gulis qronkuli ukmarisobis diagnostika da menejmenti

gaidlainis mokle versia

momzadebulia saqarTvelos kardiologTa kolejis da saqarTvelos kardiologTa sazogadoebis mier

2006w.

saqarTvelos kardiologTa kolejis da saqarTvelos kardiologTa sazogadoebis gaerTienebuli komitetis eqspertTa samuSao jgufi: vaxtang WumburiZe profesori, Terapiis erovnuli centri, nata gonjilaSvili jo-enis saxelobis samedicino centri, soso kapanaZe gadaudebeli kardiologiis centri; giorgi ramiSvili jo-enis saxelobis samedicino centri; giorgi kaWarava jo-enis saxelobis samedicino centri, zurab faRava profesori, akademikos mixeil winamZRvriSvilis saxelobis kardiologiis instituti, levan yuraSvili jo-enis saxelobis samedicino centri; gulnara tabiZe, naTia axalaZe jo-enis saxelobis samedicino centri;. zaza mgalobliSvili jo-enis saxelobis samedicino centri;

sarCevi:

zogadi mimoxilva ------------------------------------------------------------------------------- 4gulis ukmarisoba, rogorc klinikuri sindromi --------------------------- 5gulis ukmarisobis ganmarteba ---------------------------------------------------------- 6gulis qronkuli ukmarisobis klasifikacia (NYHA)----------------------------------------- 6gu-s ganviTarebis stadiebi ---------------------------------------------------------------- 7 pacientis Sefaseba ------------------------------------------------------------------------------ 8

A. pacientis sawyisi Sefaseba ---------------------------------------------------- 10B. pacientis mimdinare Sefaseba --------------------------------------------------11

Terapia ------------------------------------------------------------------------------------------------- 12 pacientebi gu-is ganviTarebis maRali riskjgufidan –

stadia A -------------------------------------------------------------------------------- 13

pacientebi gulis struqturuli paTologiiT, romelTac ara aqvT gu-is simptomatika – stadia B -------------- 13 gulis ukmarisobis simptomuri pacientebi - stadia C ------- 14

refraqteruli bolo stadiis gulis ukmarisoba – stadia D ------------------------------------------------------------------------------- 20

qalebi da mamakacebi -------------------------------------------------------------------------- 21gulis ukmarisobiT pacientebi, romlebsac aqvT Tanmxlebi paTologiebi ---------------- 22arafarmakologiuri RonisZiebebi --------------------------------------------------------24marcx. parkuWis sistoluri ukamrisobis farmakoTerapia NYHA klasifikaciis Sesabamisad ---- 25

1

ABC = kardiopulmonaruli reanimaciis 3 etapi: sasunTqi gzebi A, sunTqva B, sisxlis mimoqceva C. ACE = angiotenzin gardamqmneli fermenti ACS = mwvave koronaruli sindromi AHA/ACC = amerikis gulis asociacia/amerikis kardiologiuri kolejiaPTT = aqtivirebuli Tromboplastinis droARB = angiotenzin II –is blokerebiASA = aspiriniBMI = sxeulis masis indeqsi = wona (kg-Si) / simaRleze 2 (metr.) BNP = B tipis natriurezuli peptidi BUN = sisxlis Sardovana nitrogeniCABG = kororonarul arteriuli baipas grafti. (aorto koronaruli Suntireba)CBC = sisxlis saerTo analiziCCS = kanadis kardiologiuri asociaciaCHD = gulis koronaruli daavadebaCHF = gulis SegubebiTi ukmarisoba CK-MB = kreatinfosfokinaza MB izofermentiCPR = kardiopulmonaruli resustiqciaCPR = kardiopulmonaruli resustiqcia (reanimacia)cTnI = kardiotroponini IcTnT = kardiotroponini TCT = kompiuteruli tomografiaCx = Semomxvevi totiD5W = deqstroza 5 %-ianiEPS = eleqtrofiziologiuri kvlevaGI = gastrointestinuliGU = genitourinaruli (Sardsasqeso)GP = glukoproteiniHDL-C = maRali simkvrivis lipoprotein qolesteroliHF = gulis ukmarisobaHIT = hepariniT inducirebuli TrombocitopeniaHR = gulis SekumSvaTa sixSire IABP = intraaortuli balonuri kontrpulsacia ICD =kardioverter defibrilatori INR = saerTaSoriso normalizaciis SefardebaIV = intravenuriLAD = marcxena wina daswvrivi totiLBBB = hisis konis marcxena fexis blokadaLDL-C = dabali simkvrivis lipoprotein qolesteroliLMWH = dabalmolekuluri wonis hepariniLOE = mtkicebulebis xarisxi LV = marcxena parkuWiMET = metaboluri eqvivalentiMI = miokardiumis infarqtiNCEP = riskis daTvlis programa: http://www.nhlbi.nih.gov/about/ncep/ (kiTxvari romelSiac SegaqvT Semdegi monacemebi: saerTo qolesterini, HDL, sistoluri wneva, sqesi, asaki, eweviT Tu ara da igi gaZlevT gulis daavadebebiT 10 wliani sikvdilianobis risks)non-HDL = saerTo qolesterins gamoklebuli HDLNSVT = aramyari (xanmokle) ventrikuluri taqikardia NTG = nitrogliceriniPCI = perkutaneuli koronaruli intervenciaPTCA = perkutaneuli transluminaruli koronaruli angioplastikaRC = marjvena koronariRBBB = hisis konis marjvena fexis blokadaRV = marjvena parkuWiSTEMI = miokardiumis infarqti ST elevaciiT am jgufSi ganixileba pacientebi miokardiumis infarqtiT, romelTac e.k.g-ze aqvT persistentuli > (20-30wT) ST segmentis elevaciaTG = trigliceridebiUA = arastabiluri stenokardiaUFH = arafraqcionirebuli hepariniVF =ventrikuluri fibrilaciaVO2 = moxmarebuli Jangbadi drois garkveul monakveTSiVT =ventrikuluri taqikardia

2

WPW = volf-parkinson-uaitis sindromi

Flail leaflet = “mofarfate” qordaPreexitation = naadrevi aRgznebaniacini = vitamini B-3s.d.b. = saswrafo daxmarebis brigada

warmodgenili gaidlaini aris sruli teqstis mokle versia romlis gamoqveynebasac uaxloes momavalSi apirebs samuSao jgufi. teqsti eyrdnoba amerikis kardiologTa kolejis, amerikis gulis asociaciis da evropis kardiologTa sazogadoebis masalebs. aseve gamoyenebulia monacemebi Semdegi literaturidan e. braunvaldi, zaips libbi, gulis daavadebebi 6-e gamocema 2001w da brain p. grifini erik j. topoli kardiovaskularuli medicinis saxelmZRvanelo, 2-e gamocema 2004w. samuSao jgufma moaxdina teqstis adaptireba, rac ZiriTadSi rCeba zemoT aRniSnuli gaidlainebis farglebSi da Seesabameba maT rekomendaciebs. amasTan erTad Cven davamateT ramodenime ganmarteba da cxrili CamoTvlili literaturidan romelic Cvenis azriT daexmareba mkiTxvels mkurnalobis sqemebis swor interpretaciaSi.

es moxseneba warmoadgens gulis qronikuli ukmarisobis mkurnalobis ZiriTad principebs. ra Tqma unda igi ver iqneba sakmarisi kardiologisaTvis daavadebis srulyofili marTvisTvis. mocemul versiaSi ganxilulia mkurnalobis ZiriTadi etapebi, maTi marTva mocemulia Zalian zogadad. Sesabamisad mzaddeba sruli teqsti, romelSic ufro farTod iqneba ganxiluli detalebi. warmodgenili mokle versia saSualebas gvaZlevs swrafad gadavxedoT mkurnalobis ZiriTad principebs da igi daexmareba rogorc kardiologebs da aseve zogadi praqtikis eqimebs/ojaxis eqimebs.

samuSao jgufi acnobierebs moTxovnilebas moxdes Cveni jan-dacvis sistemis harmonizacia evropisa da amerikis samedicino sistemebis maRal samedicino standartebTan da miiCnevs, rom am procesSi gaidlainebs, ufro zustad ki maT danergvas aqvs udidesi mniSvneloba. swored es gaxda imis mizezi rom Cven aRar davucadeT sruli teqstis damTavrebas da gadavwyviteT mokle versiis gamoqveyneba. vfiqrobT teqstis TandaTan Sevsebas, rac xels ar SeuSlis implementacias, vinaidan mudmivi ganaxleba gaidlainebiT muSaobis Tanmxlebi da ganuyofeli procesia. Cveni jgufia Riaa msjelobisaTvis iseT Temebze Tu ramdenad zustad Seesabameba Cvens mier adaptirebuli rekomendaciebi evropis da a.S.S-s Sesabamis rekomendaciebs da xom ar ewinaaRmdegebian isini maT ZiriTad suliskveTebas. sifrTxiles moiTxovs agreTve rigi enobrivi sakiTxebi. Cven gadavwyviteT abreviaturebis xmareba inglisuri SriftiT. Tavad am meTodis ZiriTadi mizania 1) teqstis Semokleba. 2) abreviaturis xmareba metad iZleva ganmeorebebis saSualebas 3) iqcevs yuradRebas. vinaidan qarTulSi ar arsebobs didi asoebi am SemoklebebiT yuradRebis miqceva efeqturi ver aris. amasTan erTad zogi abreviatura imdenad damkvidrebulia rom maTi Secvla iqneboda xelovnuri da uxerxuli saxmarad. amgvarad Tuki am princips ar gavavrcelebdiT yvela Semoklebaze maSin teqstSi xan iqneboda inglisuri xan qarTuli abreviatura, rac aseve mouxerxeli iqneboda. sayuradReboa is faqtic rom mkurnalobis Tu diagnostikis zogierTi meTodi saqarTveloSi ver tardeba teqnikuri Tu finansuri mizezebidan gamomdinare. aseT SemTxvevebSi Cveni jgufi rekomendacias iZleva erTis mxriv pacientis istoriaSi Tu ambulatoriul baraTSi dafiqsirdes am gamokvlevaze Tu mkurnalobaze uaris Tqmis mizezi, raTa naTeli gaxdes rom mkurnali eqimi flobs daavadebis Tanamedrove midgomebs magram gamodis konkretuli realiebidan. Cvenis mxriv mzada varT farTo diskusiisaTvis aRniSnul Temebze da mzada varT gaviTvaliswinoT rogorc enis specialistebis aseve sazogadoebis da sxvadasxva dargis eqspertebis azri. mTavari CvenTvis am etapze Tavad gaidlainiT muSaobis Cvevis Semotanaa samedicino praqtikaSi.vfiqrobT, es midgoma etapuri iqneba saqrTveloSi medicinis ganviTarebisaTvis.

