miokardiumis infarqti ST elevaciiT STEMI - GFMA.Ge · gulis daavadebebi 6-e gamocema 2001w da brain...

miokardiumis infarqti ST elevaciiT STEMI

gaidlaini;

momzadebulia saqarTvelos kardiologTa kolejis da

saqarTvelos kardiologTa sazogadoebis mier mier 2006 w.

saqarTvelos kardiologTa kolejis da saqarTvelos kardiologTa

sazogadoebis gaerTianebuli komitetis eqspertTa samuSao jgufi: giorgi

kaWarava jo-enis saxelobis samedicino centri; aCiko CuxrukiZe gadaudebeli

kardiologiis centri; levan yuraSvili jo-enis saxelobis samedicino

centri; vaxtang WumburiZe profesori, Terapiis erovnuli centri, zaza

mgalobliSvili jo-enis saxelobis samedicino centri; nata gonjilaSvili

jo-enis saxelobis samedicino centri;, naTia axalaZe jo-enis saxelobis

samedicino centri; giorgi papiaSvili jo-enis saxelobis samedicino centri;

1

ABC = kardiopulmonaruli reanimaciis 3 etapi: sasunTqi gzebi A, sunTqva B, sisxlis

mimoqceva C. ACE = angiotenzin gardamqmneli fermenti ACS = mwvave koronaruli sindromi

AHA/ACC = amerikis gulis asociacia/amerikis kardiologiuri koleji

AF = winagulTa fibrilacia

aPTT = aqtivirebuli Tromboplastinis dro

ARB = angiotenzin II –is blokerebi

ASA = aspirini BMI = sxeulis masis indeqsi = wona (kg-Si) / simaRleze 2 (metr.)

BNP = B tipis natriurezuli peptidia

BUN = sisxlis Sardovana nitrogeni

CABG = kororonarul arteriuli baipas grafti. (aorto koronaruli Suntireba)

CBC = sisxlis saerTo analizi

CCS = kanadis kardiologiuri asociacia

CCU = intensiuri/koronaruli movlis ganyofileba

CHD = gulis koronaruli daavadeba

CHF = gulis SegubebiTi ukmarisoba

CK-MB = kreatinfosfokinaza MB izofermenti CPR = kardiopulmonaruli

CPR = kardiopulmonaruli resuscitacia (reanimacia) cTnI = kardiotroponini I cTnT = kardiotroponini T CT = kompiuteruli tomografia Cx = Semomxvevi toti D5W = deqstroza 5 %-iani

DVT = Rrma venebis Trombozi

EPS = eleqtrofiziologiuri kvleva

ECG = e.k.g.

GI = gastrointerstinuli

GU = genitourinaluri (Sardasasqeso)

GP = glukoproteini

HDL-C = maRali simkvrivis lipoprotein qolesteroli

HF = gulis ukmarisoba

HIT = hepariniT inducirebuli Trombocitopenia

HR = gulis SekumSvaTa sixSire IABP = intraaortuli balonuri kontrpulsacia ICD =kardioverter defibrilatori INR = saerTaSoriso normalizaciis Sefardeba

IV = intravenuri

LAD = marcxena wina daswvrivi toti LBBB = hisis konis marcxena fexis blokada

LDL-C = dabali simkvrivis lipoprotein qolesteroli

LMWH = dabalmolekuluri wonis heparini

LOE = mtkicebulebis xarisxi LV = marcxena parkuWi MET = metaboluri eqvivalenti

MI = miokardiumis infarqti NCEP = riskis daTvlis programa: http://heart.healthcentersonline.com/tools/calc_hd_results.cfm

(kiTxvari romelSiac SegaqvT Semdegi monacemebi: saerTo qolesterini, HDL, sistoluri

wneva, sqesi, asaki, eweviT Tu ara da igi gaZlevT gulis gulis daavadebebiT 10 wliani

sikvdilianobis risks)

non-HDL-C = saerTo qolesterins gamoklebuli HDL NSVT = aramdgradi (xanmokle) ventrikuluri taqikardia

NTG = nitroglicerini

PCI = perkutaneuli koronaruli intervencia

PTCA = perkutaneuli transluminaruli koronaruli angioplastika

2

PE = pulmonaruli embolia

RC = marjvena koronari

RBBB = hisis konis marjvena fexis blokada

RV = marjvena parkuWi

STEMI = miokardiumis infarqti ST elevaciiT am jgufSi ganixileba pacientebi miokardiumis

infarqtiT, romelTac e.k.g-ze aqvT persistentuli > (20-30wT) ST segmentis elevacia

TG = trigliceridebi UA = arastabiluri stenokardia

UFH = arafraqcionirebuli heparini

VF =ventrikuluri fibrilacia

VO2 = moxmarebuli Jangbadi drois garkveul monakveTSi

VSR = parkuWTa Sua Zgidis rubtura

VT =ventrikuluri taqikardia

WPW = volf-parkinson-uaitis sindromi

flail leaflet = “mofarfate” qorda preexitation = naadrevi aRgzneba Imaging Modality = gamosaxulebiTi kvleva

Preexitation = naadrevi agzneba (delta talRa),

Electronically paced ventricular rhythm = parkuWSi riTmis xelovnuri wamyvani

Advanced AV Block = Sorswasuli blokada

niacini = vitamini B-3 s.d.b. = saswrafo daxmarebis brigada

PM I Sesavali: ............................................................................................................................................6

a. samuSao jgufis ganmarteba: ................................................................................................6 b) cxrili 1. gaidlainSi gamoyenebuli rekomendaciebis da mtkicebulebebis

xarisxi. Sedgenilia AHA/ACC-is rekomendaciebis mixedviT mocemuli

cxrili saSualebas gvaZlevs ganvsazRvroT TiToeuli samedicino midgomis

roli pacientis mkurnalobisas. mtkicebulebebis xarisxi (LOE)-gamoyenebuli iqneba sxvadasxva samkurnalo meTodis Tu diagnostikis

rolis gansazRvrisas..................................................................................................................7 g. mwvave miokardiumis infarqtis definicia ...................................................................8 d. mwvave miokardiumis infarqtis paTogenezi: ................................................................8 v. mwvave koronaruli sindromis ganmarteba da klinikuri mimdinareoba: ........9 sqema: 1 ................................................................................................................................................9

II STEMI-s ganviTarebamde mkurnaloba................................................................................10 a. rekomendaciebi STEMI-s risk faqtorebis mqone pacientebis gamovlenisTvis.............................................................................................................................10 b. rekomendaciebi STEMI-s niSnebis naadrevi gamovlenisa da CarevisaTvis,

pacientebis ganaTleba: .............................................................................................................11 III STEMI-s Setevis dawyeba da prehospitaluri qmedeba ..............................................12

a. STEMI-T pacientebis transportireba da pirveladi reperfuziuli

mkurnalobis SerCeva .................................................................................................................12 IV. pirveladi amocnoba da marTva gadaudebeli daxmarebis departamentSi....15

a. sqema. 3 gadaudebeli daxmarebis algoriTmi/protokoli pacientSi

STEMI–s simptomebiT an niSnebiT ........................................................................................15 b. damateba: ekg-s interpretacia: .........................................................................................16 g. cxrili 3. STEMI-is diferencialuri diagnostika ................................................17 d. STEMI-s diagnoziT miRebul pacientSi rutinuli testebi ..............................18 e. reperfuziis meTodis aucileblobis da SesaZleblobis gansazRvra

pacientebSi STEMI-T ................................................................................................................20 v. reperfuziis saxis SerCeva pacientebSi STEMI-T .....................................................21

3

z. fibrinolizis Cvenebebi: .....................................................................................................22 T. STEMI-s dros fibrinolizis ukuCveneba da safrTxeebi ....................................23 cxrili 6. ........................................................................................................................................23 i. diagnostikuri koronaruli angiografia ..................................................................23 k. pirveladi PCI-s rekomendaciebi.......................................................................................24 l. pirveladi PCI-s rekomendaciebi pacientebSi romlebic ver Rebuloben

Tromboliziss raimis gamo; (Seuferebelia TrombolizisisaTvis) ....................25 m. pirveladi PCI-s rekomendaciebi klinikebisaTvis romelTac ara aqvT

kardioqirurgiuli ganyofileba .........................................................................................26 n. damxmare PCI ..............................................................................................................................26 o. gadamrCeni PCI: ........................................................................................................................26 p. PCI fibrinolizisis Semdeg:...............................................................................................27 r. mwvave qirurgiuli reperfuzia:......................................................................................28 s. zogadad urgentuli da gadaudebeli qirurgiuli revaskularizaciis

Cveneba STEMI-s dros aris Semdegi .....................................................................................28 V hospitaluri mkurnaloba.......................................................................................................29

a...CCU intensiuri/koronaruli movlis ganyofileba: ...............................................29 b. CCU-is Semdgomi mkurnaloba: ............................................................................................30 g. pacientebis gaaqtiveba:.........................................................................................................31 d. dieta:...........................................................................................................................................31 e. analgetikebi/aRgznebis sawinaaRmdego preparatebi: ..............................................31 v. antiagregantebi: ......................................................................................................................31 z. reperfuziisas damatebiTi antiTrombozuli farmakologiuri daxmareba32 T. renin-angiotenzin-aldosteronis sistemaze moqmedi preparatebi STEMI-s dros: .................................................................................................................................................35 i. glukozis kontroli STEMI-s dros:.............................................................................36 k. eleqtrolitebis balansi:..................................................................................................36 l. kalciumis arxebis blokatorebi: .................................................................................37 m. beta-blokatorebi: .................................................................................................................37 n. nitroglicerini:.....................................................................................................................38 i. sqema 4. garTulebuli STEMI. gadaudebeli mdgomareobebis marTvis

protokoli.....................................................................................................................................39 VI hemodinamikuri darRvevebi................................................................................................41 a. hemodinamikuri gazomvebi: ...................................................................................................41 b. hipotenzia: .................................................................................................................................42 g. dabali wuTmoculobiTi mdgomareoba: ........................................................................42 d. pulmonaruli Segubeba: ......................................................................................................42 e kardiogenuri Soki: ................................................................................................................43 v. marjvena parkuWis infarqti: .............................................................................................44 VII gulis ukmarisobis meqanikuri mizezebi/dabali wuTmoculobis sindromi

.............................................................................................................................................................45 a. mitraluri sarqvlis ukmarisoba:...................................................................................45 b. parkuWis Zgidis rubtura: ..................................................................................................45 g. marcxena parkuWis Tavisufali kedlis rubtura ...................................................45 d. marcxena parkuWis anevrizma:............................................................................................45 e. intraaortuli balonuri kontrpulsacia: IABP:.....................................................46 VIII ariTmiebis marTva STEMI-is Semdgom .........................................................................48 a. VF: parkuWovani fibrilacia: ............................................................................................48 b. VT: parkuWovani taqikardia ...............................................................................................48

4

g parkuWovani eqstraistolia: ..............................................................................................49 d. aCqarebuli idiventrikuluri an kvanZovani riTmiv. marjvena parkuWis

infarqti: .........................................................................................................................................49 g. supraventrikuluri ariTmia/AF.......................................................................................49

IX. bradiariTmiebi: .........................................................................................................................50 a. sinusis kvanZis disfunqcia STEMI-s Semdgom: ............................................................50 b. gamtareblobis moSla: .........................................................................................................50 d. mudmivi peisingis Cveneba bradiaritmiis da/an gamtareblobis darRvevisas

romelic asocirdeba STEMI-Tan:...........................................................................................53 e. mudmivi peisingis modelis SerCeva Cveneba bradiaritmiis da/an

gamtareblobis darRvevisas romelic asocirdeba STEMI-Tan: ..............................54 v. ganmeorebiTi tkivili STEMI-s Semdgom........................................................................54 T. STEMI-s Semdgomi aorto koronaruli Suntirebis Cvenebebi mocemuli

iqneba zogadad CABG-is gaidlainSi. .................................................................................56 X meoradi prevencia da xangZlivi marTva:.......................................................................56

a. riskis Sefaseba stacionaridan gaweris Semdgom: ..................................................56 b. cxrili 10 meoradi prevencia STEMI-s dros:.............................................................58 g. ST elevaciiT mimdinare miokardimis infarqtis ( STEMI) stacionaridan gaweris Semdgomi antiTrombozuli mkurnaloba .........................................................62 d. rekomendaciebi gaweris Semdgomi vizitebis da zogadad daavadebis

marTvis Sesaxeb: ...........................................................................................................................63 e. cxrili 11 medikamentebi romlebic gamoyeneba STEMI-s mkurnalobisas .......64

GXI gamoyenebuli masala: ............................................................................................................68

5

I Sesavali:

a. samuSao jgufis ganmarteba:

gaidlaini eyrdnoba amerikis kardiologTa kolejis, amerikis gulis

asociaciis da evropis kardiologTa asociaciis masalebs. aseve

gamoyenebulia monacemebi Semdegi literaturidan braunvaldi, zaips libbi,

gulis daavadebebi 6-e gamocema 2001w da brain p. grifini erik j. topoli

kardiovaskularuli medicinis saxelmZRvanelo, 2-e gamocema 2004w. samuSao

jgufma moaxdina teqstis adaptireba, rac ZiriTadSi rCeba zemoT aRniSnuli

gaidlainebis farglebSi da Seesabameba maT rekomendaciebs. amasTan erTad

Cven davamateT ramodenime ganmarteba da cxrili CamoTvlili literaturidan

romelic Cvenis azriT daexmareba mkiTxvels mkurnalobis sqemebis swor

interpretaciaSi.

es moxseneba warmoadgens ST elevaciiT mimdinare miokardiumis infarqtis

mkurnalobis ZiriTad principebs. cxadia igi ver iqneba sakmarisi

kardiologisaTvis daavadebirulyofili marTvisTvis. mocemul versiaSi

ganxilulia mxolod mkurnalobis ZiriTadi etapebi, aseve garTulebebi da

maTi marTva. miuxedavad zogadi xasiaTisa warmodgenili versia saSualebas

gvaZlevs swrafad gadavxedoT mkurnalobis ZiriTad principebs da igi

daexmareba rogorc kardiologebs aseve zogadi praqtikis/ojaxis da

saswrafo daxmarebis eqimebs, romelTaTvisac siswrafes da masalis

kompaqturobas didi mniSvneloba aqvs.

samuSao jgufi acnobierebs moTxovnilebas moxdes Cveni jan-dacvis sistemis

harmonizacia evropisa da amerikis samedicino sistemebis maRal samedicino

standartebTan da miiCnevs, rom am procesSi gaidlainebs, ufro zustad ki

maT implementacias aqvs udidesi mniSvneloba. swored es gaxda imis mizezi

rom Cven aRar davucadeT sruli teqstis damTavrebas da gadavwyviteT mokle

versiis gamoqveyneba. vfiqrobT teqstis TandaTan Sevsebas, rac xels ar

SeuSlis mis danergvas, vinaidan mudmivi ganaxleba gaidlainebiT muSaobis

Tanmxlebi da ganuyofeli procesia. Cveni jgufia Riaa msjelobisaTvis iseT

Temebze rogoricaa: Tu ramdenad realuria saqarTveloSi am sqemebiT

muSaoba, Tu ramdenad zustad Seesabameba Cvens mier adaptirebuli

rekomendaciebi evropis da a.S.S/-s Sesabamis rekomendaciebs da xom ar

ewinaaRmdegebian isini maT ZiriTad suliskveTebas. problematuria agreTve

rigi enobrivi sakiTxebisa. Cven gadavwyviteT abreviaturebis inglisuri

SriftiT xmareba. Cvenis azriT am MmeTodis ZiriTadi mizania 1) teqstis

Semokleba. 2) ganmeorebebis meti saSualeba da 3) yuradRebis miqceva swrafi

kiTxvisas. vinaidan qarTulSi ar arsebobs didi asoebi am SemoklebebiT

yuradRebis miqceva efeqturi ver aris. amasTan erTad zogi abreviatura

imdenad damkvidrebulia rom maTi Secvla iqneboda xelovnuri da uxerxuli

saxmarad. amgvarad Tuki am princips ar gavavrcelebdiT yvela Semoklebaze

maSin teqstSi xan iqneboda inglisuri xan qarTuli abreviatura, rac aseve

gaugebari da mouxerxeli iqneboda. sayuradReboa is faqtic rom mkurnalobis

Tu diagnostikis zogierTi meTodi saqarTveloSi ver tardeba teqnikuri Tu

finansuri mizezebidan gamomdinare. aseT SemTxvevebSi Cveni jgufi

rekomendacias iZleva, rom pacientis istoriaSi, Tu ambulatoriul baraTSi

dafiqsirdes am gamokvlevaze, Tu mkurnalobaze uaris Tqmis mizezi, raTa

naTeli gaxdes, rom mkurnali eqimi flobs daavadebis Tanamedrove midgomebs,

6

magram gamodis konkretuli realiebidan. Cvenis mxriv mzada varT farTo

diskusiisaTvis aRniSnul Temebze mizanSewonilia gaviTvaliswinoT rogorc

enis specialistebis aseve sazogadoebis da sxvadasxva dargis eqspertebis

azri. mTavari CvenTvis am etapze Tavad gaidlainiT muSaobis praqtikis

damkvidrebaa saqarTvelos samedicino sistemaSi, rac vfiqrobT etapuri iqneba

saqrTveloSi medicinis ganviTarebisaTvis.

b) cxrili 1. gaidlainSi gamoyenebuli rekomendaciebis da

mtkicebulebebis xarisxi. Sedgenilia AHA/ACC-is rekomendaciebis mixedviT

mocemuli cxrili saSualebas gvaZlevs ganvsazRvroT TiToeuli samedicino midgomis roli

pacientis mkurnalobisas. mtkicebulebebis xarisxi (LOE)-gamoyenebuli iqneba sxvadasxva

samkurnalo meTodis Tu diagnostikis rolis gansazRvrisas.

I klasi:

sargebloba > > > riskze.

procedura/mkurnaloba

unda

Catardes/dainiSnos

II-A klasi: sargebloba > > riskze

saWiroebs damatebiT

gamokvlevebs.

gonivrulia

Catardes/dainiSnos

Sesabamisi


II-B klasi:

sargebloba ≥ riskze saWiroebs damatebiT

gamokvlevebs.


SesaZlebelia gvqondes

mxedvelobaSi

III klasi: damatebiTi

gamokvlevebi aRaraa

saWiro.


ar unda

dainiSnos/Catardes

vinaidan igi

usargebloa da

SesaZloa iyos saSiSi

A-done: mravali (3-5) sxvadasxva

populaciuri

jgufebia

Sefasebuli.

efeqti da

mimarTuleba

myaria.

rekomendacia imis

Sesaxeb rom igi aris

sasargeblo/efeqturi.

monacemebis miRebulia

mravali

randomizebuli

kvleviT da meta-

analiziT.

rekomendacia

procedura/mkurnalobis

Catareba/daniSvnis

sasargeblodaa

aris zogierTi

urTierTsawinaaRmdego

monacemi mravali

randomizebuli kvlevis

da meta-analizisagan

rekomendaciis

sargebloba/efeqturoba

nakleb kargadaa

Seswavlili


monacemebi ufro metia

mravali

randomizebuli

kvlevis da meta-

analizisagan

rekomendacia rom


araa

sakmarisi monacemebia

mravali

randomizebuli da

metaanalizisagan

B-done: SezRuduali

(2-3) populaciuri

jgufebia

Safasebuli

rekomendacia imis



SezRuduli

monacemebia miRebulia

erTi randomizebuli

da

ararandomizirebuli

kvlevebisagan

rekomendacia


Catareba/dniSvnis

sasargeblodaa.

aris zogierTi


monacemi erTi

randomizirebuli da

ararandomizebuli

kvlevebisagan

rekomendaciis


nakleb kargadaa

Seswavlili

ufro meti


monacemia erTi

randomizirebuli da

ararandomizebuli

kvlevebisagan

sasargeblo/efeqturi

da SesaZloa iyos

saziano.

SezRuduli

monacemebia erTi

randomizirebulia da

ararandomizebuli

kvlevebisagan.

