Examination of a patient with OX at the prehospital stage. Recommendations for the management of patients with acute coronary syndrome at the prehospital stage Initial antithrombotic therapy in acute coronary syndrome

According to modern concepts, the course of the atherosclerotic process is characterized by periods of exacerbation with destabilization of the atherosclerotic plaque, a violation of the integrity of its tire, inflammation and the formation of parietal or obstructive

V. I. Tseluiko, Doctor of Medical Sciences, Professor, Head of the Department of Cardiology and functional diagnostics KhMAPO, Kharkov

According to modern concepts, the course of the atherosclerotic process is characterized by periods of exacerbation with destabilization of the atherosclerotic plaque, a violation of the integrity of its tire, inflammation and the formation of a parietal or obstructive thrombus. Clinical manifestation atherothrombosis is an acute coronary syndrome (ACS) that includes acute myocardial infarction with or without ST segment elevation and unstable angina. In other words, the term acute coronary syndrome refers to the period of the disease in which there is a high risk of developing or having damage to the myocardium. The introduction of the term acute coronary syndrome is necessary, since these patients require not only more careful observation, but also a quick determination of treatment tactics.

The course and prognosis of the disease largely depend on several factors: the extent of the lesion, the presence of aggravating factors, such as diabetes mellitus, arterial hypertension, heart failure, elderly age, and to a large extent from the speed and completeness of the provision medical care. Therefore, if ACS is suspected, treatment should begin at prehospital stage.

Treatment for ACS includes:

• general measures (urgent hospitalization in the ICU, ECG monitoring, control of diuresis and water balance, bed rest with its subsequent expansion in 1-3 days). In the first 1-2 days, food should be liquid or semi-liquid, then easily digestible, low-calorie, with restriction of salt and foods containing cholesterol;
• anti-ischemic therapy;
• restoration of coronary blood flow;
• secondary prevention.

In order to eliminate the pain syndrome, nitroglycerin should be used. Its positive effect is associated both with the vasodilating effect of the drug on the coronary vessels, and with positive hemodynamic and antiplatelet effects. Nitroglycerin is able to have an expanding effect on both atherosclerotically altered and intact coronary arteries, which helps to improve blood circulation in ischemic areas.

According to the ACC / ANA (2002) recommendations for the treatment of patients with ACS, nitroglycerin should be used in patients with a SBP of at least 90 mm Hg. Art. and in the absence of bradycardia (heart rate less than 50 beats per minute) in the following cases:

• during the first 24-48 hours from the development of MI in patients with heart failure, extensive anterior MI, transient myocardial ischemia and elevated blood pressure;
• after the first 48 hours in patients with repeated anginal attacks and / or congestion in the lungs.

Nitroglycerin is administered sublingually or as a spray. If pain relief does not occur or there are other indications for the appointment of nitroglycerin (for example, extensive anterior myocardial infarction), they switch to intravenous drip administration of the drug.

Nitroglycerin can be replaced with isosorbide dinitrate. The drug is administered intravenously under the control of blood pressure at an initial dose of 1-4 drops per minute. With good tolerance, the rate of administration of the drug is increased by 2-3 drops every 5-15 minutes.

The appointment of molsidomine, according to the results of a large placebo-controlled ESPRIM study conducted in Europe (Eurohean Study of Prevention of Infarct with Molsidomine Group, 1994), does not improve the course and prognosis of AMI.

Despite the undeniable positive clinical effect of nitrates, unfortunately, there are no data on the favorable effect of this group of drugs on the prognosis.

The use of β-blockers in the treatment of AMI is extremely important, since this group of drugs not only has an anti-ischemic effect, but is also the main one in terms of limiting the necrosis zone. The zone of myocardial infarction largely depends on the caliber of the occluded vessel, the size of the thrombus in the coronary artery, the conduct of thrombolytic therapy and its effectiveness, the presence of collateral circulation. There are two main ways to limit the size of MI and preserve the function of the left ventricle: restoring the patency of the occluded artery and reducing myocardial oxygen demand, which is achieved through the use of β-blockers. Early use of β-blockers allows limiting the area of ​​necrosis, the risk of developing ventricular fibrillation, early heart ruptures, and reducing the mortality of patients. The use of β-blockers in parallel with thrombolysis helps to reduce the incidence of a severe complication of thrombolysis - cerebral hemorrhage.

β-blockers in the absence of contraindications should be given as early as possible. It is preferable to administer the drug intravenously, which allows to achieve the desired positive effect more quickly and, with the development of side effects, to stop the drug intake. If the patient has not previously taken β-blockers and the response to their introduction is unknown, it is better to administer short-acting cardioselective drugs in a small dose, such as metoprolol. The initial dose of the drug can be 2.5 mg intravenously or 12.5 mg orally. With satisfactory tolerance, the dose of the drug should be increased by 5 mg after 5 minutes. The target dose for intravenous administration is 15 mg.

In the future, they switch to oral administration of the drug. The first dose of tableted metoprolol is given 15 minutes after intravenous administration. Such a pronounced variability in the dose of the drug is associated with the individual sensitivity of the patient and the form of the drug (retarded or not).

