ACS - mob coronary syndrome

IV Samorodskaya,

Xibfwb, tus kws kho mob ntawm Medical Sciences

mob coronary
syndrome

Multidisciplinary pab neeg txiav txim siab

Siv kev niaj hnub ntawm kev kho mob rau mob coronary syndrome (ACS)
- ib lub sij hawm denoting tej pab pawg ntawm cov kev soj ntsuam tej yam tshwm sim los yog cov tsos mob
uas xav tias mob myocardial infarction (MI) los yog tsis ruaj tsis khov
angina, muab kev cia siab rau ib tug tseem ceeb yuav txo tau nyob rau hauv lub tsev kho mob
lub neej no thiab txhim kho raug nyob rau hauv lub sij hawm ntev lub sij hawm.

Ob peb xyoos dhau los, kev tshawb fawb thiab thoob ntiaj teb tiam sis yog
tshab xyuas lub All-Lavxias teb sab Scientific Society of Cardiology nyob rau hauv Lavxias teb sab tswv yim pom zoo nyob rau hauv mob
thiab kev kho mob ntawm cov neeg mob nrog myocardial infarction nrog ST-ya nce (2007), tsis muaj ST nce thiab tsis ruaj tsis khov angina (2006). Nyob rau hauv 2010, luam tawm los ntawm cov European kev pom zoo
Society of Cardiology (ESC) nyob rau hauv kev xaiv ntawm txoj kev ntawm myocardial revascularization, lub teb chaws raws li kev cai rau cov kev tswj ntawm cov neeg mob nrog ACS nyob rau hauv teb chaws Australia
Teb chaws Aas Kiv, kev soj ntsuam ntawm lub thoob ntiaj teb
pom zoo nyob rau hauv cov kev tswj ntawm cov neeg mob nrog ACS. Nyob rau hauv 2013
American Heart
Society (ACCF / Aha) tau tshiab
tswv yim pom zoo rau cov kev tswj ntawm cov neeg mob nrog ACS
ST ya nce.  

Qhov kev txiav txim nyob rau hauv tactics
tus neeg mob tswj nyob rau hauv ACS li ib tug nce thiaj li tsis muaj ST-ya nce yog tsis ib txwm uniquely yooj yim, feem ntau yuav tsum tau multidisciplinary kev koom tes
ib pab neeg ntawm cov kws tshwj xeeb raws li cov kev soj ntsuam raws li kev cai, cov chav kawm ntawm tus kab mob no, uas muaj hnub nyoog ntawm tus neeg mob, tej yam kev mob
tu. Nyob rau tib lub sij hawm nyob rau hauv tag nrho cov neeg uas poob siab tias ACS
yuav tsum tau ua ib qho electrocardiogram (nyob rau hauv qhov qhaj ntawv los ntawm
kev hloov los yog questionable cov ntaub ntawv yuav tsum tau rov cov ntaubntawv povthawj siv cov Team sib 15
-30 feeb, nyob ntawm seb tus soj ntsuam mob ntawm tus neeg mob), thiab cov ua tau ntau ntawm txoj kev tshawb
rau mob enzymes, yuav tsum tau siv cov tshuaj aspirin yog suav hais tias. nyob rau hauv
Tag nrho cov tswv yim pom zoo no dua endovascular hom kev kawm
myocardial revascularization nyob rau hauv lub xub ntiag ntawm ib txog tej uas tsim nyog cov neeg ua haujlwm.
Fibrinolytic txoj kev kho (raws li ib tug thawj kauj ruam ntawm kev muab kev pab rau cov neeg mob uas ACS nrog ST-ya nce) nyob yam rau cov neeg teeb meem,
thaum nws yog tsis yooj yim sua kom ua tau stenting
rau 120 feeb tom qab
tshwm sim ntawm kev mob (nyob rau hauv qhov qhaj ntawv los ntawm contraindications thiab yog hais tias txij li thaum mob tsis yog ntau tshaj
12 xuaj moos). Thaum ACS tsis lifting fibrinolytic ST ya
txoj kev kho yog tsis muab.

