Acute coronary syndrome care at the prehospital stage. Acute coronary syndrome: emergency care, treatment, recommendations

ACUTE CORONARY SYNDROME: EMERGENCY MEDICAL CARE AT THE PREHOSPITAL STAGE

I. GENERAL CONCEPTS

Definition. Acute coronary syndrome (ACS) is a group of clinical signs or symptoms that make it highly likely to suspect myocardial infarction (MI) or unstable angina (UA) upon first contact with the patient. ACS includes conditions caused by acute ischemic changes in the myocardium: UA (new or progressive), non-ST segment elevation MI (STEMI) and ST-segment elevation MI (STEMI).

At the prehospital stage of emergency medical care (DE EMS), differential diagnosis between UA and STEMI is not carried out. Since at an early stage of diagnosis (including in a hospital) it is not always possible to differentiate between NS and MI, as well as other diseases with a similar clinical picture, it is advisable to distinguish between “probable ACS”, as a preliminary diagnosis during emergency hospitalization of the patient, and “suspected ACS” , as a secondary diagnosis in cases where another disease is the more likely cause of treatment, but ACS has not yet been excluded. It should be noted that overdiagnosis of ACS at the prehospital stage is a smaller error than underestimating the patient’s condition. In a third of cases, ACS may have an atypical course.

Classification of unstable angina (according to E. Braunwald, 1989)

The formation of coronary artery occlusion leads to insufficient oxygen supply to the myocardium with subsequent formation of necrosis of the heart muscle. Moreover, the longer the period of ischemia lasts, the greater the area and depth of necrosis. After 4-6 hours of ischemia, the zone of necrosis of the heart muscle practically corresponds to the area of ​​​​the blood supply to the affected vessel.

Treatment of ACS at the prehospital stage: modern view Prof. Tereshchenko S. N. Institute of Clinical Cardiology named after. A. L. Myasnikova. RKNPK Russian Cardiology Research and Production Complex

Acute coronary syndrome Single cause of disease but different clinical manifestations and other treatment strategies Substernal pain Acute coronary syndrome No ST elevation No troponin Unstable angina ST elevation Positive troponin MV CK MI without ST elevation MI with ST elevation

Pathogenesis of acute coronary syndrome Rupture of a vulnerable atherosclerotic plaque intracoronary thrombosis change in plaque geometry distal embolization local spasm Spasm of the coronary artery at the site of stenosis without visible stenosis myocardial oxygen demand with significant stenoses of oxygen delivery to the myocardium with significant stenoses Appearance/worsening of myocardial ischemia Symptoms of exacerbation of CAD (spicy coronary syndrome)

The goals of treatment of acute coronary syndrome are to improve the prognosis of mortality and the frequency of myocardial infarction complications. Eliminate symptoms and pain syndromes of heart failure arrhythmia...

The main tasks during the first examination are §Providing emergency care §Assessing the probable cause of chest pain (ischemic or non-ischemic) §Assessing the immediate risk of developing life-threatening conditions §Determining the indication and place of hospitalization.

Physician tactics for ACS at the prehospital stage §Initial assessment of patients with chest pain. Differential diagnosis.

Differential diagnosis of chest pain is not only a clinical, but also an organizational problem solved in diagnostic departments for patients with chest pain

DOCTOR'S TACTICS IN ACS AT THE PREHOSPITAL STAGE §Initial assessment of patients with chest pain. Differential diagnosis. §Indications for hospitalization and transportation.

The slightest suspicion (probable ACS) regarding the ischemic origin of chest pain, even in the absence of characteristic electrocardiographic changes, should be a reason for immediate transportation of the patient to the hospital.

DOCTOR'S TACTICS IN ACS AT THE PREHOSPITAL STAGE §Initial assessment of patients with chest pain. Differential diagnosis. §Indications for hospitalization and transportation. §Prehospital assessment of the level of risk of death and development of AMI in patients with ACS without ST segment elevation.

Risk stratification in non-ST ACS Acute risk of adverse outcomes in non-ST ACS (assessed during observation) High recurrent angina dynamic ST segment displacements (the more widespread, the worse the prognosis) Low during observation ischemia does not recur no ST segment depression early post-infarction angina not markers myocardial necrosis cardiac troponins (the higher, the worse the prognosis) normal levels of cardiac troponin when determined twice with an interval of at least 6 hours diabetes mellitus hemodynamic instability serious arrhythmias Eur Heart J 2002; 23: 1809 -40

DOCTOR'S TACTICS IN ACS AT THE PREHOSPITAL STAGE §Initial assessment of patients with chest pain. Differential diagnosis. §Indications for hospitalization and transportation. §Prehospital assessment of the risk level of death and MI in patients with ACS. §Treatment of OSK at the prehospital stage.

Providing emergency care Pain relief Nitroglycerin 0.4 mg p.i. or spray for p. Blood pressure >90 If ineffective, after 5 minutes Nitroglycerin 0.4 mg p.i. or spray at s. Blood pressure >90 If “03” is ineffective Morphine (especially in cases of agitation, acute heart failure) IV 2 -4 mg + 2 -8 mg every 5 -15 minutes or 4 -8 mg + 2 mg every 5 minutes or 3 - 5 mg until pain relief IV nitroglycerin for blood pressure >90 mm Hg, if there is pain, acute pulmonary congestion, high blood pressure

Basic principles of treatment of patients with ACS without ST segment elevation at the prehospital stage §Adequate pain relief §Antithrombotic therapy.

