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Contraindicationstostresstesting
AcuteMIwithin2days
Unstableanginanotpreviouslystabilizedbymedicaltherapy
Cardiacarrhythmiascausingsymptomsorhemodynamiccompromise
Symptomaticsevereaorticstenosis
SymptomaticHF
Acutepulmonaryembolus,myocarditis,pericarditis,oraorticdissection
Stressmodalities
Exercisestresstesting
ThestressmodalityofchoiceforevaluatingmostpatientsofintermediateriskforCAD(seeTable
4-2).
Bruceprotocol:Consistsof3-minutestagesofincreasingtreadmillspeed andincline.BP,heart
rate,andECGaremonitoredthroughoutthestudyandtherecoveryperiod.
TheECGportionofthestudyisconsideredpositiveif:
□ NewST-segmentdepressionsof>1mminmultiplecontiguousleads
□ Hypotensiveresponsetoexercise
□ Sustainedventriculararrhythmiasareprecipitatedbyexercise
TheDukeTreadmill Scoreprovides prognosticinformationforpatientspresentingwith chronic
angina(Table4-6).
TABLE4-6
EXERCISESTRESSTESTING:DUKETREADMILLSCORE
11
DukeTreadmillScore(DTS)=Minutesexercised–[5×maximumST-segmentdeviation]
–[4×anginascore].Anginascore:0=none,1=nottestlimiting,2=testlimiting
DTS
5 Annualmortality0.25% Low-riskstudy
−10to4 Annualmortality1.25% Intermediate-riskstudy
<–10 Annualmortality>5% High-riskstudy
Ingeneral,β-blockers,othernodalblockingagents,andnitratesshouldbediscontinuedpriortostresstesting.
11
Whenexercisetestingiscombinedwithimaging(e.g.,echocardiography),andthetestisnormalat
thetargetheartrateforage,theriskofinfarctionordeathfromCVDis<1%annuallyinpatients
withnopriorhistoryofIHD.
Inpatientswhocannotexerciseandrequirepharmacologictesting,theannualriskofinfarctionor
death in a normal study, doubles (i.e., 2% per year). This underscores the inability to perform
physicalactivityasamarkerofincreasedcardiovascularrisk.
Pharmacologicstresstesting
Inpatientswhoareunabletoexercise,pharmacologicstresstestingmaybepreferable.
Pharmacologic stressispreferredinpatientswith leftbundle branch block (LBBB)or a paced
rhythm on ECG. This is dueto the increased incidence of false-positive stress tests seen with
eitherexerciseordobutamineinfusion.
Dipyridamole,adenosine,andregadenosonare vasodilatorscommonlyusedinconjunctionwith
myocardial perfusion scintigraphy. Relative ischemia across a coronary vascular bed is
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elucidatedashealthyvesselsdilatemorethandiseasedvesselswithfixedobstruction.Thisinturn
leadstorelativechangesinperfusionthatarereflectedinthepostvasodilatorimages.
Dobutamineisapositiveinotropecommonlyusedwithechocardiographicstresstestsandmaybe
augmentedwithatropinetoachievetargetheartrateforage.
Stresstestingwithimaging
RecommendedforpatientswiththefollowingbaselineECGabnormalities:
Preexcitation(Wolf-Parkinson-Whitesyndrome)
LVH
LBBBorpacedrhythm
Intraventricularconductiondelay
RestingST-segmentorT-wavechanges
PatientsunabletoexerciseorwhodonothaveaninterpretableECGatrestorwithexercise
MaybeconsideredinpatientswithhighpretestprobabilityofIHDwhohavenotmetthethreshold
ofinvasiveangiography
Imagingmodalities
Myocardial perfusion imaging (MPI): Both PET (positron emission tomography) and SPECT
(single-photon emission tomography) use tracers that emit radiation detected by a camera in
conjunction with exercise or pharmacologic stress. PEThasbetter contrast and spatial resolution
than SPECT, but PET is much more expensive and less widely available. Perfusion imaging
comparesrestperfusiontostressperfusionimagestodiscernareasofischemiaorinfarct.Itcanbe
limitedbybodyhabitus,breastattenuation,andqualityoftheacquisitionandprocessingofimages.
SevereCADmaycausebalancedreductioninperfusionandanunderestimationofischemicburden.
