Статья
РИСК И ВЫГОДА РЕПЕРФУЗИОННЫХ СТРАТЕГИЙ В ЛЕЧЕНИИ БОЛЬНЫХ ОСТРЫМ ИНФАРКТОМ МИОКАРДА С ПОДЪЕМОМ СЕГМЕНТА ST
В обзоре обсуждаются реперфузионные стратегии у больных с острым инфарктом миокарда с подъемом сегмента ST (ИМПST) с позиций результатов, представленных в международных клинических исследованиях. Даны современные представления об инвазивной и консервативной стратегиях в лечении ИМПST в реальной клинической практике в европейских странах. Наиболее существенное влияние на выживаемость пациентов имеет время, а не метод реперфузии. Стратегия первичного чрескожного коронарного вмешательства (ЧКВ) может не уменьшать смертность при задержке дверь-баллон более 60 мин по сравнению с немедленным проведением тромболитической терапии (ТЛТ). Стратегия ЧКВ имеет преимущество над ТЛТ только в том случае, если разница во времени между этими стратегиями (дверь-баллон – дверь-игла) менее 2-х часов. При выборе способа реперфузионной терапии следует учитывать риск пациента. Первичное ЧКВ имеет ограничения, связанные с тем, что эта методика не является общедоступной, требует специальной подготовки персонала и специального оснащения. Своевременное проведение ТЛТ является приемлемым стандартом оказания помощи при ИМПST. Этот подход наиболее актуален для России. Однако фармакоинвазивная стратегия должна быть предпочтительной опцией у пациентов, леченных ТЛТ. Особого внимания в обсуждении фибринолитических препаратов заслуживают препараты второго – алтеплаза (Актилизе® ) и третьего поколения – тенектеплаза (Метализе® ). До появления Метализе® непрерывная инфузия Актилизе® рассматривалась как золотой стандарт фармакологической реперфузионной терапии. Введение Метализе® в виде однократного болюса оказывается так же эффективно, как и непрерывно вводимая алтеплаза, но с лучшим профилем безопасности. Проведение ТЛТ на догоспитальном этапе с помощью одного болюса тенектеплазы (Метализе® ) за 5-10 сек предлагает уникальную клиническую возможность для раннего назначения терапии, что способствует максимальному спасению миокарда.
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