Maintenance doses of β-blockers in the treatment of coronary artery disease:

• Propranolol 20-80 mg 2 times a day;
• Metoprolol 50-200 mg 2 times a day;
• Atenolol 50-200 mg per day;
• Betaxolol 10-20 mg per day;
• Bisoprolol 10 mg per day;
• Esmolol 50-300 mcg/kg/min;
• Labetalol 200-600 mg 3 times a day.

If there are contraindications to the use of β-blockers in the treatment of AMI, it is advisable to prescribe calcium antagonists of the diltiazem series. The drug is prescribed at a dose of 60 mg 3 times a day, increasing it with good tolerance to 270-360 mg per day. In the presence of contraindications to β-blockers, diltiazem is the drug of choice for the treatment of patients with ACS, especially those without Q-wave.

The use of calcium antagonists of the dihydroperidine series in acute coronary syndrome is justified only in the presence of anginal attacks that are not prevented by therapy with β-blockers (drugs are prescribed in addition to β-blockers) or if the vasospastic nature of ischemia is suspected, for example, with "cocaine" myocardial infarction. It should be recalled that we are talking only about long-acting calcium antagonists, since the use of short-acting drugs in this group worsens the prognosis of patients with myocardial infarction.

The next direction in the treatment of AMI is the restoration of coronary blood flow, which makes it possible to partially or completely prevent the development of irreversible myocardial ischemia, reduce the degree of hemodynamic disturbance, and improve the prognosis and survival of the patient.

Reestablish coronary circulation possibly in several ways:

• carrying out thrombolytic and antiplatelet therapy;
• balloon angioplasty or stenting;
• urgent coronary artery bypass grafting.

The results of studies conducted on 100 thousand patients indicate that effective thrombolytic therapy can reduce the risk of death by 10-50%. The positive effect of thrombolytic therapy is associated with the restoration of the patency of the affected artery due to the lysis of a thrombus in it, limiting the zone of necrosis, reducing the risk of developing heart failure due to the preservation of the pumping function of the left ventricle, improving repair processes, reducing the incidence of aneurysm formation, reducing the frequency of thrombus formation in the left ventricle and increase the electrical stability of the myocardium.

Indications for thrombolysis are:

• all cases of probable AMI in the presence of anginal syndrome lasting 30 minutes or more in combination with ST segment elevation (more than 0.1 mV) in two or more leads in the first 12 hours from the onset of the pain syndrome;
• acute complete blockade the left leg of the bundle of His in the first 12 hours from the onset of pain;
• no contraindications.

It should be noted that, despite the fact that the time interval is 12 hours, it is more effective to carry out thrombolysis at an earlier time, preferably before 6 hours, in the absence of ST segment elevation, the effectiveness of thrombolytic therapy has not been proven.

There are absolute and relative contraindications to thrombolytic therapy.

Absolute contraindications for thrombolysis are as follows.

1. Active or recent (less than 2 weeks) internal bleeding.
2. High arterial hypertension (BP over 200/120 mm Hg).
3. Recent (less than 2 weeks) surgery or trauma, especially traumatic brain injury, including cardiopulmonary resuscitation.
4. Active peptic ulcer of the stomach.
5. Suspicion of a dissecting aortic aneurysm or pericarditis.
6. Allergy to streptokinase or APSAP (you can use urokinase or tissue plasminogen activator).

Given the high risk of reocclusion after thrombolysis, after the introduction of reperfusion, antithrombin and antiplatelet therapy must be carried out.

In Ukraine, due to the low availability of invasive intervention, this therapy is the main one in restoring coronary blood flow in patients with ACS without ST segment elevation.

The next stage is anticoagulant and antiplatelet therapy. Aspirin is the standard of care for antiplatelet therapy.

Aspirin should be taken at the very beginning of the pain syndrome at a dose of 165-325 mg, it is better to chew the tablet. In the future - 80-160 mg of aspirin in the evening after meals.

If the patient is allergic to aspirin, it is advisable to prescribe inhibitors of ADP-induced platelet aggregation - clopidogrel (Plavix) or ticlopidine (Ticlid). Tiklopidin - 250 mg 2 times a day with meals.

The recommendations European Society cardiologists (2003) and ANA/AAS (2002), it is fundamentally new to include an inhibitor of ADP-induced platelet aggregation, clopidogrel, into a number of mandatory antithrombotic therapy.

The basis for this recommendation was the results of the CURE study (2001), which examined 12562 patients who received, along with aspirin, clopidogrel (first loading dose of 300 mg, then 75 mg per day) or placebo. Additional administration of clopidogrel contributed to a significant reduction in the incidence of heart attack, stroke, sudden death, the need for revascularization.

Clopidogrel is the standard of care for acute myocardial infarction, especially if it develops while taking aspirin, which indirectly indicates a lack of prophylactic antiplatelet therapy. The drug should be administered as early as possible in a loading dose of 300 mg, the maintenance dose of the drug is 75 mg per day.

The second PCI-CURE study evaluated the efficacy of clopidogrel in 2658 patients with planned percutaneous angioplasty. The results of the study indicate that the appointment of clopidogrel helps to reduce the frequency of the endpoint (cardiovascular death, myocardial infarction or urgent revascularization within a month after angioplasty) by 31%. According to the AHA/AHA (2002) recommendations, patients with unstable angina and non-ST-segment elevation myocardial infarction who are to undergo revascularization should receive clopidogrel one month before surgery and continue taking it after the intervention for as long as possible. The prescription of the drug should be mandatory.

