1. izolirebuli parkuWovani eqstraistoliis, kupletebis, NSVT-s mkurnaloba mizanSewonili araa Tuki ar axlavs hemodinamikuri darRvevebi. LOE B
d. aCqarebuli idiventrikuluri an kvanZovani riTmiv. marjvena
parkuWis infarqti:
III klasi:
1. antiariTmuli Terapia araa naCvenebi LOE B
g. supraventrikuluri ariTmia/AF klasi: I 1. myari AF an winagulebis TrTola Tuki axlavs hemodinamikuri darRvevebi
saWiroebs Semdgom mkurnalobas:
a. sinqronizebuli kardiversia. sawyisi monofazuri Soki 200 J AF-s dros da 50 J winagulTa TrTolisas. zogadi anesTeziiT an sedaciiT Tuki es
SesaZlebelia LOE C b. Tuki ariTmia grZeldeba an meordeba moxsnis Semdgom. gamoiyeneba
Semdegi medikamentebi: i/v amiodaroni LOE C, i/v digoqsini riTmis sixSiris
Sesamcireblad ( gansakuTrebiT maSin Tuki gvaqvs gulis marcxena parkuWis
ukmarisoba LOE C. 2. myari AF an winagulebis TrTola hemodinamikuri darRvevebis gareSe
magram mimdinare iSemiiT:
a. beta-blokatorebi Tuki araa ukuCveneba LOE C b. i/v diltiazemi an verapamili LOE C g. sinqronuli kardioversia. sawyisi monofazuri energia 200 J AF-s dros da 50 J winagulTa TrTolisas. zogadi anesTeziiT an sedaciiT Tuki es
Sesazlebelia LOE C
49
3. myari AF an winagulebis TrTolisas hemodinamikuri darRvevebis an
iSemiis gareSe rekomendirebulia riTmis sixSiris kontroli. mxedvelobaSi
unda gvqondes antikoagulaciuri Terapia. pacientebSi visac STEMI-s dawyebamde ar hqondaT ariTmia SeiZleba vifiqroT sinusuri riTmis
aRdgenaze. LOE C 4. re-entri paroqsizmuli SVT saWiroebs Semdgom mkurnalobas:
a. karotiduli sinusis masaJi LOE C b. i/v adenozini(6 mg swrafi bolusit 1-2 wm-Si. warumateblobisas 12 mg,
romlis gameorebac Sesazlebelia) LOE C g. i/v beta-blokerebi LOE C d. i/v diltiazemi ( 20 mg an 0,25 mg/kg-ze 2-wT-Si da Semdgomi infuzia 10 mg-
sT-Si). LOE C e. i/v digoqsini( unda vicodeT rom Sedegi iqneba daaxloebiT 1-sT-Si. 0,6
dan 1 mg-mde 70 kg-ian pacientSi.(8-15 mkg/kg-ze.) LOE C klasi III: 1. winagulovani eqstrasistolebis mkurnaloba saWiro araa. LOE C
IX. bradiariTmiebi:
a. sinusis kvanZis disfunqcia STEMI-s Semdgom:
Iklasi:
1. simptomuri sinusuri bradikardia, sinusuri pauza > 3 wm-ze, an sinusuri
bradikardia < 40-ze asocirebuli hipotenziasTan, an sistemri
hemodinamikuri darRvevebTan namkurnalevi unda iqnen: i/v atropiniT 0,6-1 mg.
bolusi ( maqs. doza: 2 mg ) Tu bradikardia persistirebs gamoiyeneba
transkutaneuri an transvenozuri ( umjobesia winagulovani) droebiTi
peisingi. LOE: C
b. gamtareblobis moSla: warmodgenilia cxrilis saxiT
50
I xarisxis AV bloki mobic I meore xarisxis AV bloki mobitc II meore xarisxis AV bloki
wina MI arawina MI
A wina MI arawina MI
wina MI arawina MI
moqmede
ba klasi moq.med klasi moq.med klasi moq.me klasi moqmed klasi moq.med klasi moqmed klasi
dakvirv
eba
I dakvirv I dakvir. I dakvir. II b dakvir. IIA dakvir. III dakvir. III
A
III
A
III
A
III
A *
III
A
III
A
III
A
III
TC
III
TC
II b
TC
II b
TC
I
TC
I
TC
I
TC
I
normaluri
TV
III
TV
III
TV
III
TV
III
TV
III
TV
II a
TV
II a
dakvirv
eba
I
dakvir.
IIb
dakvir.
IIb
dakvir.
B
IIb
dakvir.
IIb
dakvir.
III
dakvir.
