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Read dasabuTebuli [faqtebze dafuZnebuli] medicina text version

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dasabuTebuli [faqtebze dafuZnebuli] medicina klinikuri mtkicebulebani

depresiuli darRvevebi

3

j. gedesi, r. batleri, da s. hatCeri

premenstrualuri sindromi k. viati - moamzades z. kirtavam da m. kobalaZem

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klinikuri praqtikis rekomendaciebi

ST segmentis elevaciiT mimdinare miokardiumis mwvave infarqtis marTva - evropis kardiologiuri sazogadoebis saxelmZRvanelo rekomendaciebis mixedviT

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moamzades a. meliam, x. jalabaZem, z. klimiaSvilma, k. muxigulaSvilma

supraventrikuluri ariTmiebis marTva - amerikis kardiologTa kolejis, amerikis gulis asociaciis da evropis kardiologiuri sazogadoebis saxelmZRvanelo rekomendaciebis mixedviT

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moamzades a. meliam, x. jalabaZem, z. klimiaSvilma, k. muxigulaSvilma

klinikuri mimoxilva

autologiuri transfuzia

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e. vanderlinde, j. hili, n. blambergi

muclis aortis anevrizmebis skriningi mamakacebSi

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j. ernSou, e. Sou, m.r. vaimani, k.d. poskiti da b.p. hiTeri moamzada S. arCuaZem

wamlis profili

axali preparatebis mimoxilva

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moamzada nino demetraSvilma

regionaluri siaxleebi

samedicino sainformacio saswavlo centri da janmrTelobis dRe kaspSi

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i. qamxaZe

CanarTi

internetis samedicino daijesti #3-4 (97-98), 2004

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iumori samedicino Temaze

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samedicino resursebi internetSi

saintereso bmulebi revmatolgiis sakiTxebze

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moamzada z. kirtavam

informacia

saqarTvelos jandacvis veb-gverdis saaplikacio forma

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CONTENT

Evidence Based Medicine

Depressive disorders ­ What are the Effects of Treatment? J. Geddes, R. Butler, S. Hatcher - translated by Z. Kirtava, M. Kobaladze

Premenstrual Syndrome - What are the Effects of Treatment? K. Wyatt

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Clinical Practice Guidlines

Management of Acute Myocardial Infarction in patients presenting with ST-segment elevation - (based on European Society of Cardiology Guidelines) translated by A. Melia, Kh. Jalabadze, Z. Klimiashvili, K. Mukhigulashvili Management of Patients with Supraventricular Arrhythmias - based on American Cardiology College, American Heart Association and European Society of Cardiology Guidelines translated by A. Melia, Kh. Jalabadze, Z. Klimiashvili, K. Mukhigulashvili

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Clinical Reviews

Autologous Transfusion

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E.S. Vanderlinde, J.M. Heal, N. Blumberg - tranlsated by Sh. Archuadze

Screening for abdominal aortic aneurysms in men

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J.J. Earnshaw, E. Shaw, M.R. Whyman, K.R. Poskitt, and B. P. Heather - tranlsated by Sh. Archuadze

Drug Profile

New Drugs' review

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Prepared by N. Demetrashvili

Regional News

Medical Information Resource Center and Health Fair in Kaspi

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Medical Humor Internet Medical Digest - #3-4 (97-98), 2004

66 75

Medicine on the Web

Useful Medical URLs/Links on Rheumatology

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Information

Application for the Georgian Health System web-page

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dasabuTebuli medicina

depresiuli darRvevebi

jon gedesi, rob batleri, da simon hatCeri

Depressive disorders ­ What are the Effects of Treatment? John Geddes, Rob Butler, Simon Hatcher Clinical Evidence, BMJ Publishing Group klinikuri mtkicebulebani 2003 w. (IX gamoSveba)

moamzades z. kirtavam, m. kobalaZem

ganmartebebi

depresiuli darRvevebi xasiTdeba mudmivad cudi guneb-ganwyobiT, interesisa da siamovnebis/kmayofilebis SegrZnebis dakargviT da daqveiTebuli energiiT. depresia xSirad auaresebs yoveldRiur cxovelqmedebas. am mimoxilvaSi Sefasebuli randomizebuli kontrolirebuli kvlevebis (rkk) umravlesoba depresiis klasificirebisas eyrdnoba gonebrivi daavadebebis diagnostikur da statistikur saxelmZRvanelos (DSM IV) an gonebrivi da qceviTi darRvevebis saerTaSoriso klasifikacias (ICD-10). DSM IV depresiaSi gamoyofs ZiriTad depresiul darRvevas an disTimiur darRvevas. ZiriTadi depresiuli darRveva xasiaTdeba erTi an meti mniSvnelovani depresiuli epizodiT (e.i. sul cota 2 kviris ganmavlobaSi depresiuli gunebganwyoba an interesis dakargva, romelsac Tan erTvis depresiis 4 an meti damatebiTi niSani). disTimiuri darRveva xasiaTdeba imiT, rom 2 wlis ganmavlobaSi depresiuli guneb-ganwyobis dReebi Warbobs, da amas Tan erTvis damatebiTi simptomebi, romlebic ZiriTadi depresiuli darRvevis kriteriumebs ver aRwevs. ICD-10 depresiaSi gamoyofs msubuq, saSualo an mZime depresiis epizodebs. msubuq da saSualo depresias axasiaTebs depresiis simptomebi da garkveuli funqcionaluri darRveva. mZime depresias axasiaTebs damatebiT agznebuloba an fsiqomotoruli CamorCeniloba, gamovlenili somaturi simptomebiT. winamdebare mimoxilvaSi Cven viyenebT orive - DSM IV da ICD-10 - klasifikacias, magram im SemTxvevaSi, Tu randomizebul kontrolirebul kvlevebSi stacionaruli pacientebi monawileobdnen, mkurnalobis efeqturoba Sefasebuli iyo mZime depresiis dros. xandazmuli pacientebi: xandazmuli pacientebi sazogadod ganisazRvreba, rogorc 65 wlis da meti asakis adamianebi. Tumca, am mimoxilvaSi ganxiluli zogierTi randomizebuli kontrolirebuli kvlevaSi xandazmulTa jgufSi 55 welze meti asakis mqone pirebsac irTavda. depresia xandazmulebSi SeiZleba atipiurad iyos warmodgenili: guneb-ganwyobis daqveiTeba SeiZleba SeniRbuli iyos, xolo wuxili an mexsierebis darRveva ki wina planze iyos warmodgenili. xandazmul pacientebSi depresiis diferenciuli diagnostikis Catarebisas demencia unda iyos ganxiluli.

gavrceleba (avadoba / daavadebianoba)

depresiuli darRvevebi xSiria, ZiriTadi depresiis daavadebianoba Seadgens pirveladi jandacvis rgolis samedicino dawesebulebebSi mimarTvebis 5-10%-s. 2-3jer mets SeiZleba hqondes depresiis simptomebi, magram ar Seesabamebodnen ZiriTadi depresiis DSM IV­is kriteriumebs. qalebi mamakacebze orjer ufro xSirad avaddebian. depresiuli darRvevebi msoflios masStabiT invalidobis yvelaze mniSvnelovani mizezebidan meoTxe adgilzea da 2020 wlisTvis mosalodnelia, rom meore adgilic ki daikavos. xandazmuli mozrdilebi: xandazmulTa 10%-15%-s 3

aReniSnebaT depresiis simptomebi, Tumca xandazmulebSi ZiriTadi depresia SedarebiT naklebia.

etiologia / risk faqtorebi

mizezebi gaurkvevelia, magram moicavs rogorc bavSvobaSi momxdar, aseve mimdinare fsiqo-socialur problemebs.

prognozi

ZiriTadi depresiuli darRvevis pirveli epizodis gadamtan adamianTa TiTqmis naxevars momdevno 10 wlis ganmavlobaSi uviTardeba daavadebis simptomebi. xandazmuli mozrdilebi: erTma sistematurma mimoxilvam (Ziebis TariRi 1996, 12 prospeqtiuli kohortuli kvleva, 1268 adamiani, saSualo asaki 60 weli) aRmoaCina, rom prognozi SeiZleba iyos gansakuTrebulad cudi im xandazmulebSi, visi depresiac qronikulad da gamwvavebebiT mimdinareobs. meore sistematurma mimoxilvam (Ziebis TariRi 1999, 23 prospeqtiuli kohortuli kvleva 65 wels gadacilebul pirebSi, pirveli mimoxilvis mier identificirebuli 5 kvlevis CaTvliT) aRmoaCina, rom xandazmulebSi depresia momatebul sikvdilianobasTan iyo asocirebuli (15 kvleva; agregirebuli riskis maCvenebeli - 1.73; 95%-iani sarwmunoebis intervali 1.53-dan 1.95mde).

raSi mdgomareobs depresiis mkurnalobis efeqti?

Cven ver aRmovaCineT verc erTi sarwmuno mtkicebuleba imisa, rom mkurnalobis erTi saxeoba (medikamentozuri Tu sxva) depresiis simptomebis gaumjobesebaSi meores gadamwyvetad sjobdes. Tumca, vipoveT imis Zlieri damamtkicebeli sabuTi, rom zogierTi mkurnaloba marTlac efeqturia, maSin, roca sxva mkurnalobis efeqturoba saeWvo rCeba. ganxiluli meTodebidan antidepresantebis daniSvna da eleqtrokonvulsiuri Terapia warmoadgens mkurnalobis erTaderT saxes, romlis efeqturobis damamtkicebeli monacemebi arsebobs mZime da fsiqozur depresiuli daavadebebis dros. Cven ver vipoveT randomizebuli kontrolirebuli kvleva, romelSic Sedarebuli iqneboda mZime depresiuli daavadebebis medikamentozuri da aramedikamentozuri mkurnaloba.

sasargebloa: kognitiuri Terapia (msubuqi da saSuali depresiis dros) erT-erTma sistematurma mimoxilvam aRmoaCina, rom axalgazrda da xandazmul mozrdilebSi kognitiuri Terapia sagrZnoblad aumjobesebs depresiis simptomebs mkurnalobis saerTod arCatarebasTan SedarebiT.

gagrZelebuli medikamentozuri mkurnaloba msubuqi da saSualo depresiis dros amcirebs gamwvavebis risks. erTma sistematurma mimoxilvam da Semdgomma randomizebulma kontrolirebulma kvlevam daadgina, rom axalgazrda da xandazmul mozrdilebSi antidepresantebiT gagrZelebuli mkurnaloba gamojanmrTelebidan 4-6 Tvis ganmavlobaSi placebosTan 4

SedarebiT sagrZnoblad amcirebs gamwvavebis risks. erTma randomizebulma kontrolirebulma kvlevam 60 welze ufrosebSi aRmoaCina, rom dosulepiniT (doTiepiniT) gagrZelebulma mkurnalobam placebosTan SedarebiT sagrZnoblad Seamcira gamwvavebis riski 2 welze meti drois ganmavlobaSi.

eleqtrokonvulsiuri Terapia (mZime depresiis dros) 2 sistematuri mimoxilvisa da damatebiT randomizebuli kontrolirebuli kvlevebis Tanaxmad 16 welze ufros adamianebSi eleqtrokonvulsiuri Terapia mZime depresiis dros sagrZnoblad ufro metad aumjobesebs simptomebs simulirebul eleqtrokonvulsiur TerapiasTan SedarebiT.

interpersonaluri fsiqoTerapia (msubuqi da saSuali depresiis dros) erTma didma randomizebulma kontrolirebulma kvlevam daadgina, rom interpersonaluri fsiqoTerapia standartul mkurnalobasTan an antidepresantebTan SedarebiT sarwmunod aumjobesebs dawyebidan 16 kviris Semdeg depresiidan gamosvlis sixSires.

receptiT gamowerili antidepresantebi (msubuqi da saSuali depresiis dros) sistematuri mimoxilvebis Tanaxmad 16 welze ufros adamianebSi antidepresantebi placeboze ufro efeqturia depresiuli daavadebebis yvela xarisxis mkurnalobis dros. sistematurma mimoxilvam ver daadgina gamosavalSi mniSvnelovani gansxvaveba sxvadasxva tipis antidepresantis gamoyenebisas. erTma sistematurma mimoxilvam sxvadasxva xarisxis depresiuli daavadebebiT 55 welze ufros pacientebSi aRmoaCina, rom tricikluri antidepresantebi, seleqtiuri serotoninis ukuSewovis inhibitorebi, an monoaminooqsidazas inhibitorebi placebosTan SedarebiT mniSnvelovnad amcirebs im adamianTa wils, romlebic ver janmrTeldebian 26-49 dRis Tavze. Cven ver vnaxeT specifiuri monacemebi mozrdilebSi gverdiT efeqtebze. Tumca wamlebi gansxvavdeba TavianTi gverdiTi efeqtebis profiliT. erTma sistematurma mimoxilvam aRmoaCina, rom mZime depresiiT pacientebSi monoaminooqsidazis inhibitorebi triciklur antidepresantebze nakleb efeqturi iyo, magram ufro efeqturi SeiZleboda yofiliyo atipiuri depresiis dros iseTi biologiuri maxasiaTeblebiT, rogoricaa Warbi Zili, Warbi mada, guneb-ganwyobis reaqtiuloba, uaryofisadmi mgrnobeloba. erTma sistematurma mimoxilvam daadgina, rom seleqtiuri serotoninis ukuSewovis inhibitorebi triciklur antidepresantebTan SedarebiT nakleb gverdiT efeqtebs iwvevda, Tumca gansxvaveba mcire iyo. sxva sistematurma mimoxilvam da erTma retrospeqtulma kohortulma kvlevam ver daadgina mniSvnelovani monacemebi imisa, rom fluoqsetini triciklur antidepresantebsa da placebosTan SedarebiT TviTmkvlelobis ufro maRal riskTan iyo asocirebuli. erTi randomizebuli kontrolirebuli kvleva da dakvirvebis Sedegebi mowmobs imas, rom seleqtiuri serotoninis ukuSewovis inhibitorebis mkveTrad moxsna asociirebulia iseT simptomebTan, rogoricaa Tavbrusxveva, gulisreva, paresTezia, Tavis tkivili, Tavbrusxveva, da es simptomebi ufro damaxasiaTebelia mokle naxevar-daSlis periodis mqone wamlebisTvis, rogoricaa paroqsetini.

tricikluri antidepresantebi

5

erTma sistematurma mimoxilvam daadgina, rom tricikluri antidepresantebi seleqtiuri serotoninis ukuSewovis inhibitorebTan SedarebiT gverdiTi efeqtebis ufro maRal sixSiresTan aris asocirebuli, magram gansxvaveba mcirea.

savaraudod efeqturia: mkurnalobis gzebi (msubuqi da saSualo depresiis dros) 5 randomizebulma kontrolirebulma kvlevais safuZvelze mopovebul iqna imis SezRuduli dadastureba, rom antidepresantuli mkurnalobis efeqturoba SeiZleba gaumjobesdes sxvadasxva midgomis saSualebiT, aseve TanamSromlobiT pirveladi jandacvis rgolis eqimebsa da fsiqiatrebs Soris, rasac emateba pacientebis intensiuri swavleba, SemTxvevis marTva, satelefono mxardaWera, (ndobis telefoni, telefsiqologiuri konsultacia) da gamwvavebis prevenciis programebi. erTma randomizebulma kontrolirebulma kvlevam daadgina, rom verc klinikuri praqtikis gaidlainma da verc praqtikaze dafuZnebulma ganaTlebam Cveulebriv mkurnalobasTan SedarebiT ver gaaumjobesa depresiis verc dadgena da verc misi gamosavali.

antidepresantebis da fsiqologiuri mkurnalobis kombinireba (msubuqi, saSualo da mZime depresiis dros) 18-80 wlis adamianebSi Catarebuli randomizebuli kontrolirebuli kvlevebis erTma sistematurma mimoxilvam aRmoaCina, rom mZime depresiiT daavadebulebSi interspersonaluri fsiqoTerapiisa Tu kognitiuri TerapiisTvis medikamentozuri mkurnalobis damateba marto erT-erT fsiqologiuri mkurnalobasTan SedarebiT aumjobesebs simptomebs mZime depresiis dros, magram ar iZleva mniSvnelovan sxvaobas msubuqi da saSualo depresiis dros. momdevno randomizebulma kontrolirebulma kvlevebma axalgazrda da xandazmul mozrdilebSi gamoavlina, rom antidepresantebisa da fsiqoTerapiis kombinireba gacilebiT metad aumjobesebs simptomebs, vidre TiToeuli maTgani cal-calke. erTma randomizebulma kontrolirebulma kvlevam msubuqi da saSualo depresiiT daavadebul xandazmul mozrdilebSi ipova, rom kognitiurma qceviTma Terapiam dezipraminTan erTad sagrZnoblad gaaumjobesa simptomebi marto dezipraminTan SedarebiT.

fsiqoTerapia direqtivis gareSe (msubuqi da saSualo depresiis dros) erTma sistematurma mimoxilvam daadgina, rom 18 welze ufrosebSi, romelTac fsiqologiuri problemebi, depresiis CaTvliT, cota xania rac daewyoT, xanmokle (6 Tveze naklebi) direqtivis gareSe fsiqoTerapia mniSvnelovnad amcirebs simptomebis ricxvs Cveulebriv mkurnalobasTan SedarebiT, Tumca xangrZlivi mkurnalobisas (6 Tveze meti) mniSvnelovani gansxvaveba ver iqna naxuli.

problemis gadamWreli mkurnaloba (msubuqi da saSualo depresiis dros) randomizebulma kontrolirebulma kvlevebma daadgina, rom problemis gadamWreli mkurnaloba 3-6 Tvis Tavze mniSvnelovnad aumjobesebs simptomebs placebosa Tu kontrolTan SedarebiT, Tumca ver moZebna simptomebis gaumjobesebis mxriv sarwmuno sxvaoba problemis gadamWrel mkurnalobasa da medikamentozur mkurnalobas Soris.

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krazanas (mcenare - St John's Wort) efeqti msubuqi da saSualo simZimis depresiis dros sistematurma mimoxilvebiT dadginda, rom msubuqi da saSualo xarisxis depresiiT daavadebulebSi mcenare krazana - St John's Wort (Hypericum perforatum) placebosTan SedarebiT mniSvnelovnad aumjobesebs depresiis simptomebs 4-12 Tvis Tavze, magram ar SeimCneoda mniSvnelovani gansxvaveba simptomebSi krazanasa da gamowerili antidepresantebis gamoyenebis dros. mimoxilvebis Sedegebs sifrTxiliT unda movekidoT imitom, rom randomizebuli kontrolirebuli kvlevebis dros ar yofila gamoyenebuli krazanas standartizirebuli preparatebi, xolo antidepresantebis dozebi gansxvavdeboda. SemdgomSi wamyvani depresiuli daavadebis mqone 18 welze ufrosebSi Catarebulma didma randomizebulma kontrolirebulma kvlevam ver daadgina depresiis simptomebSi mniSvnelovani sxvaoba 8 kviris Tavze krazanas standartizirebuli preparatis da placebos an sertralinis gamoyenebis dros, magram, SesaZlebelia, klinikurad mniSvnelovani gansxvavebis sanaxavad arsakmarisi SesaZlebloba iyo gamoyenebuli.

efeqturoba ucnobia megobruli rCevebi - damegobreba (msubuqi da saSualo depresiis dros) erTma mcire randomizebulma kontrolirebulma kvlevam warmoadgina arasakmarisi monacemebi megobruli rCevebis (damegobrebis) Sesafaseblad.

biblioTerapia (msubuqi da saSualo depresiis dros) reklamiT mowveul axalgazrda da xandazmul mozrdilebSi Catarebuli randomizebuli kontrolirebuli kvlevebis erTma sistematurma mimoxilvam aRmoaCina mcire mtkicebuleba imisa, rom biblioTerapias SeuZlia msubuqi depresiis simptomebis moxsna kontrolsa Tu standartul mkurnalobasTan SedarebiT. sxva sistematurma mimoxilvam aRmoaCina rom im adamianebSi, visac kombinirebulad aqvs wuxili da depresia, mxolod wuxili, an qronikuli daRliloba, biblioTerapias standartul TerapiasTan SedarebiT - SeuZlia gaaumjobesos simptomebi 2-6 Tvis Tavze. gaugebaria mimoxilvebSi ganxiluli randomizebuli kontrolirebuli kvlevebis monawileebi warmoadgenen Tu ara depresiuli darRvevebis mqone adamianebs.

mkurnalobis gzebi Cveulebrivi mkurnalobis winaaRmdeg xangrZlivi gamosavalis TvalsazrisiT (msubuqi da saSualo depresiis dros) erTma randomizebulma kontrolirebulma kvlevam aRmoaCina, rom mravalsaxovani "xarisxis gaumjobesebis programam" Cveulebriv mkurnalobasTan SedarebiT mniSvnelovnad gaaumjobesa simptomebi da gazarda im adamianTa procenti, romlebic 1 wlis Tavze samsaxurs daubrundnen, magram 2 wlis gamosavalSi mniSvnelovani gansxvaveba ar iqna naxuli.

kognitiuri Terapia antidepresantebis winaaRmdeg xangrZlivi gamosavalis TvalsazrisiT (msubuqi da saSuali depresiis dros) erTma sistematurma mimoxilvam da erTma damatebiTma randomizebulma kontrolirebulma kvlevam axalgazrda da xandazmul mozrdilebSi gamwvavebis sixSireebis kombinirebiT ipova SezRuduli mtkicebuleba imisa, rom kognitiur 7

Terapias antidepresantebisgan gansxvavebiT SeuZlia dawyebidan 2 wlis Tavze gamwvavebis riskis Semcireba.

varjiSi (msubuqi da saSuali depresiis dros) erTma sistematurma mimoxilvam Raribi randomizebuli kontrolirebuli kvlevebis safuZvelze ipova SezRuduli mtkicebuleba imisa, rom varjiSs placebosTan SedarebiT simptomebis gaumjobeseba SeuZlia, da SeuZlia iyos iseTive efeqturi, rogoricaa kognitiuri Terapia an antidepresantebi.

fsiqologiuri mkurnalobis sxvadasxva saxe (kognitiuri Terapia, interpersonaluri fsiqoTerapia, problemis gadamWreli Terapia) mZime depresiis dros randomizebulma kontrolirebul kvlevebSi ver inaxa sakmarisi monacemebi imisaTvis, rom moxdes fsiqologiuri mkurnalobis sxvadasxva saxis Sefaseba mZime depresiis dros.

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dasabuTebuli medicina

premenstrualuri sindromi

katrina viati

Premenstrual Syndrome - What are the Effects of Treatment? Katrina Wyatt Clinical Evidence, BMJ Publishing Group, 2003, 9th edition klinikuri mtkicebulebani 2003 w. (IX gamoSveba)

moamzades z. kirtavam, m. kobalaZem

ganmartebebi

qals aqvs premenstrualuri sindromi, Tu is uCivis ganmeorebad fsiqologiur an somatur simptomebs (an orives), romelic vlindeba specifiurad menstrualuri ciklis luTealuri fazis dros da ixsneba menstruaciis bolos.

avadoba / daavadebianoba

reproduqtiuli asakis yvela qalis 95%-s aReniSneba premenstrualuri siptomebi. Tumca mZime, damauZlurebeli simptomebis erToblioba (premenstrualuri sindromi) aRiniSneba am qalebis mxolod 5%-Si.

etiologia / risk faqtorebi

etiologia ucnobia, magram hormonaluri da sxva (SesaZlebelia, neiroendokrinuli) faqtorebi savaraudod xels uwyobs pms-is ganviTarebas. SesaZlebelia adgili hqondes progesteronisadmi momatebul mgrZnobelobas, rac albaT gamowveulia serotoninis naklebobiT.

prognozi

garda ooforeqtomiisa, mkurnalobis Sewyvetisas simptomebi, Cveulebriv, kvlav Cndeba.

raSi mdgomareobs mkurnalobis efeqturoba? keTilmoqmedi

diuretikebi randomizirebuli kontrolirebuli kvlevebis Tanaxmad placebosTan SedarebiT spironolaqtoni aumjobesebs premenstrualuri sindromis 9

simptomebs, mkerdis mtkivneulobisa da Sesivebis CaTvliT. orma randomizirebulma kontrolirebulma kvlevam aRmoaCina, rom metolazoni an amoniumis qloridi placebosgan gansxvavebiT amcirebs premenstrualur Sesivebasa da wonaSi matebas.

arasteroiduli anTebis sawinaaRmdego wamlebi randomizirebulma kontrolirebulma kvlevebma daadgina, rom prostaglandinis inhibitorebi placebosTan SedarebiT sagrZnoblad aumjobesebs sxvadasxva premenstrualur simptomebs, magram Tumca ver amcirebs mkerdis premenstrualur tkivils.

serotoninis ukuSewovis seleqtiuri inhibitorebi erTma sistematurma mimoxilvam da momdevno randomizirebulma kontrolirebulma kvlevebma daadgina, rom serotoninis seleqtiuri ukuSewovis inhibitorebi placebosTan SedarebiT sagrZnoblad aumjobesebs premenstrualur simptomebs, magram xSirad iwvevs gverdiT efeqtebs.

savaraudod efeqturi

kognitiuri qceviTi Terapia randomizirebulma kontrolirebulma kvlevebma daadgina, rom kognitiuri qceviTi Terapia sakontrolo mkurnalobasTan SedarebiT sagrZnoblad amcirebs premenstrualur simptomebs, magram ar arsebobs sakmarisi damamtkicebeli sabuTi, rom efeqturobis masStabi ganisazRvros.

varjiSi erTma randomizirebulma kontrolirebulma kvlevam daadgina, rom aerobikis varjiSi placebosTan SedarebiT sagrZnoblad aumjobesebs premenstrualur simptomebs. sxva randomizirebuli kontrolirebuli kvlevis Tanaxmad, maRali intensiobis aerobikis varjiSi simptomebs mniSvnelovnad ukeT aumjobesebs, vidre nakleb intensuri varjiSi.

estrogenebi mcire randomizirebuli kontrolirebuli kvlevebidan miRebuli ramdenime (SezRuduli) damamtkicebeli sabuTis Tanaxmad, estradioli, placebosTan SedarebiT, simptomebs aumjobesebs, magram nebmismieri efeqtis amplituda gaurkveveli rCeba.

peroraluri kontraceptivebi randomizirebulma kontrolirebulma kvlevebiT nanaxi iqna SezRuduli mtkicebuleba imisa, rom peroraluri kontraceptivebi placebosTan SedarebiT premenstrualur simptomebs aumjobesebs.

10

Terapiuli da gverdiTi efeqtebi TiTqmis Tanabaria

bromokriptini (mxolod mkerdis simptomebi) randomizirebulma kontrolirebulma kvlevebma ipova mcire sabuTi imisa, rom bromokriptini placebosTan SedarebiT mkerdis mtkivneulobas amcirebdes, amasTanave xSiria gverdiTi movlenebi.

danazoli randomizirebulma kontrolirebulma kvlevebma daadgina, rom danazoli placebosTan SedarebiT sagrZnoblad amcirebs premenstrualur simptomebs, magram, rodesac didi xnis ganmavlobaSi gamoiyeneba, mas axasiaTebs maskulinizaciasTan dakavSirebuli mniSvnelovani gverdiTi movlenebi.

gonadorelinis analogebi randomizirebulma kontrolirebulma kvlevebma daadgina, rom gonadorelinis analogebi (wina nomenklaturebis mixedviT GnRH) placebosTan SedarebiT mniSvnelovnad amcirebs premenstrualur simptomebs. randomizirebuli kontrolirebuli kvlevebis Tanaxmad gonadorelini estrogenTan da proJesteronTan erTad (damatebiTi - addback mkurnaloba) naklebad amcirebs simptomebis gamovlenas, vidre marto gonadorelinis analogi, magram ufro metad - vidre placebo. erTma mcire randomizirebulma kontrolirebulma kvlevam simptomebis gamovlenaSi msgavsi daqveiTeba daadgina gonadorelinis analogis tibolonTan erTad gamoyenebisas gonadorelinis analogis placebosTan gamoyenebasTan SedarebiT. gonadorelinis analogebiT 6 Tveze didxans mkurnalobas Tan sdevs osteoporozis ganviTarebis mniSvnelovani riski, rac zRudavs maT sargeblianobas xangrZlivi TerapiisTvis.

araseleqtiuri serotoninis ukuSewovis inhibitori antidepresantebi/anqsiolitikebi randomizirebulma kontrolirebulma kvlevebma daadgina, rom araseleqtiuri serotoninis ukuSewovis inhibitori antidepresantebi da anqsiolitiuri wamlebi placebosTan SedarebiT sagrZnoblad aumjobesebs premenstrualuri sindromis yvelaze cota erT simptoms mainc, magram qalebis garkveuli procenti wyvets mkurnalobas gverdiTi efeqtebis gamo. mcire randomizirebuli kontrolirebuli kvlevebidan vnaxeT arasakmarisi damamtkicebeli sabuTi blokatorebisa da liTiumis efeqturobis Sesaxeb.

efeqturoba ucnobia

histereqtomia bilateraluri ooforeqtomiasTan erTad an gareSe randomizirebuli kontrolirebuli kvlevebi ver vnaxeT. dakvirvebiTma kvlevebma daadgina, rom histereqtomia bilateralur ooforeqtomiasTan erTad kurnavs pms-s. mxolod histereqtomias SeuZlia pms-is simptomebis Semcireba, magram damamtkicebeli sabuTebi mcirea imis gamo, rom kontrolis uzrunvelyofa 11

gaZnelebulia. riski igivea, rac nebismieri didi operaciis dros. ra Tqma unda, unayofoba am Carevis gardauvali da seriozuli gverdiTi efeqtia.

proJestogenebi erTi mcire randomizirebuli kontrolirebuli kvlevidan placebosTan SedarebiT proJestogenebis efeqturobis arasakmarisi damamtkicebeli sabuTi vipoveT.

piridoqsini cudi xarisxis erTi sistematuri mimoxilva piridoqsinis (B6 vitaminis) efeqturobis arasakmaris damamtkicebeli sabuTebs ixilavs. mimoxilvaSi susti randomizirebuli kontrolirebuli kvlevebis analizis Tanaxmad piridoqsini placebosTan SedarebiT simptomebs sagrZnoblad amcirebs. damatebiTma, susti meTodebis mqone randomizirebulma kontrolirebulma kvlevebma piridoqsinis efeqturobis Sesaxeb urTierTgamomricxavi faqtebi daadgina.

tiboloni erTma mcire randomizirebulma kontrolirebulma kvlevam SezRuduli raodenobis dasabuTeba ipova imis Sesaxeb, rom tibolonma placebosTan (multivitaminebTan) SedarebiT premenstrualuri simptomebis gamovlena Seamcira.

qiropraqtiuli mkurnaloba, dieturi danamatebi, endometriuli ablacia, furisulas zeTi (efamoli), laparaskopiuli bilateraluri ooforeqtomia, refleqsologia, relaqsaciuri mkurnaloba am meTodebis efeqturobis Sesaxeb arasakmarisi damamtkicebeli sabuTebi vnaxeT.

savaraudod uefeqto an saziano

proJesteroni proJesteronze erTma sistematurma mimoxilvam daadgina placebosTan SedarebiT mcire, magram mniSvnelovani gaumjobeseba zogadad premenstrualur simptomebSi, da ver naxa gverdiTi efeqtebis gamowveuli wamlis moxsnis sixSiris zrda. amasTanave, gaumjobeseba naklebad savaraudoa klinikurad mniSvnelovani rom iyos. gaurkveveli rCeba, Tu ramdenad mniSvnelovania proJesteronis daniSvnis meTodi da dro.

12

ST segmentis elevaciiT mimdinare miokardiumis mwvave infarqtis marTva da mkurnaloba

moamzades a. meliam, x. jalabaZem, z. klimiaSvilma, k. muxigulaSvilma, kardiologiuri klinika `guli~ SeTanxmebulia saqarTvelos kardiologTa asociaciasTan, prof. v.WumburiZe evropis kardiologTa asociaciasTan arsebuli muSa jgufis mier miokardiumis mwvave infarqtis Sesaxeb momzadebuli saxelmZRvanelo miTiTebebis mixedviT

www.escardio.org

miokardiumis mwvave infarqtis (mmi) gansazRvreba

miokardiumis infarqtis diagnozi dgindeba rigi klinikuri, eleqtrokardiografiuli, bioqimiuri da paTologiuri niSnebis safuZvelze. miRebulia, rom termini - miokardiumis infarqti asaxavs gaxangrZlivebuli iSemiis gamo kardiomiocitebis sikvdils. ekg-ze, Sesabamisad, SesaZloa aisaxos miokardiumis iSemiis niSnebi; kerZod, ST segmentis da T-kbilis cvlilebebi, an miokardiumis nekrozis niSnebi QRS-is specifiuri cvlilebebiT. ganviTarebadi miokardiumis mwvave infarqtis samuSao diagnozi dgeba, rodesac klinikur simptomebs (1) Tan axlavs ST segmentis elevacia; kerZod, ST-segmentis axali elevacia J wertilidan 0.2mv-iT V1-V3 ganxrebSi da 0.1mv-iT sxva ganxrebSi, an (2) ar axlavs ST-segmentis elevacia, magram gamoxatulia ST-segmentis depresia an T-kbilis cvlilebebi. klinikurad Camoyalibebuli miokardiumis infarqti SesaZloa ganisazRvros, roca Q-kbili yalibdeba V1-V3 ganxraSi, an Q0.03wm aRiniSneba I, II, aVL, aVF, V4, V5 an V6 ganxrebSi.Q miokardiumis infarqtis diagnozze SesaZloa visaubroT, roca miokardiumis mwvave iSemiis klinikuri niSnebis paralelurad sisxlSi biomarkerebis done momatebulia. miokardiumis dazianebis yvelaze sagulisxmo markeria troponini (I da T), romelic aramxolod maRali mgrZnobelobiT gamoirCeva, aramed axasiaTebs TiTqmis absolituri specifiuroba miokardiumis qsovilis mimarT. mis saukeTeso alternativas warmoadgens kreatinkinazis MB fraqciis (CK-MB) momateba, romlis qsovilovani specifiuroba naklebia troponinis amave maCvenebelze, magram Seuqcevadi dazianebis gamosavlenad CK-MB-is klinikuri specifiuroba Zalian maRalia. winamdebare saxelmZRvanelo miTiTebebi Seexeba ST segmentis myari elevaciiT mimdinare mmiis. am dros, SemTxvevaTa did nawilSi matulobs sisxlSi biomarkerebis done da yalibdeba mmi Q-kbiliT (nax. 1)1.

mtkicebulebebis klasi I klasi: mtkicebulebebi, romelTa efeqturobisa da saWiroebis Sesaxeb arsebobs erTiani Sexeduleba. II klasi: mtkicebulebebi, romelTa efeqturobisa da saWiroebis Sesaxeb arsebobs sakamaTo mtkcebulebebi da azrTa sxvadasxvaobebi; IIa klasi: efeqturoba da saWiroeba dasturdeba myari mtkicebulebebiT da SexedulebebiT. IIb klasi: efeqturoba da saWiroeba moklebulia myar mtkicebulebebs da Sexedulebebs. III klasi: mtkicebulebebi, romelTa efeqturoba da saWiroeba ar dasturdeba da zogierT SemTxvevaSi SesaZloa sazianoc iyos. rekomendaciebis sarwmunoeba: (A) maRali _ monacemebi aRebulia mravali randomizirebuli klinikuri kvlevidan, romelSic CarTuli iyo avadmyofTa didi raodenoba. (B) saSualo _ monacamebi aRebulia ramodenime randomizirebuli klinikuri kvlevidan, romelSic CarTuli iyo avadmyofTa mcire raodenoba an eyrdnoba ararandomizirebuli kvlevebis analizs. (C) dabali _ rekomendacias safuZvlad udevs muSa jgufis konsesusi.

ix. Jurnali N 3. "arastabiluri stenokardiis da ST elevaciis gareSe mimdinare mwvave miokardiumis infarqtis mkurnaloba". evropis kardiologTa asociaciis saxelmZRvanelo miTiTebebis mixedviT, 2002w an www.guli.ge , www.escardio.org .

