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ESC Pocket Guidelines2015 ESC Guidelines for the Management of Acute Coronary Syndromes in

Patients Presenting without Persistent ST-segment Elevation*

The Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-segment Elevation of the

European Society of Cardiology (ESC)

Task Force Membars: Jean-Philippe Collet (France), Christian Mueller (Switzerland), Marco Valgimigli (The Netherlands), Felicata Andreotti (Italy), Jeroen J. Bax (The Netherand), Mi-chael A. Borger (Germany), Carlos Brotons (Spain), Derek P. Chew (Australia), Baris Gencer (Swit-zerland), Gerd Hasenfuss (Germany), Keld Kjeldsen (Denmark), Patrizio Lancellotti (Belgium), Ulf Landmesser (Germany), JulindaMehilli (Germany), Debabreta Mukherjee (USA), Robert F. Storey (UK), Stephan Windecker (Switzerland).

ESC entities having participated in the development of this document:ESC Associations: Acute Cardiovascular Care Association (ACCA), European Association for Cardiovascular Prevention & Rehabilitation (EACPR), European Association of Cardiovascular Imaging (EACVI), European Association of Percutaneous Cardiovascular Interventions (EAPCI), Heart Failure Association (HFA).ESC Councils: Council on Cardiovascular Nursing and Allied Professions (CCNAP), Council for Cardiology Practice (CCP), Council on Cardiovascular Primary Care (CCPC).ESC Working Groups: Cardiovascular Pharmacotherapy, Cardiovascular Surgery, Coronary Pathophysiology and Microcirculation, Thrombosis.

ESC Staff:Veronica Dean, Nathalie Cameron, Catherine Despres - Sophia Antipolis, France.

Section Coordinators.

* Adapted from the 2015 ESC Guidelines for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-segment Elevation (European Heart Journal, 2015 - doi: 10.1093/eurteartj/ehv320)

ChairpersonMacro RoffiDivision of CardiologyUnivrsity HospitalRue gabrielle Perret-gentil 41211 Geneva 14, SwitzerlandTel: +41 22 37 23 743Fax: +41 22 37 27 229Email: [email protected]

Co-ChairpersonCarlo PatronoInstituto di FarmacologiaUniversita Cattolica del Sacro CuoreLargo F. Vito lIT-00168 Rome, ItalyTel: +39 06 30154253Fax: +39 06 3050159Email: [email protected]

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sarCevi:

abreviaturebi / akronimebi

1. definicia

2. diagnozi

2.1 dadasturebis (“Rule-in”) da

gamoricxvis (“Rule-out”) algoriTmi

2.2 ara invaziuri gamosaxulebiTi

(imaging) gamokvleva

2.3 diferencialuri diagnozi

3. riskis Sefaseba da gamosavali

4. mkurnaloba

4.1 iSemiis farmakologiuri mkurnaloba

4.2 Trombocitebis inhibicia

4.3 antikoagulacia

4.4 xangrZliv peroralur antikoagulaciis saWiroebis

mqone pacientebis marTva peroraluri

antiTrombocituli saSualebebiT

4.5 invaziuri koronaruli angiografia da

revaskularizacia

4.6 specifiuri populaciebi da mdgomareobebi

4.7 pacientebis xangrZlivi marTva

5. marTvis strategiis Sejameba

abreviaturebi / akronimebi

LMWH = dabalmolekuluri hepariniLV = marcxena parkuWiLVEF = marcxena parkuWis gandevnis fraqciaMDCT = multi deteqtoruli kompiuteruli tomografiami = miokardiumis infarqtiNAOACs = ara vitamin K-s antagonisti peroraluri antikoagulantebiNSAIDs = arasteroiduli anTebisawinaaRmdego saSualebebiNSTE ACS = ST elevaciis gareSe mimdinare mwvave koronaruli sindromiNSTEMI = ST segmentis elevaciis gareSe mimdinare miokardiumis infarqtiOACs = peroraluri antikoagulantebiPCI = perkutanuli koronaruli angioplastikaSTEMI = ST segmentis elevaciiT mimdinare miokardiumis infarqtiSYNTAX = sinergia TAXus – iT perkutanuli koronarul intervenciasa da kardioqirurgias SorisTIMI = Trombolizisi miokardiumis infarqtis drosUFH = arafraqciuli hepariniVKAs = vitamin K-s antagonisti

ACCOAST = ST-s elevaciis gareSe mimdinare miokardiumis infarqtis dros pacientebis diagnostirebis procesSi an koronaruli intervenciis dros prasugrelis moqmedebis Sedareba.agf = angiotenzin gardamqmneli fermentimks = mwvave koronaruli sindromiACT = aqtivirebuli Sededebis droARB = angiotenzinis receptorebis blokeriBMS = metalis stentiCABG = aorto koronaruli SuntirebaCAD = koronaruli arteriebis daavadebaCKD = Tirkmlis qronikuli daavadebaCRUSADE = riskis adreuli stratifikaciaCV = kardiovaskuluriDAPT = ormagi peroraluri antiTrombocituli TerapiaDES = wamliT dafaruli stentiECG = eleqtrokardiogramaFFR = fraqciuli nakadis rezervieGFR = gorglovani filtraciis siCqaris gamoTvlaGP IIb/IIIa = glikoproteinis IIb/IIIa receptorebiGRACE = mwvave koronaruli gamovlinebis globaluri registriHIT = hepariniT gamowveuli TrombocitopeniaINR = saerTaSoriso normalizaciis erTeuli

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1. definiciatkivili gulmkerdSi aris ZiriTadi klinikuri simptomi, romelic gvafiqrebinebs mwvave koronaruli sindromis (ACS) arsebobaze. eleqtrokardiografiuli (ekg) monaceme-bis mixedviT unda ganvasxvavoT pacientebis ori jgufi:

1. gulmkerdis areSi mwvave tkivilisa da ST segmentismdgradi (> 20 wT) elevaciis mqone pacientebi.am mdgomareobas ewodeba ST segmentis elevaciiT mimdina-re mwvave koronaruli sindromi (STE-ACS) da Cveulebriv warmoadgens mwvave koronaruli okluziis gamovlinebas. am pacientebis umravlesobas sabolood uviTardeba STEMI. aseTi pacientebis mkurnalobis mTavar amocanas warmoad-gens dauyovnebeli reperfuzia pirveladi angioplastikis an fibrinolizuri Terapiis meSveobiT.

2. pacientebi gulmkerdis areSi mwvave tkivilisa da ST segmentis mdgradi elevaciis gareSe.ekg cvlilebebi SeiZleba warmodgenili iyos ST segmentis gardamavali elevaciiT, ST-s mdgradi an gardamavali de-presiiT, T kbilis inversiiT, “gabrtyelebuli” T kbiliT an T kbilis fsevdonormalizaciiT, an SesaZloa normaluri ekg. Tavdapirvelad pacientebTan NSTEMI-ACS-is klinikuri spe-qtri variabiluria da SeiZleba warmodgenili iyos usimp-tomo mimdinareobiT, an mimdinare iSemiiT, eleqtruli da hemodinamikis arastabilurobiT, gulis gaCerebiT.

Mmiokardiumis infarqtis universaluri definicia• mwvave miokardiumis infarqti (MI) warmoadgens miokar-diumis iSemiis Sedegad ganviTarebul kardiomiocitebis nekrozs.• miokardiumis infarqtis diagnozis dasadgenad aucilebe-lia sxvadasxva kriteriumebis erToblioba, roca kardiuli biomarkerebis - sasurvelia maRali mgrZnobelobis kardi-uli troponinis momatebas / an klebasM zeda zRvrul maCvene-belis 99* persentilze sul cota erTi erTeuliT meti sidi-diT, Tan axlavs erT-erTi qvemoT miTiTebuli:a) iSemiis simptomebib) axali an savarudod axlad aRmocenebuli ST-T segmentis

mniSnvelovani cvlilebebi an hisis konis marcxena totis blokada 12 ganxrian ekg-zec) paTologiuri Q kbilis ganviTareba ekg-zed) gamomsaxvelobiTi meTodebiT dadgenili sicocxlis-unariani miokardiumis dakargvis an parkuWis kedlebis moZraobis regionuli darRvevebie) angiografiiT an autofsiiT dadasturebuli intrakoro-naruli Trombozi.

miokardiumis infarqti tipi I: axasiaTebs aTerosklero-zuli folaqis gaskdoma, dawyluleba, erozia, danapraleba an diseqcia, ris gamoc viTardeba sanaTurSida Trombozi erT an ramdenime koronarul arteriaSi, rac iwvevs miokar-diumis sisxlmomaragebis Semcirebas da/an distalur embo-lizacias Semdgomi miokardiumis nekrozis ganviTarebiT. pacientebs SesaZloa hqondes Tanmxlebi mZime koronaru-li artiebis daavadeba (kad), magram rogorc gamonaklisi, (SemTxvevaTa 5-dan 20%-mde), gansakuTrebiT ki qalebSi, Sei-Zleba aRiniSnebodes mxolod araobstruqciuli koronaru-li aTerosklerozi an sulac ar gamovlindes koronarebis dazianeba.

miokardiumis infarqti tipi II: miokardiumis nekrozi, ro desac sxva mdgomareobebi garda arastabiluri folaqi-sa iwvevs miokardiumis Jangbadze moTxovnasa da miwodebas Soris disbalanss. Mmeqanizmi moicavs, koronaruli arteriis spazms, koronarul endoTelur disfunqcias, taqiariTmias, bradiariTmias, anemias, respiratorul ukmarisobas, hipo-tenzias an mZime hipertenzias. bolos, kritikulad mZime pacientebSi, da pacientebSi romelTac unda CautardeT arakardiuli qirurgiuli Careva, miokardiumis nekrozi SesaZloa ganpirobebuli iyos zogierTi medikamentozuri saSualebis damazianebeli efeqtiT an toqsinebiT.

D2. diagnozi• tipiuri tkivili gulmkerdis areSi xasiaTdeba mkerdis Zvlis ukan zewolis an simZimis SegrZnebiT, romelic gadae-cema marcxena mxarSi (ufro iSviaTad orive an marjvena mxar-

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Si), qveda ybaSi, kiserSi, romelic SesaZloa iyos gardamava-li (Cveulebriv grZeldeba ramdenime wuTi) an mdgradi.• pacientebTan, romlebsac savaraudod aqvT NSTE-ACS, fizikaluri gamokvleva xSirad arainformaciulia. Ggulis ukmarisobis, hemodinamikis an eleqtruli arastabilobis niSnebis arsebobisas, swrafadaa saWiro diagnozis dazuste-ba da mkurnalobis dawyeba.• ekg gadaReba rekomendebulia pirveli samedicino kon-taqtidan 10 wuTis ganmavlobaSi. damaxasiaTebeli cvlile-bebia ST segmentis depresia, ST segmentis tranzitoruli elevacia da T kbilis cvlilebebi, Tumca ekg SeiZleba iyos normaluri. Psavaraudo niSnebisa da simptomebis mqone pa-cientebTan, ST segmentis persistiuli elevacia miuTiTebs STEMI-ze, ris gamoc saWiroa dauyovnebeli reperfuziis Catareba.K• pacientebTan NST-ACS-is arsebobis eWvis SemTxvevaSi, sa-Wiroa kardiomiocitebis dazianebis biomarkerebis, upira-tesad maRali mgrZnobelobis troponinis gansazRvra.

maRali mgrZnobelobis kardiuli troponinis gansazRviris klinikuri mniSvneloba

standartul kardiuli troponinTan SedarebiT,maRali mgrZonobelobis troponini:

• xasiaTdeba miokardiumis mwvave infarqtis maRali uaryofiTi prognozuli mniSvnelobiT.

• amcirebs miokardiumis mwvave infarqtis diagnostikis dros

• zrdis tipi 1 miokardiumis infarqtis gamovlenis sixSires da-axloebiT: absoluturi 4%-iT da SedarebiTi 20%-iT, Sesabamisi sididiT amcirebs stabiluri stenokardiis diagnozebis raode-nobas.

• 2-jer zrdis tipi 2 miokardiumis infarqtis SemTxvevebisgamovlenas.

maRali mgrZnobelobis kardiuli troponinis donis momateba ga-nixileba, rogorc kardiomiocitebis dazianebis raodenobrivi markeri (mag. rac ufro maRalia misi done, miT metia miokardiumis infarqtis albaToba).

• zRvrul dasaSveb donis sididis zemoT troponinis 5-jerad momatebas aqvs tipi 1 miokardiumis infarqtis arsebobis maRali(> 90%) dadebiTi prognozuli mniSvneloba.

• zRvrul dasaSveb donis sididis zemoT troponinis 3-jerad momatebas aqvs miokardiumis infarqtis limitirebuli (50-60%) dadebiTi prognozuli mniSvneloba da SesaZloa asocirebuli iyos sxva farTo speqtris mdgomareobebTan.

• janmrTel pirebSi xSiria troponinis mocirkulire donisaRmoCena.

kardiuli troponinis donis momatebis da/an daklebis mixedviT xdeba kardiomiocitebis mwvave da qronikuli dazinebebis dife-rencireba (rac ufro metadaa gamoxatuli cvlileba, miT ufro savaraudoa miokardiumis mwvave infarqtis arseboba).

tipi 1 miokardiumis mwvave infarqtis garda sxva mdgomareobebi, romlebic asocirebulia kardiuli troponinis donismomatebasTan

taqiariTmiebi

gulis ukmarisoba

hipertonuli krizi

kritikuli mdgomareobebi (mag. Soki/sefsisi/damwvroba)

miokarditebia

tako- cubos kardiomiopaTia

gulis struqturuli daavadebebi(mag. aortis sarqvlis stenozi)

aortis diseqcia

filtvis arteriis Tromboembolia, pulmonaluri hipertenzia

Tirkmlis disfunqcia da masTan asocirebuli kardiulipaTologia

koronaruli spazmi

mwvave nevrologiuri mdgomareobebi(mag, insulti, an subaraqnoiduli sisxlCaqceva)

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gulis kontuzia an procedurebi gulze (mag. CABG, PCI, ablacia, peisingi, kardioversia, an endomiokardiuli biofsia)

hipo an hiperTireodizmi

infiltraciuli daavadebebi (mag. amiloidozi, hemoqromatozi, sarkoidozi,sklerodermia)

miokardiumze wamlebis toqsikuri zemoqmedeba an mowamvla (mag. doqsorubicini, 5-florouracili, herceptini, gvelis nakbeni)

didi xangrZlivobis gadaZabva

rabdomiolizi

a = moicavs, miokardits, endokardits, perikarditsdidi SriftiT aRniSnulia mdgomareobebi romlebic ufro xSiradaa.

sawyisi Sefaseba emyareba klinikuri gamovlinebis erTobliobas (mag. simp-tomebi, niSnebi), 12 ganxriani ekg monacemebs da kardiul troponins. am pa-rametrebis Sefasebis Sedegad miRebuli diagnozebi moyvanilia Sesabamis grafebSi. “sxva kardiulSi” igulisxmeba miokarditi, tako-cubos kardio-miopaTia an taqiariTmia. ,,ara kardiulSi” igulisxmeba gulmkerdis Rrus daavadebebi, pnevmonia, pnevmoToraqsi. kardiuli troponini ganxiluli unda iyos rogorc raodenobrivi markeri: rac ufro maRalia misi done, miT ufro metia miokardiumis infarqtis albaToba. savaraudod kardio-vaskuluri genezis gulis gaCerebis an hemodinamikuri arastabilurobis SemTxvevebSi 12 ganxriani ekg-s gadaRebis Semdeg kvalificirebuli eqimis mier unda Catardes/gaanalizdes eqokardiografia. Tu pirveladi gamok-vlevebiT safiqrebelia aortis diseqcia an pulmonuri embolia, saWiroa - dimeris gansazRvra da multideteqtoruli kompiuteruli tomografia.STEMI = miokardiumis infarqti ST-s elevaciiT.NSTMI = miokardiumis infarqti ST-s elevaciis gareSe.UA = arastabiluri stenokardia.

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2.1. (diagnozis) dadasturebis (“rule-in”) da gamor-icxvis (“rule-out”) algoriTmebimiokardiumis infarqtis dadgenisaTvis kardiul troponins gaCnia maRali mgrZnobeloba da diagnostikuri Rirebuleba, xolo maRali mgrZnobelobis troponinis gamoyeneba iZle-va troponinis pirvel da meore testebs Soris intervalis mniSvnelovani Semcirebis saSualebas.

amiT sagrZnoblad mcirdeba diagnozis dadgenis dro, mokl-deba “emerjensSi” dayovnebis dro, momsaxurebis xarjebi. maRali mgrZnobelobis troponinis gamoyenebisas rekomen-debulia troponiniT diagnostikis 0 sT. / 3 sT. algoriTmi. alternativis saxiT SeiZleba 0 sT. / 1 sT. diagnostikuri al-goriTmis gamoyeneba.

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• miokardiumis infarqtis “gamoricxvis” uaryofiTi prog-nozuli mniSvneloba pacientebSi orive algoriTmis SemTx-vevaSi aRemateba 98%-s.• miokardiumis infarqtis dadebiTi prognozuli mniSvne-loba “dasabuTebis” kriteriumebis miRwevisas 0 sT. / 1 sT. algoriTmTis dro utoldeba 75-80%.• pacientebi, romlebic ar pasuxoben, arc “dadasturebis” da arc “gamoricxvis” kriteriumebs warmoadgenen hetero-genul jgufs da saWiroeben Semdgom gamokvlevebs Tu kar-diuli troponinis donis momatebis sxva alternatiuli ax-sna ar aris. mocimcime ariTmiis dros parkuWebis SekumSvis maRali sixSiris an arteriuli hipertenziis krizis SemTx-vevaSi, emerjensSi aranairi sxva damatebiTi gamokvlevebis Catareba ar aris saWiro. A

2.2 arainvaziuri (gamosaxulebiTi) gamokvleva• transTorakaluri eqokardiografia: rutinulad unda tardebodes emerjensSi. unda Cautardes / da Sefasdes kvalificirebuli eqimis mier NSTE-ACS diagnoziT yvela pacients misi hospitalizaciis periodSi. SeuZlia dagvexmaros gulmkerdSi tkivilis gamomwvevi sxva alternatiuli daavadebebis dadgenaSi. mag. aortis mwvave diseqcia, eqsudaciuri perikarditi, aortis sarqv-lis stenozi, hipertrofiuli kardiomiopaTia an marjvena parkuWis dilatacia, romelic mianiSnebs filtvis arteriis Tromboemboliaze. savaraudod kardiuli warmoSobis arastabiluri hemodinamikis mqone pacientebTan warmoadgens arCevis diagnostikur meTods. • datvirTvis ekg testTan SedarebiT stres-eqo. aseT gamokvlevas unda mieces upiratesoba, am ukanasknelis maRa-li diagnostikuri sizustis gamo. • multideteqtoruli kompiuteruli tomografiis meTo-diT koronaruli angiografia SeiZleba iyos gamoyenebuli koronaruli arteriebis dazianebis arsebobis gamoricxvis mizniT. 2.3 diferencialuri diagnostika emerjensSi PgulmkerdSi tkiviliT Semosuli pacientebs So-ris daavadebis mosalodneli prevalentoba SeiZleba iyos Semdegi: 5-10% STEMI, 15-20% - NSTEMI, 10% arastabiluri stenokardia, 15% sxva kardiuli daavadebebi da 50% - ara-kardiuli daavadebebi. NSTEACS-is diferencialuri diag-nostikis dros yovelTvis unda ganvixiloT iseTi sxva daa-vadebebis arseboba, romlebic realur safrTxes uqmnian pacientis sicocxles, magram amave dros eqvemdebarebian mkurnalobas, rogorebicaa: aortis diseqcia, filtvis ar-teriis Tromboembolia, daWimuli pnevmoToraqsi. yvela pa-cients arastabiluri hemodinamikiT, romelic savaraudod gamowveulia kardiovaskuluri daavadebebiT saswrafod unda Cautardes eqokardiografia.

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3. riskis Sefaseba da gamosavali• NSTE-ACS-is dros iSemiuri riskis raodenobrivi Sefase-bas riskis Skalebis meSveobiT aqvs upiratesoba mxolod klinikur SefasebasTan SedarebiT. • GRACE 2.0 riskis qulebis SefasebiT (kalkulatori (http://www.gracescore.org/) SesaZlebelia hospitaluri, 6 Tvis, 1 da 3 wlis periodebis sikdilobis riskis gansazRvra. aseve Sesa-Zlebelia 1 wlis periodSi sikvdilianobis da miokardiumis infarqtis ganviTarebis kombinirebuli riskis gamoTvla.• TIMI riskis Skala advili gamosayenebelia, Tumca misi di-skriminaciuli sizuste ufro dabalia vidre GRACE 2.0-is.• NSTE-ACS-is pacientebSi didi sisxldenebi asocirebulia momatebul sikvdilobasTan. CRUSADE sisxldenis riskis maCvenebeli (http://crusadebleeding score.org) pacientis sabaziso klinikuri da laboratoriuli monacemebis gamoyenebiT gansazRvravs hospitalur periodSi didi sisxldenebis ganviTarebis risks. Tumca am meTods gaaCnia zomieri SesaZ-leblobebi. • sicocxlisTvis saSiSi ariTmiebis ganviTarebis albaToba

NSTE-ACS is dros aRwevs 3%, romelTa udidesi nawili vi-Tardeba simptomebis dawyebidan 12 saaTis ganmavlobaSi.

NSTE-ACS -is diagnozis dadgenis Semdeg, klinikuri mdgomareobis mixedviT rekomendebuli ganyofilebebi da monitorirebisxangrZlioba

klinikuri gamovlineba ganyofileba riTmis monitoringi

arastabiluristenokardia

Cveulebrivi palata an gawera

ara

NSTEMI kardiuli ariTmie-bis ganviTarebis dabali riskiTa

intensiuri koronaruli Gan Sualeduri daxmarebis

ganyofileba (CCU). ≤ 24 sT

NSTEMI kardiuli ariT-miebis ganviTarebis saSua-lo da maRali riskiTb

intensiuri / koronaru-li an gadaudebeli dax-marebis ganyofilebaSi

> 24 sT

gulmkerdSi mwvave tkivilis dros mwvave koronaruli sindromis diferenciauli diagnostika

Mkardiuli pulmonuri vaskularuli Ggastro intestinaluri orTopediuli sxva

miokarditebi,kardiomiopaTiebia

filtvis arteriis Tromboembolia

aortis diseqcia ezofagiti, ezofaguri refluqsi an spazmi

ZvalkunTovani daavade-bebi

SfoTviTi d-bi

taqiariTmiebi(daWimuli)pnevmoToraqsi

simptomuriaortis anevrizma

peptiuri wyluli, gastriti

gulmkerdis travmaherpeszosteri

gulis mwvave ukmarisobabronqiti,pnevmonia

insulti pankreatitikunTebis dazianeba /anTeba

anemia

hipertonuli krizi plevriti qolecistiti kostoqondriti

Aaortuli sarqvlisstenozi

xerxemlis kisris nawilispaTologia

tako- cuboskardiomiopaTia

koronaruli spazmi

kardiuli travma

boldi da italikiT aRniSnulia, xSiri da mniSvnelovani mdgomareobebi. a – stenokardiis an gulmkerdSi diskomfortis mizezi SeiZleba gaxdes dilataciuri, hipertrofiuli da restriqciuli kardiomiopaTiebi.

NSTEMI - ST-s elevaciis gareSe mimdinare miokardiumis infarqti.a - Tu ar aris arc erTi CamoTvlili kriteriumi: hemodinamikuri arastabiluro-ba, didi ariTmiebi, marcxena parkuWis gandevnis fraqcia < 40%, daqveiTebuli reperfuzia, damatebiT kritikuli koronaruli stenozi an koronaruli inter-venciebTan dakavSirebuli garTulebebi.b - rodesac aris erTi an meti zemoT CamoTvlili kriteriumi.

http://www.gracescore.org/

http://www.gracescore.org/

http://crusadebleeding

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NSTEMI-ACS-is savaraudo diagnoziT pacientebisdiagnostikis, riskis Sefasebis, gamosaxulebiTi diagnostikis, riTmis monitorirebis rekomendaciebi

rekomendaciebi klasia Ddoneb

diagnostika da riskis Sefaseba

rekomendebulia, rom anamnezis, simptomebis, sasi-cocxlo niSnebis, fizikaluri gamokvlevis, ekg-s da laboratoriuli gamokvlevebis Sedegebis kom-binaciis safuZvelze moxdes ZiriTadi diagnozis, sawyisi mokle-vadian periodSi iSemiuri da sisx-ldenis riskebis Sefaseba.

