Title Kompletna revaskularizacija kod primarne perkutane koronarne intervencije Title (english) Complete revascularization in primary percutaneous coronary intervention Author Neven Relota Mentor Matias Trbušić (mentor)Committee member Boško Skorić (predsjednik povjerenstva)Committee member Nikola Bulj (član povjerenstva)Committee member Matias Trbušić (član povjerenstva)Granter University of Zagreb Defense date and country 2019-07-12, Croatia Scientific / art field, BIOMEDICINE AND HEALTHCARE Abstract Kardiovaskularne bolesti su vodeći uzrok smrtnosti u svijetu, a najčešće ljudi umiru od ishemijske bolesti srca. Najopasnija manifestacija ishemijske bolesti srca je akutni infarkt miokarda. On nastaje rupturom nestabilnog aterosklerotskog plaka na endotelu koronarne arterije koja rezultira agregacijom trombocita. Na koncu se formira tromb koji okludira koronarnu žilu. Prema nalazu 12-kanalnog EKG-a, razlikujemo infarkt miokarda sa i bez elevacije ST-segmenta (STEMI i NSTEMI). Temelj liječenja akutnog infarkta miokarda je koronarna revaskularizacija, a u načelu se postiže perkutanom koronarnom intervencijom (PCI), koja se razvojem intervencijske kardiologije sa ugradnjom stentova koji otpuštaju lijekove prometnula u zlatni standard u tretiranju infarkta. Primarna PCI definirana je kao intervencija u okludiranoj žili unutar 12 sati od pojave bolova u prsištu ili ostalih simptoma, bez prethodne trombolitičke ili druge terapije za otapanje ugruška. Strategije primarne PCI su: primarna PCI samo krvne žile odgovorne za infarkt, višežilna primarna PCI te frakcionirana PCI. Europsko kardiološko društvo u svojim smjernicama daje najvišu razinu preporuke za inicijalno tretiranje arterije koja je odgovorna za infarkt, međutim, otvoreno je pitanje kako tretirati koronarne arterije koje nisu povezane s infarktom, a sužene su. Velika većina studija je pokazala konzistentnu korist kompletne revaskularizacije u odnosu na revaskularizaciju samo infarktne arterije (IRA-only) u pacijenata sa STEMI-jem i višežilnom koronarnom bolesti. Postoje prijepori je li opravdanija uporaba višežilne primarne PCI ili frakcionirane PCI. Meta-analize su proturječne po tom pitanju, nema definitivnih dokaza, no blaga prednost među kliničarima se daje frakcioniranoj PCI. Dok se ne kreiraju jasne smjernice temeljene na velikoj randomiziranoj studiji, kliničari bi trebali svakog pacijenta sa STEMI-jem i višežilnom koronarnom bolešću promatrati individualno u odabiru optimalne strategije i vremena izvođenja PCI-a. Visokorizični NSTEMI se inicijalno zbrinjava na isti način kao STEMI. I tu istraživanja favoriziraju kompletnu revaskularizaciju, ali za razliku od STEMI-ja, daju jasnu prednost višežilnoj primarnoj PCI u odnosu na frakcioniranu PCI. Glede kardiogenog šoka, najnovije smjernice Europskog kardiološkog društva su suglasne kad je u pitanju i STEMI i NSTEMI, i ne preporuča se izvođenje rutinske revaskularizacije lezija nepovezanih s infarktom tijekom primarne PCI. Čak se smatra štetnim.
Abstract (english) Cardiovascular disease is the main cause of mortality in the world today, especially the ischemic heart disease. The most dangerous manifestation of ischemic heart disease is an acute myocardial infarction. It is the result of a rupture of a vulnerable atherosclerotic plaque, which provokes aggregation of the platelets. Finally, the clot is formed and it occludes a coronary artery. According to the standard 12-lead ECG there are two types of a myocardial infarction: with and without an ST-elevation (STEMI and NSTEMI). The basis of an acute myocardial infarction (MI) treatment is the revascularization of a coronary artery, mainly achieved by using percutaneous coronary intervention (PCI). With the development of interventional cardiology, PCI with the drug-eluting stents placement became the gold standard of a MI therapy. Primary PCI is defined as an intervention on the occluded vessel within the 12 hours timeframe since the onset of pain chest or the other symptoms, without the use of thrombolytic therapy. Strategies of the primary PCI are: culprit-vessel only primary PCI (CVO-pPCI), multivessel primary PCI (MV-pPCI) and staged PCI. The European Society of Cardiology (ESC) gives the highest recommendation for the initial treatment of the infarct-related artery (IRA) in its guidelines. However, there is an open issue of how to treat the non-IRA lesions. Most studies show the better results for the complete revascularization compared to the CVO revascularization in the patients who suffer of STEMI and the ones with the multivessel coronary artery disease (MV-CAD). There is a question whether it is better to use MV-pPCI or staged PCI. There is no consensus regarding this question, but a mild support to the use of staged PCI is showed among the clinicians. Until the clear guidelines based on a large randomized study are set, clinicians should consider every patient with STEMI and MV-CAD by individual. The high-risk NSTEMI is initially taken care of the same way as a STEMI. Here the studies also favour the use of the complete revascularization, but unlike with STEMI treatment, they prefer the MV-pPCI in comparison to the staged PCI. Regarding the cardiogenic shock, the newest ESC’s guidelines say that, no matter if it is STEMI or NSTEMI event, it is not recommended to do the routine revascularization of a non-IRA lesion during the primary PCI. It is even considered to be harmful.
Keywords
kompletna revaskularizacija
primarna perkutana koronarna intervencija
STEMI
NSTEMI
višežilna primarna PCI
frakcionirana PCI
Keywords (english)
complete revascularization
primary percutaneous coronary intervention
STEMI
NSTEMI
multivessel primary PCI
staged PCI
Language croatian URN:NBN urn:nbn:hr:105:976708 Study programme Title: Medicine Type of resource Text File origin Born digital Access conditions Open access Terms of use Created on 2020-02-13 11:31:32