The effect of aspirin and heparin on the sum of cases of death and MI in ACS without ST Meta-analysis of studies % p=0.0005 12.5 6.4 5.3 2.0 n=2488 No treatment www. acc. org n=2629 Aspirin 5 days-2 years Heparin 1 week

Factors influencing the choice of antithrombotic treatment for ACS without persistent ST Nature of myocardial ischemia and time of the last episode Risk of adverse outcome (MI, death) in the near future Approach to patient management is invasive conservative Risk of bleeding Renal function Clinical judgment of the presence of ongoing intracoronary thrombosis

Aspirin for ACS without ST. Current recommendations Initial dose European Society of Cardiology, ACS without ST (2002) Long-term use 75 -150 ≤ 100 with clopidogrel Class I (A) American College of Cardiology and Heart Association, ACS without ST (2002) 162 -325 75 - 160 I (A) Russian recommendations, ACS without ST (2004) 250 -500 75 -325, then 75 -160 (150) - European Society of Cardiology, antiplatelet agents (2004) 160 -300 75 -100 I (A ) American College of Chest Physicians (2004) 160 -325 75 -162 I (A) Eur Heart J 2002; 23: 809 -40. Circulation 2002; 106: 893 -1900. Chest 2004; 126: 513 S-548 S. Eur Heart J 2004; 25: 166 -81. Cardiology 2004, supplement.

Heparin for ACS without persistent ST on ECG 48 -72 hours for pain IV infusion of UFH SC injection of LMWH Observation 6 -12 hours High risk of thrombotic complications No signs of high risk of thrombotic complications ST troponin ... no ST normal troponin (twice at intervals >6 hours) Administration from 2 to 8 days (according to the doctor’s decision) Cancellation of heparin

Addition of clopidogrel for ACS without ST CURE Study (n=12,562) Death, MI, stroke, severe ischemia risk 34% p=0.003 11.4% 0.14 Event risk 0.12 Heparin 92% of which LMWH 54% Aspirin 0.10 9.3% 0.08 Aspirin + clopidogrel 0.06 0.04 Hours after randomization 0.02 0.00 0 Circulation 2003; 107: 966– 72 3 6 9 12 Months

Manifestations of myocardial ischemia Severe pain behind the sternum, squeezing, pressing Perspiration, sticky cold sweat Nausea, vomiting Shortness of breath Weakness, collapse

Clinical variants of MI % 65.6 status anginosus 89 status asthmaticus 7 10.5 status gastralgicus 1 6.7 arrhythmic 2 14.3 cerebral 1 - asymptomatic - 2.9 616 people 105 people Syrkin A.L.

Necessary and sufficient signs for the diagnosis of AMI One of the following criteria is sufficient for the diagnosis of AMI: - clinical picture of ACS; - the appearance of pathological Q waves on the ECG; - ECG changes indicating the appearance of myocardial ischemia: the occurrence of ST segment elevation or depression, LBP blockade;

50% of deaths are from UTIs. ST occurs in the first 1.5-2 hours from the onset of an anginal attack and most of these patients die before the arrival of the ambulance team. Therefore, the greatest efforts must be made to ensure that first medical aid is provided to the patient as early as possible, and that the volume of this assistance is optimal

Organization of EMS work for AMI Treatment of a patient with UTI. ST is a single process that begins in the prehospital stage and continues in the hospital. To do this, EMS teams and hospitals where patients with ACS are admitted must work according to a single algorithm based on common principles of diagnosis, treatment and a common understanding of tactical issues. which actually begins treatment and transports the patient to the hospital, leads to an unjustified loss of time §Each ambulance team (including paramedics) must be prepared to carry out active treatment of a patient with UTI. ST

Organization of EMS work in case of AMI §Any EMS team, having made a diagnosis of ACS and determined the indications and contraindications for appropriate treatment, must stop the pain attack, begin antithrombotic treatment, including the administration of thrombolytics (if invasive restoration of the patency of the coronary artery is not planned), and if complications develop - heart rhythm disturbances or acute heart failure - necessary therapy, including cardiopulmonary resuscitation measures §EMS teams in each locality must have clear instructions to which hospitals it is necessary to transport patients with UTI. ST or suspected UTI. ST §Doctors of these hospitals, if necessary, provide emergency medical assistance with appropriate advisory assistance

It is necessary to transport the patient as quickly as possible to the nearest specialized institution, where the diagnosis will be clarified and treatment will be continued.

The line EMS team must be equipped with the necessary equipment: 1. Portable ECG with self-powered power supply; 2. Portable device for EIT with autonomous power supply and monitoring of heart rhythm; 3. Cardiopulmonary resuscitation kit, including a device for manual ventilation; 4. Equipment for infusion therapy, including infusion pumps and perfusors; 5. Kit for installing an IV catheter; 6. Cardioscope; 7. Pacemaker; 8. System for remote transmission of ECG; 9. Mobile communication system; 10. Suction; 11. Medicines required for basic treatment of AMI

Treatment of uncomplicated UTI. ST at the prehospital stage Each ambulance team (including paramedics) must be prepared to actively treat a patient with UTI. ST Basic therapy. 1. Eliminate pain syndrome. 2. Chew a tablet containing 250 mg of ASA. 3. Take 300 mg of clopidogrel orally. 4. Start IV infusion of NG, primarily for persistent angina, hypertension, AHF. 5. Start treatment with b-blockers. Initial IV administration is preferable, especially for ischemia that persists after IV administration of narcotic analgesics or recurs, hypertension, tachycardia or tachyarrhythmia, without HF. It is expected that a primary TBA will be performed. The loading dose of clopidogrel is 600 mg.