Echocardiographic imaging: Exercise or dobutamine stress testing can be performed with
echocardiography to aid in the diagnosis of CAD. Echocardiography adds to the sensitivity and
specificityofthetestbyrevealingareaswithwallmotionabnormalities.Thetechnicalqualityofthis
studycanbelimitedbyimagingquality(i.e.,obesity).
Magnetic resonance perfusion imaging: MRI sequences obtained with contrast and vasodilator
stress testing (and very rarely exercise testing) provides viability assessment without additional
testing,aswell asevaluationforothercausesofmyocardialdysfunctionthatmaymimic IHD(i.e.,
sarcoidosisorinfiltrativecardiomyopathies).Canbeperformedinpatientswithimplantedcardiac
devices(i.e.,defibrillatorsandpacemakers).
DIAGNOSTICPROCEDURES
Coronaryangiography
Thegoldstandardforevaluatingepicardialcoronaryanatomybecauseitquantifiesthepresenceand
severityofatheroscleroticlesions,whichhasprognosticvalue.
Coronary angiography is invasive and associated with a small risk of death, MI,CVA,bleeding,
arrhythmia, and vascular complications. Therefore, it is reserved for patients whose risk–benefit
ratiofavorsaninvasiveapproachsuchas:
ST-segmentelevationMI(STEMI)patients
Mostunstableangina(UA)/non–ST-segmentelevationMI(NSTEMI)patients
Symptomatic patients with high-risk stress tests who are expected to benefit from
revascularization
ClassIIIandIVanginadespitemedicaltherapy(seeTable4-1)
Survivorsofsuddencardiacdeathorthosewithseriousventriculararrhythmias
SignsorsymptomsofHFordecreasedLVfunction
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Anginathatisinadequatelycontrolledwithmedicaltherapyforthepatient’slifestyle
Previouscoronaryarterybypassgrafting(CABG)orpercutaneouscoronaryintervention(PCI)
Suspectedorknownleftmain(≥50%stenosis)orseverethree-vesselCAD
To diagnose CADin patients with anginawho have notundergone stress testing due to a high
pretestprobabilityofhavingCAD(seeTable4-2)
Canbeusedtoevaluatepatientswhoaresuspectedofhavinganonatheroscleroticcauseofischemia
(e.g.,coronaryanomaly,coronarydissection,radiationvasculopathy).
Functional significance of intermediate stenotic lesions (50%–70% narrowing) can further be
assessedbyfractionalflowreserve(FFR)orinstantaneouswave-freeratio(iFR).
Both FFR and iFR are calculated by determining the ratio of pressure distal to the coronary
obstructiontothatoftheaorticpressure(flow)usingslightlydifferentmethods.
□ AnFFR≤0.8oriFR≤0.89isconsideredflowlimiting,andPCIdecreasestheneedforurgent
revascularizationforUAorMI,aswellasriskofrecurrentMI.
12
□ Whether PCI in stable IHD improves cardiovascular outcomes or symptoms compared to
medicaltherapyiscontroversial.
13
Anearlyinvasivestrategydidnotreducedeath,deathfromcardiovascularcauses,MI,ora
composite of the three in stable IHD.14 These patients did have decreased angina and
improvedqualityoflife.
Patientswithrecentacutecoronarysyndrome(ACS),severeangina,leftmaindisease,or
leftventricularejectionfraction(LVEF)<35%wereexcluded.
Physiological studies (FFR) were performed in only 20% of cases, and use of
intravascular imaging (intravascular ultrasound, optical coherence tomography) was not
reported.
The use of physiological studies and intravascular imaging is associated withbetter
outcomesinPCI.
15,16
21% of patients assigned to a conservative strategy eventually underwent
revascularization.
PCI for stable IHD did not improve survival, but was associated with decreased
nonprocedural MI, unstable angina,andanginaina meta-analysis. However, there was an
increasedincidenceofproceduralMI.
17
Measurement of LV filling pressures (diastolic function) and aortic and mitral valve gradients,
assessmentofregionalwallmotionandLVfunction,andassessmentforcertainaortopathiescanbe
accomplished by placing a catheter in theLV cavityor aorta directlyandmakingtheappropriate
pressuremeasurementsand/orinjectionofcontrast.
Contrast-induced nephropathy(CIN) occurs after 24–48 hours inupto5% of patientsundergoing
coronaryangiography.Inmostpatients,creatininereturnstobaselinewithin7days.18Thefollowing
areconsiderationsinthepreventionofCIN:
Thevolumeofcontrastmediausedshouldbeminimized.
