#751
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Ó íàñ ÊÀà äåëàþò ïåðåä êàðäèîõèðóðãè÷åñêèì âìåøàòåëüñòâîì âñåì ìóæ÷èíàì ñòàðøå 45 è æåíùèíàì ñòàðøå 50. Ó ïàöèåíòà ïîñëå Ð×À ñòîèò ñäåëàòü íàãðóçî÷íûé òåñò. ÕÌ - íå ìåòîä âûÿâëåíèÿ èøåìèè.
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#752
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Êîëëåãè, ó ìåíÿ âîçìîæíî íåñêîëüêî ñòðàííûé âîïðîñ. Ïðè âûÿâëåíèè ïî ÕÌ , åäèíè÷íîãî ýïèçîäà ôèáðèëëÿöèè ïðåäñåðäèé î÷åíü íåïðîäîëæèòåëüíîãî (5 - 7 ñåê. è ò. ï.) ó áåññèìïòîìíîãî â ïëàíå àðèòìèé ïàöèåíòà - âûíîñèòü ëè â äèàãíîç, íàçíà÷àòü ëè àíòèêîàãóëÿíòû, åñëè CHA2DS2-VASc áîëüøå 0?  åâðîïåéñêîì ãàéäå ïî ôï îò 2010 ã.: "Any arrhythmia that has the ECG characteristics of AF and lasts sufficiently long for a 12-lead ECG to be recorded, or at least 30 s on a rhythm strip,
should be considered as AF"  ýêñïåðòíîì êîíñåíñóñå ïî àáëàöèè ôï îò 2012 ã.: "An atrial fibrillation episode is defined as AF which is documented by ECG monitoring and has a duration of at least 30 seconds, or if less than 30 seconds, is present continuously throughout the ECG monitoring tracing. The presence of subsequent episodes of AF requires that sinus rhythm be documented by ECG monitoring between AF episode" Òî åñòü èäåò ðå÷ü î 30 ñåêóíäàõ ïðè åäèíè÷íîì ýïèçîäå. Ñ äðóãîé ñòîðîíû - íà õîëòåðå èìååì âîçìîæíî âñåãî ëèøü âåðõóøêó àéñáåðãà. Ó êîíêðåòíîãî ïàöèåíòà CHA2DS2-VASc 2 áàëëà, åñëè ýòè 5 - 7 ñåêóíä ôï ïðèíèìàòü âñåðüåç - íàäî íàçíà÷àòü ÎÀÊ. Íàøåë ñòàòüþ ïî òåìå:[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] - íî ÿñíåå íå ñòàëî Ïîêà ÎÀÊ íå íàçíà÷èë (íî ïî ïîâîäó ÈÁÑ ïîëó÷àåò ÀÑÊ), ðåêîìåíäîâàë ïîâòîðèòü ÕÌ ÷åðåç 3 ìåñ. Êòî ÷òî äóìàåò? |
#753
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Åñëè ÷åñòíî, òî äëÿ ìåíÿ ëè÷íî âîïðîñ íå ñîâñåì ïðîñòîé.
Êàê áû ÿ ïîñòóïèë â ýòîì ñëó÷àå:
×åì ÿ ðóêîâîäñòâóþñü â äàííîì ñëó÷àå: Çà: À. ß íå íàøåë óáåäèòåëüíûõ äàííûõ îòíîñèòåëüíî îáîñíîâàíèÿ cut-off â 30 ñåêóíä, êîòîðûé âïåðâûå ïîÿâèëñÿ â ãàéäå ïî ÔÏ îò 2006 ãîäà. Á. Êàê Âû óæå óïîìÿíóëè ïðîáåæêà ÔÏ íà Õîëòåðå, ìîæåò ÿâëÿòüñÿ "âåðøèíîé àéñáåðãà" è íå îòðàæàòü èñòèííîå áðåìÿ ÔÏ, ïðè ýòîì âûñîêèé áàëë ïî CHADSVASc îäíîâðåìåííî ÿâëÿåòñÿ ïðåäèêòîðîì ïðîãðåññèðîâàíèÿ ÔÏ. Ïðîòèâ: À. Âîçìîæíîñòè íåïðàâèëüíîé èíòåðïðåòàöèè çàïèñè ïðè ñòàíäàðòíîì Õîëòåðîâñêîì ìîíèòîðèðîâàíèè. Á. Îòñóòñòâèå îáúåêòèâíûõ äàííûõ ïî àíòèêîàãóëÿöèè ó äàííîé êàòåãîðèè áîëüíûõ. Ñïèñîê ëèòåðàòóðû: 1. Uptodate [Paroxysmal atrial fibrillation]: Öèòàòà:
[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Íàøåë ðÿä ðàáîò, ïîñâÿùåííûõ çíà÷åíèþ áðåìåíè ÔÏ, â òîì ÷èñëå ýòó: Îïÿòü æå ïðîäåìîíñòðèðîâàíî, ÷òî ïðîãíîñòè÷åñêîå çíà÷åíèå ÔÏ áîëåå 6 ìèíóò è 24 ÷àñîâ ïî äàííûì ìîíèòîðèðîâàíèÿ ÝÊà íå ðàçëè÷àåòñÿ. Ñëåäóåò îòìåòèòü, ÷òî ïðîãíîñòè÷åñêîå çíà÷åíèå ìåíåå è áîëåå 30 ñåêóíä íå ñðàâíèâàëîñü. 3. Ìàòåðèàëû òðåòüåé êîíñåíñóñíîé êîíôåðåíöèè EHRA/AFFNET; ðàçäåë, ïîñâÿùåííûé Silent AFib [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Ýêñòðàêò íà ðóññêîì: [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Òàêèì îáðàçîì, íåîáõîäèìû äîïîëíèòåëüíûå èññëåäîâàíèÿ.  íàñòîÿùåå âðåìÿ óðîâåíü äîêàçàííîñòè Ñ. |
#754
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çàïèñü íà ÕÌ ïîñìîòðåë - íå íàøåë ïðè÷èíû íå ñ÷èòàòü ýòî ôï (RR ðàçíûå, çóáöîâ P íåò), ëå÷åíèå ÈÁÑ íàçíà÷èë â ïîëíîì îáú¸ìå, ïî ïîâîäó ÃÁ - íà ëå÷åíèè ÀÄ ïðåèìóùåñòâåííî íîðìàëüíîå. Òîëüêî ìîæíî ëè ýòî ñ÷èòàòü ïîòåíöèàëüíî äîñòàòî÷íûì äëÿ óñòðàíåíèÿ ïðè÷èí ôï? ÿ ëè÷íî ñèëüíî â ýòîì ñîìíåâàþñü..
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#755
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Öèòàòà:
Ê ñîæàëåíèþ, ÈÁÑ èëè ÀÃ ÿ íå ìîãó íàçâàòü ïîòåíöèàëüíî îáðàòèìûìè. |
#756
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íó ðàç óæ ÿ ïðèñòàë ê êîëëåãàì, òî çàäàì åùå 1 âîïðîñ - äóìàþ, äëÿ êîëëåã ïðîñòîé . Òîæå ïðî ñëó÷àéíóþ íåîæèäàííóþ íàõîäêó íà ÕÌ. Ïàöèåíòêå ñ ðåäêèìè ïàðîêñèçìàìè ôï, êîòîðûå îíà êóïèðóåò ïðèåìîì 2 òàá. êîðäàðîíà, íà ÕÌ â íî÷íîå âðåìÿ âûÿâèëè 1 ýïèçîä ÀÂ-áëîêàäû 2 ñò. áåç ïåðèîäîâ Âåíêåáàõà, âûïàë 1 QRS, RR ïîëó÷èëñÿ 1,8 èëè 1,9 ñåê. (òî÷íåå íå ïîìíþ). Ïëàíîâî ïðèíèìàåò 2,5 ìã áèñîïðîëîëà. Íàñêîëüêî ñåðüåçíî îòíîñèòñÿ ê ýòîé áëîêàäå? íå õî÷åòñÿ îòìåíÿòü åé áåòà-áëîêàòîð (ëó÷øå îíà ñåáÿ íà íåì ÷óâñòâóåò è ïàðîêñèçìû õîòü è ðåäêèå, íî ñóáúåêòèâíî ëåã÷å ïåðåíîñèò) è óæ òåì áîëåå âåñòè ðå÷ü îá ÝÊÑ. Êëèíè÷åñêè íè ñèíêîïå, íè ãîëîâîêðóæåíèé, ïðåñèíêîïàëüíûõ ñîñòîÿíèé íåò.
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#757
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À ýòî íå àðòåôàêò?
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#758
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ASSERT
Î÷åíü èíòåðåñíîå èññëåäîâàíèå ïî ñêðûòîìó (ä-ç óñòàíîâëåí ïðè ÝÊÑ) ÌÀ è ðèñêå èíñóëüòà.
