versia 2014 - geosc.gegeosc.ge/back/axalibmuli1.pdf · 18. antiTrombotiuli mkurnaloba gv. 35 19....

versia2014

ESC / EACTS gaidalini

evropis kardiologTasazogadoebis jibis gaidlainebi

praqtikuli gaidalinebis komitetievropaSi klinikuri praqtikis

xarisxisa da pacientebis movlis gaumjobesebasaTvis

miokardiumisrevaskularizacia

© 2014 The Europian Society of Cardiology No part of these Pocket Guidelines may be ttranslated or reproduced

in any form without written permission from the ESC. The following material was adapted fom the ESC/EACTS Guidelines on Myocardial Revascularisation (European Heart Journal 2014- doi: 10. 1093/eurheartj/ehu278).

To read the full report as published by The Europian Society of Cardiology, visit our Web Site at:www. escardio.org/guidelines

Copyright Europian Society of Cardiology 2014 – All rights Reserved.The content of these Europian Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtainedupon submission of a written request to ESC, Practice Guidelines Department, Les Temlpiers – 2035 route des colles - CS 80179 Biot – 06903 Sophia Antipolis Cedex – France. Email: [email protected].

Disclaimer:The ESC Guideliens represent the views of the ESC and were produced after careful consider-ation of the scientific and medical knowledge and the evidence available at the time their dating. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recommendations or guidelines issued by the relevant public health authorities in particular in relation to good use of health care or therapeutic strategies. Health professionals are encouraged to take the ESC guidelines fully into account when exercising their clinical judment as well as in the determination and the implementation of preventive, diagnostic da or therapeutic smedical strategies.However, the ESC guidelines do not override in any way whatsoever the individual responsibility of health professionals to make appropriate and accurate decisions in cosideration of each patient’s health condition and in consultation with that patient and the patient’s caregiver here appropri-ate and/or necessery. Nor do the ESC guidelines exempt health professionals from taking careful and full cosideration of the relevant official updated recommendations or guidlelines issued by the competent public health authorities in order to manage patient/s case in light of the scientifically accepted data pusuant to their respective ethical and professional obligations. It is also the health professional responsibility to verify the appicable rules and regulations relating to drugs and mmedical devices at the time of prescription.

agf - angiotenzinis gardamqmneli fermenti; akS - aortokoronaruli Suntireba;afh - arafraqcionirebuli heparini;arb - angiotenzinis receptorebis blokatori; gfs - glomeruluri filtraciis siCqare;dmh - dabalmolekuluri heparini; dkb - dro karebidan balonirebamde; dpskb - dro pirveli samedicino kontaqtidan balonirebamde; iTb - intensiuri Terapiis bloki; Tmd - Tirkmlebis mwvave dazianeba; Tqd - Tirkmlebis qronikuli daavadeba; kad -koronaruli arteriebis daavadeba; kin - kontrastiT inducirebuli nefropaTia; kee - karotiduli endartereqtomia;mdkt - multideteqtoruli kompiuteruli tomografia; mks - mwvave koronaruli sindromi; mp - marcxena parkuWi; mpgf - marcxena parkuWis gandevnis fraqcia; oaaT - ormagi antiTrombocituli mkurnalobapad - periferiuli arteriebis daavadeba; sas - saZile arteriebis stentireba;skad - stabiluri koronaruli arteriebis daavadeba; tki - transkutanuri koronaruli intervencia;Sgx - Sesvla-gamosvlis xangrZlivoba; Ad hoc intervencia - intervencia, romelic tardeba uSualod koronarografiis Semdeg;ACEF - asaki, kreatinini, gandevnis fraqcia; ASCERT - amerikis kardiologTa kolejis fondi-gulmkerdis qirurgTa sazogadoebis (ACCF-STS) monacemTa bazis erToblivi monacemebi revaskularizaciis strategiebis SedarebiTi efeqturobis Sesaxeb; CCS -kanadis kardiovaskuluri sazogadoeba; CHA2 DS2-VASc - winagulebis fibrilaciis dros insultis riskis gansazRviris Skala. CT -kompiuteruli tomografia; EACTS - evropis kardio-Torakalur qirurgTa asociacia; EAPCI - evropis perkutanuli kardiovasku-luri intervenciebis asociacia;

ESC -evropis kardiologTa sazogadoeba; FFR -fraqciuli nakadis rezervi; GRACE - letalobis riskis Sefasebis Skala.GP = glikoproteini; HAS-BLED - sisxldenis riskis gansazRvris Skala. HbA

1c - glikolizirebuli hemoglobini;

IABP - intraaortuli balonuri kontpulsa-cia; ICD - implantirebadi kardiodefibrila-tori; IVUS - intravaskuluri ultrabgeriTi gamokvleva; LBBB - hisis konis marcxena totis sruli blokada; LVESV - L marcxena parkuWis end-sistoluri moculoba;LDL-C -dabali simkvrivis lipoproteidebis qolesterini;MACA - mTavari kardiovaskuluri gverdiTi movlenebi; MACCA - mTavari kardiovaskuluri da cerebruli gverdiTi movlenebi; NCDR - gulsisxlZarRvTa monacemebis nacionaluri registri; NSTE ACS - mwvave koronaruli sindromi ST segmentis elevaciis gareSe; NSTEMI - miokardiumis infarqti ST segmentis gareSe; (N)OAC - (ara vitamini K - s antagonistebi) peroraluri antokoagulantebiOCT - optikur-koherentuli tomografia; Off-pump - xelovnuri sisxlis mimoqcevis gareSe; On-pump - xelovnuri sisxlis mimoqceviT;OCT = optikuri koherentuli tomografia; PET - pozitron-emisiuri tomografia;STE ACS - mwvave koronaruli sindromi ST segmentis elevaciiT; STE MI - miokardiumis infarqti ST segmentis elevaciiT;STS - Torakalur qirurgTa sazogadoeba; SYNTAX - tki da aSk riskis Sefasebis Skala; TAVI = aortis sarqvlis transkaTeteruli implantacia;TIA - tranzitoruli iSemiuri Seteva.

Semoklebebi

1

ESC Chairperson: Stephan Windecker, Switzerland Philippe Kolh, BelgiumAuthors/Task Force members EACTS Chairperson

Task Force Members: Fernando Alfonso (Spain), Jean-Philippe Collet (France), Jochen Cremer (Germany), Volkmar Falk (Switzerland),Gerasimos Filippatos (Greece), Christian Hamm (Germany), Stuart J. Head (The Netherlands), Peter Ju ¨ni (Switzerland), A. Pieter Kappetein (The Netherlands),Adnan Kastrati (Germany), Juhani Knuuti (Finland), Ulf Landmesser (Switzerland),Gu¨nther Laufer (Austria), Franz-Josef Neumann (Germany), Dimitrios J. Richter (Greece), Patrick Schauerte (Germany), Miguel Sousa Uva (Portugal), Giulio G. Stefanini (Switzerland), David Paul Taggart (UK), Lucia Torracca (Italy),Marco Valgimigli (Italy), William Wijns (Belgium), and Adam Witkowski (Poland).

Other ESC entities having participated in the development of this document:Associations: Acute Cardiovascular Care Association (ACCA), European Association for Cardiovascular Prevention & Rehabilitation (EACPR), European Association of Cardio-vascular Imaging (EACVI), European Heart Rhythm Association (EHRA), Heart Failure Association of the ESC (HFA).Working groups: Working Group on Cardiac Cellular Electrophysiology, Working Group on Cardiovascular Magnetic Resonance, Working Group on Cardiovascular Pharmacol-ogy and Drug Therapy, Working Group on Cardiovascular Surgery, Working Group on Coronary Pathophysiology and Microcirculation, Working Group on Nuclear Cardiology and Cardiac Computed Tomography, Working Group on Peripheral Circulation, Working Group on Thrombosis, Working Group on Valvular Heart DiseaseCouncils: Council for Cardiology Practice, Council on Cardiovascular Primary Care, Council on Cardiovascular Nursing and Allied Professions.

evropis kardiologTa sazogadoebis jibis gaidlaini

2014 ESC/EACTS Guidelines on myocardial revascularizationThe Task Force on Myocardial Revascularization of the European Society

of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)

Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

2

sarCevi

1. rekomendaciebisa da mtkicebulebaTa doneebis cxrili gv. 3 2. Sesavali gv. 43. riskis qulebi da riskis gansazRvra gv. 64. gadawyvetilebis miRebisa da pacientis informirebis procesebi gv. 95. diagnozis strategiebi: funqciuri testebi da gamosaxulebiTi kvlevebi gv. 126. revaskularizacia stabiluri koronaruli davadebis dros gv. 137. revaskularizacia ST segmentis elevaciis gareSe mimdinare mwvave koronaruli sindromis dros gv. 158. revaskularizacia ST segmentis elevaciiT mimdinare miokardiumis infarqtis dros gv. 169. revaskularizacia gulis ukmarisobiT da kardiogenuli SokiT pacientebSi gv. 2010. Saqriani diabetiT pacientebis revaskularizacia gv. 2211. Tirkmlis qronikuli daavadebiT pacientebis revaskularizacia gv. 23 12. revaskularizacia pacientebSi, romlebic saWiroeben gulis sarqvlebze intervencias gv. 26 13. Tanmxlebi karotiduli/periferiuli arteriebis daavadeba gv. 27 14. ganmeorebiTi revaskularizacia da hibriduli procedurebi gv. 30 15 ariTmiebi gv. 32 16. aorto-koronaruli Suntirebis proceduruli aspeqtebi gv. 33 17. transkutanuri koronaruli intervenciebis proceduruli aspeqtebi gv. 34 18. antiTrombotiuli mkurnaloba gv. 35 19. moculoba-Sedegobrivi damokidebulebis gavlena revaskularizaciis procedurebze gv. 44 20. medikamenturi Terapia, meoradi prevencia da xangrZlivi dakvirvebis strategia gv. 45

3

1. rekomendaciebisa da mtkicebulebaTa donis cxrilebi

1. rekomendaciaTa klasebi

rekomendaciaTa klasebi gansazRvreba

savaraudod gamoyenebuli terminologia

I klasi

mtkicebuleba da/an zogadi SeTanxmeba, rom mocemuli mkurnaloba, an procedura warmatebis momtani, sasargeblo da efeqturia

rekomendebulia/naCvenebia

II klasi

winaaRmdegobrivi mtkicebulebebi da/an gansxvavebuli azri mocemuli mkurnalobis/proceduris sargeblianobis/efeqturobis Sesaxeb

IIa klasi

mtkicebulebaTa/mosazrebaTa umravlesoba mowmobs maTi sargeblianobis/efeqturobis Sesaxeb.

unda iyos ganxiluli

IIb klasisargeblianoba/efeqturoba naklebad dasabuTebulia mtkicebulebiT /mosazrebebiT.

SeiZleba iyos ganxiluli,

III klasi

mtkicebuleba, an zogadi SeTanxmeba, rom mocemuli mkurnaloba, an procedura araa sasargeblo/efeqturi, xolo zog SemTxvevaSi SeiZleba saziano iyos.

ar aris rekomendebuli

cxrili 2. mtkicebulebaTa done

mtkicebulebaTa done A monacemebi miRebulia mravali randomizirebuli kliniuri kvlevis, an meta-analizis Sedegad

mtkicebulebaTa done Bmonacemebi miRebulia erTi randomizirebuli klinikuri kvlevis, an farTo ararandomizirebuli kvlevebis Sedegad

mtkicebulebaTa done CSeTanxmebuli mosazrebebi miRebuli eqspertebis mier da/ an mcire kvlevebis, retrospeqtuli kvlevebis, an registrebis Sedegad.

4

2. Sesavalikoronaruli arteriebis revaskularizacias ufro meti randomize-buli klinikuri kvleva mieZRvna, vidre romelime sxva intervenciul

sqema 1. bolo 50 wlis ganmavlobaSi Catarebuli randomizirebuli kvlevebi miokardiumis revaskularizaciis Sesaxeb

5

proceduras. I sqemaze Sejamebulia miokardis revaskularizaciis sakiTxebze bolo 50 wlis ganmavlobaSi Catarebuli randomizirebuli kvlevebi.

6

3. Skalebi da riskis Sefasebacxrili 3 warmogvidgens SYNTAX Skalis misedviT qulebis Tanmimdevru-li gamoyenebis gzamkvlevs. es Skala SemuSavda koronaruli arteriebis dazianebebis anatomiuri kompleqsurobis xarisxis Sesafaseblad paci-entebTan, romlebsac aReniSnebaT marcxena mTavari Reros an sami sisx-lZarRvis dazianebebi da dadginda, rom is warmoadgens kardiuli da cerebrovaskuluri xasiaTis mniSvnelovani arasasurveli movlenebis (MACCE) damoukidebel prediqtors pki Catarebis SemTxvevaSi. am Saklis gamoyeneba xels uwyobs revaskularizaciis optimaluri strategiis SerCevas, im pacientebis gamvleniT, romlebsac aqvT arasasurveli gar-Tulebebis ganviTarebis maRali riski tki Catarebis SemTxvevaSi.

cxrili 3. SYNTAX qulebis gamomTvleli gzamkvlevi

etapi Sefasebuli parametri

aRwera

etapi 1 dominanturoba calkeuli koronaruli segmentebis xvedriTi wilis mniSvneloba gansxvavdeba koronaruli arteriis dominantobis (marjvena, an marcxena) mixedviT. SYNTAX meTodiT Tanabari dominantoba calke variantad ar ganixileba

etapi 2 koronaruli segmenti

dazianebuli koronaruli segmenti uSualod axdens gavlenas qulebis raodenobaze, radganac yovel segments garkveuli xvedriTi wili gaaCnia misi mdebareobis mixedviT, dawyebuli 0.5 quliT (mag. posterolateraluri toti) 6 qulamde (mag. mTavari Rero marcxena dominanturobis SemTxvevaSi)

marjvena dominanti xvedriTi

wili

marcxena dominanti

7

cxrili 3. SYNTAX qulebis gamomTvleli gzamkvlevi

etapi Sefasebuli parametri

aRwera

etapi 3 stenozis diametri

TiToeuli dazianebuli koronaruli segmentis qulebi mravldeba 2-ze Tu stenozis xarisxi 50-99%-ia, da 5-ze totaluri okluziis SemTxvevaSi. okluziis arsebobisas emateba damatebiTi qulebi: - okluziis xangrZlivoba > 3 Tveze, an ucnobia +1- yru mtakvi +1- „brijing” kolateralebi +1- distalurad Cans pirveli segmenti +1 uCinar segmentis dros - okluziaSi moyolili gverdiTi toti + 1 Tu diametri < 1.5 mm + 1 Tu orive < 1.5 da ≥1.5 mm diametrisaa + 0 Tu ≥1.5 mm diametrisaa (mag. bifurkaciis dazianeba)

etapi 4 trifurka-ciuli tipis dazianeba

trifurkaciuli dazianebis SemTxvevaSi qulebi emateba dazianebuli segmentebis gaTvaliswinebiT:- 1 segmenti +3- 2 segmenti +4- 3 segmenti +5- 4 segmenti +6

etapi 5 bifurkaciuli tipis dazianeba

bifurkaciuli dazianebis arsebobisas qulebi emateba medina klasifikaciis Sesabamisad- medina 1,0,0 an 0,1,0 an 1,1,0: - 1 qula- medina 1,1,1 an 0,0,1 an 1,0,1: - 2 qula Tu bifurkaciis kuTxe < 700 - 1 qula

etapi 6 aorto-ostialuri dazianeba

aorto-ostialuri dazianebisas emateba 1 qula

etapi 7 gamoxatuli daklakniloba

dazianebuli segmentis distalurad gamoxatuli daklaknilobis arsebobisa SemTxvevaSi - 2 qula.