Platelet receptor blockers IIb / IIIa are a relatively new group of drugs that bind platelet glycoprotein receptors and thereby prevent the formation of a platelet thrombus. The effectiveness of glycoprotein receptors after surgery on the coronary arteries (stenting), as well as in the treatment of high-risk patients, has been proven. Representatives of this group are: absiximab, eptifibratide and tirofiban.

According to the standard of care, unfractionated heparin or low molecular weight heparins can be used as anticoagulant therapy.

Despite the fact that heparin has been used in clinical practice for decades, the regimen for heparin therapy in AMI is not generally accepted, and the results of evaluating its effectiveness are contradictory. There are studies showing that the administration of heparin leads to a 20% reduction in the likelihood of death, along with which the results of a meta-analysis of 20 studies indicate no effect. Such a contradiction in the results of studies is largely due to the different form of administration of the drug: subcutaneous or intravenous drip. To date, it has been proven that only with intravenous drip administration of the drug is a positive effect of therapy really observed. Usage subcutaneous injection, namely this method of drug administration, unfortunately, is the most common in Ukraine, does not have a significant effect on the course and prognosis of the disease. That is, we allegedly partially comply with the recommendations for treatment, but without providing the correct treatment regimen, we cannot count on its effectiveness.

The drug should be used as follows: bolus 60-70 IU/kg (maximum 5000 IU), then intravenously drip 12-15 IU/kg/hour (maximum 1000 IU/hour).

The dosage of heparin depends on the partially activated thromboplastin time (APTT), which should be extended by 1.5-2 times to ensure the full hypocoagulation effect. But APTT, unfortunately, in Ukraine is determined only in a few medical institutions. A simpler, but little informative method, which is often used in medical institutions to control the adequacy of the dose of heparin, is to determine the time of blood clotting. However, this indicator cannot be recommended for monitoring the effectiveness of therapy due to the incorrectness of its use. In addition, the introduction of heparin is fraught with the development of various complications:

• bleeding, including hemorrhagic stroke, especially in the elderly (from 0.5 to 2.8%);
• hemorrhages at injection sites;
• thrombocytopenia;
• allergic reactions;
• osteoporosis (rarely, only with prolonged use).

With the development of complications, it is necessary to administer a heparin antidote - protamine sulfate, which neutralizes the anti-IIa activity of unfractionated heparin at a dose of 1 mg of the drug per 100 IU of heparin. At the same time, the abolition of heparin and the use of protamine sulfate increase the risk of thrombosis.

The development of complications when using heparin is largely associated with the peculiarities of its pharmacokinetics. The excretion of heparin from the body takes place in two phases: a rapid elimination phase, as a result of the drug binding to membrane receptors of blood cells, endothelium and macrophages, and a slow elimination phase, mainly through the kidneys. The unpredictability of the activity of receptor capture, and hence the binding of heparin to proteins and the rate of its depolymerization, determines the second "side of the coin" - the impossibility of predicting therapeutic (antithrombotic) and side (hemorrhagic) effects. Therefore, if it is not possible to control the APTT, it is impossible to talk about the required dose of the drug, and therefore about the usefulness and safety of heparin therapy. Even if the APTT is determined, it is possible to control the dose of heparin only with intravenous administration, since with subcutaneous administration there is too much variability in the bioavailability of the drug.

In addition, it should be noted that bleeding caused by the administration of heparin is associated not only with the effect of the drug on the blood coagulation system, but also on platelets. Thrombocytopenia is a fairly common complication of heparin administration.

The limited therapeutic window of unfractionated heparin, the difficulty of selecting a therapeutic dose, the need for laboratory monitoring and the high risk of complications were the basis for the search for drugs that have the same positive properties, but are safer. As a result, the so-called low molecular weight heparins (LMWHs) have been developed and put into practice. They have a predominantly normalizing effect on activated coagulation factors, and the likelihood of developing hemorrhagic complications during their use is much lower. LMWHs are more antithrombotic than hemorrhagic. Therefore, the undoubted advantage of LMWH is the absence of the need for constant monitoring of the blood coagulation system during treatment with heparin.

LMWHs are a heterogeneous group in terms of molecular weight and biological activity. Currently, 3 representatives of LMWH are registered in Ukraine: nadroparin (Fraksiparin), enoxaparin, dalteparin.

Fraxiparine is prescribed at a dose of 0.1 ml per 10 kg of the patient's weight 2 times a day for 6 days. Longer use of the drug does not increase the effectiveness of therapy and is associated with a greater risk of side effects.

The results of multicenter studies on the study of nadroparin indicate that the drug has the same clinical effect as heparin administered intravenously under the control of APTT, but the number of complications is significantly lower.

Thrombin inhibitors (hirudins), according to the results of several multicenter studies GUSTO Iib, TIMI 9b, OASIS, at medium doses do not differ in effectiveness from UFH, at high doses they increase the number of hemorrhagic complications. Therefore, in accordance with the recommendations of the AHA / AAS (2002), the use of hirudins in the treatment of patients with ACS is advisable only in the presence of heparin-induced thrombocytopenia.

