Treatment of patients with acute coronary syndrome at the prehospital stage. Clinical recommendations (protocols) of emergency medical care in acute coronary syndrome with the lifting of ST segment (OX PST) clinical variants of myocardial infarction
Citation:Verkin A.L., Moshina V.A. Treatment of acute coronary syndrome At the cooking stage // RMG. 2005. №2. P. 89.
The clinical manifestations of coronary heart disease are stable angina, solebral myocardial ischemia, unstable angina, myocardial infarction, heart failure and sudden death. Over the years, unstable angina was considered as an independent syndrome, which occupies an intermediate position between chronic stable angina and acute myocardial infarction. However, in recent years it has been shown that unstable angina and myocardial infarction, despite the differences in their clinical manifestationsare the consequences of the same pathophysiological process, namely, the gap or erosion of atherosclerotic plaques in combination with the joining thrombosis and embolization of more distally located areas of the vascular bed. In this regard, unstable angina and the developing myocardial infarction is currently combined by the term acute coronary syndrome (OCS).
The introduction of this term into clinical practice is dictated by considerations first of all practical order: first, the inability to quickly distinguish these states and, secondly, the need for early starting treatment before establishing a final diagnosis. As a "working" diagnosis of OKS, as it is impossible to suit the first contact of the patient and the doctor at the prehospital stage.
The relevance of the creation of weighted and carefully substantiated recommendations for the SMP doctors on the treatment of OCS is largely caused by the prevalence of this pathology. As you know, in total in the Russian Federation daily the number of SMP challenges is 130,000, including the OX from 9000 to 25,000.
Volume and adequacy emergency care In the first minutes and hours of the disease, i.e. At the cooking stage, the prediction of the disease is largely determined. Therapy is aimed at limiting the necrosis zone by relieving pain, the restoration of the coronary blood flow, reduce the work of the heart and the needs of myocardium in oxygen, as well as for treatment and prevention possible complications (Table 1).
One of the main factors determining the prediction of patients with OX is the adequacy of medical care in the first hours of the disease, since it is during this period that the highest mortality is noted. It is known that the earlier the reperfusion therapy will be carried out using thrombolytic drugs, the higher the chances of a favorable outcome of the disease. The dynamics of pathomorphological changes of myocardium at ACS is presented in Table 2.
According to Dracup K. et al. (2003), the delay from the appearance of OX symptoms before the start of therapy ranges from 2.5 hours in England to 6.4 h in Australia. Naturally, this delay is largely determined by the population density, the nature of the area (urban, rural), the living conditions, etc. Kentsch M. et al. (2002) It is believed that lateness with thrombolysis is also due to the time of day, year and weather conditions affecting the speed of transportation of patients.
As part of the program of the National Scientific and Practical Society for Emergency Medical Assistance (NNPOSMP) to optimize the treatment of various pathological conditions, an open randomized study "NOCS" was conducted on 13 stations of the SMP of Russia and Kazakhstan, one of whose tasks was to assess the effectiveness of thrombolytic therapy on in a chipboard. It was shown that thrombolytic therapy patients with ACS with a segment lifting ST is carried out in less than 20% of cases, including in a metropolis of 13%, in mid-sized cities - in 19%, in rural areas - in 9%. At the same time, the frequency of trombolytic therapy (TLT) does not depend on the time of day and season, and the SMP call time is delayed by more than 1.5 hours, and in rural areas - for 2 hours or more. Time from the appearance of pain and to the "needle" on average is 2-4 hours and depends on the terrain, time of day and season. It is especially noticeable in time gain in large cities and rural areas, at night and in the winter season. The conclusions of the work indicate that the carrying out of the flowing thrombolysis allows to achieve a decrease in mortality (13% in doghosphatic thrombolesis, 22.95% with stationary thrombolesis), the frequency of the development of post-infarction angina, without a significant effect on the frequency of recurrence of the myocardial infarction and the emergence of signs of heart failure.
The advantages of transferring the start of thrombolytic therapy to the chosen phase were shown in multicenter randomized clinical trials Great (1994) and EMIP (1993). According to the data obtained during the study of CAPTIM (2003), the results of the early beginnings of the TLT at the prehospital stage are comparable in effectiveness with the results of direct angioplasty and exceed the results of therapy begun in the hospital.
This suggests that in Russia the damage from the impossibility of the widespread spread of surgical methods of revascularization during ACS (the reasons for which, first of all, economic) can be partially compensated as early as possible early TTT.
The existing essential base concerns only the possibility of the chosen application of thrombolytic and does not contain arguments in favor of traditionally applied in patients with ox donor nitrogen oxide - nitrates, including their various forms.
According to the recommendation of the ACA / AHA (2002), the treatment of OKS provides for the use of nitroglycerin to relieve pain syndrome, reduce the work of the heart and the needs of myocardium in oxygen, limit the size of the myocardial infarction, as well as for the treatment and prevention of complications of myocardial infarction (level of confidence in). The relief of pain syndrome during acute myocardial infarction is one of the most important tasks, and it begins with sublingual taking nitroglycerin (0.4 mg in aerosol or in tablets). In the absence of the effect of the sublingual intake of nitroglycerin (three-time reception with interruptions of 5 min), it is necessary to begin therapy with narcotic analgesics (Fig. 1).
The mechanism of action of nitroglycerin, which is used in medicine for more than 100 years, is well known and no one has doubts that it is almost the only and most effective means to relieve the attack of angina.
However, the question of the most effective dosage form For the relief of anginal pain, including in the pre-hospital stage, continues to be debated. Nitroglycerin is available in five basic forms: tablets for sublingual reception, pills for oral administration, aerosol, transdermal (buccal) and intravenous. For use in emergency therapy, aerosol forms (nitroglycerin-spray) are used, pills for sublingual use and a solution for intravenous infusion.
Nitroglycerin's aerosol form has a number of indisputable advantages over other forms:
- speed of relief attack of angina (absence in composition essential oilsSlowing suction, provides a faster effect);
- the accuracy of the dosage - when pressed on the valve of the spray, the exactly defined dose of nitroglycerin is released;
- ease of use;
- safety and preservation of the drug due to special packaging (nitroglycerin - extremely volatile matter);
- long shelf life (up to 3 years) compared with the tablet shape (up to z-x months after opening the package);
- equal effectiveness with a smaller number of side effects compared with parenteral shapes;
- the possibility of using with difficulty contact with the patient and in the absence of consciousness;
- use in senior patients suffering from a decrease in salivation and slow suction of tableted forms of the drug;
- For considerations, pharmacoeconomics are obvious to the advantage of spray, one packaging of which can be enough for 40-50 (!) Patients compared with more technically complex intravenous infusion requiring the presence of an infusion system, solvent, venous catheter and the drug itself.
In the NOKS study, a comparison of the anti-inanal effect was carried out, the influence on the main parameters of hemodynamics, the frequency of development of side effects of nitroglycerin at different forms Its administration is PER OS in aerosol or intravenously infusionally.
The research technique was to assess the clinical condition, assessing the presence of pain syndrome, measuring the blood pressure, heart rate initially and after 3, 15 and 30 minutes after parenteral or sublingual administration of nitrates, ECG registration. Monitoring unwanted effects medicinal preparations. In addition, a 30-day prognosis was estimated in patients: mortality, the rate of development of Q-infarction of myocardium in patients with source OX without lifting ST segment.
