#1
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Âðà÷åáíàÿ äèñêóññèÿ
Âûíåñåíî îòñþäà: https://forums.rusmedserv.com/showthread.php?t=397024
Äîáðîãî âðåìåíè ñóòîê. Öèòàòà:
Äâîéíàÿ àíòèàãðåãàöèÿ (Êëîïèäîãðåëü+Àñïèðèí, êàê âàðèàíò Òèêàãðåëîð+Àñïèðèí) ïîêàçàíà ïîñëå ñòåíòèðîâàíèÿ, ïðîâîäèòñÿ â òå÷åíèè 12 ìåñ.; ïîñëå òîëüêî Àñïèðèí. Áîëüíîìó ñ èøåìè÷åñêîé áîëåçíüþ ñåðäöà - ïîêàçàí òîëüêî àñïèðèí. Êñàðåëòî - ðèâàðîêñîáàí - ýòî àíòèêîàãóëÿíò, îòíîñèòñÿ ê èíîìó êëàññó ïðåïàðàòîâ (íå àíòèàãðåãàíò), ïîêàçàí ïðè ìåðöàòåëüíîé àðèòìèè (íå âñåãäà), åìáîëèè ëåãî÷íîé àðòåðèè... Öèòàòà:
Öèòàòà:
Öèòàòà:
Ìîæíî èíîãäà ñî÷åòàòü ñ áåòà-áëîêàòîðîì, êàê áèñîïðîëîë èëè êàðâåäèëîë, ïîáî÷íûé ýôôåêò ìîæåò áûòü î÷åíü íèçêîå äàâëåíèå. |
#2
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Öèòàòà:
Èç Ïðàâèë ôîðóìà: Öèòàòà:
[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] - îïðåäåëåíèå ïîêàçàíèé ê àíòèêîàãóëÿíòàì ïðè ôèáðèëëÿöèè ïðåäñåðäèé. Òî, ÷òî ñåé÷àñ ñèíóñîâûé ðèòì, íå îòìåíÿåò àíòèêîàãóëÿöèþ. À åùå ÒÝËÀ åñòü â äèàãíîçå... Äîçà ðèâàðîêñàáàíà óêàçàíà âåðíàÿ, çà÷åì ïèñàòü ïàöèåíòó ïðî ïî÷å÷íóþ íåäîñòàòî÷íîñòü, åñëè ýòî íè÷åãî íå èçìåíèò? ß ïîêà íå âèäåë íè îäíîãî äîêàçàòåëüñòâà ïðîãíîñòè÷åñêîé ýôôåêòèâíîñòè èâàáðàäèíà. Äëÿ ìåíÿ ýòî î÷åðåäíîå ñëàáîå è áåññìûñëåííîå ëåêàðñòâî îò Ñåðâüå. Åñëè ó Âàñ åñòü äàííûå î åãî èññëåäîâàíèÿõ ïðè ñåðäå÷íîé íåäîñòàòî÷íîñòè, òî ïîäåëèòåñü, ïîæàëóéñòà. Åùå ðàç ïðîøó: äàâàéòå íå ñìóùàòü ÒÑ ñïîðàìè, îñîáåííî êîòîðûå íè÷åãî íå ìåíÿþò â íàïèñàííîì. Íå ñîãëàñíû - ïèøèòå â ëè÷êó èëè âñòóïàéòå âî "ÂÐÀ×È" è ïèøèòå â íåâèäèìîì äëÿ ïàöèåíòîâ ðåæèìå.
