Tbilisi 2010 Tbilisi

#3
$5
Tbilisi
2010
Tbilisi
redaqtori: giorgi CaxunaSvili med.mec.doqtori
Editor in chief: GEORGE CHAKHUNASHVILI MD.PHD.Professor
saredaqcio kolegia:
Editorial Board:
mamanti rogava
manana RuduSauri
konstantine CaxunaSvili
nino jobava (redaqtoris moadgile)
dito tabucaZe
vladimer zardaliSvili
neli TofuriZe (kolegiis mdivani)
neli badriaSvili
Temur miqelaZe
manana SvangiraZe
maia inasariZe
mixeil mWedliSvili
merab maTiaSvili
maka ioseliani
TamTa metreveli
nino Wanturaia
lali kvezereli
mamuka CxaiZe
TinaTin kutubiZe
zurab SaqaraSvili
giorgi didava
vaxtang xelaSvili
nino marinaSvili
marine xecuriani
MAMANTI ROGAVA MD.
MANANA GUDUSAURI MD.
KONSTANTINE CHAKHUNASVILI MD.PHD. PROF.
NINO JOBAVA (CoEditor) MD.
DITO TABUCAZE MD, PROF.
VLADIMER ZARDALISVILI MD.
NELI TOFURIZE (Secretary of Board) MD.
NELI BADRIASHVILI MD.
TEMUR MIKELADZE MD.
MANANA SHVANGIRADZE MD.
MAIA INASARIDZE MD.
MIKHEIL MCHEDLISHVILI MD.
MERAB MATIASHVILI MD.
MAKA IOSELIANI MD.
TAMTA METREVELI MD.
NINO CHANTURAIA MD.
LALI KVEZERELI MD.
MAMUKA CXAIDZE MD.
TINATIN KUTUBIDZE MD. PROF.
ZURAB SHAQARASHVILI MD.
GIORGI DIDAVA MD. PROF.
VAXTANG XELASHVILI
NINO MARINASHVILI
MARINE XECURIANI
ILYA M. YEMETS PROF. /ukr/
FABIO PIGOZZI PROF. /Italia/
DIRK-ANDRE CLEVENT MD. /Germany/
CONTENTS
sarCevi
saqarTvelos bavSvTa kardiologTa asociacia ........................................................................................... 5
The clinical significance of ST-segment deviation and T wave changes in children ............................................. 8
ST segmenti da T-kbili janmrTel bavSvebsa da zogierTi anTebad da araanTebad
daavadebebis dros pediatriaSi. (NEHB-is ganxrebis gamoyenebis perspeqtiva
pediatriaSi-prevenciuli kardiologiis sakiTxebi) ............................................................................... 9
QT intervalis Tanamedrove problemebi bavSvTa da mozardTa kardiologiaSi ....................... 24
MITRAL VALVE PROLAPS ......................................................................................................................................................... 28
Use of BNP and NT-proBNP in Early stage Diagnosis of
Athlete’s Cardiovascular Pathologies: Literature Overview .......................................................................................... 30
gul-sisxlZarRvTa sistemis funqciuri mdgomareoba faruli vegetatiuri
disfunqciisa da sisxlZarRvovani hi perreaqtiulobis dros sportsmen bavSvebsa
da mozardebSi (diagnostikis, mkurnalobisa da prevenciis sakiTxebi) ......................... 39
persistiuli ovaluri xvreli - Tanamedrove xedva ............................................................................ 42
Patent Foramen Ovale – Contemporary View ...................................................................................................................... 43
medikamentebis arasasurveli reaqciis monitoringis organizacia
saqarTveloSi ................................................................................................................................................................................. 44
Adverse drug reactions monitoring in Georgia .................................................................................................................... 46
klinikuri protokolebi. damtkicebulia Sps g.Jvanias saxelobis
pediatriuli klinikis stacionaris eqimebisTvis
bronquli asTmis Setevis (gamwvavebis) marTva .......................................................................................... 48
mwvave bronqioliti ................................................................................................................................................................. 50
pediatriuli gastroezofaguri refluqsi .................................................................................................... 54
neonataluri pnevmonia ......................................................................................................................................................... 58
bavSvTa asakis mwvave arahospitaluri pnevmoniis marTva .............................................................. 62
virusuli krupis sindromis (mwvave laringotraqeitis) marTva ............................................ 65
test-kiTxvarebi eqimebisTvis
test-kiTxvari eqimebisaTvis ............................................................................................................................................ 68
4
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2010 weli
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5
saqarTvelos bavSvTa
kardiologTa asociacia
s.b.k.a. Camoyalibda Tssu-s pedklinikis bazaze
1992 wels, registrirebul iqna 1999 wlisTvis.
aRniSnuli asociacia warmoadgens kavSirs,xuTi
fizikuri piris mier Camoyalibebuls, romelic
daarsda saqarTvelos 1997 wlis samoqalaqo
kodeqsis debulebebis Sesabamisad. `asociaciis~
saqmianobis vada ganusazRvrelia, aqvs damoukidebeli balansi saqarTvelosa da ucxoeTis sabanko dawesebulebebSi. am kavSiris miznebs warmoadgens _ formulirebismoZeb nagul-sisxlZarRvTa sistemis revmatituli, revmatuli, ararevmatuli dazianebebis, gulis iSemuri daavadebaTa,
miokardiumis infarqtiT, kardiopaToebis sxvadasxva formebis, bavSvTa hi potenziebis, sportuli gulis da sxva paTologiuri procesebis naadrevi diagnostirebaSi, kardiologiis ganviTareba, agreTve bavSvTa kardilogiiT dainteresebul student-axalgazrdobisadmi yovelgvari
daxmarebis gaweva. saqmianobis sagans warmoadgens gulsisxlZarRvTa usisxlo instrumentuli kvleva. e. kg. 15 ganxrSi, fag _ datvirTvisas,
eleqtrogamoTvliT velometria, pulsuri mrudebi, kapidari skopa, reografia, eqokardiografia da
sxva. agreTve, imunologiuri da genetikuri markerebis kvleva. aRsaniSnavia, rom `asociaciis~
wevrebi SeiZleba iyvnen rogorc iuridiuli aseve fizikuri pirebi, romlebic iziareben mis miznebsa da saqmianobis princi pebs werilobiTi
gancxadebis safuZvelze. `asociaciis~ wevrebs
akisriaT garkveuli ufleba-movaleobebi. monawileobis miReba wesdebiT gaTvaliswinebuli wesiT. `asociaciis~ marTvaSi, isargeblon asociaciis konsultaciebiT da rekomendaciebiT, monawileoba miiRon ganzraxul proeqtebze, miiRon
finansuri mxardaWera `asociaciis~ fondebidan,
agreTve _ gavidnen `asociaciidan~. `asociaciis~
marTvis organos warmoadgens `asociaciis~ wevrTa `saerTo kreba~, romelicmoiwveva 1 jer weliwadSi, an saWiroebisamebr. TiTo wels miekuTvneba TiTo xma. winamdebare wesdeba ZalaSia misi registraciis TariRidan. amrigad, aRniSnul
asociacis kardiologiis dargSi akisria mniSvnelovanifunqcia-movaleobebi, romelic dafuZnebulia eqimTa gulisxmierebasa da SemoqmedebiT
damokidebulebaze am dargis mimarT.
saqarTvelos bavSvTa
kardiologTa asociacia
saqvelmoqmedo aqciebi
1992wlidan 1998 wlamde mimdinareobda periodulad mosaxleobis humanitaruli gasinjvebi.
sul 1998 wlidan socialuri pediatriis fondTan erTad daiwyo saqvelmoqmedo aqciebi. aqciebSi monawileoben: gamoCenili qarTveli pediatrebi. mimdinareobs avadmyofTa labora toriu2010 weli
li da instrumentuli kvleva da sxva. urigdebaT medikamentebi. CautardaT ramdenime aTeuli
saswrafo operacia. aTobiT avadmyofs Cautarda
ufaso gamokvleva da mkurnaloba sxvadasxva
wamyvan klinikebSi.
