Ãëàâíàÿ

Ïîïóëÿðíàÿ ïóáëèêàöèÿ

Íàó÷íàÿ ïóáëèêàöèÿ

Ñëó÷àéíàÿ ïóáëèêàöèÿ

Îáðàòíàÿ ñâÿçü

ÒÎÐ 5 ñòàòåé:

Ìåòîäè÷åñêèå ïîäõîäû ê àíàëèçó ôèíàíñîâîãî ñîñòîÿíèÿ ïðåäïðèÿòèÿ

Ïðîáëåìà ïåðèîäèçàöèè ðóññêîé ëèòåðàòóðû ÕÕ âåêà. Êðàòêàÿ õàðàêòåðèñòèêà âòîðîé ïîëîâèíû ÕÕ âåêà

Öåíîâûå è íåöåíîâûå ôàêòîðû

Õàðàêòåðèñòèêà øëèôîâàëüíûõ êðóãîâ è åå ìàðêèðîâêà

Ñëóæåáíûå ÷àñòè ðå÷è. Ïðåäëîã. Ñîþç. ×àñòèöû

ÊÀÒÅÃÎÐÈÈ:






Õ³ðóðã³÷íå âòðó÷àííÿ ó ïàö³ºíò³â, ÿê³ ïðîõîäÿòü àíòèòðîìáîöèòàðíó òåðàï³þ 1 ñòðàíèöà




˳êóâàííÿ ïàö³ºíò³â, ùî ïðèéìàþòü ÏÀÒÒ, ÿê³ çâåðíóëèñÿ ç ïðèâîäó õ³ðóðã³÷íîãî âòðó÷àííÿ, çàëåæèòü â³ä òåðì³íîâîñò³, ðèçèêó óòâîðåííÿ òðîìá³â òà êðîâîòå÷³ ó êîæíîãî îêðåìîãî ïàö³ºíòà â êîæíîìó îêðåìîìó âèïàäêó. 878 Á³ëüø³ñòü õ³ðóðã³÷íèõ ïðîöåäóð ìîæíà ïðîâîäèòè ïðè ÏÀÒÒ àáî ïðè çàñòîñóâàíí³ ò³ëüêè ÀÑÊ ç ïðèéíÿòíèì ð³âíåì ðèçèêó ðîçâèòêó êðîâîòå÷³. Äëÿ âèçíà÷åííÿ ãðóïè ðèçèêó (êðîâîòå÷³ òà òðîìáîçó) ïàö³ºíòà òà îáðàííÿ íàéêðàùî¿ ñòðàòå㳿 íåîáõ³äíà âçàºìîä³ÿ ôàõ³âö³â ð³çíèõ ãàëóçåé (êàðä³îëîã³â, àíåñòåç³îëîã³â, ãåìàòîëîã³â òà õ³ðóðã³â). ijéñíî, êðîâîòå÷³, ïîâ’ÿçàí³ ç õ³ðóðã³÷íèì âòðó÷àííÿì, çá³ëüøóþòü ð³âåíü ñìåðòíîñò³ âïðîäîâæ 30 äí³â òà ó â³ääàëåíîìó ïåð³îä³. 573

 

Îáñåðâàö³éí³ äàí³ ìàñøòàáíîãî êîãîðòíîãî äîñë³äæåííÿ (âñòàíîâëåííÿ 124 844 BMS àáî DES) ïîêàçóþòü, ùî íàéñèëüí³øèìè ôàêòîðàìè ðèçèêó âèíèêíåííÿ MACE ï³ñëÿ íåêàðä³îëîã³÷íîãî õ³ðóðã³÷íîãî âòðó÷àííÿ º íååëåêòèâíå õ³ðóðã³÷íå âòðó÷àííÿ, ³íôàðêò ì³îêàðäà â àíàìíåç³ âïðîäîâæ íàéáëèæ÷èõ 6 ì³ñÿö³â ï³ñëÿ õ³ðóðã³÷íîãî âòðó÷àííÿ òà òÿæêå ñåðöåâå çàõâîðþâàííÿ.