C-done: Zalian

SezRuduali

(1-2) populaciuri

jgufebia

Safasebuli

rekomendacia imis



arsebobs mxolod

eqspertebis azri,

SemTxvevaTa

aRwera(case report)

rekomendacia


Catareba/dniSvnis

sasargeblodaa

eyrdnoba eqspertebis

azrs da SemTxvevaTa

aRweras

rekomendaciis


nakleb kargadaa

Seswavlili

eyrdnoba eqspertebis

azrs da SemTxvevaTa

aRweras

sasargeblo/efeqturi

da SesaZloa iyos

saziano.

arsebobs mxolod

eqspertebis azri,

SemTxvevaTa

aRwera(case report)

7

g. mwvave miokardiumis infarqtis definicia

amerikis kardiologTa koleji da evropis kariologTa asociaciis

gaerTianebuli komiteti mwvave miokardiumis infarqts (acute, evolving or recent MI) gansazRvravs Semdegnairad: miokardiumis nekrozis bioqimiuri markerebis,

kerZod troponinis tipiuri zrda da TandaTanobiTi vardna an CK-MB-is ufro swrafi zrda da vardna, romelsac Tan axlavs erT-erTi

CamoTvlilTagani: iSemiuri simptomebi, e.k.g-ze paT. Q kbilis gaCena da/an

cvlilebebi romlebic miokardiumis iSemiaze miuTiTeben, koronaruli

intervencia an MI-s paTologiuri gamovlinebani (findings).

d. mwvave miokardiumis infarqtis paTogenezi:

dRevandeli gagebiT miokardiumis infarqti iyofa 2 ZiriTad jgufad I

mimdinare ST elevaciiT STEMI da II mimdinare ST-elevaciis gareSe NSTEMI. termini - mwvave koronaruli sindromi TavisTavSi aerTianebs Semdeg

klinikur sindromebs: arastabilur stenokardias, Mmiokardiumis infarqts ST -segmentis elevaciis gareSe da miokardiumis infarqts ST- segmentis elevaciiT, sadac pacientebi arastabiluri stenokardiiT da miokardiumis

infarqtiT. ST- segmentis elevaciis gareSe miekuTvnebian erT jgufs, xolo

pacientebi ST- segmentis elevaciiT mimdinare miokardiumis infarqtiT

miekuTvnebian meore jgufs. termini – arastabiluri stenokardia asaxavs

sindroms , romelsac Sualeduri mdgomareoba ukavia qronikul stabilur

stenokardiasa da miokardiumis infarqts Soris. pacientebs ST- segmentis elevaciis gareSe mimdinare mwvave koronaruli sindromiT, aqvT an

arastabiluri stenokardia an ST-segmentis elevaciis gareSe mimdinare

miokardiumis infarqti. Mmwvave koronaruli sindromi ST- segmentis elevaciT uxSiresad sruldeba miokardiumis Q kbilovani infarqtiT da

iSviaTad ara Q kbilovani infarqtiT. ST– segmentis elevacis gareSe

miokardiumis infarqti uxSiresad sruldeba ara Q kbilovani miokardiumis

infarqtiT da iSviaTad Q kbilovani miokardiumis infarqtiT. ( ix. mwvave

koronaruli sindromis (ACS) ganmarteba. cxrili 1.) NSTEMI-s paTogenezi

ganxilulia Sesabamis gaidlainSi. Cven aq mokled SevCerdebiT ST-elevaciiT

mimdinare miokardiumis infarqtis paTogenezze.

STEMI-s dros prevalirebs maokluzirebeli Trombozi. daaxlobiT 2/3 dan 3/4

-mde SemTxvevebSi Trombis warmoqmnas win uswrebs folaqis fibrozuli

garsis rubtura an misi erozia, romelic ufro xSirad ar iwvevs

obstruqcias, Tumca warmoadgens substancias romelic aZlierebs

Trombocitebis aqtivacias, agregacias, adhezias da Trombinis generacias,

rasac Tavis mxriv mohyveba ukve Trombis warmoqmna da sanaTuris daxSoba.

nela ganviTarebuli okluziisas SesaZloa ar gvqondes MI . savaraudod imis gamo, rom ganviTarebas aswrebs kolateraluri qseli, rac nawilobriv

akmayofilebs miokardiumis moTxovnilebas. procesi xSirad dinamiuria, anu:

Trombozi, spontanuri Trombolizisi, vazospazmi SeiZleba erTdroulad

aRiniSnos da mogvces koronaruli nakadis gardamavali Sewyveta da

distaluri embolizacia. (es ukanaskneli iwvevs mikrovaskularul

obstruqcias, rac xels uSlis srulyofil revaskularizacias miuxedavad

epikardiuli koronaris gaxsnisa.)

8

e. mwvave miokardiumis infarqtis gavrceleba/epidemiologia:

saqarTveloSi bolo 20 wlis ganmavlobaSi raime saxis seriozuli

statistikuri kvleva, romelic am daavadebis gavrcelebas Seiswavlida ar

Catarebula. aqedan gamomdinare Cven veyrdnobiT Aa.S.S-s da evropul

monacemebs.

maTi mixedviTac a.S.S-Si yovelwliuri sikvdilianoba gulis koronaruli daavadebebiT aris

500,000-ze meti. 1,680,000 pacientis hospitalizaciis mizezi aris ACS. amis garda 200,000 dan 300,000-mde kaci kvdeba MI-T savadmyofoSi gadayvanamde. anu mwvave koronaruli sindromi

TiTqmis 2,000,000 mde adamians emarTeba yovelwliurad. aqedan STEMI aqvs daaxloebiT 500,000

adamians. evropuli monacemebiT am ukanasknelis sikvdilianoba 1 TveSi Seadgens 30-50%-s

romelTagan TiTqmis naxevari pirvel 2-sT-Si xdeba. unda aRiniSnos rom bolo xanebSi

miokardiumis infarqtis sixSires aqvs Semcirebis xolo arastabiluri stenokardiis

sixSires zrdis tendencia. igive SeiZleba iTqvas STEMI-s Sesaxeb, romlis SemTxvevebi

mcirdeba NSTEMI-s sasargeblod. zogadad SesaZloa iTqvas, rom amerikaSi yovel 29 wm-Si

romelime adamians emarTeba mwvave MI xolo am daavadebiT pacienti kvdeba yovel 1 wT-Si.

Tuki saqrTvelos mosaxleobas aviRebT 4,000,000-mde, xolo statistikas igives

davtovebT rac evropasa da a.S.S-Sia, maSin SesaZloa iTqvas, rom CvenTan

yovelwliurad gulis koronaruli daavadebebiT kvdeba daaxloebi 6600

pacienti. ACS yovelwliurad emarTeba 26,000 adamians. aqedan STEMI yovelwliurad emarTeba daaxloebiT 6600 adamians ( romelTa 30%-50% kvdeba

pirvel 1-TveSi), xolo danarCens aqvs UA/NSTEMI ( daaxloebiT 18,000-19,000). saqarTveloSi yovel 40 wT-Si romelime adamians emarTeba MI, xolo am

daavadebiT kvdeba pacienti yovel 80 wT-Si.

v. mwvave koronaruli sindromis ganmarteba da klinikuri

mimdinareoba:

sqema: 1

mwvave koronaruli sindromi ACS

ST elevaciiT ST elevaciis gareSe

ara Q kbilovani miokardiumis

infarqti Q kbilovani

miokardiumis infarqti

arastabiluri

stenokardia UA

ST elevaciis gareSeE mimdinare mwvave koronaruli sindromi ( ACS ). ufro xSirad mTavrdeba UA an ara Q-kbilovani miokardiumis infarqtiT. naklebi sixSiriT man SeiZleba gamoiwvios Q -kbilovani MI. ST elevaciiT mimdinare ACS ufro xSirad mTavrdeba Q-kbilovani MI-T da naklebad xSirad ara Q

kbilovani MI-T an UA-iT

9

tkivils miokardiumis dros klasikuri mimdinareobisas aqvs substernaluri,

moWeriTi, xasiaTi xSiri iradiaciiT marcxena xelSi, tkivili msgavsia

stenokardiuli tkivilis, oRond grZeldeba > 20wT-ze. gansxvavebiT PE-s da aortis diseqciisa tkivilis piki araa myisieri. tkivili SeiZleba

gadaecemodes kiserSi, ybaSi, mxrebSi, marjvena mklavSi, epigastriumSi. es

tkivilebi SeiZleba iyos izolirebulic, gulmkerdis tkiilis gareSec da es

ufro xSirad gvxvdeba moxucebSi da maTSi visac aqvs diabeti.

a. Tu tkivili iradirebs zurgSi da aris xanjlis CacemasaviT eWvi unda

gvqondes aortis diseqciaze. am dros mizanSewonilia CT an transezofaguri eqoskopia. b. perikarditisas tkivili Zlierdeba zurgze wolisas, da

umjobesdeba jdomisas da win gadmoxrisas. ST elevaciis difuzuri xasiaTi

erT-erTi mniSvnelovani ganmasxvavebeli niSania MI-sgan, Tumca msgavsi suraTi

SesaZloa am ukanasknelisTvisac iyos damaxasiaTebeli. Pperikarditisas ST segmentis elevacias aqvs Cazneqili xasiaTi infarqtisagan gansxvavebiT. aseve

perikarditisaTvis araa damaxasiaTebeli reciprokuli cvlilebebi. aVR-is da V1 –is garda eqokardiografiisas MI-s dros gveqneba regionaluri

kumSvadobis moSla rac erT-erTi sadiferenciacio niSania.

g. miokarditi: eqokardiografia am SemTxvaSi ver gvexmareba. diferencireba

xdeba anamnezis safuZvelze, rac miokarditisas xSirad ukavSirdeba virusul

infeqcias.

d. PE xSirad sunTqvis gaZnelebasTan erTadaa, axasiaTebs plevraluri

tkivili, am SemTxvevaSi eqokardiografias aqvs didi roli diferencialuri

diagnozis gatarebaSi.

e. ezofagialuri daavadebebi: gastroezofaguri refluqss, ezofaguri

hiperalgezias SeuZlia mogvces MI-s msgavsi diskomforti. xSirad igi gvxvdeba pacientebSic romelTac aqvT CHD, riTac diagnostireba rTuldeba.

am SemTxvevaSi mniSvneloba aqvs igi ukavSirdeba Tu ara kvebas, mcirdeba Tu

ara antacidebis xmarebisas, ramdenad axasiaTebs radiacia. v. mwvave

qolecistiti: man SeiZleba mogvces msgavsi xasiaTis tkivili da e.k.g.

cvlilebebi, rac xSirad damaxasiaTebeli qveda kedlis miokardiumis

infarqtisTvis. muclis marjvena zeda kvadratis mgrZnobeloba da

daWimuloba, cxeleba leikocitozi laparakobs qolecistitis sasargeblod.

unda aRiniSnos, rom es gansxvavebebi araa absolituri da daavadeba xSirad

SesaZloa mimdinareobdes atipiurad an romelime sxva daavadebis msgavsi

klinikiT. aqedan gamomdinare SeiZleba iTqvas rom MI-s diagnozi moiTxovs

misi diagnostikisadmi kompleqsur midgomas, romelic iTvaliswinebs

sxvadasxva faqtorebs.

II STEMI-s ganviTarebamde mkurnaloba

a. rekomendaciebi STEMI-s risk faqtorebis mqone pacientebis gamovlenisTvis

riskis gansazRvra: CHD-s ZiriTadi/mTavari risk faqtorebia: moweva, ojaxuri

istoria, lipiduri speqtris gauareseba, maRali arteriuli wneva. pacientebs

diabetiT da periferiuli arteriebis daavadebebiT aqvT STEMI-s ganviTarebis

igive riski rac daavadebulebs gulis koronaruli daavadebiT.

10

klasi I

1. yvela pacientSi regularuli intervaliT ( 3 – 5 weli ) Sefasebul unda

iqnes CHD-is ZiriTadi/mTavari risk faqtorebi ( AHA/ACC-is ganmartebiT

esenia: ojaxuri istoria, moweva, gauaresebuli lipiduri profili, maRali

arteriuli wneva, diabeti) da maTi kontrolis xarisxi. LOE : C

2. simptomuri CHD ganviTarebis 10 wliani riski unda iqnes gaTvlili yvela

pacientSi visac aqvs 2 an meti didi risk faqtori ( gaTvla warmoebs

amerikis NCEP-is programis safuZvelze ) LOE : B

3. pacientebi CHD-iT, identificirebulni unda iqnan meoradi prevenciisTvis.

pacientebi CHD-is ekvivalenti riskiT ( diabeti, Tirkmlis qr. daavadeba an 10

wliani riski > 20% gamovlenili framingemis kvleviT: ganxilul unda iqnen,

ise rogorc klinikurad gamovlenili CHD. LOE : A

10-wliani sikvdilianobis riski.

http://heart.healthcentersonline.com/tools/calc_hd_results.cfm SegiZliaT gansazRvroT

mocemuli veb gverdze ganTavsebuli formuliT.

damateba: im pacientebSi romelTac NCEP-s mixedviT aqvT 10 wliani sikvdilianobis

riski > 6%-ze, SeiZleba ganvixiloT aspirinis miReba 75-162 mg dReSi.

b. rekomendaciebi STEMI-s niSnebis naadrevi gamovlenisa da

CarevisaTvis, pacientebis ganaTleba:

klasi I

1. pacientebi STEMI-T (diskomforti an tkivili gulmkerdSi iradiaciis

gareSe, an iradiaciiT mklavSi, zurgSi, epigastriumSi, ybaSi, nikapSi, haeris

ukmarisoba, sisuste, oflianoba, gulisrevis SegrZneba Tavbrusxveva)

umjobesia klinikaSi gadayvanil iqnan saswrafo daxmarebis brigadis mier,

vidre TviTdinebiT an axloblebis mier. LOE : B 2. mkurnalma eqimma pacients da misi axloblebs unda auxsnas:

a. gulis Setevis riski LOE : C b. rogor unda amovicnoT STEMI-s simptomebi LOE : C g. saswrafo daxmarebis brigadis gamoZaxebis aucilebloba, Tu simptomebi

ar qreba an uaresdeba 5 wuTis Semdeg, miuxedavad gaurkvevlobis da eqimebis

“ tyuilad Sewuxebis” SiSisa. LOE : C d. pacientma da misma axloblebma unda icodnen moqmedebis gegma aseT

SemTxvevebisas (s.d.b-s telefonis nomrebis CarTviT) LOE : C 3. pacientebs, visTvisac nitroglicerini ukunaCvenebi ar aris, erTi abi unda

mieces enis qveS gulmkerdis areSi tkivilis an diskomfortis dros. Tu

gulmkerdSi tkivili/diskomforti ar Semcirda an gauaresda 5 wuTSi,

rekomendirebulia dauyovnebliv darekil iqnas saswrafo daxmarebis

samsaxurSi. ( LOE : C)

damateba: pacientebs unda aexsnaT, rom Tuki simptomebi ar qreba an uaresdeba, saswrafo

daxmarebis sadgurSi darekvis Semdgom pacients SiZleba erCios aspirinis miReba s.d.b-s

mosvlamde.

11

damateba: yuradReba unda mieqces imas rom zogierT pacientSi MI mimdinareobs gulmkerdSi

diskomfortis gareSe. am mxriv gansakuTrebiT sayuradReboa qalebi, diabetiT daavadebulebi,

moxucebulebi, pacientebi gulis ukmarisobiT. agreTve sayuradReboa is pacientebi

romlebsac aqvT permanentuli peismekeri da tkivili gulmkerdSi, vinaidan maTSi e.k.g.

interpretacia Zalian garTulebulia.

III STEMI-s Setevis dawyeba da prehospitaluri qmedeba

a. STEMI-T pacientebis transportireba da pirveladi

reperfuziuli mkurnalobis SerCeva

sqema 2 A hospitaluri fibrinolizisi: unda Sesruldes

stacionarSi Semosvlidan 30 wT-Si

paneli A paciemier

reperfuzia ST(fibrinoliziT

pacientebis tr

transportireb

SenarCunebuli

saswrafo daxm

aReniSneba uku

daxmarebis bri

ara aqvs fibri

aris PCI-s saSufibrinolizi (

brigadas ara a

romelsac aqvs

Si unda Cautar

SeiZleba ganvixiloT

drois grafiki

s.d.b-s

gamgz

1-wT-S

oqros dro = 60

STEMI-s simptomebis

dawyeba

s.d.b.:

• iRebs 12 ganxrian e.k.g-s

• Tuki SesaZloa (igulisxmeba

saswrafos

gamoZaxeba

da

gamogzavna

klinikaSi PCI - SesaZlebelia ix. sqema 2B

inter hospitaluri

gadayvana

avreba

i

prehospital.

Trombolizisi.

s.d.b-s mosvlidan

30 wT-Si (Tuki

SesaZloa)

pacientis transportireba s.d.b-s mier. misi mosvlidan 90-

wT-Si baloni (igulisxmeba balonis gaberva PCI-s dros)

Tuki pacient TviTdinebiT midis stacionarSi hospitalSi

moxvedridan 90-wT-Si baloni.

kvalifikacia da teqnikuri

aRWurviloba) mosvlidan

30 wT-Si Trombolizisi

gegma

s.d.b-Si

darekva

simpt.

dwyebid.

5 wT-Si

ntebi hospitalSi transportirdebian saswrafo daxmar

EMI-an pacientebSi SesaZloa ganxorcielebul iqnas f

) an kaTeterizaciiT (PCI). arCeviToba am strategiebs

ansportirebis saxes da mimRebi klinikis SesaZleblo

is dro cvalebadia yvela SemTxvevaSi, magram iSemiis

unda iyos 120 wT-s farglebSi. arsebobs 3 SesaZlebl

arebis brigadas aqvs fibrinolizis SesaZlebloba da

Cveneba, prehospitaluri fibrinolizi dawyebul unda

gadis misvlidan 30 wT-Si. (klasi I LOE: B). 2. Tu saswr

nolizis saSualeba da pacienti transportirdeba kli

aleba, pacients klinikaSi Sesvlidan 30 wT-Si unda d

karidan-nemsamde dro 30 wT klasi I LOE: B). 3. Tu sasw

qvs fibrinolizis saSualeba da pacienti transporti

kaTeterizaciis PCI saSualeba, pacients klinikaSi Se

des PCI. (karidan-balonamde dro 90 wT(klasi I LOE: B)

wT-s mTlianobaSi iSemiis dro ≤ 120 wT-is

mimReb klinikaSi

PCI - SeuZlebelia ix. sqema 2B

ebis brigadis

armakologiurad

Soris emyareba

bebs.

dro

oba: 1. Tu

pacients ar

iqnes saswrafo

afo daxmarebas

nikaSi, sadac ar

aewyos

rafo daxmarebis

rdeba klinikaSi,

svlidan 90 wT-

. (an

12

Tromblizisi romlis warumateblobis SemTxvevaSi SeiZleba gakeTdes gadamrCeni PCI. unda aRiniSnos rom PCI-s SesaZleblobebiT aRWurvil klinikebs aqvT saSualeba

ufro mSvidad da swrafad ganaxorcielon aRnisnuli mkurnalobis TiToeuli etapi,

rac Tavis mxriv aZlevs maT saSualebas SeimuSaon maT klinikaSi saukeTeso

reperfuziuli strategiia mocemuli pacientisaTvis.

intrahospitaluri gadayvana agreTve aRsaniSnavia pacientebis intrahospitaluri

gadayvana PCI-iT uzrunvelyofil klinikaSi Tu: 1. aRiniSneba fibrinolizis

ukuCveneba; 2. PCI SesaZlebelia gakeTdes ufro swrafad (pacientis sawyis mimReb

klinikaSi Semosvlidan 90 wT-Si an fibrinolizis dawyebis SesaZleblobidan 60 wT-

Si ) 3. fibrinolizi warumatebelia (e.i. keTdeba gadamrCeni PCI ). meoradi, arasaswrafo interhospitaluri gadayvana SesaZlebelia ganxilul iqnes

ganmeorebiTi iSemiis dros.

pacientis TviTdineba: pacientis gadayvana TviTdinebiT riskTan aris dakavSirebuli.

Tu pacienti miva klinikaSi sadac PCI SeuZlebelia, karebidan-nemsamde dro unda

iyos 30 wT. Tu pacienti Seva PCI-iT aRWurvil klinikaSi karebidan-balonamde dro

unda iyos 90 wT. mkurnalobis SerCeva da drois rekomendaciebi klinikaSi Sesvlis

Semdeg aris igive.

