iv. javaxiSvilis sax. Tbilisis saxelmwifo...
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1 iv. javaxiSvilis sax. Tbilisis saxelmwifo universiteti rusudan aglaZe mwvave tranzitoruli segmentur-balonuri kardiomiopaTiis sindromologiuri sistematizaciis alternativebi disertacia 2012 avtoris stili daculia
Transcript of iv. javaxiSvilis sax. Tbilisis saxelmwifo...
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iv. javaxiSvilis sax. Tbilisis saxelmwifo universiteti
rusudan aglaZe
mwvave tranzitoruli segmentur-balonuri kardiomiopaTiis
sindromologiuri sistematizaciis alternativebi
disertacia
2012
avtoris stili daculia
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sadisertacio naSromi Sesrulebulia
iv. javaxiSvilis saxelobis universiteti, medicinis fakulteti
samecniero xelmZRvanelebi:
zurab faRava
medicinis mecnierebaTa doqtori, profesori
roman SaqariSvili
medicinis mecnierebaTa doqtori, profesori
saqarTvelos mecnierebaTa akademiis wevr-korespondenti
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sarCevi
Sesavali ------------------------------------------------------------------5
Tavi I. literaturis mimoxilva ------------------------------------------ 14
1.1 mwvave balonuri sindromi – terminologia, gavrceleba, demografiuli da klinikuri maxasiaTeblebi. sadiagnozo kriteriumebi, sindromis aRmocenebis trigeruli faqtorebi-14
1.2 mwvave balonuri sindromis eleqtrokardiografiuli maxasiaTeblebi ------------------------------------------------------------------------21
1.3 mwvave balonuri sindromi da kardiospecifiuri biomarkerebi---22
1.4 mwvave balonuri sindromis mqone pacientebSi marcxena parkuWis kaTeterizaciis monacemebi da specifiuri eqokardiografiuli korelatebi ------------------------------------------------------------------------------------23
1.5 mwvave balonuri sindromis ganviTarebis etiopaTogenezuri Teoriebi ---------------------------------------------------------------------------------24
1.6 anevrizmuli subaraqnoiduli hemoragia da kardiuli darRvevebi. subaraqnoiduli hemoragiis fonze ganviTarebuli miokardiuli dazianebis neirogenuli meqanizmi -----------------------------------------27
1.7 anevrizmuli subaraqnoiduli hemoragiis fonze aRmocenebuli miokardiumis kumSvadi funqciis tranzitoruli darRveva (globaluri da/an regionuli sistoluri disfunqcia) ----------29
1.8 mwvave subaraqnoiduli hemoragia da eleqtrokardiografiuli cvlilebebi ----------------------------------------------------------------------------32
1.9 mwvave anevrizmuli subaraqnoiduli hemoragia da kardiospecifiuri biomarkerebi ---------------------------------------------35
Tavi II. gamokvleuli kontigenti da kvlevis meTodebi ----36
2.1 gamokvleuli kontigentis daxasiaTeba -----------------------------------36
2.2 kvlevis meTodebi -------------------------------------------------------------------38
2.3 statistikuri analizi ------------------------------------------------------------42
Tavi III. kvlevis Sedegebi --------------------------------------------------------43
3.1 klinikuri maxasiaTeblebi, prezentacia, trigeruli faqtorebi da Tanmxlebi paTologiebi pacientebSi apikaluri balonuri sindromiT da miokardiumis mwvave infarqtiT ------------------------------------43
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3.2 eleqtrokardiografiuli monacemebi pacientebSi mwvave apikaluri balonuri sindromiT da miokardiumis mwvave infarqtiT ----------54
3.3 eqokardiografiuli monacemebi pacientebSi mwvave balonuri sindromiT da miokardiumis mwvave infarqtiT -----------------------------------62
3.4 kardiospecifikuri markerebi, BNP da stresuli hormonebis maCveneblebi pacientebSi mwvave balonuri sindromiT da miokardiumis mwvave infarqtiT ----------------------------------------------77
3.5 koronaruli angiografiis da marcxena parkuWis ventrikulografiuli gamokvlevis Sedegebi pacientebSi mwvave balonuri sindromiT da miokardiumis mwvave infarqtiT --82
3.6 klinikuri mimdinareoba da garTulebebi pacientebSi apikaluri balonuri sindromiT da miokardiumis mwvave infarqtiT --------85
3.7 klinikuri da demografiuli maxasiaTeblebi pacientebSi anevrizmuli subaraqnoiduli hemoragiis fonze arsebuli tranzitoruli kardiomiopaTiiT da kardiuli disfunqciis gareSe ------------------------------------------------------------------------------------------------------87
3.8 eleqtrokardiografiuli cvlilebebi pacientebSi anevrizmuli subaraqnoiduli hemoragiis fonze arsebuli tranzitoruli kardiomiopaTiiT da kardiuli disfunqciis gareSe -----------------------92
3.9 kardiospecifikuri markerebis maCveneblebi pacientebSi anevrizmuli subaraqnoiduli hemoragiis fonze arsebuli tranzitoruli kardiomiopaTiiT da kardiuli disfunqciis gareSe -------------------------------------------------------------------------------------------------------98
3.10 eqokardiografiuli monacemebi pacientebSi anevrizmuli subaraqnoiduli hemoragiis fonze arsebuli tranzitoruli kardiomiopaTiiT da kardiuli disfunqciis gareSe ------------------------100
3.11 klinikuri mimdinareoba da garTulebebi pacientebSi anevrizmuli subaraqnoiduli hemoragiis fonze arsebuli tranzitoruli kardiomiopaTiiT da kardiuli disfunqciis gareSe -----------------------------------------------------------------------------------104
Tavi IV. miRebuli Sedegebis ganxilva ----------------------------107
daskvnebi -------------------------------------------------------------------------119
gamoyenebuli literatura -----------------------------------------------123
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Sesavali
aqtualoba
Tavis tvinsa da kardiovaskulur sistemas Soris damokidebuleba
kompleqsuria da gulisxmobs gulsisxlZarRvTa sistemis normaluri
funqcionirebis SenarCunebas, Tumca SesaZlebelia sxvadasxva saxis
stresuli faqtorebis zemoqmedebam fiziologiuri adaptaciuri
meqanizmebis darRveva gamoiwvios. samedicino literaturaSi
dokumentirebulia uecari sikvdilis araerTi SemTxveva gamowveuli
Zlieri emociuri Sokis (SiSis an mwuxarebis) [72, 213, 222], bunebrivi
katastrofebis an socialuri kataklizmebis zegavleniT [277]. Tumca
emociuri an fizikuri stresis pirdapiri zegavlena gulis kumSvad
funqciaze bolo dromde naklebad Seswavlil fenomens warmoadgenda.
stresTan dakavSirebuli kardiomiopaTiuri sindromi (Stress-related
cardiomyopathy syndrome) SedarebiT axali cnebaa da am saxelwodebis qveS
sxvadasxva paTologiuri mdgomareobis fonze aRmocenebuli miokardiumis
kumSvadobis tranzitoruli disfunqcia ganixileba [33], maprovocirebel
faqtorad SesaZloa gansxvavebuli klinikuri mdgomareoba mogvevlinos,
avtonomiuri StormiT inducirebuli miokardiumis tranzitoruli kumSvadi
disfunqciis aRmoceneba calkeul SemTxvevaSi SesaZloa dakavSirebuli
iyos Zlier emociur stresTan (mwvave emociur an fizikur tramvasTan)
[1,3,4], mwvave intrakranialur sisxlCaqcevasTan (anevrizmis gaskdomis
Sedegad subaraqnoiduli an parenqimuli hemoragia) [26, 51, 62, 219, 220],
feoqromocitomuri krizTan [80, 168, 224, 240, 254, 288] , kateqolaminebis
endogenur administrirebasTan [4, 210], mwvave septiuri mdgomareobasTan [44,
48, 137, 153, 192, 194, 207, 237], an kritikulad mZime daavadebebis arsebobasTan
[61, 216, 217, 253, 271].
1942 wels Cannon-is mier warmodgenil naSromSi pirvelad iqna
warmodgenili masala Zlieri SiSis an sxva emociuri faqtoris zegavleniT
gardacvlil adamianTa Sesaxeb ('" Vodoo death") da avtoris mier gamoTqmul
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iqna mosazreba paTofiziologiur meqanizmSi simato-adrenaluri sistemis
aqtiuri monawileobis Taobaze [36].
1980 wels Cebelin da Hirsch –is mier Zaladobrivad gardacvlil adamianTa
autofsiuri masalis Seswavlisas gamovlinda miokardiumis dazianebis
specifikuri, kateqolaminebiT inducirebuli miokardiuli dazianebisTvis
damaxasiaTebeli suraTi, da avtorebis mier pirvelad iqna gamoyenebuli
termini ‘adamianis stress kardiomiopaTia’ (Human stress cardiomyopathy) [37].
Semdgomma gamokvlevebma gaamyara mosazreba, rom, emociuri an fizikuri
stresiT gamowveuli miokardiuli staningis aRmocenebaSi mniSvnelovan
paTofziologiur rols TamaSobs simpatikuri regulaciuri meqanizmebis
darRveva [11, 41, 43, 145] da miokardiumze kateqolaminebiT zezRurblovani
stimulaciuri zemoqmedeba [7, 11, 13, 40]. pacientebs stresiT inducirebuli
kardiomiopaTiiT klinikuri manifestaciis momentisaTvis aReniSnebaT
sisxlSi mocirkulire kateqolaminebis da stresuli neiropeptidebis
momatebuli koncentracia [8,9, 47], rac simpaToneiruli da
adrenomedularuli sitemebis aqtivaciaze miuTiTebs. eqsperimentuli
kvlevebiT dadgenilia, rom kateqolaminebiT Warbi stimulaciis pirobebSi
adgili aqvs kardiomiocitebis specifikur dazianebas, romelic
miocitolizisis anu kumSvadi jaWvebis nekrozis (contraction band necrosis)
saxiT vlindeba da calsaxad gansxvavdeba miokardiumis iSemiiT
inducirebuli dazianebisagan [12, 70, 119, 145, 214,264].
sxvadasxva stresuli mdgomareobis fonze aRmocenebuli kardiuli
darRvevebi SesaZloa manifestirdnen klinikurad da
eleqtrofiziologiurad msgavsi, xolo paTomorfologiurad
heterogenuli simptomokompleqsiT da warmodgenili arian mwvave
tranzitoruli segmentur-balonuri kardiomiopaTiis saxiT.
mwvave fazaSi arsebuli simptomebis, ekg monacemebisa da kardiuli
markerebis matebiT mwvave tranzitoruli segmentur-balonuri
kardiomiopaTiis sxvadasxva forma mniSvnelovnad emsgavseba mwvave
koronarul sindroms, Tumca angiografiuli gamokvleva am pacientebSi ar
adasturebs koronaruli epikardiuli arteriebis hemodinamikurad
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mniSvnelovani stenozirebis arsebobas, rac iSemias rogorc sindromis
ganviTarebis SesaZlo paTogenezur safuZvels gamoricxavs [1, 2, 6, 30, 31, 57].
emociuri da fizikuri stresis fonze adgili aqvs limbiuri sistemis
aqtivacias [70], hipokampusi da tvinis insularuli nawili centralur
rols TamaSoben kardiovaskularuli sistemis funqcionirebis
regulaciaSi [55, 64]. maTi aqtivacia ganapirobebs medularuli avtonomiuri
centris stimulacias da Sedegad pre da postsinafsur neironebSi
norepinefrinis da misi neironuli metabolitebis gamoTavisuflebas [47, 49,
50]. adgili aqvs kardiul da eqstrakardiul simpaTikur nervul
daboloebebSi kateqolaminebis Warb producirebas da maT mier
sisxlZarRvTa da gulis adrenoreceptorebze stimulaciur zemoqmedebas
[279, 280].
sainteresoa is faqti, rom mwvave tranzitoruli segmentur-balonuri
kardiomiopaTiis praqtikulad yvela formis SemTxvevaSi mwvave infarqtis
pacientebTan SedarebiT sindromis manifestaciis inicialur mwvave fazaSi
mniSvnelovnad maRalia plazmaSi kateqolaminebis da maTi metabolitebis
maT Soris neiropeptid YY-s koncentracia ( es ukanaskneli postgangliuri
simpatikuri neironebidan gamoTavisufldeba). maSin rodesac
eqstraneironuli kateqolaminebis metabolitebis (metanefrini da
normetanefrini) koncentracia mmi-is stres kardiomiopaTiis mqone
pacientebSi praqtikulad identuria [280]. aRniSnuli faqti gvafiqrebinebs,
rom stresis fonze aRmocenebuli miokardiumis tranzitoruli kumSvadi
disfunqcia SesaZloa nervul daboloebebSi gamoTavisuflebuli
kateqolaminebis pirdapiri toqsiuri zemoqmedebis Sedegi iyos [83].
arsebobs mniSvnelovani msgavseba mwvave tranzitoruli segmentur-
balonuri kardiomiopaTiis sxvadasxva formas, neirogenur-stres
kardiomiopaTiasa (NSC) da mwvave balonur sindroms Soris. 2003 wels Ako
da kolegebis mier pirvelad iqna gamoTqmuli mosazreba, rom, orive
SemTxvevas safuZvlad msgavsi fiziologiuri meqanizmi udevs.
Ogamoxatulia mkveTri genderuli ganwyoba, marcxena parkuWis
tranzitoruli sistoluri disfunqciis arseboba koronaruli
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obstruqciuli daavadebis ararsebobis fonze, iSemiisaTvis
damaxasiaTebeli ekg cvlilebebis da kardiuli enzimebis koncentraciis
umniSvnelo mateba. Tumca maT Soris mniSvnelovani ganmasxvavebeli niSnebi
vlindeba regionaluri kumSvadobis da zogierTi ekg parametris
TvalsazrisiT
mwvave balonuri sindromi pirvelad gasuli saukunis oTxmocdaTiani
wlebis dasawyisSi iaponur populaciaSi iqna aRwerili [60, 225, 226],
aRniSnuli sindromi literaturaSi e.w. Tako-Tsubo kardiomiopaTiis an e.w
@’gabzaruli gulis’ ( ‚broken heart’ ) saxeliTac moixseneba [18, 30, 31].
damaxasiaTebelia marcxena parkuWis sistoluri disfunqciis specifikuri
eqokardiografiuli korelati, kerZod apikaluri da Sua segmentebis
kumSvadi funqciis mkveTri darRveva bazaluri segmentebis normaluri,
Senaxuli sistoluri funqciis fonze. regionuli kumSvadi funqciis
darRveva ar Seesabameba romelime koronaruli arteriis sairigacio zonas
da Cveulebriv reverzibeluri xasiaTisaa [82]. mwvave periodSi aRiniSneba
iSemiisTvis specifiuri kardiuli markerebis raodenobis mcire,
regionaluri darRvevebisadmi disproporciuli mateba [30, 124]. Tumca
gulis magnitur-rezonansuli da scintigrafiuli gamokvlevebiT iSemiuri
nekrozisaTvis damaxasiaTebeli cvlilebebis aRmoCena ar xerxdeba [18, 166].
endomiokardiuli biofsiiT ki zogierT SemTxvevaSi vlindeba
miocitolizisis suraTi rac kateqolamininducirebuli
kardiotoqsiurobis damadasturebeli niSania [16, 33, 69].
marcxena parkuWis reverzibeluri disfunqcia asocirebuli mwvave
subaraqnoidul hemoragiasa da sxva saxis intrakranialur
sisxlCaqcevasTan kargad cnobili fenomenia da am paTologiis mqone
pacientTa daaxloebiT 20-30%-Si vlindeba [33, 170]. aRniSnuli sindromi
nevrogenuli stres kardiomiopaTiis (e.w. ‚neurogenic stress cardiomyopathy’)
saxeliTaa cnobili da arsebobs mosazreba, rom mis paTofiziologiur
meqanizms miokardiumis nevrogenuli staningi warmoadgens [176, 177, 185].
SemTxvevaTa 75-92 %-Si aseve marcxena parkuWis kumSvad disfunqciasTan
erTad warmodgenilia sxvadasxva saxis eleqtrokardiografiuli
cvlilebebi [146, 188, 215, 219]. mwvave apikaluri balonuri sindromis
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msgavsad paTognomur ekg niSans warmoadgens T kbilis Rrma, simetriuli
inversia, QT-intervalis prolongireba, gamokveTili U-talRa an ST-
segmentis depresia prekordialur ganxrebSi, sxvadasxva tipis riTmis
darRvevis aRmoceneba. es ukanaskneli xSirad asaxavs dagvianebul
parkuWovan repolarizacias da parkuWovani ariTmiisadmi mzaobas. Ggulis
eleqtrogenezis aRniSnuli cvlilebebis meqanizms safuZvlad udevs
intensiuri simpaTikuri stimulacia, ganpirobebuli insuluri qerqis
iritaciiT. mwvave periodSi aRiniSneba miokardis dazianebis markerebis
koncentraciis mcire momateba rac kumSvadi funqciis darRvevis
disproporciulia [185, 188, 190, 191]. Aarsebobs mosazreba, rom Tavis tvinis
mwvave dazianebis fonze adgili aqvs miokardiumis simpatikur nervul
terminalebSi norepinefrinis masiur gamoTavisuflebas, rac Tavismxriv
adgilobrivad miocitebis liziss da kontraqtilur disfunqcias iwvevs
[179, 180, 182, 209]. subaraqnoiduli hemoragiis fonze aRmocenebuli
miokardiuli disfunqciisTvis damaxasiaTebelia upiratesad marcxena
parkuWis bazaluri da Sua segmentebis kumSvadi funqciis darRveva [245, 247,
255]. regionaluri disinergiis zemoTaRniSnuli modeli (upiratesad
bazaluri disfunqcia) zustad Seesabameba marcxena parkuWSi simpatikuri
nervuli daboloebebis anatomiur ganawilebas da amyarebs mosazrebas
subaraqnoiduli hemoragiis fonze miokardiumis dazianebis neirogenul
meqanizmis Taobaze [112, 123]. amasve metyvelebs is faqtic, rom plazmuri
noradrenalinisa da miokardiumis kumSvad disfunqcias Soris korelacia
anevrizmuli subaraqnoiduli hemoragiis fonze ganviTarbul
kardiomiopaTiis SemTxvevaSi kanonzomierebas ar warmoadgens [87].
ganviTarebis xasiaTiT, klinikur-laboratoriuli niSnebiT da
maxasiaTeblebiT mwvave tranzitoruli segmentur-balonuri
kardiomiopaTiis calkeuli varianti gamokveTilad emsgavseba mwvave
koronarul sindroms an iSemiiT inducirebul miokardiul dazianebas,
Tumca sruliad gansxvavebuli fiziologiuri safuZveli gaaCnia. dRemde
Riad rCeba sakiTxi, SesaZlebeli aris Tu ara zusti diferencialuri
diagnozireba klinikuri manifestaciis adreul etapze, radgan es
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principulad mniSvnelovania mkurnalobis swori taqtikis dagegmvis da
aramiznobrivi invaziuri procedurebis Catarebis asacileblad.
rogorc cnobilia neirogenuli stress kardiomiopaTia asocirebulia
vazospazmiT ganpirobebuli insultis aRmocenebis da sikvdilobis
momatebul riskTan. amdenad, mniSvnelovania SesaZlo maprovocirebeli
faqtorebisa da pacientTa maRali riskis jgufis gamovlena Semdgomi
garTulebebis prevenciis TvalsazrisiT. zemoT aRniSnulidan gamomdinare
aqtualurad migvaCnia mwvave tranzitoruli segmentur-balonuri
kardiomiopaTiis sxvadasxva formis klinikuri manifestaciis, savaraudo
riskis faqtorebis da specifikuri klinikuri maxasiaTeblebis
identificireba maTi ganviTarebis adreul etapebze daavadeba
modificirebis zomebis ganxorcielebiT.
warmodgenili kvlevis mizani
mwvave tranzitoruli segmentur-balonuri kardiomiopaTiis nozografiuli
sistematizacia, rac gaadvilebs diagnozur-prognozuli kriteriumebis
identificirebas da safuZvlad daedeba sindromisadmi Terapiuli taqtikis
optimizacias klinikur, eleqtrofiziologiur, radiologiur da
humoralur korelatebze da eTiologiur heterogenobaze fokusirebiT.
kvlevis amocanebi:
1. mwvave tranzitoruli segmentur-balonuri kardiomiopaTiis mqone
pacientebSi klinikuri da diagnostikuri maxasiaTeblebisa da marcxena
parkuWis struqturul-funqciuri mdgomareobis Seswavla, specifiuri
sadiferenciacio kriteriumebis dadgenis mizniT, agreTve kateqolaminebiT
inducirebuli kardiuli staningis Taviseburebebis Sesafaseblad.
2. anamnezuri, demografiuli, klinikuri monacemebis, Tanmxlebi
paTologiebis, daavadebis mimdinareobis Taviseburebebisa da simZimis,
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garTulebebis Sefaseba pacientebSi mwvave balonuri sindromiT,
anevrizmuli subarqnoiduli hemoragiis fonze ganviTarebuli
kardiomiopaTiiT da miokardiumis mwvave infarqtiT (STEMI);
3. eleqtrokardiografiuli monacemebis (ST-segmentis, T –kbilis, QT-
intervalis) cvlilebebis Seswavla daavadebis klinikuri manifestaciis
sxvadasxva etapze pacientebSi mwvave balonuri sindromiT, anevrizmuli
subarqnoiduli hemoragiis fonze ganviTarebuli kardiomiopaTiiT da
miokardiumis mwvave infarqtiT (STEMI).
4. marcxena parkuWis sistolur-diastoluri funqciis Sefaseba daavadebis
klinikuri manifestaciis sxvadasxva etapze pacientebSi mwvave balonuri
sindromiT, anevrizmuli subarqnoiduli hemoragiis fonze ganviTarebuli
kardiomiopaTiiT da miokardiumis mwvave infarqtiT (STEMI).
5. miokardiumis dazianebis specifiuri markerebis cvlilebebis Sefaseba
daavadebis klinikuri manifestaciis sxvadasxva etapze pacientebSi mwvave
balonuri sindromiT, anevrizmuli subarqnoiduli hemoragiis fonze
ganviTarebuli kardiomiopaTiiT da miokardiumis mwvave infarqtiT (STEMI).
6. sxvadasxva laboratoriuli parametris (eleqtrolitebi, tvinis
natriurezuli hormoni) cvlilebebis Sefaseba daavadebis klinikuri
manifestaciis sxvadasxva etapze pacientebSi mwvave balonuri sindromiT,
anevrizmuli subarqnoiduli hemoragiis fonze ganviTarebuli
kardiomiopaTiiT da miokardiumis mwvave infarqtiT (STEMI).
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naSromis samecniero siaxle
mwvave tranzitoruli segmentur-balonuri kardiomiopaTia (balonuri
sindromi, tako-cubo kardiomiopaTia) warmoadgens pirveladad SeZenili
kardiomiopaTiebis gansakuTrebul formas, Mmisi klasificireba kliniko-
eleqtrofiziologiuri da radiogamosaxulebiTi polimorfizmis
Sesabamisad racionalurs xdis aRniSnuli sindromi daiyos or
gansxvavebul jgufad: a) pirveladi forma romlis manifestireba xdeba
adreulad mwvave koronaruli sindromis msgavsi klinikuri suraTis
ganviTarebisTanave da b) meoradi forma romlis SemTxvevaSi miokardis
kontraqtiluri disfunqcia diagnozirdeba sxva mwvaved mimdinare
fonuri eqstrakardialuri paTologiis simptomokopleqsis farglebSi.
pirveli variantisTvis damaxasiaTebelia e.w. klasikuri tipi apikaluri
balonirebiT da genderul-asakobrivi specifikurobiT. meore varianti ki
adreul stadiaSi nivelirdeba srulad Camoyalibebul fonur da
komorbidul paTologiebs Soris.
balonuri kardiomiopaTiis mqone pacientebs miokardiumis mwvave
infarqtis jgufis pacientebTan SedarebiT axasiaTebT ramdenime
kardiovaskuluri riskis faqtoris erTdrouli arsebobis SedarebiT
dabali maCvenebeli da piriqiT, anamnezSi fsiqomatramvirebeli an
endogenuri, izolirebulad momqmedi stresuli faqtoris sarwmunod
maRali sixSire. ukanaskneli garemoeba xazs usvams aRniSnuli ori
paTologiis ganviTarebis meqanizmebis araerTgvarovnebas da
SesaZlebelia mniSvnelovani sadiferenciacio Rirebuleba gaaCndes.
pacientebSi mwvave tranzitoruli segmentur-balonuri kardiomiopaTiiT
identificirebuli iqna eleqtrokardiografiuli, eqokardiografiuli
da laboratoriuli maxasiaTeblebi romelTac miokardiumis mwvave
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infarqtisgan sadiferenciaciod SesaZloa mniSvnelovani praqtikuli
Rirebuleba gaaCndeT:
1. mwvave fazaSi mwvave balonuri sindromis mqone pacientebSi
miokardiumis mwvave infarqtis jgufis pacientebTan SedarebiT ST-
segmentis elevaciis xarisxi mniSvnelovnad dabalia, xolo ST-segmentis
reciprokuli depresiis ararseboba maRal sensitiur markers
warmoadgens
2. mwvave balonuri sindromis mqone pacientebSi gamoxatulia
inicialuri sistoluri funqciis da regionuri kumSvadobis indeqsis
mniSvnelovnad dabali maCvenebeli, Tumca marcxena parkuWis sarwmunod
ukeTesi diastoluri avsebis monacemi miokardiumis mwvave infarqtis
mqone pacientebTan SedarebiT.
3. damaxasiTebelia sisxlSi kateqolaminebis maRali koncentracia,
troponinis umniSvnelo, kumSvadi funqciis darRvevis disproporciuli
mateba, plazmaSi BNP-is (tvinis natriurezuli hormonis) momatebuli
koncentracia xolo miokardiumis mwvave infarqtis mqone pacientebSi
sapirispirod kardiuli markerebis mniSvnelovnad gamoxatuli mateba
kateqolaminebis normalur koncentraciasTan da BNP-is mcired
momatebul maCvenebelTan kombinaciaSi.
14
Tavi I
literaturis mimoxilva
1.1 mwvave balonuri sindromi – terminologia, gavrceleba,
demografiuli da klinikuri maxasiaTeblebi. sadiagnozo
kriteriumebi. sindromis aRmocenebis trigeruli faqtorebi.
sxvadasxva morfologiuri variantebi
mwvave balonuri sindromi warmoadgens gulis kumSvadi funqciis
tranzitoruli darRvevis im variants romelic warmodgenilia Semdegi
simptomokompleqsiT: marcxena parkuWis kumSvadobis mwvaved
ganviTarebuli tranzitoruli disfunqcia, damaxasiaTebeli specifikuri
regionaluri darRvevebiT, eleqtrokardiografiuli cvlilebebi romlebic
xSir SemTxvevaSi mkafiod emsgavsebian mwvave koronaruli sindromisTvis
damaxasiaTebel suraTs, kardiuli enzimebis mateba da koronarografiulad
intaqturi sisxlZarRvebis arseboba. sindromi pirvelad aRweril iqna
iaponiaSi 1991 wels, Dote –is da kolegebis mier warmodgenil iqna 5
pacientis SemTxveva romelSic kardiuli difunqciis axali,
damaxasiaTebeli klinikuri suraTi iqna aRwerili da kardiomiopaTia tako-
cubo kardiomiopaTiis saxeliT iqna moxseniebuli 2, [60, 82, 88, 225, 226, 259].
mogvianebiT sxvadasxva literaturul wyaroebSi sindromi moixseneboda
rogorc mwvave balonuri sindromi, mwvave apikaluri balonuri sindromi
(acute apical ballooning syndrome) [5, 6,28,108,167], ampula kardiomiopaTia (ampula
cardiomyopathy) [82, 124], tranzitoruli apikaluri balonuri kardiomiopaTia
[104, 202, 203, 204], gabzaruli gulis sindromi (broken heart syndrome) [3] da a.S .
2001 wels gamoqveynda pirveli multicentruli kvlevis Sedegebi [259]
romelic am sindromis iaponur polulaciaSi gavrcelebas asaxavda da 88
pacientis monacems aerTianebda. sindromis arseboba evropul populaciaSi
pirvelad Desmet da kolegebis mier 2003 wels iqna aRwerili [53],
warmodgenil iqna 1998-2002 wlebSi belgiaSi diagnostirebuli 13 SemTxvevis
analizi, xolo 2004 wels gamoqveynda mwvave apikaluri balonuri
15
sindromis pirveli SemTxvevebi amerikis SeerTebuli Statebis
mosaxleobaSi. [81]. mogvianebiT sindromis SemTxvevaTa arseboba
praqtikulad yvela kontinentze aRiwera [65-70, 77, 104, 139].
sindromis zusti gavrceleba ucnobia, Tumca sxvadasxva kvlevis monacemiT
mwvave balonuri sindromis diagnostireba xdeba ST-segmentis elevaciiT
mimdinare savaraudo mwvave koronaruli sindromis SemTxvevaTa 1.7-2.2%-Si
[56].
2004 wels Baybee da kolegebis mier SemuSavebul iqna mwvave balonuri
sindromis sadiagnostiko kriteriumebi, romelic Mayo-s klinikis
kriteriumebis saxeliTaa cnobili. sindromis diagnozis dasasmelad
aucilebelia Semdegi klinikuri kriteriumis arseboba:
1. marcxena parkuWis apikaluri da Sua segmentebis tranzitoruli akinezia
an diskinezia, regionaruli darRvevebi scildeba erTi koronaruli
arteriis vaskularizaciis zonas.
2. angiografiulad mniSvnelovani koronaruli obstruqciis ararseboba an
aTerosklerozuli folaqis rupturis ararseboba.
3. axlad aRmocenebuli eleqtrokardiografiuli cvlilebebi (ST-segmentis
elevacia an T kbilis inversia).
4. Semdegi paTologiebis ararseboba:
Tavis tramvuli dazianeba.
intrakranialuri sisxlCaqceva.
feoqromocitoma.
epikardiuli koronaruli arteriebis obstruqciuli daavadeba.
miokarditi.
hipertrofiuli kardiomiopaTia
16
2008 wels arsebuli masalis analizis safuZvelze SemoTavazebuli
sadiagnostiko kriteriumebi gadaxedil iqna, mciredi modificireba
ganicada da mowodebul iqna Mayo-s klinikis modificirebuli
kriteriumebi, romlebic dResdReobiT aRiarebulia apikaluri balonuri
sindromis sadiagnostiko:.
1. marcxena parkuWis Sua segmentebis tranzitoruli hipokinezia, akinezia
an diskinezia, marcxena parkuWis apikaluri ubnis kumSvadobis darRveviT an
mis gareSe. regionaruli darRvevebi scildeba erTi epikardiuli
koronaruli arteris vaskularizaciis ubans. xSiria (Tumca yovelTvis ar
gvxvdeba) maprovocirebeli stresuli faqtoris arseboba
2. angiografiulad mniSvnelovani koronaruli obstruqciis ararseboba an
aTerosklerozuli folaqis rupturis ararseboba.
3. axlad aRmocenebuli eleqtrokardiografiuli cvlilebebi (ST-segmentis
elevacia da/an T kbilis inversia) an kardiuli troponinis koncentraciis
mciredi momateba.