III
A
III
A
III
A
III
A *
III
A *
III
A
III
A
III
TC
IIb
TC
I
TC
IIa
TC
I
TC
I
TC
I
TC
I
axali an Zveli
fascikul. bloki LAFB an PFB)
TV
III
TV
III
TV
III
TV
III
TV
III
TV
IIa
TV
IIb
dakvirv
eba
I
dak
III
dak
III
dak
III
dak
III
dak
III
dak
III
A
III
A
III
A
III
A *
III
A
III
A
III
A
III
TC
II b TC
I
TC
I
TC
I
TC
I
TC
I
TC
I
hisis konis Zveli
bloki
TV
III
TV
II b TV
II b TV
II b TV
II b TV
II a TV
II a
dakvirv
eba
III
dak
III
dak
III
dak
III
dak
III
dak
III
dak
III
A
III
A
III
A
III
A*
III
A
III
A
III
A
III
hisis konis axali
bloki
51
52
TC
I TC I TC I TC I TC I TC IIb TC IIb
T
IIb
TV
IIa
TV
Ia
TV
IIa
TV
IIa
TV
I
TV
I
dak
III
dak
III
dak
III
dak
III
dak
III
dak
III
dak
III
A
III
A
III
A
III
A*
III
A
III
A
III
A
III
TC
I
TC
I
TC
I
TC
I
TC
I
TC
II B TC
II b
fascikularuli
bloki+ RBBB
TV
IIb
TV
II a
TV
II a
TV
II a
TV
II a
TV
I
TV
I
dakvirv
eba
III
dak
III
dak
III
dak
III
dak
III
dak
III
dak
III
A
III
A
III
A
III
A*
III
A
III
A
III
A
III
TC
II b
TC
II b
TC
II b
TC
II b
TC
II b
TC
II b
TC
II b
gardamavali
marjvena da
marcxena hisis
konis bloki
TV
I
TV
I
TV
I
TV
I
TV
I
TV
I
TV
I
es cxrili efuZneba winagulovan_parkuWovani ( vertikaluri grafa ) da
parkuWSida ( horizontaluri grafa ) gamtari sistemais darRvevas,
romelic SeiZleba Camoyalibdes wina kedlis mwvave infarqtis da ara ST segmentis elevaciiT mimdinare infarqtis dros. agreTve mocemulia
TiToeuli situaciis mkurnalobis Cveneba.
A = atropini, AV = atrioventrikularuli, TC = kanzeda/garegani peisingi, TV = droebiT transvenuri peisingi, LAFB = hisis konis marcxena wina fexis bloki, LPFB = hisis konis marcxena ukana fexis bloki.
moqmedeba
CamoTvlili bradiariTmiebis da gamtareblobis darRveveis samkurnalod
miCneulia 4 Terapiuli punqti
1. dakvirveba: mudmivi e.k.g-s monitoringi, aranairi Semdegi qmedeba.
2. A da A*: atropinis Seyvana intravenurad 0.6_1.0 mg-idan 5 wuTis
intervaliT maqs.. 0.04mg/kg-e. zogadad vinaidan atropins SeuZlia
gamoiwvalos mkveTri taqikardia rac araa sasurveli maqsimalurad
cdiloben Tavidan airidon am preparatis xmareba Tuki ar gveqneba
simptomuri sinusuri an Mmobitc I AV bloki.
3. TC: kanze safenebis moTavseba, mzad yofna garegani peisingisaTvis.
4. TV: droebiT venuri peisingi.
rogor unda ixelmZRvanelo cxriliT
magaliTi: 54 wlis mamakaci wina kedlis ST segmentis elevaciiT mimdinare
infarqtiT da viwro QRS kompleqsebiT. pirvel dRes ganuviTarda hisis
konis marjvena fexis sruli bloki da PR intervali am dros iyo 0.28 wm.
1. hisis konis marjvena fexis sruli bloki gamoxatavs gamtareblobis
darRvevas, cxrilSi yoradReba miaqcie “hisis konis axal bloks”.
2. ipove vertikalur grafaSi “pirveli xarisxia AV bloki”.
3. ipove “moqmedeba” da “klasi”.
4. gaiTvaliswine, rom “dakvirveba” da “atropini” aris III klasi, anu ar
aris naCvenebi; kanzeda peisingi (TC) aris I klasi; droebiTi venuri
peisingi ki (TV) IIb klasi.
