Taladadii - syndrome ba'an coronary

IV Samorodskaya,

Professor, Doctor of Medical Science

coronary ba'an
syndrome

kooxda xirfadaha kala go'aansado

Isticmaalka hababka casriga ah ee daaweynta ba'an syndrome coronary (taladadii)
- muddo midani koox kasta oo ka mid ah Calaamooyinkiisa clinical ama calaamadaha
jidaynayey looga shakisan yahay ba'an Wadnaxanuun myocardial (MI) ama aan degganayn
angina, siinaysaa rajo hoos u weyn ee isbitaalka
dhimashada iyo in la wanaajiyo saadaasha in muddo muddada dheer.

Dhowr sano ka hor, cilmi baarista iyo kuwa caalamiga ah-rogga yihiin
koobaya Sayniska All-Ruush ah Society of Wadnaha ee talooyinka Ruush on cudurka
iyo daaweynta bukaannada qaba Wadnaxanuun myocardial la quruxsan ST-qeybta (2007), oo aan u qaadis ST iyo angina deganayn (2006). In 2010, daabacday talo Yurub
Society of Wadnaha (ESC) on doorashada ee hababka revascularization myocardial, xeerarka qaranka ee maamulka bukaanka qaba taladadii ee Australia
Britain, natiijooyinka caalamiga ah
heshiis ku saabsan maaraynta bukaannada qaba taladadii. In 2013
Heart American
Society (ACCF / Ahaa) ayaa updated
talooyinka maamulka bukaanka qaba taladadii
ST quruxsan gabal.  

Go'aanka ku saabsan xeeladaha
maamulka bukaanka ee taladadii sida u qaadis ah si aan u qaadis ST-qeybta ma aha had iyo jeer si gaar ah u fudud, inta badan waxay u baahan tahay ka qaybgalka kala duwan
kooxda takhasuska ku salaysan tilmaamo caafimaad, dabcan cudurka, da'da bukaanka, xaaladaha
daryeelo. Isla mar ahaantaana in dhammaan bukaanada la tuhunsan yahay taladadii
waa inay u qabtaan baaritaanka wadnaha ah (in maqnaanshaha
isbeddel ama xogta ayaa su'aal ka ubaahantahay in noqnoqda duubo dura 15
-30 daqiiqo, ku xiran xaaladda caafimaad ee bukaanka), iyo heerarka macquulka ah ee waxbarasho
waayo, falgalka cudurada wadnaha, isticmaalka khasab ah ee aspirin waxaa loo arkaa. in
talooyinka oo dhan waxaa ka jeeclaadeen farsamooyinka endovascular
revascularization myocardial in joogitaanka ah shaqaalaha khibrad u qalma.
therapy Fibrinolytic (sida tallaabo koowaad ee bixinta daryeelka bukaanka la taladadii la quruxsan ST-gabal) ayaa weli la xiriira xaaladaha kuwa,
marka ay tahay wax aan macquul aheyn si ay u qabtaan stenting
120 daqiiqo ka dib
dhacdo xanuun (ay ka maqan yihiin sababo iyo haddii tan iyo xanuun ahayd in aan ka badnayn
12 saacadood). Marka taladadii iyadoon laga qaadin qeybta ST fibrinolytic
therapy aan la maamulo.