etapi 8 dazianebis sigrZe > 20 mm sigrzis dazianebisas - 1 qula

etapi 9 kalcifikacia gamoxatuli kalcifikaciis SemTxvevaSi - 2 qula

etapi 10 Trombi Trombis arsebobisas – emateba 1 qula

etapi 11 difuzuri dazianeba/wvrili sisxlZarRvebi

dazianebis distalurad difuzurad Seviwroebuli wvrili sisxlZarRvebis arsebobisas (mag. dazianebis distalurad sisxlZarRvis sul mcire 75%-is diametri < 2 mm) segmentebis raodenobis Sesabamisad TiTo qula emateba

8

cxrilSi moyvanilia tki da akS Semdgom uaxloves periodSi (mag. intra-hospitaluri, an 30-dRiani) revaskularizaciis mosalodneli Sede-gebis gansazRvris mizniT sxvadasxva riskis modelebis gamoyenebis rekomendaciebi.

uaxloves periodSi (intrahospitaluri, an 30-dRiani) Sedegebis gansazRvris riskis modeli

Skalaparametrebis

raodenoba gamosavalirekomen-daciebi

klinikuri anatomiuri akS tki

STS Score 40 2

intrahospitaluri an 30-dRiania

sikvdiloba, da intrahospitaluri

avadobab

I B

EuroSCORE II 18 0 intrahospitaluri sikvdiloba

IIa B IIb C

ACEF 3 0

intrahospitaluri, an

30-dRiania sikvdiloba

IIb C IIb C

NCDRCathPCI 8 0 intrahospitaluri

sikvdilobaIIb B

EuroSCORE 17 0 operaciuli sikvdiloba

III B III C

a romelic adre ganviTardebab insulti, Tirkmlis ukmarisoba, gaxangrZlivebuli ventilacia, sternalri Wrilobis Rrma infeqcia, reoperacia, hospitalizaciis xangrZlivoba < 6, an > 14 dReze

9

cxrilSi moyvanilia tki da akS Semdgom Soreul periodSi (mag. ≥ 1 wel-ze ) revaskularizaciis mosalodneli Sedegebis gansazRvris mizniT sx-vadasxva riskis modelebis gamoyenebis rekomendaciebi

Sualedur da Soreul periodSi (mag. ≥ 1 welze) Sedegebis gansazRvris riskis modeli

Skalaparametrebis raodenoba

gamosavali

rekomen-daciebi

klinikuri anatomiuri akS tki

SYNTAX 0

11(3 zogadi,8 yovel

dazianebaze)

MACCE I B I B

SYNTAX II 6 12 4 wliani sikvdiloba

IIa B IIa B

ASCERTCABG 23 2 sikvdiloba > 2

welzeIIa B

ASCERTPCI 17 2 sikvdiloba > 1

welzeIIa B

Logistic Clinical SYNTAX

3 11 1 wliani MACE da sikvdiloba

IIa B

4. gadawyvetilebis miRebis da pacientis informirebis procesebi

multidisciplinaruli gadawyvetilebis miRebis gzebi, pacientis in-formirebuli Tanxmobis pirobebi, da pacientis klinikuri mdgomare-obis mixedviT revaskularizaciuli mkurnalobis Catarebis drois gansazRvreba Sejamebulia Semdeg gverdebze ganlagebul me-4 cxrilSi

10

cxrili 4: multidisciplinuri midgomis saWiroeba, pacientis informirebuli Tanxmoba da intervenciis dro

mwvave koronaruli sindromi mravalsisxlZarRvovani stabiluri koronaruli arteriebis daavadeba (skad)

skad da ad hoc tki SemTxvevaSi daniSnuleba

winaswar SemuSavebuli kardiologiis gundis

protokolebSi

Soki STEMI NSTE-ACS

multidiscip-linuri gadawyveti-lebis saWiroeba

aucilebeli ar aris mwvave fazaSi. sisxlis mimoqcevismeqanikuri daxmareba kardiologiuri gundis protokolebis mixedviT

aucilebeli ar aris kritikuli stenozis dros aucilebeli ar aris.stabilizaciis Semdeg rekomenda-ciebi mravalsis-xlZarRvovani skad analogiuria

saWiroa saWiro ar aris

informire-buli Tanxmoba

sityvieri Tanxmoba mowmis TandaswrebiT, an, SeZlebisamebr, ojaxis Tanxmoba - gadaudeblad

SesaZloa, sakmarisi iyos sityvieri Tanxmoba mowmis TandaswrebiT, Tu kanonmdeblobiT werilobiTi sabuTi ar moiTxoveba

werilobiTi informirebuli Tanxmobaa

werilobiTi informirebuli Tanxmobaa werilobiTi informirebuli Tanxmobaa

revaskulari-zaciis dro

gadaudebeli situacia:dauyovneblad


saswrafo: SeZlebisamebr 24 saaTis ganmavlobaSi, ara ugvianes 72 saaTisa

gamoxatuli simptomebis (CCS 3) da maRali riskis koronaruli anatomiis(marcxena mTavari Reros paTologia, an misi ekvivalenti, sami sisxlZarRvis daavadeba, an LAD proqsimaluri dazianeba, an marcxena prkuWis daqveiTebuli funqcia) mqone pacientebSi revaskularizacia (akS, an tki) sasurvelia, Catardes or kviraSi. skad mqone yvela sxva SemTxvevaSi revaskularizacis (akS, an tki) sasurvelia, Catardes 6 kviraSi

Ad hoc.

procedura Catardes saukeTeso mtkicebulebebis/ xelmisawvdomobis gaTvaliswinebiTarakritikulad Seviwroebul sisxlZarRvebs adgilobrivi protokolebis mixedviT vumkurnaloT

Catardes saukeTeso mtkicebulebebis /xelmisawvdomobis gaTvaliswinebiT arakritikulad Seviwroebul sisxlZarRvebs adgilobrivi protokolebis mixedviT vumkurnaloT

Catardes saukeTeso mtkicebulebebis/xelmisawvdomobis gaTvaliswinebiT. arakritikulad Seviwroebul sisxlZarRvebs adgilobrivi protokolebis mixedviT vumkurnaloT

dagegmeT yvelaze ufro Sesaferisi Careva, rac saSualebas gvaZlevs diagnostikuri angiografiidan intervenciamde Sesaferisi drois monakveTis SerCevisTvis

intervencia Catardes Sidahospitaluri protokolebis mixedviT adgilobrivi kardiologiuri gundis meTvalyurobiT

a es SeiZleba ar exebodes im qveynebs, sadac legalurad ar moiTxoveba werilobiTi informirebuli Tanxmoba. ESC da EACTS emxrobian pacientis Tanxmobis gaformebas yvela revaskularizaciuli procedurisTvis

11

cxrili 4: multidisciplinuri midgomis saWiroeba, pacientis informirebuli Tanxmoba da intervenciis dro

mwvave koronaruli sindromi mravalsisxlZarRvovani stabiluri koronaruli arteriebis daavadeba (skad)

skad da ad hoc tki SemTxvevaSi daniSnuleba

winaswar SemuSavebuli kardiologiis gundis

protokolebSi

Soki STEMI NSTE-ACS

multidiscip-linuri gadawyveti-lebis saWiroeba

aucilebeli ar aris mwvave fazaSi. sisxlis mimoqcevismeqanikuri daxmareba kardiologiuri gundis protokolebis mixedviT

aucilebeli ar aris kritikuli stenozis dros aucilebeli ar aris.stabilizaciis Semdeg rekomenda-ciebi mravalsis-xlZarRvovani skad analogiuria

saWiroa saWiro ar aris

informire-buli Tanxmoba

sityvieri Tanxmoba mowmis TandaswrebiT, an, SeZlebisamebr, ojaxis Tanxmoba - gadaudeblad

SesaZloa, sakmarisi iyos sityvieri Tanxmoba mowmis TandaswrebiT, Tu kanonmdeblobiT werilobiTi sabuTi ar moiTxoveba

werilobiTi informirebuli Tanxmobaa

werilobiTi informirebuli Tanxmobaa werilobiTi informirebuli Tanxmobaa

revaskulari-zaciis dro



saswrafo: SeZlebisamebr 24 saaTis ganmavlobaSi, ara ugvianes 72 saaTisa

gamoxatuli simptomebis (CCS 3) da maRali riskis koronaruli anatomiis(marcxena mTavari Reros paTologia, an misi ekvivalenti, sami sisxlZarRvis daavadeba, an LAD proqsimaluri dazianeba, an marcxena prkuWis daqveiTebuli funqcia) mqone pacientebSi revaskularizacia (akS, an tki) sasurvelia, Catardes or kviraSi. skad mqone yvela sxva SemTxvevaSi revaskularizacis (akS, an tki) sasurvelia, Catardes 6 kviraSi

Ad hoc.

procedura Catardes saukeTeso mtkicebulebebis/ xelmisawvdomobis gaTvaliswinebiTarakritikulad Seviwroebul sisxlZarRvebs adgilobrivi protokolebis mixedviT vumkurnaloT

Catardes saukeTeso mtkicebulebebis /xelmisawvdomobis gaTvaliswinebiT arakritikulad Seviwroebul sisxlZarRvebs adgilobrivi protokolebis mixedviT vumkurnaloT

Catardes saukeTeso mtkicebulebebis/xelmisawvdomobis gaTvaliswinebiT. arakritikulad Seviwroebul sisxlZarRvebs adgilobrivi protokolebis mixedviT vumkurnaloT

dagegmeT yvelaze ufro Sesaferisi Careva, rac saSualebas gvaZlevs diagnostikuri angiografiidan intervenciamde Sesaferisi drois monakveTis SerCevisTvis

intervencia Catardes Sidahospitaluri protokolebis mixedviT adgilobrivi kardiologiuri gundis meTvalyurobiT

12

calkeuli situaciebSi gadawyvetilebis miRebisa da pacientis infor-mirebis rekomendaciebi.

gadawyvetilebis miRebisa da pacientis informirebis rekomendaciebi

klasia doneb

rekomendirebulia, rom koronaruli angiografiis Catarebamde pacienti informirebuli iyos proceduris sargeblianobisa da riskis, agreTve proceduris Semdgomi potenciuri samkurnalo SesaZleblobebis Sesaxeb.

I C

rekomendebulia, rom pacientebs adeqvaturad ganemartos revaskularizaciis proceduris mokle-, da grZelvadiani sargebeli da riskebi, iseve rogorc mkurnalobis sxva variantebi. informirebuli gadawyvetilebis misaRebad pacients unda mieces sakmariso dro.

I C

rekomendebulia, rom, revaskularizaciis saTanado strategiis ganxorcielebis mizniT, kardiologiurma jgufma (Heart Team) SeimuSavos am gaidlainis gaTvaliswinebiT institucionaluri protokolebi. kardioqirurgiis ararsebobis SemTxvevaSi, centrma sadac tardeba tki unda SeimuSavis sxva kardioqiurirgiul centrebTan TanamSronlobis institucionaluri protokoli.

I C

rekomendebulia, rom kardiologiurma jgufma (Heart Team) imsjelos pacientebis Sesaxeb, roca maTTan dakavSirebuli gadawyvetilebis miReba moiTxovs kompleqsur midgomebs, an ar jdeba institucionaluri protokolis CarCoebSi.

I C

5. diagnostikuri strategiebi: funqciuri testebida gamosaxulebiTi kvlevebi

savaraudod stabiluri pacientebis diagnostikuri gamokvlevebis re-komendaciebi, maTi simptomebisa da mniSvnelovani kad arsebobis pre-testiT albaTobis mixedviT warmodgenilia cxrilSi Semdeg gverdze.

a rekomendaciis klasi. b mtkicebulebis done

13

savaraudod kad da stabiluri simptomebis mqone pacientebis diagnostikuri gamokvlevebis Cveneba

asimptomuri simptomuri

mniSvnelvani daavadebis arsebobis albaTobaa

dabali(< 15%)

saSualo(15 – 85%)

maRali(> 85%)

klasi b done g klasib done g klasib done g klasi b done g

kad anatomiuri deteqcia

invaziuriangiografia

III A III A IIb A I A

CTangiografia d,v III B III C IIa A III B

funqciuri kvlevebi

stres eqo III A III A I A III A

scintigrafia III A III A I A III A

stres MRI III B III C I A III B

perfuziuliPET

III B III C I A III B

kombinirebuli, an hibriduligamosaxulebiTikvleva

III C III C IIa B III B

6. revaskularizacia stabiluri koronaruli arteriebis daavadebis dros

stabiluri kad mqone pacientebSi miokardiumis revaskularizaciis Cve neba mocemulia qvemoT moyvanil cxrilSi.

a kad pre-testuri albaToba, dabali 0-15%; saSualo 15-85%; maRali >85% stabiluri stenokardiis marTvis gaidlainebis kriteriumebis Tanaxmad. b rekomendaciis klasi. g mtkicebulebis done. d es exeba CT angiografias. e munji (asimptomuri) iSemiis skriningi SeiZleba, mxedvelobaSi viqonioT garkveuli jgufis maRali riskis mqone pacientebSi, magaliTad, Saqriani diabetis fonze. v Catareba miRebulia umetesad SedarebiT dabali pre-testuri albaTobis dros (15-50%).

14

stabiluri stenokardiiT an munji iSemiiT pacientebis revaskularizaciis Cvenebebi

kad simZime (anatomiuri da/an funqciuri) klasib doneg

prognozis gasaumjobeseblad

marcxena mTavari Reros Seviwroeba > 50%a I A

wina daRamavali arteriis nebismieri proqsimaluri stenozi > 50% I A

ori-, an sam-sisxlZarRvovani paTologia > 50% SeviwroebebiT, Tanmxlebi marcxena parkuWis funqciis daqveiTebiT (mpgf < 40%).

