ACS - syndrome coronary whakapeka

IV Samorodskaya,

Ahorangi, Doctor o Medical Sciences

coronary whakapeka
syndrome

whakatau rōpū pekanga

Mā te tikanga hou o te maimoatanga mō te syndrome coronary whakapeka (ACS)
- he wā e hūanga tetahi rōpū o tohu haumanu tohumate ranei
tuku whakapae whakapeka infarction myocardial (MI) ranei iu
angina, homai tumanako mo te whakaiti nui i roto i te hōhipera
te tahuti nei, me te whakapai ake i waitohunga i roto i te wā wā roa-.

E rave rahi matahiti i ma'iri a'e, he rangahau me te ao ngā
whakarāpopoto i te katoa-Russian Scientific Society o Cardiology i roto i ngā tūtohutanga Russian i runga i te tātaritanga
me te maimoatanga o te tūroro ki te infarction myocardial ki tairanga ST-wāhanga (2007), i waho ST tairanga me angina iu (2006). I roto i te 2010, whakaputaina e te kupu tohutohu Pākehā
Society o Cardiology (ESC) i runga i te pai rawa o ngā tikanga o revascularization myocardial, aratohu motu mo te whakahaere o te tūroro ki te ACS i Ahitereiria
Ingarangi, nga hua o te ao
whakaaro i runga i te whakahaere o te tūroro ki ACS. I te 2013
Heart American
Society (ACCF / AHA) kua whakahōutia
tūtohutanga mō te whakahaere o te tūroro ki te ACS
ST wāhanga tairanga.  

Ko te whakatau i runga i ngā tātai
whakahaere manawanui i roto i ACS hei tairanga kia kahore kore ko ST-wāhanga poipoi tonu ahurei ohie, maha titau whai wāhitanga pekanga
he rōpū o ngā tohunga i runga i aratohu haumanu, akoranga o te mate, tau o te manawanui, tikanga
tiaki. I te wa ano i roto i tūroro katoa ki ACS whakapae
Me mahi i te hiko-(i roto i te ngaro o
huringa raraunga pāhekeheke ranei hiahiatia toutou wā tuhi 15
-30 meneti, i runga i te huru haumanu o te manawanui rānei), me nga taumata ka taea o te ako
hoki whākōkī cardiac, whakaaro te whakamahi whakahauanga o ahipirini te. i roto i
Kua meinga tūtohutanga katoa tikanga endovascular
revascularization myocardial i roto i te aroaro o te kaimahi whai tohu mātanga.
therapy Fibrinolytic (rite te taahiraa matamua o te whakarato tiaki ki tūroro ki ACS ki ST-wāhanga poipoi) tonu e hāngai ana ki te hunga āhuatanga,
i te mea e taea ki te mahi i stenting
mō te 120 meneti i muri i
takanga o te mamae (i roto i te ngaro o contraindications me te mea mai i te kore neke atu i te mamae
12 haora). A, no te ACS kahore ara fibrinolytic wāhanga ST
e kore te therapy faaterehia.

Ki te te mōrea o te whakaeke ngakau, me te / ranei ona
pōauautanga teitei

kaiuru
te hanga tohutohu ngaio i roto i Europe, e whakapono ana te United States e te whakatinanatanga o
angiography coronary i roto i te 2 haora i te kau o te whakauru
e tūtohu ki te te manawanui ki te whakaekenga o angina i runga i te papamuri hauora
penei nga tohu tohe auau ranei
kite angina hihiri huringa wāhanga ST, suggestive o te whanaketanga kino
ranei infarction myocardial; hemodynamic
tapepe, arrhythmias ventricular nui. Mahi angiography (ki muri
revascularization) mō te 24 haora i muri i whakauru o te manawanui ki te hōhipera ki ACS tūtohutia i roto i te take o tiketike
mōrea o infarction myocardial, te ora-te whakawehi
pōauautanga me te mate. tūtohutia wā e rite o angiography coronary te i roto i
Hea hiahiatia tātaritanga pārōnaki o ACS ki ētahi atu
āhuatanga akiaki (Embolism pūkahukahu, wāwāhi
aneurysm te pūtahi o). I roto i te wā o te syndrome coronary whakapeka kahore wāhanga ST ara i mōrearea iti o te ora-te whakawehi
pōauautanga me te mate i roto i te hōhipera noho
maimoatanga, engari tamau tohu o angina ischemia me / ranei piri
i roto i te whakamātautau utanga, angiography coronary aru e revascularization i
e tika ana, me te taea he mea tika ki te kawe i roto i roto i te wā i homai
hohipera i roto i 72 haora i muri i whakauru ki. I roto i te
ki te uru te manawanui e ki te whare hauora, te wahi e kore e taea
mahi i te angiography coronary, kua whakawhiti te reira ki te hōhipera e tika ana (hei tauira
Rohe Vascular Center).