d. mudmivi peisingis Cveneba bradiaritmiis da/an gamtareblobis
darRvevisas romelic asocirdeba STEMI-Tan:
I klasi:
1. permanentuli ventrikuluri peisingi naCvenebia persistentuli II
xarisxis AV blokisas romelic erwymis bilateralur hisis konis fexis
bloks an III xarisxis AV bloki his-purkinies sistemaSi an mis qvemoT rac
viTardeba STEMI-s Semdgom. LOE: B 2. permanentuli ventrikuluri peisingi naCvenebia gardamavali Sorswasuli
II an III xarisxis infranodaluri blokis da asocirebuli hisis konis
fexis blokisas, Tuki blokis adgili gaurkvevelia mizanSewonilia
eleqtrofiziologiuri kvleva. LOE: B
53
3. permanentuli ventrikuluri peisingi naCvenebia persistentuli da
simptomuri II an III xarisxis AV blokisas. LOE: C II B klasi: 1. permanentuli ventrikuluri peisingi SeiZleba gaviTvaliswinoT
persistentuli II an III xarisxis AV blokisas AV kvanZis doneze. LOE: B
III klasi:
1. permanentuli ventrikuluri peisingi araa rekomendirebuli gardamavali AV blokisas, Tuki araa intraventrikuluri gamtareblobis defeqtebi. LOE: C 2. permanentuli ventrikuluri peisingi araa rekomendirebuli gardamavali AV blokisas izolirebuli marcxena wina fascikularuli blokisas LOE: B 3. permanentuli ventrikuluri peisingi araa rekomendirebuli SeZenili
marcxena wina fascikularuli blokisas AV blokis ar arsebobisas LOE: B 4. permanentuli ventrikuluri peisingi araa rekomendirebuli
persistentuli I xarisxis AV blokisas romelic Serwymulia Zvel(ara
axal) hisis konis fexis blokTan. LOE: B
e. mudmivi peisingis modelis SerCeva Cveneba bradiaritmiis da/an
gamtareblobis darRvevisas romelic asocirdeba STEMI-Tan:
I klasi
1. yvela pacienti visac aqvs mudmivi peismekeris Cadgmis Cveneba unda
Sefasdes ICD-s Cvenebaze LOE: C II A klasi
1. orkameriani peisingi pacientTaTvis romelTac aqvT sinusuri riTmi
da erTkameriani Tuki pacients aqvs winagulTa TrTola an cimcimi LOE: C
2. yvela pacienti visac aqvs mudmivi peismekeris Cadgmis Cveneba unda
Sefasdes biventrikuluri peisingis (gulis resinqronizaciuli
Terapia) Cvenebaze LOE: C
v. ganmeorebiTi tkivili STEMI-s Semdgom
gamowveulia rogorc wesi perikarditiT an iSemiiT. pirvel Tormet saaTSi
ufro mosalodnelia tkivili ukavSirdebodes iSemias. perikarditi nakleb
mosalodnelia iZleodes mniCvnelovan diskomforts gul-mkerdSi pirvel
24-sT-Si.
I perikerditi:
I klasi:
1. aspirini 650 mg (nawlavuri garsiT dafaruli) 4-6 sT-Si LOE: B 2. antikoagulacia ixsneba Tukis gamoCndeba perikardiuli gamonadeni an
zomaSi moimatebs. LOE: C
54
II A klasi:
1. Tuki aspiriniT mkurnalobaze mdgomareoba ar umjobesdeba iniSneba 1
a) kolxicini 0,6 mg oralurad yovel 12-sT-Si LOE: B an/da( 1 an orive) b) acetaminofeni 500 mg yovel 6-sT-Si oralurad LOE: B
II B klasi: 1. kortikosteroidebi rogorc ukanaskneli arCevani Tuki perikarditi
refraqterulia, vinaidan isini zrdian rubturis risks. LOE: C 2. arasteroiduli anTebis sawinaaRmdego preparatebi xanmokle droiT
vinaidan isini aseve zrdian rubturis, infarqtis eqspansiis da
Trombocitebis disfunqciis risks. LOE: B III klasi:
1. ibubrufeni ar iniSneba vinaidan igi amcirebs aspirinis
antiagregantul Tvisebas, iwvevs infarqtis eqspansias da zrdis
rubturis risks. LOE: B
II ganmeorebiTi infarqti/iSemia
I klasi:
1. Tuki pacientebs Catarebuli aqvT reperfuziuli Terapia STEMI-s gamo xdeba mkurnalobis optimizacia nitratebiT da beta-blokerebiT.
SesaZlebelia daviwyoT i/v antikoagulacia. Tuki ukve ar utardeboda. LOE: B 2. zemoT aRniSnulis garda, Tuki iSemias Tan axlavs hemodinamikuri
arastabiluroba, cudi marcxena parkuWis funqcia, da riskis qveSaa didi
zomis miokardiumi pacientebs urgentulad utardebaT kaTeterizacia da
saWiroebisas revaskularizacia mxedvelobaSi unda viqonioT
kontrpulsacia. LOE C 3. Tuki pacienti ganmeorebiTi infarqti/iSemiiiT aris revaskularizaciis
kandidati utardeba koronarografia da PCI an CABG koronaruli anatomiis
da mixedviT. L LOE B O
II A klasi:
1. Tuki aseT pacientebSi koronarografia an/da PCI ver xerxdeba da gvaqvs ganmeorebiTi ST elevaciiT mimdinare infarqti fibrinplizisi SeiZleba
gavimeoroT ( idelur SemTxvevaSi simptomebis dawyebidan 1-sT-Si). LOE C
III klasi: E
1.streptokinaza ar iniSneba ganmeorebiT Tuki maT manmde 5 dRiT adre
Cautardat Trombolizisi am preparatiT.LOE C
z. sxva garTulebebi:
T/t sisxlis mimoqcevis moSla (iSemiuri)
I klasi :
1. nevropaTologis konsultacia pacientSi STEMI-T, Tuki pacients
aReniSneba T/t sisxlis mimoqcevis moSla LOE C
55
a. riskis Sefaseba stacionaridan gaweris Semdgom:
T. STEMI-s Semdgomi aorto koronaruli Suntirebis Cvenebebi
mocemuli iqneba zogadad CABG-is gaidlainSi.