Haddii halista ah ee wadno iyo / ama ay
dhibaatooyin sare

ka qaybgalayaasha
abuurista talo xirfadeed oo ku yaalla Europe, United States ayaa aaminsan in hirgelinta
ANGIOGRAFI 2 saacadood gudahood laga bilaabo waqtiga la gelitaanka
waxaa lagu talinayaa haddii bukaanka qaba weerar of angina ku saabsan asalka caafimaadka
daaweynta ay calaamaduhu sii socdaan ama soo noqnoqon
angina arkay qeybta firfircoon isbedel ST, muujinaya horumarka dhaawac
ama Wadnaxanuun myocardial; hemodynamic
xasilooni darro, garaaca ventricular weyn. Bandhigyada ANGIOGRAFI (la xiga
revascularization) 24 saacadood ka dib markii gelitaanka bukaanka isbitaalka la taladadii waxaa lagu talinayaa in ay dhacdo sare
khatarta of Wadnaxanuun myocardial, naf-gooyada ah
dhibaatooyin iyo dhimasho. waqtiga la mid ah ANGIOGRAFI waxaa lagu talinayaa in
Xaggee loo baahan yahay ogaanshaha kala duwan ee taladadii kale
xaaladaha degdegga ah (lungemboli, dissecting
aneurysm aortic). Xaaladaha of ba'an syndrome coronary aan qeybta ST wiish halis yar ee naf-gooyada ah
dhibaatooyinka iyo dhimashada inta isbitaalka
daaweynta, laakiin joogto ah calaamadaha angina iyo / ama ischemia laaluusheen
inta lagu jiro baaritaanka load ah, ANGIOGRAFI raacay by revascularization at
lagama maarmaan ah oo ay suuragal tahay waxaa lagu talinayaa si ay u fuliyaan in muddo ah la siiyo
isbitaal 72 saacadood ka dib markii gelitaanka gudahood. In ka
haddii bukaanka loo oggolaaday in ay xarun caafimaad, halkaas oo waa wax aan macquul aheyn
oofin ANGIOGRAFI a wadnaha, waxaa loo wareejiyay isbitaalka ugu haboon ee (tus
Regional Vascular Center).

caadi
loo arkaa stenting xeelad (stent-dahaarka leh daroogada
ama Qaxwo) la tromboekstratsiey la xiriira infarct halbowlaha ah (at
loo baahdo), halka taladadii wiish c
ST qeybta
iyadoo aan loo eegin fulinta iyo saamayn ah therapy fibrinolytic (sida
Talooyinka ka ACC 2013 ka dib markii therapy fibrinolytic waxaa lagu talinayaa in ay sameeyaan
FCT iyo stenting ma aha sidii hore ka badan
2-3 saacadood). Haddii quruxsan c-qeybta coronary syndrome ba'an ST, halbowlaha infarct marka laga reebo, waxaa jira halis ah
stenoses ee halbowlayaasha kale, stenting degdeg ah ay la sameeyaa oo keliya
kuwa la wadnaha daran iyo / ama lama filaan ah cardiogenic. In kale
Xaaladaha stenting dib u la sameeyaa - baahida loo qabo iyo wakhtiyada
go'aansaday ka dib stress imtixaamaa ka hor dheecaan bukaanka ka
isbitaalka. Sida laga soo xigtay talooyinka khubarada ah ee Maraykanka ee 2013, iyada oo aan stents
daahan waxaa la doorbidayo isticmaalo xaaladaha halkaas oo bukaan-socodka uu leeyahay
cudurada iyo xaaladaha halista sare ah dhiig, jaaniska sare,
in bukaanka uusan u hoggaansamaan sano ah ee mudada antiplatelet dual gudahood
therapy, iyo waxay u badan tahay in ay sameeyaan qalliin ku xiga
hawlgallada. Intaas waxaa sii dheer, talooyin ku tilmaamay in sare u qaadis c-qeybta taladadii ST stenting 24 saacadood ka dib markii laga soo bilaabo xilliga ay
Horumarinta aan muujiyay xaaladaha 1-2 lesions vascular ay ka maqan yihiin
calaamadaha ilaalinta ee ischemia myocardial. Marar dhif ah (ka yar qaarkood
Xaaladaha) oo la sameeyo angioplasty.

Go'aanka ku saabsan habka ay u revascularization in bukaanka qaba ba'an syndrome coronary aan qeybta ST u kaca, iyo in taladadii c ST quruxsan qeybta, laakiin ay ka maqan yihiin
cidhiidhi degaanka wadnaha ee halbowleyaasha wadnaha, hubaal "eed" ee
Taladadii ama cudurka multivessel, kaas oo fulinta
Stenting waa farsamo ahaan wax aan macquul aheyn ama halis ka badan awoodda
lacagta la helay by khubaro badan (qalliinka wadnaha,
wadnaha, ku takhasusay berrinka ku dhex yaal of
cudurka Endovascular iyo daaweynta) la
clinical, qiimaynta xogta angiographic reserve socodka jajab,
ee saadaasha mudada dheer la filayay.

taageero daawo
daruuri

Marka taladadii la ST quruxsan qeybta khubaro badan waxay aaminsan yihiin in xeeladaha hadda bukaannada ku jira
Waxay ku xiran tahay inta badan oo ku saabsan nidaamka caafimaadka ee dalka
(Gobolka) si ay u qabtaan faragelinta endovascular aasaasiga ah (oo aan ka hor
thrombolysis) 2 saacadood on horumarinta astaamaha caafimaad oo bukaan ah.

