Raptova's sertseva's death. Stratification of a disease in diagnostics of ischemic ailments of the heart

RCHRH (Republican Center for Development of Health Protection of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Poly-systemic degeneration (G90.3)

Cardiology

General information

Short description

Endorsed by the Protocol
Expert committee for nutrition development of health protection of the Ministry of Health of the Republic of Kazakhstan
No. 23 dated 12.12.2013

syncope- tse syndrome, which is a clinical sign of a transitory loss of testimony, call us until the fall. An ear of syncope is shvidke, away from renewal spontaneously, outside and, very, not secret. The mechanism is based on short-term hypoperfusion of the brain (European Heart Journal, 2001, 22, 1256-1306).

Name of the protocol: Protocol for diagnostics and stratification of syncope. Patient training in the context of intervention cardiology

Fast, as vikoristovyu in the protocol:
AAP - antiarrhythmic drugs
AAT - antiarrhythmic therapy
A-B - atrioventricular
AG - arterial hypertension
ACE - angiotensin converting enzyme
ATC - anti-cardiac stimulation
VSS - Raptova Sertseva Death
VNN - vegetative deficiency
ANS - autonomic nervous system
HCM - hypertrophic cardiomyopathy
GCS - hypersensitivity of the carotid sinus
GLSH - h_pertrophy of the lіvnogo slunochka
DCMP - dilatation
CHF - congestive heart failure
іAPF - іngіbіtory angiotensin converting enzyme
ІХС - ischemic ailment heart
LSh - livy shlunochok
LOC- loss of consciousness
MZhP - mіzhshlunochkovo partitions
OG - orthostatic
PZhU - anteroposterior-lingering vuzol
CH - heart failure
SPU - sinus-atrial vuzole
Prototype indication - sinus-atrial node weakness syndrome
ULP - vushko of the left front
ТТМ - transtelephone monitoring
T-LOC - transient loss of consciousness
ФВ ЛШ - faction of the wikidu
Fvr - pharmacological rhythm renewal
FC - functional class
COPD - chronic obstructive disease
Heart rate - heart rate is very fast
EKG - electrocardiogram
EKS - electrocardiostimulator
EED - electrophysiology
Vidlunnya-KG - echocardiography
ACC - American College of Cardiology
NASPE - Pivnichno-American partnership with cardiac stimulation and
Electrophysiology
NYHA - New York Association of the Heart

Date of release to the protocol: April 2013

Coristas to the protocol: cardiologists, therapists, GPs.

Ordering for the presence of a conflict of interest:Відсутнє.

Classification

The triviality of being overwhelmed by an intervention cardiology 4 - 10 days

The lack of privacy during transient global cerebral hypoperfusion, which is characterized by a short ear, short triviality, and mimic new updates. The price of objectionableness is attributed to those included in the cause of an unaccountable camp, to transient global cerebral hypoperfusion. Without a lot of additional value, the objectionableness grows wide, and it includes both destructiveness, such as epileptic attacks and scabs. In fact, the cost of this is due to obscurity, as it hunts all damage, which is characterized by self-limiting second ability (LOC), is independent of the mechanism. With some forms of obscurity, there may be a prodromal period from different symptoms(For example, zamorochennya, nudota, darkening, weakness, and deterioration), which are overridden, but non-triviality is inevitable. Often, however, LOC will be returned without reloading. Ridko is an accurate assessment of the triviality of spontaneous episodes. Typical obscurity is short. The LOC is not more than 20 sec. However, it can be quite trivial to get a little bit of hilin. In such cases, a differential diagnosis for uncommon and other causes of LOC may be important. Renewal of obscene behavior and organization. Retrograde amnesia, wanting to be built, but not often, maybe more often, it was not thought before, especially among lith people. During the period of post-recovery, you can also supervise yourself.

A perceptive "front-necked" vikoristovuyutsya, in order to show the symptoms and signs, such as before the second testimony in obscurity, such a rank, meaning є literal, if vikoristovu in the whole context and in synonymy "prodigal". Imennik “pre-faint” or “may not be obscene” vikoristovu be aware of the fact that the mechanisms were obtained by the same mechanisms themselves, but in case of obscurity.

Reflexiveness (neurodevelopmental)

Reflexiveness is traditionally referred to as a heterogeneous group of stuns, in case of some heart reflexes, which are susceptible to being brown in the control of blood circulation, there is a period of time inappropriateness when such signals occur. and external cerebral perfusion. Reflexive obscurity is inviting to be classed at the show of the most effective nobles, to be either cute or parasympathetic. The term "Vaso-depressor type" tends to become vicious, as it relieves hypotension through the loss of vertical vasoconstrictor tone. "Cardioingibitorny" vikoristovuyutsya, if overwhelming bradycardia or asystole, and "changes" vykorystvuetsya, as the presence of offense to the mechanism.
Vasovagal obscenity (VVS), also seen as vivid obscenities, obnoxious abnormal orthostatic stress. Youmu beckon to overwhelm the prodromal signs of vegetative activation (darkness, bliss, nudota).
"Situational" obscenity is traditionally referred to as reflex obscenity, tied to the singing circumstances. Post-exercise obscenities can be trapped in young athletes as a form of reflex obscenities, both in the middle and in young people, as early manifestations of VNN persh, but they smell like a type of OG.
The lack of prejudice of the "carotid sinus" is due to a special problem. In the rare spontaneous form of the sinus, there is a mechanical manipulation of the carotid sinus. In a more frequent form of this, the triggering mechanism is not visible, but is diagnosed by the massage of the carotid sinus.
term " atypical form»To be victorious in order to describe these situations, when reflex fainting occurs as a result of non-noisy or apparently from day-to-day triggering mechanisms. The diagnosis of the disease is less than the history, and more for the inclusion of other causes of obesity (the appearance of organic heart ailments) and the recurrence of similar symptoms in orthostatic test. Such mensh readings can change readily when looking at the patient.

Orthostatic Potency and Orthostatic Intolerance Syndromes

On the basis of reflex obscurity in VNI, sympathetic eferent activity is chronically weakened, so vasoconstriction is deficient. When the arterial grip is inserted, it falls, and it is unsettled or fainting. OG appears as an abnormal change in the systolic arterial vise on the insertion. Strictly from the pathophysiological point of view, there is no overturning between reflex intractability and VNN, ale cleverly show tsikh two stan_v are often imposed, one of the most difficult differential diagnoses.

"Orthostatic intolerance" is carried to symptoms and signs that occur in an upright position through impaired blood circulation. Inconsistency is the first symptom, and is: loss of hearing / loss of hearing, pre-fainting, weakness, vomiting, drowsiness, tremulousness, darkening, loss of sound (including smallness, hearing loss, hearing loss) wuhah) і bіl in shіі (tilny / paracervіcal і area of ​​the shoulder), bіl at the lower part of the back or precardial bіl.

Classic OG - physical sign, which is the sign of a change in systolic arterial vise - 20 mm Hg. and diastolic AT - 10 mm Hg. Art. in between, there are 3 chilin pislya insertion, described in patients with pure VNN, hypovolemia, or other forms of VNN.
Pochatkova OG is characterized by an inherent decrease in the arterial vise when inserted by> 40 mm Hg. AT with a large spontaneously and quickly turn to normal, in such a rank, the period of hypotension and symptoms is short (30 s)

Inadvertently (progressively) OG is often found in people who have been abducted. To ascribe to the fallen form of the decline in compensatory reflexes and a decrease in heart elasticity in people who are sensitive to a decrease in anterior vantage. The developed OG is characterized by progressively progressive changes in the systolic arterial vise when the vertical position is taken. The visibility of the bradycardial reflex (vagal) is due to the delayed OH as reflex obesity. The OG is added, however, it can be supravodzhuvatisya reflex bradycardia, in case of arterial grip in young people, the pressure is steep, but not in young people. Postural orthostatic tachycardia syndrome. Deyaki patients, the leading rank of young women, present severe scarg for orthostatic intolerance, rather than unpleasantness, for significant changes in the frequency of heart rate (HR) [> not for 30 strokes per chilin) ​​(a.v. m. .v. m.] і the instability of the arterial grip. Postural orthostatic tachycardia syndrome is often associated with chronic syndrome vtom. The underlying pathophysiology is unclear.