 

Òîä³ ÿê ÷àñ ïðîâåäåííÿ õ³ðóðã³÷íîãî âòðó÷àííÿ àñîö³þâàâñÿ ç íàÿâí³ñòþ MACE âïðîäîâæ ïåðøèõ 6 ì³ñÿö³â ï³ñëÿ ÏÊÂ, öåé ôàêò á³ëüøå íå ìàâ çíà÷åííÿ ÷åðåç 6 ì³ñÿö³â. 663 Ñë³ä çàçíà÷èòè, ùî òèï ñòåíòà (BMS àáî DES) íå áóâ ïîâ’ÿçàíèé ç MACE ï³ñëÿ õ³ðóðã³÷íîãî âòðó÷àííÿ. Çàäëÿ çíèæåííÿ ðèçèêó êðîâîòå÷³ òà òðîìáîç³â ñë³ä â³äêëàäàòè ðåêîìåíäîâàí³, àëå íåîáîâ’ÿçêîâ³ íåêàðä³îëîã³÷í³ õ³ðóðã³÷í³ âòðó÷àííÿ äî çàâåðøåííÿ ïîâíîãî êóðñó ïðèçíà÷åíî¿ ÏÀÒÒ (íàéêðàùå ÷åðåç 6 ì³ñÿö³â íà ôîí³ ñòàá³ëüíî¿ ²ÕÑ òà ÷åðåç 1 ð³ê íà ôîí³ ÃÊÑ), ³ öå õ³ðóðã³÷íå âòðó÷àííÿ ñë³ä ïðîâîäèòè áåç ïðèïèíåííÿ çàñòîñóâàííÿ àñï³ðèíó, ÿêùî öå ìîæëèâî. Êîðîòøèé òåðì³í ÏÀÒÒ ìîæå áóòè âèïðàâäàíèé íåìîæëèâ³ñòþ â³äêëàñòè õ³ðóðã³÷íå âòðó÷àííÿ.

 

Ïðè ï³äãîòîâö³ äî õ³ðóðã³÷íèõ ïðîöåäóð â ãðóï³ â³ä âèñîêîãî äî äóæå âèñîêîãî ðèçèêó êðîâîòå÷³ ðåêîìåíäóºòüñÿ ïðèïèíèòè çàñòîñóâàííÿ êëîï³äîãðåëþ çà 5 äí³â äî õ³ðóðã³÷íîãî âòðó÷àííÿ çàäëÿ çíèæåííÿ ðèçèêó âèíèêíåííÿ êðîâîòå÷³ òà íåîáõ³äíîñò³ ïåðåëèâàííÿ êðîâ³, òà îäíî÷àñíî ïðîäîâæóâàòè ïðèéîì ÀÑÊ âïðîäîâæ ïåðåäîïåðàö³éíîãî ïåð³îäó. 879 Ïðèéîì ïðàñóãðåëþ ñë³ä ïðèïèíèòè çà 7 äí³â äî õ³ðóðã³÷íîãî âòðó÷àííÿ ÷åðåç éîãî á³ëüø òðèâàëå òà åôåêòèâíå ïðèãí³÷åííÿ óòâîðåííÿ òðîìá³â, â ïîð³âíÿíí³ ç êëîï³äîãðåëåì.

 

Ö³êàâî, ùî íåçâàæàþ÷è íà âèùó ÷àñòîòó ìàñèâíî¿ êðîâîòå÷³ çà øêàëîþ TIMI (ÂØ 4,73; 95% IJ 1,9–11,8), ïåðåëèâàííÿ òðîìáîöèòàðíî¿ ìàñè òà ïîâòîðí³ õ³ðóðã³÷í³ îáñòåæåííÿ ç ïðèâîäó êðîâîòå÷³, ïðàñóãðåëü áóâ ïîâ’ÿçàíèé ç íèæ÷èì ð³âíåì ñìåðòíîñò³ ï³ñëÿ ÀÊØ, í³æ êëîï³äîãðåëü â íåâåëèê³é ï³äãðóï³ ïàö³ºíò³â â äîñë³äæåíí³ TRITON-TIMI 38 (2,3% â ïîð³âíÿíí³ ç 8,7%, â³äïîâ³äíî; ñåðåäíº ÂØ 0,26; P=0,025). 880 Á³ëüø³ñòü âèïàäê³â ÀÊØ áóëè çàïëàíîâàíèìè òà ïðîâîäèëèñÿ ï³ñëÿ çàâåðøåííÿ ï³äãîòîâ÷èõ ïðîöåäóð, ³ çàçâè÷àé ïðèéîì äîñë³äæóâàíîãî ïðåïàðàòó ï³ñëÿ ÀÊØ â³äíîâëþâàâñÿ.  äîñë³äæåíí³ PLATO ó ï³äãðóï³ ïàö³ºíò³â, ùî ïðîõîäèëè ÀÊØ ÷åðåç 7 äí³â ï³ñëÿ îñòàííüîãî ïðèéîìó äîñë³äæóâàíîãî ïðåïàðàòó (3–5 äí³â), ò³êàãðåëîð ó ïîð³âíÿíí³ ç êëîï³äîãðåëåì áóâ òàêîæ ïîâ’ÿçàíèé ç íèæ÷èì ð³âíåì çàãàëüíî¿ ñìåðòíîñò³ (4,6% â ïîð³âíÿíí³ ç 9,2%, â³äïîâ³äíî; P=0,002) áåç ï³äâèùåíîãî ðèçèêó êðîâîòå÷³, ïîâ’ÿçàíî¿ ç ÀÊØ. 881 Á³ëüø í³æ â ïîëîâèí³ âèïàäê³â ÀÊØ ïðîâîäèëè ï³ä ÷àñ ï³äãîòîâ÷èõ ïðîöåäóð. Öå ïîÿñíþâàëî ìåíøó ê³ëüê³ñòü ñìåðòåé, ïîâ’ÿçàíèõ ç êðîâîòå÷åþ òà ³íôåêö³ºþ, òàê ñàìî ÿê ³ ìåíøîþ ê³ëüê³ñòþ ³øåì³÷íèõ óñêëàäíåíü. Âñüîãî 37% ïàö³ºíò³â íå â³äíîâèëè ïðèéîì äîñë³äæóâàíîãî ïðåïàðàòó âïðîäîâæ 7 äí³â ï³ñëÿ ïðèïèíåííÿ.