I A

rekomendebulia, pirveli samedicino kontaqtidan 10 wT-is ganmavlobaSi 12 ganxriani ekg-s gadaReba da misi interpretacia gamocdili eqimis mier. D rekurentuli simptomebis an dauzustebeli diagnozis SemTxvevaSi rekomendebulia 12 ganxri-ani ekg-s ganmeorebiTi gadaReba.

I B

damatebiTi ganxrebis (V3R, V4R, V7-V9) gadaReba rekomendebulia Tu, savaraudoa mimdinare iSemiis arseboba, xolo standartuli Eekg ganxrebis mo-nacemebi moiTxovs dazustebas.

I C

rekomendebulia kardiuli troponinis mgrZnobi-are an maRali mgrZnobelobis sinjebis Catareba da Sedegebis miReba 60 wT-Si.

I A

maRali mgrZnobelobis troponinis testis Catare-bis SesaZleblobis SemTxvevaSi, rekomendebulia (ACS) swrafi gamoricxvis protokolis gamoyeneba 0 sT. da 3sT. (sisxlis aRebis dro).

I B

swrafi dasabuTebis da gamoricxvis protoko-lis 0 sT-ze da 1 sT-ze rekomendebulia Tu maRa-li mgrZnobelobis kardiuli tropininis testis Catareba SesaZlebelia dazustebuli 0sT/1sT algoriTmiT. Tu troponinis pirveli ori testis Sedegebi ar iZleva daskvnis gamotanis saSualebas, xolo isevaa saeWvo mwvave koronaruli sindromis arseboba, rekomendebulia damatebiT tropininis testebis Catareba 3-6 sT-s Semdeg.

I B

prognozis Sesafaseblad rekomendebulia riskis Skalebis gamoyeneba. I B

koronarografiis SemTxvevaSi, pacientis sisxldenis riskis Sefaseba SeiZleba Catardes CRUS-CADE qulebis meSveobiT.

IIb B

gamosaxulebiTi diagnostika (Imaging)

pacientebTan, romlebsac ar aReniSnebaT rekuren-tuli tkivili, aqvT ekg da kardiuli (sasurvelia maRali mgrZnobelobis) troponinis normaluri maCveneblebi, magram mainc saeWvo rCeba mwvave koronaruli sindromis arseboba, invaziuri strate-giis gadawyvetilebis miRebamde rekomendebulia arainvaziuri (sasurvelia eqokg) stres testis Catareba.

I A

eqokardiografia rekomendebulia marcxena parku-Wis segmenturi da globaluri funqciis Sefasebi-sa da diagnozis dadasturebis an gamoricxvis di- ferenciaciisaTvisc.

I C

gid dabali an saSualo albaTobis da kardiuli troponinis da/an ekg arasarwmuno niSnebis arse-bobis SemTxvevaSi, mwvave koronaruli sindromis gamosaricxad SeiZleba ganxiluli iyos MDCT koronaruli angiografia, rogorc invaziuri an-giografiis alternativa.

IIb A

Mmonitoringi

riTmis uwyveti monitoringi rekomendebulia NSTEMI-is diagnozis dadgenamde an gamoricxvamde.

I C

rekomendebulia NSTEMI-iT Mpacientebis moTavseba monitorirebis SesaZleblobis mqone ganyofileba-Si.

I C

ariTmiis ganviTarebis dabali riski mqone NSTEMI-iT pacientebTan ganxiluli unda iyos riTmis mo-nitoringi 24 sT-is ganmavlobaSi an PCI Catarebam-de (imisda mixedviT, romeli iqneba pirveli)d.

IIb C

18 19

ariTmiis ganviTarebis saSualo an maRali riski mqone NSTEMI-iT pacientebTan ganxiluli unda iyos 24sT-ze meti xangrZlivobis riTmis moni-torirebae.

IIb C

arastabiluri stenokardiiT pacientebTan mimdin-are iSemiis niSnebis da simptomebis ararsebobisas, riTmis monitorirebis sakiTxi ganxiluli unda iyos SerCeviT SemTxvevebSi (roca aris eWvi koro-naruli spazmis ganviTarebaze an Tanmxlebi simp-tomebi miuTiTebs ariTmiis arsebobaze).

IIb C

ACS- mwvave koronaruli sindromi, MDCT-multi deteqtoruli kompiuteruli tomografia, NSTE-ACS - ST segmentis elevaciis gareSe mimdinare mwvave koronaruli sindromi, NSTEMI - miokardiumis infarqti ST segmen-tis elevaciiT. PCI - perkutanuli koronaruli intervencia.c - ar gamoiyeneba im pacientebTan, romlebsac NSTEMI ar daudasturda da gaewernen imave dRes.d – Tu ar aris arcerTi qvemoT miTiTebuli kriteriumi: arastabiluri hemodinamika, didi ariTmiebi, gandevnis fraqcia < 40%, warumatebeli reperfuzia, damatebiT koronaruli arteriebis kritikuli stenozi an koronarul intervenciasTan dakavSirebuli garTulebebi.e - Tuki saxezea erTi an ramdenime zemoT CamoTvlili simptomi.

4. Mmkurnaloba

4.1. iSemiis farmakoTerapia

NSTEMI- ACS-is mwvave fazaSi antiiSemiuri farmakoTerapiis rekomendaciebi


mimdinare iSemiis simptomebis arsebobisas re-komendebulia Bbeta-blokerebiT mkurnalobis adreuli dawyeba Tu ar aris am preparatebis da- niSnvis ukuCvenebebi.

I B

rekonendebulia pacientebis beta-blokerebiT mkurnalobis gagrZeleba, Tu ar aris kilipi III an ufro maRali klasis simZimis gulis ukmarisoba.

I B

tkivilis Sesamcireblad rekomendebulia nitratebis sublingvaluri an i.v. miRebac. nitratebiT i.v. mkurnaloba rekomendebu-lia, roca pacients aReniSneba stenokardiis rekurentuli Setevebi, arakontrolirebadi hipertenzia, an gulis ukmarisobis niSnebi.

I C

PTu pacientTan saeWvoa /dadasturebulia vazo-spastiuri stenokardiis arseboba, ganxiluli unda iyos kalciumis arxebis blokerebiT annitratebiT mkurnalobis sakiTxi, xolo beta-blokerebis gamoyenebas Tavi unda avaridoT.

IIa B

c - ar unda daeniSnos pacients, Tu mas axlad aqvs miRebuli sildenafili an vardenafili (bolo 24 sT-Si) an tadalafili (bolo 48 sT-Si).

22 23

4.2 Trombocitebis inhibicia

eGFR - glomeruluri filtraciis donea - ADP-iT inducirebuli Trombocitebis agregaciis 50%-iani Semcireba b - nawlavebidan absorbciis darRvevisas, efeqtma SesaZloa daayovnos, c - Semokleba SeiZleba ganxiluli iyos Tu ki es naCvenebia Trombocitebis fun-qciis testirebis da sisxldenis dabali riskis gaTvaliswinebiTd – icvleba sapasuxo reaqcia Trombocitebis transfuziaze,e – naxevrad-daSlis periodis aRnusxva dafuZnebulia plazmaSi klinikurad mniSvnelovani koncentraciis xangrZlivobaze. maSin roca Sesabamisi naxevrad-gamoyofis periodi aris 7 saaTi.

P2y12 inhibitorebi

klopidogreli Pprasugreli tikagrelori Kkangrelori

Qqimiuri klasi Tienopiridini Tienopiridiniciklopentil-

triazolopairimidinistabilizirebuli atf-is

analogi

MmiRebis Fforma Operoraluri Operoraluri Operoraluri intravenuri

Ddoza300-600 mg. peroralurad

Semdeg 75mg dReSi60 mg. peroralurad,

Semdeg 10 mg dReSi180 mg. peroralurad,

Semdeg 90 mg. dReSi

30 mkg/kg bolusiTSemdeg 4 mkg/kg /wT

infuzia

dozireba Tirkmlebis qr. daavadebis dros

me-3 xarisxi(eGFR 30-59ml/min/1.73 m2)

Aar aris saWirodozis koreqcia


Aar aris saWiro dozis koreqcia


me-4 xarisxi(eGFR15-29ml/min/1.73 m2)



Aar aris saWiro dozis koreqcia


me-5 xarisxi(eGFR <15ml/min/1.73 m2)

Ggamoiyeneba mxolidgansakuTrebuli CvenebiT

Aar arisrekomendebuli

Aar arisrekomendebuli

Aar Aarisrekomendebuli

kavSiris Seqcevadoba Seuqcevadi Seuqcevadi Seqcevadi Seqcevadi

aqtivaciaPprowamali, RviZlSi

variabeluri metabolizmiT

Pprowamali, RviZlSiprognozirebadi

metabolizmiT

Aaqtiuri wamalebi, dama-tebiT aqtiuri metaboli-

tebiTAaqtiuri wamali

datvirTvis dozis efeqtis dawyebaa 2-6 sT.b 30 wT.b 30 wT.b 2 wT

moqmedebis xangrZlivoba 3-10 dRe 7-10 dRe 3-5 dRe 1-2 sT.

Sewyveta qirurgiul Carevamde 5 dRec 7 dRec 5 dRec 1 sT

aqtiuri P2Y 12 inhibitoris plazmisnaxevrad daSlis periodid 30-60 wT. 30-60 wT.e 6-12 sT. 5-10 wT.

adenozinis ukuSekavebis inhibicia Aara Aara KkiKki (mxolod ,,araaqtiuri’’

metabolitebi

24 25

antiTrombocituli Terapiis rekomendaciebi

NSTE-ACS-is dros


peroraluri antiTrombocituli Terapia

Tu ar aris amis ukuCveneba, Aaspirinis miReba re-komendebulia yvela pacientisaTvis sawyisi pero-raluri datvirTvis doziT 150-300mg, Semdgomi Se-manarCunebeli doziaa 75-100mg dReSi xangrZlivad, mkurnalobis strategiis miuxedavad.

I A

P2Y12 inhibitorebis miReba rekomendebulia aspi-rinTan erTad, Tu ar aris amis winaaRmdegCveneba momatebuli sisxldenis riskis saxiT.

• tikagrelori (180mg datvirTvis doza, 90mg or-jer dReSi) winaaRmdegCvenebis d ararsebobisas, rekomendebulia iSemiuri garTulebebis saSualo an maRali riskis (mag. troponinis momateba) mqone yvela pacientTan, miuxedavad mkurnalobis sawyisi strategiisa, maT Soris klopidogreliT (romelic unda Sewydes, tikagreloris miRebamde) ukve nam-kurnalebi pacientebisaTvis.

• prasugreli (60 mg datvirTvis doza, 10 mg dRiuri doza), rekomendebulia pacientebTan (Tu ar aris winaaRmdegCveneba) PCI Catarebis SemTxvevaSi.

• klopidogreli (300-600 mg datvirTvis doza, 75 mg dRiuri doza), rekomendebulia pacientebTan, Tu ar aris tikagreloris an prasugrelis miRebis Sesa-Zlebloba an saWiroa peroraluri antikoagulacia.

sisxldenis maRali riskis mqone pacinetebTan wam-liT dafaruli stentis implantaciis Semdeg re-komendebulia P2Y12 inhibitorebis miReba Semokle-buli periodis 3-6 Tvis ganmavlobaSi.

IIa A

Pprasugrelis daniSvna ar aris rekomendebuli Tu ucnobia pacientis koronaruli sisxlZarRvebis anatomia.

III B

intravenuri antiTrombocituli mkurnaloba

PCI-is dros GGPIIb/IIIa inhibitorebiT mkurnalobis sakiTxi ganxiluli unda iyos mxolod gansakuTre-bul SemTxvevebSi da Trombotuli garTulebebis arsebobisas.

IIa C

PCI dros Kkangrelori gamoyeneba SeiZleba P2Y12-iT aranamkurnaleb pacientebTan.

IIa A

GGPIIb/IIIa - inhibitorebiT mkurnaloba ar aris re-komendebuli Tu ucnobia pacientis koronaruli sisxlZarRvebis anatomia.

III A

antiTrombocituli Terapiis rekomendaciebi

NSTE-ACS-is dros (gagrZeleba)


P2Y12-iT inhibitorebiT xangrZlivi Terapia

aspirinTan erTad P2Y12 inhibitorebis miReba 1 welze meti xniT SeiZleba ganxiluli iyos paci-entebis iSemiuri da sisxldenis riskis detaluri Sefasebis Semdeg.