Oxygen therapy In all cases, 2 l/min through nasal catheters in the first 6 hours § When arterial blood is saturated with O § preservation of myocardial ischemia § pulmonary congestion 2 -4 (4 -8) l/min through nasal catheters 2

Nitrates in acute myocardial infarction Indications for the use of nitrates § myocardial ischemia § acute pulmonary congestion § need to control blood pressure No contraindications § p. BP 30 mm Hg below baseline § Heart rate 100 § suspicion of right ventricular MI §

Prehospital triple antiplatelet therapy Data from the On-TIME 2 trial Prehospital IG IIb/IIIa tirofiban (25 mcg/kg bolus followed by 0.15 mcg/kg/min infusion over 18 hours) or placebo in addition to aspirin (500 mg intravenously), clopidogrel (600 mg orally) and intravenous bolus (5000 IU) UFH p=0.043 p=0.051 p=0.581

Restoration of coronary perfusion The basis of treatment of acute MI is the restoration of coronary blood flow - coronary reperfusion. Destruction of the thrombus and restoration of myocardial perfusion lead to limiting the extent of its damage and, ultimately, to improving the immediate and long-term prognosis. Therefore, all patients with UTI. ST should be immediately examined to clarify the indications and contraindications for restoration of coronary blood flow. Russian recommendations. Diagnosis and treatment of patients with acute myocardial infarction with ST segment elevation ECG. 2007 VNOK

Thrombolytic therapy in patients with AMI in 2008 according to data from 12 regions, 2008

Prehospital thrombolysis: gain in time = saving the myocardium Decision to call an ambulance Arrival of an ambulance Arrival at the hospital Occurrence of pain Diagnosis Formation in the emergency room Actilyse SK today PTCA Metalyse in the ICU tomorrow Occurrence of pain Decision to call an ambulance Metalyse in Metalyse at Arrival Diagnosis in the emergency room at the prehospital emergency stage “Early Thrombolysis” Strategy

Prehospital thrombolysis for MI with ST

USIC registry 2000: reduction in mortality with prehospital thrombolysis Mortality (%) 15 12. 2 10 5 8. 0 6. 7 3. 3 0 Prehosp. TL TL in hospital Without PCI reperfusion therapy Danchin et al. Circulation 2004; 110: 1909–1915.

VIENNA STEMI REGISTRY: Change in reperfusion strategy Thrombolysis Without reperfusion PCI 60 60 50 50 Patients (%) 40 34 26. 7 30 20 16 13. 4 10 0 VIENNA 2002 VIENNA 2003/2004 Kalla et al. Circulation 2006; 113: 2398–2405.

VIENNA STEMI REGISTRY: Time from onset of disease to treatment for different strategies 0 -2 hours 100 90 19. 5 6 -12 hours 2 -6 hours 5. 1 80 44. 4 Patients (%) 70 60 50 65. 9 40 30 20 10 50. 5 14. 6 0 PCI THROMBOLYSIS Kalla et al. Circulation 2006; 113: 2398–2405.

GRACE REGISTRY Reperfusion therapy Without reperfusion PCI only 50 48 Patients (%) 43 40 40 41 36 32 30 35 33 33 31 30 25 20 10 TLT only 35 32 26 19 13 15 0 1999 2000 2001 2002 Years 2003 2004 Eagle et al. 2007, Submitted

Treatment of uncomplicated UTI. ST at the prehospital stage Thrombolytic therapy at the prehospital stage. It is carried out if there are indications and no contraindications. When using streptokinase, at the discretion of the physician, direct-acting anticoagulants can be used as concomitant therapy. If anticoagulant use is preferred, UFH, enoxaparin, or fondaparinux may be chosen. When using fibrin-specific thrombolytics, enoxaparin or UFH should be used. Reperfusion therapy is not expected. The decision about the advisability of using direct anticoagulants may be postponed until admission to the hospital. Russian recommendations. Diagnosis and treatment of patients with acute myocardial infarction with ST segment elevation ECG. 2007 VNOK

Indications for TLT If the time from the onset of an anginal attack does not exceed 12 hours, and the ECG shows ST segment elevation ≥ 0.1 m. V, in at least 2 consecutive chest leads or 2 limb leads, or LBP block appears. The administration of thrombolytics is justified at the same time with ECG signs of true posterior MI (high R waves in the right precordial leads and ST segment depression in leads V 1 -V 4 ​​with an upward T wave). Russian recommendations. Diagnosis and treatment of patients with acute myocardial infarction with ST segment elevation ECG. 2007 VNOK

Contraindications for TLT Absolute contraindications for TLT § previous hemorrhagic stroke or stroke of unknown etiology; § ischemic stroke suffered during the last 3 months; § brain tumor, primary and metastatic; § suspicion of aortic dissection; § presence of signs of bleeding or hemorrhagic diathesis (except for menstruation); § significant closed head injuries in the last 3 months; §changes in the structure of cerebral vessels, for example, arteriovenous malformation, arterial aneurysms Russian recommendations. Diagnosis and treatment of patients with acute myocardial infarction with ST segment elevation ECG. 2007 VNOK

Checklist for making a decision by the EMS medical and paramedic team to conduct TLT for a patient with acute coronary syndrome (ACS) Check and mark each of the indicators given in the table. If all the boxes in the “Yes” column and none in the “No” column are checked, then thrombolytic therapy is indicated for the patient. If there is even one unchecked box in the “Yes” column, TLT therapy should not be carried out and filling out the checklist can be stopped. “Yes” The patient is oriented, can communicate. Pain syndrome characteristic of ACS and/or its equivalents lasting at least 15-20 minutes. , but no more than 12 hours After the disappearance of the pain syndrome characteristic of ACS and/or its equivalents, no more than 3 hours have passed. A high-quality recording of an ECG in 12 leads has been performed. The EMS doctor/paramedic has experience in assessing changes in the ST segment and bundle branch block on an ECG (test only in the absence of a remote assessment of the ECG by a specialist) There is ST segment elevation of 1 mm or more in two or more adjacent ECG leads or a left bundle branch block is registered, which the patient did not have before. The EMS doctor/paramedic has experience in performing TLT. Transporting the patient to the hospital will take more than 30 minutes It is possible to receive medical recommendations from the hospital’s cardiac resuscitator in real time During the patient’s transportation, it is possible to constantly monitor the ECG (at least in one lead), intravenous infusions (in “No”