4. Semdegi paTologiebis ararseboba:
feoqromocitoma
miokarditi
2006 wels amerikis gulis asociaciis mier sindromi Setanil iqna
kardiomiopaTiebis klasifikaciaSi rogorc pirveladad SeZenili
kardiomiopaTia [155]
mwvave balonuri sindromi upiratesad qalebSi gvxvdeba, mkveTri genderuli
ganwyoba sxvadasxva monacemebis mixedviT SemTxvevaTa 82-100%-Si fiqsirdeba
[55, 65-70] da pacientTa asaki 10-dan 89 wlamde meryeobs (saSualo asaki 58-
77 welia [23, 67]. bolomde Seswavlli araa Tu ratom aRmocendeba
sindromi upiratesad postmenopauzuri asakis qalebSi. arsebobs mosazreba,
rom sasqeso hormonebi (kerZod estrogenebi) mniSvnelovan zegavlenas
axdenen simpaTikur neirohumorul reaqciebze, iseve rogorc koronarul
vazoreaqtiulobaze [58]. sainteresoa, rom stresTan dakavSirebuli
17
miokardiuli disfunqciis praqtikulad yvela forma upiratesad
mdedrobiTi sqesis warmomadgenlebSi gvxvdeba, rac garkveul
tendenciurobaze miuTiTebs, Tumca kateqolaminebis metabolizmis
Taviseburebani qalebSi da mamakacebSi erTob kompleqsuria, mamakacebSi
qalebTan SedarebiT fonuri simpaTikuri aqtivoba maRalia [7,8], emociuri
stresis fonze plazmaSi mocirkulire kateqolaminebis koncentraciis
ufro mkveTri zrda SeiniSneba [218, 125], da kateqolaminebiT inducirebuli
vazokonstriqciis mimarT mgrZnobelobac metad gazrdilia [172], Tumca
qalebSi SeiniSneba gazrdili sensitivoba simpaTikurad inducirebuli
staningis mimarT [171, 166, 263, 265].
mwvave balonuri sindromis manifestirebis momentisaTvis yvelaze xSir
klinikur simptomebs tkivili gulis areSi (SemTxvevaTa 62-73%) da qoSini
(SemTxvevaTa 13-23%) warmoadgens [18, 19]. Tumca sindromi SesaZloa
manifestirebuli iyos kardiogenuli Sokis (4.2%) an parkuWTa fibrilaciis
saxiTac (1.5%) [265]. calkeul SemTxvevebSi sawyis simtomad SesaZloa
sinkopec iyos warmodgenili [29, 32, 39].
mwvave balonuri sindromis aRmoceneba xSir SemTxvevaSi dakavSirebulia
mwvave emociuri an fizikuri stresoris arsebobasTan [104], emociuri
stresi SesaZloa dakavSirebuli iyos ojaxis wevrebis an megobrebis
gardacvalebasTan, samsaxureobriv problemasTan, axloblebTan kamaTTan,
seriozul finansur danakargTan da a.S. [198] is SemTxvevaTa 21.7-32.5%-Si
gvxvdeba. fizikuri stresis mizezs xSir SemTxvevaSi warmoadgens mZime
fizikuri samuSao, sxvadasxva qirurgiuli Careva, asTmuri statusi,
stomatologiuri manipulacia da a.S [163], fizikuri stresoris arseboba
SemTxvevaTa 32.1-43.9 %-Si fiqsirdeba. Tumca sxvadasxva kvlevis monacemebis
mixedviT mwvave apikaluri balonuri sindromis SemTxvevaTa daaxloebiT
28.7-40.3 %-Si raime saxis maprovocirebeli fizikuri an emociuri
stresoris identificireba ar xerxdeba [102, 101]. Prasad-is da Tanaavtorebis
mier [202] mowodebuli yvelaze xSirad aRwerili maprovocirebel
faqtorebis CamonaTvalia:
18
emociuri stresis gamomwvevi sxvadasxva faqtorebi – ojaxis wevris an
megobris gardacvaleba, cudi informaciis Setyobineba: informacia
avadmyofobis Taobaze, ganqorwineba, Zlieri emociuri kamaTi, moxsenebiT
gamosvla auditoriis winaSe, finansuri danakargi, saavtomobilo
katastrofa.
fizikuri stresis ganmapirobebeli sxvadasxva faqtorebi: arakardiuli
profilis operaciebi an Carevebi (qolecisteqtomia, histereqtomia,
stomatologiuri manipulacia).
sxvadasxva mZimed mimdinare eqstrakardiuli paTologia, bronquli asTma,
qronikuli obstruqciuli bronqitis gamwvaveba, mwvave qolecistiti,
fsevdomembranozuli koliti.
Zlieri tkivili (gamowveuli kiduris motexilobiT, Tirkmlis kolikiT,
pnevmoToraqsi).
kokainis gamoyeneba.
Tireotoqsikozi.
dobutaminis infuzia stres eqokardiografiis Catarebisas.
arsebobs mosazreba, rom garkveuli paTologiebi da riskis faqtorebi
SesaZloa garkveul maprovocirebel rols TamaSobdnen mwvave apikaluri
sindromis aRmocenebaSi. Burgdorf da kolegebis mier warmodgenil masalaSi
[29] mwvave apikaluri balonuri sindromis mqone pacientebis 23.6% -s
diagnostirebuli hqonda sxvadasxva lokalizaciis avTvisebiani simsivne.
aRniSnuli maCvenebeli ramdenjerme aRemateba avTvisebiani simsivnis zogad
gavrcelebas mozrdilTa populaciaSi (7.8% evropaSi da 8.2% a.S.S.-Si) da
Sesabamisad garkveul mizez-Sedegobriv kavSirze SeiZleba miuTiTebdes [30].
avtorebis azriT, avTvisebiani simsivnis arsebobis SemTxvevaSi pacientebs
SesaZloa aReniSnebodeT momatebuli bazaluri simpaTikuri aqtivobis foni
da paraneoplaziuri mediatorebis zegavlena kardiul receptorebze [78, 69,
105].
19
Summers-is da kolegebis mier warmodgenil naSromSi gamaxvilebul iqna
yuradReba, rom mwvave apikaluri balonuri sindromis mqone pacientebSi
dafiqsirda qronikuli fsiqiatriuli paTologiebis maRali sixSire
(kerZod pacientTa 2/3-s diagnostirebuli hqonda qronikuli SfoTva an
depresia) rac zogad populaciasTan mimarTebaSi gacilebiT maRalia [251]
da sindromis aRmocenebis risk faqtorad SesaZloa iqnas ganxiluli.
Citro-s da kolegebis mier Catarebuli dakvirvebis Sedegad gamoiTqva
mosazreba rom mwvave apikaluri balonuri sindromis aRmocenebas
genderuli da asakobrivi Taviseburebebis garda qronobiologiuri
Taviseburebebic axasiaTebs [39], kerZod mwvave koronaruli sindromisgan
gansxvavebiT, romlis aRmoceneba piks zamTris sezonze aRwevs mwvave
apikaluri balonuri sindromi upiratesad zafxulis TveebSi
manifestirdeba da SemTxvevaTa raodenobrivi piki ivlisis TveSi
aRiniSneba. Tumca riT SeiZleba iyos es ganpirobebuli bundovania.
apikaluri balonuri sindromis sawyisi aRwerisas mkvlevarTa mier
ZiriTadad warmodgenili iyo kardiomiopaTiis is morfologiuri
variantebi sadac marcxena parkuWis kumSvadi funqciis darRveva ZiriTadad
warmodgenili iyo Sua da apikaluri segmentebis hipo-akineziis an
diskineziis saxiT, bazaluri segmentebis normaluri an hiperdinamiuri
sistoluri funqciis fonze [2,3,4, 106, 109]. 2006 wels Hurst da kolegebis
mier pirvelad iqna warmodgenili mwvave apikaluri balonuri sindromis
axali morfologiuri varianti, e.w mid-ventrikuluri forma (midventricular
ballooning) [105]. marcxena parkuWis specifikuri segmenturi asinergiis
suraTiT: Sua segmentebis mkveTrad darRveuli kumSvadobis fonze
apikaluri da bazaluri segmentebis normaluri kumSvadi funqciiT.
SemdgomSi sxvadasxva avtoris mier aRweril iqna apikaluri balonuri
sindromis midventrikuluri variantis araerTi SemTxveva da
statistikurad is warmodgenilia SemTxvevaTa 1/3-Si.
mwvave apikaluri balonuri sindromis farTod diagnostirebis pirobebSi
bolo wlebSi svadasxva axali morfologiuri variantis aRwerac moxda.
2006 wels van de Walle da avtorebis mier pirvelad iqna warmodgenil
20
erTeuli SemTxvevebi mwvave apikaluri balonuri sindromis e.w. invertuli
formis Taobaze (inverted apical ballooning syndrome) [271], marcxena parkuWis
bazaluri segmentebis damaxasiaTebeli disfunqciiT Sua da apikaluri
segmentebis normaluri kumSvadobis fonze. Haghi da kolegebis mier
aRweril iqna apikaluri balonuri sindromis e.w biventrikuluri formebi
[88] marjvena parkuWis gamoxatuli sistoluri disfunqciiT. xolo 2010
wels Mrdovic da kolegebis mier aRweril iqna izolirebulad marjvena
parkuWis tranzitoruli balonirebis SemTxvevebi [162]
21
1.2 mwvave balonuri sindromis eleqtrokardiografiuli
maxasiaTeblebi
mwvave apikaluri balonuri sindromis manifestaciis momentisaTvis
inicialur eleqtrokardiogramaze dafiqsirebuli cvlilebebidan yvelaze
xSiria ST-segmentis elevacia (sxvadasxva monacemebis mixedviT es
maCvenebeli 76.4 – 88.3%-s Seadgens) [30, 23, 29], aseve xSirad fiqsirdeba T-
kbilis inversia (SemTxvevaTa 58.1 -70%) da paTologiuri Q-kbilis arseboba
(25.7 - 38.3%). ST-segmentis elevacia upiratesad prekordialur ganxrebSi
gvxvdeba [2], da miokardiumis mwvave infarqtTan SedarebiT naklebad
manifestirebulia [3, 4, 134]. iSviaT niSans warmoadgens ST-segmentis
konkordantuli cvlilebebi reciprokul ganxrebSi [184], da praqtikulad
ar gvxvdeba ST-segmentis elevacia izolirebulad lateralur an qveda
ganxrebSi [183, 184]. Tamura da kolegebis monacemebiT sakmaod iSviaTad
gvxvdeba ST-segmentis elevacia V1 da aVL ganxrebSi, xolo ST-segmentis
elevacia ≥ 1mm V2-V5 ganxrebSi da imavdroulad ST-segmentis elevaciis
ararseboba V1 ganxraSi SeiZleba miuTiTebdes sindromis arsebobaze 74.2 %
mgrZnobelobiT da 80.6% specifiurobiT, da Sesabamisad klinikuri
mniSvneloba eniWebodes miokardiumis mwvave infarqtisgan adreul etapze
diferencirebaSi [256].
mwvave periodSi damaxasiaTebelia QT-intervalis prolongireba,
(SemTxvevaTa 26-48%-Si) da misi maCvenebeli saSualod 450 -501 msec meryeobs
[57]. QT-intervali uxSiresad normalizacias ganicdis klinikuri sindromis
manifestaciidan 2-3 dReSi [47].
qvemwvave periodSi paTognomur niSans warmoadgens T-kbilis Rrma inversia
romelic sxvadasxva avtoris monacemiT SemTxvevaTa 68-100% -Si aRiniSneba
[183, 184, 256].
mwvave periodSi araiSviaTad gvxvdeba ritmis sxvadasxva tipis darRveva
warmodgenili winagulTa cimcimis [50], parkuWovani eqstrasistoliis an
iSviaT SemTxvevaSi parkuWTa fibrilaciis saxiT [92].
22
1.3 mwvave apikaluri balonuri sindromi da kardiospecifiuri
biomarkerebi
praqtikulad yvela kvlevis monacemiT pacientebs mwvave apikaluri
balonuri sindromiT aReniSnebaT kardiuli markerebis koncentraciis
momateba [286]. kvlevaTa seriaSi [235, 236] sadac gansazRvruli iyo
troponinis maCvenebeli (TnT an TnI) inicialuri momentisaTvis dafiqsirda
troponinis maCveneblis gazrda saSualod 86.2%-Si (72-100%-Si), xolo 3
kvlevis monacemebis mixedviT CK-MB-is koncentraciis mateba dafiqsirda
73.9%-Si (40-100%) [53,67,68,69]. aRsaniSnavia, rom kardiuli markerebis mateba
Cveulebriv mcired gamoxatul xasiaTs atarebs da disproporciulia
arsebuli regionaluri kumSvadi funqciis darRvevis [251].
Akashi et al. monacemebiT mwvave apikaluri balonuri sindromis mqone
pacientebs xSirad aReniSnebaT mwvave fazaSi plazmaSi mocirkulire
natriurezuli peptidis (BNP – brain natriuretic peptide) koncentraciis mateba,
rac parkuWis disfunqciis markeria da misi maCvenebeli mWidro
korelaciaSia marcxena parkuWis saboloo diastolur wnevasTan [4].
23
1.4 mwvave balonuri sindromis mqone pacientebSi marcxena
parkuWis kaTeterizaciis monacemebi da specifiuri
eqokardiografiuli korelatebi
Gianni da kolegebis monacemebiT [82] 14 sxvadasxva kvlevis analizma aCvena,
rom saSualod pacientTa 80.6%-Si (CI: 73.1 -86.4%) aRiniSneboda srulad
intaqturi koronaruli arteriebis arseboba, xolo danarCen SemTxvevebSi
gamoxatuli iyo hemodinamikurad aramniSvnelovani koronaruli
stenozireba (<50%).
marcxena parkuWis gamomaval traqtSi tranzitoruli wnevis gradientis
dafiqsireba sxvadasxva kvlevis monacemebiT SesaZlebeli gaxda SemTxvevaTa
12.5-23%-Si [33, 82].
marcxena parkuWis sistoluri funqciis SefasebisTvis sxvadasxva avtoris
mier gamoyenebulia eqokardiografia, ventrikulografia an gamokvlevis
orive meTodi [2,4,30,31]. inicialuri momentisaTvis pacientebs Cveulebriv
aReniSnebaT marcxena parkuWis globaluri kumSvadi funqciis
mniSvnelovani daqveiTeba, sxvadasxva kvlevis monacemiT gandevnis fraqciis
maCvenebeli meryeobs 20-49%-s Soris [3,82], da segmenturi disfunqciis
mkveTrad damaxasiaTebeli suraTi: marcxena parkuWis Sua da apikaluri
segmentebis akinezia-diskinezia. Tumca klinikidan gaweris momentisaTvis
praqtikulad yvela avtori aRniSnavs globaluri sistoluri funqciis
mniSvnelovan gaumjobesebas manifestirebuls gandevnis fraqciis
maCveneblis mkveTri zrdiT (EF - 60-76%) da regionaluri darRvevebis
praqtikulad srul normalizacias, [4, 53, 82, 138, 140].
24
1.5 mwvave balonuri sindromis ganviTarebis etiopaTogenezuri
Teoriebi
mwvave balonuri sindromis pirveli aRweris Semdeg arsebobs konsensusi
mkvlevarTa Soris miokardiuli staningis arsebobis Taobaze, Tumca am
SemTxvevaSi macxena parkuWis tranzitoruli disfunqciis gamomwvevi zusti
etiopaTogenezi cnobili araa da mizezad ramdenime paTfiziologiuri
meqanizmia mowodebuli, romelTa Soris uxSiresad ganixileba Semdegi
Teoriebi: tranzitoruli epikardiuli vazospazmi [3], mikrovaskularuli
disfunqcia [57,78,98], midventrikuluri obstruqciuli apikaluri staningi
[45,48], kateqolamin inducirebuli miokardiuli staningi [89, 93, 105], da a.S
mwvave balonuri sindromis pirveli, ZiriTadad iaponur populaciaSi
SemTxvevebis aRwerisas aRniSnuli sindromis ganviTarebis mizezad mravali
avtori moiazrebda tranzitorul epikardiul vazospazms [59,82], Tumca
kvlevebSi spontanuri multikoronaruli epikardiuli spazmi mxolod
erTeul SemTxvevebSi iqna dafiqsirebuli (212 gamokvleuli pacientidan 3
SemTxvevaSi, 1.14%) [82], ramdenime mkvlevaris mier gamoyenebul iqna
provokaciuli sinjebi ergonovinis da acetilqolinis infuziis saxiT
Tumca multisisxlZarRvovani epikardiuli vazospazmis dafiqsireba
SesaZlebeli gaxda SemTxvevaTa mxolod 11%-Si [259], gamoiTqva mosazReba,
rom xandazmuli asakis mqone pirebSi xSiria endoTeliaruli disfunqciis
arseboba, ramac provokaciuli sinjebis Catarebisas SesaZloa gamoiwvios
koronaruli vazospazmi. Sesabamisad mravali avtori aRniSnuli hipoTezis
WeSmaritebas eWvqveS ayenebs [66, 203, 204].
2005 wels Ibanez-is da kolegebis mier Seswavlil iqna mwvave balonuri
sindromis mqone 5 pacienti, romlebsac angiografiulad ar aReniSnebodaT
mniSvnelovani koronaruli stenozireba, Tumca intrakoronaruli
ultrabgeriTi gamokvleviT dafiqsirda wina daRmaval arteriaSi gamskdari
aTerosklerozuli folaqis arseboba [107], xuTive pacientis SemTxvevaSi
gamoxatuli iyo kargad ganviTarebuli wina daRmavali arteria
(mwvervalidan qveda kedelze gadasvliT), avtorebis mier gamoiTqva
mosazreba, rom SesaZlebelia sindromis ganviTareba dakavSirebuli iyos
aTerosklerozuli folaqis rupturasTan romelic koronaris kedlSi
25
fiqsirdeba da rig SemTxvevaSi SeuZlebelia koronaruli angiografiiT
misi zusti diagnostireba, xolo kargad ganviTarebuli wina daRmavali
arteria praqtikulad marcxena parkuWis Sua da distaluri segmentebis
srul vaskularizacias ganapirobebs riTac aixsneba dazianebis didi keris
arseboba. avtorebi aseve ar gamoricxavdnen sindromis aRmocenebis
paTogenezSi kateqolaminebis rols, mwvave stresuli mdgomareobis fonze
sisxlSi matulibs pro-anTebiTi citokinebis da kateqolaminebis
koncentracia, rac Tavis mxriv ganapirobebs vazokonstriqcias da
arteriuli wnevis matebas, Sedegad aramdgradi aTerosklerozuli folaqis
mTlianobis darRvevisTvis xelSemwyobi pirobebis Seqmnas [106].
Tumca zemoTaRniSnuli meqanizmi srulad ver xsnis sindromis ganviTarebis
Taviseburebebs da regionaluri kumSvadobis darRvevis specifiur
korelats (romelic Cveulebriv ar Seesabameba erTi konkretuli
koronaris vaskularizaciis ubans).
2005 wels Mireli da avtorebis mier gamoiTqva mosazreba, rom mwvave
balonuri sindromis aRmoceneba dakavSirebuli SeiZleba yofiliyo
marcxena parkuWSi dinamiuri intraventrikuluri gradientis
ganviTarebasTan [166]. specifiuri miokardiuli arqiteqtonikis mqone
pirebSi (lokalizebuli mid-ventrikuluri septaluri hipertrofiiT)
sxvadasxva faqtorebis zegavleniT (iseTi rogoricaa dehidratacia an
plazmaSi mocirkulire kateqolaminebis momatebuli koncentracia)
SesaZlebelia aRmocendes tranzitoruli mid-ventrikuluri obstruqcia,
rac marcxena parkuWs or mofunqcionire nawilad yofs, mkveTrad gazrdili
RrusSiga wneviT distalur (apikalur) nawilSi. aRniSnuli faqtori
(mkveTrad gazrdili kedlismieri stresi) ganapirobebs marcxena parkuWis
Sua da distaluri segmentebis subendokardiul iSemias da damaxasiaTebel
kumSvad disfunqcias. maprovocirebeli faqtorebis moxsnasTan erTad ki
distaluri segmenturi funqciis aRdgenas. zemoT aRniSnuli hipoTeza
mecnieruli kamaTis sagans warmoadgens, radgan dinamiuri gradientis
arseboba mwvave apikaluri balonuri sindromis mqone pacientTa mxolod
mcire nawilSi fiqsirdeba da araa marTebuli aRniSnuli Teoriis
calsaxad gatareba mTel populaciaze.
26
dResdReobiT literaturaSi farTod ganixileba mwvave apikaluri
sindromis ganviTarebis kateqolaminerguli Teoria [203, 204, 4]. SesaZloa
kateqolaminebi trigerul rols TamaSobdnen sindromis aRmocenebaSi,
radgan xSirad gvxvdeba iseTi fsiqologiuri da fiziologiuri
maprovocirebeli faqtorebi romlebic kateqolaminebis Warb
produqciasTan arian dakavSirebuli [3, 279]. mwvave apikaluri balonuri
sindromis mqone pacientebSi plazmaSi kateqolaminebis da maTi
metabolitebis koncentracia gansazRvruli iyo sxvadasxva kvlevaSi [88,
262], SemTxvevaTa 74,3%-Si mwvave fazaSi dafiqsirda norepinefrinis
koncentraciis mateba [280].
Wittstein et al. mier Sefasebul iqna mwvave balonuri sindromis mqone 13
pacientSi da miokardiumis mwvave infarqtis mqone 7 pacientSi (gulis
ukmarisoba Killip III ) prezentaciis momentisaTvis plazmaSi mocirkulire
kateqolaminebis koncentracia. es ukanaskneli TiTqmis 3-jer ufro maRali
aRmoCnda mwvave apikaluri balonuri sindromis SemTxvevaSi [280].
avtorebis mier gamoiTqva mosazreba, rom mocirkulire kateqolaminebis
maRali koncentraciis pirobebSi SesaZlebelia miocitebis pirdapiri
dazianeba (gamowveuli cAMP-iT ganpirobebuli kalciumiT datvirTviT) [89],
rac morfologiurad kumSvadi jaWvebis nekrozis histologiuri suraTiT
SeiZleba iyos warmodgenili [57]. Tumca avtorebis azriT lokalur
sinafsSi kateqolaminebis Warbi gamoTavisufleba ar unda iyos ZiriTadi
paTfiziologiuri meqanizmi, radgan norepinefrinis koncentracia da
simpatikuri nervuli terminalebis ganawileba marcxena parkuWis bazalur
segmentebSi ufro kargad aris gamoxatuli, Sua da apikalur segmentebTan
SedarebiT [208], Tumca aseve cnobilia, rom apikalur nawils gaaCnia
momatebuli mgrZnobeloba mocirkulire kateqolaminebis mimarT, da
avtorebis azriT gasaTvaliswinebelia kateqolaminebiT inducirebuli
mikrovaskuluri disfunqciis rolic sindromis aRmocenebaSi [218].
27
1.6 anevrizmuli subaraqnoiduli hemoragia da kardiuli darRvevebi.
subaraqnoiduli hemoragiis fonze ganviTarebuli kardiomiopaTiis
neirogenuli meqanizmi
mwvave subaraqnoidul hemoragiasa da sxva saxis intrakranialur
sisxlCaqcevis fonze aRmocenebuli kardiopulmonuri disfunqcia da
sxvadasxva saxis kardiuli neirofunqciuri darRvevebi kargad cnobili
fenomenia da pirvelad aRweril iqna 1903 wels Cushing-is mier. mogvianebiT
1947 wels ki Byer da kolegebis mier pirvelad iqna aRweril mwvave
subaraqnoiduli hemoragiis fonze ganviTarebuli eleqtrokardiografiuli
cvlilebebi [34].
dResdReobiT aRiarebuli Teoriis mixedviT, cerebruli arteriis
anevrizmis rupturas mosdevs e.w simpaTikuri Stormi, es ukanaskneli
SesaZloa manifestirebul iyos mTeli rigi eqstracerebruli
fiziologiuri gamovlinebebiT: arteriuli wnevis, guliscemis da sunTqvis
sixSiris, kanis temperaturisa da sekretoruli cvlilebiT.
mwvave insultis da krunCxviTi sindromis fonze gardacvlil adamianTa
autofsiuri masalis mikroskopuli Seswavlisas aRwerilia
sebendokardiuli hemoragiis suraTi. Semdgomma kvlevebma gaamyara
mosazreba rom es cvlilebebi momatebuli simpatikur stimulaciiT unda
yofiliyo gamowveuli. Offerhaus da Van Gool aCvenes, rom intrakranialuri
hemoragiis mqone pacientebis miokardiumSi aRiniSneba kateqolaminebis
momatebuli koncentracia [45, 141, 143]. histologiurad am fonze
ganviTarebuli cvlilebebi warmodgenilia infiltrirebuli monocitebiT
garSemortymuli miocitebiT, intersticialuri hemoragiis suraTiT da
miofibrilebis degeneraciiT [49, 52, 56, 58]. aRniSnuli paTologiuri
cvlilebebi cnobilia kumSvadi jaWvebis nekrozis, miocitolisisis an
miofibrilaruli degeneraciis sexelwodebiT [59, 61, 63, 71, 118]. iSemiiT
inducirebuli dazianebisagan gansxvavebiT, sadac nekrozis kera
konkretuli koronaris vaskularizaciis ubans Seesabameba,
intrakranialuri hemoragiis dros dazianebis kerebi upiratesad
vegetatiuri nervuli daboloebebis axlos lokalizdeba da identuria
28
sxva savaraudod aseve simpaTikuri hiperstimulaciiT gamowveuli
dazianebebisa (mag. kateqolaminebis infuziis an hipoTalamusis
hiperstimulaciis fonze ganviTarebuli) [157-159, 21]. sainteresoa is faqtic,
rom miokardiumis infarqtis dros koagulaciuri nekrozi Cveulebriv
mwvave iSemiis aRmocenebidan ramdenime saaTSi yalibdeba, maSin rodesac
neirogenuli miokardiuli dazianeba ramdenime wuTis Semdeg vlindeba, da
ujredul doneze calsaxad gansxvavdeba iSemiiT inducirebuli
dazianebisagan. morfologiur suraTSi Warbobs mononuklearuli
infiltracia, adreuli kalcifikacia da kardiomiocitebis
hiperkontraqtiluri mdgomareoba [17,75, 95, 97, 116].
subaraqnoiduli hemoragiis fonze ganviTarebuli kardiuli disfunqciis
neirogenul meqanizmze metyvelebs is faqtic, rom xSirad gvxvdeba
anamnezSi raime saxis kardiuli darRvevebis ar mqone axalgazrda pirebSi
[119-121].
29
1.7. anevrizmuli subaraqnoiduli hemoragiis fonze aRmocenebuli
miokardiumis kumSvadi funqciis tranzitoruli darRveva
(globaluri da/an regionuli sistoluri disfunqcia)
mwvave subaraqnoiduli hemoragiis fonze miokardiumis globaluri da
regionaluri kumSvadi funqciis tranzitoruli darRveva gvxvdeba am
paTologiis mqone pacientTa daaxloebiT 10-28%.-Si [130, 206, 86].
miokardiuli disfunqcia Cveulebriv nevrologiuri katastrofis
aRmocenebidan mcire droSi viTardeba da SeiniSneba mWidro korelacia
marcxena parkuWis sistolur-diastolur disfunqciasa da nevrologuri
dazianebis simZimes Soris [14, 123, 196]. regionaluri kumSvadi funqciis
darRveva yvelaze TvalsaCinod pirveli 48 saaTis ganmavlobaSi vlindeba
[40], da SedarebiT gaumjobesebas ganicdis 3-8 dRis ganmavlobaSi [201].
globaluri kardiuli disfunqcia Cveulebriv reverzibeluri xasiaTisaa
da praqtikulad srul normalizacias ganicdis klinikidan gaweris
momentisaTvis [47]. sagulisxmoa is faqti, rom subaraqnoiduli hemoragiis
fonze ganviTarebuli Tavis tvinis sikvdilis dafiqsirebis SemTxvevaSi
pacientebi rigi mkvlevaris mier ganixilebian gulis transplantaciis
potenciur donorebad.
subaraqnoiduli hemoragiis fonze ganviTarebuli segmenturi miokardiuli
disfunqcia mkafiod gamorCeuli suraTiT xasiaTdeba da calsaxad
ganasxvavdeba iSemiiT inducirebuli dazianebisgan [14,15, 86, 87].
damaxasiaTebelia upiratesad marcxena parkuWis bazaluri da Sua
segmentebis kumSvadi funqciis darRveva, mwvervalis normaluri
kumSvadobis fonze [14, 250]. erT-erTi retrospeqtuli kvlevis mixedviT
subaraqanoiduli hemoragiis fonze vlindeboda globaluri da regionuli
kumSvadi disfunqcia, romelic Seqcevad xasiaTs atarebda da upiratesad
moicavda wina da winaseptaluri kedlis Sua da bazalur segmentebs [250],
Tumca regionuli disinergia aseve SesaZloa warmodgenili iyos
qvedaseptaluri da winalateraluri kedlebis Sua segmentebis
kumSvadobis darRveviTac [57]
30
marcxena parkuWis regionuli segmenturi disinergiis zemoTaRniSnuli
modeli (upiratesad bazaluri disfunqcia) zustad Seesabameba marcxena
parkuWSi simpaTikuri nervuli daboloebebis anatomiur ganawilebas da
amyarebs mosazrebas subaraqnoiduli hemoragiis fonze miokardiumis
dazianebis neirogenul meqanizmis Taobaze [110, 111, 296].
regionuli kumSvadi disfunqcia asocirebulia kardiuli markerebis
(kerZod troponin T-s) momatebul koncentraciasTan, Tumca ar aRiniSneba
asociacia regionalur sistolur disfunqciasa da mocirkulire
kateqolaminebis koncentracias Soris [45].
subaraqnoiduli hemoragiis mqone pacientebSi arsebobs myari korelacia
miokardiumis simpaTikuri denervacias da regionalur kumSvad disfunqcias
Soris, maSin rodesac am darRvevebis fonze kardiuli perfuzia normis
farglebSia [294]. funqciuri kardiuli denervaciis mqone pacientebs
aReniSnebaT regionaluri kumSvadobis gauaresebuli maCvenebeli da
kardiuli markerebis mniSvnelovnad momatebuli koncentracia kardiuli
denervaciis armqone pacientebTan SedarebiT [75]. normaluri perfuziis
arseboba Tavis mxriv gamoricxavs iSemias, rogorc kardiuli disfunqciis
aRmocenebis mizezs. pacientTa axalgazrda asaki da anevrizmis
lokalizacia Tavis tvinis wina arteriis auzSi warmoadgendnen
miokardiuli kumSvadi disfunqciis ganviTarebis damoukidebel
prediqtorebs [15, 128].
arsebobs mWidro korelacia nevrologiuri dazianebis simZimes da
regionaluri kumSvadi disfunqcias Soris [55,260,261,266], Tavis mxriv
regionaluri kumSvadi funqciis darRveva momatebuli sikvdilobis myar
prediqtors warmoadgens [58,35,38].
Zaroff da kolegebis azriT unda arsebobdes garkveuli memkvidruli
ganwyoba subaraqnoiduli hemoragiis fonze garkveuli jgufis pacientebSi
miokardiumis kumSvadi disfunqciis aRmocenebis sasargeblod [293]. mWidro
asocoacia vlindeba β-1, β-2, and α adrenoreceptorebis polimorfizmsa da
miokardiumis kumSvadi disfunqciis ganviTarebis risks Soris.
polimorfuli genotipis mqone pacientebi asocirebuli arian
31
kateqolaminebis mimarT momatebul mgrZnobelobasTan da subaraqnoiduli
hemoragiis fonze kardiuli dazianebis aRmocenebis 3-4.8-jer gazrdil
riskTan. xolo ori specifiuri genotipis kombinaciis SemTxvevaSi
kardiuli dazianebis aRmocenebis riski nevrologiuri katastrofis fonze
Sesabamisad 10-15-jer izrdeba. aRniSnuli monacemi amyarebs hipoTezas, rom
subaraqnoiduli hemaoragiis fonze aRmocenebuli kardiuli disfunqcia
neirokardiogenuli dazianebis Sedegia.