Cardial (heart-vascular)

arrhythmia

Arrhythmias are the most frequent causes of obscurity. The stench wicks haemodynamic deterioration, as it can wicklit critically change the SV and cerebral blood flow... On the other hand, the lack of obscurity is often a small number of supportive factors, including heart rate, the type of arrhythmia (suprashlunochkova or shlunochkova), the function of a louse, the position and adequacy of judicial compensation. Remains including baroreceptor nerve reflexes so it’s like and responding to the OG in arrhythmias. Neither of such supportive effects, since arrhythmia is the primary cause of obscurity, and the need for specific treatment. With true weakness syndrome sinus node sinoatrіalniy vuzol pozhkodzheniy either through abnormal automatism or through the destruction of sinoatrіal ї provinces. In this situation, the obscurity of seeing through long pauses, vicious sinus or sinus blockade, and lack of licking mechanism. With short pauses, the most frequent stuck, if the atrial tachyarrhythmia raptus (brady-tachy syndrome). As a rule, the most important form of near-atrioventricular (AV) blockade (Mobitz II blockade, "high-grade", and more AV block) is most closely related to obscurity. In cich vipadkah, the heart rhythm can be fallen as a pre-house or viscous (often abnormal) rhythm. The lack of pretense is perceived to be that the pause before turning on the water can be even longer. In addition, the rhythm of the additional rhythm usually seems to be at a relatively high frequency (25-40 uvm) .. Bradycardia also progresses repolarization and tightened up to a polymorphic shlunochkovoy tachycardia (SHT), especially type. Negligence, or mayzhe-unpredictability, appear on the cob of paroxysmal cardiac, persistent, no judgment compensation. Svіdomіst, in a zagalny vypadіvіvіvіvіvіvіt earlier, nіzh tachіcardіya end. Unsatisfactory stance is trivial, as hemodynamics are inadequate through tachycardia. As there is no spontaneous renewal, the distance from the classification is not like untidiness, but like a zupinka heart.

organic ailment

Organic heart-blistering ailments can become unsettled, if you can get over the weakened health of the heart before the blood flow. Integrity is a great interest, if it is to associate with camps, if it is permanent or dynamically obstructed by the way to the current of the lone dumbbell. Inadequate blood flow through mechanical obstruction is provided for obscurity. Protest, in some cases, non-triviality is not the result of an interconnected SV, but it can be partly through an inadvertent reflex, or OG. For example, in the case of valvular aortic stenosis, non-obtrusiveness is not the result of contiguous cardiac arrhythmia; In addition, arrhythmias, especially fibrillation of the anterior heart, are often important causes of obesity. Thus, the mechanism of obscurity can be very factorial. The insight of the heart as the cause of the problem is justified by the need for the correction of basic organic ailments, if necessary.

diagnostics

Diagnostic criteria:

First assessment, diagnosis and stratification of rhizik syncope

first estimate

The first patient's condition, which was transferred to a short-hour loss of testimony, including a retreat anamnesis, objectivity, including arterial vise in position standing, electrocardiography. Only with the urahuvannyam tsikh danih you can take a further detour:
- massage of the carotid sinus in patients younger than 40 years;
- echocardiography in the case of a confirmed illness of the heart, in case of adolescence on a new abnormal syncope in cases of heart-vascular pathology;
- EKG-monitoring during adolescence on syncope of arithmic walking;
- orthostatic probes (active (transition from the lying position to the standing position) and passive) in times, when syncope is associated with moving to the standing position, or when the patient is susceptible to the reflex mechanism.
The insignificant situation, such as neurological, blood analysis, is indicated for adolescents for non-malignant nature at the expense of evidence.
There are three main reasons for guilt on 3 main meals:
1. syncopal chain epizod?
2. Is there a reason for this?
3. Chi є otrimanі danі pіdstavoi allowance a high rizik heart-and-heart disease what about death?

ethiological diagnosis
In 25-50% of patients with primary obesity, the cause of syncope can be identified. There are a number of important moments that need to be reflected in the history of ailments. For the statement of a diagnosis, viznennya obsyachu submitted reports and indications of a diagnosis of guilt, but an anamnesis, objectivity, EKG.
In іnshomu vipadku it is difficult to put the correct diagnosis, and hence, it is possible to deprive the allowance of the cause of syncope. In connection with the cymbals, it is necessary to carry out additional information.

stratification of risik
In case of a lack of unclear etiology of syncope in case of the first situation, the next step is to assess the risk of development of the most important heart-and-heart pod_y abo raptus cardial death.
PPS- peredbachuvane minusche syncope

diagnostics

Carotid sinus massage

It has long been established that the grip in the area of ​​bifurcation of the carotid artery leads to the progress of heart failure and the reduction of the arterial grip. For some individuals, the ISS wicks, maybe wicked, an unvarying reaction. The episode of asystole of shlunochkiv, scho trivav 3 for a decrease in systolic vise less than 50 mm Hg. є signs of hypersensitivity of the carotid sinus. With spontaneous syncope, HRV can be a cause of SCD. To establish the diagnosis of SCS, it is necessary to repair spontaneous symptoms for 10 seconds when the right-sided or left-sided ISS is in position lying on the back and in the vertical with continuous frequency monitoring. heart rhythmі periodic vimіryuvannya arterial vise, scho to allow a more beautiful assessment of the vasodepressor component. It is necessary to be educated, so that GCCs often develop in the case of young people. At the same hour SCS - it is possible to reach the age of children older than 40 years.
Communication between pathological reports on the ISS and syncope is another important moment, which is the next step. There are 2 methods to fix. Accordingly, it is necessary to adjust the frequency of syncope before and after cardiac stimulation. In nonrandomized pre-adolescents, it was demonstrated that during the period of caution in patients with an implanted cardiac pacemaker, there was a lower frequency of relapses in patients with no key signs at the first assessment of the effect of cardiac stimulation.
Another method of polarization is in the analysis of the frequency of asystole episodes in patients with a cardioingbital version of the massage in the area of ​​the carotid sinus for implanted attachments. In two doslіdzhennyakh, in which the methodology was stagnated, the dovgі pauses were restored with approximately the same frequency. Otrimanie results give a positive impression on the massage in the area of ​​the carotid sinus є a reliable predictor of the development of spontaneous asystole.

Clinical features, which can be used for diagnosis at first glance:
Neuro-mediated syncope:
- the visibility of the pathology of the heart;
- trivial history of repeated syncope;
- development of syncope for unsuitable sound, smell, or pain;
- trivale standing or perebuvannya in crowded, suffocating places;
- tediousness, bloating, association with syncope;
- development of syncope for an hour or for a reception;
- development of syncope when the head is wobbling for a trivial hour, or when the carotid sinus is pressed (when the carotid sinus is puffy, it’s half an hour);
- pislya nervous tension.
Syncope, associated with orthostatic hypotension:
- development of syncope with trivial perebuvannya in position standing;
- Timchasova vzamozvyazok with the ear to the reception of the sudinozuzhuvalnyh preparations, or a change in the dose, which could lead to hypotension;
- trivial perebuvannya in position standing, especially in crowded and suffocating places;
- the manifestation of autonomous neuropathy for Parkinson's ailment;
- standing pislya nervous tension.
Syncope of cardiovascular nature:
- the manifestation of organ pathology of the heart;
- symptoms of raptor death or pathology of the ionic canals in the family history;
- change for EKG;
- refusal to attack an accelerated heartburn, when a syncope is attacked at once;
- EKG signs of syncope in case of arrhythmias:
two-beam blockade (blockade of the left or right lower part of the gas bundle in the second place with the blockade of the anterior-upper or lower-posterior nodule of the left lower part of the gas bundle);
- іnshі failure of internal drainage conductivity (triviality QRS≥ 0.12 s);
- AV blockade of another stage, type Mobitz I;
- asymptomatic inadequate sinus bradycardia (< 50 уд/мин), синоаурикулярная блокада или синусовая пауза≥3 с при отсутствии препаратов с отрицательным хронотропным эффектом;



- early repolarization;


- Q-wave, which is indicative of myocar infarction.
The main accelerated massage of the carotid sinus is neurological in nature. Slid unique massage of the carotid sinus in patients with transient ischemic attacks, who suffered an insult in the last 3 months, in patients who have a lingering noise over the sleep artery, but

Riziku stratification.
Short-line factories of high risk, the appearance of those in the secret hospital, and the provision of intensive assistance
Important organic heart disease or ischemic heart ailments (heart failure, reduced fraction of the wicked heart or myocardial infarction in anamnesis)
Clinical or EKG signs of syncope of arrhythmogenic etiology:
- attack syncope for an hour or so when lying on the back;
- more frequent sertsebittya before the hour of syncope;
- raptus deaths in family history;
- nestiyka shlunochkov tachycardia;
- two-beam blockade (blockade of the left or right lower bundle of the gas bundle in the second place with the blockade of the anterior-upper or lower-posterior distribution of the upper and lower part of the hypochondrium)
- asymptomatic sinus bradycardia (< 50 уд/мин), синоаурикулярная блокада или синусовая пауза ≥3 с при отсутствии препаратов с отрицательным хронотропным эффектом или физического напряжения;
- QRS complexes with signs of pre-excitation of shlunochki;
- dovgі or short QT intervals;
- blockade of the right nizhny p.Gisa with ST segment pidyoma in V1-V3 insertions (Brugada syndrome);
- arrhythmogenic dysplasia of the right slunker: appearance negative teeth T in the right pectoral insertions, epsilon-hvili and piznіkh slunochkovy potentials;
Important pathological conditions:
- anemia of an important stage;
- damage to the electrolyte balance.
orthostatic test
The change of the position of the body from the position of lying on the back in the vertical accumulation of the transfer of blood from the chest area in the lower pictures, so, in its turn, to reduce the venous output and instead of the CO. If the compensatory mechanisms are inadequate in reducing the arterial grip, it can lead to syncope.
On the current year there are two methods for assessing the change in position during the transition to the standing position from the recumbent position on the back.
One of them is the active orthostatic test, when the patient suddenly stands up from the supine position on the back. Another method is a passive orthostatic test (head up tilt) with a cut from 60 ° to 70 °.

active camp
The Danish test is carried out with the detection of the so-called orthostatic intolerance.
For a routine clinical routine, as a rule, a sphygmomanometer can be used for its availability and ease of use. Stagnation of the automatic pumping of the cuffs, which are programmed for re-adjustment in the case of super-precise indicators, is ineffective in connection with the narrow decrease in the arterial vise in case of orthostatic hypertension. With the aid of a sphygmomanometer, it is possible to carry out a deprivation of chotiri vimiri in chilin for one rutsi without development of stenosis of veins in them. If it is necessary to carry out more frequent tests, it is possible to further non-invasive visualization of the arterial vise and the frequency of the heart.