Age over 35 years for men and over 40 years for women Systolic blood pressure does not exceed 180 mmHg. Art. Diastolic blood pressure does not exceed 110 mm Hg. Art. The difference in systolic blood pressure levels measured on the right and left arms does not exceed 15 mmHg. Art. There are no indications in the medical history of a stroke or the presence of other organic (structural) pathology of the brain. There are no clinical signs of bleeding of any location (including gastrointestinal and urogenital) or manifestations of hemorrhagic syndrome. The submitted medical documents do not contain data on the patient undergoing long-term (more than 10 minutes) ) cardiopulmonary resuscitation or the presence of internal bleeding in the last 2 weeks; the patient and his relatives confirm this. The presented medical documents do not contain data on the past 3 months. surgical operation (including on the eyes using a laser) or serious injury with hematomas and/or bleeding, the patient confirms this. The submitted medical documents do not contain data on the presence of pregnancy or the terminal stage of any disease, and survey and examination data confirm this The submitted medical documents do not contain data on the presence of jaundice, hepatitis, renal failure in the patient and data from the survey and examination of the patient. CONCLUSION: TLT for the patient is CONTRAINDICATED confirm this _______________ (full name) SHOWN (circle as necessary, cross out as unnecessary) The sheet was completed by: Doctor / paramedic (circle as necessary ) _____________ (full name) Date ______ Time _____ Signature_______ The control sheet is sent with the patient to the hospital and filed in the medical history

Thrombolytic drugs Intravenous 1 mg/kg body weight (but not more than 100 mg): bolus 15 mg; subsequent infusion of 0.75 mg/kg body weight over 30 minutes (but not more than 50 mg), then 0.5 mg/kg (but not more than 35 mg) over 60 minutes (total infusion duration 1.5 hours). Intravenously: bolus of 2,000,000 IU and Purolaza followed by infusion of 4,000,000 IU over 30 -60 minutes. Streptokinase Intravenous infusion 1,500,000 IU over 30-60 minutes.). Tenecteplase Intravenous bolus: 30 mg for a weight of 90 kg. ST segment of the ECG. 2007 VNOK Alyeplaza

Evolution of thrombolysis First generation Streptokinase allergenic not selective for fibrin Second generation Third generation Metalyse Equivalent to Alteplase Actilyse High “gold standard” fibrin selectivity fibrin specificity not allergenic Continuous intravenous infusion Single bolus 5-10 seconds

Relative risk reduction Meta-analysis of studies with early IV beta-blockers for MI (n=52,411) 0 -5 -10 -15 -20 -13%

BETA BLOCKERS: USE IN PATIENTS WITH ACS IN 59 RUSSIAN CENTERS Data from the GRACE register (2000 -1) 100% N=2806 C ST – 50.3% Without ST – 49.7% 1 Prev. 7 days 3 During hospitalization 2 First 24 hours. 4 Recomm. at discharge 100% Without ST C ST 55. 6 54. 3 50. 7 50% 54 50% 20. 2 0% 4. 3% 2. 9 IV 60. 3 54. 5 12. 2 0% 1 2 3 4 I/O 1 2 3 4 www. cardiosite. ru

IV administration of beta-blockers for acute myocardial infarction From the first hours/day To eliminate symptoms § persistence of ischemia § tachycardia without HF § tachyarrhythmia § BP For everyone without contraindications § the feasibility of IV is discussed § if there are no contraindications

Beta blockers for UTIs. ST Drug Dose Treatment on the 1st day of the disease Metoprolol IV 5 mg 2-3 times with an interval of at least 2 minutes; The first oral dose is 15 minutes after intravenous administration. Propronolol IV 0.1 mg/kg in 2-3 doses at intervals of at least 2-3 minutes; The first oral dose is 4 hours after intravenous administration. Esmolol IV infusion at an initial dose of 0.05 -0.1 mg/kg/min, followed by a gradual increase in dose by 0.05 mg/kg/min every 10–15 minutes until the effect or dose of 0.3 mg/kg is achieved /min; for a faster onset of effect, an initial administration of 0.5 mg/kg over 2–5 minutes is possible. Emolol is usually discontinued after the second dose of an oral β-blocker if proper heart rate and blood pressure have been maintained during their combined use.

ACS P ST Data upon admission to hospital Odds ratio (confidence interval) City Clinical Hospital No. 29 (n=58) Other centers (n=1917) Time from the onset of symptoms to hospitalization (hours) 5, 48 2, 83 ST elevations on the initial ECG (%) 86.2 93.8 2.45 (1.13 ->5) Negative T on the initial ECG (%) 3.45 1.73 0.49 (0.12 -2.11) GRACE scale: proportion patients with risk of death =10% 10.3 19.4 2.08 (0.89 -4.88) Killip class I-II (%) 93.1 93.1 0.99 (0.35 -2.78 ) III (%) 5. 17 3. 86 0. 74 (0. 23 -2. 41) IV (%) 0 2. 74 1. 81 (0. 25 -13. 3) RUSSIAN REGISTRY OF ACUTE CORONARY SYNDROMES (RECORD )

ACS P ST Primary reperfusion therapy and anticoagulant treatment Odds ratio (confidence interval) City Clinical Hospital No. 29 (n=58) Other centers (n=1917) 27, 6 75, 7 0 47, 9 Streptokinase (%) 24, 1 5, 0 0. 17 (0. 09 -0. 31) T-PA (%) 3.5 22. 8 >5 81. 0 94. 0 3. 69 (1. 86 ->5) LMWH (%) 0 62 , 4 UFH (%) 100 50.5 Fondaparinux (%) 0 0.1 Bivalirudin (%) 0 0.1 Primary reperfusion (%) Primary PCI (%) TLT: Anticoagulants (%) RUSSIAN REGISTRY OF ACUTE CORONARY SYNDROMES (RECORD)

Practical approaches to the treatment of AMI Within 10 - 15 minutes Emergency treatment § morphine 2-4 mg IV until effect § RR, heart rate, blood pressure, O2 saturation ECG monitoring Preparedness for defibrillation and CPR Providing IV access ECG at 12 -ti leads Short targeted history, physical examination §O 2 4 -8 l/min for O 2 saturation >90% § § § aspirin (if not given earlier): § § clopidogrel 300 mg, chew 250 mg, suppository 300 mg or IV 500 mg age 90, if there is pain, acute congestion in the lungs, high blood pressure § solution to the issue of TLT!!!

