ACS - huʻi coronary maʻi pale

IV Samorodskaya,

Kumu, Kauka o Lapaʻau o Sciences

huʻi coronary
maʻi pale

Multidisciplinary hui hoʻoholo

E ho ohana i kēia ano o ka iapaau ana no ka huʻi coronary maʻi pale (ACS)
- he kau denoting kekahi pae o ka lapaʻau na hoailona a me symptoms
hele 'ana o kēia huʻi myocardial infarction (MI) a lolelua ka
angina, haawi manaolana no ka nui ka ho'ēmiʻana i ka haukapila
make a me ka hoʻoikaika prognosis i loko o ka lōʻihi-makahiki au.

Mau makahiki aku nei, ka noiʻi a me ka lahui LIKE i
hōʻuluʻulu manaʻo no ka i ka All-Russian Ho oholo Wae Society o Cardiology ma Lūkini koi ma kaʻike,
a me ka hana ana o nā mea maʻi me ka myocardial infarction me ST-Hoʻohana elevation (2007), me ka ST elevation, a lolelua ka angina (2006). I ka 2010, paʻiʻia ma ka Europa hoike
Society o Cardiology (ESC) ma luna o ka poʻe uʻi a o ki ina hana like o myocardial revascularization, aupuni lula no ka hooponopono ana i nā mea maʻi me ACS ma Australia
Beritania, i ka hopena o ka lahui
kona manaʻo ma ma ka hooponopono ana o nā mea maʻi me ka ACS. i ka 2013
'Amelika Heart
Society (ACCF / Aha) Ua hōʻano
koi no ka hooponopono ana i nā mea maʻi me ka ACS
ST Hoʻohana elevation.  

Ka hoʻoholo 'ana ma luna o nā kaʻa mokulele
hoʻomanawanui'ōnaehana ma ACS me ka elevation ai ole ST-Hoʻohana elevation mea,ʻaʻole e mau ana uniquely mea, pinepine pono multidisciplinary komo
kekahi kime o ka hoʻomalu ka nānā 'ana ma luna o lapaʻau lula, papa o ka maʻi, makahiki o ka hoomanawanui, ana
malama. I ka Ia manawa i loko o nā mea a pau nā mea maʻi i kēia ACS
pono hana i electrocardiogram (i loko o ka wa e kaawale aku o
loli 'ole' ikepili i koi 'ia ka puana i hoʻopaʻa'ʻanuʻu 15
-30 minuke, ke kaumaha ma muli o ka lapaʻau 'ana o ke ahonui), a me ka hiki pae o ka mahele
no ka cardiac nā'ūhū, OAXA pono o ka aspirin ua noʻonoʻo pono. i loko o
All koi i he makemake ko endovascular 'ana i kūpono
myocardial revascularization ma ke alo o ka hoao ana i ka palapala hōʻoia no kookoo.
Fibrinolytic Inc (like no i koe mua o ka hoʻolako 'malama i ka hoʻomanawanuiʻana me ACS me ST-Hoʻohana elevation) koe pili ana i ia mau wahi, i hiki,
ia he mea hiki ole ke hana stenting
no 120 minuke ma hope o
hanana o kaʻeha (i loko o ka wa e kaawale aku o contraindications, a ina no ka ua ole oi ma mua o ka eha
12 hola). A lohe o ACS me ka hookiekie ana fibrinolytic ST Hoʻohana
Inc ua i lawelawe.

