#1
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Ðóòèííàÿ PCI ïîñëå ÒËÒ
Ìíå êàê-òî äàâíî êàçàëîñü, ÷òî ñ óïðîùåíèåì äîñòóïà ê êàòëàáó è ïðîâåäåíèÿ PCI (ýòî ÿ íå ïðî íàøå êåôèðíîå çàâåäåíèå, à âîîáùå) ðóòèííîå ïðîâåäåíèå PCI ïîñëå òðîìáîëèçèñà âèäèòñÿ áðîëåå ïðîñòûì, ÷åì ischemia-guided. È òîìó ïîÿâèëîñü ïîäòâåðæäåíèå.
Routine early coronary angioplasty versus ischaemia-guided angioplasty after thrombolysis in acute ST-elevation myocardial infarction: a meta-analysis Savio P. D’Souza, Mamas A. Mamas, Douglas G. Fraser, and Farzin Fath-Ordoubadi* Aims Prompt coronary reperfusion following acute ST-segment elevation myocardial infarction is pivotal to survival. Primary angioplasty is the gold standard in restoring reperfusion, but thrombolysis needs consideration when optimal call to balloon time is not feasible. Following lysis and with evolving pharmacoinvasive therapies, the advantage of routine, early percutaneous coronary intervention (PCI) over standard ischaemia-guided PCI remains debatable. We meta-analysed studies comparing these two interventional strategies. Methods and results A MEDLINE search for randomized control studies was performed using the search terms ‘coronary, thrombolysis, early or immediate stenting, and acute ST-elevation myocardial infarction’. Further, relevant studies were identified from global cardiovascular scientific sessions/congresses. Two interventional strategies were studied in 3195 patients in eight trials and meta-analysed using a random effects model. The combined endpoint of 30-day mortality, reinfarction, and ischaemia was reached in 106/1487 (7.3%) patients in the routine early PCI group and in 199/1470 (13.5%) patients in the ischaemia-guided PCI group following lysis with odds ratio (OR) 0.47 [95% confidence interval (CI), 0.32–0.68, P , 0.0001] favouring routine early PCI, driven by significant reduction in both re-infarction OR 0.62 (95% CI, 0.42 –0.90, P , 0.011) and ischaemia OR 0.21 (95% CI, 0.10–0.47, P , 0.001). Thirty-day mortality or major bleeding rates between strategies were not significantly different. Conclusion Where primary PCI is not feasible, our meta-analysis favours routine early PCI within 24 h of thrombolysis for acute ST-elevation myocardial infarction—a strategy that is safe and a time-target that is easily achievable. Early PCI is associated with reduced recurrence of ischaemia and re-infarction, but at no increased risk of major haemorrhage. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] |
#2
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Ñ ó÷åòîì êâîò, òðóäíîñòåé âçàèìîäåéñòâèÿ ìåæäó ËÏÓ, ìíå òàêîé ïîäõîä ïðåäñòàâëÿåòñÿ ïðîáëåìàòè÷íûì. Åñëè àíãèîïëàñòèêà â ËÏÓ íåäîñòóïíà, òî è ïåðåâîä íà ×ÒÊÀ â ïåðâûå ñóòêè èíôàðêòà áóäåò ñêîðåå âñåãî ïðîáëåìàòè÷íûì (àíàëèçû íà ÂÈ×, ãàñòðîñêîïèÿ, êîòîðóþ òðåáóþò ìíîãèå àíãèîãðàôèñòû è ïð.). À ïðèìåíèìû ëè ýòè äàííûå ê ïîçäíåé ×ÒÊÀ ïîñëå ÒËÒ (áîëåå 24 ÷), áîëüøîé âîïðîñ.