X meoradi prevencia da xangZlivi marTva:
56
2. pacientebis zemoaRniSnul jgufSi saWiroa Catardes eqokardiografia,
nevrologiuri (CT, MRI...) da vaskularuli gamosaxulebiTi kvleva insultis
mizezis gamovlenis mizniT. LOE C 3. pacientebis aRniSnul jgufSi persistentuli AF-iT iniSneba Terapia
varfariniT (INR 2-3) mTeli sicocxlis manZilze LOE A 4. pacientebSi STEMI-T iSemiuri insultiT Tu mis gareSe, visac aqvs
emboliis kardialuri wyaro (AF, Trombi intrakardialurad, didi zomis
akinetiuri segmenti) unda dainiSnos Terapia varfariniT (INR 2-3) aspirinTan
erTad. (sul cota 3 Tve intramuraluri Trombis da akinetiuri ubnis
arsebobisas da mTeli cxovreba AF-s dros). varfariniT adeqvatur
antikoagulaciamde pacientma unda miiRos UFH an LMWH. LOE B II Aklasi:
1. mizanSewonilia Sefasdes pacientebSi STEMI-T iSemiuri insultis
riski. LOE A 2. mizanSewonilia pacientebSi STEMI-T da ara fataluri iSemiuri
insultiT Catardes Sesabamisi movla garTulebebis sixSiris
Sesamcireblad da funqciuri gaumjobesebis mizniT. LOE C
II B klasi:
1. karotidebis angioplastika/stentireba, 4-6 kviraSi iSemiuri
insultidan, Tuki pacientebs STEMI-T aqvT mwvave epizodi, rasac
axlavs Sida karotidis stenozi > 50%-ze, da aqvT maRali
qirurgiuli sikvdilianobis/avadobis riski STEMI-s Semdgom adreul
periodSi LOE C
Rrma venebis Trombozi DVT da pulmonaruli embolia PE:
rogorc prevencia aseve mkurnaloba ganxiluli iqneba DVT da PE-s
Sesabamis gaidlainebSi. aq ki avRniSnavT rom mkurnal eqims mxedvelobaSi
unda hqondes es garTulebebi xangZlivi woliTi/jdomiTi rejimisas da
iseT pacientebSi, romelTac amis gareSec aqvT aRniSnuli garTulebebis
maRali riski.
57
sqema 7. kaTeterizaciis da revaskularizaciis Cveneba STEMI-s Semdgom adreuli
invaziuri strategia fibrinolizisi arareperfuziuli strategia
EF > 40 % EF < 40 %
maRali riskis
gareSe †
maRali riskiT
†
kaTeterizaci
a Cvenebis
mixedviT
funqciuri
Sefaseba
EF < 40 % EF > 40 %
† maRal riskSi igulisxmeba STEMI-s riski (ix. gamosaxuleba 1 ) Semosvlisas. amasTan erTad mas emateba iseTi maRali riskis prediqtorebi rogoricaa: warumatebeli
reperfuziis niSnebi( tkivilis ganmeoreba, ek.k.g-niSnebis persistireba. ) meqanikuri garTulebebi(gulis ukmarobis uecari ganviTareba, axali Suili, Soki.)
medikament. mkurnaloba
maRali riskis
gareSe †
maRali riski †
e.k.g
interpretire
badia
e.k.g. interpretirebadi araa
fiz..datvir.
testi ar
SeuZlia
fiz. datvirT
testi ar
SeuZlia
nuklearuli
datvirT.vis
testi
datvirTvis
stress eqo
klinik. mniSv. iSemia araa
SeuZlia
fizik. datir.
testi
submaqs. dat.
testi
gaweramde
maqsimaluri
datvirTvis testi
gaweris win an
Semdgom
klinikurad mniSv. iSemia
dobutamin eqo.
kaTeterizacia da revaskularizacia Cvenebisda mixedviT
Semd. kaTeteriz.
gareSe
Semdg.