32
1.8 mwvave anevrizmuli subaraqnoiduli hemoragia da
eleqtrokardiografiuli cvlilebebi
subaraqnoiduli hemoragiis fonze ganviTarebuli eleqtrokardiografiuli
cvlilebebi, warmodgenili T kbilis Rrma inversiiT da QT intervalis
prolongirebiT pirvelad aRweril iqna Byer da kolegebis mier 1947 wels
[34] da sxvadasxva kvlevis monacemebiT fiqsirdeba pacientTa 27-100 %-Si [25,
56,62,79,118]. Brouwers da kolegebis mixedviT, subaraqnoiduli hemoragiis
fonze eleqtrokardiografiuli cvlilebebi upiratesad pirveli 72 saaTis
ganmavlobaSi vlindeba da xSirad warmodgenilia repolarizaciis
sxvadasxva tipis darRvevebiT, romelic moicavs ST-segmentis, T-kbilis, U-
kbilis cvlilebebs, QT- intervalis prolongirebas [127,132, 285]. xSiria T
kbilis inversia, romelic subaraqnoiduli hemoragiis fonze SemTxvevaTa
daaxloebiT 55%-Si aisaxeba [284]. damaxasiaTebelia Rrma, gafarToebuli
inversiuli T-kbilebi, romlebic literaturaSi e.w. ‘cerebruli’,
‘neirogenuli’ an ‘giganturi’ T-kbilis saxelwodebiT arian cnobili [92, 114,
115]. erT-erT paTognomur eleqtrokardiografiul niSans warmoadgens T-
kbilis inversiis da QT intervalis prolongirebis erTdrouli arseboba,
es ukanaskneli pacientTa 45-71 %-Si gvxvdeba [186, 296] da xSirad asaxavs
dagvianebul parkuWovan repolarizacias da parkuWovani ariTmiisadmi
mzaobas.
miokardiuli iSemiisaTvis damaxasiaTebeli ekg cvlilebebis
(eleqtrokardiografiulad gamoxatuli ST-segmentis depresiisa an iSemiuri
T kbilis) arsebobis miuxedavad subaraqnoiduli hemoragiiT gardacvlil
pacientTa autofsiuri masalis Seswavlisas ar dasturdeba koronaruli
paTologiis arseboba [79, 223]. Kono da kolegebis mier warmodgenili 12
pacientis SemTxvevaSi, romelTac subaraqnoiduli hemoragiis fonze
eleqtrokardiografiulad gamouvlindaT ST segmentis elevacia,
angiografiulad arc erT SemTxvevaSi ar dadasturda koronaruli
paTologiis an vazospazmis arseboba [58]. subaranoiduli hemoragiis mqone
406 pacientis, eleqtrokardiografiuli monacemebis Sefasebisas
33
SemTxvevaTa 19% -Si aRiniSna R kbilis amplitudes mateba, 15%-Si ST-
segmentis depresia prekordialur ganxrebSi, Tkbilis sxvadasxva tipis
cvlilebebi (32%) da QT intervalis prolongireba (23%-Si). sxva kvlevis
monacemebiT [73, 94, 100] subaraqnoiduli hemoragiis mqone pacientebSi
xSirad fiqsirdeba winagulovani depolarizaciis cvlilebebic,
gamoxatuli maRali P-kbilebi (>2.5 mm amplitudiT) da RR intervalis
Semokleba (<100 ms) [116,118]. aseve xSiria U-talRis arseboba, upiratesad
prolongirebul QT intervalTan kombinaciaSi 94,[146],
subaraqnoiduli hemoragiis fonze xSiria sxvadasxva tipis gulis riTmis
darRvevis aRmoceneba. Pasquale da kolegebis mier mwvave periodSi
Catarebuli 24-saaTiani holteris monitorirebiT pacientTa 90%-Si
sxvadasxva tipis ritmis darRveva dafiqsirda [69], xSiri iyo parkuWovani
eqstrasistoliis, parkuWovani bigeminiisa da trigeminiis, aseve ‘R-on-T’
fenomeni (SemTxvevaTa 46%-Si), supraventrikuluri taqikardiis epizodebi
(pacientTa 36%-Si), sinusuri bradikardiis (39%) da sinoatrialuri blokis
(21%) SemTxvevebi. aritmiebis aRmocenebis sixSire SedarebiT maRali iyo
nevrologiuri SemTxvevidan pirveli 48 saaTis ganmavlobaSi [10, 78, 232],
sagulosxmoa, rom aRniSnuli kvlevis mixedviT ver gamovlinda korelacia
daavadebis klinikur simZimes, anevrizmis lokalizacias, pacientis asaksa
da aritmiebis aRmocenebis sixSires Soris [20-25, 36]. Stober da kolegebis
mier aRweril iqna xSiri parkuWovani eqstrasistoliis SemTxvevebi
(pacientTa 54%-Si), asistoliis epizodebi (27%), sinusuri bradikardiis
(23%) da winagulTa fibrilaciis (4%) SemTxvevebi. ventrikuluri
taqikardiis garbenebi registrirebulia monitorirebulTa 20%-Si.
sxvadasxva tipis ritmis darRveva vlindeba pacientTa daaxloebiT erT
mesamedSi da xSiria sicocxlisaTvis saSiSi ariTmiebis iseTi rogorica
parkuWovani fibrilacia an ‚torsade de pointe’ [87].G sagulisxmoa, rom
subaraqnoiduli hemoragiis fonze aRmocenebuli ariTmiebi Cveulebriv
asocirebuli arian sikvdilobis momatebul riskTan [146,102,195,232].
mwvave subaraqnoiduli hemoragiis fonze aRmocenebuli
eleqtrokardiografiuli cvlilebebi neirogenuli meqanizmiTaa
34
ganpirobebuli. gulis eleqtrogenezis aRniSnuli cvlilebebs safuZvlad
udevs intensiuri simpaTikuri stimulacia, ganpirobebuli insuluri qerqis
disfunqciiT. mowodebulia agreTve mosazreba arqipaleo korteqsSi
ariTmogenuli centris arsebobis Sesaxeb [186, 187, 256]. marcxena wina
insularuli izolaciisas aRiniSneba momatebuli simpaTikuri aqtivoba,
marcxena wina insularuli da marjvena frontoparietaluri korteqsis
insultis SemTxvevaSi vlindeba msgavsi zemoqmedeba (efeqti)
kardiovaskulur gamosavalze. cnobilia, rom, marjvena insularuli
korteqsis hemoragia asocirebulia uecari sikvdilis momatebul riskTan
[208, 188], xolo marjvena Sua cerebraluri arteriis insulti aritmiebis
(taqiaritmiebis) aRmocenebis maRal sixSiresTan [128, 187, 190].
35
1.9 mwvave anevrizmuli subaraqnoiduli hemoragia da kardiospecifiuri
biomarkerebi
kardiuli markerebis momateba aRiniSneba subaraqnoiduli hemoragiis mqone
pacientTa daaxloebiT 10-45%-Si da arsebobs myari korelacia CK-MB-is
momatebul maCvenebelsa, ekg cvlilebebsa da aritmiebis aRmocenebis risks
Soris [116,147]. miokardiumis infarqtisgan gansxvavebiT subaraqnoiduli
hemoragiis fonze CK-MB-is koncentracia umniSvnelod matulobs,
SedarebiT mogvianebiT vlindeba da hemoragiidan daaxloebiT 4 dRis
Semdeg aRwevs pikur maCvenebels [164].
kardiuli troponini miokardiumis dazianebis specifiur markers
warmoadgens da misi koncentraciis paTologiuri mateba subaraqnoiduli
hemoragiis mqone pacientTa 20-25%-Si aRiniSneba [223, 253]. es ukanaskneli
asocirebulia ekg cvlilebebis, miokardiuli disfunqciis, filtvebis
SeSupebis, hipotenziis, marcxena parkuWovani disfunqciia da mogvianebiTi
vazospazmis ganviTarebis riskis matebasTan [92, 223, 290]. troponinis pikuri
maCvenebeli korelaciaSia sikvdilobis momatebul riskTan da gauaresebul
funqciur gamosavalTan subaraqnoiduli hemoragiis mqone pacientebSi [128,
185, 190].
36
Tavi II
II gamokvleuli kontigenti da kvlevis meTodebi
2.1 gamokvleuli kontigentis daxasiaTeba
gamokvleuli iqna 30 pacienti mwvave balonuri sindromiT, 30 pacienti
miokardiumis mwvave infarqtiT (STEMI) (sakontrolo jgufi) , 95 pacienti
anevrizmuli subaraqnoiduli hemoragiiT. 2004-2008 wlebSi avstriis q.
lincis Krankenhaus Barmherzigen Schwester- is Interne II ganyofilebaSi mwvave
koronaruli sindromis diagnoziT hospitalizirebuli 1411 pacientidan
(448 SemTxvevaSi savaraudo miokardiumis mwvave infarqti ST-s elevaciiT
(STEMI) da 963 SemTxvevaSi savaraudo miokardiumis mwvave infarqti ST-s
elevaciis gareSe (NSTEMI) 30 SemTxvevaSi diagnostirebul iqna mwvave
balonuri sindromi. yvela pacienti monacemi akmayofilebda sadiagnostiko
e.w meios klinikis kriteriumebs: (1) uecrad ganviTarebuli kardiuli
simptomebi (uxSiresad tkivili gulis areSi an dispnea), (2) axlad
aRmocenebuli eleqtrokardiografiuli cvlilebebi (ST-segmentis elevacia,
T kbilis inversia an paTologiuri Q kbilebis arseboba), (3) marcxena
parkuWis tranzitoruli sistoluri disfunqcia damaxasiaTebeli
specifiuri eqokardiografiuli an ventrikulografiuli suraTiT, Sua da
apikaluri segmentebis akinezia/hipokinezia/diskinezia bazaluri segmentebis
normaluri an hiperdinamiuri kumSvadobis fonze, (4) angiografiulad
mniSvnelovani koronaruli stenozirebis an mwvave Trombozis ararseboba.
2004-2008 wlebSi amave klinikaSi (Krankenhaus Barmherzigen Schwester- is Interne II
ganyofileba) miokardiumis wina kedlis mwvave infarqtis diagnoziT (STEMI)
hospitalizirebuli pacientebidan sakontrolo jgufisTvis SeirCa 30
pacienti mmi-iT randomulad, mkacrad identuri demografiuli da
klinikuri maxasiaTeblebiT. (1) tipiuri anginozuri tkivili, (2) ST-segmentis
elevacia >0.2 mV minimum 2 eleqtrokardiografiul ganxraSi, (3) cTnT
37
koncentracia 3-jer meti normul zeda zRvrul maCvenebelTan SedarebiT,
(4) wina daRmavali arteriis (LAD) mwvave Trombozis an okluziis
angiografiuli suraTi, romelTac CautardaT gadaudebeli PCI stentis
implantaciiT.
mesame sakvlev jgufs warmoadgenda 95 pacienti anevrizmuli
subarqnoiduli hemoragiiT, romelTa SerCeva moxda 2008-2010 wlebSi q.
Tbilisis IV klinikur saavadmyofos neiroqirurgiul ganyofilebaSi
mwvave anevrizmuli subaraqnoiduli hemoragiis diagnoziT
hospitalizirebuli pacientebidan.
yvela pacienti akmayofilebda Semdeg kriteriumebs: (1) mwvave anevrizmuli
subaraqnoiduli hemoragiis diagnozi dadasturebuli Tavis tvinis
kompiuteruli tomografiiT (2) eqokardiografiulad dadsturebuli
marcxena parkuWis axlad aRmocenebuli sistoluri disfunqcia
(globaluri da/an regionaluri kumSvadi funqciis darRveva).
samive jgufSi gamoricxvis kriteriums warmoadgenda: anamnezSi
gadatanili miokardiumis mwvave infarqti an idiopaTiuri kardiomiopaTia,
hipertrofiuli kardiomiopaTia am feoqromocitoma.
38
2.2 kvlevis meTodebi
samive jgufSi Seswavlil iqna da Sefasebuli Semdegi demografiuli da
klinikuri maxasiaTeblebi:
sqesi, asaki, sxeulis masis indeqsi, Tanmxlebi paTologiebi, Tanmxlebi
medikamentozuri Terapia, klinikuri simptomatika mwvave prezentaciis
momentisTvis, SesaZlo maprovocirebeli faqtorebi, gulis iSemiuri
daavadebis riskis faqtorebi, hospitalizaciis ganmavlobaSi aRmocenebuli
garTulebebi da sikvdilobis maCvenebeli.
standartuli 12 ganxriani eleqtrokardiografiuli kvleva (25 mm/s
siCqariT, 10mm=1.0mV kalibraciiT) utardeboda yvela pacients samive
sakvlev jgufSi klinikaSi Semosvlisas da hospitalizaciis periodSi
seriulad (mwvave da qvemwvave periodSi), dinamikaSi xdeboda Semdegi
parametrebis Sefaseba: ST-segmentis da T-kbilis cvlilebebi, Q-kbilis
arseboba, R-kbilis amplitudis cvlileba, PR- da QRS intervalis
xangrZlivoba, QT-intervalis xangrZlivoba da dispersia, U-kbilis
arsebobs, gulis riTmis Sefaseba. sinusuri bradikardia ganisazRvra
rogorc sinusuri ritmi <60 Sek/wT; PR-intervalis prolongireba > 200 ms;
ST-segmentis depresis horizontaluri an daRmavali ≥0.05 mV.
QT-intervalis prolongireba gansazRvruli iyo rogorc koregirebuli QT
intervalis gazrda >430ms (mamakacebSi) da >450ms (qalebSi), gamoTvlili
Bazzet-is formulis Sesabamisad [298]. QT dispersia ganisazRvreboda,
rogorc ekg-s 12 ganxraSi QT-intervalis minimalur da maqsimalur
mniSvnelobebs Soris sxvaoba.
transTorakaluri eqokardiografiuli gamokvleva tardeboda klinikaSi
Semosvlisas (mwvave periodSi) da gaweris momentisaTvis. gamokvleva
tardeboda aparatze Vivid 7, General Electric medical systems, 3,5-MHz pased-array
transduseriT. marcxena parkuWis segmenturi sistoluri funqciis (WMSI –
39
wall motion score index) Sefasebaxdeboda standartuli 16-segmentiani modelis
Sesabamisad [144]. marcxena parkuWis moculobis (sabooloo sistoluri da
saboloo diastoluri) da gandevnis fraqciis Sesafaseblad gamoyenebuli
iyo diskebis meTodi (biplane Simpson method) standartuli apikaluri 2
kameriani da 4 kameriani Wrilebidan da maCvenebeli Sefasebuli iyo
rogorc procenti.
mitraluri nakadis Sefaseba xdeboda pulsuri dopleriT (pulsed-wave
Doppler) 4 kamerian apikalur WrilSi diastolaSi mitraluri sarqvlis
karedebs Soris. fasdeboda transmitraluri nakadis Semdegi parametrebi:
adreuli (Ev) da gviani (Av) diastoluri avsebis siCqareebi, maTi
Tanafardoba, DT (deceleration time) maCvenebeli [231].
pulmonuri venuri nakadis Sefaseba xdeboda apikaluri midgomiT 4 kamerian
WrilSi, erT-erT pulmonur venaze fasdeboda pikuri sistoluri (S) da
pikuri anterograduli diastoluri nakadi (D) da maTi Tanafardoba (S/D).
diastoluri funqciis Sefasebisas gamoyenebuli iyo aseve pulsuri
qsovilovani dopleris monacemebi (PW tissue Doppler). monacemebis miReba
xdeboda parkuWTaSua Zgidis da marcxena parkuWis lateraluri kedlidis
bazaluri segmentebidan apikalur midgomiT 4-kamerian WrilSi. fasdeboda
pikuri sistoluri maCvenebeli, adreuli diastoluri avsebis maCvenebeli E’
da gviani diastoluri avsebis maCvenebeli A’
Strane rate imaging - 2-ganzomilebiani qsovilovani dopleriT monacemebis
miReba xdeboda parkuWTaSua Zgidis da marcxena parkuWis lateraluri
kedlidan (bazaluri segmentebidan) apikalur midgomiT 4-kamerian WrilSi.
fasdeboda pikuri sistoluri SR, adreuli diastoluri avsebis SR da
gviani diastoluri avsebis SR. postsistoluri strainis fasdeboda rogorc
sxvaoba pikur sistolur da sistolur streins Soris., xolo
postsistoluri indeqsis Sefaseba xdeboda Semdegi formuliT (pikuri
sistoluri strain – sistoluri strein / pikuri sistoluri strein) X 100)
[35].
40
yvela pacientis SemTxvevaSi gansazRvruli iyo kardiuli markerebis
koncentracia (CK, CK-MB, Troponin), hospitalizaciis momentisaTvis da
seriulad klinikidan gaweramde. kvlevisaTvis xdeboda sawyisi da
maqsimaluri maCveneblebis aRiricxva. mwvave balonuri sindroms mqone 26
pacientSi gansazRvruli iyo Troponin T, 5 pacientSi Troponin I , Sesabamisad
miokardiumis mwvave infarqtis (STEMI) jgufSi 24 da 6 pacientSi.
anevrizmuli subarqnoiduli hemoragiis fonze ganviTarebuli
kardiomiopaTiis mqone 10 pacientSi gansazRvruli iyo Troponin I (normuli
sidide: Troponin I < 0.3 ng/ml, Troponin T < 0.1 ng/ml, CK< 145 u/L).
mwvave balonuri sindromis mqone 10 da miokardiumis mwvave infarqtis mqone
8 pacientSi hospitalizaciis pirvel an meore dRes gansazRvruli iyo
sisxlSi tvinis natriurezuli peptidis koncentracia (BNP), (immunoenzymate
sandwich assy) (normuli maCvenebeli 0-99 pg/ml).
mwvave balonuri sindromis mqone 7 da miokardiumis mwvave infarqtis mqone
5 pacientSi gansazRvruli iyo 24 saaTian SardSi Tavisufali
kateqolaminebis: epinefrinis, norepinefrinis da dofaminis koncentracia.
gamoyenebuli iyo Txevadi qromatografiuli meTodi (normuli maCveneblebi:
epinefrini 4-20 ng/dl, norepinefrini 23-105 ng/dl, dofamini <450 ng/dl).
kardiuli kateterizacia Catarebul iqna mwvave apikaluri balonuri
sindromis mqone 30 da miokardiumis mwvave infarqtis (STEMI) mqone 30
pacientSi. apikaluri balonuri sindromis mqone pacientebSi saSualod
23+/-18 sT-Si simptomebis aRmocenebidan, da miokardiumis mwvave infarqtis
(STEMI) mqone pacientebSi 6+/-2 sT-Si inicialuri Setevidan. gamokvlevis
Cawera xorcieldeboda standartul proeqciebSi [190].
koronaruli arteriuli daavadeba ganisazRvra rogorc koronaruli
epikardiuli arteriis stenozireba >50%.
ventrikulografiuri gamokvleva Catarebuli iyo 29 pacientSi mwvave
apikaluri sindromiT da 20 pacientSi STEMI-iT. gamokvlevis Cawera
xdeboda marjvena wina irib 30 º proeqciaSi. saboloo diastoluri
moculobis (EDV) , saboloo sistoluri moculobis (ESV), saboloo
41
diastoluri moculobis indeqsis (EDVI), saboloo sistoluri moculobis
indeqsis (EDVI) da saboloo diastoluri wnevis (EDP) gansazRvra xdeboda
are-sigrZivi meTodiT (area-lenght method) [190].
anevrizmuli subaraqnoiduli hemoragiis mqone yvela pacientSi Catarebuli
iyo Tavis tvinis kompiuteruli tomografia diagnostirebis mizniT.
kraniotomia da anevrizmis qirurgiuli klipirebis operacia Catarebul
iqna 69 pacientSi orive sakvlevi jgufidan, romelTagan 58 SemTxvevaSi
ganxorcielda adreuli qirurgiuli Careva (simptomebis aRmocenebidan
pirveli 48 saaTis ganmavlobaSi), xolo 11 SemTxvevaSi mogvianebiTi
qirurgiuli Careva (simptomebis aRmocenebidan saSualod 16±2 dRis Semdeg).
anevrizmis anatomiuri lokalizaciis mixedviT vaxdendiT ganawilebas
Semdeg anatomiur auzebSi: (1) wina SemaerTebeli arteria, (2) Sua
cerebraluri arteria, (3) ukana cerebraluri arteria, (4) bazilaruli
da/an vertebraluri arteriebi.
pacientebSi nevrologiuri dazianebis simZime fasdeboda klinikaSi
hospitalizaciis momentisaTvis Hunt Hess-is Skalis mixedviT [234] (I -
asimptomuri, an gamoxatulia msubuqi Tavis tkivili; II – saSualo an
mkveTrad gamoxatuli Tavis tkivili, nevrologiuri deficitis niSnebi
gamoxatuli araa; III – gamoxatulia gabrueba da minimaluri nevrologiuri
deficiti; IV – stupori; V – Rrma koma).
klinikuri mimdinareobisas xdeboda simptomuri vazospazmis arsebobis
aRricxva.
42
2.3 statistikuri analizi
normaluri ganawilebis mqone maCveneblebisaTvis masala warmodgenilia
rogorc saSualo ± SD; nominaluri maCveneblebi warmodgenilia
procentuli raodenobebiT (%).
normaluri ganawilebis maCvenebelTa gansxvavebis sarwmunoeba jgufebs
Soris gaanalizebuli iyo ormimarTulebiani stiudentis t-testiT (Student t
test).
nominalur parametrebs Soris gansxvavebaTa sarwmunoeba dardeboda Fisher’s
exact testiT.
konkretul jgufSi nominalur parametrebs Soris sxvaobis sarwmunoeba
inicialuri da ganmeorebiTi gamokvlevisas gaanalizebuli iyo paired t test-iT.
yvela statistikur analizSi P<0.05 iyo miCneuli rogorc statistikurad
sarwmuno.
43
III kvlevis Sedegebi
3.1 klinikuri maxasiaTeblebi, prezentacia, trigeruli faqtorebi da
Tanmxlebi paTologiebi pacientebSi mwvave balonuri sindromiT da
miokardiumis mwvave infarqtiT
2004-2008 wlebSi klinikaSi mwvave koronaruli sindromis (448 SemTxvevaSi
savaraudo STEMI da 963 savaraudo NSTEMI) diagnoziT hospitalizirebuli 1411
pacientidan mwvave balonuri sindromi diagnostirebul iqna 30 SemTxvevaSi
(2.2%). aRniSnuli pacientebi warmoadgendnen mwvave balonuri sindromis
sakvlev jgufs.
sakvlev jgufebSi iqna Seswavlili da Sefasebuli demografiuli da
klinikuri maxasiaTeblebi.
mwvave balonuri sindromis jgufSi pacientebis saSualo asaki Sedgenda 75
± 10.2 ( diapazoni 54-90w), romelTagan 28 (93.3%) iyo qali (yvela maTgani
postmenopauzur mdgomareobaSi).
miokardiumis mwvave infarqtis sakontrolo jgufSi gaerTianda 30 pacienti
miokardiumis wina kedlis infarqtiT (STEMI), romelTa demografiuli da
askobrivi monacemebi apikaluri balonuri sindromis saklevi jgufis
identuri gaxldaT (saSualo asaki 73 ± 9, diapazoni 57 - 88w) qali 26 (86.7%)
p=NS.
mwvave balonuri sindromis mkveTri genderuli da asakobrivi Tavisebureba
romelic gamovlinda praqtikulad yvela winamorbed kvlevaSi [3,4, 30, 31, 53]
aseve dadasturda Cveni monacemebis safuZvelzec. Tumca mizezi upiratesad
sindromis aRmocenebisa xadazmuli asakis qalebSi ucnobia.
prezentaciis momentisaTvis yvelaze xSir klinikur simptoms orive sakvlev
jgufSi warmoadgenda tkivili mkerdis areSi, da am TvalsazrisiT
gansxvaveba or sakvlev jgufs Soris gamovlenil ar iqna.
44
mwvave balonuri sindromis jgufSi 24 (80%) da miokardiumis mwvave
infarqtis mqone 26 pacienti (86.7%) klinikaSi hospitalizirebul iqna
retrosternaluri lokalizaciis tkiviliT. 5 (%) pacienti balonur
sindromis da 4 (13.3%) miokardiumis mwvave infarqtis jgufSi uCioda
mxolod dispnoes, da erTi SemTxveva (3%) mwvave balonuri sindromis
jgufSi warmodgenili iyo izolirebulad hipotenziiT. (suraTi 1)
45
suraTi 1
(a) klinikuri manifestacia pacientebSi mwvave balonuri sindromiT
(b) klinikuri manifestacia pacientebSi miokardiumis mwvave infarqtiT
80%
17%
3%
tkivili
dispnea
hipotenzia
87%
13%
tkivili
dispnea
46
ar gamovlinda gansxvaveba sakvlev jgufebs Soris sxeulis masis
indeqsis da koronaruli riskis faqtorebis arsebobis TvalsazrisiT.
orive jgufSi pacientebis Sesabamisad 86.7% da 66.7% aReniSnebodaT
anamnezSi arteriuli hipertenzia, 13 pacients abs-is jgufidan da 19-s mmi -
is jgufidan gamouvlindaT dislipidemia, Sesabamisad 7-s mwvave balonuri
sindromiT da 10-s mmi-iT diagnostirebuli hqonda Saqriani diabeti.
(cxrili1) Tumca analizma aCvena rom miokardiumis mwvave infarqtis
jgufSi pacientebis umravlesobas aReniSnebodaT kardiovaskuluri riskis
ori an meti faqtoris erTdrouli Tanaarsebobis maRali sixSire
(saSualod 2.36 ± 0.76), rac mosalodneli faqtia pacientebSi, koronaruli
arteriebis dadasturebuli aTerosklerozuli dazianebiT. miuxedavad
pacientTa xandazmuli asakisa mwvave balonuri sindromis jgufSi
ramdenime kardiovaskuluri riskis faqtorebis erTdrouli arsebobis
SedarebiT dabali maCvenebeli gamovlinda (1.83 ± 0.69) rac statistikurad
mniSvnelovnad gansxvavdeboda mmi-is jgufis monacemisgan (P=0.004).
47
cxrili 1. klinikuri maxasiaTeblebi da riskis faqtorebi pacientebSi mwvave balonuri sindromiT da miokardiumis mwvave infarqtiT
mbs mmi P
asaki (w) 75 ± 10.2 (54 - 90) 73 ± 9.0 (74 - 88) 0.424
qali, n (%) 28 (93.3%) 26 (86.7%) 1
BMI (kg/m²) 24.9 ± 6.1 25.1 ± 4.7 0.913
riskis faqtorebi
hipertenzia, n (%) 26 (86.7%) 20 (66.7%) 0.742
dislipidemia, n (%) 13 (%) 19 (63.3%) 0.538
Saqriani diabeti, n (%) 7 (%) 10 (33.3%) 0.492
aqtiuri mweveli n (%) 3 (9.9%) 9 (30%) 0.288
gid ojaxuri anamnezi, n (%) 2 (6.6%) 8 (26.7%) 0.455
gid riskis faqtorebis saerTo maCvenebeli 1.83 ± 0.69 2.36 ± 0.76 0.004
klinikuri prezentacia
tkivili gulis areSi, n (%) 24 (80.0%) 26 (86.7%) 0.670
dispnea n (%) 5 (%) 4 (13.3%) 1
hipotenzia, n (%) 1 (3.3%) 0 0.333
48
rogorc cnobilia apikaluri balonuri sindromis aRmoceneba xSir
SemTxvevaSi dakavSirebulia emociuri an fizikuri stresis arsebobasTan,
da trigeruli faqtorebis identificireba sxvadasxva avtoris monacemiT
SemTxvevaTa 10-100% SesaZlebeli [33,53]. am TvalsazrisiT statistikurad
mniSvnelovani sxvaoba gamovlinda Cvens sakvlev populaciaSi mwvave
balonuri sindromis da miokardiumis mwvave infarqtis jgufebs Soris.
mwvave balonuri sindromis mqone 23 (76.6%) pacientis SemTxvevaSi
SesaZlebeli gaxda sindromis aRmocenebis maprovocirebeli stresuli
faqtoris identificireba, emociuri stresis 9 SemTxvevaSi da sxvadasxva
genezis fizikuri stresoris arseboba 14 SemTxvevaSi. fizikuri stresi
uxSiresad dakavSirebuli iyo arakardiuli genezis operaciul an
stomatologiur CatevasTan, tramviT gamowveul tkivilTan, sxvadasxva
eqstrakardiuli paTologiis gamwvavebasTan. (cxrili 2). maSin rodesac
miokardiumis mwvave infarqtis jgufSi trigeruli faqtoris arseboba
mxolod 3 SemTxvevaSi (9.9%) iqna dadasturebuli (P<0.0001).
zemoTaRniSnuli monacamebis safuZvelze SegviZlia vivaraudoT, rom mwvave
balonuri sindromis aRmocenebaSi trigeruli stresuli faqtoris
arsebobas SesaZloa mniSvnelovani paTfoziologiuri datvirTva gaaCndes.
49
cxrili 2. trigeruli faqtorebi pacientebSi mwvave balonuri sindromiT da miokardiumis mwvave infarqtiT
mbs (n=30) mmi (n=30) P
identificirebuli
maprovocirebeli faqtori 23 (76.6%) 3 (10%) <0.0001
emociuri stresori, n (%) 9 (30) 1 (3.3) 0.012
ojaxis wevris gardacvaleba 3 (10) 0 0.24
ojaxuri konfliqti 1 (3.3) 0 1
samsaxureobrivi konfliqti 2 (6.6) 1 1
sxva saxis emociuri stresi 3 (10) 0 0.24
fizikuri stresori, n (%) 14 (46.6) 2 (6.6) 0.001
mwvave pnevmonia 4 (13.3) 1 (3.3) 0.35
mwvave bronqiti 2 (6.6) 0 0.49
tramva 1 (3.3) 0 1
qirurgiuli Careva 3 (10) 0 0.24
stomatologiuri procedura 2 (6.6) 0 0.49
Zlieri fizikuri gadaRla 2 (6.6) 1 (3.3) 1
50
sakvlev jgufabSi qronikuli komorbidiTebis analizisas saintereso
Sedegebi gamovlinda. mwvave balonuri sindromis jgufSi dafiqsirda
qronikuli nevrologiuri paTologiebis maRali sixSire, 19 pacients (63.3%)
aReniSna sxvadasxva saxis qronikuli nevrologiuri daavadeba (cxrili 3,
suraTi 2,3,4), maSin rodesac miokardiumis mwvave infarqtis jgufSi
sxvadasxva saxis nevrologiuri paTologia mxolod 7 pacients
aReniSnebaoda (23.3%) (P=0.04) (cxrili 3).
ar gamovlinda statistikurad mniSvnelovani sxvaoba sakvlev jgufebs
Soris sxva paTologiebis arsebobis TvalsazrisiT, apikaluri balonuri
sindromis da miokardiumis mwvave infarqtis mqone pacientebs Tanabari
sixSiriT gamouvlindaT rigi arakardiuli paTologiebi (sxvadasxva
lokalizaciis simsivne, farisebri jirkvlis paTologia, Zval-saxsrovani
sistemis daavadebebi da a.S) (cxrili 3)
51
suraTi 2. Tanmxlebi qronikuli paTologiebi pacientebSi mwvave balonuri
sindromiT
0
20
40
60
80
100
nevr. daav. simsivne
pacientTa rao
denoba (%
)
Tanmxlebi paTologiebi
52
cxrili 3. komorbiduli anamnezi pacientebSi mwvave balonuri sindromiT da miokardiumis mwvave infarqtiT
mbs (n=30) mmi (n=30) P
nevrologiuri daavadebebi, n (%) 19 (63.3) 7 (23.3) 0.004
parkinsonis daavadeba n (%) 3 (10) 0 0.23 demencia 5 (16.6) 3 (10) 0.706 depresia 4 (13.3) 2 (6.6) 0.670
Restless leg syndrome 2 (6.6) 0 0.491 insulti 1 (3.3) 2 (6.6) 0.545
degenerative spine 3 (10) 0 0.23 epilefsia 1 (3.3) 0 1 transitoruli globaluri amnezia 2 (6.6) 0 0.491
sxva somaturi daavadebebi n (%) 10 (33.3) 11 (36.6)
avTvisebiani simsivne 3 (10) 3 (10) 1 fqod 3 (10) 1 (3.3) 0.101 hipoTirezi (subklinikuri) 2 (6.6) 2 (6.6) 0.591 hiperTireozi 0 1 (3.3) 1 periferiuli arteriuli daavadeba 2 (6.6) 2 (6.6) 1 qronikuli pankreatiti 1 (3.3) 0 1 qronikuli hepatiti 0 1 (3.3) 1 Tirkmlis qronikuli ukmarisoba 1 (6.6) 0 1 anemia 1 (6.6) 1 (3.3) 1 gonarTrozi 1 (6.6) 0 1 spondilozi 0 1 (3.3) 1 glaukoma 0 2 (6.6) 0.491 tuberkulozi 0 1 (3.3) 1
53
suraTi 3
Tanmxlebi nevrologiuri paTologia pacientebSi mwvave balonuri sindromiT
0 2 4 6 8 10 12 14 16 18
parkinsonis daavadeba
demencia
depresia
insulti
epilefsia
tranzitoruli amnezia
rls
ds
pacientebis raodenoba (%)
54
suraTi 4. nevrologiuri paTologiebis samkurnalod gamoyenebuli medikamentebi pacientebSi mwvave balonuri
sindromiT
0 1 2 3 4 5 6 7 8 9
antid
epres
anteb
i
antiqoliner
gebi
pacientebis raodenoba
medikamenti
55
3.2 eleqtrokardiografiuli monacemebi pacientebSi mwvave balonuri
sindromiT da miokardiumis mwvave infarqtiT
eleqtrokardiografiuli gamokvleva yvela pacientTan orive sakvlev
jgufSi Catarebul iqna klinikaSi hospitalizaciis pirvelive wuTebSi,
klinikuri simptomebis aRmocenebidan saSualod 3+/-0.9 sT-Si.
mwvave balonuri sindromis mqone pacientTa umravlesobas (29 (96.6%) da
miokardiumis mwvave infarqtis jgufSi yvela pacients inicialuri
eleqtrokardiografiui gamokvlevisas aReniSneboda sinusuri riTmi.
apikaluri balonuri sindromis 1 SemTxvevaSi dafiqsirda winagulTa
fibrilaciis permanentuli forma.
hospitalizaciis momentisaTvis gulis SekumSvaTa saSualo sixSiris
monacemi or sakvlev jgufs Soris mniSvnelovnad ar gansxvavdeboda
(Sesabamisad 83 ± 20 (48 - 118) da 87±±31 (39 - 155) P=0.553 (cxrili 4)
inicialur eleqtrokardiogramaze mwvave balonuri sindromis mqone 13 da
mmi-is mqone yvela 30 (100%) pacientSi dafiqsirda ST-segmentis elevacia
(suraTi 5). ST-segmentis elevacia praqtikulad erTnairi raodenobis
eleqtrokardiografiul ganxrebSi iyo warmodgenili orive jgufis
pacientebSi (5.5 ± 2.2 da Sesabamisad 5.4 ± 1.6, P= 0.904). apikaluri balonuri
sindromis jgufSi is SedarebiT xSirad fiqsirdeboda V3-V4 ganxrebSi.
Tumca ST-segmentis elevaciis xarisxi mniSvnelovnad mkveTradD
gamoxatuli iyo miokardiumis mwvave infarqtis jgufSi (11.4 ± 4.5 da
Sesabamisad 8.8 ± 3.3, P=0.04).