07.01.98-07. 02. 99ww. Tbilisi, gaisinja 9200 bav
Svi. 23.24.01.99w. aRmosavleT saqarTvelo. centri
q. Telavi. gaisinja 3500-ze meti bavSvi. 12-13-14. 02.
99 Tbilisi televiziis muSakTa Tvis Ria karis
dRe; gaisinja 100-mde bavSvi da daurigdaT medikamentebi. dedaTa da bavSvTa sadiagnostiko
centrSi da agreTve qalaqis sxvadasxva poliklinikebSi Camoyalibda maRalkvalificiur profesor-maswavlebelTa ufaso konsultaciebi
kviraSi erTjer. qalaqis wamyvan pediatriul
klinikebSi tardeba maRalkvalificiur profesor-maswavlebel Taufaso konsultaciebi TveSi erTjer. aqciebSi sxvadasxva profiliT monawileobdnen:
1. kanisa da venseneulebaTa instituti
2. parazitologiis samecniero-kvleviTi instituti da sxv. dawyebulia munisa da tilis
sawinaaRmdego profilaqtikuri RonisZiebebi
damkurnalobis etapi. aseve darigdeba Sesabamisi medikamentebi. daibeWda da gavrcelda munisa da tilis sawinaaRmdego Sesabamisi ufaso
samaxsovroebi.
12-13-14.03.99w. eqspedicia foTsa da abaSaSi. 13.
03. 99w. q. foTi,gaisinja 950 bavSvi. daurigdaT
metikamentebi.
13-14.03.99w. q. abaSa da abaSis raioni (s. qedisi, s. marani da sxv.)
29-30. 01-07. 08. 99w. gaisinja 4400 bavSvi,daurigdaT medikamentebi.
23-24-25. 08. 99 w. Catarda ufaso laboratoriuli da instrumentuli kvleva. q. xobi da q.
zugdi daurigdaT munisa da tilis sawinaaRmdego wamlebi.
04.04.99w. eqspedicia fasanaurSi kompleqsur
ad gaisinja 400-ze meti bavSvi.
07.05.99w. eqspedicia guriis regionSi. q. lan
CxuTi CautardaT ufaso laboratoriuli da
instrumentuli kvleva, daurigdaT medikamentebi.
18.05.99w. Catarda gasinjvebi q. rusTavSi (gaisinja 250-ze meti bavSvi, darigda medikamentebi).
22. 06. 99w. Catarda gasinjvebi sagarejoSi
(gaisinjda 250-ze meti bavSvi,darigda medikamentebi).
13-14.08.99 w Camoxatauri (gaisinja 1500-mde bavSvi).
15.08.99 w. baxmaro (gaisinja 2000-ze meti bavSvi-damsvenebeli) zRvis donidan 2050m.
16.08.99w. eqspediciagadavidabaxmarodan aWaris
maRalmTian raionebSi (sul gaisinja 750-ze meti
bavSvi) zRvis donidan 2300-2400m.
6
17.09.99 w. Catardakompleqsuri gamokvlevebi
Tbilisis upatrono bavSvTa saxlSi.
16.10.99w. Catarda gasinjvebi duSeTSi (gaisinja
200-mde bavSvi, darigda medikamentebi).
2000 weli
26.02.2000 w. q. gori gaisinja 500-ze meti bavSvi,
darigda medikamentebi
23.03.200 w. axalgori, gaisinja 30 bavSvi.
01.04.2000 w. marneulis r-ni sof. weraqvi gakeTda sisxlis saerTo analizi, instrumentuli gamokvlevebi - eqoskopia, encefalograma da sxva.
sul gaisinja 1500 bavSvi da momvleli.
15.04.2000. w. gurjaani kompleqsuri gasinjvebi,
gaisinja 1200-mde bavSvi darigda medikamentebi.
29.04.2000 w. q. rusTavi (kostavas #6) gaisinja
300-mde bavSvi.
05-06-07. 2000 w. gasinjulia avWalis koloni is
bavSvebi.
20.07-28.07. 2000 w. wyneTis bavSvTa saxlSi gasinjulia 60 bavSvi.
21-22-23.-7. 2000w. abaSis r-ni sof. sakieTisa da
samtrediis r-nis aRsazrdelTa skolis bavSvTa
gasinjvebi.
7-8.08. 2000 w. baxmaro-buSumi gaisinja 1925
bavSvi.
2001 w.
15.03. 2001 w. gaisinja da kompleqsuri gamokvleva Cautarda rusTavis azotis qarxnis TanamSromelTa bavSvebs.
23.06.2001w. gaisinja da kompleqsuri gamokv
levaCautarda rusTavis azotis qarxnis TanamSromelTa bavSvebs.
14-15-16. 09. 2001w. baRdadis r-ni sof. sairme, wiTelxevi, roxi, II obCa, xani, zegani, saqraula. gaisinja 2500 bavSvi.
2002 weli
10.03. 2002 w. axalgori gaisinja 250 bavSvi.
20-04. 2002wl. siRnaRis r-ni gaisinja 450
bavSvi
23-24-25-26. 2002w. xulo (aWara) sapatriarqosTan erTad gaisinja 600 bavSvi da 100 mozrdili.
27-28-29. 06. 2002w. q. Tbilisi 20 mozrdilTa poliklinika, 10 bavSvTa poliklinika, 121 bavSv Tapoliklinika gaisinja 400 bavSvi.
16-17-18-19. 07. 2002w. kodoris xeoba (afxazeTi)
gaisinja 250 bavSvi.
3-4-5-6. 2002w. mTa-TuSeTi,diklo,omalo,Senaqo,
gaisinja 200 bavSvi.
2003 weli
5. 03. 2003w. samcxe-javaxeTi gaisinja 1250
bavSvi.
17.04. 2003w. werovani gaisinja 450 bavSvi.
20.05. 2003w. borjomi gaisinja 870 bavSvi.
25.06. 2003w. mTa-TuSeTi gaisinja 320 bavSvi.
30.07. 2003w. baxmaro gaisinja 630 bavSvi.
20.08. 2003 w. zestafoni gaisinja 210 bavSvi.
7.09. 2003 w. zugdidi gaisinja 290 bavSvi.
15.10. 2003 w. raWa gaisinja 170 bavSvi.
18. 10. 2003 w. dmanisi gaisinja 180 bavSvi.
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2004 weli
marti-aprili-maisi: kaspi, gurjaani, Telavi, axmeta, lagodexi, siRnaRi, bodbe, aspinZa, axalcixe,
borjomi,Tbilisi,zestafoni,xaragauli,WiaTura
gaisinja 1728 bavSvi. socialuri pediatriis dacvis fondis mier saqarTvelos sapatriarqos TanadgomiT saqarTvelos sxvadasxva regionebSi:
zugdidi,xulo,xelvaCauri,qeda, lanCxuTi,ozurgeTi, ingiri _ Catarda saqvelmoqmedo aqciebi,
sadac gaisinja, Sesabamisi kvalificiuri samedicino konsultacia gaewia da medikamentebi daurigda 2400 bavSvs.
2005weli
mrneulis regionSi,gaisinja 700 bavSvi da 800
mozrdili.
18 ivlisi kaspi 450 bavSvi.
8 oqtomberi mcxeTis raioni 300 bavSvi.
14-15-16 oqtomberi lentexi 850 bavSvi da 200
mozardi.
