#706
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È åùå îäíî ñîîáðàæåíèå.
Åñëè âñåì-âñåì ïîâåñèòü Õîëòåðû, òî ó ñêîëüêèõ "çäîðîâûõ" áóäóò âûÿâëåíû êîðîòêèå (1-2-10 ìèíóò) ïàðîêñèçìû ÔÏ? À åñëè 48-÷àñîâûå èëè ðåâèëû? À êòî äåëàë ÝÔÈ çíàåò, ÷òî ñòèìóëÿöèåé ìîæíî çàâåñòè ÔÏ ïðàêòè÷åñêè êàæäîìó. Ãäå òà ãðàíü, êîãäà ÔÏ ìîæíî íàçâàòü íîçîëîãèåé? Íàïðèìåð, ìîëîäàÿ äåâóøêà - ýòî óæå 1 áàëë (çà ïîë), íà Õîëòåðå ñëó÷àéíî íàøëè ÔÏ äëèòåëüíîñòüþ 1 ìèíóòà, æàëîá íåò, ÷òî äåëàòü? Ïðàäàêñà èëè Êñàðåëòî?
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#707
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Ïî ïîâîäó êîíêðåòíîãî ïàöèåíòà (ïðî êîòîðîãî ÿ âîïðîñû çàäàë): íà ôîíå òèðåîòîêñèêîçà ó íåãî ïàðó ìåñÿöåâ êëèíèêà òèðåîòîêñèêîçà, â òîì ÷èñëå ñåðäöåáèåíèå ïðè âîëíåíèè, ôèç. àêòèâíîñòè, îñîáåííî â ïîñëåäíèå 2 íåäåëè, â ïîêîå ñèíóñîâûé ðèòì ñ ÷ññ 100 â ìèí. Âî âðåìÿ 16-ìèíóòíîãî ýïèçîäà ôï ïî ÕÌ - ÷óâñòâîâàë îñîáåííî ñèëüíîå ñåðäöåáèåíèå, òàê ÷òî îí ñêîðåå ÷óâñòâóåò ôï, ÷åì íåò, íî ñóáúåêòèâíî ÷åòêî íå ðàçëè÷àåò - êîãäà ó íåãî ñèíóñîâàÿ òàõè, êîãäà ôï.  ëþáîì ñëó÷àå - äî ïîñëåäíèõ 2 íåäåëü èëè 2 ìåñ. òàêîãî ñåðäöåáèåíèÿ îí íå ÷óâñòâîâàë.
Ïî ïîâîäó ìîëîäîé äåâóøêè ñ 1-ìèíóòíîé ôï íà ÕÌ - â åâðîïåéñêîì àïäåéòå: Female patients who are aged <65 and have lone AF (but still have a CHA2DS2-VASc score of 1 by virtue of their gender) are low risk and no antithrombotic therapy should be considered (IIA LOE B) Íó è ïî ïîâîäó çäîðîâûõ, êîòîðûì ìîæíî äåëàòü õîëòåðû èëè èìïëàíòèðîâàòü REVEAL - ÿ íå çíàþ, êàêîâà áóäåò ðàñïðîñòðàí¸ííîñòü áåññèìïòîìíîé ôï, íàâåðíîå òàêèå äàííûå åñòü, íî ÿ íå âèäåë. Èíòåðåñíåå âîïðîñ - à ÷òî ñ òàêèìè ïàöèåíòàìè ïîòîì äåëàòü. Íà êàðäèîëîãè÷åñêîì êîíãðåññå ïðîøëîé îñåíüþ â Ìîñêâå Ïîêóøàëîâ èç ÍÈÈ ÏÊ ðàññêàçûâàë îá èññëåäîâàíèè [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] - â í¸ì êàê ðàç ïûòàëèñü ñ ïîìîùüþ èìïëàíòèðîâàííûõ äåâàéñîâ îïðåäåëèòü êîðåëëÿöèþ ìåæäó AF burden è ðèñêîì ðàçâèòèÿ ÎÍÌÊ. Ó íèõ ïîëó÷èëîñü, ÷òî áîëåå 5,5 ÷àñîâ â ñðåäíåì çà ñóòêè ïðè ïîäñ÷åòå çà ìåñÿö - ïîâûøåííûé ðèñê ÎÍÌÊ. Ïîêóøàëîâ ãîâîðèë, ÷òî ïî äðóãèì äàííûì ýòîò ïîðîã 3,7 ÷/ñóòêè. Ýòî âñ¸ åùå ñòî ðàç ïîìåíÿåòñÿ íàâåðíîå, íî èññëåäîâàíèÿ â ýòîì íàïðàâëåíèè èäóò, âûãëÿäèò ýòîò ïîäõîä ëîãè÷íî. Òàê ÷òî ìîæåò áûòü â áóäóùåì ðåøåíèå îá àíòèêîàãóëÿöèè áóäåò ïðèíèìàòüñÿ ñ ó÷åòîì íå òîëüêî CHA2DS2-VASc (èëè ïîäîáíîé øêàëû) è íàëè÷èÿ ôï êàê òàêîâîé, íî è ñ ó÷åòîì AF burden (áëèí, ïëîõî çíàþ íå òîëüêî àíãë, íî è ñâîé ðîäíîé ðóññêèé - íå ìîãó íîðìàëüíî àäåêâàòíî çàìåíèòü äîâîëüíîå ïðîñòî¸ àíãë. ïîíÿòèå àäåêâàòíûì ðóññêèì) |
#708
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Öèòàòà:
"in patients with acute STEMI, when INR is frequently not known: in this situation, regardless of INR values, UFH should be added in moderate doses (e.g. 30–50 U/kg)." 1."Aspirin reduces periprocedural ischaemic complications and should be administered in all patients prior to any PCI procedures. Based on randomised trials and posthoc analyses, pretreatment with clopidogrel is also recommended whenever it can be accomplished. Even if there are no randomised trials on the efficacy and safety of this antiplatelet policy in patients on OAC, analyses from retrospective studies also support this recommendation in this patient group" 2. 