miokardiumis infarqti st elevaciit stemi · 2010-12-14 · rc = marjvena koronari rbbb = hisis...

miokardiumis infarqti ST elevaciiT STEMI

protokolebi

momzadebulia saqarTvelos kardiologTa kolejis da

saqarTvelos kardiologTa sazogadoebis 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

PE = pulmonaruli embolia

2

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

I. gaidlainSi gamoyenebuli rekomendaciebis da mtkicebulebebis xarisxi..........5 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..................................................................................................................................5 II. mwvave miokardiumis infarqtis definicia .......................................................................5 III. mwvave koronaruli sindromis ganmarteba da klinikuri mimdinareoba: ..........6 IV STEMI-s ganviTarebamde mkurnaloba ................................................................................7

a. rekomendaciebi STEMI-s risk faqtorebis mqone pacientebis gamovlenisTvis...............................................................................................................................7 b. rekomendaciebi STEMI-s niSnebis naadrevi gamovlenisa da CarevisaTvis,

pacientebis ganaTleba: ...............................................................................................................8 V STEMI-s Setevis dawyeba da prehospitaluri qmedeba .................................................9

a. STEMI-T pacientebis transportireba da pirveladi reperfuziuli

mkurnalobis SerCeva ...................................................................................................................9 VI. pirveladi amocnoba da marTva gadaudebeli daxmarebis departamentSi....12

a. sqema. 3 gadaudebeli daxmarebis algoriTmi/protokoli pacientSi

STEMI–s simptomebiT an niSnebiT ........................................................................................12 b. cxrili 3. STEMI-is diferencialuri diagnostika ..............................................13 g. STEMI-s diagnoziT miRebul pacientSi rutinuli testebi...............................13 d. reperfuziis meTodis aucileblobis da SesaZleblobis gansazRvra

pacientebSi STEMI-T..................................................................................................................16 e. reperfuziis saxis SerCeva pacientebSi STEMI-T ....................................................17 v. fibrinolizis Cvenebebi: ......................................................................................................18 z. STEMI-s dros fibrinolizis ukuCveneba da safrTxeebi ....................................19 T. diagnostikuri koronaruli angiografia .................................................................19

3

i. pirveladi PCI-s rekomendaciebi......................................................................................20 VI hospitaluri mkurnaloba .....................................................................................................21

a. miRebis wesi pacientisTvis STEMI-T:.............................................................................21 b. sqema 4. garTulebuli STEMI. gadaudebeli mdgomareobebis marTvis

protokoli.....................................................................................................................................23 g. cxrili 9. parkuWTa Soris Zgidis rubtura, Tavisufali kedlis

rubtura, papilaruli kunTis rubtura ...........................................................................24 e. ST elevaciiT mimdinare miokardimis infarqtis ( STEMI) stacionaridan gaweris Semdgomi antiTrombozuli mkurnaloba .........................................................27 v. cxrili 10 meoradi prevencia STEMI-s dros: ............................................................28

VII gaweris Semdgomi vizitebis rekomendacia:..................................................................30 VIII gamoyenebuli masala:............................................................................................................36

4

I. 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


II-B klasi:

sargebloba ≥ riskze saWiroebs damatebiT

gamokvlevebs.


SesaZlebelia gvqondes

mxedvelobaSi

III klasi: damatebiTi

gamokvlevebi aRaraa

saWiro.


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


monacemebi ufro metia

mravali

randomizebuli

kvlevis da meta-

analizisagan

rekomendacia rom


araa

sakmarisi monacemebia

mravali

randomizebuli da

metaanalizisagan

B-done: SezRuduali

(2-3) populaciuri

jgufebia

Safasebuli

rekomendacia imis



SezRuduli

monacemebia miRebulia

erTi randomizebuli

da

ararandomizirebuli

kvlevebisagan

rekomendacia


Catareba/dniSvnis

sasargeblodaa.

aris zogierTi


monacemi erTi

randomizirebuli da

ararandomizebuli

kvlevebisagan

rekomendaciis


nakleb kargadaa

Seswavlili

ufro meti


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



arsebobs mxolod

eqspertebis azri,

SemTxvevaTa

aRwera(case report)

rekomendacia


Catareba/dniSvnis

sasargeblodaa

eyrdnoba eqspertebis

azrs da SemTxvevaTa

aRweras

rekomendaciis


nakleb kargadaa

Seswavlili

eyrdnoba eqspertebis

azrs da SemTxvevaTa

aRweras

sasargeblo/efeqturi

da SesaZloa iyos

saziano.

arsebobs mxolod

eqspertebis azri,

SemTxvevaTa

aRwera(case report)

II. mwvave miokardiumis infarqtis definicia

amerikis kardiologTa koleji da evropis kariologTa asociaciis

gaerTianebuli komiteti mwvave miokardiumis infarqts (acute, evolving or recent MI)

5

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).

III. mwvave koronaruli sindromis ganmarteba da klinikuri

mimdinareoba:

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.)

mwvave koronaruli sindromi ACS

ST elevaciiT ST elevaciis gareSe

ara Q kbilovani miokardiumis

infarqti Q kbilovani

miokardiumis infarqti

arastabiluri

stenokardia UA

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

6

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.

IV 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.

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

7

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.

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.