2006 wlis 18 Tebervals klinikaSi Catarda
Ria karis dRe. gaisinja mxatvarTa kavSiris 20
ojaxi. martSi Ria karis dRe. gaisinja ltolvilTa 100-ze meti bavSvi. aprilSi saguramoSi
elCebis monawileobiT Catarda aqcia.
31 maiss q. rusTavSi gaisinja 450 bavSvi. 1-2 ivniss Tssu-Si Catarda Ria karis dRe.
2007 weli
_ bavSvTa kardiologia gaisinja 400 bavSvi. maT CautardaT konsultacia da klinikolaboratoriuli gamokvlevebi. 9-10 ivniss
kaspis raionSi Catarda gasvliTi gasinjvebi.
(gaisinja 300 bavSvi.
1 ivliss cxinvalis raionSi omSi monawileTa
500 bavSvi gaisinja. seqtember-oqtomberSi gaisinja 120 bavSvi.
noemberSi gaisinja JurnalistTa 100-200
ojaxi.
2006 wlis 18 Tebervals klinikaSi Catarda
Ria karis dRe. gaisinja mxatvarTa kavSiris 20
ojaxi. martSi Ria karis dRe. gaisinja ltolvilTa 100-ze meti bavSvi.
aprilSi saguramoSi elCebis monawileobiT
Catarda aqcia.
31 maiss q. rusTavSi gaisinja 450 bavSvi.
1-2 ivniss Tssu-Si Catarda Ria karis dRe. gaisinja 400 bavSvi.
maT CautardaT konsultacia da kliniko
laboratoriuli gamokvlevebi.
9-10 ivniss kaspis raionSi Catarda gasvliTi
gasinjvebi. (gaisinja 300 bavSvi.
1 ivliss cxinvalis raionSi omSi monawileTa
500 bavSvi gaisinja. seqtember-oqtomberSi gaisinja 120 bavSvi.
noemberSi gaisinja JurnalistTa 100-200
ojaxi.
2007 weli
marneuli. ufaso konsultacia Cautarda 110
bavSvs. gamovlindnen sqolioziT daavadebuli
bavSvebi. gadaecaT espanderebi da meToduri rekomendaciebi samkurnalo fizkulturis Sesaxeb.
2010 weli
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duSeTi. kansultacia Cautarda 280 bavSvs.
axaSeni. kansultacia Cautarda 85 bavSvs
2008 weli
1 ivnisi – Ria karis DdRe (gaisinja 200 bavSvi)
2 ivnisi Teddy bear (gaisinja 300 bavSvi)
14 ivnis axmeta (qaqucoba - gaisinja 450 bavSvi, romelTac CautardaT Semdegi gamokvlevebi
muclis Rrus eqoskopia,ekg da sxva. darigda Sesabamis medikametebi
27 ivnisi – saqarTvelos seqciis aRdgena
20 agvisto – Stop Russia/ igoeTis aqcia
1 seqtemberi – Stop Russia/ Tbilisi jaWvis aqcia
4 oqtomberi Ria karis DdRe konsultacia, gamokvlevebi: muclis Rrus eqoskopia, ekg da sxva.
Sedga mxatvrebis da xelvnebis moRvaweebis master-klasi bavSvebisTvis
6 dekemberi bergmanis klinikaSi ufasod gaisinja 110 bavSvi, romelTac CautardaT Semdegi
gamokvlevebi muclis Rrus eqoskopia,ekg da
sxva. darigda Sesabamis medikametebi
13.06.2009 xaSuri gaisinja 750 bavSvi
26.12.2009 barisaxo gaisinja 80 bavSvi
dRemde aqciebSi sul gaisinja 88950 bavSvi da
aTasobiT xanSiSesuli. saqvelmoqmedo aqciebi
grZeldeba.
bavSvTa kardiologiuri asociaciis mier
Catarebulia konferenciebi da simpoziumebi:
1992 w. I bavSvTa kardiologTa konferencia.
I konferencia `CvenTan erTad irwmune ukeTesi
momavlis realoba~
01.VI. 99
II konferencia `janmrTeli bavSvi mSvidobiani kavkasia~
25.XII. 99 III konferencia `dRevandeli ekonomikuri mimarTulebani pediatriaSi da misi perspeqtiva~ XXI saukunis pediatria _ invalidobis
profilaqtikis medicinad unda iqces.
01. VI. 2000 IVkonferencia `Canasaxidan bavSvis
ufleba unda iyos daculi~
27.III. 2001 Sexvedra saxalxo damcvelis ofisSi `arasrulwlovani damnaSaveebi, maTi uflebebi
da realoba~
01. 06. 2001 V (XIX) konferencia `miZRvnili
bavSvTa dacvissaerTaSorisodRisadmi~
30.03. 99, 01.06. 2000, 01.06. 2001
`bavSvTa mkurnaloba XXI saukuneSi~ simpoziumi 1, #2, #5
23.04.99.01. 06. 2000
`bavSvTa kveba XXI saukuneSi~ simpoziumi #1,
#2. 20. 05. 99. 01. 06. 2000
`orTopediuli skola~
simpoziumi #1, #2
17. 12. 99
`mukovis cidozis diagnostikisa da mkurnalobis sakiTxebi~
01. 06. 2000
axalgazrda pediatrTa XVIII konferencia
28. 02. 2001
2010 weli
7
erToblivi samecniero konferencia `respiratorul daavadebaTa Terapiis aqtualuri sakiTxebi pediatriaSi~.
01. 06. 2001
`Canasaxidan bavSvs ufleba aqvs iyos daculi~ simpoziumi #1
01. 06. 2001
`bavSvi, mozardi da ojaxuri Zaladoba~
simpoziumi #1
01. 06. 2001 `Canasaxidan bavSvs ufleba aqvs
iyos daculi~
simpoziumi #1
13. 02. 2002
`adamianis genomis proeqti~
10. 03. 2002 axalgori,matonizirebuli sasmeli
`lomisis~ prezentacia.
6. 11. 2002 saerTaSoriso konferencia Temaze:
`mukovis cidoziT da nivTierebaTa cvlis konstituciuri moSlilobiT daavadebulTa samedicino da socialuri problemebi~.
7. 11. 2002 saerTaSorisoko nferencia Temaze:
`Tandayolili infeqciebis Tanamedrove apeqtebi~.
4. 04. 2003
pediatriis aqtualuri sakiTxebi. IX konferencia.
1. 06. 2003
I internet-konferencia (X samecnieropraqtikuli konferencia) socialuri pediatriis dacvis fondi ufasod uSvebs da arigebs gazeTs `socialuri pediatria~ da Jurnals `socialuri pediatria~ (Suqdeba socialuri, samedicino, pedagogiuri, fsiqologiuri, fsiqiatriuli, religiuri da sxva aqtualuri da problemuri sakiTxebi)
19. 12. 2003 saqarTvelos bavSvTa kardiologTa II kongresi.
1. 06. 2004. II saerTaSoriso internet-konferencia. pediatriis aqtualuri sakiTxebi
22. 10. 2004. konferencia Temaze: `pediatriis
aqtualuri sakiTxebi~, romelic eZRvneboda socialuri pediatriis prezidentis, genetikosis
viqtor moroSkinis naTel xsovnas.
1. 06. 2005 pediatriis aqtualuri sakiTxebi
XIV konferencia.
9. 09. 2005 Tbilisi, merioti II saerTaSoriso konferencia `janmrTeli bavSvi mSvidobiani kavkasia~.
2006w. 1 ivnisi socialuri pediatris dacvis fondis konferencia. dekemberSi axalgazrda pediatrTa ligis eqim specialistTa
XXIII kongresi.
31.05. 2007 bavSvTa kardiologiis II kongresi.
7.12. 2007 spdf me-17 konferencia.