As follows from the given data (Table 3), there were no differences in 30-daily mortality, as there were no significant differences in the frequency of cases of the EXOLOTION OF ACS without lifting ST to the myocardial infarction (im) with the q tooth, as well as in the offensive frequency Combined end point (development of them or lethal outcome).
As a result of treatment, 54 patients 1 groups use 1 dose of aerosol contributed to the rapid relief of pain syndrome (less than 3 minutes), 78 patients needed an additional introduction of the 2nd dose of the drug with a good effect in 21, after 15 minutes the pain remained in 57 patients, which ( According to the protocol) demanded the introduction of drugs. After 30 minutes, pain syndrome was preserved only in 11 patients.
In the 2 group, the anti-naiginal effect of intravenous infusion nitroglycerin was noted significantly later. In particular, by the 3rd minute, pain disappeared only in 2 patients, by 15 minutes - the pain was maintained in 71 patients, of which 64 received a narcotic analgezia. By the 30th minute, pain syndrome remained 10 patients. The fact that the frequency of recurrence of pain syndrome was equally small in both groups.
The use of nitroglycerin in both groups led to a significant decrease in the level of the garden, and in patients receiving nitroglycerin PER OS - an insignificant reduction in the level of DDA. In patients who received the infusion of nitroglycerin, a statistically significant reduction in DDA indicators was noted. Statistically significant changes in the heart rate not noted. As expected, the infusion administration of nitroglycerin was accompanied by a significantly higher frequency of development side phenomenaassociated with a decrease in blood pressure (8 episodes of a clinically significant hypotension), but all these episodes were transient and did not require the appointment of vasopressar agents. In all cases, the hypotension was enough to suspend infusion - and after 10-15 minutes, hell returned to an acceptable level. In two cases, the continuation of infusion at a slower pace again led to the development of hypotension, which required the final abolition of nitroglycerin. With sublingual use of nitroglycerin, persistent hypotension was obtained only in two cases.
Against the background of therapy with nitrates side effects in the form of hypotension was noted when using an aerosol of 1.3%, when using an input form - at 12%; Facial hyperemia - 10.7% and 12%, respectively; Tachycardia is 2.8% and in 11% of cases, respectively, headache With sublingual administration of the drug, 29.9% was observed, and intravenous administration in 24% of cases (Table 4).
Thus, in patients with OX without lifting ST, sublingual forms of nitroglycerin on an anesthetic effect are not inferior to parenteral forms; Side effects in the form of hypotension and tachycardia with intravenous administration of nitroglycerin occur more often than with sublingual administration, and hyperemia of the face and headache occurs during intravenous administration with the same frequency as during sublingual administration.
The conclusions of the work indicate that nitroglycerin Aerosol is a drug of choice, as an antichangal remedy in the prehospital stage.
Thus, when providing therapeutic benefits, the success of urgent therapy depends largely on right choice Forms drug, dosages, method of administration, the possibility of adequate control over its effectiveness. Meanwhile, the quality of treatment at this stage often determines the outcome of the disease as a whole.
Literature
1. The effectiveness of nitroglycerin with acute coronary syndrome in the prehospital stage. // Cardiology.-2003.-№2. - P.73-76. (Suleimenova B.A., Kovalev N.N., Totsky A.D., Dmitrienko I.A., Malysheva V.V., Demyanenko V.P., Kovalev A.Z., Bookov T.B., Cork A.Yu., Dyakova T.G., Soletseva A.G., Kireeeva TS, Tuberculov K.K., Kuamargaliyev M.I., Talibov OB, Polosianz O. B., Malsagova M. A., Vertkin M.A., Velkin A.L).
2. The use of various forms of nitrates with acute coronary syndrome at the prehospital stage. // Russian Cardiology Journal.-2002.- S. 92-94. (Poloshenz O.B., Malsagova M.A., Kovalev N.N., Kovalev A.Z., Suleimenova B.A., Dmitrienko I. A., Tuberculov K.K., Prokhorovich E.A., Vertkin A.L.).
3. Clinical studies of drugs with urgent cardiological conditions in the prehospital stage. // Collection of materials of the second congress of the Cardiologists of the South federal District « Modern problems Cardiovascular pathology. " Rostov-on-Don.-2002- S. 58. (Vertkin A.L., Malsagova M.A., Poliosianz O.B.).
4. New technologies of biochemical express diagnostics of acute coronary syndrome at the prehospital stage. //
Emergency therapy.-2004.-№ 5-6.-C. 62-63. (M.A. Malsagova, M.A. Vertkin, M.I. Tishman).
Acute coronary syndrome (OX) is a group of clinical signs or symptoms, allowing to suspect myocardial infarction (im) or unstable angina (NA).
Classification
Acute coronary syndromes:
1. Case with the lifting segment ST
A) they are with the rise of the ST segment
To them with qog
They are without teeth q
B) angina printela
C) pericarditis
D) early repolarization syndrome
2.) OX without lifting segment ST
They are without teeth q
Unstable angina
Tactics of treatment depending on the type of ox
The results of the treatment of OKS largely depend on the proper actions of the doctor at the prehospital stage.
The main task of the ambulance is effective relief syndrome and possibly
early reperfusion therapy.
Algorithm for the treatment of patients with OX
Nitroglycerin sublingual (0.4 mg) or nitroglycerin aerosol every five minutes. After receiving three doses with persistent pain in chest and systolic blood pressure not lower than 90 mm Hg. Art. It is necessary to resolve the appointment of nitroglycerin intravenously in the form of infusion.
The preparation of choice for relieving pain syndrome is a morphine sulfate for 10 mg intravenously in the physiological solution of sodium chloride.
Early appointment of acetylsalicylic acid at a dose of 160-325 mg (dear). The patients who took the previously aspirin can be prescribed clopidogrel of 300 mg, followed by applying at a dose of 75 mg / day.
The immediate purpose of β-blockers is recommended to all patients if there are no contraindications to their use (atrioventricular blockades, bronchial asthma in history, acute left leaveschilding failure). Treatment It is necessary to start with short-range preparations: propranolol in a dose of 20-40 mg or metroprolol (egilov) at 25-50 mg inward or sublingual.
Elimination of factors that increase the burden on myocardium and contribute to the strengthening of ischemia: hypertension, heart rhythm disorders.
Further tactics of assistance to patients with OKS, as already mentioned, is determined by the characteristics of the ECG painting.
Patients S. clinical signs OX with a resistant elevation of the ST segment or the acute blockade of the left leg of the GIS beam in the absence of contraindications it is necessary to restore the permeability coronary artery With the help of thrombolytic therapy or primary percutaneous angioplasty.
With the possibility of thrombolytic therapy (TLT), it is recommended to be carried out at the pre-hospital stage. If the TLT manages to perform in the first 2 hours after the symptoms of the disease (especially during the first hour), it can stop the development of them and significantly reduce mortality. The TLT is not carried out if more than 12 hours have passed from the moment of an angin attack, except when the bouts of ischemia continue (pain, lifts of the ST segment).
20. Unstable angina (NSC) - the most difficult period of exacerbation of ischemic disease
hearts (IBS), damaging the development of myocardial infarction (im) or sudden death. NSC - P.
clinical manifestations and prognostic value occupies an intermediate position between
the main clinical and morphological forms of IBS - stable angina and acute infarction
myocardium.
Classification of unstable angina (Hamm S. W., Braunwald E.)