[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Subclinical Atrial Fibrillation and the Risk of Stroke "CONCLUSIONS Subclinical atrial tachyarrhythmias, without clinical atrial fibrillation, occurred frequently in patients with pacemakers and were associated with a significantly increased risk of ischemic stroke or systemic embolism. (Funded by St. Jude Medical; ASSERT ClinicalTrials.gov number, NCT00256152.)" |
#759
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Ïîâîä çàäóìàòüñÿ î öåëåñîîáðàçíîñòè ðóòèííîãî íàçíà÷åíèÿ ÕÌ.
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#760
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Öèòàòà:
Ïîïðàâüòå åñëè íå òàê. |
#761
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#762
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RE-LY, êðèòåðèè âêëþ÷åíèÿ
Öèòàòà:
electrocardiogram.*The*duration*of*atrial*fibrilla tion*should*be*at*least*30*seconds.*Electrograms*( not*marker*channels*or*mode*switch*episodes)*from* pacemakers*and*defibrillators*can*be*used*to*docum ent*only*1*episode*of*paroxysmal*or*persistent*atr ial*fibrillation." [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] |
#763
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Öèòàòà:
Öèòàòà:
 ïðèíöèïå, âî âòîðîì ñëó÷àå äîïóñòèìî íàáëþäåíèå. À âîò ñ ïåðâûì ñëó÷àåì, êàê ìíå êàæåòñÿ, âñå íåñêîëüêî ñëîæíåå. Êîììåíòàðèé è âîïðîñ ê Àëåêñàíäðó Èâàíîâè÷ó. 1. ÔÏ è òèðåîòîêñèêîç Îòíîñèòåëüíî "ñ íàòÿæêîé" èìåë â âèäó, ÷òî ó ÷àñòè (äî 30-40%) ïàöèåíòîâ ÔÏ ìîæåò ñîõðàíÿòüñÿ ïîñëå äîñòèæåíèÿ ýóòèðîèäíîãî ñîñòîÿíèÿ. Íàâñêèäêó íàøåë äàííûé îáçîð: [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] 2. ÔÏ è àíåìèÿ Åñëè ÷åñòíî, òî íèãäå íå âñòðå÷àë èíôîðìàöèþ î ïðè÷èííî-ñëåäñòâåííîé ñâÿçè ìåæäó ÔÏ è àíåìèåé. Ìîæåò èñêàë ïëîõî? + Äîïîëíèòåëüíûé âîïðîñ: ïàöèåíò, 70 ëåò, ãåìîãëîáèí 70 ã/ë, ïàðîêñèçìàëüíàÿ ôîðìà ôèáðèëëÿöèè ïðåäñåðäèé. Ïîñëå êîððåêöèè àíåìèè ìîæåì ëè ìû ãîâîðèòü î ïîëíîì èçëå÷åíèè ÔÏ? ß áû íå ñòàë. |
#764
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Öèòàòà:
Íî, åñëè óñòðàíèòü àíåìèþ, òî òÿæåñòü ïðèñòóïîâ, ÷àñòîòà èõ âîçíèêíîâåíèÿ îùóòèìî óëó÷øàòñÿ (óðîâåíü Ñ, ò.ê. ÈÌÕÎ). Àíåìèÿ æå óõóäøàåò ïî÷òè âñå, âêëþ÷àÿ ÷àñòî ñîïóòñòâóþùèå ÈÁÑ è ÕÑÍ. Áóäåò íåìíîãî ñâîáîäíîãî âðåìåíè - ïîðîþñü â ïàáìåäå - íå ìîæåò áûòü, ÷òîáû íè÷åãî òàì íå áûëî
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#765
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Àíåìèÿ - ôàêòîð ïîâûøåííîé ñìåðòíîñòè ïðè ÔÏ, íàïð.:
An important unresolved issue is whether anemia is a mediator of adverse outcomes—and therefore potentially amenable to therapeutic intervention—or merely a marker for persons with worse prognosis related to underlying illness or other factors. Anemia: An Independent Predictor of Death and Hospitalizations Among Elderly Patients with Atrial Fibrillation Shivak Sharma, MD, Brian F. Gage, MD, MSc, Elena Deych, MS, Michael W. Rich, MD Am Heart J. 2009;157(6):1057-1063[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] õîòÿ àíåêäîòèêè èç ïðîøëîãî èìåþööà: An elderly woman with severe anemia was hospitalized because of severe debility. On admission her electrocardiogram showed atrial fibrillation. After a transfusion of packed erythrocytes her rhythm converted to a normal sinus mechanism. JAMA. 1970 Jun 15;212(11):1958-9. Atrial fibrillation in severe anemia. Buxbaum J, Furgerson W.
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |