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2020, vol. 45, br. 1-2, str. 32-67
Promena paradigme za stabilnu koronarnu bolest u hronični koronarni sindromi - novine u vodiču Evropskog udruženja kardiologa iz 2019. godine
aInternistička ordinacija "Dr Bastać", Zaječar
bVojnomedicinska akademija, Klinika za kardiologiju, Beograd
cPoliklinika Belmedic, Beograd
dInternistička ordinacija "Joksimović", Bor
eSpecijalistička ordinacija za internu medicinu "Dr Pavlović-kardiologija", Beograd
fZdravstveni centar Zaječar (ZCZ), Internistička služba, Nefrološki odsek, Zaječar
gZCZ, Pedijatrijska služba, Zaječar
hZCZ, Internistička služba, Odsek invazivne kardiologije, Zaječar

e-adresadusan.bastac@gmail.com
Ključne reči: angina pektoris/stabilna; Angina Pektoris/Nestabilna; Mikrovaskularna angina; angina pektoris sa normalnim koronarnim arteriogramom (INOCA); ishemijska bolest srca; koronarna bolest; Akutni koronarni sindrom; Infarkt miokarda; Ishemija miokarda/dijagnoza/prevencija i kontrola/farmakoterapija; Revaskularizacija miokarda/perkutana koronarna intervencija/CABG
Sažetak
Iako je engleski lekar Heberden opisao anginu pektoris (AP) još pre 2 i po veka, naše razumevanje ovog sindroma, kako uzroka, optimalnog dijagnostičkog pristupa tako i lečenja, nastavlja da se razvija. Novi vodič Evropskog udruženja kardiologa iz 2019 godine donosi pre svega promenu paradigme za stabilnu koronarnu bolest (SKB) u sveobuhvatni termin hronični koronarni sindromi (HKS), koja suštinski znači da hronična koronarna bolest (HKB) ili ishemična bolest srca (IBS) ima kompleksne kliničke scenarije i može imati periode nestabilnosti u bilo kojoj evolucionoj fazi. Rezultati esencijalne COURAGE studije te najnovijih studija: ISHEMIA, ORBITA i metanaliza o HKS kao i ključne poruke Evropskog Vodiča za dijagnostiku i lečenje hroničnih koronarnih sindroma (HKS) bacaju svetlo na problematiku koronarne bolesti, bolesti koja još uvek prednjači u svetskom mortalitetu. Koronarna bolest (KB) ima duge stabilne perode ali zbog akutnih aterotrombotskih događaja, erozije ili rupture aterosklerotskog plaka može preći u neki od akutnih koronarnih sindroma (AKS). Bolest je hronična, najčešće progresivna i zato ozbiljna čak i u asimptomatskim fazama. Dinamična priroda KB ispoljava se u različitim kliničkim prezentacijama, koje kategorizujemo u bilo akutne, bilo hronične koronarne sindrome. Promena paradigme naglašava činjenicu da dinamički procesi akumulacije u aterosklerotske plakove i funkcionalne alteracije koronarne cirkulacije, mogu biti modifikovani promenom životnih navika, farmakološkom terapijom i revaskularizacijom miokarda (RM), koje dovode do stabilizacije ili regresije bolesti ali nažalost ne i do potpunog izlečenja. Od kardinalnog značaja je pažljiva evaluacija anamneze, karakterizacija anginoznih i drugih simptoma i evaluacija rizik faktora i manifestacija predhodnih kardiovaskularnih bolesti (KVB), kao i procena adekvatnosti fizičke aktivnosti i tolerancije napora. U sadašnjem vodiču za HKS je prepoznato 6 vodećih i najčešćih kliničkih sindroma-scenarija : 1. Pacijenti sa suspektnom KB i stabilnom anginom pektoris i/ili dispnejom na napor; 2. Pacijenti sa novonastalom srčanom insuficijencijom (SI) ili disfunkcijom leve komore (DLK) i suspektnom KB; 3. Asimptomatski i simptomatski bolesnici sa stabilizovanim simptomima koji traju manje od jedne 1 godine posle AKS ili skorašnje revaskularizacije miokarda (KRM); 4. Asimptomatski i simptomatski pacijenti više od 1 godine protekle posle AKS ili RM; 5. Pacijenti sa anginom pektoris i suspektnom vazospastičnom ili mikrovaskularnom bolešću; 6. Asimptomatske osobe u kojih je KB otkrivena na skriningu. Svaki od ovih scenarija je klasifikovan kao HKS i posledice su različitih evolucionih faza hronične KB, te imaju različit rizik za buduće neželjene kardiovaskularne (KV) događaje. Pretest verovatnoća (PTP) koronarne bolesti, bazirana na starosti, polu i kvalitetima simptoma, podvrgnuta je reviziji i izmenjena u odnosu na predhodni vodič iz 2013. godine. Uveden je i novi termin: Klinička verovatnoća KB (KPKB) koji uključuje kako PTP tako i razne rizik faktore aterosklerotske KB i služi da isključi ili potvrdi sumnju na KB. Opšti metodološki pristup za inicijalnu dijagnozu za pacijente sa AP i suspektnom opstruktivnom KB uključuje 6 koraka. KORAK 1-Procena simptoma i znakova za identifikaciju pacijenata sa mogućom nestabilnom AP i drugim formama AKS; KORAK 2 je procena opšteg stanja i kvaliteta života koji odlučuju o planiranju lečenja; KORAK 3 uključuje osnovne dijagnostičke procedure i procenu funkcije leve komore (LK) srca; KORAK 4 čini odredivanje Pre-test i Kliničke verovatnoće opstruktivne KB; KORAK 5 je izbor dijagnostičkog testa fizičkim ili farmakološkim opterećenjem putem EKG i vizuelizacionih (slikovnih, imidžing) metoda uključujući MSCT (MDCT) koronarnu angiografiju (CTKA, CTA) za ustanovljavanje diagnoze KB. Na kraju, KORAK 6 je procena rizika od neželjenih KV događaja, posebno mortaliteta i na bazi toga donošenje definitivne terapijske odluka uz invazivnu koronarografiju (ICA) i eventualnu RM. Ako opstruktivna KB ne može biti isključena kliničkom evaluacijom, radi se bilo neinvazivni funkcionalni imidžing test bilo anatomski imidžing putem CTKA kao inicijalni test za isključenje ili potvrdu dijagnoze KB. Za odluku o RM treba razmotriti i anatomsku i funkcionalnu procenu, izuzev kod teških koronarnih stenoza >90%. Visok rizik neželjenih KV događaja identifikuje pacijente koji bi imali veliku prognostičku korist od RM, čak i ako su asiptomatski. Uloga revaskularizacije miokarda (RM) je stavljena u kontekst novijih dokaza koji se odnose na prognostičku ulogu perkutanih koronarnih intervencija (PCI) ili koronarnog arterijskog premošćavanja graftom (CABG) u ovoj niskorizičnoj populaciji. RM je rezervisana za pacijente gde postoje jaki dokazi da bi se njom poboljšala prognoza na bazi dokaza regionalne ishemije perfuzionim imidžingom. Pacijenti sa visokim rizikom -mortalitetom od 3% godišnje i više podvrgavaju se frakcionoj rezervi koronarnog protoka (FFR) ili koronarnoj rezervi protoka (CFR) zbog RM čak i ako nemaju simptome. Primena zdravog načina života smanjuje rizik od naknadnih neželjenih KV događaja i spada u adekvatnu terapiju sekundarne prevencije. Neophodna je redovna vakcinacija protiv gripa kod svih sa HKS. Optimalnoj medikalnoj terapiji (OMT): nefarmakološkoj i farmakološkoj terapiji HKS poklanja se ogromna pažnja kao glavnoj vrsti lečenja HKS, a ne RM. Istaknuta je savremena uloga anti-ishemijskih (antianginalnih lekova): Prve linijebetablokatori (BB) i antagonisti kalcijuma (CCB) uz sublingvalni nitroglicerin, i Druge linijedugodelujući nitrati (LAN), uz novije opcije: ivabradin, nikorandil, trimetazidine, ranolazine, alopuronol i drugo. Lekovi koji poboljšavaju prognozu HKS jesu statini i acetilsalicilna kiselina (ASA) i drugi antitrombocitni lekovi i od skora male doze rivaroksabana a dodatno inhibitori angiotensin konvertaze (ACEI) i ponovo BB u specifičnim indikacijama. Anti-ishemijski tretman mora se prilagoditi pojedinačnom pacijentu na osnovu komorbiditeta, druge konkomitantne terapije, očekivane tolerancije i pridržavanja i sklonosti pacijenta. Izbor anti-ishemijskih lekova za lečenje HKS-a treba da bude prilagođen srčanom ritmu, krvnom pritisku i funkciji srca. BB i ACEI se preporučuju pacijentima sa DLK ili SI sa smanjenom ejekcionom frakcijom leve komore (HFrEF). Antitrombotska terapija je ključni deo sekundarne prevencije kod pacijenata sa HKS-om. Pacijente sa prethodnim infarktom miokarda, koji su pod visokim rizikom od ishemijskih događaja i niskim rizikom od smrtnog krvarenja, trebalo bi razmotriti dugoročnu dvostruku antiagregacionu terapiju aspirinom i bilo inhibitorom P2Y12 receptora ili rivaroksabanom sa vrlo malim dozama, osim ako nemaju indikacija za oralnu antikoagulaciju kao što je atrijalna fibrilacija (AF). Inhibitori protonske pumpe preporučuju se kod pacijenata koji primaju i samo aspirin ili kombinaciju antitrombotske terapije koji su pod rizikom od gastrointestinalnog krvarenja. Statini se preporučuju svim pacijentima sa HKS-om bez obzira na nivo LDL. ACEI (ili blokatori receptora angiotenzina-ARB) preporučuju se u prisustvu SI, dijabetesa i hipertenzije i treba ih razmotriti kod pacijenata sa visokim rizikom za neželjene događaje.
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O članku

jezik rada: srpski, engleski
vrsta rada: prikaz
DOI: 10.5937/tmg2001032B
objavljen u SCIndeksu: 26.07.2020.