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#3
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Êîãäà ÿ áûë ïðèãëàøåí ê ðóêîâîäñòâó íàøåãî ó÷ðåæäåíèÿ, äëÿ äà÷è ðàçúÿñíåíèé î ïðè÷èíàõ ðàíåå âûïîëíåííîé óñïåøíîé ×ÒÊÀ,ïîñëå óñïåøíîãî ôèáðèíîëèçà, ó ìîëîäîãî ìóæ÷èíû ñ ÎÊÑ ÏST,òî âñå ìîè óïîâàíèÿ íà äàííîå ðóêîâîäñòâî - Guidelines on myocardial revascularization.Eur Heart J (2010) First published online: August 29, 2010 "Ðóòèííîå áåçîòëàãàòåëüíîå ×Ê ïîêàçàíî ïîñëå óñïåøíîãî ôèáðèíîëèçèñà (ðàçðåøèâøèåñÿ áîëü/äèñêîìôîðò â ãðóäè è ïîäúåìû ñåãìåíòà ST), ïðåäåëàõ 24 ÷àñ,I A",ðàçìåùåííîå íà àòåðî.ðó, áûëî ïðîèãíîðèðîâàíî.  êîíå÷íîì èòîãå ñêàçàëè,÷òî ýòî ñëèøêîì íàêëàäíî äëÿ íàñ.Âûïîëíÿòü ïîñëå óñïåøíîãî òðîìáîëèçèñà(àêòèëèçå òîæå ñòîèò äåíåã) åùå è ×ÒÊÀ,èìïëàíòèðóÿ ýòîìó æå ïàöèåíòó åùå è ñòåíò(û).Äà è âîîáùå,äåÿòåëüíîñòü ñîñ öåíòðà ðåãëàìåíòèðóåòñÿ ïðèêàçîì ÌÇ,ãäå î ïðîâåäåíèè ×ÒÊÀ ïîñëå óñïåøíîãî ÒËÒ íåò íè ñëîâà.Ñîîòâåòñòâåííî, ýòî ÷óòü-ëè íå ñàìîóïðàâñòâî.Äàííîå íàïðàâëåíèå áûëî çàìîðîæåíî. òàêîì ñîñòîÿíèè íàõîäèòñÿ è ïî ñåé äåíü,íå ñìîòðÿ íà òî,÷òî áûë ïîñâÿùåí ýòîé ïðîáëåìå öåëûé êðóãëûé ñòîë,íà êîòîðîì òàê è íå áûëî ïðèíÿòî ðåøåíèå ïî äàííîìó âîïðîñó.Âñå óïåðëîñü â ïðîáëåìó äîñòàâêè ïàöèåíòîâ ñ "ïåðâè÷åê" è ïðàêòè÷åñêîìó ðàñõîäó áåíçèíà,îïðåäåëåíèþ êàòåãîðèé áîëüíûõ äëÿ ïåðåâîäà,à ïîëó÷àåòñÿ,÷òî ïðàêòè÷åñêè âñåõ íóæíî âåçòè â CatLab è ò ä.
 ïðèíöèïå,ýòà ìûñëü îò÷àñòè ïðîçâó÷àëà ó óâàæàåìîãî Tim Hunter. Âîîáùåì, ïîêà íå ïîëó÷àåòñÿ âîïëîòèòü âñå äîñòèæåíèÿ ñîâðåìåííîé ìåäèöèíñêîé íàóêè â æèçíü íà ïðàêòèêå,óâû ![]() Íî ïîñêîëüêó ìû ñóìåëè âûïîëíèòü ðÿä óñïåøíûõ âìåøàòåëüñòâ ïîñëå óñïåøíîãî ÒËÒ,â íàøèõ ðóêàõ îêàçàëèñü "êàðòèíêè",êîòîðûå îáëàäàþò áîëüøåé ñèëîé óáåæäåíèÿ, íå õóæå çàðóáåæíîãî ãàéäà,áëàãîäàðÿ ÷åìó ìû íå îñòàâëÿåì íàäåæä íà ñêîðîå èçìåíåíèå ñèòóàöèè ![]() |
#4
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Àðòåìèé, åñëè ïåðåâîäèòü ðàçãîâîð â òàêóþ ïëîñêîñòü, òî êîíå÷íî. Äëÿ èìåþùèõ ðåçèäóàëüíóþ èøåìèþ ìîæíî ïîèñêàòü ìåñòî, à íå èìåþùèå îíîé ìîãóò è òàê æèòü. Âîïðîñ î ñðîêàõ òàêæå èíåòåðåñåí. Íàâåðíîå, åñëè äåëàòü ÊÀà ÷åðåç 6 ìåñÿöåâ, òî ðå÷ü ïîéäåò óæå î ñòàáèëüíîé ÈÁÑ. À âîò, ñêàæåì, â òå÷åíèå 29 äíåé... Ýòî æå ñíèçèò 30-äíåâíóþ ëåòàëüíîñòü? Èëè íåò, ïî òâîåìó.