AllpatientsshouldreceivesomeCINprophylactictherapy:oralhydration,IVhydration,heldIV
diuretics,andstatintherapyhaveprovenbenefit.
Werecommenda3mL/kgbolusofnormalsalineatleast6hourspriortotheprocedurewitha1
mL/kgcontinuousinfusionrateuntilprocedurestart.
N-Acetyl-l-cysteinehasnoadvantageoversimplehydrationforpreventionofCIN.
CoronaryCTangiography
AnoninvasivetechniqueusedtoestablishadiagnosisofCAD.Likecardiacangiography,itexposes
thepatienttobothradiationandcontrastmaterial.
UsesarterialphasecontrastCTimagestoevaluatecoronarystenosis.Whereavailable,aproprietary
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softwarepackagecancalculateintracoronaryhemodynamicsakintoFFR.
CThasa high negative predictivevalue,so it is bettersuitedtoruleout disease forsymptomatic
patientswith a low pretestprobability forCAD,such asa patientwithrepeated emergencyroom
admissionsforchestpainorpatientswithequivocalstresstestresults.
The 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and
DiagnosisofChestPaingives CTaclass Iindicationforuse inintermediateriskpatients with
acutechestpain,withoutknownCAD,toexcludeobstructiveCAD.
19
Mayassistinidentificationofcongenitalanomaliesofthecoronaryarteries.
Due to diminished study quality, it is not useful inpatients with extensive coronary calcification
(e.g.,elderly,oradvancedCKD),coronarystents,orsmall-calibervessels.
TREATMENT
Themajorgoaloftreatmentistoreducesymptoms.
AnabsolutereductioninincidenceofMIorcardiacdeathinpatientswithstableIHDisaccomplished
mainlythroughmedicaltherapyandnotrevascularization.
Acombinationoflifestylemodification,medicaltherapy,andcoronaryrevascularizationcanbeused.
A recommendedstrategyfor the evaluationandmanagement ofthe patient with stable anginacanbe
foundinFigure4-1.
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Figure 4-1 Approach to the evaluation and management of the patient with stable ischemic heart disease based on the
ISCHEMIA trial.Of note, patients with severe limiting angina, clinicalheart failure, or left ventricle (LV) dysfunction should
proceeddirectlytocoronaryangiographytodefineunderlyingcoronaryarterydisease.Patientswithoutthesefeaturesmayfirst
undergomedicaloptimizationwithguideline-directedmedicaltherapies(GDMT).Ifthepatientissatisfiedwiththeirsymptomson
optimal GDMT andistolerating treatment without significant side effects, coronary CTA shouldthen be obtainedto rule out
significant left main disease. If no significant left main disease is present, the patient may continue medical therapywithout
further testing or intervention. If significant left main disease is present, the patient should undergo cardiac catheterization.
Patientswhoarenotsatisfiedwiththeoutcomeofoptimal GDMTmayproceeddirectlytocardiac catheterization.Information
obtainedfromcardiac catheterizationshouldthenbeusedbya multidisciplinaryteamtodetermine whethercontinuedmedical
therapy,PCI,orCABGshouldbepursued.1CABGgenerallypreferredduetoknownsurvival advantageovermedicaltherapy
alone;however,ifthecoronarylesionsarenotcomplex,PCImayoffersimilarresultstoCABGbutwithahigherneedforfuture
revascularizations.2PCI shouldbereservedforpatientswhohavehigh-gradelesions,havesevere ischemia,andarerefractory
to medical therapy. CABG, coronary artery bypass grafting; CCS, Canadian Cardiovascular Society Classification (angina);
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CTA, computed tomographyangiography; NICM,nonischemic cardiomyopathy; NYHA, New York Heart Association; PCI,
percutaneouscoronaryintervention;WMA,wallmotionabnormality.
Medical treatment is aimed at improving myocardial oxygen supply, reducing myocardial oxygen
demand, controlling exacerbating factors (e.g., anemia), and limiting the development of further
atheroscleroticdisease.
Medicaltreatmentoftenissufficienttocontrolanginalsymptomsinchronicstableangina.
Medications
Anti-ischemictherapy
β-Adrenergic antagonists (Table 4-7) control anginal symptoms by decreasing heart rate and
myocardialwork,leadingtoreducedmyocardialoxygendemand.