1

13

miokardiumis mwvave infarqtis paTogenezi

mwvave koronaruli sindromis mizezs, TiTqmis yvela SemTxvevaSi, warmoadgens koronarebSi sisxlis midinebis uecari Semcireba. igi viTardeba aTerosklerozulad Secvlil sisxlZarRvSi Trombozis ganviTarebiT, Tanmxlebi vazokonstriqciiT an mis gareSe. ST segmentis elevaciiT mimdinare mmi-is dros upiratesad okluziuri da persistuli Trombozi yalibdeba. fataluri koronaruli Trombozis 2/3-3/4 viTardeba aTerosklerozuli folaqis uecari dazianebis gamo, danarCen SemTxvevebSi mizezi xdeba folaqis erozia. koronaris sruli daxSobis gamo miokardiumis infarqtis ganviTareba xdeba iSemiis dawyebidan 15-30 wT-is Semdeg da drois mixedviT progresirebs subendokardiumidan subepikardiumisken. reperfuziulma Terapiam, maT Soris kolateraluri cirkulaciis ganviTarebam, SesaZloa gadaarCinos miokardiumi nekrozisagan. folaqis dazianebis sapasuxo Trombogenezi dinamiurad viTardeba: Trombozi da Trombolizisi, romelic xSirad dakavSirebulia vazospazmTan, paralelurad xdeba. es iwvevs sisxlis midinebis gardamaval SeCerebas da distalur emboliebs-mikrovaskulur obstruqciebs. koronaruli Trombozebis dros, Tavdapirvelad Trombocitebis agregaciis gamo ferxdeba sisxlis dineba, magram Semdgom aucilebelia fibrini aramdgradi Trombocituli Trombis stabilizaciisaTvis. amdenad orive, Trombocitebic da fibrinic, pasuxismgeblebi arian persistuli Trombis arsebobaze.

marTvisa da mkurnalobis ZiriTadi miznebeqimis ZiriTadi Zalisxmeva mimarTulia sikvdilobis Tavidan asacileblad, rac TavisTavad gulisxmobs zrunvas imisaTvis, rom moixsnas tkivili, diskomforti, stresi da SeCerdes miokardis dazianebis gavrceleba. mkurnaloba, Sesabamisad, moicavs oTx fazas: 1. gadaudebeli daxmareba, romelic gulisxmobs a)swraf sawyis diagnostikas da adreuli riskis Sefasebas; b) tkivilis moxsnas da g) gulis gaCerebis Tavidan acilebas an/da mkurnalobas. 2. adreuli mkurnaloba, romlis drosac unda gadawydes drouli reperfuziuli Terapiis Catareba da yuradReba gamaxvildes garTulebebis marTvaze. 3. Semdgomi mkurnaloba, romlis samiznesac warmoadgens mmi-is mogvianebiTi garTulebebi. 4. riskis Sefaseba da im RonisZiebebis gansazRvra, romlebic uzrunvelyofs gid-is progresirebis SeCerebas, axali infarqtis prevencias, Tavidan agvacilebs gulis ukmarisobas da sikvdils. gadaudebeli daxmareba

sawyisi diagnostika da adreuli riskis Sefaseba

gulmkerdis areSi tkivilis mqone pacientebis sawyisi diagnostika da adreuli riskis Sefaseba Zalze mniSvnelovania, raTa gamovlindes is pacientebi, romelTac adreuli, swrafi intervencia Seucvlis gamosavals. miokardiumis infarqtis samuSao diagnozis dadgena am dros pirveli rigis amocanaa. igi emyareba Zlier retrosternul tkivils, romelic grZeldeba >20wT da ar ixsneba nitroglicerinis miRebiT. mniSvnelovani informaciaa gid-is arseboba anamnezSi da tkivilis iradiacia kiserSi, qveda ybisken an marcxena zeda kidurSi. tkivili SesaZloa ar iyos Zlieri, an pacients, gansakuTrebiT xanSiSesuls, hqondes sxva Civili: advilad daRla, sisuste, sunTqvis mwvave ukmarisoba an sinkope. marTalia, ar arsebobs miokardiumis infarqtis individualuri niSnebi, magram bevr pacients aReniSneba avtonomiuri nervuli sistemis gaaqtivebis niSnebi (sifermkrTale, oflianoba) da wnevis cvalebadoba: hipertenzia an mcire pulsuri wneva. klinikurad mniSvnelovania agreTve riTmis darRveva, bradikardia an taqikardia, mesame tonis da Segubebis arseboba mcire wreSi. pirvel rigSi, operatiulad unda iqnas gadaRebuli ekg. yvelaze adreul etapzec ki igi Zalian iSviaTad aris normuli. ST segmentis elevaciis SemTxvevaSi unda gadawydes reperfuziuli Terapiis SesaZlebloba da igi, rac SeiZleba swrafad daiwyos. rig SemTxvevaSi ekg-ze ar vlindeba iSemiisaTvis damaxasiaTebeli clilebebi, amitom ekg-s dakvirveba dinamikaSi aucilebelia. damatebiT V7, V8 ganxrebis gadaReba arCeviT SemTxvevebSi (magaliTad ukana kedlis infarqtis dros) Zalze informatiulia. mmi-is adreul etapze uwyveti ekg monitoringi rac SeiZleba droulad unda uzrunvelvyoT. biomarkerebis analizi, Cveulebriv, miokardiumis infarqtis mwvave fazaSi keTdeba, magram reperfuziuli mkurnalobis dasawyebad ar SeiZleba velodoT mis pasuxs. reperfuziuli

14

Terapiis dasawyebad biomarkerebis momateba mxolod gansakuTrebul SemTxvevaSia uaRresad mniSvnelovani (mag. hisis konis marcxena fexis blokadis arsebobisas).

nax. 1. mwvave koronaruli sindromi (mks). avadmyofebs gulis areSi diskomfortiT SesaZloa hqondeT, an ar hqondeT ST segmentis elevacia. ST segmentis elevaciis mqone admyofebis did nawils uviTarebaT mokardiumis mwvave infarqti (mmi) Q kbiliT (farTo isari), mxolod mcire nawils-Qkbilis gareSe mi (wvrili isari). ST segmentis elevaciis gareSe mimdinare mks SesaZloa gamovlindes arastabiluri stenokardiis an ST segmentis elevaciis gareSe mimdinare mmi-is saxiT. Aam or mdgomareobas Soris diferencireba xdeba kardiuli markerebis gamokvlevis mixedviT. im avadmyofTa umravlesobis, romelTac ekg-ze aReniSnebaT ST segmentis elevaciis gareSe mimdinare mmi, ar CamouyalibdebaT Q kbili, anu maT eqnebaT mmi Q kbilis gareSe, mxolod mcire nawils - mmi Q kbiliT. Adapted from Antman EM, Brownwald E. Acute myocardial infarction. In Brounwald EB, ed. Heart Disease: textbook of cardiovascular Medicine. Philadelpia, PA: WB Saunders, 1997 American College of Cardiology/American Heart Association 2002 Guideline Update For Management of pts with Acute Coronary Syndrome

gulmkerdis areSi tkivilis saidentifikaciod didi adgili daikava organzomilebianma ultrabgeriTma gamokvlevam. miokardiumis regionuli kumSvadoba irRveva koronaruli sisxlZarRvis okluziidan ramodenime wuTSi, nekrozis ganviTarebamde bevrad ufro adre. amasTanave unda aRiniSnos, rom kumSvadobis regionuli darRvevebi araspecifiuria miokardiumis mwvave dazianebisaTvis. misi sxva SesaZlo mizezebi SeiZleba iyos iSemia an Zveli infarqti. organzomilebiani ultrabgeriTi gamokvleva gansakuTrebiT mniSvnelovania tkivilis sxva SesaZlo mizezis gamosavlenad, rogoricaa aortis mwvave ganSreveba, siTxe perikardiumSi, filtvis masiuri embolia. gulmkerdis areSi tkivilis diagnostikisaTvis, marTalia iSviaT SemTxvevebSi, magram warmatebiT gamoiyeneba miokardis perfuziuli scintigrafia. im SemTxvevaSi Tu anamnezi, ekg da bioqimiuri markerebi ar aris diagnostikuri, pacients Tamamad SeiZleba SevTavazoT fizikuri datvirTvis testi, romelsac SeuZlia gamoavlinos gulis iSemiuri daavadeba.

tkivilis kupireba, sunTqvis ukmarisobis da stresis moxsna

15

tkivilis moxsna upirvelesi amocanaa, radgan es ukanaskneli dakavSirebulia Warb simpatikur aqtivobasTan, rac Tavis mxriv, gansazRvravs vazokonstriqcias da Sesabamisad, zrdis gulis muSaobas. intravenuri opioidebi - morfini an, sadac es xelmisawvdomia, diamorfini - warmoadgenen yvelaze misaReb analgetikebs mocemul konteqstSi (morfini 4-8mg, Semdgom, damatebiT 2-2mg, 5wT-iani intervalebiT tkivilis moxsnamde); unda moveridoT kunTSida ineqciebs. damatebiTi dozis SemTxvevaSi yuradRebiT unda vadevnoT Tvali gverdiT movlenebis ganviTarebas. im SemTxvevaSi, Tu opoidebiT tkivili ar moixsna, xSirad efeqturia intravenuri beta-blokerebi an nitratebi . Jangbadis drouli miwodeba (2-4 ml/wT) mniSvnelovania pacientebisTvis sunTqvis ukmarisobis klinikiT, gulis ukmarisobis movlenebis arsebobisas an Sokis dros. sasurvelia JangbadiT gajerebis -saturaciis - arainvaziuri kontroli. emociuri agznebadoba bunebrivi reaqciaa tkivilze da im movlenebze, romelic, Cveulebriv, Tan axlavs kardiul Setevas. rekomendirebulia gamoviyenoT trankvilizatorebi, Tumca xSir SemTxvvevaSi opioidebi sakmarisia am problemis mosagvareblad.

prehospitaluri an adreuli hospitaluri marTva

miokardiumis infarqtis klinikuri niSnebis arsebobisas da ST segmentis mdgradi elevaciis SemTxvevaSi ZiriTadi strategia mimarTuli unda iyos meqanikuri an farmakologiuri reperfuziis droulad Casatareblad, rac SeiZleba adre, Tu ar arsebobs dadasturebuli winaaRmdegCvenebebi.

fibrinolizuri Terapia

monacemebi efeqturobis Sesaxeb

Trombolizisis Sesaxeb Catarebul randomizirebul kvlevebSi (Trombolizisi vs kontroli an Trmbolizisis erTi reJimis Sedareba meoresTan) dRemde 150 000-ze meti adamiani monawileobda. miRebuli Sedegebis mixedviT, tkivilis dawyebidan 12 sT-is ganmavlobaSi Trombolizisis Catareba maRalefeqturi saSualebaa perfuziis aRsadgenad. gamokvlevebis analizis mixedviT, tkivilis dawyebidan 6sT-Si Catarebuli TrombolizisiT avadmyofebSi ST segmentis elevaciiT an hisis konis blokadiT, yoveli 1000 namkurnalevi pacientidan 30 sicocxlis gadarCena gaxda SesaZlebeli; es ricxvi Seadgenda 20-s, Tu mkurnaloba tardeboda tkivilis dawyebidan 7-12sT-is ganmavlobSi. miokrdiumis infarqtis dawyebidan 12 sT-is Semdgom Catarebuli Trombolizisis efeqturobis Sesaxeb sakmarisi monacemebi ar arsebobs. ST-segmentis elevaciis xarisxze an hisis konis fexis blokadis tipze am meta-analizSi saubari ar aris. Tumca aRsaniSnavia, rom kvlevaTa umravlesobaSi CarTvis kriteriumad aRebulia 1 mm-ze meti ST-segmentis elevacia an hisis konis marcxena totis axlad ganviTarebuli blokada. kvlevam ISIS-2 aCvena damatebiTi efeqturoba, roca mkurnalobaSi erTvis aspirini. am SemTxvevaSi sikvdilobis kombinirebulma Semcirebam Seadgina 50 gadarCenili sicocxle 1000 namkurnaleb pacientze. aRsaniSnavia, rom absoluturi gaumjobeseba yvelaze maRali riskis mqone pacintTa qvejgufSi SeiniSna. winamdebare meta-analizis mixedviT, Trombolizisis efeqturobam ver miaRwia statistikur sarwmunoebas 75w-s gadacilebuli asakis populaciaSi. ufro metic, orma reestrulma kvlevam kiTxvis qveS daayena Trombolizisis Cveneba xandazmulebSi, aCvena ra, rom igi SeiZleba ufro zianis momtani iyos, vidre - sikeTis. Tumca Trombolizisze Catarebul kvlevaTa xelaxali analizis mixedviT, 75w. gadacilebuli asakis 3300 pacientSi, romlebsac Trombolizuri mkurnaloba CautardaT, sikvdiloba sarwmunod Semcirda (29,4%-dan 26%-mde, P= 0.03) Tu igi tardeboda simptomebis ganviTarebidan 12 sT-is ganmavlobaSi.

dro mkurnalobis dawyebamde

fibrinolizuri Terapia miT ufro efeqturia, rac ufro adre iwyeba miokardiumis infarqtis niSnebis dawyebidan. kvlevebSi sul 6 000 adamianma gaiara randomizacia prehospitalur an intrahospitaluri Trombolizisis jgufebSi da prehospitaluri mkurnalobis jgufSi adreuli sikvdilobis sarwmunod maRali Semcireba (15-20%) SeiniSna. fibrinolizisze Catarebuli kvlevebis analizis mixedviT, TiToeul dagvianebul saaTze sikvdiloba izrdeba 1.6 SemTxveviT. Catarebuli kvlevebis safuZvelze da axali, praqtikulad advilad gamosayenebeli fibrinolizuri agentebis gamoCenis Semdeg (maTi Seyvana SesaZlebelia bolusiT), rekomendirebulia Trombolizis prehospitalur etapze Catareba.

fibrinolizisis gverdiTi efeqtebi

16

Trombolizuri Terapia dakavSirebulia insultebis mcire, magram sagulisxmo raodenobasTan - es ricxvi 1000 pacientze 3.9-s Seadgens; sagulisxmoa, rom garTulebaTa absoluturi umetesoba modis mkurnalobis pirvel dReze. adreuli insultebi upiratesad hemoragiulia, mogvianebiT ki upiratesad Trombuli, an emboliuri insultebi viTardeba. didi kvlevebis monacemebiT, 1000 pacientze 2 arafataluri insulti modis, aqedan naxevari saSualo an mZime invalidobis mizezi xdeba. asaki, dabali wona, mdedrobiTi sqesi, anamnezSi hipertonia an cerebrovaskuluri daavadebebi, mkurnalobis dawyebisas sistolur-diastoluri hipertenziis arseboba warmoadgens im faqtorebs, romlebic gansazRvravs intrakraniuli hemoragiuli garTulebebis maRal risks. streptokinazis da anistreptazis Seyvanas SesaZloa mohyves hipotenzia, Tumca seriozuli alergiuli reaqciebi iSviaTia. am mizniT hidrokortizonis rutinuli gamoyeneba ar aris naCvenebi. hipotenziis SemTxvevaSi saWiroa droebiT SevaCeroT gadasxma, gadaviyvanoT pacienti trendelburgis pozaSi da avuwioT fexebi. rig SemTxvevaSi SesaZloa dagvWirdes atropini an siTxeebis gadasxma.

cxr. 1. fibrinolizuri Terapiis ukuCvenebani

absoluturi ukuCvenebani

hemoragiuli an ucnobi genezis insulti anamnezSi; iSemiuri insulti ukanaskneli 6 Tvis ganmavlobaSi centraluri nervuli sistemis dazianeba an simsivne axali zogadi travma /qirurgiuli Careva/ Tavis travma (bolo 3 kviris manZilze) gastrointestinuli sisxldena bolo Tvis ganmavlobaSi; cnobili sisxlmdeni daavadeba; aortis disseqcia

SedarebiTi ukuCveenebani

gardamavali iSemiuri Seteva bolo 6 Tvis ganmavlobaSi; oraluri antikoagulaciuri Terapia; orsuloba an 1 kvira mSobiarobis Semdeg; punqcia iseT adgilas, saidanac sisxldenis SeCereba kompresiiT rTulia; travmuli reanimacia; refraqteruli hipertenzia (sistoluri art. wneva > 180 mmHg ) TandarTuliGRviZlis daavadeba; infeqciuri endokarditi;

klinikuri analizi

dReisTvis arsebuli sarwmuno mtkicebulebebis mixedviT dgindeba, rom fibrinolizuri Terapia da aspirini, romlebsac erTad sumaciuri efeqti gaaCniaT, Zalze maRalefeqturia rogorc sikvdilobis, ise - avadobis Semcirebis - TvalsazrisiT, Tu maT droulad daviwyebT miokardiumis mwvave infarqtis samkurnalod. Trombolizuri Terapia rekomendirebulia daiwyos prehospitalur etapze, Tu es SesaZlebelia, anu arsebobs Sesabamisi garemo da kvalificiuri kadri, romelsac SeuZlia Seafasos ekg da dasvas mmi-is samuSao diagnozi. Tu ar aris winaaRmdegCveneba, ST-segmentis elevaciiT an marcxena fexis blokadiT mimdinare mmi-is dros, avadmyofebs rac SeiZleba adre unda daewyoT Trombolizuri Terapia da aspirini. realurad SesaZlebeli da amasTanave sasurvelia, Trombolizuri Terapia daiwyos saswrafos gamoZaxebidan 90 wT-Si ("call to needle"), an hospitalizaciidan 30 wT-Si ("door to needle"). fibrinolizuri Terapia ar tardeba, Tu miokardiumis infarqtis dawyebidan gasulia 12sT-ze meti da ar aris mimdinare iSemiis klinikuri da ekg niSnebi. fibrinolizuri Terapia aseve xanSiSesul pacientebsac utardebaT, Tu ar aris SesaZlebloba, Catardes meqnikuri reperfuzia.

fibrinolizuri Terapiis winaaRmdegCvenebebi

fibrinolizuri Terapiis absoluturi da SedarebiTi winaaRmdegCvenebebi mocemulia cxrilSi 1. aRsaniSnavia, rom diabeti da diabeturi neiropaTia ar aris fibrinolizis ukuCveneba.

fibrinolizuri reJimi

fibrinolizuri agentis dozireba da antiTrombuli mkurnalobis saWiroebis ixileT cxrili 2. cxrili 2. mwvave infarqtis dros gamoyenebuli fibrinolizuri saSualebebi Sesaxeb

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naCvenebia yvelaze xSirad gamoyenebuli fibrinolizuri aSualebebi N.B. aspirini eZleva yvela pacients ukuCvenebis gareSe.

fibrinolizuri agentis ganmeorebiTi gamoyeneba

reinfarqtis an reokluziis SemTxvevaSi, roca meordeba ST- segmentis elevacia an hisis konis marcxena totis bloki, saWiroa Catardes ganmeorebiTi fibrinolizuri mkurnaloba, Tu meqanikuri reperfuzia ar aris xelmisawvdomi. streptokinaza da antistreptaza ganmeorebiT ar gamoiyeneba, sanam maT mimarT sisxlSi arsebobs antisxeulebi, anu sul cota aTi wlis ganmavlobaSi. alteplaza (t-PA) da misi analogebi ki ar warmoqmnian antisxeulebs. fibrinolizuri agentebis ganmeorebiT Seyvanisas sisxldenis riski izrdeba.

damatebiTi antikoagulaciuri da antiTrombocituli mkurnaloba

zemoT ukve aRiniSna aspirinis efeqturobisa da aucileblobis Sesaxeb. pirveli doza - 150325 mg unda mieces dasaReWad (gamoiyeneT garsiT daufaravi aspirini!), Semdeg ki mcire doza ­ 75-160 mg sakmarisia dRis ganmavlobaSi misaRebad. aspirini mxolod nawilobriv axdens Trombocitebis agregaciis daTrgunvas, xolo Trombocituli glikoprotein IIb/IIIa-s inhibitorebi, romlebic bolo dros gamoCndnen farmakologiur arsenalSi, srulad ablokireben Trombocitebis agregaciis finalur fazas. angiografiuli kvlevebis mixedviT, IIb/IIIa inhibitorebis kombinaciaSi gamoyenebisas naxevar doza fibrinolitikiTa da heparinis mcire doziT miiRweva msgavsi da kidev ukeTesi Sedegi (TIMI 3), vidre mxolod fibrinolitikis sruli doziT gamoyenebisas; amave dros, am SemTxvevaSi bevrad ufro TvalsaCinoa ST-segmentis elevaciis Semcireba, rac TavisTavad niSnavs qsovilovani reperfuziis gaumjobesebas. am kombinaciis klinikuri efeqturoba da usafrTxoeba Sefasda or did kvlevaSi, sadac SeiniSna intrahospitaluri reinfarqtebis ricxvis Semcireba, xolo hemoragiebis ricxvi ar Secvlila. Tumca, am kombinaciebis rutinul gamoyenebas unda veridoT, radgan is specifiuri jgufebi, romlebSic es midgoma yvelaze efeqturi iqneba, jer kidev Sesaswavlia. heparini intensiurad gamoiyeneba fibrinolizis dros da Semdgom periodSi, gansakuTrebiT qsovilovani plazminogenis aqtivatorTan. marTalia, heparini ar Slis Trombs, magram Trombolizisidan ramodenime saaTSi an dReSi Catarebuli kvlevis mixedviT, koronaris gamavloba bevrad ukeTesia intravenuri heparinis fonze, ramdenadac Trombze axali fenis daSreveba aRar xdeba. gansxvaveba ver naxes streptokinazasTan erTad intravenuri Tu kanqveSa heparinis daniSvnis SemTxvevaSi. intravenuri heparinis xangrZlivad gamoyeneba, koronarografiulad dadasturebuli fibrinolizisis safuZvelze, ar amcirebs reokluziebis ricxvs. qsovilovani plazminogenis aqtivatoris Semdgom heparinis infuzia rekomendirebulia Sewydes 24-48 sT-Si. intravenuri hepariniT mkurnalobisas aucilebelia yuradReba; aPTT>70wm asocirebulia sikvdilobis maRal riskTan, sisxldenebTan da reinfarqtebTan (ix. cxrili 3). marTalia, ar arsebobs didi randomizirebuli kvlevis masalebi, mgram bolodroindelma mcire kvlevebma aCvena, rom aPTT-s kontroli da heparinis dozirebis Sejereba wonis mixedviT mniSvnelovnad amcirebs sisxldenebis risks.

cxrili 3. hepariniT Terapia

i/v bolusiT: 60erT/kg, maqsimum 4000 erT. i/v infuzia: 12 erT/kg 24-48 sT ganmavlobaSi, maqsimum 1000 erT/sT, samizne

heparini

aPTT unda iyos 50-70ms. aPTT unda ganisazRvros mkurnalobis dasawyisidan yovel 3, 6, 12 da 24 sT-is Semdeg .

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dabalmolekuluri heparini warmoadgens standartuli heparinis subfraqcias. am ukanasknels gaaCnia rigi upiratesobebi standartul heparinTan SedarebiT: axali Trombinis warmoqmnis prevencia, bevrad ufro marTvadi kinetika, Trombocitebis naklebi aqtivacia, Trombocitopeniis ganviTarebis naklebi SesaZlebloba da ar saWiroebs aPTT_s kontrolis. dabalmolekuluri heparini ST-segmentis elevaciis gareSe mimdinare mwvave koronaruli sindromis dros pacientebis did kohortaSi iqna Seswavlili, magram mxolod bolo dros daiwyo misi Seswavla fibrinolizur agentebTan kombinaciaSi. bolo sam angiografiul kvlevaSi enoqsiparinis an delteparinis gamoyenebisas Semcirda reokluziebis ricxvi. didi masStabis pirvelAkvlevaSi SSENT-3, romelSic enoqsiparini (30mg i/v bolusiT da 1mg/kg yovel 12sT-Si) gamoiyeneboda teneqteplazasTan erTad maqsimum 7 dRis ganmavlobaSi, hospitalSida reinfarqtebis da refraqteruli iSemiis riski sarwmunod Semcirda heparinis jgufTan SedarebiT.

perkutanuli koronaruli intervencia (PCI)

miokardiumis infarqtis adreul stadiaSi PCI_is roli SeiZleba davaxasiaToT, rogorc: (1) pirveladi PCI, (2) PCI kombinirebuli farmakologiur reperfuziur TerapiasTan da (3) "gadamrCeni PCI"- uSedego farmakologiuri reperfuziis Semdeg.

pirveladi PCI

pirveladi PCI ganisazRvreba, rogorc angioplastika an/da stentireba winaswari an Tanmxlebi fibrinolizuri Terapiis gareSe. aseT midgomas upiratesobas aniWeben, Tu misi Catareba SesaZlebelia pacientTan pirveli kontaqtidan 90 wuTis ganmavlobaSi. igi moiTxovs gamocdil gunds, amdenad igi ar SeiZleba rutinulad Catardes, Tu stacionars ara aqvs intervenciuli programebis Catarebis sakmarisi gamocdileba. axlaxan damTavrda kvleva - DANAMI_2, romelmac Seiswavla aris Tu ara pirveladi PCI upiratesi intrahospitalur TrombolizisTan SedarebiT. gamokvlevis mixedviT, 30_e dReze sikvdilobis, reinfarqtebis da insultebis kombinirebuli uaryofiTi saboloo gamosavali Semcirda mniSvnelovnad im pacientebSi, romelTac CautardaT pirveladi PCI (14,2%_8.5%, P<0,002), Tumca sikvdilobis Semcireba ar iyo sarwmuno (8.% vs 6.5% P=0.2). pirveladi PCI efeqturad icavs sisxlZarRvis gamavlobas da ukavSirdeba sisxldenebis nakleb risks fibrinolizisTan SedarebiT. sxvadasxva randomizirebul kvlevebSi, sadac fibrinolizur Terapias adarebdnen droulad Catarebul PCI_sTan, gamovlinda sisxlZarRvis gamavlobis ukeTesi aRdgena, reokluziebis naklebi ricxvi, marcxena parkuWis rezidualuri funqciis gaumjobeseba da ukeTesi klinikuri gamosavali. pacientebi, romlebsac aqvT fibrinolizuri Terapiis ukuCveneba, miekuTvnebian sikvdilobis TvalsazrisiT gansakuTrebiT maRali riskis jgufs. pirveladi PCI_is Catareba am pacientebis umravlesobaSi warmatebulia. amave dros, pirveladi PCI mkurnalobis upiratesi arCevania kardiogenuli Sokis dros. PCI kombinirebuli fibrinolizTan PCI, romelic tardeboda Trombolizuri Terapiis damTavrebisTanave, reokluziebis riskis Semcirebis mizniT da ukeTesi gamavlobis misaRwevad, mTel rig kvlevebSi warumateblad damTavrda. am kvlevebma aCvena garTulebebisa da sikvdilobis riskis mniSvnelovani zrda PCI-is Semdeg; magram bolo periodSi, gamocdilebis gazrdam, stentebis SemoRebam da ukeTesma antiTrombocitulma agentebma mniSvnelovnad gazarda fibrinolizisis Semdgomi PCI-is usafrTxoeba da efeqturoba.

gadamrCeni PCI

gadamrCeni PCI tardeba koronarze, romlis gamavloba ar aRdga fibrinolizuri Terapiis Sedegad. ori randomizirebuli kvleviT miRebuli mcire gamocdileba gviCvenebs, rom mniSvnelovan klinikuri gaumjobesebas miviRebT, Tu CavatarebT infarqt-damokidebuli koronaris rekanalizacias. marTalia, warmatebuli angioplastikis sixSire maRalia, magram kvlav rCeba upasuxo kiTxvebi: pirvel rigSi is, rom infarqt_damokidebuli koronaruli arteriis arainvaziuri Sefaseba Zalian Znelia. amasTanave, koronarul intervencias pacientebSi, romlebsac CautardaT Trombolizisi da miiRes glikoprotein IIb/IIIa antagonisti, SesaZloa moyves garTulebebi sisxldenis saxiT.

"gadarCenili" miokardiumi

miokardis perfuziuli scintigrafia Zalze informatiulia fibrinolizisis an PCI-is efeqturobis Sesafaseblad, magram misi gamoyeneba yoveldRiur praqtikaSi rTulia. teqnecium-99 SeyavT intravenurad intervenciamde da 6 saaTis ganmavlobaSi akvirdebian miokards. ganmeorebiTi ineqcia da Semdgomi dakvirveba mogvianebiT, aRdgenis fazaSi, gansazRvravs

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infarqtis saboloo formas da komprometirebuli miokardis raodenobas im ubanTan SedarebiT, romelic maRali riskis qveS iyo. GP IIb/IIIa-s antagonistebi da adreuli PCI ukanasknel wlebSi Catarda randomizirebuli kvlevebi infarqt-ganmsazRvreli koronaruli arteriis PCI_is dros absiqsimabis, rogorc damatebiTi antiTrombocituli Terapiis Sesaxeb. RAPORTI kvlevam aCvena, rom absiqsimabi aumjobesebs klinikur gamosavals (sikvdili, miokardiumis anfarqti da gadaudebeli revaskularizacia) da amcirebs bail out stentirebis saWiroebas. paralelurad, gaizarda hemoragiuli garTulebebi, rac SesaZloa gamowveuli iyo heparinis didi dozebiT. garda amisa, sikvdiloba, reinfarqti da revaskulizacia sarwmunod ar Semcirda me-6 dRes. afsiqsimabis roli pirveladi PCI-s dros Seswavlil iqna Semdeg kvlevebSi ISAR-2, CADILAC da ADMIRAL. dagrovili monacemebi gvTavazobs absiqsimabis gamoyenebas pirveladi angioplastikis dros heparinis dabal dozasTan erTad. absiqsimabis rutinuli gamoyeneba pirveladi stentirebis dros kvlav kamaTis sagania.

koronaruli arteriis Suntireba

im pacientebis ricxvi, romlebsac infarqtis mwvave fazaSi Suntirebis operacia sWirdebaT, sakmaod mcirea. igi SeiZleba Catardes warumatebeli PCI-s dros, kaTeterizaciis procesSi koronaruli arteriis uecari daxSobisas, roca PCI SeuZlebeli xdeba; amave dros, arCeviT pacientebSi kardiogenuli Sokis dros an parkuWTaSoris Zgidis defeqtis an mitraluri regurgitaciis ganviTarebis an rupturis dros kardioqirurgiasTan erTad (igulisxmeba Suntireba da valvuloplastika, Suntireba da defeqtis daxurva). cxr.4. miokardiumis infarqtis hemodinamikuri mdgomareobis klinikuri Sefaseba da maTi mkurnaloba

no rmal uri hiperdinamikuri tipi bradikardiahipotonia hipovolemia marjvena par-kuWis infarqti SegubebiTi ukmarisoba kardiogenuri Soki normaluri arteriuli wneva, guliscemisa da sunTqvis sixSire, kargi periferiuli cirkulacia taqikardia, mkafio gulis tonebi, kargi periferiuli cirkulacia. mowodebuli beta-blokerebiT mkurnaloba. "rbili hipotenzia", bradikardia, venodilatacia, narmaluri sauRle venuri wneva, daqveiTebuli qsovilovani perfuzia. Cveulebriv viTardeba qveda infarqtisas, Tumca SeiZleba provocirebuli iyos opiatebiT. ganixileba atropini an droebiTi kardiostimulacia. venokonstriqcia, dabali sauRle venuri wneva, susti qsovilovani perfuzia. mowodebulia siTxeebis infuzia. maRali sauRle venuri wneva, susti qsovilovani perfuzia an Soki, bradikardia, hipotenzia. ix.teqsti. taqikardia, taqipnoe, mcire pulsuri wneva, susti qsovilovani perfuzia, hipoqsemia, filtvebis SeSupeba. ix.teqsti. Zlier susti qsovilovani perfuzia, oliguria, mkveTri hipotenzia, mcire pulsuri wneva, taqikardia, filtvebis SeSupeba. ix.teqsti.

gulis, rogorc tumbos, ukmarisoba da Soki

sxvadasxva hemodinamikuri mdgomareobebi, romlebic, viTardeba miokardiumis infarqtis dros mocemulia cxrilSi 4. gulis ukmarisobis mizezi SesaZloa iyos ariTmia an meqanikuri garTulebebi.

gulis ukmarisoba

miokardiumis mwvave infarqtis dros marcxena parkuWis disfunqciis ganviTareba ukavSirdeba arasasurvel mokle da Soreul prognozs. klinikuri simptomebia: sunTqvis ukmarisoba, sinusuri taqikardia, mesame toni da SegubebiTi xixini filtvebSi. amasTanave, Segubeba SesaZloa aRiniSnebodes, magram ar iyos auskultaciuri monacemebi, sasicocxlo niSnebis Tvalyuris devneba mmi-is am fazaSi Zalze mniSvnelovania. gulis ukmarisobis xarisxi klasificirdeba kilipis mixedviT: klasi 1: ar aris xixini da gulis mesame toni; klasi 2: SegubebiTi xixini ar ikavebs filtvebis saproeqcio aris 50% an moismineba gulis mesame toni; klasi 3: SegubebiTi xixini ikavebs filtvebis saproeqcio aris 50%-ze mets.klasi 4: Soki.

gulis zomieri da mZime ukmarisoba

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pirvel rigSi miewodeba Jangbadi niRbis saSualebiT, magram sifrTxile gvmarTebs filtvis qronikuli daavadebebis arsebobis SemTxvevaSi. rekomendirebulia JangbadiT saturaciis kontroli. msubuqad gamoxatuli ukmarisoba advilad emorCileba diuretikebs (mag., furosemidi 20-40mg i/v), maTi gameoreba SesaZlebelia 1-4sT-is intervaliT, Tu amis saWiroeba arsebobs. Tu Sedegi ar aris damakmayofilebeli, naCvenebia intravenuri nitroglicerinis an oraluri nitratebis gamoyeneba. dozis titracia xdeba wnevis monitoringiT, raTa Tavidan aviciloT hipotonia. agf inhibitorebi iniSneba miokardiumis infarqtidan 48sT-is ganmavlobaSi, Tu ar aris hipotonia, hipovolemia an Tirkmlis sagulisxmo ukmarisoba.

gulis mZime ukmarisoba da Soki

saWiroa Jangbadis uwyveti miwodeba da diuretikebis adeqvaturi dozireba diurezis kontroliT. hipertenziis pirobebSi intravenurad iniSneba nitroglicerini, sawyisi doza 0.25mkg/kg/wT, doza izrdeba 5wT-iani intervaliT, sanam ar miiRweva sistoluri wnevis Semcireba 15mm.Hg-iT, an sistoluri wneva SenarCundeba > 90mm.Hg.. saWiroa konkretul SemTxvevaSi Sefasdes wneva filtvis arteriaSi da CaWedvis wneva, iseve rogorc gulis wuTmoculoba balonuri flotaciuri kaTeteriT. samizne sididea CaWedvis wnevisTvis <20mm.Hg da gulis indeqsi >2l/wT/m2. inotropiuli agentebi gamoiyeneba hipotenziis SemTxvevaSi. Tirkmlis hipoperfuziis niSnebis arsebobisas rekomendirebulia dofaminis intravenuri gamoyeneba doziT 2.5-5.0mkg/kg/wT. filtvis Segubebis Tanaarssebobisas sawyisi doza umjobesia iyos ­ 2.5mkg/kg/wT, dozis TandaTanobiT gazrdiT 10mkg/kg/wT an hemodinamikuri stabilurobis miRwevamde. rekomendirebulia sisxlSi Semowmdes airebi. endotraqeuli intubacia ventilaciis uzrunvelyofiT SesaZloa saWiroa gaxdes, Tu Jangbadis gajereba ar aRemateba 60mm.Hg miuxedavad 100% Jangbadis 8-10l/wT siCqariT miwodebisas bronqodilatatorebis adeqvatur dozasTan erTad. pacientebs, romelTac ganuviTardaT mwvave gulis ukmarisoba, SesaZloa hqondeT stanirebuli (reperfuziuli miokardiumi kumSvadobis daqveiTebiT) an hipoperfuziuli, sicocxlisunariani miokardiumi. hipoperfuziuli miokardiumis gamovlena da revaskularizacia xels Seuwyobs parkuWis funqciis gaumjobesebas.

kardiogenuli Soki

kardiogenuli Soki aris klinikuri mdgomareoba, romlis drosac sistoluri wneva <90mmHg da centraluri venuri avsebis wneva >20mmHg an kardiuli indeqsi < 2l/wT/m2. adreuli Trombolizisi amcirebs kardiogenuri Sokis ganviTarebis risks. kardiogenuli Sokis diagnozi ismeva im SemTxvevaSi, roca gamoiricxeba hipotenziis sxva SesaZlo mizezebi, rogoricaa hipovolemia, vazovagusuri reaqcia, eleqtrolituri disbalansi, farmakologiuri gverdiTi efeqtebi an ariTmia. kardiogenuli Soki dakavSirebulia marcxena parkuWis gavrcelebul dazianebasTan, magram SesaZloa ganviTardes marjvena parkuWis infarqtis drosac. marcxena parkuWis funqciuri mdgomareoba da masTan dakavSirebuli meqanikuri garTulebebis Sefaseba xdeba organzomilebani dopleruli eqokardiografiiT. hemodinamikis Sefaseba xdeba balonuri flotaciuri kaTeteriT. kardiuli indeqsis >2 l/kg/wT SesanarCuneblad avsebis wneva (filtvis CaWedvis wneva) unda iyos daaxl. 15 mm Hg. dofaminis mcire doza 2.5-5 mkg/wT gamoiyeneba Tirkmlis funqciis gasumjobeseblad, saWiroebis SemTxvevaSi SesaZloa gadavwyvitoT dobutaminis gamoyenebis sakiTxic. kardiogenuli Sokis dros sasurvelia Sefasdes acidozi, romlis koreqcia Zalze mniSvnelovania, radgan kateqolaminebis moqmedeba sustdeba mJavur garemoSi. balonuri tumbos gamoyeneba rekomendirebulia, rogorc damxmare saSualeba meqanikur intervenciamde. gadaudebeli PCI an qirurgiuli Careva erT-erTi yvelaze efeqturi saSualebaa sicocxlis SesanarCuneblad da rekomendirebulia Catardes rac SeiZleba droulad. im SemTxvevaSi Tu arc arTi maTgani xelmisiwvdomi ar aris an yovndeba, rekomendirebulia fibrinolizuri Terapia.

meqanikuri garTulebebi: gulis ruptura da mitraluri regurgitacia Tavisufali kedlis ruptura

Tavisufali kedlis mwvave ruptura

mas axasiaTebs kardiovaskuluri kolafsi eleqtromeqanikur disociaciasTan erTad, anu grZeldeba eleqtruli aqtivoba, roca ikargeba gulis wuTmoculoba da pulsi. pacienti ar

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pasuxobs standartul kardiopulomonarul reanimacias da iRupeba ramdenime wuTSi. Zalian iSviaTad rCeba dro qirurgiuli CarevisTvis.