8

V 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 pacientebi hospitalSi transportirdebian saswrafo daxmarebis brigadis

mier

reperfuzia STEMI-an pacientebSi SesaZloa ganxorcielebul iqnas farmakologiurad

(fibrinoliziT ) an kaTeterizaciiT (PCI). arCeviToba am strategiebs Soris emyareba

pacientebis transportirebis saxes da mimRebi klinikis SesaZleblobebs.

transportirebis dro cvalebadia yvela SemTxvevaSi, magram iSemiis dro

SenarCunebuli unda iyos 120 wT-s farglebSi. arsebobs 3 SesaZlebloba: 1. Tu

saswrafo daxmarebis brigadas aqvs fibrinolizis SesaZlebloba da pacients ar

aReniSneba ukuCveneba, prehospitaluri fibrinolizi dawyebul unda iqnes saswrafo

daxmarebis brigadis misvlidan 30 wT-Si. (klasi I LOE: B). 2. Tu saswrafo daxmarebas

ara aqvs fibrinolizis saSualeba da pacienti transportirdeba klinikaSi, sadac ar

aris PCI-s saSualeba, pacients klinikaSi Sesvlidan 30 wT-Si unda daewyos

fibrinolizi (karidan-nemsamde dro 30 wT klasi I LOE: B). 3. Tu saswrafo daxmarebis

brigadas ara aqvs fibrinolizis saSualeba da pacienti transportirdeba klinikaSi,

romelsac aqvs kaTeterizaciis PCI saSualeba, pacients klinikaSi Sesvlidan 90 wT-

Si unda Cautardes PCI. (karidan-balonamde dro 90 wT(klasi I LOE: B). (an 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 PCI - SesaZlebelia ix. sqema 2B

SeiZleba ganvixiloT

inter hospitaluri

gadayvana

drois grafiki

s.d.b-s

gamgzavreba

1-wT-Si

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.

oqros dro = 60 wT-s mTlianobaSi iSemiis dro ≤ 120 wT-is

mimReb klinikaSi

PCI - SeuZlebelia ix. sqema 2BSTEMI-s

simptomebis

dawyeba

saswrafos

gamoZaxeba

da

gamogzavna

s.d.b.:

• iRebs 12 ganxrian e.k.g-s

• Tuki SesaZloa (igulisxmeba

kvalifikacia da teqnikuri

aRWurviloba) mosvlidan

30 wT-Si Trombolizisi

gegma

s.d.b-Si

darekva

simpt.

dwyebid.

5 wT-Si

9

10

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

sqema 2 B .

11

paneli B pacientebisTvis, visac Cautarda fibrinolizi, riskis stratifikaciisTvis

rekomendirebulia arainvaziuri Sefaseba gadamrCeni an iSemiiT ganpirobebuli PCI –s saWiroebis dasadgenad. reperfuziuli Terapiis meTodis miuxedavad yvela pacientma unda

gaiaros STEMI-s meoradi prevencia. damateba: unda aRiniSnos rom STEMI-s dros prehospitalur etapze rekomendirebulia

pacientis gadayvanamde 162-325 mg aspirinis micema Lklasi I LOE: C

damateba: zogadad SeiZleba iTqvas rom cudi prognozis prediqtorebi STEMI-s dros arian asaki, gulis SekumSvaTa sixSire, arteriuli wneva, filtvebis SeSupeba da S3 toni .

cxrili 1. STEMI-s dros maRali riskis prediqtorebi ( TIMI kvleva STEMI-s riskis gansazRvrisaTvis ) damoukidebeli 30 dRiani sikvdilianobis risk faqtorebi

riskis

qulebi

jamuri

qula

saSualo

maCvenebeli

30 dRiani

sikvdiliano

bis %

min da maqs

maCvenebeli

asaki ≥ 75

3

0

0,1

0,1—0,2

asaki 65-75

2

1

0,3

0,2—0,30

diabeti

1

2

0,4

0,3—0,5

hipertenzia anamnezSi

1

3

0,7

0,6—0,9

angina anamnezSi

1

4

1,2

1,0—1,5

sistoluri wneva < 100

3

5

2,2

1,9—2,6

gulis SekumSvaTa sixSire

> 100

2

6

3,0

2,5—3,6

gulis ukmar. kilipi II--IV

2

7

4,8

3,8—6,1

wona < 67 kg

1

8

5,8

4,2—7,8

wina kedeli an LBBB

1

> 8

8,8

6,3--12

dro reperfuziamde > 4-sT

1

pirveladi PCI

riskis

arainvaziuri

Sefaseba

PCI an CABG

gadamrCeni an

iSemiis

niSnebisda

mixedviT

intrahospitaluri

mkurnaloba da

meoradi prevencia

mimRebi hospitali

sadac PCI SesaZlebelia

mimRebi hospitali

sadac PCI araa SesaZlebeli

fibrinolizisi

VI. 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 ††

gaurkvevlo

konsultant

† - ar miceT

naklebi, anN

parkuWis inf

†† - Tumca z

aspirins, uf

daReWvisas

††† - oralu

klasi. LOE ATu aris taq

pacients aReniSn

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)

bis SemTxveva

i

Tuki sisto

Tuki P > 10arqtze

ogierTi xma

ro swrafi S

ri B-blokere

) IV B-blok

ikardia da h

eba

ara

ix. suraTi ACC/AHA UA/NSTEMI pacientebis marTvis gaidlaini

12

Si gamoiZaxeT

luri wneva < 90 mmhg an bazalurze 30-iT

0 an < 50 an Tuki eWvi gvaqvs marjvena

robs nawlavuri garsiT dafarul

edegia garsis gareSe aspirinis

bi pacientebSi ukuCvenebis gareSe ( I

erebi Tuki araa ukuCveneba gansakuTrebiT

ipertenzia. ( IIa klasi LOE: B).

cxrili 2 swrafi fizikuri gasinjva gadaudebel departamentSi

1. sasunTqi gzebi, sunTqva, cirkulacia (ABC) 2. sasicocxlo niSnebi, zogadi meTvalyureoba

3. sauRle (iugularuli) venebis daWimulobis arseboba/ararseboba

4. auskultacia filtvebSi Segubebis niSnebis gamosavlenad

5. gulis auskultacia (Suili gulze an galopis riTmi)

6. T/t sisxlis mimoqcevis moSlis arseboba an ararseboba

7. pulsaciis arseboba an ararseboba

8. sistemuri hipoperfuziis arseboba an ararseboba (kanis sicive, sifermkrTale, webovaneba, aWreleba)