β-Blockerswithintrinsicsympathomimeticactivityshouldbeavoided.
Dosagecanbeadjustedtoresultinarestingheartrateof50–60bpm.
Use with caution or avoid in patients with active bronchospasm, atrioventricular (AV) block,
restingbradycardia,orpoorlycompensatedHF.
Calciumchannel blockers can be used either inconjunction withor in lieuof β-blockers in the
presenceofcontraindicationsoradverseeffectsasasecond-lineagent(Table4-8).
Calcium antagonists are often used in conjunction with β-blockers if the latter are not fully
effective at relieving anginal symptoms. Both long-acting dihydropyridines and
nondihydropyridineagentscanbeused.
Calciumchannelblockersareeffectiveagentsforthetreatmentofcoronaryvasospasm.
Nondihydropyridine agents (verapamil/diltiazem) should be avoided in patients with systolic
dysfunctionduetotheirnegativeinotropiceffects.
Nitrates,eitherlong-actingformulationsforchronicuseorsublingual/topicalpreparationsforacute
anginalsymptoms,aremoreoftenusedasadjunctiveantianginalagents(Table4-9).
Sublingualpreparationsshouldbeusedatthefirstindicationofanginaorprophylacticallybefore
engaginginactivitiesthatare knowntoprecipitateangina.Patientsshould seekpromptmedical
attentionifanginaoccursatrestorfailstorespondtothethirdsublingualdose.
Nitrate tolerance resulting in reduced therapeutic response may occur with all nitrate
preparations.Theinstitutionofanitrate-freeperiodof10–12hours(usuallyatnight)canenhance
treatmentefficacy.
ForpatientswithCAD,nitrateshavenotshownamortalitybenefit.
Nitrates are contraindicated (even in patients with ACS) for use in patients who are on
phoshodiesterase-5inhibitorsduetoriskofseverehypotension.Awashoutperiodof24hoursfor
sildenafilandvardenafiland48hoursfortadalafilisrequiredpriortonitrateuse.
Ranolazineisindicatedforanginarefractorytostandardmedicaltherapyandhasshownbenefitin
improving symptoms and quality of life. Ranolazine interacts with simvastatin metabolism and
shouldnotbeusedtogether.
Secondarypreventionmedications
Acetylsalicylic acid (ASA) (75–162 mg/d) reduces cardiovascular events, including repeat
revascularization,MI,andcardiacdeath,byapproximately33%.
20
ASA81mgappearstobesufficientformostpatients.
ASAdesensitizationmaybeperformedinpatientswithASAallergy.
Clopidogrel(75mg/d)canbeusedinthoseallergicorintolerantofASA.
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Angiotensin-converting enzyme inhibitors(ACEinhibitors) and angiotensin receptorblockers
(ARBs)havecardiovascularprotectiveeffectsthatreducetherecurrenceofischemicevents.
ACEinhibitortherapy,orARBsinthosewith ACEinhibitors intolerance,shouldbe usedinall
patientswithanLVEF<40%,hypertension,diabetes,orchronickidneydisease.
Statinshavea markedeffectinsecondaryprevention, andall patients withIHDwhocantolerate
therapyshouldbeonahigh-potencystatin(seeChapter3,PreventiveCardiology).
Insecondarypreventionofcoronaryheartdisease,statinshavethemostevidencedemonstratinga
robustmortalitybenefit.
Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors confer a mortality benefit to
patients with IHD whose LDL levels remain >70 mg/dL despite high-intensity statins. Currently,
expenseandinsurancecoveragelimittheuseofthisclassofmedications.
21
Ezetimibe also improves cardiovascular outcomes among patients withIHDwhose LDL remains
>100mg/dLdespitehigh-intensitystatintherapy.
22
InfluenzavaccinationisrecommendedforallpatientswithIHD.
TABLE4-7
Β-BLOCKERSCOMMONLYUSEDFORISCHEMICHEARTDISEASE
Drug β-ReceptorSelectivity Dose
Propranolol β1andβ
2
20–80mgbid
Metoprolol β
1
50–200mgbid
Atenolol β
1
50–200mgdaily
Nebivolol β
1
5–40mgdaily
Nadolol β1andβ
2
40–80mgdaily
Timolol β1andβ
2
10–30mgtid
Acebutolol
a
β
1
200–600mgbid
Bisoprolol β
1
10–20mgdaily
Esmolol(IV) β
1
50–300µg/kg/min
Labetalol Combinedα,β1,β
2
200–600mgbid
Pindolol
a
β1andβ
2
2.5–7.5mgtid
Carvedilol Combinedα,β1,β
2
3.125–25mgbid
a
β-Blockerswithintrinsicsympathomimeticactivity.