All patients with NSC are subject to emergency hospitalization in the chamber (blocks) of intensive observation and treatment. In parallel with the treatment, an ECG was recorded in dynamics, a general blood test, determining the activity of cardiospecific enzymes, if possible, ECCG, myocardial scintigraphy. 24-hour clinical and monitor observation.
Tasks for treatment is the relief of pain syndrome, the prevention of repeated attacks of angina, preventing the development of acute and related complications. Treatment should be started with aspirin intake. The counter-tomb of ASK is based on irreversible inhibition of platelet cyclooxygenase. As a result, platelets lose the ability to synthesize thromboxane A2 (TCH2), which induces platelet aggregation and has vasoconductive properties. As a result, the possibility of platelet aggregation and blood formation is reduced.
If there are coronary pains at the time of receipt, nitroglycerin 0.5 mg under the tongue is given, after 10-15 minutes. Reception can be repeated. In case of insufficient effect, neuroleptinalgesia is carried out, as with it. At the same time, intravenous infusions of nitroglycerin and heparin are prescribed. The initial dose of nitroglycerin preparations (1% solution of nitroglycerin, perforpanitis, or isosorbite dinitrate ockete) is 5-15 μg / min, then every 5-10 minutes. The dose increases by 10-15 μg / min., Not allowing the reduction in systolic adherence less than 100-90 mm. RT. Art.
Beta blockers have important in the treatment of NSC. They contribute to the elimination of myocardial ischemia, prevent sharp hemodynamic changes, reduce the damage to the vessels, implact the formation of lipid plaques, are preventive agents in relation to the deepening, expansion or repetition of the existing break and the ruptures of other plaques have an antiarrhythmic effect.
The initial use of beta-blockers in combination with aspirin, heparin can be used in cases where patients with NSC have hyperactivity of the sympathetic nervous system, manifested by tachycardia, hypertension, rhythm disorders. In these cases, beta-blockers can be used to receive inside, and can also be recommended intravenous administration.
With spontaneous angina, the printelated type angularity is used by calcium antagonists, of which the dihydropyridinic group - nifedipine is shown only with the NSC version. In order to relieve the attack of coronary pains, nitroglycerin is given, with insufficient effectiveness - nifedipine, offering a patient a tablet to deny for better absorption in the oral cavity. For the prevention of attacks, nitrates or calcium antagonists are prescribed preferably prolonged (amlodipine, lomir, etc.).; Verapamil can be used, dilgiam. Beta blockersPri "Clean" Vazospadic form NSC can worsen coronary blood flow. Beta blockers are considered contraindicated in those patients with spontaneous angina, in which the spasm of large coronary arteries is documented in coronary artwork with sample with ergometrine
In cases where, by the time of hospitalization there is no data for the progression of NSC, especially when the last attack of the angina was 48 hours later, there are no changes to the ECG, there is no increase in cardio-specific enzymes, treatment may be limited aspirin in combination with beta blockers, and / or nitrates. In some cases, calcium antagonists - veripamil, deyltyzene, but not nifedipine can be used. Especially in cases where beta blockers are contraindicated. Specified calcium antagonists can be combined with nitrates.
In violation heart Rhythm Antiarrhythmic treatment is carried out, including electro-impulse therapy.
In cases where for 48-72 hours, despite the active therapy, angina attacks do not change intensity and duration, indications arise to perform urgent coronaryography and discussion of surgical treatment.
An alternative to surgical treatment of the NSC is currently China and intracoronary prosthetics using intravascular prostheses (stents). The testimony for its implementation is the proximal single-sideways of at least 50% of the vessel lumen
Thus, the sequence of therapeutic measures in the treatment of NSC can be represented as follows: hospitalization in bits, appointment of aspirin, nitroglycerin, heparin, beta blockers; with vasospadic versions of NSC - nitroglycerin, calcium antagonists; With acute coronary syndrome with the lifting of the ST segment or the fresh blockade of the left leg of the Gisa beam - the use of thrombolytic drugs. In the future, the use of platelet glycoprotein receptors II BETA / III and low molecular weight heparins. With non-efficiency of drug therapy - surgery (AKS, STI, Intrakoronar prosthetics - stents). Next, the transition to planned treatment according to the generally accepted technique for chronic IBS.
21. Myocardial infarction (im) -this is a sharp focal necrotic damage to the heart muscle.
Risk factors
Tobacco and passive smoking, arterial hypertension, increased concentration
lDL cholesterol ("bad" cholesterol) in the blood, low cholesterol concentration HDL
("good" cholesterol) in the blood, high blood triglycerides, low levels of physical
activity, age, contamination of the atmosphere, men more often suffer from myocardial infarction than
women, obesity, alcoholism, diabetes, myocardial infarction in the past and manifestation
any other manifestations of atherosclerosis
CLASSIFICATION
In development stages:
Promotional period (0-18 days)
The most acute period (up to 2 hours from the beginning)
Sharp period (up to 10 days from the beginning of them)
Subighteous period (from 10 days to 4-8 weeks)
Scarring period (from 4-8 weeks to 6 months)
According to the anatomy of the lesion:
Transmural
Intramural
Subendocardial
Subepicarordial
By volume of lesion:
Large-Quality (Transmural), Q-Infarction
Small-scale, not Q-infarction
Localization of the focus of necrosis.
Myocardial infarction left ventricle (front, side, bottom, rear).
Heart top of myocardial heart attack isolated.
Miocardial infarction interventricular partition (septal).
Myocardial infarction right ventricle.
Combined localization: rear-bottom, front-side and dr.
With the flow:
Monocyclic
Stretty
Recurrents (in the 1st coronary artery, the new source of necrosis is from 72 hours to 8 days)
Repeated to them (in dr. Cor. Art., New focus of necrosis in 28 days from the previous one)
Clinical classification prepared by the United Working Group of the European Society of Cardiologists, American Cardiology College, American Heart Association and the World Cardiological Federation (2007):
Spontaneous (type 1) associated with ischemia due to the primary coronary event, such as plaque erosion and / or destruction, cracking or bundle.
Secondary to them (type 2) associated with ischemia caused by an increase in the lack of oxygen or its receipt,
Sudden coronary death (type 3), including a heart stop,
CCV-Associated by them (type 4a).
It is associated with the thrombosis of the stent (type 4B), which is confirmed by angiography or autopsy.
AKSH-Associated by them (type 5).
Pathogenesis
Distinguish the steps:
1) Ischemia 2) damage (necrobiosis) 3) necrosis 4) scarring
Ischemia may be a predictor of heart attack and lasts for quite a long time. The basis of the process is a violation of myocardial hemodynamics. Usually, the narrowing of the artery of the heart is considered to be clinically significant when limiting myocardial blood supply can no longer be compensated. Most often, this occurs when the artery is narrowing by 70% of its cross-section. When the compensatory mechanisms are exhausted, there is a damage, then the metabolism and myocardial function suffer. Changes can be reversible (ischemia). The stage of damage lasts from 4 to 7 hours. Necrosis is characterized by irreversibility of damage. After 1-2 weeks after the heart attack, the necrotic section begins to be replaced by a scar cloth. The final formation of the scar occurs after 1-2 months.
22. The clinical picture of the sharp them.The most typical manifestation of myocardial infarction is pain. The pain "gives" along the inner surface of the left hand, producing a feeling of tingling in the left hand, wrist, fingers. Other possible areas of irradiation are the fleeing belt, neck, jaw, inter-opacculent space, also mainly on the left. Thus, both localization and irradiation of pain does not differ from the attack of angina.