Yog hais tias qhov uas yuav ntawm koj lub plawv nres thiab / los yog cov
siab mob

koom
tsim tswv yim pab nyob rau hauv Teb chaws Europe, lub tebchaws United States ntseeg hais tias qhov kev siv ntawm
coronary angiography li ntawm 2 sij hawm los ntawm lub sij hawm ntawm kev txais neeg kawm
yog pom zoo yog tias ib tug neeg mob nrog ib tug nres ntawm angina rau kev kho mob tom qab
kho cov tsos mob mob los yog recur
angina cai dynamic ST ya hloov, Muab ntawm kev puas tsuaj loj hlob
los yog heart attack myocardial infarction; hemodynamic
tsis khov, tseem ceeb ventricular arrhythmias. Ua angiography (tom
revascularization) rau 24 teev tom qab tus neeg mob lub nkag mus rau ib tug lub tsev kho mob nrog ACS yog pom zoo nyob rau hauv cov ntaub ntawv ntawm siab
kev pheej hmoo ntawm myocardial infarction, txoj sia
teeb meem thiab kev tuag. Zoo li cov sij hawm poob ntawm coronary angiography yog pom zoo nyob rau hauv
Qhov twg yuav tsum tau differential mob ntawm ACS nrog rau lwm cov
ceev tej yam kev mob (pulmonary embolism, dissecting
aortic aneurysm). Nyob rau hauv tus neeg mob ntawm mob coronary syndrome tsis ya ST nqa thaum uas tsis muaj kev pheej hmoo ntawm lub neej-tuag
teeb meem thiab kev tuag thaum lub sij hawm lub tsev kho mob nyob
kev kho mob, tab sis pheej tsos mob ntawm angina thiab / los yog ischemia ntxias
thaum lub sij hawm load xeem, coronary angiography ua raws li los ntawm revascularization ntawm
tsim nyog thiab tau nws yog advisable mus nqa tawm nyob rau hauv ib tug muab lub sij hawm
pw tsev kho mob tsis pub dhau 72 teev tom qab nkag. Nyob rau hauv lub
yog hais tias tus neeg mob yog txais mus rau ib tug kho mob, qhov chaw uas nws yog tsis yooj yim sua
ua ib tug coronary angiography, nws yog pauv mus rau qhov tsim nyog hauv tsev kho mob (e.g.
Regional Vacular Center).

ntau
xam tau tias yog tactic stenting (tshuaj coated stent
los yog uncoated) nrog cov infarct txog leeg tromboekstratsiey (ntawm
tsim nyog), thaum ACS c nqa
ST ya
hais txog ntawm qhov kev siv thiab cov nyhuv ntawm fibrinolytic txoj kev kho (raws li
Pom zoo los ntawm cov 2013 ACC tom qab fibrinolytic txoj kev kho yog pom zoo kom ua
FCT thiab stenting yog tsis ntxov tshaj
2-3 teev). Yog hais tias c-ya nce mob coronary syndrome ST, tsuas yog infarct leeg, muaj yeej loj heev
stenoses nyob rau hauv lwm yam cov hlab ntsha, lawv thaum muaj xwm ceev stenting yog ua tau tsuas yog
rau cov neeg uas mob loj heev lub plawv tsis ua hauj lwm thiab / los yog cardiogenic poob siab. Nyob rau hauv lwm yam
tus neeg mob ncua stenting yog ua - qhov yuav tsum tau rau siab thiab sij hawm ntawm
txiav txim siab tom qab txoj kev nyuaj siab kev kuaj ua ntej rau tawm ntawm tus neeg mob los ntawm
tsev kho mob. Raws li cov tswv yim pom zoo ntawm cov kws txawj los ntawm lub tebchaws United States 2013, tsis muaj stents
Cov txheej yog dua li siv nyob rau hauv tus neeg mob qhov twg tus neeg mob muaj
cov kab mob thiab tej yam kev mob nrog ib tug high school cov kev pheej hmoo ntawm los ntshav, siab yuav qhov muaj tseeb,
tias tus neeg mob tsis ua raws li nyob rau hauv ib xyoos ntawm dual antiplatelet regimen
txoj kev kho, thiab nws yuav ua ua tom ntej phais
ua hauj lwm. Tsis tas li ntawd, lub tswv yim pom zoo qhia hais tias lub c-ya nce ACS ST stenting tom qab 24 teev los ntawm lub sij hawm ntawm nws
Kev loj hlob tsis muaj nyob rau hauv cov neeg 1-2 leeg tshav txhab nyob rau hauv lub qhaj ntawv ntawm
tej yam tshwm sim preservation ntawm myocardial ischemia. Nyob rau hauv tsawg zaus (nyob rau hauv tej yam
lub sijhawm) ua angioplasty.