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 ganviTarebuli LBBB, gamoxatuli ST depresia V1—V4 ganxrebSi rasac axlavs maRali R marjvena prekordial ganxrebSi da pozitiuri T kbilebi, rac aris maCvenebeli WeSmariti posterior MI-s ( miuTiTebs rom procesSi Semomxvevi

totia CarTuli)

b. cxrili 3. STEMI-is diferencialuri diagnostika

sicocxlisaTvis saSiSi

aortis diseqcia

pulmonaruli embolia

perforirebuli wyluli

daWimuli pnevmoToraqsi

ezofagealuri rubtura

mediastinitiT ( boerhavas ( borhaava) sindromi

sxva

kardiovaskularuli da

ara iSemiuri

perikarditi

atipiuri angina

adreuli repolarizacia

WPW sindromi

Rrmad invertirebuli T kbilebi

rogorc centraluri nervuli

sistemis dazianebis an

hipertrofiuli kardiomiopaTiis

asaxva

marcxena parkuWis hipertrofia

brugdas sindromi

miokarditi

hiperkaliemia

hisis konis totebis blokada

vazospastikuri angina

hipertrofiuli kardiomiopaTia

sxva arakardialuri

gastroezofagaluri refluqsi

(CERD) da spazmi

gulmkerdis kedlis tkivili

plevraluri tkivili

peptiuri wyluli

panikuri SiSi

biliaruli an pankreatuli

wyluli

xerxemlis malebi diski an

nevralgia

somaturi an fsiqogenuri tkivili

g. STEMI-s diagnoziT miRebul pacientSi rutinuli testebi

1. Sratis biomarkerebi gulis dazianebis Sesafaseblad :

kardiospecifiuri troponinebi ( ar daucado reperfuziul

strategiis Sedegebs) klasi I LOE: C 13

14

damateba : troponini upiratesi markeria miokardiumis infarqtis diagnostirebisas. CK-MB-s gazomvisas SeiZleba 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-

3 dReSi. iq sadac ver keTdeba troponini SeiZleba visargebloT CK-MB-iT.

2. sisxlis saerTo analizi (CBC); klasi I LOE: C 3. INR; klasi I LOE: C 4. aPTT klasi I LOE: C 5. eleqtrolitebi da magniumi; klasi I LOE: C 6. BUN; klasi I LOE: C 7. kreatinini; klasi I LOE: C 8. glukoza; klasi I LOE: C 9. Sratis lipidebi; klasi I LOE: C ( es ukanaskneli ar aris aucilebeli gakeTdes dauyovnebliv da

davelodoT mis pasuxs, mkurnaloba iwyeba statiniT da stacionarSi

yofnis periodSi keTdeba analizi. damateba samuSao jgufis mier)

10. gulmkerdis rentgenografia: portatuli aparatiT adgilze, unda

gvaxsovdes rom aman ar unda daayovnos reperfuziuli Terapia(Tuki

ar aris eWvi iseT potenciur garTulebaze rogoricaa aortis

diseqcia). klasi I LOE: C 11. gulmkerdis rentgenografia(portatuli aparatiT), transTorakaluri

da/an

transTorakaluri eqokardioskopia, sCT an MRI aortis diseqciis sadiferenciaciod STEMI-sagan. klasi I LOE: B 12. eqokardiografia SREMI-s diagnozis dasazusteblad da riskis

Sesafaseblad

pacientebSi vinc moxvdeba gadaudebeli daxmarebis departamentSi

aRniSnuli

diagnoziT, gansakuTrebiT maSin roca saqme gvaqvs LBBB-sTan an

parkuWovan

kardiostimulaciasTan, an eWvia ukana kedlis (posterior) STEMI-ze romelic

mimdinareobs wina ganxrebSi ST segmentis depresiiT klasi II-A LOE: B

gamosaxuleba 3. gulis biomarkerebi STEMI-s dros. mowodebulia AHA/ACC STEMI-s gaidlainis sruli 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 MI-s Semdgom

Eelevaciis saSualo

piki MI-s Semdgom sabaziso monacemebTan dabrunebis

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 ++

15

d. reperfuziis meTodis aucileblobis da SesaZleblobis

gansazRvra pacientebSi STEMI-T

cxrili 4

I safexuri: Aaris Tu ara 15 wT-ze meti da 12 sT-ze naklebi xangrZlivobis tkivili an diskomforti gulmkerdis

areSi ?

diax SeCerdi ara

II safexuri: aRiniSneba Tu ara fibrinolizis ukuCveneba7

Tu romelime qvemoTCamoTvlilze aRiniSneba pasuxi diax fibrinolizi SeiZleba iyos ukunaCvenebi

16

sistoluri a.w. 180 mm Hg-ze metia diax ara

diastoluri a.w. 110 mm Hg-ze metia diax ara

sxvaoba sistoluri wnvebis marcxena da marjvena xelze 15 mm Hg-ze meti diax ara

struqturuli cns daavadeba anamnezSi diax ara

bolo 3 Tvis manZilze Tavis qalas/saxis daxuruli trvma diax ara

axali (bolo 6 kviris ) didi travma, qirurgiuli Careva (maT Soris Tvalis lazeruli

operacia Tvalze) GI/GU sisxldena

diax ara

sisxldenis an Trombis warmoqmnis problemebi an sisxlis gaTxeleba diax ara

kardiopulmonaluri resuscitacia ( CPR) 10 wT-ze metia diax ara

orsuloba diax ara

seriozuli organuli daavadebebi(Sorswasuli simsivne an terminaluri stadia, RviZli da

Tirkmlis mZime daavadebebi )

diax ara

III safexuri

aReniSneba Tu ara pacients gamoxatuli gulis ukmarisoba an kardiogenuri Soki, iseTi

rom PCI iyos upiratesi TrombolizisTan SedarebiT ?

filtvebis Segubeba (Sua wilebze zemoT) diax ara

sistemuri hipoperfuzia diax ara

e. reperfuziis saxis SerCeva pacientebSi STEMI-T

cxrili .5

I safexuri: drois da riskis Sefaseba:

dro simptomebis dawyebidan

STEMI.-s riski fibrinolizis riski

dro, romelic saWiroa PCI-iT uzrunvelyofil laboratoriaSi gadasayvanad.