Tavisufali kedlis qvemwave ruptura

daaxloebiT SemTxvevaTa 25%-Si sisxlis mcire raodenoba CaiRvreba perikardiumis RruSi da iwvevs hemodinamikis progresul gauaresebas. klinikuri niSnebi zogjer iZleva reinfarqtis simulacis, radgan adgili aqvs tkivilis ganaxlebas da ST segmentis reelevacias. magram uxSiresad igi dakavSirebulia hemodinamikis uecar gauaresebasTan, romelsac Tan axlavs aramdgradi an mdgradi hipotonia. gamovlindeba gulis tamponadis klasikuri niSnebi, rac SesaZloa dadasturdes eqokardiografiulad. perikardiumSi siTxis arseboba ar aris sakmarisi Tavisufali kedlis qvemwvave rupturis diagnozis dasasmelad, radgan igi xSirad axlavs miokardiumis infarqts, tipiur niSans warmoadgens eqomkvrivi masa perikardiul sivrceSi (hemoperikardiumi). klinikuri mdgomareobis mixedviT unda gadawydes dauyovnebeli qirurgiuli Carevis sakiTxi. qirurgiuli Carevis molodinSi SesaZloa perikardiocentezis Catareba tamponadis niSnebis Sesamsubuqeblad.

parkuWTaSua Zgidis ruptura

parkuWTaSua Zgidis ruptura viTardeba, ZiriTadad, mmi-is adreul etapze (1-2%). qirurgiuli Carevis gareSe sikvdiloba Seadgens 54%-s pirvel kviras da 92% - erTi wlis ganmavlobaSi. diagnozi, romelzec eWvi pirvel rigSi klinikuri mdgomareobis gamo miitaneba, dasturdeba uxeSi sistoluri Suilis gaCeniT, eqokardiografiulad anda Jangbadis gansazRvriT marjvena parkuWSi. Suili SesaZloa iyos rbili an sul ar iyos. eqokardiografia gamoavlens septaluri defeqtis lokalizacias da zomas. xolo feradi dopleriT ganisazRvreba marcxnidan marjvniv Suntis arseboba. farmakologiuri mkurnaloba vzodilatatorebiT, magaliTad intravenuri nitrogliceriniT, aumjobesebs klinikur mdgomareobas Tu ar aris kardiogenuli Soki, magram cirkulatoruli gaumjobesebis misaRwevad intra-aortuli kontrpulsacia yvelaze efeqtur saSualebas warmoadgens. gadaudebeli qirurgia gadarCenis erTaderTi saSualebaa postinfarqtuli septaluri didi defeqtis dros, romelsac Tan axlavs Soki. im SemTxvevaSic ki, roca hemodinamika stabiluria, adreuli qirurgiuli Careva rekomendirebulia, radgan defeqtis zoma SeiZleba gaizardos. SesaZlebelia septaluri defeqtis perkutanuli daxurva, magram es did gamocdilebas moiTxovs. qirurgiis Semdeg hospitaluri sikvdiloba Seadgens 2560%-s, gamojanrTelebulTa 95%-s aReniSneba gulis ukmarisoba - NYHA klasi I da II. arasasurveli postoperaciuli gamosavlis prediqtorebad iTvleba kardiogenuli Soki, ukana kedlis infarqti, marjvena parkuWis disfunqcia, asaki, ariTmia da dayovneba defeqtis ganviTarebidan qirurgiamde.

mitraluri regurgitacia

mitraluri regurgitacia mmi-s xSiri garTulebaa. mas sami SesaZlo meqanizmi aqvs: I. mitraluri xvrelis gadideba imis gamo, rom xdeba marcxena parkuWis dilatacia da disfunqcia. II. dvrilisebri kunTis disfunqcia, romelic ZiriTadad qveda infarqtis dros viTardeba; III. dvrilisebri kunTis ruptura. dvrilisebri kunTis ruptura vlindeba hemodinamikis uecari gauaresebiT. Suili xSirad rbilia, mitraluri regurgitaciis xarisxi fasdeba feradi dopleriT. papilaruli kunTis wilobiTi an totaluri rupturis yvelaze xSiri mizezia posteromedialuri dvrilisebri kunTis infarqti marjvena an Semomxvevi arteriis auzSi okluziis gamo. zogierT pacientSi diagnozis dasazusteblad saWiro xdeba transezofaguri eqokardiografiis Catareba.

rutinuli profilaqtikuri Terapia mwvave fazaSi

rekomendaciis klasi aspirini 150-325 mg (damcavi garsisi gareSe) intravenurad beta-blokerebi: yvela pacientSi, Tu araa ukuCveneba; peroraluri beta-blokerebi: rogorc i/v formebi agf-inhibitorebi: oraluri formebi pirvelive dRidan yvela pacientSi, Tu araa ukuCveneba; maRali riskis pacientebSi nitratebi kalciumis antagonistebi magniumi lidokaini I X X IIa IIb III mtkicebulebis done A A

X X X X X X

A A A B A B

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kardiogenuli Soki, filtvis SeSupeba, romelsac Tan axlavs mitraluri regurgitacia, moiTxovs gadaudebel qirurgias. momzadebis periodSi rekomendirebulia intra-aortuli tumbo da koronaruli angiografia. sarqvlis gamocvla arCevis meTodia, rodesac adgili aqvs dvrilisebri kunTis rupturas. rodesac ruptura ar aris, unda Catardes infarqtgamomwvevi arteriis meqanikuri reperfuzia.

ariTmia da gamtareblobis darRvevebi

ariTmia da gamtareblobis darRvevebi Zalze damaxasiaTebelia mmi-is adreul etapze. rig SemTxvevebSi es aris sicocxlisaTvis saSiSi ariTmiebi, rogoricaa parkuWovani taqikardia, parkuWTa fibrilacia da sruli AV blokada, romlebic moiTxoven dauyovnebel Carevas. xSir SemTxvevaSi ariTmia asaxavs seriozul dazianebas, mimdinare iSemias, gulis rogorc tumbos ukmarisobas, avtonomiuri tonusis darRvevas, hipoqsias, eleqtrolitebis (mag. hipokalemia) da mJava-tutovani wonasworobis darRvevas, rac droulad unda gamovlindes da gamoswordes. mkurnalobis saWiroebisa da gadaudebeli Carevis sakiTxi wydeba imis da mixedviT, rogor aisaxeba ariTmia hemodinamikaze. parkuWovani taqikardia (ptVT)

parkuWovani eqtopiuri ritmi

parkuWovani eqtopiuri ritmi an riTmis rTuli darRvevebi (multiformuli kompleqsebi, mokle ganarbeni, an R-T-ze fenomeni) Zalian xSiria mmi-is pirvel dRes. maTi roli parkuWovani fibrilaciis prediqtorad sakamaToa. specifiuri Terapia am SemTxvevaSi ar aris saWiro.

parkuWovani taqikardia

aramdgradi pt-s SesaZloa pacienti subieqturad ver grZnobdes; Sesabamisad, igi ar saWiroebs mkurnalobas. gaxangrZlivebul epizodebs SesaZloa mohyves gulis ukmarisobis ganviTareba, hipotenzia an gadavides parkuWovan fibrilaciaSi. beta blokerebi, Tu maT mimarT ukuCveneba ar arsebobs, warmoadgenen pirveli rigis preparatebs. Tu arsebobs parkuWovani fibrilaciis ganviTarebis (an ganmeorebis) maRali SesaZlebloba, arCevis preparats lidokaini warmoadgens: sawyisi datvirTvis dozaa 1mg/kg (i/v), Semdeg am dozis naxevari yovel 8-10wT-Si 4mk/kg maqsimalur dozamde, an uwyveti infuzia 1-3mg/wT dozirebiT. intravenuri amiodaroni (5mg/kg pirvel saaTSi, Semdeg - 900-1200mg 24sT-is ganmavlobaSi) SesaZloa ukeTesi arCevani iyos, gansakuTrebiT pacentebSi ganmeorebadi parkuWovani taqikardiis an fibrilaciis arsebobisas. eleqtroSokuri Terapia naCvenebia hemodinamikurad aramdgradi pt-s dros. Tu defibrilatori ar aris xelmisawvdomi, SesaZloa prekordiuli muStic efeqturi aRmoCndes. parkuWovani taqikardia unda ganvasxvavoT aCqarebul idioventrikulur ritmisagan, romelic reperfuziis Cveuli, arasaSiSi garTulebaa; parkuWovani SekumSvebis ricxvi am SemTxvevaSi ar aRemateba 120'.

parkuWovani fibrilacia

unda Catardes dauyovnebeli defibrilacia. saWiroa Sesruldes RonisZiebebi, romlebic mocemulia kardio-pulmonuri-reanimaciis da gadaudebeli daxmarebis 2000 w-is saxelmZRvanelo miTiTebebSi (gaidlainebSi).

supraventrikuluri ariTmiebi

mmi-is SemTxvevaTa 20% rTuldeba winagulTa fibrilaciiT da uxSiresad ukavSirdeba marcxena parkuWis seriozul dazianebas da gulis ukmarisobas. igi Cveulebriv TviTonve ixsneba, Tumca, SesaZloa ganmeordes. xSir SemTxvevaSi parkuWebis SekumSvis sixSire ar aris maRali, ariTmia kargad gadaitaneba da ar saWiroebs gadaudebel Carevas. beta-blokerebi da digoqsini warmatebiT aneleben sixSires; amiodaroni ukeTesi arCevania, radgan iwvevs ariTmiis Sewyvetas. SesaZloa gamoviyenoT eleqtroSoki, magram mas SesaZloa mivmarToT mxolod gansakuTrebul SemTxvevebSi, radgan mocimcime ariTmia am dros xSiri recidivebiT xasiaTdeba. sxva supraventrikuluri ariTmiebi Zalze iSviaTia da, rogorc wesi, TviTonve ixsneba, Carevis gareSe. beta blokerebi SesaZloa efeqturi iyos, Tu ar aris winaaRmdegCveneba. ar aris rekomendirebuli verapamilis gamoyeneba. intravenuri adenozinis (atf-is) gamoyeneba gonivrulia, Tu gamoricxulia winagulTa TrTolva da hemodinamikuri statusi stabiluria. ekg monitoringi aucilebelia.

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sinusuri bradikardia da AV blokadebi

sinusuri bradikardia xSiria mmi-is ganviTarebis pirvel saaTebSi, gansakuTrebiT - qvemo infarqtis dros. rig SemTxvevaSi amis mizezi opioidebi xdebian. bradikardias SesaZloa Tan axldes mZime hipotenzia, Tumca igi kargad pasuxobs i/v atropins (0.3-0.5mg, maqsimaluri 1.5-2.0 mg ulufebad) da Zalze iSviaTad moiTxovs stimulacias. I xarisxis AV blokada ar saWiroebs mkurnalobas. II xarisxis I tipis AAV blokada (mobitici I venkebaxiT) dakavSirebulia qveda infarqtTan da iSviaTad iwvevs hemodinamikis gauaresebas. aseT SemTxvevaSi, pirvel rigSi mivmarTavT atropins; uefeqtobis SemTxvevaSi droebiTi kardiostimulaciaa saWiro. II xarisxis II tipis AAV blokada (mobitici II) da sruli AV bloki saWiroebs eleqtrodis dauyovnebel moTavsebas marjvena parkuWSi, gulis ukmarisobis an hipotoniis SemTxvevaSi ki kardiostimulaciis uzrunvelyofas. hisis konis romelime fexis axali blokadis ganviTareba, rogorc wesi, miuTiTebs wina kedlis gavrcelebul dazianebaze. am SemTxvevaSi arsebobs sruli blokadis da gulis ukmarisobis ganviTarebis didi SesaZlebloba. aseT SemTxvevaSi eleqtrodis profilaqtikuri moTavseba marjvena RruSi dagvicavs iseTi arasasurveli garTulebebisagan, rogoricaa sruli blokada, asistolia, asistolia Sokis Semdeg, bi-an trifascikuluri blokada. sxvagvarad, saWiroa daviwyoT gulmkerdis masaJi da droulad uzrunvelvyoT transTorakaluri stimulacia.

rutinuli profilaqtikuri Terapia mwvave fazaSi

aspirini aspirinis efeqturoba dadasturda kvlevaSi ISIS-2, sadac aspirinis da streptokinazis erTad gamoynebam sumaciuri Sedegi aCvena. gansxvavebiT Trombolizisagan, aspirinis SemTxvevaSi ar arsebobs zusti mtkicebuleba miRebis droisa da efeqturobis Sesaxeb. miuxedavad amisa, aspirini unda mieces yvela pacients miokardiumis infarqtis an SesaZlo mwvave koronaruli sindromis dawyebidan rac SeiZleba adre. arsebobs aspirinis daniSvnaze Tavis Sekavebis mxolod ramdenime ukuCveneba: zemgrZnobeloba, sisxlmdeni peptiuri wyluli, diskrazia an RviZlis mZime paTologia. iSviaT SemTxvevebSi man SesaZloa gamoiwvios bronqospazmi bronquli asTmis mqone pacientebSi. antiariTmiuli preparatebi marTalia dadasturebulia, rom lidokaini amcirebs parkuWovani fibrilaciis ganviTarebis saSiSroebas mmi-is mwvave fazaSi, magram mniSvnelovnad zrdis asistoliis ganviTarebis risks. amdenad, preparatis profilaqtikuri gamoyeneba ar aris gamarTlebuli. beta blokerebi mmi-is mwvave fazaSi intravenuri beta blokerebi gamoiyenes uamrav kvlevaSi, radgan arsebobda mosazreba, rom maT SeuZliaT Seamciron infarqtis zoma, fataluri ariTmiebis ganviTarebis riski da moxsnan tkivili. Catarebuli 28 kvlevis masalebze dayrdnobiT beta blokerebis gamoyenebiT yoveli 1000 pacientidan 6 sicocxlis gadarCenaa SesaZlebeli. es kvlevebi, ZiriTadad, Catarebulia fibrinolizuri Terapiis an pirveladi PCI-is damkvidrebamde. Trombolizisis farTod gavrcelebis Semdeg Catarda ori didi randomizirebuli kvleva intravenuri beta blokerebis monawileobiT. Sedegebi ar iZleva saSualebas daskvnis gasakeTeblad. GUSTO-1-is Sedegebis post-hok analizi (gamoyenebulia atenololi) da sistemuri mimoxilva ar iZleva sakmaris safuZvels beta blokerebis rutinuli gamoyenebisaTvis. mmi-is am etapze beta blokerebis gamoyenebis saukeTeso Cvenebaa taqikardia, SedarebiTi hipertenzia da tkivili, romelic naklebad pasuxobs opoidebs. gonivrulia, pirvel rigSi gamoviyenoT xanmokle moqmedebis preparatebi dozis frTxili titraciiT. nitratebi 2041 avadmyofis monawileobiT Catarebuli 10 didi kvlevis meta-analizis mixedviT, intravenuri nitratebi daaxloebiT erTi mesamediT amcireben sikvdilobas. kvlevaSi GISSI-3 19,394 avadmyofis monawileobiT, Sedarda intravenuri nitroglicerinis rutinuli da SerCeviTi gamoyeneba mmi-is sawyis fazaSi, rodesac gamoxatuli iyo mimdinare iSemiis niSnebi da seleqciuri administrireba. kvlevaSi ISIS-4 oraluri mononitrati avadmyofebs eZleodaT mwvave fazaSi da Semdeg erTi Tvis ganmavlobaSi, ar aCvena rame dadebiTi Sedegi. aseve warumateblad damTavrda ESPRIM kvlevac, romelSic molsidomini, azotis oqsidis donori, gamoiyeneboda. amdenad, nitratebis gamoyenebas mmi-is sawyis etapze ara aqvs sarwmuno dadebiTi Sedegi, amdenad misi rutinuli gamoyeneba ar aris rekomendirebuli.

cxrili reperfuziuli Terapia. 24

kalciumis antagonistebi im gamokvlevebis meta analizis mixedviT, romelic kalciumis antagonistebis mmi-is adreul etapze gamoyenebiT Catarda, gamovlinda gverdiTi movlenebis arasarwmuno zrda. mmi-is mwvave fazaSi kalciumis antagonistebis profilaqtikuri gamoyenebis Cveneba, praqtikulad ar arsebobs. angiotenzin-gardamqmneli fermentis (agf) inhibitorebi dResdReobiT dadgenilia, rom agf inhibitorebi aucilebelia dainiSnos pacientebSi gauaresebuli gandevnis fraqciiT an im SemTxvevaSi, Tu mmi-is adreul fazaSi aReniSnaT gulis ukmarisobis niSnebi. maTi efeqturoba gamovlinda kvlevebSi GISSI-3, ISIS-4 da Cinuri kvleva, sadac mmi-is ganviTarebidan 24sT-Si agf inhibitorebis daniSvnisas ukve me-4 - 6 kviridan SeiniSna sikvdilobis mcire, magram sarwmuno Semcireba. Tumca kvleva CONSENSUS II warumatebeli aRmoCnda eCvenebina dadebiTi Sedegi am mimarTulebiT. es SesaZloa SemTxveviT moxda, an amis mizezi iyo intravenuri formis agf inhibitorebis gamoyeneba mmi-is adreul etapze. agf inhibitorebis monawileobiT Catarebuli kvlevebis sistemuri analizi iZleva sarwmuno monacemebs, rom maTi gamoyeneba mmi-is mwvave fazidan usafrTxoa, kargad aitaneba pacientis mier da mcired, magram sarwmunod amcirebs 30-dRian sikvdilobas. amdenad, arsebobs sayovelTao azri, rom agf inhibitorebi unda dainiSnos mmi-is ganviTarebidan 24 sT-is ganmavlobaSi, Tu ar arsebobs ukuCveneba. magnezia magneziis gamoyenebiT Catarebulma rigi kvlevebis meta-analizma aCvena mniSvnelovani Sedegebi, magram SemdgomSi Catarebuli didi randomizirebuli kvleva ISIS-4 ver daadastura wina kvlevebis Sedegebi; mizezad saxeldeboda magneziis gamoyenebisa araoptimaluri reJimi. axlaxan damTavrda didi kvleva MAGIC, romelmac daadastura, rom magneziis gamoyeneba moklebulia dadebiT Sedegebs. glukoza-insulin-kaliumis infuzia arsebobs eqperimentuli da mcire raodenobis klinikuri mtkicebulebebi, rom glukozainsulin-kaliumis infuzias SeuZlia dadebiTi gavlena moaxdinos iSemiuri miokardis metabolizmze da Sesabamisad, gaaumjobesos klinikuri gamosavali. 1928 pacientis klinikuri monacemebis analizis mixedviT hospitaluri sikvdiloba Semcirda 28%-iT (95% CI =10-43%). aTas pacientze gadarCenilma sicocxlem Seadgina 49 (95% CI, 14-83%). rekomendacia am SedarebiT xelmisawvdomi mkurnalobis rutinul gamoyenebaze damokidebulia kvlevaze, romelic amJamad mimdinareobs da mTavari saboloo wertilia sikvdilobaze zegavlenis Seswavla. infarqtis sxvadsxva formebis mkurnaloba

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marjvena parkuWis infarqti

marjvena parkuWis infarqtis swori diagnostireba Zalze mniSvnelovania, radgan mkurnalobis taqtika, miT ufro Sokis ganviTarebis SemTxvevaSi, radikalurad gansxvavdeba marcxena parkuWis mmi-is mkurnalobis taqtikidan. marjvena parkuWis infarqtze eWvi migvaqvs, rodesac arsebobs sami Zalze specifiuri, magram naklebad mgrZnobiare, klinikuri triada pacientebSi qveda kedlis infarqtiT: hipotenzia, sufTa filtvebi da sauRle venebSi wnevis momateba. ST-segmentis elevacia V4R-Si Zalzed damaxasiaTebelia. es ganxra unda Caiweros yovelTvis Sokis dros, Tu ara rutinulad yvela SemTxvevaSi. Q kbili da ST segmentis elevacia V1-3 ganxrebSi aseve informatiulia diagnozis sasargeblod. eqokardiografias SeuZlia daadasturos diagnozi Semdeg SemTxvevebSi: marjvena parkuWi dilatirebulia, hipokineziuria an akinetikuria, marjvena winagulic aseve gadidebulia da mcire trikuspidaluri regurgitacia mniSvnelovani xdeba marjvena venuri xvrelis dilataciis gamo. roca marjvena parkuWis infarqti rTuldeba hipotenziiT an SokiT, mniSvnelovania SevinarCunoT marjvena parkuWis predatvirTva. sasurvelia moveridoT (Tu SesaZlebelia) vazodilatatorebis gamoyenebas, mag: opioidebs, nitratebs, diuretikebs da agf inhibitorebs. xSir SemTxvevaSi efeqturia siTxeebis infuzia: maTi gadasxma iweba maRali siCqariT, mag. 200 ml 10 wT-Si, Semdgomi dozirebis kontroli damokidebulia hemodinamikur mdgomareobaze. marjvena parkuWis infarqti xSirad rTuldeba mocimcime ariTmiiT. misi kupireba droulad unda moxdes, radgan am SemTxvevaSi winagulebis normaluri muSaobis uzrunvelyofa Zalze mniSvnelovania marjvena parkuWis avsebis uzrunvelsayofad. Sesabamisad, blokadis SemTxvevaSi saWiroa uzrunvelvyoT orkameriani droebiTi stimulacia, miuxedavad imisa, rom matulobs kaTeterdamokidebuli fibrilaciis riski. marjvena mmi-is dros arsebobs rigi kiTxvebi Trombolizisis efeqturobaze, magram hipotenziis SemTxvevaSi albaT main sasurvelia igi Catardes. PCI warmoadgens Trombolizisis karg alternativas swrafi hemodinamikuri efeqtis misaRwevad.

miokardiumis infarqti Saqriani diabetis mqone pacientebSi

miokardiumis infarqtis mqone pacientTa erT meoTxeds aqvs Saqriani diabeti da es maCvenebeli, mosalodnelia, rom gaizrdeba. diabetis mqone pacientebTan simptomebi SesaZlebelia atipiuri iyos, xolo gulis ukmarisoba am SemTxvevaSi uxSiresi garTulebaa. sikvdiloba diabetian pacientebSi mmi-is dros orjer ufro maRalia aradiabetianebTan SedarebiT. aris monacemebi, rom diabetiani pacientebi ar Rebuloben intensiur mkurnalobas garTulebebis SiSis gamo. diabeti ar aris Trombolizisis ukuCveneba, retinopaTiis arsebobis drosac ki. rac Seexeba beta blokerebs da agf inhibitorebs, maTi efeqturoba gacilebiT maRalia am pacientebSi aradiabetianebTan SedarebiT umniSvnelo garTulebebis xarjze. mwvave fazaSi metaboluri kontrolis gauareseba da hiperglikemia sikvdilobis damoukidebel prediqtors warmoadgens. glukozis kontroli da insulin-glukozis infuzia insulinis Semdgomi administrirebiT mniSvnelovnad amcirebs Soreul sikvdilobas.

pacientis marTva da mkurnaloba mmi-is mogvianebiT etapze

asimptomuri pacienti an pacienti minimaluri dazianebiT SesaZloa gaeweros saxlSi ramodenime dReSi, magram maTTvis, visac aReniSneba marcxena parkuWis mniSvnelovani disfunqcia an aqvT axali garTulebebis maRali riski, rekomendirebulia ufro xangrZlivi hospitalizacia. marcxena parkuWis mniSvnelovani disfunqciis mqone pacientebs 12-24 sT-is ganmavlobaSi aqvT woliTi reJimi; es aris periodi, romlis drosac gairkveva, rTuldeba Tu ara mmi. gaurTulebel SemTxvevebSi pacients SeuZlia wamojdes sawolSi pirveli dRis bolos da miiRos sakvebi an TviTonve Caitaros tualeti. sawolidan wamodgomis da fexiT mcire xniT siarulis (200m) ufleba mas eZleva meore dRidan; kibeebze siarulis ufleba mas ukve ramdenime dReSi eZleva. im SemTxvevaSi, Tu mmi-is mimdinareoba garTulda gulis ukmarisobiT, ariTmiiT an SokiT, pacientebi rCebian sawolSi ufro didxans da maTi gaaqtiveba xdeba nela da damokidebulia simptomebze da miokardis dazianebis xarisxze. hospitalSida garTulebebis marTva da mkurnaloba

Rrma venebis Trombozi da filtvis embolia

msgavsi garTulebebi amJamad Zalze iSviaTia, Tu pacienti gulis ukmarisobis gamo didxans ar rCeba sawolSi. aseT SemTxvevebSi rekomendirebulia dabalmolekuluri heparinis profilaqtikuri gamoyeneba. msgavsi garTulebis SemTxvevaSi iniSneba dabalmolekuluri heparinis Terapiuli doza, Semdgom ki oraluri antikoagulanti sul cota 3-6 Tve.

intraventrikuluri Trombi da sistemuri embolia

intraventrikuluri Trombis gamovlena eqokardioskopiulad xdeba; igi gansakuTrebiT xSiria marcxena parkuWis gavrcelebuli infarqtis SemTxvevaSi. im SemTxvevaSi, Tu Trombi moZravia an protuberantuli, mkurnalobaSi erTvis heparini an dabalmolekuluri heparini, xolo Semdeg xangrZlivad (3-6 Tve) pacients eZleva oraluri antikoagulanti.

perikarditi

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mwvave perikarditi mmi-is garTulebaa, romelic asocirdeba cud prognozTan. igi iwvevs tkivils, romelic SesaZloa SecdomiT CaiTvalos rogorc anginaluri tkivilis ganaxleba an reinfarqti. tkivili am dros, Tavisi xasiTiT, mwvavea da ukavSirdeba mdebareobis Secvlas an sunTqvis fazebs. diagnozs adasturebs perikardiumis xaxunis arseboba. Tu tkivili Zlieria, SeiZleba vumkurnaloT maRali dozis oraluri an i/v aspiriniT, sxva arasteroiduli anTebis sawinaaRmdego saSualebebiT an steroidebiT. hemoragiuli gamonadeni tamponadiT Cveulebriv araa damaxasiaTebeli da SesaZloa dakavSirebuli iyos antikoagulaciur mkurnalobasTan. perikardiocentezis saWiroeba dgeba, Tu hemodinamika uaresdeba. parkuWovani taqiariTmiebi mmi-s mogvianebiT etapze parkuWovan taqikardias da parkuWovan fibrilacias, romelic viTardeba pirvel dRes, aqvs naklebi prognozuli mniSvneloba. ariTmiebi, romlebic viTardeba mogvianebiT, SesaZlebelia kvlav ganmeordes da ukavSirdeba sikvdilianobis maRal risks. mmi-is ganviTarebidan erTi kviris Semdeg ganviTarebuli parkuWovani taqikardia an fibrilacia ukavSirdeba miokardiumis seriozul dazianebas; saWiroa Sefasdes koronaruli anatomia da parkuWovani funqcia. Tu ariTmiis mizezi iSemiaa, unda gadawydes PCI an qirurgiuli Careva. sxva SemTxvevaSi ganixileba sxvadasxva Terapiuli midgoma, Tumca jerjerobiT arc erTi maTganis upiratesoba sarwmunod dadgenili ar aris. maT Sorisaa beta-blokerebi, amiodaroni, eleqtrofiziologiiT SerCeuli antiariTmiuli Terapia da/an ICD. cxr.4. miokardiumis mkurnaloba

normaluri hiperdinamikuri tipi bradikardiahipotonia hipovolemia marjvena infarqti gulis SegubebiTi par-kuWis

infarqtis

hemodinamikuri

mdgomareobis

klinikuri

Sefaseba

da

maTi

normaluri arteriuli wneva, guliscemisa da sunTqvis sixSire, kargi periferiuli cirkulacia taqikardia, mkafio gulis tonebi, kargi periferiuli cirkulacia. mowodebuli beta-blokerebiT mkurnaloba. "msubuqi hipotenzia", bradikardia, venodilatacia, narmaluri sauRle venuri wneva, daqveiTebuli qsovilovani perfuzia. Cveulebriv viTardeba qveda infarqtisas, Tumca SeiZleba provocirebul iyos opoidebiT. ganixileba atropini an droebiTi kardiostimulacia. venokonstriqcia, dabali sauRle venuri wneva, susti qsovilovani perfuzia. mowodebulia siTxeebis infuzia. maRali sauRle venuri wneva, susti qsovilovani perfuzia an Soki, bradikardia, hipotenzia. ix.teqsti. taqikardia, taqipnoe, mcire pulsuri wneva, hipoqsemia, filtvebis SeSupeba. ix.teqsti. susti qsovilovani perfuzia,

ukmarisoba kardiogenuri Soki

Zlier susti qsovilovani perfuzia, oliguria, mkveTri hipotenzia, mcire pulsuri wneva, taqikardia, filtvebis SeSupeba. ix.teqsti.

riskis Sefaseba, reabilitacia da meoradi prvencia.

riskis Sefaseba

miokardiumis infarqtis Semdeg saWiroa Sefasdes reinfarqtisa da sikvdilis riski. maRali riskis mqone pacientebisTvis unda gatardes zomebi am garTulebaTa Tavidan asacileblad. avadmyofis mdgomareobis klinikuri Sefaseba, infarqtis zomisa da marcxena parkuWis gandevnis fraqciis gansazRvra xdeba infarqtis ganviTarebidan pirveli 24-48 sT-is ganmavlobaSi, xolo Semdgomi gamokvlevis vada damokidebulia daavadebis mimdinareobaze. tradiciulad, inducirebuli iSemiis gamosavlenad, maqsimaluri datvirTviT datvirTvis testi tardeba 6 kviris ganmavlobaSi. perfuziuli scintigrafia vazodilatatorebis gamoyenebiT da eqokardiografia dobutaminiT ufro informatiulia adreuli riskis Sesafaseblad. gamokvlevis es meTodebi saSualebas iZleva nanaxi iqnes gansxvaveba infarqtis zonidan daSorebul midamoSi iSemiur da infarqtis ubanSi arsebul cocxal zonebs Soris. perfuziuli scintigrafia da streseqoskopia SesaZlebelia Catardes infarqtis dawyebidan 5 dReSi. maTi Sedegebi gamoiyeneba koronaruli angiografiis Catarebis CvenebisaTvis an medikamenturi mkurnalobisaTvis. warmatebuli pirveladi koronaruli intervenciis Semdeg adreuli riskis Sefaseba nakleb informatiulia. am SemTxvevaSi umTavresi sakiTxia iSemiis dadgena infarqtidan moSorebul adgilas. aseT pacientebSi naCvenebia 6 kviris Tavze streseqoskopia ekg an sxvadasxva vizualizaciis meTodiT.

klinikuri Sefaseba da Semdgomi Careva.

nax.1 gviCvenebs mmi-is Semdeg riskis Sefasebis algoriTms. mwvave fazaSi maRali riskis kriteriumebia hipotenzia, persistiuli gulis ukmarisoba, avTvisebiani ariTmiebi, persistiuli

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tkivili gulis areSi, anginaluri tkivilis ganaxleba mokle periodSi an stenokardiuli Seteva mcire fizikuri datvirTvisas.

maRali riskis pacientebs miekuTvnebian agreTve asakovani pacientebi, pacientebi mravali risk-faqtorebiT, gadatanili infarqtiT. isini warmoadgenen kandidatebs adreuli koronaruli angiografiisaTvis. Tu angiografia gamoavlens anatomiur defeqts, romelic SesaZloa gamoasworos intervenciam da amave dros sicocxlisunariani miokardiumis arseboba dadasturebulia, naCvenebia revaskularizaciis Catareba. pacientebi, romelTac ara aqvT maRali riskis klinikuri markerebi, miekuTvnebian dabali riskis jgufs da maT SemTxvevaSi ganixileba Soreuli riskis Sefaseba. aseT pacientebs koronaruli angiografia xSirad stacionarSive utardebaT, Tumca mowodebulia sawyisi datvirTvis testis Catarebac. mwvave fazis Semdeg prognozis Sefaseba damokidebulia marcxena parkuWis disfunqciis xarisxze, narCen da arsebul iSemiaze, romlebic obieqturad dadasturebulia miokardiumis perfuziuli scintigrafiiT an eqokardiografiiT. gandevnis fraqcia da sistolis bolos moculoba warmoadgenen sikvdilobis myar prediqtorebs. amasTanave, saWiroa Sefasdes iSemiis gavrceleba, radgan sicocxlisunariani, magram iSemiuri miokardi, momavali arasasurveli garTulebebis kargi substratia maRali riskis pacientebs miekuTvnebian avadmyofebi marcxena parkuWis gandevnis fraqciiT <35% an isini, romelTa iSemizirebuli miokardiumi aRemateba sicocxlisunariani miokardiumis 50%-s. aseT pacientebSi mowodebulia koronarografiis Catareba, xolo Semdgomi marTva iseTivea, rogorc mxolod klinikuri kriteriumebiT Sefasebisas. vizualizaciis meTodebiT (scintigrafia, eqoskopia) Sefasebul dabali riskis pacientebs miekuTvnebian isini, visac marcxena parkuWis gandevnis fraqcia >50% an isini, romelTac aqvT SezRuduli an saSualod gamoxatuli iSemiuri movlenebi da iSemizirebuli miokardiumis masa naklebia sicocxlisunariani masis 20%-ze. aseTi pacientebi SesaZlebelia namkurnalevi iqnen konservatiulad, intervenciis gareSe.