3

damateba: vinaidan zoigerTi samkurnalo midgomis teqnikuri ganxorcieleba jer kidev SeuZlebelia saqarTveloSi, mkurnalobis dros mizanSewonilad migvaCnia pacientis istoriaSi gakeTdes Sesabamisi Canaweri rac daasabuTebs Tu ratom ar xdeba am meTodis gamoyeneba.

gulis ukmarisoba aris udidesi da mzardi problema msoflioSi. a.S.S.-Si 5 milion pacients aqvs HF da yovelwliurad 550,000-ze mets esmeva diagnozi pirvelad. HF aris 12 - 15 milioni ambulatoriuli vizitis da 65 milioni sawoldRis mizezi. 1990-99 wlebSi pirveladi gulis ukmarisobiT hospitalizaciebis ricxvi gaizarda 810,000 dan 1 000 000 mde. xolo meoradisa da pirveladisa erTad 2,4-dan 3,6 milionamde. 2001 wels daaxloebiT 53 000 pacienti gardaicvala am dignoziT. am daavadebiT ganpirobebuli letaloba izrdeba gaumjobesebuli mkurnalobis miuxedavad. aRniSnulis mizezi unda iyos MI-s dros adreuli letalobis Semcireba, rac zrdis SemdgomSi HF-iT daavadebulTa raodenobas. daavadebis sixSire 65 wels zeviT aris 10 yovel 1000 adamianze da mis gamo hospitalizirebuli pacientebis 80% aris 65 welze meti asakisa. Tuki saqrTvelos mosaxleobas aviRebT 4,000,000-mde, xolo statistikas igives davtovebT rac evropasa da a.S.S-Sia, maSin SesaZloa iTqvas, rom CvenTan 66670 pacients aqvs HF da yovelwliurad 7330-ze mets udgindeba diagnozi pirvelad. letloba daaxloebiT weliwadSi Seadgens 700 pacients.

cxrili 1. rekomendaciebis da mtkicebulebebis xarisxi AHA/ACC-is mixedviT

I klasi: sargebloba > > > riskze. procedura/mkurnaloba unda Catardes/dainiSnos

II-a klasi: sargebloba > > riskze saWiroebs damatebiT gamokvlevebs. gonivrulia Catardes/dainiSnos Sesabamisi procedura/mkurnaloba

II-b klasi:sargebloba riskze saWiroebs damatebiT gamokvlevebs.procedura/mkurnaloba SesaZlebelia gvqondes mxedvelobaSi

III klasi:damatebiTi gamokvlevebi aRaraa saWiro. procedura/mkurnaloba ar unda dainiSnos/Catardes vinaidan igi usargebloa da SesaZloa saSiSic iyos

A-done: mravali (3-5)sxvadasxva populaciuri jgufia Sefasebuli.

efeqti da mimarTuleba myaria.

rekomendacia imis Sesaxeb rom igi aris sasargeblo/efeqturi.

monacemebi miRebulia mravali randomizebuli kvleviT da meta-analiziT.

rekomendacia procedura/mkurnalobisCatareba/daniSvnis sasargeblodaa

mravali randomizebuli kvleviTa da meta-analiziT miRebuli zogierTi monacemi urTierTsawinaaRmdegoa

rekomendaciis sargebloba/efeqturoba naklebadaa Seswavlili

mravali randomizebuli kvleviT da meta-analiziT miRebuli monacemebi ufro urTierTsawinaaRmdegoa

rekomendacia rom procedura/mkurnaloba araa

mravali randomizebuli kvleviTa da metaanaliziT miRebuli sakmarisi monacemebia

B-done: SezRuduali (2-3) populaciuri jgufebia Safasebuli

rekomendacia imis Sesaxeb rom igi aris sasargeblo/efeqturi.

erTi randomizebuli da ararandomizebuli kvlevebiT miRebulia SezRuduli monacemebi.

rekomendacia procedura/mkurnalobisCatareba/daniSvnis sasargeblodaa.

aris zogierTi urTierTsawinaaRmdego monacemi miRebulia erTi randomizebuli da ararandomizebuli kvlevebiT

rekomendaciis sargebloba/efeqturoba naklebadaa Seswavlili

erTi randomizebuli da ararandomizebuli kvlevebiT miRebulia ufro meti urTierTsawinaaRmdego monacemi

sasargeblo/efeqturi da SesaZloa iyos saziano.

erTi randomizebulia da ararandomizebuli kvlevebiT mirebulia SezRuduli monacemebi.

C-done:Zalian SezRuduli (1-2) populaciuri jgufebia Safasebuli

rekomendacia imis Sesaxeb rom igi aris sasargeblo/efeqturi.

arsebobs mxolod eqspertebis azri, SemTxvevaTa aRwera(case report)

rekomendacia procedura/mkurnalobisCatareba/dniSvnis sasargeblodaa

eyrdnoba eqspertebis azrs da SemTxvevaTa aRweras

rekomendaciis sargebloba/efeqturoba naklebadaa Seswavlili

eyrdnoba eqspertebis azrs da SemTxvevaTa aRweras

sasargeblo/efeqturi da SesaZloa iyos saziano.

arsebobs mxolod eqspertebis azri, SemTxvevaTa aRwera(case report)

4

gu rogorc klinikuri sindromigu kompleqsuri klinikuri sindromia, romelic viTardeba iseTi funqciuri darRvevis Sedegad, romelic iwvevs gulis kumSvadobis an avsebis unaris daqveiTebas. gulis ukmarisobis kardinaluri niSnebia dispnoe da advilad daRla, datvirTvis unarianobis SezRudva da siTxis Sekaveba, rac iwvevs Segubebas mcire wreSi da periferiul edemas, yovelive amcirebs pacientis funqciur SesaZleblobas da auaresebs sicocxlis xarisxs. ar aris aucilebeli rom siTxis Sekaveba da datvirTvis unarianobis SezRudva gamovlindes erTdroulad, zog pacients aqvs datvirTvis unarianobis mniSvnelovani daqveiTeba da hipervolemiis mcire gamoxatuleba maSin, rodesac zogjer Tavdapirvelad vlindeba SeSupeba da naklebad dispnoe da advilad daRla.

HF-is klinikuri sindromi SesaZlebelia ganpirobebuli iyos perikardiumis, miokardiumis, endokardiumis da magistraluri sisxlZarRvebis dazianebiT. ZiriTadad gulis ukmarisobis simptomebi dakavSirebulia marcxena parkuWis (LV) funqciuri darRvevis farTo speqtrTan, romelic SesaZlebelia varirebdes normaluri LV-is zomis da SenarCunebuli gandevnis fraqciidan, dilatirebuli LV da daqveiTebuli gandevnis fraqciiamde. pacientTa umetesobaSi miuxedavad gandevnis fraqciisa, erTdrouladaa diastoluri da sistoluri disfunqcia. CHD, hipertenzia, dilataciuri kardiomiopaTia da sarqvlovani paTologia, Sesabamisi TanmimdevrobiT, HF-is uxSiresi mizezia. dilataciuri kardiomiopaTiani pacientebis daaxloebiT 30% aqvs genetikuri datvirTva.zogadad gulis ukmarisoba aris klinikuri sindromi, romelic xasiaTdeba specifikuri simptomebiT (dispnea da advilad daRla) da niSnebiT (SeSupeba da xixini). fizikaluri kvlevisas HF-is dasadgenad ar arsebobs erTi diagnostikuri testi, vinaidan igi warmoadgens klinikur diagnozs da emyareba anamnezsa da fizikalur kvlevebs.

gulis ukmarisobis ganmarteba evropis kardiologTa asociaciis mier Semdegnairad aris warmodgenili: (I da II kriteriumis dakmayofileba aucilebelia)

I. gulis ukmarisobis simptomebi (datvirTvis an mosvenebis dros) da

II. gulis kunTis disfunqciis (sistoluri an diastoluri) obieqturi dadastureba (umjobesia eqokardiografiiT) mosvenebaSi da datvirTvis fonze rodesac diagnozi saeWvoa.

daIII. adeqvaturi pasuxi gulis ukmarisobis winaaRmdeg mimarTul mkurnalobaze

gulis ukmarisobis niu _ iorkis gulis asociciis (NYHA) klasifikacia

cxrili 2

funqciuri klasi ganmartebaI klasi

II klasi

III klasi

IV klasi

pacients aqvs gulis paTologia, romelic ar iwvevs fizikuri aqtivobis SezRudvas. Cveuli fizikuri datvirTvisas ar viTardeba advilad daRla, gulis frialis SegrZneba, dispnoe da anginuri tkivili.

pacients aqvs gulis paTologia, romelic iwvevs fizikuri aqtivobis mcired SezRudvas. Cveuli fizikuri datvirTvisas viTardeba advilad daRla, gulis frialis SegrZneba, dispnoe da anginuri tkivili.

pacients aqvs gulis paTologia, romelic mniSvnelovnad zRudavs fizikur aqtivobas. mcire fizikuri datvirTvisasac viTardeba advilad daRla, gulis frialis SegrZneba, dispnoe da anginuri tkivili.

pacients aqvs gulis paTologia, simptomuria minimalur datvirTvasa da mosvenebul mdgomareobaSic.

5

gulis ukmarisobis mqone pacientis gamosavali rogorc wesi arakeTilsaimedoa Tuki ar moxerxda ZiriTadi paTologiis gamosworeba. aseTi pacientebis naxevari iRupeba 4 wlis ganmavlobaSi, xolo pacientebis 50%i gulis ukmarisobis mZime formiT iRupeba 1 wlis ganmavlobaSi. Tumca funqciuri klass axasiaTebs gauaresebis (anu II dan IIISi, III dan IVSi gadasvlis) tendencia, pacientebis umravlesobaSi igi ar gamoixateba permanentuli progresirebiT. daavadebis simptomebi ganicdian cvlilebebs miuxedavad stabiluri daniSnulebisa da marcxena parkuWis funqciisa. zog pacientSi aRiniSneba mniSvnelovani gaumjobeseba rasac Tan axlavs funqciuri da struqturuli gaumjobesebac. Ceulebriv igi ukavSirdeba medikamentur mkurnalobas, romelic raRaTqma unda ar unda iqnas Sewyvetili. aseve aRsaniSnavia rom sakmaod xSirad pacientis simptomebi ar Seesabameba gulis kunTis disfunqciis xarisxs. Tumca simptomebis persistireba Terapiis fonze naTlad mianiSnebs arakeTilsaimedo prognozze.