The pain with myocardial infarction is very strong, perceived as a docking, tearing, burning, "pocket in the chest". Sometimes this feeling is so unbearable, which makes shout. Also, as well as during angina, there may be no pain, but discomfort in the chest: a sense of strong compression, compression, the feeling of gravity "pulled the hoop, squeezed into vice, pressed the heavy slab." Some people have only stupid pain, the tweeters numbness in combination with severe and long-term oversized pain or discomfort in the chest.
The beginning of anginal pain with myocardial infarction is sudden, often in night or preliminary clock. Pain sensations develop wavely, periodically decrease, but do not stop completely. With each new wave, pain or discomfort in the chest increases, the maximum is quickly achieved, and then weaken.
The pain attack or discomfort in the chest lasts more than 30 minutes, sometimes for hours. It is important to remember that for the formation of myocardial infarction, there is a sufficient duration of an anginal pain for more than 15 minutes. Another important distinctive feature of myocardial infarction is the lack of a decrease or cessation of pain in a state of rest or when taking nitroglycerin (even repeated).
CLINICAL OPERATIONS OF MOCARD SHIPT:
astmatic option It is characterized by the development of the attack of cardiac asthma or pulmonary edema (see the corresponding section). More often happens in the elderly patients;
gastralgic (Abdominal) The option begins with pain in the epigastrium and for sternum, nausea, maybe vomiting. Sometimes pains irradiate at the bottom of the abdomen, signs of dynamic intestinal obstruction may appear. It is especially difficult to recognize this variant of myocardial infarction in patients with peppercase of the stomach and duodenal intestine in history. However, the palpation of the abdomen in this case does not cause significant pain, the stomach is soft, there are no symptoms of irritation of peritoneum, which does not correspond to the patient's complaints on very strong pain. (Just do not forget that myocardial infarction and sharp surgical diseases may occur at the same time!);
cerebral The option is manifested as an acute violation of cerebral circulation. The loss of consciousness, epileptiform convulsions, violation of speech, paresis and paralysis can be noted. This can be explained as the simultaneous development of myocardial infarction and stroke (spasm of vessels or thrombus in the same time in the heart and brain vessels) and complications of them, for example, the Morgali-Adams - Stokes syndrome (arrhythmia) caused by brain hypoxia;
arrhythmic option - the emergence of for the first time different rhythm and conductivity disorders;
cheerbolic (atypical) The myocardial infarction version is manifested only by changes to the ECG, sometimes revealed by accident.
23. ECG : In acute Stages (damage stage, most often from 20 minutes to 2 hours) - in the leads of the ECG recorded above the infarct area - a monophase curve: the ST segment is sharply lifted above the insulating, forms an arc, addressed by convexity upstairs, merging directly with a high positive T. T. In acute The stage of them, which continues up to 10 days (more often than one week), is formed a focus of necrosis. At the same time, the ECG is registered pathological Deep and wide prong Q and decreased Tusk R.The deeper and wider the tooth Q, the less the prong r, and when transmural infarct Teeth R. at all disappear. ST segment begins to gradually decline, but remains above isolate, and prong. T becomes negative. In leads, opposite localization, they are registered on the ECG reciprocal changes. They are in the acute period of them inverse the main. In the subacline The stage in the leads recorded above the area of \u200b\u200bthem, the QRS complex remains the same, as in the sharp stage, the ST segment is close to the isoelectric line, the Tusk T is deep, negative, equilateral ("coronary" craft of the park). The duration of this stage is 4-5 weeks.
In the scarring stage, the QRS complex is preserved as in the subacute stage, but in a year and the more pathological teeth q can decrease or even disappear, and the voltage of the R teeth can increase somewhat. It is explained by the compensatory myocardial hypertrophy in the scar. The ST segment is located on a isoelectric line, T becomes less negative, or smoothed, or even weakly positive. The duration of this stage is an average of 8 weeks and more than the occurrence of myocardial infarction. The main sign of the scar stage is the lack of the further dynamics of the ECG.
Laboratory data
Already a few hours after the development of them in the blood, the number of leukocytes increases and 3-7 days maintained mainly due to neutrophils (the leukocyte formula shift to the left). For the first days of the disease, a decrease in the number of eosinophils is characterized up to the aezinophilia. Soe in the first days remains normal and begins to increase after 1-2 days, after increasing the temperature and increase the number of leukocytes. By the end of the week, leukocytosis decreases, and ESO increases ("symptom of scissors"). The maximum ESP is usually observed between the 8th and 12th day of the disease, in the future gradually decreases and after 3-4 weeks it returns to normal.
The most valuable method of laboratory diagnostics - Investigation of the activity of serum enzymes. Early and informative in diagnostic is the definition of troponin-t. It appears in 6-8 hours, reaches a maximum in 24-36 hours and is saved by an increased 10-14 days.
Creatinophosphokinease activity (KFK) increases, especially its isoenzyme - MV. It is noted after 6-8 hours from the beginning of them and normalizes 2-3 days. Amineotransferase increases (especially AST and to a lesser degree of Alt). In AST, the initial increase is observed in 8-12 hours, the maximum rise in the 2nd day and is normalized to 3-7 days. The activity of lactate dehydrogenase (especially the first isoenzyme - LDH 1) increases after 24-48 hours from the beginning of the disease, the maximum increase of 3-5 days and is normalized to 8-15 days. It also increases in serum, the content of sialic acids and C-reactive protein, which are held on elevated numbers to 2 weeks.
Widely used to diagnose them definition mioglobin In the blood, which normally does not exceed 85 ng / ml. The important advantage of this test is its earlier appearance: an average of 2-3 hours earlier than increasing the activity of the "early" from enzymes - KFK-MV.
From others additional methods diagnostics The largest "resolution" ability has radioisotope research methods, in particular, scintigraphy with technetium and waist . It allows you to diagnose them where other methods are powerless.
Treatment by
1. Reflection of pain syndrome.
2. Restoration of coronary blood flow.
3. Reducing the work of the heart and the needs of myocardium in oxygen.
4. Limiting the size of myocardial infarction.
5. Treatment and prevention of complications of myocardial infarction.
1.Morphine intravenously fractional
Adequate anesthesia, reduction of pre- and post-loading, psycho-motor excitation, myocardial needs in oxygen (2-5 mg intravenously every 5-15 minutes to completely eliminate pain syndrome or before the appearance of side effects)
2.S. treptocinase (streptase)
Restoration of coronary blood flow (thrombolysis), pain relief syndrome, limiting the size of myocardial infarction, decreased mortality (1.5 million meters intravenously in 60 minutes)
3. Heparin Intravenously inkjet (if the thrombolesis is not carried out) a warning or limitation of coronary thrombosis, the prevention of thromboembolic complications, decreased mortality (10,000-15000 meters intravenously)
4. Nitroglycerin or Isosorbide dinitrate intravenously drip. Reviving pain syndrome, decrease in myocardial infarction and mortality (10 μg / min. With increasing speed by 20 μg / min every 5 minutes under the control of heart rate and ad_
5. Beta adrenoblocators: Propranolol (OZZIZID) Reduced myocardial needs in oxygen, pain relief syndrome, reduction of necrosis, prevention of ventricular fibrillation and left ventricle, repeated myocardial infarction, decreased mortality (1 mg / min every 3-5 minutes to a total dose of 10 mg)
6. Acetylsalicy Love Acid (Aspirin)The relief and prevention of processes associated with platelet aggregation; With early (!) Appointment reduces mortality (160-325 mg.