noa
whakaaro stenting rauhanga (stent tarukino-pani
ranei Kore Uwhi) ki te pā ana infarct iatuku tromboekstratsiey (i
tika), ia ACS c anga
ST wāhanga
ahakoa o te whakatinanatanga, me te pānga o te therapy fibrinolytic (rite
tūtohu tūtohutanga i te ACC 2013 i muri i therapy fibrinolytic te ki te mahi i
Ko e kore mua atu i FCT me stenting
2-3 haora). Ki te c-wāhanga poipoi whakapeka syndrome coronary ST, anake infarct iatuku, i reira e nui
stenoses i roto i te tahi atu pera, whakamana ratou stenting whawhati tata te anake
hoki te hunga ki te kore nui ngakau, me te / ranei ru cardiogenic. I roto i te tahi atu
whakamana take stenting roa te - te hiahia hoki me te wā o
faaoti i muri i te ahotea whakamatautau mua ki te ruke o te manawanui i
hōhipera. E ai ki nga kupu tohutohu o ngā tohunga i te United States 2013, kahore stents
Kei te pai te whakamahi i te paninga i roto i te wā i reira kua te manawanui
mate me ngā āhuatanga ki te mōrea nui o toto, tūponotanga tiketike,
e kore e te manawanui ū i roto i te tau o te talena antiplatelet rua
therapy, he me reira pea ki te mahi i pokanga muri
ngā mahi. I tua atu, tohu nga tūtohutanga e te c-wāhanga poipoi ACS ST stenting i muri i te 24 haora i te kau o tona
Whanaketanga kore whakaaturia i roto i te wā 1-2 pāpaka iaia i roto i te ngaro o
tiaki tohu o ischemia myocardial. I roto i te wā onge (i raro i etahi
āhuatanga) i mahi angioplasty.

Ko te whakatau e pā ana ki te tikanga o te revascularization i roto i te tūroro ki te syndrome coronary whakapeka kahore ara ST wāhanga, me i ACS c ST wāhanga tairanga, engari i roto i te ngaro o
whāiti rohe coronary o iatuku pūngākau, tino "hara" i roto i
ACS ranei he mate multivessel, i roto i nei te whakatinanatanga o
Stenting Ko tū taea mōrearea e nui te kaha o ranei
riro te painga e rave rahi tohunga (taote Cardiovascular,
mafatu, he mātanga i te parae o
tātaritanga Endovascular me maimoatanga) ki te
haumanu, te aromātai raraunga angiographic rahui rere hautanga,
te waitohunga wā roa-tūmanakohia.

tautoko rongoā
tika

A, no te ACS ki ST wāhanga poipoi whakapono maha tohunga e nga tātai o te tūroro i roto i te nāianei
Tei te reira te nuinga i runga i te pūnaha hauora o te whenua o
(Region) ki te mahi i wawaotanga endovascular tuatahi (kahore mua
thrombolysis) mō te 2 haora i runga i te whanaketanga o tohu haumanu i roto i te manawanui.

Ki te tūmanakohia reira e te wa i te whakapā tuatahi ki te manawanui
kaimahi hauora i mua ki te raveraa angiography coronary ka neke atu i te 2
haora, nga tūroro
(I roto i te ngaro o contraindications) me te mahi thrombolysis ki
tuku muri ki te whare hauora mō te raveraa i angiography me te revascularisation
infarction i roto i 3-24 haora. I roto i aua wā, ki te te papamuri o thrombolysis
neke atu i te 50% o te taumata tuatahi retrosternal me / ranei mau ST wāhanga poipoi
mamae, whakaatu ana te manawanui whawhati tata angiography coronary. Ki te angitu,
thrombolysis angiography coronary me revascularization (ki te tohua) kia
kia whakamana i roto i te 24 haora. kī nga tūtohutanga e
Ka taea e revascularization whakapai ake i te waitohunga me tona whakatinanatanga i roto i 24-60
haora i muri i te tīmatanga o te tohu haumanu, engari anake i roto i te hunga wā i reira
He angina recurrent me / ranei ischemia myocardial kitea i roto i
rangahau mauhaa.

i roto i
Tei runga i te momo o ACS me tikanga revascularization Ko mātua
tautoko tarukino, i ngā antiplatelet,
therapy antiplatelet, beta-blockers therapy, inhibitors o angiotensin tahuri
whākōkī, statins. Kei te whakaritea takitahi Drug therapy
Tei runga i te āhua o ACS pakeke, aroaro soputsvuyuschie māuiuitanga. Ko te
Ka arotahi tēnei whakaputanga anake i runga i te therapy antiplatelet,
tikanga ◊oatu fakataha o revascularization myocardial.