Unfortunately not always drug treatment ACS provides stabilization of the condition and prevents the development of complications. Therefore, it is extremely important to ask the following questions if the treatment of this group of patients is insufficiently effective (preservation of anginal syndrome, episodes of ischemia during Holter monitoring or other complications): are the most effective drugs whether the optimal forms of administration and doses of drugs are used and whether it is time to recognize the expediency of invasive or surgical treatment.

If the result of treatment is positive and the patient's condition has stabilized, it is necessary to conduct a stress test (against the background of the withdrawal of β-blockers) to determine further treatment tactics. The impossibility of exercise testing or withdrawal of β-blockers on clinical grounds automatically makes the prognosis unfavorable. Low tolerance to physical activity is also evidence of high risk and determines the expediency of coronary angiography.

It is mandatory to carry out the following preventive measures:

• lifestyle modification;
• the appointment of maintenance antiplatelet therapy (aspirin 75-150 mg, clopidogrel 75 mg or a combination of these drugs);
• the use of statins (simvastatin, atorvastatin, lovastatin);
• use of ACE inhibitors, especially in patients with signs of heart failure.

And, finally, one more aspect that should be considered is the feasibility of using metabolic therapy for ACS. According to the recommendations of the ANA/AHA and the European Society of Cardiology (2002), metabolic therapy is not the standard treatment for ACS, as there are no convincing data from large studies confirming the effectiveness of this therapy. Therefore, those funds that can be spent on drugs with a metabolic effect, it is more reasonable to use them for really effective means, the use of which is the standard of care and can improve the prognosis, and sometimes save the patient's life.

Update: October 2018

The term "acute coronary syndrome" refers to a very life-threatening emergency. In this case, the blood flow through one of the arteries that feed the heart decreases so much that a larger or smaller section of the myocardium either ceases to perform its function normally, or even dies. The diagnosis is valid only during the first day of the development of this condition, while doctors differentiate - the person has manifested unstable angina or this is the beginning of myocardial infarction. At the same time (while the diagnosis is being carried out), cardiologists are doing everything possible measures to restore the patency of the damaged artery.

Acute coronary syndrome requires emergency care. If we are talking about myocardial infarction, then only during the first (from the appearance initial symptoms) 90 minutes it is still possible to inject a drug that will dissolve the blood clot in the artery that feeds the heart. After 90 minutes, doctors can only help the body in every possible way to reduce the area of ​​the dying area, maintain basic vital functions and try to avoid complications. Therefore, sudden pain in the heart, when it does not go away within a few minutes of rest, even if this symptom appeared for the first time, requires the immediate call of an ambulance. Do not be afraid to sound like an alarmist and seek medical help, because irreversible changes in the myocardium are accumulating every minute.

Next, we will consider what symptoms, in addition to pain in the heart, you need to pay attention to, what needs to be done before the ambulance arrives. We will also tell about who is more likely to develop acute coronary syndrome.

A little more about terminology

Currently, acute coronary syndrome refers to two conditions that manifest similar symptoms:

Unstable angina

Unstable angina is a condition in which, against the background of physical activity or rest, there is pain behind the sternum, which has a pressing, burning or squeezing character. Such pain gives to the jaw, left hand, left shoulder blade. It can also be manifested by pain in the abdomen, nausea.

Unstable angina is said to be when these symptoms or:

• just arose (that is, before a person performed loads without heart pain, shortness of breath or discomfort in the abdomen);
• began to occur at a lower load;
• become stronger or last longer;
• began to appear at rest.

At the heart of unstable angina is a narrowing or spasm of the lumen of a larger or smaller artery that feeds, respectively, a larger or smaller portion of the myocardium. Moreover, this narrowing should be more than 50% of the diameter of the artery in this area, or an obstacle in the path of blood (this is almost always an atherosclerotic plaque) is not fixed, but fluctuates with the blood flow, sometimes more, sometimes less blocking the artery.

myocardial infarction

Myocardial infarction - without ST-segment elevation or with ST-segment elevation (this can only be determined by ECG). It occurs when more than 70% of the diameter of the artery is blocked, as well as in the case when a “flew off” plaque, blood clot or fat droplet clogged the artery in one place or another.

Non-ST elevation acute coronary syndrome is either unstable angina or non-ST elevation infarction. At the stage before hospitalization in a cardiological hospital, these 2 states are not differentiated - there are no necessary conditions and equipment for this. If the ST segment elevation is visible on the cardiogram, a diagnosis of Acute myocardial infarction can be made.

The type of disease - with or without ST elevation - depends on the treatment of acute coronary syndrome.

If the formation of a deep (“infarct”) Q wave is already immediately visible on the ECG, the diagnosis is “Q-myocardial infarction”, and not an acute coronary syndrome. This suggests that a large branch of the coronary artery is affected, and the focus of the dying myocardium is quite large (large-focal myocardial infarction). This disease occurs when a large branch of the coronary artery is completely blocked by a dense thrombotic mass.