7. Magnesium sulfate (kormagnezine) Reducing the needs of myocardium in oxygen, pain relief syndrome, reduction of necrosis size, prevention of heart rate disorders, heart failure, decrease in mortality (1000 mg of magnesium (50 ml of 10%, 25 ml of 20% or 20 ml of 25% solution) intravenously for 30 minutes.)
Stage 1. Estimation of the gravity of the state and risk of death
At this stage, it is necessary to collect anamnesis and patient complaints. Anamnesis of the present disease is collected, as well as related and suffering diseases. Then the patient is inspected with the assessment of the frequency of respiratory movements, auscultation of the lungs,Also checked for peripheral edema and other signs of decompensation (increase in liver, hydrotorax)
Stage 2. Analysis of the electrocardiogram
ECG with acute coronary syndrome. Options for shifting ST segment when damaged. There is a change in or displacement of the ST segment, the change in the T. T.
Stage 3. Treatment of acute coronary syndrome at the pre-hospital stage
Principles of treatment at the prehospital stage:
- Adequate anesthesia
- initial antithrombotic therapy
- Treatment of complications
- Fast and careful transportation in the medical institution
Anesthesia:
- nitroglycerin under control arterial pressure
- V / in Analgin + Dimedrol
- V / in morphine 1% - 1.0 per 20.0 saline.
Possible complications:
-
- acute heart failure
Initial antithrombic therapy with acute coronary syndrome
- Aspirin 1 tab. Check out (with intolerance to clopidogrel 300 mg.)- Heparin 5 thousand units. (by appointing a doctor).
Emergency hospitalization in an intensive care unit: for trombolytic therapy (introduction of streptocinase, streptodecase), as well as to solve the issue of coronary and balloon coronary angioplasty
According to modern ideas, the current of the atherosclerotic process is characterized by periods of exacerbation with the destabilization of atherosclerotic plaques, the integrity of its tire, inflammation and the formation of an intuition or comprehensive
V.I. Tyulyko, d. N., Professor, Head of the Department of Cardiology and Functional Diagnostics of the HMAPO, Kharkiv
According to modern concepts, the current of the atherosclerotic process is characterized by periods of exacerbation with the destabilization of an atherosclerotic plaque, the intake of its tires, inflammation and formation of a cloth or fascinating thrombus. The clinical manifestation of atherotromability is acute coronary syndrome (OCC), which includes acute myocardial infarction with the element of the ST or without a segment and unstable angina. In other words, the term acute coronary syndrome implies a period of the disease in which there is a high risk of development or the presence of myocardial damage. The introduction of the term acute coronary syndrome is necessary, since these patients require not only more careful observation, but also to quickly determine the tactics of treatment.
The course and prognosis of the disease is largely dependent on several factors: the volume of lesion, the presence of aggressive factors, such as diabetes, arterial hypertension, heart failure, elderly age, and largely from the speed and completeness of the provision of medical care. Therefore, when suspected of the OKS, treatment should begin at the pre-hospital stage.
OX treatment includes:
- general events (urgent hospitalization in Orit, ECG monitoring, control of diuresis and water balance, Bed regime, followed by an expansion of it in 1-3 days). In the first 1-2 days of food should be a liquid or semi-liquid, in the future light-chaired, low-calorie with the restriction of salt and products containing cholesterol;
- anti-acemic therapy;
- restoration of coronary blood flow;
- secondary prophylaxis.
In order to eliminate pain syndrome, nitroglycerin should be applied. Its positive effect is associated with both the vasodilating effect of the drug on coronary vessels and with positive hemodynamic and antitrombocyte effects. Nitroglycerin is capable of providing an expanding effect on atherosclerotically modified, and intact coronary artery, which contributes to the improvement of the blood circulation of the styled areas.
According to the recommendations of ASS / Ana (2002) on the treatment of patients with OCS, nitroglycerin is advisable to apply patients with a garden not lower than 90 mm Hg. Art. and in the absence of bradycardia (CSS less than 50 shots per minute) in the following cases:
- during the first 24-48 hours from the development of them in patients with heart failure, extensive forward of them, transient myocardial ischemia and elevated blood pressure;
- after the first 48 hours patients with repeated anginal attacks and / or stagnation in the lungs.
Nitroglycerin is used sublingual or in the form of a spray. If the relief of pain syndrome does not occur or there are other indications for the purpose of nitroglycerin (for example, an extensive foreground of myocardial infarction), go to intravenous drip administration of the drug.
Instead of nitroglycerin, you can use isosorbide dinitrate. The drug is introduced intravenously drip under the control of blood pressure in the initial dose of 1-4 drops per minute. With good tolerability, the rate of administration of the drug is raised by 2-3 drops every 5-15 minutes.
The appointment of Molidomin, according to the results of a largely controlled placebo of ESPRIM research conducted in Europe (Eurohean Study of Prevention of Infarct with Molsidomine Group, 1994), does not improve the course and forecast of Oim.
Despite the indisputable positive clinical effect of nitrates, unfortunately, there is no data on the favorable influence of this group of preparations for the forecast.
The use of β-blockers in the treatment of OIM is extremely important, since this group of drugs does not only have an anti-acechematic effect, but is the main one from the standpoint of the restriction of the necrosis zone. The zone of myocardial infarction largely depends on the caliber of the occlusive vessel, the dimensions of the thrombus in ka, carrying out thrombolytic therapy and its effectiveness, availability collateral blood circulation. There are two main ways to limit the size of them and maintain the function of the left ventricle: restoration of the occlusive artery and reducing the need of myocardium in oxygen, which is achieved through the use of β-blockers. Early use β-blockers allows you to limit the area of \u200b\u200bnecrosis, the risk of developing ventricular fibrillation, early heart breaks, decreased mortality of patients. The use of β-blockers in parallel with thrombolysis contributes to a decrease in the frequency of the development of severe complication of thrombolysis - hemorrhage into the brain.
β-blockers in the absence of contraindications should be assigned as early as possible. Preferred is intravenous administration of the drug, which allows you to more quickly achieve the desired positive effect and, with the development of side effects, stop the receipt of the medicine. If the patient has not previously taken β-blockers and the reaction to their introduction is unknown, it is better to introduce short-range cardioslective preparations in a small dose, for example metoprolol. The initial dose of the drug may be 2.5 mg intravenously or 12.5 mg inside. With satisfactory tolerability, the dose of the drug should be increased by 5 mg in 5 minutes. Target dose with intravenous administration - 15 mg.
In the future, go to oral administration of the drug. The first dose of tablet metoprolol is given 15 minutes after intravenous administration. Such pronounced dose variability of the drug is associated with the individual sensitivity of the patient and the form of the drug (retaluth or not).
Supporting doses of β-adrenoblockers in the treatment of IBS:
- Propranolol 20-80 mg 2 times a day;
- Metoprolol 50-200 mg 2 times a day;
- Atenolol 50-200 mg per day;
- Betaxolol 10-20 mg per day;
- Bisoprolol 10 mg per day;
- Esmolol 50-300 μg / kg / min;
- Labetalol 200-600 mg 3 times a day.
In the presence of contraindications to the use of β-blockers in the treatment of Oim, it is advisable to appoint calcium antagonists of a diltiam ". The drug is prescribed at a dose of 60 mg 3 times a day, increasing it with good tolerability to 270-360 mg per day. In the presence of contraindications to β-blockers, diltiazez is a drug selection for the treatment of patients with OX, especially without a tooth Q.