Inā i ka pilikia o ka naau kīmopō a me / ai kona
kiʻekiʻe complications

i komo
e pili ana i ka 'oihana aʻo ma Europe, o ka Amerika Huipuia, i manaoio i ka manaʻo o ka
coronary angiography i loko o 2 hola, mai ka manawa mai o ke komo
Ua paipai ina ke hoomanawanui me ka kaua o ka angina ma 'inikua kāʻei kua
ana i ka symptoms hoomau ole recur
angina malama hōʻeuʻeu ST Hoʻohana loli, suggestive o ka poho ulu
ole myocardial infarction; hemodynamic
instability, nui ventricular arrhythmias. Hana angiography (me ka hope
revascularization) no ka 24 hola ma hope o ka noi komo 'o ka hoʻomanawanuiʻana i ka haukapila me ACS ua paipaiʻia ma ka hihia o ke kiʻekiʻe
pilikia o myocardial infarction, ola-na olelo hooweliweli e
complications a me ka make. Similar manawa o coronary angiography ua paipaiʻia i loko o
Where koi palena pauʻike, o ACS a me nā
mamao aku ana (pulmonary embolism, dissecting
aortic aneurysm). Ma na hihia o ka huʻi coronary maʻi pale ole Hoʻohana ST ke eaʻe ma haahaa kamepiula o ke ola-na olelo hooweliweli e
complications a me ka make iloko o haukapila noho
lapaʻau, akā, hoʻohune symptoms o angina a me / ai ischemiaʻonou
i ka haawe hoao, coronary angiography ukali ma ka revascularization ma
e pono ai, a hiki ia mea kupono e lawe mai i loko o ka hāʻawi au
hospitalization i loko o 72 hola ma hope o ke komo. i ka
ina o ka hoʻomanawanui ua hoʻokomo i ka 'inikua hale, kahi i mea hiki ole
hana i kekahi coronary angiography, ka mea, ua hoololiia no ka haukapila kūpono (e laʻa me
Regional Vascular Center).

pono ole
noonoo tactic stenting (lāʻau-lole komoʻuʻuku nona stent
ole uncoated) me ka infarct pili artery tromboekstratsiey (ma
pono), iā ACS pela aku ke eaʻe
ST Hoʻohana
nānā 'ole o ka manaʻo a me ka hopena o fibrinolytic Inc (e like me
Koi mai ka 2013 ACC ma hope o fibrinolytic Inc ua? Aeiiaiaoaony e hana
FCT a stenting mea i mua o
2-3 hola). Inā l-Hoʻohana elevation huʻi coronary maʻi pale ST, koe nae infarct artery, malaila i kaumaha
stenoses i loko o nā arteries, kā lākou pilikia stenting ua hana wale
no ka poe me ka loa naʻau hoʻokō 'ole' a / ai cardiogenic kŰia. i 'ē aʻe
hihia hoolohi stenting ua hana - i ka pono no ka a me ka manawa o
Hoʻoholo ihola ma hope o ka ho'āʻo ma stress mamua e hookuuia o ka hoʻomanawanui mai
haukapila. E like me nā koi o ka poe akamai, mai ka United States 2013, me ka stents
Na ka penaʻana Ua kaʻoi loa hoʻohana 'ia i loko o na hihia a pau o ka hoʻomanawanui i
maʻi a me na kumu me ka pilikia kiʻekiʻe o ke kahe ana ke koko, kiʻekiʻe pahiki,
i ka hoʻomanawanui 'aʻole e hooko i loko o ka makahiki o ke pālua antiplatelet regimen
Inc, a me ia mea paha e hana mahopeʻoki kino
hana. Eia kekahi, ke koi i hōʻike mai ia i ka C-Hoʻohana elevation ACS ST stenting ma hope o 24 hora, mai ka manawa mai o kona
Development i hōʻike 'ia i loko o nā hihia 1-2 vascular lesions i loko o ka wa e kaawale aku o
hoailona mālama 'ana o myocardial ischemia. Ma pohihihi keia hihia (ma lalo o kekahi
wahi, i hiki) i hana angioplasty.

I ka olelo hooholo e pili ana i ke ano o ka revascularization i loko o nā mea maʻi me ka huʻi coronary maʻi pale ole Hoʻohana ST ala, a ma ACS pela aku ST Hoʻohana elevation, akā, i loko o ka wa e kaawale aku o
coronary hualoaʻa hou o coronary arteries, maopopo leʻa "hewa" ma
ACS a he multivessel mai, ma a ka manaʻo o
Stenting mea technically ole paha kamepiula e aku i ka 'auhau o ka
ka pono ua loaa ma kekahi mauʻano poʻe (mea'ōnaehana mānowai koko surgeon,
cardiologist, he hoʻomalu i loko o ke kula o
Endovascularʻike, a me ka lapaau) me ka
lapaʻau, angiographicʻikepili loiloi fractional pele no?,
ka mea i manaoia loa-makahiki prognosis.

ka lapaʻauʻia kākoʻo
pono

A lohe o ACS me ST Hoʻohana elevation nui na poe akamai i manaoio i ka papa nā kaʻa mokulele o na nā mea maʻi i loko o ka
Ua hilinaʻi nui pili kēia ma luna o ka'āina o ka ola'ōnaehana
(Nui māhele'āina) e hana iniiaiie endovascular 'uao (me mamua
thrombolysis) no 2 hola ma luna o ka ulu o ka lapaʻau symptoms i loko o ka hoʻomanawanui.