Tilt test (passive orthostatic test)
priming
Tilt test allows you to create a neuro-mediated reflex in laboratory minds. The purchase of blood and the change in venous flow due to orthostatic replacement and impairment of the venous reflex. As a result of hypotensiveness and increase the supportive decrease in heart rate, it will lead to a decrease in the size of the patient's vessel, as a result of galvanizing the sympathetic impulses and hyperactivity of the vagus.
The tilt-test is susceptible to a critical situation, if reflex syncope develops into a link with trivial moving in the position of standing. However, this test can also be positive in patients with lower forms of reflex syncope and sinus node weakness syndrome.
Methodology
Tilt-test in clinical practice for evaluating patients from the syncope of undesirable etiology, Kenny in 1986; ... Naybils often use a low dose of intravenous isoproterenol injection technique; at the same dose, incrementally increase the average frequency of the heart by approximately 20-25% of the average frequency. It is also common to use the nitroglycerin injection technique for a 20-hour pause on the drug. In patients who have been thwarted, an ear of dough immediately added with nitroglycerin without an anterior passive phase (without leaks) can be effective. The offense of methods is perceived to be achieved with a high frequency of positive results (61-69%) and a high specificity (92-94%). It is not possible to accept a child 4 years before the test. At the connection with the need for catheterization of the vena, the preparatory phase with the intake of isoproterenol becomes 20 min, while for nitroglycerin - only 5 min.
Shown. NS An even passive orthostatic test is shown in patients with non-verifiable patients with the first diagnosis of reflex syncope.
There is no need for a tilt-test in patients, for those who have a diagnosis of reflex syncope of symptoms, because of the history of ailments, for those with a single illness or for those with professional syncope attacks, etc. ). Seemingly, a passive orthostatic test can be informative in patients with a high heart disease, or for syncope of arrhythmic genesis, however, a cardiovascular cause is responsible for retinal dosage. In patients with a time-consuming second testimony, association with sudomas, an orthostatic test is also possible for the diagnosis of syncope of epileptic genesis. The Danish test can also be tested in patients with frequent episodes of the past in witness and adolescence on psychiatric problems, in case of trauma for the manifestation of the reflex nature of syncope. In addition, an orthostatic test is stagnant in a sick person who has been diagnosed with a syncope and a pathology, which is supervised by the second testimony.
Tilt-test is used to differentiate between pure reflex syncope and non-classical forms of orthostatic hypotension. However, this result does not show how effective the treatment is. Tilt-test of the ASA knowledge is informative for revealing the patient's mental strength to reflex syncope, and hence, on the basis of its results, it can be recognized as a test.
Refer to the tilt test. The results of the tilt-test can be caused either for reflex hypotension / bradycardia, or for OG, associated with syncope. The nature of the response to the cyclic reflex appears to be largely due to the dominant component - vasodepressor or cardioingbital (as evidenced by cardioingibitorny, vasodepressor caused by a type of negative). If the result is negative, the tilt test is not necessary for the diagnosis of reflex syncope.
On the current year, the validity of indications for the tilt-test of the factor, as well as the start of AT and heart rate per hour of syncope, has been set on a regular basis. For those who were younger, they were referred to a tilt test, which imaged the state of the hour of spontaneous syncope, and were considered to be an additional implanted loop adjuster. A positive cardiovascular response to a tilt test is indicative of a high quality of development of spontaneous syncope of asymmetric genesis. The appearance of a positive vasodepressor or altered form does not include the possibility of asystole before the hour of spontaneous syncope.
Folding and contraindication. Tilt-test is a non-furnace diagnostic method. There is no way about one type of death for every hour of the day. However, there is evidence of the possibility of developing life-threatening shlunochkovy arrhythmias, vicious injections of isoproterenol in case of manifestation in a patient IXS, or a syndrome of weakness of the sinus node. There is no information about the acceleration of the test with nitroglycerin. Can roll slightly side effects when this test is carried out, there is a frequent sercebitty when taking isoproterenol abo head bill when taking nitroglycerin. Uninvolved on a low risk of acceleration side effects Still, I recommend to prepare reanimation equipment.
Prototype indications prior to the tilt-test with isoproterenol є IXC, uncontrolled hypertension, vivid viddil lingering, significant aortic stenosis. For safety reasons, the test should be performed in patients with confirmed arrhythmias.
Electrocardiographic monitoring (invasive and non-invasive)
EKG-monitoring is used to diagnose intermittent brady and tachyarrhythmia. In a given hour, a number of types of EKG monitoring in outpatient minds are available: standard outpatient holter EKG monitoring, monitoring in the minds of a stationary, a podiatrist, a call home and a home assistant.
The gold standard for the diagnosis of syncope is the establishment of a link between symptoms and documented arrhythmias. Authors are able to detect asymptomatic significant arrhythmia, revealed at first glance trivial asystole (more than 3 seconds), supra-mucous tachycardia (more than 160 beats / xv), as well as malignant tachycardia The duration of the syncope per hour of the documented arrhythmia allows the diagnosis of the cause of the syncope, which is not a specific diagnostic indicator.
As a rule, EKG-monitoring of the readings only in quiet drops, if there is a lack of arrhythmic etiology of syncope before the hour of preparation before the test. However, it was shown that arrhythmia (as a rule, asystole) for an hour of syncope occurs practically in 50% of individuals older than 40 years with repeated episodes of syncope, without reliable structural damage to the heart, with a normal ECG picture.

Monitoring in the minds of the stationary
Monitoring in the minds of the stationary of testimony in case of high imbalance development in a patient with life-threatening arrhythmias. EKG-monitoring for a few days can provide diagnostic value for ailments with EKG-changes, but also with key features, which can influence the artistic ethology of syncope, especially if it is carried out in syncronization However, in the given minds, the diagnostic value of the EKG-monitoring is to blame for 16%;

Holter monitoring
V happy practice to carry out Holter monitoring, a standard 24-48 year old or a 7-day administrator is required. However, most patients have symptoms, as a rule, do not repeat themselves during the hour of monitoring. At the same time, the value of Holter monitoring decreases to 1-2%. In 15%, the symptoms are not associated with arrhythmia. In such a rank, among the patients of this category, the breakdown of the rhythm can be potentially victorious as the cause of syncope. By itself, Holter monitoring is not an expensive method, however, when testing for diagnostic purposes, patients with syncope are markedly growing. The Danish method of diagnostic value in ailments with syncope with frequent symptoms. Dosvid pіdkazuє, that danіy cohort of patients often mіsce psychogenne pseudosіnkope.

Name records of pods in prospective mode
Registrar podії - tse znіshnіy adjud, which vikoristovuyutsya for assessment, I will become a patient before an hour show symptoms. The Danish type of recorder is informative for patients with increased heart rate, but not for diagnostics in patients with syncope.

Zovnishny loops of the restaurant
The whole type of attachment can loop memory, allowing the restoration of the data and the output of the electrocardiogram for a trivial hour. Become active as a patient, give rise to symptoms, so you can get a dan in 5-15 minutes. The Danish type will adhere to the patient for the additional help of contact electrodes of a pedagogue. Є Informations about the need for the corresponding donations received during the victorian loop-backs and holter monitoring, for the improvement of the diagnostic value of these methods. However, pacinti can see the indication of the ringing tide, which is not enough for the connection between the EKG-signs and syncope in individuals with infrequent episodes of syncope.