13

sqema 2 B .

panel

rekom

saWir

gaiar

damat

pacien

cxril

gansaz

asaki ≥

asaki 6

diabeti

hiperte

angina

sistol

gulis

> 100

gulis

wona <

wina ke

dro re

riskis

arainvaziuri

Sefaseba

fibrinolizisi

mimRebi hospitali

sadac PCI araa SesaZlebeli

pirveladi PCI

PCI an CABG

gadamrCeni an

iSemiis

niSnebisda

mixedviT

intrahospitaluri

mkurnaloba da

meoradi prevencia

mimRebi hospitali

sadac PCI SesaZlebelia

i B pacientebisTvis, visac Cautarda fibrinolizi, riskis stratifikaciisTvis

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

os STEMI-s meoradi prevencia. eba: unda aRiniSnos rom STEMI-s dros prehospitalur etapze rekomendirebulia

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

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

riskis

qulebi

jamuri

qula

saSualo

maCvenebeli

30 dRiani

sikvdiliano

bis %

min da maqs

maCvenebeli

75

3

0

0,1

0,1—0,2

5-75

2

1

0,3

0,2—0,30

1

2

0,4

0,3—0,5

nzia anamnezSi

1

3

0,7

0,6—0,9

anamnezSi

1

4

1,2

1,0—1,5

uri wneva < 100

3

5

2,2

1,9—2,6

SekumSvaTa sixSire

2

6

3,0

2,5—3,6

ukmar. kilipi II--IV

2

7

4,8

3,8—6,1

67 kg

1

8

5,8

4,2—7,8

deli an LBBB

1

> 8

8,8

6,3--12

perfuziamde > 4-sT

1

14

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

IV. pirveladi amocnoba da marTva gadaudebeli

daxmarebis departamentSi

a. sqema. 3 gadaudebeli daxmarebis algoriTmi/protokoli

pacientSi STEMI–s simptomebiT an niSnebiT

STEMI-s simptomebis

dawyeba

saswrafo daxmareba

miiyvans pacients

gadaudebeli daxmarebis

ganyofilebaSi

pacienti Semodis

gadaudebeli daxmarebis

ganyofilebaSi

triada romelic mniSvnelovnia stacionarSi miRebisas:

• STEMI-s simptomebis da niSnebis Sefaseba (Cvenebis klasi I LOE: C) • 12-ganxriani e.k.g (Semosvidan 10 wT-Si unda iyos gadaRebuli Tuki ara gvaqvs STEMI-s niSnebi da pacienti kvlav simptomuria seriuli e.k.g yovel 10-wT-Si. (Cveneba klasi I LOE:C) • Tuki pacients aqvs qveda kedlis MI unda gadaviRoT marjvena mxrivi ganxrebic marjvena parkuWis

infarqtis dasadgenad Cvenebis klasi I LOE: B)

gadaudebel saeqTno daxmarebas: kardiomonitoringi,

O2-is miwodeba Tuki SaO2 < 90% klasi I LOE B O2-is miwodeba yvela Semosul pacients STEMI-T miuxedavad

SaO2>90%. 6-sT-is ganmavlobaSi 2-3l Cveneba klasi II-A LOE C IV- D5W, sisxlis analizi ( cxrili 7) nitroglicerini † aspirini ††

† - ar miceT

naklebi, anN

parkuWis in

†† - Tumca z

aspirins, uf

daReWvisas

††† - oralu

klasi. LOE ATu aris ta

gaurkvevlo

konsultant

pacients aReniS

STEMI ? diax

Sefaseba:

• dro simptomebis dawyebidan

• STEMI-s riski ( ix. 1 gamosaxuleba damatebebSi )

• fibrinolizis riski

• dro romelic esaWiroeba PCI-iT aRWurvil

klinikamde

reperfuziuli Terapiis SerCeva da

uzrunvelyofa (cxr. 5 sqema 2 )

sxva Terapiis SerCeva:

• morfini

• aspirini ††

• antiTrombozuli mkurnaloba(heparini)

• nitrati (saWiroebisamebr gulmkerdis

areSi tkivilis an diskomfortis

SemTxvevaSi) †

• beta-blokerebi †††

gadaudebeli daxmarebis eqimi afasebs pacients:

anamnezi/istoria (Cvenebis klasi I LOE: C) fizikuri gamokvleva (2 cxrili) (Cvenebis

klasi I LOE: C) ekg interpretacia (Cvenebis klasi I LOE: C)

Tuki sistoluri wneva < 90 mmhg an bazalurze 30-iT

Tuki P > 100 an < 50 an Tuki eWvi gvaqvs marjvena

farqtze

ogierTi xmarobs nawlavuri garsiT dafarul

ro swrafi Sedegia garsis gareSe aspirinis

ri B-blokerebi pacientebSi ukuCvenebis gareSe ( I

) IV B-blokerebi Tuki araa ukuCveneba gansakuTrebiT

qikardia da hipertenzia. ( IIa klasi LOE: B).

bis SemTxvevaSi gamoiZaxeT

i

neba

ara

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

15

damateba: STEMI-s e.k.g. niSnad fasdeba: ST elevacia ≥ 0,2 mV (2mm) V1-V4 ganxraSi da ≥0,1 mV(1mm) sxva gulmkerdis ganxrebSi, mwvaved g ST depresia V1—V4 ganxrebSi rasac axlavs maRali R marj dial ganxrebSi da pozitiuri T kbilebi, rac aris maCvenebeli WeSmariti posterior MI-s ( miuTiTebs rom procesSi Semomxvevi

totia CarTuli)

b. damateba: ekg-s interpretacia:

e.k.g-s mixedviT infarqtis gamomwvevi sisx

gamosaxuleba 4.

sqema romliTac sargebloben jo-enis

miRebulia 2 sqemis kombinirebis Sedegad: romelic Tavis mxriv aRebulia

Pproqsimalur

perforatoris

proqsimaluradaa

T ↑ V1— 6 I, aVL and

ar or bundle branch

irveli septaluri

Distal LAD or Diagonal distaluri LAD an TviTon diagonali

i

istaluradaa an

V1—4 or I, aVL, V5 V6

oderate to large inferior (poetrior, lateral, right ventricular) saSualo an didi qveda

kedeli ( ukana,

lateraluri, marjvena

parkuWovani)

ST ↑ II, III, aVF and any of the following:

a. V1 V3R, V4R b. V5—6 c. R >S in V1—V2

istalur nawilSi

III, aVF only

anviTarebuli LBBB, gamoxatuli

vena prekor

lZarRvis verificireba:

saxelobis samedicino centrSi, igi

Topol EJ. Van de Werf FJ Acute myocardial infarction: early diagnosis and menegment. In: Topol EJ. ed.Textbook of cardiovascular medicine. vinaidan am sqemidan Semomxvev totsa da marjvena koronars Soris Wirda diferencireba igi Sevsebuli iqna:

Braunwald Zipes Libby Heart sesease A Textbook of Cardiovascular Medicine 2001 6 edition

roximal LAD i LAD

Proximal to first septal perforator stenozi

Sfasicul

pirveli septaluri block

Mid LAD Sua LAD

Proximal to large diagonal but distal to eirst septal perforator stenozi didi

diagonalis

proqsimaluradaa

magram distalurad

ST ↑ V1— 6 I, aVL

p

perforatorisagan

Distal to large Diagonal or diagonal itself stenozidi diagonalis

d

d

Tavad diagonalSia Proximal R

T ↑ S

—

M

C or Left circumflex stenozi marjvena

koronaris

proqsimaluradaa an

SemomxvevSia

ST ↑ II,

Small inferior cire zomis qveda m

kedeli

Distal RCA or left circumflex branch stenozi aris

arjvena koronaris m

d

an Semomxvevis

totSia

ST ↑ V4R= proximal RC ST isoelect. V4R = Distal RC ST ↓ V4R = CX

diafragmuli

kedlis

infarqtis

fonze marjvena

ganxrebis

mixedviT

SesaZloa

uli

is

vimsjeloT

daintereseb

isxlZarRvs

lokalizaciaze

16

amosaxulg eba 5. e.k.g. kriteriumebi m.m.i.-s diagnostikisTvis LBBB-is fonze: am sqemaSi 3 qulas da mets aqvs 90%-ian specifiuroba da 88%-ini albaToba

irebulia Sgarbosa EB, Prinski SL iographic ing acut farction ft bundle brunch block. N

ed 1996; 334: 481

kriteriumebi qulebi

ST ↑ ≥1mm konkordantul 5

ST ↑ ≥ 1mm ganxrebSi V1,V 3

↑ ≥ 5mm diskordantuli QRS -is 2

k.g. kriteriumebi m.m.i.-is diagnostikisaTvis RBBB-is fonze: cvlad T kbilisa QRS-isgan diskordantulad gveqneba QRS

gadi meTvalyureoba

ugularuli) venebis daWimulobis arseboba/ararseboba

lenad

li gulze an gal is riTmi)

Slis arseboba a ararseboba

. pulsaciis arseboba an ararseboba

bovaneba,

ubtura

iT ( boerhavas ( borhaava)

laruli da

i

atipiuri angina

adreuli repolarizacia

rmad invertirebuli T kbilebi

ri nervuli

stemis dazianebis an

iopaTiis

axva

ia

brugdas sindromi

miokarditi

sis konis totebis blokada

zospastikuri angina

stroezofagaluri refluqsi

i

liaruli an pankreatuli

lebi diski an

igi adapt

diagnoses o, Barbagelata A, et al. Electrocard

f evolvEngl J M

e mypcardial in in the resence of le- 487

i QRS-is 2 or V3

ST e.

na -is

konkordantuli T kbili V1,V2 an V3 ganxrebSi (fsevdonormalizacia).

cxrili 2 swrafi fizikuri gasinjva gadaudebel departamentSi

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

3. sauRle (i

4. auskultacia filtvebSi Segubebis niSnebis gamosav

5. gulis auskultacia (Sui op

6. T/t sisxlis mimoqcevis mo n

7

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

g. cxrili 3. STEMI-is diferencialuri diagnostika

sicocxlisaTvis saSiSi

aortis diseqcia

daWimuli pnevmoToraqsi

pulmonaruli embolia ezofagealuri r

mediastinit

perforirebuli wyluli

sindromi

sxva

kardiovasku

ra iSemiur

perikarditi

marcxena parkuWis hipertrof

a

WPW sindromi

hiperkaliemia

R

rogorc centralu

si

hipertrofiuli kardiom

as

hi

va

hipertrofiuli kardiomiopaTia

sxva arakardialuri

ga

(CERD) da spazmi

gulmkerdis kedlis tkivil

bi

wyluli

xerxemlis ma

17

plevraluri tkivili

vralgia

maturi an fsiqogenuri tkivili

STEMI-s diagnoziT miRebul pacientSi rutinuli testebi

1. Sratis biomarkerebi gulis dazianebis Sesafaseblad :

kardiospecif daucad

strategiis Se : C damateba : tro onini upiratesi markeria mio

diagnostireb azomvisas SeiZl ba gamogvrCes mcire

zomis ifarqti. rogorc wesi iReben orives. vinaidan troponini

momatebuli rCeba 1-kviridan 10-14 dRemde, stacionarSi am periodSi

ganviTarebuli gulmkerdSi tkivilis Sesafaseblad gamoiyeneba CK-MB. vinaidan igi sabaziso dones ubrundeba procesis damTavrebidan 2-

2. sisxlis saerTo analizi (CBC); klasi I LOE: C

4. 5. OE: C 6. 7. 8. 9. ( es ukanaskneli

da

yof

dis rentgenogra tatul atiT adgilze, unda

uziuli Terapia(Tuki

otenciur garTulebaze rogoricaa aortis

OE: C atiT), transTorakaluri

ioskopia, sCT an MRI aortis diseqciis asi I LOE: B is dasazusteblad da riskis

par

ro

peptiuri wyluli

panikuri SiSi

ne

so

d.

iuri troponinebi ( ar o reperfuziul

degebs) klasi I LOEp kardiumis infarqtis

isas. CK-MB-s g e

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

3. INR; klasi I LOE: C

aPTT klasi I LOE: C eleqtrolitebi da magniumi; klasi I LBUN; klasi I LOE: C kreatinini; klasi I LOE: C glukoza; klasi I LOE: C Sratis lipidebi; klasi I LOE: C

ar aris aucilebeli gakeTdes dauyovnebliv da

velodoT mis pasuxs, mkurnaloba iwyeba statiniT da stacionarSi

nis periodSi keTdeba analizi. damateba samuSao jgufis mier)

gulmker10. fia: por i apar

gvaxsovdes rom aman ar unda daayovnos reperf

ar aris eWvi iseT p

diseqcia). klasi I L11. gulmkerdis rentgenografia(portatuli apar

da/an

transTorakaluri eqokard

sadiferenciaciod STEMI-sagan. kl12. eqokardiografia SREMI-s diagnoz

Sesafaseblad

pacientebSi vinc moxvdeba gadaudebeli daxmarebis departamentSi

aRniSnuli

diagnoziT, gansakuTrebiT maSin roca saqme gvaqvs LBBB-sTan an

kuWovan

kardiostimulaciasTan, an eWvia ukana kedlis (posterior) STEMI-zemelic

18

mimdinareobs wina ganxrebSi ST segmentis depresiiT klasi II-A LOE: B gamosaxuleba 3.

STEMI-s gaidlainis sruli

gulis biomarkerebi STEMI-s dros. mowodebulia AHA/ACC teqstidan

uwyveti wiTeli aris gulis troponini, romelic matebas iwyebs 6-sT-Si da piks 36-sT-Si

aRwevs. (reperfuziis dros wiTeli wyvetili xazi piki ufro adrea 20-24 sT-Si). CK-MB aseve matebas iwyebs 6-sT-Si da piks 20-24-sT-Si aRwevs. uwyveti mwvane. (reperfuziisas igi

piks 16-18-sT-Si aRwevs). unda AaRiniSnos rom cTnI momatebuli rCeba 7-10 dRe xolo cTnT 10-14 dRe reperfuziis gareSe CK-MB reperfuziis gareSe normas 2 dReSi ubrundeba

Mmarkerebi MI-s gamosavlenad

markeri sawyisi Sefaseba Eelevaciis saSualo sabaziso monacemebTan dabrunebis

MI-s Semdgom piki MI-s Semdgom dro

Myoglobin 1 - 4 sT 6 sT 18 - 24 sT

CK-MB 3 - 12 sT 10 - 24 sT 48 - 72 sT

MB-isoforms

1 - 6 sT 4 - 12 sT 38 sT

cTnI 3 - 12 sT 10 - 24 sT 5 - 10 dRe

cTnT 3 - 12 sT 12 - 24 sT 5 - 14 dRe

Suggested testing schedule for cardiac markers

markeri < 6 sT 6 - 12 sT 12 - 24 sT 24 - 48 sT > 48 sT

Myoglobin +++ + - - - Troponin I + ++ +++ +++ +++ Troponin T + ++ +++ +++ +++ CK-MB + ++ +++ - - MB- isoforms ++

19

e. reperfuzi T uc ob esaZleb s

Rvra pacientebSi STEMI T

4

is me odis a ilebl is da S lobi

gansaz -

cxrili

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

ar

eSi ?

diax ara SeCerdi

II safexuri: aRiniSneba Tu ara fibrinolizis ukuCveneba7

Tu romelime qvemoTCamoTvlilze aRiniSneba pasuxi diax fibrinolizi SeiZleba iyos ukunaCvenebi

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

a

vaoba sistolur a.w. Soris marcxena da marjvena xelze 15 mm Hg-ze meti diax ara

ruqturuli cns daavadeba anamnezSi diax ara

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

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

GI/GU

a

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

si

diastoluri a.w. 110 -ze metia diax armm Hg

sx

st

bo

ax

operacia Tvalze) sisxldena

diax ra

sisxldenis an Trombis warmoqmnis problemebi an sisxlis gaTxeleba diax ara

lmonaluri resuscitacia ( CPR) 10 wT-ze metia diax ara kardiopu

orsuloba diax ara

se

Tirkmlis mZime daavadebebi )

diax ara

20

III safexuri

stemuri hipoperfuzia diax ara

.5

fi olizis riski

dro, romelic saWiroa PCI-iT uzrunvelyofil laboratoriaSi gadasayvanad.

safexuri: fibrinolizis Tu invaziuri strategia? upiratesobis gansazRvra?

naklebia da invaziuri strategiis dro

sazRvrul farglebSi arc erTi strategias

vs.

fibrin

) ( ix. qvemoT)

laboratoria Seesabameba standarts

• karebidan balonamde dro < 90 wT

arebidan balonamde dros

igulisxmeba Trombolizisis dawyebis

saZlebloba) dro < 1 sT-ze

eba

• kaTeterizaciis laboratoria

dakavebulia

• sisxlZarRvovani midgoma

garTulebulia

PCI laboratories unar-Cvevebi ar

EMI maRali riskiT

kardiogenuri Soki (am SemTxvevaSi

8-sT

75w-ze >

asi II-A LOE B

enebis klasi II-A E B

iltvebis Segubeba (Sua wilebze zemoT) diax ara f

aReniSneba Tu ara pacients gamoxatuli gulis ukmarisobaan kardiogenuri Soki, iseTi

rom PCI iyos upiratesi TrombolizisTan SedarebiT ?

si

v. reperfuziis saxis SerCeva pacientebSi STEMI-T

cxrili

I safexuri: drois da riskis Sefaseba:

dro simptomebis dawyebidan

STEMI iski .-s r

brin

II

Tu pacientis Semosvlis dro 3 sT-ze

SesaZloa iyos gaidlainiT gan

upiratesoba ar aq

olizi upiratesia Tuki:

P

invaziuri strategia upiratesia Tuki:

stacionarSi adreuli moxvedrisas (

PCI≤ 3-sT-ze simptomebis dawyebidan da

im SemTxvevaSi Tuki invaziuri

strategia gviandeba

† da aqvs qirurgiuli uzrunvelyofa

• k

gamoklebuli karebidan nemsamde (

Se

invaziuri strategia ar ganixil

rogorc arCevani Tuki:

• Seesabameba

standarts †

ST

•

nacvlad 12 sT-isa aRebulia 1

infarqtis dawyebidan da 75w asakis

qvemoT pacientebisaTvis klasi I LOE:A xolo maTTvis visasac aski >

kl

• kilipis klasi ≥ 3. CvLO

21

fibrinolizisze ukuCveneba

igulisxmeba sisxl

invaziuri Carevis dayovneba:

a xangZlivdeba

alonamde dro > 90wT-

karebidan balonamde dros

moklebuli karebidan nemsamde (

awyebis SesaZlebloba) dro > 1

denis da

trakranialuri hemoragiis gazrdili

lasi I LOE: B

me-11

rilSi

stacionarSi Semosvlis dagvianeba > 3

sT-ze simptomebis dawyebidan

Tuki infarqtis diagnozi saeWvoa da/an

pirveladi PCI-s rekomendaciebSi gaTvaliswinebuli SemTxvevebi

† P ri ze

weli b weliwadSi )

z fibrinolizis Cvenebebi:

I klasi:

1. ukuCvenebebis ar arsebobisas, fibr niSneba

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

2. ukuCvenebebis ar arsebobisas aRniSnuli mkurnaloba tardeba STEMI-s d n gasulia ≤ 12 sT da pacients aqvs axali

savaraudod axali LBBB LOE: A

aqvs

riti ukana kedlis infarqti LOE: C -s

a da ST elevacia aris meti 0,1 mV sul

cota 2 mimdebare prekordiul ganxraSi an or mimdebare kidurebis

i LOE: B

• transportireb

• karebidan b

ze

•

ga

igulisxmeba Trombolizisis

d

sT-ze

in

riskebi

k

Trombolizisis dozebi aris

cxrilSi

ukuCvenebebi mocemuli me-6 cx

CI-s standartebSi igulisxmeba operato s gamcdileba ( pirveladi PCI > 75 SemTxveva

rveladi PCI > 36 SemTxevazeadSi) da gunduri muSaobis gamocdile a ( pi

.

inolizisuri mkurnaloba i

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

mdebare kidurebis ganxraSi LOE: A mi

ros Tuki simptomebis dawyebida

an

II A klasi:

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

12 ganxriani e.k.g-s mixedviT WeSma

2. ukuCvenebebis ar arsebobisas aRniSnuli mkurnaloba tardeba STEMIdros, Tuki simptomebis dawyebidan gasulia 12-dan 24 sT-mde Tuki

iSemiis simptomebi grZeldeb

ganxraS

22

III 1.fibrroml

2. F r

ganxr

gamok

damate efeqturoba naklebia im pacientTa jgufSi romelsac

edlis infarqti, Tuki mas Tan ar axlavs RV infarqti an ST-segmentis obaze

bi

cxrili 6.

i), 3. cnobili avTvisebiani intrakranialuri

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

m i

a a) 7.

s an saxis daxuruli travma

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

s

amnezSi 3 Tveze

ebadi

a

i

T Tuki maT aqvT revaskularizaciis Cveneba

3. qirurgiuli koregireba ventrikuluri zgidis rubturisas/mkacri

s

pacientebSi persistentuli hemodinamikuri da/an eleqtruli

lurobisas. LOE: C

klasi:

inolizisuri Terapia ar iniSneba asimptomatur pacientebSi

ebSiac STEMI-s simptomebi daiwyo 24-sT-iT adre. LOE: C ib inolizisuri Terapia ar iniSneba pacientebSi romlebSiac 12

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

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

ba: Trombolizisis

aqvs qveda k

depresia prekordialur ganxrebSi, rac miuTiTebs rom didi ubanis arseb

riskis qveS.