II safexuri: fibrinolizis Tu invaziuri strategia? upiratesobis gansazRvra?

Tu pacientis Semosvlis dro 3 sT-ze naklebia da invaziuri strategiis dro

SesaZloa iyos gaidlainiT gansazRvrul farglebSi arc erTi strategias

upiratesoba ar aqvs.

fibrinolizi upiratesia Tuki:

P

invaziuri strategia upiratesia Tuki:

stacionarSi adreuli moxvedrisas (

≤ 3-sT-ze simptomebis dawyebidan da

im SemTxvevaSi Tuki invaziuri

strategia gviandeba) ( ix. qvemoT)

PCI laboratoria Seesabameba standarts

† da aqvs qirurgiuli uzrunvelyofa

• karebidan balonamde dro < 90 wT

• karebidan balonamde dros

gamoklebuli karebidan nemsamde (

igulisxmeba Trombolizisis dawyebis

SesaZlebloba) dro < 1 sT-ze

invaziuri strategia ar ganixileba

rogorc arCevani Tuki:

• kaTeterizaciis laboratoria

dakavebulia

• sisxlZarRvovani midgoma

garTulebulia

• PCI laboratories unar-Cvevebi ar

Seesabameba

standarts †

STEMI maRali riskiT

• kardiogenuri Soki (am SemTxvevaSi

nacvlad 12 sT-isa aRebulia 18-sT

infarqtis dawyebidan da 75w asakis

qvemoT pacientebisaTvis klasi I LOE: A xolo maTTvis visasac aski > 75w-ze >

klasi II-A LOE B

• kilipis klasi ≥ 3. Cvenebis klasi II-A LOE B

17

18

invaziuri Carevis dayovneba:

• transportireba xangZlivdeba

• karebidan balonamde dro > 90wT-

ze

• karebidan balonamde dros

gamoklebuli karebidan nemsamde (

igulisxmeba Trombolizisis

dawyebis SesaZlebloba) dro > 1

sT-ze

fibrinolizisze ukuCveneba

igulisxmeba sisxldenis da

intrakranialuri hemoragiis gazrdili

riskebi

klasi I LOE: B

Trombolizisis dozebi aris me-11

cxrilSi

ukuCvenebebi mocemuli me-6 cxrilSi

stacionarSi Semosvlis dagvianeba > 3

sT-ze simptomebis dawyebidan

Tuki infarqtis diagnozi saeWvoa da/an

pirveladi PCI-s rekomendaciebSi gaTvaliswinebuli SemTxvevebi

† PCI-s standartebSi igulisxmeba operatoris gamcdileba ( pirveladi PCI > 75 SemTxvevaze

weliadSi) da gunduri muSaobis gamocdileba ( pirveladi PCI > 36 SemTxevaze weliwadSi )

v. fibrinolizis Cvenebebi:

I klasi:

1. ukuCvenebebis ar arsebobisas, fibrinolizisuri mkurnaloba iniSneba

STEMI-s dros Tuki simptomebis dawyebidan gasulia ≤ 12-sT da ST elevacia

aris meti 0,1 mV sul cota or mimdebare prekordiul ganxraSi an or

mimdebare kidurebis ganxraSi LOE: A 2. ukuCvenebebis ar arsebobisas aRniSnuli mkurnaloba tardeba STEMI-s dros Tuki simptomebis dawyebidan gasulia ≤ 12 sT da pacients aqvs axali

an savaraudod axali LBBB LOE: A

II A klasi:

1. ukuCvenebebis ar arsebobisas aRniSnuli mkurnaloba tardeba STEMI-s dros Tuki simptomebis dawyebidan gasulia ≤ 12 sT da pacients aqvs

12 ganxriani e.k.g-s mixedviT WeSmariti ukana kedlis infarqti LOE: C 2. ukuCvenebebis ar arsebobisas aRniSnuli mkurnaloba tardeba STEMI-s

dros, Tuki simptomebis dawyebidan gasulia 12-dan 24 sT-mde Tuki

iSemiis simptomebi grZeldeba da ST elevacia aris meti 0,1 mV sul

cota 2 mimdebare prekordiul ganxraSi an or mimdebare kidurebis

ganxraSi LOE: B III klasi:

1.fibrinolizisuri Terapia ar iniSneba asimptomatur pacientebSi

romlebSiac STEMI-s simptomebi daiwyo 24-sT-iT adre. LOE: C

19

2. Fibrinolizisuri Terapia ar iniSneba pacientebSi romlebSiac 12

ganxrian e.k.g.-ze mxolod ST segmentis depresiaa im SemTxvevebis

gamoklebiT roca ara gvaqvs WeSmariti marcxena parkuWis infarqti. LOE: A

damateba: Trombolizisis efeqturoba naklebia im pacientTa jgufSi romelsac

aqvs qveda kedlis infarqti, Tuki mas Tan ar axlavs RV infarqti an ST-segmentis depresia prekordialur ganxrebSi, rac miuTiTebs rom didi ubanis arsebobaze

riskis qveS.

z. STEMI-s dros fibrinolizis ukuCveneba da safrTxeebi

absoluturi ukuCveneba: 1. raime adreuli intrakranialuri hemoragia, 2.

cnobili cerebrovaskularuli dazianeba (mag: arteriovenozuri

paTologiebi), 3. cnobili avTvisebiani intrakranialuri

neoplazma(pirveladi an metastazuri), 4. iSemiuri insulti bolo 3 Tvis

manZilze garda mwvave iSemiuri Setevisa bolo 3 sT-s manZilze 5. eWvi

aortis diseqciaze 6. sisxldena an sisxlmdeni diaTezi (menzesis garda) 7.

bolo 3 Tvis manZilze, Tavis qalis an saxis daxuruli travma

SedarebiTi ukuCveneba 1. anamnezSi qr., mkacri, Znelad kontrolirebadi

hipertenzia 2. mkacri ukontrolo hipertenzia (sistoluri 180 mmHG-ze meti,

3. diastoluri 110 mmHG-ze meti) es ukuCveneba SesaZloa iyos absolituri

ukuCveneba dabali riskis STEMI-s dros 4. anamnezSi 3 Tveze adrindeli

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. arakompresirebadi vaskularuli punqcia 8.