I A

iSemiis didi zona (> mp-is 10%) I B

erTaderTi darCenili gamavali koronaruli arteriis stenozi > 50% I C

simptomuri gaumjobesebisaTvis

koronaruli arteriis stenozi > 50%a fizikuri aqtiurobis SemzRudavi stenokardiis, an misi eqvivalentis fonze, romelic ar eqvemdebareba medikamentur mkurnalobas

I A

rekomendaciebi skad pacientebis miokardiumis revaskularizaciis meTodis (tki, Tu akS) SerCevisaTvis, koronaruli anatomia iZleva orive proceduris Catarebis SesaZleblobas da qirurgiuli sikvdilobis riski dabalia

rekomendaciebi kad simZimis mixedviTakS tki

klasia doneb klasia doneb

erTi- an ori arteriis Seviwroeba LAD proqsimaluri stenozis gareSe

IIb C I C

erTi arteriis dazianeba LAD proqsimaluri stenoziT

I A I A

ori arteriis Seviwroeba LAD proqsimaluri stenoziT

I B I C

marcxena mTavari Reros dazianeba SYNTAX SkaliT ≤ 22 qulaze

I B I B

marcxena mTavari Reros dazianeba SYNTAX SkaliT 23-32 qula

I B IIa B

marcxena mTavari Reros dazianeba SYNTAX SkaliT > 32 qulaze

I B III B

sami arteriis dazianeba SYNTAX SkaliT ≤ 22 qulaze

I A I B

sami arteriis dazianeba SYNTAX SkaliT 23-32 qula

I A III B

sami arteriis dazianeba SYNTAX SkaliT > 32 qulaze

I A III B

rekomendaciebi stabiluri kad-iT pacientebis miokardiumis revaskular-izaciis meTodis (tki, Tu akS) SerCevisaTvis, roca koronaruli anatomia iZleva orive proceduris Catarebis SesaZleblobas da qirurgiuli sikvdi-lobis riski dabalia.

a dadasturebuli iSemiis, an fnr < 0.80 fonze, Tu stenozis xarisxi < 90%.b mtkicebulebaTa klasi – g mtkicebulebaTa done

a mtkicebulebaTa klasi. b mtkicebulebis done

15

7. revaskularizacia ST segmentis elevaciis gareSemimdinare mwvave koronaruli sindromis dros

ST segmentis elevaciis gareSe mimdinare mwvave koronaruli sindro-mis (NSTE-ACS) SemTxvevaSi, angiografiisa da revaskularizaciis Cat-arebis dro unda ganisazrvros pacientis riskis profilis mixedviT. me-5 cxrilSi mocemulia maRali riskis pirveladi da meoradi kriteri-umebi, romlebi warmoadgenen invaziuri Carevis Cvenebebs.

cxrili 5. maRali riskis kriteriumebi, romlebic warmoadgenen invaziuri Carevis Cvenebebs.

pirveladi kriteriumebi

1. troponinis Sesaferisi momateba an kleba

2. ST-s an T kbilis dinamiuri cvlilebebi (simptomuri an usimptomo)

3. GRACE Skali > 140 qula

meoradi kriteriumebi

4. Saqriani diabeti

5. Tirkmlis ukmarisoba (ggfs < 60 mj/wT/1.73m2)

6. marcxena parkuWis gandevnis fraqcia < 40%

7. adreuli postinfarqtuli stenokardia

8. axlo periodSi Catarebuli tki

9. adre Catarebuli akS

10. saSualodan maRal donemde GRACE riskis qulebi

(http://www.gracescore.org)

16

rekomendaciebi NSTE-ACS-iT pacientebis invaziuri gamokvlevisa da mio-kardiumis revaskularizaciis Catarebis drois gansazRvris Sesaxeb mocemulia cxrilSi.

rekomendaciebi invaziuri gamokvlevisa da revaskularizaciis drois gansazRvrisaTvis ST segmentis gareSe mimdinare mwvave koronaruli sindromis dros

klasia doneb

gadaudebeli koronaruli angiografia (< 2 sT) rekomendebulia Zalian maRali iSemiuri riskis jgufis pacientebSi (refraqteruli stenokardia Tanmxlebi gulis ukmarisobasobiT, an kardiogenuli SokiT, an sicocxlisTvis saSiS parkuWovani ariTmiebiT, an hemodinamikis arastabilurobiT)

I C

adreuli invaziuri Careva (< 24 sT) rekomendebulia sul mcire erTi pirveladi maRali riskis kriteriumis mqone pacientebSi (cxrili 5).

I A

invaziuri strategia (< 72 sT pirveli gamovlenida) naCvenebia sul mcire erTi maRali riskis kriteriumis (cxrili 5), an rekurentuli simptomebis arsebobisas.

I A

rekurentuli simptomebis armqone dabali riskis pacientebSi invaziuri gamokvlevis Catarebis Cvenebebis gansazRvrisaTvis rekomendirebuli inducirebadi iSemiis aranvaziuri dokumentireba testebiT.

I A

rekomendebulia, rom revaskularizaciis strategiis gansazRvrisas (ad hoc samizne stenozis tki/ Tu mravalsisxlZarRvovani tki/akS) gaTvalisinebuli unda iyos pacientis klinkur mdgomareba, Tanmxlebi daavadebebis arseboba, koronaruli arteriebis dazianebebis gavrceleba da xarisxi (mag. SYNTAX qulebi), lokaluri kardiologiuri gundis protokolis Sesabamisad.

I C

koronaruli arteriebis mniSvnelovani dazianebebis tki meTodiT mkurnalobisas rekomendirebulia axali Taobis wds gamoyeneba.

I A

8. revaskularizacia ST segmentis elevaciiT mimdinare miokardiumis infarqtis dros

reperfuziuli mkurnalobis droulad Catareba warmoadgens STEMI pacientebis marTvisas sakvanZi sakiTxs, rameTu amgvari mkurnalo-bis maqsimaluri efeqti miiRweva simptomebis ganviTarebidan pirveli 2-3 saaTis ganmavlobaSi Catarebuli reperfuziis SemTxvevaSi. STEMI optimaluri mkurnaloba unda daefiZnos sxvadasxva donis teqnolo-


17

giuri aRWurvilobis mqone adgilobrivi saavadmyofebs Soris urT-ierTTanamSromlobas, romlebsac daakavSirebs efeqturad momqmedi saswrafo daxmarebis samsaxuri. am urTierTkavSiris mizania uzrunve-lyos optimaluri momsaxureba minimaluri dagvianebebiT, raTa gaaum-jobesebs klinikuri gamosavlebi – rogorc es me-2 sqemazea naCvenebi.

sqema 2 STEMI pacientebis pre- da intrahospitaluri marTva da reperfuziis strategia pirveli samedicino kontaqtidan 12 saaTis ganmavlobaSi intervenciis idealuri drois miTiTebiT.

simptomebis gamovlena

psk → STEMI diagnostireba

pacient

is d

ayovneba

dp

skb <

120 wT

iTb an piveladi tkiarmqone hospitali

piveladi tkiSemZle hospitali

Sg

x

tki Tu dpksb ≤ 120wTda Sgx ≤ 30 wT

gadaudebladgadayvana tki

SemZle centrSi

diax arapirveladi tki

gadamrCeni tki

gadaudeblad

ara

diax

warmatebulifibrinolizisi?

gadaudebelifibrinolizisi

3-24 saaTSi

koronaroangiografiakardiogenuli Sokis SemTxvevaSi gadaudeblad gadaiyvaneT tki centrSi

iSem

iis

sru

li

xang

rZl

ivo

ba

dp

skb

< 9

0 wT

dkb

< 6

0 wT

dkb = dro karebidan balonirebamde; dpskb = dro pirveli samedicino kontaqtidan balonirebamde; iTb = intensiuri Terapiis bloki; tki = transkutanuri koronaruli intervencia; Sgx = Sesvla-gamosvlis xangrZlivoba; STEMI = ST segmentis elevaciiT mimdinare miokardiumis mwvave infarqtipsk = pirveli kontaqti medikosebTan.

18

STEMI dros miokardiumis pirveladi tki meSveobiT reperfuziis reko-mendaciebi aRwerili qvemoT moyvanil cxrilSi

STEMI dros pirveladi transkutanuri koronaruli intervenciis meSveobiT miokardiumis reperfuziis rekomendaciebi: Cvenebebi da organizaciuli sakiTxebi

klasia doneb

Cveneba

reperfuziuli mkurnaloba naCvenebia yvela im SemTxvevaSi, roca simptomebis aRmocenebidan gasulia < 12 sT-ze da aris ST segmentis mdgradi elevacia, an (savaraudod) axladganviTarebuli LBBB.

I A

pirveladi tki rekomendebuli, rogorc fibrinolizTan SedarebiT upiratesobis mqone reperfuziis meTodi, Tu tardeba droulad, gamocdili personalis mier

I A

Tu simptomebis dawyebidan > 12 sT gasuli, pirveladi tki naCvenebia mimdinare iSemiis an sicocxlisTvis saSiSi ariTmiebis arsebobisas, an ganmeorebiTi tkivilisa da ekg cvlilebis SemTxvevaSi.

I C

pirveladi tki naCvenebia STEMI gamowveuli mZime gulis ukmarisobiT an kardiogenuli SokiT pacientebTan, miuxedavad simptomebis aRmocenebidan gasuli droisa.

I B

pirveladi tki meSveobiT reperfuziis Catarebis SesaZlebloba unda iyos ganxiluli im SemTxvevebSi, roca pacientebis hospitalizacia xdeba simptomebis aRmocenebidan mogvianebiT periodSi (12-48 saaTi)

IIa B

organizaciuli sakiTxebi

STEMI prehospitaluri marTva unda emyarebodes adgilobrivi jandacvis qsels, romelic organizebuli unda iyos referfuziuli mkurnalobis droulad da efeqturad CatarebisaTvis, da uzrunvelyos pirvelad tki Catareba rac SeiZleba meti pacientebisaTvis.

I B

rekomendebulia, rom yvela gadaudebel samedicino samsaxurebi, mimRebi ganyofilebebi, koronaruli blokebi da kaTeterizaciis laboratoriebi xelmZRvanelobden STEMI marTvis werilobiTi protokolebiT, sadac gaTvaliswinebuli iqneba adgilobrivi geografiuli Taviseburebani.

I C

rekomendebulia, rom pirveladi tki centrebma uzrunvelyon 24 saaTiani muSaobis reJimi kviraSi 7 dRis ganmavlobaSi, da pirveladi tki rac SeiZleba swrafi Catareba hospitalizaciidan araugvianes 60 wuTis ganmavlobaSi.

I B

pacienti, romlebic igzavneba specializirebul centreSi pirveladi tki Casatareblad pirdapir unda iyos Seyvanili kaTeterizaciis laboratoriaSi intesniuri Terapiis (emerjencis) gverdis avliT.

IIa B


19

cxrilSi miTiTebulia pirveladi tki proceduruli warmarTvis rekomendaciebi

pirveladi tki-iT reperfuzia ST EMI dros

klasia doneb

strategia

pirveladi tki unda Semoifarglos mxolod samizne (infarqtdamokidebuli) arteriiT, garda kardiogenuli Sokis SemTxvevebisa da tki Semdgomi mdgradi iSemiisa.

IIa B

STEMI pacientis arainfarqtdamokidebuli arteriis gadavadebuli revaskularizaciis sakiTxi unda iyos ganxiluli, Tu mas gamouvlinda ramodenime koronaruli arteriis dazianebebi, da pirveladi tki Semdgomi dReebis, an kvirebis ganmavlobaSi aReniSna iSemiis simptomebi.

IIa B

pirveladi tki proceduris dros arainfarqtdamokidebuli arteriebis mniSvnelovani Seviwroebebis dauyovnebeli revaskularizaciis Catarebis sakiTxi SeiZleba iyos ganxiluli garkveul SemTxvevebSi

IIb B

akS Catarebis sakiTxi ganxiluli unda iyos, Tu pacients aReniSneba mimdinare iSemia da infarqtdamokidebuli arteriis tki Catareba ver xerxdeba.

IIa C

teqnikuri sakiTxebi

pirveladi tki dros rekomendebulia stentirebis (da ara mxolod balonuri angioplastikis) Catareba.

I A

pirveladi tki dros upiratesoba eniWeba axali Taobis wamliT dafaruli stentebis gamoyenebas.

I A

radialuri midgomas eniWeba upiratesoba femoralur midgomasTan SedarebiT, Tu proceduras asrulebs gamocdili operatori.

IIa A

garkveul SemTxvevbSi SeiZleba ganxilul iyos Trombis aspiraciis Catarebis sakiTxi.

IIb A


20

Trombolizisis Catarebis Semdeg pacientis marTvisa da miokardiumis revaskularizaciis rekomendaciebi warmodgenilia qvemoT mocemul cxrilSi

pacientis marTvisa da miokardiumis revaskularizaciis rekomendaciebi fibrinolizisis Catarebis Semdeg

klasia doneb

fibrinolizisis Catarebis Semdgomi 24 saaTis ganmavlobaSi rekomendebulia yvela pacientis gadayvana tki centrSi

I A

warmatebuli fibrinolizisis Semdgomi 24 sT-is ganmavlobaSi rekomendirebulia koronaroangiografiis Catareba infarqtdamokidebuli arteriis revaskularizaciis ganzraxviT.

I A

fibrinolizisis Semdgomi kardiogenuli Sokis, an mZime gulis ukmarisobis dros rekomendirebulia gadaudebeli angiografia savaraudo revaskularizaciis Catarebis ganzraxviT.

I B

warumatebeli Trombolizisis (ST segmentis elevaciis < 50% Semcireba, an mdgradi tkivili 60 wuTis ganmavlobaSi) SemTxvevaSi naCvenebia gadaudebeli gadamrCeni tki

I A

warmatebuli Trombolizisis Semdeg ganviTarebuli rekurentuli iSemiis, hemodinamikuri arastabilurobis da sicocxlisTvis saSiSi parkuWovani ariTmiebis ganviTarebis, an reokluziis niSnebis gamovlenis SemTxvevaSi rekomendirebulia gadaudebeli tki.

I A

warmatebuli Trombolizisis Semdeg stabiluri pacientisTvis optimaluria angiografiis Catareba Semdgomi 3- 24 saaTis gamnavlobaSi.

IIa A

9. revaskularizacia gulis ukmarisobisa da kardiogenuli Sokis mqone pacientebSirevaskularizaciis rekomendaciebi gulis qr. ukmarisobiT da marcx-ena parkuWis sistoluri disfunqciiT pacientebSi moyvanil cxrilSi

revaskularizaciis rekomendaciebi gulis qr. ukmarisobisa da marcxena parkuWis sistoluri disfunqciis mqone pacientebSi (gandevnis fraqcia ≤ 35%)

klasia doneb

akS rekomendebulia marcxena mTavari Reros gamoxatuli stenozisa da misi eqvivalentis wina daRmavali da Semomxvevi arteriebis proqsimaluri stenozis mqone pacientebSi

I C

koronaruli mravalsisxlZarRvovani dazinebebisa da wina daswvrivi arteriis mniSvnelovani stenozirebis Tanaarsebobis akS rekomendebulia, kardiovaskuluri sikvdilobisa da hospitalizaciis Semcirebis mizniT.

I B

akS dros marcxena parkuWis anevrizmeqtomiis Catareba unda iyos ganxiluli didi anevrizmis arsebobis SemTxvevaSi, Tu aris: anevrizmis gaskdomis riski, formirebulia didi Trombi, an anevrizma aris ariTmiis mizezi.

IIa C

miokardiumis revaskularizacia unda iyos ganxiluli sicocxlisunariani miokardiumis arzsebobis SemTxvevaSi

IIa B

21

revaskularizaciis rekomendaciebi gulis qr. ukmarisobisa da marcxena parkuWis sistoluri disfunqciis mqone pacientebSi (gandevnis fraqcia ≤ 35%) (gagrZ.)

klasia doneb

akS marcxena parkuWis qirurgiul aRdgenasTan erTad, SeiZleba, ganxiluli iyos pacientebTan, romlebTac aReniSnebaT wina daswvrivi arteriis sisxlmomaragebis teritoriis danawibureba, Tu operaciis Sedegad mosalodnelia, rom marcxena parkuWis end-sistoluri moculobis iqneba < 70 ml/m2.

IIb B

tki Catareba SeiZleba iyos ganxiluli, Tu koronaruli arteriebis anatomia amisaTvis Sesaferisia, arsebobs sicocxlisunariani miokardi, xolo qirurgiuli Careva naCvenebi ar aris.

IIb C

miokardiumis revaskularizacia mks fonze ganviTarebuli kardiogenu-li Sokis mkurnalobis qvakuTxedia. amitom, aseT situaciaSi naC venebia gadaudebeli koronaruli angiografia. 3 sqema asaxavs kardiogenuli Sokis mqone pacientebis mTavari triaJsa da mkurnalobis etapebs

sqema 3 kardiogenuli SokiT pacientebis mkurnaloba

kardiogenuli SokiT pacientebi

• medikamenturi Terapia • revaskularizacia• inotropuli Careva • reperfuzia• xelovnuri ventilacia • meqanikuri garTulebebis rekonstruqcia

pacienti arastabiluria

pacienti stabiluria

xanmokle meqanikuri damxmare sisxlis

mimoqcevis Catareba

xelovnuri ventilaciidan moxsna

gulis funqciisgaumjobeseba

gulis funqciisgaumjobeseba ar aRiniSneba

gulis funqciisgaumjobeseba

xelovnuri ventilaciidan dadamxmare sisxlis

mimoqcevidan moxsna

SeafaseT nevrologiuri statusi/ sxva organoebis

funqcia

standartulimkurnaloba

Seuqcevadi nevrologiuri deficiti

normaluri nevrologiuri funqcia

aparatebidan moxsna

meqanikuri sisxlis mimoqceva sxva SesaZlo mkurnalobis dawyebamde,

an gulis gadanergvamde


22

Semdegi cxrili warmogvidgens miokardiumis revaskularizaciis re-komen daciebs mks fonze ganviTarebuli gulis mwvave ukmarisobis mqo-ne pacientebSi

mks fonze ganviTarebuli gulis mwvave ukmarisobis mqone pacientebis marTvis rekomendaciebi

klasia doneb

naCvenebia gadaudebeli eqokardiografia marcxena parkuWis da sarqvlovani aparatis funqciis Sesafaseblad, agreTve sxva meqanikuri garTulebebis gamosaricxad.

I C

gulis mwvave ukmarisobiT, an kardiogenuli SokiT garTulebuli mks dros naCvenebia gadaudebeli invaziuri gamokvleva

I B

STEMI, an NSTE-ACS fonze ganviTarebuli kardiogenuli Sokis dros, naCvenebia gadaudebeli tki Tu koronaruli anatomia amis saSualebas iZleva.

I B

Tu kardiogenuli SokiT pacientis koronaruli anatomia Seuferebelia gadaudebeli tki CatarebisTvis, rekomendirebulia gadaudebeli akS

I B

miokardiumis mwvave infarqtis fonze ganviTarebuli meqanikuri garTulebebiT gamowveuli hemodinamikis arastabilurobis SemTxvevaSi rekomendirebulia gadaudebeli qirurgiuli Careva.

I C

iabP unda iyos ganxiluli, Tu pacients meqanikuri garTulebebis gamo ganviTarebuli hemodinamikis arastabiluroba / kardiogenuli Soki

IIa C

miokardiumis mwvave infarqtis dros ganviTarebuli meqanikuri garTulebebis mqone pacientebis mdgomareoba gadaudeblad unda ganixilos kardiologiurma gundma.

I C

mks fonze ganviTarebuli kardiogenuli SokiT pacientebTan ganxiuli unda iyos xanmokle damxmare sisxlis mimoqcevis Catareba.

IIb C

parkuWTaSua Zgidis defeqtis transkutanuri aRdgenis sakiTxi SeiZleba ganxiluli iyos kardiologiuri gundis mier.

IIb C

iabP rutinuli gamoyeneba kardiogenuli Sokis mqone pacientebSi rekomendebuli ar aris

III A

10. revaskularizacia diabetis mqone pacientebSi

zogadad, skad da mks dros diabetiT da diabetis armqone pacientebi-satvis revaskularizaciis Cvenebebi erTnairia. Saqriani diabetiT pa-cientebis revaskularizaciis specifiuri rekomendaciebi mocemulia momdevno cxrilSi.


23

revaskularizaciis specifiuri rekomendaciebi Saqriani diabetiT pacientebSi

klasia doneb

STEMI SemTxvevaSi droulad Catarebuli pirveladi tki ufro metad rekomendebulia fibrinolizTan SedarebiT.

I A

NSTEACS pacientebSi adreuli invaziuri strategia ufro metad rekomendirebuli arainvaziur mkurnalobasTan SedarebiT.

I A

stabilur, mravasisxlZarRvovani dazianebebis da/an iSemiis niSnebis mqone pacientebSi revaskularizacia naCvenebia kardiuli garTulebebis Sesamcireblad

I B

stabiluri mravalsisxlZarRvovani kad da misaRebi qirurgiuli riskis SemTxvevebSi akS rekomendebulia ufro metad, vidre tki.

I A

stabiluri mravalsisxlZarRvovani kad, roca SYNTAX qulebi ≤ 22 tki ganxiluli unda iyos rogorc akS-s alternativa.

IIa B

axali Taobis wamliT dafaruli stentebis gamoyenebas aqvs upiratesi rekomendacia, metalis stentebTan SedarebiT

I A

ganxiuli unda iyos SuntirebisaTvis ormxrivi gulmkerdis Sida arteriebis gamoyeneba

IIa B

metforminiT namkurnalebi pacientebSi angiografiis/tki Semdgomi 2-3 dRis ganmavlobaSi saWiroa Tirkmlis funqciis monitorireba.

I C

11. revaskularizacia Tirkmlis qronikuli daavadebis mqone pacientebSi

qvemoT mocemul cxrilSi moyvanilia Tirkmlis qronikuli daavadeb-iT pacientebis revaskularizaciis rekomendaciebi

Tirkmlis zomieri, an mZime qronikuli daavadebis arsebobisas pacientebis revaskularizaciis specifiuri rekomendaciebi

klasia doneb

mravalsisxlZarRvovani kad da simptomur/iSemiis mqone pacientebSi, tki-s SedarebiT akS unda ganixilos rogorc upiratesobis mqone meTodi, Tu qirurgiuli riski misaRebia da sicocxlis mosalodneli xangrZlivoba 1 welze metia

IIa B

mravalsisxlZarRvovani kad da simptomebis/iSemiis mqone pacientebSi maRali qirurgiuli riski an 1 welze naklebi mosalodneli sicocxlis xangrZlivobis SemTxvevaSi, tki unda ganixilos rogorc upiratesobis mqone meTodi, akS-sTan SedarebiT,

IIa B

ganxiluli unda iyos koronaroangiografiis Semdeg akS gadavadeba, sanam sakontrasto nivTierebis zemoqmedeba Tirkmlis funqciaze ar gaivlis.

IIa B


24

Tirkmlis zomieri, an mZime qronikuli daavadebis arsebobisas pacientebis revaskularizaciis specifiuri rekomendaciebi (gagrZeleba)

ganxiluli unda iyos akS Catareba momuSave gulze, rogorc upiratesobis mqones xelovnuri sisxlis mimoqceviT Catarebul operaciasTan SedarebiT

IIb B

axali Taobis wamliT dafaruli stentebis gamoyenebas eZleva upiratesi rekomendacia metalis stentebTan SedarebiT.

I B

koronaruli angiografiisa da miokardiumis revaskularizaciis dros kontrastiT inducirebuli nefropaTiis prevenciis rekomendaciebi mocemulia momdevno cxrilSi.

kontrastiT inducirebuli nefropaTiis prevenciis rekomendaciebi

rekomendacia doza klasia doneb

koronaroangiografias, an mdkt - Catarebis win

unda Sefasdes kortrastiT inducirebuli Tirkmlebis mwvave dazianebis riski.

IIa C

zomieridan mZimemde xarisxis Tqd mqone pacientebi

rekomendebulia izotonuri fiziologiuri xsnaris gadasxma g I A

rekomendebulia dabal-, an izo-osmo-laruli sakontrasto nivTierebebis gamoyeneba

< 350 ml an < 4 ml/kg an mTeli kontrastuli nivTierebis moculoba/gfs < 3.4

I A

ganxiluli unda iyos xanmokle maRali dozebiT statinebis xmareba

rozuvastatini 40/20 mg an atorvastatini 80 mg an simvastatini 80 mg

IIa A

izo-osmoluri sakontrasto nivTie-rebebis xmareba ganxiluli unda iyos rogorc upiratesi dabal-osmolur nivTierebebTan SedarebiT

IIa A

gamoyenebuli sakontrasto nivTierebis moculoba dayvanili unda iyos minimumamde.

IIa B


25

kontrastiT inducirebuli nefropaTiis prevenciis rekomendaciebi

rekomendacia doza klasia doneb

zomieridan mZimemde xarisxis Tqd mqone pacientebi

furosemidiT marTuli hidratacia SeiZleba ganxiluli iyos rogorc upiratesobis mqone, standartul hidrataciasTan SedarebiT garTulebebis maRali riskis mqone pacientebSi, an roca proceduris win profilaqtikuri hidrataciis Catareba SeuZlebelia

dasawyisSi, fiziologiuri xsnaris 250 ml bolusiT 30 wuTis ganmavlobaSi (mp disfunqciis dros Semcirdes ≤ 150 ml-mde), rasac unda mivayoloT i/venurad furosemidis bolusi (0.25-0.5 mg/kg). siTxis infuziis siCqare ise unda daregulirdes, rom gautoldes gamoyofili Sardis raodenobas. roca Sardis gamoyofa > 300 ml/sT iqneba, pacientebs utardebaT koronaruli procedurebi. siTxis gamozomili Canacvleba SenarCunebuli unda iqnas proceduris mimdinareobisas da mkurnalobis Semdgomi 4 saaTis ganmavlobaSi

IIb A

N-acetilcisteinis gamoyeneba standartuli hidrataciis magier araa naCvenebi

III A

natriumis bikarbonatis 0.84% xsnaris infuzia standartuli hidrataciis magivrad araa naCvenebi

III A

mZime Tqd

SeiZleba ganxiluli iyos profilaqtikuri hemofiltraciis Catareba kompleqsuri tki Catarebamde 6 saaTiT adre

IIb B

rogorc profilaqtikuri RonisZieba, prevenciuli Tirkmlis gadanergva araa rekomendebuli

III B

a mtkicebulebaTa klasi. b mtkicebulebis doneg gansakuTrebiT roca pacientis ggfs < 40 ml/wT/1.73

26

12. revaskularizacia sarqvlovani intervenciis saWiroebis mqone pacientebSi

qvemoT moyvanili cxrili moicavs sarqvlovani intervenciisa da mio-kardiumis revaskularizaciis erToblivi Catarebis rekomendaciebs pirveladi diagnozisa da sarqvlovani paTologiis tipis mixedviT

rekomendaciebi koronaruli da sarqvlovani intervenciebis kombinirebis Sesaxeb

klasia doneb

diagnostikuri meTodebi

koronaruli angiografia rekomendebulia roca pacients aqvs mZime sarqvlovani paTologia, ris gamoc igegmeba sarqvelze operacia da aris romelime qvemoT CamoTvlili:• kad anamnezSi• eWvi miokardiumis iSemiaze• mp sistoluri disfunqcia• > 40 welze asakis mamakacebi, qalebi - menopauzis Semdeg, • ≥ 1 kardiovaskularuli risk-faqtori

I C

koronaroangiografia rekomendebulia meoradi mitraluri regurgitaciiT pacientebis gamokvlevisas.

I C

CT angiografia ganxiuli unda iyos sarqvelze operaciamde gulis mZime sarqvlovani paTologiis da kad dabali albaTobis mqone pacientebSi, an Tu i koronaroangiografiis Catareba teqnikurad ver xerxdeba, an dakavSirebulia maRal riskTan.

IIa C

sarqvelze pirveladi Careva da koronaruli revaskularizacia

akS rekomendebulia aortis/mitralur sarqvelze operaciisas, roca mTavari koronaruli arteriebis Seviwroebulia > 70% -iT.

I C

akS Catareba ganxiluli unda iyos aortis/mitralur sarqvelze operaciisas, roca mTavari koronaruli arteriebi Seviwroebulia 50-70%-iT.

IIa C

tki ganxiluli unda iyos TAVI saWiroebis SemTxvevaSi, roca koronaruli arteriis proqsimalur segmentSi aris > 70% Seviwroeba.

IIa C

pirveladi revaskularizacia da ara-koronaruli intervenciebimitralur sarqvelis qirurgia rekomendebulia mZime mitraluri regurgitaciis da mpgf > 30% mqone pacientebSi romlebsac utardebaT akS

I C

mitraluri sarqvlis qirurgia ganxiluli unda iyos zomieri mitraluri regurgitaciis mqone pacientebSi, romlebsac utardebaT akS simptomuri gaumjobesebis mizniT.

IIa B

zomieri, an mZime mitraluri regurgitaciis aRdgena unda ganxiluli iyos pacientebSi, romlebsac aqvT akS pirveladi Cvenebebi da mpgf ≤ 35%

IIa B

27

rekomendaciebi koronaruli da sarqvlovani intervenciebis kombinirebis Sesaxeb (gagrZeleba)

klasia doneb

pirveladi revaskularizacia da ara-koronaruli intervenciebi

stres testi Catareba unda iyos ganxiluli akS pirveladi Cvenebis mqone pacientebSi Tanmxlebi zomieri mitraluri naklovanebiT, iSemiis da regurgitaciis simZimis SefasebisaTvis.

IIa C

aortis sarqvlis qirurgia unda iyos ganxiluli pacientebTan, romlebsac aqvT akS pirveladi Cvenebebi da Tanmxlebi zomieri aortuli stenozi (sarqvlis farTobi 1.0-1.5 sm2 [0.6 sm2/m2 – 0.9 sm2/m2] an saSualo aortuli gradienti 25-40 mm.vwy.sv.