Inā ka mea, ua manaoia i ka manawa, mai ka mua hui 'ana me ka hoʻomanawanui
'inikua limahana mamua i hana coronary angiography e e oi ma mua o 2
hola, na nā mea maʻi
(I ka wa e kaawale aku o contraindications) pono hana thrombolysis me
mahope haawi i ka? aaieou no ka hana angiography a me ka revascularisation
infarction i loko o 3-24 hola. Ma ia mau hihia a pau, ina i ke kāʻei kua o ka thrombolysis
ST Hoʻohana elevation, hoopaa mai la oi ma mua o 50% o ka loiloi mua 'ilikai a me / ai retrosternal
ʻeha, ka hoʻomanawanui hōʻike pilikia coronary angiography. Inā holomua,
thrombolysis coronary angiography a me ka revascularization (ina hōʻike) ke
e hana i loko o 24 hola. Nā koi olelo ia
revascularization hiki hoʻoikaika 'ana i ka prognosis a me kona manaʻo ma 24-60
hola ma hope o ka hoouka kaua ana o lapaʻau symptoms, akā, wale ma ia mau hihia a pau
Aia mau recurrent angina a / a myocardial ischemia 'akomi i ka wa
vocal haʻawina.

mai
Ke kaumaha ma muli o ka 'ano o ACS a me revascularization iaoiaeii ka muli o
lāʻau kākoʻo, i ka loaʻa o antiplatelet,
antiplatelet Inc, Hoʻokolohua-blockers Inc, nā mea kūpale o ka angiotensin hoʻololi '
'ūhū, statins. Uluwehi O Inc ua pākahi like
Ke kaumaha ma muli o ka kinona o ACS oolea, alo soputsvuyuschie pathology. ka
Kēia puke, e kālele ana wale ma antiplatelet Inc,
e hele pū ana ano o myocardial revascularization.

Hoʻohana elevation ACS me S T

ka
na hihia endovascular revascularization ki ina hana like
hoonoho iho i ka "papalua 'antiplatelet Inc i nā moʻolelo
acetylsalicylicʻakika (ʻAsa) a me ka clopidogrel (a prasugrel paha
ticagrelor). Asa ua hāʻawi ai i ka mea mua e loaa ana 150-300 mg (250-500 mg paha ma ke ano o
i / ma ka bolus) i ukali ia e ka laʻau heluna o 75-100 mg / lā hoʻouka mahele lāʻau
600 mg o clopidogrel (i kakahiaka nui me hiki) hahai ma ka hooponopono ana o 75
mg / lā no 9-12 mahina prasugrel - 60 mg hoʻouka mahele lāʻau, i ukali ia e
lawe 10 mg / lā, a ticagrelor - 180 mg hoʻouka mahele lāʻau, i ukali ia e
lawe 90 mg 2 manawa i ka lā. Nāʻikepili no ka hou ana
GPIIb-IIIa nā mea kūpale i manaoia e ia ma kiʻekiʻe kamepiula o intracoronary thrombosis i loko o nā mea maʻi undergoing angioplasty a me / ai stenting
coronary arteries.

ka
koi Nice (UK) memo i
Hoʻomanawanui iki mai ma kiʻekiʻe kamepiula o ka mea'ōnaehana mānowai koko hanana (ʻana o 6 mahina
make ma mua o 3%), a ma lalo i ka coronary angiography a me ka revascularization
i loko o 96 hola, mai ka manawa o ka komo oaeouee? hoikeia
hookohu o ka eptifibatide a tirofiban. Abciximab ua hoonohoia like me ka Inc,
e hele pū ana endovascular revascularization ina ole
Hana, e hāʻawi aku 'ē nā mea kūpale o GPIIb-IIIa. It E e kaulana ia i loko o
Haʻalele Celebs alakaʻi (UK) koi
Europa Society o Cardiology "koho" ua haawiia mai abciximab (Grade
nāʻikepili au), i ka mea ia manawa no ka eptifibatide
ole tirofiban E hoʻopaʻa i Class iia,.