kaTeterizaciiT
farmakologiuri stres testi
adenozini an
dipiridamoli
revaskul
arizacia
Cvenebis
mixedviT
b. cxrili 10 meoradi prevencia STEMI-s dros:
mizani
rekomendaciebi
moweva
mizani: sruli Sewyveta
pacienti da misi ojaxi mkacrad
unda gafrTxildes mowevis sruli
Sewyvetis Sesaxeb ( Tavidan unda
iqnes aridebuli misi TandraswebiT
ojaxis wevrebis mier moweva)
saWiroebisas SesaZloa
farmakologiuri Terapiis daniSvnac
( nikotinis Canacvleba da “
Bupropion”-i)
sisxlis wnevis kontroli
mizani: < 140/90 mmhg an < 130/80
mmhg qronikuli Tirkmlis
naklovanebis an diabetis dros
Tuki wneva ≥ 120/80 mmhg • daiwyeT cxovrebis stilis
modifikacia (wonis kontroli,
fizikuri aqtivoba, alkoholis
Warbi gamoyenebis Tavidan arideba,
marilis xmarebis zomieri Semcireba,
dietaSi xilis, bostneulis, dabal-
cximiani produqtebis didi
xvedriTi wili)
Tuki wneva ≥ 140/90 mmhg an > 130/80 mmhg pacientebSi Tirkmlis
qronikuli ukmarisobiT an diabetiT:
• daamateT wnevis Sesamcirebeli
medikamentebi
lipiduri menejmenti ( Tuki TG < 200 mg/dl)
mizani: LDL-C mniSvnelovnad <
100 mg/dl-ze)
daiwyeT dieta yvela pacientSi. (
saerTo kaloraJSi gajerebuli
cximi < 7%-ze da qolesteroli <
2000 mg/dReSi.) urCieT wonis
kontroli da fizikuri aqtivoba.
urCieT omega-3 cximovani mJavis
xmarebis gazrda.
gansazRvreT lipiduri speqtri da
daiwyeT medikamenturi mkurnaloba
Semdegi sqemis mixedviT:
LDL -C < 100 mg/dl ( sabaziso an
mkurnalobis fonze)
• gamoiyeneT/gaagrZeleT statinebi
mizani misi Semcireba 70 mg/dl-is
58
qvemoT statinebi
LDL ≥ 100 mg/dl ( sabaziso an
mkurnalobis fonze)
• moaxdineT LDL-is Semamcirebeli
medikamentozuri mkurnalobis
intensifikacia. upiratesoba eniWeba
statinebs. )
lipiduri menejmenti ( TG ≥ 200 mg/dl
mizani: ara HDL-C mniSvnelovnad
naklebi 130 mg/dl-ze *
Tuki TG ≥ 150 mg/dl an HDL < 40 mg/dl :
• xazi gausviT wonis kontrolis da
mowevis Sewyvetis mniSvnelobas
TG aris 200-499 mg/dl
• LDL-C Semamcirebeli Terapiis
ESmdgom, † mxedvelobaSi gqondes
fibrati an niacini ††
Tuki TG aris ≥ 500 mg/dl
• mxedvelobaSi iqonie fibratis an
niacinis dawyeba LDL is Semamcirebeli Terapiis win. †
• mxedvelobaSi iqonie omega-3 mJavis
dawyeba
fizikuri aqtivoba
minimaluri mizani: 30 wT 3-4 dRe
kviraSi;
optimaluria yovel dRe
gansazRvreT riski, upiratesad
datvirTvis testiT. pacientebs
urCieT 30-60 wT-iani aqtivoba.
umjobesia yovel dRe magram minimum
3-4 jer kviraSi.(fexiT siaruli,
sirbili, velosipedi, aerobika.)
aseve urCieT dRis ganmavlobaSi
ufro aqtiuri moZraoba: siaruli,
saxlis samuSaoebi. gulis
reabilitaciuri programebi
pacientebisaTvis mravlobiTi risk
faqtorebiT unda mimdinareobdes
eqimis meTvalyureobiT.
wonis kontroli
mizani: sxeulis masis indeqsi BMI = 18,5-24,9 kg/m2 welis garSemoweriloba:
qalebSi: 88,9 sm
kacebSi 101,6 sm
gamoTvaleT BMI ( sasurvelia 18,5-
24,9 kg/m2 da gazomeT welis
garSemoweriloba( 101-sm kacebSi da
89-sm qalebSi). periodulad
gadaamowmeT. Tuki monacemebi
aradaamkmayofilebelia pacients
urCieT metad gaaqtiveba da
cxovrebis wesis modificireba.