07.10.08. konferencia `bavSvis da mozardis~
kardiologiuri seqcia (Tbilisi).
20.12.08 socialuri pediatriis dacvis fondis da ESMNS erToblivi meore konferencia
(Tbilisi).
12.06.2009 socialuri pediatriis dacvis
fondis XX konferencia
18.12.2009 socialuri pediatriis dacvis
fondis XXI konferencia
8
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THE CLINICAL SIGNIFICANCE OF ST-SEGMENT DEVIATION
AND T WAVE CHANGES IN CHILDREN.
G.Chakhunashvili1,N.Jobava2,K.Chakhunashvili3.
Pediatric Clinic of Tbilisi State Medical University1,
Prophylactic Centre for Mother an Child2,
Treating-Prophylactic Centre3, Tbilisi, Georgia.
Aims. The study objective was to examine the prognostic predictive information of Twave abnormalities in children. The T-wave abnormality criterion was based on a new set
of normal T-wave amplitude limits differentiated by gender, age, electrocardiographic
lead, and QRS axis.
Methods: Total of 658 patients in the age of 0 to 15 were analyzed during the period of
1979-2006 years suspected of an acute ischemic incident Thirteen categories of T-wave
abnormalities were tested prospectively. Patients with following diseases were studied:
115 cases of juvenile rheumatic arthritis (:83 -with artricular and 32- Extra-articular form)
71 - Acute Non-rheumatoid carditis,125 - recurrent tonsilo- pharyngitis and 60 - congenital heart disease, 96 - mitral valve prolapse (MVP) and 85 - myocardial dystrophy. We
have included 205 children in control group.
Results: Quantitative T-wave analysis in an electrocardiographic core laboratory
revealed 6 of 13 pre-specified categories of T-wave abnormalities that were significantly
associated with an adverse outcome. T-wave abnormalities had no prognostic value
when ST-segment depression was also present, but this occurred in only 7.9% of
patients. T-wave abnormalities as the sole manifestation of ischemia were common
(74.4%). Patients with abnormal T waves in 1 of 6 selected abnormality categories
(70.3%) had a significantly higher risk of death, acute myocardial infarction, and refractory angina (11% vs 3%; P = 0.018).
Conclusion: Thus, T-wave abnormalities in patients presenting with non ST-segment
elevation acute coronary syndromes are common and should not automatically be
regarded as benign phenomena. Quantitative T- wave analysis provides optimal risk
stratification.
2010 weli
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9
ST segmenti da T-kbili janmrTel bavSvebsa da zogierTi
anTebad da araanTebad daavadebebis dros pediatriaSi.
(NEHB-is ganxrebis gamoyenebis perspeqtiva pediatriaSiprevenciuli kardiologiis sakiTxebi)
g. CaxunaSvili; n. jobava;
k. CaxunaSvili
Tssu-s g. Jvanias saxelobis pediatriuli
klinika
aTerosklerozisa da gid-is winamZRvrebi
bavSvTa asaks ekuTvnis. aqedan gamomdinare
prevenciuli RonisZiebebis dawyeba gadmotanili unda iyos pediatriaSi, miT umetes Tu
bavSvTaA asakSi gadatanili iqna iseTi daavadebebi, romelTa drosac dazianebuli iqna
gul-sisxlZarRvTa sistema, gamovlenili koronaruli ukmarisobiTa da gulis SekumSvadobis funqciis darRveviT. bolo wlebSi
moZraoba,,Cardial ridc in the yonuy-CRY” Zalian
mniSvnelovani RonisZiebebis gatarebisaken
mogviwodebs da aramarto sxvadasxva daavadeba gadatanili bavSvebsa da mozrdilebSi.
erT-erTi mniSvnelovani sakiTxia ST segmentisa da T-kbilis cvlilebani sportsmenebSi,
Tumca dRevandeli Sromis sagans es ukanaskneli ar warmoadgens.
aRniSnuli naSromis masalas warmoadgens
1997-2009ww Tbilisis bavSvTa saavadmyofoebSi(#2, rkinigzis #6) Tssu pediatriuli klinikasa da Tbilisis dedaTa da bavSvTa samkurnalo-profilaqtikur centrSi Catarebuli kompleqsuri klinikur-instrumentuli gamokvlevis Sedegebi.
Ggaanalizebulia 0-dan 15-wlamde asakis
658 avadmyofi, maT Soris 308 gogona, 350 vaJi.
sakontrolo jgufs Seadgenda imave asakis
120 praqtikulad janmrTeli bavSvi(gogona,
vaJi).
maTi SerCevis kriteriumi iyo somaturi,
arainfeqciuri da mwvave infeqciuri daavadebebis ar arseboba gamokvlevamde 3 kviris
ganmavlobaSi, Civilebis ar qona, biologiuri
asakis Sesabamisoba sapasporto monacemebTan.
Nnozologiebis mixedviT Seswavlili iqna:
revmatoiduli arTritis 115 SemTxveva(maT
Soris saxsrovani forma-83, saxsrovan-visceruli-32), ararevmatiuli karditi-71, tonzilogenuri kardiopaTia-125, gulis Tandayolili mankebi-60 SemTxveva(maT Soris wSZd-13,
2010 weli
pSZd-15, falos tetrada-10, aortis koarqtacia-12, aortis sarqvlis stenozi-10), mitraluri sarqvlis prolafsi-96, vegetosisxlZarRvovani distonia-85, miokardiodistrofia-80.
avadmyofebis ganawileba asakisa da klinikuri formebis mixedviT mocemulia cxrilSi
#1.
Seswavlili da gaanalizebuli iqna 120
praqtikulad janmrTel bavSvSi ST segmentis
cdomisa da T-kbilis farTi 12 Cveulebriv da
NeHb-is(A.D.I.) ganxrebSi.
eleqtrokardiogramas varegistrirebdiT
12 zodadad miRebul da 3 NeHb-is(A.D.I.) ganxraSi. Eeleqtrokardiogramis vizualuri Sefasebis garda vatarebdiT Semdegi parametrebis gaangariSebas: gulis SekumSvaTa sixSires,
atrio-ventrikuluri
gatarebis
dros(P-Rintervali), eleqtruli sistolis xangrZlivobas(QT), P kbilis amplitudas da siganes. repolarizaciis procesis mdgomareobis
Sesafaseblad vsazRvravdiT ST- segmentis
mdgomareobas, T-kbilis amplitudas da mis
farTs, romelsac vTvlidiT s.s. ostropolecis(1977) meTodiT. ST=M.h
sadac M - T kbilis siganea misi simaRlis
Suis doneze,
h - T- kbilis simaRle.
marcxena parkuWis eleqtrul aqtivobas
vafasebdiT Semdegi maCveneblebiT: Ravr ampituda, Rv6 amplituda, Qv5-v6 siRrme, Sv1 ampituda, R1+SIII+Sv1+Rv6 kbilebis sumaruli sidide.
marcxena parkuWis gadatvirTvis eleqtrokardiografiul maCveneblad viyenebdiT m.
gomirato sandruCis da g. bonos kriteriumebs: gulis eleqtruli RerZis gadaxra marcxniv; RavL 8mm-ze metia(eleqtruli RerZis
vertikaluri mdebareobis dros) da RavF 8mmze metia(eleqtruli RerZis vertikaluri mdebareobis dros). Rv6 amplituda 25mm-ze metis,
Qv5-v6 siRrme 4mm-ze metia, Rv5 20mm-ze metia,
marcxena gulmkerdis ganxraSi Sinagani gadaxris dros 0,45-ze metia ; Tv5-v6 ganrTxmulia an uaryofiTia.