ST-segmentis reciprokuli cvlilebebi (reciprokuli depresia) dafiqsirda
mwvave balonuri sindromis mxolod 1 SemTxvevaSi, maSin rodesac
miokardiumis mwvave infarqtis mqone 13 pacients gamouvlinda inicialur
fazaSi aRniSnuli eleqtrokardiografiuli cvlileba (P=0.032).
mwvave balonuri sindromis mqone pacientTa TiTqmis naxevars (14 pacients
(46.6%) aReniSna T- kbilis inversia, maSin rodesac miokardiumis mwvave
56
infarqtis jgufSi aRniSnuli warmodgenili iyo pacientTa mxolod 13.3%-Si
(P=0.05). T- kbilis inversia aseve mniSvnelovnad met eleqtrokardiografiul
ganxraSi iyo warmodgenili mwvave balonuri sindromis mqone pacientebSi
(4.2 ± 1.3 da Sesabamisad 3.0 ± 1.1 P=0.021), da uxSiresad fiqsirdebaoda
Semdeg eleqtrokardiografiul ganxrebSi: I, aVL, V4-V6.
mwvave periodSi QT-intervalis prolongireba gamoixata mwvave balonuri
sindromis 17 (56.6%) da miokardiumis mwvave infarqtis 8 (26.6%) SemTxvevaSi
(P=0.035), statistikurad mniSvnelovnad gaxangrZlivebuli aRmoCnda
koregirebuli QT-intervalis maCvenebelic or jgufs Soris (P=0.0014).
mniSvnelovani sxvaoba gamovlinda jgufebs Soris
eleqtrokardiografiuli maxasiaTeblebis TvalsazRisiT qvemwvave
periodSic (inicialuri Setevidan 48 saaTis Semdeg) (cxrili 5).
ST-segmentis elevacia SenarCunda Sesabamisad mwvave balonuri sindromis
mqone 2 da miokardiumis mwvave infarqtis mqone 4 pacientSi (P=1).
orive jgufSi pacientebis absolutur umravlesobaSi gamoixata T-kbilis
inversia, Tumca aRsaniSnavia, rom mwvave balonuri sindromis mqone
pacientebSi T-kbilis inversia mniSvnelovnad met eleqtrokardiografiul
ganxraSi iyo warmodgenili (6.7 ± 0.95 da Sesabamisad 5.5 ± 1.2 P=0.013).
mwvave balonuri sindromis SemTxvevaSi Rrma, inversiuli T-kbilebi
upiratesad fiqsirdeboda prekordialur ganxrebSi, da Cveulebriv
pacientTa umravles SemTxvevaSi aRiniSnebaoda mTeli hospitalizaciis
manZilze (suraTi 6, 7) . sainteresoa is faqti, rom mwvave periodSi
balonuri sindromis mqone 6 da miokardiumis mwvave infarqtis mqone 4
pacients eleqtrokardiografiulad aReniSnebodaT paTologiuri Q-kbilis
arseboba, Tumca qvemwvave periodSi statistikurad mniSvnelovani sxvaoba
gamoixata jgufebs Soris, Q-kbili fiqsirdeboda mwvave balonuri
sindromis mqone mxolod 2 da miokardiumis infarqtis mqone 10 pacientSi
(P=0.02)
57
cxrili 4. ekg monacemebi inicialuri momentisaTvis pacientebSi mwvave balonuri sindromiT da miokardiumis mwvave infarqtiT
inicialuri monacemebi mbs (n=30) mmi (STEMI) (n=30) P
ST-segmentis elevacia (pacientebis raodenoba) 13 (43.3%) 30 (100%) <0.0001
T-kbilis inversia (pacientebis raodenoba) 14 (46.6%) 4 (13.3%) 0.005* paTologiuri Q-kbilis arseboba (pacientebis raodenoba) 6 (20%) 4 (13.3%) 0.48
ST-segmentis elevacia (ekg ganxrebis raodenoba) 5.5 ± 2.2 5.4 ± 1.6 0.904
T-kbilis inversia
(ekg ganxrebis raodenoba) 4.2 ± 1.3 3.0 ± 1.1 0.021
paTologiuri Q-kbilis arseboba (ekg ganxrebis raodenoba) 2.6 ± 1.1 2.5 ± 1.7 0.928
ST-segmentis elevacia (mm) 8.8 ± 3.3 11.4 ± 4.5 0.04* ST-segmentis depresia reciprokul ganxrebSi 1(3%) 13 (43.3%) 0.032*
QT-intervalis prolongireba 17 (56.6%) 8 (26.6%) 0.035* HR 83 ± 20 (48-118) 87±31 (39 - 155) 0.553 PR 181 ±36 ms (112-250) 183 ± 40 ms (134 - 240) 0.838 QTc 467 ± 67 ms (372-599) 421 ± 30 ms (384 - 468) 0.0014*
* - statistikurad mniSvnelovani sxvaoba
58
suraTi 5. eleqtrokardiografiuli cvlilebebi klinikuri manifestaciis momentisaTvis pacientebSi mwvave balonuri sindromiT
59
cxrili 5. ekg monacemebi qvemwvave fazaSi pacientebSi mwvave balonuri sindromiT da miokardiumis mwvave infarqtiT
abs (n=30) mmi (STEMI) (n=30) P Value
ST-segmentis elevacia (pacientebis raodenoba) 2 (6.6%) 4 (13.3%) 1
T-kbilis inversia (pacientebis raodenoba) 29 (96.6%) 29 (96.6%) 1
paTologiuri Q-kbilis arseboba (pacientebis raodenoba 2 (6.6%) 10 (33.3%) 0.02*
ST-segmentis elevacia (ekg ganxrebis raodenoba) 3.3 ± 0.6 3.7 ± 1.3 0.482
T-kbilis inversia
(ekg ganxrebis raodenoba) 6.7 ± 0.95 5.5 ± 1.2 0.013*
HR 80 ± 16 (54-124) 83.6 ± 17 (56 - 114) 0.489 PR 185 ± 38 ms (140-250) 170 ± 32 (112 - 230) 0.203 QTc 461 ± 104ms (340-576) 426 ± 32 (420 - 481) 0.089
* - statistikurad mniSvnelovani sxvaoba
60
suraTi 6. eleqtrokardiografiuli cvlilebebi dinamikaSi pacientebSi balonuri sindromiT 23/10/06 25/10/06 30/10/06 03/11/06 06/11/06 11/12/06
61
suraTi 7. tipiuri eleqtrokardiografiuli cvlilebebi qvemwvave fazaSi pacientebSi mwvave balonuri sindromiT
62
3.3 eqokardiografiuli monacemebi pacientebSi mwvave balonuri sindromiT
da miokardiumis mwvave infarqtiT
inicialuri eqokardiografiuli gamokvleva Catarebul iqna rogorc mwvave
balonuri sindromis mqone pacientebis ise miokardiumis mwvave infarqtis
jgufSi klinikaSi hospitalizaciis pirvel saaTebSi.
mwvave apikaluri balonuri sindromis mqone pacientebSi dafiqsirda
marcxena parkuWis globaluri kumSvadi funqciis zomieri daqveiTeba,
segmenturi disfunqciis mkveTrad specifiuri suraTiT: marcxena parkuWis
Sua da apikaluri segmentebis gamoxatuli hipo-akinezia an diskinezia,
bazaluri segmentebis Senaxuli kumSvadi funqciis fonze, Aapikaluri
balonuri sindromis jgufSi regionaluri asinergiis zona scildeboda
erTi romelime konkretuli koronaruli arteriis vaskularizaciis ubans,
maSin rodesac miokardiumis mwvave infarqtis jgufSi ZiriTadad aRiniSna
regionaluri kumSvadi funqciis daqveiTeba konkretuli koronaruli
arteriis vaskularizaciis zonaSi.
sawyisi eqokardiografiuli parametrebis Sefasebisas orive sakvlev
jgufSi gamovlinda miokardiumis sisqis praqtikulad erTnairi
parametrebi, ar iqna nanaxi statistikurad sarwmuno gansxvaveba jgufebs
Soris parkuWTaSua Zgidis (Sesabamisad 10.9 ± 2.7 da 10.7 ± 2.45 p=0.65) da ukana
kedlis sisqis TvalsazrisiT (Sesabamisad 10.8 ± 2.2 da 10.5 ± 0.25 p=0.28).
inicialuri Sefasebisas globaluri sistoluri funqcia mkveTrad iyo
daqveiTebuli mwvave apikaluri balonuri sindromis mqone 8 da
miokardiumis mwveve infrqtis mqone 7 pacientSi, zomierad Sesabamisad 11 da
9 pacientSi, msubuqad Sesabamisad 6 da 8 pacientSi, da normis farglebSi
iyo 5 da 6 pacientSi Sesabamisi sakvlevi jgufidan (suraTi 8). orive
sakvlev jgufSi inicialur eqokardiografiuli gamokvlevisas dafiqsirda
sawyisi gandevnis fraqciis saSualo maCveneblis zomieri daqveiTeba.,
Tumca mwvave balonuri sindromis mqone pacientebSi marcxena parkuWis
gandevnis fraqciis sawyisi maCvenebeli statistikurad mniSvnelovnad
dabali aRmoCnda miokardiumis mwvave infarqtis jgufSi analogiur
63
parametrTan SedarebiT ( EF- 38.2 ± 10.8% da Sesabamisad 43.6 ± 6.9% (p =0.02).
(cxrili 6)
64
cxrili 6
inicialuri eqokardiografiuli monacemebi pacientebSi mwvave balonuri sindromiT da miokardiumis mwvave infarqtiT
eqokardiografiuli komponenti mwvave balonuri sindromi m.m.i P
(n=30) (n=30)
mp-is saboloo diastoluri moculoba (ml/m2) 64 .7 ± 18.2 55.3 ± 12.7 0.02*
mp-is saboloo sistoluri moculoba (ml/m2) 42.9 ± 16.5 30.2 ± 9.6 <0.001*
mp-is gandevnis fraqcia (%) 38.2 ± 10.8 43.6 ± 6.9 0.02*
parkuWTaSua Zgidis sisqe diastolaSi (mm) 10.9 ± 2.7 10.7 ± 2.45 0.65
ukana kedlis sisqe diastolaSi (mm) 10.8 ± 2.2 10.5 ± 1.5 0.28
regionaluri kumSvadobis indeqsi 2.17±0.4 1.88±0.35 0.035* apikaluri segmentis akinezia (%) 28 (93.3%) 20 (66.6%) 0.02* wina kedlis bazaluri segmentis 22 (73.3%) 13 (43.3%) 0.035*
Senaxuli kumSvadoba (%)
mp - marcxena parkuWi; * statistikurad mniSvnelovani sxvaoba
65
suraTi 8
gandevnis fraqciis maCveneblebi sawyisi eqokardiografiuli gamokvlevisas
pacientebSi mwvave balonuri sindromiT da miokardiumis mwvave infarqtiT
0 2 4 6 8 10 12
mbs
mmi
8
7
11
9
6
8
5
6
>55 45-55 30-45 <30
66
mwvave balonuri sindromis jgufSi dafiqsirda marcxena parkuWis saboloo
diastoluri moculoboTi indeqsis (LVEDWI) da saboloo sistoluri
moculoboTi indeqsis mniSvnelovnad maRali maCvenebeli.
sainteresoa is faqti, rom regionaluri kumSvadi funqciis TvalsazrisiT
jgufebs Soris gamovlinda statistikurad sarwmuno gansxvaveba
regionaluri asinergiis lokalizaciis da disinergiuli segmentebis
raodenobis TvalsazrisiTac: mwvave balonuri sindromis jgufSi 28
SemTxvevaSi (93.3%) dafiqsirda apikaluri segmentis kumSvadobis darRveva
maSin rodesac mmi-is jgufSi mxolod 20 pacientSi 66.6 (%) (p=0.02), xolo
wina kedlis bazaluri nawilis normaluri kumSvadi funqcia aRiniSna
mwvave balonuri sindromis mqone 22 pacientSi (73.3%) da miokardiumis
mwvave infarqtis mqone mxolod 13 pacientSi (46.6%) (PP=0.035). (cxrili 1)
miokardiumis mwvave infarqtis jgufSi gamovlinda regionaluri
kumSvadobis indeqsis statistikurad mniSvnelovnad dabali maCvenebeli
(2.17±0.4 da 1.88±0.35 p=0.035) rac metyvelebs im faqtze, rom inicialuri
eqokardiografiuli gamokvlevisas apikaluri balonuri sindromis mqone
pacientebSi aRiniSneboda marcxena parkuWis meti segmentis (ufro didi
farTobis) kumSvadi funqciis darRveva (cxrili 6).
dinamiuri gradientis arseboba marcxena parkuWis gamomaval traqtSi
gamovlenil ar iqna arc erT pacientSi orive sakvlevi jgufidan.
aseve arc erT jgufSi ar iqna nanaxi statistikurad sarwmuno gansxvaveba
marjvena parkuWis TandarTuli dazianebis arsebobasTan mimarTebaSi.
marcxena parkuWis sawyisi diastoluri parametrebis Sefasebisas
mniSvnelovani gansxvaveba gamoikveTa or sakvlev jgufs Soris:
mwvave balonuri sindromis jgufSi aRiniSna mitralur nakadze adreuli
diastoluri pikis (E) SedarebiT dabali maCvenebeli (0.71 ± 0.25)
miokardiumis mwvave infarqtis jgufTan SedarebiT (0.87 ± 0.26) (p=0.018),
xolo qsovilovani dopleriT gansazRvruli adreuli diastoluri
siCqaris maCvenebeli (Ea) praqtikulad erTnairi gaxldaT: (Sesabamisad 0.07±
67
0.25 mwvave balonuri sindromis mqone pacientebSi da 0.07 ± 0.2
miokardiumis mwvave infarqtis jgufSi).
E/Ea Tanafardoba, romelic marcxena parkuWis avsebis wnevis Sefasebis
arainvaziuri parametria statistikurad maRali aRmoCnda miokardiumis
mwvave infarqtis jgufSi (15.8 ± 4.5 da 12.1 ± 4.2 p=0.004 ) (cxrili 7)
inicialuri eqokardiografiuli gamokvlevisas mwvave apikaluri balonuri
sindromis jgufSi 10 SemTxvevaSi dafiqsirda normaluri diastoluri
funqcia, 14 SemTxvevaSi I xarisxis diastoluri disfunqcia (gauaresebuli
relaqsaciis tipi), 5 SemTxvevaSi II xarisxis diastoluri disfunqcia
(fsevdonormalizaciis tipi), da 1 SemTxvevaSi III xarisxis diastoluri
disfunqcia (restriqciuli tipi) (suraTi 9).
maSin rodesac miokardiumis mwvave infarqtis jgufSi 7 pacientSi
dafiqsirda normaluri diastoluri funqciis maCvebnebeli, 10 pacientSi I
xarisxis diastoluri disfunqcia (gauaresebul relaqsacia), 12 SemTxvevaSi
II xarisxis diastoluri disfunqcia (fsevdonormalizaciis tipi), da 1
SemTxvevaSi III xarisxis diastoluri disfunqcia (restriqciuli tipi)
(suraTi 10).
68
cxrili 7
inicialuri doplerografiuli monacemebi
eqokardiografiuli komponenti mwvave balonuri sindromi m.m.i P
(n=30) (n=30)
transmitraluri nakadi
E (m/s) 0.71 ± 0.25 0.87 ± 0.26 0.018*
A (m/s) 0.9 ± 0.28 0.71± 0.25 0.007*
DT (ms) 226 ± 38 196 ± 31 0.001*
E/A 0.82 ± 0.3 1.2 ± 0.6 0.002*
Ea (m/s) 0.07± 0.02 0.07 ± 0.03 1
E/Ea 12.1 ± 4.2 15.8 ± 6.5 0.004*
* statistikurad mniSvnelovani sxvaoba
69
suraTi 9 diastoluri funqcia pacientebSi apikaluri balonuri sindromiT
1 – normaluri diastoluri funqcia
2 - I xarisxis diastoluri disfunqcia (gauaresebuli relaqsaciis tipi)
3 - II xarsxis diastoluri disfunqcia (fsevdonormalizaciis
tipi)
4 - III xarisxis diastoluri disfunqcia (restriqciuli tipi)
33%
42%
21%
4%
1
2
3
4
70
suraTi 10 diastoluri funqcia pacientebSi miokardiumis mwvave infarqtiT
1 – normaluri diastoluri funqcia
2 - I xarisxis diastoluri disfunqcia (gauaresebuli relaqsaciis tipi)
3 - II xarsxis diastoluri disfunqcia (fsevdonormalizaciis
tipi)
4 - III xarisxis diastoluri disfunqcia (restriqciuli tipi)
ganmeorebiTi eqokardiografiuli kvleva Catarda iniacialuri momentidan
mwvave balonuri sindromis jgufSi (30 pacientSi) saSualod 15 ± 3 da
miokardiumis mwvave infarqtis jgufSi (27 pacientSi) saSualod 14 ± 4 dRis
Semdeg (p=NS).
Sefasda gandevnis fraqciis maCvenebeli da regionaluri kumSvadi funqciis
indeqsi, TiToeul jgufSi sxvaoba inicialur da ganmeorebiT monacemebs
23%
34%
40%
3%
1
2
3
4
71
Soris da agreTve orive sakvlev jgufebs Soris sxvaoba TiToeuli
komponentis TvalsazrisiT.
statistikurad sarwmuno gansxvaveba dafiqsirda gandevnis fraqciis sawyis
da ganmeorebiT maCveneblebs Soris sxvaobis TvalsazrisiT mwvave
balonuri sindromis jgufSi. aRiniSna globaluri sistoluri funqciis
mkveTri gaumjobeseba (EF=56.3 ± 7.4%) (p<0.0001) grafiki1.
am jgufSi ganmeorebiTi eqologiuri gamokvlevisas 24 pacientSi
dafiqsirda gandevnis fraqciis normaluri maCvenebeli da 6 SemTxvevaSi
marcxena parkuWis gandevnis fraqciis msubuqi daqveiTeba (suraTi 11).
apikaluri balonuri sindromis jgufSi dafiqsirda mkveTri gaumjobeseba
aseve regionaluri disinergiis TvalsazrisiT, 24 pacientSi aRiniSna
regionaluri kumSvadi funqciis sruli normalizacia, xolo 6 pacientSi
dafiqsirda marcxena parkuWis Sua da apikaluri segmentebis hipokinezia,
Tumca inicialur eqokardiografiul gamokvlevasTn SedarebiT am
konkretul pacientebSic aRiniSna regionaluri kumSvadi funqciis
gaumjobeseba. mTlianobaSi apikaluri balonuri sindromis jgufSi
regionaluri kumSvadi funqciis indeqsi statistikurad mniSvnelovnad
gaumjobesda inicialur maCvenebelTan SedarebiT (2.17±0.4 da 1.2 +/- 0.24
p=0.001) .
miokardiumis mwvave infarqtis jgufSi marcxena parkuWis gandevnis
fraqciis maCvenebli sawyis monacemTan SedarebiT gaizarda 47.4 ± 11.6 %
(p=0.002). Tumca am jgufSi ganmeorebiTi eqologiuri gamokvlevisas mxolod
12 SemTxvevaSi dafiqsirda marcxena parkuWis gandevnis fraqciis
normaluri maCvenebeli (EF>55%), 9 pacientSi gamovlinda msubuqad
daqveiTebuli gandevnis fraqcia (45-55%), 5 SemTxvevaSi zomierad (30-45%) ,
xolo 1 pacientSi mkveTrad daqveiTebuli gandevnis fraqciis monacemi
(<30%). (suraTi 11)
72
suraTi 11
gandevnis fraqciis maCveneblebi ganmeorebiT eqokardiografiuli gamokvlevisas
pacientebSi mwvave balonuri sindromiT da miokardiumis mwvave infarqtiT
0 5 10 15 20 25
mbs
mmi
1
5
6
9
24
12
>55 (%) 45-55 (%) 30-45 (%) <30 (%)
73
jgufebs Soris saboloo monacemebis analizisas statistikurad
mniSvnelovani sxvaoba dafiqsirda or sakvlev jgufs Soris
gandevnis fraqciis maCveneblis da regionaluri kumSvadi funqciis
indeqsis TvalsazrisiT: ganmeorebiTi Sefasebisas mwvave balonuri
sindromis jgufSi gamovlinda mniSvnelovnad maRali gandevnis
fraqciis maCvenebeli (56.3 ± 7.4 Sesabamisad 47.4 ± 11.6 % (p = 0.0012). da
regionaluri kumSvdi funqciis indeqsis mniSvnelovnad dabali
monacemi (1.2 +/- 0.24 da 1.5 +/- 0.3, p=0.004) (cxrili 8 )
cxrili 8
ganmeorebiTi eqokardiografiuli monacemebi pacientebSi mwvave balonuri
sindromiT da miokardiumis mwvave infarqtiT
eqokardiografiuli mwvave balonuri
komponenti sindromi (n=30) m.m.i (n=27) P
mp-is gandevnis fraqcia (%) 56.3 ± 7.4 47.4 ± 11.6 0.0012
regionaluri kumSvadobis
indeqsi 1.2 ± 0.24 1.5 ± 0.3 0.004
74
grafiki 1
gandevnis fraqciis inicialuri (a) da ganmeorebiTi (b) maCvenebeli
pacientebSi mwvave balonuri sindromiT
(a)
(b)
30; 60
0
10
20
30
40
50
60
70
0 5 10 15 20 25 30 35
EF (
%)
pacientebi
gandevnis fraqciis inicialuri maCvenebeli
30; 67
0
10
20
30
40
50
60
70
80
0 5 10 15 20 25 30 35
EF (
%)
pacientebi
gandevnis fraqciis ganmeorebiTi maCvenebeli
75
eqokardiografiulma gamokvlevam mniSvnelovani sxvaoba gamoavlina mwvave
apikaluri balonuri sindromis da miokardiumis mwvave infarqtis
pacientebSi. mwvave periodSi inicialuri Sefasebisas mwvave balonuri
sindromis mqone pacientebs aReniSnebaT ufro mniSvnelovnad daqveiTebuli
globaluri sistoluri funqcia da regionaluri asinergiis ufro mkafiod
gamoxatuli suraTi, rac Teoriulad marcxena parkuWis dazianebis ufro
did keraze unda metyvelebdes da Sesabamisad SedarebiT mZime klikuri
prognozis ganmsazRvreli unda iyos. Tumca paradoqsulia is faqti, rom,
mwvave balonuri sindromis mqone pacientebSi Cvens kvlevaSi, iseve rogorc
sxva winamorbed kvlevebSi, dafiqsirda marcxena parkuWis rogorc
globaluri, ise regionaluri kontraqtiluri funqciis praqtikulad
sruli normalizacia, da miokardiumis mwvave infarqtis jgufTan
SedarebiT mniSvnelovnad gamoxatuli gaumjobeseba rogorc regionaluri,
ise globaluri kumSvadi funqciis TvalsazrisiT. rac kidev erTxel
metyvelebs apikaluri balonuri sindromis SemTxvevaSi sicocxlisunariani
miokardiumis arsebobis sasargeblod.
sainteresoa is faqti, rom mwvave periodSi mwvave balonuri sindromis
jgufSi dafiqsirda ukeTesi diastoluri avsebis maCveneblebi, miuxedavad
ufro dabali gandevnis fraqciis maCveneblis da SedarebiT maRali
saboloo diastoluri moculobis arsebobisa. winamorbedma kvlevebma
aCvena, rom miokardiumis mwvave infarqtis mqone pacientebSi marcxena
parkuWis diastoluri funqciis Sefasebis parametrebi da avsebis wneva
warmoadgenen mniSvnelovan prognozul parametrebs sicocxlisunariani
miokardiumis arsebobis Sefasebisas [198, 199]. marcxena parkuWis
diastoluri funqcia mniSvnelovnad aris damokidebuli parkuWis
relaqsaciis unarze da kedlis elastiurobaze, miokardiumis infarqtis
SemTxvevaSi akineziuri segmentebis arseboba da SemdgomSi nawiburis
Camoyalibeba mniSvnelovan zegavlenas axdens marcxena parkuWis am
parametrebze. aRiniSneba korelacia miokardiumis fibrozis xarisxs,
sicocxlisunariani miokardiumis arsebobas da diastoluri disfunqciis
xarisxs Soris [193] Sesabamisad, SedarebiT Senaxuli diastoluri funqcia
mwvabe balonuri sindromis mqone pacientebSi SesaZloa aseve metyvelebdes
76
miokardiuli staningis sasargeblod da miokardiumis mwvave infarqtis
mqone pacientebTan SedarebiT ukeTesi pronozis ganmsazRvreli erT-erTi
faqtori iyos.
77
3.4 kardiospecifiuri markerebis (troponini, kreatinfosfokinaza), Tavis
tvinis natriurezuli peptidis (BNP) da stresuli hormonebis
maCveneblebi pacientebSi mwvave balonuri sindromiT da
miokardiumis mwvave infarqtiT
orive sakvlev jgufSi, pacientebSi mwvave balonuri sindromiT da
miokardiumis mwvave infarqtiT, yvela SemTxvevaSi gansazRvruli iyo
kardiuli markerebis koncentracia (CK, CK-MB, Troponin), hospitalizaciis
momentisaTvis (klinikuri simptomebis aRmocenebidan saSualod 4-6 sT-is
Semdeg) da seriulad klinikidan gaweramde. mwvave balonuri sindroms
mqone 26 pacientSi gansazRvruli iyo Troponin T, 4 pacientSi Troponin I ,
Sesabamisad miokardiumis mwvave infarqtis jgufSi 24 pacientis
SemTxvevaSi Troponin T da 6 SemTxvevaSi Troponin I. CK ganisazRvra yvela
pacientSi rogorc mwvave balonuri sindromis ise miokardiumis mwvave
infarqtis jgufSi.
winamorbedi kvlevebis monacemebis msgavsad [33,52,3,4,5] Cvens kvlevaSic
dafiqsirda kardiuli markerebis koncentraciis momateba pacientebSi
mwvave balonuri sindromiT, literaturaSi arsebuli monacemebis mixedviT
pozitiuri kardiuli markerebi aRieniSnebaT apikaluri balonuri
sindromis mqone pacientTa saSualod 73.9 %-s (diapazoni sxvadasxva
kvlevis mixedviT meryeobs 40-100%-s Soris) [203,204],
hospitalizaciis momentisaTvis troponinis momatebuli koncentracia
aRiniSna mwvave balonuri sindromis mqone 20 pacientSi da miokardiumis
mwvave infarqtis jgufSi 19 pacientSi, Sesabamisad kreatinfosfokinazas
momatebuli koncentracia dafiqsirda mwvave balonuri sindromis mqone 12
da miokardiumis mwvave inarqtis mqone 10 pacientSi (suraTi 12).
troponinis sawyisi maCvenebeli mwvave mwvave balonuri sindromis jgufSi
meryeobda 0.01 ng/ml dan 2.5 ng/ml mde da saSualod Seadgenda 0.42 ±± 0.52
ng/ml-s. maSin rodesac miokardiumis mwvave infarqtis jgufSi
78
troponinis SedarebiT maRali sawyisi maCvenebeli dafiqsirda 1.9 ± 2.2 ng/ml
(diapazoni 0.01 dan 6.9 mg/ml-mde) (P=0.0032).
mniSvnelovani gansxvaveba gamovlinda sakvlev jgufebs Soris
kreatinfosfokinazas sawyis maCvenebelTan dakavSirebiTac. miokardiumis
mwvave infarqtis jgufSi kretininfosfokinazac sawyisi saSualo
maCvenebeli Seadgenda 1204.8 ± 1404.7 I/U-s (diapazoni 86 dan 4946 I/U-mde),
maSin rodesac mwvave balonuri sindromis mqone pacientebSi
kreatinfosfokinazas sawyisi koncentracia umniSvnelod iyo momatebuli
(185 ±±183.5, diapazoni 10-dan 699 I/U-mde) mniSvnelovnad dabali iyo
sakontrolo jgufTan SedrebiT (P=0.0004)
kardiuli markerebis pikuri koncentracia orive sakvlev jgufSi
dafiqsirda simptomebis ganviTarebidan saSualod 12-24 saaTis Semdeg.
rogorc kardiuli troponinis ise kreatinfosfokinazas koncentraciis
mateba aRiniSna orive sakvlevi jgufis yvela pacientSi, Tumca
miokardiumis mwvave infarqtis jgufSi gamovlinda troponinis ise
kreatinfosfokinazas koncentraciis mniSvnelovani zrda, maSin rodesac
mwvave
balonuri sindromis jgufSi kardiuli markerebis koncentracia
umniSvnelod gaxldaT momatebuli da statistikurad mniSvnelovnad
dabali iyo sakvlev jgufTan mimarTebaSi (P<0.0001) (cxrili 9)
79
suraTi 12
kardiuli markerebis momateba inicialuri Sefasebisas pacientebSi mwvave
balonuri sindromiT da miokardiumis mwvave infarqtiT
0
5
10
15
20
25
mbs mmi mbs mmi
troponin pozitiuri
troponin negatiuri
kretinfosfokinaza positiuri
kreatinfosfokinaza negatiuri
80
cxrili 9
kardiuli markerebis koncentracia pacientebSi mwvave balonuri sindromiT da miokardiumis mwvave infarqtiT
mwvave balonuri
sindromi m.m.i P
sawyisi maCveneblebi
Troponin T (ng/mL)* 0.42 ± 0.52 1.9 ± 2.2 0.0032 (0.01 to 2.5) (0.01 to 6.9)
Cretine kinase (U/L) ** 185 ± 183.5 1204.8 ± 1404.7 0.0004 (10 to 699) (86 to 4946)
pikuri maCvenebeli
Troponin T (ng/mL)* 0.6 ± 0.56 5.6 ± 4.7 <0.0001 (0.1 to 2.5) (0.3 to 15.4)
Creatine Kinase (U/L)** 236.3 ± 183.3 2224.1 ± 1878.6 <0.0001 (51 to 699) (327 to 6861)
normuli parametrebi: CK < 145 U/l; Troponin T < 0.1ng/mL
* apikaluri balonuri sindromis jgufi - 26 pacientSi, da Mmmi-is jgufi 24 pacienti
** apikaluri balonuri sindromis jgufi - 30 pacienti, da Mmmi-is jgufi 30 pacienti
81
mwvave balonuri sindromis mqone 10 da miokardiumis mwvave infarqtis mqone
8 pacientSi hospitalizaciis mwvave periodSi (hospitalizaciis pirvel an
meore dRes) gansazRvruli iyo sisxlSi Tavis tvinis natriurezuli
peptidis (BNP) koncentracia.
orive sakvlevi jgufis yvela pacientSi dafiqsirda momatebuli
maCvenebeli, Tumca aRsaniSnavia, rom balonuri sindromis mqone pacientebSi
BNP-is koncentracia mniSvnelovnad maRali iyo miokardiumis infarqtis
mqone pacientebTan SedarebiT (Sesabamisad 937.9 +/- 555.4 (378 - 2004) da 276 +/-
150 (152 - 560) p=0.006)
mwvave balonuri sindromis mqone 7 da miokardiumis mwvave infarqtis mqone
5 pacientSi gansazRvruli iyo 24 saaTian SardSi Tavisufali
kateqolaminebis: epinefrinis, norepinefrinis da dofaminis koncentracia.
SardSi kateqolaminebis kncentraciis mciredi mateba dafiqsirda balonuri
sindromis mqone 2 pacientSi, miokardiumis mwvave infarqtis jgufSi
SardiT gamoyofili kateqolaminebis raodenoba normis farglebSi iyo
(p=0.46).