IIa A

zogadi rekomendaciebi

protonuli tumbos inhibitorebis kombinacia ormag antiTrombocitul TerapiasTan erTad re-komendebuli pacientebTan, romlebsac aqvT gas-trointestinuri sisxldenis saSualoze maRali riski (mag. anamnezSi gastrointestinuri wylu-li/hemoragia, antikoagulantebiT mkurnaloba, arasteroiduli anTebis sawinaaRmdego saSuale-bebis / kortikosteroidebis miReba an ori an meti Semdegi niSani: asaki ≥ 65 wl, dispefsia, gastro-ezofaguri refluqsi, helicobacter pylori da alkoho-lis qronikuli gamoyeneba).

I B

I A

I B

I B

I B

26 27

Tu P2Y12 inhibitorebiT mkurnalobaze myof paci-entebTan, gegmiuri, didi arakardiuli qirurgiu-lie Carevis win unda Sewydes sul mcire 5 dRiT adre tikagreloris an klopidogrelis, da 7 dRiT adre prasugrelis miReba, Tu pacienti ar imyofe-ba iSemiis ganviTarebis maRali riskis jgufSi.

IIb C

Tu arakardiuli qirurgiuli Carevis gadadeba SeuZlebelia an aRiniSneba garTuleba sisxldenis saxiT, SeiZleba ganxiluli iyos P2Y12 inhibito-ris miRebis Sewyvetis sakiTxi, Tu metalis sten-tebiT da axali Taobis wamliT dafaruli sten-tebiT PCI-is Catarebis Semdeg gasulia minimum 1 da 3 Tve, Sesabamisad.

IIb C

CABG = aortokoronaruli SuntirebaDAPT = ormagi (peroraluri) antiTrombocituli TerapiaGPIIb/IIIa = glikoprotein IIb/IIIaNSAID = arasteroiduli anTebis sawinaaRmdego saSualebebiPCI = perkutanuli koronaruli intervenciac - nawlavebSi araxsnadi Semogarsuli preparati. 75-150 mg i.v. Tu perora-luri miReba SeuZlebelia.d - tikagreloris miRebis winaaRmdegCveneba: gadatanili intrakrania-luri hemoragia an mimdinare sisxldena. Pprasugrelis winaaRmdegCveneba: gadatanili intrakranialuri hemoragia, gadatanili insulti an tranzi-toruli iSemia an mimdinare sisxldena. Pprasugreli zogadad ar aris naC-venebi > = 75 wlis, agreTve < 60 kg-ze wonis pacientebSi. e - rekomendaciebi arakardiuli qirurgiuli CarevisTvis mocemulia se-qciaSi 5.6.6.2. Msrul teqstSi (www.escardio.org/guidelines; doi 10.1093/euroheartj/ehv320, ixile seqcia 5.6.6.2. antiTrombocituli Terapiis perioperaciuli marTvis rekomendaciebi NSTE ACS-iT pacientebSi koronarul Suntirebis Catarebisas.

P2Y12 –inhibitorebiT mkurnalobis dawyebis dro

NSTE-ACS-iT pacientebTan invaziuri strategiis SemTxveva-Si tikagreloris an klopidogrelis miRebis optimaluri dro ar aris srulyofilad Seswavlili, ar aris Camoya- libebuli am medikamentebiT proceduris wina mkurnalo-bis rekomendaciebi. ACCOACT-is monacemebze dayrdnobiT prasugreliT winaswari mkurnaloba ar aris rekomendebu-

li. NSTE-ACS-iT pacientebis konservatiuli mkurnalobis SemTxvevaSi, rekomendebulia P2Y12 - inhibitorebis miRebis dawyeba diagnozis dadgenidan rac SeiZleba swrafad, Tu ar aris amis winaaRmdegCvenebebi.

GGP IIb/IIIa inhibitorebis dozireba Tirkmlis normaluri da

darRveuli funqciiT pacientebSi

medikamenti rekomendacia

Tirkmlis normaluri funqcia an

CKD1-2 stadia

(eGFR>=60mL/min/1,73m2)

CKDme-3 stadia eGFR 30-59

mL/min/ m1,73m2

CKDme-4 stadia

eGFR15-29mL/

min/1,73m2

CKDme-5 stadia eGFR<15mL/min/1,73m2

Eptifibatide

bolusiT 180µg/kg i.v

ineqcia 2µg/kg/min

Bbolusi ar aris

rekomen-debuli,

infuziis siCqaris Semcire-ba1µg/kg/min Tu

eGFR 50mL/min/1,73m²

ar arisrekomen-debuli


Tirofiban

bolusiT 25 µg/kg an 10 µg/kg i.v ineqcia 0.15µg/kg/min


Bbolusi ar aris

rekomen-debuli,

infuziis siCqaris

Semcireba 0.0µg/kg/

min


http://www.escardio.org/guidelines

28 29

Abciximab

bolusiT 25 µg/kg an 10 µg/kg i.v

ineqcia 0.125µg/kg/min

(max.0.10µg/kg/min)

Aar arsebobs specifikuri rekomenda-cia Abciximab-is gamoyenebis Sesaxeb, aseve ar aris rekomendacia misi do- zirebis Sesaxeb Tirkmlis ukmariso-bis dros, saWiroa sisxldenis riskis

frTxili Sefaseba.

CKD = Tirkmlis qronikuli daavadeba, eGFR = gorglovani filtraciis siCqaris gamoTvla; i.v = intravenuri.cxrilSi moyvanili medikamentebis gamoyenebis rekomendaciebi sxavada-sxva qveynebSi SeiZleba iyos gansxvavebuli.

4.3 antikoagulacia

Aantikoagulantebis dozireba Tirkmlis normaluri da

darRveuli funqciiT pacientebTan

medikamenti rekomendacia

Tirkmlis nor-maluri funqcia an CKD 1-3stadia

(eGFR ≥ 30mL/min/1,73m²

CKD me-4 stadia

(eGFR15-29mL/min/1,73m²)

CKD me-5 stadia

(eGFR15-<15mL/min/1,73m²)

arafraqcini-rebuliheparini

* koronarul angiografiamde: 60-70 IU/kg i.v (max.5000IU) da infu-zia (12-15 IU/kg/h)

(max.1000IU/h), samizne aPPT 1.5-2.5× kontroli

* PCI –is dros 70-100 IU/kg i.v (50-70 IU/kg Tu

erTdroulad ix-mareba GPIIb/IIIa inhibitorebi)

dozisregulacia

ar aris

dozisregulacia

ar aris

enoqsaparini1mg/kg s.c.

dReSi orjer1mg/kg s.c.

dReSi erTjerAar aris re-

komendebuli

fondaparinuq-si

2.5 mg/kg s.c.erTjer dReSi

ar aris reko-mendebuli

Tu eGFR<20ml/min/73m²

Aar aris re-komendebuli

bivalirudinibolusiT 0.75mg/

kg i.v infuzia 1.75mg/kg/h

Abolusis regulacia ar

aris, infu-ziis siCqare

mcirdeba 1 mg/kg/h-mde

Ddializis dros Abolusis regulacia ar aris, infuziis siCqare mcird-

eba 0.25mg/kg/h-mde

eGFR = gorglovani filtraciis siCqare; IU = saerTaSoriso erTeuli; i.v = intravenuri, s.c. = kanqveS.cxrilSi moyvanili medikamentebis gamoyenebis rekomendaciebi sxavadasx-va qveynebSi SeiZleba iyos gansxvavebuli. ix. seqcia 5.8.3.1. srul teqstSi (xelmisawvdomia www.escardio.org/guidelines doi 10.1093/euroheartj/ehv320, seqcia 5.8.3.1. antiTrombuli preparatebis dozireba Web addenda-Si).

NSTE-ACS-is dros antikoagulaciis rekomendaciebi

rekomendaciebiklasia Ddoneb

parenteraluri antikoagulacia rekomendebulia diagnozis dadgenis periodidan, iSemiis da sisxldenis riskiebis gaTvaliswinebiT.

I B

mkurnalobis strategiis ganurCevlad rekomen-debulia fondaparinuqsi (2.5 mg s.c. dReSi), romel-sac gaaCnia yvelaze kargad gamoxatuli efeqturo-ba-usafrTxoebis profili.

I B

PCI-is dros, rogorc UFH pda GPIIb/IIIa inhibitore-bis kombinaciis alternativa, rekomendebulia bi-valirudini (0.75 mg/kg i.v bolusiT Semdeg 1.75 mg/kg /h 4 saaTamde proceduris Semdeg).

I A

http://www.escardio.org/guidelines

30 31

Tu PCI utardeba pacients, romelsac manamde ar mi-uRia sxva antikoagulantebi, rekomendebulia UFH 70-100 IU/kg i.v (50-70 IU/kg kombinaciaSi GPIIb/IIIa in-hibitorebTan).

I B

Tu PCI utardeba pacients, romelic ukve Rebulob-da fondaparinuqss (2.5 mg s.c. dReSi) proceduris dros rekomendebulia intravenurad UFH-is bo-lusis Seyvana (70-85 IU/kg an 50-60 IU/kg kombinaciaSi GPIIb/IIIa-inhibitorebTan).

I B

enoqsaparinis (1 mg/kg s.c orjer dReSi) an UFH-is ga-moyeneba rekomendebulia, roca fondaparinuqsi ar aris xelmisawvdomi.

I B

Tu PCI utardeba pacients romelsac ukve ukeTdeba enoqseparini, ganxiuli unda iyos amave preparatiT antikoagulaciis gagrZelebis sakiTxi.

IIa B

UFH-iT dawyebuli mkurnalobis fonze, PCI-is dros UFH-is bolusis Seyvana SeiZleba ACT-s damatebiTi kontroliT.

IIb B

PCI-is Semdeg ganxiluli unda iyos Aantikoagulaci-uri mkurnalobis Sewyvetis sakiTxi, Tu ar aris amis sxva Cvenebebi.

IIa C

gadasvla UFH-iT mkurnalobidan LMWH-is miRebaze ar aris rekomendebuli.

III B

NSTEMI-iT pacientebTan, parenteraluri antiko-agulaciis Sewyvetis Semdeg SeiZleba ganvixiloT sakiTxi rivaroqsabanis dabali doziT (2.5 mg dReSi 2-jer daaxloebiT 1 wlis ganmavlobaSi) mkurnalo-bis Taobaze, Tu am pacientebs ara aqvT gadatanili insulti/TIA, aReniSnebaT iSemiis maRali riski, sisxldenis dabali riski da isini Rebuloben aspi-rins da klopidogrels.

IIb B

ACT - aqtivirebuli Sededebis dro, GPIIb/IIIa = glikoprotein IIb/IIIa , i.v = intravenuri, LMWH = dabali molekuluri wonis heparini, NSTEMI = ST elevaciis gareSe mimdinare miokardiumis infarqti, NSTE ACS = ST elevaciis gareSe mimdinare mwvave koronaruli sindromi, PCI = perkutaneuli koronaruli intervencia, TIA = tranzitoruli iSemiis Seteva, s.c = kanqve-Sa, UFH = arafraqciuli heparini.

4.4 xangrZliv peroralur antikoagulantur mkurnalobaze myof pacientebTan peroraluri antiTrombocituli saSualebebis gamoyenebis regulacia

PCI-sTan dakavSirebuli sisxldenis riskisSemcirebis strategia

• PCI-sTan antikoagulantebis dozireba unda moxdes sxeulis wo-nis da Tirkmlis funqciis gaTvaliswinebiT, gansakuTrebiT qaleb-Si da moxucebSi.

• sasurvelia radialuri midgoma

• protonuli tumbos inhibitorebis miReba im pacientebisaT-vis, romlebic imyofebian ormag antiTrombocitul Terapiaze da aqvT gastrointestinuri sisxldenis saSualoze maRali riski (mag. anamnezSi gastrointestinuri wyluli/hemoragia, antikoagu-lantebiT mkurnaloba, anTebis sawinaaRmdego arasteroiduli sa-Sualebebis /kortikosteroidebis miReba an ori an meti Semdegi ni-Sani: asaki ≥ 65, dispefsia, gastroezofaguri refluqsi, helicobacter pylori da alkoholis qronikuli miReba).