LIST OF ABBREVIATIONS.

INTRODUCTION.

CHAPTER 1. LITERATURE REVIEW.

1.1. The concept of OKS.

1.2. Laboratory diagnosis of acute myocardial infarction.

1.3. Treatment of acute coronary syndrome: prehospital thrombolysis.

1.4. Treatment of acute coronary syndrome: nitrates.

CHAPTER 2. MATERIAL AND METHODS OF RESEARCH.

2.1. Study design.

2.2. Research materials.

2.3. Research methods.

CHAPTER 3. RESULTS OBTAINED.

3.1. Results of biochemical diagnostics using rapid tests.

3.2. Temporal characteristics of medical care for patients with acute coronary syndrome with elevation of the BT segment.

3.3. Dependence of the time characteristics of medical care for patients with ACS with 8T segment elevation on the nature of the terrain.

3.4. Dependence of the time characteristics of medical care for patients with acute coronary syndrome with elevation of the 8T segment on the time of year.

3.5. Dependence of the time characteristics of medical care for patients with ACS with elevation of the BT segment on the time of day.

3.6. ECG dynamics after thrombolytic therapy.

3.7. Reperfusion rhythm disturbances.

3.8 Clinical outcomes of acute coronary syndrome depending on the conditions and timing of thrombolytic therapy.

3.9. Results of monitoring blood pressure and heart rate in groups of patients receiving nitrates intravenously and sublingually.

3.10. Dynamics of pain syndrome in different groups of patients.

3.11. Frequency of use of narcotic analgesics in different patient groups.

3.12. Side effects of nitrates.

3.13. Algorithm for the management of patients with ACS at the prehospital stage.

CHAPTER 4. DISCUSSION OF RESULTS.

Recommended list of dissertations

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Please note that the scientific texts presented above are posted for informational purposes only and were obtained through original dissertation text recognition (OCR). Therefore, they may contain errors associated with imperfect recognition algorithms. There are no such errors in the PDF files of dissertations and abstracts that we deliver.

The prevalence of cardiovascular diseases (CVD) in Ukraine has reached extremely wide proportions. The number of patients, according to statistics from recent years, is 47.8% of the country's population: 43.2% of them are patients with arterial hypertension (AH); 32.1% – with coronary heart disease (CHD) and 12.7% – with cerebrovascular diseases (CVD). With such a prevalence, CVDs cause 62.5% of all deaths (CHD - 40.9%, CVD - 13.6%), which is the worst indicator in Europe.

N.F. Sokolov, Ukrainian Scientific and Practical Center for Emergency Medicine and Disaster Medicine; T.I. Ganja, A.G. Loboda, National Medical Academy of Postgraduate Education named after P.L. Shupika, Kyiv

In the current situation, improving the quality of CVD treatment is one of the priorities. First of all, this concerns the prehospital stage, since the future fate of patients with acute coronary syndrome (ACS), hypertension, and heart rhythm disturbances largely depends on the correct actions of the doctor during this period.

It has now been proven that atherosclerosis is a disease with phases of stable progression and exacerbations. The period of exacerbation of chronic coronary heart disease is called acute coronary syndrome. This term combines clinical conditions such as myocardial infarction (MI), unstable angina (UA) and sudden cardiac death. The appearance of the term ACS is due to the fact that although MI and NS have different clinical manifestations, they have the same pathophysiological mechanism: rupture or erosion of an atherosclerotic plaque with varying degrees of thrombosis, vasoconstriction and distal embolization of the coronary vessels. According to modern concepts, the main factors that lead to the destabilization of an atherosclerotic plaque are systemic and local inflammation. In turn, the agents that contribute to the development of inflammation are very diverse: infections, oxidative stress, hemodynamic disorders (hypertensive crisis), systemic immune reactions, etc. The lipid-filled core of the plaque, which opens after its rupture, is highly thrombogenic. This leads to the launch of a cascade of reactions: platelet adhesion on the damaged surface, activation of platelets and the blood coagulation system, secretion of serotonin and thromboxane A2, platelet aggregation. The development of acute thrombosis in a coronary vessel affected by an atherosclerotic process can be facilitated not only by plaque rupture, but also by increased blood clotting, which is more often observed in smokers, in women who use oral contraceptives, in young patients who have had an MI.

Inhibition of natural activation of plasminogen induces hypercoagulation and can lead to the development of extensive MI even in angiographically poorly altered arteries. Plasminogen activation follows a circadian rhythm with a decline in the early morning hours, when the likelihood of MI, sudden death, and stroke is greatest.

If the thrombus does not completely block the lumen of the vessel, the clinical picture of NS develops. In the case when a thrombus in a coronary vessel causes its complete occlusion, MI occurs, especially in the absence of developed collateral circulation, which often occurs in young patients. This can also occur with hemodynamically insignificant coronary stenosis.

Based on changes in the ECG, two main forms of ACS are distinguished: with and without ST segment elevation.

Patients with ST segment elevation, as a rule, have transmural myocardial ischemia caused by complete occlusion of the coronary artery by a thrombus, and extensive necrosis develops. Patients with ST segment depression experience ischemia, which may or may not form necrosis because coronary blood flow is partially preserved. Infarction in these patients develops without the appearance of a Q wave on the ECG (non-Q wave MI). In the case of rapid normalization of the ECG and the absence of an increase in the level of markers of myocardial necrosis, a diagnosis of NS is made.

The identification of two forms of ACS is also associated with different prognosis and treatment tactics in these groups of patients.

OKS forms

Acute coronary syndrome with ST segment elevation or acute left bundle branch block

Persistent ST segment elevations indicate acute complete occlusion of the coronary artery, possibly in the proximal portion. Because a large area of ​​the left ventricular myocardium is at risk of damage, the prognosis for these patients is the most severe. The goal of treatment in this situation is to quickly restore vessel patency. For this purpose, thrombolytic drugs are used (in the absence of contraindications) or percutaneous angioplasty.

