AKUTNI KORONARNI SINDROM SA ST ELEVACIJOM (STEMI) PREHOSPITALNA TROMBOLITIČKA TERAPIJA
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1 71 UDK BROJEVI: ; ISSN (2014) br.1, p ID BROJ: AKUTNI KORONARNI SINDROM SA ST ELEVACIJOM (STEMI) PREHOSPITALNA TROMBOLITIČKA TERAPIJA ACUTE CORNARY SYNDROME WITH ST ELEVATION (STEMI) - PREHOSPITAL TROMBOLITIC THERAPY Ranka Bulajić (1), Vuk Niković (2) 1.CAPE BRETON REGIONAL HOSPITAL, CANADA, 2. ZAVOD ZA HITNU MEDICINSKU POMOĆ CRNE GORE, PODGORICA, CRNA GORA Sažetak: Uvod: Akutni koronarni sindrom (AKS) odnosi se na bilo koju grupu simptoma koji su povezani sa opstrukcijom koronarnih arterija. Najčešći simptom koji upućuju na dijagnoza AKS je bol u grudima, koji se često širi u levu ruku ili ugao vilice, bol je u vidu pritiska, a povezan je sa mučninom i znojenjem. Akutni koronarni sindrom obično se javlja kao rezultat jednog od tri problema : infarkt miokarda sa ST elevacijom (30% infarkt miokarda bez ST elevacije (25%) ili nestabilna angina (38%).Trombolitički tretmana Metalysom je indikovan kod infarkta miokarda sa ST elevacijom ili kod novonastalog bloka leve grane u unutar 6 sati od pojave simptoma infarkta miokarda. Prikaz bolesnika: Prikazan je slučaj muškarca starog 55 godina koji je imao infarkt miokarda a kojem je ordinirana tropolitička terapija od strane hitne medicinske pomoći na terenu. Nakon 10 kilometara svakodnevne, uobičajene jutarnje vožnje bicikla, pacijet je osetio bol u grudima praćen otežanim disanjem. Hitna medicinsku pomoć pozvana je u 06,24h. U sanitetskom vozilu hitne medicinske pomoći urađen elektrokardiogram na kojem se prikazuje ST elevacija u prekordijalnim odvodima od V1 do V6. Arterijski krvni pritisak je bio 160/90 mmhg, srčana frekvenca 70/min, saturacija kiseonika SpO 2 96%, stanje svesti GCS 15. Odmah je ordinirana terpija Zofran 4 mg, Aspirin 500 IV,4000 IJ Heparina, Vendal 10 mg. U 06,55h ordinirana je Metalysa amp. 6000IJ-30mg i infuzija Ringer laktata 500 ml. Pacijent je transportovan u kliniku za Hitnu medicnsku pomoć gde su urađene laboratorisjke analize i ultrasonografija srca. Troponin ng/ml, ASAT 170 U/L,ALAT 81 U/L, Gama GT 148 U/ LDH 341 U/L, Laktat 5.8 mmol/l. Ultrasongorafija srca je pokazao akineziju prednjeg zida i septuma kao i povećanje dijametra leve komore na 3.19 cm. U toku opservacije ST elevacija se redukovala ali je pacijent i dalje imao bol u grudima nakon čeka je odlučeno da se uradi perkutana koronarna intervencija PCI. Nalaz PCI je pokazao proksimalnu LAD stenozu od 90% TIMI III i pacijentu je plasiran STENT. Zaključak:Primena prehospitalne trombolize u akutnom koronarnom sindromu sa elevacijom ST segmenta je vrlo važna za preživljavanje pacijenata i smanjenje komplikacija nakon AKS Ključne reči: bol u grudima, značaj rane dijagnostike akutnog koronarnog sindroma, prehospitalna tromboliza KORESPONDENCIJA/CORRESPONDENCE Ranka Bulajić Cape Bretom Regional Hospital, Canada Telefon: : , E-pošta: vuknikovic@yahoo.com
2 72 ORIGINALNI RAD/ORIGINAL PAPERS UVOD Akutni koronarni sindrom (AKS) odnosi se na bilo koju grupu simptoma koji su povezani sa opstrukcijom koronarnih arterija. Najčešći simptom koji upućuju dijagnoza AKS je bol u grudima, koji se često širi u leve ruku ili ug ao vilice, bol je u vidu pritiska, a povezan je sa mučninom i znojenjem. Akutni koronarni sindrom obično se javlja kao rezultat jedne od tri problema : infarkt miokarda sa ST elevacijom (30%),infarkt miokarda bez ST elevacije (25%) ili nestabilna angina ( 38%) [1,2]. Trombolitički tretman Metalysom je indikovan kod infarkta miokarda sa ST elevacijom ili kod novonastalog bloka leve grane u unutar 6 sati od pojave simptoma infarkta miokarda.prehospitalni tretnam