ACS - nnukwu akwara syndrome

IV Samorodskaya,

Prọfesọ, Doctor nke Medical Sciences

nnukwu akwara
syndrome

Multidisciplinary otu kpebie

Iji oge a na ụzọ nke ọgwụgwọ maka nnukwu akwara syndrome (ACS)
- a okwu nke na-anọchi ìgwè ọ bụla nke na-adakarị ịrịba ama ma ọ bụ ihe mgbaàmà
ikwe enyo enyo nnukwu myocardial infarction (MI) ma ọ bụ ejighị n'aka
rịaworo, na-enye olileanya maka a ịrịba Mbelata ke ọgwụ
enwe ma melite prognosis na ogologo oge oge.

Ọtụtụ afọ gara aga, nnyocha na mba na na ọnọdụ na-
achikota All-Russian Scientific Society of Cardiology na Russian kwe nkwa na nchoputa
na ọgwụgwọ nke ọrịa na myocardial infarction na ST-agba elu (2007), na-enweghị ST elu na-ejighị n'aka rịaworo (2006). Na 2010, bipụtara na European nkwanye
Society of Cardiology (ESC) na oke nke ụzọ nke myocardial revascularization, mba ụkpụrụ nduzi maka management nke ọrịa na ACS na Australia
Britain, na-arụpụta nke mba
otutu mmadu kwenyere na management nke ọrịa na ACS. na 2013
American Heart
Society (ACCF / AHA) ka emelitere
na-atụ aro maka management nke ọrịa na ACS
ST nke elu.  

The mkpebi na eme
ndidi management na ACS ka dị elu otú na-enweghị ST-agba elu ọ bụghị mgbe niile pụrụ iche dị mfe, na-achọkarị multidisciplinary òkè
a otu nke ọkachamara dabeere na-adakarị ụkpụrụ nduzi, N'ezie nke ọrịa, afọ nke ọrịa, ọnọdụ
elekọta. N'otu oge niile ọrịa na-enyo enyo na ACS
ga-arụrụ ihe ngwá (na-anọghị nke
mgbanwe ma ọ bụ na-enyo enyo data chọrọ ugboro ugboro na ndekọ etiti 15
-30 nkeji, dabere na-adakarị ọnọdụ onye ọrịa), na o kwere omume na-etoju nke ọmụmụ
maka gbasara obi enzymes, amanyere bụ iwu nke ojiji nke aspirin a na-ewere. na
All na-atụ aro na-họọrọ endovascular usoro
myocardial revascularization na ọnụnọ nke nwere ahụmahụ ruru eru mkpara.
Fibrinolytic ọgwụ (dị ka a nzọụkwụ mbụ nke na-elekọta ndị ọrịa na ACS na ST-agba elu) na-anọgide mkpa ka ndị ọnọdụ,
mgbe ọ gaghị ekwe omume na-arụ stenting
maka 120 nkeji mgbe
omume nke mgbu (na-anọghị nke contraindications na ọ bụrụ na ebe ọ bụ na mgbu bụ karịa
12 awa). Mgbe ACS enweghị eweli fibrinolytic ST nke
ọgwụ na-adịghị ndinọ.

