Ūminis krūtinės skausmas – pradinis pacientų įvertinimas ir diagnostikos rekomendacijos

Ūminis krūtinės skausmas – pradinis pacientų įvertinimas ir diagnostikos rekomendacijos

Įvadas

Pagrindinis šių rekomendacijų tikslas yra pagerinti suaugusių pacientų, kuriems neseniai pasireiškė krūtinės skausmas, išeitis. Tam reikalinga informacija apie diagnostinius tyrimus, padedančius greitai ir tiksliai nustatyti diagnozę (elektrokardiograma, didelio jautrumo troponino tyrimas, daugiasluoksnė kompiuterinės tomografijos angiografija, funkciniai tyrimai). Visais atvejais būtina sumažinti pacientą varginantį skausmą tuomet, kai dar atliekamas ištyrimas, o tikra skausmą sukėlusi priežastis dar nėra nustatyta.

 

Pacientai, kuriuos vargina ūminis krūtinės skausmas ar diskomfortas krūtinėje ir kuriems įtariamas ūminis koronarinis sindromas

Ūminis koronarinis sindromas (ŪKS) apima nestabiliąją krūtinės anginą (NKA), miokardo infarktą (MI) su ST segmento pakilimu (STEMI) ir be ST segmento pakilimo (NSTEMI). Šiose gairėse neatsižvelgiama į vietą, kurioje sveikatos priežiūros specialistas susiduria su pacientu, turima omenyje tai, kad pacientai gali kreiptis pagalbos bet kuriuo paros metu ir bet kurioje vietoje.

  1. Pradinis įvertinimas ir nukreipimas į ligoninę:
    • Skubiai patikslinkite, ar pacientas šiuo metu jaučia krūtinės skausmą. Jeigu pacientas skausmo nejaučia, patikslinkite, kada buvo paskutinis skausmo epizodas, ypač jei skausmas pasireiškė per pastarąsias 12 val.
    • Nustatykite, ar krūtinės skausmas gali būti širdinės kilmės, atsižvelgdami į:
      • krūtinės skausmo anamnezę;
      • kardiovaskulinius rizikos veiksnius;
      • išeminės širdies ligos anamnezę ir bet kokį anksčiau taikytą jos gydymą;
      • anksčiau taikytų diagnostikos metodų dėl krūtinės skausmo rezultatus.
    • Pirmiausia įvertinkite šiuos simptomus, galinčius indikuoti ŪKS buvimą:
      • krūtinės ir (ar) kitų vietų (pvz., rankų, nugaros, žandikaulio) skausmas, trunkantis ilgiau negu 15 min.;
      • krūtinės skausmas, pasireiškiantis su pykinimu ir vėmimu, ryškiu prakaitavimu, oro trūkumu; ypač atkreipti dėmesį, kai yra išvardytų simptomų derinys;
      • krūtinės skausmas, pasireiškiantis su hemodinamikos nestabilumu;
      • naujai atsiradęs krūtinės skausmas arba staigus stabiliosios krūtinės anginos pablogėjimas, kai skausmo epizodai dažnai kartojasi, esant mažam fiziniai krūviui arba ramybėje, ir dažnai trunka daugiau negu 15 min.
    • Nenaudokite paciento atsako į nitrogliceriną kaip diagnostinio kriterijaus.
    • Nevertinkite ŪKS simptomų skirtingai moterims ir vyrams. Kai kuriems ŪKS pacientams krūtinės skausmas gali nebūti dominuojantis simptomas.
    • Nevertinkite ŪKS simptomų skirtingai įvairioms etninėms pacientų grupėms. Nenustatyta jokių svarbių skirtumų tarp ŪKS simptomų, pasireiškiančių etninėse grupėse.
    • Nukreipkite pacientą į ligoninę neatidėliotinai skubiajai pagalbai (angl. Emergency), jeigu įtariate ŪKS (žr. 1.3. punktą) ir:
      • pacientas šiuo metu skundžiasi krūtinės skausmu ARBA
      • šiuo metu pacientas skausmo nejaučia, bet skausmo epizodas buvo per pastarąsias 12 val. ir ramybės elektrokardiogramoje yra pakitimų arba elektrokardiogramos tyrimas šiuo metu neprieinamas.
    • Jeigu įtariate ŪKS (žr. 1.3. punktą), tačiau nėra indikacijų neatidėliotinam ištyrimui, nukreipkite pacientą į ligoninę skubiam ištyrimui tą pačią dieną (angl. Urgent Same Day Assessment), kai:
      • krūtinės skausmas pasireiškė per pastarąsias 12 val., tačiau šiuo metu pacientas skausmo nejaučia ir jo ramybės elektrokardiograma normali ARBA
      • paskutinis skausmo epizodas buvo prieš 12–72 val.
    • Nukreipkite pacientą į ligoninę (pagal paciento kliniką nuspręskite, neatidėliotinam ar skubiam ištyrimui tą pačią dieną), jeigu įtariate ŪKS (žr. 1.3. punktą), kai:
      • paciento skausmas praėjo IR
      • yra komplikacijų, pavyzdžiui, plaučių edemos, požymių.
    • Jeigu įtariate ŪKS pacientui, kurio paskutinis skausmo epizodas buvo prieš daugiau negu 72 val. ir nėra jokių komplikacijų požymių:
      • detaliai kliniškai ištirkite pacientą (žr. punktus 4.2. ir 4.3.);
      • įvertinkite paciento ramybės EKG ir ištirkite paciento troponino koncentraciją kraujyje;
      • interpretuodami troponino tyrimo rezultatą, atsižvelkite į nuo skausmo epizodo praėjusį laiką.
    • Nukreipkite pacientą neatidėliotinai skubiai pagalbai, jeigu jis serga įtariamu arba patvirtintu ŪKS ir jam toliau tęsiasi krūtinės skausmas.
    • Kai įtariate ŪKS, atsižvelgdami į esamas sąlygas, kuo anksčiau pradėkite paciento gydymą ir užrašykite ramybės EKG, bet neatidėliokite paciento pervežimo į ligoninę.
    • Jeigu neįtariate ŪKS, apsvarstykite kitas krūtinės skausmo priežastis, kai kurios iš jų gali būti grėsmingos gyvybei (žr. punktą 6.5)
  2. Ramybės 12 derivacijų EKG:
    • išrašykite EKG taip greitai, kaip tik įmanoma. Nukreipdami pacientą į ligoninę, stenkitės jo EKG persiųsti ligoninei dar iki paciento atvykimo. Turėkite omenyje, kad paciento skubus pervežimas į ligoninę neturėtų būti atidėtas dėl EKG užrašymo ir išsiuntimo.
    • EKG rodmenys:
      • lokalus ST segmento pakilimas arba nauja KHKB – galimas MI su ST segmento pakilimu;
      • lokalus ST segmento nusileidimas, gilus neigiamas T dantelis – galimas MI be ST segmento pakilimo arba nestabilioji KA;
      • kiti ramybės EKG, ypač Q ir T dantelių, pokyčiai turėtų sukelti stiprų ŪKS įtarimą;
      • neatmesti ŪKS, esant normaliai ramybės EKG.
    • Jeigu ŪKS įtarimas išlieka, tačiau EKG parodymai nepatikimi:
      • kartotinai užrašykite ramybės EKG;
      • pakartotinai peržiūrėkite anksčiau užrašytas EKG;
      • užrašykite papildomas EKG derivacijas;
      • iš paciento klinikos nuspręskite, kaip dažnai užrašyti pakartotines EKG;
      • dėl EKG interpretacijos pasitarkite su patyrusiu profesionalu, taip pat atkreipkite dėmesį ir į automatinę aparato išvadą.
    • Jeigu klinikinis ištyrimas ir ramybės EKG išvada sumažina ŪKS diagnozės tikimybę, apsvarstykite kitas ūmines būkles, ypač tas, kurios gali grėsti gyvybei – plaučių embolija, aortos disekacija, plaučių uždegimas. Tęskite paciento stebėjimą.
  3. Skubus įtariamo ŪKS gydymas (simptomų valdymas):
    • pradinis ŪKS gydymas turėtų prasidėti iš karto, kai kyla jo įtarimas, tačiau jis neturi uždelsti paciento pervežimo į ligoninę. Tolesnės rekomendacijos turėtų būti vykdomos atsižvelgiant į visas esamas aplinkybes;
    • kuo greičiau mažinkite paciento skausmą. Skausmas gali sumažėti skyrus nitroglicerino (skirti po liežuviu arba už žando), tačiau pirmenybę skirkite intraveniniams opioidams (pvz., morfinui), ypač kai įtariamas ūminis MI;
    • kuo greičiau skirkite pacientui įvadinę aspirino 300 mg dozę, nebent yra aiškių įrodymų, kad pacientas šiam vaistui jautrus. Jeigu aspirino skiriate prieš pacientui atvykstant į ligoninę, turite tai aiškiai pažymėti paciento įrašuose ir perduoti ligoninės personalui. Kitus antiagregantus skirkite tik ligoninėje (atsižvelkite į atitinkamas rekomendacijas);
    • deguonies rutiniškai kiekvienam pacientui neskirkite, tačiau užtikrinkite, kad paciento kraujo įsotinimas (deguonies saturacija, SpO2) deguonimi būtų stebima pulsoksimetru kiekvienam pacientui kuo anksčiau, idealu – prieš atvykstant į ligoninę. Skirkite deguonies:
      • jeigu paciento SpO2 yra mažiau nei 94 proc. ir nėra hiperkapninio kvėpavimo nepakankamumo rizikos; SpO2 turėtų būti palaikomas 94–98 proc.;
      • jeigu pacientas serga lėtine obstrukcine plaučių liga (LOPL) ir yra hiperkapninio kvėpavimo nepakankamumo tikimybė; SpO2 turėtų būti palaikomas 88–92 proc., iki kol bus prieinamas kraujo dujų tyrimas;
    • tęskite paciento, kurį vargina ūminis krūtinės skausmas, stebėjimą, kol bus patvirtinta diagnozė. Remdamiesi paciento klinika, spręskite, kaip dažnai turėtų būti skiriamas skausmą mažinantis ir kitus simptomus lengvinantis gydymas, užrašomos pakartotinės ramybės EKG, stebimi paciento būklės parametrai: arterinis kraujospūdis, širdies susitraukimų dažnis, širdies ritmas, deguonies saturacija pulsoksimetru;
    • apie kitą reikalingą gydymą ir tyrimus spręskite remdamiesi atitinkamomis rekomendacijomis ar vietiniais protokolais tada, kai nustatyta tiksli diagnozė.
  4. Pacientų su įtariamu ŪKS pirminis klinikinis ištyrimas ir įvertinimas ligoninėje:
    • užrašykite 12 derivacijų ramybės EKG ir paimkite kraujo mėginį didelio jautrumo troponino I arba T koncentracijai kraujyje ištirti iš karto, kai pacientas atvyksta į ligoninę;
    • fizinio ištyrimo metu nustatykite:
      • paciento hemodinamikos būklę;
      • galimų komplikacijų, pavyzdžiui, plaučių edemos ar kardiogeninio šoko, požymius;
      • nekoronarinių ūminio krūtinės skausmo priežasčių, pavyzdžiui, aortos disekacijos, požymius.
    • Surinkite išsamią paciento anamnezę, išskyrus atvejus, kai ramybės EKG matomi aiškūs ūmaus MI su ST segmento pakilimu požymiai (lokalus ST segmento pakilimas, galbūt nauja KHKB). Išsiaiškinkite:
      • paciento skausmo charakteristiką;
      • lydinčius simptomus;
      • širdies ir kraujagyslių ligas anamnezėje,
      • širdies ir kraujagyslių ligų rizikos veiksnius;
      • buvusius tyrimus ar gydymą dėl panašių simptomų ir jų rezultatus.
  1. Biožymenų naudojimas ŪKS diagnostikoje:
    • nenaudokite didelio jautrumo troponino tyrimo pacientams, kuriems ŪKS neįtariamas.
    • pacientams, turintiems didelę ar vidutinę MI išsivystymo riziką, atlikite didelio jautrumo troponino tyrimus, remdamiesi vietinėmis ar tarptautinėmis MI diagnostikos rekomendacijomis.
    • Pacientams su maža MI rizika:
      • atlikite pakartotinį troponino tyrimą po 10–12 val., jeigu pirmasis yra teigiamas;
      • jeigu, atlikus pirmąjį didelio jautrumo troponino tyrimą, jo rezultatas siekia žemiau nei aptikimo riba ( angl. Lower Limit of Detection), pakartotinio tyrimo galite neatlikti;
    • Užtikrinkite, kad pacientai suprastų, kad pirmo tyrimo metu aptikta padidėjusi troponino koncentracija nerodo, kad jiems tikrai yra MI.
    • Nenaudokite natriuterinių peptidų ar didelio jautrumo CRB ūminio koronarinio sindromo diagnostikoje.
    • Interpretuojant didelio jautrumo troponino testo rezultatus, turėkite omenyje:
      • paciento kliniką;
      • laiką nuo simptomų pradžios;
      • ramybės EKG radinius;
      • MI be ST segmento pakilimo pretestinę tikimybę;
      • įtariamo ŪKS trukmę;
      • tikimybę, kad kai kuriems pacientams troponino koncentracija gali būti padidėjusi lėtiškai;
      • 99-tosios procentilės slenkstis troponino I ir T gali būti skirtingas moterims ir vyrams.
    • Diagnozuojant MI, naudokite universalų MI apibrėžimą. Ūminis MI – nustatytas biožymenų (pirmenybę teikiant didelio jautrumo širdies troponinui) didėjimas ir / ar mažėjimas su bent viena reikšme, didesne negu viršutinės normos ribos 99-oji procentilė, ir bent vienas iš šių požymių:
      • išemijos simptomai;
      • nauji ar galimai nauji ženklūs ST-T pakitimai ar nauja KHKB;
      • patologinių Q bangų atsiradimas EKG;
      • vaizdinimo tyrimais nustatyti nauji miokardo gyvybingumo sumažėjimo požymiai arba nustatytas naujas regioninis širdies sienelės judrumo sutrikimas;
      • trombo nustatymas vainikinėje arterijoje angiografijos ar autopsijos metu.
    • Kai pacientui, kuriam įtariamas ŪKS, nustatoma padidėjusi troponino koncentracija, prieš patvirtindami ŪKS diagnozę, atmeskite kitas galimas padidėjusios koncentracijos priežastis (pvz., miokarditą, aortos disekaciją, PATE).
    • Patvirtinus ŪKS diagnozę, toliau remkitės atitinkamomis rekomendacijomis pagal nustatytą tikslią patologiją (NKA, MI su ar be ST segmento pakilimu).
    • Pakartotinai įvertinkite ir nustatykite, ar krūtinės skausmo priežastis gali būti širdies patologija pacientams, kurių troponino koncentracija nepadidėjusi ir nėra jokių ūminių ramybės EKG pokyčių. Įtariant miokardo išemiją, naudokitės stabiliosios KA rekomendacijomis.
    • Įtariant PATE ar aortos disekaciją, atlikite KT, įtariant ŪKS komplikacijas (pvz., plaučių edemą) ar kitas patologijas (pvz., pneumotoraksą, plaučių uždegimą), atlikite krūtinės ląstos rentgenogramą.
    • Jeigu ŪKS diagnozė atmetama, tačiau pacientas turi širdies ir kraujagyslių ligų rizikos veiksnių, remkitės atitinkamomis gairėmis, skirtomis gydyti šias ligas, pavyzdžiui hipertenziją, stabiliąją KA ir kitas.

 

Stabilus krūtinės skausmas pacientams, kuriems įtariama stabilioji KA

  1. Klinikinis paciento įvertinimas.
    • Renkant paciento anamnezę, turi būti detaliai išsiaiškinama:
      • skausmo charakteristika (vieta, plitimas, stiprumas, trukmė, dažnumas, skausmą provokuojantys ir lengvinantys veiksniai);
      • lydintys simptomai, tokie kaip dusulys;
      • KA, MI, vainikinių kraujagyslių revaskuliarizacija, bet kokia kita širdies ir kraujagyslių sistemos liga anamnezėje;
      • visi kardiovaskuliniai rizikos veiksniai.
    • Fizinio ištyrimo metu:
      • nustatykite širdies ir kraujagyslių ligų rizikos veiksnius;
      • nustatykite širdies ir kraujagyslių ligų požymius;
      • įvertinkite galimas nekoronarines KA priežastis (ryškią aortos stenozę, kardiomiopatiją)
      • atmeskite kitas krūtinės skausmo priežastis.
    • Diagnozavimas pagal klinikinį ištyrimą:
      • tipinio KA skausmo požymiai:
        • veržiantis diskomfortas krūtinėje arba kakle, pečiuose, žandikaulyje, rankose (bent vienoje, keliose ar visose vietose);
        • sukeliamas fizinės įtampos;
        • palengvėjantis ramybėje arba nuo nitroglicerino per maždaug 5 min.
      • Pagal šiuos požymius įvertinkite, ar krūtinės skausmas tipiškas KA. Tipiškumo kriterijai:
        • visų 3 tipinio krūtinės anginos skausmo požymių buvimas yra apibrėžiamas kaip tipinė KA;
        • 2 iš 3 požymių buvimas – netipinė KA;
        • vieno arba nė vieno iš 3 požymių buvimas – neangininis krūtinės skausmas;
      • tipinės ir atipinės KA ir neangininio krūtinės skausmo tikimybės vertinimas neturi skirtis vyrams ir moterims, taip pat tarp etninių grupių;
      • veiksniai, kuriuos būtina turėti omenyje diagnozuojant, nes jie didina stabiliosios KA tikimybę:
        • amžius;
        • vyriškoji lytis;
        • kardiovaskuliniai rizikos veiksniai:
          • rūkymas;
          • diabetas;
          • hipertenzija;
          • dislipidemija;
          • šeiminė ankstyvosios vainikinių arterijų ligos anamnezė;
        • kita kardiovaskulinė liga;
        • anksčiau nustatyta pažengusi vainikinių arterijų liga – buvęs MI, vainikinių arterijų revaskuliarizacija;
      • Skausmo požymiai, kurie mažina stabiliosios KA tikimybę:
        • krūtinės skausmas yra pastovus arba trunkantis ilgą laiko tarpą ir (ar)
        • nesusijęs su fiziniu aktyvumu ir (ar);
        • provokuojamas įkvėpimo metu ir (ar);
        • susijęs su galvos svaigimu, dažnu širdies plakimu, dilgčiojimu ar rijimo sutrikimais;
        • šiais atvejais reikėtų apsvarstyti kitas krūtinės skausmo priežastis, pavyzdžiui, virškinimo arba kaulų ir raumenų sistemos patologijas.
      • Jeigu pacientui nustatomas tipinis angininis krūtinės skausmas, tačiau maža vainikinių arterijų ligos tikimybė, apsvarstyti kitas galimas KA priežastis, pavyzdžiui, hipertrofinę kardiomiopatiją.
      • Visiems pacientams, tiriamiems dėl stabiliosios KA, atlikite kraujo tyrimus įvairioms patologijoms, kurios gali bloginti paciento būklę, pavyzdžiui, anemijai nustatyti.
      • Jeigu stabiliosios KA diagnozė atmetama, tačiau pacientas turi širdies ir kraujagyslių ligų rizikos veiksnių, remkitės atitinkamomis gairėmis, skirtomis gydyti šias ligas, pavyzdžiui, hipertenziją ir kitas.
      • Pacientams, kuriems stabiliosios KA diagnozė negali būti atmesta remiantis klinikiniu ištyrimu, kuo anksčiau užrašykite ramybės 12 derivacijų EKG.
      • Neatmeskite stabiliosios KA diagnozės, jeigu EKG be patologinių pokyčių.
      • netęskite diagnostinių tyrimų pacientams, kurių klinikinis ištyrimas rodo neangininį krūtinės skausmą, nebent jų EKG matomi ST-T pakitimai arba patologinės Q bangos.
      • Ramybės 12 derivacijų EKG pakitimai, kurie gali rodyti miokardo išemiją arba buvusį MI:
        • patologinės Q bangos;
        • KHKB;
        • ST segmento ir T bangos pakitimai;
        • EKG rodmenis reikia vertinti su anamnestiniais duomenimis ir paciento rizikos veiksniais.
      • Jeigu paciento skundai tipiški stabiliajai KA, remkitės vietiniais stabiliosios KA gydymo protokolais, kol laukiate galutinių tyrimų išvadų.
      • Skirkite aspiriną tik tuo atveju, kai paciento skundai tipiški stabiliajai KA. Neskirkite aspirino papildomai, jeigu pacientas jau jį vartoja arba yra jam alergiškas.
      • Jeigu klinikinis ištyrimas rodo tipinę ar netipinę anginą, skirkite pacientui toliau gairėse aprašomus diagnostinius tyrimus.
      • Daugumai pacientų, kuriems po klinikinio ištyrimo diagnozuojamas neangininis krūtinės skausmas, papildomų diagnostinių tyrimų nereikia. Išliekant įtarimų, kad paciento skausmas gali būti išeminės kilmės, skirkite toliau gairėse aprašomus diagnostinius tyrimus.
  1. Diagnostiniai tyrimai:
    • diagnostiniai tyrimai pacientams, kuriems stabilioji KA negali būti atmesta po klinikinio ištyrimo;
      • siuntime diagnostiniams tyrimams aprašykite paciento krūtinės skausmo požymius (tipiškumui įvertinti);
      • skirdami diagnostinius tyrimus, remkitės ne tik rekomendacijomis, bet ir klinikine patirtimi, atsižvelkite į paciento pageidavimus ir gretutines ligas;
      • 64 sluoksnių (arba daugiau) KT vainikinių arterijų angiografiją skirkite:
        • jeigu klinikinio ištyrimo metu nustatėte tipinę arba atipinę anginą ARBA
        • klinikinio ištyrimo metu nustatėte neangininį krūtinės skausmą, tačiau 12 derivacijų ramybės EKG matomi ST-T pokyčiai arba Q bangos;
      • pacientams su patvirtinta vainikinių arterijų liga (pvz., buvęs MI, vainikinių arterijų revaskuliarizacija), kurie patiria krūtinės skausmą, dėl kurio išeminės kilmės esate neužtikrinti, skirkite neinvazinį funkcinį ištyrimą (žr. 2.3. punktą). Vietoj funkcinio vaizdinimo tyrimo galite skirti krūvio EKG.
    • Papildomi diagnostiniai tyrimai:
      • jeigu 64 sluoksnių (ar daugiau) KT vainikinių kraujagyslių angiografijoje matoma neaiškios hemodinaminės reikšmės vainikinių arterijų liga arba KT vainikinių kraujagyslių angiografijos vaizdai neturi diagnostinės reikšmės, skirkite neinvazinį funkcinį ištyrimą (žr. 2.3. punktą)
      • jei neinvazinis funkcinis ištyrimas neleidžia nustatyti tikslios diagnozės, skirkite koronarografiją kaip trečios eilės tyrimą.
    • Neinvazinis funkcinis ištyrimas miokardo išemijai nustatyti.
      • Neinvazinio funkcinio ištyrimo rūšys:
        • miokardo perfuzijos scintigrafija su vieno fotono emisijos kompiuterine tomografija (angl. Single photon emission computed tomography – SPECT);
        • kūvio echokardiografija;
        • širdies magnetinio rezonanso tomografijos miokardo perfuzijos tyrimas;
        • širdies magnetinio rezonanso tomografija nustatyti krūvio sukeltiems sienelių judrumo sutrikimams (krūvio sukeltai išemijai).
      • Skirdami vieną iš šių tyrimų, įvertinkite pacientų pageidavimus, gretutines ligas, galimas kontraindikacijas (pvz., negalią, išsekimą, sumažėjusį fizinį pajėgumą), taip pat tyrimų prieinamumą.
      • Neskirkite MRT vainikinių kraujagyslių angiografijos kaip stabiliosios KA diagnostinio tyrimo.
      • Neskirkite krūvio EKG diagnozuoti arba atmesti stabiliąją KA pacientams, kuriems nėra patvirtintos vainikinių arterijų ligos.
    • Diagnozės nustatymas:.
      • Hemodinamiškai reikšminga vainikinių arterijų liga nustatyta KT vainikinių kraujagyslių angiografijos tyrimu – ≥70 proc. stenozė bent viename didžiajame vainikinės arterijos segmente arba ≥50 proc. stenozė kairiosios vainikinės arterijos kamiene.
      • Veiksniai, kurie didina miokardo išemiją ir kuriems esant ≥50 proc. stenozė jau gali būti laikoma hemodinamiškai reikšminga vainikinių arterijų liga:
        • sumažėjęs deguonies tiekimas: anemija, vainikinių arterijų spazmas;
        • padidėjęs deguonies poreikis: tachikardija, kairiojo skilvelio hipertrofija;
        • didelis išemijos pažeisto miokardo plotas: proksimaliai esantys pažeidimai;
        • ilga stenozė.
      • Veiksniai, kurie mažina miokardo išemiją, dėl kurių ≥70 proc. stenozė gali išlikti asimptominė:
        • gerai išsivystęs kolateralių tinklas;
        • mažas išemijos pažeists miokardo plotas: distaliai esantys pažeidimas, senas MI pažeistos vainikinės arterijos maitinimo zonoje.
      • Stabiliosios KA diagnozė patvirtinama, kai
        • reikšminga vainikinių arterijų liga nustatyta koronarografijos arba 64 sluoksnių (ar daugiau) KT vainikinių kraujagyslių angiografijos tyrimu (žr. 2.4.1 punktą) ARBA
        • vienu iš neinvazinio funkcinio ištyrimo metodų nustatyta grįžtama miokardo išemija.
      • Ieškokite kitų krūtinės skausmo priežasčių, kai
        • reikšminga vainikinių arterijų liga koronarografijos arba 64 sluoksnių (ar daugiau) KT vainikinių kraujagyslių angiografijos tyrimu nenustatyta ARBA
        • vienu iš neinvazinio funkcinio ištyrimo metodų nenustatyta grįžtama miokardo išemija.

 Pacientų, besiskundžiančių krūtinės skausmu, informavimas

  • Pacientai gali jausti nerimą, kai krūtinės skausmo priežastis nežinoma. Aptarkite su pacientu jo susirūpinimo priežastis.
  • Išaiškinkite pacientui visas galimas jo simptomų priežastis.
  • Aiškiai išdėstykite pacientui visus galimus pasirinkimo variantus kiekviename diagnostinio proceso etape. Visus sprendimus priimkite kartu, atsižvelkite į paciento pageidavimus:
    • skatinkite žmones užduoti klausimus;
    • suteikite galimybę su jumis diskutuoti;
    • paaiškinkite tyrimų rezultatus ir pagrįskite tolesnių tyrimų reikalingumą.
  • Informuokite apie visus pacientui skiriamus tyrimus vartodami kasdienę kalbą, be medicininių terminų. Aptarkite:
    • tyrimo tikslą, naudą, taip pat galimybę, kad tyrimas gali ir nenustatyti konkrečios diagnozės;
    • tyrimo trukmę;
    • galimą tyrimo metu patiriamą diskomfortą, tyrimo invaziškumą;
    • nepageidaujamų įvykių riziką.
  • Suteikite informaciją apie diagnostinių tyrimų sukeliamą riziką, įskaitant ir radiacinę apšvitą.
  • Atsižvelkite į paciento fizinę negalią ar intelekto sutrikimus, regėjimo, klausos sutrikimus, mokėjimą skaityti ir rašyti lietuvių kalba; visi šie veiksniai gali lemti, kad pacientas nesupras jam pateiktos informacijos arba supras ją neteisingai.
  • Jeigu krūtinės skausmas yra ne širdinės kilmės, paaiškinkite pacientui, kad jį gali reikėti siųsti tolesniems diagnostiniams tyrimams pas kitus specialistus.
  • Suteikite pacientams visą informaciją, kur kreiptis, jeigu krūtinės skausmas kartosis.

Kamilė Čerlinskaitė

Vilniaus universiteto Medicinos fakultetas

Parengta pagal 2016 metais atnaujintas NICE gaires.


129 mintys apie “Ūminis krūtinės skausmas – pradinis pacientų įvertinimas ir diagnostikos rekomendacijos

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