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#3
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Èâàáðàäèí ñëåäóåò ðàññìàòðèâàòü äëÿ óìåíüøåíèÿ ðèñêà ãîñïèòàëèçàöèè è ñìåðòè îò ñåðäå÷íî-ñîñóäèñòûõ ïðè÷èí ó ïàöèåíòîâ ñ ñèìïòîìàòèêîé, ñ Ô ≤35%, ñèíóñîâûì ðèòìîì è ×ÑÑ ≥70 óä./ìèí, íåñìîòðÿ íà ëå÷åíèå îïòèìàëüíûìè äîêàçàííûìè äîçàìè ÁÁ (èëè ìàêñèìàëüíî ïåðåíîñèìûìè äîçàìè), èÀÏÔ, ÀÐÌ.. (IIà,Â) ÐÅÊÎÌÅÍÄÀÖÈÈ ESC ÏÎ ÄÈÀÃÍÎÑÒÈÊÅ È ËÅ×ÅÍÈÞ ÎÑÒÐÎÉ È ÕÐÎÍÈ×ÅÑÊÎÉ ÑÅÐÄÅ×ÍÎÉ ÍÅÄÎÑÒÀÒÎ×ÍÎÑÒÈ 2016
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#4
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Öèòàòà:
Ïåðèíäîïðèë òîæå èçó÷àëè è îí êàêèå-òî êîìáèíèðîâàííûå òî÷êè óëó÷øàë âìåñòå ñ èíäàïàìèäîì. Âñå-ðàâíî åìó íåò ìåñòà, ò.ê. åñòü ëó÷øå, ÷åì îí. Áåç íàçîéëèâîãî ìàðêåòèíãà íè îäèí ïðåïàðàò îò Ñåðüâå íå áûë áû ïîïóëÿðåí âîîáùå.
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#5
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Öèòàòà:
Ñîãëàñíî åâðîïåéñêèé ðåêîìåíäàöèÿì, ïåðîðàëüíàÿ àíòèêîàãóëÿíòíàÿ òåðàïèÿ ïðè ôèáðèëëÿöèè ïðåäñåðäèé (à ó ïàöèåíòà ïàðîêñèçìàëüíàÿ ôèáðèëëÿöèÿ ïðåäñåðäèé - ñì âûïèñêó îò äåêàáðÿ) ïàöèåíòàì ìóæñêîãî ïîëà ïðè CHA2DS2-VASc 2 è áîëåå, à ó íàøåãî ïàöèåíòà 3 áàëëà - ÕÑÍ, èíôàðêò ìèîêàðäà, âîçðàñò. Ðèñê èíñóëüòà ïðè ïàðîêñèçìàëüíîé è ïîñòîÿííîé ôîðìå ôèáðèëëÿöèè ïðåäñåðäèé ñîïîñòàâèì. Íå ãîâîðÿ î òîì, ÷òî ó ïàöèåíòà åñòü ïîìèìî ôèáðèëëÿöèè ïðåäñåðäèé äðóãîå ïîêàçàíèå - ÒÝËÀ. Öèòàòà:
Ïî ïîâîäó ïî÷å÷íîé ôóíêöèè, Âû èíñòðóêöèþ ê Êñàðåëòî êîãäà-íèáóäü ÷èòàëè? Âû â êóðñå, ÷òî ïðè êëèðåíñå êðåàòèíèíà 15-50 ìë/ìèí? ïðèìåíÿþò äîçó 15 ìã Öèòàòà:
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Ñ óâàæåíèåì |
#6
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Öèòàòà:
8 randomized controlled trials with an overall number of 17,812 participants were included in this review. After 12 months, compared with placebo, ivabradine was not associated with reduction in cardiovascular mortality (RR 0.95, 95% CI 0.88 to 1.02), reduction of all-cause mortality (RR 0.98, 95% CI 0.90 to 1.06) and reduction of hospitalization for heart failure (RR 0.87, 95% CI 0.68 to 1.11). It was not found differences in safety considering cardiac adverse events between ivabradine and placebo (RR 0.96, 95% CI 0.89 to 1.02). [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#7
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Öèòàòà:
Ïðî èâàáðàäèí. |
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#8
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Ïîñëåäíèå ðåêîìåíäàöèè Åâðîïåéñêîãî ñîîáùåñòâà êàðäèîëîãîâ.