82
3. 5 koronaruli angiografiis da marcxena parkuWis
ventrikulografiuli gamokvlevis Sedegebi pacientebSi mwvave
balonuri sindromiT da miokardiumis mwvave infarqtiT
koronaruli angiografiuli gamokvleva Catarebul iqna orive sakvlevi
jgufis (mwvave balonuri sindromi da miokardiumis mwvave infarqti) yvela
pacientSi. balonuri sindromis mqone pacientebis jgufSi simptomebis
aRmocenebidan saSualod 25.1 +/-21 da miokardiumis mwvave infarqtis jgufSi
mwvave klinikuri prezentaciidan saSualod 3.4 ±1.8 sT-Si.
mwvave balonuri sindromis mqone 29 da miokardiumis mwvave infarqtis
mqone 20 pacients aseve Cautarda marcxena parkuWis ventrikulografiuri
gamokvleva.
koronarografiuli gamokvleviT mwvave balonuri sindromis jgufSi
arcerT SemTxvevaSi ar gamovlinda klinikurad mniSvnelovani koronaruli
stenozis (Seviwroeba >50% koronaruli arteriis diametris) an mwvave
Trombozis arseboba. 14pacientis SemTxvevaSi dafiqsirda sruliad
intaqturi koronarebis arseboba, xolo danarCen 16 SemTxvevaSi
koronaruli stenozirebis xarisxi <50%. (6 SemTxvevaSi wina daRmaval
arteriaze (mid LAD) <40%, 4 pacientSi marcxena Semomxvev koronarul
arteriaze (LCx) <40%, 1 SemTxvevaSi Reroze (LMA) <30%, 4 pacientSi marjvena
koronarul arteriaze (RCA) <40%, da 1 SemTxvevaSi muscle bridge (mid LAD).
miokardiumis mwvave infarqtis jgufSi 30 pacientSi aRiniSna wina
daRmavali arteriis (LAD) klinikurad mniSvnelovani koronaruli
stenozirebis an mwvave okluziis angiografiuli suraTi. 16 SemTxvevaSi
(53.3%) proqsimaluri da 14 SemTxvevaSi (46.7%) Sua segmentis. yvela
SemTxvevaSi ganxorcielda warmatebuli revaskularizacia stentis
implantaciiT.
mwvave balonuri sindromis jgufSi 29 SemTxvevaSi da miokardiumis mwvave
infarqtis 20 pacientSi Catarda marcxena parkuWis ventrikulografia.
mwvave balonuri sindromis jgufSi gamovlinda regionaluri kumSvadi
83
funqciis darRvevis specifiuri suraTi, mkveTrad darRveuli Sua da/an
apikaluri segmentebis kumSvadi funqciiT da bazaluri segmentebis
hiperkontratiluri funqciiT apikaluri balonuri sindromis mqone 28
pacientSi (suraTi 13), xolo 2 SemTxvevaSi ventrikulografiiT
demonstrirebul iqna marcxena parkuWis bazaluri segmentebis da
mwvervalis normaluri kumSvadobis fonze Sua segmentebis gamoxatuli
akinezia, (balonuri sindromis e.w. midventrikuluri forma).
84
(a) (b)
suraTi 13
mwvave balonuri sindromi, ventrikulografia, marcxena parkuWis saboloo diastoluri (a) da saboloo sistoluri (b)
gamosaxuleba
85
3. 6 klinikuri mimdinareoba da garTulebebi pacientebSi mwvave
balonuri sindromiT da miokardiumis mwvave infarqtiT
orive jgufiSi pacientebis hospitalizaciis xangrZlivoba praqtikulad
identuri iyo. hospitalizaciis saSualo xangrZlivoba pacientebSi mwvave
balonuri sindromiT Sedgenda 8.5 +/-5.2 dRes (diapazoniT 2-23) da
miokardiumis mwvave infarqtis jgufSi 10 +/- 6.9 (3-28) (p=NS).
mwvave balonuri sindromis jgufSi dafiqsirda hospitalSiga sikvdilobis
nulovani maCvenebeli, miokardiumis mwvave infarqtis jgufSi sikvdilobis
maCenebelma Sedgina 10 %. miokardiumis mwvave infarqtis jgufSi
hospitalizaciis periodSi garTulebebis sixSire mcired maRali iyo mwvave
balonuri sindromis mqone pacientebTan SedarebiT (cxrili 10), Tumca
rogorc sikvdilobis maCveneblis, ise garTulebebis sixSiris
TvalsazrisiT jgufebs Soris statistikurad sarwmuno gansxvaveba ar
dafiqsirda.
86
cxrili 10. hospitalSiga garTulebebi
mbs (n=30) mmi (n=30) P Value
hospitalizaciis xangrZlivoba (n ) 8.5 ± 5.2 (3 - 23) 10 ± 6.9 (3 - 30) 0.34
garTulebebi 5 (16.6%) 11 (36.7%) 0.14
VT/ parkuWovani fibrilacia, n (%) 1(3.3%) 4 (13.3%) 0.35
filtvebis SeSupeba n (%) 3 (10%) 4 (13.3%) 1
mocimcime aritmiis paroqsizmi, n (%) 1 (3.3%) 4 (13.3%) 0.35
RviZlis mwvave iSemiuri dazianeba, n (%) 0 1 (3.3%) 1
kardiuli inotropuli saSualebebis gamoyeneba,
n (%) 2 (13.3%) 7 (23.3%) 0.14
sikvdiloba, n (%) 0 3 (10%) 0.24
87
3.7 klinikuri da demografiuli maxasiaTeblebi, nevrologiuri
dazianebis simZime da anevrizmis lokalizacia pacientebSi
anevrizmuli subaraqnoiduli hemoragiis fonze arsebuli
tranzitoruli kardiomiopaTiiT da kardiuli disfunqciis gareSe
2007-2011 wlebSi mwvave subaraqnoiduli sisxlCaqcevis gamo klinikaSi
hospitalizirebuli 129 pacientidan kvlevaSi CaerTo 95 pacienti, 42 (44.2%)
qali da 53 (55.7%) mamakaci saSualo asakiT 55±16 (diapazoni 34-72w).
14 pacienti gamoricxul iqna kvlevidan anamnezSi arsebuli sxvadasxva
kardiuli paTologiis arsebobis gamo, 20 SemTxvevaSi ar iyo Catarebuli
eqokardiografiuli gamokvleva.
pacientebi gadanawildnen or jgufSi marcxena parkuWis globaluri da
segmenturi kumSvadi funqciis mdgomareobis mixedviT. 16 SemTxvevaSi
inicialuri eqokardiografiuli gamokvlevisas dafiqsirda marcxena
parkuWis kumSvadi funqciis globaluri da/an regionuli darRveva
(anevrizmuli subaraqnoiduli hemoragiis fonze arsebuli kardiomiopaTia),
xolo danarCeni 79 pacientis SemTxvevaSi gamovlinda marcxena parkuWis
normaluri sistoluri funqcia.
sakvlev jgufebSi yuradRebiT iqna Seswavlili da Sefasebuli
demografiuli, anamnezuri da klinikuri maxasiaTeblebi.
asakobrivi monacemebi orive sakvlev jgufSi praqtikulad identuri
gaxldaT: saSualo asaki pirvel sakvlev jgufSi (58 ± 9 diapazoni 43-72) da
Sesabamisad pacientebSi kardiuli disfunqciis gareSe (53 ± 14 diapazoniT
34-68). Tumca miokardiumis kumSvadi disfunqciis mqone pacientebSi
mniSvnelovnad Warbobda qalebis procentuli gadanawileba (68.7% da
Sesabamisad 39.2%).
ar gamovlinda gansxvaveba sakvlev jgufebs Soris sxeulis masis
indeqsis da koronaruli riskis faqtorebis arsebobis TvalsazrisiT.
88
orive jgufSi pacientebis Sesabamisad 8 (50%) da 40 (%) pacients
aReniSnebodaT anamnezSi arteriuli hipertenzia, 3 pacients I jgufidan da
19-s II jgufidan gamouvlindaT dislipidemia (p=NS), Sesabamisad 1 da 10-s
orive jgufidan diagnostirebuli hqonda Saqriani diabeti. ori an
ramdenime koronaruli riskis faqtoris erTdrouli Tanaarsebobis
TvalsazrisiTac jgufebs Soris statistikurad mniSvnelovani sxvaoba ar
dafiqsirda (cxrili 11).
pacientebSi nevrologiuri dazianebis simZime fasdeboda klinikaSi
hospitalizaciis momentisaTvis Hunt Hess-is Skalis mixedviT (I -
asimptomuri, an gamoxatulia msubuqi Tavis tkivili; II – saSualo an
mkveTrad gamoxatuli Tavis tkivili, nevrologiuri deficitis niSnebi
gamoxatuli araa; III – gamoxatulia gabrueba da minimaluri nevrologiuri
deficiti; IV – stupori; V – Rrma koma).
nevrologiuri simZimis saSualo sumaruli maCvenebeli orive jgufSi
warmoadgenda 2.15+/-1.1. Tumca, pacientebs, marcxena parkuWis kumSvadi
disfunqciiT gaaCndaT II sakvlev jgufTan SedarebiT mZime nevrologiuri
darRvevebi (Hunt Hess – 2.75 ±1.2 da Sesabamisad 2.0 ± 1 ) P=0.03, inicialuri
nevrologiuri statusis Sefasebisas kardiuli disfunqciis mqone
SemTxvevaTa 56.25%-Si (9 pacienti) nevrologiuri statusi Sefasda rogorc
≥ 3, maSin rodesac meore jgufSi mxolod 27.8%-Si (22 pacienti)
gamovlinda Hunt-Hess ≥ 3 (P=0.04). (grafiki 2 )
kompiuteruli tomografiuli gamokvleva Catarda simptomebis
ganviTarebidan saSualod 2.3+/-1.6 dReSi. jgufebs Soris aRiniSna
sagulisxmo sxvaoba anevrizmis lokalizaciis TvalsazrisiT: (cxrili 11).
41 SemTxvevaSi (11 pacientSi miokardiumis kumSvadi disfunqciiT da 30
normaluri kumSvadi funqciiT) anevrizma lokalizebuli iyo wina
SemaerTebeli arteriis auzSi, 44 SemTxvevaSi (Sesabamisad 4 da 40
SemTxvevaSi) Tavis tvinis Sua arteriis auzSi, 7 pacientis SemTxvevaSi
anevrizma lokalizebuli gaxldaT ukana cerebraluri arteriis auzSi
(Sesabamisad 1 SemTxvevaSi pirveli jgufidan da 6 pacientSi meore
jgufidan), 3 pacientSi marcxena parkuWis normaluri kumSvadi funqciiT
89
da arcerT pacientSi marcxena parkuWis kumSvadi disfunqciiT anevrizma
lokalizebuli iyo vertebraluri an bazilaruli arteriis auzSi.
90
cxrili 11° klinikuri maxasiaTeblebi anevrizmuli subaraqnoiduli hemoragiis mqone pacientebSi marcxena parkuWis sistoluri
disfunqciiT (I jg) da sistoluri disfunqciis gareSe (II jg)
I jgufi (16) II jgufi (79) P
asaki (w) 58 ± 9 (43 - 72) 53 ± 14 (34 - 68) 0.08
qali, n (%) 11 (68.7 %) 31 (39.2 %) 0.05
BMI (kg/m²) 23.9 ± 4.1 24.1 ± 4.3 0.86
gid riskis faqtorebi
hipertenzia, n (%) 8 (50%) 40 (50.6%) 1
dislipidemia, n (%) 3 (18.75%) 19 (24%) 0.75
Saqriani diabeti, n (%) 1 (6.25%) 10 (12.6%) 0.68
aqtiuri mweveli n (%) 7 (43.75%) 49 (62%) 0.26
gid ojaxuri anamnezi, n (%) 2 (12.5%) 18 (22.7%) 0.51
Hunt-Hess indeqsi 2.75+/-1.2 2.0+/- 1.0 0.03*
Hunt-Hess ≥ 3 9 (56.25%) 22 (27.8%) 0.04*
anevrizmis lokalizacia
wina SemaerTebeli arteriis auzi 11 30 0.03*
Sua cerebraluri arteriis auzi 4 40 0.40
ukana cerebraluri arteriis auzi 1 6 1
bazilaruli da vertebraluri
arteriis auzi 0 3 1
* statistikurad sarwmuno sxvaoba
91
grafiki 2
nevrologiuri dazianebis simZime pacientebSi anevrizmuli
subaraqnoiduli hemoragiis fonze (a) marcxena pakuWis kumSvadi
disfunqciiT da (b) kumSvadi disfunqciis gareSe
(a)
(b)
0
1
2
3
4
5
6
0 2 4 6 8 10 12 14 16 18
Hu
nt-
He
ss in
de
qsi
pacientebis raodenoba
pacientebi marcxena parkuWis kumSvadi funqciis darRveviT
0
1
2
3
4
5
6
0 10 20 30 40 50 60 70 80 90
Hu
nt-
He
ss s
core
pacientebis raodenoba
pacientebi marcxena parkuWis normaluri kumSvadi funqciiT
92
3.8 eleqtrokardiografiuli cvlilebebi pacientebSi anevrizmuli
subaraqnoiduli hemoragiis fonze arsebuli tranzitoruli
kardiomiopaTiiT da kardiuli disfunqciis gareSe
eleqtrokardiografiuli gamokvleva yvela pacientTan orive sakvlev
jgufSi Catarebul iqna subaraqnoiduli hemoragiis klinikuri simptomebis
aRmocenebidan 3+/- 1.4 dReSi.
inicialuri eleqtrokardiografiuli gamokvlevisas orive sakvlevi
jgufis yvela pacientSi aRiniSneboda sinusuri riTmi.
gulis SekumSvaTa saSualo sixSiris monacemi ori jgufis pacientebs
Soris mniSvnelovnad ar gansxvavdeboda (Sesabamisad 73 ± 15 (50-102) da
77±±18 (45 - 125) P=0.36. bradikardia (gcs<60S/wT) aRiniSna I-Si 4 da meore
jgufSi 11 SemTxvevaSi.
klinikuri mimdinareobisas eleqtrokardiografiuli cvlilebebis
SedarebiT maRali sixSire dafiqsirda pacientebSi marcxena parkuWis
sistoluri disfunqciiT. SemTxvevaTa 3/4 Si (12 pacienti) gamovlinda
sxvadasxva tipis eleqtrokardiografiuli cvlileba, rac yvelaze xSirad
repolarizaciis fazis darRvevis saxiT iyo warmodgenili, sistoluri
disfunqciis mqone 4 pacientis SemTxvevaSi eleqtrokardiografiulad
dafiqsirda paTologiuri UU kbilebi, 4 SemTxvevaSi T kbilis Rrma inversia
prekordialur ganxrebSi da 7 pacients gamouvlinda QT koregirebuli
intervalis prolongireba (suraTi 13). maSin rodesac, pacientebSi marcxena
parkuWis normaluri sistoluri funqciiT sxvadasxva tipis
eleqtrokardiografiuli darRvevebi SemTxvevaTa mxolod 24%-Si (19
SemTxvevaSi) gamovlinda (P<0.001), da uxSiresad QT intervalis
prolongirebiT da paTologiuri UU kbilebis arsebobiT iyo ganpirobebuli.
(suraTi 14,15,16)
4 pacients I da 10-s II sakvlev jgufSi monitorirebisas hispitalizaciis
pirvel 48 saaTSi gamouvlinda sxvadasxva tipis ritmis darRveva (xSiri
parkuWovani eqstrasistolia, parkuWovani bigeminiis epizodebi,
supraventrikuluri taqikardiis xanmokle epizodi), Tumca aritmiis
93
arsebobis TvalsazrisiT jgufebs Soris statistikurad mniSvnelovani
sxvaoba ar dafiqsirda (cxrili 12).
94
cxrili 12° ekg maxasiaTeblebi anevrizmuli subaraqnoiduli hemoragiis mqone pacientebSi sistoluri disfunqciiT (I jg) da
sistoluri disfunqciis gareSe (II jg)
I jgufi (16) II jgufi (79) P
T-kbilis inversia 4 (25%) 2 (2.5%) 0.006*
U-kbilis arseboba 4 (25%) 10 (12.6%) 0.24
QT-intervalis prolongireba 7 (43.7%) 18 (22.8%) 0.106
ST-segmentis depresia 3 (18.7%) 1 (1.26%) 0.01*
HR 73 ± 15 (50-102) 77 ± 18 (45 - 125) 0.36
PR 185 ± 38 ms (140-250) 170 ± 32 (112 - 230) 0.15
QTc 447 ± 104ms (340-576) 426 ± 32 (420 - 481) 0.43
bradikardia 4 (25%) 11 (13.9%) 0.25
parkuWovani eqstrasistolia 2 (12.5%) 10 (12.6%) 1
supraventrikuluri paroqsizmuli taqikardia 1 (6.25%) 2 (2.5%) 0.42
* statistikurad sarwmuno sxvaoba
95
suraTi 14. eleqtrokardiografiuli cvlilebebi pacientebSi marcxena parkuWis kumSvadi disfunqciiT
19%
19%
33%
14%
5%
10%
T-kbilis inversia
U-kbilis arseboba
QT-intervalis prolongireba
ST-segmentis depresia
supraventrikuluri paroqsizmuli taqikardia
96
suraTi 15. eleqtrokardiografiuli cvlilebebi pacientSi subaraqnoiduli hemoragiis fonze ganviTarebuli
kardiuli disfunqciiT
97
suraTi 16. T kbilis specifiuri cvlilebebi pacientSi subaraqnoiduli hemoragiis fonze ganviTarebuli kardiuli
disfunqciiT
98
3.9 kardiospecifikuri markerebis maCveneblebi pacientebSi
anevrizmuli subaraqnoiduli hemoragiis fonze arsebuli
tranzitoruli kardiomiopaTiiT da kardiuli disfunqciis gareSe
18 pacientSi ( 10 pacientSi marcxena parkuWis sistoluri disfunqciiT da 8
pacientSi marcxena parkuWis normaluri sistoluri funqciiT)
gansazRvruli iyo kardiuli troponinis (cTnI ) koncentracia klinikuri
prezentaciis momentidan saSualod 3 +/-1.7 dRis Semdeg.
marcxena parkuWis sistoluri disfunqciis mqone 7 SemTxvevaSi (70%)
aRiniSna kardiuli markeris pozitiuri maCvenebeli, maSin rodesac
marcxena parkuWis normaluri kumSvadi funqciis arsebobisas mxolod 1 (%)
SemTxvevaSi gamovlinda kardili troponinis maCveneblis normidan
gadaxra (P=0.024).
marcxena parkuWis sistoluri disfunqciis mqone pacientebSi aseve
mniSvnelovnad maRali iyo cTnI saSualo maCvenebeli sakontrolo jgufTan
SedarebiT (1.6+/-1.8 da 0.15+/-0.3) P=0.03 (grafiki 3)
99
grafiki 3
Troponin I-s monacemebi pacientebSi mwvave subaraqnoiduli hemoragiis fonze arsebuli kardiomiopaTiiT da
pacientebSI marcxena parkuWis normaluri sistoluri funqciiT
-1
0
1
2
3
4
5
6
0 2 4 6 8 10 12
pacientebi
pacientebi kardiuli disfunqciis gareSe
pacientebi miokardiumis kumSvadi disfunqciiT
100
3.10 eqokardiografiuli monacemebi pacientebSi anevrizmuli
subaraqnoiduli hemoragiis fonze arsebuli tranzitoruli
kardiomiopaTiiT da kardiuli disfunqciis gareSe
inicialuri eqokardiografiuli gamokvleva Catarda subaraqnoiduli
hemoragiis klinikuri simptomebis manifestirebidan saSualod 2.1 +/-1.4 dRis
Semdeg. 16 pacientSi gamoixata marcxena parkuWis sistoluri disfunqcia
(marcxena parkuWis gandevnis fraqciis saSualo maCvenebeli EF-49.8+/-9.4 (34
– 63%). 10 SemTxvevaSi manifestirebuli iyo globaluri kumSvadi funqciis
difuzuri daqveiTeba, da rig SemTxvevbSi gamoxatuli segmenturi
disfunqcia, xolo 6 pacientSi gamoixata regionaluri asinergiis ubnebi,
normaluri globaluri kumSvadobis fonze (suraTi 17).
disinergiis ubnebi upiratesad moicavda marcxena parkuWis wina,
winaseptaluri da qvedaseptaluri kedlis Sua da bazalur segmentebs.
101
suraTi 17
marcxena parkuWis kumSvadi funqciis monacemebi pacientebSi mwvave subaraqnoiduli hemoragiis fonze
arsebuli kardiomiopaTiiT
0 1 2 3 4 5 6
mp-is kumSvadi funqciis normaluri maCvenebeli
mp-is kumSvadi funqciis msubuqi daqveiTeba
mp-is kumSvadi funqciis zomieri daqveiTeba
pacientebis raodenoba
regionaluri asinergiis ubnebi
regionaluri asinergiis ubnebi ar vlindeba
102
inicialuri Sefasebidan saSualod 23+/-4.2 dReSi kumSvadi disfunqciis
mqone 8 pacientSi Catrebuli ganmeorebiTi eqokardiografiuli
gamokvlevisas 6 SemTxvevaSi marcxena parkuWis sistoluri funqciis sruli
normalizacia gamovlinda EF-60.6+/-1.9 (marcxena parkuWis gandevnis
fraqciis diapazoni 48 – 63%). (grafiki 4)
pacientebSi marcxena parkuWis sistoluri disfunqciis gareSe aRiniSna
globaluri sistoluri funqciis normaluri maCvenebeli, da regionaluri
kumSvadi funqciis Senaxuli modeli, Tumca aRsaniSnavia is faqtic, rom
SemTxvevaTa 1/3-Si gamoxatuli iyo marcxena parkuWis hiperdinamiuri
sistoluri funqcia.
103
grafiki 4
gandevnis fraqciis inicialuri da ganmeorebiTi maCvenebeli pacientebSi marcxena parkuWis sistoluri disfunqciiT
0
10
20
30
40
50
60
70
0 2 4 6 8 10 12 14 16 18
EF (
%)
pacientebis raodenoba
inicialuriSefaseba
ganmeorebiTi Sefaseba
104
3.11 klinikuri mimdinareoba da garTulebebi pacientebSi
anevrizmuli subaraqnoiduli hemoragiis fonze arsebuli
tranzitoruli kardiomiopaTiiT da kardiuli disfunqciis
gareSe
kraniotomia da anevrizmis qirurgiuli klipirebis operacia Catarebul
iqna 69 pacientSi orive sakvlevi jgufidan, romelTagan 58 SemTxvevaSi
ganxorcielda adreuli qirurgiuli Careva (simptomebis aRmocenebidan
pirveli 48 saaTis ganmavlobaSi), xolo 11 SemTxvevaSi mogvianebiTi
qirurgiuli Careva (simptomebis aRmocenebidan saSualod 16±2 dRis Semdeg).
pacientTa 60%-Si (10 pacienti I sakvlevi jgufidan da 47 meore sakvlevi
jgufidan) klinikuri mimdinareobisas aRmocenda cerebruli vazospazmi,
Tumca aRsaniSnavia is faqti rom simptomuri vazospazmi ganuviTarda
pacientTa mxolod 1/4-s (6-s pirveli sakvlevi jgufidan da 18-s meore
sakvlevi jgufidan). simptomuri vazospazmis diagnostireba xdeboda
doplerografiuli an angiografiuli monacemebis da klinikuri
mimdinareobisas mogvianebiTi iSemiuri kerovani deficitis aRmocenebis
safuZvelze.
kardiuli disfunqciis mqone pacientebSi aRiniSna adreuli simptomuri
vazospazmis aRmocenebis maRali maCvenebeli im pacientebTan SedarebiT
romelTac aReniSnebodaT marcxena parkuWis normaluri kumSvadoba (P=0.04).
eqsperimentuli modelidan cnobilia, rom kalcium-damokidebuli da
kalcium-damoukidebel vazokonstriqcia safuZvlad udevs vazospazmis
ganviTarebas. zemoT aRniSnuli multifaqtoruli procesia da mravali
komponentis urTierTqmedebis Sedegad aRmocendeba. sisxlis daSlis
produqtebis (kerZod oqsihemoglobinis) subaraqnoidul sivrceSi moxvedra,
Tavisufali radikalebis zemoqmedeba, vazokonstriqciul da vazoreaqtiul
substanciebs Soris disbalansi, anTebiTi procesis mediatorebis
gamoTavisufleba, endoTeliaruli proliferacia da apoptozi ganixileba
ZiriTad gamSveb paTogenezur meqanizmebad [147].
105
pacientebSi marcxena parkuWis sistoluri disfunqciiT gamovlinda
garTulebebis sumaruli maCveneblis da sikvdilobis statistikurad
mniSvnelovnad maRali monacemi (P=0.035). (cxrili 13) sikvdilis yvela
SemTxveva ganpirobebuli iyo mZime nevrologiuri statusiT, da am
pacientebSi dafiqsirebuli iyo generalizebuli cerebruli vazospazmi.
106
cxrili 13° klinikuri mimdinareoba da gamosavali anevrizmuli subaraqnoiduli hemoragiis mqone pacientebSi marcxena parkuWis
sistoluri disfunqciiT (I jg) da sistoluri disfunqciis gareSe (II jg)
I jgufi (16) II jgufi (79) P
qirurgiuli klipirebis operacia 11 58 0.5
adreuli Careva 8 50 0.68
mogvianebiTi Careva 3 8 0.68
simptomuri vazospazmi 6 18 0.2
adreuli 5 8 0.04*
T.t-is kerovani dazianebis simptomebi 1 2 0.42
ganmeorebiTi sisxldena 0 2 1N
pnevmonia 0 1 1
filtvebis mwvave SeSupeba 1 0
okluziuri hidrocefalia 2 1 0.07
garTulebebis sumaruli maCvenebeli 7 22 0.039*
sikvdiloba 6 11 0.035*
107
IV miRebuli Sedegebis ganxilva
Cvenma kvlevam gaamyara ukve arsebuli monacemebi imis sasargeblod, rom
mwvave balonuri sindromis klinikuri manifestacia Cveulebriv mwvave
koronaruli sindromis klinikuri gamovlinebis identuria, da mxolod
simptomologiuri SefasebiT SeuZlebelia am ori paTologiis
diferencialuri diagnostika.
mwvave balonuri sindromis aRmoceneba xSir SemTxvevaSi asocirebulia
anamnezSi sxvadasxva tipis stresuli faqtoris arsebobasTan, 23 (76.6%)
pacientis SemTxvevaSi SesaZlebeli gaxda sindromis aRmocenebis
maprovocirebeli stresuli faqtoris identificireba (emociuri stresis 9
SemTxvevaSi da sxvadasxva genezis fizikuri stresoris arseboba 14
SemTxvevaSi), rac mniSvnelovnad aRemateba miokardiumis mwvave infarqtis
jgufSi aRniSnuli faqtoris arsebobas (P<0.0001).
fsiqologiuri Tu fizikuri stresuli faqtoris zegavleniT plazmaSi
mocirkulire kateqolaminebis koncentracia umwvaves periodSi matulobs,
rac sxvadasxva kvlevis monacemebiTac dasturdeba [264, 9, 47],
kateqolaminebis Warbi producirebis da cirkulaciaSi moxvedris
pirobebSi maTi zemoqmedeba SesaZlebelia kardiomiocitebze pirdapiri
stimulaciis (pirveladi miogenuri efeqti) da/an kateqolaminebiT
inducirebuli mikrovaskuluri disfunqciis saxiT gamovlindes [214].
kateqolaminebis maRali koncentraciis pirobebSi miocitebis pirdapiri
dazianeba (gamowveuli cAMP-iT ganpirobebuli kalciumiT datvirTviT)
morfologiurad kumSvadi jaWvebis nekrozis histologiuri suraTiT
SeiZleba iyos warmodgenili [114, 119, 87, 264].
Cven sakvlev populaciaSi balonuri sindromis mqone pacientebSi sisxlSi
mocirkulire kateqolaminebis koncentracia ar gansazRvrula, SardSi
kateqolaminebis koncentracia ganisazRvra mxolod 7 pacientSi da
umniSvnelod maRali iyo miokardiumis mwvave infarqtis jgufTan
SedarebiT. ar Catarebula miokardiumis histologiuri kvleva, Tumca
108
maprovocirebeli stresuli trigeris arsebobis statistikurad
mniSvnelovnad maRal maCvenebels miokardiumis mwvave infarqtis mqone
pacientebTan SedarebiT ((P<0.0001) SesaZloa mniSvnelovani
paTfiziologiuri datvirTva gaaCndes da aRniSnuli faqti amyarebdes
mosazrebas sindromis ganviTarebis kateqolaminerguli Teoriis
sasargeblod.
iseve rogorc winamorbedi kvlevebSi [28, 29, 66] Cvens mier Seswavlili
tranzitoruli balonuri sindromis mqone pacientebis umravlesoba (93.3%)
postmenopauzuri asakis qalbatonia (saSualo asaki 75 ± 10.2), calsaxad
naTeli araa, Tu ra SeiZleba iyos mkveTri genderuli ganwyobis mizezi,
cnobilia rom sasqeso hormonebi mniSvnelovan zegavlenas axdenen
simpaTikur neirohumorul reaqciebze, iseve rogorc koronarul
vazoreaqtiulobaze. sainteresoa, rom mwvave tranzitoruli segmentur-
balonuri kardiomiopaTiis sxvadasxva forma upiratesad mdedrobiTi
sqesis warmomadgenlebSi gvxvdeba, rac garkveul paTfiziologiur
ganwyobaze miuTiTebs, Tumca kateqolaminebis metabolizmis Taviseburebani
qalebSi da mamakacebSi erTob kompleqsuria, mamakacebSi simpaTikuri
aqtivobis SedarebiT maRali sawyisi done aRiniSneba [102,108], emociuri
stresis fonze plazmaSi mocirkulire kateqolaminebis ufro maRali
koncentracia SeiniSneba [215], da kateqolaminebiT inducirebuli
vazokonstriqciis mimarT mgrZnobeloba gazrdilia [116, 119], Tumca qalebSi
SeiniSneba gazrdili mzaoba simpatikurad inducirebuli staningis mimarT
[143].
miokardiumis mwvave infarqtis mqone pacientebi ar gansxvavdebodnen
calkeuli koronaruli riskis faqtorebis arsebobis TvalsazrisiT mwvave
balonuri sindromis mqone pacientebisgan, Tumca am ukanasknel jgufSi
ramdenime kardiovaskuluri riskis faqtoris erTdrouli arsebobis
SedarebiT dabali maCvenebeli gamovlinda (1.83 ± 0.69) (P=0.004). SesaZloa
vivaraudoT, rom, xandazmuli asakis miuxedavad pacientTa gulis iSemiuri
daavadebis aRmocenebis riski aRniSnuli jgufis populaciaSi SedarebiT
dabalia, da sindromis aRmocenebaSi koronaruli aTerosklerozis roli
naklebad savaraudoa, rac dasturdeba kidevac gulis mkvebavi
109
sisxlZarRvebis angiografiuli gamokvlevisas klinikurad mniSvnelovani
(>50%) koronaruli stenozis ar arsebobiT.
pirvelad Cvens mier Seswavlil mwvave balonuri sindromis mqone
populaciaSi dafiqsirda Tanmxlebi nevrologiuri paTologiis arsebobis
maRali sixSire (63.3%) rac statistikurad mniSvnelovnad maRali iyo
miokardiumis mwvave infarqtis mqone pacientebTan SedarebiT (P=0.04). 2010
wels Summers-is da kolegebis mier gamoqveynebul naSromSi gamaxvilebul
iqna yuradReba faqtze, rom rom mwvave apikaluri balonuri sindromis
mqone pacientebSi dafiqsirda qronikuli fsiqiatriuli paTologiebis
maRali sixSire [251], xolo Burgdorf da kolegebis mier warmodgenil
masalaSi mwvave apikaluri balonuri sindromis mqone pacientebSi maRali
sixSiriT gamovlinda sxvadasxva lokalizaciis avTvisebiani simsivne [29].
gamoiTqva mosazreba, rom avTvisebiani simsivnis mqone pacientebs SesaZloa
aReniSnebodeT momatebuli bazaluri simpaTikuri aqtivoba da Sesabamisad
stresuli situaciis pirobebSi gaaCndeT momatebuli riski stresiT
inducirebuli darRvevebis aRmocenebisaTvis.