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#5
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Ìíå êàæåòñÿ, ÷òî âñå-òàêè íåëüçÿ â îäíó êó÷ó ñìåøèâàòü âñåõ áîëüíûõ ÈÌ êîòîðûì áûë ïðîâåäåí òðîìáîëèçèñ. Ãðóïïà äîñòàòî÷íî ãåòåðîãåííàÿ. Ðàçìåð ÈÌ, íàëè÷èå ñîïóòñòâóþùèõ îñëîæíåíèé, óñïåõ èëè íåóäà÷à ÒËÒ è òä èìåþò âàæíîå çíà÷åíèå. Ñîîòâåòñòâåííî â çàâèñèìîñòè îò ýòîãî òàêòèêà ìîæåò ìåíÿòüñÿ.
Êðîìå òîãî, â áîëüøèíñòâå èññëåäîâàíèé íà ýòó òåìó, â êà÷åñòâå îäíîé èç ïåðâè÷íûõ êîíå÷íûõ òî÷åê âûáèðàëàñü ðåçèäóàëüíàÿ èøåìèÿ. Ìíå êàæåòñÿ, ýòî íå ñîâñåì âåðíî. ÒËÒ ñòåíîçû ïîêà åùå ðàñòâîðÿåò. Ïðè ñðàâíåíèè ñìåðòåé è ðåèíôàðêòîâ ìåæäó èññëåäóåìûìè ãðóïïàìè ðåçóëüòàòû èíûå. |
#6
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Ìíå êàæåòñÿ, ÷òî äëÿ íàãëÿäíîñòè ãðóïïó ñ ýôôåêòèâíûì ñèñòåìíûì òðîìáîëèçèñîì ìîæíî ñîïîñòàâèòü ñ ãðóïïîé ïîñëå óäà÷íîé àñïèðàöèè òðîìáîòè÷åñêèõ ìàññ. Ñêîëüêèõ áîëüíûõ ïîñëå àñïèðàöèè Âû ãîòîâû îòïóñòèòü áåç ñòåíòà? Ãäå-òî ñëûøàë, ÷òî ðèñê ïîâòîðíîãî èíôàðêòà ïîñëå ýôôåêòèâíîãî òðîìáîëèçèñà â òå÷åíèå ìåñÿöà ñîñòàâëÿåò 40%. Ñ÷èòàþ àêòèâíóþ òàêòèêó áîëåå îáîñíîâàííîé, áåç îãðàíè÷åíèÿ ïî âðåìåíè. ×åì ðàíüøå, òåì ëó÷øå, íî åñëè íåëüçÿ â ïåðâûå ñóòêè, òî äàæå ÷åðåç ìåñÿö íå ïîçäíî...
Ñ óâàæåíèåì, Ëåâ. |
#7
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×åðåç ìåñÿö ìîæåò è íå ïîçäíî, íî íå ñòîëü íóæíî.