• peroralur antikoagulantur Terapiaze myofi Ppacientebi: • PCI tardeba VKAs da NAOACs Sewyvetis gareSe; • pacientebi romlebic Rebuloben VKA-s ar unda miiRon UFH Tu INR aris >2.5;P • pacientebi, romlebic Rebuloben NAOACs miuxedavad misi bolo miRebidan gasuli droisa emateba dabali doziT parenteraluri antikoagulantebi (mag. enoqsaparini 0.5mg/kg i.v an UFH 60 IU/kg.);A • aspirini naCvenebia, magram Tavi unda avaridoT P2Y12 inhibitorebiT winaswar mkurnalobas; • GPIIb/IIIa-is gamoyeneba mxolod gansakuTrebuli periproceduruli garTulebebis dros.

GPIIb/IIIa = glikoproteinis IIb/IIIa inhibitorebi, INR = saerTaSoriso normalizebuli fardoba, VKAs = vitamin K-s antagonisti, NAOACs = ara vitamin K-s antagonisti peroraluri antikoagulantebisTvis, NSAIDs = arasteroiduli anTebisawinaaRmdego saSualebebi, OACs = peroraluri antikoagulantebi, UFH = arafraqciuli heparini, PCI = perkutanuli koronaruli angioplastika.

34 35

xangrZlivi peroraluri antikoagulaciuri mkurnalobis

saWiroebisas NSTE-ACS-iT pacientebTan kombinirebuli

antiTrombocituli da antikoagulaciuri Terapiis

rekomendaciebi


peroraluri antikoagulanciuri Terapiis mka-fio Cvenebebis arsebobisas (mag. mocimcime ariTmia CHA2DS2-VASc maCvenebliT ≥ 2, axali venuri Trom-boembolia, marcxena parkuWis Trombozi an meqni-kuri sarqveli), peroraluri antikoagulantebis miReba rekomendebulia antiTrombocituli Tera-piis damatebis saxiT.

I C

adreuli invaziuri koronaruli angiografia (24 saaTis ganmavlobaSi) Catarebis sakiTxi ganxiluli unda iyos saSualo da maRali riskis pacientebSic, miuxedavad peroraluri antikoagulantebiT mkur-nalobisa, imisaTvis rom daCqardes mkurnalbis meTodis SerCeva (medikamentozuri vs.PCI vs.CABG) da ganisazRvros optimaluri antiTrombocituli reJimi.

IIa C

peroraluri antikoagulaciuri mkurnalobis fon-ze koronarul angiografiamde pacientebisaTvis damatebiT ormagi antiTrombocituli Terapia as-piriniT da P2Y12-inhibitorebiT ar aris rekomen-debuli.

III C

pacientebi, romlebsac utardebaT koronaruli stentireba

antikoagulacia

PCI-is dros, parenteraluri antikoagulacia re-komendebulia, NOAC SemTxvevaSi - miuxedavad bo-lo dozis miRebis droisa, xolo vitamin K-s anta- gonistebiT namkurnaleb pacientebSi Tu INR-i aris < 2,5.

I C

ganxiluli unda iyos periprocedurul fazaSi vi-tamin K-s antagonistebiT an NOAC-is uwyveti an-tikoagulaciuri Terapiis Catarebis sakiTxi.

IIa C

xangrZlivi peroraluri antikoagulaciuri mkurnalobis

saWiroebisas NSTE-ACS-iT pacientebTan kombinirebuli

antiTrombocituli da antikoagulaciuri Terapiis

rekomendaciebi (gagrZeleba)


antiTrombocituli Terapia

NSTE-ACS-iT da mocimcime ariTmiiT pacientebTan, Tu CHA2DS2-VASc maCvenebeli Seadgens 1 (kacebSi) da 2 (qalebSi) ganxiluli unda iyos koronaruli stentirebis Semdeg ormagi antiTrombocituli Terapiis, rogorc sammagi Terapiis alternativis sakiTxi.

IIa C

sisxldenis dabali riskis SemTxvevaSi (HAS-BLED ≤ 2), miuxedavad implantirebuli stentebis tipi-sa, ganxiluli unda iyos: 6 Tvis ganmavlobaSi sam-magi Terapiis Catarebis sakiTxi: peroraluri antikogulntebiT, aspiriniT (75-100 mg/dReSi) klopidogreliT 75mg/dReSi. 6-dan 12 Tvemde mkur-naloba grZeldeba peroraluri antikogulntebiT kombinaciaSi aspirinTan (75-100mg/dReSi) an klopi-dogrelTan 75mg/dReSi.

IIa C

sisxldenis maRali riskis dros (HAS-BLED ≥ 3), miuxedavad implantirebuli stentebis tipisa, ganxiluli unda iyos 1 Tvis ganmavlobaSi samma-gi Terapiis Catarebis sakiTxi - peroraluri an-tikoagulantebiT, aspiriniT (75-100 mg/dReSi) da klopidogreliT 75 mg/dReSi. Semdgom periodSi (12 Tvemde) mkurnaloba peroraluri antikoagulan-tebiT da aspiriniT (75-100 mg/dReSi) an klopido-greli 75 mg/dReSi.

IIa C

36 37

xangrZlivi peroraluri antikoagulaciuri mkurnalobissaWiroebisas NSTE-ACS-iT pacientebTan kombinirebuliantiTrombocituli da antikoagulaciuri Terapiisrekomendaciebi (gagrZeleba)


pacientebi, romlebsac utardebaT koronaruli stentireba

antiTrombocituli mkurnaloba (gagrZeleba)

ormagi Terapia peroraluri antikoagulantebiTa da klopidogreliT 75 mg/dReSi SeiZleba Catardes, rogorc alternativa sammagi antiTrombocituli Terapiisa, pacientebTan romlebsac aReniSnbaT HAS-BLED ≥ 3 da stentis Trombozis dabali riski.

IIb B

tikagreloris da prasugrelis gamoyeneba,rogorc sammagi Terapiis nawilis ar aris rekomendebuli

III C

sisxlZarRvebTan midgoma da stentis saxeebi

koronaruli angiografiisa da koronaruli inter-venciis dros radialuri midgomaa ufro metad re-komendebuli, femoralur midgomasTan SedarebiT.

I A

peroralur antikoagulantebze myof pacien-tebTan ganxiluli unda iyos axali Taobis wamliT dafaruli stentebis implantaciis sakiTxiiT.

IIb B

medikamenturi mkurnalobaze myofi pacientebi

peroralur antikoagulantebis garda erTi anti-Trombocituli preparatiT 1 wlis ganmavlobaSi mkurnalobis Catarebis sakiTxi unda iyos ganxilu-li.

IIb C

CHA2 DS2-VAsc = gulis ukmarisoba, arteriuli hipertenzia asaki ≥ 75 [2qula] diabeti, insulti [2qula] - vaskularuli daavadebebi asaki 65-74 seqsi; NOACs = ara vitamin K-s antagonisti peroraluri antikoagulan-tebisTvis; NSTE ACS = ST elevaciis gareSe mimdinare mwvave koronaruli sindromi; OACs = peroraluri antikoagulantebi, es exeba rogorc vitamin K-s aseve ara vitamin K-s antagonist peroralur antikoagulantebs;PCI = perkutanuli koronaruli angioplastika;

VKA = vitamin K-s antagonisti sammagi Terapia exeba aspirins, klopido-grels da peroralur antikoagulantebs; HAS-BLED = sisxldenis maCve- nebeli, moicavs hipertenzias Tirkmlis/RviZlis darRveul funqcias, insults, anamnezSi sisxldenis arsebobas an misadmi winaswarganwyobas labiluri INR - (internacionaluri, normalizebuli fardoba) xandazmu-li asaki (> 65 weli), medikamentebi, romlebic zrdian sisxldenis risks an alkoholis moxmareba. antiTrombocitul medikamentebTan erTad NOAC preparatebi iniSneba ufro dabali dozebiT, (mag. dabigatrani 2×110mg, rivaroqsabani 1×15 mg da apiqsaban 2×2.5 mg). rodesac VKA kombinirebulia antiTrombocitul saSualebebTan INR ar unda iaRematebodes 2.5.a - rekomendaciis klasi;b - mtkicebulebaTa done.c - riskis kriteriumebi CamoTvlilia cxrilSi 13 srul teqstSi (naxva Sesa-Zlebelia www.escardio.org/guidelines;doi/10.1093/euroheartj/ehv320).

NSTE ACS dros sisxldenis marTvis da sisxlistransfuziis rekomendaciebi


VKA - asocirebuli, sicocxlesTan saSiSi sisxldenis dros pirvel rigSi ganxiluli unda iyos antikoagulaciis efeqtis swrafi ganeitraleba oTx faqtoriani proTrombinis kompleqsis kon-centratiT, vidre gayinuli plazmis an rekombini-rebuli aqtivirebuli VII faqtoris gamoyenebiT. damatebiT, jeradad, i.v. nel-nela SeyavT vitamini K-s 10 mg.

IIa C

NOAC-Tan asocirebuli aqtiuri, sicicxlisaTvis saSiSi sisxldenis SemTxvevaSi ganxiluli unda iyos proTrombinis kompleqsuri koncentratiT an aqtivirebuli proTrombinis kompleqsis koncen-tratiT pacientis mkurnalobis sakiTxi.

IIa C

anemiis dros, Tu ar aris aqtiuri sisxldenis niS-nebi, magram hematokriti < 25% an hemoglobinis done aris < 7 g/dl. an aris hemodinamikis arastabi-luroba SeiZleba ganxiluli iyos hemotransfuzi-is Catarebis sakiTxi.

IIb C

ACS = mwvave koronaruli sindromi, NOACs = ara vitamin K-s antagonisti peroraluri antikoagulantebi, NSTE ACS = ST elevaciis gareSe mimdinare mwvave koronaruli sindromi; VKA = vitamin K-s antagonisti.a - rekomendaciis klasi;b - mtkicebulebaTa done.

38 39

4.5 invaziuri koronaruli angiografiada revaskularizacia invaziuri koronaruli angiografiis da

revaskularizaciis rekomendaciebi NSTE-ACS dros


dauyovnebeli invaziuri strategia (< 2sT)

rekomendebulia Tu pacientebs aReniSnebaT

qvemoT miTiTebuli Zalian maRali riskis

kriteriumebidan sul cota erT-erTi:

• hemodinamikis Aarastabiluroba an

kardiogenuli Soki;

• rekurentuli an mimdinare tkivili gulmkerdSi,

romelic refraqerulia medikamenturi

mkurnalobis mimarT;

• sicocxlisaTvis saSiSi ariTmia an gulis gaCe-

reba;

• miokardiumis infarqtis meqanikuri

garTulebebi;

• gulis mwvave ukmarisoba Tanmxlebi

refraqteruli stenokardiiT an ST segmentis

cdomiT;

• ST segmentis an T kbilis rekurentuli

dinamiuri cvlilebebi, gansakuTrebiT

gardamavali ST-s elevaciiT.

I C

adreuli invaziuri strategia (< 24sT)

rekomendebulia Tu pacientebs aReniSnebaT

qvemoT miTiTebuli maRali riskis

kriteriumebidan sul cota erT-erTi:

• miokardiumis infarqtis maniSnebeli

troponinis donis momateba an dakleba;

• ST segmentis an T kbilis dinamiuri cvlilebebi

(simptomuri an Cumi);

• GRACE riskis qulebi >140.

I A

40 41

invaziuri strategia (< 72sT) rekomendebulia pacientebSi, romlebsac aReniSnebaTminimum erTi mainc qvemoT miTiTebuli: • saSualo riskis kriteriumebidan sul cota erT-erTi: o Saqriani diabeti o Tirkmlis ukmarisoba (eGFR<60ml/min/1.73m²) o LVEF < 40% an gulis SegubebiTi ukmarisoba o Aadreuli postinfarqtuli stenokardia o Aaxlad Catarebuli koronaruli intervencia o Aadre Catarebuli koronaruli Suntireba o GRACE maCvenebeli > 109 da < 140 an• rekurentuli simptomebi an arainvaziuri gamokvlevebiT dadgenili iSemia.

I A

zemoT CamoTvlili riskis kriteriumebis da rekurentuli simptomebis ararsebobis SemTxveva-Si, invaziuri gamokvlevebis gadawyvetilebis miRe-bamde rekomendebulia iSemiis gamovlenis mizniT arainaziuri MmeTodebis (sasurvelia gamosaxulebi-Ti) Catareba.