IIa C


13. Tanmxlebi karotiduli/periferiuli arteriebis daavadeba

akS win saZile arteriis daavadebis skriningis rekomendaciebi Semdeg cxrilSia moyvanili.

saZile arteriis gamokvlevis rekomendaciebi aorto-koronarul Suntirebamde

klasia doneb

pacientebTan, romelTac utardebaT akS, rekomendebulia kranialuri arteriebis dopler ultrabgeriTi skanireba, Tu maT anamnezSi aReniSnebaT insulti/tiS, an Suili auskultaciiT.

I C

doplerografia unda iyos ganxiluli, roca pacientebs aqvT mravalsisxlZarRvovani kad, pad, an > 70 wlis asaki.

IIa C

mrI, Ct, an digitaluri subtraqciuli angiografia SeiZleba ganvixiloT, Tu ultrabgeriT dadgenilia saZile arteriebis stenozi > 70% da igegmeba miokardiumis revaskularizacia.

IIb C

arastabiluri kad mqone pacientebSi, romlebic saWiroeben gadaudebel akS da ara aqvT uaxloes warsulSi gadatanili insulti/giS karotiduli arteriebis Seviwroebebis skriningi araa naCvenebi.

III B


28

karotiduli arteriebis revaskularizaciis rekomendaciebi akS saWi-roebis mqone pacientebSi mocemulia qvemoT moyvanil cxrilSi

saZile arteriebis rekanalizaciis rekomendaciebi aorto-koronaruli Suntirebis saWiroebisas

klasia doneb

sas an kee unda tardebodes specialistebis gundis mier, romelsac miRebuli aqvs 30 dReSi kombinirebuli sikvdiloba/insultis maCveneblebi:< 3% adre nevrologiuri simptomebis armqone pacientebSi< 6% anamnezSi nevrologiuri simptomebis mqone pacientebSi

I A

rekomendebulia, rom karotiduli revaskularizaciis Cvenebebis dadgena moxdes yvela SemTxvevaSi individualurad, multidisciplinuri gundis ganxilvis Sedegad nevrologis monawileobiT.

I C

procedurebis Catarebis dro (sinqronulad, Tu etapobrivad) unda gansazRvron lokaluri specialistebis mier da klinikuri suraTis mixedviT, pirveli zemoqmedeba unda moxdes ufro metad simptomatiur teritoriaze.

IIa C

< 6 Tvis periodSo gadatanili giS/insultiT pacientebi karotiduli revaskularizacia rekomendebulia saZile arteriebis 70-99% stenozis arsebobisas

I C

karotiduli revaskularizacia Seizleba ganxiluli iyos arteriebis 50-69% stenozis asrebobisas, klinikuri mdgomareobisa da individualuri faqtorebis gaTvaliswinebiT

IIb C

pacientebi < 6 Tvis ganmavlobaSi gadatanili giS/insultis gareSekarotiduli revaskularizacia SeiZleba ganxiluli iyos bilateraluri karotiduli 70-99%-iani stenoziT mamkacebTan an saZile arteriis 70-99%-iani stenozis da kontrlateraluri okluziis arsebobisas

IIb C

karotiduli revaskularizacia SeiZleba ganxiluli iyos mamkacebTani karotiduli 70-99%-iani stenoziT da gadatanili ipsilateraluri usimptomo cerebruli infarqtiT.

IIb C


karotiduli arteriebis revaskularizaciis meTodis SesarCevi reko-mendaciebi Semdeg cxrilSia aRwerili

29

saZile arteriebis revaskularizaciis meTodis SerCevis rekomendaciebi

klasia doneb

pacientebTan, romelTac utardebaT akS, karotiduli revaskularizaciis meTodis (sas an kee) SerCeva unda moxdes Tanmxlebi daavadebebis, supra-aortuli arteriebis anatomiis, akS saswrafoebis da lokalur gamocdilebis gaTvaliswinebiT.

IIa B

aspirinis miReba rekomendebulia uSualod saZile arteriis revaskularizaciis win da proceduris damTavrebisTanave

I A

ormagi antiagregaciuli mkurnaloba aspiriniTa da klopidogreliT rekomendebulia pacientebSi, romelTac CautardaT sas sul mcire 1 wlis ganmavlobaSi

I B

kee ganxiluli unda iyos Semdeg SemTxvevebSi: • radiaciis Semdgomi, an postqirurgiuli stenozi• simsuqne, mokle kiseri, traqeostoma, xorxis dambla• saZile arteriis sxvadasxva donis stenozi, an SigniTa saZile arteriis zemo nawilis stenozi• mZime Tanmxlebi davadebebiT, romlebi sas-Tvis winaaRmdegCvenebaa.

IIa C


kad da pad mqone pacientebis marTvis rekomendaciebi moyvanilia Semdeg cxrilSi

koronaruli arteriebis daavadebisa da periferiuli arteriebis daavadebis mqone pacientebis marTvis rekomendaciebi

klasia doneb

mks mqone pacientebSi rekomendebulia gadavdoT vaskularuli operacia da jer vumkurnaloT kad-s, garda iseTi SemTxvevebisa roca operaciis gadadeba safrTxes uqmnis sicocxles, an kiduris SenarCunebas.

I C

akS da tki Soris arCevani unda Catardes kad marTvis zogadi rekomenaciebis Sesabamisad: kad formis, Tanmxlebi daavadebebisa da klinikuri mdgomareobis gaTvaliswinebiT.

I C

maRali riskis sisxlZarRvovani operaciis win miokardiumis profilaqtikuri revaskularizaciis Catareba SeiZleba ganxilul iyos stabilur pacientebTan, Tu maT aqvT gavrcelebuli iSemiis persistuli niSnebi, an maRali kardiuli riski.

IIb B

a mtkicebulebaTa klasi. b mtkicebulebaTa done. g maRali gulsisxlZarRvovani riski (monacemebis mixedviT gulsisxlZarRvovani riski > 5%): 1) aortis an sxva msxvili sisxlZarRvis operatiuli mkurnaloba; 2) qirurgiuli Careva periferiul sisxlZarRvebze.

30

14. ganmeorebiTi revaskularizacia da hibriduliprocedurebi

akS Semdgomi iSemia SeiZleba, ganviTardes an natiuri sisxlZarRvebis daavadebis progresirebiT an Suntebis degeneraciuli dazinebis gamo. me-6 cxrilSi mocemulia akS Semdeg Suntebis gamavlobis maCveneblebi, literaturis monacemebis mixedviT.

cxrili 6. Suntebis gamavloba akS Semdeg

iSunti 1 wlis gamavloba 4-5 wlis gamavloba ≥ 10 wlis gamavloba

venuri Sunti 75-95% 65-85% 32-71%sxivis arteria 92-96% 90% 63-83%marcxena gulmkerdis Sida arteria

> 95% 90-95% 88-95%

marjvena gulmkerdis Sida arteria

> 95% > 90% 65-90%

ganmeorebiTi revaskularizaciis rekomendaciebiklasia doneb

adreuli postoperaciuli iSemia da Sintis ukmarisobakoronaruli angiografia rekomendebulia, Tu pacients aReniSneba:• perioperaciuli miokardiumis infarqtis damadasture-beli iSemiis simptomebi da/an biomarkerebis cvlilebebi. • iSemiuri ekg cvlilebebi, romlebic miuTiTeben riskis qveS myofi miokardis did zonaze.• axladaRmocenebuli mp asinergiuli ubnebi.• hemodinamikuri arastabiluroba

I C

rekomendebulia, rom kardiologiurma gundma saswrafod miiRos gadawyvetileba ganmeorebiTi akS an tki Catarebis Taobaze, lokaluri SesaZleblobebis, riskis qveS myofi iSemiuri ubnis zomis, Tanmxlebi daavadebebis da klinikur mdgomareobis gaTvaliswinebiT.

I C

akS Semdgomi adreuli iSemiis SemTxvevaSi, reoperaciasTan SedarebiT upiratesoba eniWeba tki, Tu es teqnikurad SesaZlebelia.

IIa C

tki Catarebis SemTxvevaSi ganxiluli unda iyos natiuri arteriebis an gulmkerdis Sida arteriis revaskularizacia, da ara okluzirebuli an mZimed daziznebuli venuri Suntebis intervencia.

IIa C

akS da tki Semdgom ganmeorebiTi revaskularizaciis rekomendaciebi gadmocemulia momdevno cxrilSi

31

ganmeorebiTi revaskularizaciis rekomendaciebi (gagrZ.)klasia doneb

daavadebis progresireba da Suntebis gviani daxSobaganmeorebiTi revaskularizacia naCvenebia, roca medikamenturi Terapiis miuxedavad pacients aReniSneba mZime simptomatika an gamoxatuli iSemiis niSnebi, xolo Careva teqnikurad Sesrulebadia

I B

tki – Tu misis Catareba SesaZlebelia, unda ganvixiloT rogorc mkurnalobis prioritetuli meTodi, akS-Tan SedarebiT

IIa C

Suntirebuli natiur arteriis tki unda ganvixiloT, rogorc prioritetuli midgoma, Tu es teqnikurad SesaZlebelia.

IIa C

gulmkerdis SigniTa arteriis Suntad gamoyenebas unda mieces upiratesoba, roca es SesaZlebelia.

I B

ganmeoreba akS unda iyos ganxiluli, Tu pacientis gulmkerdis Sida arteriuli Sunti wina daswvriv arteriasTan daxSulia.

IIa B

ganmeorebiTi akS SeiZleba, gaviTvaliswinoT iseTi dazianebebisa da koronaruli koronarebis anatomiuri monacemebis fonze, rac tki revaskularizacias ar eqvemdebareba

IIb C

gamvali gulmkerdis Sida arteriuli SuntiT pacientebis tki SeiZleba iyos ganxiluli, Tu es teqnikurad SesaZlebelia

IIb C

venuri Suntebis tki-is dros rekomendebulia wamliT dafaruli stentebis gamoyeneba

I A

venuri Suntebze tki-is dros distaluri damcavi mowyobilobebis gamoyebaa rekomendebulia.

I B

restenoziganmeorebiTi tki rekomendebulia, Tu es teqnikurad SesaZlebelia

I C

stentSida restenozebis arsebobisas rekomendebulia wamli dafaruli stentebis gamoyeneba.

I A

stentSida restenozebis arsebobisas rekomendebulia wamli dafaruli balonis gamoyeneba.

I A

IVUS da/an OCT Catareba unda iyos ganxiluli stentirebasTan dakavSirebuli meqanikuri problemebis gamosavlenad

IIa C

stentis Trombozigadaudebeli tki rekomendebulia stentisa da sisxlZarRvis gamavlobis aRsadgenad da miokardis reperfuziisTvis

I C

rekomendebulia ormagi antitrobocituri Terapia klopidogrelze ufro Zlieri P2Y12 inhibitorebis (prasugreli, an tikagrelori) gamoyenebiT.

I C

Ganxiluli unda iyos damatebiT Trombis aspiracia da maRali wneviT balonuri dilatacia.

IIa C

IVUS da/an OCT unda iyos ganxiluli, stentTan dakavSirebuli meqanikuri problemebis dasadgenad

IIa C

hibriduli procedurebi


32

15. ariTmiebi

miokardiumis revaskularizaciis Semdeg ganviTarebuli ariTmiebis mkurnalobis rekomendaciebi moyvanilia cxrilSi.

revaskularizaciis Semdgomi ariTmiebis mkurnalobis rekomendaciebi

klasia doneb

akS Semdgeg winagulTa fibrilaciis aRmocenebis sixSiris Semcirebis mizniT rekomedebulia beta blokerebis daniSvna, Tu ar aris maTi gamoyenebis ukuCveneba.

I A

winagulTa fibrilaciis ganviTarebis maRali riskis mqone pacientebisaTvis ganxiluli unda iyos profilaqtikuri mizniT amiodaronis pre-operaciuli daniSvna.

IIa A

miuxedavad antiagregaciuli mkurnalobisa, tki dros/Semdeg axladaRmocenebuli winagulTa fibrilaciis SemTxvevaSi pacientebSi matulobs insultisa da emboliis riski. amitom, aseT SemTxvevebSi ganxiluli unda iyos antikoagulantebis daniSvna, rogorc es rekomendirebulia winagulTa fibrilaciiT pacinetebisaTvis saTanado gaidlainebis rekomendaciebis Sesabamisad.

IIa C

vinaidan akS Semdeg axladganviTarebuli winagulTa fibrilaciis fonze matulobs insultisa da emboliis riski, SeiZleba ganxiluli iyos aseT pacientebTan antikoagulaciis Catareba sul cota 3 Tvis ganmavlobaSi, SemdgoSi insultis riskis gadafasebiT.

IIa C

insultis riskis Semcirebis TvalsazrisiT, winagulTa fibrilaciiT pacientebSi SeiZleba iyos ganxiluli akS-Tan SeuRlebuli marcxena winagulis danamatis qirurgiuli okluzia /amokveTa

IIb C


33

miokardiumis revaskularizaciis fonze parkuWovani ariTmiis preven-ciis rekomendaciebi ixileT momdevno cxrilSi.

revaskularizaciiT parkuWovani ariTmiis prevenciis rekomendaciebi

klasia doneb

hospitlis gareT ganviTarebuli gulis gaCerebis Semdeg gadarCenil pacientebTan ganxiluli unda iyos gadaudebeli koronarografiis da, saWiroebis SemTxvevaSi revaskularizaciis Catarebis sakiTxi, ekg monacemebis miuxedavad, Tu aSkarad ar ikveTeba ariTmiis ganviTrebis sxva arakoronaruli mizezi.

IIa B

pacientTan eleqtruli Stormis SemTxvevaSi, ganxiluli unda iyos urgentuli koronarografiisa da saWiroebis Sesabamisad - revaskularizaciis Catarebis sakiTxi.

IIa C

kad-iT da marcxena parkuWis gandevnis fraqciiT <35% pacientebTan, profilaqtikurad ICD implantaciamde ganxiluli unda iyos rezidualuri iSemiis gamosavlenad testirebis da Semdgomi revaskularizaciis Catarebis sakiTxi. revaskularizaciis Semdgomi 6 YTvis ganmavlobSi rekomendirebulia marcxena parkuWis Seqcevadi remodelirebis Sefaseba sanam profilaqtikuri mizniT iqneba ICD implantatirebuli.

IIa B


16. aorto-koronaruli Suntirebis proceduruli aspeqtebi

cxrilSi mocemulia rekomendaciebi akS proceduruli aspeqtebis Sesaxeb

rekomendaciebi aorto-koronaruli Suntirebis proceduruli aspeqtebis Sesaxeb

klasia doneb

operaciebis Catareba rekomendebulia gulis qirurgiisaTvis specialuri aRWurvilobis mqone hospitlebSi da daxelovnebuli gundis mier, specialuri werilobiTi protokolebis mixedviT.

I B

fexebze Wrilobebis garTulebebis Semcirebis mizniT, ganxiluli unda iyos venebis endoskopiuri preparireba.

IIa A

ganxiluli unda iyos gulmkerdis Sida arteriis rutinuli skeletinizaciuri preparireba.