Wāhanga tairanga ACS kahore S T

Ko te
ngā take pēnei i ngā tikanga revascularization endovascular
whakaritea he "rua therapy antiplatelet 'e ngā waha
waikawa ahipirini (ASA) me clopidogrel (prasugrel ranei ranei
ticagrelor). Kei te whakaritea ASA ki te tuatahi te fariiraa 150-300 mg (250-500 mg ranei i te puka o
i roto i te / i roto i te bolus) aru e te inenga o 75-100 mg / ra uta horopeta
600 mg o clopidogrel (rite wawe rite taea) aru e whakahaere o 75
mg / ra hoki 9-12 marama prasugrel - 60 mg uta horopeta, aru e
tango 10 mg / ra, ticagrelor ranei - 180 mg uta horopeta, aru e
tango 90 mg 2 nga wa i te ra. Tuhinga mō te whakamahi anō
E whakaaro GPIIb-IIIA inhibitors ki kia i mōrearea nui o Thrombosis intracoronary i roto i tūroro pangia angioplasty stenting me / ranei
iatuku pūngākau.

Ko te
tūtohutanga NICE (UK) tuhipoka e
Tūroro i mōrearea nui o ngā Cardiovascular (matapae 6 marama
te tahuti nei i te 3%) ka waiho i raro ki te angiography coronary me revascularization
i roto i 96 haora i te wa whakaaturia te mahi whakauru
whakarite o te eptifibatide tirofiban ranei. i whakaritea Abciximab te rite te therapy,
◊oatu fakataha revascularization endovascular ki te kahore
Te āhei ki te tautapa atu inhibitors o GPIIb-IIIA. Me kï reira e i roto i
Haunga te arata'iraa NICE (UK) tūtohutanga
homai Pākehā Society o Cardiology "manakohanga" te abciximab (Grade
Ahau tohu), i te wa ano hoki eptifibatide
ranei tirofiban Tautuhia Class IIa.

Kōwhiringa me te horopeta
anticoagulants ki te mahi i angiography
revascularization i roto i tūroro, kahore ACS
e hāngai ana ara ST wāhanga takoto i runga i
Te raupapatanga o te mōrea o te thrombotic, rere pūroto, me te hemorrhagic pōauautanga. I mōrea tiketike rawa
takahanga rere pūroto (hei tauira, ka tapepe hemodynamic whakangutungutu ora-te whakawehi arrhythmias) manawanui
tukua hāngai ki X-ray, me te tautapatia reira
heparin unfractionated (UFH) rite / i roto i te bolus o 60 U / kg ki muri
whaowhia i roto i te revascularization roto i te taha ki te rua
therapy antiplatelet. I mōrea tiketike o te toto e taea te whakamahi
monotherapy bivalirudin bolus o 0.75 mg / kg aru e whaowhia o 1.75
mg / kg / hr. Hoki tūroro ki te mōrea toharite o ngā rere pūroto (hei tauira,
hemodynamics eu, engari he whakamātautau troponin pai, Maoritanga
angina, huringa hihiri i roto i te wāhanga ST), whakaritea nei mo ngā tukanga urutomo 24-48
haora e whai ake nei ngā kōwhiringa maimoatanga tīari mua ki angiography coronary
whakaritea revascularization myocardial endovascular:

• Hoki tūroro <75 tau

heparin Unfractionated 60 U / kg i te puka o te i runga i / i roto i te bolus,
na te whaowhia raro i te mana o te wa thromboplastin wāhanga whakahohe
(APTT) enoxaparin ranei 1 mg / kg s.c. x 2 ia ra Fondaparinux 2.5 mg ranei / ra
Bivalirudin subcutaneously 0.1 mg / kg ranei rite / i roto i te bolus aru e whaowhia
0.25 mg / kg / haora

• Hoki tau tūroro ≥75

heparin Unfractionated 60 U / kg i te puka o te i runga i / i roto i te bolus,
Na e whaowhia i raro i te mana APTT

Ranei enoxaparin 0.75 mg / kg x 2
ra Fondaparinux ranei 2.5 mg / ra subcutaneously Bivalirudin 0.1 mg / kg rite te ranei
Ahau / bolus aru e whaowhia o 0,25 mg / kg / hr.

I roto i
tūroro ki te mōrea iti o ngā Cardiovascular (kahore te whakanui ake
troponin ko ST huringa wāhanga), whakaritea atu momo
maimoatanga me te fondaparinux whakaritea (2.5 mg / ra subcutaneously) enoxaparin ranei (1
mg / kg s.c., 2 nga wa he ra i roto i te tūroro ≥75 tau - 0.75 mg) me heparin unfractionated (60 U / kg
rite i roto i te / bolus, aru i te whaowhia i raro i aPTT mana).