Mmarjvena parkuWis eleqtruli aqtivoba
fasdeboda Semdegi maCveneblebis mixedviT :
Ravr ampituda, Rv1 amplituda, Sv5 siRrme,
,fdidsf rfhlbjkjubf
10
R1I+S1+Sv6+Rv1 kbilebis sumaruli sidide.
marjvena parkuWis gadatvirTvis eleqtrokardiografiul maCveneblad gamoiyeneboda m.
Ggomirato sandruCis da g. bonos kriteriumebi: RavR metia 4mm-ze, Rv1 17mm-ze metia, R/S V1
ganxraSi metia 4-mm-ze, Q-R forma V1-2 ganxraSi.
Sinagani gadaxris dro V1-2 metia 0,03s;
gulis eleqtruli RerZis gadaxra marvniv
110 gradusze metia.
winagulis eleqtruli aqtivobis Sesafaseblad vsazRvravdiT P2 kbilis sidides(mmSi), xangrZlivobas(wm-Si), kbilis fazis dadebiTobasa da uaryofiTobas.
Eeleqtrokardiografiuli cvlilebebis
gamoxatulebis xarisxs vafasebdiT m. k.
skolkovas(1976w0 klasifikaciis mixedviT.
ekg-ze zomierad gamoxatul cvlilebebs Seesabameba gulis ritmis gamoxatuli darRveva, T-kbilis gamoxatuli da myari Semcireba,
P-kbilisa da QRS-kompleqsis Tvisobrivi
cvlilebebi, PQintervalis aramyari dagrZeleba, kargad gamoxatul cvlilebebs warmnoadgens guliscemis ritmis aramyari moSla,
Sida winagulovani da winagulovan-parkuWovani gamtareblobis darRveva, T-kbilis myari
Semcireba, ST-intervalis cdoma, miokardiumis
eleqtruli aqtivobis myari cvlilebebi. ST
segmentis cvlilebebi iSemiiT mimdinare daavadebebis dros SeiZleba iyos, magram ST segmentis cdoma an misi aweva standartul ganxraSi 1mm-iT, an gulmkerdis ganxraSi 2mm-iT
SeiZleba janmrTelebSic aRiniSnos.
ix. sur. #2 ST segmentis paTologiuri
cvlilebebis konstataciisaTvis saWiroa daregistrirdes an misi qvemoT daxriloba inversiuli T kbilTan, an misi Semcireba 2mm-ze
metiT sawyis donesTan SedarebiT. roca ST
metia 0,08wm-ze (Sefrey p Morruy 1995). Aamas garda Cven vawarmoebdi ST segentis cdomisa da
T kbilis cvlilebaTa xarisxobriv daxasiaTebas. isazRvreboda ST segmentis cdomis
farTobi, T kbilis farTobi da maTi jami dinamikaSi. ST segmentisa da T kbilis monacemebi janmrTel bavSvebSi ganxilulia specialurad calke TavSi.
Tavi I
ST segmentisa da T kbilis monacemebi janmrTel bavSvebSi
elektrokardiografia rogorc gulis
struqturis funqciis eleqtruli aqtivobis
meqanizmebis da gamtareblobiTi sistemis
morfo-funqciuri mdgomareobis gamokvlevis
saSualeba dRemde ar kargavs Tavis mniSvne-
cxrili #1
avadmyofebis ganawileba asakisa da klinikuri formebis mixedviT
0-3w
# klinikuri
1
3-6w
6-10w
10-15w
diagnozi
mded
mamr
sul
mded mamr
sul
mded
mamr
sul mded mamr sul
ararevmatiuli
17
20
37
6
9
19
5
6
11
3
1
4
24
23
47
11
14
25
7
8
15
2
1
3
6
5
11
24
24
48
12
18
30
4
9
8
17
24
30
54
17
12
29
karditi
2
gulis Tandayolili
mankebi-
3
mitraluri sarqvlis
3
7
10
15
25
prolafsi
4
tonzilogenuri
kardiopaTia
5
miokardiodistrofia
10
10
20
11
10
21
12
10
22
9
8
17
6
vegetosisxlZarRvo
1
0
1
1
0
1
15
20
35
20
28
48
0
1
1
1
0
1
17
21
38
15
28
43
saxsrovan-visceruli)
0
0
0
0
0
0
7
8
15
8
9
17
sul
67
67
134
78
87
165
92
103
195
71
93
164
vani distonia
7
revmatoiduli
arTriti(saxsrovani
forma,
2010 weli
,fdidsf rfhlbjkjubf
lobas, ufro metic TandaTan viTardeba da
ixveweba. yuradRebas imsaxurebs iseTi damatebiTi eleqtrokardiografiuli ganxrebi
rogoricaa gulmkerdis Soreuli marjvena
ukana marcxena da orTogonaluri ganxrebi.
farTod gamoiyeneba eleqtrokardiografuli kvlevis SedarebiT axali saxeobebi – kardiointervalografia.
Eeleqtrokardiograma aris gulis biodenebis mrudi, romelic Sedgeba kbilebisa da
intervalebisagan. Nnormalur ekg-ze ganarCeven 6kbils(P,Q,R,S,T,U) DA Sesabamisad maT Soris intervalebs(PQ, RS-T). yvela kbils Tavisi morfologia aqvs. Sefasebisas yuradReba
eqceva : mis amplitudas anu mis simaRles(mm)
izoeleqtruli xazidan, mis sifarTes anu
xangrZlivobas(wm), konturebis sizustes, mimarTulebas izoeleqtruli xazidan zemoT(+), an qvemoT(-). intervalebis Sefaseba
xdeba xangrZlivobisa da formis mixedviT,
ekg-ze agreTve arCeven e.w. kompleqsebs, romlebic moicavs zogierT kbils da intervals.
Kkompleqsi gulis agznebis erTiani gamovlinebaa. Aarsebobs ori kompleqsi winagulovani
da parkuWovani. winagulovan kompleqss warmoadgens ZiriTadad P kbili, parkuWovani kompleqsi Seesabameba QRST(Q-T) intervals, romlis SemadgenlobaSi Sedian: sawyisi nawili
QRS kompleqsi, dasasruli nawili T kbili da
Sualeduri nawili RS-T segmenti.
kbili asaxavs agznebas winagulebis miokardiumSi, misi mimarTuleba Cveulebriv dadebiTia. P-Q intervali Seesabameba periods
winagulebis agznebis dawyebidan parkuWebis
agznebis dawyebamde(0,08-0,18s), Q-kbili asaxavs
agznebis gavrcelebas atrioventrikuluri
kvanZidan parkuWTa Zgideze, dvrilisebr kunTze, igi Cveulebriv yovelTvis uaryofiTia.
R-kbili yovelTvis zemoT aris mimarTuli
(garda deqstrokardiisa), igi asaxavs marjvena da marcxena parkuWebis kedlebis potencialebs. sadiagnostiko mniSvneloba aqvs R
da S kbilebis Tanafardobas. janmrTel bavSvebSi xandaxan adgili aqvs R kbilis eleqtrul alteracias. S kbili asaxavs miokardiumis bazaluri ubnebis ramdenadme dagvianebul agznabs. uxSiresad igi uaryofiTia. T
kbili asaxavs parkuWebis miokardiumis swrafi repolarizaciis process. janmrTel bavSvebSi is dadebiTia, garda AVR ganxrisa romelSic yovelTvis uaryofiTia. SesaZlebelia T kbili uaryofiTi iyos agreTve III, V (13) da iSviaTad V (4) ganxrebSi.