HF -is ganviTarebis stadiebi da rekomendebuli Terapia stadiebis mixedviT

stadia A stadia BHF-is maRali riskiT, magram gulis struqturuli daavadeba struqturuli paTologiis magram HF-is simptomebis gareSe da simptomebis gareSe

Terapia Terapia

stadia C stadia D

gulis struqturul refraqteruli HF, romelicpaTologia HF simptomebiT saWiroebs specialur intervenciebs

pacientebi:

hipertenziiT aTerosklerozuli daavadebiTdiabetiTsimsuqniTmetaboluri sindromiTkardiotoqsinebis gamoyenebiTdilataciuri kardiomiopaTiis ojaxuri istoriiT

pacientebi

gadatanili MILV remodelireba marcxena parkuWis hipertrofiis da dabali EF-is CaTvliTasimptomuri gulis sarqvlovani daavadeba

mizani1. hipertenziis mkurnaloba 2. sigaretis mowevis Sewyveta3. lipiduri cvlis regulacia4. regularuli varjiSi4. alkoholis miRebis Sewyveta5. metaboluri sindromis mkurn. medikamentebi

1. ACE inhibitorebi an ARB Cvenebis mix.

mizaniigive rac stadia A-s

medikamentebi

ACE inhibitorebi an ARB beta blokerebi Cvenebis mixedviT

pacientebis seleqtiur jgufSi

1. kardioverter/defibrilat.

6

Terapia Terapia

gulis ukmarisoba rogorc progresirebadi paTologia

marcxena parkuWis disfunqcia iwyeba miokardiumis dazianebiT an stresiT da umeteswilad progresirebadi procesia. progresirebis manifestacias warmoadgens LV geometriis da struqturis Secvla, is dilatirdeba da/an hipertrofirdeba da xdeba sferuli. am process LV-is remodelireba ewodeba. endogenuri neirohormonaluri sistema did rols TamaSobs remodelirebaSi da amdenad CHF-s progresirebaSi. gulis ukmarisobian pacientebs aqvT mocirkulire da qsovilovani norepinefrinis, angiotenzin II-is, aldosteronis, endoTelinis, vazopresinis da citokinebis momatebuli raodenoba, romelebsac SeuZlia imoqmedon gulis struqturasa da funqciaze. es faqtorebi aramarto zrdis hemodinamikur stress natriumis Sekavebis da vazokonstriqciis gziT, aramed axdens pirdapir toqsiur gavlenas gulis ujredebze da astimulirebs miokardiumis fibrozs, rac Semdgom kidev ufro auaresebs gulis muSaobas.

pacientis Sefaseba

qvemoT mocemulia pacientis sawyisi klinikuri Sefaseba, romelic warmogvidgeba HF-is niSnebiT.

I klasi:

Ppacientebi:

gulis struqturuli daavadebiT dasunTqvis ukmarisobiT, datvirTvisadmi Semcirebuli tolerantobiT

pacientebi:

1. mkveTrad gamoxatuli simptomebiT mosvenebisas miuxedavad maqsimaluri mkurnalobisa (isini visac aqvs ganmeorebiTi hospitalizaciebi da maTi binaze gawera sariskoa specializebuli intervenciis gareSe

mizani: igive rac A da B stadiis dros marilis SezRudva

medikamentebi

diuretikebi da siTxeebis SezRudvaACE inhibitorebibeta blokerebi

medikamentebi seleqtiur jgufSi

aldosteronis antagonistebiARBdigitalisihidralazini/izosorbit dinitrati

seleqtiur pacientebSi:

biventrikuluri peisingiICD

mizani:igive rac A.B.C.Sesaferisi movla

arCevani:

gansakuTrebuli movla (a.S.S-Si pacientebi Tavsdebian sastumroebSi Sesabamisi med personalis meTvalyureobiT)eqstraordinaluri RonisZiebebi:

gulis transplantaciaqronikulad inotropebipermanentuli meqanikuri daxmarebaeqsperimentaluri qirurgia an medikamentebi

7

1. anamnezuri monacemebi da fizikaluri gamokvleva, HF-is ganviTarebis an progresirebis ganmapirobebeli kardialuri da arakardialuri darRvevebis gamovlena. LOE C

2. anamnezidan unda dazustdes: alkoholis miReba warsulsa da awmyoSi, narkotikuli nivTierebebis gamoyeneba, “alternatiuli Terapia”, qimioTerapiuli mkurnaloba. LOE C.

3. rutinuli datvirTvis unarianobis Sefaseba HF-is mqone pacientebSi. LOE C4. moculobiTi (volemiuri) statusis da orTostatikuri arteriuli wnevis Sefaseba, wonis da simaRlis

gazomva, sxeulis masis indeqsis daTvla. LOE: C5. laboratoriuli kvleva moicavs: sisxlis saerTo analizs, Sardis analizs, eleqtrolitebis gansazRvras

sisxlSi, BUN-s, kreatinins, glukozis gansazRvras uzmoze (an glikolizebuli hemoglobinis gansazRvras) lipidur speqtrs, RviZlis funqciuri testebs. a.S. LOE: C

6. e.k.g., gulmkerdis rentgenografia (wina-ukanaPA da lateraluri Wrilebi), organzomilebiani eqokardiografia da doplerografia LV zomis, gandevnis fraqciis, kedlebis sisqis da sarqvlovani funqciis Sesafaseblad. LOE: C

7. koronarografia rekomendebulia gulis ukmarisobiT daavadebuli yvela pacientisTvis, romlebsac aqvT anginuri simptomatika an iSemia, garda im pacientebisa, romlebTanac SeuZlebelia revaskularizacia. LOE: B

II A. klasi:1. koronarografia im pacientebisaTvis visac tkivili aqvs gulmkerdis areSi (kardialuri an

arakardialuri) da ara aqvs revaskularizaciis ukuCveneba. LOE: C2. koronarografia mizanSewonilia HF-ian pacientebSi, romlebSic savaraudoa CHD arseboba,

magram ar aqvT anginuri simptomatika, garda im pacientebisa, romlebTanac revaskularizacia SeuZlebelia. LOE: C

3. rekomendebulia HF-s da CHD-ian pacientebSi miokardiumis iSemiisa da sicocxlisunarianobis Sefaseba arainvaziuri gamosaxulebiTi saSualebiT, garda im pacientebisa, romelTac revaskularizacia ver gaukeTdeba. LOE: B

4. datvirTvis unarianobis SezRudvis mizezis dadgenis mizniT rekomendebulia datvirTvis testi, arteriul sisxlSi Jangbadis saturaciis da gazTa cvlis gansazRvrasTan erTad. LOE: C

5. rekomendebulia maqsimaluri datvirTvis testi, gazTa cvlis maCveneblebis kontroliT HF-iani maRali riskis pacientebis gamosavlenad, romlebic gulis transplantaciis da sxva uaxlesi meTodebiT mkurnalobis kandidatebs warmoadgenen. LOE: B

6. HF-ian zogierT pacientSi mizanSewonilia hemoqromatozis, ZiliT ganpirobebuli sunTqvis darRvevebis da Sidsis skriningi. LOE: C

7. revmatizmis, amiloidozis da feoqromocitomis sadiagnostiko testebis Catareba mizanSewonilia im HF-ian pacientebSi, romlebSic maRalia am daavadebis arsebobis albaToba. LOE: C

8. endomiokardiumis biofsia SesaZloa saWiro iyos HF-is mqone pacientebSi specifikuri daavadebebis sadiagnostikod. LOE: C

9. B tipis natriurezuli peptidis gansazRvra mizanSewonilia im pacientebSi, romlebic saWiroeben urgentul Terapias da romlebSic HF-is klinikuri diagnozi ar aris dazustebuli. LOE: A

II B klasi.

1. arainvaziuri gamosaxulebiTi kvlevebi SesaZloa gamoyenebuli iqnes CHD Sesafaseblad HF pacientebSi LV disfunqciiT. LOE: C

2. holteris monitoringi SesaZloa saWiro iyos HF-is mqone pacientebSi, romlebsac gadatanili aqvT miokardiumis infarqti. amave pacientebSi saWiroa eleqtrofiziologiuri kvleva ventrikuluri taqikardiis gamowvevis SesaZleblobis dasadgenad. LOE: C

IIIklasi.

1. HF-is mqone pacientebSi endomiokardiuli biofsia rutinulad. LOE: C2. gasaSualoebuli signalis e.k.g.-s rutinuli gamoyeneba LOE: C3. rekomendebuli ar aris neirohormonebis donis rutinuli gansazRvra HF-is mqone pacientebSi.

LOE: C

HF-is mqone pacientebis seriuli klinikuri Sefaseba rekomendaciebi:

I klasi:1. yovel vizitis dros unda Sefasdes pacientis Cveulebriv sayofacxovrebo pirobebisas

datvirTvisunarianoba. LOE: C2. yoveli vizitis dros unda Sefasdes HF-is mqone pacientTa siTxis moculoba da wona. LOE: C

8

3. yovel vizitze unda gairkves iRebs Tu ara pacienti alkohols, sigarets, “alternatiul Terapias”, qimioTerapias Uda dazustdes icavs Tu ara dietas da zRudavs Tu ara marils. LOE: C

II A. klasi:

1. ganmeorebiTi kardioeqoskopia da LV zomis da remodelirebis Sefaseba, aqedan SesaZloa mogveces mniSvnelovani informacia im pacientebis Sesaxeb romelTac SeecvalaT klinikuri statusi an mkurnaloba. LOE: C

II B klasi:

1. BNPP-s monitoringiT Terapiis marTva ar aris kargad dadgenili LOE: C

A. pacientebis sawyisi Sefaseba

1. pacientebis identifikacia

rogorc wesi, pacientebi, romelTac aqvT marcxena parkuWis disfunqcia an HF, eqims mimarTaven Semdegi CivilebiT: 1. datvirTvis unarianobis Semcireba, rac gamoixateba datvirTvisas qoSiniT da advilad daRlis gaCeniT. 2. hipervolemiis sindromi - periferiuli edema, momatebuli wneva sauRle venebSi da hepatomegalia did wreSi Segubebis damaxasiTebeli niSnebia. Tumca kargi mkurnalobis fonze xSiria gulis ukmarisobis SemTxvevebi hepatomegaliisa da kidurebze SeSupebebis gareSe, xolo sauRle venebis gadaWimva (momatebuli wnevis gamo) xSirad ar aReniSnebaT umZimesi gulis ukmarisobis drosac ki. 3. simptomebiT an usimptomod sxva kardiologiuri an arakardiologiuri paTologiis gamo. LV-is dilatacia an disfunqcia SesaZloa nanaxi iqnes sxva mizeziT pacientis gamokvlevisas mag: paTologiuri ekg, hipertenzia an hipotenzia, Saqriani diabeti, ariTmia, mmi da sxva.