Ọ bụrụ na ihe ize ndụ nke nkụchi obi ma / ma ọ bụ ya
elu nsogbu

sonyere
eke ọkachamara ndụmọdụ Europe, na United States na-ekwere na mmejuputa iwu nke
akwara angiography n'ime awa 2 si oge nke mbanye
na-atụ aro bụrụ na onye ọrịa na onye agha nke rịaworo na ọgwụ na ahụ ike ndabere
n'imeso mgbaàmà ịnọgide ma ọ lọghachiri
rịaworo hụrụ ike ST nke mgbanwe, na-egosi nke mmebi development
ma ọ bụ myocardial infarction; hemodynamic
akwusighi, ịrịba ventricular arrhythmias. Ịrụ angiography (na ụdi
revascularization) maka 24 awa mgbe ndidi mbanye a n'ụlọ ọgwụ ACS na-atụ aro bụrụ na nke elu
ize ndụ nke myocardial infarction,-eyi ndụ egwu
nsogbu na ọnwụ. Yiri oge akwara angiography na-atụ aro na
Ebe chọrọ esi nchoputa nke ACS na ndị ọzọ
ngwa ngwa na ọnọdụ (akpa ume embolism, ịtụle
aortic aneurysm). N'ọnọdụ nke nnukwu akwara syndrome enweghị nke ST inwego na ala n'ihe ize ndụ nke na-egbu
nsogbu na ọnwụ n'oge ọgwụ stay
ọgwụgwọ, ma persistent mgbaàmà nke rịaworo na / ma ọ bụ ischemia rata
n'oge ibu ule, akwara angiography sochiri revascularization na
mkpa na o kwere omume, ọ bụ ihe amamihe na-ebu na a nyere oge
ụlọ ọgwụ 72 awa mgbe mbanye. na
ma ọ bụrụ na onye ọrịa na-kwetara na a ọgwụ owuwu, ebe ọ na-agaghị ekwe omume
ịrụ a akwara angiography, ọ na-agafere na kwesịrị ekwesị ọgwụ (e.g.
Regional vaskụla Center).

nkịtị
atụle tactic stenting (ọgwụ ọjọọ na-ntekwasa stent
ma ọ bụ uncoated) na infarct metụtara akwara tromboekstratsiey (na
dị mkpa), mgbe ACS c inwego
ST nke
n'agbanyeghị nke mmejuputa iwu-na mmetụta nke fibrinolytic ọgwụ (dị
Aro si 2013 ACC mgbe fibrinolytic ọgwụ na-atụ aro na-arụ
FCT na stenting bụghị tupu
2-3 awa). Ọ bụrụ na c-agba elu nnukwu akwara syndrome ST, ma e wezụga infarct akwara, e nwere oké njọ
stenoses na ndị ọzọ akwara, ha mberede stenting a rụrụ naanị
n'ihi na ndị na oké obi odida na / ma ọ bụ cardiogenic ujo. na ndị ọzọ
ikpe na-egbu oge stenting a rụrụ - mkpa na usoro iheomume nke
kpebiri mgbe nchegbu na-anwale tupu ihapu nke ọrịa
ụlọ ọgwụ. Dị ka na-atụ aro ndị ọkachamara si United States na 2013, na-enweghị stents
The mkpuchi na-ọkacha mma na-eji ikpe ebe ndidi nwere
ọrịa na ọnọdụ na a elu n'ihe ize ndụ nke na-agba ọbara, elu puru,
na ọrịa anaghị ime n'ime otu afọ nke sọrọ antiplatelet Usoro
ọrịa, na ọ bụ eleghị anya ịrụ ụdi ịwa
arụmọrụ. Ọzọkwa, na-atụ aro gosiri na c-agba elu ACS ST stenting mgbe awa 24 si oge nke ya
Development bụghị gosiri na mgbe 1-2 vaskụla ọnya na-anọghị nke
ịrịba ama ichebe myocardial ischemia. Na obere okwu (n'okpuru ụfọdụ
ọnọdụ) rụrụ angioplasty.

The mkpebi banyere usoro nke revascularization na ọrịa na nnukwu akwara syndrome enweghị nke ST ịrị elu, na ACS c ST nke elu, ma na-anọghị nke
akwara obodo ibelata nke akwara akwara, maa "ikpe" na
ACS ma ọ bụ nwere multivessel ọrịa, na nke mmejuputa
Stenting bụ nyochawa agaghị ekwe omume ma ọ bụ n'ihe ize ndụ nke karịrị ike nke
uru na-natara site ọtụtụ ndị ọkachamara (obi dọkịta na-awa,
cardiologist, a ọkachamara na ubi nke
Endovascular nchoputa na ọgwụgwọ) na
adakarị, angiographic data nwale fractional eruba idobere,
na-atụ anya na ogologo oge prognosis.

ọgwụ support
bụchaghị

Mgbe ACS na ST nke elu ọtụtụ ndị ọkachamara kweere na ugbu a si eme nke ọrịa na
Ọ na-adabere n'ụzọ dị ukwuu na mba ahụ ike usoro
(Region) ịrụ isi endovascular aka (na-enweghị tupu
thrombolysis) maka 2 awa na mmepe nke-adakarị mgbaàmà na a ndidi.