Loops are implanted
Loop restorations (IPR) are implanted; The stock of the storage battery charge is close to 36 months. Daniy has got a memory loop to save the ability to save EHC records in retrospective mode. You can get assets by a patient or a kimos іnshim, call me a letter to a syncope. Also, the recording can be automatically activated in case of early arrhythmias. The data can be analyzed online. Perevagami victoriannya ІПР є triviality and accuracy of the restoration of the EKG-indicators. However, є і a number of shortcomings, the need for more surgical engagement Do not find it insignificant, the foldability of the development of supraventricular and supine arrhythmias, the possibility of becoming overexcited, for it’s gross on the data in the memory card, as well as on the part of the given attachment. Nutrition for the road given to the method can be peer-reviewed in the development of a very high diagnostic value in the context of standard diagnostic visits. However, for the whole it is necessary to bring the authenticity of the possibility of detecting the interconnection of the EHC-sign with the syncope itself from the stasis of the given method in the great number of patients. Seasonally, as a rule, you can play in quiet situations, if the reason for the syncope is that all the standard diagnostic calls were carried out has become unclear. For 5 months of IPR evidence, the EHC-sign of syncope was detected in 88% of patients with a retarded cohort. In the analysis of 9 days, 506 patients with syncope were included unclear ethology When standard methods were used to treat the disease, it was found that the correlation between EKG-failures and syncope was established in 176 (35%) patients; of them, 56% had an asystole (aka bradycardia in decile vypadki) before the hour of the established stage, 11% had tachycardia, and 33% had no arrhythmias. In seven pre-malignancies it is shown that the pre-malignant stump is not associated with arrhythmias. This is given to me in respect, but when there is a documented arrhythmia, the witness is pre-syncopal and completely syncopal stanions are not interchangeable. І navpak, the presence of a confirmed arrhythmia in the pre-syncope is a diagnostic marker.
In case of syncope of an uncomfortable etiology, IPR can also become stagnant in other diseases, so it becomes interesting for physicians and presenters:
- in patients with a transmission of epilepsy, in those with a disease it appeared ineffective;
- in patients with transmission of neuro-mediated syncope (the etiology of spontaneous syncope can be embedded in the nature of the treatment);
- in patients with a blockade of the lower bundle of Gis, in those with a paroxysmal AV block, the most imovirna, unaffected by a negative response during an electrophysiological assessment.
- in patients with susceptible structural lesions of the heart and / or non-trivial mucus tachyarrhythmias, in some mucus tachyarrhythmias, the most sensitive to negative diagnoses
- among children with unacceptable unclear ethology.

Distance (in home minds) telemetry
Not so long ago, the systems were broken up, calling and implanting, as a result of the restoration of EKG-indicators (with a loop memory for 24 years) for a trivial hour and transmitting the data to the service center via a mouthless call. Dobovі danі or danі, as to inform about the ymіrnіst of development of the podії, supervise from the center of the lykar. It is notable for the recognized results, such a mobile telemetry system can provide a high diagnostic value for patients with syncope, or presyncopically, with callable active loop adjusters. It is necessary to further improve the potential value of these systems for diagnostics of patients with syncope.

Classification of electrocardiographic recordings
In connection with heterogeneity, there is a sign and variability in the rhythm disturbance, established by the IPR every hour of syncope, by the observers of the International Study on Syncope of Unknown Ethiology (ISSUE), the structure of the classification which can be stashed in the given advances and clinical practice. The EHC records have been divided into 4 groups for this classification. The main characteristic is the basic change to the rhythm and transmission of the mechanism in the basis of syncope.

Electrocardiographic monitoring for syncope - if vicoristovuvati?
It is impossible to indulge only on the data of the EKG-monitoring. Likars need to know the results of the first assessment of the sick person. In some situations, for example, if the key facts are reliably involved in the reflex nature of syncope and even if there are infrequent episodes of syncope, there is no need for EKG-monitoring. In ailments with frequent manifestations of symptoms, for the syncope of an imovir arrhythmic nature, it is not possible to be referred to a group of high rhizic, it is possible to have an IPR. ІПР stagnates, as a rule, only, if the etiology of syncope does not go far beyond the help of other diagnostic methods. In one day, 60 bully children were randomized into 2 groups. In one of them, standard diagnostic methods were taken into account, and the most recent loop-backs, tilt-test, electrophysiological dosage (EED); in the іnshіy group, diagnostics was carried out in the form of ІПР. Otrimanie results and inform about those that storing IPR in cob diagnostics makes great diagnostics value in case of standard methods(52 and 20% allegations). However, the development of life-threatening arrhythmias and a decreased fraction of the wickedness of the lynx (35%). They carry out the tests, as well as with the control of diagnostic capabilities, the tilt-test, the test with adenosine triphosphate (ATP), electrophysiological conditions and non-trivial EKG-monitoring, re-testing according to the early stage Diagnostics is a standard in case of adolescence for an arrhythmic nature of syncope, as for the help of these methods it is not necessary to provide identification. It is also possible to learn about early ethological treatment.
In the future, there will be a breakdown of the system, for the help of which it will be possible to restructuring signals, such as the EKG, and seeing signs that are characteristic of spontaneous syncopal stuns (in such a case) there will be no need to provide provocation. At the connection with the cymbals, in order to identify the causes of syncope, based on standard methods, there is a wider scope for the implantation of the restoration. However, in patients with structural damage of the heart, I will increase the high efficiency of the development of life-threatening arrhythmias, and the change will become a result of the implantation of an electric defibrillator or an IPR. If you want to diagnose bradyarrhythmia, as a supervascular syncope, diagnostic criteria, if you need to carry out additional tests using the method of differentiation of cardiac mechanisms of syncope. It is often the cause of paroxysmal bradyarrhythmia in patients without structural damage to the heart and normal ECG picture.

Electrophysiological dosage
Diagnostic efficiency of the EED when the cause of syncope is established, it is often possible to start the transmission of failures, as well as the EED protocol.
In 8 days, 625 patients were included with syncope, in whom EED was carried out, it was shown that a positive result was also important for patients with structural heart ears.
In total Danish method do not see high sensitiveness and specificity. At the foregoing recommendations, the price of food is given in the report. Moreover, in the last few years, new diagnostic methods, for example, trivial monitoring, were more informative. Slid also vrahuvati, so EED is no longer acknowledged to patients with a reduced fraction of the wikid of a lone dwarf, for that, in the given vidings, there are no reasons for this. From the data of the publications for the rest of the fate, depriving 2% of the ailments from the syncope of undesirable etiology, the cardiologist signifies the EED. Likars of the specialties mean that it grows faster. The method is still used for diagnostics in specific clinical situations, pererakhovanih lower.

Transmission of intermittent bradycardia
Lykar with high vigor, let the bradycardia as the cause of syncope be taken before specific tests are performed if asymptomatic sinus bradycardia (< 50 уд/мин) или синусно-предсердную блокаду, которая обычно регистрируется на 12 отведениях ЭКГ или при ЭКГ-мониторинге.
There is a lack of diagnostic value in the renewal of the function of the sinus-atrial university (CHVFSV). Period> 1.6 or 2 s for CHVFSV і> 525 ms for the first hour of renewal of the sinus-atrial university function (SINA). In the observational dosage of the bullet, the interconnection is shown between the apparent podvizhennogo CHVFSV with EED and injected stimulation on the symptoms. In the last small prospective dosage it was demonstrated that in patients with OVVFSU> 800 ms the development of syncope is 8 times higher, but not in the sick with a lower indicator.
Syncope in patients with blockages of the lower bundle of the Gis (including atrioventricular block of the high step)
Patients with BNPG are characterized by a viscous AV block. Two factors add to the increase in the risk of AV block in patients with BNPG: syncope in the anamnesis and an hour spent from the Hiss beam in the shlunochki (HV-interval). The history of syncope is evident from 2 to 17% at the beginning of 42 months. Іmovіnіstі of AV-blockade to become 4, 12 and 24% in patients with HV-interval< 55 мс (норма), >70 ms і> 100 ms indicative.
The development of the blockade of the lower bundle of the Gis in response to the stimulation of the anterior an important predictor of the contamination of the AV block, the ale dian method is low sensitivity.
The development of blockade of the lower bundle of Gis in the presence of class I antiarrhythmic drugs can also provoke a spontaneous AV block. The predictive value of the pharmacologically provoked increase in the HV-interval up to the level of> 129 ms without AV block is unrelated. On the other side, about 1/3 of the ailments had a negative appearance with EED with the implantation of the IPR, an AV block developed in the lower one. In such a rank, EED is low sensitivity and specificity.
According to the analysis of the data of 9 days, in which taking the part of 1761 patients, the level of mortality of the sklavs is 28% in 40 months; in 32% of cases, rapt death was indicated. At the same time, it means that no syncope, no podvzheniya HV-interval was associated with a greater risk of death, and therapy with the speed of the cardiac pacemaker did not change the rate of death.
At the end of the day, it means that the method of increasing the HV-interval is not allowed, in case of provocation of the AV-blockage by the path of cardiac