2. struqturuli an funqciuri darRvevis aRmoCena anamnezis srulad Sekreba da fizikaluri gamokvleva warmoadgens pirvel nabijs CHF-is ganviTarebis mizezis dasadgenad. yvelaze martivi diagnostikuri saSualeba aris organzomilebiani eqokardiografia, miokardiumis, sarqvlebis da perikardiumis Sefasebis mizniT. unda gaeces pasuxi sam ZiriTad SekiTxvas: 1. marcxena parkuWis gandevnis fraqcia SenarCunebulia Tu daqveiTebuli; 2. LV-is struqtura normaluria Tu ara; 3. aris Tu ara sarqvlovani, perikardiumis an marjvena parkuWis paTologia. gulmkerdis rentgenograma da e.k.g. ver iqneba sawyisi bazisi mizezis gansasazRvravad.

3. HF -is mizezis Seswavla.

gulis ukmarisobis mizezebis dadgena mniSvnelovania, vinaidan zogierT SemTxvevaSi igi gankurnebadi an Seqcevadia.

gulis ukmarisobis mizezebis Sefaseba anamnezis mixedviT

cxrili 3

9

anamneziT unda dazustdes ojaxuri istoria

1. hipertenzia2. Saqriani diabeti3. dislipidemia4. sarqvlovani paTologia5. koronaruli da periferiuli sisxlZarRvovani

paTologia6. miopaTia7. revmatizmi8. mediastinumis cdoma9. ZilTan dakavSirebuli sunTqviTi darRvevebi10. kardiotoqsikuri agentebis gamoyeneba11. alkoholis gamoyeneba12. sigaretis moweva13. kolagenozebi14. sqesobrivi gziT gadamdebi daavadebebi15. fariseburi jirkvlis disfunqcia16. feoqromocitoma17. simsuqne

1. aTerosklerozuli daavadebis mimarT 2. winaswarganwyoba3. uecari sikvdili4. miopaTia5. gamtareblobis darRvevebi6. taqiariTmiebi7. kardiomiopaTia (auxsneli HF)8. ConCxis kunTebis miopaTia

4. laboratoriuli testebi:

laboratoriululma kvlevebma SesaZloa gamoavlinos mdgomareobebi, romlebic ganapirobeben CHF-s. pacientis sawyisi kvleva moicavs sisxlis saerTo analizs, Sardis analizs, SratSi eleqtrolitebis (natriumis, kaliumis, kalciumis da magniumis CaTvliT), glikolizebuli hemoglobinis da lipiduri speqtris gansazRvras, Tirkmlis da RviZlis funqciur testebs, gulmkerdis rentgenografias, ekg-s. Seswavlili unda iqnes farisebri jirkvali (TSH gansazRvra), vinaidan hipoTireozic da hiperTireozic SesaZloa iyos am daavadebisis rogorc pirveladi, ise xelisSemwyobi mizezi.B tipis natriurezuli peptidis momatebuli done asocirebulia daqveiTebul LV gandevnis fraqciasTan, LV hipertrofiasTan, LV maRali avsebis wnevasTan, MI da iSemiasTan, Tumca SesaZloa BNP momateba ganpirobebuli iyos pulmonaruli emboliiT da qronikuli obstruqciuli bronqitiT. igi sensitiuria aseve sxva biologiuri faqtorebis mimarT, rogoricaa asaki, sqesi, wona da Tirkmlis funqcia.

5. CHD arsebobis Sefaseba CHD-s safuZvlad udevs gulis ukmarisobis daaxloebiT 2/3-s da endoTeliaruli difunqciis, iSemiis da MI –s gziT xels uwyobs mis ganviTarebas.

BB. pacientebis mimdinare Sefaseba

mas Semdeg, rac dadgindeba CHF-is ganmapirobebeli struqturuli paTologia, unda moxdes pacientis klinikuri Sefaseba, rogorc sawyis ise Semdgom vizitebze. pacientis klinikuri Sefaseba gulisxmobs simptomebis Seswavlas, daavadebis ganviTarebis mokle da grZelvadiani letalobis riskis Sefasebas.pacientis klinikuri statusis Sefaseba principulia mkurnalobis swori SerCevisaTvis. sawyisi da Semdgomi vizitebis dros unda dazustdes simptomebis saxe, simZime da xangrZlivoba, ramac SesaZloa gaauaresos pacientis funqciuri klasi.mniSvnelovania volemiis statusis gansazRvra, ris mixedviTac moxdeba diuretikis saWiroebis gansazRvra, natriumis siWarbis da deficitis Sefaseba, ramac SesaZloa Seamciros CHF –is Terapiis efeqturoba.

Terapia

gulis ukmarisobis mkurnalobis miznebi evropis kardiologTa sazogadoebis mier Semdegnairad aris mowodebuli:

prevencia prevencia da kontroli im daavadebebisa, romelTac mivyavarT gulis kunTis disfunqciamde da

gulis ukmarisobis ganviTarebamde

1

gulis kunTis disfunqciis SemTxvevaSi daavadebis progresirebis prevencia avadobis Semcireba rac gulisxmobs

cxovrebis xarisxis gaumjobesebas, ganmeorebiTi hospitalizaciebis sixSiris Semcirebas

sikvdilianobis Semcirebasicocxlis gaxangrZliveba

gulis ukmarisobis sxvadasxva stadiis mkurnalobisTvis rekomendebuli kardiovaskularul sistemaze moqmedi preparatebi romlebic akmayofileben zemoT moyvanil moTxovnebs:

cxrili 4 medikamenti stadia a stadia b stadia gACE inhibitoribenazeprilikaptoprilienalaprilifozinoprililizinoprilimoeqsipriliperindopriliquinapriliramiprilitrandolaprili

HH, DnH, Dn

HH, Dn

HH, Cv riski

HH, Cv riski

H

_MI-s Semdeg

HF _MI -s Semdeg

___

MI -s SemdegMI -s Semdeg

_HF

HF HF

HF _

_HF

MI -s Semdeg

MI -s Semdeg

angiotenzin II rec. blokerebikandesartanieprosartaniirbesartanilozartaniolmesartanitelmisartanivalsartani

HH

H, DnH, Dn

HH

H, Dn

___

Cv riski__

MI -s Semdeg

HF_____

MI -s Semdeg,

HFaldosteronis antagonistebieplerenonispironolaqtoni

HH

MI -s Semdeg_

MI -s Semdeg

HFbeta blokerebiacebutololiatenololibetaqsololibisoprololi Timololikarteololi

karvedilolilabetalolimetoprolol suqcinatimetoprolol tartratinadololipenbutololipindololipropranololi

HHHHHH

HHHHHHHH

_MI -s Semdeg

___

MI -s Semdeg

__

MI -s Semdeg___

MI -s SemdegMI -s Semdeg

___

HF

_ MI -s

Semdeg_

HF

______

digoqsini _ _ HF

H_ hipertenzia, Cv riski – kardiovaskularuli paTologiebis Semcireba momavalSi; Dn– diabeturi nefropaTia; HF – gulis ukmarisoba;

pacientebi HF-is ganviTarebis maRali riskjgufidan – stadia A

1

sxvadasxva faqtori da Cveva aris asocirebuli gulis struqturul paTologiasTan da maTi aRmoCena SesaZloa am paTologiebis gamovlinebamde. am faqtorebis naadrevi modifikacia amcirebs CHF-is ganviTarebis risks.

rekomendaciebi:I klasi:

1. HF-is ganviTarebis maRali risk-jgufis pacientebSi kontrolirebuli unda iyos sistoluri da diastoluri hipertenzia LOE: A

2. pacientebSi maRali riskiT lipiduri speqtris darRvevebis menejireba LOE: A3. pacientebSi HF-is maRali riskiT da Saqriani diabetiT glukozis menejireba LOE: C4. unda aekrZaloT sigaretis moweva, Warbi alkoholis miReba da narkotikuli nivTierebebis

gamoyeneba, vinaidan isini zrdian HF-is ganviTarebis risks. LOE: C5. unda aRdges sinusuri riTmi an kontrolirdes parkuWTa SekumSvis sixSire supraventrikuluri

taqikardiebisas im pacientebSi, romelTac aqvT HF-is ganviTarebis maRali riski. LOE: B6. unda iqnes koregirebuli fariseburi jirkvlis funqcia. LOE: C 7. pacientebSi, romelTac aqvT CHF-is ganviTarebis maRali riski, periodulad unda Sefasdes HF-is

simptomatika. LOE: C8. im pacientebSi romlebsac aqvT HF ganviTarebis maRali riski da dadgenili aqvT sisxlZarRvTa

aTerosklerozi saWiroa HF-is meoradi prevencia. LOE: C9. pacientebSi, romlebsac aqvT kardiomiopaTiis ojaxuri istoria an utardebaT kardiotoqsiuri

intervenciebi, saWiroa LV funqciis arainvaziuri Sefaseba. LOE: C

II A klasi: 1. ACE inhibitorebi gamoiyeneba HF-is prevenciisaTvis pacientebSi romlebsac anamnezSi aqvT

sixlZarRvTa aTerosklerozuli daavadeba, Saqriani diabeti da hipertenzia. LOE: A2. angiotenzin II receptoris blokerebi (ACE inhibitoris mimarT intolerantobis SemTxvevaSi)

gamoiyeneba HF-is prevenciisaTvis pacientebSi, romlebsac anamnezSi aqvT sixlZarRvTa aTerosklerozuli daavadeba, Saqriani diabeti da hipertenzia. LOE: C

III klasi:1. ar aris rekomendebuli kvebiTi danamatebis rutinuli gamoyeneba gulis struqturuli paTologiis

prevenciisTvis. LOE: C

pacientebi gulis struqturuli paTologiiT, romelTac ara aqvT HF-is simptomatika – stadia B

im pacientebisTvis, romelTac gadatanili aqvT MI an aqvT LV remodelireba, arian HF-is ganviTarebis maRal riskjgufSi, sawyisi kvlevebi igivea rac I klasis rekomendaciebiT A stadiis pacientTaTvis.

rekomndaciebi:I klasi:

1. yvela pirveli klasis rekomendacia A stadiis pacientTaTvis rekomendebulia aseve B stadiis pacientebisTvisac.