Ọ bụrụ na ọ na-atụ anya na oge mbụ na kọntaktị na onye ọrịa
n'ụlọ ọgwụ tupu n'ịrụ akwara angiography ga-ihe karịrị 2
awa, ndị ọrịa
(Na na-anọghị nke contraindications) ga-arụrụ thrombolysis na
ụdi nnyefe ụlọọgwụ ịrụ angiography na revascularisation
infarction n'ime 3-24 awa. N'ọnọdụ ndị ahụ, ma ọ bụrụ na na ndabere nke thrombolysis
ST nke elu-edebe ihe karịrị 50% nke mbụ larịị na / ma ọ bụ retrosternal
mgbu, ọrịa na-egosi na mberede akwara angiography. Ọ bụrụ na ihe ịga nke ọma,
thrombolysis akwara angiography na revascularization (ma ọ bụrụ na e gosiri) nwere ike
-rụrụ n'ime 24 awa. The na-atụ aro kwuru na
revascularization nwere ike melite prognosis na ya, mmejuputa iwu site 24-60
awa mgbe mmalite nke na-adakarị mgbaàmà, ma naanị na ndị ahụ ebe
E nwere ntighari rịaworo na / ma ọ bụ myocardial ischemia achọpụtara n'oge
instrumental ọmụmụ.

si
Dabere ụdị nke ACS na revascularization usoro bụ manye
ọgwụ support, nke na-agụnye antiplatelet,
antiplatelet ọgwụ, beta-blockers ọgwụ, inhibitors nke angiotensin n'ịtụgharị
enzyme, statins. Aṅụ ọgwụ na-n'otu n'otu gbanwee
Dabere na udi nke ACS ogo, ọnụnọ soputsvuyuschie daa ọrịa. The
Akwụkwọ a ga-elekwasị anya naanị na antiplatelet ọgwụ,
ịdọkapụta ụzọ nke myocardial revascularization.

Nke elu ACS enweghị S T

The
dị otú ahụ ikpe endovascular revascularization ụzọ
họpụtara a "abụọ 'antiplatelet ọgwụ ahụ na-agụnye onu
acetylsalicylic acid (ASA) na clopidogrel (ma ọ bụ prasugrel ma ọ bụ
ticagrelor). ASA-ekenye mbụ anata 150-300 mg (250-500 mg ma ọ bụ na ụdị
na / na bolus) sochiri a onunu ogwu nke 75-100 mg / ụbọchị loading dose
600 mg nke clopidogrel (dị ka n'oge dị ka o kwere) sochiri ochichi nke 75
mg / ụbọchị maka 9-12 ọnwa prasugrel - 60 mg loading dose, sochiri
na-ewere 10 mg / ụbọchị, ma ọ bụ ticagrelor - 180 mg loading dose, sochiri
na-ewere 90 mg 2 ugboro n'ụbọchị. Egosi maka inwekwu ojiji
GPIIb-IIIa inhibitors na-atụle ga-na elu n'ihe ize ndụ nke intracoronary thrombosis na ọrịa n'ịnwụ angioplasty na / ma ọ bụ stenting
akwara akwara.

The
na-atụ aro EZIGBO (UK) na-ekwu na
Ọrịa na elu n'ihe ize ndụ nke obi ihe (atumatu 6 ọnwa
enwe karịa 3%) na doro akwara angiography na revascularization
n'ime 96 awa si oge nnabata-eme gosiri
nhọpụta nke eptifibatide ma ọ bụ tirofiban. Abciximab họpụtara dị ka a ọgwụ,
ịdọkapụta endovascular revascularization ma ọ bụrụ na ọ dịghị
Ikike na-ekenye ndị ọzọ inhibitors nke GPIIb-IIIa. Ọ ga-kwuru na na
N'adịghị ka EZIGBO nduzi (UK) na-atụ aro
European Society of Cardiology "mmasị" e nyere abciximab (mezuwo
na-egosi na m), n'otu oge maka eptifibatide
ma ọ bụ tirofiban Nịm Class IIa.