transfer of tachycardia
For patients who have syncope before the attack of an accelerated heart rate (perhaps, over-slurry tachycardia), EED may be designated for assessing the exact mechanism.
In patients from the saved fraction of the lynx, who have suffered myocardial infarction, the cause of the syncope can be helped by provocation of the trivial monomorphic tachycardia. Induction of slurry fibrillation does not flaunt specific criteria. The visibility of the indigestion arrhythmia allows a group of patients to see, in some arrhythmias it is a small cause of syncope.
Evidence about acne and the degree of efficiency of the EED and provocative test for the intake of antiarrhythmic drugs in the 1st class in ailments with syncope and with Brugada syndrome should be superb. In the meta-analysis of pre-ventricular disease, which included 1,036 participants, it was established, but in 56% of them there was no need to provoke supraventricular, or to stimulate the onset of those who didn’t have enough
Adenosine triphosphate test
A given test has not been given a bolus transfer (< 2 с) 20 мг АТФ (или аденозина) во время ЭКГ-мониторинга. Отклонениями от нормы считаются АВ-блокада с длительностью асистолии желудочка более 6 с или АВ-блокада более 10 с. Патологический ответ на АТФ-пробу отмечался у некоторых пациентов с синкопе неясной этиологии (в основном у женщин пожилого возраста без структурных изменений сердца), однако в группе контроля такой ответ на пробу не был зарегистрирован. Полученные данные дают основание полагать, что пароксизмальная АВ-блокада может быть причиной синкопе неизвестного генеза. Тем не менее в последних исследованиях была установлена взаимосвязь между АВ-блокадой, спровоцированной АТФ-пробой, и изменениями на ЭКГ (полученные при помощи ИПР) во время спонтанного синкопе. Роль высвобождения эндогенного аденозина в развитии некоторых форм синкопе при пароксизмальной АВ-блокаде (так называемое аденозин-чувствительное синкопе) остается предметом исследований.

Echocardiography and other methods of visualization
The most informative method for diagnostics of structural heart disease є echocardiography, including an assessment of structural and functional indicators of hemodynamics. The ehocardiography data are even more important for the stratification of risiks in case of a decrease in the fraction of the wicked louse. If structural ailments of the heart are evident, it is necessary to carry out additional tests to reveal a possible cardiac cause of syncope. For an additional method of echocardiography, the cause of syncope can be found in an insignificant number of patients, for example, with stenosis of the aortic valve, anterior myxoma, tamponade. It’s possible to indulge in this tribute, but it’s obvious that there’s no need to carry out additional tests.
In some cases (aortic enlargement and hematoma, embolism legendary artery, Pukhlina heart, ailments of the pericardium and myocardium, congenital anomalies of the coronary arteries) can be performed transesophageal echocardiography, computer tomography, Magnetic resonance tomography.
Test for physical availability
Syncope, association with physical navantazhennym, - to finish off a childish phenomenon. The method of diagnostics is blamed for zastosovuvatisya deprived of the quiet, who had an episode of syncope for an hour physical navantazhennya for all at once she wrote. It is necessary to make a detailed record of the EKG and AT-monitoring before the test hour and during the renewal phase, so as the syncope can be made as soon as the renewal is taking place, so at once it is sent. That tsі danі needs to look out okremo. As soon as syncope has developed during the physical development, then it can be cardiac for a certain reason (there is a wish in some occasional cases about the manifestation of a significant reflex enlargement of the sudin). Mechanism in the basis of syncope, as it was immediately written, is better for everything reflexive. It has been shown that AV blockade of the II or III degree, that it is victorious before the hour of tachycardia on the basis of the new option, develops distal to the AV node and has a progressive character. Dani EKG calmly provide informative information for the detection of intraventricular conduction damage. There are a lot of reliable tributes that can be used to recommend that a test be carried out for physical problems in the out-of-town population of ailments with syncope.
Assessment of the mental state
There are two powerful mechanisms that sound syncope and mental health. Accordingly, the reception of psychoactive drugs in a possible way through the development of OG or the syndrome of an increased QT interval. The use of drugs in this category can be even more significant inheritance, which is at the same time responsible for insurance coverage.
In other words, there can be so called functional attacks. Understanding "functional" means a camp, similar to somatic. At the same time, it is unwise to explain the somatic mechanism, the protest of the psychological evidence. You can see 2 groups of patients for differential diagnostics lose the evidence. In both groups, the patients do not control their own hands and do not refer to the visiting followers. In one of the groups of macroruchi, they are similar to those in epileptic sudomas; so attack as pseudo-epilepsy, attack non-epileptic character, psychogenic non-epileptic attacks. In the іnshіy group macroruhi is not meant to be, that attacks are similar to syncope or trivial loss of testimony. Smells rejected the name of psychogenic syncope, pseudo-syncope, syncope of psychiatric walking, syncope of undesirable etiology. On the other hand, it does not mean that the other two terms do not indicate syncope, and that, in case of functional loss of evidence, it does not mean cerebral hypoperfusion.
It is important to consider the view between the functional second and the similar body and the frequency of the somatic mechanism: in case of pseudoepilepsy, the brain activity is not rebuilt, it does not decrease the rate of AT
There is no reliable frequency of such attacks, in terms of the world it is medical mortgage... So, in specialty clientele the frequency of functional losses of testimonials, of some epilepsy, varying from 15 to 20%, and in syncope clientele to become 6%.

diagnostics
Pseudo-syncope, as a rule, is trivial more, less syncope: patients can lie on a pile of chilin, sometimes up to 15 minutes or more. Also, the frequency of attacks is characteristic of the new one, up to decile times per day, and it is practical to see clearly significant trigger factors. With a functional short-term loss of evidence, it is also possible to physical education (approximately in 50% of cases). In case of epileptic syndrome and syncope of the eyes, as a rule, it appears, in case of functional loss of evidence, it is closed. Maybe we should be cinnamy when fixing a tribute in case of an attack: indicators of muscular tone (video recording or neurological condition), AT, heart rate, EKG. Stay alive and well, oskilki functional breakdown easy to recognize and diagnose in addition to helping to make an accurate diagnosis. Such data, rejected during tilt-testing, as a loss of testimony from the second control of ruffs, a normal level of arterial pressure, heart rate is very fast, and a normal picture of the EKG, allowing syncope to be eliminated and more forms.
The revelation of nature and syncope is also important for the production correct diagnosis... Explain to the patient, who has a psychogenic character, to finish it smoothly. There can be a child's mind to think that he is especially responsible for those who are seen with him, because everyone is involved, no one is simulated attack. However, the ailment itself is sprymay їkh as mimovіlne, and for all that so. It is necessary to talk about the ailment to the extent of the attacks against the evidence. All the same to allow the vibrati to the correct lіkuvannya.

Differential diagnosis

As a rule, the differentiation of syncopal stamina is of a non-syncopal nature, and it is possible to additionally collect an anamnesis, and it can be done in a smooth manner for an hour. It is necessary to eat food:
1. What is the amount of money lost?
2. What is the rate of loss of transitory svidomostyu svidkim development attack abo nontrivalo?
3. Did the child begin spontaneously, more or less, with inheritance?
4. Having lost the postural tone of the patient?
As soon as the nutritional supply is positive, then, I can help you with syncope. If I would like it to be negative on one food, then before we continue to assess syncope, it will turn on the formation of a loss of evidence.

Likuvannya beyond the cordon

stratification of risik often vicarious to assess the risk and additional help in the accepted solution. Tsei pіdhіd base on these statistical models, which are predictive factors, and unified in the development of the system for evaluating the risk to help the drug users accept solutions. In the rest of the rock, the powerless systems appeared, I will become a patient for a quick assessment.

by the way, TIMI rooting system for patients NOT stable angina(PS) for no reason ST vikoristov 7 available indicators for determining the risk of tornadoes and ischemic events. Rizik range of variability Falling as a number of emerging FRs: from 5% (occurrence of 0-1 factors) to 41% (occurrence of 6-7 factors).

V doslіdzhennyakh It is important to look at nutrition, attributable to the stratification of the population. About the possibility of storing quietly the same approaches and systems for the development of the risky and altered to different populations, as in practice, to stagnate only the children of the children. Prognostic indicators of the next vibrate are independent of the end results. Chinese results (results) and time parameters are available.

zrozumіlim guilty butti and the very idea of ​​stratification. It is necessary to improve the accuracy in the assessment of little positive inheritance, for that the appearance of coryste is similar to that of the condition, as it is not significant for therapy.

The paradox of risik-likuvannya... Among the early adopters, the paradox of "risik-likuvannya" was promoted, in other words, we are sick with a greater risik, meaningfully we spent more time, as the guilty bully was successful. This is a paradoxical butt, because ailments from a group of a high rhizik could be removed from a group of high rhiziks. The price of viplivay is from mirkuvannya, but the same decrease in rhizik is the same in groups of cob raznim rizik.