 

Òàêèì ÷èíîì, ïðèïèíåííÿ ïðèéîìó ³íã³á³òîð³â P2Y12 íå ðåêîìåíäóºòüñÿ â ãðóïàõ âèñîêîãî ðèçèêó, â ÿêèõ ïðîäîâæóºòüñÿ ³øåì³ÿ, òà âèñîêèì àíàòîì³÷íèì ðèçèêîì (íàïðèêëàä, óðàæåííÿì ñòîâáóðà ËÊÀ àáî òÿæêèì áàãàòîñóäèííèì óðàæåííÿì). Òàêèì ïàö³ºíòàì ñë³ä ïðîõîäèòè ÀÊØ, ïðîäîâæóþ÷è ïðèéîì ³íã³á³òîð³â P2Y12, ³ â òîé æå ÷àñ ïðèä³ëÿþ÷è îñîáëèâó óâàãó çìåíøåííþ ðèçèêó âèíèêíåííÿ êðîâîòå÷³. Ìîæå áóòè âèïðàâäàíèì – õî÷à á ó ïàö³ºíò³â äóæå âèñîêî¿ ãðóïè ðèçèêó – óòðèìàííÿ â³ä çàñòîñóâàííÿ ³íã³á³òîð³â P2Y12 ïåðåä õ³ðóðã³÷íèì âòðó÷àííÿì, íàâ³òü ñåðåä òèõ, ó êîãî º àêòèâíà ³øåì³ÿ, òà ïðèä³ëèòè óâàãó ïåðåõ³äí³é ñòðàòå㳿 (äèâ³òüñÿ íèæ÷å). Ñë³ä ïîâåðíóòèñÿ äî ÏÀÒÒ ÿêîìîãà øâèäøå, âêëþ÷àþ÷è íàâàíòàæóâàëüíó äîçó êëîï³äîãðåëþ, ò³êàãðåëîðó àáî ïðàñóãðåëþ (ÿêùî ìîæëèâî âïðîäîâæ 24 ãîäèí ï³ñëÿ õ³ðóðã³÷íîãî âòðó÷àííÿ), òèì íå ìåíø îïòèìàëüíèé ÷àñ â³äíîâëåííÿ çàñòîñóâàííÿ ë³êàðñüêîãî çàñîáó ï³ñëÿ õ³ðóðã³÷íîãî âòðó÷àííÿ ç ïðèâîäó ÀÊØ çàëèøàºòüñÿ íåâèçíà÷åíèì.