streptokinaza/antistrptaza adrindeli gamoyeneba (5 dReze adre) an

alergiuli reaqcia am agentze 9. orsuloba 10. aqtiuri peptiuri wyluli

11. antikoagulantis miReba anamnezSi: rac maRalia INR miT maRalia

sisxldenis riski

T. diagnostikuri koronaruli angiografia

klasi I

1. pirveladi PCI-s kandidatebi LOE: A 2. pacientebi kardiogenuri SokiT Tuki maT aqvT revaskularizaciis Cveneba LOE: A 3. qirurgiuli koregireba ventrikuluri zgidis rubturisas/mkacri

sarqvlis naklovanebisas LOE: B 4. pacientebSi persistentuli hemodinamikuri da/an eleqtruli

arastabilurobisas. LOE: C

klasi III

1. koronaruli angiografia ar unda Catardes pacientebSi Tanmxlebi mZime

daavadebebiT sadac revaskularizaciis riski ufro metia vidre

sargebloba. LOE: C

20

i. pirveladi PCI-s rekomendaciebi

klasi 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

(balonuri inflacia 90 wT-Si Semosvlidan) gamocdili eqimis mier

(romelic akeTebs 75 pirveladi PCI proceduras weliwadSi).

procedura mxardaWeril unda iqnes gamocdili personalis mier

Sesatyvis laboratoriaSi (yovel wels laboratories mier

gakeTebuli unda iyos 200 PCI aqedan 36 mainc pirveladi PCI STEMI-s dros da unda qondes qirurgiuli uzrunvelyofa). (LOE A )

specifiuri sakiTxebi: rac exmareba eqims gadawyvetilebis miRebaSi airCios

mkurnalobis meTodi;

a. pirveladi PCI unda Catardes rac SeiZleba swrafad, samedicino

kontaqtidan-balonamde an karidan-balonamde dro 90 wT. (LOE A )

b. Tu simptomebis xangrZlivoba aris 3 sT-s farglebSi da mosalodneli

karidan balonamde drois da mosalodneli karidan-nemsamde drois sxvaoba

aris:

• 1 sT-s farglebSi _ upiratesoba eZleva PCI (LOE B ) • metia 1 sT-ze upiratesia fibrinolizuri Terapia. (LOE B )

g. Tu simptomebis xangrZlivoba 3 sT-ze metia, pirveladi PCI upiratesia da unda gakeTdes rac SeiZleba xanmokle droSi samedicino kontaqtidan-

balonamde an karidan-balonamde 90 wT-is farglebSi (LOE B ) a. pirveladi PCI unda Catardes pacients 75 wlis qvemoT ST-elevaciiT an

LBBB-T, romelTac ganuviTardaT Soki MI-dan 36 sT-Si da arian

revaskularizaciisTvis Sesaferi (Carevis teqnikuri SesaZlebloba

sisxlZarRvis antomiuri da dazianebisTaviseburebebis gamo.) da igi

SeiZleba 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 )

b. pirveladi PCI unda Cautardes pacientebs mkacri SegubebiTi gulis

ukmarisobiT, da/an filtvebis SeSupebiT (kilipi III) simptomebis

dawyebidan 12 sT-is ganmavlobaSi. samedicino kontaqtidan balonamde an

karidan-balonamde dro unda iyos rac SeiZleba mokle, 90 wT-is

farglebSi. ( LOE B )

klasi II A

1. pirveladi PCI 75 wlis an mis zeviT asakis pacientebSi STEMI_T an LBBB-T, visac ganuviTarda Soki infarqtidan 36 sT-Si da

Sesaferisia (anatomiurad da teqnikurad) revaskularizaciisTvis,

rac SesaZloa Cautares Sokidan 18 sT-Si. pacientebi romelTac

21

manamde hqondaT kargi funqciuri statusi, mdgomareoba Sesaferisia

revaskularizaciisTvis da pacieti Tanaxmaa invaziur Carevaze,

SesaZloa arCeul iqnan invaziuri strategiisTvis. . ( LOE B ) 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 )

klasi II B

1 pirveladi PCI-is sargebloba STEMI-an pacientebSi romlebic

fibrinolizisisaTvis Sesaferisni arian, ar aris kargad

gansazRvruli, rodesac PCI-is atarebs operatori, romelsag aqvs 75

PCI proceduraze naklebi Catarebuli weliwadSi. ( LOE C )

klasi III

1. pirveladi PCI ar unda Cautardes arainfarqtul arteriaze

pacientebSi hemodinamikuri arastabilurobis gareSe. ( LOE C ) 2. pirveladi PCI ar unda Cautardes asimptomur pacientebs Tuki STEMI-

s dawyebidan gasulia 12 sT-ze meti da Tu isini arian

hemodinamikurad da eleqtrofiziologiurad stabilurebi. ( LOE C )

VI hospitaluri mkurnaloba

a. miRebis wesi pacientisTvis STEMI-T:

1. IV fiziologiuri an D5W imisaTvis rom SevinarCunoT venuri

midgoma

2. SeamowmeT sasicocxlo funqciebi yovel 1,5-sT-Si. eqTanma unda

seatyobinos eqims Tuki P< 60-ze an > 100-ze. Wneva Tuki

sistoluri > 150 an < 100-ze. sunTqvis sixSire Tuki > 22-ze an <

8-ze.

3. ek.g. monitoringi ariTmiis da ST-cvlilebebis gamosavlenad

4. dieta: dasawyisSi kvebas ar vaZlebT, mxolod wyali. Semdeg

dieta: marilis SezRudva, dabal qolesteriniani sakvebi.

5. stabilizaciis Semdgom wamojdoma da Semdeg msubuqad

gaaqtiveba.