Haddii la filayo in wakhti ka soo xiriir hore bukaanka
shaqaalaha caafimaadka ka hor inta aan fulineynin ANGIOGRAFI noqon doono in ka badan 2
saacadood, bukaanka
(Maqnaanshaha sababo) waa inay u qabtaan thrombolysis la
dhalmada xiga xarunta hawl ANGIOGRAFI iyo revascularisation
Wadnaxanuun 3-24 saacadood gudahood. Xaaladaha kuwa, haddii asalka ah ee thrombolysis
ST quruxsan qeybta la hadhay in ka badan 50% heerka bilowga ah iyo / ama retrosternal
xanuun, bukaanka muujinaysaa ANGIOGRAFI degdegga ah. Haddii guul,
thrombolysis ANGIOGRAFI iyo revascularization coronary (haddii lagu tilmaamay) waxaa laga yaabaa
in la sameeyo 24 saacadood gudahood. Talooyinkaas waxay sheegtay in
revascularization hagaajin kartaa saadaal iyo fulinta iyada oo 24-60
saacadood ka dib bilawga calaamadaha clinical, laakiin kaliya marka ay
Waxaa jira angina soo noqnoqda iyo / ama ischemia myocardial la ogaado inta lagu jiro
waxbarashada qalabka.

out
Iyada oo ku xidhan nooca taladadii iyo habka revascularization waa ku khasab
taageero daroogada, oo ay ku jiraan antiplatelet,
therapy antiplatelet, therapy beta-blockers, inhibitors ee angiotensin diinta
enzyme, statins. therapy daroogada waxaa si gaar ah u Hagaajinay
Iyada oo ku xidhan qaab reer darnaanta taladadii, cudurada soputsvuyuschie joogaan. The
Daabacaadan waxaa diiradda lagu saari doonaa oo kaliya on therapy antiplatelet,
hababka la socda ee revascularization myocardial.

quruxsan qeybta taladadii aan S T

The
Xaaladaha noocaas ah hababka revascularization endovascular
magacaabay "therapy double 'a antiplatelet oo ay ku jiraan afka
acetylsalicylic acid (ASA) iyo clopidogrel (ama prasugrel ama
ticagrelor). ASA waxa lagu qoray in marka hore la helo 150-300 mg (250-500 mg ama qaab
ee / in bolusdose) raacay by qiyaasta ah qiyaas loading 75-100 mg / maalintiiba
600 mg ah clopidogrel (sida ugu dhaqsaha badan) ku xiga maamulka of 75
mg / maalintiiba for 9-12 bilood prasugrel - dose loading 60 mg, raaceen by
qaadashada 10 mg / maalintiiba, ama ticagrelor - 180 dose loading mg, raaceen by
qaadashada 90 mg 2 jeer maalintii. Tilmaamayaasha loo isticmaalo dheeraad ah
inhibitors GPIIb-IIIa waxaa loo arkaa in ay halis sare thrombosis intracoronary in bukaan qaliin lagu qalo iyo / ama stenting
halbowleyaasha wadnaha.

The
talooyinka NICE (UK) baaqaday in
Bukaan-socodka oo halis weyn ku ah dhacdooyinka wadnaha (saadaaliyey 6 bil
dhimashada ka badan 3%) oo sakhiray in ANGIOGRAFI iyo revascularization
96 saacadood laga bilaabo wakhtiga gudahood joogtada gelitaanka muujiyay
ballan of eptifibatide ama tirofiban. Abciximab sida therapy la magacaabay,
revascularization endovascular socda haddii aan la helin
Kartida inuu ku meeleeyo inhibitors kale ee GPIIb-IIIa. Waa in la ogaadaa in
Si ka duwan hanuun NICE talooyinka (UK)
European Society of Wadnaha "doorashada" waxaa la siiyaa abciximab (Grade
Waxaan tilmaamo), waqti isku mid ah loogu talagalay eptifibatide
ama tirofiban Calan Class IIa.