QRST kompleqsi asaxavs parkuWTa miokardiumSi agznebis gavrcelebis da Sewyvetis
process. ( Pesiakov D. F. 1967). ST segmenti normaSi TiTqmis izoeleqtrulia,Seesabameba
2010 weli
11
parkuWebis agznebis faziT mTlian mocvasa
da dawyebiT repolarizacias, xolo T kbili
asaxavs agznebis Sewyvetis dros. ST segmentis QRS komleqsTan Sedarebis adgili aRiniSneba J wertiliT, mis mdebareobas mniSvneloba aqvs ST segmentis cdomis gansazRvrisaTvis. Tkbilis Semdeg modis T-P horizontaluri intervali, romelic gulis simSvidis
mdgomareobas Seesabameba. Tkbilis Semdeg modis U kbili. Mmas igivenairi polaroba aqvs
rogorc T kbils.
QT intervali asaxavs eleqtrul sistolas. masSi gamoyofen or fazas: “agznebis fazas” Q-T intervali (Q kbilis dasawyisidan
T kbilis dasawyisamde), “agznebis Sewyvetis
fazas” T1-T intervali (T kbilis dasawyisidan- T kbilis dasasrulamde)
asakis mixedviT bavSvebSi ekg xasiaTdeba
varilurobiT, kbilebisa da intervalebis
xangrZlivoba ufro moklea vidre mozrdilebSi. xSirad gvxvdeba uaryofiTi T kbili,
QRS kompleqsis sawyisi deformacia (W da M
ti pis), uaryofiTi, orfaziani anu gadasworebuli R kbili (III ganxra), xSirad adreul
asakSi aris wvetiani P kbili, Rrma Q kbili (IIIII ganxra) da a.S. axalSobilTa ekg unda ganixilebodes fiziologiuri Taviseburebebidan gamomdinare(dabadebis Semdgomi sisxlis
mimoqcevis gardaqmna). Aam dros ekg-ze wina
planze gamodis Tkbilis cvlilebebi: marjvena
gulmkerdis ganxrebSi T6 kbili dadebiTia 47dRis asakamde, Semdeg igi xdeba uaryofiTi
da prepubertatul asakSi xdeba dadebiTi. T
kbilis forma axalSobilebSi mWidrodaa dakavSirebuli filtvis arteriasa da marjvena parkuWSi arsebul wnevasTan. sanam es wneva metia 35mmvws-ze manamde T dadebiTia. V pirvel ganxraSi marcxena. prekardialur ganxaraSi bavSvebis naxevars T kbili uaryofiTi an
orfaziani aqvs. standartul da gaZlierebul ganxrebSi kidurebidan T kbili dabalia,
zogjer sul gadasworebuli, xolo III ganxraSi uaryofiTi. ST segmenti izoeleqtrul
xazzea sicocxlis pirvel dReebSi T1-T intervali aWarbebs Q-T intervals. dRenaklulebSi T kbili dabalamplitudiania, gulmkerdis ganxrebSi 15dRemde uaryofiTia V3 ganxraSi. ST segmenti ganicdis cdomas izoeleqtruli xazidan, miT ufro metad rac ufro metia dRenaklulobis xarisxi. T kbilis dabali amplituda da uaryofiTi pozicia aseve
dakavSirebulia dRenaklulobis xarisxTan.
III xarisxis dRenaklulebSi ekg yvela maCvenebeli mxolod me-20 dRes uTanabrdeba janmrTeli axalSobilis pirvel dRes.
Cvil bavSvebSi ekg TandaTan ganicdis
cvlilebebs, rac dakavSirebulia guliscemis
sixSiris SecvlasTan, kunTovani da nervuli
12
sistemis momwifebasTan, rac Seexeba kerZod T
kbils, igi II da III standartul ganxrebSi
dadebiTia, III standartul ganxraSi SeiZleba
iyos dadebiTic, orfazianic, izoeleqtrulic
da uaryofiTic. AVL ganxraSi aqvs dadebiTi
T kbili umravlesobas, xolo AVF ganxraSi
yvelas. uaryofiTi T kbili registrirdeba
V(1) V(2) ganxrebSi marcxena gulmkerdis ganxrebSi T kbili yvelas dadebiTi aqvT.
adreuli asakis (1-3 weli) bavSvebSi adgili aqvs standartul ganxrebSi R da T kbilis Tanafardobis darRvevas T kbilis matebis xarjze, pirvel or standartul ganxraSi T kbili Seadgens R kbilis 1/3-1/4 nawils.
am asakSi ukve marjvena parkuWovani upiratesoba icvleba marcxena parkuWis upiratesobiT.
skolamdeli asakis (3-6 weli) bavSvebvis
ekg-saTvis damaxasiaTebelia R,S,T kbilebis
momateba standartul ganxrebSi(I-II-III). erTpolusian gulmkerdis ganxrebSi SesaZlebelia iyos uaryofiTi T kbili, xolo marjvena gulmkerdis ganxrebSi aRiniSneba S-T intervalis cdoma.
saskolo asakis (7-15 weli) bavSvebis ekg TandaTan zrdasruli adamianisas uaxlovdeba, Tumca jer kidev rCeba labiluri pulsi da sinusuri ariTmiis gamovlinebebi. rac Seexeba
tkbils III standartul da marjvena gulmkerdis ganxrebSi (zogjer V3-V4-Sic) SeiZleba iyos
uaryofiTi. II standartul ganxraSi T kbilis Sefardeba R kbilTan Seesabameba – 1:3; 1:4-s.
rogorc zemoaRniSnulidan gamomdinareobs sxva ramdenime TaviseburebebTan erTad,
bavSvTa asakSi ekg-sTvis damaxasiaTebelia
uaryofiTi T kbilis arseboba(III. V1-V4 ganxrebi).
normaluri ekg-dan gadaxra SeiZleba moxdes janmrTel gulze refleqsurad, Tavis
tvinis qerqis mxriv, SeiZleba vegetatiuri
nervuli sistemis aSlilobiT iyos gamowveuli, SesaZloa iyos miokardiumis dazianebis
(distrofia, sklerozi, sisxlCaqceva) Sedegi
an koronaluri sisxlis mimoqcevis darRvevis gamo da a.S. ekg-is yvelaze labiluri
elementi aris ST segmenti misi cvlilebebi
ganixileba T kbilis cvlilebebTan erTad.
normaSi ST mTlianad ar emTxveva izoeleqtrul xazs, zusti horizontaluri mimarTuleba ST segmentisaTvis unda CaiTvalos paTologiad(garda III ganzrisa). paTologiad iTvleba ST segmentis izoeleqtruli xazidan
daweva an aweva standartul ganxrebSi 1 mmze metad da gulmkerdis ganxrebSi 1,5-2 mm-ze
metad. agreTve misi formis Secvlad. Tumca
maRali T kbilis SemTxvevaSi ST segmentis
2mm-iT aweva da uaryofiTi an orfaziani T
kbilis SemTxvevaSi 1,5 mm-iT daweva SeiZleba
,fdidsf rfhlbjkjubf
paTologiad ar CaiTvalos.
sxvadasxva paTologiurma procesebma (iSemiuri daavadeba, mwvave perikarditebi, vegetaturi da endokrinuli darRvevebi) SeiZleba gamoiwvion ST segmentis cdoma zemoT.
magram aseTive cvlileba SeiZleba hqondeT
janmrTel bavSvebs vagotoniisa da parkuWebis adreuli repolarizaciis sindromis
dros. ST segmentis cdoma zemoT an qvemoT.
agreTve QRS kompleqsis amplitudis da siganis momateba, warmoadgens paTologias da
Cveulebriv Tan axlavs miokardiumis trofikis kerovani an difuzuri moSla (repolarizaciis pirveladi darRveva). ST segmentis daweva SeiZleba aRiniSnebodes koronaluri
ukmarisobis dros, magram specifikur niSnad
ar iTvleba, SeiZleba ganpirobebuli iyos
funqciuri mizeziT da ara organuli dazianebiT. Mmiokardiumis infarqti da filtvis
arteriis embolia, rogorc wesi, mimdinareobs
ST segmentis cvlilebiT. infarqtis mwvave
stadiaSi ekg-s aqvs monofazuri mrudis saxe.