akutnog koronarnog sindroma i ordiniranje trombolitičke terapije uz strogo definisane indikacije ima veliki značaj u povećanoj stopi preživljavanja pacijenata jer sa razlogom trombolitičku terapiju nazivaju i hemijski by-pass.veličina spašenog srčanog tkiva nakon trombolitičeke terapije obrnuto je proprocionalan sa trajanjem okluzije koronarnih arterija u prvih 6 sati posle prvih simptoma od akutnog infarkta, kada ishemija miokarda postane nepovratna[2,5] PRIKAZ SLUČAJA Muškarac star 55 godina nakon 10 kilometara svakodnevne, uobičajene jutarnje vožnje bicikla osetio je bol u grudima praćen otežanim disanjem.hitna medicinska pomoć pozvana u 06,24h.U sanitetskom vozilu hitne medicinske pomoći urađen je elektrokardiogram na kome se prikazuje ST elevacija u prekordijalnim odvodima od V1 do V6. ( Slika 1) Arterijski krvni pritisak 160/90 mmhg, srčana frekvenca 70/min., saturacija kiseonika SpO 2 96%, stanje svesti - GCS 15. Pacijetnu odmah ordinirana terpija Zofran 4 mg, Aspirin 500 IV.,4000IJ Heparina, Vendal 10 mg. U 06:55h ordinirana Metalysa amp.6000ij - 30mg i infuzija Ringer laktata 500 ml. ( Slika 2) Slika 1. EKG zapis nakon dolaska ekipe HMP (ST elevacija u prekordijalnim odvodima od V1 do V6. Slika 2. Terapija ordinirana u sanitetskom vozilu HMP
3 73 Slika 3. Kontrolni EKG urađen u toku transporta Pacijent transportovan u Kliniku za hitnu medicnsku pomoć gde su urađene laboratorisjke analize, ponovni EKG ( slika 4) i ultrasonografija srca. Laboratorijske vrednosti su bile: Troponin ng/ml, ASAT 170 U/L,ALAT 81 U/L, Gama GT 148 U/ LDH 341 U/L, Laktat 5.8 mmol/l. Urađena je ultrasongorafija srca koja pokazuje akineziju prednjeg zida i septuma kao i povećanje dijametra leve komore na 3.19 cm.( Slika 5) Slika 4. EKG u ambulanti Klinike za hitnu medicinsku pomoć
4 74 ORIGINALNI RAD/ORIGINAL PAPERS Slika 5. Ultrasongorafija srca (akinezija prednjeg zida i septuma, povećanje dijametra lijeve komore na 3.19 cm) U toku opservacije, ST elevacija se redukovala ali je pacijent i dalje imao bol u grudima nakon čeka je odlučeno da se uradi perkutana koronarna intervencija PCI. Nalaz PCI je pokazao proksimalnu LAD stenozu od 90% TIMI III i pacijentu je plasiran STENT. (Slika 6, 7, 8 ) Pacijent nakon intervencije preveden na odjeljenje kardiolgoje gde je nakon
5 75 hospitalizacije u trajanju od 7 dana otpušten kući uz redovnu kardiološku terapiju. Slika 6. Koronarne arterije pre stenta ( proksimalna LAD stenoza od 90% TIMI III
6 76 ORIGINALNI RAD/ORIGINAL PAPERS Slika 7. Koronarne arterije posle stenta Slika 8. STENT na proksimalnoj LAD ( lekom obložen ) DISKUSIJA Reperfuziona terapija u akutnom infarktu miokarda sa ST elevacijom (STEMI) je terapija izbora. Kliničarima su danas na raspolaganju različite reperfuzione strategije: trombolitička terapija (TT), perkutana koronarna intervencija (PCI) ili njihova kombinacija.[3]. Ukoliko ne postoje kontraindikacije, treba započeti trombolizu unutar 30 minuta od postavljanja dijagnoze STEMI (snimanje i tumacenje EKG -a) (klasa preporuke IIa, nivo dokaza A). Transport bolesnika do sanitetskog vozila treba da bude na kardiološkoj stolici ili nosilima (od trenutka postavljanja dijagnoze STEMI bolesnik ne treba da napravi nijedan dodatni napor). U sanitetskom vozilu HMP pacijent mora biti na nosilima sa podignutim uzglavljem. Svi lekovi daju se isključivo intravenski, supkutano ili oralno.