When assessing the effect trick it is necessary to come to the same respect for the endurance results before the end of the hour, which was carried out with caution. In articles devoted to CVD ailments, the emphasis is often only on the heart-shaped podії, incl. heart-sudinu death. However, of greater interest is the overwhelming mortality of all causes.

yaksho trick after death is heart-warming, but rather to bring to death for any reason, then for the patient it is not worth it either. It is especially important for the sick of the kidnapped vik, who may be able to avoid the other's illnesses with a competing risik. Moreover, the prospect of a decrease in mortality in the closest possible life of a surgical engagement may not be of value to a patient, as a fellow patient, or an accelerated decrease in life, for the whole hour at a time. In preschool children, I’ll become healthy often ignore, if the stench is important for the sick. Such a vuzky specific look at the endurance results and the preliminaries does not allow universally evaluating them.

vinika problem And from the assessment of the great number of final results, in addition, in all cases, it is possible to reduce the number of false positive results. The most important aspect of linking with the results, considered in the past, the fact that promis (or surrogate) indicators, for example, faction wikidu (FV), do not expect to be used with "solid" points of interest, such as viz.

7697 0

In connection with this, the prognosis for patients with stable angina may vary greatly, and the current strategy of treatment has significantly expanded - from symptomatic therapy up to high-tech and expensive methods, high-tech forecast, - the European Association of Cardiologists (2006) has proponent stratified the rhizic in patients with stable angina pectoris. With the help of the risky, the reason was heart-and-death death and IM, and in some cases, and in some cases, heart-and-heart inheritance.

The process of stratifying the risk is transferred to two types:

• responds to food from the drive of the forecast, which are diagnosed by the ailments themselves, robot teachers, insurance companies, licensed specialties fellow sickness;
• vibrate adequately lykuvannya.

With the victorious methods of treatment, especially revascularization and / or intensive pharmacotherapy, the prediction can only be reached in the singing groups of patients with high rhizik, at that time, in the case of the first few patients In connection with the cym, it is necessary to see the patients, to be brought to the group of high rhizik, in some of the most imovir the cinnamon is more aggressive in the early stage of the situation.

In the recommendations of the EOK (2006), the criterion for high risk is a heart-vascular mortality rate of more than 2%, an average risk of less than 1-2% and a low risk of less than 1% in a week. Until now, a practical model for assessing the risk has not been broken down, but it includes all possible aspects of the strategy, possibly alternative ideas, based on the results of clinical reports. As soon as possible, all ailments need to carry out critical care, more - non-invasive follow-ups with the help of an assessment of the functions of the LH and - to fix them.

1. Stratification of rizik on the presentation of key donations

The history of the ailment and the results of the physical routine allow to correct more importantly predictive information. At the end of the day for stratification, there can be EHC vicarians and laboratory tests, pererakhovani vishche. Installed, scho diabet, AG, MS, curriculum and hypercholesterolemia allow the transfer of development of uncomfortable inheritance in ailments with stable angina pectoris and other manifestations of IXC. Unwelcome prognostic value of ma vіk, as well as transfers ІМ, symptoms of heart failure, the nature of overturning angina pectoris (firstly, it is progressive) and ії severity, especially when there is a reason for symptoms. The peculiarities of attacks of angina pectoris, their frequency and manifestation of EKG-changes in calmness are important predictors of death and IM. At the display of these indications, it is possible to develop a simple index, which allows the transfer of unpleasant inheritances, especially by reaching out to the most fate.

Physical conditions are also additional help in assessment. Evidence of peripheral vascular lesions ( lower kintzivok abo sleepy arteries), in order to develop risiks, the development of heart-vascular acceleration in patients with stable angina pectoris. Unfriendly prognostic factors include such symptoms of heart failure, which add to the function of the LH.

In patients with stable angina pectoris, in those who have symptoms of EKG at rest (signs of a postponed IM, blockade of the left lower part of the Gus bundle, hypertrophy of the LS, AV block of II-III stages abo FP), rhizic of the heart and vascular disease EKG.

2. Stratification of risk for additional stress tests

The prognostic value of these samples may not only start with the detection of myocardial myocardium as such, but the assessment of the threshold for development, the breadth and severity of obvious changes (EHCG and scintigraphy) and transferability. The results of stress tests did not follow from the clinics' tributes. In such a rank, navantazhuvalny probes allow you to correct additional information about the heart-vascular rhizic in a particular patient.

2.1. EKG s navantazhennyam

One hour, the results of anti-aging tests and key parameters, as well as the distribution of predictive indexes, such as Duke's index, were found to be an effective approach to the stratification of ailments in the IXC of such a group. The Duke Index is an index that can be used at the end of the day for delivery, for the removal of the ST segment and for the diagnosis of angina pectoris in the event of replacement.

Rozrakhunok tredmil-index, JACC, 1999 ..

Treadmill-index = A - -,

de A - the triviality of new options and hilines; B - the output of the ST segment in millimeters (in the course of completion and after completion); C - index of angina pectoris;

0 - angina pectoris;

1 - angina pectoris є;

2 - stenocardia to produce up to zupinka doslіdzhennya.

2.2. Stress echocardiography

Stress EchoKG is also possible with the success of the vicarist for the stratification of the heart-vascular acceleration. In case of a negative test result, the incidence of unpleasant inheritance (death or IM) becomes less than 0.5% in ric. Rizik factor is the number of regional rapidity breakdowns in calmness and at navantazhenny (what is more, tim vische risik). The vision of a visitor of a high risk allows the food to be seen as far away as possible.

2.3. Myocardial perfusion scintigraphy

Normal results with high ymovіrnіstyu indicate a friendly prognosis. Navpaki, the deterioration of perfusion is associated with the important IXC and a high heart-vascular rhizik. Great and widening of perfusion defects, which occur during stress tests, past the ischemic dilatation of LSH for the test and the accumulation of ² ° Тl in the legends due to the increase in the pharmacological progression of the probable problem.

3. Stratification of risik on the premises of the function of shlunochkiv

The most important predictor of vision for the given term is the LS function. In ailments, stable angina pectoris mortality is increasing in the world of a decrease in the fraction of the LSh. With a fraction of wikid in calm, less than 35%, the mortality rate is 3%. The size of shlunochkiv is also more important in predictive value, as I will reverse the results of nasal tests in patients with stable angina pectoris.

4. Stratification of rhizik on the presentation of coronary angiography

The breadth, severity and localization of stenosis of the coronary arteries may be more important prognostic values ​​in patients with angina pectoris.

The CASS register has a 12-fold visibility on aphids drug therapy in patients with unchanged coronary arteries, it was 91%, in ailments with injuries of one judgment - 74%. two - 59% and three - 50% (p<0,001). У больных с выраженным стенозом главного ствола коронарной артерии, получающих фармакотерапию, прогноз неблагоприятный. Наличие тяжёлого проксимального стеноза левой передней нисходящей артерии также значительно снижает выживаемость.

Pozdnyakov Yu.M., Martsevich S.Yu., Koltunov I.V., Urinsky A.M.