Acute coronary syndrome without ST segment elevation

In this option, changes in the ECG are characterized by persistent or transient depression of the ST segment, inversion, smoothing or pseudo-normalization of the T wave. In some cases, the ECG in the first hours is normal, and the management tactics for such patients include eliminating pain and myocardial ischemia using aspirin, heparin , β-blockers, nitrates. Thrombolytic therapy is ineffective and may even worsen the prognosis of patients.

The diagnosis of ACS at the prehospital stage is based on clinical manifestations (anginal status) and ECG diagnosis.

Anginal status

ACS with ST segment elevation

Diagnosis is based on the presence of anginal pain in the chest for 20 minutes or more, which is not relieved by nitroglycerin and radiates to the neck, lower jaw, and left arm. In elderly people, the clinical picture may be dominated not by pain, but by weakness, shortness of breath, loss of consciousness, arterial hypotension, cardiac arrhythmias, and symptoms of acute heart failure.

ACS without ST-segment elevation

Clinical manifestations of an anginal attack in patients with this variant of ACS may include angina at rest lasting more than 20 minutes, new-onset angina of functional class III, progressive angina (increased frequency of attacks, increased duration, decreased tolerance to physical activity).

Acute coronary syndrome may have an atypical clinical course. Atypical manifestations: epigastric pain with nausea and vomiting, stabbing pain in the chest, pain syndrome with signs characteristic of pleural damage, increasing shortness of breath.

In these cases, correct diagnosis is facilitated by indications of a history of coronary artery disease and changes in the ECG.

ECG diagnostics

ECG is the main method for assessing patients with ACS, on the basis of which a prognosis is made and treatment tactics are selected.

ACS with ST segment elevation

• ST segment elevation ≥ 0.2 mV in leads V1-V3 or ≥ 0.1 mV in other leads.
• The presence of any Q wave in leads V1-V3 or a Q wave ≥ 0.03 s in leads I, avL, avF, V4-V6.
• Acute left bundle branch block.

ACS without ST-segment elevation

ECG signs of this variant of ACS are ST segment depression and changes in the T wave. The likelihood of this syndrome is greatest when the clinical picture is combined with ST segment depression exceeding 1 mm in two adjacent leads with a predominant R wave or more. A normal ECG in patients with symptoms characteristic of ACS does not exclude its presence. In this case, it is necessary to exclude other possible causes of the patient’s complaints.

Treatment of patients with ACS

The results of treatment of ACS largely depend on the correct actions of the doctor at the prehospital stage. The main task of the emergency physician is to effectively relieve pain and possibly carry out early reperfusion therapy.

Treatment algorithm for patients with ACS

• Sublingual nitroglycerin (0.4 mg) or nitroglycerin aerosol every five minutes. After taking three doses, if chest pain persists and systolic blood pressure is at least 90 mm Hg. Art. it is necessary to resolve the issue of prescribing nitroglycerin intravenously as an infusion.
• The drug of choice for pain relief is morphine sulfate 10 mg intravenously in a saline sodium chloride solution.
• Early administration of acetylsalicylic acid in a dose of 160-325 mg (chew). Patients who have previously taken aspirin can be prescribed clopidogrel 300 mg followed by 75 mg/day.
• Immediate administration of β-blockers is recommended for all patients unless there are contraindications to their use (atrioventricular blockade, history of bronchial asthma, acute left ventricular failure). Treatment should begin with short-acting drugs: propranolol at a dose of 20-40 mg or metroprolol (egilok) at 25-50 mg orally or sublingually.
• Elimination of factors that increase the load on the myocardium and contribute to increased ischemia: hypertension, cardiac arrhythmias.

Further tactics of providing care to patients with ACS, as already mentioned, are determined by the characteristics of the ECG picture.

Patients with clinical signs of ACS with persistent ST segment elevation or acute left bundle branch block, in the absence of contraindications, should restore the patency of the coronary artery using thrombolytic therapy or primary percutaneous angioplasty.

Whenever possible, thrombolytic therapy (TLT) is recommended to be performed in the prehospital setting. If TLT can be performed within the first 2 hours after the onset of symptoms (especially within the first hour), this can stop the progression of myocardial infarction and significantly reduce mortality. TLT is not performed if more than 12 hours have passed since the anginal attack, with the exception of when ischemic attacks continue (pain, ST segment elevations).

Absolute contraindications to TLT

• Any history of intracranial bleeding.
• Ischemic stroke within the last three months.
• Structural lesions of cerebral vessels.
• Malignant neoplasm of the brain.
• Closed head injury or facial injury in the last three months.
• Dissecting aortic aneurysm.
• Gastrointestinal bleeding over the past month.
• Pathology of the blood coagulation system with a tendency to bleeding.

Relative contraindications to TLT

• Refractory arterial hypertension (systolic blood pressure more than 180 mm Hg).
• History of ischemic stroke (more than three months old).
• Traumatic or prolonged (more than 10 minutes) cardiopulmonary resuscitation.
• Major surgery (up to three weeks).
• Puncture of a vessel that cannot be pressed.
• Peptic ulcer in the acute stage.
• Anticoagulant therapy.

In the absence of conditions for TLT, as well as in patients with ACS without ST segment elevation on the ECG, the prescription of anticoagulants is indicated: heparin 5000 U intravenous bolus or low molecular weight heparin - enoxaparin 0.3 ml intravenous bolus, followed by continuation of treatment in a hospital setting.