ST segmentis rkalisebri simrude miuTiTebs
perikarditze, izoxazidan qvemoT cdoma zemoT mimarTuli simrudiT da uaryofiT an
orfazian T kbilSi gadasvla registrirdeba parkuWTa hi pertrofiis da hisis konis
fexis blokadis dros. ST segmentis sxvadasxva cvlilebani.
T kbilis cvlileba gulisxmobs mis momatebas, gabrtyelebas da mimarTulebis Secvlas. Avr ganxraSi T kbili yovelTvis uaryofiTia. uaryofiTi T kbili gulmkredis yvela
ganxraSi SeiZleba hqondeT Cvili an adreuli asakis janmrTel bavSvebsac. asakTan erTad T veqtoris RerZis mimarTuleba ixreba
win rasac mosdevs uaryofiTi T kbilis amogdeba gulmkerdis ganxrebidan marcxnidan
marjvena mimarTulebiT. janmrTel bavSvebSi
mesame ganxraSi SeiZleba hqondeT uaryofiTi
T kbili, magram uaryofiTi T kbili romelime or standartul ganxraSi paTologiis niSania. T kbilis simaRle normaSi icvleba R
kbilis simaRlis paralelurad. T kbilis paTologiuri Secvla imavdroulad QRS kompleqsis Secvlis gareSe miuTiTebs parkuWis
miokardiumSi aRdgeniTi da cvliTi procesebis darRvevaze da aRiniSneba distrofiisa
da anTebis (repolarizaciis pirveladi darRveva) dros, xolo es cvlilebebi xdeba erTdroulad
miokardiumis
hi pertrofiis
dros (repolarizaciis meoradi cvlileba).
uaryofiTi T I-II, T V5-6 kbilebi aRiniSneba
marcxena parkuWis hi pertrofiis dros (hi pertonuli daavadeba, mwvave nefriti da gTm),
xolo uaryofiTi T III, T V1-2 kbilebi marjvena parjuWis hi pertrofiis dros (gTm, mitraluri stenozi, filtvismieri guli), magram
2010 weli
,fdidsf rfhlbjkjubf
SesaZlebelia iyos janmrTel bavSvebSic.
uaryofiTi, deformirebuli T kbili SesaZloa iyos parkuWebis miokardiumSi sisxlmomaragebis darRvevis niSani (miokardiumis
iSemia, mikoardiodistrofia, miokarditi, perikarditi). maRali, wvetiani T kbili gvxvdeba
vagotoniis, hi perkalemiis, miokardiumis subendokardiuli iSemiis, parkuWebis diastoluri gadatvirTvis dros. maRali viwro wvetiani kbili mokle izoeleqtrul ST segmentis fonze hi perkalemiis dros aucilebelia
gavarCioT maRali, momrgvalebuli, farTo T
kbilisagan bradikardiis fonze da wamoweuli ST segmentisagan vagotoniis dros. T kbilis amplitudis Semcireba SeiZleba iyos
hi pokalemiis simpatikotomis dros. T kbilis
gamoxatuli damokleba an dagrZeleba SeiniSneba eleqtrolituri balansis darRvevis
fonze da revmatiuli karditis dros.
gulze neirogenuli zemoqmedeba aisaxeba
ekg-s cvlilebebiT: maRali T kbili viwro fuZiT ST segmentis aRmaval mimarTulebasTan
erTad SeiZleba iyos nevrozis da vagusis
tonusis gaZlierebis dros. Tumca amgavri
cvlileba SeiZleba iyos repolarizaciis
procezze adrenerguli adaptaciur-trofikuli zegavlenis gamo da asaxavdes repolarizaciis optimalur mdgomareobas (ufrosi asakis bavSvebSi da sportsmenebSi). adrindeli
mosazreba, rom maRali wvetiani T kbili vagotoniis, xolo dabali, brtyeli simpatikotoniis damaxasiaTebelia ukanaskneli monacemebiT
saTuoa. T kbilis reaqcia neirogenul zemoqmedebaze yovelTvis erTgvarovani ar aris.
amgvarad, miokardiumis repolarizaciis fazis cvlileba (T kbili da ST segmenti), romelic miokardiumSi aRdgeniT procesebs asaxavs, moiTxovs diferenciacias. isini bavSvebSi gvxvdeba rogorc gulis organuli dazianebis (miokarditi, miokardiodistorfia, koronaluri ukmarisoba, perikarditi, parkuWTa hi pertrofia), ise eqstrakardialuri (vegetatiuri, hormonuli, eleqtrolituri-darRvevebis
an sxeulis mdebareobis Secvlis) mizezebis
Sedegad. Mmiokardiumis aRdgenis faza sxvadasxva faqtorebis (hemodinamikuri, bioqimiuri, fizikuri, neirogenuri) gavlenis qveSaa.
amitom T kbili da ST segmenti gamoirCevian
arastabilurobiT. T kbilisa da ST segmentis cvlilebiT SesaZlebelia Suilis bunebis dadgena (organuli Tu funqciuri) SesaZlebelia funqciuri sinjebis daxmarebiT.
rac Seexeba janmrTel bavSvebSi ekg-s Taviseburebebs gulmkerdis marjvena Soreul
ganxrebSi, T kbilTan dakavSirebiT SeiZleba
iTqvas rom igi miuxedavad eleqtruli RerZis mdebareobisa V7R ganxramde, rogorc we2010 weli
13
si, uaryofiTia, misis siRrme asakTan erTad
TandaTan mcirdeba V3R ganxridan V7R ganxramde bavSvebis nawilSi V5R ganxridan V6R
ganxramde T kbili iyo dadebiTi mimarTulebis, V3R-V7R ganxrebSi ki dadebiTi mimarTuleba narCundeboda. magram T kbilis amplituda FTandaTan mcirdeboda srul gaqrobamde V6R an V7R ganxrebSi. SevniSnavT, rom
msgavsad QRS kompleqsis RS-Si gadasvlisa
gulmkerdis gaxrebidan V3 gaxrebSi gulmkerdis marjvena naxevridanac arsebobs gardamavali forma. rogorc dakvirvebebma gvaCvena, RS formidan (marjvena parkuWis biopotencialebi) QR formaSi (marcxena parkuWebis
biopotencielebi) gadasvlis zona lokalizebuli unda iyos V4R an V5RganxrebSi.
janmrTeli bavSvebis ekg-is elementebis raodenobrivma da xarisxobrivma analizma NeHbis ganxrebSi gvaCvena Semdegi Taviseburebani:
D D (“dorsalis”) ganxraSi – naxevarze met
bavSvebs P kbili aqvs orfaziani meore dadebiTi fazis prevalirebiT. P kbilis amplituda yvela asakobriv jgufSi ar aRemateba
2mm-s da meryeobs 0,25-2mm-is farglebSi. parkuWovan kompleqss aqvs QR da QRS forma. Aam
ganxrebSi Q kbili registrirdeba yvela
asakSi 100%-Si. S kbili registrirdeba SemTxvevaTa 25%-Si, misi amplituda 6,5mm-s ar aRemateba. T kbili TiTqmis yovelTvis dadebiTia, misi amplituda daaxloebiT—— 3,5+5,75—— mm-ia. (ix. Dcrili#3).