2. beta blokerebi da ACE inhibitorebi eniSneba yvela pacients, romelsac aqvs gadatanili MI, miuxedavad EF-s da HF-is arsebobisa. LOE: A 3. beta blokerebi aris naCvenebi yvela pacientSi MI-s gareSe, romlebSic aris Semcirebuli EF da

ara aqvT HF-is simptomebi LOE: C4. ACE inhibitorebi unda deniSnos pacientebs Semcirebuli EF-iT da HF-is simptomebis gareSe,

Tundac maT gadatanili ar hqondeT MI. LOE: A5. angiotenzin II receptoris blokerebi unda deniSnos ACE inhibitoris mimarT intolerantul

pacientebs, romlebsac gadatanili aqvT MI, aqvT dabali gandevnis fraqcia, da ara aqvT HF. LOE: B

6. Bpacientebi romelTac ara aqvT gulis ukmarobis simptomebi MI-s Semdeg unda mkurnalobdnen Sesabamisi gaidlainiT. LOE: C

7. koronaruli revaskularizacia rekomendebulia HF-is mxriv usimptomo pacientebSi Sesabamisi rekomendaciebis mixedviT (ix. stabiluri da arastabiluri stenokardiis rekomendaciebi). LOE: A

8. sarqvlis gamocvla an SekeTeba rekomendirebulia pacientebSi hemodinamikurad mniSvnelovani sarqvlovani stenoziT an regurgitaciiT da HF-is simptomebis ar

arsebobisas sarqvlovani paTologiebis gaidlainis mixedviT. LOE: B

1

II A klasi:1. ACE inhibitorebi an angiotenzin II receptorebis blokerebis gamoyeneba rekomendebulia

usimptomo pacientebSi arteriuli hipertenziis da LV-is hipertrofiis dros. LOE: B

2. angiotenzin II receptorebis blokerebis gamoyeneba rekomendebulia usimptomo pacientebisaTvis dabali gandevnis fraqciiT, romlebic intolerantuli arian ACE inhibitorebis mimarT. LOE: C

3. implantirebadi kardioverter-defibrilatoris implantacia rekomendebulia im pacientebisTvis, romelTac aqvT iSemiuri kardiomiopaTia, imyofebian optimalur medikamentur Terapiaze, MI-dan gasuliaA minimum 40 dRe, gandevnis fraqcia ≤ 30%, miekuTvnebian NYHA I klass da mosalodnelia kargi funqciuri statusis SenarCuneba uaxloesi 1 wlis ganmavlobaSi. LOE: B

II B klasi:1. ICD implantacia rekomendebulia im paciantTaTvis, romelTac aqvT araiSemiuri

kardiomopaTia, gandevnis fraqcia ≤ 30%, arian NYHA I klasSi, imyofebian optimalur medikamentur Terapiaze da mosalodnelia kargi funqciuri ststusis SenarCuneba uaxloesi 1 wlis ganmavlobaSi. LOE: C

III klasi:

1. digitalisi ar gamoiyeneba HF-is mxriv usimptomo pacientebSi, romelTac aqvT dabali gandevnis fraqcia, sinusuri riTmi da ara aqvT anamnezSi HF simptomebi. vinaidan misi zianis riski ar aris dabalansebuli mosalodneli sargebliT. LOE: C

2. kvebiTi danamatebi CHF prevenciisTvis da mkurnalobisTvis ar gamoiyeneba. LOE: C3. uaryofiTi inotropuli efeqtis mqone kalciumis antagonistebis gamoyeneba SesaZloa saziano

iyos, asimptomuri pacientebisaTvis dabali gandevnis fraqciiT da MI-s Semdgom. LOE: C

gulis ukmarisobis simptomuri pacientebi - stadia C

1. pacientebi daqveiTebuli gandevnis fraqciiT

I klasis rekomendaciebi A da B stadiis pacientebisaTvisac HF-is mimdinare an anmnezSi arsebuli simptomebiT misaRebia. aRniSnul rekomendaciebs yovelTvis emateba marilis zomieri SezRudva sxeulis masis yoveldRiur kontrolTan erTad, rac SesaZlebels xdis Sardmdenebis dabali da usafrTxo dozebis metad efeqtur gamoyenebas. am pacientebisTvis metad mniSvnelovania imunizacia influenza-s da pneumococcus-is vaqcinebiT, romllebic amcirebs respiratoruli infeqciebis risks. marTalia, am stadiis pacientTaTvis ar aris rekomendebuli Zlieri fizikuri datvirTva da sporti, magram dozirebuli fizikuri aqtivoba unda iyos nebadarTuli (es ar exeba pacientebs qronikuli gu-is gamwvavebiT, an pacientebs savaraudo miokarditiT). CHF-is mqone pacientebSi fizikuri aqtivobis SezRudvam SesaZloa ganapirobos adinamia da Semciros datvirTvisadmi tolerantoba.

rekomendaciebiI klasi:

1. A da B stadiisTvis arsebuli I klasis rekomendaciebi misaRebia aseve C stadiisTvisac. 2. Sardmdenebis gamoyeneba da marilis SezRudva rekomendebulia pacientebSi mimdinare an

anamnezSi arsebuli HF-s simptomebiT da Semcirebuli EF-iT romelTac aqvT siTxis Sekavebis (hipervolemiis) niSnebi. LOE: C

3. ACE inhibitorebi rekomendebulia yvela pacientTaTvis dabali gandevnis fraqciiT da HF—is mimdinare an anamnezSi arsebuli simptomebiT, Tu ar aris preparatis daniSvnis raime ukuCveneba. LOE: A

4. beta blokerebi (bisoprololi, karvediloli, metoprololi) rekomendebulia awmyoSi an warsulSi simptomuri yvela stabiluri pacientisTvis, romlebsac aReniSnebaT daqveiTebuli gandevnis fraqcia, garda im pacientebisa, romelTaTvisac beta blokeri ukunaCvenebia. LOE: A

5. angiotenzin II receptorebis blokeris gamoyeneba rekomendebulia pacientebisaTvi mimdinare an warsulSi arsebuli HF-is simptomebiT da Semcirebuli EF-iT, romlebic intolerantulni arian ACE inhibitorebis mimarT. LOE: A

6. pacients ar unda daeniSnos, da Tu daniSnuli aqvs unda moexsnas, Tuki es SesaZlebelia, medikamentebi, romlebic auareseben pacientebis klinikur statuss mimdinare an warsulSi arsebuli HF-is simptomebiT da Semcirebuli EF-iT, (arasteroiduli anTebis sawinaaRmdego preparatebi, zogierTi antiariTmuli medikamenti, zogierTi kalciumis antagonisti) LOE: B

1

7. HF-is mqone pacientebisTvis datvirTvisunarianobis Sefasebis mizniT rekomendebulia maqsimaluri datvirTvis testi (gazometriiT an mis gareSe). LOE: C

8. dozirebuli varjiSi sasargebloa, rogorc damatebiTi RonisZieba, pacientebSi HF-is simptomebiT awmyoSi an warsulSi, romelTac daqveiTebuli gandevnis fraqcia aqvT. LOE: B

9. awmyoSi an warsulSi simptomuri HF-is mqone pacientebisTvis daqveiTebuli EF-iT, romlebsac anamnezSi aqvT gulis gaCereba, parkuWTa fibrilacia an arastabiluri hemodinamikiT mimdinare parkuWovani taqikardia, meoradi prevenciis saxiT rekomendebulia ICD-is implantacia. LOE: A

10. pacientebi CHD-iT, romlebSic MI-dan gasulia, sul mcire, 40 dRe da aqvT gandevnis fraqcia ≤ 30%, arian NYHA II an III klasSi, imyofebian optimalur medikamentur Terapiaze da mosalodnelia kargi funqciuri statusis SenarCuneba 1 welze meti periodis ganmavlobaSi, uecari sikvdilis pirveladi prevenciis mizniT rekomendebulia ICD implantacia. LOE: A

11. araiSemiur kardiomiopaTiian NYHA II-III fk-is pacientebSi, 30%-ze naklebi gandevnis fraqciiT, romlebic imyofebian optimalur medikamentur Terapiaze da mosalodnelia erT welze meti periodis ganmavlobaSi kargi funqciuri statusis SenarCuneba, uecari sikvdilis pirveldi prevenciis mizniT rekomendirebulia ICD-is implantacia. LOE: B

12. simptomuri pacientebi, romlebic arian NYHA II-III fk klasSi, aqvT 35%-ze naklebi gandevnis fraqcia, arian optimalur medikamentur Terapiaze da aqvT intraventikuluri desinqronizacia, razec miuTiTebs QRS-kompleqsis 120 msze meti xangrZlivoba, saWiroeben resinqronizaciul Terapias, Tu ara aqvT rame ukuCveneba. LOE: A

13. aldosteronis antagonistebis damateba rekomendebulia saSualo an saSualo-mZime simptomur HF-ian pacientebSi dabali gandevnis fraqciiT, romlebTanac SesaZloa kreatininis da kaliumis monitoringi. kreatinini mamakacebSi unda iyos ≤2,5 mg/dl da ≤2,0 mg/dl qalebSi. kaliumis done sisxlSi unda iyos ≤ 5 mmol/l. Tuki monitoringi SeuZlebelia, unda Tavidan iqnas Sefasebuli mosalodneli sargebeli da riski. LOE: B

II A. klasi.

1. angotenzin II receptorebis blokerebis gamoyeneba aris alternativa ACE inhibitorebisa, pacientebSi mcire an saSualo HF-is simptomebiT da Semcirebuli EF-iT, gansakuTrebiT maSin roca isini Rebuloben am medikamentebs sxva raime CvenebiT. LOE: C

2. digoqsini rekomendebulia simptomur pacientebSi, romelTac dabali gandevnis fraqcia aqvT hospitalizaciis sixSiris Semcirebis mizniT. LOE: B

3. hidralazinis da nitratis kombinaciis damateba saWiroa pacientebSi romlebsac aqvT dabali gandevnis fraqcia, iReben ACE inhibitorebs da betablokers, magram simptomebi kvlav persistirebs. LOE: B

4. ICD implantacia naCvenebia pacientebSi romelTac aqvT gandevnis fraqcia 30%dan 35%mde, arian NYHA II-III f.k.-Si, iReben optimalur medikamentur Terapias da mosalodnelia 1 welze meti periodis ganmavlobaSi kargi funqciuri statusis SenarCuneba. LOE: B

II B klasi:

1. nitratis da hidralazinis kombinacia SesaZlebelia gamoyenebul iqnes awmyosa an warsulSi simptomur pacientebSi dabali EF-iT, romlebic ver iReben ACE inhibitorebs an angiotenzin II receptoris blokerebs wamlis mimarT intolerantobis, hipotenziis an Tirkmlis ukmarisobis gamo. LOE: C

2. angiotenzin II receptoris blokerebis damateba rekomendebul Terapiaze myof dabali gandevnis fraqciias mqone pacientebisaTvis SesaZlebelia ganvixiloT, simptomTa persistirebis SemTxvevaSi. LOE: B

III klasi:1. ACE inhibitorebis, angiotenzin II receptoris blokerebisa da aldosteronis antagonistis

kombinaciis rutinuli gamoyeneba simptomur pacientebSi romelTac dabali gandevnis fraqcia aqvT, ar aris rekomendebuli. LOE: C

2. kalciumis arxebis blokerebis rutinuli gamoyeneba ar aris naCvenebi HF simptomebiani pacientebisaTvis dabali EF-iT. LOE: A