T. STEMI-s dros fibrinolizis ukuCveneba da safrTxee

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

cnobili cerebrovaskularuli dazianeba (mag: arteriovenozuri

paTologieb

n

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

ortis diseqciaze 6. sisxldena an sisxlmdeni diaTezi (menzesis gard

bolo 3 Tvis manZilze, Tavis qali

S

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

meti, 3. diastoluri 110 mmHG-ze meti) es ukuCveneba SesaZloa iyo

absolituri ukuCveneba dabali riskis STEMI-s dros 4. anadrindeli iSemiuri Seteva, demencia, an intrakranialuri paTologia,

romelic ar ifareba absolituri ukuCvenebebiT 5. travmuli an

gaxangrZlivebuli (10 wT-ze meti) CPR an didi operacia(3 kviraze nakleb

droSi ) 6. axali (2-4 kviris) Sinagani sisxldena 7. arakompresir

vaskularuli punqcia 8. streptokinaza/antistrptaza adrindeli gamoyeneb

(5 dReze adre) an alergiuli reaqcia am agentze 9. orsuloba 10. aqtiur

peptiuri wyluli 11. antikoagulantis miReba anamnezSi: rac maRalia INRmiT maRalia sisxldenis riski

i. diagnostikuri koronaruli angiografia

klasi I

1. irveladi PCI-s kandidatebi LOE: A 2. pacientebi kardiogenuri Soki

OE: A L

arqvlis naklovanebisas LOE: B 4.

arastabi

klasi III

23

1. koronaruli angiografia ar unda Catardes pacientebSi Tanmxlebi mZime

asi I zogadi ganxilva

1. Tu dauyovnebliv SesaZlebelia, pirveladi PCI Catarebul unda iqnes

pacientebSi STEMI-T (WeSmaritad ukana kedlis m.i.-s CaTvliT) an

axali an savaraudod axali hisis konis marcxena fexis blokadisas,

simptomebis dawyebidan 12 sT-Si. Tuki Careva tardeba dadgenil droSi

svlidan) gamocdili eqimis mier

(romelic akeTebs 75 pirveladi PCI proceduras weliwadSi).

il unda iqnes gamocdili personalis mier

Sesatyvis laboratoriaSi (yovel wels laboratories mier

speci

mkurn

a. pi

konta

b. T

karid sxvaoba

aris:

upiratesia fibrinolizuri Terapia. (LOE B ) g. Tu simptomebis xangrZlivoba 3 sT-ze metia, pirveladi PCI upiratesia

dan-

vaskularizaciisTvis Sesaferi (Carevis teqnikuri SesaZlebloba

s a igi

S

e.

daavadebebiT sadac revaskularizaciis riski ufro metia vidre

sargebloba. LOE: C

k. pirveladi PCI-s rekomendaciebi

kl

(balonuri inflacia 90 wT-Si Semo

procedura mxardaWer

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

fiuri sakiTxebi: rac exmareba eqims gadawyvetilebis miRebaSi airCios

alobis meTodi;

rveladi PCI unda Catardes rac SeiZleba swrafad, samedicino

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

u simptomebis xangrZlivoba aris 3 sT-s farglebSi da mosalodneli

an balonamde drois da mosalodneli karidan-nemsamde drois

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

da unda gakeTdes rac SeiZleba xanmokle droSi samedicino kontaqti

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

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

re

isxlZarRvis antomiuri da dazianebisTaviseburebebis gamo.) d

eiZleba Catardes Sokis ganviTarebidan 18 sT-Si Tu Semdgomi

mkurnalobis gagrZeleba araa azrs moklebuli pacientis survilis.

ukuCvenebebis an imis gamo rom invaziuri CarevisaTvis mdgomareoba

Seuferebelia (igulisxmeba Carevis teqnikuri SeuZlebloba

sisxlZarRvis anatomiuri Taviseburebebis da dazianebis

Taviseburebebis gamo. (LOE A )

pirveladi PCI unda Cautardes pacientebs mkacri SegubebiTi gulis

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

24

dawyebidan 12 sT-is ganmavlobaSi. samedicino kontaqtidan balonamde

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

farglebSi. ( LOE B )

si II A

an

kla

I_T an

sTvis,

tares Sokidan 18 sT-Si. pacientebi romelTac

manamde hqondaT kargi funqciuri statusi, mdgomareoba Sesaferisia

ularizaciisTvis da pacieti Tanaxmaa invaziur Carevaze,

SesaZloa arCeul iqnan invaziuri strategiisTvis. . ( LOE B )

kla

1 p ba STEMI-an pacientebSi romlebic

fibrinolizisisaTvis Sesaferisni arian, ar aris kargad

5

)

1. eriaze

OE C ) 2. -

hemodinamikurad da eleqtrofiziologiurad stabilurebi. ( LOE C )

l. r

Rebul

Tr b

klasi

1. pirveladi PCI sruldeba STEMI-s dros pirvel 12 sT-Si Tuki

klasi II-

rombolizisisaTvis,. simptomebis dawyebida 12-24

sT-Si Tu saxezea romelime CamoTvlilTagan:

mkacri CHF ( LOE C )

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

Sesaferisia (anatomiurad da teqnikurad) revaskularizacii

rac SesaZloa Cau

revask

2. pirveladi PCI SesaZloa Cautardes pacientebs visac simptomebi

daewyo 12-dan 24 sT-is ganmavlobaSi da aReniSneba erTi an ramdenime

qvemoTCamoTvlilTagani:

a) mkacri SegubebiTi gulis ukmarisoba. ( LOE C ) b) hemodinamikuri an eleqtrlituri arastabiluroba ( LOE C ) g) persistentuli iSemiuri simptomebi ( LOE C )

si II B

irveladi PCI-is sargeblo

gansazRvruli, rodesac PCI-is atarebs operatori, romelsag aqvs 7

PCI proceduraze naklebi Catarebuli weliwadSi. ( LOE C

klasi III

pirveladi PCI ar unda Cautardes arainfarqtul art

pacientebSi hemodinamikuri arastabilurobis gareSe. ( L pirveladi PCI ar unda Cautardes asimptomur pacientebs Tuki STEMIs dawyebidan gasulia 12 sT-ze meti da Tu isini arian

pi veladi PCI-s rekomendaciebi pacientebSi romlebic ver

oben Tromboliziss raimis gamo; (Seuferebelia

om olizisisaTvis)

I

pacienti Seuferebelia TrombolizisisaTvis ( LOE C ) A

1. gonivrulia gavakeToT pirveladi PCI pacientebSi STEMI-T, Tuki isini

Seuferebeli arian T

•

• hemodinamikuri an eleqtruli arastabiloba ( LOE C ) • iSemiuri simptomebi persistirebs ( LOE C )

25

m. p r

ara a

kl

asi II-B 1. pirveladi i romelsac ara aqvs

li/SeTanxmebuli gegma

Sesaferisi hemodinamikuri daxmarebis fonze. am SemTxvevaSic

ba pacientebiT romelTac aqvT STEMI an MI axali

an savaraudod axali LBBB-iT e.k.g-ze da SesaZlebelia maTSi Careva

lad Sesruldes ( balonis gaberva 90-wT-Si) operatoris mier

klasi

aqvs

qirur

uaxlo

gaday

PCI

uri

m

am ukanasknelis da Trombolizisis kombinaciis Semdgom.

damxmare PCI SesaZloa Sesruldes rogorc reperfuziuli strategiis

wili maRali riskis pacientebSi roca PCI ver sruldeba gadaudeblad da

oca sisxldenis riski aris dabali LOE: B

Ceni PCI:

romelTa asaki < 75w. aqvT

TEMI an LBBB da romelTac MI ganuviTardaT 36 sT-is farglebSi da

isxlZarRvebi Sesaferisia (anatomiurad da teqnikurad)

i veladi PCI-s rekomendaciebi klinikebisaTvis romelTac

qvT kardioqirurgiuli ganyofileba

asi I da II-A ara aqvs

kl

PCI SeiZleba Sesruldes hospitalS

kardioqirurgia im SemTxvevaSi, Tuki arsebobs kardioqirurgiul

saoperacio oTaxSi gadayvanis dadasturebu

procedura izRude

drou

romelic weliwadSi asrulebs sul cota 75 PCI-s. aqedan 36 pirveladi PCI (( LOE C ) III

1. pirveladi PCI ar unda Catardes hospitalSi romelsac ara

giuli ganyofileba da ara aqvs damtkicebuli/SeTanxmebuli gegma

s stacionarSi kadioqirurgiuli ganyofilebis saoperacioSi

vanisTvis, Sesaferisi hemodinamikuri uzrunvelyofiT. ( LOE C )

n. damxmare

ganmarteba: damxmare PCI-Si igulisxmeba dagegmili PCI sawyisi farmakologi

Carevis Semdgom, rogoricaa fibrinolizisi sruli doziT, naxevari doza

b/IIIa-is inhibitoris gadasxmis Semdgofibrinolizisis Semdgom, glukoprotein II

an

klasi I da II-A ara aqvs

klasi II-B 1.na

r

o. gadamr

I klasi:

1. gadamrCeni PCI unda Sesruldes pacientebSi

Ss

26

r s, xolo PCI SeiZleba Sesruldes Sokis dawyebidan

-sT-Si. Tuki es Careva araa amao imis gamo rom pacients es ar surs, an

nvaziuri mkurnalobaze aris ukuCvenebebi/SeuTavseblobi. LOE: B

E B

sT-

(anatomiurad/teqnikurad) revaskularizaciisaTvis, xolo PCI SeiZleba Sesruldes Sokis dawyebidan 18-sT-Si. es exebaT pacientebs

ac aqvT kargi funqcionaluri statusi da Tanaxmani arian

2.

p.

kl

aferisia), PCI tardeba, roca aris obieqturi monacemebi romlebic adastureben ganmeorebiT

(recurent) infarqts LOE: C PCI unda Catardes

saSualo an mkacri, spontanuri an provocirebadi miokardiumis

miisas STEMI is Semdgom aRdgenis fazaSi LOE: B

klasi

1. i romelTa

vani

2. s PCI Tuki aris dokumentirebuli klinikuri

gulis ukmarisobis mwvave epizodi, miuxedavad imisa rom Semdgomi

sebisas SesaZloa LVgandevnis fraqcia iyos ≥ 40%-ze LOE: C

klasi

1. saZloa ganvixiloT rogorc invaziuri strategiis

evaskularizaciisaTvi

18

Semdgomi i

2. gadamrCeni PCI unda Cautardes pacientebs mkacri SegubebiTi gulis

ukmarisobiT, (kilipi) III. simptomebis dawyebidan gasulia ≤ 12 sT-ze( LO)

II-A klasi:

1. PCI mizanSewonilia Sesruldes seleqtiur pacientebSi ≥ 75w. romelTac aqvT STEMI an LBBB da romelTac MI ganuviTardaT 36

is farglebSi da romelTa sisxlZarRvebi Sesaferisia

romelT

invaziur Carevaze. LOE: B mizanSewonilia Sesruldes gadamrCeni PCI Tuki aris erTerTi

CvenebaTagani:

• hemodinamikuri an eleqtruli arastabiluroba LOE: C • persistentuli iSemiuri simptomebi LOE: C

PCI fibrinolizisis Semdeg:

asi I

1. pacientebSi (Tuki sisxlZarRvTa anatomia Ses

2. pacientebSi romelTa anatomia Sesaferisia,

iSe

3. pacientebSi romeTa anatomia Sesaferisia, PCI unda Catardes kardiogenuri Sokis an hemodinamikuri arastabiluriobisas

(ixgadamrCeni PCI) LOE: B

IIA mizanSewonilia Catardes PCI rutinulad pacientebS

gandevnis fraqcia ≤ 40%-ze, aqvT CHF an seriozuli parkuWo

ariTmia. LOE: C mizanSewonilia Catarde

Sefa

IIB rutinuli PCI Senawili fibrinolizisuri Terapiis Semdgom. LOE: B

27

ganmarteba:

• warmat luria da aris

veneba rac zrdis

afrTxoebas (garda im zemoTCamoTvlili SemTxvevebisa rac aCqarebs invaziur

revas)

.warumatebeli Trombolizisis SemTxvevaSi moqmedebs gadamrCeni Trombolizisis

beli Trombolizis niSnebia: simptomebis moxsna,(SeiZleba

avSirdebodes analgezias an nawilobri inervacias, rac gvxvdeba zogierT

izisi iTvleba warumateblad da tardeba gadamrCeni (es gansakuTrebiT

ni daavadeba

parkuWis infarqti, romelic ZiriTadSi

g ba. vinaidan am dros Wirs pacientis

xsna xelovnuri sisxlis mimoqcevidan.

audebeli qirurgiuli

vaskularizaciis Cveneba STEMI-s dros aris Semdegi

I klasi

1. warumatebeli PCI persistentuli tkivilis da arastabiluri

hemodinamikisas pacientebSi romelTac aqvT Sesaferisi anatomia

q

2. ia

medikamentur mkurnalobaze, isi

atomia qirurgiuli CarevisaTvis, miokardiumis mnisvnelovani areali

eS da ar arian kandidatebi Trombolizisis an PCI-s LOE: B o

STEMI LBBB-iT an

ents es

ebuli Trombolizisis Semdgom Tuki mdgomareoba stabi

PCI-s igi umjobesia Sesruldes dReeebis an kvireebis Semdgom, C

us

Ca

•

sqema. warmate

uk

pacientebSi), aCqarebuli idioventrikuluri riTmi, hemodinamikis stabilizacia STsegmentis elevaciis 50-70%-iT Semcireba Trombolizisis dawyebidan 90-wT-Si. Tuki

Trombolizisis dawyebidan 90 wT-Si ara gvaqvs reperfuziis aSkara niSnebi

Trombol PCIexeba wina kedlis infarqts). gansakuTrebiT unda aRiniSnos, rom kardiogenuri

Sokis ganviTarebisas ra Tqma unda ar velodebiT 90-wT-is gasvlas.

r. mwvave qirurgiuli reperfuzia:

zogadad gadaudebeli qirurgiuli reperfuzia unda Sesruldes STEMI-s dros Tuki gvinda

am dros pirdapiri an gadamrCeni PCI-s Catareba magram pacients aReniSneba marcxena mTavari/ZiriTadi koronaris kritikuli stenozi an mkacri 3 sisxlZarRvova

omelic miudgomelia PCI-sTvis. r

gansakuTrebul SemTxvevas warmoadgens marjvena

vevlineba rogorc gadaudebeli CABG-s ukuCvene

mo

s. zogadad urgentuli da gad

re

irurgiuli CarevisaTvis. LOE: B persistentuli an ganmeorebiTi iSemia romelic refraqterul

pacientebSi romelTac aqvT Sesafer

an

riskis qv

3. postinfarqtuli VSR da mitraluri sarqvlis naklovanebis gam

operaciisas LOE: B 4. kardiogenuri Soki 75w naklebi asakis pacientebSi -T an

ukana kedlis MI-s gamo romelTac Soki unviTardebaT infarqtidan 36-sT-Si

da aqvT marcxena mTavari/ZiriTadi totis mkacri stenozi, mkacri

multisisxlZarRvovani daavadeba da arian revaskularizaciisaTvis

Sesaferisi kandidatebi, rac Tavis mxriv SesaZloa Catardes Sokis

ganviTarebidan 18-sT-Si. Tuki es Careva araa amao imis gamo rom paci

28

ar surs, an Semdgomi invaziuri mkurnalobaze ukuCvenebebis/SeuTavseblobis

arsebobis gamo. LOE: A 5. sicocxlisaTvis saSiSi parkuWvani ariTmiebi marcxena mTavari/Zi

koronaris stenozisas romelic ≥ 50%-ze. an/da 3 sisxlZarRvovani

daavadebisas LOE: B IIA klasi:

1. gadaudebeli CAB

riTadi

G SesaZloa iyos rogorc pirveladi reperfuziuli

an

T. gansakuTrebiT maSin Tu saxezea mkacri stenozi marcxena mTavari/ZiriTadi koronaris an multi sisxlZarRvovani

deba. LOE: B

I-s

s

atebi rac Tavis mxriv SesaZloa Catardes Sokis

III kl

1.

2. atebuli epikardiuli

reperfuziisas magram warumatebeli mikrovaskularuli

fuziisas LOE: C

hospitaluri mkurnaloba

..CCU intensiuri/koronaruli movlis ganyofileba:

r garemos sadac pacients unda

grZeldebodes e.k.g. monitoringi da puls oqsimetria da sadac unda iyos

saSualeba hemodinamikuri monitoringisTvis da defibrilaciis. LOE: C 2 re,

gina(stenokardia), wneva, gulis ukmarisoba. da Semowmdes adeqvaturia Tu

nare mkurnaloba. LOE: A

strategia pacientebisaTvis Sesaferisi anatomiiT, romlebic ara

arian PCI-s an Trombolizisis kandidatebi da STEMI-s dawyebdgasulia 6-12 s

daava

2. gadaudebeli CABG SeiZleba iyos efeqturi pacientebSi romelTa

asaki ≥ 75w da aReniSnebaT STEMI-T an LBBB-iT an ukana kedlis Mgamo, romelTac Soki unviTardebaT infarqtidan 36-sT-Si da aqvT

marcxena mTavari/ZiriTadi totis mkacri stenozi, mkacri

multisisxlZarRvovani daavadeba da arian revaskularizaciisaTvi

Sesaferisi kandid

ganviTarebidan 18-sT-Si. Tuki es Careva araa amao imis gamo rom

pacients es ar surs, an Semdgomi invaziuri mkurnaloba

ukuCvenebebia/SeuTavsebelia LOE: B

asi

gadaudebeli CABG ar tardeba roca gvaqvs persistentuli angina

magram miokardiumis mcire zonaa riskis qveS da pacienti

hemodinamikurad stabiluria. LOE: C gadaudebeli CABG ar tardeba warm

reper

V

a.

I klasi:

1. CCU unda warmoadgendes mSvid da wynau

. unda ganisazRvros kontrolirebulia Tu ara riTmis sixSi

an

ara mimdi

29

3. unda ganisazRvros Jangbadis micemis saWiroeba: (stabilur pacientSi 6

sT-is semdgom sadac SO2 > 90%-e mxedvelobaSi unda gvqondes misi moxsna.

LOE: C

-

ac aqvT

uZliaT daxmarebis aRmoCena da utardebaT

orze e.kg. gamosaxuleba unda iyos optimizirebuli. raTa ar

CU-is gamoyeneba terminaluri pacientebis

lia

amo terminaluri

mdgomareoba). LOE: C

b. CCU-is Se

I klasi:

pacientebi dabali riskis T romelTac CautardaT warmatebuli

eperfuzia PCI-T SesaZlebelia gadavidnen ganyofilebaSi CCU-is gavlis

g

2 ganmavlobaSi arian klinikurad

abilurni, (ara aqvT ganmeorebiTi iSemia, gulis ukmarisoba, kuri darRveva an ariTmia romelic iwvevs am moSlilobas) unda

CCU-dan ganyofilebaSi im

irobiT, rom saWiroebisas SesaZlebeli iqneba e.k.g. monitoringi da

qsimetria. LOE C . mizanSewonilia pacientebi STEMI-s Semdgom romelTac aqvT ariTmia

arRvevs hemodinamikas (AF kontrolirebulin sixSiriT,

.

urad

valifikaciis eqTnis momsaxureba LOE C

4. am ganyofilebaSi pacientebTan unda muSaobdnen eqTnebi romelT

Sesabamisi kvalifikacia da ician movlis zogadi principebi, aseve

gadaudebeli mdgomareobebisas Se

regularuli trainingebi. LOE: C 5. ganyofilebis muSaoba unda eyrdnobodes Sesabamis protokolebs. LOE: C 6. monitgamogvrCes ST segmentis deviacia an riTmis moSla LOE: C III klasi:

1. mizanSewonili araa CmisaRebad, romelTac emarTebaT STEMI da “sadac resuscitaciaar tardeba”(igulisxmeba pacientebi, sadac winaswar cnobi

rom mas aqvs zogadad raime cxva daavadebis g

mdgomi mkurnaloba:

STEMI-1.

r

areSe. LOE C . pacientebi STEMI-T Tuki 12-24-sT is

st

hemodinami

gadavidnen CCU-dan ganyofilebaSi. LOE C II A klasi: 1. mizanSewonilia pacientebi STEMI-s Semdgom romelTac darCaT kinikurad

gamoxatuli gulis ukmarisoba gadavidnen

p

o

2romelic ar

aramyari VT-s paroqsizmebi 30-wm-ze naklebi xangZlivobiT) gadadian CCU-dan

ganyofilebaSi im pirobiT, rom saWiroebisas SesaZlebeli iqneba e.k.g

monitoringi, defibrilatori da kvalificiuri eqTanis momsaxureba LOE C II B klasi 1. mizanSewonilia pacientebi STEMI-s Semdgom romelTac aqvT klinik

mniSvnelovani pulmonaruli daavadeba da saWiroeben Jangbadis did nakads

an arainvaziur maskiT ventilacias gadadian CCU-dan ganyofilebaSi im

pirobiT, rom SesaZlebeli iqneba puls oqsimetria da Sesabamisi

k

30

g. pacientebis gaaqtiveba:

II A 1. pacientebSi hemodinamikuri arastabiluro

meordeboda, stabulizaciis 12-24 sT-is Semdeg

biT an maTSi visac iSemiuri tkivilebi

SesaZlebelia wamojdomis nebis

sawolSi gaaqtiveba rasac moyveba aqtivobis donis TandaTanobiTi zrda.