Wae a me ka mahele lāʻau
anticoagulants e hana angiography
revascularization i loko o nā mea maʻi me ka ACS
hookiekie ana ST Hoʻohana hoʻoholo ma muli ia
Stratification o ka pilikia o ka thrombotic, ischemic a me ka hemorrhagic complications. At kiʻekiʻe loa kamepiula
ischemic hanana (no ka laʻana, ka wā hemodynamic instability refractory ola-hooweliweli arrhythmias) ahonui
hoʻopakele 'ana me ka X-Ray a me ia ua häʻawi mai
unfractionated heparin (UFH) i / ma ka bolus o 60 U / kg me ka hope
infusion oiai ka revascularization i loko o ka huipūʻana me ka papalua
antiplatelet Inc. Ma kiʻekiʻe kamepiula o ke kahe ana ke koko hiki ke hoʻohana
monotherapy bivalirudin bolus o 0,75 mg / kg ukali ma infusion o 1,75
mg / kg / HR. No nā mea maʻi me ka awelika kamepiula o ischemic hanana (no kekahi laʻana,
ka pilina paʻa hemodynamics, akā, he maikaʻi troponin hōʻike, relapsed
angina, hōʻeuʻeu hou i loko o ka ST Hoʻohana), a ua hoʻopaʻa 'ia no invasive hana 24-48
hola kēia lapaʻau nā koho like paha i kahi ma mua o ke coronary angiography
? oaony endovascular myocardial revascularization:

• No nā mea maʻi <75 makahiki

Unfractionated heparin 60 U / kg i loko o ka palapala o ka / ma ka bolus,
laila, i ka infusion ma lalo o ana o ka ho'ā 'hapa thromboplastin manawa
(APTT) ole enoxaparin 1 mg / kg s.c. m 2 no ka lā a me Fondaparinux 2,5 mg / lā
Bivalirudin subcutaneously ole 0,1 mg / kg i / ma ka bolus hahai ma infusion
0,25 mg / kg / hola

• No nā mea maʻi ≥75 makahiki

Unfractionated heparin 60 U / kg i loko o ka palapala o ka / ma ka bolus,
laila infusion ma lalo o ka mana hoʻomalu ma APTT

A i 'ole enoxaparin 0,75 mg / kg m 2
Fondaparinux lā a 2,5 mg / lā subcutaneously a Bivalirudin 0,1 mg / kg like me ka
I / bolus ukali ma infusion o 0,25 mg / kg / HR.

i
hoʻomanawanui iki mai me ka haʻahaʻa pilikia o ka mea'ōnaehana mānowai koko hanana (me ka mahuahua
troponin a me ST Hoʻohana loli), oi makeʻe kulana? oaony
lapaau a hāʻawi fondaparinux (2.5 mg / lā subcutaneously) ole enoxaparin (1
mg / kg s.c., 2 manawa i ka lā i loko o nā mea maʻi ≥75 makahiki - 0,75 mg) a me ka unfractionated heparin 60 U / kg (
like ma ka / bolus, i ukali ia e infusion ma lalo o ka mana hoʻomalu ma aPTT).

ACS me ST Hoʻohana elevation  

ma keia
lapaʻau kulana home 'ole ua ia he "papalua" ACK antiplatelet Inc (150-300 mg hōʻike waha ai
250-500 mg i / ma ka bolus hahai ma ka hooponopono ana o 75-100 mg / lā) a me ka prasugrel
(60 mg hoʻouka mahele lāʻau ukali ma ka hooponopono ana o 10 mg / lā), a ticagrelor (hoʻouka mahele lāʻau o ka 180 mg
ukali ma aaieieno? o 90 mg 2 manawa i ka lā) 'ole clopidogrel (hoʻouka mahele lāʻau 600
ukali ma ka hooponopono
75 mg / lā). Nā koi o ka Europa Society o Cardiology mai nei i
prasugrel a me ka ticagrelor clopidogrel oi mana ma ka hua'ōlelo o ka hoemi
alapine (frequency) alu ischemic endpoints a me stent thrombosis i loko o nā mea maʻi
MI elevation ST, a me ka mea, aole e hoʻonui i ka pilikia o ka
loa kahe ana ke koko. E like me na koi ana o ka hoki 2013 mea ole prasugrel
Ua pono no ka hoʻomanawanui iki mai me
ka mōʻaukala o ke hahau a me TIA. I ka hanana mea ma mua o ke komo i ka
'inikua kula e hana coronary angiography a stenting ahonui
fibrinolysis i ka hanaia, a ia ua emi o 24 hola, a no ka mea ia manawa i ole hoʻohana
clopidogrel (prasugrel), a laila, clopidogrel hoʻouka mahele lāʻau o 300 mg,
Prasugrel mea he 60 mg.