3. xangrZlivad inoptropebis infuzia SesaZloa saziano iyos da ar aris rekomendebuli, garda im pacientebisaTvis romelTac daavadebis bolo stadia aqvT da mdgomareoba ver stabilizdeba standartuli medikamenturi TerapiiT. LOE: C

4. kvebiTi danamatebis gamoyeneba gulis ukmarisobis mkurnalobisTvis ar aris naCvenebiHmaTTvis visac awmyoSi an warsulSi hqondaT HF-is simptomebi da romelTac daqveeiTebuli gandevnis fraqcia aqvT. LOE: C

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5. hormonaluri Terapia gamoiyeneba mxolod am hormonebis ukmarisobis SemTxvevaSi maTi Canacvlebis mizniT, sxva SemTxvevaSi maTi gamoyeneba SesaZloa saziano iyos simptomur pacientebSi dabali gandevnis fraqciiT. LOE: C

rekomendaciebi gulis qronikuli ukmrisobis mkurnalobaSi peroraluriSardmdenebis gamoyenebis Sesaxebcxrili 5

Mmedikamenti sawyisi dRiuri doza maqsimaluri dRiuri doza

moqmedebis xangrZlivoba

maryuJze moqmedi Sardmdenebi

bumetanidifurosemiditorasemidi

0,5-1,0 mg 1-2-jer20-40 mg 1-2 jer10-20 mg 1jer

10 mg600 mg200 mg

4-6 sT6-8 sT12-16 sT

Tiaziduri Sardmdenebi

qlorTiazidiqlortalidonihidroqlorTiazidiindapamidimetolazoni

250-500 mg 1-2 -jer12,5-25 mg 1-jer25 mg 1-2 -jer2,5 mg 1-jer2,5 mg 1-jer

1000 mg100 mg200 mg5 mg20 mg

6-12 sT24-72 sT6-12 sT36 sT12-24 sT

kaliumis Semnaxveli Sardmdenebi

amiloridispironolaqtonitriamtereni

5 mg 1-jer12,5-25 mg 1-jer50-75 mg 2-jer

20 mg50 mg200 mg

24 sT2-3 dRe7-9 sT

maryuJis sekvenciuri blokada

metolazoni

hidroqlorTiazidi

2,5-10 mg 1-jer + maryuJze moqmedi Sardmdenebi

25-100 mg 1-2-jer + maryuJze moqmedi

1

qlorTiazidi (iv) Sardmdenebi500-1000 mg 1-jer + maryuJze moqmedi Sardmdenebi

Sardmdenebis intravenuri gamoyeneba mZime gulis ukmrisobis dros

cxrili 6

medikamenti sawyisi doza maqsimaluri erTjeradi doza

maryuJze moqmedi Sardmdenebi

bumetanidifurosemiditorsemidi

1,0 mg40 mg10 mg

4-8 mg160-200 mg100-200 mg

Tiaziduri Sardmdenebi

qlorTiazidi 500 mg 1000 mg

maryuJis sekvenciuri blokadaqlorTiazidi 500-1000 mg 1-2-jer + maryuJze moqmedi Sardmdenebi 1-jer. metolazoni 2,5-5 mg p.o. 1-2-jer dReSi + maryuJze moqmedi Sardmdenebi

intravenuri infuziebi

bumetanidi

furosemidi

torsemidi

1 mg iv, Semdeg 0,5-2 mg/sT infuzia.

40 mg iv, Semdeg 10-40 mg/sT infuzia.

20 mg iv, Semdeg 5-20 mg/sT infuzia.

renin - angiotenzin - aldosteronis sistemis inhibitorebis da beta blokerebis gamoyeneba gulis ukmarisobis dros

cxrili 7

Mmedikamenti sawyisi dRiuri doza maqsimaluri doza

ACE inhibitorebi

kaptoprilienalprilifozinoprililiziniprili

6,25 mg 3-jer2,5 mg 2-jer5-10 mg 1-jer2,5-5 mg 1-jer

50 mg 3-jer10-20 mg 2-jer40 mg 1-jer20-40 mg 1-jer

1

perindopriliquinalapriliramiprilitrandolaprili

2 mg 1-jer5 mg 2-jer1,25-2,5 mg 1-jer1 mg 1-jer

8-16 mg 1-jer20 mg 2-jer10 mg 1-jer4 mg 1-jer

angiotenzin II rec. blokerebi

kandesartanilozartanivalsartani

4-8 mg 1-jer25-50 mg 1-jer20-40 mg 2-jer

32 mg 1-jer50-100 mg 1-jer160 mg 2-jer

aldosteronis antagonistebi

spironolaqtonieplerenoni

12,5-25 mg 1-jer25 mg 1-jer

25 mg 1-2-jer50 mg 1-jer

beta blokerebi

bisoprololikarvediloli

metoprolol suqcinati gaxangrZlivebuli moqmedebis

1,25 mg 1-jer3,125 mg 2-jer

12,5-25 mg 1-jer

10 mg 1-jer25 mg 2-jer50mg 2-jer pacientTaTvis>85 kg200 mg 1-jer

rekomendaciebi aldosteronis antagonistebiT mkurnalobis fonzehiperkalemiis riskis Sesamcireblad

1. Tirkmlis daqveiTebuli funqcia warmoadgens hiperkalemiis ganviTarebis maRal risks aldosteronis antagonistebiT mkurnalobisas. riski progresulad matulobs rodesac Sratis kreatinini > 1,6 mg/dl. (Tumca Tu kreatinini > 2,5 mg/dl-ze SesaZlebelia aldosteronis antagonistebis xmareba didi sifrTxiliT da kreatininis xSiri SemowmebiT) moxucebSi da im pacientebSi, romelTac aqvT mcire kunTovani masa Sratis kreatinini ver asaxavs glomerulur filtracias, glomeruluri filtracia da kreatininis klirensi rekomendebulia iyos 30 ml-ze meti.

2. aldosteronis antagonisti ar unda dainiSnos, Tu sawyisi kaliumis Semcveloba SratSi aRemateba 5 Mmmol/l;

3. spironolaqtonis sawyisi dozaa 12,5 mg, romelic izrdeba 25 mg-mde, xolo eplerenonisa - 25 mg, romelic izrdeba 50 mg-mde.

4. hiperkalemiis ganviTarebis risks zrdis ACE inhibitorebis maRali dozebis gamoyeneba (kaptoprili ≥ 75 mg/dR,G enalaprili da lizinoprili ≥ 10 mg/dR ).

5. arasteroiduli anTebis sawinaaRmdego preparatebi da ciklooqsigenaza-2 inhibitorebi Tavidan unda iqnes aridebuli;

6. kaliumis danamatebi unda Semcirdes an Sewydes.

7. Sratis kaliumis da Tirkmlis funqciis gansazRvra rekomendebulia Terapiis dawyebidan 3 dReSi da Semdeg 1 kviraSi, Semdgom ki minimum TveSi erTxel 3 Tvis ganmavlobaSi.

8. diarea an dehidrataciis sxva mizezi dauyovnebliv unda iyos aRmofxvrili.

parkuWovani ariTmiebis da uecari sikvdilis prevencia

pacientebs, romelTac aqvT LV-is dilatacia da dabali gandevnis fraqcia, xSirad uviTadebaT aramdgradi da mdgradi (gaxangrZlivebuli) parkuWovani taqikardia. letaloba am pacientebSi

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ganpirobebulia rogorc arauecari (mag. progresirebadi gu), ise uecari sikvdiliT. uecari sikvdili xSirad ganpirobebulia ariTmiiT, Tumca sxva mizezebic arsebobs, iseTi rogoricaa MI, eleqtrolituri disbalansi, pulmonaruli an sistemuri emboliebi da sxva sisxlZarRvovani paTologiebi. HF-is mqone pacientebSi uecari sikvdilis yvelaze xSiri mizezi ventrikuluri ariTmiebia, Tumca aseve SesaZloa mizezi iyos bradiariTmia da pulsis gareSe mimdinare supraventrikuluri taqikardiebi.

gulis resinqronizaciuli Terapia

NYHA III-IV klasis da dabali EF-is mqone pacientebis daaxloebiT 1/3-s aqvs 120 ms-ze meti QRS-is xangrZlivoba. es eleqtrokardiografiuli niSani, romelic miuTiTebs gamtareblobis paTologiaze, gamoiyeneba parkuWTa dissinqronizaciiani pacientebis gamosavlenad. dissinqronizaciis meqanikuri zegavlena gulis kumSvad funqciaze moicavs: parkuWis suboptimalur avsebas, dp/dt –s Semcirebas (parkuWis kontraqtilobis Zalisa da wnevis matebis siCqare), mitraluri regurgitaciis gaxangrZlivebas da parkuWTaSua Zgidis paradoqsul moZraobas. ventrikuluri dissinqronizacia asocirebulia HF-is mqone pacientebis maRal letalobasTan. dissinqronizaciuri SekumSva SesaZloa daZleul iqnes marjvena da marcxena parkuWebis sinqronuli elqtruli aqtivaciiT biventrikuluri peismekeris saSualebiT. am saxis Terapias gulis resinqronizaciuli Terapia ewodeba. is aumjobesebs gulis kumSvadobas da amcirebs mitraluri regurgitaciis xarisxs. rodesac gulis resinqronizaciuli Terapia emateba optimalur medikamentur Terapias, xdeba mniSvnelovani gaumjobeseba sicocxlis xarisxSi, funqciur klasSi, datvirTvisunarianobaSi (izrdeba pacientis mier gavlili manZili 6 wT-ian siarulis testSi).

varjiSiramdenime kvlevam aCvena rom varjiSi amcirebs simptomebs, zrdis datvirTvisunarianobas da aumjobesebs cxovrebis xarisxs HF-is mqone paxcientebSi. SedarebiT mZime avadmyofebisaTvis rekomendebulia dReSi 2-3jer 5 wuTiani msubuqi varjis epizodebi, xolo SedarebiT ukeTesi funqciuri statusis mqone avadmyofebisaTvis naCvenebia 20-30wuTiani datvirTvebi 3-5jer kviraSi.