LOE C

I i: cientebs STEMI-T romlebSiac araa ganmeorebiTi iSemiis epzodebi, gulis

diet :

( saerTo kaloraJSi gajerebuli cximi <

qolesteroli < 2000 mg/dReSi.) urCieT wonis kontroli da

fizikuri aqtivoba. urCieT omega-3 cximovani mJavis xmarebis gazrda. LOE C

omelTac aqvT aRgzneba an Secvlili qceva rac ukavSirdeba

hospitalizacias LOE C 2 da

aWiroebisas Cautardes specialistis konsultacia. LOE C

vrilebiT iqneba axsnili srul teqstSi da PCI-s

aspirini:

klasi:

i

acientSi visac ara aqvs

lergia masze. LOE: A

u

micema da

II klas

1. paukmarisobis simptomebi, an seriozuli riTmis darRvevebi ar unda gaugrZeldeT

woliTi reJimi 12-24 sT-is Semdgom.

LOE C

d. a

I klasi:

1. daiwyeT dieta yvela pacientSi.

7%-ze da

e. analgetikebi/aRgznebis sawinaaRmdego preparatebi:

II A klasi:

mizanSewonilia gamoviyenoT damamSvideblebi pacientebSi STEMI-T 1.

r

. mizanSewonilia Sefasdes pacientis qceva da aRgznebis done

s

v. antiagregantebi:

(maTi gamoyeneba ufro daw

gaidlainSi romelic dasruldeba 2007 welSi).

I

1. STEMI-s dros sawyisi doza 162-325 mg per.os. da Semdeg SemnarCunebeldoza 75-162 mg ganusazRvreli vadiT yvela p

a

†† - Tumca zogierTi xmarobs nawlavuri garsiT dafarul aspirins, ufro

swrafi Sedegia garsis gareSe aspirinis daReWvisas

31

Tienopiridinebi

I klasi:

klopidrogeli iniSneba pacientebSi vinc ver iRebs aspirins

permgrZnobelobis an mniSvnelovani gastrointersticiuli garTulebebis

mo. LOE: C miReba grZeldeba stentirebis Semdgom sul cota 1 Tve

re metal stentis implantaciis Semdgom da ramodenime Tve drug-eluting mdgom( 3-Tve sirolimus da 6 Tve paclitaxe-is Semdgom) da grZeldeba

i. . LOE: B

ki tardeba STEMI-s dros reperfuzia PCI-T, maSin

A klasi: iwyeben rac SeiZleba adre STEMI-s dros Tuki igegmeba pirveladi

ptifibatidi IIb-Si)

ogiuri

ogadi rekomendacia heparnisTvis: mwvane koronaruli sindromis dros (ACS ) igi mareba 2-3 dRidan 7-8 dRemde

afraqcionirebuli heparini UFH

SemTxvevebSi roca reperfuziuli Terapia ar tardeba:

klasi:

i/v UFH ( bolusi 60 U/kg da max 4000 U da Semdeg 12 U/kg/sT max 1000 U) unda moviyenoT pacientebSi STEMI-s Semdgom, romlebic arian sistemuri

didi zomis an wina kedlis MI, AF, namnezSi emboliuri epizodi, LV Trombi an kardiogenuri Soki). LOE: C

nilia, ie -T visa da

iebis

ilia igi gagrZeldes gaweramde (igulisxmeba gaaqtiveba) LOE: C

1.

hi

ga

2. klopidrogelis

bastentis Se

12 Tve pacientebSi romelTac ara aqvT sisxldenis maRali risk

Ddamateba: Tu

klopidrogels aZleven 400 mg-s xolo Semdeg agrZeleben 75 mg dRiurad glukoprotein IIb/IIIa inhibitorebi

II

PCI (stentiT an stentis gareSe). LOE: B (AHA/ACC gaidlainiT absqsimabi IIa jgufSia, xolo tirofibani

e

z. reperfuziisas damatebiTi antiTrombozuli farmakol

daxmareba

z

ix

ar

im

I

1.

ga

emboliebis maRali riskis jgufSi, (a

IIa klasi:

1. mizanSewo rom pac ntebSi STEMI c ar ga utania

reperfuziuli Terapia da romelTac ara aqvT raime ukuCveneba

antikoagulaciis mimarT UFH dainiSnos intravenurad an kanqveSa ineqc

saxiT sul cota 48-sT. im pacientebSi romelTa mdgomareoba moiTxovs

xangZliv woliT reJims da/an aqtiobis donis minimumamde dayvanas

mizanSewon

32

damateba: am SemTxvevaSi UFH-s i/v dozaa: 60-70 U/kg bolusi (magr

maqsimaluri dozaa 4000 erT) da Semdeg 12-15U/kg/sT (maqsim. dozaa 1000

erT/kg-ze.) da aPTT narCundeba 50-70-is farglebSi. kanqveSa ineqciebis dr

sxvadasxva kvlevebSi gamoyenebuli dozebia 7500 U 2-jer an 5000 U 3

12,500 U 2-jer.

am

os

-jer an

T:

klasi:

UFH unda dainiSnos i/v im pacientebSi STEMI-T romelTac reperfuzia

utardaT alteplaziT, teneqteplaziT an reteplaziT. doza: bolusi 60

,5-2

T 50-70 wm) LOE: C UFH iniSneba intravenurad pacientebSi Trombolizisis mere, romelic

ia araseleqtiuri fibrinolitikebiT (mag: streptokinaza)

en

cientebSi

streptokinziT reperfuziis Semdgom LOE: C

veSa ineqciebis dros sxvadasxva kvlevebSi gamoyenebuli

ozebia 7500 U 2-jer an 5000 U 3-jer an 12,500 U 2-jer. dReisaTvis arsebuli

ac gamoixateba reperfuziul Terapiasa da pacientis adreuli

gaa

UFH –

klasi:

1. pacientebi romlebsac utardebaT PCI an qirurgiuli revaskularizacia

nda miiRon UFH. LOE: C

dReisaTvis arsebuli praqtika rac gamoixateba pacientis adreuli

gaaqtivebaSi moiTxovs am monacemebis gadaxedvas da kiTxvis qves ayenebs

UFH –is am reJimebiT xmarebas.

arafraqcionirebuli heparini UFH im SemTxvevebSi roca reperfuziuli

Terapia tardeba Trombolizisi

I 1.

Ca

U/kg(maqs. 4000U) da Semdeg 12U/kg/sT(maqs. 1000 U/sT) aPTT unda SenarCundes 1iT meti sakontroloze (daaxloebi

2.Catarebul

romlebsac aqvT sistemuri emboliebis ganviTarebis maRali riski

(miokardiumis wina kedlis an didi zomis infarqti, AF, gadatanili

Trromboemboliuri epizodi, an LV-is Trombi. LOE: B 3. Trombocitebi mowmdeba yoveldRiurad pacientebSi romlebic Rebulob

UFH-s. LOE: C IIB klasi:

1. mizanSewonilia davniSnoT UFH intravenurad pa

damateba: kanqd

praqtika, r

qtivebaSi moiTxovs am monacemebis gadaxedvas da kiTxvis qveS ayenebs

is am reJimiT xmarebas.

arafraqcionirebuli heparini UFH, im SemTxvevebSi, roca reperfuzia

tardeba PCI-T:

I

u

33

ganmarteba: roca reperfuzia xdeba PCI-T UFH-is i/v bolusis dozaa

U/kg

70-100

dros aqtiuri Sededebis dro procedurisas HemoTec-iT sul cota 250-300

ron-iT 300-350 da Semdgom aPTT narCundeba 1,5-2,0-iT meti

oza mcirdeba 50-70 U/kg-mde da procedurisas

tiuri Sededebis dro 200 orive meTodiT, xolo Semdgom aPTT-i igive

:

.. LMWH (samkurnalo doziT) unda gamoviyenoT pacientebSi STEMI-s ali riskis jgufSi,

MI, AF, anamnezSi emboliuri epizodi, LV Trombi

IB klasi:

reperfuziuli Terapiis damatebiTi farmakologiuri daxmarebis

valsazrisiT LMWH SeiZleba ganvixiloT rogorc UFH-is alternativa,

cientebSi 75 wlis qvemoT romlebic Rebuloben Trombolizisur

erapias.( Tuki Sratis kreatinini araa > 2,5 mg/dl-ze kacebSi da 2,0 mg/dl-

neqcia 12-sT-Si erTxel saavadmyofodan gaweramde. es kombinacia

iT Trombolizisis dros srulyofiladaa Seswavlili. LOE: B

ti

LMWH

miuxed H-

is kar

rekomendaciebis Camosayalibeblad.

am

da Hemochsakontroloze (50-70wm). Tuki gamoiyeneba glukoprotein IIb/IIIa antagonistebi bolusis d

aq

reJimiT.

dabal-molekuluri wonis heparini heparini LMWH LMWH im SemTxvevebSi roca reperfuziuli Terapia ar tardeba

I klasi:

1

Semdgom, romlebic arian sistemuri emboliebis maR

(didi zomis an wina kedlis

an kardiogenuri Soki). LOE: C

LMWH im SemTxvevebSi reperfuziuli Terapia tardeba TrombolizisiT:

I1.

T

pa

T

ze meti qalebSi) enoqseparinis 30 mg i/v boluss moyveba 1 mg/kg ze kanqveS

i

teneqteplaz

III klasi: 1. LMWH ar gamoiyeneba zemoT aRniSnul situaciebSi, rogorc UFH-is

alternativa Tuki pacientis asaki ≥ 75 w. LOE: B 2. LMWH ar gamoiyeneba zemoT aRniSnul situaciebSi, rogorc UFH-is

alternativa Tundac maSin roca pacientis asaki < 75 welze, Tuki

Sratis kreatinini > 2,5 mg/dl-ze kacebSi da 2,0 mg/dl-ze me

qalebSi) LOE: B

im SemTxvevebSi reperfuzia tardeba PCI-T:

avad imisa rom arsebobs pozitiuri informacia rom LMWH aris UFgi alternativa, monacemebi jer araa sakmarisi garkveuli

34

pirdapiri antiTrombini:

i TrombocitopeniiT HIT SeiZleba

mxedvelobaSi gvqondes bivalirudini rogorc heparinis alternativa

streptokinazis Semdeg. HERO 2 is kvlevaSi gamoyenebuli dozebia: i/v

bolusi 0,25 mg/kg da Semdgom 0,5 mg/kg/sT-S 12-sT-s manZilze xolo

-sT. doza mcirdeba Tuki aPTT> 75-ze pirvel 12-

sT-Si. LOE: B

T. re

dros:

I kla

1. ACE unda dainiSnos per.os pirvel 24-sT-Si STEMI-s awyebidan, pacientebSi wina kedlis infarqtiT, pulmonaruli SegubebiT,

Lmarcxena parkuWis EF-iT < 40%-ze, Tuki ar aRiniSneba hipotenzia (sisit.

LOE: A

ARB iniSneba STEMI-s dros pacientebSi romelTac aqvT wina paragrafSi

uli Cveneba da autanloba ACE LOE: C

,

enzia (sist. wneva < 100 mmhg an sabaziso

is

: B

CE inhibitorebis swrafi titraciis sqema hopspitalizebul pacientebSi

loa gamoyenebuli iqnas pacientebSi tendenciiT hipotoniisken

aZloa

vlilebebis ganviTareba. am mdgomareobas Sokis wina periodi,

reSoki ewodeba.(“nearly shock”)

IIA klasi:

1. pacientebSi hepariniT gamowveul

Semdeg 0,25mg/kg-ze 36

nin-angiotenzin-aldosteronis sistemaze moqmedi preparatebi STEMI-s

si:

inhibitorebid

wneva < 100 mmhg an sabaziso wnevaze 30%-iT naklebi) da ukuCvenebebi am

medikamentis mimarT.

2.

gansazRvr inhibitorebis mimarT.

IIa klasi:

1. ACE inhibitorebis daniSvna pirvel 24-sT-Si STEMI-s dawyebidan SeiZleba

iyos sasargeblo pacientebSi romelTac ar aqvT wina kedlis infarqti,

pulmonaruli Segubeba da marcxena parkuWis gandevnis fraqcia < 40%-ze

Tuki araa arteriuli hipot

wnevaze 30%-iT naklebi) da ukuCvenebebi am medikamentis mimarT ( Tumca am

pacientebSi sargebloba naklebia vidre I klasSi moxvedril pacienteb

jgufSi) LOE

III klasi: 1. i/v ACE inhibitorebi ar eZleva pirvel 24-sT-Si STEMI-s dawyebidan hipotenziis riskis gamo(gamonaklisi SeiZleba iyos refraqteruli

hipertenzia) A(sqema SesaZ

da gulis SegubebiTi ukmarisobiT. am dros saWiroa saWiroa gulis

wuTmoculobis swrafi gazrda, vinaidan winaaRmdeg SemTxvevaSi Ses

Seuqcevadi c

p

kaptoprili:

sawyisi doza 12,5 mg peroralurad (6,25 mg pacientebSi hiponatremiiT,

azotemiiT, siTxis danakargiT, orTostatikuri hipotenziiT).

35

2 sT-Si gavzardoT doza 25 mg-mde

6sT-Si gavzardoT doza 50 mg-mde 3 -jer dReSi

aboloo mizani 150 mg dReSi.

viZlia mivceT 1 sT-iT adre an erTi saaTis Semdeg ACE hibitoris miRebidan.

i hiponatremiiT,

orTostatikuri hipotenziiT)

a 10 mg-mde 2- jer dReSi.

boloo mizani 20 mg dReSi.

iZlia mivceT 1 sT-iT adre an erTi saaTis Semdeg pirveli

ozis miRebidan.

nelodan. erik

klasi:

Tvis STEMI-T da garTulebuli

mdinareobiT. LOE B IIa klasi:

1.

perglikemia mizanSewonilia daeniSnoT insulinis i/v infuzia glukozis

ciisaTvis, maSinac ki roca daavadeba gaurTuleblad

etis

ualizacia insuliniT, insulinis analogebiT,

poglikemiuri saSualebebis kombinirebis gziT. LOE C

eleqtrolitebis balansi:

. maTi deficiti unda gamoswordes. siswrafe damokidebulia sisxlSi maT

oneze da Tanmxleb klinikur movlenebze. LOE: C

mizanSewonilia magniumis deficitis gasworeba, gansakuTrebiT

i STEMI-T romlebic iRebdnen diuretikebs infarqtamde LOE: C

s

Sardmdeni Seg

in

enelaprili:

sawyisi doza 5 mg peroralurad (2,5 mg pacientebS

azotemiiT, siTxis danakargiT,

6 sT-Si gavzardoT doza 10 mg-mde.

12sT-Si gavzardoT doz

sa

Sardmdeni Segv

d

sqema mowodebulia: kardiovaskularuli medicinis saxelmZRva

j. topoli II gamocema 2002w.

i. glukozis kontroli STEMI-s dros:

I

1. insulinis i/v infuzia sisxlis glukozis normalizaciisaTvis

rekomendirebulia pacientebisa

mi

STEMI-s mwvave fazis dros (pirvel 24-48-sT-Si) pacientebs romelTac aqvT

hi

normaliza

mimdinareobs. LOE B 2. STEMI-s mwvave fazis Semdgom mizanSewonilia moaxdinon diab

mkurnalobis individ

oraluri hi

saqrTvelos kardiologTa koleji rekomendacias iZleva STEMI-s dros Saqris cifrebis normalizaciad CaiTvalos glukoza < 150 mg/dl-isfarglebSi

k.

I klasi:

1

d

II A klasi:

1..

pacientebS

36

2. VT “torsade depoint” Tan asocirebuli QT-intervalis gaxangZlivebiT

I klasi:

n

. kalciumis arxebis blokatorebi:

apamili an diltiazemi pacientebs romlebSiac

eta-blkerebi uefeqtoa da/an ukunaCvenebia. iSemiis sakontrolod an

ekuWovani riTmis sixSiris Sesamcireblad Tuki STEMI-s dros pacients emarTeba AF an winagulTa TrTola da ara aqvs CHF da LV disfunqcia an AV

b

I klasi:

i an diltiazemi ukunaCvenebia pacientebSi SYEMI-T da

od,

okerebi unda dainiSnos STEMI-s dawyebidan rac eiZleba adre Tuki araa raime ukuCveneba maT mimarT. miuxedavad imisa

rdeba Tu ara reperfuzia (Trombolizisi an/daPCI-i) LOE: A 2. Tuki beta-blokeri ver iniSneba STEMI-s dawebidan 24-sT-Si imis gamo, rom

raime ukuCvenebaa, am periodis gavlis Semdgom maTi daniSvnis

esaZlebloba Tavidan unda Sefasdes. LOE: C ebi romlebic Rebuloben beta-blokerebs pirvel 24 sT-Si STEMI-s

miReba iwyeba

namkurnalebi unda iqnes i/v Mg ( bolusi 5 wT-is ganmavlonbaSi) LOE: C

II

1. dokumentirebuli eleqtrolituri deficitis an torsade depoint” Ta

asocirebuli VT-is gareSe ar SeiZleba Mg rutinulad gadasxma riskis

donis miuxedavad. LOE: A

l

IIa klasi:

1. miznSewonilia mivceT ver

b

pa

loki. LOE: A II

1. verapamil

adocirebuli CHF da LV disfunqciiT. LOE: C 2. nifedipinis (swrafad xsnadi forma) ukunaCvenebia STEMI-s samkurnalvinaidan axasiaTebs refleqsuri simpaTikuri aqtvaciis gamo taqikardia da

hipotenzia. LOE: B

m. beta-blokatorebi: I klasi: 1. oraluri beta-bl

S

ta

S

3. pacient

dawyebidan da ara aqvT gverdiTi movlenebi agrZeleben maT miRebas

adreuli aRdgenis fazaSi. xolo isini visTanac betablokerebi ar iqna

dawyebuli pirvel 24-sT-Si da visTanac araa ukuCvenebebi maTi

adreul aRgenis fazaSi. LOE: A

IIa klasi:

1. mizanSewonilia beta-blokerebis i/v daniSvna STEMI-s dawyebidan rac SeiZleba adre, Tuki araa raime ukuCveneba, gansakuTrebiT maSin Tuki gvaqvs

taqiariTmia an hipertenzia. LOE: A

37

38

marteba: pacientebSi (Tuki araa raime ukuCveneba) beta-blokerebi

rmoadgenen pacientebi romelTac

. nitroglicerini:

a naCvenebia

STEMI-s dawyebidan 48-sT-is manZilze pacientebSi persistentuli iSemiiT, CHF-

daniSvna (rogoricaa beta-blokerebi an ACE-ebi.) romlebic dadasturebulad amcireben sikvdilianobas. LOE: A

ntebSi Tuki sistoluri wneva < 100 mmhg . wneva 30%-iT naklebia pacientis sabaziso wnevaze an gvaqvs

an

inhibitorebi (sindenafili. xolo 48-sT tadafil-is SemTxvevaSi) LOE: B

gn

grZeldeba minimum 6-Tve. gamonakliss wa

koronarografiisas gamouvlindaT mxolod 1 sisxlZarRvis

stenozi/okluzia romlis reperfuziac warmatebiT ganxorcielda. maTSi

beta blokerebi iniSneba 5-28 dRe. (samuSao jgufis ganmarteba)

n

I klasi:

1. pacients mimdinare tkiviliT aZleven sublingvalur nitroglicerins

(0,4mg) 5 wT-iani intrevalebiT ris Semdgomac dRis wesrigSi SesaZloa

dadges i/v infuziis sakiTxi. LOE: C i/v nitroglicerinis infuzi

iT, hipertenziiT. nitroglicerinis i/v infuziis gamo Tavidan ar unda

aviridoT sxva medikamentebis

inhibitor

2. nitratebi sasargebloa STEMI-s dawyebidan 48-sT-is Semgomac, pacientebSi

persistentuli iSemiiT, CHF-iT, hipertenziiT da im SemTxvevaSi Tuki maTi

miReba xels ar uSlis im medikamentebis daniSvnas (rogoricaa beta-

blokerebi an ACE-inhibitorebi.) romlebic dadasturebulad amcireben

letalobas. LOE: B II-Bklasi:

1. nitratebis xmareba STEMI-s dawyebidan pirveli 24-48-sT-is Semdgom

persistentuli iSemiis an CHF-is ar arsebobisas SeiZleba iyos sasargeblo

Tumca es sargebloba savaraudod mcirea da kargad araa Seswavlili. LOE: B III klasi:

1. nitratebi ar iniSneba pacie

an art

bradikardia ( P < 50-ze wT-Si) an taqikardia ( P > 100-ze wT-Si )

marjvena parkuWis infarqti. LOE: C aseve im pacientebSi romlebsac wina 24-sT-is ganmavlobaSi miRebulia aqvT fspodiesTerazas

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

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

39

mwvave pulmonaruli edema hipovolemia kardiogenuri Soki

dabali wuT.moc.

brad taq.

naxeT ariTmiis marTva

STEMI-s Semdgom.

ariTmia

furosemidi: IV 0,5-1,0 mg/kg 0,5

axlad ganviTarebuli mwv. pulm.

edemaze. 1,0 mwvave an qr.

moculobiT gadatvirTvaze,

Tirkmlis ukmarobisas.

morfini: IV 2- 4 mg

Jangbadi/intubacia: saWiroebisas

nitroglicerini: Sl, Semdeg IV 10-20 mkg/wT Tuki sist.wneva >100 mmhg

dofamini: IV 5-15 mkg/kg/wT Tu

sist.wneva 70-100 da Sokis niSnebia

dobutreqsi: IV 2-20 mkg/kg/wT Tu

sist.wneva 70-100 da Sokis niSnebi

araa

siTxeebi

sisxlis transfuzia

mizezis gamosworeba

gaiTvaliswineT

vazopresorebi

SeinarCune sist.wneva

> 100 mmhg da ara

naklebi 30-isa sabazo

wnevasTan SedarebiT

sist. wneva > 100

mmhg

sist.wneva 70-100 mmhg

Sokis niSnebis gareSe

sist.wneva 70-100 Sokis

niSnebiT

sist.wneva < 70 mmhg

Sokis niSnebiT

ACE inhibitorebi umjobesia xanmokle

moqmedebis rogoricaa

kaptoprili 6,25 mg

nitroglicerini 10-

20 mkg/wT IV

dobutamini 2-20 mkg/kg/wT IV

dofamini 5-15

mkg/kg/wT IV

norepinefrini 0,5—30

mkg/wT IV

Semdgomi/damatebiTi diagnostikur/Terapiuli RonisZiebebi:

diagnostikuri: pulmonaruli arteries kaTeteri, eqokardiografia, angiografia miokardiumis infarqti/iSemiisTvis, damatebiTi diagnostikuri RonisZiebebi.