Cvens mier Seswavlil populaciaSi qronikuli nevrologiuri
paTologiebis arsebobis maRali sixSire safuZvels gvaZlevs vivaraudoT,
rom garkveuli Tanmxlebi paTologia mniSvnelovan maprovocirebel rols
TamaSobs mwvave balonuri sindromis aRmocenebaSi. qronikuli
nevrologiuri daavadebebi Tu fsiqiatriuli sferos aSlilobebi
zegavlenas axdenen centraluri nervuli sistemis normaluri
funqcionirebaze [252, 253], da SesaZloa mniSvnelovani paTfiziologiuri
datvirTva gaaCndeT maprovocirebeli stresul situaciaSi mwvave balonuri
sindromis aRmocenebis xelSemwyobad. Sesabamisad am faqtorebis Tu
daavadebebis identificirebas da maRali riskis jgufis gamovlenas
mniSvnelovani praqtikuli Rirebuleba gaaCnia.
mniSvnelovani Taviseburebebi gamovlinda mwvave balonuri sindromis
miokardiumis mwvave infarqtisgan diferencirebis
eleqtrokardiografiuli maxasiaTeblebis TvalsazrisiT:
110
mwvave periodSi ST-segmentis elevacia upiratesad prekordialur
ganxrebSi aris gamoxatuli, da miokardiumis mwvave infarqtTan SedarebiT
naklebad manifestirebulia. iSviaTad fiqsirdeba ST-segmentis
konkordantuli cvlilebebi reciprokul ganxrebSi, xSir
eleqtrokardiografiul niSans warmoadgens T-kbilis inversia, romelic
aseve mniSvnelovnad met eleqtrokardiografiul ganxraSia warmodgenili.
qvemwvave periodSi mwvave apikaluri balonuri sindromis SemTxvevaSi Rrma,
inversiuli T-kbilebi upiratesad fiqsirdeba prekordialur ganxrebSi,
mniSvnelovnad met eleqtrokardiografiul ganxraSia warmodgenili da
Cveulebriv xangrZlivi drois manZilze rCeba gamoxatuli.
mwvave balonuri sindromis mqone pacientebSi xSiria QT inervalis
prolongireba da miokardiumis mwvave infarqtis mqone pacientebTan
SedarebiT mniSvnelovnad gaxangrZlivebuli QTc maCvenebeli. QT inervals,
rogorc parkuWTa eleqtruli aqtivobis maxasiaTebels mniSvnelovani
prediqtiuli Rirebuleba gaaCnia ariTmiaTa aRmocenebis prognozirebis
TvalsazrisiT. miuxedavad im faqtis, rom QT inervalis prolongireba
mwvave balonuri sindromis mqone pacientTa did umravlesobaSi aRiniSneba
(sxvadasxva kvlevis monacemTa mixedviT 50-100% )[4,5], Zalzed iSviaTia
fataluri ariTmiebis (maT Soris 'torsade de pointes') aRmocenebis sixSire.
sainteresoa is paradoqsuli faqti, rom erT-erTi kvlevis mixedviT
mamakacebSi mwvave balonuri sindromTan asocirebuli QT inervalis
gaxangrZliveba 'torsade de pointes' aRmocenebis momatebul riskTan aris
dakavSirebuli, maSin rodesac qalebSi msgavsi asociacia ar vlindeba,
miuxedavad QT inervalis mniSvnelovani prolongirebisa [134]. aRniSnuli
kanonzomiereba bolomde Seswavlili ar gaxlavT, Tumca SesaZlebelia
dakavSirebuli iyos hormonul faqtorebTan, an avtonomiur inervaciul
meqanizmebis TaviseburebasTan qalebsa da mamakacebSi.
eqokardiografiulma gamokvlevam mwvave balonuri sindromis mqone
pacientebSi mniSvnelovani Tavisebureba da miokardiumis mwvave infarqtTan
SedarebiT gansxvavebuli morfologiuri suraTi gamoavlina. sxva
winamorbedi kvlevebis msgavsad gamoixata marcxena parkuWis sistoluri
111
disfunqciis specikfiuri eqokardiografiuli korelati, kerZod apikaluri
da Sua segmentebis kumSvadi funqciis mkveTri darRveva bazaluri
segmentebis normaluri an hiperdinamiuri sistoluri funqciis fonze.
regionuli kumSvadi funqciis darRveva ar Seesabameba konkretuli
koronaruli arteriis sairigacio zonas da disinergiuli segmentebis
raodenoba mniSvnelovnad aRemateba erTo koronaruli arteriis
vaskularizaciis ubans.
sawyis stadiaSi mwvave balonuri sindromis mqone pacientebs aReniSnebaT
ufro mniSvnelovnad daqveiTebuli globaluri sistoluri funqcia
(Sesabamisad EF- 38.2 ± 10.8% da 43.6 ± 6.9% (p =0.02). da regionuli disinergiis
ufro mkafiod gamoxatuli suraTi (regionaluri kumSvadobis indeqsis
statistikurad mniSvnelovnad maRali maCvenebeli 2.17±0.4 da 1.88±0.35
p=0.03), rac Teoriulad marcxena parkuWis dazianebis ufro did keraze
metyvelebs da Sesabamisad SedarebiT cudi klinikuri prognozis
ganmsazRvreli unda iyos. Tumca paradoqsulia is faqti, rom, Cvens
kvlevaSi, iseve rogorc sxva winamorbed kvlevebSi [29,34,39], tranzitoruli
balonuri sindromis mqone pacientebSi dafiqsirda marcxena parkuWis
rogorc globaluri, ise regionaluri kontraqtiluri funqciis
praqtikulad sruli normalizacia da miokardiumis mwvave infarqtis
jgufTan SedarebiT mniSvnelovnad ukeTesi maCvenebeli rogorc
regionaluri, ise globaluri kumSvadi funqciis TvalsazrisiT. zemoT
arniSnuli calsaxad metyvelebs balonuri sindromis SemTxvevaSi
sicocxlisunariani miokardiumis arsebobis sasargeblod.
sainteresoa is faqti, rom mwvave periodSi tranzitoruli balonuri
sindromis jgufSi dafiqsirda ukeTesi diastoluri avsebis maCveneblebi
(miuxedavad ufro dabali gandevnis praqciis da SedarebiT maRali
saboloo diastoluri moculobis arsebobisa). E/Ea Tanafardoba, romelic
marcxena parkuWis avsebis wnevis Sefasebis arainvaziuri parametria
statistikurad mniSvnelovnad dabali aRmoCnda miokardiumis mwvave
infarqtis mqone pacientebTan SedarebiT (15.8 ± 4.5 da 12.1 ± 4.2 p=0.004).
112
klinikuri kvlevebi cxadyofs, rom marcxena parkuWis diastoluri
funqciis Sefasebis parametrebi da avsebis wneva warmoadgenen pronozul
maCveneblebs sicocxlisunariani miokardiumis arsebobis Sefasebisas
miokardiumis mwvave infarqtis mqone pacientebSi [98, 99, 113]. marcxena
parkuWis diastoluri funqcia mniSvnelovnad aris damokidebuli parkuWis
relaqsaciis unarze da kedlis elastiurobaze, miokardiumis infarqtis
SemTxvevaSi akineziuri segmentebis arseboba da SemdgomSi nawiburis
Camoyalibeba mniSvnelovan zegavlenas axdens marcxena parkuWis am
parametrebze [108, 113, 152]. aRiniSneba korelacia miokardiumis fibrozis
xarisxs, sicocxlisunariani miokardiumis arsebobas da diastoluri
disfunqciis xarisxs Soris [199, 200, 228, 229,] Sesabamisad, SedarebiT
Senaxuli diastoluri funqcia mwvave balonuri sindromis mqone
pacientebSi SesaZloa aseve metyvelebdes miokardiuli staningis
sasargeblod da miokardiumis mwvave infarqtTan SedarebiT ukeTesi
pronozis ganmsazRvreli erT-erTi faqtori iyos.
kardiospecifiuri markerebis (troponinis da kreatinfosfokinazas)
koncentraciis mateba sxvadasxva kvlevis monacemze dayrdnobiT mwvave
balonuri sindromis mqone pacientTa 40-100% aRiniSneba [198,204,205,290].
kardiuli troponini miokardiumis dazianebis maRali sensivobis
specifikuri markeria da kardiomiocitis dazianebis deteqciis erT-erT
saukeTeso saSualebas warmoadgens. rogorc kardiuli troponinis ise
kreatinfosfokinazas koncentraciis mateba aRiniSna Cveni sakvlevi
populaciis orive jgufis yvela pacientSi, Tumca miokardiumis mwvave
infarqtis jgufSi gamovlinda kardiospecifiuri markerebis koncentraciis
mniSvnelovani zrda, maSin rodesac tranzitoruli balonuri sindromis
jgufSi kardiuli markerebis rogorc sawyisi, ise pikuri maCvenebeli
umniSvnelod gaxldaT momatebuli da statistikurad mniSvnelovnad
dabali iyo miokardiumis mwvave infarqtTan mimarTebaSi (P<0.0001). mwvave
balonuri sindromis mqone pacientebSi kardiuli markerebis mciredi,
regionaluri kumSvadi funqciis darRvevis disproporciuli mateba
miokardiuli staningis sasargeblod metyvelebs da SesaZloa miokardiumis
113
mwvave infarqtTan SedarebiT ukeTesi prognozis ganmsazRvreli erT-erTi
faqtori iyos.
paradoqsulia is faqti, rom balonuri sindromis mqone pacientebs
aReniSnebaT tvinis natriurezuli hormonis (BNP) mniSvnelovnad maRali
koncentracia klinikuri mimdinareobis mwvave periodSi miokardiumis mwvave
infarqtis mqone pacientebTan SedarebiT. miuxedavad praqtikulad erTnairi
sawyisi hemodinamikuri parametrebis da SedarebiT mkveTrad gamoxatuli
diastoluri disfunqciis suraTis, BNP -is maCvenebeli TiTqmis 4-jer
dabali saSualo monacemi dafiqsirda miokardiumis mwvave infarqtis mqone
pacientebSi.
BNP-is koncentraciis SesmCnev matebas kardiuli markerebis umniSvnelod
momatebul koncentraciasTan kombinaciaSi SesaZlebelia mniSvnelovani
sadiagnostiko Rirebuleba gaaCndes.
koronarografiuli gamokvleviT mwvave apikaluri balonuri sindromis
jgufSi arcerT SemTxvevaSi ar gamovlinda klinikurad mniSvnelovani
koronaruli stenozis (Seviwroeba >50% koronaruli arteriis diametris)
an mwvave Trombozis arseboba. balonuri sindromis SemTxvevaSi kumSvadi
disfunqciis reverzibeluri xasiaTi, kardiuli markerebis umniSvnelo,
kumSvadi disfunqciis disproporciuli mateba, damaxasiaTebeli
eleqtrokardiografiuli cvlilebebi, intaqturi koronarebis arseboba
iSemias rogorc sindromis ganviTarebis SesaZlo paTogenezur safuZvels
gamoricxavs.
anevrizmuli subaraqnoiduli hemoragiis fonze aRmocenebuli sistoluri
disfunqcia (marcxena parkuWis globaluri da/an regionaluri kumSvadi
funqciis darRveviT manifestirebuli) arcTu iSviaTad aris warmodgenili,
da Cvens monacembze dayrdnobiT SemTxvevaTa 16.8%-Si iyo gamovlenili.
Cvens mier Seswavlil kontigentSi anevrizmuli subaraqnoiduli hemoragiis
fonze aRmocenebuli kardiomiopaTiiT, marcxena parkuWis kumSvadi
funqciis darRveva nevrologiuri katastrofis aRmocenebidan pirvelsave
dReebSi gamovlinda. iseve rogorc winamorbed kvlevebSi Cvenma
114
monacemebmac daadastura mWidro kavSiri kardiuli disfunqciis
ganviTarebasa da nevrologiuri dazianebis simZimes Soris. pacientebs
marcxena parkuWis kumSvadi disfunqciiT gaaCndaT mZime nevrologiuri
darRvevebi II sakvlev jgufTan SedarebiT (Hunt Hess – 2.75 ±1.2 da Sesabamisad
2.0 ± 1 ) P=0.03, inicialuri nevrologiuri statusis Sefasebisas kardiuli
disfunqciis mqone SemTxvevaTa 56.25%-Si (9 pacienti) nevrologiuri statusi
Sefasda rogorc ≥ 3, maSin rodesac meore jgufSi mxolod 22 SemTxvevaSi
(27.8%) gamovlinda Hunt-Hess ≥ 3 (P=0.04).
arsebobs mosazreba, rom Tavis tvinis mwvave dazianebis fonze adgili aqvs
miokardiumis simpatikur nervul terminalebSi norepinefrinis masiur
gamoTavisuflebas, rac Tavismxriv adgilobrivad miocitebis liziss da
kontraqtilur disfunqcias iwvevs [92, 159].
eqsperimentuli kvlevebiT dadgenilia, rom kateqolaminebiT Warbi
stimulaciis pirobebSi adgili aqvs kardiomiocitebis specifikur
dazianebas, romelic histologiurad miocitolizisis anu kumSvadi
jaWvebis nekrozis (contraction band necrosis) saxiT vlindeba da calsaxad
gansxvavdeba miokardiumis iSemiiT inducirebuli dazianebisagan [].
Cveni kvlevis farglebSi ar ganxorcielebula simpatikuri aqtivobis
Sefaseba, an mocirkulire kateqolaminebis koncentraciis gansazRvra,
Tumca mWidro korelaciuri kavSiri nevrologiuri dazianebis simZimes da
marcxena parkuWis kumSvadi disfunqciis aRmocenabas Soris, asevev am
ukanasknelis xSir SemTxvevaSi gamoxatuli reverzibeluri xasiaTi
miokardiumis araiSemiuri genezis dazianebis sasargeblod unda
metyvelebdes, da neirogenuli staningis arsebobaze mianiSnebdes. Cveni
kvlevis farglebSi pacientebs ar CatrebiaT koronaruli arteriebis
angiografiuli gamokvleva, Tumca sagulisxmoa is faqti, rom sxvadasxva
kvlevis monacemiT anevrizmuli subaraqnoiduli hemoragiis fonze
ganviTarebuli tranzitoruli kardiomiopaTiis mqone pacientebis
koronarografiuli gamokvlevisas mniSvnelovani koronaruli stenozirebis
(>50%) arseboba ar dasturdeba [104, 107, 109,124, 138,139].
115
rig avtorTa monacemebze dayrdnobiT [4,138] pacientTa axalgazrda asaki
da mdedrobiTi sqesi warmoadgendnen miokardiuli kumSvadi disfunqciis
ganviTarebis damoukidebel prediqtorebs, Cvens kvlevaSi ar gamovlinda
mniSvnelovani asakobrivi sxvaoba pacientebSi anevrizmuli subaraqnoiduli
hemoragiis fonze miokardiumis kumSvadi disfunqciiT da mis gareSe,
Tumca dafiqsirda statistikurad mniSvnelovani gansxvaveba genderuli
TvalsazrisiT. marcxena parkuWis sistoluri disfunqcia upiratesad
warmodgenili iyo mdedrobiTi sqesis warmomadgenlebSi (P=0.05). winamorbed
kvlevebSic Ting da Tanaavtorebis, aseve Mayer da kolegebis mier
dadasturda qalTa mniSvnelovani siWarbe sxvadasxva saxis kardiuli
darRvevebis (eleqtrokardiografiuli cvlilebebi, miokardis kumSvadi
disfunqcis, kardiuli markerebis koncentraciis mateba) mqone pacientebs
Soris [215].
kateqolaminebis metabolizmis Taviseburebani qalebSi da mamakacebSi
erTob kompleqsuria, mamakacebSi qalebTan SedarebiT sawyisi simfatikuri
aqtivoba ufro maRalia [214, 268], Tumca qalebSi SeiniSneba gazrdili
mzaoba simpatikurad inducirebuli staningis mimarT [268, 269]. riTac
SesaZlebelia aixsnas mdedrobiTi sqesis dominireba subaraqnoiduli
hemoragiis fonze ganviTarebuli tranzitoruli kardiomiopaTiis jgufSi.
Cvens mier Seswavlil kontigentSi subaraqnoiduli hemoragiis fonze
ganviTarebuli tranzitoruli kardiomiopaTiis mqone pacientTa 62.5%-Si
anevrizma lokalizebuli iyo Tavis tvinis wina arteriis auzSi, rac
statistikurad mniSvnelovnad aRemateboda sakvlev jgufSi aRniSnuli
arteriis auzSi anevrizmis arsebobas (P=0.03). wina SemaerTebeli arteriis
rupturas Tan axlavs hipoTalamusis meoradi iSemia da Sedegad
kateqolaminebis Warbi producireba, rac amyarebs mosazrebas
kateqolamiinducirebuli staningis aRmocenebis sasargeblod.
zogierTi avtoris monacemiT [40,41] subaraqnoiduli hemoragiis fonze
aRmocenebuli miokardiuli disfunqciisTvis damaxasiaTebelia upiratesad
marcxena parkuWis bazaluri da Sua segmentebis kumSvadi funqciis
116
darRveva. regionuli disinergiis zemoTaRniSnuli modeli (upiratesad
bazaluri disfunqcia) zustad Seesabameba marcxena parkuWSi simpatikuri
nervuli daboloebebis anatomiur ganawilebas da amyarebs mosazrebas
subaraqnoiduli hemoragiis fonze miokardiumis dazianebis veget-
adrenerguli meqanizmis Taobaze.
Cvens mier gamokvleul SemTxvevebSi regionaluri asinergiis mkveTrad
gamoxatuli eqologiuri korelati ar SeimCneoda, regionaluri kumSvadi
funqciis darRveva ZiriTadad warmodgenili iyo marcxena parkuWis Sua
segmentebis hipo-akineziiT da/an marcxena parkuWis difuzuri hipokineziiT,
hiperkineziuri ubnebis gareSe. miokardis kontraqtiluri funqciis
segmenturi disociaciis sakmarisad reliefuri, magram ara mkveTri xarisxi
SeiZleba axsnil iyos subaraqnoiduli sisxlCaqcevis debiutidanve mZime
mimdinareobiT (Hunt-Hess>2). am pirobebSi miokards naklebi resursi unda
gaaCndes dauzianebeli segmentebis hiperkineziis uzrunvelsayofad, rac
tipiur SemTxvevebSi ganapirobebs balonuri kardiomiopaTiis sarwmunod
diferencirebul eqovizualur suraTs.
Tumca aRsaniSnavia is faqti, rom normaluri kumSvadi funqciis mqone
pacientebSi xSirad iyo gamoxatuli marcxena parkuWis hiperdinamiuri
kontraqtiluri funqcia, rac SesaZloa subaraqnoiduli hemoragiis fonze
stresul faqtorebis zegavleniT ganpirobebul inotropul pasuxs
warmoadgendes. SemdgomSi rekomendirebulia mravalricxovan populaciaSi
Sefasdes aRniSnuli kanonzomiereba.
kardiuli disfunqciis mqone pacientebSi gamovlinda adreuli simptomuri
vazospazmis aRmocenebis SedarebiT maRali maCvenebeli im pacientebTan
SedarebiT romelTac aReniSnebodaT marcxena parkuWis normaluri
kumSvadoba (P-0.04). eqsperimentuli modelidan cnobilia, rom kalcium-
damokidebuli da kalcium-damoukidebel vazokonstriqcia safuZvlad
udevs cerebruli vazospazmis ganviTarebas. sisxlis daSlis produqtebis
subaraqnoidul sivrceSi gamoTavisufleba ganapirobebs simptomis
aRmocenebas pirdapiri da arapirdapiri gziT. Tavisufali radikalebis
zemoqmedeba, vazokonstriqciul da vazoreaqtiul substanciebs Soris (
117
endoTelini, araqidonis mJavis metabolitebi, prostaglandinebi,
prostaciklini) disbalansi, anTebiTi procesis mediatorebis
gamoTavisufleba, vaskuluri tonis maregulirebeli neironuli
meqanizmebis darRveva, endoTeliaruli proliferacia da apoptozi
ganixileba ZiriTad gamSveb paTogenezur faqtorebad [156, 157].
mniSvnelovnad migvaCnia mwvave tranzitoruli segmentur-balonuri
kardiomiopaTiis sxvadasxva morfologiuri variantis klinikur WrilSi
Sefaseba. mwvave balonuri sindromis iniciluri aRwerisas tipiuri
morfologiuri varianti warmodgenil iyo marcxena parkuWis Sua da
apikaluri segmentebis kumSvadi funqciis darRveviT, Tumca mogvianebiT,
sindromis farTod gamovlenasTan erTad aRweril iqna sxvadasxva
fenotipuri variantebi: balonuri sindromis midventrikuluri forma [12,
239], izolirebuli marjvena parkuWovani balonuri sindromi,
biventrikuluri varianti da e.w. '"invertuli balonuri sindromic" [271. es
ukanaskneli mniSvnelovnad emsgavseba subaraqnoiduli hemoragiis da saxva
intrakranialuri sisxlCaqcevebis fonze arsebuli kumSvadi funqciis
darRvevis suraTs. sainteresoa is faqtic, rom nevrologiuri
katastrofebis fonze aRmocenebuli miokardis kumSvadobis darRveva
upiratesad moicavs marcxena parkuWis bazalur segmentebs, an
warmodgenilia kumSvadi funqciis difuzuri daqveiTebiT, Tumca bolo
wlebSi rig avtorTa mier aRweril iqna subaraqnoiduli hemoragiis fonze
aRmocenebuli kumSvadobis tranzitoruli darRvevis suraTi, romelic
marcxena parkuWis Sua da apikaluri segmentebis akinezia/diskineziis saxiT
iyo warmodgenili, bazaluri segmentebis normaluri an hipermobiluri
kumSvadobis fonze [189].
mwvave balonuri sindromis Cvens mier Seswavlil populaciaSi SemTxvevaTa
did nawilSi (28 pacienti) sindromi manifestirebul iyo morfologiuri
variantiT, sadac mwvave fazaSi segmenturi kumSvadi funqciis darRveva
warmodgenili iyo marcxena parkuWis Sua da apikaluri segmentebis
hipokineziis, akineziis da/an diskineziis saxiT (e.w klasikuri tako-cubo).
118
xolo SemTxvevaTa mcire nawilSi (2 pacienti), regionuli asinergia
moicavda ZiriTadad marcxena parkuWis Sua segmentebs, normaluri
apikaluri da bazaluri kumSvadobs fonze, warmodgenili iyo mwvave
balonuri sindromis e.w. midventrikuluri forma. Cvens mier Seswavlil
populaciaSi ar gamovlinda sxva morfologiuri variantebi (e.w
invertuli tako-cubo kardiomiopaTia, marjvena parkuWovani mwvave
balonuri sindromi an bi-ventrikuluri forma), Tumca klinikur praqtikaSi
gasaTvaliswinebelia zemoT aRniSnuli sxva struqturuli formebis da
heterogenuri variantebis arsebobac.
arsebobs monacemebi, rom rig pacientebSi sindromis ganmeorebiTi
aRmocenebisas aseve SesaZlebelia warmodgenili iyos kumSvadi funqciis
darRvevis gansxvavebuli fenotipuri varianti: apikaluri,
midventrikuluri Tu bazaluri [238]. aRniSnuli faqti amyarebs mosazrebas,
rom mwvave tranzitoruli segmentur-balonuri kardiomiopaTiis
ganviTarebis meqanizmSi mniSvneloba ar unda eniWebodes arsebul
anatomiur struqturebs da upiratesad ganpirobebuli unda iyos
adrenerguli receptorebis gansxvavebuli eqspresiiT. as ukanaskneli
SesaZlebelia dinamiur process warmoadgendes da drois gansazRvrul
intervalSi cvalebadobas ganicdides. β-adrenerguli receptorebis
gansxvavebuli simkvrive da /an gadanawileba miokardiumis sxvadasxva
ubanSi SesaZlebelia pasuxismgebeli iyos tranzitoruli kardiomiopaTiis
ara mxolod aRmocenebaze, aramed segmenturi kumSvadi funqciis sxvadasxva
lokalizaciiT ganviTarebaze.
zemoT aRniSnulidan gamomdinare sagulisxmod migvaCnia mwvave
tranzitoruli segmentur-balonuri kardiomiopaTiis erTgvari
sistematizacia, rogorc topikur-regionaluri niSniT, aseve trigeruli
faqtoris gaTvaliswinebiTac
119
daskvnebi
1. mwvave tranzitoruli segmentur-balonuri kardiomiopaTia
warmoadgens savaraudod adrenergiuli zemoqmedebiT inducirebul
paTologiur mdgomareobas, gamoxatuls miokardis regionuri
staningiT da globaluri eleqtrul-kontraqtiluri remodelirebiT.
igi moicavs farTo fenotipikur speqtrs, romlis heterogenobas
gansazRvravs eTiologiuri faqtori da fonuri paTologiis simZime.
gamovlenilia, agreTve iribi mtkicebulebebi am procesSi miokardis
mikrocirkulaciuri rezervis da adrenerguli reaqtiulobis
eqspresiis mniSvnelovani rolis Sesaxeb.
2. genderuli aspeqti mkveTrad dominanturia,Aamavdroulad
sagulisxmoa, rom balonuri sindromis aRmocenebis sixSire
sarwmunod maRalia postmenopauzuri asakis pirebSi, maSin rodesac
anevrizmuli subaraqnoiduli hemoragiis fonze aRmocenebuli
sistoluri disfunqciis SemTxvevaSi msgavsi asakobrivi
kanonzomiereba ar vlindeba.
3. balonuri kardiomiopaTiis mqone pacientebs miokardiumis mwvave
infarqtis jgufis pacientebTan SedarebiT axasiaTebT ramdenime
kardiovaskuluri riskis faqtoris erTdrouli arsebobis SedarebiT
dabali maCvenebeli (P=0.04) da piriqiT, anamnezSi fsiqomatramvirebeli
an endogenuri, izolirebulad momqmedi stresuli faqtoris
sarwmunod maRali sixSire (Sesabamisad 76.6% da 9.9%, p<0.0001).
ukanaskneli garemoeba xazs usvams aRniSnuli ori paTologiis
ganviTarebis meqanizmebis araerTgvarovnebas. mocemul garemoebasTan
erTad zemoTxsenebuli ori mwvave paTologiis (mwvave balonuri
sindromi da miokardiumis mwvave infarqti) paTogenezur
araerTgvarovnebas aseve adasturebs nevrologiuri komorbidebis
120
(epilefsia, parkinsonizmi, demencia) mkveTrad warmodgenili asimetria
(Sesabamisad 63.3% da 23.3%, p=0.004).
4. mwvave fazaSi mwvave balonuri sindromis mqone pacientebSi
miokardiumis mwvave infarqtis jgufis pacientebTan SedarebiT ST-
segmentis elevaciis xarisxi mniSvnelovnad dabalia ( Sesabamisad 8.8
± 3.3 da 11.4 ± 4.5 p=0.04), xolo ST-segmentis reciprokuli depresiis
ararseboba maRal sensitiur markers warmoadgens (mgrZnobeloba-92%,
specifiuroba 43% (95% CI 0.62-0.99 da 0.25 -0.62 Sesabamisad).
mwvave periodSi balonuri sindromis mqone pacientebSi gamoxatulia
marcxena parkuWis globaluri sistoluri funqciis mniSvnelovani
darRveva, regionuri asinergiis mkafiod gamoxatuli suraTiT.
inicialuri sistoluri funqciis (p=0.02) da regionuri kumSvadobis
indeqsis mniSvnelovnad dabali maCvenebeli (p=0.035), Tumca marcxena
parkuWis sarwmunod ukeTesi diastoluri avsebis monacemi (p=0.004)
miokardiumis mwvave infarqtis mqone pacientebTan SedarebiT.
5. mwvave balonuri sindromis dinamikaSi gamovlenili marcxena
parkuWis kumSvadi funqciis praqtikulad sruli normalizacia
miuTiTebs ara mxolod sistoluri disfunqciis tranzitorul
xasiaTze, aramed stanirebuli miokardis sruli funqciuri
restituciis donemde reverzibelobaze rogorc regionuri (p=0.004)
ise globaluri sistoluri funqciis TvalsazrisiT (p=0.0012).
6. mwvave nevrologiuri paTologiiT provocirebuli tranzitoruli
segmentur-balonuri kardiomiopaTiis fenotipikuri variantisTvis
damaxasiaTebelia kumSvadi funqciis difuzuri daqveiTeba,
hiperkineziuri ubnebis arsebobis gareSe. marcxena parkuWis
kontraqtiluri funqciis segmenturi disociaciis sakmarisad
reliefuri, magram ara mkveTri xarisxi SeiZleba axsnil iyos fonuri
daavadebis gansakuTrebiT mZime mimdinareobiT. am pirobebSi miokards
naklebi resursi unda gaaCndes dauzianebeli segmentebis
121
hiperkineziis uzrunvelsayofad, rac tipiur SemTxvevebSi
ganapirobebs balonuri kardiomiopaTiis sarwmunod diferencirebul
eqovizualur suraTs.
7. mwvave tranzitoruli segmentur-balonuri kardiomiopaTiis
sadiferenciacio diagnozur markerad SiZleba iyos gansazRvruli
Semdegi humoraluri faqtorebis kompozicia: sisxlSi
kateqolaminebis maRali koncentracia, troponinis umniSvnelo,
kumSvadi funqciis darRvevis disproporciuli mateba, da plazmaSi
BNP-is (tvinis natriurezuli hormonis) momatebuli koncentracia.
8. mwvave segmentur-balonuri kardiomiopaTiis klasificireba kliniko-
eleqtrofiziologiuri da radioanatomiuri polimorfizmis
Sesabamisad racionalurs xdis aRniSnuli sindromis droSi
disocirebul da generirebis xasiaTis mixedviT or gansxvavebul
jgufad dayofas: (a) pirveladi forma romlis manifestireba xdeba
adreulad mwvave koronaruli sindromis msgavsi klinikuri suraTis
ganviTarebisTanave da (b) meoradi forma, romlis SemTxvevaSi
miokardis kontraqtiluri disfunqcia diagnozirdeba sxva mwvaved
mimdinare fonuri eqstrakardiuli paTologiis simptomokopleqsis
farglebSi. pirveli varisntisTvis damaxasiaTebelia e.w. klasikuri
tipi apikaluri balonirebiT da genderul-asakobrivi
specifikurobiT. meore varianti ki adreul stadiaSi nivelirdeba
srulad Camoyalibebul fonur da komorbidul paTologiebs Soris,
rac ganapirobebs misken mizanmimarTul sadiagnozo arsenalis
dagvianebiT mobilizebas mxolod im klinikur fazaSi, romelic
xasiaTdeba laboratorul instrumentuli kvlevis da pirvel rigSi
radioimijingis mniSvnelovnad gansxvavebuli monacemebiT. zemo
aRniSnulidan gamomdinare mwvave tranzitoruli balonuri
sindromis meoradi forma, (literaturaSi asocirebuli ew
"invertirebul takocubosTan") ar unda Seicavdes fenotipikuri
varabelobis niSnebs.
122
9. mwvave tranzitoruli segmentur-balonuri kardiomiopaTiis
nomenklaturuli definicia srulad asaxavs mis klasificirebas
pirveladi SeZenili kardiomiopaTiebis rigSi rogorc topikuri,
klinikur-eleqtrofiziologiuri, anatomiuri, genderuli da
asakobrivi maxasiaTeblebis, ise paTofiziologiuri meqanizmis
saerTo daskvniTi rgolis - miokardis Seqcevadi adrenerguli
staningis Sesabamisad.
123
gamoyenebuli literatura
1. Abe Y, Kondo M, Matsuoka R, Araki M, Dohyama K, Tanio H. Assessment of clinical
features in transient left ventricular apical ballooning. J Am Coll Cardiol 2003;
41(5):737-42.
2. Akashi YJ, Nakazawa K, Sakakibara M, Miyake F, Koike H, Sasaka K. The clinical
features of Takotsubo cardiomyopathy. QJM. 2003; 96: 563–573.
3. Akashi YJ, Nakazawa K, Sakakibara M, Miyake F, Musha H, Sasaka K.. 123
I-MIBG
Myocardial Scintigraphy in patients with ―Takotsubo‖ cardiomyopathy. J Nucl Med
2004; 45(7):1121-7.
4. Akashi YJ, Nakazawa K, Sakakibara M, Miyaki F, Sasaka K. Reversible left ventricular
dysfunction ―takotsubo‖ cardiomyopathy related to catecholamine cardiotoxicity. J
Electrocardiol. 2002; 35: 351–356.
5. Ako J, Sudhir K, Farouque HM, Honda Y, Fitzgerald PJ. Transient left ventricular
dysfunction under severe stressbrain-heart relationship revisited. Am J Med
2006;119:10-17.
6. Ako J, Takenaka K, Uno K, et al. Reversible left ventricular systolic dysfunction—
reversibility of coronary microvascular abnormality Jpn Heart J 2001;42:355-363.
7. Allman FD, Herold W, Bosso FJ, Pilati CF. Time-dependent changes in norepinephrine-
induced left ventricular dysfunction and histopathologic condition. J Heart Lung
Transplant. 1998; 17: 991–997.
8. Ammann P, Maggiorini M, Bertel O, Haenseler E, Joller-Jemelka HI, Oechslin E,
Minder EI, Rickli H, Fehr T. Troponin as a risk factor for mortality in critically ill
patients without acute coronary syndromes. J Am Coll Cardiol. 2003; 41: 2004–2009.
9. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey
WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P,
Wenger NK, Wright RS, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman
EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R,
Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart
Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002
Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation
Myocardial Infarction); American College of Emergency Physicians; Society for
Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons; American
Association of Cardiovascular and Pulmonary Rehabilitation; Society for Academic
124
Emergency Medicine. ACC/AHA 2007 guidelines for the management of patients with
unstable angina/non–ST-elevation myocardial infarction. J Am Coll Cardiol. 2007; 50:
e1–e157.
10. Andreoli A, di Pasquale G, Pinelli G, Grazi P, Tognetti F, Testa C. Subarachnoid
hemorrhage: frequency and severity of cardiac arrhythmias. Stroke. 1987; 18: 558–564.
11. Angelakos ET. Regional distribution of catecholamines in the dog heart. Circ Res. 1965;
16: 39–44.
12. Aubert JM, Ennezat PV, Tricot O, Darchis J, Bauchart JJ, Auffray JL, et al Mid-
ventricular ballooning heart syndrome. Echocardiography 2007;24: 329–34.
13. Bajwa EK, Boyce PD, Januzzi JL, Gong MN, Thompson BT, Christiani DC. Biomarker
evidence of myocardial cell injury is associated with mortality in acute respiratory
distress syndrome. Crit Care Med. 2007; 35: 2484–2490.
14. Banki N, Kopelnik A, Tung P, Lawton MT, Gress D, Drew B, Dae M, Foster E, Parmley
W, Zaroff J. Prospective analysis of prevalence, distribution, and rate of recovery of left
ventricular systolic dysfunction in patients with subarachnoid hemorrhage. J Neurosurg.