Ìîí³òîðèíã ë³êóâàííÿ ç àíàë³çîì áåçïîñåðåäíüî á³ëÿ ë³æêà õâîðîãî ïåðåäáà÷àëè ñêîð³øå ÿê îïö³þ äî ïðîòîêîëó ïåðåðèâàííÿ ë³êóâàííÿ, í³æ çàñòîñóâàííÿ âèïàäêîâîãî, ñïåöèô³÷íîãî ïåð³îäó. Ïðèãí³÷åííÿ òðîìáîöèò³â ó â³äïîâ³äü íà çàñòîñóâàííÿ êëîï³äîãðåëþ âèçíà÷ຠêðîâîòå÷ó, ïîâ’ÿçàíó ç ÀÊØ, 882 à ñòðàòåã³ÿ, çàñíîâàíà íà ïåðåäîïåðàö³éíîìó äîñë³äæåíí³ òðîìáîöèòàðíî¿ ôóíêö³¿, äëÿ âèçíà÷åííÿ ÷àñó ïðîâåäåííÿ ÀÊØ ó ïàö³ºíò³â, ùî ïðèéìàëè êëîï³äîãðåëü, ïðèçâîäèòü äî ñêîðî÷åííÿ ÷àñó î÷³êóâàííÿ íà ~ 50% ó ïîð³âíÿíí³ ç ðåêîìåíäîâàíèì ó ïîòî÷íèõ Ðåêîìåíäàö³ÿõ. 883 Ç öèõ ïðè÷èí îíîâëåííÿ ðåêîìåíäàö³é Àñîö³àö³¿ òîðàêàëüíèõ õ³ðóðã³â 2012 ðîêó ïåðåäáà÷àº, ùî â³äêëàäàííÿ àíòèòðîìáîöèòàðíî¿ òåðàﳿ íà äåíü ÷è äâà îá´ðóíòîâàíå äëÿ çíèæåííÿ ðèçèêó êðîâîòå÷³ òà óòâîðåííÿ òðîìá³â ó ïàö³ºíò³â ç ÃÊÑ. 879

 

Ó ñèòóàö³ÿõ äóæå âèñîêîãî ðèçèêó, òàêèõ ÿê ïåðøèé òèæäåíü ï³ñëÿ âñòàíîâëåííÿ ñòåíòà, ïåðåäáà÷àºòüñÿ, ùî ïàö³ºíòà ïðîòÿãîì 5 äí³â ïåðåä õ³ðóðã³÷íèì âòðó÷àííÿì ìîæëèâî ñë³ä ïåðåêëþ÷èòè ç êëîï³äîãðåëþ íà àíòèòðîìáîöèòàðíèé çàñ³á ç êîðîòêèì ïåð³îäîì íàï³ââèâåäåííÿ (íàïðèêëàä, âíóòð³øíüîâåíí³ ³íã³á³òîðè ÃÏ IIb/IIIa, ò³ðîô³áàí àáî åïòèô³áàòèä) ç ïðèïèíåííÿì âëèâàííÿ çà 4 ãîäèíè äî õ³ðóðã³÷íîãî âòðó÷àííÿ, 884 ´ðóíòóþ÷èñü âèêëþ÷íî íà ôàðìàêîäèíàì³÷íèõ òà ôàðìàêîê³íåòè÷íèõ äîñë³äæåííÿõ íà ï³äòðèìêó öüîãî ï³äõîäó.

 

Ó äîñë³äæåíí³ «Ïåðåõ³äíà àíòèêîàãóëÿö³ÿ ó ïàö³ºíò³â, ÿê³ ïîòðåáóþòü òèì÷àñîâîãî ïåðåðèâàííÿ òåðàﳿ âàðôàðèíîì ïðè ðåêîìåíäîâàíèõ ³íâàçèâíèõ ïðîöåäóðàõ àáî õ³ðóðã³÷íîìó âòðó÷àíí³» (BRIDGE) áóëî äîñë³äæåíî çàñòîñóâàííÿ êàíãðåëîðó (âíóòð³øíüîâåííîãî çâîðîòíî-ä³þ÷îãî ³íã³á³òîðà P2Y12 ðåöåïòîð³â òðîìáîöèò³â) ïîð³âíþâàëîñü ç ïëàöåáî äëÿ ïåðåõîäó ïàö³ºíò³â, ÿê³ ïðèéìàëè ò³ºíîï³ðèäèí, äî ïðîâåäåííÿ ÀÊØ. 854

 

Ïðèéîì ïåðîðàëüíèõ ³íã³á³òîð³â P2Y12 áóëî ïðèïèíåíî çà 48 ãîäèí äî ÀÊØ. Êàíãðåëîð ïðèçâ³â äî âèùîãî ð³âíÿ ï³äòðèìêè ïðèãí³÷åííÿ òðîìáîöèò³â (îñíîâíèé î÷³êóâàíèé ðåçóëüòàò, P2Y12 ðåàãóþ÷èõ îäèíèöü <240; 98,8% (83/84) â ïîð³âíÿíí³ ç 19,0% (16/84), â³äïîâ³äíî; ÂÐ 5,2; 95% IJ 3,3–8,1; P<0,001). Ïåðåõ³ä çà äîïîìîãîþ ïðîäîâæåííÿ ³íôóç³é êàíãðåëîðó íå çá³ëüøèâ ÷àñòîòè ìàñèâíèõ êðîâîòå÷ ïåðåä õ³ðóðã³÷íèì âòðó÷àííÿì.