Terapiuli: 1) intraaortuli balonuri kontrpulsacia, 2) reperfuzia/revaskularizacia, 3) SeiZleba gamoviyenoT dobutamin, dofaminis kombinacia.

40

parkuWTaSua Zgidis rubtura parkuWis Tavisufali kedlis

rubtura

papilaruli kunTis rubtura

sixSire/gavrcel

eba

1-3% pacientebSi romelTac ar

CatarebiT reperfuziuli Terapia

0,2-0,34% pacientebSi visac

Cautarda Trombolizisi

3,9% Sokiani pacientebisa

0,8-6,2% Trombolizisi ar amcirebs

risks; pirveladi PTCA savaraudod

amcirebs.

1% posteromedialuri ufro

xSirad gvxvdeba vidre

anterolateraluri.

dro

aqvs 2 piki 24 sT-Si da Semdeg 3-5

dReSi jamSi viTardeba 1-14 dReSi





klinikuri

manifestacia

tkivili gulmkerdSi, sunTqvis

gaZneleba, hipotenzia

anginuri, plevraluri, an

perikardiuli tkivili gul-mkerdSi,

sinkope, hipotenzia, ariTmiebi,

gulisreva, mousvenroba, hipotenzia,

uecari sikvdili.

sunTqvis gaZnelebis uecari

dawyeba da pulm. SeSupeba.

hipotenzia.

fizikuri

niSnebi

uxeSi holosistoluri Suili,

gaZlierebuli S3 da 2 gulis

toni, pulmonaruli edema, RV da LV ukmarisoba, kardiogenuri

Soki

iugularuli venebis

dilatacia(pacientebis 29%)

paradoqsuli pulsi(47%)

eleqtromeqanikuri dissociacia,

kardiogenuri Soki.

nazi Suili, marjvena parkWis

gadatvirTvis cvalebadi niSnebi,

mkacri pulmonaruli Segubeba,

kardiogenuri Soki

eqokardiografi

uli niSnebi

parkuWTaSua Zgidis defeqti,

marcxnidan marjvniv Sunti,

marjvena nawilebis gadatvirTva

5 mm-ze meti [perikardiuli siTxe

romelic yovelTvis ar

vizualizdeba, Sreobrivi,maRal

akustikuri eqo signali

perikardiumis Signdan(Trombuli

masa) Semavali karis vizualizacia,

tamponadis niSnebi

LV –s hiperkontraqtiloba,

gawyvetili papilar. kunTi, flail qorda, mkacri mitraluri

naklovaneba.

marjvena gulis

kaTeterizacia

gazrdili Jangbadis saturacia

gulis marjvena nawilebSi,

giganturi V-talRebi.

ventrikulografii mgrZnobeloba

dabalia, tamponadis klasikuri

niSnebi xSirad araa(diastoluri

wnevebis gaTanabreba gulis marcxena

da marjvena nawilebs Soris)

gulis marjvena nawilebSi

Jangbadis saturacia ar

matulobs., giganturi V talRebi,

Zalian maRali PCWP

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

VI hemodinamikuri darRvevebi

a. hemodinamikuri gazomvebi:

I klasi:

1. pulmonaruli arteriis kaTeteriT monitoringi saWiroa Semdeg

SemTxvevebSi:

a. Tuki hipotenzia progresirebs, miuxedavad siTxeebis infuziisa an Tuki

es RonisZieba ukunaCvenebia LOE: C b. Tuki gvaqvs eWvi meqanikur garTulebaze (VSR, papilaruli kunTis an

Tavisufali kedlis rubtura) LOE: C 2. intraarteriuli wnevis monitoringi saWiroa Tuki:

a. saxezea wnevis mkveTrad vardna (sist. art. wneva < 80 mmhg) LOE: C. b. kardiogenuli Soki. LOE: C g. Tuki pacientebs utardebaT vazopresorebit/inotropebiT mkurnaoba.

LOE: C

II A klasi:

1. pulmonaruli arteriis kaTeteriT monitoringi SeiZleba saWiro iyos

Semdeg SemTxvevebSi:

a Tuki hipotenzia mimdinareobs pulmonaruli Segubebis gareSe da igi ver

swordeba siTxeebis gadasxmaze. LOE C b. kardiogenuli Soki

g. mkacri an progresirebadi CHF an pulmonaruli SeSepeba romelic

swrafad ar swordeba TerapiiT LOE C d. persistentuli hipoperfuziis niSnebi rodesac ara gvaqvs filtvebSi

Segubeba LOE C g. pacientebi romelTac mkurnaloba utardebaT

vazopresorebit/inotropebiT. LOE C. 2. intraarteriuli wnevis monitoringi SeiZleba saWiro iyos pacientebSi,

romlebic Rebuloben i/v natriumis nitroprusids an sxva

vazodilatatorebs. LOE C II B klasi:

1. intraarteriuli wnevis monitoringi SeiZleba saWiro iyos pacientebSi,

romlebic Rebuloben i/v inotropebs LOE C III klasi:

1. pulmonaruli arteriis kaTeteriT monitoringi rekomendirebuli araa

pacientebSi STEMI-T Tuki maT ara aqvT hemodinamikuri an respiratoruli

darRvevebi. LOE C 2. intraarteriuli wnevis monitoringi araa rekomendirebuli pacientebSi

STEMI-T romelTac ara aqvs pulmonaruli Segubeba da aqvT adeqvaturi

qsovilTa perfuzia meqanikuri kardiocirkulatoruli daxmarebis gareSe.

LOE C

41

b. hipotenzia:

I klasi:

1. Tuki pacients ar aReniSneba moculobiTi gadatvirTvis niSnebi,

rekomendirebulia siTxeebis i/v infuzia. LOE: C 2. ariTmia Tuki igi iwvevs hemodinamikur darRvevebs unda gamoswordes. LOE: C 3. IABP ixmareba im SemTxvevaSi Tuki sxva CareviT pacientis mdgomareoba ar

umjobesdeba, da Tuki Semdgomi invaziuri mkurnaloba araa azrs

moklebuli pacientis survilis, ukuCvenebebis/Seusabamobis arsebobis gamo. LOE: B 4. vazopresorebi iniSneba im semTxvevaSi Tukis hipotenzia ar gamoswordeba

siTxeebis infuziiT. LOE: C 5. Tuki invaziuri gazomvebi araa Catarebulia, saWiroa eqoskopiuri

gamokvleva raTa Sefasdes meqanikuri garTulebebis arseboba. LOE: C

g. dabali wuTmoculobiTi mdgomareoba:

I klasi:

1. unda Sefasdes marcxena parkuWis funcia da SesaZlo meqanikuri

garTulebebis SesaZlebloba unda ganisazRvros eqokardiografiulad,

Tuki manmade ar iyo Sefasebuli invaziurad. LOE: C 2. rekomendirebuli mkurnaloba dabali wuTmoculobiTi mdgomareobisaTvis

moicavs:

a. inotropul daxmarebas LOE: C b. IABP-s LOE: B g. meqanikuri reperfuzias PCI-T an CABG-T LOE: B d. meqanikuri garTulebebis qirurgiuli koregireba. LOE: B III klasi:

1. beta blokerebi da kalciumis antagonistebi ar iniSneba pacientebSi

dabali wuTmoculobiT stadiaSi, rodesac igi ganpirobebulia gulis

rogorc tumbos funqciis daqveiTebiT. LOE: C

saubaria STEMI-is fonze mimdinare garTulebaze, romelic wamoadgens pre-

Sokur mdgomareobas

d. pulmonaruli Segubeba:

I klasi:

1. Jangbadis micema mizanSewonilia arteriuli saturaciis SesanarCuneblad

> 90%-ze pacientebSi pulmonaruli SegubebiT. LOE C 2. morfinis sulfati eZleva pacients pulmonaruli SegubebiT. LOE C 3. aseT SemTxvevebSi iwyeba ACE inhibitorebis titracia. 1-6,25mg kaptoprili

eZleva pacients pulmonaruli SegubebiT, Tuki sistoluri wneva naklebi

araa 100 mmhg an 30 mmhg-Ti naklebi sabaziso wnevaze. pacientebi dabali

42

wneviT da pulmonaruli SegubebiT xSirad saWiroeben inotropebs da

vazopresobs da/an IABP-s adeqvaturi perfuziis SenarCunebis mizniT. LOE: A

4. nitratebi iniSneba Tuki sistoluri wneva naklebi araa 100 mmhg an 30 mmhg-Ti naklebi sabaziso wnevaze. pacientebi dabali wneviT da

pulmonaruli SegubebiT xSirad saWiroeben inotropebs da vazopresobs

da/an IABP-s adeqvaturi perfuziis SenarCunebis mizniT. LOE: C 5. diuretikebi saS. an mcire dozebiT(furosemidi, torsemidi, bumetanidi)

iniSneba pacientebSi pulmonaruli SegubebiT Tuli mas Tan axlavs

hipervolemiuri mdgomareoba. winaaRmdeg semTxvevaSi saWiroa sifrTxile

diuretikenbis xmarebisas. LOE: C 6. beta blokerebi iniSneba aseT pacientebSi gaweris win, meoradi

prevenciisTvis, maT visac am droisaTvis aReniSnebaT gulis ukmarisobis

niSnebi am medikamentis titracia iwyeba dabali dozebiT. LOE: B 7. xangZlivi aldosteronis blokada iniSneba post-STEMI pacientebSi gaweris win, Tuki aseT pacientebs ara aqvT renaluri

disfunqcia(kreatinini ≥ 2,5 mg/dl kacebSi da 2,0 mg/dl qalebSi} an

hiperkaliemia(kaliumi ≥ 5,0 mEq/L} da rolebic ukve iReben ACE inhibitorebs, LVEF ≤ 40% da aqvT romelime diabeti an simptomaturi

gulis ukmarisoba. LOE: C 8. eqokardiografia unda DSesruldes urgentulad raTa Sefasdes RV da LV funqcia da gamoiricxos meqanikuri garTulebebi. LOE: C II B klasi: 1. pacientebSi, romelTac aReniSnebaT refraqteruli pulmonaruli

Segubeba SeiZleba mizansewonili iyos IABP-s xmareba. LOE: C

III klasi:

1. beta blokerebi da kalciumis antagonistebi ar iniSneba mwvaved

pacientebSi STEMI-T romelTac aqvT aSkara monacemebi pulmonaruli

Segubebis an dabali-wuTmoculobis niSnebi. LOE: B

e kardiogenuri Soki:

I klasi:

1. IABP rekomendirebulia pacientebSi STEMI-T da kardiogenuli SokiT Tuki

igi swrafad ver swordeba farmakologiuri CareviT. am SemxvevaSi IABP aris mastabilizirebeli faqtori koronarografiis da revaskularizaciisaTvis. LOE: B 2. pacientebSi STEMI-T da kardiogenuli SokiT rekomendirebulia

hemodinamikis intraarteriuli monitoringi. LOE: C 3. adreuli revaskularizacia PCI an CABG rekomendirebulia pacientebSi,

romelTa asaki < 75w-ze da romlebsac aqvT STEMI, Tuki kardiogenuli Soki

ganuviTardaT infarqtis dawyebidan 36-sT-ze adre, xolo invaziuri Careva SesaZlebelia Sokis dawyebidan 18-sT-ze adre da Tuki Semdgomi invaziuri

mkurnaloba azrs araa moklebuli pacientis survilis da

ukuCvenebebis/Seusabamobis arsebobis gamo. LOE: A

43

4. pacientebSi STEMI-T da kardiogenuli SokiT romlrbSiac ver xerxdeba

invaziuri Careva tardeba fibrinolizisi ukuCvenebebis ar arsebobisas.

LOE: B 5. eqokardiografia tardeba aseT pacientebSi meqnikuri garTulebebis

Sesafaseblad, Tuki am mizniT ar gamoiyeneba invaziuri RonisZiebebi. LOE: B II A klasi: 1. pacientebSi kardiogenuli SokiT pulmonaruli arteriis kaTeteriT

monitoringi SeiZleba iyos sasargeblo. LOE: C 2. adreuli revaskularizacia PCI an CABG rekomendirebulia pacientebSi,

romelTa asaki > 75w-ze da romlebsac aqvT STEMI, Tuki kardiogenuli Soki

ganuviTardaT infarqtis dawyebidan 36-sT-ze adre, xolo invaziuri Careva SesaZlebelia Sokis dawyebidan 18-sT-ze adre da Tuki Semdgomi invaziuri

mkurnaloba azrs araa moklebuli pacientis survilis da

ukuCvenebebis/Seusabamobis arsebobis gamo LOE: A

v. marjvena parkuWis infarqti:

I klasi:

1. pacientebs qveda kedlis STEMI-T da hemodinamikuri darRvevebiT unda

gadaeRoT marjvena prekordiuli ganxrebi (V4R) ST-segmentis elevaciis

gamosavlenad da CautardeT eqokardiografiuli meTvalyureoba, marjvena

parkuWis ukmarisobis gamovlenis mizniT. LOE: B 2. marjvena parkuWis STEMI-s dros Semdegi principebi gamoiyeneba: a. miRweuli unda iqnes adreuli reperfuzia Tuki es Sesazlebelia. LOE: C b. uzrunvelyofili unda iqnes winagulebis da parkuWebis sinqronizacia

da bradikardia unda gamoswordes. LOE: C g. uzrunvelyofili unda iqnas marjvena parkuWis optimaluri

predatvirTva, rac saWiroebs siTxeebis infuzias hemodinamikurad

arastabilur pacientebSi romlebSic sauRle venebis wneva dabali an

normaluria. LOE: C d. marjvena parkuWis postdatvirTva unda iqnes optimizirebuli rac

moiTxovs Tanmxlebi marcxena parkuWis disfunqciis mkurnalobas. LOE: C e. inotropebi gamoiyeneba hemodinamikuri arastabilurobisas rac ar

swordeba siTxeebis gadasxmaze. LOE: C IIA klasi: 1. marjvena parkuWis klinikurad mniSvnelovani infarqtis dros, Tuki igi

CABG-is gakeTeba yovndeba 4 kvira raTa marjvena parkuWma aRidginos

kontraqtiloba. LOE: C

44

VII gulis ukmarisobis meqanikuri mizezebi/dabali

wuTmoculobis sindromi

a. mitraluri sarqvlis ukmarisoba:

I klasi:

1. pacientebSi STEMI-T, romelsac axlavs papilaruli kunTis rubtura,

mizanSewonilia urgentuli kardioqirurgiuli Careva, Tuki Semdgomi

invaziuri mkurnalobis gagrZeleba azrs araa moklebuli pacienti

survilis, ukuCvenebebis/Seusabamobis arsebobis gamo. LOE: B 2. CABG keTdeba mitraluri sarqvlis ukmarisobis gamo Catarebul

operaciasTan erTad. LOE: B

b. parkuWis Zgidis rubtura:

I klasi:

1. pacientebSi STEMI-T romelic garTulebulia VSR-iT mizanSewonilia

urgentuli kardioqirurgiuli Careva, Tuki Semdgomi invaziuri

mkurnalobis gagrZeleba azrs araaa moklebuli pacienti survilis,

ukuCvenebebis/Seusabamobis arsebobis gamo. LOE: B 2. CABG keTdeba marcxena parkuWis VSR-is gamo Catarebuli operaciasTan

erTad LOE: B

g. marcxena parkuWis Tavisufali kedlis rubtura

I klasi:

1. aseT pacientebSi mizanSewonilia urgentuli kardioqirurgiuli Careva.

Tuki Semdgomi invaziuri mkurnalobis gagrZeleba azrs araaa moklebuli

pacienti survilis, ukuCvenebebis/Seusabamobis arsebobis gamo. LOE: B 2. CABG keTdeba marcxena parkuWis Tavisufali kedlis rubturs

qirurgiul SekeTebasTan erTad LOE: B

d. marcxena parkuWis anevrizma:

II A klasi

1. pacientebSi STEMI-T romelTac ganuviTardebaT parkuWovani ariTmia, rac

asocirdeba parkuWovan taqiariTmiebTan, romelTa kontroli Wirs da/an

gulis rogorc tumbos ukmarisobasTan, romelis rezistentulia

mkurnalobis mimarT mizanSewonilia Catardes anevrizmeqtomia da CABG

qirurgia LOE: B

45

46

e. intraaortuli balonuri kontrpulsacia: IABP:

I klasi:

1. IABP gamoyenebuli unda iqnes pacientebSi STEMI-T romelTac aReniSnebaT

hipotenzia (sist. art. wneva < 90 mmhg an 30 mmhg-iT naklebi sabaziso

saSualo arteriul wnevaze, da romelic ar swordeba sxva

Carevaze/mkurnalobaze da Tuki Semdgomi invaziuri mkurnalobis

gagrZeleba azrs araa moklebuli pacienti survilis,

ukuCvenebebis/Seusabamobis arsebobis gamo.. LOE: B 2. IABP rekomendirebulia STEMI-s dros Tuki mas axlavs dabali

wuTmoculobiTi stadia. LOE: B ix. sqema 4 3. kardiogenuri Sokisas roca igi ver swordeba swrafad farmakologiur

TerapiiT. igi aris mastabilizirebeli RonisZieba aseT pacientebSi

angiografiis win. LOE: B ix. sqema 4 4. IABP unda gamoviyenoT rogorc damatebiTi RonisZieba medikamentozur

mkurnalobaze STEMI-an pacientSi Tuki mas aReniSneba rekurentuli

iSemiuri xasiaTis diskomforti gulmkerdSi an hemodinamikuri

arastabiluroba, dabali gandevnis fraqcia an didi zomis miokardiumi

riskis qveS, aseT pacientebi saWiroeben urgentul gulis kaTeterizacias

da revaskularizacia saWiroebisamebr. LOE: C II-A klasi: 1. IABP gamoiyeneba pacientebSi STEMI-T romelTac aReniSnebaT

polimorfuli VT miokardiumis iSemiis Semcirebis mizniT. LOE: C II-B 1. IABP-is gamoyeneba SeiZleba iyos mizanSewonili pacientebSi STEMI-T

refraqteruli pulmonaruli Segubebis mkurnalobis mizniT LOE: C

47

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

Semdgom

ara gvaqvs parkuWTa fibrilacia da myari ventrikuluri

taqikardia STEMI-dan 48-sT-Si da gandevnis fraqcia gaizoma

infarqtidan 1-Tvis Semdeg

EF ≤ 30% EF=31- 40% EF > 40%

gvaqvs eleqt.

arastabilur

oba? mag:

NSVT

ICD EPS + - ICD ara

ganmeorebiTi iSemiuri tkivili an diskomforti STEMI-s SEmdgom

12-ganxriani

e.k.g.

medik. mkurnalobias

optimizacia

antikoagulaciis dawyeba

Tu manamade ar iyo

balonuri kontrpulsacia

hemodinamikuri

arastabilurobis, dabali

kumSvadi funqciis, an

Tuki miokardis didi

ubania riskis qveS

iSemiis meoradi mizezebis

gasworeba

ST elevacia ara diax

aris

revaskulari

zaciis

kandidati ?

ara

diax

iSemia

kontroldeba

medik.

optimizaciiT ?

diax

ganix.

ganmeorebiTi

Trombolizi

si

gegmiuri

kaTeterizacia

urgentuli

kaTeterizacia

gaiTvaliswine

IABP

ara

SesaZleb

elia

swrafi

kaTeteri

zacia ?

ganixile re-Trombolizisis SesaZlebloba

streptkinazisaTvis 2 dRidan 5 wliwadSi

ganmeorebiTi xmareba SedarebiTi ukuCvenebaa

ara

PCI an CABG diax

klasi

III

LOE: B

klasi II-A.