3. è 4. "Current guidelines recommend bridging therapy with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) to cover the temporary discontinuation of OAC, if the risk of thromboembolism is considered high (8). These recommendations are based on circumstantial evidence and there are no large randomised trials to support the recommendations. Indeed, there are no randomised trials comparing different strategies to manage long-term OAC during PCI. The safety and feasibility of heparin bridging therapy has been evaluated in patients who receive long-term OAC and require interruption of OAC for elective surgery or an invasive procedure (63–67). Spyropoulos et al. (64) showed a major bleeding rate of 3.3% with UFH and 5.5% with LMWH in 901 patients with bridging therapy for an elective surgical or invasive procedure. Another recent study (65) reported a 6.7% incidence of major bleeding with LMWH bridging therapy in patients at risk of arterial embolism undergoing elective noncardiac surgery or an invasive procedure, but also lower (2.9%) rates of major bleeding have been reported. Reports focusing on PCI are limited, but MacDonald et al. (68) reported that 4.2% of 119 patients developed enoxaparin-associated access site complications during LMWH bridging therapy after cardiac catheterisation. Thus, there is some suggestion that UFH is better than LMWH for bridging to manage OAC for PCI." 5. "Periprocedural anticoagulation has traditionally been performed with UFH or more recently with LMWHs or direct thrombin inhibitors." P.S.: èñòî÷íèê - [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Íó, è êîíå÷íî, ïðåäïî÷òèòåëåí ëó÷åâîé äîñòóï. Êñòàòè íàøåë â ýòîì äîêóìåíòå ïîëîæåíèå î ïðèìåíåíèè ñòåíòîâ ñ óñêîðåííîé ýíäîòåëèçàöèåé. "In patients with very high bleeding risk, DES should be avoided (100) and balloon angioplasty (without stenting) is an option if an acceptable result can be achieved. In this case OAC might be combined with aspirin or a thienopyridine ADP-receptor antagonist in the usual dose. If, however, a stent is needed, BMS, especially “less thrombogenic stents” (carbon- or titanium-nitric-oxide-coated stents, stents with biodegradable coating, or antibody-coated stents capturing endothelial progenitor cells may perhaps need a shorter duration of combination antiplatelet therapy. In general, DES should be avoided in patients under OAC at present. However new third generation DES seem to have accelerated re-endothelialisation and might therefore become of interest in the near future. Respective registries (e.g. the Italian MATRIX registry) and trials to test their usefulness are currently performed" |
#709
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Angio, áëàãîäàðþ çà îòâåò!
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#710
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Óâàæàåìûå êîëëåãè! Ó ìåíÿ ïîä íàáëþäåíèåì ïàöèåíòêà Ë. 72-õ ëåò. ÅÅ äèàãíîç: ÈÁÑ: ïîñòîÿííàÿ ôîðìà ôèáðèëëÿöèè ïðåäñåðäèé, íîðìîôîðìà, ÕÑÍ II À, ÔÊ III, ôîí: ãèïåðòîíè÷åñêàÿ áîëåçíü III ñòàäèÿ, ðèñê4.…ÎÍÌÊ (05.2013ã.)