 

Çàì³íà ÏÀÒÒ ÍÌà ÷è ÍÔÃ. 885 Ïðè õ³ðóðã³÷íèõ ïðîöåäóðàõ â ãðóïàõ â³ä íèçüêîãî äî ïîì³ðíîãî ðèçèêó êðîâîòå÷³ õ³ðóðãàì ñë³ä â³äìîâèòèñÿ â³ä îïåðàö³¿ ïðè ïðîäîâæåíí³ ÏÀÒÒ.

 

Ìîæíà çðîáèòè âèñíîâîê, ùî êëîï³äîãðåëü ï³ñëÿ ÀÊØ âèÿâëÿºòüñÿ áåçïå÷íèì òà åôåêòèâíèì â³äïîâ³äíî äî íàéíîâ³øîãî ìåòà-àíàë³çó ï’ÿòè ðàíäîì³çîâàíèõ äîñë³äæåíü òà øåñòè íååêñïåðèìåíòàëüíèõ äîñë³äæåíü, ÿê³ âêëþ÷àëè 25 728 ïàö³ºíò³â, ùî ïðèéìàëè êëîï³äîãðåëü äîäàòêîâî äî ÀÑÊ çàì³ñòü ïðèéîìó ò³ëüêè ÀÑÊ, ÿêèé ïîêàçàâ êðàùå ðàííº ðîçêðèòòÿ âåíîçíîãî òðàíñïëàíòàòó (ÂÐ 0,59; 95% IJ 0,43–0,82; P=0,02) òà íèæ÷èé ð³âåíü âíóòð³øíüîë³êàðíÿíî¿ ñìåðòíîñò³ âïðîäîâæ 30 äí³â (0,8% â ïîð³âíÿíí³ ç 1,9%; P<0,0001). 886 Ïîêðàùåííÿ ð³âíÿ ñìåðòíîñò³ ï³ñëÿ ÀÊØ ó äîñë³äæåííÿõ PLATO òà TRITON-TIMI 38 ïåðåäáà÷àº, ùî ò³êàãðåëîð òà ïðàñóãðåëü ìîæíà çíîâó ïî÷èíàòè ïðèéìàòè ï³ñëÿ ÀÊØ; îäíàê ñâ³ä÷åííÿ îáìåæåí³ ëèøå îäí³ºþ òðåòèíîþ ïàö³ºíò³â, ÿê³ â³äíîâèëè ïðèéîì ò³êàãðåëîðó ó PLATO ³ â³äñóòí³ñòþ ðàíäîì³çîâàíîãî îö³íþâàííÿ. 881

 

Ïàö³ºíòè ç ã³ïåð÷óòëèâ³ñòþ äî àöåòèëñàë³öèëîâî¿ êèñëîòè. Ìîæíà ïðîâåñòè ïðîöåäóðó øâèäêî¿ äåñåíñèá³ë³çàö³¿ ïàö³ºíòàì ç ã³ïåð÷óòëèâ³ñòþ äî ÀÑÊ, ÿêèì íåîáõ³äíà òåðàï³ÿ öèì ïðåïàðàòîì. 898 Êëîï³äîãðåëü â äîç³ 75 ìã íà äîáó º â³äïîâ³äíîþ àëüòåðíàòèâîþ äëÿ ïàö³ºíò³â ç íåïåðåíîñèì³ñòþ àáî àëåð㳺þ íà ÀÑÊ ïðè äîâãîòðèâàëîìó ë³êóâàíí³. 899 Àëüòåðíàòèâíî ó âèïàäêó íåïåðåíîñèìîñò³ àñï³ðèíó ìîæíà â³ääàòè ïåðåâàãó íîâ³òíüîìó ³íã³á³òîðó P2Y12 (ïðàñóãðåëþ àáî ò³êîãðåëîðó) íàä êëîï³äîãðåëåì, ÿê ºäèí³é àíòèòðîìáîöèòàðí³é òåðàﳿ îáìåæåíîãî òåðì³íó çàñòîñóâàííÿ (â³ä 1 äî 6 ì³ñÿö³â) ï³ñëÿ ÏÊÂ.

