6 курс / Кардиология / Джон_Кэмм_Болезни_сердца_и_сосудов_2011
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ГЛАВА 15. СОПУТСТВУЮЩАЯ ПАТОЛОГИЯ ПРИ СЕРДЕЧНОСОСУДИСТЫХ ЗАБОЛЕВАНИЯХ
Frank Ruschitzka
ВВЕДЕНИЕ
Новое в медицине зарождается на стыке различных специальностей.
Пауль Хугенхольц
В то время как происходит быстрое внедрение новых подходов к визуализации, интервенционным вмешательствам, а различные устройства и приборы существенно изменили структуру нашей специальности, кардиологам по-прежнему необходим взгляд, выходящий за рамки своей дисциплины. Обеспечение контакта с коллегами других специальностей не только еще более оптимизирует ведение наших пациентов, особенно пожилых, у которых часто имеется сопутствующая патология, но также важно с точки зрения научного обмена, что лучше всего описывается термином взаимообогащения. В связи с этим в данное издание книги была добавлена настоящая глава, которая дает шанс тем, кто уже знает "все о чем-либо" узнать "коечто обо всем". В частности, были добавлены разделы об инсульте, патологии почек и эректильной дисфункции (ЭД).
ЭД, патология почек и инсульты широко распространены у больных с сердечно-сосудистой патологией. Исходы и течение этих состояний существенно выигрывают от возрастающего внимания к мониторированию сердечно-сосудистых факторов риска и их коррекции, и усиливают внимание к ассоциированными факторам риска, которые должны тщательно выявляться и соответствующим образом лечиться.
Патология почек может быть как причиной, так и следствием болезней сердечно-сосудистой системы. Продолжительность жизни больных с заболеваниями почек в большой степени зависит от сердечно-сосудистых проблем. Так, среди пациентов на гемодиализе риск сердечно-сосудистой смерти в 10 раз превышает таковой в общей популяции, и даже незначительное нарушение функции почек существенно увеличивает сердечно-сосудистый риск. В связи с этим выявление ССЗ у больных с патологией почек является важнейшей задачей, даже среди тех, у кого отсутствуют какие-либо симптомы.
И напротив, наличие почечного повреждения является установленным фактором риска развития патологии сердца. В связи с этим, больные с патологией сердца нуждаются в обязательной тщательной оценке функции почек (креатинина сыворотки, скорости клубочковой фильтрации и протеинурии).
Во всем мире инсульт является третьей по частоте причиной смерти после ИМ. 80% инсультов связаны с локальной ишемией, а оставшиеся 20% приходится на кровоизлияния. Атеросклероз (ведущий к тромбоэмболии или локальной окклюзии артерии) и сердечные эмболии - ведущие причины инсультов. Между немодифицируемыми (возраст старше 55 лет, афроамериканская раса, мужской пол, предшествовавшая транзиторная ишемическая атака, отягощенная наследственность) и модифицируемыми (гипертензия, дислипидемия, курение) факторами риска инсульта и патологии сердца существуют четкий параллелизм.
Тогда как основным звеном первичной профилактики инсульта является контроль уровня АД, при остром инсульте снижение АД производится только при очень высоких значениях, превышающих
220/110 мм рт.ст.
Вторичная профилактика инсульта после кардиогенных транзиторных ишемических атак или инсульта, как правило, производится при помощи антикоагулянтов для приема внутрь, которые превосходят ацетилсалициловую кислоту по эффективности. Антиагрегантная терапия показана пациентам с ишемическим инсультом и отсутствием источника эмболии. Как монотерапия клопидогрелом, так и его комбинация с медленно высвобождающимся дипиридамолом превосходят по эффективности АСК.
У пациентов с симптомным стенозом внутренней сонной артерии хорошо изучена эффективность стентирования и эндартерэктомии, которые имеют равнозначные исходы.
ЭД - преимущественно сосудистое заболевания с факторами риска, схожими с ИБС. Поражает примерно две трети пациентов с ИБС. Любой пациент с ЭД, даже в отсутствии сердечных симптомов должен рассматриваться как больной с сердечно-сосудистой патологией, пока не доказано обратное. Поскольку ЭД может быть ранним маркером коронарной или иной сосудистой патологии, мужчины с ЭД должны быть тщательно обследованы и стратифицированы в отношении сердечно-сосудистого риска, а их сердечно-сосудистые факторы риска должны быть соответствующим образом корригированы.
Хотя ингибиторы фосфодиэстеразы пятого типа (ФДЭ-5) существенно преобразовали возможности лечения ЭД, они противопоказаны больным, получающим нитраты.
ГЛАВА 15А. СЕРДЦЕ И МОЗГ
Hans-Christoph Diener, Heinrich Mattle,
Michael Böhm and Frank Ruschitzka
РЕЗЮМЕ
Среди наиболее распространенных причин смертности третье место занимает инсульт. Примерно в 25% случаев всех инсультов источником эмболии служит сердце, чаще предсердия. Лечение острого инсульта следует проводить в специализированных инсультных отделениях. Системная тромболитическая терапия с применением тканевого рекомбинантного активатора плазминогена (в пределах терапевтического окна 4,5 ч) или эндоваскулярная реканализация (до 6 ч) позволяют снизить частоту инвалидизации после ишемического инсульта. Вторичную профилактику инсульта после кардиогенной транзиторной ишемической атаки или инсульта целесообразно проводить антикоагулянтами для приема внутрь, которые предпочтительнее ацетилсалициловой кислоты (аспирина♠). Антиагрегантная терапия показана пациентам с ишемическим инсультом при отсутствии кардиальных источников эмболии. Как монотерапия клопидогрелом, так и комбинация клопидогрела с медленно высвобождающимся дипиридамолом предпочтительнее монотерапии аспирином♠. У пациентов с клиническими проявлениями стеноза внутренней сонной артерии высокой степени эндартерэктомия реже, чем стентирование и баллонная ангиопластика, сопровождается осложнениями при сопоставимых отдаленных результатах.