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pacientebis marTva, ganurCevlad maTi riskis jgufSi mikuTvnebisa, unda emyarebodes arsebul simptomokompleqss. ase magaliTad, xSiri stenokardiuli Setevebi moiTxovs koronarografiis Catarebas, im dros roca usimptomo an naklebi CivilebiT mimdinare mdgomareobis marTva usafrTxod SeiZleba farmakologiuri saSualebebiT. yvela pacientSi unda ganisazRvros metaboluri risk-faqtorebi, rogoricaa saerTo, dabali- da maRali simkvrivis lipoproteidebis qolesterini, trigliceridebi da glukoza sisxlSi.

staningi da hibernacia

infarqtgadatanil pacientebSi Zalze mniSvnelovania miokardiumis sicocxlisunarianobis Sefaseba. miokardiumis infarqtis Semdeg marcxena parkuWis disfunqciis ganviTarebis mizezi SesaZlebelia iyos nekrozuli miokardiumi, infarqtis teritoriaze arsebuli sicocxlisunariani, magram "gabruebuli" miokardiumi (e.w. `staningiT~), sicocxlisunariani miokardiumi hibernaciiT (`miZinebuli~), an maTi kombinacia. Cveulebriv, staningi SesaZlebelia aRdges infarqtidan 2 kviraSi, Tu iSemia ar grZeldeba, magram Tu iSemia grZeldeba, staningi gadadis hibernaciaSi da funqciis aRsadgenad ukve revaskularizacia. zemoTaRniSnuli midgomebi yvelaze xSirad gamoiyeneba mZime marcxenaparkuWovani ukmarisobis mqone pacientebSi, sadac revaskularizacia savaraudod dadebiT Sedegs gamoiRebs. Tu wamyvani simptomebi ar ukavSirdeba marcxena parkuWis ukmarisobas, es midgoma kargavs azrs. sicocxlisunariani miokardiumis gamosavlenad mowodebulia mravali diagnostikuri saSualeba, magram upiratesoba eniWeba stres-eqoskopiasa da perfuziul scintigrafias. kompleqsuri gamokvlevebisaTvis gamoiyeneba agreTve magnitur-rezonansuli pozitronul emisiuri tomografia.

ariTmiis rikis Sefaseba

holteris monitorireba da eleqtrofiziologiuri gamokvleva SesaZlebelia dagvexmaros ariTmiebis ganviTarebisadmi maRali riskis pacientebis gamovlenaSi. riTmis variabeloba, QTintervalis dispersiuloba, barorefleqsuri mgrZnobeloba da gviani potencialebi SesaZlebelia gamoviyenoT prognozis Sesafaseblad, Tumca saWiroa agreTve rigi mogvianebiTi testebis Catarebac. rogorc kvleva MADIT II aCvena, defibrilatorebis profilaqtikurma Canergvam postinfarqtul pacientebSi gandevnis fraqciiT <30%, gaaumjobesa sicocxlis xangrZlivoba, Tumca saWiroa Semdgomi kvlevebi, raTa dadgindes am meTodis upiratesoba.

reabilitacia

reabilitaciis amocanaa pacienti daubrundes sicocxlis Cveul reJims, samuSaoze siarulis CaTvliT. igi moicavs samedicino, socialur-ekonomiur da fsiqologir aspeqtebs. reabilitacia naCvenebia gamoxatuli marcxena parkuWis ukmarisobis mqone avadmyofebisaTvisac. es procesi unda daiwyos gaweridan SeZlebisdagvarad swrafad da unda gagrZeldes kvirebisa da Tveebis ganmavlobaSi. reabilitaciis meTodebi dawvrilebiTaa aRwerili evropis kardiologTa asociaciis reabilitaciis muSa jgufis moxsenebaSi. fsiqologiuri da social-ekonomikuri aspeqtebi

cxovrebis stilis Secvla

koronaruli daavadebis SesaZlebeli Sedegebi ganxilul unda iqnes pacientebTan da maT TavmdgomebTan hospitalizaciis peiodSi da individualurad unda moxdes jansaRi kvebis reJimis SerCeva, wonis kontroli, TambaqosTvis Tavis danebeba da varjiSebi.

sigareti da dieta

sarwmuno monacemebis mixedviT, sigaretze Tavis danebeba TiTqmis orjer amcirebs sikvdilobas. SeiZleba iTqvas, es aris yvelaze efeqturi prevenciuli saSvaleba meoradi pevenciis dros.L The Lyon Diet Heart Study aCvena, rom xmelTaSua zRvis tipis dieta amcirebs gulis iSemiuri movlenebis ricxvs infarqtgadatanil avadmyofebSi momdevno oTxi wlis ganmavlobaSi. xmelTaSua zRvis dieta gulisxmobs kvebis racionSi didi raodenobiT ujeri cximebis, xilis da bostneulis Semcvelobas najeri cximebis xarjze. antioqsidantebis, rogorc dieturi danamatebis, rolze infarqtis Semdgom periodSi sarwmuno monacemebi ar arsebobs.

antiTrombocituli da antikoagulaciuri mkurnaloba

The Antiplatelet Trialists Collaboration metanalizi adasturebs sikvdilobis da reinfarqtebis ricxvis Semcirebas 25%-iT, rodesac mkurnalobaSi erTvis aspirini 75-325mg. arsebobs agreTve sarwmuno monacemebi, romlis mixedviTac aspirinis mcire doza ufro efeqturia da aqvs SedarebiT naklebi gverdiTi movlenebi.

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oraluri antikoagulntebis rutinuli gamoyeneba, an maTi kombinireba aspirinTan ar aris rekomendirebuli, Tu ar aris gansakuTrebuli mdgomareoba-wina kedlis akinezia, mocimcime ariTmia, Trombi marcxena parkuWSi. am SemTxvevebSi arsebobs oraluri antikoagulantebis efeqturobis maRali SesaZlebloba, magram randomizirebuli kvlevebi am mimarTulebiT jer ar Catarebula. axlaxan damTavrda didi kvleva mmi-is Semdgom periodSi klopidogrelis monawileobiT. jerjerobiT ar arsebobs sarwmuno monacemebi, romlebic reperfuziuli Terapiis Semdgom periodSi klopidogrelis da aspirinis kombinaciis rutinul gamoyenebas dauWerda mxars. pacientebs, romlebic ver itanen aspirins, klopidogreli karg alternativas warmoadgens.

beta-blokerebi

miokardiumis infarqtgadatanil pacientebSi beta-blokerebi 25%-iT amcireben reinfarqtebis da sikvdilobis ricxvs. es dadasturda ramodenime did da mcire kvlevebSi. am kvlevebSi CarTuli wamlebi iyo Semdegi: propranololi, metoprololi, Timololi, acebutololi da karvediloli, romelTa efeqturoba sarwmunod maRali iyo. amdenad, 82 randomizirebuli kvlevis meta-analizis safuZvelze rekomendirebulia miokardiumis infarqtis gadatanis Semdeg yvela pacientisTvis beta-blokerebis xangrZlivad daniSvna, Tu ar aris ukuCveneba maT mimarT.

kalciumis antagonistebi

dihidropiridinebis monawileobiT Catarebulma kvlevebma ver gamoavlina kalciumis blokerebis efeqturoba postinfarqtul periodSi. isini iniSneba mxolod gansakuTrebuli mdgomareobebis dros. aseve verapamilis da dilTiazemis daniSvna dasaSvebia, Tu betablokerebis mimarT arsebobs autanloba.

nitratebi

dResdReobiT ar arsebobs sarwmuno monacemebi postinfarqtul periodSi nitratebis (rogorc oraluri, ise - transdermuli) efeqturobis Sesaxeb (ISIS-4, GISSI-3). amave dros, isini kvlav rCebian pirveli rigis saSualebebad stenokardiis dros.

angiotenzin gardamqmneli fermentebis (agf) inhibitorebi

dRemde Catarebuli kvlevebis Sedegebis safuZvelze, agf inhibitorebi iniSneba mmi-is ganviTarebis adreuli etapidan da maTi miReba grZeldeba infarqtis gadatanidan 4-5 wlis ganmavlobaSi, im SemTxvevaSic ki, Tu ar aris miokardiumis disfunqcia. maTi efeqturoba kidev ufro maRalia Saqriani diabetis mqone pacientebSi.

hipolipidemiuri saSualebebi

dRes ukve eWvs ar iwvevs hipolipidemiuri saSualebebis daniSvnis aucilebloba hiperlipidemiis SemTxvevaSi, rodesc dietiT ver miiRweva qolesterinis normuli done (4S, CARE, LIPID Study da sxva). zogadad, da aseve postinfarqtul pacientebSi, hipolipidemiuri saSualebebi iniSneba, Tu dietis miuxedavad sisxlSi saerTo qolesterinis done >190mg% (4,9mmol/l) an/da dabali simkvrivis lipoproteidebis qolesterini - >115mg% (2.97mmol/l). axlaxan dasrulebuli HPS kvlevis mixedviT, statinebiT mkurnaloba sasurvelia maSinac, roca lipidebi momatebuli araa. kamaTi grZeldeba imis Taobaze, Tu mwvave movlenebidan ramden xanSia sasurveli statinebiT mkurnalobis dawyeba. bolo monacemebiT, Sveduri registris mixedviT, rac ufro adre iwyeba mkurnaloba da rac ufro agresiulia igi, miT ufro maRalia hipolipidemiuri murnalobis efeqturoba.

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meoradi prevencia

rekomendaciis klasi Tambaqos moxmarebis Sewyveta glikemiis kontroli diabetian pacientebSi art. wnevis kontroli hipertenziiT avadmyofebSi xmelTaSua zRvis tipis dieta 1g poliujeri cximovani mJavebis damateba racionSi aspirini 75-160mg dRiurad; aspirinis autanlobis SemTxvevaSi klopidogreli (75mg dReSi) oraluri antikoagulantebi oraluri beta-blokerebi yvela pacientSi, Tu araa ukuCveneba gagrZeldes pirvel dRes dawyebuli agf-inhibitorebi statinebi: Tu saerTo qolesterini >190mg% an dabali simkvrivis qolesterini >115mg% fibratebi: Tu maRali simkvrivis qolesterini <45mg/dl an trigliceridebi >200mg% kalciumis antagonistebi (verapamili an dilTiazemi), Tu betablokerebi ukunaCvenebia da araa gulis ukmarisoba nitratebi stenokardiis ararsebobisas I X X X X X X X X X X X X X X IIa IIb III mtkicebulebis done C B C B B A C B A A A A B A

supraventrikuluri ariTmiebis marTva

supraventrikuluri ariTmiebi da maTi mkurnaloba ­ amerikis kardiologTa kavSiris, amerikis gulis asociaciis, evropis kardiologTa asociaciis mier 2003 w. momzadebuli saxelmZRvanelo miTiTebebis mixedviT

riTmis darRvevebis klinikuri Taviseburebani, zogadi Sefaseba da mkurnaloba

a. pacientis Sefseba

1. klinikuri istoria da fizikaluri gamokvleva

eqimTan vizitis dros pacientebi metwilad asimptomurni arian. ariTmiasTan dakavSirebuli maTi Civilebi uxSiresad Semdegia: gulis friali, advilad daRla, mousvnroba, diskomforti mkerdis areSi, dispnoe, presinkope, an ufro iSviaTad, sinkope. ariTmiasTan dakavSirebuli simptomebis swori analizi mniSvnelovani gasaRebia ariTmiis tipis gansazRvraSi. supraventrikuluri taqikardia SesaZloa yvela asakobriv jgufSi Segvxvdes da gamovlindes an minimaluri simptomebiT, kerZod, guliscemis aCqarebiTa da gulis frialiT, an gaxdes sinkopes mizezi. Tu ariTmias axasiaTebs ganmeoreba, iwyeba swrafad da swrafadve mTavrdeba, igi iTvleba paroqsizmulad. mniSvnelovania ganisazRvros guliscemis aCqarebis regularoba; araregularuli riTmis mizezi SeiZleba iyos naadrevi SekumSva (eqstrasistola), mocimcime ariTmia an multifokaluri winagulovani taqikardia (MAT). es ukanaskneli Cveulebriv im pacientebSi gvxvdeba, romlebsac filtvis daavadebebi awuxebT. sinusuri taqikardia, rogorc wesi, araparoqsizmulia, TandaTanobiT Cqardeba da aseve mTavrdeba. sinusuri taqikardiis mqone pacientebSi unda moviZioT gamomwvevi faqtorebi-stresorebi, rogoric SesaZloa iyos infeqcia, siTxis kargva da a. S. regularuli da paroqsizmuli guliscemis aCqarebis epizodebi, romlebic iwyeba da mTavrdeba uecrad, ufro metad miuTiTebs atrioventrikuluri reciprokuli (AVRT) da nodaluri reciprokuli taqikardiis (AVNRT) arsebobaze. vagusuri sinjebiT taqikardiis dasruleba metyvelebs atrioventrikuluri reentris meqanizmiT mimdinare ariTmiaze (AVRT, AVNRT). poliuria, romelsac xSirad uCivian

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pacientebi, gamowveulia winagulSi wnevis gazrdis Sedegad winagulis natriurezuli hormonis gamoyofiT, rac Seupovari supraventrikuluri ariTmiebisTvisaa damaxasiaTebeli. supraventrikuluri ariTmiebis (SVT) gamo pacientTa 15%-s SesaZloa ganuviTardes sinkope, rac Cveulebriv xdeba swrafi SVT dawyebisTanave an taqikardiis uecrad moxsnis Semdeg. sinkope SesaZlebelia asocirdebodes swrafi damatebiTi gzebiT gatarebis paTologiasTan da gamowveuli iyos Tamxlebi struqturuli daavadebebiT, rogoricaa aortis xvrelis stenozi, hipertrofiuli kardiomiopaTia, an cerebrovaskuluri daavadebebi. simptomebis mravalferovneba ganpirobebulia ventrikulur riTmiT, gulis Tanmxlebi daavadebebiT, SVT-is xangrZlivobiT da pacientis individualuri aRqmiT. Tu SVT grZeldeba kvirebisa da Tveebis manZilze, da epizodebi xSiria - man SesaZlebelia gamoiwvios taqikardia-ganpirobebuli kardiomiopaTia. anamnezis Sekrebisas sayuradReboa SVT epizodebis sixSire, xangrZlivoba, aRmocenebis xasiaTi da gamomwvevi mizezi. SVT xasiaTdeba klinikuri gamovlinebis heterogenobiT, ufro xSirad gvxvdeba gulis sagulisxmo struqturuli darRvevebis gareSe, axalgazrdebSi. taqikardiisas gamokvlevebi standartulia da xSirad ver iZleva miniSnebas diagnozis diferencirebisaTvis.

2. gamokvlevebi

aucileblad unda gadaviRoT 12-arxiani ekg da SeviswavloT igi anomaluri riTmis, sinusuri taqikardiis, ST-segmentis cvlilebebis, preegzitaciis, gaxangrZlivebuli QTintervalisa da Tanmxlebi struqturuli daavadebebis arsebobaze. Cveulebriv ekg-ze preegzitaciis arsebobisa da regularuli paroqsizmuli taqikardiis istoriis SemTxvevaSi winaswari diagnozia AVRT. specifikuri Terapia ganxilulia qvemoT. araregularuli da paroqsizmuli taqikardiis arseboba anamnezSi, bazisur ekg-ze preegzitaciis (naadrevi agznebis) niSnebi miuTiTebs winagulTa fibrilaciis (AF) arsebobaze da saWiroa aseTi pacientebis dauyovnebeli eleqtrofiziologiuri gamokvleva, ramdenadac isini imyofebian uecari sikvdilis maRali riskis qveS. zogjer diagnozis dasma xdeba taqikardiis dros gadaRebuli 12arxiani ekg-is guldasmiTi SeswavliT. 12-arxiani ekg-is avtomaturi analizis funqcia xSirad iZleva cdomilebas. Tu aRiniSneba farTokompleqsovani an ucnobi genezis taqikardia, pacienti unda gavagzavnoT riTmologTan. viwrokompleqsovani taqikardiis SemTxvevaSi riTmologTan gazavna unda moxdes wamlebis mimarT rezistentobisas, an Tu pacienti uarzea gaagrZelos mudmivi farmakoTerapia. igive exeba yvela pacients ariTmiis dros ganviTarebuli sinkopeTi da sunTqvis gaZnelebiT. sikvdilianobis maRali riskis gamo riTmologTan unda iqnen gagzavnili agreTve WPW sindromiT pacientebic. eqoskopiuri gamokvleva tardeba gulis struqturuli daavadebis gamosaricxad. 24-saaTiani holteris monitorireba unda CautardeT ariTmiis xSiri (ramdenime epizodi kviraSi), magram - tranzitoruli - mimdinareobisas. naklebad xSiri mimdinareobis ariTmiebis dasafiqsireblad ufro mizanSewonilia maryuJovani Camweris gamoyeneba. datvirTvis testis Catareba naCvenebia mxolod im SemTxvevaSi, Tu ariTmiis aRmoceneba sarwmunod ukavSirdeba fizikur datvirTvas. transezofaguli eleqtrofiziologiuri (ef) gamokvleva gamoiyeneba garkveul SemTxvevebSi, rodesac klinikuri niSnebiT ver xerxdeba ariTmiis genezis dadgena. misi Catareba araa naCvenebi, Tu igegmeba invaziuri ef gamokvleva. invaziuri ef da radiosixSiruli ablacia gamoiyeneba paroqsizmuli regularuli ariTmiebis diagnostirebisa da mkurnalobisaTvis. misi gamoyeneba SesaZlebelia empiriuladac, Tu saxezea preegzitaciis an gaurkveveli niSnebi.

3. marTva

pacientebSi, rodesac savaraudoa riTmis esa Tu is darRveva, TumcaRa igi araa dokumentirebuli kardiografiulad, mkurnalobas unda hqondes simptomuri xasiaTi. Tu winamorbedi ekg normaluria da pacienti aRwers eqstrasistoliisaTvis damaxasiaTebel Civilebs, unda ganvixiloT da SevafasoT Semdegi faqtorebi: kofeinis, alkoholis, nikotinis moxmareba, medikamenturi reJimis cvlileba, an hiperTireoidizmi. eqstrasistolebi xSirad Tavs iCens mosvenebis mdgomareobaSi da datvirTvisas axasiaTebs kleba. Tu simptomebi da klinikuri mimdinareoba migvaniSnebs ariTmiis paroqsizmul xasiaTze da amave dros, mosvenebis ekg ar gviqmnis warmodgenas ariTmiis meqanizmze, damatebiTi gamokvlevebis Catareba SesaZloa arc iyos aucilebeli (eleqtrofiziologiur gamokvlevamde da/an ablaciamde). pacients unda vaswavloT vagusuri manevrebi. beta-blokerebis daniSvna SesaZlebelia empiriulad, Tu xels ar gviSlis gamoxatuli bradikardia (gSs<50'). maRali

32

ariTmogenuli moqmedebis gamo I da III klasis antiariTmiuli saSualebebi ar iniSneba ariTmiis dokumentirebis gareSe (ix. qvemoT).

b. pacientebis Sefaseba dokumenturad dadasturebuli ariTmiis mixedviT

1. diagnostika

Tu SesaZlebelia, ekg-s Cawera unda moxdes 12 Tanamimdevrul ganxraSi uSualod taqikardiis dros, Tumca amave dros dauyovnebliv unda moxdes ariTmiis kupireba, Tuki is arRvevs hemodinamikas. rogorc minimumi, sasurvelia monitorTan mierTeba defibrilaciamde, im SemTxvevaSic ki, Tu saxezea kardiogenuri Soki an gulis gaCereba. a.

viwro QRS-kompleqsovani taqikardiis diferenciuli diagnozi

Tu QRS-kompleqsi viwroa (naklebia 120ms), taqikardia TiTqmis yovelTvis supraventrikuluria da diferencireba damokidebulia mis meqanizmze (sur.1). Tu ar Cans P kbilebi an winagulovani aqtivaciis raime niSani da RR intervali regularulia, yvelaze mosalodnelia AVNRT meqanizmi. AVNRT dros SesaZloa P-kbilis aqtivoba gadaifaros QRSkompleqsiT, ris gamoc mas fsevdo-R kbilis forma eqneba V1-Si da/an fsevdo-S kbilisa - qveda ganxrebSi. Tu P-kbili gamoxatulia da igi daSorebulia QRS-kompleqsidan >70ms, yvelaze savarudoa AVRT. Tu taqikardiisas RP>PR, maSin saqme gvaqvs atipiur AVNRT, kvanZovani reciprokuli taqikardiis permanentul formasTan (PJRT) (AVRT neli damatebiTi gziT), an AT. adenozinze an karotidul masaJze pasuxis mixedviT viwro QRS-kompleqsovani taqikardiis dros, SesaZloa damatebiT vimsjeloT misi ganviTarebis meqanizmze (sur.2). 12-arxiani ekg-is uzrunvelyofa sasurvelia am sinjebis Catarebis dros. Tu P-kbili ar Cans, sasurvelia transezofaguri ekg Canaweris gamoyeneba.

viwro

QRS taqikardia

(QRS xangrZlivoba naklebia 120 ms)

taqikardia regularulia?

ki ara

Cans

ara

winagulebis cimcimi winagulovani taqikardia/TrTolva variabeluri gatarebiT, multifokaluri winagulovani taqikardia

P kbilebi?

ki

AV (MAT)

winagulebis sixSire metia parkuWebis sixSireze?

ki

winagulebis TrTolva an winagulovani taqikardia

ara

SeafaseT

RP intervali

mokle (RP<PR)

grZeli (RP>PR)

(RP naklebia vidre PR)

(RP ufro grZelia, vidre PR)

winagulovani taqikardia atipiuri

RP naklebia 70 ms

dizopiramidi, prokainamidi qinidini

RP metia 70 ms

PJRT AVNRT

AVRT AVNRT

winagulovani taqikardia

33

Semoklebebi:

AVRT AV reciprokuli taqikardia AVNRT AV nodaluri reciprokuli taqikardia PJRT paroqsizmuli reciprokuli kvanZovani taqikardia

sur. 1. viwro QRS taqikardiis diferenciuli diagnostika

r egul ar ul i viw r o

QRS

taqikar d ia

ad eno zini

i/v

si x S i r e a r i c v l e ba

sixSir e T and aT an mcir d eba, Semd eg kvl av C q a r e ba

uec r ad wyd eba

Seupo var i taqikar d ia gar d amaval i

winagul o vani maR al i xar isxis A V bl o kiT

· pr epar at is d o za ar aad eqvatu r ia · ganixil eba par kuW o vani taqikar d iis SesaZl ebl o ba (f a sc i k u l u r i a n z e d a p i r u l i w a r m o S o b i s )

· · ·

sinusur i t aqikar d ia f o kal ur i w inagul o vani taqikar d ia ar apar o qsizmul i kvanZo vani t aqikar d ia

· ·

· ·

A V N R T A V no d al ur i r ecipr o kul i taqikar d ia A V R T A V r ecipr o kul i taqikar d ia s i n u s u r i r e-en try

f o kal ur i w inagul o vani taqikar d ia

· ·

ad eno zinis d o zir eba: I d o za II d o za su r .2 . a d e n o zi n i s

winagul ebis T r T o l va winagul o vanii taqikar d ia

ad eno zini 6 m g , i /v b o l u s i T , S e m d e g f i zi o l o g i u r i xsnar is sw r af i Seyvana 1 2 m g i /v b o l u s i T , S e m d e g f i zi o l o g i u r i xsnar is sw r af i Seyvana

ATP 10m g 20m g

i/v g a m o y e n e b i T v i w r o Q R S t a q i k a r d i i s d i f e r e n c i u l i d i a g n o s t i k a

34

Tu QRS-kompleqsi gafarToebulia (aRemateba 120 ms), mniSvnelovania diferencireba SVT da parkuWovan taqikardias (VT) Soris (sur.3). farTo QRS taqikardiisas ar SeiZleba iseTi medikamentebis gamoyeneba, rogoricaa verapamili an dilTiazemi, vinaidan VT-s SemTxevaSi maT SeuZliaT hemodinamikuri kolafsis gamowveva. hemodinamikuri stabiluroba taqiariTmiis dros ar gamoricxavs VT-s. Tu ar xerxdeba SVT-is diagnozis dadastureba, pacientebs unda vumkurnaloT ise, rogorc VT-is SemTxvevaSia mowodebuli. farTo QRS-kompleqsiani taqikardia SesaZloa daiyos sam jgufad: 1) SVT hisis konis fexis blokiT (BBB) an aberaciiT, 2) SVT impulsis damatebiTi gzebiT gatarebiT, 3) parkuWovani taqikardia VT.

SVT hisis konis totis blokiT (BBB). hisis konis totis bloki SesaZloa arsebobdes damoukideblad an mxolod taqikardiis dros ganviTardes, roca maRal sixSireze hisis konis erT-erTi toti refraqteruli xdeba. BBB ara mxolod sixSiredamokidebulia, aramed viTardeba `grZeli-mokle~ Tanamimdevrobis (long-short sequence) dawyebisas. hisis konis totis bloki SesaZloa aRmocendes nebismieri supraventrikuluri ariTmiisas. Tu sixSiredamokidebuli bloki aRmocendeba orTodromuliAAVRT dros da blokis mxare emTxveva damatebiTi gzis mdebareobis mxares (ipsilateraluria), taqikardiis sixSire SesaZloa dabali iyos. SVT impulsis damatebiTi gziT gatarebiT. es mdgomareoba SesaZloa aRmocendes winagulovani taqikardiis, winagulebis TrTolva/cimcimis, AVNRT an antidromuli AVRT dros. impulsi antegradulad tardeba damatebiTi gziT, retrogradulad ki AV kvanZiT an meore damatebiTi gziT. farTo QRS-kompleqsiani taqikardia LBBB (hisis konis marcxena totis blokadis) morfologiiT SesaZloa aRmocendes agreTve sxva tipis damatebiTi gzebis arsebobisas, rogoricaa atriofascikuluri, nodofascikuluri, an nodoventrikuluri traqtebi. parkuWovani taqikardia. ZiriTadi ekg kompleqsovani taqikardiis meqanizmebis ganxilvisas.

kriteriumebi aRwerilia farTo

QRS-

disociacia, rodesac parkuWTa SekumSvis sixSire aRemateba winagulebisas, umTavresad moiuTiTebs VT-ze (sur.4), Tumca mxolod SemTxvevaTa 30%-Sia SesaZlebeli misi naTlad garCeva. Serwymuli kompleqsebi warmoadgens gatarebuli sinusuri (an supraventrikulur) impulsisa da AV disociaciis fonze parkuWTa depolarizaciis dros warmoqmnil kompleqsTa erTgvar "nazavs". es kompleqsebi paTognomuria VT-saTvis. retrograduli VA bloki SesaZloa warmoiqmnas spontanurad an karotiduli sinusis masaJiT. Tu dadginda, rom P kbilis arseboba ar aris aucilebeli taqikardiis SenarCunebisaTvis, anu karotiduli masaJi uefeqtoa, unda vifiqroT VT-is arsebobaze. marTalia P kbilis ararseboba miuTiTebs VT-ze, misi Secnoba rTuldeba farTo QRS taqikardiis dros.

atrioventrikuluri disociacia. AV

35

far T o

r egul ar ul ia

Q R S taqikard ia ( Q RS > 120 m s )

ar ar egul ar ul ia

Q R S id ent ur ia T u ar a

sinusur i r itmis d r o s ar sebul i Q RS -isa? T u ki, Sefasd es a) SV T d a BB B b) antid r o mul i A V RT vagusur i cd ebi an ad eno zini

winagul ebis cimcimi winagul ebis T r T o l va/ winagul o vani taqikard ia cval ebad i A V gatar ebiT da a) hisis ko nis f exis bl o ki an b) ant egrad ul i gat ar eba d amatebiT i gziT

mio kar d iumis inf ar qti an gul is str u qtu r ul i d aavad eba anamnezSi? T u ki, savar aud o a V T.

erT i-er T ze

A V urT ier T kavSir i? 1:1 (P=Q R S )

ar a

parkuW ebis SekumSvis sixSir e metia winagul ebis SekumSvis sixSir eze

par kuWebis SekumSvis sixSir e metia winagul ebis Seku mSvis sixSir eze

ki

Q R S mo r f o l o gia pr eko r d iul ganxr ebSi

pakuWo vani t aqikar d ia

(V T)

winagul o vani t aqikard ia winagul ebis T rT o l va

pakuWo vani taqikard ia

tipiu ri R BB B an

L BB B

ko nko rd ant ul i cvl il ebebi. R /S T anafar d o ba ar aris, R- d an gad axr amd e V 1 ­ Si metia 60m s

S- is

VT

SV T

saxezea LB BB V 1 - Si R metia 30m s, an manZil i R d an S- is gad axr amd e V 1 ­ Si met ia 60m s

saxezea

el eqt r ul i R er Zi +90-d an ­90-md e

RB B B qR , R s an R r V 1 -Si

su r. 3. far T o

Q R S t aqikar d iis d ifer enciul i d iagno zi

sur. 4. AV disociacia VT dros, kbilebi.

isrebiT miTiTebulia P

Tumca AV disociaciis dadgenaSi dagvexmareba fizikaluri monacemebi: araregularuli qvemexisebri A talRebi sauRle venebis pulsaciis dros da pirveli tonis simaRlis cvlileba. P kbilis garCevaSi daxmarebas gagviwevs saylapavSida ekg.

QRS kompleqsis sifarTe. QRS sifarTe > 140ms marjvena totis blokiT (RBBB) da > 160ms marcxena totis blokiT (LBBB) miuTiTebs VT-is arsebobaze. QRS sifarTe ar aris sakmarisi kriteriumi VT da SVT-sagan gasarCevad, Tu impulsi tardeba damatebiTi gamtari gziT. SVT-s mqone pacientebs SesaZloa aReniSnoT QRS >140ms (RBBB) da >160ms (LBBB) im SemTxvevebSic, Tuki taqikardiamde aRiniSneboda BBB, damatebiTi gamtari gza, an tardeboda mkurnaloba Ia an Ic

klasis antiariTmiuli saSualebebiT.

QRS kompleqsis konfiguracia taqikardiis dros. V1 da V6 ganxrebi gamoiyeneba VT da SVT sadiferenciaciod. Tu RS intervali aRemateba 100 mwm-s nebismier prekordiul ganxraSi, ZiriTadad savaraudoa VT.