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#8
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Öèòàòà:
Ñðàâíåíèå, êàê ìíå êàæåòñÿ, óäà÷íîå. Ïðàâäà îïûò òðîìáîýêñòðàêöèè íåáîëüøîé. Çàáàâíî, ÷òî íåñêîëüêî äíåé íàçàä ÿ óæå ïèñàë ïðî òî, ìîæíî ëè îñòàâëÿòü áîëüíîãî áåç ñòåíòà ïîñëå ×ÒÊÀ (ïðè êîòîðîé ïðîèñõîäèò ðàçðûâ áëÿøêè, ñâîåãî ðîäà "ìèíè-ÎÊÑ" (À.Å Ó. (ñ))). Ýòî, êàê ìíå êàæåòñÿ, áîëåå óäà÷íûé ïðèìåð, òàê êàê ñ îäíîé àíãèîïëàñòèêîé (áåç ñòåíòà) ìíîãèì äîâåëîñü ïîðàáîòàòü î÷åíü ìíîãî. Äàâàéòå ñïðîñèì ìàòåðûõ àíãåëîãðàôåðîâ, â 90-å, êîãäà ìàññîâûõ ñòåíòèðîâàíèé íå áûëî, êîãäà ïðîèñõîäèëî îñíîâíîå ÷èñëî òðîìáîçîâ, è êàê ÷àñòî îíè âîçíèêàëè? |
#9
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Ñðàâíåíèå ìíå êàæåòñÿ íå î÷åíü óäà÷íîå. Õîòÿ áû ïî òîìó, ÷òî ÒËÒ îáëàäàåò ñèñòåìíûì ïðîëîíãèðîâàííûì äåéñòâèåì, à òðîáîýêñòðàêöèÿ ðàçîâûì ëîêàëüíûì. Äóìàþ åñòü è äðóãèå îòëè÷èÿ.
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#10
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Åñëè íå îøèáàþñü, ïîñëå òðîìáîëèçèñà íàñòóïàåò íåêîòîðàÿ àêòèâàöèÿ òðîìáîöèòîâ. Ýòèì, â ÷àñòíîñòè, îáúÿñíÿåòñÿ ðåêîìåíäàöèÿ ïðîâîäèòü ×Ê ÷åðåç 3 ÷ ïîñëå óñïåøíîãî ëèçèñà. Ïîýòîìó, íå âñå ýôôåêòû òðîìáîëèçèñà íà òðîìá è åãî ñóáñòðàò - "îáîñòðèâøóþñÿ" áëÿøêó, ìîæíî ñ÷èòàòü ïîëîæèòåëüíûìè. Íå ãîâîðÿ óæå î ïîâûøåííîì ðèñêå êðîâîòå÷åíèé è ò.ä.
P.S. Ò ïîëóâûâåäåíèÿ ñòðåïòîêèíàçû - îêîëî 23 ìèíóò. Íå äóìàþ, ÷òî â òàêîé ñèòóàöèè ìîæíî ãîâîðèòü î ïðîëîíãèðîâàííûõ ýôôåêòàõ ñàìîãî ïðåïàðàòà. |
#11
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Ó tPA âîîáùå ìèíóò 5...
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#12
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×Ê ðåêîìåíäóþò ïðîâîäèòü ÷åðåç 3 ÷àñà ïîñëå ëèçèñà âî èçáåæàíèå ãåìîððàãè÷åñêèõ îñëîæíåíèé, à íå òðîìáîòè÷åñêèõ...
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#13
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In order to avoid an early PCI during the prothrombotic period following fibrinolysis, on the one hand, and to minimize the risk of reocclusion, on the other hand, a time window of 3 – 24 h following successful fibrinolysis
is recommended. (ESC GUIDELINES. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation) ........ |
#14
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Îäîáðÿëêà íà Audovichenko íå ðàáîòàåò...
Èìåííî èç ñîîáðàæåíèÿ îïàñíîñòè ãåìîððàãè÷åñêèõ îñëîæíåíèé, êàðäèîëîãè "íå äàâàëè" íàì ýòèõ ïàöèåíò ðàíåå 3 ÷àñîâ îò ÒËÒ. Ýòî áûë èõ åäèíñòâåííûé äîâîä:-) |
#15
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Öèòàòà:
[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] òàì æå åñòü åùå ññûëêè. |