2. pacientebi gulis ukmarisobiT da normaluri gandevnis fraqciiT

am jgufis pacientebis menejmenti emyareba arteriuli wnevis, gulis SekumSvaTa sixSiris, sisxlis moculobis da miokardiumis iSemiis kontrols, romlebic axdenen mniSvnelovan gavlenas parkuWis relaqsaciaze.

rekomendaciebi:

I klasi:

1. HF-is mqone pacientebSi, romlebsac normaluri gandevnis fraqcia aqvT, kontroli unada gaewios sistolur da diastolur wnevas Sesabamisi rekomendaciebis mixedviT. LOE: A

2. pacientebSi, romelTac aqvT winagulTa fibrilacia, unda moxdes parkuWTa SekumSvaTa sixSiris kontroli. LOE: C

3. pulmonaruli Segubebisa da periferiuli edemas kontrolis mizniT saWiroa Sardmdenebis gamoyeneba HF-is mqone pacientebSi, romlebsac normaluri gandevnis fraqcia aqvT. LOE: C

II A klasi:

1. HF-is mqone pacientebisaTvis, romelTac aqvT normaluri gandevnis fraqcia da koronaruli arteriebis daavadeba, rekomendebulia koronaruli revaskularizacia im SemTxvevaSi, rodesac miokardiumis iSemia iwvevs gulis funqciis gauaresebas. LOE: C

II B klasi:1. sinusuri riTmis aRdgenam da SenarCunebam SesaZloa gaaumjobesos winagulTa fibrilaciiT da

HF-iT daavadebuli simptomuri pacientebis mdgomareoba. LOE: C2. gulis ukmarisobis simptomatikis Semcirebis mizniT betablokerebis, ACE inhibitorebis,

angiotenzin II receptoris blokerebis da kalciumis antagonistebis gamoyeneba SesaZloa efeqturi iyos pacientebSi, romelTac nomaluri gandevnis fraqcia da kontrolirebuli hipertenzia aqvT. LOE: C.

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3. ar aris dadgenili digitalisis mniSvneloba gulis ukmarisobis simptomatikis SemcirebisaTvis, im pacientebSi, romlebsac normaluri gandevnis fraqcia aqvT. LOE: C

diferencialuri diagnozi

1. HF-is mcdari diagnozi.2. gandevnis fraqciis arakoreqtuli gazomva.3. pirveladi sarqvlovani paTologia.4. restriqciuli kardiomiopaTia, amoloidozi, sarkoidozi, hemoqromatozi.5. perikardiumis konstriqcia.6. epizoduri, LV-is Seqcevadi disfunqcia.7. mZime hipertenzia, miokardiumis iSemia.8. HF asocirebuli gazrdil metabolur moTxovnasTan: anemia, Tireotoqsikozi, arterioven uri

fistula.9. qronikuli pulmonaruli daavadeba, marjvena gulis ukmarisoba.10. pulmonaruli hipertenzia dakavSirebuli pulmonaruli sisxlZarRvebis daavadebasTan.11. atrialuri miqsoma.12. gaurkveveli warmoSobis diastoluri disfunqcia.13. simsuqne.

refraqteruli bolo stadiis gulis ukmarisoba - stadia D

manam sanam CaiTvleba, rom pacients aqvs refraqteruli gulis ukmarisoba, unda davrwmundeT rom gamoyenebuli iqna sruli optimaluri Terapia. kvlevebi, romlebic I klasis rekomendaciebiT gankuTvnilia A, B, C stadiis pacientebisaTvis, misaRebia aseve D stadiis pacientebisTvisac. rodesac Terapiis Semdgomi etapi aRar arsebobs, saWiroa pacientTa specialuri movla sicocxlis bolo stadiaze.

rekomendaciebi: I klasi:

1. siTxis raodenobis skurpulozuri Sefaseba da kontroli bolo stadiis gulis ukmarisobis dros. LOE: B

2. rekomendebulia gulis transplantaciisTvis pacientTa gagzavna. LOE: B 3. saubari pacientebis ojaxis wevrebTan, rodesac Terapiis miuxedavad rCeba mZime

simptomatika. LOE: A4. refraqteruli bolo stadiis gulis ukmarisobis pacientebs, romlebsac implantirebuli aqvT ICD,

unda miewodoT informacia defibrilatoris inaqtivaciis SesaZleblobis Sesaxeb. LOE: C

II A klasi:

1. refraqtreuli gulis ukmarisobiT daavadebul pacientebSi, romelTa mosalodneli letaloba uaxloes 1 weliwadSi 50%-ia, mudmivi an saboloo Terapiis saxiT SesaZloa LV damxmare aparatis gamoyeneba. . LOE: B.

II B klasi:

1. refraqteruli gulis ukmarisobis dros SesaZloa saWiro gaxdes svan-gancis kaTeteri mZime simptomebis persistirebis SemTxvevaSi. . LOE: C

2. reftraqteruli CHF-is dros meoradi mitraluri regurgitaciis mkurnalobis mizniT, mitraluri sarqvlis plastikis an protezirebis efeqturoba ar aris sabolood dadgenili. . LOE: C

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3. xangrZlivad inotropebis i.v. infuzia SesaZloa gamoyenebul iqnes rogorc paliaturi RonisZieba refraqteruli bolo stadiis gulis ukmarisobis dros. . LOE: C

III klasi:

1. LV nawilobrivi ventrikuleqtomia ar aris rekomnedebuli araiSemiuri kardiomiopaTiian pacientebSi refraqteruli bolo stadiis gulis ukmarisobis dros. . LOE: C

2. inotropebis infuzia rutinulad refraqteruli bolo stadiis gulis ukmarisobis dros ar aris rekomendebuli. . LOE: B

gulis transplantaciis Cvenebebi

absoluturi Cveneba:

1. CHF-iT ganpirobebuli hemodinamikuri arastabilurobis SemTxvevaSi: refraqteruli kardiogenuli Soki; organoTa perfuziis SesanarCuneblad i/v inotropebuli preparatebis saWiroeba; g) pikuri VO2 < 10 ml/kg/wT anaerobuli metabolizmis gaCeniT.

2. mZime anginuri simptomatika romelic zRudavs pacientis minimalur aqtivobas da SeuZlebelia raime saxis revaskularizacia.

3. rekurentuli simptomuri ventrikuluri ariTmia, romelic refraqterulia yvela Terapiuli RonisZiebis mimarT.

SedarebiTi Cveneba:

1. pikuri VO2 11 ml/kg/wT-dan 14 ml/kg/wT-mde ( an mosalodnelis 55%) da pacientis aqtivobis mniSvnelovani SezRudva;

2. rekurentuli arastabiluri iSemia, romelic ar eqvemdebareba sxva intervencias;3. siTxis balansisa da Tirkmlis funqciis rekurentuli arastabiluroba, romelic ar aris ganpirobebuli

pacientis daudevrobiT medikamentebis mimarT.

arasakmarisi Cveneba:

1. dabali gandevnis fraqcia;2. anamnezSi NYHA II-IV klasis gu; 3. pikuri VO2 > 12 ml/kg/wT(da mosalodnelis 55%-ze meti) sxva Cvenebis gareSe.

qalebi da makacebi

bevri eqimi gulis ukmarisobas ZiriTadad mamkacebis daavadebad miiCnevs, vinaidan maT ufro xSirad aqvT koronaruli risk-faqtorebi, Tumca CHF-iani pacientebis meti wili modis moxuc qalebze, romelTac umeteswilad aqvT normaluri gandevnis fraqcia.

2

gulis ukmarisobis mqone pacientebi, romlebsac aqvT Tanmxlebi paTologiebi

rekomendaciebi

I klasi:

1. yvela zemoT aRniSnuli rekomendacia ekuTvnis HF-is mqone pacientebs, romlebsac aqvT Tanmxlebi sxva paTologia, Tu ar aris raime gamonaklisi. . LOE: C

2. CHF-is mqone pacientebSi kontrolirebuli unda iqnes sistoluri da diastoluri hipertenzia da Saqriani diabeti Sesabamisi rekomendaciebis mixedviT. . LOE: C

3. CHF-is mqone pacientebSi stenokardiis mkurnalobisas gamoyenebuli unda iqnas antiagregantebi, nitrati da beta blokeri. . LOE: B

4. CHF-is mqone pacientebs CHD-iT unda CautardeT koronaruli revaskularizacia Sesabamisi rekomendaciebis mixedviT. . LOE: A

5. antikoagulacia unda daeniSnoT pacientebs, romlebsac aqvT winagulTa fibrilaciis paroqsizmuli, persistentuli an mudmivi forma, an Tromboembolia anamnezSi. . LOE: A

6. rekomendebulia parkuWTa SekumSvis sixSiris kontroli beta blokerebiT an amiodaroniT (Tu beta blokeris ukuCvenebaa) HF-is mqone pacientebSi, romlebsac aqvT winagulTa fibrilacia. LOE: A

7. pacientebs romelTac gulis ukmarisobis garda aqvT gulis koronaruli daavadeba ematebaT mkurnaloba stabiluri stenokardiis gaidlainis mixedviT . LOE: C

8. pacientebs eniSnebaT antiagregantebi mi-s da uecari sikvdilis prevenciis mizniT Tuki maT aqvT Tanmxlebi gulis koronaruli daavadeba. LOE: B

II A klasi:

1. rekomendebulia parkuWTa SekumSvis sixSiris kontroli digitalisiT HF-is mqone pacientebSi, romlebsac aqvT winagulTa fibrilacia. . LOE: A

2. amiodaronis gamoyeneba rekomendebulia HF-is mqone pacientebSi rekurentuli winagulovani ariTmiebis da parkuWovani taqikardiiT ganpirobebuli ICD ganmuxtvebis sixSiris Semcirebis mizniT. . LOE: B

II B klasi:

1. winagulTa fibrilaciis dros sinusuri riTmis aRdgenis da SenarCunebis strategia ar aris sabolood dadgenili. LOE: C

2. ar aris dadgenili antikoagulaciis sargebloba HF-is mqone pacientebSi, romlebsac ara aqvT winagulTa fibrilacia an Tromboembolia anamnezSi. . LOE: B

3. ar aris dadgenili eriTropoezis stimulaciis efeqturoba HF-is mqone pacientebSi, romlebsac aqvT anemia. . LOE: B

III klasi:

1. I da III klasis antiariTmuli preparatebi ar aris rekomendebuli HF-is mqone pacientepSi ventrikuluri ariTmiebis prevenciis mizniT. . LOE: A

2. HF-is mqone pacientebSi asimptomuri parkuWovani ariTmiebis pirveladi mkurnalobis mizniT antiariTmuli preparatebis gamoyeneba ar aris rekomendebuli. . LOE: A

gulis ukmarisobis gamwvavebis ZiriTadi mizezebi:arakardialuri kardialuri

daniSnulebis darRveva dietis darRveva axali medikamentebi (antiariTmikebi

garda kordaronisa, beta blokerebi, NSAID ebi, verapamili, dilTiazemi)

winagulTa cimcimi sxva ariTmiebi bradikardia miokardiumis iSemia/infarqti mitraluri an trikuspidaluri

2

infeqcia alkoholis Warbad miReba Tirkmlebis ukmarisoba pulmonaruli embolizmi hipertenzia Ciyvi anemia

naklovanebis gaCena an gauareseba predatvirTvis mkveTri Semcireba

(mag. zedmeti diurezi agf inhibitorebis gamoyenebasTan erTad, nitratebi)

SemTxvevebi rodesac HF pacienti unda gaigzavnos specializirebul kardiologiur klinikaSi:

ver dgindeba gulis ukmarisobis mizezi sistoluri wneva naklebia 100mm vw sv. Sratis kreatinini > 150 μmol/L Sratis natriumi < 130 mmol/l mZime qronikuli da mwvave gulis ukmarisobis SemTxvevaSi Tu ki gulis ukmarisobis mizezs sarqvlovani paTologia warmoadgens

Aarafarmakologiuri RonisZiebebi:

1. wonis monitoringi: naCvenebia yoveldRiuri awonva dilis tualetis Semdgom. 3dReSi wonis 2kg Ti momatebis SemTxvevaSi eqimis konsultacia diuretikis dozis modifikaciisaTvis.