36

QRS kompleqsis uaryofiTi konkordantuloba prekordiul ganxrebSi miuTiTebs VT-is arsebobaze ("uaryofiTi konkordantuloba" niSnavs, rom QRS kompleqsi yvela prekordiul ganxraSi erTnairi da uaryofiTia, anu realurad fiqsirdeba QS). pozitiuri konkordantuloba ar gamoricxavs antidromul AVRT marcxena ukana damatebiTi gziT gatarebiT.

parkuWovani Serwymuli kompleqsebis arseboba mianiSnebs taqikardiis parkuWovan genezze. QS kompleqsi miuTiTebs miokardiumis dazianebaze da gvxvdeba VT-is SemTxvevaTa ~40%Si miokardiumis infarqtis Semdeg. hiperkaliemiis, gulis mZime ukmarisobis da antiariTmiul saSualebebiT mkurnalobisas, kompleqsis sifarTe da morfologia nakleb specifiur kriteriums warmoadgens. miuxedavad ekg QRS-kompleqsovani taqikardiiT xSirad rCebian kriteriumebisa, pacientebi farTo aradiagnostirebulni. dadebiTi pasuxi or kiTxvaze: `aris Tu ara anamnezSi miokardiumis infarqti?~ da `aRmocenda Tu ara pirvelad msgavsi taqikardia infarqtis Semdeg?~, maRali sarwmunoebiT miuTiTebs VT-is arsebobaze. 2. marTva rodesac ekg da klinikuri kriteriumebis gaTvaliswinebiT saboloo diagnozis dasma SeiZleba, mwvave da xangrZlivi mkurnaloba mimarTuli unda iyos gamomwvevi meqanizmis gaTvaliwinebiT. (ix. Tavi "specifiuri ariTmiebi"). Tuki miuxedavad Catarebuli saTanado kvlevebisa farTo QRS -taqikardiis specifiuri diagnostika ver moxerxda, maSin pacients unda vumkurnaloT ise, rogorc vumkurnalebdiT mas dadasturebuli VT-is SemTxvevaSi. hemodinamikurad stabiluri da regularuli taqikardiis mkurnalobis algoriTmi mocemulia sur.5.

hemodinamikurad stabiluri regularuli taqikardia

viwro

QRS

* ganisazRvros SesaZlebloba

farTo

QRS

SVT

VT an ucnobi meqnizmi

*

SVT

ventrikuluri taqikardia

supra-

SVT+BBB

(ix. viwro QRS)

preeqsitaciuli

SVT

vagusuri sinjebi

i/v prokainamidi

i/v sotaloli

i/v adenozini i/v verapamili/dilTiazemi i/v -blokeri

i/v lidokaini i/v amiodaroni (pacientebSi

marcxena parkuWis daqveiTebuli funqciiT)

moixsna

ki

ara, grZeldeba taqikardia blokiT

AV

moixsna

i/v ibutilidi** i/v prokainamidi i/v flekainidi

plus AVkvanZis blokerebi

ki

ara

an stimulacia gadaZabviT/kardioversia

kardioversia

Semokleba:

BBB hisis konis blokada * - unda Caiweros 12 ganxraSi - adenozini frTxilad unda gamoviyenoT gid avadmyofebSi

37

sur. 5. hemodinamikurad stabiluri regularuli taqikardiis mwvave marTva.

viwro da farTo QRS kompleqsovani taqikardiebis kupirebisaTvis yvelaze efeqturi da swrafi saSualeba aris kardioversia. mas ar mimarTaven, Tu riTmis darRveva ar iwvevs hemodinamikur arastabilurobas.

a. viwro QRS kompleqsovani taqikardiis gadaudebeli mkurnaloba

regularuli viwro QRS taqikardiis dros vagusuri sinjebi (rogoricaa valsalvas, karotiduli sinusis masaJi, saxis civ wyalSi Cayofa) tardeba taqikardiis mosaxsnelad an AV gamtareblobis Sesacvlelad. warumateblobis SemTxvevaSi, hemodinamikurad stabilur pacientebSi ariTmiis kupirebisaTvis saWiroa i/v antiariTmiuli saSualebebis Seyvana. arCevis preparatebs warmoadgens adenozini (atf) an aradihidropiridinuli kalciumis arxebis blokerebi (sur.3). i/v kalciumis arxebisa da beta-blokerebis gamoyenebisas aucilebelia maqsimaluri sifrTxilis gamoCena, vinaidan mosalodnelia hipotenziuri da/an bradikardiuli efeqtebis potencireba. aucilebelia agreTve ekg Cawera vagusuri sinjebisa da medikamentebis Seyvanisas, vinaidan pasuxi dagvexmareba ariTmiis SecnobaSi im SemTxvevaSic ki, Tu ver moxerxda misi kupireba (sur.2). taqikardiis kupireba bolo QRS kompleqsis Semdeg P kbiliT, miuTiTebs AVRT an AVNRT-is arsebobaze. taqikardiis kupireba QRS kompleqsiT miuTiTebs VT, romelic adenozinis mimarT xSirad aramgrZnobiarea. taqikardiis gagrZeleba AV blokiT sarwmunod miuTiTebs AT an winagulebis TrTolvaze, gamoricxavs AVRT-s, xolo AVNRT-is arsebobas metad arasarwmunos xdis.

b. farTo QRS kompleqsovani taqikardiis marTva gadaudebel etapze.

dauyovnebeli garegani kardioversia hemodinamikurad arastabiluri taqikardiis mkurnalobis radikaluri saSualebaa. Tu taqikardia supraventrikuluri xasiaTisaa da hemodinamikurad stabiluria, misi marTva iseve xdeba, rogorc viwro QRS kompleqsiani taqikardiis (sur.2). randomizebuli, Tumca mcire masStabis kvlevebis mixedviT i/v prokainamidisa da/an sotalolis gamoyeneba rekomendirebulia stabiluri faro QRS kompleqsovani taqikardiis kupirebisaTvis. rekomendirebulia amiodaronis gamoyenebac. misi efeqturoba aRemateba prokainamidisa da sotalolis efeqturobas marcxena parkuWis (LV) daqveiTebuli funqciis da gulis ukmarisobis niSnebis mqone pacientebSi. specifiur SemTxvevebSi (preegzitaciuri taqikardia da digitalisuri intoqsikaciiT gamowveuli VT) SesaZlebelia alternatiuli mkurnalobis sqemis gamoyeneba. araregularuli farTo QRS kompleqsovani taqikardiis (mag. AF preegzitaciiT) kupirebisaTvis rekomendirebulia eleqtruli kardioversia. xolo Tu hemodinamika stabiluria, mowodebulia i/v ibutilidi, flekainidi an prokainamidi. g. Semdgomi mkurnaloba da meTvalyureoba ucnobi etiologiis farTo QRS kompleqsovani taqikardiis warmatebuli kupirebis Semdeg pacienti aucileblad unda gaigzavnos konsultaciisaTvis ariTmologTan. pacientebi stabiluri viwro QRS taqikardiiT, normaluri LV funqciiTa da ekg sinusuri riTmis dros (preegzitaciis niSnebis gareSe) SesaZloa ar saWiroebdnen specifiur mkurnalobas. gamonaklisia is pacientebi, romelTac aReniSnebaT medikamentebisadmi rezistentoba an tolerantoba, agreTve isini, vinc uarzea miiRos wamlebi mTeli cxovrebis manZilze. mkurnaloba moicavs kaTeterul ablacias an farmakoTerapias. da bolos, sikvdilianobis maRali riskis gaTvaliswinebiT WPW sindromis mqone simptomuri pacientebi (preegzitaciiT an ariTmiiT) saWiroeben damatebiT gamokvlevebs.

supraventrikuluri taqikardiis diagnostika da marTva

Management of Cardiac arrhythmias by L.I. Ganz, E.Brounwald AHA/ACC/ESC Guidelines on Management of of Patients with Supraventricular Arrhythmias, 2003 supraventrikuluri taqiariTmiebi klinikur praqtikaSi sakmaod farTodaa gavrcelebuli, amasTan igi vlindeba yvela asakis pacientebSi, damoukideblad imisa, figurirebs Tu ara gulis struqturuli daavadebebi.

paTofiziologia

yvela taqiariTmia, romelTa aRmocenebasa da SenarCunebaSi monawileobas Rebuloben winagulovani da/an AV-kvanovani struqturebi, ganixileba, rogorc supraventrikuluri

38

taqiariTmiebi. imisda mixedviT, Tu romeli gamtari gzebi monawileoben mis aRmocenebaSi, supraventrikuluri taqiariTmiebi SeiZleba daiyos or tipad: 1) winagulovani taqiariTmiebi, romlebic saWiroeben mxolod winagulovan qsovils da 2) taqiariTmiebi, romlebic saWiroeben AV-kvanZs. supraventrikuluri taqikardia (SVT) SeiZleba iyos paroqsizmuli (PSVT) da ganuwyveteli. winagulovani taqiariTmiebi

winagulovani taqikardia

winagulovani taqikardia supraventrikuluri taqikardiis tipia, romelic aRmocendeba winagulis qsovilebSi. igi aseve unifokalur an eqtopiur taqikardiad moixsenieba, supraventrikuluri taqiariTmiebis SedarebiT iSviaTi formaa, gansakuTrebiT ki - mozrdilebSi. winagulovani, anu `grZeli RP taqikardia~ eleqtrokardiografiulad xasiaTdeba imiT, rom P kbili gacilebiT ufro axloa momdevno QRS-kompleqsTan, vidre wina QRS-Tan. P-kbilis morfologia, rac saSualebas iZleva dadgindes taqikardiis warmoSobis adgili, damokidebulia taqikardiis fokusis mdebareobaze. aRniSnuli ariTmiis aRmocenebas safuZvlad udevs re-entry, avtomatizmi da trigeruli meqanizmebi. aRsaniSnavia, rom arareentrul taqikardiebs upiratesad uwyveti xasiaTi aqvT, ris gamoc maRalia taqikardia-inducirebuli kardiomiopaTiis ganviTarebis riski.

sinusuri taqikardia

sinusuri taqikardia ­ fiziologiuri reaqciaa organizmis sxvadasxva gzebiT agznebaze. cnobilia, rom sinoatriuli (SA) kvanZi inervirdeba simpatikuri da parasimpatikuri nervuli sistemebis daboloebebiT, amasTan simpatikuri aqtivacia, iseve rogorc vagaluri reaqciebis blokireba, iwvevs taqikardias. pulsis sixSireze sisxlSi mocirkulire kateqolaminebic axdenen gavlenas. sinusuri taqikardiis gamomwvevi zogadi mizezebidan aRsaniSnavia iseTebi, rogoricaa: tkivili, aforiaqeba, sicxe, hipotenzia, hipoqsia, hiperTireoidizmi da hipovolemia. imis gaTvaliswinebiT, rom sinusuri taqikardia organizmis fiziologiuri reaqciaa sxvadasxa tipis gaRizianebebze, mkurnalobis ZiriTadi aqcenti mimarTuli unda iqnas aRniSnuli mizezebis aRmofxvrisaken.

Seusabamo sinusuri taqikardia

es gaxlavT aseve sinusuri taqikardia, im gansxvavebiT, rom ar arsebobs misi ganviTarebisaTvis saWiro TvalsaCino mizezi. am SemTxvevaSi pacientebs mSvid mdgomareobaSic stabilurad maRali pulsi aqvT da igi kidev ufro mkveTrad imatebs umniSvnelo datvirTvaze. imis gamo, rom hiperTireoidizmsa da feoqromocitomas SeuZliaT Seusabamo sinusuri taqikardiis imitireba, aucilebelia am paTologiebis gamoricxva. mkurnalobis principebi - ix. cxrili 1

mkurnaloba medikamenturi arafarmakologiuri

rekomendacia marilisa da siTxeebis moxmarebis gazrda maRal sasTumalze Zili fizikuri varjiSebi kompresiuli windebi fludrokortizoni bisoprololi bisoprololi +fludrokortizoni klonidini midodrini meTilfenidati fluoqsetini eriTropoetini ergotamini fenobarbitoni sinusis kvanZis modifikacia, kaTeteruli ablacia

Cvenebis klasi

sarwmunoebis done

IIa IIa IIa IIa IIa IIa IIa IIb IIb IIb IIb IIb IIb IIb

III

B B B B B B B B B C C B B C B

farmakologiuri mineralokotikoidebi

-blokerebi -blokerebi

mineralokortikoidebi centraluri simpaTolitikebi periferiuli aqtivatorebi centraluri aqtivatorebi serotoninis inhibitorebi sxva

+

intervenciuli kaTeteruli ablacia

39

cxrili 1. posturuli orTostatiuli taqikardiis sindromis mkurnaloba.

posturuli orTostatiuli taqikardiis sindromi

posturuli orTostatiuli taqikardia avtonomiuri neiropaTiebis erT-erTi gamovlinebaa. igi moicavs Zlier orTostatiul hipotenzias avtonomiuri neiropaTiis arsebobisas da vazovagalur sinkopes avtonomiuri neiropaTiis sxva gamovlinebis ararsebobisas. asocirdeba sxvadasxva simptomTan, rogoricaa advilad daRla, gulis "friali", slokini, uxasiaToba. posturuli orTostatiuli taqikardiis diagnozi daismeba, Tu adgili aqvs posturul sinusur taqikardias (moimatebs bazisurTan SedarebiT > 30 an aRemateba 120') vertikalkur mdgomareobaSi gadasvlisas, posturuli hipotenziis niSnebis gareSe. am tipis taqikardiis diagnostirebisaTvis aucilebelia orTostatiuli sinjis (tilt-table test) Catareba. mkurnalobis principebi naCvenebia cxr. 2.

mkurnaloba medikamenturi intervenciuli

rekomendacia

Cvenebis klasi

sarwmunoebis done

-blokerebi

verapamili, dilTiazemi kaTeteruli ablacia-sinusis kvanZis destruqcia

I IIa IIb

C C C

cxrili 2. Seusabamo sinusuri taqikardiis mkurnaloba.

sinusis kvanZis reciprokuli taqikardia

igi warmoadgens re-entry-s tipis winagulovan taqikardias, sadac re-entry-s wre moicavs SA kvanZs an peri-SA-kvanZovan qsovilebs. am SemTxvevaSi P-kbilebi sinusuri genezis P-kbilebis identuri an praqtikulad identuria. iseve rogorc sxva tipis reciprokuli taqikardiebi, sinusis kvanZovani re-enty-li taqikardia sinusuri da Seusabamo sinusuri taqikardiebisagan gansxvavebiT xasiaTdeba uecari dasawyisiTa da dasasruliT. klinikurad aRniSnuli ariTmia SedarebiT iSviaTad vlindeba, igi SeiZleba SemTxveviT aRmoCenili iqnas eleqtrofiziologiuri (EP) kvlevisas da mas upiratesad aramdgradi xasiaTi aqvs.

multifokaluri winagulovani taqikardia

es ariTmia diagnostirdeba, rodesac winagulTa araregularul SekumSvaTa fonze, sixSiriT wuTSi sul mcire 100', morfologiurad vlindeba minimum 3 tipis P-kbili. es ariTmia ZiriTadad uviTardebaT mwvave paTologiebis mqone asakovan pacientebs, gansakuTrebiT pulmonuri daavadebebis arsebobisas. diskretuli P kbilebi invertuli izoeleqtruli segmentiT, ganasxvavebs mas mocimcime ariTmiisagan.

mocimcime ariTmia

taqiariTmiebSi igi yvelaze ufro xSiri formaa, romelic marjvena da marcxena winagulebSi arsebuli mravlobiTi mikro re-entry-s rgolis Sedegia.

winagulTa TrTolva

igi makro reentruli ariTmiaa. winagulTa TrTolva moicavs stereotipur marjvena winagulovan wres (tipiuri saaTis isris sawinaaRmdego da saaTis isrisken mimarTuli isTmusdamokidebuli TrTolva) an sxva wreebs (atipiuri TrTolva). atipiuri forma ZiriTadad gvxvdeba postoperaciul an gulis Tandayolili paTologiebis mqone pacientebSi.

A-V

kvanZovani taqiariTmiebi

AV nodaluri reentruli taqikardia (AVNRT)

40

supraventrikulur paroqsizmul taqikardiebs Soris yvelaze xSirad gvxvdeba AVNRT; mokle RP taqikardia misi tipiuri formaa. am dros P-kbili an STanTqmulia QRS-kompleqsSi da igi ekg-ze SeumCnevelia, an fiqsirdeba QRS-kompleqsis ST-segmentSi gadasvlis adgilas. AVNRT-is atipiuri formaa "grZeli RP-taqikardia" da igi eleqtrokardiografiulad unifokaluri winagulovani taqikardiis msgavsia 1:1-ze A:V gamtareblobiT. AVNRT uviTardebaT pacientebs, romelTac AV kvanZSi aqvT mofunqcionire swrafi da neli gamtari gzebi. sinusuri riTmis fonze anterogradul gamtareblobas axorcielebs swrafi gza. Tuki uecrad aRmocenebul winagulovan eqstrasistolas swrafi gza wina agznebis Semdeg jer kidev refreqterul periodSi daxvdeba, agznebas gaatarebs neli gza. Tuki am gamtareblobis xangrZlivoba sakmarisia imisTvis, rom swrafma gzam moaswros refraqteruli periodidan gamosvla, igi depolarizaciis talRas retrogradulad gaatarebs da aRagznebs winagulebs. amgvarad Seikvreba reentris wre. misgan gansxvavebiT, atipiuri AVNRT-is provocirebas ZiriTadad iwvevs parkuWovani eqstrasistola, rasac mohyveba agznebis retrograduli gatareba neli gziT, xolo swrafi gza abrunebs mas ukan anterogradulad. pacients SesaZloa hqondes taqikardiis erT-erTi tipi, TumcaRa zog SemTxvevaSi EP gamokvlevis dros orive formis inducireba xdeba xolme. imis gaTvaliswinebiT, rom infranodaluri qsovilebi re-enrty-s jaWvis AVNRT SesaZloa gamovlindes 2:1 infranodaluri blokiT, rac Semadgeneli nawilia, amsgavsebs mas winagulovan taqikardias 2:1 A:V gamtareblobiT.

A-V reentruli (reciprokuli) taqikardia (AVRT)

Cveulebriv, AV kvanZi da his-purkinies sistema warmoadgens winagulebsa da parkuWebs Soris impulsis moZraobis normalur gamtar sistemas. damatebiTi gamtari gzis arsebobis SemTxvevaSi, romelic SeiZleba mdebareobdes mitraluri an trikuspidaluri rgolebis irgvliv, iqmneba mokle SemaerTebeli eleqtruli xidi winagulsa da parkuWs Soris. Tuki agzneba anterogradulad vrceldeba damatebiTi gzis meSveobiT, maSin eleqtrokardiografiulad isaxeba parkuWTa preegzitaciis niSnebi da vlindeba Wolf-Parkinson-White-is (WPW) sindromi sinusuri riTmis fonze. WPW-s mqone pacientebSi upiratesad adgili aqvs orTodromul AVRT-s. am SemTxvevaSi makro re-entry-s wreSi impulsis anterogradul gatarebas anxorcielebs AV kvanZi, xolo retrograduls ­ damatebiTi gza. AVNRT-s msgavsad, orTodromuli AVRT aseve mokle RP taqikrdiaa da P­kbilebi xSirad SesamCnevia ST-segmentis fonze. ufro iSviaTad re-entry-s jaWvSi SesaZloa impulsis SebrunebiTi gatareba. am SemTxvevaSi isaxeba farTo QRSkompleqsovani taqikardia, romelsac antidromuli AVRT ewodeba. WPW-s mqone pacientebSi xSiria mocimcime ariTmis da winagulTa TrTolvis SemTxvevebi. AV kvanZisgan gansxvavebiT damatebiT gzaTa umravlesobas aqvT swrafi aradekrementuli gamtareblobis unari da im SemTxvevaSi Tuki parkuWTa SekumSvis sixSire miaRwevs 250-300 wuTSi, iqmneba supraventrikuluri taqikardiis parkuWTa fibrilaciaSi gadazrdis winapiroba. aseT SemTxvevaSi maRalia uecari sikvdilis ganviTarebis riski. zogierT damatebiT gzas axasiaTebs mxolod retrograduli gamtaroba. aseT SemTxvevaSi sinusuri riTmis fonze parkuWTa preegzitaciis niSnebi ar vlindeba da pacientebi ganixilebian, rogorc faruli WPW-s mqoneni. faruli WPW-s dros AVRT yovelTvis orTodromulia, xolo aseT dros winagulTa fibrilaciis an TrTolvis SemTxvevaSi parkuWTa zexSiri preegzitaciis gamo uecari sikvdilis ganviTarebis riski ar arsebobs. zogierTi faruli damatebiTi gza xasiaTdeba neli gamtareblobiT. aseT avadmyofebSi orTodromul AVRT-s, romelsac grZeli RP intervali axasiaTebs, permanentuli kvanZovani reciprokuli taqikardia (PJRT) ewodeba. radganac am ariTmias permanentuli xasiaTi aqvs da SeuZlia taqikardia-inducirebuli kardiomiopaTiis gamowveva.

araparoqsizmuli kvanZovani taqikardia (NPJT)

am tipis taqikardia Zalzed iSviaTia. AVNRT-isa da AVRT-isgan gansxvavebiT, romlebic re-entry-uli bunebisa arian, igi upiratesad AV kvanZSi momatebuli avtomatizmiTa da trigeruli aqtivobiTaa gamowveulia. eleqtrokardiografiulad hgavs AVNRT-s, TumcaRa SesaZloa viwrokompleqsovani taqikardiis fonze A-V disociaciiT aisaxos. NPJT upiratesad digitalisiT intoqsikaciisas an sarqvlis proTezirebis Semdgom adreul stadiaze aRmocendeba. iSviaT SemTxvevaSi ki aRiniSneba miokardiumis mwvave infarqtis drosac. mkurnalobis principebi - ix. cxrili 3.

41

ariTmiis tipi fokaluri kvanZovani taqikardia

rekomendacia

Cvenebis klasi

sarwmunoebis done

-blokerebi

flekaionidi propafenoni sotaloli amiodaroni kaTeteruli ablacia digitalisuri intoqsikaciis Semcireba hipokaliemiis koreqcia miokardiumis iSemiis mkurnaloba

araparoqsizmuli kvanZovani taqikardia

IIa IIa IIa IIa IIa IIa I I

I

C C C C C C C C C C

-blokerebi, blokerebi

kalciumis

arxebis

IIa

cxrili 3. fokaluri da araparoqsizmuli kvanZovani taqikardiebis mkurnaloba

kvanZovani eqtopiuri taqikardia (JET)

es aseve araparoqsizmuli arareciprokuli taqikardiaa, romelic upiratesad pediatriul literaturaSia aRwerili. am ariTmias SesaZloa NPJT-is msgavsi meqanizmi hqondes. upiratesad JET aRiniSneba Tandayolili gulis mankebis gamo Catarebuli qirurgiuli operaciebis Semdeg. igi xasiaTdeba Zalzed maRali gulis SekumSvaTa ricxviT da asocirebulia sikvdilianobis did maCvenebelTan. epidemiologia suraventrikuluri taqikrdiebis gavrcelebis Sesaxeb monacemebi sakamod varirebs. vrcel populaciaSi eleqtrokardiografiuli skriningis maCveneblebi aCvenebs, rom WPW-is ekg niSnebi fiqsirdeba 1000 dan 1-2 SemTxvevaSi, TumcaRa igi yvela pacientTan klinikurad ar vlindeba. aSS-is Stat viskonsinSi Catarebul epidemiologiur kvlevaSi - Marshfield Epidemiologic Study Area (MESA) simptomuri PSVT prevalirebda 1000-dan 2,25 SemTxvevaSi. am kvlevis Tanaxmad PSVT qalebSi ufro Warbobda, vidre mamakacebSi. WPW-s mqone pacientebis garda, SVT-is mqone avadmyofTa prognozi sasikeToa da misi mkurnaloba simptomTa sagrZnoblad Semsubuqebis saSualebas iZleva. supraventrikuluri ariTmiebi SeiZleba gamovlindnen gulis struqturuli daavadebebis fonze an mis gareSec. WPW-s da gulis struqturuli paTologiis ar arsebobis SemTxvevaSi SVT-is gamo uecari kardiuli sikvdilis ganviTarebis riski sakmaod dabalia. WPW-is SemTxvevaSi uecari sikvdilis ganmapirobebeli faqtoria winagulTa TrTolva/cimcimis dros parkuWTa SekumSvis Zalzed maRali sixSire, romelic qmnis ariTmiis parkuWTa fibrilaciad transformirebis winapirobas. riskis es faqtori korelaciaSia damatebiTi gamtari gzis anterogradul refraqterul periodTan. am riskis arsebobis gamo, simptomuri pacientebisaTvis eleqtrofiziologiuri gamokvleva (raTa ganisazRvros damatebiTi gzis anterograduli refraqteruli periodi) Semdgomi kaTeteruli ablaciiT, warmoadgens Terapiis upirveles saSualebas. misgan gansxvavebiT, asimptomuri pacientebis marTva kvlavindeburad kamaTis sagania, radgan aseT avadmyofebSi uecari kardiuli sikvdili Zalze iSviaTia. asimptomur WPW pacientebSi uecari sikvdilis riski Sefasebulia, rogorc daaxloebiT 1:1000. aRsaniSnavia isic, rom asimptomuri WPW-s mqone avamdyofebi usimptomoni rCebian preegzitaciis gamovlenis Semdgomac; ufro metic, umetes maTganSi damatebiTi gza kargavs impulsis anterogradulad gatarebis unars da Sesabamisad mcirdeba sikvdilianobis riskic. am faqtorebis gaTvaliswinebiT, aseT SemTxvevebSi eleqtrofiziologTa umravlesoba ar Tvlis saWirod damatebiTi specialuri diagnostikuri testebis Catarebas an mkurnalobas, Tuki es pacientebi ar arian transportis sferoSi momuSaveni an aTletebi. zogierTi mkvlvari ki saWirod Tvlis Cautardes eleqtrofiziologiuri gamokvleva usimptomo pacientebsac da mokle refraqterobis mqone damatebiTi gzis SemTxvevaSi ganxorcieldes misi ablacia.

faqtorebi, romlebic ukavSirdeba uecari sikvdilis maRal risks: (jozefsonis mixedviT) riskis Sefasebis kriteriumebi a) simptomuri WPW-s mqone pacientebSi riskis faqtorebia

42

miRebuli: _ mamrobiTi sqesi; _ mokle RP (umoklesi RR mocimcime ariTmiis dros < 220 mwm); _ damatebiTi gzis septaluri mdebareoba; _ kateqolaminebis maRali done sakamaTo: ramodenime damatebiTi gzis arseboba b) asimptomuri WPW-s mqone pacientebSi ar aris mtkicebulebebi uecari kardiuli sikvdilis riskis zrdis Sesaxeb g) garTulebebis dabali riski ganisazRvreba, Tu _ saxezea gardamavali preegzitacia; _ farmakologiuri agentebis fonze delta talRa qreba; _ datvirTvis sinjis dros ikargeba preegzitacia.

diagnostika ariTmiebis diagnostikuri kvleva damokidebulia pacientis mdgomareobaze. avadmyofebs, visac dokumentirebuli taqikardiis gareSe aqvT gulis frialis SegrZneba, unda CautardeT eleqtrokardiografia da sxva gamokvlevebi gulis struqturuli paTologiebis dasadgenad. xSir SemTxvevaSi ambulatoruli ekg-monitoringi warmoadgens efeqtur saSualebas ariTmiis dokumentirebisaTvis. manifestirebuli WPW sindromis SemTxvevaSi taqikardiis gamovlena mniSvnelovania, TumcaRa saTanado adeqvaturi gadawyvetilebebis misaRebad igi aucileblobas ar warmoadgens, radgan yvela pacients sinkopiT da WPW sindromiT aucileblad unda Cautardes eleqtrofiziologiuri gamokvleva. taqikardiis dokumentireba iZleva SVT-is tipebis diferencirebis saSualebas. umetes SemTxvevaSi, Tuki SesaZloa P-kbilebis garCeva, arsebobs 1:1-ze damokidebuleba P da QRS kompleqsebs Soris. Tuki P talRebsa da QRS kompleqsebs Soris Tanafardoba aRemateba erTs, praqtikulad, yovelTvis adgili aqvs winagulovan taqikardias, Tumca, SemTxvevaTa 10%-Si aseTi Tanafardoba SeiZleba iyos parkuWovani taqikardiis drosac. iSviaTad, AVNRT vlindeba 2:1 infranodaluri blokiT. AVRT-s ki aucileblad 1:1 A-V Tanafardoba unda hqondes. multifokaluri winagulovani taqikardiis (MAT) SemTxvevaSi P kbilebis morfologia varirebs da parkuWTa SekumSvis sixSire araregularia. taqikardiebi 1:1-ze A-V TanafardobiT, SesaZloa daiyos QRS kompleqsisa da Semdgomi Pkbilis urTierTmdebareobis mixedviT. amasTan mokle RP taqikardiebi gacilebiT ufro xSiria, vidre grZeli RP taqikardiebi (ix. cxrili 4)

43

mokle RP taqikardiebis umravlesobas warmoadgens AVNRT-s da AVRT-s. AVNRT-is dros winagulebisa da parkuWebis aqtivacia praqtikulad erTdroulad xdeba, ris gamoc P- kbili umetesad QRS kompleqsSi ikargeba. P-kbilebis manifestirebis SemTxvevaSi igi warmoadgens mcire naWdevs QRS komleqsis ST-segmentSi gadasvlis adgilas. orTodromuli AVRT-is dros parkuWTa aqtivacia win uswrebs winagulebis depolarizacias, ris gamoc P-kbilebi ufro xilvadia STsegmentze. antidromuli AVRT-sas QRS kompleqsebi farToa, amasTan sinusuri riTmis dros fiqsirdeba delta talRebi. gulis SekumSvaTa sixSire AVNRT-sa da AVRT-s dros praqtikulad erTnairia da amitom am parametriT maTi diferencireba ver moxerxdeba. QRS-is alternacia upiratesad damaxasiaTebelia AVRT-saTvis, TumcaRa iSviaT SemTxvevebSi igi AVNRT-s drosac vlindeba (ix. cxrili 5).

grZeli RP taqikardiebis eleqtrokardiografiuli gansxvaveba uxSiresad rTuli amocanaa. PJRT da atipiuri AVNRT-s dros winaguli depolarizirdeba retrograduli impulsiT. amis gamo ukana ganxrebSi (II, III, aVF) P-kbilebi invertulia. winagulovani taqikardiisas P-kbilebis RerZi da morfologia damokidebulia ariTmiis fokusis lokalizaciaze. amgvarad, Tuki isini dadebiTia ukana ganxrebSi, aseTi taqikardia winagulovania. samagierod, grZeli RP taqikardia invertuli P-kbilebiT, SesaZloa warmoadgendes: winagulovan taqikardias, PJRT-s an aratipiur AVNRT-s. im SemTxvevaSi, rodesac ekg-Ti ver xerxdeba ariTmiis identifikacia, vagaluri cdebis Catareba an adenozinis i/v infuzia efeqturi damxmare meTodebia. taqikardia, romelic gardamavali AV blokis miuxedavad kvlav grZeldeba, winagulovani warmoSobisaa. AVRT da

44

AVNRT, xSir SemTxvevebSi kupirdebian adenozinis infuziiT. winagulovani taqikardia aseve SesaZloa iyos adenozin-sensitiuri. amasTan aRsaniSnavia, rom taqikardia, romelic mTavrdeba blokirebuli P-kbiliT, umetes wilad AVNRT an AVRT-ia. rodesac dokumentirdeba PSVT, mizanSewonilia damatebiTi gamokvlevebis Catareba gulsisxlZarRvTa sistemis sxva paTologiebis savaraudo arsebobis gamosavlenad. ase magaliTad, eqokardiografiuli gamokvleva saWiroa gulis struqturuli daavadebebis dasadgenad, gansakuTrebiT ki rekurentuli SVT-s SemTxvevaSi. igi aseve aucilebelia CautardeT WPW sindromian avadmyofebs marjvniv mdebare damatebiTi gziT, raTa gamoricxuli iqnas ebSteinis anomalia. sasurvelia aseve pacientebis Semowmeba hiperTireoidizmze. xolo rac Seexeba datvirTvis testsa da koronarografias, maTi rutinuli Catareba aucilebeli araa da isini unda ganxorcieldes mxolod specialuri Cvenebis SemTxvevaSi. supraventrikuluri ariTmiebis gadaudebeli mkurnaloba miuxedavad imisa, rom garegani kardioversia efeqturad wyvets PSVT-Ta umravlesobas, misi ganxorcieleba iSviaTad xdeba, radgan pacientTa umravlesoba hemodinamikurad stabiluria. stabilur pacientebSi regularuli SVT-Ti sawyis etapze gamoiyeneba vagaluri refleqsebi. Tuki isini araefeqturi aRmoCndnen, saWiroa intravenurad AV kvanZis mablokirebeli preparatebis Seyvana. PSVT-s kupirebaSi adenozini da verapamili praqtikulad Tanabrad efeqturni arian. adenozini pacientebSi xSirad iwvevs iseT movlenebs, rogoricaa Sexurebis SegrZneba, sunTqvis gaZneleba da tkivili mkerdSi. TumcaRa imis gamo, rom am preparats Zalzed mokle naxevardaSlis periodi gaaCnia, yvela es movlena swrafadve gadadis. adenozinis sawyisi dozaa 6 mg i/v bolusad Seyvanili, siTxiT Semdgomi swrafi CarecxviT. 12 mg an ufro meti doza SeiZleba gamoyenebuli iqnas pirvel ineqciaze saTanado pasuxis ararsebobisas. dipiridamoli axdens adenozinis efeqtis potencirebas; amitomac, transplantirebuli gulis mqone pacientebi, romlebic Rebuloben dipiridamols, Zalzed mgrZnobiareni arian adenozinis mimarT. bronquli asTmis mqone avadmyofebSi adenozins SeuZlia bronqospazmis provocireba. Teofilini sawinaaRmdegod moqmedebs, ris gamoc pacientebi, romlebic qronikulad iReben Teofilins, refraqterulni arian adenozinis mimarT an saWiroeben ufro maRal dozas. da bolos, SemTxvevaTa 12%-Si adenozins SeuZlia mocimcime ariTmiis gamowveva, rasac umTavresad adgili aqvs dadasturebuli an saeWvo WPW-s SesaZlo arsebobisas. PSVT-s swrafi kupirebisaTvis aseve xSirad gamoiyeneba verapamili. SedarebiT xangrZlivi naxevardaSlis periodis qonis gamo, igi gansakuTrebiT efeqturia rekurentuli an uwyveti taqikardiis mqone pacientebSi. marcxena parkuWis disfunqciis arsebobisas gasaTvaliswinebelia preparatis uaryofiTi inotropuli efeqti. misi dozirebaa 2,5-5 mg bolusiT yovel 5-10 wuTSi PSVT-s kupirebamde. amasTan saWiroa TA-is mudmivi kontroli. Ca2+-is antagonistebi (an betablokerebi) gansakuTrebiT efeqturia winagulovani taqikardiis mqone pacientebSi. garda amisa, AV kvanZis blokireba saSualebas iZleva gakontroldes parkuWTa SekumSvis sixSire maSinac ki, rodesac taqikardia persistulia. dilTiazemi da beta-blokerebi SesaZloa aseve efeqturni iyvnen PSVT-is mosaxsnelad, TumcaRa, adenozinTan da verapamilTan SedarebiT, amis dasadastureblad jer kidev arasakmarisi monacemi arsebobs. pasuxi farmakologiur Terapiaze damokidebulia ariTmiis meqanizmze. adenozinis da verapamilis adeqvaturi i/v doza SemTxvevaTa 90%-Si axdens AVNRT da AVRT-s kupirebas. SedarebiT naklebia maTi efeqturoba winagulovani taqiariTmiebis dros. ase magaliTad, adenozini mxolod iSviaT SemTxvevaSi axdens eqtopiuri atrialuri taqikardiebis moxsnas. PSVT-sadmi tolerantuli pacientebi, visTanac ariTmis kupireba moxda intensiuri Terapiis blokSi, ar saWiroeben rutinulad stacionarSi darCenas. aucilebelia yovelTvis dafiqsirdes ekg ariTmiis terminaciis Semdeg, raTa gamovlenili iqnas WPW sindromi. msgavsi stabiluri pacientebi binaze gawerilni unda iqnen xangrZlivi daniSnulebiT. MAT-is mkurnaloba ZiriTadad mimarTulia am dros arsebuli Tanmxlebi metaboluri darRvevebisa da pulmonuri paTologiebis aRmosafxvrelad. sakmaod efeqturia K+-is da Mg2+-is gamoyeneba. MAT iSviaTad asocirdeba TeofiliniT an digitalisiT intoqsikaciasTan. Ca2+-is blokerebi iZleva AV gamtareblobis kontrolis saSualebas. miuxedavad imisa, rom betablokerebsac msgavsi moqmedeba aqvT, maTi gamoyeneba arsebuli filtvebis paTologiis gamo SezRudulia. WPW sindromis mqone pacientebi winagulTa TrTolviT da/an fibrilaciiT saWiroeben mkurnalobis gansxvavebul algoriTms. AV kvanZis mablokirebeli agentebi, rogorebicaa (Caantagonistebi, beta-blokerebi, digoqsini, adenozini) kidev ufro aCqareben impulsis gamtareblobas damatebiTi gziT da amiT zrdian taqikardiis parkuWTa fibrilaciaSi transformirebis risks. amis gamo maTi gamoyeneba farTokompleqiani mocimcime ariTmiisa da winagulTa TrTolvisas winaaRmdegnaCvenebia. sinusuri riTmis aRsadgenad, hemodinamikurad