 

Òðîìáîöèòîïåí³ÿ, ñïðè÷èíåíà ãåïàðèíîì. Ó ïàö³ºíò³â ç òðîìáîöèòîïåí³ºþ, ñïðè÷èíåíîþ ãåïàðèíîì, íå ñë³ä çàñòîñîâóâàòè àí³ ÍÔÃ, àí³ ÍÌà âíàñë³äîê ì³ðêóâàíü ùîäî ïåðåõðåñíî¿ ðåàêòèâíîñò³.  òàêîìó âèïàäêó á³âàë³ðóäèí áóäå íàéêðàùèì âàð³àíòîì àíòèêîàãóëÿíòà; ³íøèìè àëüòåðíàòèâàìè º àðãàòðîáàí, õ³ðóäèí, ëåï³ðóäèí òà äàíàïàðî¿ä.

 

Òàáëèöÿ 60. Çàãàëüí³ ðåêîìåíäàö³¿ ùîäî àíòèòðîáîöèòàðíî¿ òåðàﳿ

Ðåêîìåíäàö³¿ Êëàñ à гâåíü b Ïîñèëàííÿ ñ
Ó ïàö³ºíò³â ç êðîâîòå÷åþ êèøêîâî-øëóíêîâîãî òðàêòó àáî âèðàçêîâîþ õâîðîáîþ â àíàìíåç³ ðåêîìåíäóºòüñÿ çàñòîñîâóâàòè ³íã³á³òîðè ïðîòîííîãî íàñîñà â êîìá³íàö³¿ ç ÏÀÒÒ, òà â³äïîâ³äíî ó ïàö³ºíò³â ç ³íøèìè ð³çíîìàí³òíèìè ôàêòîðàìè ðèçèêó (íàïðèêëàä, ³íô³êóâàííÿ Helicobacter pylori, â³ê ≥ 65 ðîê³â, à òàêîæ îäíî÷àñíå çàñòîñóâàííÿ àíòèêîàãóëÿíò³â, ñòåðî¿äíèõ àáî íåñòåðî¿äíèõ ïðîòèçàïàëüíèõ çàñîá³â) ² À 900, 901
Êëîï³äîãðåëü â äîç³ 75 ìã íà äîáó âèçíà÷åíèé ÿê àëüòåðíàòèâíèé çàñ³á ó âèïàäêó íåïåðåíîñèìîñò³ ÀÑÊ ïàö³ºíòàìè ç³ ñòàá³ëüíîþ ²ÕÑ. I   
Äîñë³äæåííÿ òðîìáîöèòàðíî¿ ôóíêö³¿ àáî ãåíåòè÷íå òåñòóâàííÿ ìîæå ïðèéìàòèñÿ äî óâàãè â îñîáëèâèõ âèïàäêàõ ï³äâèùåíîãî ðèçèêó (íàïðèêëàä, íàÿâí³ñòü òðîìáîçó ñòåíòà â àíàìíåç³; ïîâ’ÿçàí³ ïðîáëåìè; ï³äîçðè ùîäî ðåçèñòåíòíîñò³; âèñîêèé ðèçèê êðîâîòå÷³). IIb Ñ  
Ðåãóëÿðíå äîñë³äæåííÿ ôóíêö³¿ òðîìáîöèò³â àáî ãåíåòè÷íå òåñòóâàííÿ (ùîäî êëîï³äîãðåëþ òà ÀÑÊ) çàäëÿ êîðèãóâàííÿ àíòèòðîìáîöèòàðíî¿ òåðàﳿ ïåðåä òà ï³ñëÿ ðåêîìåíäîâàíîãî ñòåíòóâàííÿ íå ðåêîìåíäóºòüñÿ III À 778, 892
Ïåðåðèâàííÿ ë³êóâàííÿ
Íå ðåêîìåíäóºòüñÿ ïåðåðèâàòè àíòèòðîìáîöèòàðíó òåðàï³þ ðàí³øå ðåêîìåíäîâàíîãî òåðì³íó I Ñ  
Ïàö³ºíòàì, ùî ïðèéìàþòü ³íã³á³òîðè P2Y12, ÿêèì ïîòð³áíî íå íåâ³äêëàäíå çíà÷íå õ³ðóðã³÷íå âòðó÷àííÿ (âêëþ÷àþ÷è ÀÊØ) ñë³ä âðàõóâàòè òå, ùî õ³ðóðã³÷íå âòðó÷àííÿ ñë³ä â³äêëàñòè ùîíàéìåíøå íà 5 äí³â ï³ñëÿ ïðèïèíåííÿ ïðèéîìó ò³êàãðåëîðó àáî êëîï³äîãðåëþ, òà íà 7 äí³â ï³ñëÿ çàñòîñóâàííÿ ïðàñóãðåëþ, ÿêùî º êë³í³÷íà ìîæëèâ³ñòü, òà çà âèêëþ÷åííÿì ïàö³ºíò³â ãðóïè âèñîêîãî ðèçèêó âèíèêíåííÿ ³øåì³÷íèõ óñêëàäíåíü. IIà Ñ  
Ñë³ä ïðèéíÿòè äî óâàãè ñõåìó ïðèéîìó êëîï³äîãðåëþ ï³ñëÿ ÀÊØ ÷åðåç òå, ùî â³í ââàæàºòüñÿ áåçïå÷íèì IIà Ñ  
Ñë³ä ïðèéíÿòè äî óâàãè ñõåìó ïðèéîìó ò³êàãðåëîðó àáî ïðàñóãðåëþ ÀÊØ ÷åðåç òå, ùî â³í ââàæàºòüñÿ áåçïå÷íèì IIà Ñ  
Äîñë³äæåííÿ òðîìáîöèòàðíî¿ ôóíêö³¿ ñë³ä çàñòîñîâóâàòè äëÿ ïåðåðèâàííÿ àíòèòðîìáîöèòàðíî¿ òåðàﳿ ó ïàö³ºíò³â, ùî ïðîõîäÿòü õ³ðóðã³÷íå âòðó÷àííÿ ç ïðèâîäó ÀÊØ IIà Ñ  

