Статья
ЛЕЧЕНИЕ ИНФАРКТА МИОКАРДА С ПОДЪЕМОМ СЕГМЕНТА ST У БОЛЬНЫХ, КОТОРЫЕ ПОЗДНО ОБРАТИЛИСЬ ЗА МЕДИЦИНСКОЙ ПОМОЩЬЮ ИЛИ У КОТОРЫХ НЕВОЗМОЖНО ПРОВЕДЕНИЕ РЕПЕРФУЗИОННОЙ ТЕРАПИИ
Несмотря на широкую доступность фармакологических и механических методов реперфузии, в значительной части случаев инфаркта миокарда (ИМ) с подъемом сегмента ST все еще не назначают реперфузионной терапии, а некоторых больных расценивают как «не подходящих для реперфузии». Только малая часть таких ситуаций связана со спонтанной реперфузией или наличием противопоказаний к применению фибринолитиков или механической реперфузии. В последних публикациях активно обсуждается граница между «своевременным» и «поздним» обращением за медицинской помощью, целесообразность чрескожного вмешательства у больных, которые поздно обратились за медицинской помощью, а также влияние пола и возраста на возможность и/или выбор реперфузионной терапии. В настоящее время при надлежащем практическом применении научных доказательств и клинических рекомендаций реперфузионную терапию должны получать большинство нуждающихся в ней больных ИМ с подъемом сегмента ST. Фармакологическая нетромболитическая терапия таких больных четко определена в современных рекомендациях. Имеющиеся данные свидетельствуют о том, что у больных, не получающих реперфузионного вмешательства, антикоагулянтная терапия низкомолекулярным гепарином обеспечивает четкое уменьшение летальности. В сравнении с обычным лечением (введение нефракционированного гепарина или плацебо) фондапаринукс существенно снижает частоту летальных исходов и повторных ИМ без увеличения частоты серьезных кровотечений или инсультов. При лечении поздно обратившихся больных ИМ с подъемом сегмента ST (позднее первых 12 ч после появления симптомов) клиническая оценка и стратификация риска представляются наиболее важными элементами, помогающими выбору терапевтического вмешательства.
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