45

arastabiluri pacientebi dauyovnebliv saWiroeben kardioversias. hemodinamikurad stabilur pacientebSi, ki gamoyenebuli unda iqnas prokainamidi. es preparati amcirebs amcirebs ra gamtareblobas rogorc damatebiT gzaSi, ise AV kvanZSi da iwvevs sinusuri riTmis swraf aRdgenas. pacientTa xangrZlivi mkurnaloba PSVT-s mqone pacientTa xangrZlivi marTvis strategiam mniSvnelovani cvlilebebi ganicada mas Semdeg, rac dadasturda radiosixSiruli kaTeteruli ablaciis maRalefeqturoba aseTi pacientebis TerapiaSi. WPW-s mqone avadmyofebs (xangrZlivi mkurnaloba ix. cxrili 6), aseve gaurkveveli sinkopes mqone avadmyofebs an mocimcime ariTmiis dros parkuWTa preegzitaciis niSnebis arsebobis SemTxvevaSi da winaaRmdegCvenebebis ararsebobisas, aucileblad unda CautardeT eleqtrofiziologiuri gamokvleva da Semdgom, kaTeteruli ablacia. radgan WPW-is mqone simptomur pacientebSi maRalia uecari sikvdilis ganviTarebis riski, maTTvis mkurnalobis dasawyisSive rekomendirebulia kaTeteruli ablacia. aseT dros arsebobs Teoriuli riski imisa, rom AV kvanZis mablokirebeli preparatebiT xangrZlivma mkurnalobam gaauaresos mdgomareoba winagulTa TrTolvis an cimcimis ganviTarebis TvalsazrisiT. amasTan ar arsebobs sakmarisi monacemebi WPW-s gamo arsebul PSVT-s dros iseTi preparatebis xangrZlivad gamoyenebaSi, rogoricaa beta-blokerebi, Ca-antagonistebi an digoqsini. im SemTxvevaSi, Tuki aseT pacients ar Cautarda kaTeteruli ablacia, mkurnalobis saukeTeso meTodad iTvleba AV-kvanZis blokerebisa da I klasis antiariTmuli preparatebis kombinireba, romlebsac SeuZliaT damatebiTi gzis gamtarobis daqveiTeba. miuxedavad imisa, rom zogierTi klinicisti mouwodebs WPW-s gareSe simptomuri PSVT-is yvela pacientTaTvis ablaciis Catarebas, ufro mizanSewonilia Tavdapirvelad Terapiis ufro konservatuli meTodebis arCeva. avadmyofebi PSVT-s pirveli epizodiT, an iSviaTi rekurentuli, advilad tolerantuli taqikardiiT, SeiZleba iyvnen qronikuli mkurnalobis gareSe. maT SesaZloa warmatebiT gamoiyenon vagaluri manevrebi, romlebis xSirad efeqturia ariTmiis kupirebaSi. Tuki aseTi epizodebi xSiria, maSin mizanSewonilia AV kvanZis mablokirebeli agentebis qronikuli gamoyeneba. TumcaRa beta-blokerebis, Ca-antagonistebis da digoqsinis efeqturobis Sesaxeb mwiri monacemebi arsebobs. alternativas warmoadgens kaTeteruli ablacia, romelic pirveli rigSi unda ganxorcieldes, Tuki PSVT-s Tan sdevs mniSvnelovani simptomatika, an pacientebi uars acxadeben xangrZliv medikamentur Terapiaze. im SemTxvevaSi, Tu PSVT refraqterulia A-V gamtareblobis sxvadasxva blokatorebis mimarT, maSin I an III klasis antiariTmul preperatebTan SedarebiT ufro rekomendirebulia kaTeteruli ablacia, radganac aRniSnul preperatebis SemTxvevaSi maRalia kumulirebis, toqsiurobis an proariTmiis ganviTarebis albaToba. winagulovani taqikardiebis dros ablaciis efeturoba iseTive maRali araa, rogorc AVNRT-sa da AVRT-s SemTxvevaSi, TumcaRa taqikardiis es tipi Zalzed refreqterulia medikamenturi Terapiis mimarT. mniSvnelovan gamonakliss warmoadgens Seusabamo sinusuri taqikardia. radganac sinoatriuli kvanZi marjvena winagulis mniSvnelovan adgils ikavebs, kaTetaruli ablacia Zalzed Znelia da dakavSirebulia did riskTan. aseT SemTxvevaSi beta-blokerebisa da Ca-antagonistebis agresiuli gamoyenebaa rekomendirebuli.

ariTmia rekomendacia kaTeteruli ablkacia flekainidi, propafenoni sotaloli, amiodaroni, -blokerebi verapamili, dilTiazemi, digoqsini kaTeteruli ablacia kaTeteruli ablacia flekainidi, propafenoni sotaloli, amiodaroni Cvenebis klasi rekomendaciis done

WPW sindromi (preegzitaciiTa da simptomuri ariTmiiT), kargi tolerantobiT WPW sindromi (AF swrafi gatarebiT an cudi tolerantuli AVRT) cudi tolerantuli AVRT (preegzitaciis gareSe)

I IIa IIa III I I IIa IIa IIb III I I I IIa IIb IIb III I IIa

B C C C B B C C C C C B B B B C C C B

-blokerebi AVRT iSviaTi an erTi epizodi

verapamili, dilTiazemi, digoqsini aranairi vagaluri manevrebi verapamili, dilTiazemi, -blokerebi "jibeSi" kaTeteruli ablacia sotaloli,amiodaroni flekainidi, propafenoni, digoqsini aranairi kaTeteruli ablacia

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asimptomuri eqsitacia

pre-

uwyveti taqikardiis mqone pacientebSi, romlebsac amasTanave aReniSnebaT araiSemiuri kardiomiopaTia, es ukanaskneli SesaZloa iyos ariTmiiT gamowveuli. aseT avadmyofebSi mkurnalobis sawyis meTodad mizanSewonilia ablacia, radganac igi medikamentur mkurnalobasTan SedarebiT ufro efeqturia da amasTanave, ariTmiis Sewyveta aumjobesebs marcxena parkuWis funqcias. PSVT-s dros kaTeteruli ablaciis xarjT-efeqturoba damokidebulia taqikardiis aRmocenebis sixSireze, simptomTa simZimeze da medikamenturi Terapiis mimarT refraqterobaze. im pacientTaTvis, vinc xSirad xvdeba intensiuri Terapiis blokSi da sWirdebaT hospitalSi dayovneba, ablacia iZleva finansuri danaxarjebis dazogvis saSualebas. ufro metic, simptomur SVT-s mqone avadmyofebSi radiosixSiruli ablacia medikamentur TerapiasTan SedarebiT gacilebiT myarad amsubuqebs simptomebs da aumjobesebs cxovrebis xarisxs. es ki iZleva im daskvnis gamotanis SesaZleblobas, rom SVT-s mkurnalobaSi adreuli intervencia unda iqnas mowodebuli, gansakuTrebiT ki axalgazrda pacientebSi. Sejameba SVT metad mniSvnelovan samedicino problemas warmoadgens. miuxedavad imisa, rom arseboben sxvadasxva meqanizmis ariTmiebi, AVNRT da AVRT (damatebiTi gziT) gvxvdeba SemTxvevaTa umravlesobaSi. simptomuri WPW-s mqone pacientebSi kaTeteruli ablacia ganixileba mkurnalobis sawyis meTodad. usimptomo WPW avadmyofebis optimaluri marTvis principebi kvlavindeburad diskusiis sagnad rCeba. WPW-s ararsebobis SemTxvevaSi ki PSVT­is mqone pacientebis Terapia individualuria.

Management of Patients with Supraventricular Arrhythmias ­ based on American Cardiology College, American Heart Association and European Society of Cardiology Asociation Guidelines

European Heart Journal 24(20): 1857-1897: 2003 translated by A. Melia, Kh. Jalabadze, Z. Klimiashvili, K. Mukhigulashvili www.escardio.org http://www.escardio.org/knowledge/guidelines/Guidelines_Management_of_Patients_with_Supraventricu lar_Arrhythmias.htm

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klinikuri mimoxilva

autologiuri transfuzia

elizabeT vanderlinde, joana hili, neil blambergi

BMJ 2002, 324 (30 March):772-5©

moamzada Sorena arCuaZem

1980-ian wlebSi aiv-epidemiis dawyebisTanave alogenuri transfuziis alternativebis mimarT interesi, gansakuTrebiT gegmiuri qirurgiuli operaciebis dros, mkveTrad gaizarda. erT-erT alternativas, romelic dRes aSS-sa da evropis zogierT qveyanaSi sisxlis donaciis 5%-s Seadgens, autologiuri transfuzia warmoadgens. igi pacientis mier qirurgiuli operaciis win sisxlis donacias gulisxmobs. aSS-sTan SedarebiT naklebad gavrcelebis miuxedavad, did britaneTSi axlaxan gamoqveynda aRniSnuli proceduris saxelmZRvanelo principebi. mocemul statiaSi aRwerilia autologiuri transfuziis sami ZiriTadi tipi da yuradReba maxvildeba TiToeuli maTganis upiratesobasa da naklze. mniSvnelovani Tezisebi autologiuri transfuzia (sakuTari sisxlis gadasxma) amcirebs alogenuri transfuziis (donoruli sisxlis gadasxmis) aucileblobas da amitom farTed gamoiyeneba gegmiuri operaciebis dros autologiuri transfuzia erT-erTia im ramdenime meTodidan, romlebic alogenuri transfuziis alternativas warmoadgenen gamoyenebuli sami ZiriTadi teqnika Semdegia - predepozituri autologiuri transfuzia, intraoperaciuli mwvave normovolemiuri hemodilucia da aRdgeniTi (intra- an postoperaciuli) autologiuri transfuzia. dasabuTebuli medicinis monacemebi metyveleben, rom autologiuri transfuzia ufro xarj-efeqturia, vidre alogenuri transfuzia da bolo dros gamosavalic gaumjobesda

meTodebi Index Medicus-Si moviZieT publikaciebi autotransfuziis Temaze. mravali aRweriTi da meTodologiuri statia aRniSnuli proceduris efeqturobas alogenuri sisxlis transfuziis gamoyenebis Semcirebis kuTxiT ganixilavs. uaxlesi wignebi da mimoxilviTi publikaciebi eZRvneba autotransfuziis sami tipis teqnikuri da klinikuri aspeqtebis detalur aRweras. aRiarebulia, rom es procedura alogenuri sisxlis gamoyenebas amcirebs, magram mtkicebulebaTa xarisxi cvalebadobs da SesaZlo xarvezebi, rogorebicaa droebiTi anemia, araa amomwuravad Seswavlili. autotransfuzia - sisxlis gadasxmis usafrTxoebaze zrunvis saSualeba transfuzia warmoadgens potenciur samkurnalo proceduras, romelsac Tanamedrove samedicino meTodebi udevs safuZvlad. amJamad, alogenuri transfuziis mniSvnelobis gadafaseba xdeba da sayovelTaod aRiarebuli praqtikuli meTodebis alternativebi aRniSnuli proceduris usafrTxoebis principebis gaTvaliswinebiT ganixileba. maT ujreduli masis Semcireba da zogierT SemTxvevebSi droebiTi hipotenzia miekuTvneba. autologiuri transfuziis gamoyenebisaTvis yvelaze uaxles stimuls warmoadgens mtkicebuleba, rom alogenurma transfuziam SesaZloa, postoperaciul periodSi baqteriuli infeqciebisa da poliorganuli ukmarisobis riskis gazrdamde migviyvanos.

©

- statiis gamoqveyneba SeTanxmebulia BMJ-s redaqciasTan 48

meore potenciur faqtors sisxlze moTxovnilebis gazrda warmoadgens, rasac kvalificiuri, moxalise da janmrTeli donorebis populaciis Semcireba axlavs Tan. autologiuri transfuziis sami ZiriTadi meTodia predepozituri transfuzia, mwvave normovolemiuri hemodilucia da sisxlis intra- da postoperaciuli aRdgena.

predepozituri autologiuri transfuzia

predepozituri autologiuri transfuzia operaciamdel periodSi ganmeorebiT flebotomias gulisxmobs. saWiro autosisxlis raodenobidan (Cveulebriv, 2-4 doza anu 1-2 litri) gamomdinare sisxlis Segroveba gegmiuri operaciis win 3-5 kviriT adre iwyeba. bolo donaciidan operaciamde sul mcire 48-72 saaTi unda gavides, rac sisxlis moculobis aRdgenis saSualebas iZleva. TiToeul proceduris dros pacienti 0.5 litr sisxls abarebs, romelic sterilur plastikur konteinerebSi Tavsdeba. antikoagulacia glukozis citratis xsnaris damatebiTa miiRweva. sisxli operaciis dromde inaxeba. upiratesobebi predepozituri autotransfuzia faqtiurad gamoricxavs virusTa transmisias da imunuri meqanizmebiT ganpirobebul hemolizur, pirogenul an alergiul reaqciebs. am gverdiTi efeqtebis sixSire meryeobs 1 : 1,000,000-dan (aiv-saTvis) 5%-mde (pirogenuli reaqciebisTvis). garda amisa, transfuziis Semdgomi imunomodulaciis Tavidan acilebis gziT igi postoperaciul periodSi infeqciuri garTulebebisa da simsivnis recidivis risks amcirebs. imunomodulacia gulisxmobs ujreduli imunitetis dasustebas, romelsac, rogorc damtkicebulia, aqvs adgili alogenuri, magram ara autologiuri, transfuziis Semdgom.

xarvezebi SesaZloa, Segrovili sisxlis TiTqmis naxevari gamouyenebeli darCes. es imiTaa gamowveuli, rom damatebiTi alogenuri transfuziis Tavidan acilebis mizniT, Cveulebriv, pacientisagan miRebuli sisxlis raodenoba msgavs SemTxvevebSi sisxlze rutinul moTxovnilebas unda aWarbebdes. Warbi sisxli iSviaTad xmardeba sxva pacientebs, radgan autodonorebis umetesoba alogenuri sisxlis donaciis mkacr moTxovnebs ver akmayofilebs. autodonaciis programebis Rirebuleba da sisxlis danakargi alogenuri transfuziis RirebulebebTan SedarebiT autosisxlis Segrovebis fasebis gazrdas ganapirobebs. moculobiTi gadatvirTva, baqteriuli kontaminacia da administraciuli an samedicino personalis Secdomebis Sedegad sisxlis jgufebis ABO-sistemis mixedviT SeuTavseblobiT gamowveuli hemolizuri reaqciebi damatebiT risk faqtorebs warmoadgens. pacientTa SerCeva preoperaciuli autologiuri donaciis gamoyeneba mxolod gegmiuri operaciebis SemTxvevebSia dasaSvebi. pacientebs unda hqondeT survili da SeeZloT operaciis win sisxlis gadasxmis centrebSi gaemgzavron, rac savaraudod, mouxerxebeli da stresulia maTTvis da samsaxurebSi maTs Sromisunarianobas amcirebs. gamomdinare iqidan, rom aRniSnul meTods zogjer operaciis periodSi anemiamde mivyavarT (rac

49

SesaZloa ver gamoswordes qirurgiul operaciamde), sisxlis saerTo moculoba, sisxlis formiani elementebis moculoba, venuri midgoma da hemodinamikis stabiluroba mniSvnelovanwilad gansazRvravs pacientTa SerCevas. 30-40 kg-ze mcire sxeulis masis mqone bavSvebi, Cveulebriv, kandidatTa ricxvs ar miekuTvnebian, magram mozrdil pacientebs autodonaciaze mxolod mwvave hemodinamikuri problemebis, aqtiuri sistemuri infeqciebis an sisxlis Cabarebis dros seriozuli reaqciebis (mag. krunCxvebi) anamnezis SemTxvevebSi eubnebian uars. proceduris periodSi an erTi kviriT adre diareis mqone pirebma autosisxlis baqteriuli dabinZurebis gazrdili riskis gamo donorobaze uari unda Tqvan. marTalia, moxalise donorebTan SedarebiT autodonorebs iseTi garTulebebis SedarebiT meti sixSire axasiaTebT, rogoricaa gulis wasvla an Tavbrusxveva (upirveles yovlisa maTi gamoucdelobisa da

SedarebiT ufrosi asakis gamo), magram maTi es reaqciebi iSviaTadaa mZime xarisxis.

intraoperaciuli mwvave normovolemiuri hemodilucia

mwvave normovolemiuri hemodilucia warmoadgens autologiuri transfuziis erT-erT meTods, romelic uSualod operaciis win operaciul an saanesTezio blokSi sruldeba. aRniSnuli proceduris gamoyeneba SezRudulia da mas mxolod im SemTxvevaSi mimarTaven, Tu qirurgiuli operaciis msvlelobisas mniSvnelovani (1 litrze meti, an sisxlis saerTo moculobis >20%) sisxlis dakargvaa mosalodneli. pacientisagan iReben 1,0-1,5 litr sisxls da imavdroulad, sisxlis saerTo moculobas kristaloidebiT da/an koloidebiT avseben. sisxls antikoagulantebiT amuSaveben da mis reinfuzias operaciul blokSi qirurgiuli operaciuli sisxldenis dros an misi SeCerebidan mcire xnis gavlis Semdeg axorcieleben. hemodiluciis gziT sisxlis dazogvis efeqti intraoperaciuli sisxldenis dros eriTrocitebis masis dakargvis Semcirebis gziTYmiiRweva.

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upiratesobebi hemodilucia predepozituri autologiuri donaciisaTvis damaxasiaTebeli upiratesobebis garda ramdenime damatebiT sargebels uzrunvelyofs. misi ganxorcieleba nebismieri tipis qirurgiuli operaciebis win SeiZleba da sistemuri infeqcia mas xels ar uSlis. pacienti proceduris dros anesTeziis qveS imyofeba, rac stress amcirebs. garda amisa, anesTeziologi uzrunvelyofs sisxlis cirkulaciis kvalificiur monitorirebas. sisxli mxolod mcire xniT inaxeba oTaxis temperaturis pirobebSi. amrigad, Sededebis faqtorebisa da sisxlis ujredebis danakargi minimaluria. predepozituri transfuziisagan gansxvavebul damatebiT upiratesobebs misi naklebi Rirebuleba (testireba da jvaredini SeTavseba araa saWiro) da sisxlis minimaluri danakargi (rogorc wesi, sisxlis umetesi an mTeli moculoba pacients ubrundeba) miekuTvneba. sisxli adgilze inaxeba, rac gamoricxavs an minimumamde amcirebs administraciul xarjebs da administraciuli an samedicino personalis Secdomebis Sedegad sisxlis jgufebis ABO-sistemis mixedviT SeuTavseblobis risks.

xarvezebi cirkulirebuli eriTrocitebis masa sagrZnoblad da erTbaSad mcirdeba. sisxlis moculobis aRsadgenad koloiduri xsnarebis gamoiyenebis SemTxvevaSi alergiuli reaqciebis an sisxlis Sededebis paTologiis riski matulobs. sxva xarvezebs damatebiTi Rirebuleba da agreTve, proceduris Semsrulebeli anesTeziologisaTvis erTgvari mouxerxebloba warmoadgens. garda amisa, meTodi SesaZloa, anesTeziologis mxridan damatebiT swavlebas an gamocdilebas moiTxovdes. hemodiluciasTan asocirebuli mwvave anemiiT gamowveuli avadobisa da sikvdilobis sakiTxebze farTomasStabiani kvlevebi araa Catarebuli. amgvarad, aRniSnuli meTodis usafrTxoebis Sesaxeb jer-jerobiT savaraudo xasiaTs atarebs.

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pacientebis SerCeva gegmiuri qirurgiuli operaciebi (magaliTad, gulis sarqvlebis proTezireba, menjis da barZayis saxsrebis arTroplastika, xerxemlis rekonstruqcia), romlis drosac sisxlis danakargi Cveulebriv, 1-2 litrs Seadgens, hemodiluciisaTvis Sesaferis kategorias miekuTvneba. aRniSnuli proceduris kandidatebis SerCevisas ZiriTad SemzRudvel faqtors pacientis mier eriTrocitebis dabali donis cudi amtanoba warmoadgens. Rrma anemiis mqone pacientebi, Cveulebriv, am procedurisaTvis cudi kandidatebi arian.

aRdgeniTi (intra- da postoperaciuli) autologiuri transfuzia

intraoperaciulad eriTrocitebis aRdgena qirurgiuli operaciis dros dakarguli sisxlis Segrovebasa da reinfuzias iTvaliswinebs. operaciuli Wrilobidan dakarguli sisxlis aspiracia xdeba specialur centrifugaSi. SemdgomSi Sededebis Tavidan acilebis mizniT sisxls citrati an heparini emateba da Trombebisa da misi naSTebisagan ifiltreba. centrifugireba eriTrocitebis koncentrirebas da eleqtrolitebis xsnarebiT maTi garecxvis saSualebas iZleva. sabolood, koncentrati pacients ubrundeba. proceduris dros gamoiyeneba rogorc martivi, iafi, steriluri, antikoagulantis Semcveli konteinerebi, aseve Zviri, rTuli, maRali siCqaris ujreduli filtrebiT aRWurvili mowyobilobebi. postoperaciuli sisxlis aRdgena Wrilobidan drenirebuli sisxlis aRdgenasa da reinfuzias (winaswari gasufTavebiT an mis gareSe) niSnavs.

upiratesobebi aRniSnuli procedura alogenuri eriTrocituli masis transfuziis usafrTxo da efeqtur alternativadaa aRiarebuli, magram predepozitur autologiur donaciasTan an hemodiluciasTan SedarebiT naklebi monacemebi moipoveba misi klinikuri Sedegebis Sesaxeb. es meTodi gvTavazobs igive upiratesobebs, rasac hemodilucia, Tumca sisxlis

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moculobis SenarCunebis mizniT kristaloidebisa da koloidebis infuzias ar moiTxovs. Warbi sisxldenis SemTxvevaSi intraoperaciulad araerTi litri sisxlis gadarCena SeiZleba, bevrad metis, vidre autologiuri transfuziis sxva meTodebis saSualebiT.

xarvezebi intraoperaciulad aRdgenili sisxli, hemodiluciis gziT miRebulisagan gansxvavebiT, koagulaciis TvalsazrisiT intaqturi araa, Tumca Jangbadis transportirebis unari da eriTrocitebis aRdgena sruliad Seesabameba alogenuri sisxlis analogiur monacemebs. Wrilobis zedapirze sisxlis Sededeba koagulaciuri faqtorebisa da Trombocitebis moxmarebas iwvevs. garda amisa, gausufTavebeli aspirirebuli sisxli sxvadasxvagvari qsovilovani faqtorebis gazrdil koncentracias Seicavs. didi moculobis intraoperaciuli sisxlis aRdgenis iSviaT garTulebebs miekuTvneba mJavatutovani wonasworobisa da eleqtrolitebis balansis darRveva, arasteriluri masalebis, infeqciuri agentebis an simsivnuri ujredebis sistemuri diseminacia, aeroan siTxismieri embolizmi da diluciuri koagulopaTia. "aRdgenili sisxlis sindromi" aRwerilia da igi poliorganul ukmarisobiTa da moxmarebis koagulopaTiiT xasiaTdeba.

pacientebis SerCeva sisxlis intraoperaciul aRdgenas xSirad mimarTaven kardiologiuri qirurgiuli operaciebis, travmatologiuri operaciebis da RviZlis transplantaciis dros. misi gamoyenebis ukuCvenebebs operaciul areSi baqteriuli infeqciis an simsivnuri ujredebis arseboba, qirurgiuli Wrilobis zedapirze mikroboWkovani kolagenisa da sxva ucxosxeulovani masalebis moxmareba miekuTvneba. sisxlis aseTi gziT aRdgena autotransfuziis yvelaze Zviri meTodia, radgan ZviradRirebul aRWurvilobas saWiroebs. misi gamoyeneba mxolod im procedurebis drosaa mizanSewonili, romlebsac mniSvnelovani (>1l - 2 litri) sisxldakargva sdevs Tan.

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klinikuri gamosavlebis monacemebi

dakvirvebiTi kvlevebi ­ mecnierebma autotransfuziisa da mxolod alogenuri sisxlis

gadasxmis recipientebis klinikuri mdgomareoba Seadares. 16 kvlevidan aTma autodonorebSi arasaxarbielo postoperaciuli movlenebis (upirveles yovlisa, infeqciebis) statistikurad sarwmuno Semcireba gamoavlina. aqedan xuT kvlevaSi autotransfuziasTan asocirebuli gaumjobesebuli Sedegebis sxvaoba alogenur transfuziasTan SedarebiT statistikurad damajerebeli iyo, xolo xuTSi ­ ara. erTma samecniero jgufma aCvena, rom operaciis Semdgomi garTulebebis mixedviT alogenur transfuziebs mis alternativasTan SedarebiT sagrZnobi upiratesoba aqvs.

randomizebuli kvlevebi

randomizebuli kvlevebis garkveuli nawili mcire masStabisaa da moxsenebaTa xarisxi cvalebadobs. dResdReobiT CvenTvis xelmisawvdomi SemTxveviTi SerCevis principis 5 kvlevidan oTxma autologiuri transfuziebis recipientebSi alogenurTan SedarebiT ukeTesi klinikuri Sedegebi aCvena, rac postoperaciuli infeqciebis Semcirebas Seexeboda. erTma Seswavlam autosisxlis recipientebSi koloreqtaluri simsivnis recidivebis sixSiris daqveiTebis tendencia gamoavlina. autologiuri sisxlis gadasxmebis Semdeg pacientebis 1/3-s alogenuri transfuziac Cautarda, radgan Zlieri sisxldenis gamo sisxlis danakargis srulad aRdgena mxolod sakuTari sisxliT ver moxerxda. amrigad, randomizebuli kvlevebi adastureben dakvirvebiTi Ziebis Sedegebs ­ autologiuri transfuziis gziT SesaZlebelia postoperaciuli garTulebebis riskis Semcireba. dResdReobiT es Sedegebi aRniSnuli procedurebis gamoyenebis uZlieres arguments warmoadgens.

autologiuri transfuziebis "ekonomiuroba"

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zogierTi Seswavla postoperaciuli infeqciebis gazrdil risks eZRvneba, rac alogenuri, da ara autologiuri, transfuziis Semdgom imunomodulacias ukavSirdeba. am kvlevebis Sedegad dadginda, rom autologiuri sisxlis gadasxma ekonomiuria da Tanxebis dazogvis SesaZleblobac ki iZleva. erTma Ziebam, romlis drosac transfuziis SesaZlo imunomodulaciuri efeqtebi ar iyo gaTvaliswinebuli, autotransfuziis ekonomiuroba ver daadastura. amerikuli statiebis mixedviT, aivepidemiis pirvel wlebSi autologiuri donaciis gziT transfuziasTan dakavSirebuli riskis minimumamde Semcirebis survilis Semdeg fasis ekonomiurobas meorexarisxovani mniSvneloba eniWeboda. mas Semdeg, rac aiv-isa da hepatitis virusebis testirebis gaumjobesebasTan erTad pacientebSi sisxlis gadasxmis usafrTxoebiT gamowveulma SeSfoTebam iklo, autologiur transfuziaze moTxovnileba SedarebiT Semcirda.

sxva koncefciebi, romlebic sisxlis gadasxmebs agvacilebs Tavidan eriTropoetins, eriTrocitebis producirebis hormons, stabiluri mdgomareobis mqone simsivnur pacientebsa da dRenaklul axalSobilebSi transfuziebis saWiroebis Semcireba SeuZlia. mas qirurgiul pacientebSi alogenuri transfuziis (autologiuri sisxlis SegrovebasTan erTad an mis gareSe) saWiroebis Semcirebis mizniTac mimarTaven. operaciis periodSi anemiisa da operaciis msvlelobisas sisxlis dakargvis daqveiTeba SesaZlebelia meqanikuri hemostazis gaumjobesebis (antifibrinolizuri saSualebebis, magaliTad, aprotininis saSualebiT), flebotomiis SezRuduli gamoyenebis (mxolod ZiriTadi analizebisaTvis) da mikronimuSebis laboratoriuli meTodebis danergvis gziT. autologiuri transfuzia sisxlis marTvis axali koncefciis, e.w. - "usisxlo medicina da qirurgia", nawils Seadgens. is eriTripoetinis, sisxlis dakargvis minimizaciaze mimarTuli qirurgiuli meTodebis an fibrinolizis damTrgunveli preparatebis gamoyenebas gulisxmobs; SesaZlebeli xdeba ufro Rrma anemiis atana da flebotomiasac iSviaTad ­ ZiriTadad mxolod diagnostikuri testebisaTvis mimarTaven. am meTodebis nawili arc teqnikuri sirTuleebiT da arc maRali RirebulebiT xasiaTdeba, rac SedarebiT naklebad ganviTarebul pirobebSi

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maTs gamoyenebas

SesaZlebels xdis. aRsaniSnavia agreTve iseTi mniSvnelovani

upiratesoba, rogoricaa autotransfuziis gamoyenebis SesaZlebloba im pirebSi, romlebic alogenur transfuziaze uars amboben (mag. ieRovas mowmeeebi), aseve im kritikul SemTxvevebSi, rodesac naklebi sixSiriT gadasxmebia naCvenebi.

Autologous Transfusion Elizabeth S Vanderlinde, Joanna M Heal, Neil Blumberg BMJ 2002, 324 (30 March):772-5

Since the AIDS epidemic of the early 1980s the interest in alternatives to allogeneic transfusion has grown, particularly for elective surgery. One alternative that currently accounts for over 5% of the blood donated in the United States and some countries in Europe is autologous transfusion, obtained primarily by preoperative donation. Although autologous transfusion is used less widely in the United Kingdom than in the United States, guidelines on its use have recently been published in the United Kingdom. The article describes the three main types of autologous transfusion - predeposit transfusion, intraoperative hemodillution, and intraoperative/postoperative salvage - and draw attention to the advantages and disadvantages of each technique. The evidence from observational and controlled trials comparing autologous with allogeneic transfusion is also reviewed and it shows that autologous transfusion is more cost-effective than allogenic transfusion and that clinical outcomes are improved.