6. O2 2/l wT-Si 6-sT-is stabilizaciis Semdgom Tuki SO2>.90%-ze

moxseniT

medikamentebi:

1. nitroglicerini: sublingvalurad 0,4 mg tkivilis an

diskomfortis moxsnamde misi IV infuzia hipertenziis an

persistentuli tkivilisas romelic pasuxobs nitroglicerins.

22

2. aspirini: 162-325 mg dasaReWad.(umjobesia nawlavuri garsis

gareSe). SemnarCunebeli doza 75-162 mg. SesaZklebelia nawlavuri

garsiT dafarulic.

3. beta-blokeri: ukuCvenebebis ar arsebobisas. Wnevis da P-is kontroliT

4. ACE inhibitori: per. Os. wina kedlis infarqtis, Segubebisas

mcire wreSi,

an Tuki EF < 40 % -ze.

5. angitenzin receptorebis blokerebi: ARB: daiwyeT Tuki

intolerantobaa ACE-s mimarT.

6. IV morfini: 2-4mg 2-8 mg inkrementebiT 5-15 wuTiani intervalebiT

7. SfoTvis momxsneli saSualebebo

8. yabzobis sawinaaRmdego preparatebi

b. sqema 4. garTulebuli STEMI. gadaudebeli mdgomareobebis marTvis protokoli

klinikuri niSnebi: Soki, hipoperfuzia, gulis SegubebiTi ukmarisoba, pulmonaruli edema. ZiriTadi klinikuri suraTi:

23

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 So s niSnebi

araa

siTxeebi

sisxlis transfuzia

mizezis gamosworeba

gaiTvaliswineT

vazopresorebi

SeinarCune si .wneva

> 100 mmhg da a

naklebi 30-isa sabazo

wnevasTan SedarebiT

sist. wneva > 100

mmhg

sist eva 70-100 mmhg

Sok 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/ :

diagnostikuri: pulmonaruli arter ografia, angiografia miokardiumis farqti/iSemiisTvis, damatebiTi diagnostikuri RonisZiebebi.

Terapiuli: 1) intraaortuli balon reperfuzia/revaskularizacia, 3) S leba gamoviyenoT dobutamin, dofaminis kombinacia.

ki

st

ar

Terapiuli RonisZiebebi

ies kaTeteri, eqokardi

uri kontrpulsacia, 2)

in

eiZ

.wn

is

24

g. cxrili 9. parkuWTa Soris Zgidis rubtura, Tavisufali kedlis rubtura, papilaruli kunTis rubtura

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





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

sqema 5 ICD-is Cveneba pacientisaTvis STEMI_T da dabali EF -iT sqema 6. ganmeorebiTi iSemiis/infarqtis marTva STEMI-s Semdgom

25

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

medik. mkurnalobias

optimizacia

12-ganxriani

e.k.g.

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 ?

ara

ganixile re-Trombolizisis SesaZlebloba

streptkinazisaTvis 2 dRidan 5 wliwadSi

ganmeorebiTi xmareba SedarebiTi ukuCvenebaa

diax PCI an CABG

klasi II-A.

LOE: B

klsi I

LOE: B klasi

II-B LOE: B

klasi

III

LOE: B

ara

diax

klasi

II-B LOE: B

d. sqema 7. kaTeterizaciis da revaskularizaciis Cveneba STEMI-s Semdgom adreuli

invaziuri strategia fibrinolizisi arareperfuziuli strategia

26

EF > 40 % EF < 40 %

maRali riskis

gareSe †

maRali riskiT

†

kaTeterizaci

a Cvenebis

mixedviT

funqciuri

Sefaseba

EF < 40 % EF > 40 % Semdg.

kaTeterizaciiT

Semd. kaTeteriz.

gareSe

maRali riski † maRali riskis

gareSe †

e.k.g

interpretire

badia

e.k.g. interpretirebadi araa

fiz..datvir.

testi ar

SeuZlia

fiz. datvirT

testi ar

SeuZlia

datvirTvis

stress eqo

nuklearuli

datvirT.vis

testi

SeuZlia

fizik. datir.

testi

submaqs. dat.

testi

gaweramde

maqsimaluri

datvirTvis testi

gaweris win an

Semdgom

klinikurad mniSv. iSemia klinik. mniSv. iSemia araa medikament. mkurnaloba kaTeterizacia da revaskularizacia Cvenebisda mixedviT

† 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.)

farmakologiuri stres testi

adenozini an

dipiridamoli

dobutamin eqo.

revaskul

arizacia

Cvenebis

mixedviT

e. ST elevaciiT mimdinare miokardimis infarqtis ( STEMI) stacionaridan gaweris Semdgomi antiTrombozuli mkurnaloba

27

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


aspirinze araa

alergiuli

aspirinze

alergia aqvs

araa

antikoagula

ciis Cveneba

aris

antikoagulaciis

Cveneba ††††

araa

antikoagula

ciis Cveneba

aris

antikoagulaci


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

mg‡†† +

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.

v. cxrili 10 meoradi prevencia STEMI-s dros:

mizani

rekomendaciebi

moweva

mizani: sru Sewyv

pac misi oja mk a u

gafrTxildes mowevis sruli Sewyvetis Sesaxeb (

Tavidan unda iqnes aridebuli misi TandraswebiT

ojaxis wevrebis mier moweva) saWiro as

SesaZloa farmakologiuri Terapiis daniSvnac (

nik is Canacvleba a “ u n

sisxlis wnevis

kontroli

mizani: < 140/90 mmhg an <

130/80 mmhg qronikuli

Tirkmlis n lovane

an diabetis dros

Tuki wneva ≥ 120/80 m

• daiwyeT nis

ko l zikuri i o s Warbi

gamoyenebis Tavidan arideba, marilis xmarebis

zomieri Semcireba, dietaSi xilis, bostneulis,

da i produqtebis didi xv Ti wili)

Tuki wneva ≥ 140/90 mm mpacientebSi Tirkmlis qronikuli ukmarisobiT

an diabetiT:

• d m nevis Ses r tebi

lipiduri me ment

Tuki TG < 200 mg/dl)

mizani: LDmniSvnelov < 100

mg/dl-ze)

daiwyeT dieta yvela pacientSi. ( saerTo

kaloraJSi gajerebuli cximi < 7%-ze da

qolesteroli < 2000 mg/dRe onis

kontroli da fizikuri aqtivoba. urCieT omega-3

cximovani mJavis xmar

gansazRvreT lipiduri speqtri da daiwyeT

medikamenturi mkurnaloba Semdegi sqemis mixedviT:

LD 100 mg/ abaziso an mkurnalobis

fonze)

• gamoiyeneT/gaagrZeleT statinebi mizani misi

Semcireba 70 mg/dl-is qvemoT statinebi

LDL ≥ 100 mg/dl ( sabaziso an mkurnalobis fonze)

• moaxdineT LDL Semamcirebeli

medikamentozuri mkurnalobis intensifikacia.

upi a eni statinebs. )

lipiduri m ejment

TG ≥ 200 mg/dl

mizani: ara L-C mniSvnelovnad naklebi

130 mg/dl-ze *

Tu 150 mg an HDL < 40 mg/dl :

• xazi gausviT wonis kontrolis da mowevis

Sewyvetis mniSvnelobas

TG is 200-499

• LDL-C Semamci erapi mdgom, †

ienti da xi

d

mhg

aqt

hg an > 130/80

amci

ebis

acr

B

voba,

ebel

Si.)

gazr

d

prop

al

i

u

da.

nd

io

k

med

rCi

a

ebis

”-i)

holi

edri

mhg

ikamen

eT w

li eta

otin

cxovrebis stilis modifikacia (wo

ro i, fi

l-cximian

nt

ba

bis ak

aa ateT w

nej

L-C nad

i (

L -C < dl ( s

-is

Weba

/dl

ratesob

ki TG ≥ i ( en

HD ar mg

re

/dl

beli T is ES

28

mxedvelobaSi gqondes fibrati an niacini ††

Tuki TG aris ≥ 500 mg/dl

mxedvelobaSi iqonie fibratis an niacinis

emamcirebeli Terapiis win. †

• mxedvelobaSi iqonie omega-3 mJavis dawyeba

minimaluri mizani: 30

wT 3-4 dRe kviraSi;

optimaluria yovel

dRe

i ufro

tiuri moZraoba: siaruli, saxlis samuSaoebi.

lis reabilitaciuri programebi

Ti risk faqtorebiT

,9

/m2

welis

garSemoweriloba:

qalebSi: 88,9 sm

kacebSi 101,6 sm

-sm qalebSi). periodulad gadaamowmeT. Tuki

s

.

diabetis kontroli:

mizani HbA1c < 7%-ze.

T

.

antiTrombocitebi/antik

oagulantebi

ogeli 75 mg an varfarini Tuki aspirini

iT )

renin-angiotenzin-

a is

b

lis MI, adre

ciiT Segubeba

afiuli

bis blokerebi

torebis autanlobisas, da

•

dawyeba LDL is S

fizikuri aqtivoba

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 ganmavlobaS

aq

gu

pacientebisaTvis mravlobi

unda mimdinareobdes eqimis meTvalyureobiT.

gamoTvaleT BMI ( sasurvelia 18,5-24,9 kg/m2 da

gazomeT welis garSemoweriloba( 101-sm kacebSi da

wonis kontroli

mizani: sxeulis masis

indeqsi BMI = 18,5-24kg

89

monacemebi aradaamkmayofilebelia pacient

urCieT metad gaaqtiveba da cxovrebis wesis

modificireba

hipoglikemiuri dieta da Terapia raTa mivaRwio

normalurTan axlo Saqris

cifrebs uzmoze da HbA1c < 7%-ze

aspirini 75-162 mg Tuki araa ukuCveneba.

klopidr

ukunaCvenebia. (es ukanaskneli INR-is kontrol

ldosteron sistem

lokerebi

ACE inhibitorebi yvela pacientSi. daiwyeT adre

maRali riskis pacientebSi ( wina ked

gadatanili MI, kilipi II-ze meti gulis

ukmarisoba. (S3 galopi, auskulta

mcire wreSi, gulis ukmarisobis radiogr

niSnebi. EF ≤ 40%-ze.

angiotenzinis receptore

pacientebSi ACE-inhibiromelTac aqvT maTi daniSvnis Cveneba.

29

gom

jaxis eqimisaTvis)

aruli daavad

adaixedo

hibitorebis, beta-bloker bis, statinebis optimaluri dozebi. LOE: C unda gadafasdes riskebiefasebas da SesaZloa hol

is 31-40% an ufro dabal

pacients da mis axloble

OE: C mieqces p

lur

n unda visaubr

tivoba, samuSaoze dabru

mogzauroba(frena Tu saWesTan jdoma)

iSvnelovani renaluri ukmarisobis ††† an

romlebic iReben ACE aqvT

beta blokerebi

aiwyeT yvela pacientSi romelsac ara aqvs

oba

diabetis marTva

mowmdeba

varfarini si Cvenebebi aris qvemoT mocemul cxrilSi.

i

aldosteronis blokatorebi pacientebSi

mn

hiperkaliemiis gareSe ††††

inhibitorebs, aqvT EF < an toli 40 %-ze. da

diabeti an gulis ukmarisoba.