I A

radialuri midgomis gamocdilebis mqone centreb-Si, rekomendebulia koronarografiisa da koro-naruli intervenciebis Catareba radialuri gziT.

I A

rekomendebulia koronaruli intervenciebis Ca- tareba axali Taobis wamliT dafaruli stentebis gamoyenebiT.

I A

mravalsisxlZarRvovani (koronaruli) daziane-bebis SemTxvevaSi, gid pacientebTan revaskular-izaciis strategiis SerCeva (mag. samizne koro-naruli dazianebis dauyovnebeli intervencia, ramodenime arteriis erTdrouli intervencia, koronaruli Suntireba) unda moxdes pacientebis klinikuri statusis da Tanmxlebi daavadebebis, iseve rogorc koronarebis dazianebis simZimis (gavrceleba, dazianebis xasiaTi, SYNTAX qulebi) gaTvaliswinebiT lokaluri gundis protokolis mixedviT.

I C

invaziuri koronaruli angiografiis da revaskularizaciis re-komendaciebi NSTE-ACS dros (gagrZeleba)


Tu pacientis sisxldenis maRali riskis arsebobis gamo, igegmeba xanmokle (30 dRe) ormagi peroraluri antitrombocituli Terapiis Catareba, upiratesoba unda mieces metalis stentebis gamoy-enebas, wamliT dafaruli stentebTan SedarebiT.

IIb B

eGFR = gorglovani filtraciis siCqaris gamoTvla. GRACE = mwvave koro-naruli garTulebebis globaluri registri.LVEF = marcxena parkuWis gandevnis fraqcia.SYNTAX = SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery.

koronaruli Suntirebis perioperaciul periodSi

antiTrombocituli Terapiis marTva NSTE ACS-iT pacientebSi


miuxedavad revaskularizaciis strategiisa, as-pirinTan erTad pacientebisaTvis rekomendebulia P2Y12 inhibitorebis miReba 12 Tvis ganmavlobaSi, Tu ar aris amis ukuCvenebebi, rogoricaa sisxlde-nis momatebuli riski.

I A

rekomendebulia, rom gulis jgufma (Heart Team) individualurad gansazRvros pacientis sisxldenis da iSemiis riskebi, koronaruli Suntirebis Catarebis dro, aseve dagegmos ormagi antiTrom-bocituli Terapia.

I C

arastabiluri hemodinamikis, mimdinare iSemiis an Zalian maRali riskis matarebeli koronaruli anatomiis arsebobis SemTxvevaSi, rekomendebuli koronaruli Suntirebis Catareba dayovnebis ga-reSe, miuxedavad antiTrombocituli Terapiisa.

I C

Tu ar aris aqtiuri sisxldena, koronaruli Sun-tirebidan 6-24 saaTis Semdeg rekomendebulia Aas-pirinis miReba.

I A

rekomendebulia dabali doziT aspirinis miRebis gagrZeleba koronaruli Suntirebis operaciamde.

I B

42 43

koronaruli Suntirebis perioperaciul periodSi antiTrom-

bocituli Terapiis marTva NSTE - ACS-iT pacientebSi

(gagrZeleba)


ormag antiTrombocitul Terapiaze myofi das-tabilurebuli pacientebisaTvis, koronaruli Suntirebis Catarebis saWiroebis arsebobisas re-komendebulia: tikagreloris da klopidogrelis miRebis Sewyveta operaciamde 5 dRiT adre, xolo prasugrelis - 7 dRiT adre.

IIa B

koronaruli Suntirebis Semdeg ganxiluli unda iyos P2Y12 inhibitorebis miRebis ganaxlebis sakiTxi, usafrTxoebis gaTvaliswinebiT.

IIa C

koronaruli Suntirebis mizeziT P2Y12 inhibi-torebis Sewyvetis Semdeg, rac SeiZleba mokle droSi SeiZleba ganxiluli iyos sakiTxi Trombo- citebis funqciis testirebis Catarebis Taobaze.

IIa B

ACS = mwvave koronaruli sindromi; CABG = aorto-koronaruli Suntire-ba; DAPT = ormagi oraluri antiTrombuli Terapia; a - rekomendaciis kla-si; b - mtkicebulebaTa done.

4.6 specifikuri populaciebi da mdgomareobebi

rekomendaciebi NSTE-ACS –iT xandazmuli pacientebisTvis


antiTrombocituli saSualebebis daniSvna re-komendebulia, sxeulis wonis da Tirkmlis fun-qciis Sesabamisad.

I C

xandazmul pacientebSi invaziuri strategiis da saWiroebis SemTxvevaSi revaskularizaciis Catarebis sakiTxi ganxiluli unda iyos, misi saer-To mdgomareobis, Tanmxlebi daavadebebis, Carevis potenciuri riskebisa da sargeblis, sicocxlis mosalodneli xangrZliobis, cxovrebis xarisxis, pacientis Sefasebisa da survilebis gaTvalis-winebiT.

IIa A

gverdiTi efeqtebis prevenciisTvis Aganxilu-li unda iyos beta-blokerebis, agf inhibitore-bis, angiotenzinis receptorebis blokerebis da statinebis daeniSvnis sakiTxebi.

IIa C

ACE = angiotenzinis fermentis inhibitori; ARB = angiotenzinis blok-eri; NSTE-ACS = mwvave koronaruli sindromi ST-s elevaciis gareSe; a - re-komendaciis klasi; b - mtkicebulebaTa done.

rekomendaciebi diabetiT daavadebuli pacientebisTvis

NSTE-ACS -is dros


sisxlSi glukozis kontroli

rekomendebulia NSTE-ACS-iT yvela pacientis skriningi diabetis arsebobaze, agreTve sisxlSi glukozis donis xSiri monitoringi Tu pacients ukve dadgenili aqvs diabeti an Semosvlisas aReniSna hiperglikemia.

I C

Tu mwvave koronaruli sindromiT pacients daudginda sisxlSi glukozis done > 10 mmol/l (180mg/DL), Gganxiluli unda iyos glukozis dam-wevi Terapiis Catarebis sakiTxi Tanmxlebis daa-vadebebis gaTvaliswinebiT, ise rom Tavidan iyos acilebuli hipoglikemia.

IIa C

mwvave koronaruli sindromiT xandazmul pacien-tebTan, romlebsac aqvT mZime kardiovaskuluri daavadebebi, diabetis xangrZlivi anamnezi, da sxva Tanmxlebi daavadebebi, ganxiluli unda iyos glukozis naklebad mkacri monitoringis sakiTxi, rogorc mwvave, ise Semdgom fazebSi.

IIa C

antiTrombocituli mkurnaloba da invaziuri strategia

antiTrombocituli Terapiis Catareba rekomen-debulia, rogorc diabetiT daavadebulebSi, ise diabetis ar mqone pacientebSi.

I C

invaziuri strategiaa ufro metadaa rekomendebu-li, vidre arainvaziuri marTva.

I A

44 45

koronaruli angiografiis an PCI-is Semdeg mom-devno 2-3 dRis ganmavlobaSi, rekomendebulia PTirkmlis funqciis monitoringis Catareba im pa-cientebTan, romlebsac ukve hqondaT Tirkmlis funqciis daqveiTeba an itarebda mkurnalobas metforminiT.

I C

PCI - Catarebisas rekomendebulia axali Taobis wamliT dafaruli stentebis gamoyeneba, metalis stentebTan SedarebiT.

I A

mravalsisxZarRvovani dazianebebis mqone dasta-bilizirebul pacientebTan, misaRebi qirurgiuli riskis arsebobisas, rekomendebuli koronaruli Suntirebis Catareba, koronarul intervenci-asTan SedarebiT.

I A

mravalsisxZarRvovani dazianebebis Pmqone paci-entebTan, Tu SYNTAX score ≤ 22, koronaruli Sun-tirebis alternativad ganxiluli unda iyos PCI Catrebis sakiTxi.

IIa B

PCI - perkutanuli koronaruli intervencia.a - rekomendaciis klasi;b - mtkicebulebaTa done.

rekomendaciebi pacientebisTvis, romelTac aqvT

NSTE-ACS da Tirkmlebis qronikuli daavadeba


rekomendebulia, yvela pacientTan Tirkmlisfunqciis Sefaseba eGFR- is saSualebiT.

I C

rekomendebulia iseTive pirveli rigis antiTrom-bocituli Terapiis Catareba, rogorc Tirkmlis normaluri funqciis SemTxvevaSi, saWiroebisas Sesaferisi dozebis SerCeviT.

I B

Tirkmlis disfunqciis xarisxis gaTvaliswinebiT, T, rekomendebulia peroraluri antikoagulan-tebis magier arafraqcinirebuli heparinis an Se- saferisi dozebiT fondaqsiparini, enoqsiparini, bivaluridini an GPIIb/IIIa inhibitorebis gamoyene-ba.

I B

Tu eGFR < 30ml/min/1.73m²-ze (fondaqsiparinisTvis eGFR < 20ml/min/1.73m²), antikoagulantebis kan-qveSa da i/v ineqciebis magivrad rekomendebulia arafraqcinirebuli heparinis i/v infuzia aPTT-s mixedviT dozis regulirebiT.

I C

invaziuri strategiis SemTxvevaSi, rekomendebu-lia pacientebis hidratacia izotonuri xsnariT, agreTve dabal an izo-osmolaruli sakontrasto nivTierebis (rac SeiZleba mcire moculobiT) ga-moyeneba.

I A

koronaruli angiografia, da saWiroebis SemTx-vevaSi revaskularizaciis Catareba rekomendebu-lia imis Semdeg rac detalurad Sefasdeba Careve-bis riski da sargebli, Tirkmlis disfunqciis simZimis gaTvaliswinebiT.

I B

koronarul intervenciis Catarebisas rekomen-debulia axali Taobis wamliT dafaruli stentis gamoyeneba, metalis stentebTan SedarebiT.

I B

Tu pacients aqvs koronarebis mravalsisxlZarR-vovani dazinebebi, misi sicocxlis mosalodneli xangrZlivoba >1 welze, xolo qirurgiuli Care-vis riskis misaRebia, ganxiluli unda iyos koro-naruli Suntirebis Catarebis upiratesoba, koro-narul intervenciasTan SedarebiT.

IIa B

Tu pacients aqvs koronarebis mravalsisxlZarR-vovani dazianebebi, misi sicocxlis mosalodneli xangrZlivoba <1 welze, xolo qirurgiuli Care-vis riskis maRalia, ganxiluli unda iyos koro-naruli intervenciebis Catarebis upiratesoba koronaruli SuntirebasTan SedarebiT.

IIa B

aPTT - aqtivizirebuli parcialuri Tromboplastinis dro,eGFR - gamoTvlili gorglovani filtraciis done.a - rekomendaciis klasi;b - mtkicebulebaTa done.

46 47

NSTE-ACS-is dros mwvave gulis ukmarisobiT pacientebis

marTvis rekomendaciebi


marcxena parkuWis da sarqvlebis funqciis Sefase-bisaTvis, agreTve meqanikuri garTulebebis gamo-saricxad, rekomendebulia eqokardiografiis gadaudeblad Catareba.

I C

koronaruli angiografiiis gadaudeblad Catare-baa rekomendebuli, Tu gulis mwvave ukmarisobas Tan axlavs refraqteruli stenokardia, ST-seg-mentis cvelilebebi an kardiogenuli Soki.

I B

kardiogenuli Sokis dros rekomendebulia gadaudebeli PCI Catareba, Tuki koronarebis anatomia amis saSualebas iZleva.

I B

kardiogenuli Sokis dros, roca pacientis koronaruli anatomia ar iZleva PCI Catarebis Sesa-Zleblobas, rekomendebulia gadaudebeli koro-naruli Suntireba.

I B

NSTEMI-ACS-is fonze ganviTarebuli meqanikuri garTulebebis SemTxvevaSi, pacientis mdgomareo-ba dauyovleblad unda ganixilis gulis jgufma.

I C

meqanikuri garTulebebiT gamowveuli ara-stabiluri hemidinamikis / kardiogenuli Sokis ganviTarebis SemTxvevaSi ganxiluli unda iyos intraaortuli balonuri kontrpulsaciis Cata-rebis sakiTxi.

IIa C

kardiogenuli Sokis dros SeiZleba ganxiluli iyos pacientTan moklexniani sisxlismimoqcevis meqanikuri daxmarebis Catarebis sakiTxi.