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klinikuri mimoxilva

muclis aortis anevrizmebis skriningi mamakacebSi

j. ernSou, e. Sou, m.r. vaimani, k.d. poskiti da b.p. hiTeri BMJ, May 2004; 328: 1122 - 1124.©

moamzada Sorena arCuaZem

[email protected] yovelwliurad inglissa da uelsSi muclis aortis gaxeTqvis mizeziT 6000-mde mamakaci iRupeba. Tumca es maCvenebeli mamakacebis sikvdilobis mxolod 2%-s Seadgens, aRniSnuli samedicino problema Tavidan acilebadia. GmiT umetes, rom sxva aTerosklerozul mdgomareobebTan dakavSirebuli sikvdilobis daqveiTebisagan gansxvavebiT, misi gavrceleba, gansakuTrebiT, SotlandiaSi, mzardi tempiT matulobs. es statia aortis skriningis erovnuli programis saWiroebas aSuqebs. modelad glosterSiris anevrizmis skriningis proeqti iqna gamoyenebuli, romelic ukve 13 wlis ganmavlobaSi moqmedebs.

skriningis mxardamWeri mtkicebulebebi

muclis aortis ultrabgeriTi gamokvlevis aRniSnuli proeqti mosaxleobis skriningis programis yvela kriteriums akmayofilebs, Tumca masSi mxolod mamakacebi monawileoben. anevrizmis skriningis uaxlesma multicentrulma kvlevam aRmoaCina, rom 4 wliani dakvirvebis Sedegad mamakacebSi anevrizmiT gamowveuli sikvdilobis maCvenebeli 42%-iT Semcirda. imedovneben, rom Semdgomi Seswavla saerTo mosaxleobis mcire, Tumca sagrZnob Semcirebas gamoavlens. aseve dadginda, rom skriningis aRniSnuli programa iseve ekonomiuria, rogorc sxva analogiuri proeqtebi da gadarCenili sicocxlis TiToeuli wlis Rirebuleba 28 aTas funt sterlings udris. es informacia wina, mcire randomizebuli kvlevebis monacemebs eyrdnoba da man aortis anevrizmis skriningis erovnuli masStabebis programis mizanSewonilobis Sesaxeb debatebi warmoSva. amJamad, gaerTianebuli samefos nacionaluri skriningis komiteti afasebs ukve arsebul monacemebs da rekomendaciebisagan jerjerobiT Tavs ikavebs. glosterSiris gamocdileba gviCvenebs, Tu rogor SeuZlia, imoqmedos skriningis programam.

glosterSiris anevrizmis skriningis proeqti

muclis aortis anevrizmis skriningi glosterSiris 1990 wlis seqtemberSi gamocxadda. mxaris zogadi praqtikis medikosebTan registrirebul 65 wlis asaks miRweul mamakacebs zogadi praqtikis lokalur kabinetebSi muclis aortis ultrabgeriT gamokvlevas sTavazoben. glosterSiris mxaris mosaxleoba 560,000-s Seadgens da yovelwliurad aRniSnul gamokvlevaze 3000 mamakacs iwveven. skriningis programas medda koordinatori uZRveba, xolo ultrabgeriT gamokvlevebs specialistebis mcire jgufi atarebs, romelTac samsaxuris safasurs kursebis mixedviT uxdian. imisaTvis, rom aRniSnuli samedicino gamokvleva mxareSi mcxovreb 65 wlis asakis yvela mamakacs SesTavazon, kviraSi skriningis 3-4 kursia saWiro. saaTis ganmavlobaSi 10 mamakacis gamokvlevas aswreben. rotaciis principiT yovelwliurad 85 monawile kabinetidan TiToeulis vizireba xdeba. menejeri skriningisaTvis SerCeuli mamakacebis sias adgens da maT mosawvev baraTsa da programis sainformacio furclebs ugzavnis. pacientebs kvlevis damTavrebisTanave acnoben Sedegs. Tavdapirveli kapitaluri danaxarjebis Semdeg, romlebic portatuli ultrabgeriTi aparatis, kompiuteris da printeris SeZenas moxmarda, proeqtis mimdinare Rirebuleba weliwadSi 43,000 funt sterlings udris. 26 mm-ze naklebi diametris aortis mqone pirebs amSvideben da aTavisufleben. amgvarad, erTjeradi gamokvlevis Sedegad anevrizmis gamoricxva SesaZlebelia

©

- statiis gamoqveyneba SeTanxmebulia BMJ-s redaqciasTan 57

cocxali mamakacebis 95%-Si. 26-39 mm diametris aortis qona yovelwliuri skriningis Cvenebas warmoadgens. 40 mm-ze meti diametris aortis mqone mamakacebi glusesterSaiaris sisxlZarRvTa oTxi qirurgidan erT-erTis dRis stacionars mimarTaven. am kategoriis pacientebs gamokvleva yovel 6 TveSi erTxel utardebaT, radgan aortis gafarToebis Semdeg misi zrdis tempi araregularul xasiaTs iZens. aortis 55 mm-ze metad gafarToebis SemTxvevaSi gaTvaliswinebulia gegmiuri operacia. 13 wliani dakvirvebis Sedegad, aRniSnul mxareSi anevrizmiT gamowveuli sikvdilobis sixSire aortis anevrizmis gaxeTqvis mqone pacientebis ricxvTan erTad mniSvnelovnad Semcirda. vinaidan skriningis sqema progresulad gafarTovda da dasawyisSi 65 welze meti asakis mamakacebs gamokvleva ar utardebodaT, qveyanaSi anevrizmis operaciebis raodenoba mniSvnelovnad ar Secvlila. gasul aTwleulSi skriningis Sedegad gamovlenili muclis aortis anevrizmis gegmiuri operaciebis ricxvi gaizarda, xolo SemTxveviT aRmoCenil an gaxeTqil anevrizmebze ganxorcielebuli operaciuli Carevis raodenoba sagrZnoblad daeca. garda amisa, skriningis Sedegad gamovlenili anevrizmebis qirurgiul mkurnalobasTan dakavSirebuli sikvdilobis sixSire (3%) mniSvnelovnad CamorCeba SemTxveviT aRmoCenili anevrizmebis analogiur maCvenebels (9%). aman glosterSiris mxareSi anevrizmebis gegmiur operaciebTan asocirebuli saerTo sikvdiloba Seamcira. operaciaTa letaluri gamosavali 1994-98 wlebTan SedarebiT 1999-2003 wlebSi, Sesabamisad, 6,5%-dan (306-dan 20 SemTxveva) 4,4%-mde (251 SemTxvevidan 10) daeca. skriningis sqemasTan dakavSirebul problemas is warmoadgens, rom skriningSi monawileobas mamakacebis 15% ver axerxebs da maTi udidesi nawili anevrizmis mqone mamakacebs moicavs. aseve kvlevis farglebs miRma rCebian 65 welze nakleb asakSi anevrizmis gaxeTqvis mqone mamkacebi (glosterSirSi aRniSnul SemTxvevaTa daaxloebiT 10%).

anevrizmis skriningis nacionaluri programa

skriningis sxva proeqtebis msgavsad, anevrizmis kvlevis nacionaluri programa verasodes SeZlebs SemTxvevaTa 100%-is gamovlenas. aseve, verasodes agvacilebs Tavidan anevrizmis gaxeTqvis da am garTulebiT gamowveuli sikvdilobis yvela SemTxvevas. idealuri iqneboda ekonomiuri programis Seqmna, romelic anevrizmebis maqsimalur raodenobas gamoavlenda. pirveli gadawyvetileba Seexeba sakiTxs, Tu sad unda ganxorcieldes programa. gaerTianebul samefos ojaxis eqimebis farTo sistema gaaCnia da maTi qirurgiuli kabinetebi optimaluri adgilia sawyisi skriningis Casatareblad. es moiTxovs ojaxis eqimebis Tanxmobas (86-dan mxolod erTma ganacxada uari monawileobaze), maTi pacientebis sqesisa da asakis registris xelmisawvdomobas da oTaxs gamokvlevisaTvis. ultrabgeriTi mowyobiloba gadaadgilebas advilad eqvemdebareba da glosterSirSi TiToeuli praqtikosis viziti weliwadSi mxolod erTxelaa aucilebeli. meore gadawyvetileba skriningis asaks Seexeba. glosterSirSi is 65 wels Seadgens, rodesac mamakacebis umetesoba ukve pensiazea da SeuZliaT, sakuTar janmrTelobas meti yuradReba dauTmon. skriningis asakis 60 wlamde Semcireba im mamakacebis umeteobas gamoavlens, romelTac 65 welze axalgazrda asakSi anevrizmis gaxeTqva ganuviTardaT. Tumca es gaaormagebs proeqtis Rirebulebas, radgan 65 wlis asakSi ganmeorebiTi skriningi iqneba saWiro. alternatiul midgomas warmoadgens skriningis asakad 65 wlis SerCeva da paralelurad gamokvlevis SeTavazeba anevrizmis risk faqtorebis (Tambaqos moweva da hipertenziisa da arteriuli daavadebebis ujaxuri anamnezi) mqone SedarebiT axalgazrda mamakacebisaTvis. nacionaluri skriningis progresulad gavrcelebis SemTxvevaSi, naklebad savaraudoa, rom man mniSvnelovani gavlena iqonios gegmiur qirurgiul aqtivobaze. Tumca skriningis dasasrulisaTvis 65 welze meti asakis yvela mamakaci iqneba gamokvleuli, meore mxriv, gegmiuri sisxlZarRvovani samsaxuri ver gauZlebs datvirTvas. es didi politikuri gadawyvetilebaa; garkveul weliwads 65 wlis asakis pirebis skriningis dawyeba SesaZloa, usamarTlod iqnes miCneuli. Tumca skriningi SesaZloa aseve CautardeT ufrosi asakis im mamakacebs, romlebic Tavad moiTxoven gamokvlevas (rogorc prostatis simsivnis skriningis programis SemTxvevaSi). udidesi investiciebi dasWirdeba skriningis aparaturas, rogorc mobilurs zogadi praqtikis

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kabinetebSi samuSaod, aseve sisxlZarRvovani laboratoriis aRWurvilobas SedarebiT didi zomis (40-55 mm) anevrizmebze dakvirvebisaTvis. mimdinare kvlevebi miznad isaxavs efeqturobis maqsimizaciis ganzraxviT mcire zomis anevrizmebis ganmeorebiTi skriningis ricxvis minimumamde Semcirebas. nacionaluri masStabis skriningi mxolod im SemTxvevaSi iqneba efeqturi da gamarTlebuli, Tu minimumamde Semcirdeba anevrizmis gegmiur operaciebTan asocirebuli sikvdilobis maCvenebeli. farTo monacemTa bazebisa da randomizebuli kvlevebis Sedegebis mixedviT sikvdilobis saSualo maCvenebeli gaerTianebul samefoSi 6-7%-s Seadgens. programis xarisxis garantia umniSvnelovanesi iqneba ultrabgeriTi gamokvlevis specialistebisa da vaskularuli qirurgebisaTvis. didi britaneTisa da irlandiis vaskularuli qirurgebis sazogadoebam erovnuli sisxlZarRvTa monacemTa baza daafuZna, romelSic aortis procedurebis Sesaxeb informaciaa Tavmoyrili da romelsac amJamad, sazogadoebis daaxloebiT erTi mesamedi iyenebs. qirurgebs, romlebic skriningis Sedegad gamovlenili anevrizmebis operaciul mkurnalobas axorcieleben, SesaZloa, monacemTa bazaSi Sesabamisi informaciis Setana mosTxovon, rogorc xarisxis garantirebis meTodi. dabolos, nacionaluri skriningis programas eqneba aTerosklerozis mqone im mamakacebis gamovlenis upiratesoba, romlebsac aseve gulis infarqtis gazrdili riski aReniSnebaT. pacientebis jgufs qcevis wesebis Secvlis Sesaxeb rekomendaciebi miecema. mcire anevrizmebis kvlevis mogvianebiTi Sedegebis Tanaxmad, aRniSnuli gziT letaluri SemTxvevebis raodenobis Semcirebaa SesaZlebeli. garda amisa, mcire anevrizmebis mqone pacientebs SeuZliaT anevrizmis zrdis tempebis Semcirebis meTodebis kvlevebSi miiRon monawileoba.

alternativa

ukanaskneli 50 wlis ganmavlobaSi muclis aortis gaxeTqili anevrizmis Ria qirurgiuli operaciis Sedegebi umniSvnelod Seicvala. saavadmyofoTa umetes nawilSi sikvdiloba 50%-s aWarbebs. endovaskularuli operacia mosaxerxebelia. gaxeTqili anevrizmis ganyofilebebSi arsebuli sruliad sawinaaRmdego situaciisagan gansxvavebiT, sisxlmdeni anevrizmebis marTvis gzebis fundamentur gaumjobesebaSi sagrZnobi winsvla aRiniSneba. Tumca mis ganxorcielebas mxolod qirurgebisa da radiologebisagan Semdgari mizandasaxuli kvalificiuri gundi SeZlebs did regionalur centrebSi. aortis gaxeTqili anevrizmis endovaskularuli operaciis samsaxuri regionaluri centrebis da pacientebis gasaadgileblad aucilebeli satransporto sistemebis organizebisaTvis Sesabamis finansirebas saWiroebs. anevrizmebis nacionaluri skriningis programa gaxeTqili anevrizmebis SemTxvevebis ricxvis Semcirebis gziT aseTi samsaxuris saWiroebas agvacilebs Tavidan. J.J. Earnshaw, E. Shaw, M.R. Whyman, K.R. Poskitt, and B.P. Heather Screening for Abdominal Aortic Aneurysms in Men BMJ, May 2004; 328: 1122 - 1124. Every year about 6000 men die from a ruptured abdominal aortic aneurysm in England and Wales. Although this represents only about 2% of all deaths in men, the condition is largely preventable. It is also a disease that seems to be increasingly prevalent, at least in Scotland, despite the fact that deaths from other atherosclerotic conditions are reducing. The article explores the requirements for a national aortic screening programme, using as a model the Gloucestershire aneurysm screening project, which has been running for 13 years.

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wamlis profili

axali preparatebis mimxilva

moamzada nino demetraSvilma

gul-sisxlZarRvovani daaavadebebi

preparati:

preparatis mwarmoebeli kompania: Pfizer preparatis statusi: damtkicebulia 2004 wlis ianvarSi medikamenti gamoiyeneba: hipertenziis/stenokardiis mkurnalobisaTvis zogadi informacia: preparati kadueti (amlodipini + atorvastatini) gamoiyeneba hipertenziis, qronikuli stabiluri anginisa da vazospastiuri anginis mkurnalobisas. kadueti aerTianebs gul-sisxlZarRvovani daavadebis samkurnalod gamoyenebul or medikaments, kerZod ki amlodipinsa (norvaski, lotreli) da atorvastatins. is gamoiyeneba ori gansxvavebuli mdgomareobis mkurnalobis dros: maRali wnevisa da hiperqolesterinemiis dros. kadueti gamoiyeneba hipertenziis, qronikuli stabiluri anginisa da vazospastiuri anginis mkurnalobisaTvis. is aseve gamoiyeneba pirveladi disbetalipoprotenemiis, Sratis Timoglobulinis donis awevisas, hiperqolesterinemiisa da Sereuli dislipidemiis dros. amasTan erTad sasurvelia misi antiaTerosklerozuli dietis dros gamoyeneba. amlodipinis, rogorc sawyisi antihipertoniuli saSualebis rekomendirebuli misaRebi doza aris 5 mg erTxel dReSi abebis saxiT, dasaSvebi maqsimaluri doza ki aris 10 mg erTxel dReSi.

gverdiTi movlenebi: kaduetis miRebasTan asocirebuli arasasurveli gverdiTi movlenebi SeiZleba iyos: · Tavis tkivili; · muclis tkivili / disfagia; · tkivili mkerdis areSi; · gamonayari; · gulisreva; · uZiloba; · Tavbrusxveva.

gastroenterologiuri daaavadebebi:

preparati: avastini (bevasizumabi)

preparatis mwarmoebeli kompania: Genetech preparatis statusi: damtkicebulia 2004 wlis TebervalSi medikamenti gamoiyeneba koloreqtaluri simsivneebis mkurnalobisas 60

zogadi informacia: preparati avastini (bevasizumabi) aris anti-sezf (VEGF - sisxlZarRvovani endoTeliuri zrdis faqtori) monoklonuri antisxeuli, romelic gamoiyeneba soliduri simsovneebis mkurnalobis dros. avastini - intravenur 5-fluorouracil-ze dafuZnebul qimioTerapiasTan erTad - aris mkurnalobis pirveladi arCevani swori da msxvili nawlavis metastazuri karcinomis dros. avastinis rekomendirebuli doza aris 5 mg/kg 14 dReSi erTxel intravenurad daavadebis progresirebis dadgenamde. gverdiTi movlenebi: avastatinis miRebasTan asocirebuli arasasurveli Sedegebi: · sisuste; · gulis wasvla; · diarea; · abdominaluri tkivili; · sxvadasxva lokalizaciis tkivili (Tavis, mkerdis); · Rrma venebis Trombozi; · hipertenzia; · muclis sisxxlZarRvebis Trombozi; · leikopenia; · neitropenia.

hematologia:

preparati: vidaza (azacitidini)

preparatis mwarmoebeli kompania: Pharmion Corporation preparatis statusi: damtkicebulia 2004 wlis maisSi medikamenti gamoiyeneba: mielodisplastiuri sindromis mkurnalobisas zogadi informacia: vidaza (azacitidini) aris anti-neoplastikuri pirimidin nukleozidis analogi, romelic gamoiyeneba im mielodisplastiuri sindromis ramodenime qvetipis samkurnalod, romlebic gamowveulia Zvlis tvinis mier sisxlis ujredebis formirebis anomaliebiT, rac arasakmarisi janmrTeli sisxlis ujredebis warmoqmnaSi gamoixateba. medikamenti citotoqsikur efeqts axdens swrafad gamyof ujredebze, maT Soris simsivnur ujredebzec, ramac SesaZloa xeli Seuwyos im genebis normaluri fuqciebis aRdgenas, romlebic akontroleben ujredebis diferencirebasa da proliferacias. vidaziT mkurnaloba gansakuTrebiT sasurvelia mielodisplastiuri sindromis Semdegi qvetipebis dros: · refraqteruli anemia; · refraqteruli anemia beWdisebri sideroblastebiT; · qronikuli mielomonocituri leikemia; 61

vidaza keTdeba kanqveS, sawyisi doziT: 75 mg/m2 yovedRiurad Svidi dRis ganmavlobaSi yovel oTx kviraSi. doza SesaZloa gaizardos 100 mg/m2, Tu sawyisi doza arasakmarisia da toqsikuroba ar SeiniSneba. gverdiTi movlenebi: · Trombocitopenia; · neitropenia; · gulisreva; · saxsrebis tkivili; · madis dakargva; · saineqcio adgilis eriTema amasTan erTad sacdel cxovelebSi orsulobis periodSi vidazas miRebisas gamomJRavnda potencialuri teratogenurobis da embriotoqsiurobis niSnebi. New Drugs Review by N. Demetrashvili 3 recently approved by FDA drugs are reviewed: Caduet (Amlodipin + Atorvastatin) ­ for Hypertension/Heart Angina, Avastin (Bevasizumab) ­ for colorectal cancer treatment and Vidaza (Azacitidin) ­ for myelodis[plastic syndrome informaciis wyaro: http://www.centerwatch.com/patient/drugs/dru847.html

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regionaluri siaxleebi

samedicino saswavlo sainformacio centri da `janmrTelobis dRe~ kaspSi

ia qamxaZe, arasamTavrobo organizacia `sicocxlis Zala~, kaspis diagnostikuri klinika

samedicino personalis kvalifikacia da informatiuloba rom uSualod aisaxeba pacientebis samedicino daxmarebis donis, maTi janmrTelobis aRdgenisa da sicocxlis SenarCunebaSi es odiTganve cnobili aqsiomaa. dRevandeli medicinis ganviTarebis uswrafesi tempebi aucileblad iTxovs Tanamedrove sainformacio sistemebis gamoyenebasa da medikosTa uwyvet ganaTlebas. gansakuTrebuli saWiroeba am TvalsazrisiT igrZnoba regionebis doneze, radganac uaxlesi informaciis miReba garkveul problemebTanaa dakavSirebuli. am mxriv kaspis raionSi metad progresuli nabiji gadaidga. arasamTavrobo organizaciam ,,sicocxlis Zala'' (xelmZRvaneli - eqimi iamze qamxaZe, romelmac swavlebis kursi gaiara emoris universitetis mowinave klinikebSi) "Mercy Corps" da USAID-is dafinansebiT ganaxorciela proeqti aRmosavleT saqarTvelos saTemo mobilizaciis iniciativis programis egidiT, romlis ZiriTadi idea iyo samedicino saswavlo-sainformacio centris Seqmna da misi meSveobiT raionis eqimebis codnis donis amaRleba; saboloo mizani ki - raionis mosaxleobis janmrTelobis gaumjobeseba. saswavlo sainformacio centris prezentacia moxda ianvris bolos da mieZRvna prezident mixeil saakaSvilis inauguracias. samedicino saswavlo sainformacio centri aRiWurva kompiuteruli da tele-video teqnikiT, saTanado saofise mowyobilobebiT. ganxorcielda raionSi pirveli internet kavSiri, romlis meSveobiTac medicinis muSakebi Rebuloben mowinave informacias. maT exmarebian centris TanamSromlebi - kompiuterisa da inglisuri enis specialistebi, romlebic internetSi awarmoeben maTTvis saintereso masalis moZiebasa da Targmnas. garda eqimebisa, centris xSiri stumrebi arian samedicino institutebisa da saeqTno kolejis studentebi da aseve - gimnaziis is moswavleebi, romelTa survilia TavianTi momavali cxovreba daukavSiron medicinas da jandacvas. saswavlo-sainformacio centri teritoriulad mdebareobs kaspis cementis qarxnis bazaze arsebul diagnostikur klinikasTan, romelic aRWurvilia atlantidan (jorjia, aSS) Semowiruli mowinave samedicino teqnikiT, rac saSualebas iZleva dainteresebulma profesionalebma miiRon aparaturasTan muSaobis praqtikuli unar-Cvevebi. proeqtis dafinansebiT moxda mowinave perioduli samedicino presis gamowera. amerikeli kolegebis daxmarebiT Seiqmna saswavlo videoTeka da patara samedicino biblioTeka. proeqtis farglebSi Catarda ori konferencia. pirveli samedicino konferencia 24 marts Catarda Temaze: `infeqciur sneulebaTa mkurnalobisa da prevenciis Tanamedrove aspeqtebi~. mowveuli iyvnen samedicino akademiis infeqciur sneulebaTa kaTedris wamyvani specialistebi batoni aleko nanuaSvili da qalbatoni manana maxvilaZe. moxsenebiT warsdgnen raionis eqimebic. meore konferencia Catarda 7 ivniss Temaze ,,gul-sisxlZarRvTa sistemis daavadebebi - medicinis saerTo problema''. konferencia gaxsna Sromis, janmrTelobisa da socialuri dacvis ministris moadgilem batonma merab qorCilavam, romelmac damswre sazogadoebas gadasca ministris baton vladimer WipaSvilis misalmeba, misi saxeliT aRuTqva Tanadgoma da usurva warmatebebi profesionalur saqmianobaSi. konferencias eswrebodnen raionis samedicino sazogadoeba, donori organizacia `mersi qoris~ warmomadgenali qalbatoni qeTi ugulava, emoris universitetis profesori batoni ken uokeri amerikel studentebis jgufTan erTad, saqarTvelos mTavari saxelmwifo sanitaruli eqimi batoni nikoloz Savdia, saxelmwifo sanitaruli

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zedamxedvelobis sazRvris dacvis departamentis Tavmjdomare batoni daviT gagua, erovnuli saswavlo sainformacio centris direqtori batoni zviad kirtava, organizacia ,,partnioroba janmrTelobisaTvis'' saeqTno programis xelmZRvaneli qalbatoni naTela farcxalaZe, presis warmomadgenlebi. konferencias gulTbili maspinZloba gauwia s/s ,,kaspis cementis qarxnis'' koleqtivma, romlis saaqto darbazSic Catarda es RonisZiebebi. konferenciaze moxsenebiT gamovidnen samedicino akademiis kardiologiis kaTedris gamge profesori irakli megrelaZe, amave kaTedris docenti qalbatoni manana gorgoSiZe, romelTac isaubres iseT aqtualur sakiTxebze, rogoricaa gulis ukmarisobis Tanamedrove paTogenezisa da mkurnalobis mimarTulebani da filtvis Tromboembolia. maRali iyo iyo raionis eqimebis aqtiurobac, romelTac warmoadgines moxsenebebi ,,fetaluri da neonataluri ariTmiebi'' (i. qamxaZe ­ kaspis diagnostikuri klinika) da ,,kardiologiuri garTulebebis riski arakardioqirurgiuli operaciebis dros (raisaavadmyofos eqimi-anesTeziologi i. bestavaSvili). britanulma farmacevtulma firmam ,,Glaxo Smith Kline'' warmoadgina axali kardiologiuri preparatebi. prof. ken uokerma, Seajama ra konferencia, aRniSna ,,vismendi ra aq warmodgenil moxsenebebs, vfiqrobdi, rom isini daamSvenebda nebismieri wamyvani sauniversiteto klinikebis konferenciebs. gilocavT, rom Tqven am centris meSveobiT xeli migiwvdebaT mowinave samedicino informaciaze, romlis gareSec warmoudgenelia Tanamedrove eqimis srulfasovani profesiuli saqmianoba~. mravali madlobis sityva iTqva donori organizaciebis misamarTiT da arasamTavrobo organizacia `sicocxlis Zala~-sa da saswavlo-sainformacio centris TanamSromlebis friad saWiro da aucilebeli saqmianobis Sesaxeb. raionis eqimebis mxriv gamoiTqva survili, raTa gagrZeldes saswavlo sainformacio centris saqmianoba da SesaZlebeli gaxdes aseTi maRali akademiuri donis konferenciebze maT mieniWoT kredit-saaTebi. isini imeds gamoTqvamdnen, rom centris potenciali mravali saintereso da saWiro profesiuli RonisZiebis Catarebis sawindari iqneba momavalSic. imedia, aseT imedismomcem dasawyiss saTanado daxmareba eqneba qveynis da raionis xelmZRvanelobis mxridanac da sainformacio-saganmanaTleblo centri momavalSic bevr saWiro da progresul wamowyebas Caudgeba saTaveSi. amerikis saerTaSoriso janmrTelobis kavSiris (AIHA) mxardaWeriT saaqcio sazogadoebis `kaspicementis~ personalisaTvis 2004 wlis 18 ivliss kaspSi Catarda janmrTelobis dRe. am RonsZiebaSi monawileoba miiRes organizacia `partniorebi saerTaSoriso ganviTarebisaTvis~ (atlanta, aSS) warmomadgenlebma ­ eqTnebma ­ prof. judi uoldma, masaio niSiamam da amanda nikersonma da maTma Tbiliselma partniorebma - eqimebma naTela farcxalaZem da nino xaraiSvilma (`partniorebi janmrTelobisaTvis~/bavSvTa centraluri saavadmyofo), Tbilisis akad. o. RuduSauris sax. erovnuli samedicino centris mTarma eqTanma qeTevan garsevaniSvilma da amave centris eqvsma eqTanma. stumrebs maspinZloba gauwia RonisZiebis organizatorma, eqimma ia qamxaZem da misma gundma. Catarda gul-sisxlZarRvTa da diabetis adreuli skriningi. muSamosamsaxureTa anonimuri da nebayoflobiTi testireba moicavda sisxlis wnevis, simaRlis, wonis, sxeulis masis, mTliani qolesterinis, maRali simkvrivis lipiduri qolesterinis da sisxlSi Saqris gazomvebs, janmrTelobis riskis gamoangariSebas da samedicino konsultaciebs 100-mde muSa-mosamsaxurisaTvis, romelTac aseve miewodaT cxovrebis jansaRi wesisa da daavadebaTa prevenciis masalebi. monawileTa janmrTelobis monacemebi amerikaSi gaanalizdeba da agregirebuli Sedegebi miewodeba kaspis cementis qarxnis xelmZRvanelobas.

Medical Information Learning Resource Center and Health Fair in Kaspi Ia Kamkhadze, Kaspi diagnostic clinic, NGO Power of Life

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In January 2004, new Medical Learning Resource Center has been opened in Kaspi at the basis of the Diagnostic Clinic at Kaspi Cement Factory. This was initiative of the NGO Power of Life (head ­ Dr. Ia Kamkhadze), supported by funding from "Mercy Corps" and USAID. In the project framework also two conferences have been held ­ in March ­ Treatment and Prevention of Infectious Diseases, and recently ­ on June 7th ­ Cardiovascular Diseases ­ common problem of Medicine. The latter conference was attended by the Deputy Minister of Health, Dr. Merab Korchilava, Representative of Mercy Corps Ms. Kety Ugulava, Emory University Professor, head of Atlanta-Tbilisi Partnership - Dr. Kenneth Walker, Emory University Medical Students and other dignitaries. Prof. Irakli Megreladze and Assoc. Prof. Manana Gargoshidze from Tbilisi Medical Academy for Postgraduate Education have presented lectures about heart failure and thromboemboly of pulmonary artery, whilst Dr. Kamkhadze and Dr. Bestavashvili from Kaspi ­ Fetal and neonatal arrhythmia and Cardiovascular complications during surgical operations, respectively. The conference was also sponsored by Glaxo Smith Kline. With the financial support of American International Health Alliance (AIHA) a health and wellness event was held for the employees of Joint Stock Company - Kaspi Cement Factory on Sunday, July 18, 2004. Prof. Judith L. Wold, PhD, RN, Masayo Nishiyama, RN, and Amanda Nickerson, RN (Partners for International Development, Atlanta, GA, USA), Dr. Natela Partskhaladze, Dr. Nino Kharaishvili (Partners for Health NGO, Tbilisi, Georgia), Ketevan Garsevanishvili (Head Nurse of Gudushauri National Medical Center) and six nurses from this Center, with the help of local team of Dr. Ia Kamkhadze, had offered screening for detecting early signs of cardiovascular disease and diabetes. Anonymous and free blood pressure checks, height, weight and body mass index measurements, total cholesterol, HDL cholesterol and blood glucose measurements, health risk appraisal and medical health consultations for 100 people allowed participants of the health fair to learn about their health risks and gain more knowledge on how to improve their health status. Data about the health of the participants will be analyzed in the US and aggregate data will be communicating to the Cement Factory Management.

janmrTelobis dRe kaspSi

janmrTelobis dRis monawileebi

atlanteli da Tbiliseli medikosebi `kaspicementis~ muSebis gasinjvebs

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internetis samedicino daijesti #3-4 (97-98)

30.06.2004*

Internet Medical Digest

· ·

·

menjis fuZis kunTebis varjiSma SeiZleba Secvalos viagra alkoholis zomieri raodenoba amcirebs gulis daaavadebaTa risks rimonabanti wonaSi dasaklebi, sigaretis Sewyvetis samkurnalo da

metaboluri sindromis risk-faqtorebis makontrolebeli axali saSualeba · · · · · · gastroezofaguri refluqsi baretis saylapavis gareSe ar warmoadgens kibos

risk-faqtors menjis qronikuli tkivilis klinikuri marTvis axali gaidlaini sifilisi (aTaSangi) antibiotikebisadmi mdgradi gaxda Casaxvis sawinaaRmdego abebi qalebs agresiuls xdis yava SesaZloa gaxdes moklevadiani mexsierebis daqveiTebis mizezi Cai aumjobesebs mexsierebas

· · · · cancer · · · · ·

Pelvic floor exercise could replace Viagra Heart Attack Recovery Enhanced by Any Alcoholic Drinks, Not Just Red Wine Rimonabant - effective treatment for smoking cessation, weight loss, and controlling metabolic syndrome Gastroesophageal reflux in the absence of Barrett's esophagus does not appear to predispose to esophageal new guidelines for the clinical management of chronic pelvic pain Syphilis became resistant to antibiotics Hormonal contraceptives could make women aggressive Coffee could become reason of impairment of short-term memory Tea helps memory

risk factors

menjis fuZis kunTebis varjiSma SeiZleba Secvalos viagra

*

- teqnikuri mizezebis gamo Jurnali da daijesti daibeWda 2004 wlis agvistoSi

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menjis fuZis kunTebis varjiSi male SeiZleba yoveli mamakacis fizkulturuli (fitnesis) reJimis elementad iqces: kvlevam aCvena, rom igi mniSvnelovnad aumjobesebs seqsualur potencias. impotent mamakacTa jgufze Catarebulma kvlevam aCvena, rom maTgan TiTqmis naxevarma moaxerxa seqsualuri potenciis aRdgena mas Semdeg rac menjis kunTebis varjiSis kursi gaiares. dReSi 30-wuTiani regularuli varjiSebi sakmarisi aRmoCnda imisaTvis, rom kacebma, romelTac ereqciis SenarCuneba 30 wamze metxans ar SeeZloT, am maCveneblis 5-jer gaumjobeseba SeZles! britanelma jandacvis eqspertebma ganacxades, rom aRniSnulma kvlevam naTelyo aseTi varjiSis efeqturoba yvela janmrTel mamakaczec da kacebis im 10%-zec, romelTac ereqciis disfunqcia awuxebT. kvlevis dizainis mixedviT 55-kaciani jgufi or TiTqmis Tanabar nawilad iyo gayofili: 1) 28 piri, romelTac mxolod jansaRi cxovrebis wesis dacvis rCevebi mieca (mag., alkoholisaTvis Tavis arideba da sxv.), da 2)romelTac daeniSnaT Sorisis kunTebis varjiSis reJimi. varjiSis mizania iSiokavernozuli da bulbokavernozuli kunTebis SekumSva, romlebic Sorisis midamoSi ­ saTesle parksa da ukana tans (anuss) Soris ­ arian ganTavsebuli. varjiSi Sedgeboda am kunTebis 10-10 wamiani SekumSvebisagan ­ mdgomare, mjdomare da mwoliare poziciaSi, ­ imis msgavsad, rogorc amas adamiani moSardvis SeCerebis dros akeTebs. sakontrolo jgufSi sami Tvis Semdeg praqtikulad gaumjobeseba ar aRiniSneboda, maSin roca Sorisis kunTebis varjiSma zemoTmoyvanili brwyinvale Sedegebi gamoiRo. kvlevis bolos ukve yvela piri iqna gadayvanili varjiSze, da sabolood maTgan 40%-s ereqcia normaluri gaxda, xolo kidev 33%-s potencia gauumjobesda. rogorc kvlevis xelmZRvanelma, dasavleT inglisis universitetis (bristoli, didi britaneTi) profesorma greis dorim (Grace Dorey) ganacxada, `menjis kunTebis varjiSi ereqciuli disfunqciiT Sepyrobili yvela mamakacis mkurnalobis sawyisi elementi unda gaxdes, nacvlad fsiqoTerapiis an medikamentebis Tavidanve daniSvnisa~. amave dros man imasac xazi gausva, rom janmrTel mamakacebSic Sorisis varjiSi iwvevs ereqciis xangrZlivobisa da Zalis gaumjobesebas. ase rom, am varjiSs SeuZlia mamakacis impotenciis profilaqtika da misi gamoyeneba naCvenebia seqsualuri janmrTelobis gasaxangrZliveblad maSinac, roca ereqciuli disfunqciis niSnebi jer saxeze araa. rogorc zogad praqtikosTa samefo kolejis pres-mdivanma kati mosma (Catti Moss) ganacxada, `am saxis varjiSiT bevri adamiani miiRebs sargebels. yovelTvis aSkara iyo, rom regularuli varjiSiT adamianTa janmrTeli cxovreba ufro xangrZlivi da ufro ukeTesi xarisxis SeiZleba gaxdes. axla naTelia, rom varjiSma aseve SeiZleba gaaumjobesos da gaaxangrZlivos seqsualuri cxovrebac~.

Pelvic floor exercise could replace Viagra Pelvic floor exercises could soon become a part of every man's fitness regime: research suggests they can dramatically improve sexual prowess. A study conducted on a group of impotent men found that almost half regained a normal level of sexual performance after being put on a course of pelvic exercises. The men, all of whom were unable to maintain an erection for more than 30 seconds, found they could perform for up to five times longer after spending 30 minutes a day strengthening their pelvic floor muscles. Health experts said that the research highlighted the major benefits that such a regime could have on the sexual prowess of all men, as well as the 10 per cent of Britons who suffer erectile dysfunction.

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Of the 55 men recruited for the study, published in the British Journal of General Practice, half were given lifestyle advice alone -- such as reducing alcohol intake -- while the rest were put on a regime to strengthen their pelvic floor. The majority of those doing the exercises, which involve tensing the ischiocavernosus and bulbocavernosus muscles around the perineum -- the area between the scrotum and the anus -- showed marked improvement in maintaining an erection. The exercises involved contracting the pelvic floor muscles for 10-second periods -- while standing, sitting or lying down -- as if the man was trying to stop a flow of urine or wind escaping. While the 28 men given lifestyle advice showed no improvement after three months, those exercising recorded a marked improvement. By the study's end, all 55 had been put on exercises, with 40 per cent attaining normal erectile function, and another third showing improved performance. Grace Dorey, visiting professor at the University of the West of England, Bristol, and lead author of the research, said that the results showed that pelvic floor exercises should be the first treatment for all men with erectile disorders. Such exercises could also prevent impotence in men, and even improve the performance of those who do not have problems. "It was a real surprise," she said. "Strengthening up the muscles not only improved strength, but also endurance. "When men are going through a normal sex life, they should be looking to these exercises to extend their sex life. If you are performing reasonably well, this research would suggest that you may be able to improve your performance further," the professor said. Catti Moss, the general health spokeswoman for the Royal College of General Practitioners, said: "A wide range of people could benefit from this. We have always known that people who exercise regularly last better and last longer in health terms, but now it appears that this could apply to sex as well."

alkoholis zomieri raodenoba amcirebs gulis daaavadebaTa risks amerikelma mecnierebma daadgines, rom ara marto wiTeli Rvino, aramed sxva sasmelebic zomieri odenobiT xels uwyoben gulis daavadebaTa (kerZod, - gulis iSemiuri daavadebis) riskis Semcirebas da, aseve ­ gulis Setevis Semdeg gamojanmrTelebas, iuwyeba internet-Jurnali Seniorjournal.com. ron korTiusi da misi kolegebi misuris kolumbiis universitetidan swavlobdnen alkoholis efeqts cxovelTa sisxlZarRvebze. maT daadgines, rom im cxovelebSi, romelTac yovel 48 saaTSi eZleodaT adamianisaTvis alkoholis 1 porciis proporciuli doza, mniSvnelovnad iklebda cila p-seleqtinis Semcveloba. es cila e.w. adhezantia da Cveulebriv xels uwyobs anTebis ujredebis ­ limfocitebis mimagrebas sisxlZarRvTa kedlebze. anTeba p-seleqtinis monawileobiT viTardeba gid-is ­ koronaruli ukmarisobis drosac. aseT SemTxvevaSi hipoqsiiT gamowveuli dazianebebi kidev ufro Rrma xasiaTisaa. xolo alkoholis zomieri dozebis gavleniT p-seleqtinis done qveiTdeba, sisxlZarRvi gluvi da nakleb webovani xdeba da masze limfocitebi ise veRar emagrebian, rac saboloo jamSi anTebis da iSemiis Semcirebas uwyobs xels. amave dros korTiusi afrTxilebs mosaxleobas, rom cdis Sedegebi ar niSnavs guliT avadmyofebSi alkoholis "licenzirebas" - misi mZime uaryofiTi efeqtebis gamo tvinis ujredebsa da arteriul wnevaze, rac miRebuli dozis proporciulad izrdeba. yovelTvis, rodesac alkohols iRebT, amiT tvinis ujredebs anadgurebT, amitom Cveni amocanaa, gamovyoT alkoholis dadebiT Tvisebebis matarebeli komponentebi imaTgan, romlebic uaryofiTi efeqtebiT xasiaTdebian. igive exeba Tambaqosac, romlis zogierTi Semadgeneli komponenti, mag ­ kapsacini, msgavsi dadebiTi efeqtiT xasiaTdeba, magram es mciredi sargebeli araferia im damangrevel efeqtTan SedarebiT, rasac TambaqoSi Semavali nikotini da kancerogenuli fisebi atareben.