stable angina

1. Aigun Sh.S. The results of surgical treatment of aneurysms of the cranial aorta in patients 70 years and older: Author's abstract. dis. ... Cand. honey. sciences. M 2004; 136-138.
2. Bєlov Yu.V., Komarov R.N. Tactics of surgical treatment of multifocal stenotic lesions of arterial basins. Khirurgiya 2007; 3: 60-64.
3. Gologorskiy V.A. Assessment of the functional stan of the development of the patient's organisms before the operation. Advisor in anesthesiology and reanimatology. M 1982; 137-139.
4. Dmitrieva Yu.S. Stagnation of the EuroSCORE system for the assessment of the operative risk in patients with heart valve defects and dilatation of the lingering slurry: Abstract of the thesis. dis. ... Cand. honey. sciences. M2011; 10-14.
5. Kazanchyan P.O., Popov V.A., Sotnikov P.G., Kozorin M.G., Kazakov A.Yu. Surgical tactics in patients with aneurysm of the cranial aorta and ischemic ailment of the heart. Breast and heart-sudina хір 2008; 2: 30-35.
6. Krasnikov M.P. Assessment of a surgical rhizic at one-stage operations of prosthetic repair of the visual aortic cavity and revascularization of the myocardium: Abstract of the thesis. dis. ... Cand. honey. sciences. M 2013; thirty.
7. Lisitsky D.A. Minimal invasive reconstructive surgery of multiple lesions of the brachiocephalic arteries, cranial aorta and arteries of the lower symptoms: Author's abstract. dis. ... Dr. med. sciences. M 2007; 32.
8. Olimi Sh. Prediction of operative risk in surgery of aneurysms of the cranial aorta: Author's abstract. dis. ... Dr. med. sciences. M 2009 to rock; 42-44.
9. Prediction and prevention of cardiac acceleration of non-cardiac surgery. All-Russian Science Partnership of Cardiologists M 2011; 6.
10. Svetukhin A.M., Zvyagin A.A., Slepnev S.Yu. The system of an active assessment of the severity of the sick. Khirurgiya 2002; 9: 57-61.
11. Svetukhin A.M., Zvyagin A.A., Slepnev S.Yu. The system of an active assessment of the severity of the sick. Khirurgiya 2002; 10: 60-69.
12. Fletcher Z., Fletcher S., Wagner E. Clinical Epidemiology: Basics of Evidence-Based Medicine. M 1998; 120-140.
13. Brooks M.J., Sutton R., Sarin S. Comparison of Surgical Risk Score. POSSUM and P-POSSUM in higher-risk surgical patients. Br J Surg 2005; 92: 10: 1288-1292.
14. Campillo-Sotto A., Flores-Pastor B., Soria-Aledo V., Cande-Arenas M. et al. The POSSUM scoring system: an instrument for measuring quality in surgical patients. Cir Esp 2006; 80: 6: 395-399.
15. Nayloi C.D., Slaughter P.M. Outcomes of Coronary Artery Surgery in Ontario. Cardiovascular Health and services in Ontario (Institute for Clinical Evaluative Sciences 1999; 10: 39-45.
16. Cullen D. et al. Therapeutic Intervention Scoring System. A method for quantitative comparison of patient care. Crit Care Med 1974; 2: 57.
17. Dickie H., Vedio A., Dundas R. et al. Relationship between TISS and ICU cosl. Intensive Care Med 1998; 24: 1009.
18. Oakes G.H., Feindel Ch., Purdham D., Tu J.V., Wang J., Kingsbury K. Report on adult cardiac surgery in Ontario 2012; 3-20.
19. Knaus W., Zimmerman J., Wagner D. et al. APACHE acute physiology and chronic health evaluation: A physiologically based classification system. Crit Care Med 1981; 9: 951.
20. Knaus W., Drapper E., Wagner D. et al. APACHE II: A severity of disease classification system. Crit Care Med 1985; 13: 818.
21. Knaus W., Douglas P., Wagner D. et al. The APACHE III Prognostic System: Risk Prediction of Hospital Mortality for Critically III Hospitalized Adults / Chest 1991; 100: 1619-1636.
22. Knee A., Cullen D. Therapeutic Intervention Scoring System: Update, 1983. Crit Care Med 1983; 11: 1.
23. Lemeshow S., Teres D., Pastodes J. et al. A method for predicting survival and mortality of ICU patients using objectively derived weights. Crit Care Med 1985; 13: 519.
24. Lemeshow S., Teres D., Avrunin J. et al. Refining intensive care unit outcome prediction by using changing probabilities of mortality. Crit Care Med 1988; 16: 470.
25. Lemeshow S., Klar J., Teres D. et al. Mortality probability models for patients in the intensive care unit for 48 and 72 hours: A prospective multicenter study. Crit Care Med 1994; 3: 22: 1351-1358.
26. Mirsad Kocila et al. Assessment of the initial and modified Parsonnet score in mortality prediction of the patients operated in the Serajevo heart center. Bosnian Journal of Basic Medical Sciences 2010; 10: 2: 165-168.
27. Michael Walker, Maureen Hazel, Nadeem Esmail. A comporative Analysis of Mortality Rates Associated with coronary Artery Bypass Graft (CABG) Surgery in Ontario and Select US States. Studies in health care Policy (FRASER INSTITUTE) 2009 rock; 6.
28. Midwinter M.J., Tytherleigh M., Ashley S. Estimation of mortality and Morbidity risk in vascular surgery using POSSUM and the Portsmouth predictor equation. B 1999; 86: 4: 471-474.
29. Nashef S. A., Roques F., Michel P. et al. European system for cardiac operative risk evaluation (EuroSCORE). Eur Cardiothorac Surg 1999; 16: 9-13.
30. Nilsson J., Algotsson L., Hoglund P. et al. Comparison of 19 pre-operative risk stratification models in open-heart surgery. Eur Heart J 2006; 27: 7: 867-874.
31. Prytherch D.R., Ridler B.M.F., Ashley S. Audit Research Committee of the Vascular Society of Great Britain and Ireland. Risk-adjusted predictive models of mortality after index arterial operations using a minimal data set. Br J Surg 2005; 92: 6: 714-718.
32. Spencer Gary, Wang J., Donovan L., Jack V. Tu. Report on Coronary Artery Bypass Surgery in Ontario, Fiscal Years 2005/06 and 2006/07. Institute for Clinical Evaluative Sciences 2008; 2-10.
33. Teres D., Lemeshow S., Avrunin J. et al. Validation of the mortality prediction model for ICU patients. Crit Care Med 1987; 15: 208.

Table 3

Note:

* The accuracy of the value of the zagalny heart-vascular rhizik must be laid down without the need for more clinical and instrumental and biological treatment of the ailment. Without data, ultrasound of the heart and sudin for the diagnosis of HLS and the increase of the stage (or the presence of plaque) of sleepy arteries up to 50% of AH ailments can be reduced to a low or middle risk to replace a high a; ** add. - dodatkovy rizik

Patients with a high and a high rizik

Table 4

* GFR according to MDRD formula (ml / hv / 1.73 m 2) = 186 x (creatinine / 88, μmol / l) -1.154 x (vik, rocky) -0.203 for women, multiply the result by 0.742

** Clearance to creatine according to the Cockcroft-Gault formula = (88 x (140 - vik, rocky) x mass, kg (ml / hv)) / (72 x creatine, μmol / l) for women, multiply the result by 0.85

diagnosis formulation

When the diagnosis was formulated according to the possibility, the most likely to blame, the appearance of FR, POM, AKS, heart-vascular rhizic was displayed. The step of advancing the arterial clutch is obligatory for the children to be diagnosed with the AG, for those who are ill, it is necessary to write the age of the great aggravation, which in Russia There is a three-stage classification of GB, GBI stage of transferring the visibility of PZZ, GB of II stage - the presence of changes from the side of one or even decile organ-targets. diagnosis of GB III stage to get up at the presence of the AKC.

When the AKS is out, the term "hypertensive ailment", due to its high prognostic significance, naturally borrows the first position in the structure of diagnostics. With the presence of the AKC, it is supervised by a high level of damage to the function, or it will state form, For example, gostry coronary syndrome(GCS), "hypertensive ailment" in the structure of the diagnosis of heart-vascular pathology can not be considered.

Apply the diagnosis formula:

GB stage I. Stage of hypertension 2. Dyslipidemia. Rizik 2 (middle).

GB II stage. Stage of hypertension 3. Dyslipidemia. GLSH. Rizik 4 (even temple).

GB III stage. Stage AG 2. IXC. Angina pectoris II FC. Rizik 4 (even temple).

GB stage I. Stage AG 1. SD type 2. Rizik 3 (high).

IXC. Angina pectoris III FC. Postinfarction (velikovischevy) and atherosclerotic cardiosclerosis. GB III stage. The feet of AG 1 are reached. Rizik 4 (arch high).

GB II stage. Stage of hypertension 3. Dyslipidemia. GLSH. Obesity II Art. Loss of glucose tolerance. Rizik 4 (even temple).

Pheochromocytoma of the right nadirnik. AG 3 steps. GLSH. Rizik 4 (even temple).

Ethiology

There are a lot of previous ones to see the following formulas: sensitive hypertension (EH) may be the result of the interrelationship of recessionary officials, who are screwing up to hypertensive reactions in recent years

in 81% of ailments, the relatives of mali have an arterial vise. Spadkovi factors, which can be brought up to the development of the EG, can be brought up to the sphere of the central regulation of the arterial vise / "stress geni" /.

From the clinical practice of the form EG, from the point of view of G.F. Langa, є the inheritance of mental overstrain, pouring into his mental sphere of emotional negative character, mental traumatization.

Recessively overwhelming sensitivity up to kitchen salt and alterations of salt appetite.

Metabolic health effects Obesity - it is seen as one of the provincial officials of the formation of the GB of the middle of the inhabitants of economically developed regions.

EG is recognized to the number of the most widespread diseases of the heart-vascular system: it becomes 95% of all types of hypertension. Secondly, it was taken in respect of the AG, which is the result of the primary control of the organisms. For the data of epіdemiologicheskih doslіdzhen, held in іznih lands, the stench is stored 5-6% of the middle of the sick, who are suffering on the AG.

pathogenesis

Yak vіdomo, rіven arterial vise is used to relieve the heart vikidu blood and peripheral vascular support. The development of arterial hypertension can be inherited:

pidvischennya peripheral support, poured spasm of peripheral sudin;

the improvement of the blood-thinning of the heart as a result of the intensification of the robot and the growth of the internal vascular volume of the child (accumulated with sodium in the body);

the addition of an increased amount of sinewy lassitude and the advancement of the peripheral support.

In normal minds, the growth of the chilinous volume is reduced to the lowering of the peripheral support, as a result of which the arterial grip does not move. Thus, the regulation of the arterial grip becomes the optimal control of the pressor and depressor systems to the body.

To the pressor system, carry:

sympathetic-adrenal (SAS);

renin-angiotensinov (RAS);

aldosterone;

antidiuretic hormone system (vasopresin);

system of prostaglandin Fa * and cyclic nucleotides.

The depressor system includes:

aortocarotid zone (reflexion from which leads to a decrease in the arterial vise);

system of depressed prostaglandins;

kalikrein-kininovu system;

atrial natriuretic factor;

endothelium dependent relaxing factor.