IIa B

Saqriani diabetiT pacientebSi, an bilateralurad arteriuli Suntebis gamoyenebis gadawyvetilebis SemTxvevaSi rekomendirebulia gulmkerdis Sida arteriis rutinuli skeletonizaciuri preparireba.

I B

34

rekomendaciebi aorto-koronaruli Suntirebis proceduruli aspeqtebis Sesaxeb (gagrZel.)

klasia doneb

rekomendebulia miokardiumis sruli revaskularizacia I Brekomendebulia wina daswvrivi arteriis Suntireba gulmkerdis SigniTa arteriiT

I B

< 70 asakis pacientebTan ganxiluli unda iyos ormxrivi gulmkerdis Sida arteriebiT Suntireba.

IIa B

sxivis arteriis Suntis gamoyeneba rekomendebulia mxolod samizne koronaruli sisxlZarRvebis mkveTris Seviwroebebis arsebobisas.

I B

venebis cudi xarisxis SemTxvevaSi sruli arteriuli revaskularizaciaa rekomendebulia pacientis asakis miuxedavad.

I C

sruli arteriuli revaskularizacia unda iyos ganxiluli Tu pacientis sicocxlis mosalodneli xangrZlivoba mniSvnelovania.

IIa B

rekomendebulia aortaze manipulaciebis minimaluramde dayvana. I BOff-pump operaciebis didi gamocdilebis centrebSi maRali riskis jgufis pacientebTan ganxiluli unda iyos Off-pump akS.

IIa B

aRmavali aortis gamoxatuli aTerosklerozuli dazinebis SemTxvevaSi, perioperaciuli insultis riskis Semcirebis mizniT, rekomendirebulia akS Catareba Off-pump da/an non-touch on-pump techniques gamoyenebiT.

I B

wina daswvrivi arteriis izolirebuli SeviwroebiT pacientebTan ganxiluli unda iyos minimalurad invaziuri akS Catarebis sakiTxi.

IIa C

70-ze meti asakis da/an gamoxatuli generalizebuli aTerosklerozuli dazianebebiT pacientebTan ganxiluli unda iyos aRmavali aortis ekg-Ti trigeruli CT skanirebis an epiaortuli skanirebis sakiTxi.

IIa C

ganxiluli unda iyos intraoperaciulad SuntebSi sisxlis nakadis gazomvebis rutinulad Catareba.

IIa C


17. transkutanuri koronaruli intevenciis proceduruli aspeqtebi

fraqciuli nakadis rezervis (FFR), intravaskuluri ultrabgeriTi kv-levis (IVUS) da optikuri koherentuli tomografis (OCT) gamoyenebisa da klinikuri mniSvnelobis rekomendaciebi moyvanilia Semdeg cxrilSi.

35

rekomendaciebi intrakoronaruli diagnostikuri teqnikis klinikuri mniSvnelobis Sesaxeb

klasia doneb

stabilur pacientebSi, roca iSemiis mtkicebulebebi araris xelmisawvdomi, FFR gamoavlens koronarebis hemodinamiurad mniSvnelovan Seviwroebebs.

I A

mravalsisxlZarRvovani paTologiis mqone pacientebSi FFR warmoadgens tki gzamkvlevs.

IIa B

garkveul pacientebSi IVUS iZleva stentis implantaciis optimizacias.

IIa B

IVUS gamoyeneba „daucveli marcxena mTavari Reros” dazianebis simZimis Sesafaseblad da mkurnalobis optimizaciisaTvis

IIa B

IVUS an OCT warumatebeli stentirebis meqanizmis SefasebisaTvis. IIa CIVUS garkveul pacientebSi stentis implementaciis optimizaciisTvis

IIb C


specifiuri dazianebebis tki mkurnalobis rekomendaciebi mocemulia Sem-deg cxrilSi.

specifiuri dazianebebis mkurnalobis rekomendaciebi

klasia doneb

ostialuri tipis Seviwroebebis tki SemTxvevaSi ganxiluli unda iyos wamliT dafaruli stentebis gamoyeneba.

IIa B

bifurkaciuli tipis Seviwroebebis tki SemTxvevaSi, sasurvelia jer stentis implantacia mTavar arteriaSi, Semdgomi - saWiroebis mixedviT, gverdiTi totis balonuri dilataciiT da stentirebiT an mis gareSe.

IIa A

qronikuli okluziis perkutanuli rekanalizaciis Catareba ganxiluli unda iyos im SemTxvevaSi, roca mosalodnelia gulis kunTis Sesabamisi ubnis iSemiis Semcireba da/an stenokardiis Semsubuqeba.

IIa B

qronikuli okluziis retrograduli rekanalizaciis Catarebis sakiTxi, SeiZleba iyos ganxiluli warumtebeli antegraduli rekanalizaciis Semdeg, an garkveul pacientebTan rogorc pirveladi meTodi.

IIb C


18. antiTrombotuli mkurnaloba

stabiluri kad-iT pacientebTan tki Catarebis SemTxvevaSi antiTrom-botuli mkurnalobis rekomendaciebi warmodgenilia Semdeg cxrilSi.

36

rekomendaciebi stabiluri koronaruli arteriebis daavadebis mqone pacientebis antiTrombuli mkurnalobisTvis, romlebsac unda CautardeT transkutanuri koronaruli intervencia

klasia doneb

winaswari antiagregantuli mkurnalobagegmiuri tki SemTxvevaSi roca anatomiuri Taviseburebebi cnobilia, rekomendirebulia 600 mg klopidogreliT mkurnalobis dawyeba proceduramde 2 an meti saaTiT adre,

I A

mniSvnelovani kad arsebobis maRali albaTobis SemTxvevaSi, SeiZleba gavnixiloT klopidogreliT pacientis winaswari mkurnalobis dawyeba.

IIb C

pacientis 75 mg klopidogreliT mkurnalobis fonze, Tu mas daudginda tki Cveneba, SeiZleba ganxiluli iyos proceduris win axali datvirTvis dozis 600 mg klopidgrelis micemis sakiTxi.

IIb C

antiagregaciuli Terapia tki procesSiaspirini naCvenebia gegmiuri stentirebis proceduramde. I Baspirinis oraluri doza 150-300 mg (an 80 - 150 mg i/venurad) rekomendebulia, Tu pacienti manamde aspirins ar Rebulobda

I C

gegmiuri stentirebis SemTxvevaSi rekomendebulia klopidogreli mkurnaloba (datvirTvis doziT 600 mg, an meti, 75 mg dRiurad - SemanarCunebeli doza)

I A

GP IIb/IIIa antagonistebis gamoyeneba ganxiluli unda iyos mxolod gansakuTrebul SemTxvevebSi.

IIa C

antiagregaciuli mkurnaloba stentirebis Semdegmetalis stentebis implantaciis Semdeg oaaT naCvenebia sul cota 1 Tvis ganmavlobaSi

I B

wamliT dafaruli stentebis implantaciis Semdeg oaaT naCvenebia 6 Tvis ganmavlobaSi.

I C

wamliT dafaruli stentebis implantaciis SemTxvevaSi, Tu pacients aqvs sisxldenis maRali riski, SeiZleba ganvixiloTs oaaT (< 6 Tveze) periodis Semokleba.

IIb A

antiagregantuli monoTerapia, Cveulebriv aspiriniT, rekomendirebulia mTeli sicocxlis ganmavlobaSi

I A

rekomendebulia pacientebis informireba antiagregaciuli mkurnalobis mniSvnelobis Sesaxeb

I C

iSemiis maRali riskis da sisxldenis dabali riskis mqone pacientebTan, oaaT SeiZleba dainiSnos 6 Tveze meti xangrZlivobiT

IIb C

antikoagulaciuri mkurnalobaarafraqcionirebuli heparini 70-100 U/kg I Bbivalirudini (0.75 mg/kg bolusiT, Semdeg 1.75 mg/kg/sT proceduris Semdeg 4 sT. ganmavlobaSi) hepariniT gamowveuli Trombocitopeniis SemTxvevaSi

I C

bivalirudini (0.75 mg/kg bolusiT, Semdeg 1.75 mg/kg/sT proceduris Semdeg 4 sT. ganmavlobaSi) sisxldenis maRali riskis pacientebis jgufSi.

IIa A

enoqsaparini i/venurad 0.5 mg/kg IIa Ba mtkicebulebaTa klasi. b mtkicebulebis done

37

NSTE-ACS pacientebis antiTrombuli mkurnalobis rekomendaciebi ix. momdevno cxrilSi

antiTrombuli mkurnalobis rekomendaciebi NSTE-ACS pacientebisaTvis, romlebsac utardebaT tki

klasia doneb

antiagregaciuli mkurnaloba

miuxedavad mkurnalobis strategiisa, ukuCvenebebis ararsebobisas, aspirini rekomendebulia yvela pacientisTvis, sawyisi doziT 150-300 mg (an 80-150 mg i/venurad) da SemanarCunebeli doziT 75-100 mg dRiurad xangrZlivi droiT

I A

aspirinTan erTad rekomendrebulia P2Y12

inhibitorebis miReba daaxloebiT 12 Tvis ganmavlobaSi, Tu araris winaaRmdegCveneba sisxldenis maRali riskis saxiT. mkurnalobis sxva variantebia:

I A

• prasugreli (60 mg datvirTvis doza, 10 mg dRiuri doziT) eniSnebaT pacientebs, romelTa koronaruli anatomia cnobilia da romlebic emzadebian tki-saTvis.

I B

• tikagrelori (180 mg datvirTvis dozza, 90 mg orjer dReSi) iSemiuri movlenebis zomieridan - maRali riskis mqone pacientebSi, miuxedavad sawyisi mkurnalobis strategiisa, klopidogreliT namkurnalebi pirebis CaTvliT.

I B

• klopidogreli (600 mg datvirTvis doza, 75 md dRiuri doza) mxolod maSin, roca prasugreli, an tikagrelori xelmiuwvdomelia

I B

GP IIb/IIIa antagonistebis gamoyeneba unda ganxiluli iyos gadaudebel situaciebSi an Trombotuli garTulebebisas.

IIa C

GP IIb/IIIa antagonistebiT winaswari mkurnalobis dawyeba, ar aris rekomendebuli, Tu pacientis koronaruli anatomia ar aris Seswavlili.

III A

prasugreliT winaswari mkurnaloba, roca koronaruli anatomia araaris Seuswavlelia, araris rekomendebuli.

III B

antikoagulaciuri mkurnaloba

pacientebisaTvis, romlebsac utardebaT tki, antiTrombocitarul mkurnalobasTan erTad naCvenebia antikoagulaciuli Terapia.

I A

antikoagulaciuri mkurnalobis SerCeva xdeba rogorc iSemiis, ise sisxldenis riskebis gaTvaliswinebiT, agreTve preparatebis efeqturoba/usafrTxoebis profilis gaTvaliswinebiT.

I C

tki dros bivalirudini (0.75 mg/kg bolusiT, Semdeg 1.75 mg/kg/sT doziT daax. 4 saaTis ganmavlobaSi proceduris Semdeg) rekomendebulia rogorc afh alternativa, GP IIb/IIIa antagonistebTan erTad

I A

afh rekomendebulia tki dros, roca bivalirudinis gamoyeneba araris Sesazlebeli.

I C

38

antiTrombuli mkurnalobis rekomendaciebi NSTE-ACS pacientebisaTvis, romlebsac utardebaT tki (gagrZ.)

klasia doneb

fondaparinuqsiT namkurnaleb (2.5 mg dReSi kanqveS) pacientebSi, tki Catarebisas rekomendirebulia afh erTi bolusi (85 U/kg, an 60 U/kg, Tu erTdroulad gamoiyeneba GP IIb/IIIa antagonisteb.) Seyvana.

I B

enoqsaparinis kanqveSa ineqciebiT namkurnaleb pacientebSi tki dros ganxiluli unda iyos enoqsapariniT mkurnalobis gagrZeleba.

IIa B

invaziuri proceduris Semdeg, ganxiluli unda iyos antikoagulaciis Sewyveta, Tu ar arsebobs sxva Cveneba

IIa C

afh da dmwh urTierTCanacvleba ar aris rekomendebuli. III Ba mtkicebulebaTa klasi. b mtkicebulebis done

antiTrombocituli mkurnalobis rekomendaciebi STEMI pacintebisaT-vis, romlebsac utardebaT pirveladi tki mocemulia Semdeg cxrilSi

STEMI pacientebis antiTrombuli mkurnalobis rekomendaciebi pirveladi tki dros

klasia doneb

antiTrombocituli mkurnalobamkurnalobis sawyisi strategiis miuxedavad, aspirini rekomendebulia yvela pacientisTvis sawyisi doziT 150-300 mg (an 80-150 mg i/venurad) da SemanarCunebeli doziT 75-100 mg dRiurad xangrZlivi drois ganmavlobaSi, Tu ar aris amis winaaRmdegCvenebebi.

I A

aspirinTan erTad rekomendebulia P2Y12

inhibitorebis miReba daaxloebiT 12 Tvis ganmavlobaSi, Tu ar aris winaaRmdegCveneba sisxldenis maRali riskis saxiT. SesaZlo variantebia:

I A

• prasugreli (60 mg datvirTvis doza, 10 mg dRiuri doziT) ukuCvenebis ararsebobisas.

I B

• tikagrelori (180 mg datvirTvis doza, 90 mg orjer dReSi) ukuCvenebis ararsebobisas.

I B

• klopidogreli (600 mg datvirTvis doza, 75 md dRiuri doza), roca prasugrelis, an tikagreloris gamoyeneba ar aris xelmisawvdomi an ukunaCvenebia.

I B

pacientisaTvis P2Y12

inhibitorebis micema rekomendebulia pirveli samedicino kontaqtisTanave.

I B

GP IIb/IIIa antagonistebi gamoyeneba, ganxiluli unda iyos gadaudebel SemTxvevebSi an no-reflow-s ganviTarebisas, an Trombotuli garTulebebisas.

IIa C

39

STEMI pacientebis antiTrombuli mkurnalobis rekomendaciebi pirveladi tki dros (gagrZ.)

klasia doneb

intervenciamde GP IIb/IIIa-is daniSvna, SeiZleba ganxiluli iyos maRali riskis mqone pacientebSi, roca igegmeba maTi gadayvana pirveladi tki Casatareblad

IIb B

antikoagulantebitki dris rekomencirebulia yvela pacientTan antikoagulantebis gamoyeneba antiatrombocituli mkurnalobis damatebiT.

I A

antikoagulantebis SerCeva xdeba rogorc iSemiis, ise sisxldenis riskis gaTvaliswinebiT, preparatis efeqturoba/usafrTxoebis profilis Sesabamisad

I C

arafraqciuli heparini:70-100 U/kg i/v bolusiT, Tu ar igegmeba GP IIb/IIIa antagonistebis gamoyeneba 50-70 U/kg i/v. bolusiT GP IIb/IIIa antagonistebTan kombinaciaSi.

I C

bivalirudini 0.75 mg/kg i/v bolusiT, Semdeg 1.75 mg/kg/sT doziT proceduridan . 4 saaTis ganmavlobaSi.