Choice na dose
anticoagulants ịrụ angiography
revascularization na ọrịa na-enweghị ACS
eweli ST nke kpebisiri ike dabere na
Stratification nke ize ndụ nke thrombotic, ischemic na hemorrhagic nsogbu. Na nnọọ elu n'ihe ize ndụ
ischemic ihe (ihe atụ, mgbe hemodynamic akwusighi refractory-eyi ndụ egwu arrhythmias) ndidi
nye kpọmkwem X-ray na ọ na-e kenyere
unfractionated heparin (UFH) ka / na a bolus 60 U / n'arọ na ụdi
infusion n'oge revascularization na njikọ na a abụọ
antiplatelet ọgwụ. Na elu n'ihe ize ndụ nke ọbara ọgbụgba ike ga-eji
monotherapy bivalirudin bolus nke 0,75 mg / n'arọ sochiri infusion nke 1,75
mg / kg / Ọrụ Nchịkwa. Maka ọrịa na nkezi ize ndụ nke ischemic ihe (ihe atụ,
mụ hemodynamics, ma a mma troponin ule, laghachiri
rịaworo, ike mgbanwe ndị na-ST nke), nke a na ndokwa maka invasive usoro 24-48
awa na-esonụ omume nhọrọ adị tupu akwara angiography
zubere endovascular myocardial revascularization:

• Maka ọrịa
  

Unfractionated heparin 60 U / n'arọ n'ụdị on / na bolus,
mgbe ahụ infusion n'okpuru akara nke na-arụ ọrụ ele mmadụ anya n'ihu thromboplastin oge
(APTT) ma ọ bụ enoxaparin 1 mg / n'arọ s.c. x 2 kwa ụbọchị ma ọ bụ Fondaparinux 2,5 mg / ụbọchị
Bivalirudin subcutaneously ma ọ bụ 0,1 mg / n'arọ ka / na a bolus sochiri infusion
0,25 mg / kg / hour

• Maka ọrịa ≥75 afọ

Unfractionated heparin 60 U / n'arọ n'ụdị on / na bolus,
mgbe infusion n'okpuru akara APTT

Ma ọ bụ enoxaparin 0,75 mg / n'arọ x 2
Fondaparinux ụbọchị ma ọ bụ 2,5 mg / ụbọchị subcutaneously ma ọ bụ Bivalirudin 0,1 mg / n'arọ ka a
M / bolus sochiri infusion nke 0,25 mg / kg / Ọrụ Nchịkwa.

na
ọrịa na a ala n'ihe ize ndụ nke obi ihe (enweghị amụba
troponin na ST nke mgbanwe), ọzọ mgbanwe zubere
ọgwụgwọ na kenyere fondaparinux (2,5 mg / ụbọchị subcutaneously) ma ọ bụ enoxaparin (1
mg / n'arọ s.c., 2 ugboro n'ụbọchị na ọrịa ≥75 afọ - 0,75 mg) na unfractionated heparin (60 U / n'arọ
dị ka ọ na / bolus, sochiri infusion n'okpuru akara aPTT).

ACS na ST nke elu  

na nke a
adakarị ọnọdụ na-kenyere a "abụọ" ACK antiplatelet ọgwụ (150-300 mg ọnụ ma ọ bụ
250-500 mg ka / na a bolus sochiri ochichi nke 75-100 mg / ụbọchị) na prasugrel
(60 mg loading dose sochiri ochichi nke 10 mg / ụbọchị), ma ọ bụ ticagrelor (loading dose of 180 mg
sochiri ochichi nke 90 mg 2 ugboro n'ụbọchị) ma ọ bụ clopidogrel (loading dose 600
sochiri ochichi
75 mg / ụbọchị). The Aro nke European Society of Cardiology na-ekwu na
prasugrel na ticagrelor clopidogrel irè karị na okwu nke mbenata
ugboro jikọtara ischemic endpoints na stent thrombosis na ọrịa
MI elu ST, na ọ na-adịghị na-amụba ihe ize ndụ nke
oké ọbara ọgbụgba. Dị ka na-atụ aro nke ịnyịnya ibu 2013 abụghị prasugrel
Ọ na-atụ aro maka ọrịa na
a akụkọ ihe mere eme nke ọrịa strok ma ọ bụ TIA. Na omume na tupu abanye
ọgwụ na ahụ ike na alụmdi ịrụ akwara angiography na stenting ndidi
fibrinolysis e rụrụ na ọ bụ ihe na-erughị 24 awa na n'ihi na n'otu oge na-adịghị eji
clopidogrel (prasugrel), mgbe ahụ clopidogrel loading dose bụ 300 mg,
Prasugrel bụ a 60 mg.