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Heart Attack Recovery Enhanced by Any Alcoholic Drinks, Not Just Red Wine For years researchers have tried to determine why the French have such a lower rate of cardiovascular disease, given the amount of fat consumed in their diets. Red wine has been identified as one of the suspects in maintaining a healthy heart, but now a University of Missouri-Columbia researcher has found that alcohol, in moderation, from any source not only maintains a healthy heart, but can reduce the damage to affected tissue following a heart attack. When a heart attack occurs, blood flow is reduced to several areas of the body. When the blood flow is restored, several processes take place in the body that actually cause more harm to the damaged tissue. When the blood supply is reestablished, the blood carries white blood cells to the areas damaged by the reduction in blood delivery. Unfortunately, these blood cells act like miniature hand grenades as they stick to the walls of the arteries and release toxic chemicals into the damaged tissues, causing additional cell death. "Following a heart attack, physicians try to establish reperfusion, or normalize the blood flow in the body," said Ron Korthuis, distinguished professor and chair of medical pharmacology and physiology. "The damaged tissues begin releasing a variety of molecules that attract the white blood cells to the damaged areas. When the white blood cells arrive, they attach to the adhesion molecules on the blood vessel walls and then start destroying the damaged tissue. One type of adhesion molecule that is affected by the alcohol ingestion is P-selectin" P-selectins make the artery walls sticky enough that the white blood cells will attach when they are in the affected areas. Using an animal model, Korthuis found that when alcohol was introduced to the system at a rate of one drink every 48 hours, the alcohol would trigger a chemical reaction in the body that would make the artery walls slick and stop the white blood cells from attaching to the damaged tissue. In subjects that were treated with the alcohol, the tissue affected by the low blood flow was much healthier and stronger than the untreated tissue. However, Korthuis warns that this is not a license to drink. "Every time you take a drink of alcohol, you're killing brain cells," Korthuis said. "We're trying to identify these chemical reactions so that we can develop a drug that would start this chain reaction, but not have the side effects of alcohol. We've also found other natural compounds have similar effects such as capsaicin, a compound in Tabasco sauce that creates that hot sensation." Korthuis' research will be published this fall in Microcirculation. He also has been published in the American Journal of Physiology and Free Radicals Biology and Medicine on similar research studies.

III fazis ori sxvadasxva kvlevis Sedegebma uCvena, rom rimonabanti warmoadgens wonaSi dasakleb da sigaretis mowevis Sewyvetis axali efeqtur samkurnalo saSualebas, aseve - metaboluri sindromis risk-faqtorebis makontrolebel da Semamcirebel saSualebas. rimonabanti axali wamlebis, kerZod seleqciuri CB1 -blokatorebis erT-erTi warmomadgenelia. rogorc dr-ma anTenelim (Dr. Anthenelli) ganacxada: "rimonabants Seswevs unari, iyos pirveli wamali gulis daavadebis ori mTavari risk-faqtoris ­ sigaretis mowevisa da simsuqnis ­ mkurnalobaSi". prof. anTenelim aRniSna, rom rimonabantis gverdiTi efeqtebi jerjerobiT ar aris cnobili. igi mimarTulia im ujredebis receptorebis winaaRmdeg, romlebic akontroleben cximebis wvasa da dagrovebas. cxovelebSi Catarebuli kvlevidan gamomdinare, igi SesaZloa gaxdes hiperaqtiuri alkoholTan da zogierT wamalTan, kerZod kokainTan mimarTebaSi, Tumca dRemde mkvlevarebi mis efeqts mxolod Tambaqoze da wonaze cdian. rogorc medicinis mecnierebaTa doqtorma, sidni smitma (Sidney C. Smith Jr.) ganacxada, "im dros, roca aSS-Si 50 milion adamians SesaZloa ganuviTardes metaboluri sindromi, es Zalze sasiamovno siaxlea. Tumca, aRmoCenebi jer winaswar xasiaTs atarebs". prof. smiti, romelic ar iRebda monawileobas kvlevaSi, darwmunebulia

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imaSi, rom risk-faqtorebis prevencirebaSi pirveli da umTavresi mainc "cxovrebis stilis Secvlaa". meore mxriv, medicinis mecnierebaTa doqtori alan snaidermeni (Allan Sniderman), romelic aseve ar iyo kvlevis monawile, miiCnevs, rom metaboluri sindromis risk-faqtorebis Tundac mcirediT SezRudva mniSvnelovan gaumjobesebas iZleva.

Results from a pair of phase III studies of an investigational drug - Rimonabant - suggest that it is an effective treatment for smoking cessation, weight loss, and as a means of controlling or reducing metabolic syndrome risk factors. Rimonabant is a member of a new drug class called selective CB1 blockers. Dr. Anthenelli said rimonabant has the potential to be the first "drug to treat the two major risk factors for heart disease: smoking and obesity." Dr. Anthenelli told Medscape that so far there are no disadvantages to rimonabant. The drug targets cell receptors that control how fat is burned and stored. Animal studies also suggest that it may become hyperactive when exposed to excess alcohol or to drugs like cocaine, but so far the researchers are concentrating on tobacco and weight. Sidney C. Smith Jr., MD, told Medscape that "at a time when 50 million people in the U.S. may be affected by metabolic syndrome, this is very good news. But these are early findings." Dr. Smith, who was not involved in the study, said that he remains convinced that the first line of risk factor prevention should be "lifestyle modification." But Allan Sniderman, MD, who also was not involved in the study, said that even small reductions in metabolic syndrome score produce "significant improvements in outcome."

meanoba-ginekologiis amerikulma kolejma Seqmna menjis qronikuli tkivilis klinikuri marTvis axali gaidlaini da gamoaqveyna igi Jurnalis `obsTeTriqs end jaineqoloji" 2004 w. martis nomerSi. ganmartebis Tanaxmad, menjis qronikuli tkivili warmoadgens sul mcire 6 Tvis xangrZlivobis araciklur tkivils, romelSic CarTulia menji, muclis wina kedeli, weli da dundulebi, da imdenad seriozulia, rom SeuZlia gamoiwvios Sromisuunaroba da samedicino daxmarebis aucilebloba. avtorebis Tanaxmad, 18-dan 50 wlamde asakis qalebis daaxloebiT 15-20%-s aReniSneba menjis qronikuli tkivili, romelic erT welze met xans grZeldeba. specifiur gamomwvev faqtorebs miekuTvneba: endometriozi, intersticialuri cistiti da nawlavebis anTeba, magram gasinjva da testireba xSirad ar iZleva diagnozis dasmis saSualebas. myar mecnierul safuZvelze (A donis mtkicebuleba) dayrdnobiT, mkurnaloba moicavs kombinirebul oralur kontraceptivebs - pirveladi dismenoreis dros; gonadotropinis gamomyofi hormonis antagonistebs - endometriozTan da nawlavebis anTebasTan dakavSirebuli tkivilis dros; COX-2 inhibitorebs da sxva arasteroidul anTebis sawinaaRmdego wamlebs - saSualo siZlieris tkivilis, gansakuTrebiT, menstrualuri ciklis dros arsebuli tkivilis dros; maRali dozis progestinebs endometriozTan da menjis sisxlsavseobis sindromTan dakavSirebuli qronikuli tkivilis dros; da I da III fazis endometriozuli dazianebebis laparoskopul destruqcias. aramyar mecnierul safuZvelze dayrdnobiT, mkurnaloba moicavs gavis nervis stimulacias, rac efeqturia qalTa TiTqmis 60%-Si; vitamin B1 an magniumis damatebebs dismenoreisaTvis; abdominalur kedelSi, saSosa da gavaSi specialuri ineqciebis Seyvanas; magnitur Terapias invalidobis dasaZlevad da tkivilis Sesamcireblad, agreTve akupunqturasa da kanis nervuli stimulaciis Terapias - pirveladi dismenoreis dros. histereqtomia, romelic mimarTulia reproduqciuli sistemis organoTa tkivilis mosasxnelad, efeqturia qalebis 75-95%-Si.

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The American College of Obstetricians and Gynecologists (ACOG) has developed new guidelines for the clinical management of chronic pelvic pain and published them in the March issue of Obstetrics and Gynecology. The proposed definition of chronic pelvic pain is noncyclical pain of at least six months' duration involving the pelvis, anterior abdominal wall, lower back, and/or buttocks, and serious enough to cause disability or to necessitate medical care. Approximately 15% to 20% of women aged 18 to 50 years have chronic pelvic pain lasting more than one year, according to the authors. Specific causes may include endometriosis, interstitial cystitis, or irritable bowel syndrome, but examination and testing are often nondiagnostic. Treatment options supported by good, consistent scientific evidence (level A) include combined oral contraceptives for primary dysmenorrhea; gonadotropin-releasing hormone agonists for pain associated with endometriosis and irritable bowel syndrome; COX-2 inhibitors and other NSAIDs for moderate pain, especially for menstrual pain; progestins in daily, high doses for chronic pain associated with endometriosis and pelvic congestion syndrome; and laparoscopic destruction of stages I to III endometriotic lesions. Treatment options supported by only limited or inconsistent evidence (level B) include sacral nerve stimulation, which is effective in up to 60% of women; vitamin B1 or magnesium supplements for dysmenorrhea; trigger point injections into the abdominal wall, vagina, and sacrum; magnetic field therapy of abdominal trigger points to improve disability and reduce pain; and acupuncture and transcutaneous nerve stimulation (TENS) therapies for primary dysmenorrhea. Hysterectomy for relief of pain associated with reproductive tract symptoms is effective in 75% to 95% of women.

gastroezofaguri refluqsi baretis saylapavis gareSe ar warmoadgens kibos riskfaqtors gastroezofaguri refluqsi, e.w. baretis saylapavis (mokle saylapavis qvemo nawili dafarulia kuWis kardiis lorwovaniT, saxezea saylapavis wyluli da striqtura, diafragmuli xvrelis Tiaqari) ararsebobis SemTxvevaSi, ar warmoadgens saylapavi milis kiboswina mdgomareobas, aqveyneben britaneli mkvlevarebi Jurnalis `gaT" 2004 w. agvistos nomerSi. `gastroezofaguri refluqsi TavisTavad udavod warmoadgens baretis saylapavi milis ganviTarebis xelSemwyob, mTavar risk-faqtors", ganacxada Reuters Health-sTan saubarSi prof. masud solaimani-dodaranma (Masoud Solaymani-Dodaran). `magram baretis saylapavis arsebobis gareSe, - mxolod refluqsis mqone adamianebSi - naklebad savaraudoa saylapavi milis kibos ganviTareba".

Gastroesophageal reflux in the absence of Barrett's esophagus does not appear to predispose to esophageal cancer, UK researchers report in the August 2004 issue of Gut. "We should make it clear that we are not suggesting that gastroesophageal reflux is not a major risk factor for Barrett's esophagus," lead researcher Dr. Masoud Solaymani-Dodaran told Reuters Health. "We believe that reflux is on the causal pathway of Barrett's esophagus and we would expect people with Barrett's esophagus to have had either gastroesophageal reflux for longer or of a greater degree." "In the absence of a diagnosis of Barrett's esophagus," Dr. Solaymani-Dodaran concluded, "people with reflux do not appear to have greatly increased risk of esophageal cancer."

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sifilisi (aTaSangi) antibiotikebisadmi mdgradi gaxda amerikelma mkvlevarebma daadgines, rom sxvadasxva regionebSi sifilisis SemTxvevaTa 11-88% gamowveulia mkrTali treponemis iseTi StamebiT, romelTa winaaRmdeg mimarTuli standartuli mkurnaloba peroraluri antibiotikebiT araefeqturia. Sedegebis Tanaxmad, romlebic miiRes eqimma Seila lukhartma (Dr. Sheila A. Lukehart) da misma kolegebma sietlSi, sifilisis gamomwvevma baqteriam mutaciis wyalobiT dakarga mgrZnobeloba azitromicinze. aseTi tipis rezistentuli Stamebi eqimebs yovelwliurad sul ufro da ufro xSirad xvdebaT da igi sakmaod swrafad vrceldeba dedamiwaze. azitromicini sifilisis winaaRmdeg popularul wamlad 1990-ian wlebSi iqca. adre daavadebas mkurnalobdnen penicilinis ineqciebiT, Tumca, am ineqciebis mtkivneulobis gamo, eqimebi eZebdnen antibiotiks, romlis miRebac abebis saxiT iqneboda SesaZlebeli. axla ki, rezistentobis maRali riskis arsebobis gamo, lukharti eqimebs urCevs abebis daniSvnas mxolod im SemTxvevaSi, Tu pacienti didi xnis manZilze iqneba dakvirvebis qveS, raTa droulad moxdes Terapiis efeqturobis Sefaseba.

Syphilis became resistant to antibiotics American researchers have found, that some 11%-88% of all cases of syphilis are caused by bacteria, towards which the conditional antibiotic treatment is not effective anymore. According to results of Dr. Sheila A. Lukehart and her colleagues from Seattle, strains of treponema palidum became resistant to azythromycin due to mutations. Such strains are getting more frequent and are spread throughout the planet every year. Azythromycin became popular medicine against syphilis in 1990s. Before that penicillin injections have been the drug of choice, but doctors have been interested to replace it on peroral antibiotic. Now Dr. Lukehart advises colleagues not to depend on azythromycin, unless the patient will receive it as long term treatment under an observation during which the doctor could evaluate the drug-effectiveness timely.

Casaxvis sawinaaRmdego abebi qalebs agresiuls xdis amerikelma mkvlevarebma daadgines, rom Casaxvis sawinaaRmdego, hormonaluri saSualebebis miReba SesaZloa iwvevdes agresias, Tanaxmad Reuters-isa. preparat `provera"-s kvleva warmoebda cxovelebSi, Tumca mkvlevarebi varaudoben, rom analogiuri gverdiTi efeqtebi damaxasiaTebelia adamianebisTvisac, pirvel rigSi ki im qalebisTvis, romlebsac seqsualuri darRvevebi awuxebT. kvlevis xelmZRvaneli, eqimi karen peizoli (Dr. Karen Pazol) emoris universitetidan atlantaSi, miRebuli Sedegebis safuZvelze eqimebs urCevs _ yuradReba miaqcion qalebis fsiqologiur Taviseburebebs manam, sanam maT dauniSnaven Casaxvis sawinaaRmdego abebs. `provera", igive medroqsiprogesteroni warmoadgens progesteronis ­ im hormonis analogs, romelic amcirebs estrogenis gamomuSavebas. kontracepciis garda, `provera" gamoiyeneba sarZeve jirkvlis, endometriumis da Tirkmelebis kibos samkurnalod. estrogenis donis momatebasTan erTad, seqsualuri ltolva Zlierdeboda, xolo medroqsiprogesteroni ki, piriqiT - aqveiTebda mas. im cxovelebSic, romlebic iRebdnen `provera"-s, aRiniSna agresiuli qmedebebi da mousvenroba. progesterons aseTi gverdiTi efeqtebi ar axasiaTebda. mkvlevarebi varaudoben, rom `provera"-s gavlena ganwyobasa da qcevaze SesaZloa aixsnas imiT, rom es preparati ufro `Zlieria" Cveulebriv progesteronTan SedarebiT da estrogenis gamomuSavebas ufro mniSvnelovnad amcirebs. amJamad, mkvlevarebma daiwyes axali eqsperimentis Catareba, romlis mixedviTac cnobili gaxdeba

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ganwyobilebis Secvla mudmivia, Tu is damaxasiaTebelia mxolod mkurnalobis kursis dasawyisisTvis.

Hormonal contraceptives could make women aggressive American researchers have found that hormonal contraceptives could induce aggressiveness, according to Reuter's Health. Though contraceptive Provera pills have been tested in animals, the similar effects are expected also in humans, especially in females with sexual disturbances. Dr. Karen Pazol from Emory University in Atlanta, GA advices to physicians to pay attention to the psychological peculiarities of their female patients, before administering Provera (medroxiprogesteron), which represents analogue of pregesteron and decreases level of estrogen. Besides contraception, Provera is used to treat endometrial, breast and kidney cancers. Provera, in contrary to estrogen, decreases sexuality. However, it was noted in experimental animals ­ that Provera increased aggressive actions and anxiety. That isn't noticed when progesterone is used. Researchers speculate that Provera might be stronger than natural progesterone and more significantly decreasing level of estrogen. Now the scientists are planning to find out how prolonged that side effect can be, or whether it appears only at initial stage of treatment.

yava SesaZloa gaxdes moklevadiani mexsierebis daqveiTebis mizezi yava SesaZloa gaxdes moklevadiani mexsierebis daqveiTebis mizezi. mowinave kvlevebis saerTaSoriso skolis mkvlevarma, valeria leskma (Valerie Lesk) italiaSi, daadgina, rom kofeini xels uSlida adamianebs im sityvis moZebnasa da warmoTqmaSi, romelic maT ukve icodnen da romelic maT ase vTqvaT, enis wverze qondaT, ityobineba BBC News-i. am fenomens asec ewodeba: `enis wveris fenomeni". leski, romlis statiac dabeWdilia JurnalSi `biheivioral fsaiqoloji", Tvlis, rom kofeini tvinis sxva funqciebis xarjze, aZlierebs mis zogierT funqcias, kerZod, yuradRebas da sifxizles, samagierod misi uaryofiTi gavlena pirvel rigSi moklevadian mexsierebaze aisaxeba. Tumca, valeria leski da misi kolega, stefan uombli (Stephen Womble) trinitis kolejidan dublinSi, aRniSnaven, rom mexsierebis daqveiTeba sakmaod arCeviTia. gaaCnia imas, Tu ris gaxsenebas cdilobs adamiani. kofeini SesaZloa daexmaros an xeli SeuSalos mas raimes gaxsenebaSi. kolejis studentTa erT jgufs misces 200 mg kofeini, rac Seesabameba 2 Wiqa magar yavas, xolo meore jgufs misces placebo. Semdeg, moxaliseebs Txoves 100 martiv kiTxvaze pasuxis gacema, rac moiTxovda mokle pasuxebs. magaliTad kiTxvaze: `ra ewodeba Zveli egviptis damwerlobas~, pasuxad igulisxmeba `ieroglifi~. TiToeul kiTxvaze pasuxis gacemamde, studentebs SesTavazes _ gacnobodnen 10 sityvian CamonaTvals. am CamonaTvalSi 2-8 sityva swori pasuxis msgavsad JRerda. magaliTad: sityva `ierarqia" JRers msgavsad sityvisa `ieroglifi", xolo danarCeni sityvebi araviTar kavSirSi ar iyvnen swor pasuxTan. Tu studenti kiTxvas swor pasuxs ver gascemda, mecnierebi mas swori pasuxis dasawyiss, pirvel ramdenime asos karnaxobdnen, magaliTad: `ie~ sityvidan `ieroglifi~. da Tu studenti amis Semdegac ver SeZlebda swori pasuxis gacemas, maSin mkvlevarebi am SemTxvevas iniSnavdnen, rogorc `enis wveris~ efeqts. Tu CamonaTvalSi miTiTebuli sityvebi swor pasuxTan ar iyvnen kavSirSi, kofeinis momxmarebeli studentebi mas ufro didi gaWirvebiT ixsenebdnen, vidre isini, romlebic Rebulobdnen placebos.

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`zogierT SemTxvevaSi kofeini moklevadian mexsierebaze dadebiTad moqmedebs, zogierT SemTxvevaSi ki ­ piriqiT", acxadebs valeria leski. `kofeini im SemTxvevaSi axdens dadebiT gavlenas moklevadian mexsierebaze, roca im informacias, rac saWiroebs gaxsenebas, aqvs kavSiri azrTa mimdinare jaWvTan, xolo meore SemTxvevaSi, igi, piriqiT, xels uSlis gaxsenebas", ganmartavs leski. Coffee could become reason of impairment of short-term memory. Researcher of the International School of Advanced Studies (Italy), Dr. Valerie Lesk and her team have established, that Coffeine hinders person's ability to find and pronounce words which he/she knows, and which person had at a tip of one's tongue. This phenomenon is called "tip-of-the-tongue". Article by Lesk et al in journal Behavioral Psychology concludes, that coffeine while imcreasing some of the functions of brain, like attention and alertness, however, could hinder other functions ­ first of all ­ short-term memory. the study was performed on students who received 200 mg of coffein, which is equivalent to 2 cups of strong tea. At the same time, both Lesk and her colleague Dr. Stephen Womble from Trinity College in Dublin, emphasize, that memory impairment might be expressed in quite different volume, depending on what a persons tries to remember. Coffeine might be both helpful and hindering for memory. It improves short-term memory, when the information to be remembered has relation with the ongoing chain of mind, but if it doesn't that, coffein may reduce the chance to remember such information.

Cai aumjobesebs mexsierebas mecnierebma albaT saukeTeso gamarTleba mouZebnes im pirebs, visac aqamde Cais gadametebul moxmarebas sayvedurobdnen: Cai, savaraudod, aumjobesebs tvinis funqciebs. mwvane da Sav Caize Catarebulma kvlevebma uCvenes, rom Cais regularuli miRebas SeuZlia Seamciros asakTan dakavSirebuli mexsierebis daqveiTebisa da alchaimeris daavadebis ganviTarebis riski. dr-ma ed okelom da misma kolegebma niukaslis universitetis samedicino mcenareebis kvlevis centridan aRmoaCines, rom Cais SeuZlia dablokos tvinis is enzimebi, romlebic iwveven acetilqolinis daSlas, es ukanaskneli ki warmoadgens nervul ujredebs Soris impulsebis mediators. marTalia, dRemde mecnierebs srulad ver auxsniaT alchaimeris daavadebis mizezi, magram faqtia, rom am daavadebiT Sepyrobil pirTa tvinSi acetilqolinis Zalze dabali done fiqsirdeba da mis samkurnalod swored is preparatebia efeqturi, romelTac acetilqolinis donis momateba SeuZliaT. igive exeba asakTan dakavSirebul mexsierebis Cveulebriv daqveiTebas. ase rom acetilqolinis destruqciis SeCerebiT CaiSi arsebul komponentebs SeuZliaT SeaCeron neiromediatoris Semcvelobis asakTan dakavSirebuli Semcirebis procesi da ar dauSvan acetilqolinis donis mkveTri daqveiTeba. Savi Cai da mwvane Cai erTi da imave mcenaris produqtebia, oRond Savi ufro gvian ikrifeba da ufro fermentirebulia. `Savi Cai axdens tvinis ori enzimis blokirebas, xolo mwvane ­ samisas. amitom mwvane Cais efeqti erT kviramde grZeldeba, xolo Sai Cais ­ mxolod 1-2 dRe~, - ambobs dr. okelo, romlis statia gamoqveynda JurnalSi `fitoTerapi riserC~. `Tu adamianis organizmSi igive procesebi xdeba, rasac Cven laboratoriaSi davakvirdiT, maSin dReSi 5-10 Wiqa Cais miRebam unda normamde gazardos tvinis ujredebSi acetilqolinis raodenoba, Tu is manamde dabal doneze iyo~ ­ ganacxada dr-ma okelom.

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Tea helps memory Scientists have come up with the ideal riposte for those accused of taking too many tea breaks: tea keeps your brain healthy, they say. Tests on green and black tea suggest that regular tea drinking could help prevent age-related memory loss and keep dementias such as Alzheimer's disease at bay. Ed Okello and colleagues at the Medicinal Plant Research Centre at Newcastle University discovered that tea blocks brain enzymes that destroy acetylcholine, a neurotransmitter that carries messages between brain cells. Though scientists do not fully understand the causes of Alzheimer's disease, those affected have extremely low levels of acetylcholine in their brains. Drugs to treat the condition work by boosting the neurotransmitter back to normal levels. Normal age-related memory loss is also linked to a loss of acetylcholine. By halting the destruction of acetylcholine - a natural and necessary process in healthy brains - chemicals in tea could prevent levels of the neurotransmitter dropping too low. Black tea is derived from the same plant as green tea, but is fermented. Both types blocked two brain enzymes, while green tea also blocked the effects of a third. "The beneficial effects of green tea lasted for a week, but with black tea, the effect wore off after a day," said Dr Okello, whose study appears in the journal Phytotherapy Research. "If this works in the body like it does in the lab, anything like five to 10 cups of tea a day would help the levels of acetylcholine if you have too little," said Dr Okello.

iumori samedicino Temaze

moxuci pacienti eqimTan mivida, romelmac yuradRebiT gasinja da bolos uTxra: `kargi ambavic maqvs TqvenTvis da cudic. romliT daviwyo?~ pacienti: `jer cudi miTxariT.~ eqimi:`vfiqrob ori wlis sicocxle-Ra dagrCeniaT~. pacienti: `ra saSinelebaa!!! ori weli da Cemi sococxle damTavrdeba!??? amis mere aRarc vici, ra jandaba unda iyos kargi ambavi!~ eqimi: `is, rom alchaimeris daavadebac gaqvT da ukve sam TveSi yvelaferi dagaviwydebaT, rac ki giTxariT~.

eqimi:`karg janze xarT. 80 wels ueWvelad miaRwevT~. pacienti: `magram, eqimo, me ukve var 80-is~. eqimi: `aba, me ras geubnebodiT!~

axali pacienti mivida eqimis ofisSi da saocrad gaukvirda, rodesac eqTanma fardaCamofarebul tixarTan miiyvana da sTxova, mTlianad gaexada. `ki magram, me mxolod Cabrunebuli fexis frCxilis Cveneba mindoda, da gaxda raRa saWiroa?~ ­ gaaprotesti avadmyofma. `es Cveni wesia~, - auRelveblad miugo eqTanma ­ yvelam unda gaixados!~ `suleluri wesia,~ - miugo gaRizianebulma pacientma ­ `gaiZulon tanze gaixado, rom fexis TiTi dagiTvalieron!~

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`Sen kidev ra giWirs! ~­ gaisma tixris iqeT, meore fardis ukan ­ `me, magaliTad, mxolod telefonis SesakeTeblad movedi!~

This old man visits his doctor and after a thorough examination, the doctor tells him, "I have good news and bad news, what would you like to hear first?" Patient: Well, give me the bad news first. Doctor: I estimate that you have about two years left. Patient: OH NO! That's awful! In two years, my life will be over! What kind of good news could you probably tell me, after this??? Doctor: You also have Alzheimer's. In about three months you are going to forget everything I told you.

Doctor: You're in good health. You'll live to be 80. Patient: But, doctor, I am 80 right now. Doctor: See, what did I tell you.

A new patient was quite upset when the doctor's nurse led him to a small, curtained cubicle and told him to undress. "But I only want the doctor to look at an ingrown toenail!" he protested. "Our rule is that everyone must undress," replied the nurse as she handed him a very skimpy johnny. "That's a stupid rule," grumbled the patient, "making me undress just to look at my toe." "That's nothing," growled a voice from the next cubicle. "I just came to fix the phones!"

76

revmatologiuri veb-gverdebi

moamzada zviad kirtavam

American College of Rheumatology amerikis revmatologTa kolejis (warsulSi ­ amerikis revmatologTa asociaciis) oficialuri veb-gverdi, romelic aerTianebs aSS-is praqtikulad yvela revmatologiur dawesebulebasaa da profesionals. sami umTavresi mimarTuleba Semdegia: ganaTleba,/profesiuli daxelovneba, mkurnaloba da samecniero kvleva. aris warmodgenili ACR produqtebi, kerZod, - ZiriTadi sawvrTneli programebi (kurikulumebi) da maTi momwodeblebi (provaiderebi), slaidebi, audiokasetebi da kompaqt diskebi konferenciebisa da seminarebis masalebiT. kodirebisa da dokumentaciis masalebi, magaliTad avadmyofobis eleqtronuli istoriis Sedgenis masalebi. http://www.rheumatology.org/index.asp Arthritis Foundation arTritis fondi. uaRresad sasargeblo da mZlavri veb-resursi, romelic ZiriTadad arTritiT daavadebulTa saganamnaTleblo miznebs, fondebis mogrovebas, programebis Sesaxeb informireba da pacientTa qselis informirebas emsaxureba. http://www.arthritis.org/default.asp Medscape Rheumatology medskeip warmoadgens jandacvis profesionalTaTvis gankuTvnil veb-gverdebidan `uxucess~. mas gaaCnia revmatologiuri seqcia ­ medskeip reumatoloji. igi Seicavs axal ambebis, klinikur informacias jibis (palmtop) kompiuterebisaTvis, konferenciebis Sinaarss, siaxleebs mkurnalobaSi, klinikuri praqtikis gaidlainebs, Jurnalebis statiebis Sinaarsebs, uwyveti samedicino ganaTlebis (usg) masalebs, rCeul srulteqstur statiebs da sxva saintereso revmatologiur resursebs. rheumatology.medscape.com Doctor's Guide doqtors gaid hgavs medskeips, magram ufro met saerTaSoriso axal ambebs gTavazobT. aq aris `revmatoiduli arTritis~ da `danareCeni revmatologiis~ seqciebi, romelsac CamoSladi menius yuTi gaaCniaT. gverds gaaCnie Semdegi seqciebi: revmatologiis siaxleebi, klinikuri SemTxvevebi, sxva gverdebze SemoTavazebuli usg kursebis bmulebi. SeiZleba personaluri individualuri saWiroebebiT gverdis dakompleqteba. www.docguide.com Pediatric Rheumatology Page niu-iorkis specialuri qirurgiis saavadmyofos pediatrebis mier momzadebuli gverdi, romelzec mocemulia informacia rogorc eqimebisatvis, aseve ­ pacientebisaTvis ­ kerZod, mSoblebisaTvis informacia bavSvTa revmatologiuri profilis daavadebebis diagnostiklisa da marTvis sakiTxebze. eqqimebiisaTvis ­ daavadebaTa mkurnalobis gaidlainebi da TviT_Sefasebis testebi. www.goldscout.com Topics in Clinical Rheumatology - A CME Activity From Johns Hopkins University jons hopkinsis da arTritis fondis merilend Capteris TanadafinansebiT Seqmnili es gverdi saukeTeso resursia usg ganaTlebisatvis. saWiroa 20 dolaris saregistracio gadasaxadis gadaxda. kursi moicavs 8 leqcias, striming-video teqnologiiT, yovekli leqciis bolos testi ­ SefasebiT. http://hopkins-arthritis.com/course/91500/registration.html Journal of Rheumatology

77

erT-erTi seriozuli revmatologiuri Jurnali, romelic inglisur enaze kanadaSi gamodis http://www.jrheum.com/

78

s a m e d i c i n o v e b ­ g v e r d e b i: www.healthministry.ge www.MoLHSA.ge www.health.net.ge

erovnuli sainformacio saswavlo centri (essc) iv. javaxiSvilis q. #51 tel 94 13 88 faqsi 94 13 91 el-fosta: [email protected] interneti: www.nilc.org.ge

internetis veb-gverdis monacemebis forma organizaciebisaTvis

SeiZleba mowodebul iqnas rogorc qarTul, aseve - inglisur enebze, * - aRniSnulia aucilebeli punqtebi

1. * organizaciis dasaxeleba: 2. * organizaciis misamarTi:

sruli dasaxeleba da abreviatura (rogorc qarTul, aseve - inglisur enebze)

qalaqi, kodi, quCa, nomeri, oTaxebis nomeri (rogorc qarTul, aseve 3. * telefoni #1: 4. telefoni #2: 5. faqsi: 6. el-fosta: 7. veg-gverdi:

arsebuli URL anda sasurveli abreviatura inglisurad

+995-32-xx xx xx +995-32-xx xx xx +995-32-xx xx xx

8. organizaciis struqtura:

1. ganyofilebebis CamonaTvali 2. TanamSromelTa raodenoba 3 SeiZleba iyos organizaciuli gegma

9. * organizaciis xel-li piri: * gvari, saxeli

10. organizaciis miznebi: mokle aRweriloba (maqs 100 sityva)

79

11. organizaciis proeqtebi:

mimdinare:

CamonaTvali da TiToeul proeqtze: 1. dasaxeleba 2. mokle aRweriloba (daaxlebiT 100 sityva TiToeul proeqtze) 3. dafinansebis wyaro 4. ganxorcielebis periodi 5. regioni, sadac mimdinareobda 6. beneficiarTa raodenoba 7. proeqtSi monawileTa raodenoba 8. biujeti Sesrulebuli: CamonaTvali da TiToeul proeqtze igive tipis informacia

12. organizaciis gegmebi:

mokle informacia, anda Tu proeqtis zusti monaxazi arsebobs, maSin imave formiT, rac mimdinare proeqtebzea miTiTebuli:

13. organizaciis mier sxva iuridiul Tu fizikur pirebTan TanamSromlobis sfero:

gasaRebi sityvebi: Keywords

organizacia sTavazobs: (eqspertiza /servisi)

organizacias sWirdeba: (eqspertiza /servisi)

14. organizaciis partniorebi:

miuTiTeT is organizaciebi, romelTanac gindaT, rom Tqveni gverdidan iyos bmuli, mag. jandacvis saministros romelime departamenti, romelime saerTaSoriso organizacia (mag.

damfinansebeli) da a.S. 15. organizaciis simbolo (logo):

.jpg, .gif anda romelime sxva grafikuli faili, sasurvelia mcire zomis (ara Corel)

16. * sakontaqto piris monacemebi (araa aucilebeli direqtoris, umjobesia ­

sainformacio/teqnikuri personalis monacemebi)

* telefoni * faqsi * el-fosta mobiluri telefoni

80

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