When to Suspect Acute Coronary Syndrome

The alarm should be sounded if you or your relative makes the following complaints:

• Pain behind the sternum, the distribution of which is shown with a fist, and not with a finger (that is, a large area hurts). The pain is burning, baking, strong. Not necessarily defined on the left, but may be located in the middle or with right side sternum. Gives to the left side of the body: half of the lower jaw, arm, shoulder, neck, back. Its intensity does not change depending on the position of the body, but there may be (this is typical for ST-segment elevation syndrome) several attacks of such pain, between which there are several almost painless "gaps".
  It is not removed by nitroglycerin or similar drugs. Fear joins the pain, sweat appears on the body, there may be nausea or vomiting.
• Dyspnea, which is often accompanied by a feeling of lack of air. If this symptom develops as a sign of pulmonary edema, then suffocation increases, a cough appears, pink frothy sputum may be coughed up.
• Rhythm disturbances, which are felt as interruptions in the work of the heart, discomfort in the chest, sharp tremors of the heart against the ribs, pauses between heartbeats. As a result of such non-rhythmic contractions, at worst, a loss of consciousness occurs very quickly, at best, it develops headache, dizziness.
• Pain may be felt in the upper abdomen and may be accompanied by loose stools, nausea, and vomiting. that brings no relief. It is also accompanied by fear, sometimes - a feeling of rapid heartbeat, non-rhythmic contraction of the heart, shortness of breath.
• In some cases, acute coronary syndrome may begin with loss of consciousness.
• There is a variant of the course of acute coronary syndrome, manifested dizziness, vomiting, nausea, in rare cases - focal symptoms (facial asymmetry, paralysis, paresis, impaired swallowing, and so on).

The increased or more frequent pain behind the sternum, about which the person knows that this is how his angina pectoris manifests itself, increased shortness of breath and fatigue, should also alert. A few days or weeks later, 2/3 of people develop an acute coronary syndrome.

A particularly high risk of developing acute cardiac syndrome in such people:

• smokers;
• overweight people;
• alcohol abusers;
• lovers of salty dishes;
• leading a sedentary lifestyle;
• coffee drinkers;
• having a lipid metabolism disorder (for example, high cholesterol, LDL or VLDL in a blood lipid profile);
• with a diagnosis of atherosclerosis;
• at established diagnosis unstable angina;
• if atherosclerotic plaques are detected in one of the coronary (which feed the heart) arteries;
• who have already suffered a myocardial infarction;
• lovers to eat chocolate.

First aid

Help needs to start at home. In this case, the first action should be to call an ambulance. Further, the algorithm is as follows:

1. It is necessary to lay the person on the bed, on his back, but at the same time the head and shoulders should be raised, making an angle of 30-40 degrees with the body.
2. The clothes and belt must be unbuttoned so that the person’s breathing does not hamper anything.
3. If there is no sign of pulmonary edema, give the person 2-3 aspirin (Aspekard, Aspetera, Cardiomagnyl, Aspirin-Cardio) or Clopidogrel (i.e. 160-325 mg aspirin) tablets. They need to be chewed up. This increases the likelihood of dissolution of a blood clot, which (by itself, or layered on an atherosclerotic plaque) blocked the lumen of one of the arteries that feed the heart.
4. Open the vents or windows (if necessary, the person needs to be covered): this way more oxygen will flow to the patient.
5. If arterial pressure more than 90/60 mmHg, give the person 1 tablet of nitroglycerin under the tongue (this drug dilates the blood vessels that feed the heart). Repeatedly give nitroglycerin can be given 2 more times, with an interval of 5-10 minutes. Even if after a 1-3-time admission a person feels better, the pain is gone, you should not refuse hospitalization in any case!
6. If before that a person took drugs from the group of beta-blockers (Anaprilin, Metoprolol, Atenolol, Corvitol, Bisoprolol), after aspirin he should be given 1 tablet of this drug. It will reduce myocardial oxygen demand, giving it the opportunity to recover. Note! A beta-blocker may be given if the blood pressure is greater than 110/70 mmHg and the pulse is greater than 60 beats per minute.
7. If a person is taking antiarrhythmic drugs (for example, Aritmil or Kordaron), and he feels a rhythm disturbance, you need to take this pill. In parallel, the patient himself should begin to cough deeply and strongly before the ambulance arrives.
8. All the time before the ambulance arrives, you need to be near the person, observing his condition. If the patient is conscious and feels a sense of fear, panic, he needs to be reassured, but not soldered with motherwort valerian (reanimation may be needed, and a full stomach can only interfere), but reassure with words.
9. In case of convulsions, a person nearby should help ensure patency respiratory tract. To do this, it is necessary, taking the corners of the lower jaw and the area under the chin, to move the lower jaw so that the lower teeth are in front of the upper ones. From this position, you can do mouth-to-nose artificial respiration if spontaneous breathing is gone.
10. If the person stops breathing, check the pulse on the neck (on both sides of the Adam's apple), and if there is no pulse, proceed to resuscitation: 30 straight-arm pressure on the lower part of the sternum (so that the bone moves down), after which - 2 breaths into the nose or mouth. The lower jaw must be held by the area under the chin so that the lower teeth are in front of the upper ones.
11. Locate the ECG tapes and medications the patient is taking to show them to healthcare professionals. They won't need it in the first place, but they will need it.