TABLE4-8
CALCIUMCHANNELBLOCKERSCOMMONLYUSEDFORISCHEMICHEARTDISEASE
Drug DurationofAction UsualDosage
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Dihydropyridines
Nifedipine Long 30–180mgdaily
Amlodipine Long 5–10mgdaily
Felodipine(SR) Long 5–10mgdaily
Isradipine Medium 2.5–10mgdaily
Nicardipine Short 20–40mgtid
Nondihydropyridines
Diltiazem
Immediaterelease Short 30–90mgqid
Slowrelease Long 120–360mgdaily
Verapamil
Immediaterelease Short 80–160mgtid
Slowrelease Long 120–480mgdaily
TABLE4-9
NITRATEPREPARATIONSCOMMONLYUSEDFORISCHEMICHEARTDISEASE
Preparation Dosage Onset(min) Duration
Sublingualnitroglycerin 0.3–0.6mgPRN 2–5 10–30min
Aerosolnitroglycerin 0.4mgPRN 2–5 10–30min
Oralisosorbidedinitrate 5–40mgtid 30–60 4–6h
Oralisosorbidemononitrate 10–20mgbid 30–60 6–8h
OralisosorbidemononitrateSR 30–120mgdaily 30–60 12–18h
2%Nitroglycerinointment 0.5–2intid 20–60 3–8h
Transdermalnitroglycerinpatches 5–15mgdaily >60 12h
Intravenousnitroglycerin 10–200µg/min <2 Duringinfusion
Revascularization
Coronaryrevascularization
Ingeneral,medicaltherapywithatleasttwoclassesofantianginalagentsshouldbeattemptedbefore
medicaltherapyisconsideredafailureandcoronaryrevascularizationpursuedinstableangina.
Relief of angina symptoms is the most common objective ofall revascularization procedures for
stableangina.
The indicationfor all revascularization procedures should consider theacuity of presentation, the
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extent of ischemia, and the ability to achieve full revascularization. The selection of
revascularizationshouldbetailoredtotheindividualpatientand,incomplexcases,includetheuse
ofamultidisciplinaryheartteam.
The choice between PCI and CABG surgery is dependent on the coronary anatomy, medical
comorbidities,andpatientpreference.
Ingeneral,patientswithcomplexanddiffusediseaseordiabetesdobetterwithCABG,whereas
PCI in select patients with the proper coronary anatomy can provide comparable results as
CABG.
23
The Syntax Score is a validated angiographic model that can aid the clinician in determining
outcomesafterPCIorCABG.Ingeneral,patientswithaloworintermediateSyntaxScoredoas
wellorbetterwithPCIcomparedtoCABG24(availableathttp://www.syntaxscore.com/).
The Society of Thoracic Surgeons (STS) score can help determine the risk of mortality and
morbidity associated with CABG and should be determined for all patients when considering
surgicalrevascularization(availableathttp://riskcalc.sts.org/).
Revascularization is shown to improve survival in the following circumstances as compared to
medicaltherapy:
CABG for >50% left main CAD that has not been grafted (unprotected). PCI is a reasonable
alternative for patients with left main disease if the patient is a poor surgical candidate (STS
score>5)andhasafavorablemorphologyforPCI(lowSyntaxScore).PCI,intherightclinical
context,canofferratesofMI,CVA,ordeathsimilartoCABG.
25
CABG for three-vessel disease or two-vessel disease that includes the proximal left anterior
descending(LAD)artery.
CABGforpatients with two-vessel disease, not includingthe LADartery, ifthere is extensive
ischemia (>20% myocardium at risk)or inpatientswith isolated proximal LAD artery disease
whenaninternalmammaryarteryrevascularizationisperformed.
CABG,ascomparedtoPCIormedicaltherapy,inpatientswithmultivesseldiseaseanddiabetes,
ifaleftinternalmammaryarterytotheLADarterycanbeplaced.26PCImayoffersimilarsurvival
outcomes indiabetics with multivessel disease anda low SyntaxScore (<22) butdoes have a
higherneedforrepeatrevascularization.