"Ivabradine reduces the elevated heart rate often seen in HFrEF and has also been shown to improve outcomes, and should be considered when appropriate." Èâàáðàäèí ñíèæàåò ñåðäå÷íûå ñîêðàùåíèÿ - îáû÷íî ïîâûøåííûå ïðè ÑÍ ñ óìåíüøåííîé ôðàêöèåé âûáðîñà ëåâîãî æåëóäî÷êà. "Ivabradine should be considered to reduce the risk of HF hospitalization or cardiovascular death in symptomatic patients with LVEF ≤35%, in sinus rhythm and a resting heart rate ≥70 bpm despite treatment with an evidence-based dose of betablocker (or maximum tolerated dose below that), ACE-I (or ARB), and an MRA (or ARB)." Êëàññ 2À, óðîâåíü Ñ Bo¨hm M, Borer J, Ford I, Gonzalez-Juanatey JR, Komajda M, Lopez-Sendon J, Reil J-C, Swedberg K, Tavazzi L. Heart rate at baseline influences the effect of ivabradine on cardiovascular outcomes in chronic heart failure: analysis from the SHIFT study. Clin Res Cardiol 2013;102:11–22. Swedberg K, Komajda M, Bo¨hm M, Borer J, Robertson M, Tavazzi L, Ford I. Effects on outcomes of heart rate reduction by ivabradine in patients with congestive heart failure: is there an influence of beta-blocker dose?: findings from the SHIFT (Systolic Heart failure treatment with the I(f) inhibitor ivabradine Trial) study. J Am Coll Cardiol 2012;59:1938–1945. |
#9
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Öèòàòà:
Âû íå óëîâèëè ìîé ãëàâíûé ìåññàäæ: Çà÷åì ýòî çíàòü ÒÑ? Õîòèòå ïîäèñêóòèðîâàòü ïðî èâàáðàäèí - çàâåäèòå òåìó âî âðà÷åáíîì îòäåëå. Ìîæåò ê Âàì òàì ïðèñîåäèíÿòñÿ äðóãèå ñîòðóäíèêè Ñåâðüå. Ïîæàëóéñòà, íå ñìóùàéòå ïàöèåíòà, ïîæàëóéñòà!  èâàáðàäèíå ìåíÿ âñåãäà óäèâëÿëà íåñëûõàííîñòü ïîêàçàíèé ê íåìó: ñèíóñîâûé ðèòì ñ ó÷àùåíèåì, êîòîðîå íå óáèðàþò áåòàáëîêàòîðû èëè êîãäà ìèíèìóì áåòàáëîêàòîðîâ ðîíÿþò äàâëåíèå. Ýòî î÷åíü-î÷åíü ðåäêî.  ñâîåé æèçíè ÿ ñîãëàñèëñÿ îñòàâèòü íàçíà÷åííûé èâàáðàäèí òîëüêî 1 ðàç. Áîëüøå îí ìíå íè ðàçó íå ïîíàäîáèëñÿ. Íà ïðîãíîç îí íå âëèÿåò - ñì. êîììåíòàðèè ïî òåìå.