What should emergency physicians do?

Medical care for acute coronary syndrome begins with simultaneous actions:

• ensuring vital functions. To do this, oxygen is supplied: if breathing is independent, then through nasal cannulas, if there is no breathing, then tracheal intubation and artificial ventilation are carried out. If blood pressure is critically low, they begin to inject special drugs into the vein that will increase it;
• parallel registration of the electrocardiogram. They look at it whether there is an ST rise or not. If there is a rise, then if there is no possibility of quick delivery of the patient to a specialized cardiological hospital (subject to sufficient staffing of the departing team), thrombolysis (thrombus dissolution) can be started outside the hospital. In the absence of ST elevation, when the likelihood that the clot clogging the artery is “fresh” that can be dissolved, the patient is taken to a cardiological or multidisciplinary hospital, where there is an intensive care unit.
• elimination of pain syndrome. For this, narcotic or non-narcotic painkillers are administered;
• in parallel, with the help of rapid tests (strips where a drop of blood is dripped, and they show whether the result is negative or positive), the level of troponins is determined- markers of myocardial necrosis. Normally, troponin levels should be negative.
• if there are no signs of bleeding, anticoagulants are injected under the skin: "Clexane", "Heparin", "Fraksiparin" or others;
• if necessary, "Nitroglycerin" or "Izoket" is administered intravenously;
• intravenous beta-blockers may also be started reducing myocardial oxygen demand.

Note! It is possible to transport the patient to and from the car only in the supine position.

Even the absence of ECG changes against the background of complaints characteristic of acute coronary syndrome is an indication of hospitalization in a cardiology hospital or intensive care unit of a hospital that has a cardiology department.

Treatment in a hospital

1. Against the background of continuing therapy necessary to maintain vital functions, a 10-lead ECG is re-recorded.
2. Again, already (preferably) by a quantitative method, the levels of troponins and other enzymes (MB-creatine phosphokinase, AST, myoglobin), which are additional markers of myocardial death, are determined.
3. When the ST segment is elevated, if there are no contraindications, a thrombolysis procedure is performed.
   Contraindications to thrombolysis are the following conditions:
   • internal bleeding;
   • traumatic brain injury less than 3 months ago;
   • "upper" pressure above 180 mm Hg. or "lower" - above 110 mm Hg;
   • suspicion of aortic dissection;
   • a stroke or brain tumor;
   • if a person has been taking anticoagulant drugs (blood thinners) for a long time;
   • if there was an injury or any (even laser correction) surgery in the next 6 weeks;
   • pregnancy;
   • exacerbation of peptic ulcer;
   • hemorrhagic eye diseases;
   • the last stage of cancer of any localization, severe degrees of liver or kidney failure.
4. In the absence of ST-segment elevation or its decrease, as well as in the case of T-wave inversion or newly emerged blockade of the left bundle branch block, the question of the need for thrombolysis is decided individually - according to the GRACE scale. It takes into account the age of the patient, his heart rate, blood pressure, the presence of chronic heart failure. The calculation also takes into account whether there was a cardiac arrest before admission, whether ST is elevated, whether troponins are high. Depending on the risk on this scale, cardiologists decide whether there is an indication for thrombus-dissolving therapy.
5. Markers of myocardial damage are determined every 6-8 hours on the first day, regardless of whether thrombolytic therapy was performed or not: they are used to judge the dynamics of the process.
6. Other indicators of the body's work are also necessarily determined: levels of glucose, electrolytes, urea and creatinine, the state of lipid metabolism. A chest X-ray is taken to assess the condition of the lungs and (indirectly) the heart. Doppler ultrasound of the heart is also performed to assess the blood supply to the heart and its current condition, to predict the development of complications such as heart aneurysm.
7. Strict bed rest - in the first 7 days, if the coronary syndrome ended in the development of myocardial infarction. If a diagnosis of unstable angina has been established, a person is allowed to get up earlier - on the 3-4th day of illness.
8. After suffering an acute coronary syndrome, a person is prescribed several drugs for continuous use. These are angiotensin-converting enzyme inhibitors (Enalapril, Lisinopril), statins, blood thinners (Prasugrel, Clopidogrel, Aspirin-cardio).
9. If necessary, to prevent sudden death, an artificial pacemaker (pacemaker) is installed.
10. After some time (depending on the patient's condition and the nature of the ECG changes), if there are no contraindications, a study such as coronary angiography is performed. This is an x-ray method, when a contrast agent is injected through a catheter passed through the femoral vessels into the aorta. It enters the coronary arteries and stains them, so doctors can clearly see what kind of patency each segment of the vascular path has. If there is a significant narrowing in some area, it is possible to carry out additional procedures that restore the original diameter of the vessel.

Forecast

The overall mortality rate for acute coronary syndrome is 20-40%, with most patients dying before they reach the hospital (many from a fatal arrhythmia such as ventricular fibrillation). The fact that a person has a high risk of death can be said by the following signs:

• a person over 60 years old;
• his blood pressure dropped;
• increased heart rate;
• acute heart failure has developed above Kilip class 1, that is, there are either only moist rales in the lungs, or the pressure in the pulmonary artery has already increased, or pulmonary edema has developed, or a state of shock has developed with a drop in blood pressure, a decrease in the amount of urine separated, impaired consciousness;
• the person has diabetes;
• a heart attack developed along the anterior wall;
• the person has had a myocardial infarction.