The use of calcium antagonists of a dihydroperidine series with acute coronary syndrome is justified only in the presence of anginal attacks that are not warned by the therapy β-blockers (drugs are prescribed to β-blockers) or with suspected vasospacy of ischemia, for example, with a "cocaine" myocardial infarction. It should be recalled that we are talking only about the calcium antagonists of a prolonged action, since the use of short-scale drugs of this group worsens the forecast of patients with myocardial infarction.
The next direction of the treatment of OIM is the restoration of coronary blood flow, which allows partially or completely preventing the development of irreversible myocardial ischemia, reduce the degree of impaired hemodynamics, improve the prognosis and survival of the patient.
Restore coronary blood circulation is possible by several paths:
- carrying out thrombolytic and antitrombocyte therapy;
- balloon angioplasty or stenting;
- urgen Aorticorona Shunting.
The results of studies conducted on 100 thousand patients indicate that effective thrombolytic therapy reduces the risk of death by 10-50%. The positive effect of thrombolytic therapy is associated with the restoration of the affected artery due to lysis in it, a tomb, restricting the necrosis zone, a decrease in the risk of heart failure due to maintaining the pump function of the left ventricle, improving the processes of reparation, reducing the frequency of the formation of aneurysm, a decrease in the frequency of blood cloves in the left ventricle and Increase the electrical stability of myocardium.
The testimony for carrying thrombolysis are:
- all cases of probable OIM in the presence of an anginal syndrome with a duration of 30 minutes and more in combination with the lifting of ST segment (more than 0.1 mV) in two or more leads in the first 12 hours from the start of pain syndrome;
- outlook arising full blockade Left legs of the GIS bundle in the first 12 hours of the appearance of pain syndrome;
- no contraindications.
It should be noted that, despite the fact that the time interval is outlined by 12 hours, the conducting of thrombolysis in earlier time is more efficient, it is desirable to 6 hours, in the absence of elevation of the ST segment, the effectiveness of thrombolytic therapy is not proven.
Allocate absolute and relative contraindications to the conduct of thrombolytic therapy.
Absolute contraindications to carry out thrombolysis are the following.
- Active or recent (up to 2 weeks) internal bleeding.
- High arterial hypertension (hell over 200/120 mm Hg).
- Recent (up to 2 weeks) surgical intervention or injury, especially the cranial and brain, including cardiovascular resuscitation.
- Active peptic ulcer of the stomach.
- Suspicion of the aortic aortic aneurysm or pericarditis.
- Allergies to streptocynase or APSAP (you can use a urchinase or fabric activator plasminogen).
Given the high risk of reoccusion after thrombolysis, after the introduction of reperfusion, antithrombinic and antitrombocitary therapy must be carried out.
In Ukraine, in view of the low availability of invasive intervention, this therapy is the main in the restoration of coronary blood flow in patients with OX without eleaving the ST segment.
The next stage is anticoagulant and antitrombocyte therapy. The standard of antitrombocitary therapy is aspirin.
Aspirin should be taken at the very beginning of pain syndrome at a dose of 165-325 mg, the tablet is better to warm up. In the future - 80-160 mg aspirin in the evening after eating.
If the patient is allergic to aspirin, it is advisable to assign inhibitors of the ADF-induced aggregation of platelets - clopidogrel (Plavix) or Tiklopidine (tiklid). Tiklopidine - 250 mg 2 times a day during meals.
In the recommendations of the European Society of Cardiologists (2003) and Ana / AAS (2002), it is fundamentally new to inclusion in a number of mandatory means of antithrombotic therapy inhibitor of the ADF-induced aggregation of platelets - clopidogrel.
The basis for this recommendation was the results of the CURE (2001) study, in which 12562 patients were examined, which were obtained, along with aspirin, clopidogrel (the first load dose of 300 mg, then 75 mg per day) or placebo. Additional appointment of clopidogrel contributed to a reliable reduction in infarct frequency, stroke, sudden death, need for revascularization.
Clopidogrel is the standard of therapy of acute myocardial infarction, especially if it developed against the background of aspirin intake, which indirectly indicates the insufficiency of prophylactic antitrombocyte therapy. The drug should be prescribed as early as possible in the loading dose of 300 mg, which supports the dose of the drug is 75 mg per day.
In the second study, the PCI-CURE was evaluated by the effectiveness of clopidogrel in 2658 patients with the planned conduct of percutaneous angioplasty. The results of the study indicate that the appointment of clopidogrel contributes to a decrease in the frequency of the end point (cardiovascular death, the development of myocardial infarction or the conduct of urgent revascularization within a month after angioplasty) by 31%. According to the recommendations of Ana / AAS (2002), patients with unstable angina and myocardial infarction without elevation of the ST segment, which will be revascularized, should receive clopidogrel a month before the operation and continue its reception after intervention as long as possible. The prescription of the drug must be mandatory.
Platelet receptor IIIIB / IIII blockers are a relatively new group of drugs that bind the glycoprotein receptors of platelets and thereby preventing the formation of platelet blood cloth. Proved the effectiveness of glycoprotein receptors after surgery on coronary arteries (stenting), as well as in the treatment of high-risk patients. Representatives of this group are: Absiximab, Eptifibrata and Tyrofiban.
According to the treatment standards, unfractionated heparin or low molecular weight heparins can be used as anticoagulant therapy.
Despite the fact that heparin is applied in clinical practice for decades, the scheme for conducting heparinetherapy under the OIM is not generally accepted, and the results of the evaluation of its effectiveness is contradictory. There are results of studies indicating that the introduction of heparin leads to a decrease in the likelihood of death 20%, along with which the results of meta-analysis 20 studies indicate the absence of effect. Such a contradiction in the results of studies is significantly deregulated various form The administration of the drug: subcutaneous or intravenous drip. To date, it is proved that only with intravenous drip administration of the drug there is indeed a positive effect of therapy. Using subcutaneous administrationNamely, this method of administering the drug, unfortunately, is the most common in Ukraine, does not have reliable impact on the course of the course and forecast of the disease. That is, we allegedly partially carry out recommendations for treatment, but without providing the correct therapy scheme, it is impossible to count on its effectiveness.
The drug should be applied as follows: Bolus 60-70 U / kg (maximum 5000 units), then intravenously drip 12-15 units / kg / hour (maximum 1000 units / hour).
The dosage of heparin depends on the partially activated thromboplastine time (AFTT), which must be led by 1.5-2 times to ensure a complete hypocoagulation effect. But the APTTV, unfortunately, is determined only in several hospitals. More simple, but little informative method, which is often used in medical institutions to control the adequacy of the dose of heparin, is determining blood coagulation time. However, this indicator cannot be recommended to control the effectiveness of therapy due to the incorrect of its use. In addition, the introduction of heparin is fraught with the development of various complications:
- bleeding, including hemorrhagic stroke, especially in elderly (from 0.5 to 2.8%);
- hemorrhages in injection places;
- thrombocytopenia;
- allergic reactions;
- osteoporosis (rarely, only with long-term use).
In the development of complications, it is necessary to administer the antidota of heparin - protamine sulfate, which neutralizes the anti-iIa activity of the nephracial heparin at a dose of 1 mg of the drug per 100 japarin. At the same time, the abolition of heparin and the use of protamin sulfate increase the risk of thrombosis.