ß ïðèìåíèëà ê íåé ñëåäóþùóþ ëåêàðñòâåííóþ òåðàïèþ:äèãîêñèí ïî 0,5 òàáëåòêè óòðîì, ãèïîòèàçèä 25 ìã-1 òàáë. óòðîì, êîíêîð 20 ìã. óòðîì, ðåíèïðèë 20ìã., êàðäèîìàãíèë 75 ìã. â îáåä, ðåíèïðèë 20 ìã. âå÷åð, êàïîòåí è ôèçèîòåíç ïðè ïîâûøåíèè äàâëåíèÿ â òå÷åíèè äíÿ âûøå, ÷åì 140/90 Ïàöèåíòêà â òå÷åíèå ñóòîê èçìåðÿåò ÀÄ, öèôðû íà òàêîé òåðàïèè äîñòèãàþò è 180 è200/100-110 Îòìå÷àþò ðîäñòâåííèêè, ÷òî ïðè ðàçãàäûâàíèè ïàççëîâ, ëèáî êàêîé-ëèáî äðóãîé óìñòâåííîé (ïîñèëüíîé ïîñëå ïåðåíåñåííîãî èíñóëüòà)ðàáîòîé, óðîâåíü àðòåðèàëüíîãî äàâëåíèÿ 120-130/80-90 Ïîäñêàæèòå, êàêîâà ìîæåò áûòü êîððåêöèÿ ìîåé òåðàïèè, ÷òîáû â ýòîì ñëó÷àå äîñòèãíóòü öåëåâîãî óðîâíÿ ÀÄ? Ïîæàëóéñòà! |
#711
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#712
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Öèòàòà:
1) íåïðàâèëüíî èçìåðÿåòñÿ ÀÄ (ñì. ïî êðåïëåííûå òåìû â ðàçäåëå êàðäèîëîãèÿ) 2) âûñîêàÿ ýìîöèîíàëüíàÿ ëàáèëüíîñòü, ýìîöèîíàëüíûé ñòðåññ Åñëè ýòè ôàêòû íå ó÷åñòü è îðèåíòèðîâàòüñÿ íà 180-200 Hg, òî Âû áóäåòå ïåðåëå÷èâàòü ïàöèåíòêó. Ïðåäëàãàþ ïðîâåñòè ÑÌÀÄ è îðèåíòèðîâàòüñÿ íà ñðåäíèå öèôðû çà ñóòêè. Íîðìà - îñòàâèòü âñå êàê åñòü Âûñîêèå öèôðû - êîððåêöèÿ Âûñîêàÿ ëàáèëüíîñòü ÀÄ - ïîãîâîðèòü ñ ïàöèåíòêîé, ðîäñòâåííèêàìè è ïîäóìàòü î àíòèäåïðåññàíòàõ/êëîíàçåïàìå. |
#713
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Ñïàñèáî!
Ñïàñèáî çà îòâåòû, ó÷òó!
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#714
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Öèòàòà:
Øêàëà ðàñ÷åòà ðèñêà èíñóëüòà ïðè ÔÏ: [Èçîáðàæåíèÿ äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì] ß íàñ÷èòàë 8 áàëëîâ (èç 9 âîçìîæíûõ!, åñëè òîëüêî äèàáåòà äåéñòâèòåëüíî íåò)! Ïàöèåíòêå íóæíà íå ñìåøíàÿ äîçà ñîìíèòåëüíîãî ãåíåðèêà àñïèðèíà, à ÂÀÐÔÀÐÈÍ ñ ïîäáîðîì ïî ÌÍÎ 2-3! È Âàðôàðèí íóæåí óæå â÷åðà...
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#715
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Ïîñîâåòóéòå, ñ êàêîé äîçèðîâêè âàðôàðèíà ìíå íóæíî íà÷àòü, òÿíó ñ åãî íàçíà÷åíèåì ëèøü ïîòîìó, ÷òî ïàöèåíòêó íàáëþäàþ íà äîìó-ïîêà íåò âîçìîæíîñòè èçìåðèòü ÌÍÎ
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#716
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Öèòàòà:
Èíôîðìèðóþ, ÷òî ñóùåñòâóþò ïðèáîðû äëÿ äîìàøíåãî èçìåðåíèÿ ÌÍÎ (êîàãó÷åê, ïî òèïó äîìàøíåãî èçìåðåíèÿ ñàõàðà: êàïëÿ íà òåñò-ïîëîñêó). Îíè äîðîãîñòîÿùèå, íî åñëè ïàöèåíòêå èëè ðîäñòâåííèêàì ïî êàðìàíó, òî ýòî âàðèàíò àäåêâàòíîãî êîíòðîëÿ ÌÍÎ íà äîìó. Êðîìå òîãî, ñóùåñòâóþò ðàçíûå ïëàòíûå ëàáîðàòîðèè (ïðî Òîìñê íå çíàþ) ñ âîçìîæíîñòüþ çàáîðà êðîâè íà äîìó. ×åì ÷àùå è íàâÿç÷èâåå êîíòðîëèðóåòñÿ ÌÍÎ, òåì ìåíüøå øàíñîâ íà îñëîæíåíèÿ è òåì ëó÷øå âûæèâàåìîñòü.