59
diabetis kontroli:
mizani HbA1c < 7%-ze.
hipoglikemiuri dieta da Terapia
raTa mivaRwioT normalurTan axlo
Saqris cifrebs uzmoze da HbA1c < 7%-ze.
antiTrombocitebi/antikoagulantebi
aspirini 75-162 mg Tuki araa
ukuCveneba. klopidrogeli 75 mg an
varfarini Tuki aspirini
ukunaCvenebia. (es ukanaskneli INR-is kontroliT )
renin-angiotenzin-aldosteron
sistemis blokerebi
ACE inhibitorebi yvela pacientSi.
daiwyeT adre maRali riskis
pacientebSi ( wina kedlis MI, adre gadatanili MI, kilipi II-ze meti
gulis ukmarisoba. (S3 galopi,
auskultaciiT Segubeba mcire wreSi,
gulis ukmarisobis radiografiuli
niSnebi. EF ≤ 40%-ze.
angiotenzinis receptorebis
blokerebi pacientebSi ACE-inhibitorebis autanlobisas, da
romelTac aqvT maTi daniSvnis
Cveneba.
aldosteronis blokatorebi
pacientebSi mniSvnelovani renaluri
ukmarisobis ††† an hiperkaliemiis
gareSe †††† romlebic iReben ACE inhibitorebs, aqvT EF < an toli 40
%-ze. da aqvT diabeti an gulis
ukmarisoba.
HF
beta blokerebi
daiwyeT yvela pacientSi romelsac
ara aqvs ukuCveneba da SearCieT
optimaluri doza. gaagrZeleT
monitoringi dozis optimizaciis
mizniT (monitorings gansakuTrebuli
mniSvneloba aqvs pacientebSi gulis
ukmarisobiT)
diabetis marTva hipoglikemiuri Terapia. efeqturoba
mowmdeba HbA1C-iT romelic unda
iyos 7%-ze naklebi.
varfarini misi Cvenebebi aris qvemoT mocemul
cxrilSi. damatebiT SeiZleba
aRiniSnos rom varfarini SeiZleba
mieces pacients STEMI-s Semdgom Tuki
60
61
aqvs LV disfunqcia da didi zomis regionaluri kumSvadobis moSla.
LOE IIA
g. ST elevaciiT mimdinare miokardimis infarqtis ( STEMI) stacionaridan gaweris Semdgomi antiTrombozuli mkurnaloba
62
pacienti gaweris win
stentireba
ar Cautarda
stentireba
Cautarda
aspirinze araa
alergiuli
aspirinze
alergia aqvs
araa
antikoagulaci
is Cveneba
aris
antikoagulaci
is Cveneba ††††
araa
antikoagulaci
is Cveneba
aris
antikoagulaci
is Cveneba ††††
aspirinze araa
alergiuli
aspirinze
alergia aqvs
araa
antikoagula
ciis Cveneba
aris
antikoagulaciis
Cveneba ††††
araa
antikoagula
ciis Cveneba
aris
antikoagulaci
is Cveneba ††††
ASA 75-162 mg I klasi LOE A.
ASA 75-162 mg
+ varfarini
(INR 2,0-3,0) ††† I klasi LOE B.
klopidrogeli
(plaviqsi)* 75
mg I klasi LOE C
ASA 75-162 mg + klopidroge
li (plaviqsi)
75 mg I klasi
LOE B. †
ASA 75-162 mg + klopidrogeli
(plaviqsi) 75
mgࠠ +
varfarini (INR 2,0-3,0) IIB klasi LOE C †††
klopidroge
li (plaviqsi)
75 mg +
varfarini (
INR 2,0-3,0) I klasi LOE C †††
varfarini
(INR 2,0-3,0) I klasi LOE B.
klopidroge
li (plaviqsi)
75 mg I klasi
LOE B.
alternativaa
ASA 75-162 mg
+ varfarini
(INR 2,0-3,0) II A klasi LOE B.
an varfarini
( INR-2,5-3,5) I klasi LOE B
alternativaa
varfarini
(INR 2,5-3,5) I klasi LOE B
an varfarini
( INR-2,5-3,5) II A klasi LOE B.
* klopidrogels aqvs upiratesoba varfarinTan SedarebiT naklebi sisxldeniT garTulebebis
gamo. amasTan erTad pacientebis umravlesoba arCevs mis miRebas.
† 12-Tvis ganmavlobaSi
†† klopidrogeli ixsneba 1-TveSi ( Tu gamoyenebulia bare metal stenti, grZeldeba ramodenime
Tve Tu gamoyenebulia drug-diluting stentebi( 3 Tve sirolimus-is Semdeg 6-Tve paclitaxel-is Semdeg) ixsneba sisxldenebis potenciuri safrTxeebis Sesamcireblad.
grZeldeba aspirini varfarinTan erTad Cvenebis mixedviT (winagulTa fibrilacia, Trombuli masa
gulis RruebSi, cerebraluri emboli, didi zomis regionaluri kumSvadobis moSla)
††† umjobesia INR-i iyos qveda zRvrisken. 75 wlis qvemoT am medikamentebis kombinacias aqvs
naklebi sisxldenis garTulebebi
†††† STEMI-s Semdgom antikoagulaciis Cvenebaa wina kedlis didi zomis MI an LV-s Trombi
eqokardiografiaze. am dros antikoagulacia grZeldeba 6 kvira ( ra Tqma unda antikoagulacias
aqvs sxva Cvenebebi romlebic ar ukavSirdeba MI-s. mag winagulTa fibrilacia.