[4].ako je transport do sale za kateterizaciju nemoguć u ukupnom vremenu od 90 do 120 minuta (vreme proteklo od prvog EKG-a u prehospitalnim uslovima do otvaranja koronarne arterije) lekar HMP je dužan da ordinira prehospitalnu trombolizu, ukoliko ne postoje kontraindikacije. LITERATURA 1. Jump up Achar SA, Kundu S, Norcross WA (2005). "Diagnosis of acute coronary syndrome". Am Fam Physician 72 (1): PMID Grech ED, Ramsdale DR (June 2003). "Acute coronary syndrome: unstable angina and non-st segment elevation myocardial infarction". BMJ 326 (7401): doi: /bmj PMC PMID Antman, E.M., Anbe, D.T., Armstrong, P.W., Bates, E.R., Green, L.A., Hand, M., Hochman, J.S., Krumholz, H.M., Kushner, F.G., Lamas, G.A., Mullany, C.J., Ornato, J.P. (2004) ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: Executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol, 44(3): Van de Werf F., et al. Management of acute myocardial infarcti on in patients presenting with persistent STsegment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardio logy. Eur Heart J 2008; 29 (23): American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Scienc Part 10: Acute Coronary SyndromesRobert E. O'Connor, Chair; William Brady; Steven C. Brooks; Deborah Diercks; Jonathan Egan; Chris Ghaemmaghami; Venu Menon; Brian J. O'Neil; Andrew H. Travers; Demetris Yannopoulos
7 77 ACUTE CORNARY SYNDROME WITH ST ELEVATION (STEMI) - PREHOSPITAL TROMBOLITIC THERAPY Summary: INTRODUCTION: Acute coronary syndrome(acs) refers to any group of symptoms attributed to obstruction of the coronary arteries. The most common symptom prompting diagnosis of ACS is chest pain, often radiating of the left arm or angle of the jaw, pressure-like in character, and associated with nausea and sweating. Acute coronary syndrome usually occurs as a result of one of three problems: ST elevation myocardial infarction (30%), non ST elevation myocardialinfarction (25%) or unstable angina (38%).Metalyse is indicated for the thrombolytical treatment of suspected myocardial infarction with persistent ST elevation or recent left bundle branch block within 6 hours after the onset of acute myocardial infarction symptoms. The amount of salvageable heart tissue is inversely related to the duration of coronary artery occlusion, up to 6 hours after the first symptoms of acute myocardial infarction (AMI), when myocardial ischaemia becomes irreversible. CASE REPORT: This is a case report about a 55 years old man who had a myocardial infarction and was treated with tromboliytic therapy in the prehospital setting by the emergency service.the patient rode a bicycle in the morning for about 10 km. While riding he felt chest pain, filling shortness of breath. Passerby called Emergeny services at 6:24 am. In the emergency car ECG was done which showed a ST segment elevation from V1 to V6. Arterial pressure was 160/90mmHg, hart frequency 70/min, SpO2 96%, GCS 15.In the car was administered therapy: Zofran 4mg, Aspirin 500 IV. Heparin IJ, Vendal 10mg, and in 6:52Metalyse amp IJ/10ml : 6000/1KG 55kg. Ringerlactate 500 ml IV. When patient arrived in Emergency department, laboratory analisys and heartultrasonography weremade.heart ultrasonography was showed akinesia of the septum and anterior heart wall size of left ventricul 3.19 cm.within 120 minutes primary coronary angiography was made, which showed proximal LAD stenosis 70% - 90% TIMI III, a implatation STENT. CONCLUSION:Prehospital thrombolysis in acute coronary syndrome with ST-segment elevation is very important for patient survival and reduce complications after ACS Key words: Chest pain,the importance of early diagnosis of acute coronary syndrome, prehospital thrombolysis
ACUTE CORONARY SYNDROME WITHOUT ST ELEVATION (NSTEMI)
58 PRIKAZ SLUČAJA/CASE REPORT UDK BROJEVI: 616.12-073.7 COBISS.SR-ID 222251788 ISSN 1451-1053 (2016) br.1 p.58-65 AKUTNI KORONARNI SINDROM BEZ ST ELEVACIJE (NSTEMI) ACUTE CORONARY SYNDROME WITHOUT ST ELEVATION
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