IIa A

enoqsaparini i/v 0.5 mg/kg doziT GP IIb/IIIa antagonistebTan erTad an maT gareSe

IIa B


oraluri antikoagulaciur Terapiaze myofi pacientebisaTvis tki Cat-arebisas antiTrombocituli mkurnalobis rekomendaciebi warmodge-nilia qvemoT moyvanil cxrilSi.

oraluri antikoagulaciur Terapiaze myofi pacientebisaTvis tki Catarebisas antiTrombocituli mkurnalobis rekomendaciebi

klasia doneb

oraluri antikoagulaciis mtkice Cvenebebis SemTxvevaSi (mag. mocimcime ariTmia CHA

2 DS

2-VAS

g qulebi ≥ 2, venuri

Tromboembolizmi, mp Trombi, an meqanikuri sarqveli) rekomendirebulia oraluri antikoagulaciis Catareba antiatrombocitul mkurnalobasTan erTad.

I C

oralur antikoagulaciis saWiroebis mqone pacientebis jgufSi, axali Taobis wds gamoyenebas aqvs upiratesoba metalis stentebTan SedarebiT, mxolod dabalia (HAS-BLED ≤ 2) sisxldenis riski SemTxvevebSi.

IIa C

stabiluri koronaruli daavadebiT da mocimcime ariTmiiT pacientebSi metalis an wds stentebis implantaciis Semdeg, roca CHA

2 DS

2-VAS

g qulebi ≥ 2 sisxldenis dabali riskis fonze (HAS-

BLED ≤ 2), ganxiluli unda iyos sammagi mkurnaloba sakiTxi: (N)OAC, aspiriniT (75-100 mg/dReSi) da klopidogreliT 75 mg/dReSi - sul cota 1 Tvis ganmavlobaSi, rasac mohyveba ormagi Terapia (N)OAC da aspiriniT 75-100 mg dReSi an klopidogreliT (75 mg/dReSi), daaxloebiT 12 Tvis ganmavlobaSi

IIa C

40

oraluri antikoagulaciur Terapiaze myofi pacientebisaTvis tki Catarebisas antiTrombocituli mkurnalobis rekomendaciebi (gagrZ.)

klasia doneb

stabiluri kad-iT da mocimcime ariTmiiT pacientebSi, roca CHA2

DS2-VAS

g qulebi ≥ 1, sammagi Terapiis alternativad ganxiluli

unda iyos ormagi antitrombocituli Terapia. IIa C

mks da winagulTa fibrilaciiT pacientebSi sisxldenis dabali riskis fonze (HAS-BLED ≤ 2) implantirebuli stentebis tipis miuxedavad, ganxiluli unda iyos sawyisi sammagi Terapiis Catareba (N)OAC, aspiriniT (75-100 mg/dReSi) da klopidogreliT 75 mg/dReSi, 6 Tvis ganmavlobaSi, Semdgomi ormagi Terapiis - (N)OAC da aspiriniT 75-100 mg dReSi an klopidogreliT (75 mg/dReSi), romelic grZeldeba 12 Tvemde.

IIa C

peroraluri antikoagulaciis saWiroebisas, sisxldenis maRali riskis pacientebis jgufSi (HAS-BLED ≥3) implantirebuli stentebis tipis, agreTve klinikuri mdgomareobis (skad Tu mks) miuxedavad ganxiluli unda iyos sawyisi sammagi Terapia (N)OAC, aspiriniT (75-100 mg/dReSi) da klopidogreliT 75 mg/dReSi 1 Tvis ganmavlobaSi, Semdgomi ormagi TerapiiT (N)OAC da aspiriniT 75-100 mg dReSi, an klopidogreliT (75 mg/dReSi).

IIa C

ormagi Terapia (N)OAC da klopidogreliT 75 mg/dReSi SeiZleba ganxiluli iyos rogorc sammagi Terapiis alternativa garkveul SemTxvevebSi.

IIb B

tikagrelorisa da prasugrelis gamoyeneba, rogorc sammagi Terapiis Semadgeneli komponentebisa,araris rekomendebuli.

III C

antikoagulaciuri mkurnaloba tki Semdeg mks-iT pacientebSi

sisxldenis dabali riski mqone garkveuli kategoriis pacientebTan, romlebic Rebuloben aspirins da klopidogrels, tki Catarebis SemTxvevaSi SeiZleba ganxiluli iyos dabali doziT rivaroqsabanis (2,5 mg orjer dReSi) daniSvna.

IIb B

tki dros antikoagulaciuri mkurnalobaze myofi pacientebis parenteraluri antikoagulaciaparaenteraluri antikoagulantebis damatebiT miRebaa rekomendirebuli, miuxedavad peroraluri antikoagulantis bolo dozis miRebis droisa

I C

pirveladi tki dasrulebisTanave ganxiluli unda iyos paraenteraluri antikoagulantebis (bivalirudini, enoqsaparini, an afh) miRebis Sewyveta.

IIa C


41

qirurgiuli Careva saWiroebis SemTxvevaSi ormag antiTrombocitul mkurnalobaze myofi pacientebis marTva xdeba Carevis saswrafoebis, Trombotuli garTulebebisa da sisxldenis individualuri riskis sa-fuZvelze, rogorc es warmoadgenilia sqemaze 4-ze.

Tirkmlebis qr. daavadebiT, pacientebma sxva danarCenebis msgavsad, un-da miiRon igive pirveli rigis antiTrombuli preparatebi, Tu araris winaaRmdegCvenebebi. dozebis SerCeva, unda moxdes Tirkmlebis funq-ciis gaTvaliswinebiT da SesaZloa, zogierT antiTrombul preparats mieniWos upiratesoba, rogorc es me-7 cxrilSia mocemuli,

sqema 4. ormag antiTrombocitul mkurnalobis fonze pacientebis pre-oper-aciuli marTvis algoriTmi gegmiuri/aucilebeli operaciis saWiroebisas

kardiuli/arakardiuli operacia

gadaudebeli naxevrad gegmiurida saswrafo

gegmiuri

operacia individualurigadawyvetileba

davicadoT aucilebeli

ormagi antiagregaci-uli mkurnalobis

dasrulebamde

Trombozis riski

sisxldenisriski

gaagrZeleT aspirini + P2Y12 inhibitorebi

gaagrZeleT aspiriniSeaCereT P2Y12 inhibitorebi

SewyviteT aspirinic

da P2Y12 inhibitorebic

42

cxrili 7. Tirkmlis qr. daavadebiT pacientebSi antiTrombuli preparatebis dozirebis koreqcia

rekomendaciebiaspirini koreqcia saWiro ar arisklopidogreli koreqcia saWiro ar aris

prasugrelikoreqcia saWiro ar aris. ar aris am preparatis gamoyenebis gamocdileba saboloo stadiis Tirkmlis ukmarisobis/dializis dros.

tikagrelorikoreqcia saWiro ar aris. ar aris am preparatis gamoyenebis gamocdileba saboloo stadiis Tirkmlis ukmarisobis/dializis dros.

enoqsaparini

i/venuri gamoyenebisas, kerZod tki dros dozis koreqcia saWiro ar aris.Tu kreatininis klirensi < 30 ml/wT kanqveSa ineqciebis doza unda ganaxevrrdes.

arafraqiuliheparini bolusis dozis koreqcia saWiro ar aris

fondaparinuqsi

Tirkmlis zomieri ukmarisobis (gfs 30-59 ml/wT) SemTxvevaSi doza mcirdeba 2.5 mg-dan 1.5 mg-mde kanqveS, erTjer dReSi. preparati ukunaCvenebia Tirkmlis mZime ukmarisobis (gfs < 30 ml/wT) dros.

bivalirudini

• Tirkmlis zomieri ukmarisobis (gfs 30-59 ml/wT) dros saWiroa sawyisi infuzia ufro dabali doziT – 1.4 mg/kg/sT• Tirkmlis mZime ukmarisobis (gfs < 30 ml/wT) dros bivalirudini ar unda dainiSnos..• bolusis dozis Semcireba saWiro ar aris

absiqsimabi specifiuri rekomendaciebi ar arsebobs. sifrTxiliT gaiTvaliswineT sisxldenis riski

eptifibatidi

• Tirkmlis zomieri ukmarisobis (gfs ≥ 30 da < 50 ml/wT) dros unda gamoviyenoT i/v bolusi 180 mkg, Semdgomi xangrZlivi infuzia 1.0 mkg/kg/wT doziT.• Tirkmlis mZime ukmarisobis (gfs < 30 ml/wT) dros eptifibatidi ar unda dainiSnos.

tirofibani Tirkmlis mZime ukmarisobis(gfs < 30 ml/wT) dros infuziis doza sasurvelia Semcirdes 50%-iT(0.05 mkg/kg/wT).

43

Semdeg cxrilSi warmodgenilia pacientebis antitrombocituli Tera-piis zogadi rekomendaciebi miokardiumis revaskularizaciis Cat-arebis dros.

antiagregaciuli mkurnalobis zogadi rekomendaciebi

klasia doneb

protonis tumbos inhibitorebis gamoyeneba oaaT-sTan kombinaciaSi rekomendebulia im pacientebTan, romlebsac anamnezSi aqvT kuWnawlavidan sisxldena an peptiuri wyluli, agreTve sxvadasxva riskis faqtori (mag. Helicobacter pylori inficireba, asaki > 65 welze, antikoagulantebiT Tanmxlebi mkurnaloba, anTebis sawinaaRmdego arasteroiduli preparatebis an steroidebis gamoyeneba).

I A

skad dros aspirinis autanlobis SemTxvevaSi naCvenebia alternativis saxiT klopidogreli 75 mg dReSi gamoyeneba.

I B

Trombocitebis funqciis gamokvleva, an genetikuri testireba SeiZleba ganvixiloT specifiur maRali riskis situaciebSi (mag. anamnezSi stentis Trombozi, rezistentobis eWvi; sisxldenis maRali riski).

IIb C

trombocitebis funqciis rutinulad gamokvleva, an genetikuri testi (klopidogreli, aspirini) antiagregantuli mkurnalobis koregirebisTvis gegmiur stentirebamde, an mis Semdeg, rekomendebuli ar aris.

III A

mkurnalobis SewyvetaantiTrombocituli Terapiis Sewyveta mkurnalobis dagegmil periodSi ar aris rekomendirebuli. I C

P2Y12

inhibitorebiT mkurnalobis fonze ara-gadaudebeli, didi moculobis operaciis saWiroebisas (akS CaTvliT), unda ganvixiloT qirurgiuli Carevis gadavadebis sakiTxi 5 dRiT mainc tikagreloris, an klopidogrelis, xolo sul mcire 7 dRiT – prasugrelis miRebis Sewyvetis Semdeg, Tu es klinikurad misaRebia da Tu pacientis ara aqvs iSemiuri garTulebebis maRali riski.

IIa C

ganxiluli unda iyos akS Semdeg klopidogreliT mkurnalobis aRdgena, rogorc ki es usafrTxod CaiTvleba.

IIa C

ganxiluli unda iyos akS Semdeg tikagreloriT mkurnalobis aRdgena, rogorc ki es usafrTxod CaiTvleba.

IIa C

Trombocitebis funqciis gamokvleva gamoyenebuli unda iyos ufro antiagregaciuli mkurnalobis SeCerebis gadawyvetilebis misaRebad, vidre akS garkveuli droiT gadavadebis saWiroebis gansazRvisaTvis.

IIa C


44

19. gamocdileba-Sedegianobis urTierTdamokidebuleba revaskularizaciis procedurebis Catarebisas

operatoris gamocdileba gavlenas axdens Sedegebze, gansakuTrebiT kritikul, rTul situaciebSi. momsaxurebis Sedegebis gaujobeseba mWidrodaa dakavSirebuli saavadmyofos mTeli gundis TiToeuli wevris gamocdilebis zrdasTan. Semdeg cxrilSi moyvanilia rekomen-daciebi akS-Si da tki-Si treiningis, gamocdilebisa da operatoris/instituciuri kompetenturobis Sesaxeb.

rekomendaciebi aorto-koronaruli Suntirebisa da transkutanuri koronaruli intervenciisaTvis saWiro treiningis, gamocdilebis da operatoris/instituciuri kompetenciebis Sesaxeb

klasia doneb

kardioqirurgiaSi damoukidebeli saqmianobis dawyebamde, rezidentma mzadebis periodSi unda Seasrulos zedamxedvelobis qveS sul cota 200 akS operacia

IIa C

klinikis wliuri samuSao datvirTvis moculoba unda iyos sul mcire 200 akS operacia

IIa C

rekomendebulia, rom gulmkerdis Sida arteriis gamoyenebiT Suntireba unda tardebodes rutinulad > 90%-ze SemTxvevaSi.

I B

rekomendebulia akS Sedegebis asaxva erovnul registrebSi da/an EACTS monacemTa bazaSi

I C

intervenciul kardiologiaSi mzadebisas rezidentebma unda gaiaron treiningi 1-2 wliani programa iseT dawesebulebaSi, sadac mimdinareobs mwvave koronaruli sindromiT pacientebis momsaxureba 24 saaTis da kviraSi 7 dRis ganmavlobaSi, da yovelwliurad tardeba sul cota 800 tki.

IIa C

intervenciul kardiologiaSi damoukidebeli saqmianobis dawyebamde, rezidentma mzadebis periodSi unda Seasrulos pirveli operatoris rolSi an damoukideblad sul cota 200 tki procedura, romelTaganac erTi mesamedi unda iyos gadaudebeli, an mks SemTxveva.

IIa C

nacionalurma sazogadoebebma unda SeimuSaon rekomendaciebi dawesebulebisa da operatorisaTvis wliurad Casatarebeli samuSao datvirTis taobaze. evrogaerTianebis specialuri komisiis rekomendaciebi operatorisa da saavadmyofos samuSao datvirTvis Sesaxeb qvemoTaa warmodgenili:

IIa C

mwvave koronaruli sindromis dros tki unda Caataros specialuri mzadebis mqone operatorma, romelic weliwadSi atarebs sul mcire 75 proceduras iseT dawesebulebaSi, sadac organizebulia am kategoriis pacientebis momsaxureba 24 saaTis da kviraSi 7 dRis ganmavlobaSi, da tardeba sul cota 400 intervenciuli proceduraa weliwadSi.

IIa C

45

rekomendaciebi aorto-koronaruli Suntirebisa da transkutanuri koronaruli intervenciisaTvis saWiro treiningis, gamocdilebis da operatoris/instituciuri kompetenciebis Sesaxeb (gagrZ.)

klasia doneb

• stabiluri kad dros tki unda Caataros specialuri mzadebis mqone operatorma, romelic atarebs wliurad sul mcire 75 manipulacias, iseT dawesebulebaSi, sadac tardeba sul mcire 200 koronaruli intervencia weliwadSi

IIa C

• dawesebulebebi, sadac wliuri tardeba < 400 tki, unda daamyaron, TanamSromloba didi datvirTvis mqone centrebTan (> 400 tki meti weliwadSi) protokolebis, gamocdili operatore- bisa da damxmare personalis erToblivi gamoyenebis mizniT.