Qhov kev txiav txim txog cov qauv ntawm cov revascularization nyob rau hauv cov neeg mob uas mob coronary syndrome tsis ya ST sawv, thiab nyob rau hauv ACS c ST ya nce, tab sis nyob rau hauv qhov qhaj ntawv los ntawm
coronary zos narrowing ntawm coronary hlab ntsha, twv yuav raug hu "tsis muaj txim" nyob rau hauv
ACS los yog muaj multivessel kab mob, nyob rau hauv uas qhov kev siv ntawm
Stenting yog technically tsis yooj yim sua los yog kev pheej hmoo tias tshaj lub peev xwm ntawm
cov kev pab tau txais los ntawm ob peb cov kws txawj (plawv kws phais neeg,
kev kho plawv, ib tug kws nyob rau hauv lub teb ntawm
Endovascular mob thiab kev kho mob) nrog cov
soj ntsuam, cov ntaub ntawv ntsuam xyuas angiographic fractional txaus zeem cia,
cov kev tsim long-term raug.

Tshuaj kev pab txhawb nqa
tas

Thaum ACS nrog ST ya nce cov kws txawj ntseeg tau hais tias tam sim no tactics ntawm tus neeg mob nyob rau hauv lub
Nws nyob lom zem ntau nyob rau hauv lub teb chaws tus noj qab haus huv system
(Thaj av) ua thawj endovascular pab (tsis muaj ua ntej
thrombolysis) rau 2 teev nyob rau hauv txoj kev loj hlob ntawm kev soj ntsuam cov tsos mob nyob rau hauv ib tug neeg mob.

Yog hais tias nws yuav tsum hais tias lub sij hawm los ntawm tus thawj kev sib cuag nrog tus neeg mob
kev kho mob cov neeg ua ua ntej kom ua tau coronary angiography yuav tsum tau ntau tshaj 2
teev, tus neeg mob
(Nyob rau hauv lub qhaj ntawv ntawm contraindications) yuav tsum tau ua thrombolysis nrog
tom ntej tus me nyuam mus rau lub tsev kho mob rau kev ua tau zoo angiography thiab revascularisation
infarction hauv 3-24 teev. Nyob rau hauv cov neeg mob, yog hais tias tus keeb kwm yav dhau ntawm thrombolysis
ST ya nce muab khaws cia tseg ntau tshaj 50% ntawm cov thawj theem thiab / los yog retrosternal
mob, tus neeg mob qhia tau hais tias thaum muaj xwm ceev coronary angiography. Yog hais tias muaj kev vam meej,
thrombolysis coronary angiography thiab revascularization (yog qhia) yuav
yuav tsum tau tsis pub dhau 24 teev. Lub tswv yim pom zoo hais tias
revascularization yuav ua tau kom lub raug thiab nws cov kev siv los ntawm 24-60
teev tom qab qhov pib ntawm kev soj ntsuam mob, tiam sis tsuas yog nyob rau hauv cov mob uas
Muaj recurrent angina thiab / los yog heart attack myocardial ischemia kuaj thaum lub sij hawm
instrumental cov kev tshawb fawb.

tawm
Nyob ntawm seb lub hom ACS thiab revascularization txoj kev yog yuav tsum
tshuaj them nyiaj yug, uas muaj xws li antiplatelet,
antiplatelet txoj kev kho, beta-blockers txoj kev kho, inhibitors ntawm angiotensin converting
enzyme, statins. Tshuaj kho yog ib lub zuj zus tom
Nyob rau hauv tus duab ntawm ACS heev, muaj soputsvuyuschie pathology. Cov
Qhov no ntawv yuav tsom tsuas yog nyob rau antiplatelet txoj kev kho,
nrog txoj kev ntawm myocardial revascularization.