IIb C

kardiogenuli Sokis Adros intraaortuli balonuri kontrpulsaciis rutinulad Catareba ar aris rekomendebuli.

III B

a - rekomendaciis klasi;b - mtkicebulebaTa done.

NSTE-ACS-is Semdgomi gulis ukmarisobiT pacientebis

marTvis rekomednaciebi


pacientebis mdgomareobis stabilizaciis Semdeg, Tu marcxena parkuWis gandevnis fraqcia ≤ 40%-ze, sikvdilobis, miokardiumis infarqtis, gulis uk-marisobiT ganpirobebuli hospitalizaciis riskis Semcirebis mizniT, rekomendebulia agf inhibito-ris (an ar blokeris, Tuki aris agf inhibitorisautanloba) gamoyeneba.

I A

pacientebis mdgomareobis stabilizaciis Semdeg, Tu marcxena parkuWis gandevnis fraqcia ≤ 40%-ze, sikvdilobis, miokardiumis infarqtis, gulis uk-marisobiT ganpirobebuli hospitalizaciis riskis Semcirebis mizniT, rekomendebulia beta-blokerebis daniSvna.

I A

Tu pacients agf inhibitorebiT (an arb, agf inhib-itorebis autanlibis SemTxvevaSi), beta-blokere-biT mkurnalobis miuxedavad aReniSneba gulis uk-marisobis mdgradi simptomebi (NYHA Class II-IV) da marcxena parkuWis gandevnis fraqcia ≤ 35, rekomen-debulia gulis ukmarisobiT ganpiribebuli hospitalizaciis da sikvdilianobis riskis Semcirebis mizniT mineralkortikoidebis receptorebis an-tagonistebis gamoyeneba.

I A

marcxena parkuWis gandevnis fraqsiiT ≤ 40% paci-entebTan kardiovaskuluri hospitaluzaciis da sikvdilianobis riskis Semcirebis mizniT rekomen-debulia mineralkortikoidebis receptorebis an-tagonistebi, upiratesad eplerenonis gamoyeneba.

I B

48 49

Tu mwvave Setevidan 40 dRis Semdeg, miuxedvad op-timaluri medikamenturi Terapiisa pacients aqvs parkuWis mZime disfunqcia (gandevnis fraqcia ≤ 35%) da gulis ukmarisobis simptomebi, amave dros araris naCvenebi revaskularizaciis Catareba, re-komendebulia CRT-D, an ICD implantaciaa (QRS kom-pleqsis xangrZlivobis gaTvaliswinebiT). amasTan erTad pacients unda hqondes 1 welze meti mosalodneli sicocxlis xangrZlivoba kargi funqci-uri statusiT.

I A

Kgid pacientebTan, romelTa marcxena parkuWis gan-devnis fraqcia ≤ 35%, pirveladi profilaqtikis mizniT CRT-D/ICD implantaciamde, ganxiluli unda iyos rezidualur iSemiaze testirebis da Semd-gomi revaskularizaciis Catarebis sakiTxi. reva-skularizaciis Semdeg, pirveladi profilaqtikis mizniT CRT-D/ICD implantaciis Catarebamde, ganxi-luli unda iyos 6 Tvis ganmavlobaSi Seqcevadi re-modelurebis Sefasebis sakiTxi.

IIa B

agf - angiotenzinis gardamqmneli fermentis inhibitori, arb - angioten-zinis receptoris blokeri, CRT-D - kardiuli resinqronizaciuli Tera-pia defibrilatoriT, ICD - implantirebadi kardioverter defibrilato-ri.

NSTE-ACS-iT da winagulTa fibrilaciiT pacientebis marTvis rekomendaciebi


Tu ar aris winaaRmdegCveneba, rekomendebulia yvela pacientisaTvis antikoagulantebisdaniSvna.

I A

winagulTa fibrilaciiT pacientebTan kardi-uli troponinis donis momatebis SemTxvevaSi, ganxiluli unda iyos iSemiis arsebobis dadgenis mizniT gamokvlevebis Catarebis sakiTxi.

IIb C

pacientebi swrafi parkuWovani riTmiT

arastabiluri hemodinamikiT pacientebTan rekomendebulia eleqtruli kardioversia.

I C

eleqtruli an farmakologiuri kardioversia amiodaroniT rekomedebulia Eim SemTxvevaSi, Tu miRebulia sinusis riTmis araurgentulad aRdgenis (riTmis kontrolis strategia) gadawyvetileba. es strategia gamoyenebul unda iyos mxolod im pacientebTan, romlebsac aqvT 48 sT-ze naklebi xangrZliobis winagulTa fibri-laciis pirveli epizodi (an pacientebTan, rom-lebsac transezofagialuri eqokardiografiis ar daudgindaT marcxena winagulis Trombozi) an Tu antikoagulaciuri Terapia Tardeboda sul cota bolo 3 kviris ganmavlobaSi.

I C

intravenurad beta-blokerebis Seyvana rekomen-debulia stabiluri hemodinamikis mqone pacien-tebTan winagulTa fibrilaciaze swrafi parku-Wovani pasuxis (riTmis) SenelebisaTvis.

I C

parkuWovani riTmis kontrolis mizniT Ksagule glikozidis intravenuri Seyvana SeiZleba iyos ganxiluli, Tu beta-blokerebis gamoyeneba ar iyos sakmarisad efeqturi.

IIb C

winagulTa fibrilaciaze swrafi parkuWovani pasuxis Senelebis mizniT aradihidropiridi-nuli kalciumis antagonistebis (verapamili, dilTiazemi) intravenuri Seyvana SeiZleba iyos ganxiluli gulis ukmarisobis simptomebis ar mqone pacientebTan, romlebic ar Rebuloben be-ta-blokerebs.

IIb C

I klasis antiariTmiuli saSualebis gamoyeneba ar aris rekomendebuli (mag. enkainidi, flekainidi).

III B

ernakalantis gamoyeneba ar arisrekomendebuli.

III C


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rekomendaciebi trombocitopeniis samarTavad

NSTE-ACS-is mqone pacientebSi


GPIIb/IIIa receptoris blokeris da/an heparin-is (arafraqciuli an dabalmolekuluri) dauy-ovnebeli Sewyvetaa rekomendebuli mkurnalobis dros ganviTarebuli Trombocitopeniis SemTx-vevaSi < 100,000 / µL (an sawyisi raodenobis > 50%-ze Semcirebis SemTxvevaSi).

I C

GPIIb/IIIa receptoris blokatorebiT Pnamkurnaleb pacientebTan aqtiuri didi sisxldenis an mZime (< 10 000/ µL) asimptomuri Trombicitopeniis gan-viTarebis SemTxvevaSi, rekomendebulia Trom-bocitebis transfuzia.

I C

dokumentirebuli an savaraudo hepariniT in-ducirebuli trombocitopeniis SemTxvevaSi rekomendebulia araheparinuli antikoagulan-tebiT mkurnaloba.

I C

hepariniT inducirebuli trombocitopeniis pre-venciis mizniT rekomendebulia im antikoagulan-tebis gamoyeneba, romelTac dabali aqvT an ara aqvT trombocitopeniis ganviTarebis riski, an ara-fraqcinirebuli an dabalmolekuluri hepa-rinis gamoyeneba mokle drois ganmavlobaSi.

I C


4.7 marTva xangrZlivi periodis ganmavlobaSi

NSTE-ACS-is Semdgom xangrZliv periodSi pacientebismarTvis rekomendaciebi

rekomendaciebi (antiTrombocituli mkurnalo-bis rekomendaciebis ix. nawili 5.2.9 da 5.3.3.)c.

klasia Ddoneb

rekomendebulia yvela patientisaTvis cxovrebis jansaRi wesis Sesrulebis rCeva (sigaretis Sewyve-ta, regularuli fizikuri aqtivoba, janmrTeli kveba).

I A

rekomendebulia, rac SeiZleba adre maRali inten-sivobiT statinebiT mkurnalibis dawyeba da misi xangrZlivad gagrZeleba, Tu ar aris amis ukuCve- neba.

I A

agf inhibitorebis gamoyeneba mizanSewinilia, Tu ar aris amis ukuCveneba da pacients aqvs marcxe-na parkuWis gandevnis fraqcia ≤ 40%-ze, gulis ukmarisobis simptomebi, arteriuli hipertenzia da diabeti. agf inhibitorebis autanlibis SemTx-vevaSi, alternativas warmoadgens arb-is gamoi-yeneba.

I A

beta-blokerebis gamoyeneba mizanSewinilia, Tu ar aris amis ukuCveneba da pacients aqvs marcxena parkuWis gandevnis fraqcia ≤ 40%-ze.

I A

mineralkortikoidebis receptorebis antago-nistebis, gansakuTrebiT eplerenonis gamoyeneba rekomendebulia, roca gandevnis fraqcia ≤ 35% da pacients aReniSneba gulis ukmarisoba an Saqri-ani diabeti NSTE-ACS-is Semdeg, magram ara aqvs Tirkmlebis mniSvnelivani disfunqcia an hiperka-lemiad.

I A

rekomendebuli samizne diastoluri wnevaa< 90 mmHg, (diabetiT daavadebulebSi < 80 mmHg). I A

ganxiluli unda iyos pacientis CarTva kargad struqturizebul kardioreabilitaciis pro-gramaSi, raTa moxdes misi cxovrebis stilis modi- ficireba da mkurnalobisadmi damyolobis gazr-da.

IIa A

arastatinuri antilipiduri preparatebis gamoyenebis sakiTxi unda iyos ganxiluli, roca maqsi-malurad asatani dozebiT statinebiT mkurnalo-bis miuxedavad LDL qolesterolis done ≥ 70mg/dl L(≥ 1,8 mmol/l)e.

IIa B

sistoluri wnevis samizne sidided unda iyosganxiluli < 140mm/Hg.

IIa B

agf - agf inhibitori, Aarb-angiotenzinis gardamqmneli fermentis inhibitori, LDL - dabali simkvrivis lipiproteini. a - rekomendaciis klasi; b - mtkice-bulebaTa done; c - ixileT sruli teqsti5.3.3 rekomendaciebi antikoagulaciu-ri TerapiisTvis NSTE-ACS; d - Sratis kreatinini < 221 unimol/l (2,5mg/DL) kace-bisTvis da <177unimol/l (2,0mg/DL) qalebisTvis, Sratis kaliumi < 5 mmol/l; e- gaidlainis dasrulebis periodSi rekomendacia exeba ezetimabs.

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5. MmarTvis strategiis Sejameba

pirveli safexuri: sawyisi DSefaseba da mimarTulebebi

• NSTE-ACS-ze eWvis SemTxvevaSi Yyvela pacienti unda gaigza-vnos gadaudebeli samedicinis momsaxurebis ganyofilebaSi da swrafad unda iyos gamokvleuli kvalificiuri eqimebis mier.• dro pirveli samedicino kontaqtidan ekg-s gadaRebamde ar unda aRematebodes 10 wT-s.