LOE: B

klsi I

LOE: B

klasi

II-B LOE: B

klasi

II-B LOE: B

ara

diax

VIII ariTmiebis marTva STEMI-is Semdgom

a. VF: parkuWovani fibrilacia:

klasi I :

1. parkuWovani fibrilacia an VT pulsis gareSe saWiroebs asinqronul

eleqtrul soks monofazurs swyisi energia 200 J. ganmeorebiTi ganmuxtva

200-300 da warumateblobisas 360 J. LOE B. klasi IIA:

2. Tuki parkuWovani fibrilacia an VT pulsis gareSe

refraqterulia eleqtrikul Sokze mizansewonilia daviwyoT

amiodaroni(300mg bolusi intravenurad da Semdeg gavimeorebT

asinqronul ganmuxtvas LOE B 3. mizanSewonilia gamovasworoT eleqtruli da mJava tutovani

wonasworoba ( K SevinarCunoT > 4 mEq/L da Mg > 2 mg/dl raTa

Tavidan aviciloT VF-is ganmeoreba LOE C klasi IIB :

1. el SokisTvis refraqteruli VT an VF-is mkurnaloba prokainamidis i/v

infuziiT. Tumca amas aqvs SezRuduli Rirebuleba, vinaidan

medikamentis infuzia saWiroebs SedarebiT xangZliv dros. LOE C klasi III:

1. rutinuli gamoyeneba antiaritmuli preparatebis fibrinolizisur

mkurnalobasTan erTad naCvenebi araa. LOE B.

b. VT: parkuWovani taqikardia klasi I :

1. myari ( > 30 wm-ze an hemodinamikuri kolafsis gamomwvevi) polimorfuli VT –s dros asinqronuli monofazuri eleqtruli Soki 200 J ganmeorebiTi

ganmuxtva 200-300 da warumateblobisas 360 J. LOE B. 2. myari VT-s epizodebi rasac axlavs angina, filtvebis SeSupeba,

hipotenzia(sist. art. wneva < 90 mmhg-ze) saWiroebs sinqronizirebul el.

Soks 100 j monfazurs. warumateblobisas TandaTanobiT zrdian energias.

sasurvelia anesTezia Tuki hemodinamoka gvaZlevs saSualebas. LOE B. 3. myari ( > 30 wm-ze an hemodinamikuri kolafsis gamomwvevi) monomorfuli VT –s dros romelic ar asocirdeba anginasTan, filtvebis SeSupebasTan,

hipotenziasTan saWiroebs:

a. amiodarons 150 mg i/v infuzia 10-wT-Si (alternatiuli dozaa 5mg/kg-ze)

gaimeoreT igive doza yovel 10-15wT-Si saWiroebisas. alternatiuli dozaa

360 mg 6-sT-si Semdeg 540 mg Semdgom 18 –sT-Si. jamurma dozam ar unda

gadaaWarbos 2,2 g 24-sT-Si. LOE B. klasi IIA: 1. mizanSewonilia refraqteruli polimorfuli VT-s mkurnaloba:

a. iSemiisa da adrenaluri stimulaciis Semcirebis mizniT,Terapiul

saSualebebTan erTad mxedvelobasi qona iseTi saSualebebis rogoricaa: IABP, PCI an CABG LOE B b. eleqtrolitebis Semdgomi normebi; K > 4 mEq/l da magneziumi > 2 mg/dl LOE C.

48

g. Tuki pacients aqvs bradikardia < 60-ze wT-Si an QTc gaxangZlvebulia

droebiTi peisingi maRali sixSiriT. LOE C. klasi IIB: 1. monomorfuli VT romelic ar asocirdeba anginasTan, filtvebis

SeSupebasTan, hipotenziasTan saWiroebs prokainamidis boluss da infuzias. LOE B.

klasi III: 1. lidokainis profilaqtikuri mizniT rutinuli gamoyeneba araa

rekomendirebuli izolirebuli parkuWovani eqstrasistolebis kupletebis,

garbenebi acqarebuli idioventrikuluri riTmis an NSVT-is samkurnalod. LOE B. 2. rutinuli gamoyeneba antiaritmuli preparatebis fibrinolizisur

mkurnalobasTan erTad naCvenebi araa. LOE B.

g parkuWovani eqstraistolia:

klasi III:

1. izolirebuli parkuWovani eqstraistoliis, kupletebis, NSVT-s mkurnaloba mizanSewonili araa Tuki ar axlavs hemodinamikuri darRvevebi. LOE B

d. aCqarebuli idiventrikuluri an kvanZovani riTmiv. marjvena

parkuWis infarqti:

III klasi:

1. antiariTmuli Terapia araa naCvenebi LOE B

g. supraventrikuluri ariTmia/AF klasi: I 1. myari AF an winagulebis TrTola Tuki axlavs hemodinamikuri darRvevebi

saWiroebs Semdgom mkurnalobas:

a. sinqronizebuli kardiversia. sawyisi monofazuri Soki 200 J AF-s dros da 50 J winagulTa TrTolisas. zogadi anesTeziiT an sedaciiT Tuki es

SesaZlebelia LOE C b. Tuki ariTmia grZeldeba an meordeba moxsnis Semdgom. gamoiyeneba

Semdegi medikamentebi: i/v amiodaroni LOE C, i/v digoqsini riTmis sixSiris

Sesamcireblad ( gansakuTrebiT maSin Tuki gvaqvs gulis marcxena parkuWis

ukmarisoba LOE C. 2. myari AF an winagulebis TrTola hemodinamikuri darRvevebis gareSe

magram mimdinare iSemiiT:

a. beta-blokatorebi Tuki araa ukuCveneba LOE C b. i/v diltiazemi an verapamili LOE C g. sinqronuli kardioversia. sawyisi monofazuri energia 200 J AF-s dros da 50 J winagulTa TrTolisas. zogadi anesTeziiT an sedaciiT Tuki es

Sesazlebelia LOE C

49

3. myari AF an winagulebis TrTolisas hemodinamikuri darRvevebis an

iSemiis gareSe rekomendirebulia riTmis sixSiris kontroli. mxedvelobaSi

unda gvqondes antikoagulaciuri Terapia. pacientebSi visac STEMI-s dawyebamde ar hqondaT ariTmia SeiZleba vifiqroT sinusuri riTmis

aRdgenaze. LOE C 4. re-entri paroqsizmuli SVT saWiroebs Semdgom mkurnalobas:

a. karotiduli sinusis masaJi LOE C b. i/v adenozini(6 mg swrafi bolusit 1-2 wm-Si. warumateblobisas 12 mg,

romlis gameorebac Sesazlebelia) LOE C g. i/v beta-blokerebi LOE C d. i/v diltiazemi ( 20 mg an 0,25 mg/kg-ze 2-wT-Si da Semdgomi infuzia 10 mg-

sT-Si). LOE C e. i/v digoqsini( unda vicodeT rom Sedegi iqneba daaxloebiT 1-sT-Si. 0,6

dan 1 mg-mde 70 kg-ian pacientSi.(8-15 mkg/kg-ze.) LOE C klasi III: 1. winagulovani eqstrasistolebis mkurnaloba saWiro araa. LOE C

IX. bradiariTmiebi:

a. sinusis kvanZis disfunqcia STEMI-s Semdgom:

Iklasi:

1. simptomuri sinusuri bradikardia, sinusuri pauza > 3 wm-ze, an sinusuri

bradikardia < 40-ze asocirebuli hipotenziasTan, an sistemri

hemodinamikuri darRvevebTan namkurnalevi unda iqnen: i/v atropiniT 0,6-1 mg.

bolusi ( maqs. doza: 2 mg ) Tu bradikardia persistirebs gamoiyeneba

transkutaneuri an transvenozuri ( umjobesia winagulovani) droebiTi

peisingi. LOE: C

b. gamtareblobis moSla: warmodgenilia cxrilis saxiT

50

I xarisxis AV bloki mobic I meore xarisxis AV bloki mobitc II meore xarisxis AV bloki

wina MI arawina MI

A wina MI arawina MI

wina MI arawina MI

moqmede

ba klasi moq.med klasi moq.med klasi moq.me klasi moqmed klasi moq.med klasi moqmed klasi

dakvirv

eba

I dakvirv I dakvir. I dakvir. II b dakvir. IIA dakvir. III dakvir. III

A

III

A

III

A

III

A *

III

A

III

A

III

A

III

TC

III

TC

II b

TC

II b

TC

I

TC

I

TC

I

TC

I

normaluri

TV

III

TV

III

TV

III

TV

III

TV

III

TV

II a

TV

II a

dakvirv

eba

I

dakvir.

IIb

dakvir.

IIb

dakvir.

B

IIb

dakvir.

IIb

dakvir.

III

dakvir.

III

A

III

A

III

A

III

A *

III

A *

III

A

III

A

III

TC

IIb

TC

I

TC

IIa

TC

I

TC

I

TC

I

TC

I

axali an Zveli

fascikul. bloki LAFB an PFB)

TV

III

TV

III

TV

III

TV

III

TV

III

TV

IIa

TV

IIb

dakvirv

eba

I

dak

III

dak

III

dak

III

dak

III

dak

III

dak

III

A

III

A

III

A

III

A *

III

A

III

A

III

A

III

TC

II b TC

I

TC

I

TC

I

TC

I

TC

I

TC

I

hisis konis Zveli

bloki

TV

III

TV

II b TV

II b TV

II b TV

II b TV

II a TV

II a

dakvirv

eba

III

dak

III

dak

III

dak

III

dak

III

dak

III

dak

III

A

III

A

III

A

III

A*

III

A

III

A

III

A

III

hisis konis axali

bloki

51

52

TC

I TC I TC I TC I TC I TC IIb TC IIb

T

IIb

TV

IIa

TV

Ia

TV

IIa

TV

IIa

TV

I

TV

I

dak

III

dak

III

dak

III

dak

III

dak

III

dak

III

dak

III

A

III

A

III

A

III

A*

III

A

III

A

III

A

III

TC

I

TC

I

TC

I

TC

I

TC

I

TC

II B TC

II b

fascikularuli

bloki+ RBBB

TV

IIb

TV

II a

TV

II a

TV

II a

TV

II a

TV

I

TV

I

dakvirv

eba

III

dak

III

dak

III

dak

III

dak

III

dak

III

dak

III

A

III

A

III

A

III

A*

III

A

III

A

III

A

III

TC

II b

TC

II b

TC

II b

TC

II b

TC

II b

TC

II b

TC

II b

gardamavali

marjvena da

marcxena hisis

konis bloki

TV

I

TV

I

TV

I

TV

I

TV

I

TV

I

TV

I

es cxrili efuZneba winagulovan_parkuWovani ( vertikaluri grafa ) da

parkuWSida ( horizontaluri grafa ) gamtari sistemais darRvevas,

romelic SeiZleba Camoyalibdes wina kedlis mwvave infarqtis da ara ST segmentis elevaciiT mimdinare infarqtis dros. agreTve mocemulia

TiToeuli situaciis mkurnalobis Cveneba.

A = atropini, AV = atrioventrikularuli, TC = kanzeda/garegani peisingi, TV = droebiT transvenuri peisingi, LAFB = hisis konis marcxena wina fexis bloki, LPFB = hisis konis marcxena ukana fexis bloki.

moqmedeba

CamoTvlili bradiariTmiebis da gamtareblobis darRveveis samkurnalod

miCneulia 4 Terapiuli punqti

1. dakvirveba: mudmivi e.k.g-s monitoringi, aranairi Semdegi qmedeba.

2. A da A*: atropinis Seyvana intravenurad 0.6_1.0 mg-idan 5 wuTis

intervaliT maqs.. 0.04mg/kg-e. zogadad vinaidan atropins SeuZlia

gamoiwvalos mkveTri taqikardia rac araa sasurveli maqsimalurad

cdiloben Tavidan airidon am preparatis xmareba Tuki ar gveqneba

simptomuri sinusuri an Mmobitc I AV bloki.

3. TC: kanze safenebis moTavseba, mzad yofna garegani peisingisaTvis.

4. TV: droebiT venuri peisingi.

rogor unda ixelmZRvanelo cxriliT

magaliTi: 54 wlis mamakaci wina kedlis ST segmentis elevaciiT mimdinare

infarqtiT da viwro QRS kompleqsebiT. pirvel dRes ganuviTarda hisis

konis marjvena fexis sruli bloki da PR intervali am dros iyo 0.28 wm.

1. hisis konis marjvena fexis sruli bloki gamoxatavs gamtareblobis

darRvevas, cxrilSi yoradReba miaqcie “hisis konis axal bloks”.

2. ipove vertikalur grafaSi “pirveli xarisxia AV bloki”.

3. ipove “moqmedeba” da “klasi”.

4. gaiTvaliswine, rom “dakvirveba” da “atropini” aris III klasi, anu ar

aris naCvenebi; kanzeda peisingi (TC) aris I klasi; droebiTi venuri

peisingi ki (TV) IIb klasi.

d. mudmivi peisingis Cveneba bradiaritmiis da/an gamtareblobis

darRvevisas romelic asocirdeba STEMI-Tan:

I klasi:

1. permanentuli ventrikuluri peisingi naCvenebia persistentuli II

xarisxis AV blokisas romelic erwymis bilateralur hisis konis fexis

bloks an III xarisxis AV bloki his-purkinies sistemaSi an mis qvemoT rac

viTardeba STEMI-s Semdgom. LOE: B 2. permanentuli ventrikuluri peisingi naCvenebia gardamavali Sorswasuli

II an III xarisxis infranodaluri blokis da asocirebuli hisis konis

fexis blokisas, Tuki blokis adgili gaurkvevelia mizanSewonilia

eleqtrofiziologiuri kvleva. LOE: B

53

3. permanentuli ventrikuluri peisingi naCvenebia persistentuli da

simptomuri II an III xarisxis AV blokisas. LOE: C II B klasi: 1. permanentuli ventrikuluri peisingi SeiZleba gaviTvaliswinoT

persistentuli II an III xarisxis AV blokisas AV kvanZis doneze. LOE: B

III klasi:

1. permanentuli ventrikuluri peisingi araa rekomendirebuli gardamavali AV blokisas, Tuki araa intraventrikuluri gamtareblobis defeqtebi. LOE: C 2. permanentuli ventrikuluri peisingi araa rekomendirebuli gardamavali AV blokisas izolirebuli marcxena wina fascikularuli blokisas LOE: B 3. permanentuli ventrikuluri peisingi araa rekomendirebuli SeZenili

marcxena wina fascikularuli blokisas AV blokis ar arsebobisas LOE: B 4. permanentuli ventrikuluri peisingi araa rekomendirebuli

persistentuli I xarisxis AV blokisas romelic Serwymulia Zvel(ara

axal) hisis konis fexis blokTan. LOE: B

e. mudmivi peisingis modelis SerCeva Cveneba bradiaritmiis da/an

gamtareblobis darRvevisas romelic asocirdeba STEMI-Tan:

I klasi

1. yvela pacienti visac aqvs mudmivi peismekeris Cadgmis Cveneba unda

Sefasdes ICD-s Cvenebaze LOE: C II A klasi

1. orkameriani peisingi pacientTaTvis romelTac aqvT sinusuri riTmi

da erTkameriani Tuki pacients aqvs winagulTa TrTola an cimcimi LOE: C

2. yvela pacienti visac aqvs mudmivi peismekeris Cadgmis Cveneba unda

Sefasdes biventrikuluri peisingis (gulis resinqronizaciuli

Terapia) Cvenebaze LOE: C

v. ganmeorebiTi tkivili STEMI-s Semdgom

gamowveulia rogorc wesi perikarditiT an iSemiiT. pirvel Tormet saaTSi

ufro mosalodnelia tkivili ukavSirdebodes iSemias. perikarditi nakleb

mosalodnelia iZleodes mniCvnelovan diskomforts gul-mkerdSi pirvel

24-sT-Si.

I perikerditi:

I klasi:

1. aspirini 650 mg (nawlavuri garsiT dafaruli) 4-6 sT-Si LOE: B 2. antikoagulacia ixsneba Tukis gamoCndeba perikardiuli gamonadeni an

zomaSi moimatebs. LOE: C

54

II A klasi:

1. Tuki aspiriniT mkurnalobaze mdgomareoba ar umjobesdeba iniSneba 1

a) kolxicini 0,6 mg oralurad yovel 12-sT-Si LOE: B an/da( 1 an orive) b) acetaminofeni 500 mg yovel 6-sT-Si oralurad LOE: B

II B klasi: 1. kortikosteroidebi rogorc ukanaskneli arCevani Tuki perikarditi

refraqterulia, vinaidan isini zrdian rubturis risks. LOE: C 2. arasteroiduli anTebis sawinaaRmdego preparatebi xanmokle droiT

vinaidan isini aseve zrdian rubturis, infarqtis eqspansiis da

Trombocitebis disfunqciis risks. LOE: B III klasi:

1. ibubrufeni ar iniSneba vinaidan igi amcirebs aspirinis

antiagregantul Tvisebas, iwvevs infarqtis eqspansias da zrdis

rubturis risks. LOE: B

II ganmeorebiTi infarqti/iSemia

I klasi:

1. Tuki pacientebs Catarebuli aqvT reperfuziuli Terapia STEMI-s gamo xdeba mkurnalobis optimizacia nitratebiT da beta-blokerebiT.

SesaZlebelia daviwyoT i/v antikoagulacia. Tuki ukve ar utardeboda. LOE: B 2. zemoT aRniSnulis garda, Tuki iSemias Tan axlavs hemodinamikuri

arastabiluroba, cudi marcxena parkuWis funqcia, da riskis qveSaa didi

zomis miokardiumi pacientebs urgentulad utardebaT kaTeterizacia da

saWiroebisas revaskularizacia mxedvelobaSi unda viqonioT

kontrpulsacia. LOE C 3. Tuki pacienti ganmeorebiTi infarqti/iSemiiiT aris revaskularizaciis

kandidati utardeba koronarografia da PCI an CABG koronaruli anatomiis

da mixedviT. L LOE B O

II A klasi:

1. Tuki aseT pacientebSi koronarografia an/da PCI ver xerxdeba da gvaqvs ganmeorebiTi ST elevaciiT mimdinare infarqti fibrinplizisi SeiZleba

gavimeoroT ( idelur SemTxvevaSi simptomebis dawyebidan 1-sT-Si). LOE C

III klasi: E

1.streptokinaza ar iniSneba ganmeorebiT Tuki maT manmde 5 dRiT adre

Cautardat Trombolizisi am preparatiT.LOE C

z. sxva garTulebebi:

T/t sisxlis mimoqcevis moSla (iSemiuri)

I klasi :

1. nevropaTologis konsultacia pacientSi STEMI-T, Tuki pacients

aReniSneba T/t sisxlis mimoqcevis moSla LOE C

55

a. riskis Sefaseba stacionaridan gaweris Semdgom:

T. STEMI-s Semdgomi aorto koronaruli Suntirebis Cvenebebi

mocemuli iqneba zogadad CABG-is gaidlainSi.

X meoradi prevencia da xangZlivi marTva:

56

2. pacientebis zemoaRniSnul jgufSi saWiroa Catardes eqokardiografia,

nevrologiuri (CT, MRI...) da vaskularuli gamosaxulebiTi kvleva insultis

mizezis gamovlenis mizniT. LOE C 3. pacientebis aRniSnul jgufSi persistentuli AF-iT iniSneba Terapia

varfariniT (INR 2-3) mTeli sicocxlis manZilze LOE A 4. pacientebSi STEMI-T iSemiuri insultiT Tu mis gareSe, visac aqvs

emboliis kardialuri wyaro (AF, Trombi intrakardialurad, didi zomis

akinetiuri segmenti) unda dainiSnos Terapia varfariniT (INR 2-3) aspirinTan

erTad. (sul cota 3 Tve intramuraluri Trombis da akinetiuri ubnis

arsebobisas da mTeli cxovreba AF-s dros). varfariniT adeqvatur

antikoagulaciamde pacientma unda miiRos UFH an LMWH. LOE B II Aklasi:

1. mizanSewonilia Sefasdes pacientebSi STEMI-T iSemiuri insultis

riski. LOE A 2. mizanSewonilia pacientebSi STEMI-T da ara fataluri iSemiuri

insultiT Catardes Sesabamisi movla garTulebebis sixSiris

Sesamcireblad da funqciuri gaumjobesebis mizniT. LOE C

II B klasi:

1. karotidebis angioplastika/stentireba, 4-6 kviraSi iSemiuri

insultidan, Tuki pacientebs STEMI-T aqvT mwvave epizodi, rasac

axlavs Sida karotidis stenozi > 50%-ze, da aqvT maRali

qirurgiuli sikvdilianobis/avadobis riski STEMI-s Semdgom adreul

periodSi LOE C

Rrma venebis Trombozi DVT da pulmonaruli embolia PE:

rogorc prevencia aseve mkurnaloba ganxiluli iqneba DVT da PE-s

Sesabamis gaidlainebSi. aq ki avRniSnavT rom mkurnal eqims mxedvelobaSi

unda hqondes es garTulebebi xangZlivi woliTi/jdomiTi rejimisas da

iseT pacientebSi, romelTac amis gareSec aqvT aRniSnuli garTulebebis

maRali riski.