Ya nce ACS tsis S T

Cov
xws li mob endovascular revascularization txoj kev
tau xaiv ib tug "ob 'antiplatelet txoj kev kho uas muaj xws li qhov ncauj
acetylsalicylic acid (ASA) thiab clopidogrel (los yog prasugrel los yog
ticagrelor). ASA yog muab mus rau tus thawj tau txais 150-300 mg (250-500 mg los yog nyob rau hauv daim ntawv ntawm cov
nyob rau hauv / nyob rau hauv bolus) raws li los ntawm ib tug ntau npaum ntawm 75-100 mg / hnub loading koob tshuaj
600 mg ntawm clopidogrel (raws li thaum ntxov li sai tau) raws li los ntawm koom haum saib xyuas ntawm 75
mg / hnub rau 9-12 lub hlis prasugrel - 60 mg loading koob, ua raws li los ntawm
noj 10 mg / hnub, los yog ticagrelor - 180 mg loading koob, ua raws li los ntawm
noj 90 mg 2 lub sij hawm ib hnub twg. Indications rau ntxiv siv
GPIIb-IIIa inhibitors pom tau hais tias yuav kis tau ntawm intracoronary thrombosis nyob rau hauv cov neeg mob niaj angioplasty thiab / los yog stenting
coronary hlab ntsha.

Cov
tswv yim pom zoo ZOO (UK) sau ntawv uas
Cov neeg mob yuav muaj mob plawv txheej xwm (npaj 6 lub hli
lub neej no tshaj 3%) thiab raug rau coronary angiography thiab revascularization
tsis pub dhau 96 teev los ntawm lub sij hawm lub kev txais neeg kawm niaj hnub qhia
lub sij hawm ntawm eptifibatide los yog tirofiban. Abciximab yog tsa los ua ib tug txoj kev kho,
accompanying endovascular revascularization hais tias tsis muaj
Muaj peev xwm mus muab lwm yam inhibitors ntawm GPIIb-IIIa. Nws yuav tsum tau muab sau tseg tias nyob rau hauv
Tsis zoo li ZOO taw qhia (UK) pom zoo
European Society of Cardiology "nyiam" yog muab abciximab (Qib
indications I), nyob rau tib lub sij hawm rau eptifibatide
los yog tirofiban muab Class IIa.

Xaiv thiab koob tshuaj
anticoagulants ua angiography
revascularization nyob rau hauv cov neeg mob tsis muaj ACS
lifting ST ya txiav txim raws li
Stratification ntawm kev pheej hmoo ntawm thrombotic, ischemic thiab hemorrhagic teeb meem. Thaum heev uas yuav muaj
ischemic txheej xwm (piv txwv li, thaum hemodynamic instability refractory txoj sia arrhythmias) neeg mob
tauj ncaj qha nrog X-ray thiab nws yog muab
unfractionated heparin (UFH) raws li / nyob rau hauv ib tug bolus ntawm 60 U / kg tom
Txoj kev lis ntshav thaum lub sij hawm revascularization nyob rau hauv nrog ib tug muab ob npaug rau
antiplatelet txoj kev kho. Thaum yuav muaj los ntshav yuav siv tau
monotherapy bivalirudin bolus ntawm 0.75 mg / kg ua raws li los ntawm Txoj kev lis ntshav ntawm 1.75
mg / kg / hr. Rau cov neeg mob nrog ib tug nruab nrab uas yuav muaj ischemic txheej xwm (piv txwv li,
ruaj khov hemodynamics, tab sis ib tug zoo troponin xeem, relapsed
angina, dynamic hloov nyob rau hauv lub ST ya), uas yog teem rau tus txheej txheem 24-48
teev tom qab kev kho mob muaj nyob ua ntej rau coronary angiography
npaj endovascular myocardial revascularization:

• Rau cov neeg mob <75 xyoo

Unfractionated heparin 60 U / kg nyob rau hauv daim ntawv ntawm rau / nyob rau hauv bolus,
ces tus Txoj kev lis ntshav nyob rau hauv kev tswj ntawm lub tshuab txais ib nrab thromboplastin lub sij hawm
(APTT) los yog enoxaparin 1 mg / kg s.c. x 2 ib hnub los yog Fondaparinux 2.5 mg / hnub
Bivalirudin subcutaneously los yog 0.1 mg / kg li / nyob rau hauv ib tug bolus ua raws li los ntawm Txoj kev lis ntshav
0.25 mg / kg / teev

• Rau cov neeg mob ≥75 xyoo

Unfractionated heparin 60 U / kg nyob rau hauv daim ntawv ntawm rau / nyob rau hauv bolus,
ces Txoj kev lis ntshav nyob rau hauv kev tswj APTT

Los yog enoxaparin 0.75 mg / kg x 2
Fondaparinux hnub los yog 2.5 mg / hnub subcutaneously los yog Bivalirudin 0.1 mg / kg raws li ib tug
I / bolus ua raws li los ntawm Txoj kev lis ntshav ntawm 0.25 mg / kg / hr.

Nyob rau hauv
cov neeg mob nrog ib tug tsawg pheej hmoo ntawm kev mob plawv txheej xwm (tsis ua
troponin thiab ST ya hloov), ntau conservative npaj
kev kho mob thiab muab fondaparinux (2.5 mg / hnub subcutaneously) los yog enoxaparin (1
mg / kg s.c., 2 lub sij hawm ib hnub twg nyob rau hauv cov neeg mob ≥75 xyoo - 0.75 mg) thiab unfractionated heparin (60 U / kg
raws li nyob rau hauv / bolus, ua raws li los ntawm Txoj kev lis ntshav nyob rau hauv kev tswj aPTT).

ACS nrog ST ya nce  

Nyob rau hauv no
soj ntsuam qhov teeb meem no yog muab ib tug "ob" ACK antiplatelet txoj kev kho (150-300 mg lus los yog
250-500 mg li / nyob rau hauv ib tug bolus ua raws li los ntawm koom haum saib xyuas ntawm 75-100 mg / hnub) thiab prasugrel
(60 mg loading koob tshuaj raws li los ntawm koom haum saib xyuas ntawm 10 mg / hnub), los yog ticagrelor (loading koob tshuaj ntawm 180 mg
ua raws li los ntawm koom haum saib xyuas ntawm 90 mg 2 lub sij hawm ib hnub twg) los yog clopidogrel (loading koob tshuaj 600
ua raws li los ntawm koom haum saib xyuas
75 mg / hnub). Cov lus pom zoo ntawm tus nyob sab Europe Society of Cardiology hais tias
prasugrel thiab ticagrelor clopidogrel zoo tshaj nyob rau hauv cov nqe lus ntawm kev txo
zaus ua ke ischemic endpoints thiab stent thrombosis nyob rau hauv cov neeg mob
MI nce ST, thiab nws tsis ua rau kom cov kev pheej hmoo ntawm
mob loj heev los ntshav. Raws li cov tswv yim pom zoo ntawm lub nroog Yeiuxalees 2013 yog tsis prasugrel
Nws pom zoo rau cov neeg mob uas
ib tug keeb kwm ntawm stroke los yog tia. Nyob rau hauv cov kev tshwm sim hais tias ua ntej yuav nkag mus kawm rau hauv lub
lub tsev kho mob kom ua tau coronary angiography thiab stenting neeg mob
fibrinolysis twb ua thiab nws yog tsawg tshaj li 24 teev thiab rau tib lub sij hawm twb tsis siv
clopidogrel (prasugrel), ces clopidogrel loading koob tshuaj yog 300 mg,
Prasugrel yog ib tug 60 mg.