The development of complications in the use of heparin is largely due to the peculiarities of its pharmacokinetics. The elimination of heparin from the body takes place in two phases: the rapid removal phase, as a result of the binding of the drug with membrane blood cells, endothelium and macrophages, and the phase of slow removal, mainly through the kidneys. The unpredictability of the activity of receptor capture, which means that the binding of heparin with proteins and the speed of its depolymerization causes the second "side of the medal" - the impossibility of predicting therapeutic (antithrombotic) and side (hemorrhagic) effects. Therefore, if there is no possibility to control the APTTV, it is impossible to talk about the necessary dose of the drug, which means that the usefulness and safety of heparinotherapy cannot be. Even if the AFTT is determined, it is possible to control the dose of heparin only with intravenous administration, since with subcutaneous administration too large variability of the bioavailability of the drug.
In addition, it should be noted that the bleeding caused by the introduction of heparin is associated not only with the influence of the drug on the rolling system of blood, but also on platelets. Thrombocytopenia is quite frequent complicing the introduction of heparin.
The limitations of the therapeutic window of the nephricalized heparin, the complexity of the selection of the therapeutic dose, the need for laboratory control and the high risk of complications were the basis for finding drugs with the same positive properties, but more secure. As a result, so-called low molecular weight heparins (NMG) were developed and implemented. They provide a predominantly normalizing effect on activated coagulation factors, and the likelihood of developing hemorrhagic complications is significantly lower. NMG largely possess antithrombotic than hemorrhagic effect. Therefore, the undoubted advantage of NMG is the lack of need for constant control of the coagulation system of blood in the process of treatment with heparin.
NMG is a heterogeneous group for molecular weight and biological activity. Currently, 3 representatives of the NMG were registered in Ukraine: Nadroparin (Fractional), Enexaparine, Dalstiparin.
Fractiparine is prescribed at a dose of 0.1 ml per 10 kg of weight patient 2 times a day for 6 days. A longer use of the drug does not increase the effectiveness of therapy and is associated with a large risk of developing side effects.
The results of multi-center studies on the study of obverse indicate that the drug has the same clinical effect, as well as administered intravenously drip under the control of the ACTV Heparin, but the number of complications is reliably below.
Thrombin inhibitors (giraudines), according to the results of several multicenter studies Gusto IIB, Timi 9B, Oasis, in the average doses of efficiency are not different from the NFG, in large - increase the number of hemorrhagic complications. Therefore, in accordance with the recommendations of Ana / AAS (2002), the use of girudines in the treatment of patients with OX is suitable only in the presence of heparin-chosen thrombocytopenia.
Unfortunately, not always medicia treatment OX provides status stabilization and prevents the development of complications. Therefore, it is extremely important with insufficient effectiveness of the treatment of this group of patients (maintaining anginal syndrome, episodes of ischemia under Holter monitoring or other complications) to ask the following questions: whether in the treatment of patients are used effective drugswhether the optimal forms of administration and dose of drugs are applied and it is not possible to recognize the feasibility of invasive or surgical treatment.
If the result of the treatment is positive and the patient's condition stabilized, it is necessary to carry out a load test (on the background of the abolition of β-blockers) to determine the further tactics of treatment. The inability to carry out load testing or cancellation of β-blockers on clinical features automatically makes the forecast to unfavorable. Low tolerance for physical exertion is also a high risk testimony and causes the feasibility of coronaryogiography.
Mandatory is the following preventive activities:
- modification of lifestyle;
- the appointment of supporting antitrombocyte therapy (aspirin 75-150 mg, clopidogrel 75 mg or a combination of these drugs);
- application of statins (Simvastatin, Atorvastatin, Lovastatin);
- using aPF inhibitors, especially in patients with signs of heart failure.
And finally, another aspect on which it is necessary to stop - the expediency of using metabolic therapy at ACS. According to the recommendations of An Ana / AAS and the European Cardiology Society (2002), metabolic therapy is not a standard for treating ACS, since there are no convincing data of large studies confirming the effectiveness of this therapy. Therefore, those tools that can be spent on drugs with metabolic effects are more reasonable to use on really effective meansThe use of which is the standard of treatment and allows you to improve the forecast, and sometimes save the life of the patient.
The prevalence of cardiovascular diseases (CVD) in Ukraine has achieved extremely broad scale. The number of patients, according to statistics of recent years, is 47.8% of the population of the country: 43.2% of them are patients with arterial hypertension (AG); 32.1% - with ischemic heart disease (IBS) and 12.7% - with cerebrovascular diseases (CHS). With such a prevalence of CVD, it is the cause of 62.5% of all deaths (IBS - 40.9%, the CCS is 13.6%), which is the worst indicator in Europe.
N.F. Sokolov, Ukrainian Scientific and Practical Center for Emergency Medicine and Medicine Catastrophe; T.I. Gandja, A.G. Loboda, national medical Academy Postgraduate education named after P.L. Shupika, Kiev
In the current situation, improving the quality of CVD treatment is one of the priorities. First of all, this applies to the doggown stage, since the proper extent of the doctor during this period, the further fate of patients with acute coronary syndrome (OCS), AG, heart rate disorders depend largely.
It is currently proved that atherosclerosis is a disease with phases of stable flow and exacerbations. A period of exacerbation of chronic ischemic heart disease is called acute coronary syndrome. This term combines such clinical conditions as myocardial infarction (im), unstable angina (NA) and sudden heartfelt death. The appearance of the OX term is due to the fact that although they have different clinical manifestations, but they have the same pathophysiological mechanism: a gap or erosion of atherosclerotic plaques with different degrees of thrombosis, vasoconstriction and distal embolization of coronary vessels. According to modern ideas, the main factors that lead to the destabilization of atherosclerotic plaques are systemic and local inflammation. In turn, agents contributing to the development of inflammation are very diverse: infections, oxidant stress, hemodynamic disorders (hypertensive crisis), systemic immune responses, etc. Filled with lipids of the poisoner, which is revealed after its break, high-threaten. This leads to the launch of the reaction cascade: platelet adhesion on the damaged surface, the activation of platelets and the coagulation system, the secretion of serotonin and thromboxane A2, platelet aggregation. The development of acute thrombosis in an amazed atherosclerotic process of the Vessel can contribute not only to the gap of the plaque, but also increased blood coagulation, which is more often noted in smokers, in women who use oral contraceptives, young patients who have undergone them.
The braking of the natural activation of plasminogen induces hypercoagulation and can lead to the development of an extensive one even with angiographically little changed arteries. The activation of plasminogen is subject to circadian rhythms with a decline in early morning hours, when the probability of them, sudden death and stroke the greatest.
If the thrombus does not completely overlap the clearance of the vessel, the clinical picture of the NA is developing. In the case when the thrombus in the Vernoe vessel causes its full occlusion, it arises, especially in the absence of developed collateral blood circulation, which is more often the case in young patients. This can also occur with hemodynamically insignificant coronary stenosis.
Based on changes to the ECG there are two main forms of OX: with lifting and without lifting segment ST.
In patients with elevation of ST segment, as a rule, there is transmural myocardial ischemia, due to complete occlusion of the coronary artery thrombus, extensive necrosis develops. In patients with depression segment ST arises ischemia, which can form or not form necrosis, as coronary blood flow is partially saved. The infarction in these patients is developing without appearing on ECG TOTAL Q (they are without q). In the case of rapid normalization of the ECG and the lack of increasing the level of markers of myocardial necrosis, the NA is diagnosed.