IIa C

arasaswrafo maRali riskis tki procedurebi, rogoricaa distaluri marcxena mTavari Reros paTologia, bifurkaciuri tipis kompleqsuri dazianebebi, erTaderTi gamavali koronaruli arteria, da rTuli qr. okluziebi, unda Catardes saTanado momzadebis operatoris mier iseT centrebSi, romlebsac gaaCniaT intesiuri daxmarebis palatebSi pacientbis marTvis da xelovnuri sisxlis mimoqcevis gamoyenebis Sesazleblobebi, agreTve upiratesoba unda mieces adgilobrivi kardioqirurgiuli samsaxuric arsebobas.

IIa C


20. medikamenturi mkurnaloba, meoradi prevencia da xangrZlivi dakvirvebis strategiebi.

meoradi prevencia da kardiuli reabilitacia revaskularizaciis Sem-dgomi periodis ganuyofeli Semadgeneli nawilia, radganac amgvari midgoma amcirebs pacientebis avadobasa, sikvdilobas, aumjobesebs maT simptomur mdgomareobas da momsaxurebis xarjTefeqturobas. qvemoT moyvanil cxrilSi mocemulia xangrZlivi medikamenturi Tera-piis, meoradi prevenciisa da kardiuli reabilitaciis rekomendaciebi

miokardiumis revaskularizaciis Semdgom prognozis gaumjobesebis mizniT xangrZlivi medikamenturi mkurnalobis, cxovrebis stilis Secvlis, kardiuli reabilitaciis programaSi CarTvis rekomendaciebi

klasia doneb

koronaruli arteriebis daavadebakad-iT pacientebiaTvis, revaskularizaciis Semdeg naCvenebia statinebiT mkurnalobis Catareba LDL-C samizne donis < 70 mg/dl (< 1.8 mmol/l) misaRwevad, Tu araris amis ukuCvenebebi.

I A

46

miokardiumis revaskularizaciis Semdgom prognozis gaumjobesebis mizniT xangrZlivi medikamenturi mkurnalobis, cxovrebis stilis Secvlis, kardiuli reabilitaciis programaSi CarTvis rekomendaciebi (gagrZ.)

klasia doneb

koronaruli arteriebis daavadebaaspirinis dabali doziT (75-100 mg/dReSi) miReba rekomendebulia kad-iT yvela pacientisTvisg I A

aspirinis autanlobis SemTxvevaSi alternativis saxiT rekomendebulia klopidogrelis miReba

I B

age inhibitorebi rekomendebulia kad-iT yvela pacientisTvis sxvadasxva Tanmxlebi paTologiuri mdgomareobebis (mag. gulis ukmarisoba, hipertenzia, an Saqriani diabeti) arsebobis SemTxvevaSi. age inhibitorebis autanlobisas SemTxvevaSi, maT alternativas warmoadgns arb jgufis preparatebi.

I A

yvela pacients unda mieces rCevebi cxovrebis stilis Secvlis Taobaze (Tambaqos moxmarebis Sewyveta, regularuli fizikuri aqtiuroba da janmrTeli kveba)

I A

hospitalizaciis da invaziuri intervenciebis Catarebis Semdeg yvela pacientebs unda erCios kardiuli reabilitaciis programebSi monawileoba cxovrebis stilis modificirebisa da mkurnalobis Sedegebis gaumjobesebis mizniT.

IIa A

koronaruli arteriebis daavadeba da hipertenziakad-iT pacientebisaTvis rekomendirebulia sistoluri arteriuli wnevis samizne cifrebi < 140 mm.vwy.sv

IIa A

yvela pacientisTvis rekomendebulia diastoluri wnevis samizne cifrebi < 90 mm.vwy.sv. Saqriani diabetis dros rekomendebuli diastoluri wnevis samizne donea < 85 mm.vwy.sv

I A

koronaruli arteriebis daavadeba da 2 tipis Saqriani diabeti

mikrovaskuluri garTulebebis prevenciis mizniT rekomendirebulia HbA

1c done < 7.0%.

I A

koronaruli arteriebis daavadeba da gulis qronikuli ukmarisoba

gulis ukmarisobiT da marcxena parkuWis gandevnis fraqciis < 40% yvela pacientisatvis rekomendirebulia age –inhibitorebiT mkurnalobia, Tu es ar aris ukunaCvenebi

I A

arb naCvenebia age inhibitorebs autanlobis SemTxvevaSi, roca pacients aReniSneba. gulis ukmarisoba, an miokardiumis infarqtis Semdgom marcxena parkuwis gandevnis fraqcia < 40%

I A

beta blokerebiT pacientebis mkurnaloba naCvenebia gulis ukmarisobiT da marcena parkuWis disfunqciiT yvela pacinetisaTvis, Tu ar aris amis ukuCveneba.

I A

47


miokardiumis revaskularizaciis Semdgom daavadebis progresirebiT an restenozis gamowveuli simptomebis an iSemiiis rekurensi moiTxovs yuradRebas. miokardiumis revaskularizaciis Semdeg pacientebze da-kvirvebisa da marTvis strategiis rekomendaciebi moyvanilia Semdeg cxrilSi.

pacientebze dakvirvebisa da maTi marTvis rekomendaciebi miokardiumis revaskularizaciis Semdeg

klasia doneb

asimptomuri pacientebiwarmosaxviTi diagnostikis adre periodSi Catareba SeiZleba ganxiluli iyos pacientTa garkveul jgufebSig IIa C

rutinuli stres testi Catarebis sakiTxi SeiZleba iyos ganxiiluli tki-is Catarebidan > 2 wlis, xolo akS-dan > 5 wlis Semdeg

IIb C

maRali riskis (mag. daucveli marcxena mTavari Reos stenozi) tki-is Semdeg mogvianebiT periodSi (3-12 TveSi) SeiZleba ganxiluli iyos sakontrolo angiografiis Catarebis sakiTxi, miuxedavad simptomuri statusisa.

IIb C

miokardiumis revaskularizaciis Semdgom prognozis gaumjobesebis mizniT xangrZlivi medikamenturi mkurnalobis, cxovrebis stilis Secvlis, kardiuli reabilitaciis programaSi CarTvis rekomendaciebi (gagrZ.)

klasia doneb

koronaruli arteriebis daavadeba da gulis qronikuli ukmarisoba

aldosteronis receptoris antagonistebis gamoyeneba naCvenebia, roca age inhibitorebiT (an arb) da beta blokerebiT mkurnalobis miuxedavad pacients aReniSneba gulis ukmarisobis simptomebisa (NYHA II=IV fk) persistuloba da gandevnis fraqciis < 35%.

I A

ivabradinis gamoyeneba ganxiluli unda iyos gulis ukmarisobis mizeziT gamowveuli hospitalizaciis sixSiris Semcirebis mizniT, Tu pacients aReniSneba sinusuri riTmi > 70 wuTSi, gandevnis fraqciis < 35%, da gulis ukmarisobis mdgradi simptomebi (NYHA II-IV fk), miuxedavad age inhibitorebiT (an arb), beta blokerebiT (an maqsimalurad asatani doziT) da mineralokortikoidebis receptoris antagonistebiT (an arb) maqsimalurad asatani dozebiT mkurnalobisa,.

IIa B

48

pacientebze dakvirvebisa da maTi marTvis rekomendaciebi miokardiumis revaskularizaciis Semdeg (gagrZ.)

klasia doneb

simptomuri pacientebistres-testiT dadgenili dabali riskis monacemebis SemTxvevaSig rekomendebulia, medikamenturi Terapiis gaZliereba da cxovrebis stilis cvlilebebi

I C

stres testiT zomieri-maRali riskis maCveneblebis gamovlenisasd rekomendebulia koronarografiis Catareba I C

a mtkicebulebaTa klasib mtkicebulebaTa done g pacientTa specifiuri jgufebi, romelTaTvis naCvenebia adreuli warmosaxviTi stres testi:• usafrTxoebis aucilebeli moTxovnilebis mqone profesiis pirebi(mag. pilotebi, mZRolebi, myvinTavebi) da Zalovani sportsmenebi• pacientebi, romlebsac SesaZloa, SerCeuli dasvenebis periodSi Jangbadis intensiuri moxmareba dasWirdeT.• klinikuri sikvdilisgan gadarCenili pacientebi• pacientebi arasruli, an suboptimaluri revaskularizaciis Semdgom, Tundac asimptomurebi• pacientebi, romelTac revaskularizaciis procesi gaurTuldaT(perioperaciuli mi), an rTuli procedurebis gadatana mouxdaT(gamoxatuli disseqcia tki dros, endartereqtomia akS procesSi da sxv.)• Saqriani diabetis mqone pacientebi(gansakuTrebiT, insulinis saWiroebisas)• mravalsisxlZarRvovani paTologiisa da zomierad gamoxatuli narCeni dazianebebis, an munji iSemiuri cvlilebebis mqone pacientebi.d warmosaxviTi stres-testis dros saSualo, an maRali riskis maCveneblad iTvleba iSemiuri cvlilebebi dabali intensiobis datvirTvisas, iSemiis naadrevi gamovlineba, kedlis moZraobis gamoxatuli daqveiTebis mravlobiTi zona, an perfuziis Seqcevadi defeqti.

agf - angiotenzinis gardamqmneli fermenti; akS - aortokoronaruli Suntireba;afh - arafraqcionirebuli heparini;arb - angiotenzinis receptorebis blokatori; gfs - glomeruluri filtraciis siCqare;dmh - dabalmolekuluri heparini; dkb - dro karebidan balonirebamde; dpskb - dro pirveli samedicino kontaqtidan balonirebamde; iTb - intensiuri Terapiis bloki; Tmd - Tirkmlebis mwvave dazianeba; Tqd - Tirkmlebis qronikuli daavadeba; kad -koronaruli arteriebis daavadeba; kin - kontrastiT inducirebuli nefropaTia; kee - karotiduli endartereqtomia;mdkt - multideteqtoruli kompiuteruli tomografia; mks - mwvave koronaruli sindromi; mp - marcxena parkuWi; mpgf - marcxena parkuWis gandevnis fraqcia; oaaT - ormagi antiTrombocituli mkurnalobapad - periferiuli arteriebis daavadeba; sas - saZile arteriebis stentireba;skad - stabiluri koronaruli arteriebis daavadeba; tki - transkutanuri koronaruli intervencia;Sgx - Sesvla-gamosvlis xangrZlivoba; Ad hoc intervencia - intervencia, romelic tardeba uSualod koronarografiis Semdeg;ACEF - asaki, kreatinini, gandevnis fraqcia; ASCERT - amerikis kardiologTa kolejis fondi-gulmkerdis qirurgTa sazogadoebis (ACCF-STS) monacemTa bazis erToblivi monacemebi revaskularizaciis strategiebis SedarebiTi efeqturobis Sesaxeb; CCS -kanadis kardiovaskuluri sazogadoeba; CHA2 DS2-VASc - winagulebis fibrilaciis dros insultis riskis gansazRviris Skala. CT -kompiuteruli tomografia; EACTS - evropis kardio-Torakalur qirurgTa asociacia; EAPCI - evropis perkutanuli kardiovasku-luri intervenciebis asociacia;

ESC -evropis kardiologTa sazogadoeba; FFR -fraqciuli nakadis rezervi; GRACE - letalobis riskis Sefasebis Skala.GP = glikoproteini; HAS-BLED - sisxldenis riskis gansazRvris Skala. HbA

1c - glikolizirebuli hemoglobini;

IABP - intraaortuli balonuri kontpulsa-cia; ICD - implantirebadi kardiodefibrila-tori; IVUS - intravaskuluri ultrabgeriTi gamokvleva; LBBB - hisis konis marcxena totis sruli blokada; LVESV - L marcxena parkuWis end-sistoluri moculoba;LDL-C -dabali simkvrivis lipoproteidebis qolesterini;MACA - mTavari kardiovaskuluri gverdiTi movlenebi; MACCA - mTavari kardiovaskuluri da cerebruli gverdiTi movlenebi; NCDR - gulsisxlZarRvTa monacemebis nacionaluri registri; NSTE ACS - mwvave koronaruli sindromi ST segmentis elevaciis gareSe; NSTEMI - miokardiumis infarqti ST segmentis gareSe; (N)OAC - (ara vitamini K - s antagonistebi) peroraluri antokoagulantebiOCT - optikur-koherentuli tomografia; Off-pump - xelovnuri sisxlis mimoqcevis gareSe; On-pump - xelovnuri sisxlis mimoqceviT;OCT = optikuri koherentuli tomografia; PET - pozitron-emisiuri tomografia;STE ACS - mwvave koronaruli sindromi ST segmentis elevaciiT; STE MI - miokardiumis infarqti ST segmentis elevaciiT;STS - Torakalur qirurgTa sazogadoeba; SYNTAX - tki da aSk riskis Sefasebis Skala; TAVI = aortis sarqvlis transkaTeteruli implantacia;TIA - tranzitoruli iSemiuri Seteva.

Semoklebebi

versia2014

ESC / EACTS gaidalini

evropis kardiologTasazogadoebis jibis gaidlainebi

praqtikuli gaidalinebis komitetievropaSi klinikuri praqtikis

xarisxisa da pacientebis movlis gaumjobesebasaTvis

miokardiumisrevaskularizacia

© 2014 The Europian Society of Cardiology No part of these Pocket Guidelines may be ttranslated or reproduced

in any form without written permission from the ESC. The following material was adapted fom the ESC/EACTS Guidelines on Myocardial Revascularisation (European Heart Journal 2014- doi: 10. 1093/eurheartj/ehu278).

To read the full report as published by The Europian Society of Cardiology, visit our Web Site at:www. escardio.org/guidelines

Copyright Europian Society of Cardiology 2014 – All rights Reserved.The content of these Europian Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtainedupon submission of a written request to ESC, Practice Guidelines Department, Les Temlpiers – 2035 route des colles - CS 80179 Biot – 06903 Sophia Antipolis Cedex – France. Email: [email protected].

Disclaimer:The ESC Guideliens represent the views of the ESC and were produced after careful consider-ation of the scientific and medical knowledge and the evidence available at the time their dating. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recommendations or guidelines issued by the relevant public health authorities in particular in relation to good use of health care or therapeutic strategies. Health professionals are encouraged to take the ESC guidelines fully into account when exercising their clinical judment as well as in the determination and the implementation of preventive, diagnostic da or therapeutic smedical strategies.However, the ESC guidelines do not override in any way whatsoever the individual responsibility of health professionals to make appropriate and accurate decisions in cosideration of each patient’s health condition and in consultation with that patient and the patient’s caregiver here appropri-ate and/or necessery. Nor do the ESC guidelines exempt health professionals from taking careful and full cosideration of the relevant official updated recommendations or guidlelines issued by the competent public health authorities in order to manage patient/s case in light of the scientifically accepted data pusuant to their respective ethical and professional obligations. It is also the health professional responsibility to verify the appicable rules and regulations relating to drugs and mmedical devices at the time of prescription.

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