HF

d

ukuCveneba da SearCieT optimaluri doza.

gaagrZeleT monitoringi dozis optimizaciis

mizniT (monitorings gansakuTrebuli mniSvnel

aqvs pacientebSi gulis ukmarisobiT)

hipoglikemiuri Terapia. efeqturoba

HbA1C-iT romelic unda iyos 7%-ze naklebi.

mi

damatebiT SeiZleba aRiniSnos rom varfarini

SeiZleba mieces pacients STEMI-s Semdgom Tuki

aqvs LV disfunqcia da didi zomis regionalur

kumSvadobis moSla. LOE IIA

VII gaweris Semd i vizitebis rekomendacia

(o :

I klasi:

1. gaweris Semdgomi vizitebisas unda

rdiovaskul

Sefasdes aqvs Tu ara paciets

ebis simptomebi; LOE: C s misi daniSnuleba da SerCeuli unda iqnes ACE

ka

2. vizitisas unda g

in e

3. rac moicavs marcxena parkuWis funqciis

teris monitorings pacientebisTvis sadac EF

i mxedvelobaSi gvqondes ICD-is saWiroeba LOE: C bs unda aexsnaT pirveladi prevenciis roli

acientis fsiqologiur statuss, ( depresia,

LOE: C

S

ar

4.L5. yuradReba unda SfoTva, Zili da socia

6. pacientTa

i aqtivoba)

oY iseT sakiTxebze rogoricaa: fizikuri

nebis vadebi, seqsualuri aqtivoba

LOE: C aq

30

7. pacientis axloblebs un bis

Seswavla da praqtikuli t : C 8. pacientTan da mis axlob

sakiTxebze: a. gulis “ Setevis” riski LOE: C rogor gamovicnoT miok diumis infarqtis niSnebi LOE: C

vurCioT darekon saswra

matulobs 5 wuTis Semdgom d”

Sewuxeba. LOE: C d. pacientebma unda icodn axmarebis

brigadas. LOE: C ia reabi itaciis programaSi pacientis CarTva da

meoradi profilaqtika, ga

risk faqtorebi romelTa

saSualo an maRali risk faqtorebi ( maTTSi varjiSi eqimis

edamxedvelobiT (tredmil an veloergometri)

lia LOE: C cxrili 11 medikamentebi r

medikamenti

da vkiTxot surT Tu ara CPR-is safuZvle

reiningi saavadmyofodan gaweris Semdgom LOElebTan erTad unda vimsjeloT Semdeg

b. ar

g. fo daxmarebis sadgurSi Tuki simptomebi

( xandaxan pacientebs eridebaT vinmes “tyuila

en Tu rogr daukavSirdnen saswrafo d

e. rekomendirebul l

nsakuTrebiT maTTvis visac aqvs mravlobiTi

modificirebac SesaZlebelia an maTi visac aqvs

z i

mizanSewoni

omlebic gamoyeneba STEMI-s mkurnalobisas

pirveli 24-sT

hospitalizaciis

manZilze

gawerisas da

xangZlivi

mkurnalobisas

dasaReWad (

aspirini

umjobesia ara

enteruli

garsiT

dafaruli)

162-325 mg

75-162 mg dRiuri

75-162 mg dRiuri

ganusazRvreli

vadiT

streptokinaza

ibrinolf izisuri

1,5 MU IV 30-60

wT-is

Terapia

ixileT

ukuCvenebebi da

Cvenebebi me-6

rilidan

manZilze

alteplaza IV cx

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

31

dozaa 100 mg

reteplaze 10

U IV bolusi

2wT-Si Semdeg

gaimeoreT 30

wT-Si 10 U IV

bolusi 2 wT-

Si

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.

arafraqcionirebadi

heparini UFH

60 U/kg ( maqs.

4000 U ) 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 normasTan

SedarebiT ( 50-

70-s Soris) 48

sT-is

ganmavlobaSi

ix. 8 sqema

antiTrombozuli

mkurnalobis

rekomendaciebisTvis

keri

beta-blo

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

per-os

per-os ganusazRvreli

vadiT

32

sxva

ukuCvenebebi,

gatitreT

wnevis da

kreatininis

kontroliT

angiotenzin II-is

blokatori ARB

ARB unda dainiSnos

pacientebSi

visac aqvs ACE inhibitorebis autanloba da

igive Cveneba

rac am

ukanasknelT

iseve rogorc

pirvel 24-sT-Si

iseve rogorc

pirvel 24-sT-Si

aldosteronis

okada bl

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

aqvT gulis

ukmarisoba an

diabeti.

igive rac

hospitalizaciisas.

33

nitroglicerini

sublingvaluri

NTG 0,4 mg

yovel 5 wT-Si

Tuki rCeba

tkivili an

diskomforti

gulmkerdSi.

IV s NTG guli

ukmarisobis,

hipertenziis,

persistentuli

iSemiisas rac

pasuxobs

nitratebs

oralurad Tuki

iSemia

grZeldeba an

aris

ukontrolo

hipertenzia

atinebi

st

daiwyeT

lipiduri

profiles

gareSe

ganusazRvreli

vadiT Tuki LDL-C aris 100 mg an meti. gazardeT

manam sanam igi

ar gaxdeba

mniSvnelovnad

naklebi zemoT

aRniSnul

doneze ( an

toli 70 mg/dl)

morfin sulfati

IV 2-4 mg da

zrda 2-8 mg-iT 5-

15 wT-iani

intervalebiT

tkivilis

kontrolisaTvis

cientis

naTleba

pacientisTvis

mniSvnelovania

imis codna Tu

rogor

Secvalos

cxovrebis

stili STEMI-s Semdgom.

informacias

medikamenturi

pa

ga

34

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

farmakologiuri

Terapia. da

CavrToT mowevis

Sewyvetis

programaSi

rjiSi

va

axsna-ganmarteba

siarulis

dawyeba

rekomndacia

varjiSis da

aqtivobis donis

Sesaxeb

35

VIII gamoyenebuli masala:

teqsti eyrdnoba amerikis gulis asociaciis da amerikis

kolejis 2004w ( sruli teqsti da jibis gaidlaini) asev

kardiologTa asociaciis ( 2003w sruli teqsti) Sesabam

damatebaSi gamoyenebulia masalebi: 1. ACC/AHA gaidlain

teqstidan

2004w.

2. ESC gaidlainis sruli teqstidan

2003w.

3. braunvaldi, zaips libbi, gulis

debebi 6-e gamocema 2001w

4 fini opoli

r

saxelmZRvanelo, 2-e gamocema 2004w.

kardiologTa

e evropis

is gaidlainebs.

is sruli

daava

. brain p. gri

kardiovaskula

erik j. t

uli medicinis

36

miokardiumis infarqti st elevaciit stemi · 2010-12-14 · rc = marjvena koronari rbbb = hisis...

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