57

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

invaziuri strategia fibrinolizisi arareperfuziuli strategia

EF > 40 % EF < 40 %

maRali riskis

gareSe †

maRali riskiT

†

kaTeterizaci

a Cvenebis

mixedviT

funqciuri

Sefaseba

EF < 40 % EF > 40 %

† maRal riskSi igulisxmeba STEMI-s riski (ix. gamosaxuleba 1 ) Semosvlisas. amasTan erTad mas emateba iseTi maRali riskis prediqtorebi rogoricaa: warumatebeli

reperfuziis niSnebi( tkivilis ganmeoreba, ek.k.g-niSnebis persistireba. ) meqanikuri garTulebebi(gulis ukmarobis uecari ganviTareba, axali Suili, Soki.)

medikament. mkurnaloba

maRali riskis

gareSe †

maRali riski †

e.k.g

interpretire

badia

e.k.g. interpretirebadi araa

fiz..datvir.

testi ar

SeuZlia

fiz. datvirT

testi ar

SeuZlia

nuklearuli

datvirT.vis

testi

datvirTvis

stress eqo

klinik. mniSv. iSemia araa

SeuZlia

fizik. datir.

testi

submaqs. dat.

testi

gaweramde

maqsimaluri

datvirTvis testi

gaweris win an

Semdgom

klinikurad mniSv. iSemia

dobutamin eqo.

kaTeterizacia da revaskularizacia Cvenebisda mixedviT

Semd. kaTeteriz.

gareSe

Semdg.

kaTeterizaciiT

farmakologiuri stres testi

adenozini an

dipiridamoli

revaskul

arizacia

Cvenebis

mixedviT

b. cxrili 10 meoradi prevencia STEMI-s dros:

mizani

rekomendaciebi

moweva

mizani: sruli Sewyveta

pacienti da misi ojaxi mkacrad

unda gafrTxildes mowevis sruli

Sewyvetis Sesaxeb ( Tavidan unda

iqnes aridebuli misi TandraswebiT

ojaxis wevrebis mier moweva)

saWiroebisas SesaZloa

farmakologiuri Terapiis daniSvnac

( nikotinis Canacvleba da “

Bupropion”-i)

sisxlis wnevis kontroli

mizani: < 140/90 mmhg an < 130/80

mmhg qronikuli Tirkmlis

naklovanebis an diabetis dros

Tuki wneva ≥ 120/80 mmhg • daiwyeT cxovrebis stilis

modifikacia (wonis kontroli,

fizikuri aqtivoba, alkoholis

Warbi gamoyenebis Tavidan arideba,

marilis xmarebis zomieri Semcireba,

dietaSi xilis, bostneulis, dabal-

cximiani produqtebis didi

xvedriTi wili)

Tuki wneva ≥ 140/90 mmhg an > 130/80 mmhg pacientebSi Tirkmlis

qronikuli ukmarisobiT an diabetiT:

• daamateT wnevis Sesamcirebeli

medikamentebi

lipiduri menejmenti ( Tuki TG < 200 mg/dl)

mizani: LDL-C mniSvnelovnad <

100 mg/dl-ze)

daiwyeT dieta yvela pacientSi. (

saerTo kaloraJSi gajerebuli

cximi < 7%-ze da qolesteroli <

2000 mg/dReSi.) urCieT wonis

kontroli da fizikuri aqtivoba.

urCieT omega-3 cximovani mJavis

xmarebis gazrda.

gansazRvreT lipiduri speqtri da

daiwyeT medikamenturi mkurnaloba

Semdegi sqemis mixedviT:

LDL -C < 100 mg/dl ( sabaziso an

mkurnalobis fonze)

• gamoiyeneT/gaagrZeleT statinebi

mizani misi Semcireba 70 mg/dl-is

58

qvemoT statinebi

LDL ≥ 100 mg/dl ( sabaziso an

mkurnalobis fonze)

• moaxdineT LDL-is Semamcirebeli

medikamentozuri mkurnalobis

intensifikacia. upiratesoba eniWeba

statinebs. )

lipiduri menejmenti ( TG ≥ 200 mg/dl

mizani: ara HDL-C mniSvnelovnad

naklebi 130 mg/dl-ze *

Tuki TG ≥ 150 mg/dl an HDL < 40 mg/dl :

• xazi gausviT wonis kontrolis da

mowevis Sewyvetis mniSvnelobas

TG aris 200-499 mg/dl

• LDL-C Semamcirebeli Terapiis

ESmdgom, † mxedvelobaSi gqondes

fibrati an niacini ††

Tuki TG aris ≥ 500 mg/dl

• mxedvelobaSi iqonie fibratis an

niacinis dawyeba LDL is Semamcirebeli Terapiis win. †

• mxedvelobaSi iqonie omega-3 mJavis

dawyeba

fizikuri aqtivoba

minimaluri mizani: 30 wT 3-4 dRe

kviraSi;

optimaluria yovel dRe

gansazRvreT riski, upiratesad

datvirTvis testiT. pacientebs

urCieT 30-60 wT-iani aqtivoba.

umjobesia yovel dRe magram minimum

3-4 jer kviraSi.(fexiT siaruli,

sirbili, velosipedi, aerobika.)

aseve urCieT dRis ganmavlobaSi

ufro aqtiuri moZraoba: siaruli,

saxlis samuSaoebi. gulis

reabilitaciuri programebi

pacientebisaTvis mravlobiTi risk

faqtorebiT unda mimdinareobdes

eqimis meTvalyureobiT.

wonis kontroli

mizani: sxeulis masis indeqsi BMI = 18,5-24,9 kg/m2 welis garSemoweriloba:

qalebSi: 88,9 sm

kacebSi 101,6 sm

gamoTvaleT BMI ( sasurvelia 18,5-

24,9 kg/m2 da gazomeT welis

garSemoweriloba( 101-sm kacebSi da

89-sm qalebSi). periodulad

gadaamowmeT. Tuki monacemebi

aradaamkmayofilebelia pacients

urCieT metad gaaqtiveba da

cxovrebis wesis modificireba.

59

diabetis kontroli:

mizani HbA1c < 7%-ze.

hipoglikemiuri dieta da Terapia

raTa mivaRwioT normalurTan axlo

Saqris cifrebs uzmoze da HbA1c < 7%-ze.

antiTrombocitebi/antikoagulantebi

aspirini 75-162 mg Tuki araa

ukuCveneba. klopidrogeli 75 mg an

varfarini Tuki aspirini

ukunaCvenebia. (es ukanaskneli INR-is kontroliT )

renin-angiotenzin-aldosteron

sistemis blokerebi

ACE inhibitorebi yvela pacientSi.

daiwyeT adre maRali riskis

pacientebSi ( wina kedlis MI, adre gadatanili MI, kilipi II-ze meti

gulis ukmarisoba. (S3 galopi,

auskultaciiT Segubeba mcire wreSi,

gulis ukmarisobis radiografiuli

niSnebi. EF ≤ 40%-ze.

angiotenzinis receptorebis

blokerebi pacientebSi ACE-inhibitorebis autanlobisas, da

romelTac aqvT maTi daniSvnis

Cveneba.

aldosteronis blokatorebi

pacientebSi mniSvnelovani renaluri

ukmarisobis ††† an hiperkaliemiis

gareSe †††† romlebic iReben ACE inhibitorebs, aqvT EF < an toli 40

%-ze. da aqvT diabeti an gulis

ukmarisoba.

HF

beta blokerebi

daiwyeT yvela pacientSi romelsac

ara aqvs ukuCveneba da SearCieT

optimaluri doza. gaagrZeleT

monitoringi dozis optimizaciis

mizniT (monitorings gansakuTrebuli

mniSvneloba aqvs pacientebSi gulis

ukmarisobiT)

diabetis marTva hipoglikemiuri Terapia. efeqturoba

mowmdeba HbA1C-iT romelic unda

iyos 7%-ze naklebi.

varfarini misi Cvenebebi aris qvemoT mocemul

cxrilSi. damatebiT SeiZleba

aRiniSnos rom varfarini SeiZleba

mieces pacients STEMI-s Semdgom Tuki

60

61

aqvs LV disfunqcia da didi zomis regionaluri kumSvadobis moSla.

LOE IIA

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

62

pacienti gaweris win

stentireba

ar Cautarda

stentireba

Cautarda

aspirinze araa

alergiuli

aspirinze

alergia aqvs

araa

antikoagulaci

is Cveneba

aris

antikoagulaci

is Cveneba ††††

araa

antikoagulaci

is Cveneba

aris

antikoagulaci


aspirinze araa

alergiuli

aspirinze

alergia aqvs

araa

antikoagula

ciis Cveneba

aris

antikoagulaciis

Cveneba ††††

araa

antikoagula

ciis Cveneba

aris

antikoagulaci


ASA 75-162 mg I klasi LOE A.

ASA 75-162 mg

+ varfarini

(INR 2,0-3,0) ††† I klasi LOE B.

klopidrogeli

(plaviqsi)* 75

mg I klasi LOE C

ASA 75-162 mg + klopidroge

li (plaviqsi)

75 mg I klasi

LOE B. †

ASA 75-162 mg + klopidrogeli

(plaviqsi) 75

mg‡†† +

varfarini (INR 2,0-3,0) IIB klasi LOE C †††

klopidroge

li (plaviqsi)

75 mg +

varfarini (

INR 2,0-3,0) I klasi LOE C †††

varfarini

(INR 2,0-3,0) I klasi LOE B.

klopidroge

li (plaviqsi)

75 mg I klasi

LOE B.

alternativaa

ASA 75-162 mg

+ varfarini

(INR 2,0-3,0) II A klasi LOE B.

an varfarini

( INR-2,5-3,5) I klasi LOE B

alternativaa

varfarini

(INR 2,5-3,5) I klasi LOE B

an varfarini

( INR-2,5-3,5) II A klasi LOE B.

* klopidrogels aqvs upiratesoba varfarinTan SedarebiT naklebi sisxldeniT garTulebebis

gamo. amasTan erTad pacientebis umravlesoba arCevs mis miRebas.

† 12-Tvis ganmavlobaSi

†† klopidrogeli ixsneba 1-TveSi ( Tu gamoyenebulia bare metal stenti, grZeldeba ramodenime

Tve Tu gamoyenebulia drug-diluting stentebi( 3 Tve sirolimus-is Semdeg 6-Tve paclitaxel-is Semdeg) ixsneba sisxldenebis potenciuri safrTxeebis Sesamcireblad.

grZeldeba aspirini varfarinTan erTad Cvenebis mixedviT (winagulTa fibrilacia, Trombuli masa

gulis RruebSi, cerebraluri emboli, didi zomis regionaluri kumSvadobis moSla)

††† umjobesia INR-i iyos qveda zRvrisken. 75 wlis qvemoT am medikamentebis kombinacias aqvs

naklebi sisxldenis garTulebebi

†††† STEMI-s Semdgom antikoagulaciis Cvenebaa wina kedlis didi zomis MI an LV-s Trombi

eqokardiografiaze. am dros antikoagulacia grZeldeba 6 kvira ( ra Tqma unda antikoagulacias

aqvs sxva Cvenebebi romlebic ar ukavSirdeba MI-s. mag winagulTa fibrilacia.

* ara HDL qolesteroli = saerTo q esterols minus HDL-i. † mizania ara HDL-C < 130 mg/dl-ze

†† niacini unda gamoviyeno lo i nitoringiT

††† kreatinini ≤ 5 mg/dl i da lSi

†††† kaliumi ≤ 5 Eq/L

d. rekomendaciebi eri mdgomi vizitebis da zogadad

daav ebis marTvi sax

klas :

1. gaweris Semdgomi viziti unda asaxavdes kard s i tomebis

dinamikas da funqcion ur )

2. unda moxdes mimdina mku adafase r

titraciis gziT ACE i ito okerebi a i imaluri

dozebi.

3. riskis gansazRvra da gegmiuri reabilitacia unda gadaixedos da

gagrZeldes. es unda moicavdes ma uWis funqciis Sefasebas,

SesaZloa ho eris monitor pacientebSi m I EF iyo 31-40% an ufro dabali. v a tebSi mxedvelobaSi unda

gvqondes ICD-is implantacia. O4. mkurnalma unda au pa misi oja

prevenciis principebi. ( )

5. pacientis fsiqologiuri statusi unda Sefasdes da yuradReba unda

mieqces iseTi niSnebis arsebobas rac miuTiTebs aze,

Zilis moSlilobaze d ocial i qcevis Secv

6. Semdgomi vizitebisas mkurnalis mier unda ganisazRvros fizikuri

aqtivobis done, samsaxurSi dabrunebis vada, seq

mgzavrobis da manqanis tareb saZlebloba

mgzavrobis sakiTxebi. fizikuri datvirTvis done gamoixateba metaboluri

eqvivalentiT T-Si. (damatebebSi gamosaxuleba 2) ( LOE C )

7. mkurnalma cients a misi xis wevr da SesTavazos CPR-is ZiriTadi principebis a d i survi mTxvevaSi SesTavazos

treiningis kursebze reb E C ) 8. mkurnlma pacientTan da maTi ojaxis wevrebTan erTad unda ganixilos

Semdegi sakiTxebi:

a. pacientis gulis Setevis riski ( LOE C ) b. rogor gamovicnoT STEMI-s simptomebi. ( LOE C ) g. sas fos gamoZaxe auc oba Tu mptomebi ar umjobesdeba an

uaresdeba 5 wT-Si. Tundac rom ar iyvnen darwmunebuli mdgomareobis

simZimeSi. ( LOE C ) d. amasTan unda aexsnaT potenciuri kardiologiuri incidentis gamocnobis

da Semdgomi moqmedebis gegma. saswrafoSi darekvis CaTvliT. ( LOE C ) e. gulis reabilitaciis programebi rekomendirebulia pacientTaTvis

gansakuTrebiT ki maTTvis vinc saWiroebs mravlobiTi risk faqtorebis

modificirebas an/da cientebi, romelTac aqvT garTulebebis saSualo

an maRali riski da ebS rjiSi ebu

ol

d eq mis mo

2 mg/dl qa

T mxo

kacS

iova

ba d

s d

ro

xis

de

la

sua

sev

2,

m

gaw

s Se

s Se

eb: ad

i I

kul

a und

stat

elT

wevre

resia

. (LO

uri

TviT

aru

a S

ine

a po

bs

ze

E C

aqt

mf

l

ei

b

st

meo

, aR

)

ivo

rin

simp

Ces

s opt

-STEM

radi

gzneb

ba,

aviT

al

re

nhib

kl

rn

r

ass. (LOE Calobis g

ebis, B-bl

rcxena park

s im

idan am pacien

E C) ts d

lt ing

in

(Lcienxsnas

LOE Ca

p

ze

l

e

a s ur

is Se , a

ME

pa d

axsn

dasw

oja

a maT

a. ( LO

e

l

bs un

is Se

wra bis ilebl ki si

is pa

roml iac va rekomendir lia.

63

e. cxrili 11 medikamentebi romlebic ga neba STEMI-s moye

mkurnalobisas

pirveli 24-sT

hospitalizaciis

manZilze

gawerisas da

xangZlivi

mkurnalobisas

medikamenti

75-162 mg dRiuri

75-162 mg

dRiuri

dasaReWad (

umjobesia ara

aspirini

enteruli garsiT

dafaruli) 162-325

ganusazRv-

reli vadiT

mg

fibrinolizisuri

Terapia

ixileT ukuCvenebebi

da Cvenebebi me-6

cxrilidan

streptokinaza 1,5

MU IV 30-60 wT-is

manZilze

alteplaza IV

bolusi 15 mg.

infuzia 75 mg/kg-ze

30 wT-Si (maqsimumi

50 mg)

Semdeg 50 mg/kg (

maqs. 35 mg) 60 wT-Si.

jamSi maqsimaluri

dozaa 100 mg

reteplaze 10 U IV bolusi 2wT-Si

Semdeg gaimeoreT 30

wT-Si 10 U IV

bolusi 2 wT-S

i

teneqteplaza IV

bolusi 10-15 wm-Si

30 mg Tuki wona <

60 mg. 35 mg Tuki

wona aris 60-69 kg.

40 mg 70-79kg-ze, 45

mg 80-89 kg-ze da 50

mg > 90 kg-ze.

64

60 U/kg ( maqs. 4000 U arafraqcionirebadi

heparini UFH ) IV bolusi. Semdeg

infuzia 12 U/kg/sT-

Si. max. 1000 U/sT-Si. aPTT 1,5-2,0 normasTan

SedarebiT ( 50-70-s

Soris)

aPTT 1,5-2,0 ix. 8 sqema

antiTrombozu

li

mkurnalobis

normasTan

SedarebiT ( 50-

70-s Soris) 48

sT-is

ganmavlobaSi

rekomendaciebi

sTvis

beta-blokeri

per-os

per-os

per-os ganusazRvreli

vadiT

ACE inhibitori

ACE inhibitori yvela pacientSi

wina kedlis

infarqtiT,

pulmonaruli

SegubebiT, EF < 40

%-ze Tuki araa

hipotenzia da sxva

ukuCvenebebi,

gatitreT wnevis da

kreatininis

kontroliT

per-os

per-os ganusazRvreli

vadiT

angiotenzin II-is

blokatori ARB

ARB unda dainiSnos pacientebSi visac

aqvs ACE inhibitorebis autanloba da ive ig

Cveneba rac am

ukanasknelT

iseve rogorc

pirvel 24-sT-Si

iseve rogorc

pirvel 24-sT-

Si

aldosteronis

blokada

yvela pacientSi

Tirkmlis mniSv.

ukmarisobis

gareSe (

kreatinini < 2,5

mg/dl kacSi ada

2 mg/dl

qalebSi) an

hiperkaliemiis

gareSe K <

5mEq/l

romlebic

iReben ACE-s, EF < an toli 40%

da romelTac

igive rac

hospitalizaci

isas.

65

aqvT gulis

ukmarisoba an

diabeti.

nitroglicerini

sublingvaluri

NTG 0,4 mg yovel 5

wT-Si Tuki rCeba

tkivili an

diskomforti

gulmkerdSi.

IV NTG gulis

ukmarisobis,

hipertenziis,

persistentuli

iSemiisas rac

pasuxobs nitratebs

oralurad Tuki

iSemia

grZeldeba an

aris

ukontrolo

hipertenzia

statinebi

daiwyeT

lipiduri

profiles

ganusazRvreli

vadiT Tuki

LDL-C aris 100 gareSe

mg an meti.

gazardeT manam

sanam igi ar

gaxdeba

mniSvnelovnad

naklebi zemoT

aRniSnul

doneze ( an

toli 70

mg/dl)

morfin sulfat

i

IV 2-4 mg da zrda

2-8 mg-iT 5-15 wT-

iani intervalebiT

tkivilis

kontrolisaTvis

66

pacientis ganaTleba

pacientisTvis

mniSvnelovania

imis codna Tu

rogor

Secvalos

cxovrebis

stili STEMI-s Semdgom.

informacias

medikamenturi

mkurnalobis

Sesaxeb

meoradi

garTulebebis

prevenciisTvis

aseve didi

mniSvneloba

aqvs. iseve

rogorc

codnas Tu

rogor

gamoicnos

gulis

simptomebi da

Tu rodis

gamoiZaxos

saswrafo

daxmarebis

brigada

dieta

axsna

saturirebuli

cximebiT da

qolesteroliT

dabali dietis

aucileblobis

da mniSvnelobis

Sesaxeb

Sesabamisi

dietis

rekomendireba

moweva

avukrZaloT moweva

avukrZaloT

moweva

avukrZaloT

moweva.

saWiroebisas

farmakologiu

ri Terapia. da

CavrToT

mowevis

Sewyvetis

programaSi

67

varjiSi

axsna-ganmarteba

siarulis

dawyeba

rekomndacia

varjiSis da

aqtivobis

donis Sesaxeb

ogTa

i

teqstidan

2001w

. topoli

cinis

cema 2004w.

GXI gamoyenebuli masala:

teqsti eyrdnoba amerikis gulis asociaciis da amerikis kardiol

kolejis 2004w ( sruli teqsti da jibis gaidlaini) aseve evropis

kardiologTa asociaciis ( 2003w sruli teqsti) Sesabamis gaidlainebs.

damatebaSi gamoyenebulia masalebi: 1. ACC/AHA gaidlainis srul

teqstidan

2004w.

2. ESC gaidlainis sruli

2003w.

3. braunvaldi, zaips libbi, gulis

daavadebebi 6-e gamocema

4. brain p. grifini erik j

kardiovaskularuli medi

saxelmZRvanelo, 2-e gamo

68

miokardiumis infarqti ST elevaciiT STEMI - GFMA.Ge · gulis daavadebebi 6-e gamocema 2001w da brain...

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Transcript of miokardiumis infarqti ST elevaciiT STEMI - GFMA.Ge · gulis daavadebebi 6-e gamocema 2001w da brain...