NSTE-ACS-s samuSao diagnozi da sawyisi marTva unda emyare-bodes Semdeg parametrebs:• gulmkerdSi tkivilis xasiaTi, xangrZlivoba da mdgra-doba; simptomebze orientirebuli fizikaluri gamokvleva (mag: arteriuli wneva, guliscemis sixSire, kardiopulmona-ruli auskultacia, Killip-iT daklasificireba)• gid-is arsebobis albaTobis Sefaseba emyareba pacientis tkivilis xasiaTs, asaks, sqess, risk faqtorebs, adre dadge-nil gid, aTerosklerozis arakrdiul gamovlinebebs. • 12 ganxriani ekg (ST segmentis cdomilebebis an iSemiis da nekrozis sxva niSnebis gamosavlenad).

zemoT aRniSnuli pacientis monacemebis safuZvelze, Sesa-Zlebelia winaswari diagnozis Camoyalibeba erT-erTi qve-moT miTiTebulis formiT: • STEMI• NSTE-ACS mimdinare iSemiiT da arastabiluri hemodina-mikiT• NSTE-ACS mimdinare iSemiis da hemodinamikis arastabilu-robis gareSe• NSTE-ACS naklebad savaraudoa• STEMI-iT pacientebis mkurnalobis sakiTxebi ganxilulia evropis kardiologTa sazogadoebis Sesabamis gailainSi. • xandazmulebSi, diabetiT daavadebul pacientebTan “nak-lebad savaraudoa” diagnozis gamotana saWiroa garkveuli

sifrTxiliT, mxolod maSin roca aSkaraa mdgomareobissxvagvari interpretacia.• sawyisi samkurnalo saSualebebi unda moicavdes nit-ratebs (sublungvalurad da i.v) gulmkerdSi mdgradi tki-vilis, arteriuli hipertenziis da gulis ukmarisobis kupirebisTvis. OoqsigenoTerapia gamoyenebuli unda iyos mxolod im SemTxvevebSi, roca Jangbadis saturacia < 90%-ze an sunTqviTi ukmarisoba.M morfini (i/v an kanqveS.) an sxva alternatiuli opioidebi gamoiyeneba mdgradi, Zlieri tki-vilis dros.• mimdinare gulmkerdis tkivilis da Pgaurkveveli ekg monacemebis SemTxvevaSi, dauyovlebla tardeba eqokar-diografia (Tu saWiroa CT angiografia), sxva alternatiuli diagnozebis gamosaricxad, (rogoricaa pulmonuri Trom-boembolia, perikarditi da aortis diseqcia) an NSTE-ACS-is damadasturebeli damatebiTi monacemebis misaRebad (mag. parkuWis kedlebis moZraobis segmenturi darRvevebi).• mimdinare iSemiis an hemodinamikuri darRvevebis (klini-kuri monacemebi unda Seesabamisebodes eqokardiografi-ulad parkuWis kedlis regionuli kumSvadobis darRvevebs), mqone pacients dauyovneblad unda Cautardes koronaro-grafia miuxedavad ekg an biomarkerebis monacemebisa, si-cocxlisaTvis saSiSi parkuWovani ariTmiebis prevenciisa da miokardiumis dazianebis (nekrozis) SemofargvlisaTvis.• hospitalizaciisTanave unda Catardes sul mcire Semdegi tipis sisxlis analizebi: (sasurvelia maRali mgrZnobel-obis) kardiuli tropinini T an I, Sratis kreatinini, hemo-globini, hematokriti, Trombicitebis raodenoba, sisxlSi glukoza, Tu pacienti Rebulobs VKA-s damatebiTad – isaz-Rvreba INR. tropininis analizis pasuxi xelmisawvdomi unda iyos 60 wuTSi, maRali mgrZnobelobis troponinis gansaz-Rvris SemTxvevaSi analizi unda ganmeordes 1-3 sT-Si. • NSTE-ACS-ze eWvis SemTxvevaSi, am diagnozis dadasture-bamde an gamoricxvamde, pacientebi dakvirvebisTvis unda moTavsdnen gadaudebeli medicinis an gulmkerdis tkivilis (chest pain unit) ganyofilebaSi. NSTE-ACS dadasturebis Sem-TxvevaSi hospitalizaciis adreul periodSi unda ganisazR-vros lipiduri profili.

54 55

• mimdinare iSemiis SemTxvevaSi gadaudebeli revaskulari-zaciis proceduris dawyebamde pacients unda daekras defi-brilatoris safenebi. samedicino personali trenirebuli unda iyos kardiuli reanimaciis CatarebaSi da maTTvis xel-misawvdomi unda iyos defibrilatori.

meore safexuri: diagnozis dadastureba, risksSefaseba da riTmis monitorireba

• 12 ganxriani ekg da troponinis pirveli analizis monace-mebis mixedviT NSTE-ACS diagnozis dadasturebis Semdeg pacients unda daewyos mkurnaloba antiTrombocituli, (rogorc aRwerilia mesame nabijSi) da antianginaluri (nit- ratebi da beta-blokerebi) saSualebebiT.• pacientis Semdgomi marTva efuZneba antianginaluri mkurnalobis efeqturobas da riskis gansazRvras GRACE 2.0 riskis Sefasebis (http://www.gracescore.org/WebSite/default.aspx?ReturnUrl=%2f) SkaliT, iseve rogorc troponinis momde-vno analizebis Sedegebs (maRalo mgrZnobelobis troponini unda ganisazRvros 1-3 sT-Si).• eqokardiografia sasargebloa iSemiis da nekrozuli ub-nebis arsebobaze mimaniSnebeli monacemebis (mag. regionuli hipo- an akinezia) dasadgenad da unda dauyovneblad Catar-des yvela SemTxvevaSi, roca aris eWvi, rom pacientis hemo-dinamikis arastabiluroba gamowveulia kardiovaskuluri mizezebiT.• aortis diseqciaze an pulmonarul emboliaze eWvis SemTx-vevaSi unda Catardes eqokardiografia, D-dimeris testi, CT-angiografia, Sesabamisi gaidlainis mixedviT.• kardiuli ariTmiebis ganviTarebis dabali riskis mqone NSTEMI-iT pacientebTan (romlebsac ar aReniSnebaT Semdegi kriteriumebi: hamodinamikis arastabiluroba, didi ariT-miebi, gandevnis fraqcia < 40%-ze, warumatebeli reperfu-zia, sxva kritikuli koronaruli Seviwroebebi, an interven-ciasTan dakavSirebuli garTulebebi) ganxiluli unda iyos riTmis monitorireba 24 sT-s ganmavlobaSi an koronarul intervenciis Catarebamde (imis mixedviT romeli dadgeba

pirveli), • kardiuli ariTmiebis ganviTarebis saSualo an maRali riskis mqone NSTEMI-iT pacientebTan (Tu aris erTi an meti zemoT aRniSnuli kriteriumi) ganxiluli unda iyos 24sT-ze meti xangrZliobis riTmis monitorireba.

Mmesame safexuri: antiTrombotuli mkurnaloba

• NSTE-ACS-is dros gadawyvetileba antiTrombotuli reJi-mis Sesaxeb unda eyrdnobodes mkurnalobis arCeul strate-gias (konservatiuli Tu invaziuri), iseve rogorc revasku-larizaciis meTods (PCI Tu CABG)• AantiTrombotuli Terapiis dozebis dadgenisas gaTva- liswinebuli unda iyos pacientis asaki da Tirkmlis funq-cia.• rekomendirebulia aspiriniT da parenteraluri antiko-agulantebiT mkurnaliba. NSTEMI-iT pacientebis konserva-tiuli mkurnalibisas, Tu ar aris sisxldenis maRali riski, klopidogrelTan SedarebiT upiratesoba aqvs tikagrelo-ris daniSvnas. • pacientebTan, romlebTanac igegmeba marTvis invaziuri strategia, tikagreloris micemis zusti dro dadgenili ar aris, maSin roca prasugrelis miReba rekomendebulia mxolod angiografiis Semdeg uSualod koronaruli inter-venciis win.

MmeoTxe safexuri: invaziuri strategia • rekomendebulia koronarografiis da saWiroebis SemTxve-vaSi revaskularizaciis Catareba radialuri midgomiT. yo-veli pacientis riskis profilis gaTvaliswinebiT, pirveli samedicino kontaqtis momentidan koronarografia Catare-bis drois mixedviT SeiZleba daiyos 4 kategoriaT:• gadaudebeli invaziuri strategia (< 2sT). STEMI-is analo-giurad, NSTEMI-is dros es strategia unda iyos gamoyenebu-li, Tu pacients aReniSneba mimdinare iSemia sul mcire erTi

56 57

Zalian maRali riskis kriteriumiT. im SemTxvevaSi Tu samedicino centrs ara aqvs STEMI marTvis specialuri pro-grama, saWiroa zemoT aRniSnuli kategoriis pacientis dauyovneblad gadayvana sxva Sesaferis centrSi. • adreuli invaziuri strategia (< 24sT). am kategoriis pa-cientTa didi umravlesoba dadebiTad reagirebs sawyis me-dikamentur mkurnalobaze, Tumca aqvT momatebuli riski da saWiroeben angiografiis da Semdgomi revaskularizaciis adreulad Catarebas. am kategorias miekuTvnebian pacien-tebi, sul cota erTi maRali riskis kriteriumiT. kaTete- rizaciis laboratoriis arqonis SemTxvevaSi pacienti droulad unda iyos gadayvanili Sesaferis klinikaSi. • invaziuri strategia (< 72sT). es aris rekomendebuli ma-qsimaluri dayovnebis dro koronarografiis CaTarebamde pacientebisaTvis, romlebsac ara aqvT rekurentuli simp-tomebi, magram aReniSnebaT sul cota erT saSualo riskis kriteriumi. am kategoriis pacientebis gadayvana kaTete- rizaciis laboratoriis mqone hospitalSi ar aris gadaude-blad saWiro, magram 72sT-iani fanjara koronaruli an-giografiis Casatareblad unda iyos daculi.• seleqtiurad (arCeviTad) invaziuri strategiakardiovaskuluri garTulebebis dabali riskis kategorias ganekuTvnebian pacientebi, Tu maT ar aReniSnebaT: steno-kardiis rekurensi, gulis ukmarisobis simptomebi, sawyis da Semdeg ekg-ze specifiuri cvlilebebi, aseve troponinis (sasurvelia maRali mgrZnobelobis) momateba. aseT SemTx-vevebSi, invaziuri gamokvlevis gadawyvetilebis miRebis win rekomendebulia arainvaziuri stres testis (umjobesia gamosaxulebiTi) Catareba inducirebadi iSemiis gamosav-lenad.

mexuTe safexuri: revaskuarizaciis formebi

• dastabilurebuli NSTE-ACS pacientebisTvis PCI da CABG Catarebis rekomendaciebi iseTivea, rogorc stabiluri gid-is dros. erTi arteriis dazinebis SemTxvevaSi, arCe-vis meTods warmoadgens samizne arteriis stentireba. ko-

ronarebis mravalsisxlZarRvovani dazinebebis SemTxvevaSi gadawyvetileba revaskularizaciis meTodis Sesaxeb miRe-buli unda iyos individualurad, gulis gundis mier gan- xilvis saFfuZvelze. • Tanmimdevrul midgomas SeiZleba upiratesoba hqondes garkveul pacientebTan, da gulisxmobs jer samizne arte-riis stentirebas, xolo Semdgom dadasturebuli iSemiis SemTxvevaSi – danarCeni koronaruli arteriebis Suntire-bas. • erTi antiTrombocituli preparatiT (mag. aspirini) nam-kurnaleb pacientebSi, koronaruli intervenciis Catarebis SemTxvevaSi rekomendebulia damatebiT P2Y12 inhibitore-bis miReba (upiratesoba aqvs prasugrels an tikagrelors, klopidogrelTan SedarebiT).• antikoagulanti unda SeirCes iSemiis da sisxldenis riske-bis gaTvaliswinebiT da ar unda Seicvalos koronaruli in-tervenciis dros. Tu pacienti imyofeba fundaparinoqsiT mkurnalobaze, koronarul intervenciamde unda damate- biT daeniSnos arafraqcinirebuli heparini. Tu pacienti adre antikoagulantebs ar Rebulobda, ganxiluli unda iyos bivalirudinis gamoyeneba.• P2Y12 inhibitorebiT mkurnalobis fonze dagegmili ko-ronaruli Suntirebis SemTxvevaSi, unda Sewydes aRniSnuli preparatebis miReba da gadaidos operacia, Tu klinikuri mdgomareoba da angiografiuli monacemebi gvaZlevs amis saSualebas.• Tu koronaruli angiografiis Sedegebis mixedviT re-vaskularizaciis Catareba ar aris naCvenebi koronaruli arteriebis dazinebis gavrcelebisa da cudi distaluri nawilebis gamo, stenokardiis mkurnaloba unda warimarTos medikamenturi Terapiis gaZlierebis gziT.

meeqvse safexuri: saavadmyofodan gawerada Semdgomi marTva

• miuxedavad imisa, rom NSTE-ACS-is yvelze saSiSi garTu-lebebi viTardeba adreul fazaSi, miokardiumis infarqtis

58 59

da letalobis riski rCeba momatebuli uaxloesi ramdenime Tvis ganmavlobaSi.• gaweris Semdeg yvela NSTE-ACS pacientisaTvis mizanSewo-nilia risk-faqtorebis intensiuri modifikacia da cxo-vrebis stilis Secvla, agreTve kardiuli reabilitaciis programaSi CarTva, rac xels Seuwyobs medikamenturi mkur-nalobis efeqturobas, risk-Ffaqtorebis modifikacias, rac Tavis mxriv gaaumjobesebs gamosavals.

SeniSvnebi:

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SeniSvnebi: SeniSvnebi:

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SeniSvnebi: SeniSvnebi:

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SeniSvnebi:

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