a Êëàñ ðåêîìåíäàö³¿

b гâåíü ñâ³ä÷åíü

c Ïîñèëàííÿ

ÀÑÊ=àöåòèëñàë³öèëîâà êèñëîòà; ÀÊØ=àîðòîêîðîíàðíå øóíòóâàííÿ; ÏÀÒÒ=ïîäâ³éíà àíòèòðîìáîöèòàðíà òåðàï³ÿ.

18. Ðåôðàêòåðíà ñòåíîêàðä³ÿ

 

Òåðì³í «ðåôðàêòåðíà ñòåíîêàðä³ÿ» âèçíà÷àºòüñÿ ÿê «õðîí³÷íèé ñòàí, âèêëèêàíèé êë³í³÷íî ï³äòâåðäæåíîþ ðåêóðåíòíîþ ³øå쳺þ ì³îêàðäà çà íàÿâíîñò³ óðàæåííÿ êîðîíàðíèõ ñóäèí, ÿêà íå ìîæå áóòè àäåêâàòíî êîíòðîëüîâàíà êîìá³íàö³ºþ ìåäèêàìåíòîçíî¿ òåðàﳿ, àíã³îïëàñòèêè àáî àîðòîêîðîíàðíîãî øóíòóâàííÿ». Äëÿ ö³º¿ ãðóïè ïàö³ºíò³â ðåêîìåíäîâàí³ ðÿä íîâèõ ôàðìàêîëîã³÷íèõ çàñîá³â ³ íåìåäèêàìåíòîçíèõ ìåòîä³â ë³êóâàííÿ (äèâ. Òàáëèöþ 61).

 

Äî íåôàðìàêîëîã³÷íèõ â³äíîñÿòüñÿ ìåòîäè çîâí³øíüî¿ êîíòðïóëüñàö³¿ ³ íåéðîñòèìóëÿö³¿. ¯õ çàñòîñóâàííÿ ïîêàçàëî, ùî âîíè ìîæóòü ïîëåãøèòè ñèìïòîìè ³ ïîêðàùèòè ÿê³ñòü æèòòÿ ïàö³ºíò³â, õî÷à ïåðåêîíëèâ³ äîêàçè ùîäî çìåíøåííÿ ³øå쳿 ³ ñìåðòíîñò³ ÿê ³ ðàí³øå â³äñóòí³.