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#10
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Åñëè íå òîëüêî ÷èòàòü ãàéäû è âåðèòü èì 100% êàê â èñòèíó ïîñëåäíåé èíñòàíöèè ÝÁÌ, òî âîò êàê ýòî ìîæåò âûãëÿäåòü ñî ñòîðîíû ïðàêòèêóþùåãî âðà÷à:
J Card Fail. 2016 Sep;22(9):726-30. The Room Where It Happens: A Skeptic's Analysis of the New Heart Failure Guidelines. Packer M. New heart failure guidelines have been issued during the past several months, both in the United States and in Europe, in response to recent advances in and the approval of new drugs for the treatment of heart failure. Although guidelines documents are often viewed as authoritative and purely evidence-based, there are replete with meaningful (and inexplicable) inconsistencies, which derive from a review of the same body of scientific data by different groups. This satirical review highlights several examples of the entertaining foolishness of recent guideline documents in the good-natured hope that physicians will understand what the guidelines are, and more importantly, what they are not. Specifically, this paper describes the emergence of a new nonexistent disease; the strange battle between 2 bradycardic drugs (digoxin and ivabradine); the confusion that reigns over the positioning and dosing of inhibitors of the renin-angiotensin system; and the special recommendations that have been issued for certain special populations. As Otto von Bismarck remarked, guideline deliberations are like sausages; it is better not to see them being made. Yet, even after they are ready for public view, we should be cautious. Practitioners who rely on them for clinical decision-making engage in an unnecessary form of self-deception; those who read them literally and adhere to them strictly do not practice evidence-based medicine; and those who delve into them in a search for the truth are destined to be disappointed.
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#11
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Öèòàòà:
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Ñ óâàæåíèåì |
#12
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Êàê ïðî÷èòàåøü âîò òàêîé "ôèíàíñîâî íåçàâèñèìûé" ñàìèçäàò, òî ìîæíî ïîäóìàòü, ÷òî è òðèìåòàçèäèí óæå âêëþ÷èëè â åâðîðåêîìåíäàöèè ïî ÕÑÍ, íàðàâíå ñ äðóãèì ëå÷åíèåì:
The Role Of Ivabradine And Trimetazidine In The New ESC HF Guidelines [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Trimetazidine in the new 2016 European guidelines on heart failure and beyond [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] ïðè÷åì â ýòèõ ïóáëèêàöèÿõ ñêâîçèò ñîæàëåíèå, äåñêàòü êàêèå íåäîâåð÷èâûå áûëè â 2012 ãîäó - íè ñëîâà î òðèìåòà-, íåñìîòðÿ íà äâà êèòàéñêèõ ìåòà-àíàëèçà, íî âîò ïîñëå òîãî åùå äâà ïîÿâèëîñü è âñ¸, "ãíóòñÿ øâåäû", îñîáåííî êàê ïîëüñêèå ëèòåðàòóðíûå ìåòà-àíàëèçàòîðû ïîêàçàëè 72% ïðåèìóùåñòâî â âûæèâàíèè, ñðàçó ïîïàë â ãàéä "ïðîïèñàëñÿ è øàáàø" (Ñ)
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#13
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Òàê ìîñêîíèäèí/ôèçèîòåíç ñòàë èç öåíòðàëüíîãî àëüôà-áëîêàòîðà áëîêàòîðîì èìèäàçîëèíîâûõ ðåöåïòîðîâ (ñïåöèàëüíî äëÿ Ðîññèè) è âîøåë â îäíî èç ðóêîâîäñòâ ïî ëå÷åíèþ ãèïåðòåíçèè â ÐÔ íàðàâíå ñ îñíîâíûìè ãðóïïàìè ïðåïàðàòîâ. ×åãî çà äåíüãè íå ïðèäóìàåøü
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#14
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Äîáðîãî âðåìåíè ñóòîê óâàæàåìàÿ êîëëåãà.