* ara HDL qolesteroli = saerTo q esterols minus HDL-i. † mizania ara HDL-C < 130 mg/dl-ze
†† niacini unda gamoviyeno lo i nitoringiT
††† kreatinini ≤ 5 mg/dl i da lSi
†††† kaliumi ≤ 5 Eq/L
d. rekomendaciebi eri mdgomi vizitebis da zogadad
daav ebis marTvi sax
klas :
1. gaweris Semdgomi viziti unda asaxavdes kard s i tomebis
dinamikas da funqcion ur )
2. unda moxdes mimdina mku adafase r
titraciis gziT ACE i ito okerebi a i imaluri
dozebi.
3. riskis gansazRvra da gegmiuri reabilitacia unda gadaixedos da
gagrZeldes. es unda moicavdes ma uWis funqciis Sefasebas,
SesaZloa ho eris monitor pacientebSi m I EF iyo 31-40% an ufro dabali. v a tebSi mxedvelobaSi unda
gvqondes ICD-is implantacia. O4. mkurnalma unda au pa misi oja
prevenciis principebi. ( )
5. pacientis fsiqologiuri statusi unda Sefasdes da yuradReba unda
mieqces iseTi niSnebis arsebobas rac miuTiTebs aze,
Zilis moSlilobaze d ocial i qcevis Secv
6. Semdgomi vizitebisas mkurnalis mier unda ganisazRvros fizikuri
aqtivobis done, samsaxurSi dabrunebis vada, seq
mgzavrobis da manqanis tareb saZlebloba
mgzavrobis sakiTxebi. fizikuri datvirTvis done gamoixateba metaboluri
eqvivalentiT T-Si. (damatebebSi gamosaxuleba 2) ( LOE C )
7. mkurnalma cients a misi xis wevr da SesTavazos CPR-is ZiriTadi principebis a d i survi mTxvevaSi SesTavazos
treiningis kursebze reb E C ) 8. mkurnlma pacientTan da maTi ojaxis wevrebTan erTad unda ganixilos
Semdegi sakiTxebi:
a. pacientis gulis Setevis riski ( LOE C ) b. rogor gamovicnoT STEMI-s simptomebi. ( LOE C ) g. sas fos gamoZaxe auc oba Tu mptomebi ar umjobesdeba an
uaresdeba 5 wT-Si. Tundac rom ar iyvnen darwmunebuli mdgomareobis
simZimeSi. ( LOE C ) d. amasTan unda aexsnaT potenciuri kardiologiuri incidentis gamocnobis
da Semdgomi moqmedebis gegma. saswrafoSi darekvis CaTvliT. ( LOE C ) e. gulis reabilitaciis programebi rekomendirebulia pacientTaTvis
gansakuTrebiT ki maTTvis vinc saWiroebs mravlobiTi risk faqtorebis
modificirebas an/da cientebi, romelTac aqvT garTulebebis saSualo
an maRali riski da ebS rjiSi ebu
ol
d eq mis mo
2 mg/dl qa
T mxo
kacS
iova
ba d
s d
ro
xis
de
la
sua
sev
2,
m
gaw
s Se
s Se
eb: ad
i I
kul
a und
stat
elT
wevre
resia
. (LO
uri
TviT
aru
a S
ine
a po
bs
ze
E C
aqt
mf
l
ei
b
st
meo
, aR
)
ivo
rin
simp
Ces
s opt
-STEM
radi
gzneb
ba,
aviT
al
re
nhib
kl
rn
r
ass. (LOE Calobis g
ebis, B-bl
rcxena park
s im
idan am pacien
E C) ts d
lt ing
in
(Lcienxsnas
LOE Ca
p
ze
l
e
a s ur
is Se , a
ME
pa d
axsn
dasw
oja
a maT
a. ( LO
e
l
bs un
is Se
wra bis ilebl ki si
is pa
roml iac va rekomendir lia.
63
e. cxrili 11 medikamentebi romlebic ga neba STEMI-s moye
mkurnalobisas
pirveli 24-sT
hospitalizaciis
manZilze
gawerisas da
xangZlivi
mkurnalobisas
medikamenti
75-162 mg dRiuri
75-162 mg
dRiuri
dasaReWad (
umjobesia ara
aspirini
enteruli garsiT
dafaruli) 162-325
ganusazRv-
reli vadiT
mg
fibrinolizisuri
Terapia
ixileT ukuCvenebebi
da Cvenebebi me-6
cxrilidan
streptokinaza 1,5
MU IV 30-60 wT-is
manZilze
alteplaza IV
bolusi 15 mg.
infuzia 75 mg/kg-ze
30 wT-Si (maqsimumi
50 mg)
Semdeg 50 mg/kg (
maqs. 35 mg) 60 wT-Si.
jamSi maqsimaluri
dozaa 100 mg
reteplaze 10 U IV bolusi 2wT-Si
Semdeg gaimeoreT 30
wT-Si 10 U IV
bolusi 2 wT-S
i
teneqteplaza IV
bolusi 10-15 wm-Si
30 mg Tuki wona <
60 mg. 35 mg Tuki
wona aris 60-69 kg.
40 mg 70-79kg-ze, 45
mg 80-89 kg-ze da 50
mg > 90 kg-ze.
64
60 U/kg ( maqs. 4000 U arafraqcionirebadi
heparini UFH ) IV bolusi. Semdeg
infuzia 12 U/kg/sT-
Si. max. 1000 U/sT-Si. aPTT 1,5-2,0 normasTan
SedarebiT ( 50-70-s
Soris)
aPTT 1,5-2,0 ix. 8 sqema
antiTrombozu
li
mkurnalobis
normasTan
SedarebiT ( 50-
70-s Soris) 48
sT-is
ganmavlobaSi
rekomendaciebi
sTvis
beta-blokeri
per-os
per-os
per-os ganusazRvreli
vadiT
ACE inhibitori
ACE inhibitori yvela pacientSi
wina kedlis
infarqtiT,
pulmonaruli
SegubebiT, EF < 40
%-ze Tuki araa
hipotenzia da sxva
ukuCvenebebi,
gatitreT wnevis da
kreatininis
kontroliT
per-os
per-os ganusazRvreli
vadiT
angiotenzin II-is
blokatori ARB
ARB unda dainiSnos pacientebSi visac
aqvs ACE inhibitorebis autanloba da ive ig
Cveneba rac am
ukanasknelT
iseve rogorc
pirvel 24-sT-Si
iseve rogorc
pirvel 24-sT-
Si
aldosteronis
blokada
yvela pacientSi
Tirkmlis mniSv.
ukmarisobis
gareSe (
kreatinini < 2,5
mg/dl kacSi ada
2 mg/dl
qalebSi) an
hiperkaliemiis
gareSe K <
5mEq/l
romlebic
iReben ACE-s, EF < an toli 40%
da romelTac
igive rac
hospitalizaci
isas.
65
aqvT gulis
ukmarisoba an
diabeti.
nitroglicerini
sublingvaluri
NTG 0,4 mg yovel 5
wT-Si Tuki rCeba
tkivili an
diskomforti
gulmkerdSi.
IV NTG gulis
ukmarisobis,
hipertenziis,
persistentuli
iSemiisas rac
pasuxobs nitratebs
oralurad Tuki
iSemia
grZeldeba an
aris
ukontrolo
hipertenzia
statinebi
daiwyeT
lipiduri
profiles
ganusazRvreli
vadiT Tuki
LDL-C aris 100 gareSe
mg an meti.
gazardeT manam
sanam igi ar
gaxdeba
mniSvnelovnad
naklebi zemoT
aRniSnul
doneze ( an
toli 70
mg/dl)
morfin sulfat
i
IV 2-4 mg da zrda
2-8 mg-iT 5-15 wT-
iani intervalebiT
tkivilis
kontrolisaTvis
66
pacientis ganaTleba
pacientisTvis
mniSvnelovania
imis codna Tu
rogor
Secvalos
cxovrebis
stili STEMI-s Semdgom.
informacias
medikamenturi
mkurnalobis
Sesaxeb
meoradi
garTulebebis
prevenciisTvis
aseve didi
mniSvneloba
aqvs. iseve
rogorc
codnas Tu
rogor
gamoicnos
gulis
simptomebi da
Tu rodis
gamoiZaxos
saswrafo
daxmarebis
brigada
dieta
axsna
saturirebuli
cximebiT da
qolesteroliT
dabali dietis
aucileblobis
da mniSvnelobis
Sesaxeb
Sesabamisi
dietis
rekomendireba
moweva
avukrZaloT moweva
avukrZaloT
moweva
avukrZaloT
moweva.
saWiroebisas
farmakologiu
ri Terapia. da
CavrToT
mowevis
Sewyvetis
programaSi
67
varjiSi
axsna-ganmarteba
siarulis
dawyeba
rekomndacia
varjiSis da
aqtivobis
donis Sesaxeb
ogTa
i
teqstidan
2001w
. topoli
cinis
cema 2004w.
GXI gamoyenebuli masala:
teqsti eyrdnoba amerikis gulis asociaciis da amerikis kardiol
kolejis 2004w ( sruli teqsti da jibis gaidlaini) aseve evropis
kardiologTa asociaciis ( 2003w sruli teqsti) Sesabamis gaidlainebs.
damatebaSi gamoyenebulia masalebi: 1. ACC/AHA gaidlainis srul
teqstidan
2004w.
2. ESC gaidlainis sruli
2003w.
3. braunvaldi, zaips libbi, gulis
daavadebebi 6-e gamocema
4. brain p. grifini erik j
kardiovaskularuli medi
saxelmZRvanelo, 2-e gamo
68
69