Doorashada iyo dose
Daawada xinjirowga si ay u qabtaan ANGIOGRAFI
revascularization in bukaanka aan taladadii
kor u qeybta ST eegayo
Stratification ee halista dhibaatooyin thrombotic, ischaemic iyo dhiigbaxa. Halis aad u sarreeya
dhacdooyinka ischaemic (tusaale ahaan, marka xasilooni hemodynamic naf-gooyada ah garaaca madax adkaadeen) bukaanka
si toos ah gaarsiisay X-ray iyo waxaa loo xilsaaray
heparin unfractionated (UFH) sida / in bolusdose ah 60 U / kg la xiga
faleebo lagu jiro revascularization ee lala double a
therapy antiplatelet. At khatarta sare ee dhiig ayaa loo isticmaali karaa
monotherapy bolusdose bivalirudin of 0.75 mg / kg raacay by galiyey of 1.75
mg / kg / hr. Bukaanka (tusaale ahaan halista celcelis ahaan dhacdooyinka ischaemic,
hemodynamics xasiloon, laakiin baaritaan troponin wanaagsan, relapsed
angina, isbedel firfircoon ee qeybta ST ah), kaas oo la qorsheeyay ee habraaca invasive 24-48
saacadaha soo socda fursadaha daaweynta ka hor ka jira in ANGIOGRAFI
qorsheeyay revascularization myocardial endovascular:

• Bukaanka <75 sano

heparin Unfractionated 60 U / kg ee foomka of on / in bolusdose,
markaas galiyey gacanta waqti thromboplastin qayb ka shaqeysiin
(APTT) ama enoxaparin 1 mg / kg s.c. x 2 maalin kasta ama Fondaparinux 2.5 mg / maalintiiba
Bivalirudin subcutant ama 0.1 mg / kg sida / in bolusdose ah soo raacay by galiyey
0,25 mg / kg / saacaddiiba

• Muddo sanado ah bukaanada ≥75

heparin Unfractionated 60 U / kg ee foomka of on / in bolusdose,
markaas galiyey gacanta APTT

Ama enoxaparin 0.75 mg / kg x 2
maalin Fondaparinux ama 2.5 mg / subcutant maalin ama Bivalirudin 0.1 mg / kg sida a
Waxaan / bolusdose raacay by galiyey of 0.25 mg / kg / hr.

In
bukaan halis yar dhacdooyinka wadnaha (iyada oo aan sii kordhaya
troponin iyo ST isbedel qeybta), more muxaafidka qorsheeyay
daaweynta iyo fondaparinux xilsaaray (2.5 mg / maalintiiba subcutant) ama enoxaparin (1
mg / kg s.c., 2 jeer maalintii in bukaanka ≥75 sano - 0.75 mg) iyo heparin unfractionated (60 U / kg
sida in / bolusdose, raaceen by galiyey hoos aPTT control).

Taladadii la ST quruxsan qeybta  

In this
xaaladda caafimaad oo lagu qoro therapy a antiplatelet ACK "double" (150-300 mg oo afka ah ama
250-500 mg sida / in bolusdose ka soo daba socday maamulka of 75-100 mg / maalintiiba) iyo prasugrel
(60 mg dose loading raaceen maamulka of 10 mg / maalintiiba), ama dose ticagrelor (loading of 180 mg
ku xiga maamulka of 90 mg 2 jeer maalintii) ama clopidogrel (loading dose 600
ku xiga maamulka
75 mg / maalintiiba). The Talooyin of Society Yurub ee Wadnaha ayaa sheegay in
prasugrel iyo clopidogrel ticagrelor wax ku ool ah marka la eego yaraynta
inta jeer ee la isku daray maxsuulka dambe ischaemic iyo thrombosis stent in bukaanka
MI quruxsan ST, iyo waxa aanu u kordhin khatarta ah
dhiig aad u daran. Sida laga soo xigtay talooyinka dameerka 2013 ma aha prasugrel
Waxaa lagu talinayaa in bukaanka qaba
taariikh stroke ama TIA. Haddii ay dhacdo in ka hor galay
hay'adda caafimaadka si ay u qabtaan ANGIOGRAFI iyo bukaanka stenting
fibrinolysis waxaa lagu sameeyaa oo ay ahayd in ka yar 24 saacadood oo muddo la mid ah aan la isticmaali
clopidogrel (prasugrel), ka dibna qiyaas loading clopidogrel waa 300 mg,
Prasugrel waa 60 mg ah.

