Лечение острого инфаркта миокарда с подъемом сегмента ST

Практическое применение результатов клинических исследований

Результаты клинических исследований часто не внедряются в практику, в то время как практические врачи нередко продолжают пользоваться малоэффективными или неэффективными средствами. Например, в двух крупных исследованиях было показано, что примерно 40% больных острым инфарктом миокарда, сопровождающимся подъемом сегмента ST, не получают реперфузионную терапию [232,233]. Существует необходимость в постоянном обучении врачей и оценке внедрения новых методов лечения в клиническую практику. Вероятность широкого использования методов лечения, обладающих доказанной эффективностью, выше в лечебных учреждениях, которые принимают участие в многоцентровых исследованиях.

Рекомендации

Больные

Больные с острым сердечным приступом имеют право на быстрое установление диагноза, купирование боли, реанимационные мероприятия и реперфузионную терапию (при наличии показаний).

Ведением больных с предполагаемым или подтвержденным инфарктом миокарда должны заниматься медицинские работники, имеющие необходимые навыки и квалификацию. Они должны иметь доступ к современным методам диагностики и лечения. Кроме того, следует обеспечить адекватные наблюдение, реабилитацию и вторичную профилактику после выписки больных из стационара. Больных и их близких следует информировать о симптомах сердечного приступа и мерах, которые следует предпринять при их появлении.

Кардиологи

Кардиологи в сотрудничестве с врачами отделений интенсивной терапии и администрацией должны организовать оптимальную систему ведения больных инфарктом миокарда. Она по крайней мере должна предполагать обучение сотрудников скорой помощи, внедрение эффективных методов диагностики и лечения в приемных отделениях и разработку алгоритмов реперфузионной терапии.

Кардиологи вместе с анестезиологами должны обеспечить обучение других врачей и парамедиков навыкам реанимационных мероприятий. Необходимо вести учет сроков от обращения за медицинской помощью до начала тромболитической терапии и от поступления в стационар до реперфузии. Первый срок не должен превышать 90 минут, в то время как у больных с четкими показаниями к реперфузии тромболизис или вмешательство на коронарных артериях должны быть начаты не позднее чем через 20 и 60 минут соответственно после госпитализации.

Необходимо также вести учет частоты фармакологической или механической реперфузии у больных с определенным инфарктом миокарда, госпитализированных в течение 12 ч после появления симптомов с подъемом сегмента ST или блокадой левой ножки пучка Гиса. Этот показатель должен превышать 90%.

Вмешательство на коронарных артериях может служить альтернативой тромболитической терапии при наличии соответствующих навыков у персонала и необходимого оборудования. Результаты первичных вмешательств следует включать в региональные и национальные регистры.

Большинство больных неосложненным инфарктом миокарда, особенно перенесших успешную реперфузию, могут быть выписаны из стационара через 4-5 дней [235].

Необходимо внедрять адекватные стратегии оценки риска коронарных осложнений. Они предполагают определение функции левого желудочка и выполнение нагрузочных проб (ЭКГ, сцинтиграфия или эхокардиография).

Всем больным необходима программа реабилитации, которую проводят с учетом индивидуальных особенностей пациента.

В лечебном учреждении следует иметь программу борьбы с курением. Медицинские работники должны не только рекомендовать пациентам бросить курить, но и помогать им справиться с тягой к табаку.

Необходимо вести учет проводимых мер вторичной профилактики после инфаркта миокарда. При отсутствии противопоказаний всем больным следует назначать аспирин, бета-блокаторы и ингибиторы АПФ.

У всех больных следует определить уровни липидов плазмы, предпочтительно в первый день. При повышении концентрации липидов назначают диету. Если она окажется неэффективной, применяют гипо- липидемические средства в соответствии с рекомендациями Европейского общества кардиологов [219].

Врачи общей практики

В тех странах, где больные с сердечным приступом в первую очередь обращаются к врачам общей практики, последние должны иметь навыки оказания неотложной помощи. Если семейный врач имеет необходимую квалификацию, то он может проводить дефибрилляцию и тромболитическую терапию. Врачей общей практики следует привлекать к осуществлению программ неотложной помощи больным с заболеваниями сердца.

Врач общей практики должен как можно быстрее осмотреть больного после выписки из стационара, обеспечить адекватную его реабилитацию и контролировать проведение вторичной профилактики.

Органы здравоохранения

Органы здравоохранения должны способствовать



Литература

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