Literature

1. Treatment of acute myocardial infarction in patients with ST segment elevation at the onset of illness: main recommendations of the working group of the European Cardiological Fellowship, 2003 // Heart and Judges. – 2003. – No. 2. – P. 16-27.
2. Treatment of myocardial infarction with ST segment elevation: recommendations of the American College of Cardiology and the American Heart Association // Heart and Judgment. – 2005. – No. 2 (10). – pp. 19-26.
3. Dolzhenko M.N. European recommendations for the diagnosis and treatment of acute coronary syndrome // Therapy. – 2006. – No. 2. – P. 5-13.
4. Raptova cardiac death: risk factors and prevention / Recommendations of the Ukrainian Scientific Association of Cardiologists. – K., 2003. – 75 p.
5. Cardiovascular diseases: classification, diagnostic schemes and treatment / Edited by professors V.M. Kovalenka, M.I. Looting. – K., 2003. – 77 p.

Vertkin A.L., Moshina V.A., Topolyansky A.V., M.A. Malsagova
Department of Clinical Pharmacology (Head - Prof. Vertkin A.L.) Moscow State Medical and Dental University (Rector - Academician of the Russian Academy of Medical Sciences N.D. Yushchuk), National Scientific and Practical Society of Emergency Medical Care

Modern tactics for managing patients with acute ischemic myocardial injury are based on the characteristics of the pathogenesis and morphology of coronary heart disease (CHD). The morphological substrate of IHD is an atherosclerotic plaque, the condition of which largely determines the clinical variants of the disease: unstable angina, myocardial infarction with a Q wave and myocardial infarction without a Q wave. Since in the first hours (and sometimes even a day) from the onset of the disease it can be difficult to differentiate acute myocardial infarction and unstable angina, to designate a period of exacerbation of coronary artery disease, the term “acute coronary syndrome” (ACS) has recently been used, which is understood as any group of clinical signs that allow one to suspect myocardial infarction or unstable angina. ACS is a term that is valid at the first contact between a doctor and a patient; it is diagnosed on the basis of pain (prolonged anginal attack, new onset, progressive angina) and ECG changes, and therefore is especially suitable for the prehospital stage of diagnosis and treatment of destabilized coronary artery disease.

The relevance of creating balanced and carefully substantiated recommendations for emergency physicians on the treatment of ACS is largely due to the prevalence of this pathology. As you know, in the Russian Federation the daily number of emergency calls is 130,000, including from 9,000 to 25,000 for ACS.

The volume and adequacy of emergency care in the first minutes and hours of illness, i.e. at the prehospital stage largely determines the prognosis of the disease. A distinction is made between ACS with ST segment elevation or acute complete block of the left bundle branch and without ST segment elevation. A high risk accompanies ST-segment elevation ACS; these patients are indicated for thrombolytic therapy and, in some cases, hospitalization in a hospital with the possibility of cardiac surgery. It is known that the earlier reperfusion therapy using thrombolytic drugs is carried out, the higher the chances of a favorable outcome of the disease. Moreover, in accordance with data obtained in the CAPTIM study (2003), the results of early initiation of thrombolytic therapy (TLT) at the prehospital stage are comparable in effectiveness to the results of direct angioplasty and are superior to the effectiveness of treatment started in the hospital. This allows us to believe that in Russia, the damage from the impossibility of widespread dissemination of surgical methods of revascularization for ACS (the reasons for which are primarily economic) can be partially compensated for by the earliest possible start of TLT.

For the success of TLT therapy for ST-segment elevation ACS, its early initiation plays a critical role - optimally, within 1 hour after the development of pain. It is no coincidence that the standard of care for patients with ACS in the UK is to perform TLT within 1 hour of the onset of symptoms (Department of Health. National Service Framework for coronary heart disease. 2000).

In the clinical guidelines developed by the working group of the European Society of Cardiology and the European Resuscitation Council for the treatment of acute heart attacks at the prehospital stage, TLT is recommended in the case of the existence of local programs for prehospital thrombolysis, the availability of qualified personnel at the stage of prehospital treatment, in another situation - in case of delay with transportation for more than 30 minutes or delay in reperfusion therapy in the hospital for more than 60 minutes. The American College of Cardiology, together with the American Heart Association, classifies recommendations for the prehospital use of thrombolytics as recommendations with an insufficient evidence base and provides for the use of thrombolytic agents in situations where the expected loss of time for transporting the patient is more than 90 minutes.

Thus, the need for TLT therapy at the prehospital stage is determined mainly by the time from the onset of ACS symptoms to the start of therapy. According to Dracup K. et al ., 2003, this delay in different countries ranges from 2.5 hours in England to 6.4 hours in Australia. A delay in therapy is most often observed with the development of ACS in women, the elderly, with the development of ACS against the background of diabetes mellitus, atrial fibrillation, as well as in the evening and night hours (Berton G. et al., 2001, Gurwitz J. H. et al. ., 1997, Kentsch M. et al., 2002). The time from the onset of ACS symptoms to the start of therapy is largely determined by population density, the nature of the area (urban, rural), living conditions, etc. (Bredmose P.P., et al., 2003, Ottesen M.M. et al., 2003, Vertkin A.L. 2004).

According to the results of our study, in Russia, at the prehospital stage for ACS with S segment elevation, TLT is performed in less than 20% of cases, including in a metropolis in 13%, in medium-sized cities - in 19%, in rural areas - in 9 % (Vertkin A.L., 2003). The frequency of TLT does not depend on the time of day or season, but the time to call an ambulance is delayed by more than 1.5 hours, and in rural areas by 2 hours or more. The time from the onset of pain to the “needle” is on average 2 to 4 hours and depends on the area, time of day and season. The gain in time is especially noticeable in large cities and rural areas, at night and in the winter season. The conclusions of our work indicate that prehospital thrombolysis can reduce mortality (13% with prehospital thrombolysis, 22.95% with inpatient thrombolysis), the incidence of post-infarction angina without significantly affecting the incidence of recurrent myocardial infarction and the appearance of signs of heart failure .