ACS ki ST wāhanga poipoi  

I roto i tenei
whakaritea āhuatanga haumanu te he "rua" therapy Ack antiplatelet (150-300 mg waha ranei
250-500 mg rite / i roto i te bolus aru e whakahaere o 75-100 mg / ra) me prasugrel
(60 mg uta horopeta aru e whakahaere o 10 mg / ra), ranei ticagrelor (uta horopeta o 180 mg
aru i te whakahaere o te 90 mg 2 nga wa i te ra) ranei clopidogrel (uta horopeta 600
aru i te whakahaere
75 mg / ra). Ko te tūtohutanga a te Pākehā Society o Cardiology ta e
prasugrel me ticagrelor clopidogrel whai hua ake i roto i ngā o te whakaiti
auau ngā endpoints rere pūroto, me te stent Thrombosis i roto i tūroro
MI tairanga ST, a kore e whakanui i te reira i te mōrea o
pakaruhanga toto. e kore he prasugrel E ai ki nga kupu tohutohu o te kaihe 2013
taunaki ana mō ngā tūroro ki
he hītori o te patunga Tia ranei. I roto i te kaupapa e mua ki tomo te
institution hauora ki te mahi angiography coronary me stenting manawanui
I whakamana fibrinolysis a ko reira iti iho i te 24 haora, me te kore hoki te wā ano i whakamahia
clopidogrel (prasugrel), ka clopidogrel uta horopeta ko 300 mg,
Prasugrel Ko te 60 mg.

I mōrea tiketike
Thrombosis intracoronary, me ki therapy antiplatelet rua
E taunaki ana te reira i te whakamahi o inhibitors GPIIb-IIIA (abciximab / v bolus o 0,25 mg / kg aru e whaowhia o 0,125 mg / kg / min ki
te taumata mōrahi o te 10 mg / min mō te 12 haora.). I reira i reira he kore
tuturu taunakitanga pai nui GPIIb-IIIA inhibitors ka whakamahia i roto i
prehospital i mua i catheterization ranei.

rite te
whakamahia UFH anticoagulation therapy te (i roto i te / i roto i te bolus 60 U / kg i roto i ngā ki te inhibitor GPIIb-IIIA / bolus ranei 100 U / kg waho
GPIIb-IIIA) inhibitor. Bivalirudin rite monotherapy hei utu UFH i roto i ngā ki te inhibitor o GPIIb-IIIA rite tūtohutia e ACC 2013
taunaki ana mō ngā tūroro ki mōrea tiketike o nui toto (bolus o 0.75 mg / kg aru e whaowhia o 1.75
mg / kg / haora); I te wa ano, e kore te fondaparinux tūtohu hoki o te tūpono tiketike
Thrombosis pū tōngāmimi.

E ai ki whai i te tauākī i
Kei te whakamahia hōhipera therapy antiplatelet rua hoki i te iti rawa 12 marama.

kia utua ngā whakarongo ki te huinga o
clopidogrel me iraoho papu inhibitors, noa whakamahia hoki te ārai o
toto gastrointestinal. E ai ki te whakaaro o te rōpū mahi mo te ārai o te thrombotic
a ngā fifi hemorrhagic ICSI whakamahi o taero ki tūroro
e kore e whakaaturia tūpono iti o GI toto, kia ratou te whakamahi katoatia kia wehewehea i runga i te pūtake o
tango ki pūkete nga painga me ngā mōrea. anake
Ppi rongoā i te rōpū - pantoprazole - e kore te "whakataetae" klopidoglelya
hoki isoenzyme CYP2C19. I te tahi atu te ringa
kahore tamataraa haumanu-kounga teitei te aromātai i te pānga o te tahi
tono pantoprazole me clopidogrel
ki te whakaiti i te tūponotanga o te Cardiovascular katoatia me hemorrhagic
pōauautanga. Tērā kia H2 ppi blockers receptor - famotidine, ranitidine.

rongoā ngā
therapy

E faataahia Beta-blockers i roto i te 24 haora tuatahi i te wa o te tūroro katoa ki ACS
i roto i te ngaro o te kore ngakau ki syndrome putanga iti,
ru cardiogenic me contraindications paerewa ki te whakamahi o tenei rōpū o taero.
blockers Urunga peta tonu puta noa i te wā o te hohipera, me i muri i
tauākī.
E whakaritea ACE inhibitors
tūroro katoa ki te infarction myocardial mārōrō, pana hautanga iti iho i te 40% i roto i te ngaro o
contraindications. Ki te mea i reira he contraindications mō inhibitors ACE e whakamahia blockers
angiotensin II receptor. te raveraa ra
aldosterone tohua i roto i te tūroro ki te kore te ngakau symptomatic
a / ko te aroaro ranei o te mate huka. whakamahi auroa o statins katoa whakaaturia
tūroro ki ACS (kahore he contraindications).