At kiʻekiʻe kamepiula
intracoronary thrombosis, a me ka pālua antiplatelet Inc
Ua ia kekahi hoʻohana o GPIIb-IIIa nā mea kūpale (abciximab / V bolus o 0,25 mg / kg ukali ma infusion o 0,125 mg / kg / min i
ka i kā mākou nui o 10 mg / min no ka 12 hola.). I keia manawa, he mea ole
paa loa hoike nui ka hoʻokōʻana GPIIb-IIIa nā mea kūpale ka wā i hoʻohana ma
prehospital a ma mua catheterization.

like me ka
UFH anticoagulation Inc ua hoʻohana 'ia (i / ma ka bolus 60 U / kg i ka hui pu ana, me ka GPIIb-IIIa inhibitor a / bolus 100 U / kg me
GPIIb-IIIa) inhibitor. Bivalirudin like monotherapy kahi UFH ma ka hui pu ana, me ka inhibitor o GPIIb-IIIa i paipai e ACC 2013
Ua pono no nā mea maʻi me ka kiʻekiʻe pilikia o ka nui kahe ana ke koko (bolus o 0,75 mg / KG ukali ma infusion o 1,75
mg / kg / hora); I ka Ia manawa, ua i paipai fondaparinux no o ke kamepiula kiʻekiʻe
catheter thrombosis.

E like me ka olelo penei, mai
haukapila pālua antiplatelet Inc ua hoʻohana 'ia no ma ka liʻiliʻi 12 mahina.

E e uku ia kekahi noonoo no ka hui malu pu ana o
clopidogrel a me ka proton EII ni nā mea kūpale, olelo hoʻohana no ka Kāohi o
gastrointestinal kahe ana ke koko. E like me ka kona manaʻo ma o ka hana pae no ka Kāohiʻana o ka thrombotic
a me ka hemorrhagic complications ICSI hui hoʻohana ana ai 'ana i nā mea maʻi
haahaa pilikia o ka GI kahe ana ke koko ka i hoikeia mai, kā lākou concurrent ana e ke aʻoaʻo ma o ka muli o
lawe i loko no o ka pomaikai a me ka pilikia. wale
PPI ka lapaʻauʻia, mai ka pūʻulu - pantoprazole - i ka "competitor" klopidoglelya
no ka isoenzyme CYP2C19. Ma ka 'ē aʻe lima
ole kiʻekiʻe-kbps lapaʻau e hookolokolo ai ka loiloi 'ana i ke kanawai o ke ami
ana pantoprazole a me ka clopidogrel
e emi i ka pilikia o concurrent mea'ōnaehana mānowai koko a me ka hemorrhagic
complications. ʻOkoʻa PPI e h2 mea loaʻa blockers - famotidine, ranitidine.

oaeouee ka lapaʻauʻia
Inc

Hoʻokolohua-blockers e ia i loko o ka mua 24 hola, mai ka manawa mai o nā mea maʻi a pau me ka ACS
i ka wa e kaawale aku o ka naau ole me ka haʻahaʻa auaiaea maʻi pale,
cardiogenic hawewe a me ka maʻamau contraindications i ka hoʻohana 'ana i kēia pae o ka ai'.
Komo Hoʻokolohua blockers hoomau ma ka wā o ka hospitalization, a ma hope o
māmala'ōlelo e hōʻike ana.
ACE nā mea kūpale i hookohuia
All nā mea maʻi me ka anterior myocardial infarction, ejection hapa emi o 40% i loko o ka wa e kaawale aku o
contraindications. Inā he mau contraindications no ACE nā mea kūpale i hoʻohana blockers
angiotensin II mea loaʻa. hakaka
aldosterone hōʻike i nā mea maʻi me ka symptomatic naʻau ole
a me / ai ole ia i ke alo o mimikō. Hooloihi ae i hoʻohana i nā mea a pau statins e hōʻike '
hoʻomanawanui iki mai me ACS (ʻaʻohe contraindications).