At halis sare
thrombosis intracoronary, oo ay la socdaan daaweynta antiplatelet dual
Waxay ku talinaysaa isticmaalka inhibitors GPIIb-IIIa (abciximab / bolusdose v ah 0,25 mg / kg raacay by galiyey of 0,125 mg / kg / min inay
heerka ugu sareeya ee 10 mg / min 12 saacadood.). Waqtigan xaadirka ah ma laha waa
caddaymo oolnimada weyn GPIIb-IIIa inhibitors marka loo isticmaalo in
prehospital ama ka hor sanka.

sida a
therapy daawada xinjirowga lidka UFH waxaa loo isticmaalaa (ee / in bolusdose 60 U / kg isku dhafan oo inhibitor a GPIIb-IIIa ama / bolusdose 100 U / kg oo aan
GPIIb-IIIa) inhibitor. Bivalirudin sida monotherapy halkii UFH isku dhafan oo inhibitor ah GPIIb-IIIa sida ay ku taliyeen ACC 2013
Waxaa lagu talinayaa in bukaanka qaba khatarta sare ee dhiig-bax weyn oo (bolusdose of 0.75 mg / kg raacay by galiyey of 1.75
mg / kg / saac); Isla mar ahaantaana, fondaparinux laguma talinayo sababtoo ah khatarta sare
thrombosis kateetarka.

Sida lagu sheegay war ka soo socota ka
isbitaalka therapy antiplatelet dual waxaa loo isticmaalaa ugu yaraan 12 bilood.

fiiro gaar ah in la bixiyo, in isku darka ee
clopidogrel iyo bamka proton inhibitors, caadi ahaan loo isticmaalo ka hortagga
dhiigbaxa caloosha iyo mindhicirka. Sida laga soo xigtay aragtida guud ee kooxda wadashaqayn ee ka hortagga thrombotic
iyo dhibaatooyinka dhiigbaxa ICSI isku daro isticmaalka daroogada bukaanka
halis yar oo dhiigbax ah GI aan la muujiyay, isticmaalkooda waafaqsan waa in shakhsi ahaan ku saleysan
iyada oo la tixgelinayo faa'iidooyinka iyo halista. oo keliya
PPI daawo ka tirsan - pantoprazole - ma ah "tartan" klopidoglelya
waayo, CYP2C19 isoenzyme. Dhinaca kale
ma tijaabo oo tayo sare leh qiimaynta saamaynta wadajirka ah
codsanaya pantoprazole iyo clopidogrel
si loo yareeyo khatarta ka mid ah wadnaha oo raacsan iyo dhiigbaxa
dhibaatooyinka. Haddii kale PPI H2 laga yaabaa blockers receptor - famotidine, ranitidine.

daawo joogtada ah
therapy

Beta-blockers loo qoondeeyay in 24 saacadood ee ugu horeeya laga bilaabo wakhtiga oo dhan bukaanka qaba taladadii
in maqnaanshaha wadnaha la soo saarka hooseeyo syndrome,
lama filaan ah cardiogenic iyo sababo heerka isticmaalka kooxdan oo ah daroogada.
blockers beta Admission sii mudada isbitaal iyo ka dib
statements.
celiyeyaasha ACE ayaa la magacaabay
Dhammaan bukaanada qaba Wadnaxanuun myocardial jilibka, jajab ejection ka yar 40% ay ka maqan yihiin
sababo. Haddii ay jiraan sababo waayo, celiyeyaasha ACE waxaa loo isticmaalaa blockers
angiotensin II receptor. Doodeen
aldosterone tilmaamay in bukaanka qaba calaamadaha wadnaha
iyo / ama joogitaanka diabetes. isticmaalka daba dheeraaday oo dhan statins muujiyay
bukaanka qaba taladadii (sababo lahayn).