 

Òàáëèöÿ 61. Òåðàïåâòè÷í³ ìîæëèâîñò³ ë³êóâàííÿ ðåôðàêòåðíî¿ ñòåíîêàð䳿

Ðåêîìåíäàö³¿ Êëàñ гâåíü äîêàçîâîñò³
ÏÇÊ (ÅÅÑÐ) ìîæå çàñòîñîâóâàòèñü äëÿ ïîëåãøåííÿ ñèìïòîì³â ó ïàö³ºíò³â ç³ ñòåíîêàð䳺þ, ðåôðàêòåðíîþ äî îïòèìàëüíî¿ ìåäè÷íî¿ òåðàﳿ òà ðåâàñêóëÿðèçàö³éíèõ ñòðàòåã³é. IIa B
×ÅÌÑ (TENS) ìîæå çàñòîñîâóâàòèñÿ äëÿ ïîëåãøåííÿ ñèìïòîì³â ó ïàö³ºíò³â ç³ ñòåíîêàð䳺þ, ðåôðàêòåðíîþ äî îïòèìàëüíî¿ ìåäè÷íî¿ òåðàﳿ òà ðåâàñêóëÿðèçàö³éíèõ ñòðàòåã³é. IIb C
ÑÑÌ (SCS) ìîæå çàñòîñîâóâàòèñÿ äëÿ ïîëåãøåííÿ ñèìïòîì³â òà ÿêîñò³ æèòòÿ ó ïàö³ºíò³â ç³ ñòåíîêàð䳺þ, ðåôðàêòåðíîþ äî îïòèìàëüíî¿ ìåäè÷íî¿ òåðàﳿ òà ðåâàñêóëÿðèçàö³éíèõ ñòðàòåã³é. IIb B
ÒÌÐ (TMR) íå ïîêàçàíà ïàö³ºíòàì ï³ñëÿ óñóíåííÿ ñèìïòîì³â ðåôðàêòåðíî¿ ñòåíîêàð䳿. III A

 

ÏÇÊ (ÅÅÑÐ) = ï³äñèëåíà çîâí³øíÿ êîíòðïóëüñàö³ÿ; ×ÅÌÑ (TENS) = ÷åðåçøê³ðíà åëåêòðîì³îñòèìóëÿö³ÿ; ÑÑÌ (SCS) = ñòèìóëÿö³ÿ ñïèííîãî ìîçêó; ÒÌÐ (TMR) = òðàíñì³îêàðä³àëüíà ðåâàñêóëÿðèçàö³ÿ.

19. Ïåðâèííà ìåäè÷íà äîïîìîãà

˳êàð³ ïåðâèííî¿ ëàíêè ïîâèíí³ â³ä³ãðàâàòè âàæëèâó ðîëü ó ³äåíòèô³êàö³¿ òà âåäåíí³ ïàö³ºíò³â ç³ ñòàá³ëüíîþ ²ÕÑ. Çîêðåìà:

  1. Âèÿâëÿòè ïàö³ºíò³â ç ñèìïòîìàòèêîþ, ÿêà ïåðåäáà÷ຠìîæëèâèé ä³àãíîç ñòàá³ëüíî¿ ²ÕÑ, äëÿ ïîäàëüøîãî îáñòåæåííÿ ³ ë³êóâàííÿ.
  2. Âèÿâëÿòè õâîðèõ ç ï³äâèùåíèì ðèçèêîì ðîçâèòêó ²ÕÑ òà ïðîâîäèòè ðîáîòó ùîäî ìîäèô³êàö³¿ ôàêòîð³â ðèçèêó, âêëþ÷àþ÷è çì³íè ñïîñîáó æèòòÿ ³ òåðàïåâòè÷í³ çàõîäè, ç ìåòîþ çìåíøåííÿ ¿õ ðèçèêó ó ìàéáóòíüîìó.
  3. Çàáåçïå÷èòè, ùîá ïàö³ºíòè ç³ ñòàá³ëüíîþ ²ÕÑ ðîçóì³ëè çíà÷åííÿ ïðèéîìó, ÿê ñèìïòîìàòè÷íèõ, òàê ïðîãíîç-ìîäèô³êóþ÷èõ ïðåïàðàò³â, òîáòî îáîõ ñêëàäîâèõ îïòèìàëüíî¿ ìåäèêàìåíòîçíî¿ òåðàﳿ, à ó â³äïîâ³äíèõ âèïàäêàõ – ïåðåâàãè ÏÊ àáî ÀÊØ.
  4. Çàáåçïå÷èòè, ç â³äïîâ³äíèìè ³íòåðâàëàìè, ñèñòåìàòè÷íèé ìåäè÷íèé íàãëÿä/ äèñïàíñåðèçàö³þ ïàö³ºíò³â ç³ ñòàá³ëüíîþ ²ÕÑ äëÿ ïîâòîðíî¿ îö³íêè êë³í³÷íèõ ñèìïòîì³â, ïðèéîìó ìåäèêàìåíò³â ³ ôàêòîð³â ðèçèêó.

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