Ñ îäíîé ñòîðîíû íå õî÷ó ðàçâîäèòü ôëóä, íî ïîçâîëþ Âàì çàìåòèòü, ÷òî ïðàâèëà õîðîøåãî òîíà íèêòî íå îòìåíÿë, õîòÿ, êîíå÷íî, âûñøåå îáðàçîâàíèå íå ãàðàíòèÿ èíòåëëèãåíòíîñòè. Èçâèíèòå. Öèòàòà:
Öèòàòà:
Öèòàòà:
Mega JL, Braunwald E, Wiviott SD, Bassand JP, Bhatt DL, Bode C, Burton P,Cohen M, Cook-Bruns N, Fox KA, Goto S, Murphy SA, Plotnikov AN,Schneider D, Sun X, Verheugt FW, Gibson CM. Rivaroxaban in patients with a recent acute coronary syndrome. N Engl J Med 2012;366:9–19. Öèòàòà:
- ïàöèåíò íàõîäèòñÿ â ðåàëüíîé æèçíè (â îòëè÷èè îò íàøåé âèðòóàëüíîé áåñåäû), è êðîâîòå÷åíèå ñ äâóìÿ àíòèàãðåãàíòàìè å íåîáðàòèìûì àíòèêîàãóëàíòîì, îñòàíàâëèâàòü ïðèäåòñÿ òàêæå â ðåàëüíîñòè, âñïîìèíàÿ ïðè ýòîì î íèçêîì ñêîðå HAS_BLEED... Ó íàñ åñòü òàêîå âûðàæåíèå, âîïðîñ î òîì áóäåò èëè íåò êðîâîòå÷åíèå ó ïàöèåíòà ñ òðîéíîé òåðàïèåé, íå ñòîèò. Ñòîèò âîïðîñ î òîì, êîãäà îíî ñëó÷èòñÿ. Åñòü, äàííûå, ÷òî ðèñê èíñóëüòà, ïðè ïàðîêñèçìàëüíîé è ïåðìàíåíòíîé ìåðöàòåëüíîé àðèòìèè, íå îäèíàêîâ. È âûøå îí, ýòîò ðèñê ïðè ïåðìàíåíòíîé ôîðìå, ÷òî â ïðèíöèïå ëîãè÷íî. Âèäèìî, â áëèæàéøåå âðåìÿ áóäåò îïóáëèêîâàíî. Öèòàòà:
Öèòàòà:
Ëþáîé çäðàâîìûñëÿùèé ÷åëîâåê, âðà÷, òåì áîëåå - äîëæåí çàäàòüñÿ âîïðîñîì - îäíà è òà æå äîçèðîâêà ïðè êëèðåíñå 16 (ïðåä äèàëèçíàÿ ñòàäèÿ) è 49 ìë/ìèí (ïî÷òè íîðìà)? Êàê òàê? Ìû íå èñïîëüçóåì íîâûå àíòèêîàãóëàíòû ïðè êëèðåíñå íèæå 30... ________________________ Ê ñîæàëåíèþ íå èìåþ ïðèâèëåãèé ïèñàòü â "ñêðûòûõ" ñîîáùåíèÿõ, åùå ðàç ïðîøó ïðîùåíèÿ çà îòêðûòîå îáñóæäåíèå. À ïèñàòü Âàì êîëëåãà ëè÷íûå ñîîáùåíèÿ ïîñëå Âàøèõ ñòîëü òàêòè÷íûõ îòâåòîâ, èçâèíèòå, íå èìåþ. |
#15
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Öèòàòà:
À Âàøè ðàçúÿñíåíèÿ îòíîñèòåëüíî ðàçíèöû ìåæäó àíòèêîàãóëÿíòàìè è àíòèàãðåãàíòàìè, ÿ ñ÷èòàþ ïðîñòî òðàìâàéíûì õàìñòâîì. ×åëîâåê, êîòîðûé íå çíàåò ðåêîìåíäàöèé, âäðóã âçäóìàë ïîó÷àòü àçàì ÷åëîâåêà, êîòîðûé ìíîãî ëåò çàíèìàåòñÿ àíòèòðîìáîòè÷åñêîé òåðàïèåé. Öèòàòà:
Öèòàòà:
Ïî ïîâîäó ïàðîêñèçìàëüíîé è ïîñòîÿííîé ôîðìû, îäíî èç ïîñëåäíèõ èññëåäîâàíèé [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Öèòàòà:
Öèòàòà:
à ñ ÷åãî Âû ðåøèëè, ÷òî ÿ õî÷ó âñòóïàòü ñ Âàìè â ëè÷íóþ ïåðåïèñêó?
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Ñ óâàæåíèåì |