The allocation of two forms of the OX is also associated with a different forecast and therapeutic tactics in these groups of patients.
Forms of OX
Acute coronary syndrome with ST segment lifting or acutely arising blockade of the left leg of a beam of His
Resistant lifts of ST segment indicate the acute complete occlusion of the coronary artery, possibly in proximal Department. Since the risk of damage is subject to a large area of \u200b\u200bmyocardial left ventricle, the forecast for these patients is the most severe. The purpose of treatment in this situation is fast recovery vessel passability. For this, thrombolytic preparations are used (in the absence of contraindications) or percutaneous angioplasty.
Acute coronary syndrome without lifting segment ST
In this embodiment, changes to the ECG are characterized by a stealless or transient depression of the ST segment, inversion, smoothness or pseudonormalization of T. T. In some cases, the ECG in the first hours is normal, and the tactics of such patients are to eliminate pain and myocardium ischemia using aspirin, heparin , β-blockers, nitrates. Thrombolytic therapy is ineffective and may even worsen the prediction in patients.
The diagnosis of OKS on the pre-hospital stage is based on clinical manifestations (anginal status) and ECG diagnostics.
Angry status
OX with lifting segment st
The diagnosis is carried out on the basis of the presence of anginal pain in the chest for 20 minutes and more, which is not stopped by nitroglycerin and irradiages in the neck, low jaw, left hand. In the elderly people in the clinical picture can prevail not painful syndrome, but weakness, shortness of breath, loss of consciousness, arterial hypotension, violation of the heart rhythm, the phenomena of acute heart failure.
OX without lifting segment st
The clinical manifestations of an anginal attack in patients with this option of OXC may be a rest angina for a duration of more than 20 minutes, which first arose angularity angina of the ІІІ functional class, progressive angina (the increase in attacks, an increase in their duration, decreased tolerance to physical exertion).
Acute coronary syndrome may have an atypical clinical course. Atypical manifestations: Epigastric pain with nausea and vomiting, stitching pain in the chest, pain syndrome with signs characteristic of the defeat of the pleura, increasing shortness of breath.
In these cases, the proper diagnosis contributes to the presence in the history of IBS and changes to the ECG.
ECG diagnostics
ECG is the main method of evaluating patients with OX, on the basis of which a prediction is built and the healing tactic is built.
OX with lifting segment st
- Elevation of the segment of ST ≥ 0.2 mV in leads V1-V3 or ≥ 0.1 mV in other leads.
- The presence of any teeth Q in leads V1-V3 or teeth q ≥ 0.03 s in leads I, AVL, AVF, V4-V6.
- Inside the blockade of the left leg of the Gis beam.
OX without lifting segment st
ECG signs of this version of the OX - depression of ST segment and changing the T. T. The likelihood of this syndrome is the most high when combined clinical picture With the depression of ST segment, exceeding 1 mm in two adjacent leads with the prevailing teeth R or more. Normal ECG in patients with symptoms characteristic of OCC does not exclude its presence. At the same time, it is necessary to exclude others possible reasons Patient complaints.
Treatment of patients with OX
The results of the treatment of OKS largely depend on the proper actions of the doctor at the prehospital stage. The main task of an ambulance is an effective relief of pain syndrome and possibly the early reperfusion therapy.
Algorithm for the treatment of patients with OX
- Nitroglycerin sublingual (0.4 mg) or nitroglycerin aerosol every five minutes. After taking three doses with a preserving pain in the chest and systolic blood pressure not lower than 90 mm Hg. Art. It is necessary to resolve the appointment of nitroglycerin intravenously in the form of infusion.
- The preparation of choice for relieving pain syndrome is a morphine sulfate for 10 mg intravenously in the physiological solution of sodium chloride.
- Early appointment of acetylsalicylic acid at a dose of 160-325 mg (dear). The patients who took the previously aspirin can be prescribed clopidogrel of 300 mg, followed by applying at a dose of 75 mg / day.
- The immediate purpose of β-blockers is recommended to all patients if there are no contraindications to their use (atrioventricular blockades, bronchial asthma in history, acute left-detective failure). Treatment It is necessary to start with short-range preparations: propranolol in a dose of 20-40 mg or metroprolol (egilov) at 25-50 mg inward or sublingual.
- Elimination of factors that increase the burden on myocardium and contribute to the strengthening of ischemia: hypertension, heart rhythm disorders.
Further tactics of assistance to patients with OKS, as already mentioned, is determined by the characteristics of the ECG painting.
Patients with clinical signs of an ox with a resistant elevation of the ST segment or the acute blockade of the left leg of the GIS bundle in the absence of contraindications it is necessary to restore the coronary artery's permeability with thrombolytic therapy or primary pervalic angioplasty.
With the possibility of thrombolytic therapy (TLT), it is recommended to be carried out at the pre-hospital stage. If the TLT manages to perform in the first 2 hours after the symptoms of the disease (especially during the first hour), it can stop the development of them and significantly reduce mortality. The TLT is not carried out if more than 12 hours have passed from the moment of an angin attack, except when the bouts of ischemia continue (pain, lifts of the ST segment).
Absolute contraindications to TLT
- Any intracranial bleeding as anamnesis.
- Ischemic stroke over the past three months.
- Structural damage to the brain vessels.
- Malignant brain neoplasm.
- Closed cranial injury or face injury in the last three months.
- The aortic aneurysm.
- Gastrointestinal bleeding over the past month.
- The pathology of the blood coagulation system with a tendency to bleeding.
Relative contraindications for TLT
- Refractive arterial hypertension (systolic hell of more than 180 mm Hg. Art.).
- Ischemic stroke in history (older than three months).
- Traumatic or long-term (more than 10 minutes) Cardiovary resuscitation.
- Large surgical operation (up to three weeks).
- Puncture of the vessel, which can not be pressing.
- Peptic ulcer in the stages of exacerbation.
- Anticoagulant therapy.
In the absence of conditions for conducting the TLT, as well as in patients with OX without lifting ST segment, the ECG shows the purpose of anticoagulants: heparin 5000 units intravenously or low molecular weight heparin - anxaparine 0.3 ml intravenously, followed by a continuation of treatment under the hospital.
Literature
- Lіkuvannya Ghostoya Інфаркту міokard at Pazієntіv z Ellevatsіyu segment ST in Debutі Zakhvoruvannya: GOVNI WORDING RECORDSІ ROBOCHO GROUP OIROPEY CARDIOLOGICAL PROFESSION, 2003 // SERTSE І Sudini. - 2003. - № 2. - P. 16-27.
- Lіkuvannya Інфаркту міокарда з Елеваціюu segment ST: Recommenders of american cardiologist і і і амоскосіації і і АСЦіві состорі ице і издиний. - 2005. - № 2 (10). - P. 19-26.
- Dolzhenko M.N. European recommendations on the diagnosis and treatment of acute coronary syndrome // Therapy. - 2006. - № 2. - P. 5-13.
- Raptova Card_alna Death: Factorizing Ta Prof_laktika / Recommenders Kardіologist Kardіologist. - K., 2003. - 75 p.
- Sudinni Sudinnі Zakhvornnya: Clasifіkatsіya, Shema Diagnostiki Ta Lіkuvannye / Options Profomniv V.M. Kovalenka, M.І. Moody. - K., 2003. - 77 p.