In case of hypertensive ailments є the failure of the pressor and depressor systems in young people, there is an increase in the activity of the pressor system and a decrease in the activity of the depressor systems.

For not tsіlkom yasnim causes in ailments on GC pіdvischuєtsya pressor aktivnіst gіpotalamo-gіpofіzarnoї Zoni, scho Veda to gіperproduktsії kateholamіnіv (pіdvischena aktivnіst CAC), about scho svіdchit pіdvischennya dobovoї ekskretsії of secheyu noradrenalіnu scho slit in bіlshіy mіrі zrostaє in Minds fіzichnogo that emotsіynogo stresu ...

The result of the activation of CACє These are the changes that zoom in on the arterial vise:

peripheral venoconstruction supervises the increase in blood flow to the heart and heart wikidu;

the growth of the number of hearts is very fast, but in the same period with the increased shock volume, it is also the same until the increase in the heart wikidu;

growth of the posterior peripheral op_r of sudin due to the act_vats__ Pi-receptors in the peripheral arterioles.

Quite a few middle factors of the loan are the activation of the RAS. Alterations in the place of AT II in the blood plasma of the wiklica trivial spasm of smooth muscles of the peripheral arterioles and rіzke pіdvischennya OPS.

AT II pouring into іnshі fresh systems: 1) vyklyuchi spragu, vіn veda until podvischennya vyroblenya vasopressin, which is a zumovlyu spasm of sudin і overlap the rіdini in the body; 2) activating aldosterone - the hormone of measles supra-nasal vulvais, which will increase the absorption of sodium and water into the body (increase the mass of circulating blood).

Trivial spasm of arterioles spraying in the place of Ca ++ ions in the cytoplasm of smooth fibers, which is tied to the spasmodic zooming peculiarities of the transport of ions through the penetrating membranes.

Pіdvischennya aktivnostі presornih faktorіv poєdnuєtsya of attenuation depresornih vplivіv of the aortic arch i sinocarotid Zoni, zmenshennyam viroblennya kіnіnіv, nedostatnoyu aktivatsієyu viroblennya peredserdnogo natrіyuretichnogo i endotelіyzalezhnogo relaxing faktorіv, zmenshennyam vidіlennya prostaglandinіv scho volodіyut depresornі vplivom (E2, D, A) i prostatsiklіnu L zmenshennyam viroblasting ingibitor renin - a phospholipid peptide.

The pathogenesis of hyperadrenergic and sodium (obsyag) depleted forms of GB is always seen in the pathogenesis of this type of lanka. They stay for an hour to see the calciferous form of the ailment.

clinika

skargi:

headaches;

noise, dzv_n in vuhah;

zamorochennya;

stomachache;

I have a pain in the heart;

interruptions in the robotic heart.

Syndromes that characterize the heart disease:

syndrome of myocardial damage (hypertrophy);

arithmic syndrome.

Syndromes that characterize the damage to organs and systems:

chronic heart failure syndrome;

cerebral syndrome (hemorrhage in the brain).

A typical picture of arterial hypertension:

Most early and long-term skargs on headaches... To embrace, dull wounds in the middle of the day, grow weak until the middle of the day, pulsating heat pains in time, heaviness in the forehead and early eyes of the head in the evenings, "unclear", clouded, "dull" head. It is more to be accommodated in case of rationalization and physical adaptation. Between the arterial grip and the intensity of the headaches, do not depend on the acute parallelism, perhaps because the pain relief is sub-active.

Pidvischennya arterial vise, crimson headache, can supervise noise and zenkot v heads and wuhah, pawn wuh, zamorochennyam with blues.

Strengthen the reception of healthy and hearing aids. Patients are often turbulent at the sight of the viglyad "Shroud", migotinnya "fly" in the field of view, you can have a diplopia and a vipadannya of a field of view.

Hvorі skary on I have a pain in the area of ​​the heart. More, clearly connected with the AT pidyomas, in their own way, because of the seriousness in the area of ​​heart, triviality, in general, the weakness in the world of lower arterial grip.

Re-entangling the heart with a vice is often done until the skarg appears on heartbreak, interruptions in the robot heart.

Skargi to tell you about the development of heart failure. Zadishka can be illuvated stepwise or paroxysmal / heart asthma /.

at callous look It is a good one to be identified by the sheer curvatures. Often, there is a trace of a trace of a high peripheral support for a rakhunok spasm of the sudin with a low heart wikidi. If AG is supervised by a high heart wikid, then the compensatory expansion of the capillaries of the shkiri can lead to hyperemia. In such a vipadku re

Nadlishkova masa tila. In this hour, a wider expansion in the designation of the excess mass of tila has neglected the formula for the index of mass tila / ІМС, kg / m 2 / = mass (kg) / sp_st (m 2).

Inspection of the region of the heart vyavlya the change of the position of the top post. In case of concentric hypertrophy, it may or may not be in accordance with the norms. Zsuv of the highest postage is called spostering deprivation during the dilatation of the lavochka. In the whole range of high-end shipments, it is not only left, but downward. In case of hypertrophy of the meat of the lithic lid, the upper post razlitiy (more than 2 cm 2), high, perfection ("raising" or "dome-like").

The shaping of exchange arteries makes it possible to assess the character of their pulsations. The pulse becomes firm ( p. durus), Let's turn ( p. plenus), Great ( p. magnus), May be smart ( p. celer).

at percussion to replace the cordon with a single dullness of the heart, for the rakhunok of the growth of the livy dumbbell. The heart grows in diameter, and then in the length. The configuration of the heart appears to be aortic.

Auscultatory with an increase in the hypertrophy of the lilac duck, the sweetness of the I tone at the top of the heart decreases. Good vidomii sign of the development of an arterial vise - the emphasis of the second tone on the aorta. Yakshcho vin is a musical (tympanic) type of display, then it is due to the seriousness and triviality of hypertension, as well as to the reduction of the aorta.

Auscultatory method of viznachennya arterial vise behind the aid of the tonometer, fragmentation of N.S. We are short, to become the main method, to be stuck in the classroom practice.

Diagnostic program

Cycle of ailments AH:

to confirm the stability of the arterial vise;

viciousness of the secondary nature of AT;

to establish factories of AT risk;

to assess the appearance of certain organ-targets, heart-judges and others who are ill;

assessment of individual steps of the IXC and heart-vascular acceleration.

Outside physical dosage includes:

2-3 times vim_ryuvannya arterial vise;

rosrakhunok index masi tila;

full-time screening for the stage of retinopathy;

advancement of the heart-vascular system: heart breakdown, change of tones, appearance of noise; signs of heart failure; pathology of arteries;

drowsiness of legends (wheezing);

doslіdzhennya black empty(Sudden noise, increased nirok, pathological pulsation of the aorta);

delayed pulsation of peripheral arteries, appearance of embryos;

doslіdzhennya nervous system to clarify the presence of cerebrovascular pathology.

Obov'yazkovі doslіdzhennya, which is carried out with the method of detecting the defeat of the organs of targets and officials:

analysis of the section;

zagalny blood analysis;

blood sugar;

biochemical analysis of blood (calcium, sodium, creatinine, glucose, cholesterol, lipoproteins of high grade);

EKG in 12 entries.

Dodatkovy methods of preschooling:

roentgenologic provision of breast organs. At the period of the cob, concentric hypertrophy, it can be deprived of the rounded upper part of the lone slut. In case of a large turn of the hypertrophy of the lower part of the Legeny field, the upper part of the lower part of the Legeny field drops slightly to the bottom and changes. On the roentgenogram in the middle projection, it is possible to increase the size of the lower half of the arch from the half of the segment of the half-cut close to 10 cm and the large diameter up to 16 cm, as well as the increase in the diameter of the heart;

EXO-KG - the greatest specificity (90%) and sensitivity (90%) in the presence of hypertrophy of the louse. Signs of hypertrophy are to serve as a sign of the back wall of a little louse і / or a mid-section partition up to a size of 10-11 mm;

the post-mortem examination of the bottom allows the assessment of the steps of the microcirculatory bed (hypertensive angioretinopathy);

Ultrasound nirok;

ultrasonography of arteries;

angiography.

Differential diagnosis

Differential diagnosis of hypertension should be performed with secondary hypertension.

Table 5

lykuvannya

Meta likuvannya hvorikh AG - the maximum reduction of the heart-vessel disease and lethality, which is not only a decrease in AT, but ale and correction of all the emerging officials of the disease.

Principles of non-drug treatment:

vidmova vid kurinnya;

reduction of excess weight;

reduction in the consumption of kitchen salt (up to 4.5 g / dobu);

reduction in ethanol consumption (for people 20-30 g ethanol per day, for women 10-20 g);

modification of food (increase in the production of vegetables, fruits, seafood, food fat);

improvement of physical activity (walking, swimming).

Principles of drug therapy:

ear of lіkuvannya with minimum doses of one drug;

with a lack of effect of one drug (maximum dose), go to the drug in the first class;

vikoristannya poєdnan preparations_v for reaching the maximum effect.