2006; 105: 15–20
15. Banki NM, Kopelnik A, Dae MW, Miss J, Tung P, Lawton MT, Drew BJ, Foster E,
Smith W, Parmley WW, Zaroff JG. Acute neurocardiogenic injury after subarachnoid
hemorrhage. Circulation. 2005; 112: 3314–3319.
16. Barger AC, Herd JA, Liebowitz MR. Chronic catheterization of coronary artery
induction of ECG pattern of myocardial ischemia by intracoronary epinephrine. Proc
Soc Exp Biol Med. 1961; 107: 474–477.
17. Baroldi F. Different morphological types of myocardial cell death in man. In: Fleckstein
A, Rona G, eds. Recent Advances in Studies in Cardiac Structure and Metabolism.
Pathophysiology and Morphology of Myocardial Cell Alteration. Vol 6. Baltimore, Md:
University Park Press, 1975.
18. Barriales Villa R, Bilbao Quesada R, Iglesias Río E, Bayón Meleiro N, Mantilla
González R, Penas Lado M. Transient left ventricular apical ballooning without
coronary stenoses syndrome: importance of the intraventricular pressure gradient. Rev
Esp Cardiol 2004; 57(1):85-8.
19. Bayés de Luna A, Fiol-Sala M. Electrocardiographic pattern of injury: ST-segment
abnormalities Electrocardiography in Ischemic Heart Disease. Oxford:
Blackwell/Futura; 2008. pp. 80.
125
20. Bell JR, Fox AC. Pathogenesis of subendocardial ischemia. Am J Med Sci.
1974;268(1):3-13.
21. Benedict CR, Loach AB. Clinical significance of plasma adrenaline and noradrenaline
concentrations in patients with subarachnoid hemorrhage. J Neurol Neurosurg
Psychiatry. 1978; 41: 113–117.
22. Bernardini, G. L., & DeShaies, E. M. (2001). Critical care of intra-cerebral and
subarachnoid hemorrhage. Current Neurology and Neuroscience Reports, 1(6), 568–
576.
23. Bertolet BD, Freund G, Martin CA, Perchalski DL, Williams CM, Pepine CJ.
Unrecognized left ventricular dysfunction in an apparently healthy cocaine abuse
population. Clin Cardiol. 1990; 13: 323–328.
24. Bland JM, Altman DG. Statistical methods for assessing agreement between two
methods of clinical measurement. Lancet 1986;1(8476):307-310.
25. Brouwers PJ, Wijdicks EF, Hasan D, Vermeulen M, Wever EF, Frericks H, van Gijn J.
Serial electrocardiographic recording in aneurysmal subarachnoid hemorrhage. Stroke.
1989; 20: 1162–1167.
26. Bulsara KR, McGirt MJ, Liao L, Villavicencio AT, Borel C, Alexander MJ, Friedman
AH. Use of the peak troponin value to differentiate myocardial infarction from
reversible neurogenic left ventricular dysfunction associated with aneurysmal
subarachnoid hemorrhage. J Neurosurg. 2003; 98: 524–528
27. Burch GE, Meyers R, Abildskov JA. A new electrocardiographic pattern observed in
cerebrovascular accidents. Circulation. 1954; 9: 719–723.
28. Burgdorf C, von Hof K et al. Regional alterations in myocardial sympathetic innervation
in patients with transient left-ventricular apical ballooning (Tako-Tsubo
cardiomyopathy). J Nucl. Cardiol. 2008; 15(1):65-72
29. Burgdorf C, Haghi D, Kurowski V, Radke PW. Tako-tsubo (stress-induced) cardiomyopathy
and cancer. Ann Intern Med. 2010 Jun 15;152(12):830-1
30. Bybee KA, Kara T, Prasad A, et al. Systemic review: transient left ventricular apical
ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann
Intern Med 2004; 141(11):858-65.
31. Bybee KA, Motiei A, Syed I, Kara T, Lennon R, Murphy J, Wright RS, Rihal C.
Electrocardiography cannot reliably differentiate transient left ventricular apical
ballooning syndrome from anterior ST-segment elevation myocardial infarction. J
Electrocardiol. 2007; 40: 38.e1–e6.
126
32. Bybee KA, Murphy J, Wright RS, Prasad A, Rihal CS, Chareonthaitawee P. Acute
impairment of regional myocardial glucose utilization in the apical ballooning
(Takotsubo) syndrome. J Nuc Cardiol. 2006; 13: 244–250.
33. Bybee KA, Prasad A. Stress-related cardiomyopathy syndromes. Circulation. 2008;
118:397-409.
34. Byer E, Ashman R, Toth LA. Electrocardiogram with large upright T wave and long Q-
T intervals. Am Heart J. 1947; 33: 796–801.
35. Cannesson M, Tanabe M, Suffoletto MS, McNamara DM, Madan S, Lacomis JM,
Gorcsan J. A novel two-dimensional echocardiographic image analysis system using
artificial intelligence-learned pattern recognition for rapid automated ejection fraction. J
Am Coll Cardiol. 2007; 49: 217–326.
36. Cannon WB. ―Voodoo‖ death. Am Anthropologist. 1942; 44 (new series): 169–118.
37. Cebelin M, Hirsch CS. Human stress cardiomyopathy. Hum Pathol. 1980; 11: 123–132.
38. Cechetto DF, Hachinski V. Cardiovascular consequences of experimental stroke. In:
Cechetto DF, Hachinski V, eds. Bailliere‘s Clinical Neurology, Neurocardiology. Vol 6.
London, UK: WB Saunders; 1997: 297–308.
39. Ceitro R, et al Chronobiological Patterns of Onset of Tako-Tsubo Cardiomyopathy. J
Am Coll Cardiol, 2009; 54:180-181
40. Cheshire WP, Saper CB. The insular cortex and cardiac response to stroke. Neurology.
2006; 66: 1296–1297.
41. Cheung RTF, Hachinski V. The insula and cerebrogenic sudden death. Arch Neurol.
2000; 57: 1685–1688.
42. Colonna P, Montisci R, Galiuto L, Meloni L, Iliceto S. Effects of acute myocardial
ischemia on intramyocardial contraction heterogeneity: a study performed with
ultrasound integrated backscatter during transesophageal atrial pacing. Circulation
1999;100(17):1770-1776.
43. Connor RCR. Myocardial damage secondary to brain lesions. Am Heart J. 1969; 78:
145–148.
44. Court O, Kumar A, Parrillo JE, Kumar A. Clinical review: myocardial depression in
sepsis and septic shock. Crit Care. 2002; 6: 500–508.
45. Crago, E., Kerr, M. S., Kong, Y., Baldisseri, M., Horowitz, M., Yonas, H., et al. (2004).
The impact of cardiac complications on outcome in the SAH population. Acta
Neurologica Scandinavica, 110, 248–253.
127
46. Cropp CF, Manning GW. Electrocardiographic change simulating myocardial ischaemia
and infarction associated with spontaneous intracranial haemorrhage. Circulation. 1960;
22: 25–38.
47. Cruickshank JM, Neil-Dwyer G, Degaute JP, Hayes Y, Kuurne T, Kytta J, Vincent JL,
Carruthers ME, Patel S. Reduction of stress/catecholamine-induced cardiac necrosis by
beta 1-selective blockade. Lancet. 1987; 2: 585–589.
48. Cunnion RE, Schaer GL, Parker MM, Natanson C, Parrillo JE. The coronary circulation
in human septic shock. Circulation. 1986; 73: 637–644.
49. Dae MW, De Marco T, Botvinick EH, O‘Connell JW, Hattner RS, Huberty JP, Yuen-
Green MS. Scintigraphic assessment of MIBG uptake in globally denervated human and
canine hearts: implications for clinical studies. J Nucl Med. 1992; 33: 1444–1450.
50. Dae MW, O‘Connell JW, Botvinick EH, Ahearn T, Yee E, Huberty JP, Mori H, Chin
MC, Hattner RS, Herre JM, Munoz L. Scintigraphic assessment of regional cardiac
adrenergic innervation. Circulation. 1989; 79: 634–644.
51. Davies KR, Gelb AW, Manninen PH, Boughner DR, Bisnaire D. Cardiac function in
aneurysmal subarachnoid haemorrhage: a study of electrocardiographic and
echocardiographic abnormalities. Br J Anaesth. 1991; 67: 58–63.
52. De Marco T, Dae M, Yuen-Green MS, Kumar S, Sudhir K, Keith F, Amidon TM, Rifkin
C, Klinski C, Lau D, Botvinick EH, Chatterjee K. Iodine-123 metaiodobenzylguanidine
scintigraphic assessment of the transplanted human heart: evidence for late
reinnervation. J Am Coll Cardiol. 1995; 25: 927–931.
53. Desmet WJ, Adriaenssens BF, Dens JA. Apical ballooning of the left ventricle: first
series in white patients. Heart 2003; 89(9):1027-31.
54. DiCarli MF, Prcevski P, Singh TP, Janisse J, Ager J, Muzik O, Vander Heide R.
Myocardial blood flow, function, and metabolism in repetitive stunning. J Nucl Med.
2000; 41: 1227–1234.
55. Dikshit BB. The production of cardiac irregularities by excitation of the hypothalamic
centres. J Physiol. 1934; 81: 382–394.
56. Dimant J, Grob D. Electrocardiographic changes and myocardial damage in patients
with acute cerebrovascular accidents. Stroke. 1977; 8: 448–455.
57. Donahue D, Movahed MR. Clinical characteristics, demographics and prognosis of
transient left ventricular apical ballooning syndrome. Heart Fail Rev. 2005; 10: 311–316.
58. Donaldson, J. W., & Pritz, M. B. (2001). Myocardial stunning secondary to aneurysmal
subarachnoid hemorrhage. Surgical Neurology, 55(1), 12–16; discussion 16.
128
59. Doshi R, Neil-Dwyer G, Stott A. Hypothalamic and myocardial lesions after
subarachnoid hemorrhage. J Neurol Neurosurg Psychiatry. 1977; 40: 821–826
60. Dote K, Sato H, Tateshi H, Uchida T, Ishihara M. Myocardial stunning due to
simultaneous multivessel coronary spasm: a review of 5 cases. J Cardiol 1991;
21(2):203-14.
61. Drislane F, Samuels M, Kozakewich H, Schoen FJ, Strunk RC. Myocardial contraction
band lesions in patients with fatal asthma: possible neurocardiologic mechanisms. Am
Rev Respir Dis. 1987; 135: 498–501.
62. Dujardin KS, McCully RB, Wijdicks EFM, Tazelaar HD Seward JB, McGregor CGA,
Olson LJ. Myocardial dysfunction associated with brain death: clinical,
echocardiographic, and pathologic features. J Heart Lung Transplant. 2001; 20: 350–
357.
63. Dunleavy, K., Finck, A., Overstreet, W., & Presciutti, M. (2005). Improving care for
patients with subarachnoid hemorrhage. Nursing, 35(11), 26–27.
64. Eckardt M, Gerlach L, Welter FL. Prolongation of the frequency corrected effects of
humeffects of human insular cortex stimulation. Neurology electrocardiographic
abnormalities. Neurosurgery 1999; 44:34–40.
65. Elesber A, Bybee KA, Prasad A, Wright RS, Lerman A, Rihal CS. Right ventricular
dysfunction in the transient apical ballooning syndrome: incidence and impact on
clinical outcome. J Am Coll Cardiol. 2006; 47: 1082–1083.
66. Elesber A, Lerman A, Bybee KA, et al. Myocardial perfusion in apical ballooning
syndrome: correlate of myocardial injury. Am Heart J 2006; 152(3):469.e9-13.
67. Elesber A, Prasad A, Lennon R, Lerman A Rihal CS. Four-year recurrence rate and
prognosis of the apical ballooning syndrome. J Am Coll Cardiol. 2007; 50: 448–452.
68. Elesber AA, Prasad A, Bybee KA, et al. Transient cardiac apical ballooning syndrome:
prevalence and clinical implication of right ventricular involvement. J Am Coll Cardiol
2006; 47(5):1082-3.
69. Elian D, Osherou A, Matetzky S, Hod H, Guetta V, Feinberg MS, Di Segni E. Left
ventricular apical ballooning syndrome: not an uncommon variant of acute myocardial
infarction in women. Clin Cardiol. 2006; 29: 9–12.
70. Eliot RS, Todd GL, Pieper GM, Clayton FC. Pathophysiology of catecholamine-
mediated myocardial damage. J S C Med Assoc. 1979; 75: 513–518.
71. Elrifai AM, Bailes JE, Shih S-R, Diazumba S, Brillman J. Characterization of the
cardiac effects of acute subarachnoid hemorrhage in dogs. Stroke. 1996; 27: 737–742.
129
72. Engel G. Sudden and rapid death during psychological stress. Ann Intern Med. 1971; 74:
771–782.
73. Ennezat PV, Pesenti-Rossi D, Aubert JM, Rachenne V, Bauchart JJ, Auffray JL, et al.
Transient left ventricular basal dysfunction without coronary stenosis in acute cerebral
disorders: a novel heart syndrome (inverted Takotsubo). Echocardiography
2005;22:599-602
74. Estorch M, Camprecios M, Flotats A, Mari C, Berna L, Catafau AM, Ballester M,
Narula J, Carrio I. Sympathetic reinnervation of cardiac allografts evaluated by 123I-
MIBG imaging. J Nucl Med. 1999; 40: 911–916.
75. Fabinyi G, Hunt D, McKinley L. Myocardial creatine kinase isoenzyme in serum after
subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry. 1977; 40: 818–820.
76. Fiol M, Carrillo A, Cygankievicz I, et al. New Electrocardiographic algorithm to locate
the occlusion in left anterior descending coronary artery Clin Cardiol 2009;32:E1-E6.
77. Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid
hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 1980; 6:
1–9.
78. Folland ED, Parisi AF, Moynihan PF, Jones DR, Feldman CL, Tow DE Assessment of
left ventricular ejection fraction and volumes by real-time, two-dimensional
echocardiography. A comparison of cineangiographic and radionuclide techniques.
Circulation 1979; 60(4):760-6.
79. Frontera JA, Parra A, Shimbo D, Fernandez A, Schmidt JM, Peter P, Claasen J,
Wartenberg KE, Rincon F, Badjata N, Naidech A, Connolly ES, Mayer A. Cardiac
arrhythmias after subarachnoid hemorrhage: risk factors and impact on outcome.
Cerebrovasc Dis. 2008; 26: 71–78.
80. Frustaci A, Loperfido F, Gentiloni N, Caldarulo M, Morgante E, Russo MA.
Catecholamine-induced cardiomyopathy in multiple endocrine neoplasia. Chest. 1991;
99: 382–385.
81. Gerbaud E, Montaudon M, Leroux L, et al. MRI for the diagnosis of left ventricular
apical ballooning syndrome (LVABS). Eur Radiol. 2008. May;18(5):947-954 Epub
2008 Jan 31.
82. Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E. Apical ballooning
syndrome or takotsubo cardiomyopathy: a systemic review. Eur Heart J 2006l;
27(13):1523-9.
130
83. Goldstein DS, Holmes C, Li ST, Bruce S, Metman LV, Cannon RO 3rd. Cardiac
sympathetic denervation in Parkinson disease. Ann Intern Med 2000; 133(5):338-47.
84. Gorcsan J, Kanzaki H, Bazaz R, Dohi K, Schwartzman D. Usefulness of
echocardiographic tissue synchronization imaging to predict acute response to cardiac
resynchronization therapy. Am J Cardiol. 2004; 93: 1178–1181
85. Gottlieb R, Burleson KO, Kloner RA Babior BM, Engler RL. Reperfusion injury
induces apoptosis in rabbit cardiomyocytes. J Clin Invest. 1994; 94: 1621–1628.
86. Greenshoot JH, Reichenbach DD. Cardiac injury and subarachnoid haemorrhage. J
Neurosurg. 1969; 30: 521–531.
87. Hachinski VC, Smith KE, Silver MD, Gibson CJ, Ciriello J. Acute myocardial and
plasma catecholamine changes in experimental stroke. Stroke. 1986; 17: 387–390.
88. Haghi D, Athanasiadis A, Papavassiliu T, Suselback T, Fluecter S, Mahrholdt H,
Borggrefe M, Sechtem U. Right ventricular involvement in Takotsubo cardiomyopathy.
Eur Heart J. 2006; 27: 2433–2439.
89. Haghi D, Fluechter S, Suselbeck T, Kaden JJ, Borggrefe M, Papavassiliu T.
Cardiovascular magnetic resonance findings in typical versus atypical forms of the acute
apical ballooning syndrome (Takotsubo cardiomyopathy). Int J Cardiol. 2007.
August21;120(2):205-211 Epub 2006 Dec 15.
90. Hammond HK, Roth DA, Ford CE, Stamnas GW, Ziegler MG, Ennis C. Myocardial
adrenergic denervation supersensitivity depends on a postreceptor mechanism not linked with
increased cAMP production. Circulation 1992; 85(2):666-79.
91. Hanekom L, Jenkins C, Jeffries L, et al. Incremental value of strain rate analysis as an
adjunct to wall-motion scoring for assessment of myocardial viability by dobutamine
echocardiography: a follow-up study after revascularization. Circulation
2005;112(25):3892-3900
92. Harrod CG, Bendok BR, Batjer HH. Prediction of cerebral vasospasm in patients
presenting with aneurysmal subarachnoid hemorrhage: a review. Neurosurgery. 2005;
56: 633–654;discussion 633–654.
93. Hashimoto K, Uehara T, Ishida Y, Nongi H, Kusuoka H, Nishimura T. Paradoxical
uptake of F-18 fluorodeoxyglucose during the sub-acute phase in patients with acute
myocardial infarction. Ann Nucl Med. 1996; 10: 93–98.
94. Haverkamp W, Breithardt G, Camm AJ, Janse MJ, Rosen MR, Antzelevitch C, et al.
The potential for QT prolongation and proarrhythmia by non-antiarrhythmic drugs:
131
clinical and regulatory implications: report on a policy conference of the European
Society of Cardiology. Eur Heart J. 2000; 21: 1216–1231
95. Hawkins WE, Clower BR. Myocardial damage after head trauma and simulated
intracranial haemorrhage in mice: the role of the autonomic nervous system. Cardiovasc
Res. 1971; 5: 524–529.
96. Hays, A., & Diringer, M. N. (2006). Elevated troponin levels are associated with higher
mortality following intracerebral hemorrhage. [See comment]. Neurology, 66(9), 1330–
1334.
97. Hearse DJ, Humphrey SM, Bullock GR. The oxygen paradox and the calcium paradox:
two facets of the same problem? J Moll Cell Cardiol. 1978; 10: 641–668.
98. Hillis GS, Møller JE, Pellikka PA, et al. Noninvasive estimation of left ventricular filling
pressure by E/e′ is a powerful predictor of survival after acute myocardial infarction. J
Am Coll Cardiol. 2004;43(3):360-367.
99. Hillis GS, Ujino K, Mulvagh SL, Hagen ME, Oh JK. Echocardiographic indices of
increased left ventricular filling pressure and dilation after acute myocardial infarction. J
Am Soc Echocardiogr. 2006;19(4):450-456.
100. Hirashima Y, Takashima S, Matsumura N, Kurimoto M, Origasa H, Endo S. Right
sylvian fissure subarachnoid hemorrhage has electrocardiographic consequences. Stroke.
2001; 32: 2278–2281.
101. Hoesel LM, Niederbichler AD, Ward PA. Complement-related molecular events in
sepsis leading to heart failure. Mol Immunol. 2007; 44: 95–102.
102. Hoffmann R, Altiok E, Nowak B, et al. Strain rate measurement by Doppler
echocardiography allows improved assessment of myocardial viability inpatients with
depressed left ventricular function. J Am Coll Cardiol. 2002;39(3):443-449.
103. Horowitz MB, Willet D, Keefer J. The use of cardiac troponin-I (cTnI) to determine
the incidence of myocardial ischemia and injury in patients with aneurysmal and
presumed aneurysmal subarachnoid hemorrhage. Acta Neurochir. 1998; 140: 87–93.
104. Hurst RT, Prasad A, Takotsubo Cardiomyopathy: A Unique Cardiomyopathy With
Variable Ventricular Morphology. J Am Coll Cardiol Img, 2010; 3:641-649
105. Hurst RT, Askew JW, Reuss CS, Lee RW, Sweeney JP, Fortuin FD, Oh JK, Tajik
AJ. Transient midventricular ballooning: a new variant. J Am Coll Cardiol. 2006; 48:
579–583.
106. Ibanez B, Benezet-Mazuecos J. Takotsubo Syndrome: A Bayesian approach to
interpreting its pathogenesis. Mayo Clin Proc. 2006; 81: 732–735
132
107. Ibanez B, Novarro F, Cordoba M, M-Alberca P, Farre J. Tako-tsubo transient left
ventricular apical ballooning: is intravascular ultrasound the key to resolve the enigma?
Heart 2005; 91(1):102-4.
108. Ingul CB, Stoylen A, Slordahl SA. Recovery of stunned myocardium in acute
myocardial infarction quantified by strain rate imaging: a clinical study. J Am Soc
Echocardiogr. 2005;18(5):401-410.
109. Ito K, Sugihara H, Katoh S, Azuma A, Nakagawa M. Assessment of Takotsubo
(ampulla) cardiomyopathy using 99mTC-tetrofosmin myocardial SPECT: comparison
with acute coronary syndrome. Ann Nucl Med. 2003; 17: 115–122.
110. Jacob WA, Van Bogaert A, DeGroot-Lasseel MHA. Myocardial ultrastructural and
haemodynamic reactions during experimental subarachnoid haemorrhage. J Moll Cell
Cardiol. 1972; 4: 287–298.
111. Jain R, Deveikis J, Thompson BG. Management of patients with stunned
myocardium associated with subarachnoid hemorrhage. Am J Neuroradiol. 2004; 25:
126–129
112. Jamal F, Kukulski T, Strotmann J, et al. Quantification of the spectrum of changes in
regional myocardial function during acute ischemia in closed chest pigs: an ultrasonic
strain rate and strain study. J Am Soc Echocardiogr. 2001;14(9):874-884.
113. Jamal F, Kukulski T, Sutherland GR, et al. Can changes in systolic longitudinal
deformation quantify regional myocardial function after an acute infarction? An
ultrasonic strain rate and strain study. J Am Soc Echocardiogr. 2002;15(7):723-730.
114. Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet. 1975;
1: 480–484.
115. Jensen JK, Christensen SR, Bak S, Atar D, Hoilund-Carlson PE, Mickley H.
Frequency and significance of troponin T elevation in acute ischemic stroke. Am J
Cardiol. 2007; 99: 108–112.
116. Jeon TJ, Lee JD, Ha JW, Yang WI, Cho SH. Evaluation of cardiac adrenergic
neuronal damage in rats with doxorubicin-induced cardiomyopathy using iodine-131
MIBG autoradiography and PGP 9.5 immunohistochemistry. Eur J Nucl Med. 2000; 27:
686–693.
117. Josué O. Hypertrophie cardiaque cause par l‘adrenaline and la toxine typhique. C R
Soc Biol (Paris). 1907; 63: 285–287.
118. Kantor HL, Krishnan SC. Cardiac problems in patients with neurologic disease.
Cardiol Clin. 1995; 13: 179–208.
133
119. Karch SB, Billingham ME. Myocardial contraction bands revisited. Hum Pathol.
1986; 17: 9–13.
120. Karplus JP, Kreidl A. Gehirn und Sympathicus. Sympathicusleitung im Gehirn und
Halsmark [German]. Pflugers Arch. 1912; 143: 109–127.
121. Karplus JP, Kreidl A. Gehirn und Sympathicus. Uber Beziehungen der
Hypothalamaszentren zu Blutdruck und innerer Sekretion [German]. Pflugers Arch.
1927; 215: 667–674.
122. Kassell NF, Peerless SJ, Durward QJ, Beck DW, Drake CG, Adams HP. Treatment
of ischemic deficits from vasospasm with intravascular volume expansion and induced
arterial hypertension. Neurosurgery. 1982; 11: 337–343.
123. Kawahara E, Ikeda S, Miyahara Y, Kohno S. Role of autonomic nervous dysfunction
in electrocardiographic abnormalities and cardiac injury in patients with acute
subarachnoid hemorrhage. Circ J. 2003; 67: 753–756.
124. Kawai S, Suzuki H, Yamaguchi H, Tanaka K, Sawada H, Aizawa T, et al. Ampulla
cardiomyopathy (―Takotsubo‖ cardiomyopathy) – reversible left ventricular dysfunction:
with ST segment elevation. Jpn Circ J 2000; 64(2):156-9
125. Kawano H, Okada R, Yano K. Histological study on the distribution of autonomic nerves in
the human heart. Heart Vessels 2003; 18(1):32-9.
126. Kawasaki T, Azuma A, Sawada T, Sugihara H, Kuribayashi T, Satoh M, Shimizu Y,
Nakagawa M. Electrocardiographic score as a predictor of mortality after subarachnoid
hemorrhage. Circ J. 2002; 66: 567–570.
127. Khechinashvili G, Asplund K. Electrocardiographic changes in patients with acute
stroke: a systematic review. Cerebrovasc Dis. 2002; 14: 65–66.
128. Khush K, Kopelnik A, Tung P, Banki N, Dae M, Lawton M, Smith W, Drew B,
Foster E, Zaroff J. Age and aneurysm position predict patters of left ventricular
dysfunction after subarachnoid hemorrhage. J Am Soc Echocardiogr. 2005; 18: 168–
174.
129. Kneale BJ, Chowienczyk PJ, Brett SE, Coltart DJ, Ritter JM. Gender differences in
sensitivity to adrenergic agonists of forearm resistance vasculature. J Am Coll Cardiol.
2000; 36: 1233–1238.
130. Kono T, Morita H, Kuroiwa T, Onaka H, Takatsuka H, Fujiwara A. Left ventricular
wall motion abnormalities in patients with subarachnoid hemorrhage: neurogenic
stunned myocardium. J Am Coll Cardiol. 1994; 24: 636–640.
134
131. Kopelnik A, Zaroff JG. Neurocardiac injury in neurovascular disorders. Crit Care
Clin. 2007; 22: 733–752.
132. Koskelo P, Punsar SO, Sipila W. Subendocardial haemorrhage and ECG changes in
intracranial bleeding. BMJ. 1964; 1: 1479–1483.
133. Kosty, T. (2005). Cerebral vasospasm after subarachnoid hemorrhage: An update.
Critical Care Nursing Quarterly, 28(2), 122–134.
134. Kosuge M, Toshiaki E, Kiyoshi H, et al. Simple and accurate electrocardiographic
criteria to differentiate Takotsubo cardiomyopathy from anterior acute myocardial
infarction J Am Coll Cardiol 2010;55:2514-2516.
135. Kothavale A, Banki NM, Kopelnik A, Yarlagadda S, Lawton MT, Ko N, Smith WS,
Drew B, Foster E, Zaroff JG. Predictors of left ventricular regional wall motion
abnormalities after subarachnoid hemorrhage. Neurocrit Care. 2006; 4: 199–205.
136. Kovethal A, Banki NM, Kopelnik A, Yarlagadda S, Lawton MT, Ko N, Smith WS,
Drew B, Foster E, Zaroff J. Predictors of left ventricular regional wall motion
abnormalities after subarachnoid hemorrhage. Neurocrit Care. 2006; 04: 199–205.
137. Krishnagopalan S, Kumar A, Parrillo JE, Kumar A. Myocardial dysfunction in the
patient with sepsis. Curr Opin Crit Care. 2002; 8: 376–388.
138. Kume T, Akasaka T, Kawamoto T, Watanabe N, Yoshitani H, Akiyama M, Koyama
Y, Neishi Y, Tsukiji M, Yoshida K. Relationship between coronary flow reserve and
recovery of regional left ventricular dysfunction in patients with tako-tsubo-like transient
left ventricular dysfunction. J Cardiol. 2004; 43: 123–129.
139. Kurisu S, Inoue I, Kawagoe T, at al. Myocardial perfusion and fatty acid metabolism
in patients with tako-tsubo-like left ventricular dysfunction. J Am Coll Cardiol 2003;
41(5):743-48.
140. Kurisu S, Sato H, Kawagoe T, et al. Tako-tsubo-like left ventricular dysfunction
with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial
infarction. Am Heart J 2002;143(3):448-455.
141. Kuroiwa T, Morita H, Tanabe H, Ohta T. Significance of ST segment elevation in
electrocardiograms in patients with ruptured cerebral aneurysms. Acta Neurochir
(Wien). 1995; 133: 141–146.
142. Kurowski V, Kaiser A, von Hof K, Killermann DP, Mayer B, Hartmann F,
Schunkert H, Radke PW. Apical and mid-ventricular transient left ventricular
dysfunction syndrome (Tako-tsubo cardiomyopathy): frequency, mechanisms, and
prognosis. Chest. 2007; 132: 809–816.
135
143. Lambert G, Naredi S, Eden E, Rydenhag B, Friberg P. Sympathetic nervous
activation following subarachnoid hemorrhage: influence of intravenous clonidine. Acta
Anaesthesiol Scand. 2002; 46: 160–165.
144. Lang RM, Beirig M, Devereux RB, Flachskampf FA, Foster E, Pelikka PA, Picard
MH, Roman MJ, Seward J, Shanewise JS, Solomon SD, Spencer KT, Sutton MS,
Stewart WJ; Chamber Quantification Writing Group; American Society of
Echocardiography‘s Guidelines and Standards Committee; European Association of
Echocardiography. Recommendations for chamber quantification: a report from the Am
Society of Echocardiography‘s Guidelines and Standards Committee and the Chamber
Quantification Writing Group. J Am Soc Echocardiogr. 2005; 18: 1440–1463.
145. Lang SA, Maron MB, Bosso FJ, Pilati CF. Temporal changes in left ventricular
function after massive sympathetic nervous system activation. Can J Physiol Pharmacol.
1994; 72: 693–700.
146. Lanzino G, Kongable GL, Kassell NF. Electrocardiographic abnormalities after
nontraumatic subarachnoid hemorrhage. J Neurosurg Anesthesiol. 1994; 6: 156–162.
147. Lee VH, Mulvagh SL, Widjicks EF. Mechanisms of neurogenic stress
cardiomyopathy after aneurysmal subarachnoid hemorrhage. Neurocrit Care. 2006; 5:
243–249.
148. Lee, V. H., Connolly, H. M., Fulgham, J. R., Manno, E. M., Brown, R. D., Jr., &
Wijdicks, E. F. (2006). Tako-tsubo cardiomyopathy in aneurysmal subarachnoid
hemorrhage: An underappreciated ventricular dysfunction. Journal of Neurosurgery,
105(2), 264–270.
149. Levine HD. Non-specificity of the electrocardiogram associated with coronary heart
disease. Am J Med. 1953; 15: 344–350.
150. Li ST, Holmes C, Kopin IJ, Goldstein DS. Aging-related changes in cardiac sympathetic
function in humans, assessed by 6-18F-fluorodapamine PET scanning. J Nucl Med 2003;
44(10):1599-603.
151. Lyseggen E, Skulstad H, Helle-Valle T, et al. Myocardial strain analysis in acute
coronary occlusion: a tool to assess myocardial viability and reperfusion. Circulation
2005;112(25):3901-3910.
152. MacIntyre K, Stewart S, Capewell S, Chalmers JW, Pell JP, Boyd J, Finlayson A,
Redpath A, Gilmour H, McMurray JJ. Gender and survival: a population-based study of
201,114 men and women following a first acute myocardial infarction. J Am Coll
Cardiol. 2001; 38: 729–735.
136
153. Maeder M, Fehr T, Rickli H, Ammann P. Sepsis-associated myocardial dysfunction.
Chest. 2006; 129: 1349–1366.
154. Mann DL, Kent RL, Parsons B, Adrenergic effects on the biology of the adult
mammalian cardiocyte. Circulation 1992; 85(2):790-804.
155. Maron BJ, Towbin JA, Thiene G, Antzelvich C, Corrado D, Arnett D, Moss AJ,
Seidman CE, Young JB. American Heart Association contemporary definitions and
classification of the cardiomyopathies: American Heart Association scientific statement
from the Council on Clinical Cardiology, Heart Failure and Transplantation Committee;
Quality of Care and Outcomes Research and Functional Genomics and Translational
Biology Interdisciplinary Working Groups; and Council on Epidemiology and
Prevention. Circulation. 2006; 113: 1807–1816.
156. Mashaly HA, Provencio JJ. Inflammation as a link between brain injury and heart
damage: the model of subarachnoid hemorrhage. Cleveland Clinic J Med. 2008; 75
(suppl 2): S26–S30.
157. Masuda T, Sato K, Yamamota S, Matsuyama N, Shimohama T, Matsunaga A,
Obuchi S, Shiba Y, Shimizu S, Izumi T. Sympathetic nervous activity and myocardial
damage immediately after subarachnoid hemorrhage in a unique animal model. Stroke.
2002; 33: 1671–1676.
158. Matsunari I, Schricke U, Bengel FM, Haase HU, Barthel P, Schmidt G, Nekolla SG,
Schoemig A, Schwaiger M. Extent of cardiac sympathetic neuronal damage is
determined by the area of ischemia in patients with acute coronary syndromes.