27
PCI or CABGinpatients whohavesurvived suddencardiac deathduetoischemic ventricular
tachycardia(VT).
Due tothe morbidity ofa repeat CABG, PCIis often used to improvesymptoms inpatientswith
recurrentanginaafterCABG.
The use of internal mammary artery grafts is associated with 90% graft patency at 10 years,
comparedwith40%–50%forsaphenousveingrafts.Thelong-termpatencyofaradialarterygraftis
80% at 5 years. After 10 years of follow-up, 50% of patients develop recurrent angina or other
adversecardiaceventsrelatedtolateveingraftfailureorprogressionofnativeCAD.
TherisksofelectivePCIinclude<1%mortality,a2%–5%rateofnonfatalMI, and<1%needfor
emergent CABG for an unsuccessful procedure. Patients undergoing PCI have shorter
hospitalizationsbutrequiremorefrequentrepeatrevascularizationprocedurescomparedtoCABG.
Elderly patients represent a unique population when considering revascularization due to
comorbidities,frailty,thephysiologyofagingasitrelatestodrugmetabolismandcardiopulmonary
function, andconcernover polypharmacy.Ingeneral, this populationhasbeenunderrepresentedin
most trials but still derives benefitfrom revascularization to relieve symptoms. Frailty shouldbe
heavily considered when considering a procedure or counseling about the benefits of
revascularization.
It is reasonable to revascularize selected patients with severe LV dysfunction (EF < 35%), as
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evidencedbythelong-termmortalitybenefitseenwithCABGintheSTICHEStrial.
28
Viabilitytesting (nuclearperfusionimagingor MRI) mayprovide some assistancetotheclinician
whentryingtodeterminethepossiblebenefitofrevascularizationinpatientswithpriorMIorsevere
LVdysfunctionbutisstilllargelyunproven.
Monitoring/Follow-Up
Closepatientfollow-upisacriticalcomponentofthetreatmentofCADbecauselifestylemodification
andsecondaryriskfactorreductionrequireserialreassessmentandinterventions.
Allpatientsshouldbeaggressivelytreatedforthetraditionalriskfactorsmentionedabove.
Relativelyminorchangesinanginalsymptoms canbesafelytreated withtitration and/or additionof
antianginalmedications.
Significantchangesinanginalcomplaints(frequency,severity,ortimetoonsetwithactivity)shouldbe
evaluated by either stress testing (usually in conjunction with an imaging modality) or cardiac
angiographyaswarranted.
Cardiacrehabilitationoranexerciseprogramshouldbeofferedorinstituted.
AcuteCoronarySyndromes,UnstableAngina,andNon–STSegmentElevationMyocardialInfarction
GENERALPRINCIPLES
Definition
NSTEMI and UA are closely related conditions whose pathogenesis and clinical presentations are
similarbutdifferinseverity.
Ifcoronaryflowisnotsevereenoughortheocclusiondoesnotpersistlongenoughtocausemyocardial
necrosis(asindicatedbypositivecardiacbiomarkers),thesyndromeislabeledUA.
NSTEMIisdefinedbyanelevationofcardiacbiomarkersandtheabsenceofST-segmentelevationon
theECG.
NSTEMI,likeSTEMI,canleadtocardiogenicshock.
AHA/ACCguidelinesprovideamorethoroughoverviewofNSTEMI/UA.
29,30
Epidemiology
TheannualincidenceofACSis>780,000events,with70%beingNSTEMI/UA.
AmongpatientswithACS,approximately60%haveUAand40%haveMI(one-thirdofMIspresent
withanacuteSTEMI).
At1year,patientswithUA/NSTEMIareatconsiderableriskfordeath( 6%),recurrentMI( 11%),
and need for revascularization ( 50%–60%). It is important to note that although the short-term
mortalityofSTEMIisgreaterthanthatofNSTEMI,thelong-termmortalityissimilar.
31,32
PatientswithNSTEMI/UAtendtohavemorecomorbidities,bothcardiacandnoncardiac,thanSTEMI
patients.
Women with NSTEMI/UA have worse short-term and long-term outcomes and more complications
compared to men. Much of this has been attributed to delays in recognition of symptoms and
underutilizationofguideline-directedmedicaltherapyandinvasivemanagement.
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