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

Modern management of patients with acute ischemic myocardial injury is based on the pathogenesis and morphology of coronary heart disease (CHD). The morphological substrate of IHD is an atherosclerotic plaque, the state of which largely determines the clinical variants of the disease: unstable angina, myocardial infarction with a Q wave and myocardial infarction without a Q wave. Since in the first hours (and sometimes days) from the onset of the disease, it can be difficult to differentiate acute myocardial infarction and unstable angina pectoris, to designate the period of exacerbation of coronary artery disease, the term "acute coronary syndrome" (ACS) has recently been used, which means any group clinical signs to suspect myocardial infarction or unstable angina. ACS is a term that is valid at the first contact between a doctor and a patient, it is diagnosed on the basis of pain syndrome (prolonged anginal attack, first-time progressive angina pectoris) and ECG changes, and therefore is especially suitable for the pre-hospital diagnosis and treatment of IHD destabilization.

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

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

For the success of TLT therapy in ACS with ST segment elevation, the most important role is played by its early start - optimally, within 1 hour after the onset of pain. It is no coincidence that the standard of care for patients with ACS in the UK is TLT within 1 hour from the onset of symptoms (Department of Health. National Service Framework for coronary heart disease. 2000).

The clinical guidelines developed working group of the European Society of Cardiology and the European Council for Resuscitation for the Treatment of Acute Heart Attacks in the Prehospital Stage, TLT is recommended if there are local programs for prehospital thrombolysis, the availability of qualified personnel at the stage of prehospital treatment, in a different situation - in case of a delay in transportation of more than 30 minutes or delaying inpatient reperfusion therapy by more than 60 minutes. The American College of Cardiology, in conjunction with the American Heart Association, have categorized recommendations for the prehospital use of thrombolytics as low-evidence-based recommendations and provide for the use of thrombolytic agents in situations where the expected loss of time to transport a patient is more than 90 minutes.

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

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

According to the recommendation of the ACA / AHA (2002), the treatment of ACS involves the use of nitroglycerin to relieve pain, reduce preload and myocardial oxygen demand, limit the size of myocardial infarction, as well as to treat and prevent complications of myocardial infarction. The recommendations developed by the working group of the European Society of Cardiology and the European Council for the Resuscitation of Acute Heart Attacks in the prehospital stage do not recommend the widespread use of nitrates, but their use in persistent pain or the presence of heart failure is recognized as justified.

Relief of pain in ACS begins with sublingual administration of nitroglycerin (0.4 mg in aerosol or tablets). In the absence of effect from sublingual administration of nitroglycerin (three doses with breaks of 5 minutes), therapy with narcotic analgesics is indicated. It should be noted that there have been no serious studies of the effectiveness of nitrates in non-ST elevation ACS on the ECG, especially since there has not been a comparative study of the effectiveness of various dosage forms nitroglycerin. Nitroglycerin comes in five main forms: sublingual tablets, oral tablets, spray/aerosol, transdermal (buccal), and intravenous. When providing emergency care, aerosol forms (nitroglycerin spray), tablets for sublingual use and solution for intravenous infusion are used.

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

In our study, a comparative evaluation of the efficacy and safety of the use of nitroglycerin in the form of an aerosol (123 patients) or intravenous infusion (59 patients) was carried out in non-ST elevation ACS. were evaluated clinical condition, the presence of pain, blood pressure and heart rate, ECG at baseline and 15, 30 and 45 minutes after parenteral or sublingual administration of nitrates. There was also monitoring unwanted effects medicines. In addition, a 30-day prognosis in patients was assessed: mortality, the incidence of Q-myocardial infarction in patients with initial non-ST elevation ACS.

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

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

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

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

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

Algorithm for managing a patient with ACS at the prehospital stage

Bibliography:

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

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

Clinical researches drugs for emergency cardiological conditions at the prehospital stage.// Collection of materials of the second congress of cardiologists of the Southern Federal District " Contemporary Issues cardiovascular disease". Rostov-on-Don.-2002-S. 58. (Vertkin A.L., Malsagova M.A., Polosyants O.B.).

Step 1. Assess the severity of the condition and the risk of death

Stage 2. Analysis of the electrocardiogram

Stage 3. Treatment of acute coronary syndrome at the prehospital stage

Anesthesia:
- nitroglycerin under the control of blood pressure
- intravenous analgin + diphenhydramine
- IV morphine 1% - 1.0 per 20.0 saline.

Possible complications:
-
- acute heart failure

Initial antithrombotic therapy in acute coronary syndrome

Emergency hospitalization in the intensive care unit: for thrombolytic therapy (introduction of streptokinase, streptodecase), as well as to resolve the issue of coronary angiography and balloon coronary angioplasty

One of the most dangerous diseases is acute coronary syndrome, emergency care for it can save a person's life. Such common diseases as atherosclerosis, coronary heart disease and others can lead to it.

What is OKS?