Na elu n'ihe ize ndụ
intracoronary thrombosis, tinyere sọrọ antiplatelet ọgwụ
Ọ na-atụ aro iji ihe GPIIb-IIIa inhibitors (abciximab / v bolus nke 0,25 mg / n'arọ sochiri infusion nke 0,125 mg / kg / min na
na kacha larịị nke 10 mg / min maka 12 awa.). Ugbu e nweghị
kwuo ihe àmà ukwuu arụmọrụ GPIIb-IIIa inhibitors mgbe eji na
prehospital ma ọ bụ tupu catheterization.

dị ka a
UFH anticoagulation ọgwụ na-eji (na / na bolus 60 U / n'arọ na Nchikota na a GPIIb-IIIa inhibitor ma ọ bụ / bolus 100 U / n'arọ enweghị
GPIIb-IIIa) inhibitor. Bivalirudin ka monotherapy kama UFH na Nchikota na ihe inhibitor nke GPIIb-IIIa dị ka na-atụ aro site ACC 2013
Ọ na-atụ aro maka ọrịa na elu n'ihe ize ndụ nke isi na-agba ọbara (bolus nke 0,75 mg / n'arọ sochiri infusion nke 1,75
mg / kg / hour); N'otu oge ahụ, fondaparinux adịghị atụ aro n'ihi na elu n'ihe ize ndụ
catheter thrombosis.

Dị ka okwu ndị a si
ọgwụ sọrọ antiplatelet ọgwụ na-eji maka na ọ dịghị ihe ọzọ 12 ọnwa.

Akpan akpan ntị ga-akwụ ụgwọ iji Nchikota
clopidogrel na proton mgbapụta inhibitors, ọtụtụ ndị na-eji maka mgbochi nke
eriri afọ ọbara ọgbụgba. Dị ka otutu mmadu kwenyere nke na-arụ ọrụ otu maka mgbochi nke thrombotic
na hemorrhagic nsogbu ICSI jikọtara iji ọgwụ ọrịa
ala ihe ize ndụ nke gị ọbara ọgbụgba na-adịghị gosiri, ha concurrent ojiji a ga-ndị mmadụ na ndabere nke
ewere n'ime akaụntụ uru na ihe ize ndụ. naanị
Mba ọgwụ si otu - pantoprazole - bụghị a "osompi" klopidoglelya
maka isoenzyme CYP2C19. N'aka nke ọzọ
dịghị elu-edu na-adakarị ọnwụnwa eleru mmetụta nke nkwonkwo
itinye pantoprazole na clopidogrel
iji belata ihe ize ndụ nke concurrent obi na hemorrhagic
nsogbu. Alternatively mba nwere ike H2 ihe nnabata blockers - famotidine, ranitidine.

eme ọgwụ
ọgwụ

Beta-blockers e kenyere na mbụ 24 awa site n'oge niile ọrịa na ACS
na-anọghị nke obi odida na ala mmepụta syndrome,
cardiogenic ujo na ọkọlọtọ contraindications na eji nke a ìgwè nke ọgwụ ọjọọ.
Admission beta blockers iso ofụri oge nke ụlọ ọgwụ na mgbe
okwu.
Ace inhibitors na-ahọpụta
All ọrịa na ihu myocardial infarction, ejection nta erughị 40% na-anọghị nke
contraindications. Ọ bụrụ na e nwere contraindications maka Ace inhibitors na-eji blockers
angiotensin II ihe nnabata. akụ ọkpọ
aldosterone gosiri na ọrịa na symptomatic obi ọdịda
na / ma ọ bụ ọnụnọ nke-arịa ọrịa shuga. Ruo ogologo oge iji niile statins gosiri
ọrịa na ACS (dịghị contraindications).