Circulation. 2000; 101: 2579–2585.
159. Mayer S, Lin J, Homma S, Solomon R, Lennihan L, Sherman D, Fink M, Beckford
A, Klebanoff L. Myocardial injury and left ventricular performance after subarachnoid
hemorrhage. Stroke. 1999; 30: 780–786.
160. Sanchez-Recalde A, Iborra C, Costero O, Moreno R, Lopez de Sa E, Sobrino JA, et
al Takotsubo cardiomyopathy—a new variant and widening disease spectrum. ―Inverted
Takotsubo‖ pattern related to catecholamine- toxicity. Int J Cardiol 2007
161. McNair JL, Clower BR, Sanford RA. The effect of reserpine pretreatment on
myocardial damage associated with simulated intracranial haemorrhage in mice. Eur J
Pharmacol. 1970; 9: 1–6.
162. Mrdovic I, Kostic J, Perunicic J, Asanin M, Vasiljevic Z, Ostojic M. Right
Ventricular Takotsubo Cardiomyopathy. J Am Coll Cardiol 2010;55;1751
137
163. Meerson FZ. Pathogenesis and prophylaxis of cardiac lesions in stress. Adv
Myocardiol. 1983; 4: 3–21.
164. Mehta NJ, Khan IA, Gupta V, Jani K, Gowda RM, Smith P. Cardiac troponin I
predicts myocardial dysfunction and adverse outcomes in septic shock. In J Cardiol.
2004; 95: 13–17.
165. Melville KI, Blum B, Shister HE, Silver MD. Cardiac ischemic changes and
arrhythmias induced by hypothalamic stimulation. Am J Cardiol. 1963; 12: 781–791.
166. Merli E, Sutcliffe S, Gori M, Sutherland GG. Tako-Tsubo cardiomyopathy: new
insights into the possible underlying pathophysiology. Eur J Echocardiogr 2006;
7(1):53-61.
167. Mertes P, Carteaux J, Jaboin Y, Pinelli G, el Abassi K, Dopff C, Atkinson J,
Villemot J, Burlet C, Boulange M. Estimation of myocardial interstitial norepinephrine
release after brain death using cardiac microdialysis. Transplantation. 1994; 57: 371–
377.
168. Meune C, Bertherat J, Dousset B, Jude N, Bertagna X, Duboc D, Weber S. Reduced
myocardial contractility assessed by tissue Doppler echocardiography is associated with
increased risk during adrenal surgery of patients with pheochromocytoma: report of a
preliminary study. J Am Soc Echocardiogr. 2006; 19: 1466–1470.
169. Miller JA, Dacey RG Jr, Diringer MN. Safety of hypertensive hypervolemic therapy
with phenylephrine in the treatment of delayed ischemic deficits after subarachnoid
hemorrhage. Stroke. 1995; 26: 2260–2266.
170. Miss JC, Kopelnik A, Fisher LA, Tung PP, Banki NM, Lawton MT, Smith WS,
Dowd CF, Zaroff JG. Cardiac injury after subarachnoid hemorrhage is independent of
the type of aneurysm therapy. Neurosurgery. 2004; 55: 1244–1251.
171. Momose M, Kobayashi H, Ikegami H, Matsuda N, Hachida M, Kasanuki H,
Kuskabe K. Regional cardiac sympathetic reinnervation in transplanted human hearts
detected by 123
I-MIBG SPECT imaging. Ann Nucl Med. 2000; 14: 333–337.
172. Mori H, Ishikawa S, Kojima S, et al. Increased responsiveness of left ventricular
apical myocardium to adrenergic stimuli. Cardiovasc Res 1993; 27(2):192-8.
173. Muizelaar JP, Becker DP. Induced hypertension for the treatment of cerebral
ischemia after subarachnoid hemorrhage: direct effect on cerebral blood flow. Surg
Neurol. 1986; 25: 317–325.
174. Muller O, Roguelov C, Pascale P. A basal variant form of the transient
'midventricular' and 'apical' ballooning syndrome. QJM. 2007 Nov;100(11):738-9.
138
175. Murphree SS, Saffitz JE. Quantitative autoradiographic delineation of the
distribution of beta-adrenergic receptors in canine and feline left ventricular
myocardium. Circ Res. 1987; 60: 568–579.
176. Naidech AN, Kreiter KT, Janjua N, Ostapkovich ND, Parra A, Commichau C,
Fitzsimmons BM, Connolly S, Mayer S. Cardiac troponin elevation, cardiovascular
morbidity, and outcome after subarachnoid hemorrhage. Circulation. 2005; 112: 2851–
2856.
177. Naredi S, Lambert G, Eden E, Zall S, Runnerstam M, Rydenhag B, Friberg P.
Increased sympathetic nervous activity in patients with nontraumatic subarachnoid
hemorrhage. Stroke. 2000; 31: 901–906.
178. Nef HM, Mollman H, Kostin S, Troidl C, Voss S, Weber M, Dill T, Rolf A, Brandt
R, Hamm CW, Elsasser A. Tako-tsubo cardiomyopathy: interindividual structural
analysis in the acute phase and after functional recovery. Eur Heart J. 2007; 28: 2456–
2464.
179. Neil-Dwyer G, Cruickshank J, Stratton C. Beta-blockers, plasma total creatine kinase
and creatine kinase myocardial isoenzyme, and the prognosis of subarachnoid
hemorrhage. Surg Neurol. 1986; 25: 163–168.
180. Neil-Dwyer G, Walter P, Cruickshank J, Doshi B, O'Gorman P. Effect of
propranolol and phentolamine on myocardial necrosis after subarachnoid haemorrhage.
BMJ. 1978; 2: 990–992.
181. Noordzij PG, Boersma E, Bax JJ, Feringa HH, Schreiner F, Schouten O, Kertai MD,
Klein J, van Urk H, Elhendy A, Poldermans D. Prognostic value of routine preoperative
electrocardiography in patients undergoing noncardiac surgery. Am J Cardiol. 2006; 97:
1103–1106.
182. Norris JW, Hachinski VC, Myers MG, Callow J, Wong T, Moore RW. Serum
cardiac enzymes in stroke. Stroke. 1979; 10: 548–553.
183. Ogura R, Hiasa Y, Takahashi T, et al. Specific findings of the standard 12-lead ECG
in patients with 'Takotsubo' cardiomyopathy: comparison with the findings of acute
anterior myocardial infarction Circ J 2003;67:687-690
184. Ogura R, Kosuge M, Simple and Accurate Electrocardiographic Criteria to
Differentiate Takotsubo Cardiomyopathy From Anterior Acute Myocardial Infarction. J
Am Coll Cardiol, 2010; 55:2514-2516
139
185. Ohtsuka T, Hamada M, Kodama K, Sasaki O, Suzuki M, Hara Y, et al.: Images in
cardiovascular medicine. Neurogenic stunned myocardium. Circulation 101:2122–2124,
2000
186. Oppenheimer S, Wilson J, Guiraudon C, Cechetto D. Insular cortex stimulation
produces lethal cardiac arrhythmias: a mechanism of sudden death? Brain Res. 1991;
550: 115–121.
187. Oppenheimer SM, Cechetto DF. Cardiac chronotropic organization of the rat insular
cortex. Brain Res. 1990; 533: 66–72.
188. Oppenheimer SM, Gelb A, Girvin JP, Hachinski VC. Cardiovascular effects of
human insular cortex stimulation. Neurology. 1992; 42: 1727–1732.
189. Ottomo.S, et al. Two Cases of Transient Left Ventricular Apical Ballooning
Syndrome Associated with Subarachnoid Hemorrhage. Anesth Analg. 2006
Sep;103(3):583-6.
190. Smith, Jr, et al. ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary
Intervention. J Am Coll Cardiol, 2006; 47:1-121
191. Parekh N, Venkatesh B, Cross D, Leditschke A, Atherton J, Miles W, Winning A,
Clague A, Rickard C. Cardiac troponin I predicts myocardial dysfunction in aneurysmal
subarachnoid hemorrhage. J Am Coll Cardiol. 2000; 36: 1328–1335.
192. Park J-H, Kang S-J, Song J-K, Kim HK, Lim CM, Kang D-H, Koh Y. Left
ventricular apical ballooning due to severe physical stress in patients admitted to the
medical ICU. Chest. 2005; 128: 296–302.
193. Park TH, Nagueh SF, Khoury DS, et al. Impact of myocardial structure and function
postinfarction on diastolic strain measurements: implications for assessment of
myocardial viability. Am J Physiol Heart Circ Physiol. 2006. February;290(2):H724-
H731 Epub 2005 Sep 23.
194. Parker MM, Shelhamer JH, Bacharach SL, Green MV, Natanson C, Frederick TM,
Damske BA, Parrillo JE. Profound but reversible myocardial depression in patients with
septic shock. Ann Intern Med. 1984; 100: 483–490.
195. Parodi G, Del Pace S, Salvadori C, Carrabba N, Olivotto I, Gensini GF. Tuscany
registry of Tako-Tsubo cardiomyopathy: left ventricular apical ballooning syndrome as a
novel cause of acute mitral regurgitation. J Am Coll Cardiol. 2007; 50: 647–649.
140
196. Parr, M. J., Finfer, S. R., & Morgan, M. K. (1996). Reversible cardiogenic shock
complicating subarachnoid haemorrhage. BMJ, 313(7058), 681–683.
197. Pavin D, Le Breton H, Daubert C. Human stress cardiomyopathy mimicking acute
myocardial syndrome. Heart. 1997; 78: 509–511.
198. Pislaru C, Bruce CJ, Anagnostopoulos PC, et al. Ultrasound strain imaging of altered
myocardial stiffness: stunned versus infarcted reperfused myocardium. Circulation 2004.
June15;109(23):2905-2910 Epub 2004 Jun 1.
199. Pislaru C, Bruce CJ, Seward JB, Greenleaf JF. Distinctive changes in end-diastolic
wall thickness and postsystolic thickening in viable and infarcted myocardium. J Am
Soc Echocardiogr. 2004;17(8):855-862.
200. Pitts WR, Vongpatanasin W, Cigarroa JE, Hillis LD, Lange RA. Effects of
intracoronary infusion of cocaine on left ventricular systolic and diastolic function in
humans. Circulation. 1998; 97: 1270–1273.
201. Pollick C, Cujec B, Parker S, Tator C. Left ventricular wall motion abnormalities in
subarachnoid hemorrhage: an echocardiographic study. J Am Coll Cardiol. 1988; 12:
600–605.
202. Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress
cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J 2008.
March;155(3):408-417 Epub 2008 Jan 31.
203. Prasad A. Apical ballooning syndrome: an important differential diagnosis of acute
myocardial infarction. Circulation. 2007; 115: e56–e59.
204. Prasad SB, Richards DA, Sadick N, Ong ATL, Kovoor P. Clinical and
electrocardiographic correlates of normal coronary angiography in patients referred for
primary percutaneous coronary intervention Am J Cardiol 2008;102:155-159.
205. Prosser J, MacGregor L, Lees KR, Diener HC, Hacke W, Davis S. Predictors of
early cardiac morbidity and mortality after ischemic stroke. Stroke. 2007; 38: 2295–
2302.
206. Provencio JJ, Vora N. Subarachnoid hemorrhage and inflammation: bench to bedside
and back. Semin Neurol. 2005; 25: 435–444.
207. Quenot J-P, Le Teuff G, Quantin C, Doise J-M, Abrahamowicz M, Masson D,
Blettery B. Myocardial injury in critically ill patients. Chest. 2005; 128: 2758–2764.
208. Raab W, Stark E, MacMillan WH, Gigee WR. Sympathogenic origin and anti-
adrenergic prevention of stress-induced myocardial lesions. Am J Cardiol. 1961; 8: 203–
211.
141
209. Ramappa P, Thatai D, Coplin W, Gellman S, Carhuapoma JR, Quah R, Atkinson B,
Marsh JD. Cardiac troponin I: a predictor of prognosis in subarachnoid hemorrhage.
Neurocrit Care. 2007; 8: 398–403.
210. Raper R, Fisher M, Bihari D. Profound, reversible, myocardial depression in acute
asthma treated with high-dose catecholamines. Crit Care Med. 1992; 20: 710–712.
211. Reardon M, Malik M. QT interval change with age in an overtly healthy older
population. Clin Cardiol. 1996; 19: 949–952.
212. Reuss CS, Lester SJ, Hurst RT, Askew JW, Nager P, Lusk J, Altemose GT, Tajik
AJ. Isolated left ventricular basal ballooning phenotype of transient cardiomyopathy in
young women. Am J Cardiol. 2007; 99: 1451–1453.
213. Richter CP. On the phenomenon of sudden death in animal and man. Psychosomatic
Med. 1957; 19: 191–198.
214. Rona G. Catecholamine cardiotoxicity. J Moll Cell Cardiol. 1985; 17: 291–306.
215. Rudehill A, Olsson GL, Sundqvist K, Gordon E. ECG abnormalities in patients with
subarachnoid haemorrhage and intracranial tumours. J Neurol Neurosurg Psychiatry.
1987; 50: 1375–1381.
216. Ruiz Bailen M, Aguayo de Hoyos E, Lopez Martnez A, Daz Castellanos MA, Ruiz
Navarro S, Fierro Roson LJ, Gomez Jimenez FJ, Issa-Massad Khozouz Z. Reversible
myocardial dysfunction, a possible complication in critically ill patients without heart
disease. J Crit Care. 2003; 18: 245–252.
217. Sadamatsu K, Tashiro H, Maehira N, Yamamoto K. Coronary microvascular
abnormality in the reversible systolic dysfunction observed after noncardiac disease. Jpn
Circ J 2000; 64(10):789-92
218. Sakata K, Iida K, Mochizuki N, Physiological changes in human cardiac sympathetic
innervation and activity assessed by 123
I-Metaiodobenzylguanidine (MIBG) imagine. Circ J
2009; 73(2):310-5.
219. Sakr YL, Lim N, Amaral AC, Ghosn I, Carvalho FB, Renard M, Vincent JL.
Relation of ECG changes to neurologic outcome in patients with aneurysmal
subarachnoid hemorrhage. Int J Cardiol. 2004; 96: 369–373.
220. Samuels MA. Neurally induced cardiac damage. Neurol Clin. 1993; 11: 273–292.
221. Samuels MA. Neurogenic heart disease: a unifying hypothesis. Am J Cardiol. 1987;
60: 15J–19J.
222. Samuels MA. The brain-heart connection. Circulation. 2007; 116: 77–84.
142
223. Sandhu R, Aronow WS, Rajdev A, Sukhifa R, Amid H, D'Aquila K, Sangha A.
Relation of cardiac troponin I levels with in-hospital mortality in patients with ischemic
stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Am J Cardiol. 2008;
102: 632–634.
224. Sardesai SH, Mourant AJ, Sivathandon Y, Farrow R, Gibbons DO.
Phaeochromocytoma and catecholamine induced cardiomyopathy presenting as heart
failure. Br Heart J. 1990; 63: 234–237.
225. Sato H, Tateishi H, Uchida T. Takotsubo-type left ventricular dysfunction due to
multivessel coronary spasm. In: Kodama K, Haze K, Hori M, eds. Clinical Aspects of
Myocardial Injury: From Ischemia to Heart Failure. Tokyo, Japan: Kagakuhyoronsha
Publishing Co; 1990: 56–64.
226. Sato K, Masuda T, Izumi T. Subarachnoid hemorrhage and myocardial damage:
clinical and experimental studies. Jpn Heart J. 1999; 40: 683–701.
227. Satoh H, Tateishi H, Uchida T. Takotsubo-type cardiomyopathy due to multivessel
spasmIn: Kodama K, Haze K, Hon M, editors. Clinical Aspect of Myocardial Injury.
From Ischemia to Heart Failure (in Japanese). Tokyo: Kagakuhyouronysa Co; 1990. pp.
56-64.
228. Schelbert HR, Buxton D. Insights into coronary artery disease gained from metabolic
imaging. Circulation. 1988; 78: 496–505.
229. Schelbert HR, Henze E, Phelps ME, Kuhl DE. Assessment of regional myocardial
ischemia by positron-emission computed tomography. Am Heart J. 1982; 103: 588–597.
230. Schievink WI. Intracranial aneurysms. N Engl J Med. 1997; 336: 28–40.
231. Schiller N, Shah P, Crawford M, DeMaria A, Devereux R, Feigenbaum H, Gutgesell
H, Reichek N, Sahn D, Schnittger I, Silverman N, Tajik A. Recommendations for
quantitation of the left ventricle by two-dimensional echocardiography. American
Society of Echocardiography Committee on Standards, Subcommittee on Quantitation
of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr. 1989; 2: 358–367.
232. Schuiling WJ, Algra A, deWeerd AW, Leemans P, Rinkel JE. ECG abnormalities in
predicting secondary cerebral ischemia after subarachnoid haemorrhage. Acta
Neurochir. 2006; 148: 853–858.
233. Schuiling WJ, Dennesen PJ, Tans JT, Algra A, Rinkel GJ. Troponin I in predicting
cardiac or pulmonary complications and outcome in subarachnoid hemorrhage. J Neurol
Neurosurg Psychiatry. 2005; 76: 1565–1569.
143
234. Hunt WE, Hess RM. ―Surgical risk as related to time of intervention in the repair of
intracranial aneurysms.‖ Journal of Neurosurgery 1968 Jan;28(1):14-20.
235. Seth PS, Aurigemma GP, Krasnow JM, Tighe DA, Untereker WJ, Meyer TE. A
syndrome of transient left ventricular apical wall motion abnormality in the absence of
coronary disease: a perspective from the United States. Cardiology. 2003; 100: 61–66.
236. Sharkey S, Lesser J, Zenovich A, et al. Acute and reversible cardiomyopathy
provoked by stress in women from the United States. Circulation 2005; 111(4):472-9.
237. Sharkey SW, Shear W, Hodges M, Herzog CA. Reversible myocardial contraction
abnormalities in patients with acute noncardiac illness. Chest. 1998; 114: 98–105.
238. Shimizu M, Kato Y, Masai H, Shima T, Miwa Y. Recurrent episodes of Takotsubo-
like transient apical ballooning occurring in different regions: a case report. J Cardiol.
2006; 48: 101–107
239. Shimizu M, Takahashi H, Fukatsu Y, et al. Reversible left ventricular dysfunction
manifesting as hyperkinesis of the basal and the apical areas with akinesis of the mid
portiona case report. J Cardiol 2003;41:285.
240. Shub C, Cueto-Garcia L, Sheps SG, Ilstrup DM, Tajik AJ. Echocardiographic
findings in pheochromocytoma. Am J Cardiol. 1986; 57: 971–975.
241. Simula S, Lakka T, Laitinen T, Remes J, Kettunen R, Kuikka J, Hertikainen J.
Cardiac adrenergic denervation in patients with non-Q-wave versus Q-wave myocardial
infarction. Eur J Nucl Med. 2000; 27: 816–821.
242. Singal PK, Kapur N, Dhillon KS, Beamish RE, Dhalla NS .Role of free radicals in
catecholamine-induced cardiomyopathy. Can J Physiol Pharmacol 1982; 60(11):1390-7.
243. Skulstad H, Edvardsen T, Urheim S, et al. Postsystolic shortening in ischemic
myocardium: active contraction or passive recoil? Circulation 2002;106(6):718-724.
244. Solomon SD, Glynn RJ, Greaves S, Ajani U, Rouleau JK, Menapace F, Arnold JM,
Hennekens C, Pfeffer MA. Recovery of ventricular function after myocardial injury in
the reperfusion era: the healing and early afterload reducing therapy study. Ann Intern
Med. 2001; 134: 451–458.
245. Sommargren CE, Zaroff JG, Banki N, Drew BJ. Electrocardiographic repolarization
abnormalities in subarachnoid hemorrhage. J Electrocardiol. 2002; 35 (suppl): 257–262.
246. Sommargren CE. Electrocardiographic abnormalities in patients with subarachnoid
hemorrhage. Am J Crit Care. 2002; 11: 48–56.
247. Sommargren CE. Electrocardiographic abnormalities in patients with subarachnoid
hemorrhage. Am J Crit Care. 2002; 11: 48–56. di Pasquale G, Pinelli G, Andreoli A,
144
Manini G, Grazi P, Tognetti F. Holter detection of cardiac arrhythmias in intracranial
subarachnoid hemorrhage. Am J Cardiol. 1987; 59: 596–600.
248. Stollberger C, Finsterer J, Schneider B. Tako-tsubo-like left ventricular
dysfunctionclinical presentation, instrumental findings, additional cardiac and non-
cardiac diseases and potential pathomechanisms. Minerva Cardioangiol 2005;53:139-
145.
249. Stoylen A, Heimdal A, Bjornstad K, Torp HG, Skjaerpe T. Strain rate imaging by
ultrasound in the diagnosis of regional dysfunction of the left ventricle.
Echocardiography 1999;16(4):321-329.
250. Sugimoto K, Watanage E, Yamada A, Iwase M, Hirotoshi S, Hishida J, Ozaki Y.
Prognostic implications of left ventricular wall motion abnormalities associated with
subarachnoid hemorrhage. Int Heart J. 2008; 49: 75–85.
251. Summers M, Ryan J, Pre-Morbid Psychiatric and Cardiovascular Diseases in Apical
Ballooning Syndrome (Tako-Tsubo/Stress-Induced Cardiomyopathy). J Am Coll
Cardiol, 2010; 55:700-701,
252. Takatsu H, Nishida H, Matsuo H, et al. Cardiac sympathetic denervation from the
early stage of Parkinson‘s disease: Clinical and experimental studies with radiolabeled
MIBG. J Nucl Med 2000; 41(1):71-7.
253. Taki J, Nakajima K, Hwang EH, et al. Peripheral sympathetic dysfunction in patients
with Parkinson‘s disease without autonomic failure is heart selective and disease
specific. Eur J Nucl Med 2000; 27(5):566-73.
254. Takizawa M, Kobayakawa N, Uozumi H, Yonemura S, Kodama T, Fukusima K,
Takeuchi H, Kaneko Y, Kaneko T, Fujita K, Honma Y, Aoyagi T. A case of transient
left ventricular ballooning with pheochromocytoma, supporting pathogenetic role of
catecholamines in stress-induced cardiomyopathy or Takotsubo cardiomyopathy. Int J
Cardiol. 2007; 114: e15–17.
255. Tanabe M, Crago E, Suffoletto M, Hravnak M, Kassam A, Horowitz M, Gorcsan J.
Relation of elevation in cardiac troponin-I to clinical severity, cardiac dysfunction and
pulmonary congestion in patients with aneurysmal subarachnoid hemorrhage. Am J
Cardiol. 2008; 102: 1545–1550.
256. Tamura A. et al. A New Electrocardiographic Criterion to Differentiate Between
Takotsubo Cardiomyopathy and Anterior Wall ST-Segment Elevation Acute Myocardial
Infarction. AM J Card. 2011, 108: 630-33.
145
257. Todd MM, Hindman BJ, Clarke WR, Torner JC. Mild intraoperative hypothermia
during surgery for intracranial aneurysm. N Engl J Med. 2005; 352: 135–145.
258. Toyama T, Tanaka H, Nuruki K, Shirao T. Prinzmetal‘s variant angina associated
with subarachnoid hemorrhage: a case report. Angiology. 1979; 30: 211–218.
259. Tsuchihashi K, Ueshima K, Uchida T, et al. Angina Pectoris-Myocardial Infarction
Investigators in Japan Transient left ventricular apical ballooning without coronary
artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. J Am
Coll Cardiol. 2001;38(1):11-18.
260. Tung P, Kopelnik A, Banki N, Ong K, Ko N, Lawton MT, Gress D, Drew B, Foster
E, Parmley W, Zaroff J. Predictors of neurocardiac injury after subarachnoid
hemorrhage. Stroke. 2004; 35: 548–553
261. Tung PP, Olmsted E, Kopelnik A, Banki NM, Drew BJ, Ko N, Lawton MT, Smith
W, Foster E, Young WL, Zaroff JG. Plasma B-type natriuretic peptide levels are
associated with early cardiac dysfunction after subarachnoid hemorrhage. Stroke. 2005;
36: 1567–1571.
262. Ueyama T, Hano T, Kasamatsu K, Yamamoto K, Tsuruo Y, Nishio I. Emotional
stress induces transient left ventricular hypokinesis in the rat via activation of the cardiac
adrenoceptors: a possible animal model of ―tako-tsubo‖ cardiomyopathy. Circ J. 2002;
66: 712–713.
263. Ueyama T, Kasamatsu K, Hano T, et al. Emotional stress induces transient left
ventricular hypocontraction in the rat via activation of cardiac adrenoceptorsa possible
animal model of ‗tako-tsubo‘ cardiomyopathy. Circ J 2002;66:712-713.
264. Ueyama T, Senba E, Kasamatsu K, et al. Molecular mechanism of emotional stress-
induced and catecholamine-induced heart attack J Cardiovasc Pharmacol 2003;41(Suppl
1):S115-S118.
265. Ueyama T. Emotional stress-induced Tako-tsubo cardiomyopathyanimal model and
molecular mechanism. Ann N Y Acad Sci 2004;1018:437-444.
266. Urbaniak, K., Merchant, A. I., Amin-Hanjani, S., & Roitberg, B. (2007). Cardiac
complications after aneurysmal subarachnoid hemorrhage. Surgical Neurology, 67(1),
21–28; discussion 28–29.
267. Urheim S, Edvardsen T, Torp H, Angelsen B, Smiseth OA. Myocardial strain by
Doppler echocardiography: validation of a new method to quantify regional myocardial
function. Circulation 2000;102(10):1158-1164.
146
268. Vaccarino V, Abramson JL, Veledar E, Weintraub WS. Sex differences in hospital
mortality after coronary artery bypass surgery: Evidence for a higher mortality in
younger women. Circulation. 2002; 105: 1176–1181.
269. Vaccarino V, Parsons L, Every NR, Barron HV, Krumholz HM. Sex-based
differences in early mortality after myocardial infarction: National Registry of
Myocardial Infarction 2 Participants. N Engl J Med. 1999; 341: 217–225.
270. van den Bergh WM, Algra A, van der Sprenkel JW, Tulleken CA, Rinkel GJ.
Hypomagnesemia after aneurysmal subarachnoid hemorrhage. Neurosurgery. 2003; 52:
276–282
271. Van de Walle SO, Gevaert SA, Gheeraert PJ, De Pauw M, Gillebert Transient
stress-induced cardiomyopathy with an "inverted takotsubo" contractile pattern. Mayo
Clin Proc. 2006 Nov;81(11):1499-502.
272. Villareal RP, Archari A, Wilansky S, Wilson JM. Anteroapical stunning and left
ventricular outflow tract obstruction. Mayo Clin Proc. 2001; 76(1):79-83.
273. von Vogelsang, A. C., Wengstrom, Y., & Forsberg, C. (2004). Patient information
after ruptured intracranial aneurysm. Journal of Advanced Nursing, 48(6), 551–559.
274. Vongpatanasin W, Tuncel M, Mansour Y, Arbique D, Victor RG. Transdermal
estrogen replacement therapy decreases sympathetic activity in postmenopausal women.
Circulation. 2001; 103: 2903–2908.
275. Wagner GS, Macfarlane P, Wellens H, et al. AHA/ACCF/HRS recommendations for
the standardization and interpretation of the electrocardiogram: part VI: acute
ischemia/infarction J Am Coll Cardiol 2009;53:1003-1011.
276. Wang M, Yip GW, Wang AY, et al. Peak early diastolic mitral annulus velocity by
tissue Doppler imaging adds independent and incremental prognostic value. J Am Coll
Cardiol. 2003;41(5):820-826.
277. Watanabe H, Kodama M, Okura Y, Aizawa Y, Tanabe N, Chinushi M, Nakamura Y,
Nagai T, Sato M, Okabe M. Impact of earthquakes on Takotsubo cardiomyopathy.
JAMA. 2005; 294: 305–307.
278. Weidemann F, Wacker C, Rauch A, et al. Sequential changes of myocardial function
during acute myocardial infarction, in the early and chronic phase after coronary
intervention described by ultra-sonic strain rate imaging. J Am Soc Echocardiogr.
2006;19(7):839-847.
279. White M, Wiechmann R, Roden R, Hagan M, Wollmering M, Port J, Hammond E,
Abraham W, Wolfel E, Lindenfeld J, et al. Cardiac beta-adrenergic neuroeffector
http://www.ncbi.nlm.nih.gov/pubmed?term=Gheeraert%20PJ%5BAuthor%5D&cauthor=true&cauthor_uid=17120407
147
systems in acute myocardial dysfunction related to brain injury. Evidence for
catecholamine-mediated myocardial damage. Circulation. 1995; 92: 2183–2189.
280. Wittstein IS, Thiemann DR, Lima JA, et al. Neurohumoral features of Myocardial
stunning due to sudden emotional stress. N Engl J Med 2005; 352(6):539-48.
281. Wityk RJ, Pessin MS, Kaplan RF, Caplan LR. Serial assessment of acute stroke
using the NIH Stroke Scale. Stroke. 1994; 25: 362–365.
282. Wood R, Commerford PJ, Rose AG, Tooke A. Reversible catecholamine-induced
cardiomyopathy. Am Heart J. 1991; 121: 610–613.
283. Woolf PD, Hamill RW, Lee LA, Cox C, McDonald JV. The predictive value of
catecholamines in assessing outcome in traumatic brain injury. J Neurosurg. 1987; 66:
875–882.
284. Yarlagadda, S., Rajendran, P., Miss, J. C., Banki, N. M., Kopelnik, A., Zaroff, J. G.,
et al. (2006). Cardiovascular predictors of in-patient mortality after subarachnoid
hemorrhage. Neurocritical Care, 5(2), 102–107.
285. Yasu T, Owa M, Omura N, Katsuki T, Saito M: Transient ST elevation and left
ventricular asynergy associated with normal coronary artery in aneurysmal subarachnoid
hemorrhage. Chest 103:1274–1275, 1993
286. Yasu T, Tone K, Kubo N, Saito M. Transient mid-ventricular ballooning
cardiomyopathya new entity of Takotsubo cardiomyopathy. Int J Cardiol
2006;110:100-101.
287. Yeh T Jr, Wechsler AS, Graham LJ, Loesser KE, Sica DA, Wolfe L, Jakoi ER.
Acute brain death alters left ventricular myocardial gene expression. J Thorac
Cardiovasc Surg. 1999; 117: 365–374.
288. Yoshinaga K, Torii H, Tahara M. A serial echocardiographic observation of acute
heart injury associated with pheochromocytoma crisis. Int J Cardiol. 1998; 66: 199–202.
289. Young, P., Finn, B. C., Pellegrini, D., Soloaga, E. D., & Bruetman, J. E. (2006).
Paroxysmal sympathetic storm after diffuse axonal head injury. Medicina, 66(5), 439–
442.
290. Yuki K, Kodama Y, Onda J, Emoto K, Morimoto T, Uozumi T. Coronary vasospasm
following subarachnoid hemorrhage as a cause of stunned myocardium: case report. J
Neurosurg. 1991; 75: 308–311.
291. Zaroff J, Rordorf G, Newell J, Ogilvy C, Levinson J. Cardiac outcome in patients
with subarachnoid hemorrhage and electrocardiographic abnormalities. Neurosurgery.
1999; 44: 34–39.
148
292. Zaroff JG, Babcock WD, Shiboski SC, Solinger LL, Rosengard BR: Temporal
changes in left ventricular systolic function in heart donors: results of serial
echocardiography. J Heart Lung Transplant 22:383–388, 2003
293. Zaroff JG, Pawlikowska L, Miss JC, Yarlagadda S, Ha C, Achrol A, Kwok P,
McCulloch CE, Lawton MT, Ko N, Smith W, Young WL. Adrenoreceptor
polymorphisms and the risk of cardiac injury after subarachnoid hemorrhage. Stroke.
2006; 37: 1680–1685.
294. Zaroff JG, Rordorf GA, Ogilvy CS, Picard MH. Regional patterns of left ventricular
systolic dysfunction after subarachnoid hemorrhage: evidence for neurally mediated
cardiac injury. J Am Soc Echocardiogr. 2000; 13: 774–779.
295. Zaroff JG, Rordorf GA, Titus JS, Newell JB, Nowak NJ, Torchiana DF, Aretz HT,
Picard MH, Macdonald RL. Regional myocardial perfusion after experimental
subarachnoid hemorrhage. Stroke. 2000; 31: 1136–1143.
296. Zaroff, J. G., Rordorf, G. A., Newell, J. B., Ogilvy, C. S., & Levinson, J. R. (1999).
Cardiac outcome in patients with subarachnoid hemorrhage and electrocardiographic
abnormalities. Neurosurgery, 44(1), 34–39; discussion 39–40.
297. Zhang Y, Chan AY, Yu CM, et al. Strain rate imaging differentiates transmural from
non-transmural myocardial infarction: a validation study using delayed-enhancement
magnetic resonance imaging. J Am Coll Cardiol. 2005;46(5):864-871.
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