Thaum kis tau
intracoronary thrombosis, nrog rau dual antiplatelet txoj kev kho
Nws xav siv GPIIb-IIIa inhibitors (abciximab / v bolus ntawm 0.25 mg / kg ua raws li los ntawm Txoj kev lis ntshav ntawm 0,125 mg / kg / min rau
lub qib siab tshaj plaws ntawm 10 mg / min rau 12 xuab moos.). Tam sim no muaj yog tsis muaj
conclusive pov thawj ntau dua efficiency GPIIb-IIIa inhibitors thaum siv nyob rau hauv
prehospital los yog ua ntej hnab cug zis.

raws li ib tug
UFH anticoagulation txoj kev kho yog siv (nyob rau hauv / nyob rau hauv bolus 60 U / kg nyob rau hauv ua ke nrog nrog ib tug GPIIb-IIIa inhibitor los yog / bolus 100 U / kg tsis muaj
GPIIb-IIIa) inhibitor. Bivalirudin li monotherapy es tsis txhob UFH nyob rau hauv ua ke nrog nrog ib tug inhibitor ntawm GPIIb-IIIa li pom zoo los ntawm ACC 2013
Nws pom zoo rau cov neeg mob uas muaj kev pheej hmoo ntawm loj los ntshav (bolus ntawm 0.75 mg / kg ua raws li los ntawm Txoj kev lis ntshav ntawm 1.75
mg / kg / teev); Nyob rau tib lub sij hawm, fondaparinux yog tsis pom zoo vim hais tias ntawm lub high school uas muaj feem yuav
catheter thrombosis.

Raws li cov nqe lus nram qab no los ntawm
tsev kho mob dual antiplatelet txoj kev kho yog siv rau tsawg kawg 12 lub hlis.

Kev mloog yuav tsum tau them mus rau lub ua ke ntawm
clopidogrel thiab proton twj tso kua mis inhibitors, feem ntau yog siv rau cov kev tiv thaiv ntawm
hnyuv los ntshav. Raws li cov kev pom zoo ntawm cov ua hauj lwm pab rau cov kev tiv thaiv ntawm thrombotic
thiab hemorrhagic teeb meem ICSI ua ke siv cov tshuaj rau cov neeg mob
tsawg pheej hmoo ntawm kev GI los ntshav yog tsis qhia, lawv txhawb kev siv yuav tsum tau tus kheej nyob rau hauv lub hauv paus ntawm
noj mus rau hauv tus account cov kev pab cuam thiab txaus ntshai. tsuas
PPI tshuaj los ntawm cov pab pawg neeg - pantoprazole - tsis yog ib tug "competitor" klopidoglelya
rau isoenzyme CYP2C19. Nyob rau lwm cov tes
tsis muaj high-zoo soj ntsuam xyuas cov nyhuv ntawm tus txha
thov pantoprazole thiab clopidogrel
los txo cov kev pheej hmoo ntawm cov hlab plawv tus txhawb thiab hemorrhagic
teeb meem. Xwb PPI yuav H2 receptor blockers - famotidine, ranitidine.

niaj hnub noj tshuaj
txoj kev kho

Beta-blockers raug nyob rau hauv thawj 24 teev los ntawm lub sij hawm ntawm tag nrho cov neeg nrog ACS
nyob rau hauv lub qhaj ntawv ntawm lub plawv tsis ua hauj lwm nrog cov uas tsis muaj tso zis syndrome,
cardiogenic poob siab thiab txheem contraindications rau kev siv ntawm no pab pawg neeg ntawm cov tshuaj.
Nkag beta blockers txuas ntxiv thoob plaws lub sij hawm ntawm tsev kho mob thiab tom qab
cov nqe lus.
ACE inhibitors tsa
Tag nrho cov neeg mob uas anterior myocardial infarction, ncaws tawm feem tsawg tshaj li 40% nyob rau hauv lub qhaj ntawv ntawm
contraindications. Yog hais tias muaj yog contraindications rau ACE inhibitors yog siv blockers
angiotensin receptor II. antagonists
aldosterone qhia nyob rau hauv cov neeg mob uas mob lub plawv tsis ua hauj lwm
thiab / los yog cov muaj mob ntshav qab zib. Heev siv ntawm tag nrho cov statins qhia
cov neeg mob uas ACS (tsis muaj contraindications).