The term ACS is understood as acute disorders of the blood supply to the heart - myocardial infarction and unstable angina. As a rule, acute coronary syndrome develops in people suffering from coronary heart disease and other types of angina pectoris. It can be provoked by physical activity, emotional experiences, the use of large doses of caffeine, and the use of certain drugs. Risk factors for the development of ACS: overweight, sedentary lifestyle, smoking, alcohol abuse, consumption of large amounts of salt, caffeinated foods, chocolate. ACS develops more often and is more severe in men.

Symptoms of ACS, according to which diagnosis is also possible:

1. 1. Pain behind the sternum or on the left side chest- pressing, squeezing. It is not relieved by taking analgesics and nitroglycerin, does not go away on its own within half an hour (a distinguishing feature from angina pectoris). The pain radiates under the left shoulder blade, in the left shoulder and arm, in the left half of the neck and lower jaw, sometimes in the left half of the abdomen and left leg.
2. 2. Shortness of breath, in some cases - suffocation and signs of pulmonary edema.
3. 3. Paleness, cold sweat, weakness up to fainting, fear of death.
4. 4. Violations heart rate, weak pulse, drop in blood pressure.
5. 5. Less typical case - pain in the stomach (gastralgic form of ACS). Distinguishing sign from exacerbation of gastritis or peptic ulcer- shortness of breath and heart rhythm disturbances.

If the patient has pain characteristic of ACS, even if there are no other signs or they are mild, it is necessary to call an ambulance. How faster patient gets to the hospital, the more chances he has for subsequent rehabilitation. It is imperative to reassure the patient, because the fear of death that occurs as a symptom of ACS is quite justified, and emotional experiences aggravate the patient's condition.

What to do in a critical case?

In acute coronary syndrome, time is of the essence. According to the WHO, if the blood flow in the heart is restored within an hour and a half, then a complete rehabilitation of the patient after ACS is possible.

First aid for ACS is a measure to stabilize the patient's condition that can be applied at home. The first thing the patient needs to do is stop physical activity, unfasten the collar, belt and other interfering elements of clothing, take a reclining position with legs down (for example, sit on the edge of the bed, leaning on the pillows). This position reduces the risk of pulmonary edema. It is necessary to ensure the maximum possible influx of fresh air - open windows and, if necessary, doors in the room. It is extremely undesirable to move, therefore, the surrounding people should take care of the patient until the ambulance arrives.

The second thing to do is medical relief of the condition. The patient should be given acetylsalicylic acid (1-2 tablets), nitroglycerin under the tongue - 1 tablet every 10 minutes. Perhaps the use of sedatives - valerian, motherwort in tablets. It is possible to take nitroglycerin only if the patient's blood pressure is not lower than 90 mm Hg, if it is not possible to measure it, then it is necessary to focus on the patient's condition. If taking nitroglycerin did not cause a significant deterioration, then you can take the next pill. Sedative drugs should not be used in the form of alcohol solutions and tinctures, so as not to aggravate the patient's condition. The acceptance criterion is the same as for nitrates - blood pressure or the patient's condition. If the patient has lost consciousness, then drug therapy should not be carried out until the doctor arrives. You can take beta-blockers if you have them on hand.

It is important to monitor the patient's condition, as complications of the coronary syndrome may develop: pulmonary edema, impaired cerebral circulation. It is necessary to talk with the patient, calm him down, because the emotional state is also an important part of emergency care for acute coronary syndrome. The patient needs to calm down and maintain a positive attitude.

The algorithm for providing emergency care for ACS for ambulance workers is more complex and effective. It includes on-site diagnosis of ACS and measures to stabilize the patient's condition.

The first thing the cardiology ambulance team will do is take an ECG. Its results are the main criterion for the diagnosis of acute coronary syndrome. Already in the first minutes of the ECG, 2 types of ACS are distinguished - with the rise of the ST segment (caused by a thrombus that completely blocks the lumen of the vessel) and without the rise of this segment (caused by other causes, except for a thrombus).

The brigade's next steps are as follows:

1. 1. The patient should be half-sitting with legs down or lying on his back, if there is no pulmonary edema, all interfering clothing should be removed or unbuttoned.
2. 2. Oxygen therapy - an oxygen mask on the face, in severe cases - intubation.
3. 3. Nitroglycerin, Acetylsalicylic acid, beta-blockers - if the patient is conscious, and if these drugs have not been taken before.
4. 4. Heparin, Fraxiparine and other anticoagulants subcutaneously.
5. 5. Morphine or other narcotic analgesics intravenously once. It is important to monitor the patient's breathing, because narcotic analgesics depress the respiratory center and can lead to respiratory arrest.
6. 6. If there is a rise in the ST segment - thrombolytic drugs.
7. 7. Elimination of complications of ACS, if any.
8. 8. Delivery of the patient to the cardiological hospital.

It is believed that pain in the heart with angina pectoris lasts no more than 10 minutes and disappears on its own, and with ACS - more than half an hour and does not stop on its own. But if the pain in the heart that has arisen does not go away after taking nitroglycerin and remains for more than 10 minutes, it is necessary to call an ambulance without waiting until half an hour has passed, since time plays a decisive role in this case.