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#717
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Íåò âåðîøïèðîíà , òèàçèä çàìåíèòü íà ïîñòîÿííûé òîðàñåìèä, äîáàâèòü àíòàãîíèñòû êàëüöèÿ..... åùå ìíîãî ÷åãî ìîæíî äëÿ íîðìàëèçàöèè ÀÄ. À âîò êàïòîïðèë ýïèçîäè÷åñêè è òîëüêî êàê ðåàêöèÿ íà öèôðû òîíîìåòðà -ýòî òî÷íî ðàñøàòûâàåò ãèïåðòîíèþ âñëåäñòâèè íåïðîäîëæèòåëüíîãî ïåðèîäà äåéñòâèÿ.
Áèñîïðîëîë ìîæíî ðàçäåëèòü íà 2 ïðèåìà, ìåíüøå áóäåò ïèêîâàÿ ãèïîòåíçèÿ óòðîì(+ ýíàëàïðèë). Âàðôàðèí íåîáõîäèì îäíîçíà÷íî. |
#718
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Óâàæàåìûå êîëëåãè, ÿ âñ¸ î òîì æå
Management of Patients With Atrial Fibrillation ACC/AHA îò àïðåëÿ 2013 ã.: in patients with AF associated with thyrotoxicosis, oral anticoagulation (iNr 2.0 to 3.0) is recommended to prevent thromboembolism, as recommended for AF patients with other risk factors for stroke. (Level of Evidence: C) 4. once a euthyroid state is restored, recommendations for antithrombotic prophylaxis are the same as for patients without hyperthyroidism. (Level of Evidence: C) - ÷òî ÿ ïîíÿë ïðèáëèçèòåëüíî òàê "ïåðîðàëüíàÿ àíòèêîàãóëÿöèÿ ïàöèåíòàì ñ ô. ï. íà ôîíå òèðåîòîêñèêîçà ïîêàçàíà òàê æå, êàê ïàöèåíòàì ñ äðóãèìè ôàêòîðàìè ðèñêà ïðè ô. ï. Ïîñëå äîñòèæåíèÿ ýóòèðåîçà âîïðîñ îá àíòèêîàãóëÿöèè - òàê æå êàê ó îñòàëüíûõ ïàöèåíòîâ áåç òèðåîòîêñèêîçà" Guidelines for the management of atrial fibrillation ESC 2010 ã.: In patients with active thyroid disease, antithrombotic therapy is recommended based on the presence of other stroke risk factors. (I C) - "ó ïàöèåíòîâ ñ àêòèâíûì çàáîëåâàíèåì ùèòîâèäíîé æåëåçû àíòèêîàãóëÿíòíóþ òåðàïèþ ðåêîìåíäóåì ïðè íàëè÷èè äðóãèõ ôàêòîðîâ ðèñêà" ß ïðàâèëüíî ïîíèìàþ, ÷òî ïî ýòîìó âîïðîñó êîëëåêòèâíîå ìíåíèå àìåðèêàíñêèõ ýêñïåðòîâ ïðîòèâîïîëîæíî êîëëåêòèâíîìó ìíåíèþ åâðîïåéñêèõ? |
#719
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#720
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íàñêîëüêî ÿ ïîíÿë, àìåðèêàíöû ñ÷èòàþò òèðåòîêñèêîç äîïîëíèòåëüíûì ïîêàçàíèåì ê ïåðîðàëüíûì àíòèêîàãóëÿíòàì ïðè ô. ï. (ðåêîìåíäóåòñÿ íàçíà÷àòü òàê æå, êàê è ïðè íàëè÷èè äðóãèõ ôàêòîðîâ ðèñêà) Åâðîïåéöû â òàêîé æå ñèòóàöèè ïðåäëàãàþò ðåøàòü âîïðîñ îá àíòèêîàãóëÿíòàõ íåçàâèñèìî îò óðîâíÿ àêòèâíîñòè ùèòîâèäíîé æåëåçû.
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