2. dieta: marilis miRebis SezRudva erT erTi mniSvnelovani komponentia mZime gulis ukmarisobis warmatebuli mkurnalobisaTvis

3. miRebulia siTxis SezRudva 1,5-2 litramde dReSi mZime da saSualo gulis ukmarisobis dros. 4. daSvebulia mcire raodenobiT alkoholis miReba: dReSi 200ml Rvino an 1 kaTxa (400ml) ludi.

raTqmaunda gamonaklisia alkoholuri kardiomiopaTiis SemTxvevebi rodesac alkoholi kategoriulad akrZalulia:

5. wonis dakleba rekomendirebulia yvela pacientisaTvis. sasurveli sxeulis masis indeqsi (smi) am SemTxvevaSi 25-30. (smi = wona(kg)/simaRleze2(m) )

6. sxeulis masis paTologiuri kleba, kaxeqsia warmoadgens cudi gamosavlis erTerT prediqtors. Tuki smi< 22, naCvenebia sxeulis masis momateba kunTovani masis xarjze, adeqvaturi kvebiTa da varjiSiT.

7. moweva – aucileblad und aiqnes Sewvetili, riSTvisac mizanSewonilia sxvadasxva saSualebebisa da nikotinis Semcveli saSualebebis gamoyeneba.

marcxena parkuWis sistoluri ukmarisobis farmakoTerapia

sikvdilianobisa da avadobis Sesamcireblad

gu simptomebis Sesamcireblad

NYHA I agf inhibitoriT Terapiis gagrZeleba, arb gamoyeneba agf infibitorebis autanlobis SemTxvevaSi, gagrZeldes aldosteronis antagonistebi Tu mi Semdgomi periodia, da daematos beta blokeri

Semcirdes an moixsnas diuretiki

2

NYHA II agf inhibitoriwarmoadgens pirveli rigis Terapias, arb-s gamoyeneba agf infibitorebis autanlobis SemTxvevaSi, daematos beta blokeri, daematos aldosteronis antagonistebi Tu mi Semdgomi periodia

+/- diuretiki - siTxis Sekavebis mixedviT

NYHA III agf inhibitori + arb an mxolod arb gamoyeneba agf infibitorebis autanlobis SemTxvevaSi, beta blokeridaematosaldosteronis antagonistebi

+ diuretiki + digitalisi Tu mainc simptomuria

NYHA IV agf inhibitori/arbbeta blokerialdosteronis antagonistebi

+ diuretiki + digitalisi + droebiTi inotropuli daxmareba

qvemoT moyvanili cxrili warmoadgens gulis ukmarisobis progresirebasTan erTad farmakoTerapiis racionaluri gamoyenebis magaliTs. pacientebis Taviseburebebidan gamomdinare gasaTvaliwinebelia aseve individualuri midgoma

damatebebi:

gulis ukmarisobian pacientebSi SeZlebisdagvarad ar unda gamoviyenoT Semdegi medikamentebi:

arasteroiduli anTebis sawinaaRmdego preparatebi I jgufis antiariTmuli preparatebi (qinidini, novokainamidi, etacizini, flekainidi,

dizopiramidi da sxva) kalciumis antagonistebi (verapamili, dilTiazemi, xanmokle moqmedebis

dihidropiridinebi tricikluri antidepresantebi (mag. amitriptilini)) kortikosteroidebi liTiumi

ACE inhibitorebis swrafi titraciis sqema hopspitalizebul pacientebSikaptoprili:

sawyisi doza 12,5 mg peroralurad (6,25 mg pacientebSi hiponatremiiT, azotemiiT, siTxis danakargiT, orTostatikuri hipotenziiT).2 sT-Si gavzardoT doza 25 mg-mde6sT-Si gavzardoT doza 50 mg-mde 3 -jer dReSi saboloo mizani 150 mg dReSi.Sardmdeni SegviZlia mivceT 1 sT-iT adre an erTi saaTis Semdeg ACE inhibitoris miRebidan.

enalaprili:

sawyisi doza 5 mg peroralurad (2,5 mg pacientebSi hiponatremiiT, azotemiiT, siTxis danakargiT, orTostatikuri hipotenziiT)

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6 sT-Si gavzardoT doza 10 mg-mde.12sT-Si gavzardoT doza 10 mg-mde 2- jer dReSi. saboloo mizani 20 mg dReSi.Sardmdeni SegviZlia mivceT 1 sT-iT adre an erTi saaTis Semdeg pirveli dozis miRebidan.

ACE inhibitorebis qronikuli SemanarCunebeli dozebia:kaptoprili 50 mg 3-jer dReSi;enalaprili 10 mg 2-jer dReSi;ramiprili 20 mg 1-jer dReSi;lizinoprili 20 mg 1-jer dReSi. Textbook of Cardiovascular MedicineSecond Edition, 2002Editor Eric J.Topol

beta blokerebi

gamoiyeneba NYHA II-III klasis pacientebSi.* (SesaZloa gamoyenebul iqnas NYHA I pacientebSi, romelTac gadatanili aqvT MI an aqvT hipertenzia, aseve NYHA IV klasis euvolemiur pacientebSi, romlebsac ar aqvT moculobiTi gadatvirTvis niSnebi da simptomebi).

ukunaCvenebia pacientebSi, romelTac anamnezSi aqvT mZime RviZlis ukmarisoba, bronqospazmi, bradikardia (HR <50 simptomebis gareSe an < 60 simptomebiT), AV blokada, sinusis kvanZis disfunqcia mudmivi peismekeris gareSe, Segubeba, simptomuri hipotenzia.

Tu gaCnda Tavbrusxveva, CHF-is gauareseba (edema, wonis mateba, dispnea), mniSvnelovani bradikardia, beta blokeri SesaZloa Semcirdes an moixsnas: A pirvelad unda gaizardos diuretikisa an agf inhibitoris doza. saWiroebis SemTxvevaSi SesaZlebelia beta blokeris dozis droebiT Semcireba.

hipotenziis SemTxvevaSi pirvelad unda SevamicirT vazodilatatoris doza. saWiroebis SemTxvevaSi SesaZlebelia beta blokeris dozis droebiT Semcireba.

bradikardiis SemTxvevaSi unda Semcirdes an moixsnas preparatebi romelic aneleben gulis SekumSvaTa sixSires, saWiroebis SemTxvevaSi SesaZlebelia beta blokeris dozis droebiT Semcireba, moxsna naCvenebia mxolod cxadi aucilebelobis SemTxvevaSi.

yovelTvis izruneT beta blokeris titraciis ganaxlebaze maSinve rogorc ki pacientis mdgomareoba dastabilurdeba:

beta blokeris ganaxleba unda moxdes:1. Tu preparatis Sewyvetidan gasulia < 72 sT da ar aris kardiogenuli Soki, preparati

unda ganaxldes igive doziT;2. Tu preparatis Sewyvetidan gasulia > 72 sT da < 7 dRe da ar aris kardiogenuli Soki,

preparati unda ganaxldes ganaxevrebuli doziT;3. Tu preparatis Sewyvetidan gasulia > 7 dRe an iyo kardiogenuli Soki, preperati unda

ganaxldes minimaluri doziT da unda moxdes misi xelaxali titracia* beta blokerebi gamoiyeneba mxolod gulis ukmarisobian euvolemiur pacientebSi – saqarTvelos kardiologTa koleji.

Manual of Cardiovascular MedicineSecond Edition, 2004EditorsBrian P. GriffinEric J.TopolThe Cleveland Clinic Foundation. Cleveland, Ohaio

sagule glikozidebi:

sagule glikozidebi naCvenebia winagulTa cimcimisa da nebismieri xarisxis gulis ukmarisobis Tanaarsebobisas. Gsagule glikozidebis gamoyeneba amcirebs parkuWTa SekumSvaTa sixSires, da axdens dadebiT zegavlenas parkuWTa funqciasa da pacientis TviTSegrZnebaze.

digoqsinisa da beta blokerebis erTdroulad gamoyeneba ufro efeqturia vidre zemoxsenebuli preparatebis marto gamoyeneba pacientebSi winagulTa cimcimiT.

digoqsini ar amcirebs sikvdilianobas gulis ukmarisobiT daavadebul pacientebSi, magram misi gamoyenebisas mcirdeba hospitalizaciebis sixSire (gansakuTrebiT gulis

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ukmarisobis gauaresebiT gamowveuli hospitalizaciis sixSire) im pacientebSi romelTac aReniSnebaT sinusuri riTmi, da romlebic itareben mkurnalobas agf inhibitorebiT, beta blokerebiT, diuretikebiTa da mZime gulis ukmarisobis SemTxvevaSi spironolaqtoniT.

teqsti eyrdnoba amerikis gulis asociaciis da amerikis kardiologTa kolejis aseve evropis kardiologTa sazogadoebis Sesabamis gaidlainebs. gamoyenebulia:amerikis gulis asociaciis da amerikis kardiologTa kolejis samuSao jgufis gulis ukmarisobis gaidlainis mokle versia. 2005 w.

evropis kardiologTa sazogadoebis gulis ukmarisobis gaidlaini. sruli teqsti 2005w.kardiovaskularuli medicinis saxelmZRvanelo, brain p. grifini, erik j. topoli, 2-e gamocema 2004w.kardiovaskularuli medicina, erik j. topoli, me-2 gamocema 2002 w.

saqarTvelos kardiologTa kolejis da saqarTvelos kardiologTa sazogadoebis gaerTienebuli komitetis eqspertTa samuSao jgufi:

vaxtang WumburiZe: profesori. Terapiis erovnuli centri

nata gonjilaSvili: jo-enis saxelobis samedicino centri

soso kapanaZe: profesori. Gadaudebeli kardiologiis centri

giorgi ramiSvili:. jo-enis saxelobis samedicino centri

giorgi kaWarava: jo-enis saxelobis samedicino centri

zurab faRava: profesori. Kkardiologiis instituti

levan yuraSvili: jo-enis saxelobis samedicino centri

zaza mgalobliSvili: jo-enis saxelobis samedicino centri

gulnara tabiZe: profesori. Kkardiologiis instituti

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naTia axalaZe: jo-enis saxelobis samedicino centri

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