According to the recommendations of the ASA/AHA (2002), treatment of ACS involves the use of nitroglycerin to relieve pain, reduce preload and myocardial oxygen demand, limit the size of myocardial infarction, as well as for the treatment and prevention of complications of myocardial infarction. In the recommendations developed by the working group of the European Society of Cardiology and the European Resuscitation Council for the treatment of acute heart attacks in the prehospital stage, the widespread use of nitrates is not recommended, but their use in persistent pain or the presence of heart failure is considered justified.

Relief of pain in ACS begins with sublingual administration of nitroglycerin (0.4 mg in an aerosol or in tablets). If there is no effect from sublingual administration of nitroglycerin (three doses with breaks of 5 minutes), therapy with narcotic analgesics is indicated. It should be noted that there have not been any serious studies of the effectiveness of nitrates in ACS without ST segment elevation on the ECG, much less a comparative study of the effectiveness of various dosage forms of nitroglycerin. Nitroglycerin comes in five main forms: sublingual tablets, oral tablets, spray/aerosol, transdermal (buccal), and intravenous. When providing emergency care, aerosol forms (nitroglycerin spray), tablets for sublingual use and a solution for intravenous infusion are used.

The advantages of nitroglycerin in the form of a spray over other forms include the speed of relieving an attack of angina (the absence of essential oils in the composition, which slow down absorption, provides a faster effect); dosage accuracy (pressing the valve of the canister releases a precisely specified dose of nitroglycerin); ease of use; safety and security of the drug due to special packaging (nitroglycerin is an extremely volatile substance); long shelf life (up to 2 years) compared to the tablet form (up to 3 months after opening the package); equal effectiveness with fewer side effects compared to parenteral forms; possibility of use when contact with the patient is difficult and in the absence of consciousness; Possibility of use in elderly patients suffering from decreased salivation. In addition, from the point of view of pharmacoeconomics, the use of a spray is also more justified: one package can be enough for 40-50 patients, while intravenous administration is technically more complex and requires an infusion system, a solvent, a venous catheter and the drug itself.

Our study conducted a comparative assessment of the effectiveness and safety of the use of nitroglycerin in the form of an aerosol (123 patients) or intravenous infusion (59 patients) for ACS without ST-segment elevation. The clinical condition, presence of pain, blood pressure and heart rate, ECG at baseline and 15, 30 and 45 minutes after parenteral or sublingual administration of nitrates were assessed. Undesirable drug effects were also monitored. In addition, the 30-day prognosis of patients was assessed: mortality, incidence of Q-myocardial infarction in patients who initially had ACS without ST-segment elevation.

During therapy with nitroglycerin in the form of a spray, the pain syndrome was relieved in 82.1% of patients after 15 minutes, in 97.6% after 30 minutes, and in all patients in this group after 45 minutes. With intravenous administration of nitroglycerin, the pain was relieved in 61% of patients after 15 minutes, in 78% after 30 minutes, and in 94.9% of patients after 45 minutes. It is very important that the frequency of pain recurrence was equally low in both groups.

The use of nitroglycerin in both groups led to a significant decrease in the level of SBP, and in patients receiving nitroglycerin orally, an insignificant decrease in the level of DBP. In patients receiving nitroglycerin infusion, a statistically significant decrease in DBP was noted. There were no statistically significant changes in heart rate. As would be expected, infusion of nitroglycerin was accompanied by a significantly higher incidence of side effects associated with a decrease in blood pressure (8 episodes of clinically significant arterial hypotension), however, all these episodes were transient and did not require the use of vasopressor agents. In all cases of hypotension, it was enough to stop the infusion and after 10-15 minutes the blood pressure returned to an acceptable level. In two cases, continued infusion at a slower pace again led to the development of hypotension, which required permanent discontinuation of nitroglycerin. With sublingual use of nitroglycerin, hypotension was noted in only two cases.

During nitrate therapy, facial hyperemia was detected when using a spray in 10.7%, and when using intravenous infusion of nitroglycerin - in 12% of cases; tachycardia - in 2.8% and 11% of cases, respectively; headache with sublingual administration of the drug was observed in 29.9% of cases, and with intravenous administration in 24% of cases.

Thus, in patients with ACS without ST elevation, sublingual forms of nitroglycerin are not inferior to parenteral forms in their analgesic effect; side effects in the form of arterial hypotension and tachycardia with intravenous administration of nitroglycerin occur more often than with sublingual administration, and facial flushing and headache occur with intravenous administration with the same frequency as with sublingual administration. All this allows us to consider the optimal use of nitroglycerin in the form of a spray as an antianginal agent in the treatment of ACS at the prehospital stage.

The results of our research and analysis of the data available in the literature and existing clinical recommendations allowed us to develop the following algorithm for managing a patient with ACS at the prehospital stage.

Algorithm for managing a patient with ACS at the prehospital stage

Bibliography:

The effectiveness of nitroglycerin in acute coronary syndrome at the prehospital stage. // Cardiology.-2003.-No. 2. – P.73-76. (Suleimenova B.A., Kovalev N.N., Totsky A.D., Dmitrienko I.A., Malysheva V.V., Demyanenko V.P., Kovalev A.Z., Buklov T.B., Kork A.Yu., Dyakova T.G., Soltseva A.G., Kireeva T.S., Tuberkulov K.K., Kumargalieva M.I., Talibov O.B., Polosyants O.B., Malsagova M. A., Vertkin M.A., Vertkin A.L.).

The use of various forms of nitrates in acute coronary syndrome at the prehospital stage. // Russian Journal of Cardiology.-2002.- P. 92-94. (Polosyants O.B., Malsagova M.A., Kovalev N.N., Kovalev A.Z., Suleimenova B.A., Dmitrienko I.A., Tuberkulov K.K., Prokhorovich E.A., Vertkin A.L.).

Clinical studies of drugs for emergency cardiac conditions at the prehospital stage.// Collection of materials of the second congress of cardiologists of the Southern Federal District “Modern problems of cardiovascular pathology”. Rostov-on-Don.-2002- P. 58. (Vertkin A.L., Malsagova M.A., Polosyants O.B.).