A(“Anterior”) ganxraSi – P kbili dadebiTia,
iSviaTad orfaziani, misi amplituda yvela
asakobriv jgufSi meryeobs 0,5-2mm-is farglebSi kbilis sawyisi uaryofiTi faza ufro
naklebia vidre dadebiTi. parkuWocan kompleqss aqvs QR, QRS forma. am ganxraSi R kbilis amplituda ufro metia vidre D da I
ganxraSi. S kbili yovelTvis gamoxatulia. T
kbili yovelTvis dadebiTia da misi amplituda A ganxraSi ufro maRalia, vidre D da I
ganxraSi. (ix. cxrili 3)
I (“inferior”) ganxraSi – P kbili, rogorc
wesi, gamoxatulia. Mxolod bavSvebis nawili
hqondaT sustad dadebiTi (0,5mm). parkuWovan
kompleqss aqvs rS an RS da iSviaTad QR
forma T kbili ZiriTadad yovelTvis iyo dadebiTi, mxolod zogierTi hqondaT – orfaziani an uaryofiTi. uaryofiTi T kbili daufiqsirdaT im bavSevbs romelTac V4 ganxraSi hqodaT uaryofiTi, sustad dadebiTi an
orfaziani T kbili. QRS kompleqsis formis
da eleqtruli RerZis mimarTulebas Soris
kanonzomieri damokidebuleba nebis ganxrebSi ar dafiqsirebula. Mmagram zogierT bavSvebSi aRiniSna pirvel ganxraSi kbilebis amplitudis kavSiri eleqtruli RerZis mimarT
,fdidsf rfhlbjkjubf
14
gulis Semobrunebis dros: saaTis isris sawinaagmdegod mobrunebisas registrirdeboda
forma R da QR, saaTis isris mimarTulebiT
ki – rS an RS anu ufro zustad S kbili
Rrmavdeboda.
koregirebul orTogonul ganxrebSi ekg
kbilebis formiT mogvagonebis: X ganxraSi –
ekg-s I, avl, V6, ganxris, Y ganxraSi – ekg-s II,
AVFganxras, Z ganxraSi – V1, V2 ganxrisas.
Kkoregirebul orTografiul ganxrebsac
aqvs garkveuli asakobrivi Taviseburebebi amplitudis da drois parametrebis mxriv ekgis asakobrivi Taviseburebebi (4-dan 15 wlamde) ufro Z ganxraSi Cans. Aasakis matebasTan
erTad aRiniSneba R kbilis amplitudis Semcireba, maSin roca es kbili umniSvnelod icvleba. T kbili asakTan erTad imatebs xangrZlivobiTac da amplitudiTac. Uumcros asakobriov jgufSi (4-6 weli) xSirad registrirdeba (73%) uaryofiTi T kbili, maSin roca 10-12 wlis bavSvebs uaryofiTi an orfaziani T kbili SemTxvevaTa 15% -Si aReniSnebaT.
amgvarad, ganvixiloT ST segmentisa da T
kbilis cvlilebani sxvadasxva asakobriv
jgufebSi sakuTar masalaze dayrdnobiT, Tu
rogor gamoiyureba isini cxrilebis, suraTebisa da diagramebis meSveobiT.
#3 cxrilSi mocemulia T kbilis maximaluri da minimaluri simaRle, ekg-s 15 ganxraSi (12 Cveulebrivi da 3 NeHb-is) janmrTel
bavSvTa sxvadasxva asakobriv jgufebSi. #3
cxrilis monacemebSi asaxulia Cvens SromaSi.
T kbilis farTobi ganisazRvreba Semdegi
formuliT: S=2/3.a.h. sadac a aris sigane, xolo h simaRle. Sesabamisad diagramebi #-# 115 asaxaven T kbilis maqsimalur da minimalur farTs mm2, ekg-s 15 ganxraSi -12 Cveulebrivi da 3 NeHb-is, janmrTel bavSvTa sxvadasxva asakobriv jgufebSi.
Ddiagramebi #-# 1(a)-15(a) asaxavs dadebiTi
da uaryofiTi T kbilis SemTxvevaTa raodenobebs procentebSi. #4 da #5 cxrilSi mocemulia ST segmentis maqsimaluri cdoma
izoeleqtruli xazis zemoT da qvemoT(mm-iT
da mm2-iT). ST segmentis farTobi ganisazRvreboda Semdegi formuliT:
ST=QT1-QRS
S st=ST>XST
Ddiagramebi #-# 16-22 asaxaven ST segmentis
farTobs aRniSnul ganxrebSi.
#3 cxrilSi kargad Cans TiToeul ganxraSi T kbilis maqsimaluri dadebiTi, maqsimaluri da minimaluri simaRleebi, aseve uaryo-
fiTi minimaluri da maqsimaluri siRrmeebi.
rac Seexeba naxazebsa da diagramebs, isini saSualebas iZlevian bavSvebSi(asakis miuxedavad) ganisazRvros depresiuli T kbilis
arseboba:
I standartul ganxraSi – pirveli asakobrivi jgufis garda( diagrama #1).
II standartul ganxraSi-yvela asakobvriv
jgufSi(, diagrama #2)
AVF-Si pirvel or asakobriv jgufSi (diagrama#6),
V4-Si- bolo or asakobriv jgufSi (diagrama #10),
V5 da V6-Si-yvela asakobriv jgufSi (diagrama #11-12).
Ees ukanaskneli warmoadgens rogorc dRenaklul, ise droul axalSobilTa kardiologiaSi wamyvan sadiagnostiko kriteriumebs, romelic mniSvnelovania rogorc dasawyisSi daavadebaTa mkurnalobisaTvis, ise
misi dinamikis Sefaseba-prognozirebisaTvis
da rac mTavaria, reabilitaciis periodSi,
ukve mozrdilTa gul-sisxlZarRvTa sistemis daavadebaTa prevenciisaTvis.
rac Seexeba ST segmentis cdomas izoeleqtruli xazis zemoT igi bavSvTa asakis yvela periodSi gvxvdeba, magram uxSiresad ar
cdeba 1mm-s(cxrili #4), xolo izoeleqtrul
xazs qvemoT V5 da V6 ganxrebs garda maqsimaluri siRrme aqac umetes wilad 1mm-mdea
(cxrili #5).
Uunda aRiniSnos, rom ST segmentisa da T
kbilis morfologiuri cvlilebani unda ganixilebodes erTian konteqstSi: ST segmentis izoeleqtruli xazidan zemoT an qvemoT
cdoma misi formis gaTvaliswinebiT(rkalisebri, naxevarmTvarisebri, wvetiani, orfaziani+- an -+), rogor ST segments mosdevs da risi gagrZelebaa. Aamitom migvaCnia T kbilis
cvlilebisa da ST intervalis cdomis orientirad unda ganvixiloT ara T-P intervali, aramed P-Q segmenti, radgan praqtikulad
is ufro stabiluria da TiTqmis arasdros
ar ganicdis cdomas. Ggarda amisa, misi ST intervalTan siaxlovis gamo, am ukanasknelis
umniSvnelo cdomac ki SesamCnevia. arcTu iSviaTad T_P intervalis cdoma izoeleqtruli xazidan zemoT SeiZleba gamowveuli iyos
T kbilis daRmavali muxlis da momdevno P
kbilis SerwymiT taqikardiis an mkveTrad gamoxatuli UUkbilis dros.
ST intervalis cdomis xarisxi unda gaizomos izoeleqtruli xazidan, romelic P_Q
segmentis gagrZelebas warmoadgens. imasTan
dakavSirebiT, rom S_T intervalis forma Se2010 weli
,fdidsf rfhlbjkjubf
iZleba sxvadasxvagvari iyos, izoeleqtruli
xazidan intervalis cdomis donis gansazRvrisaTvis, Cveni azriT, unda gamoviyenoT S_T
intervalis QRS kompleqsTan SeerTebis wertili da ara S_T intervalis Suawertili.
Ekg-ze is wertili, rogorc wesi SesamCnevia,
igi repolarizaciis procesis dawyebas Seesabameba (#1). es wertili ucxour literaturaSi aRiniSneba aso J-Ti (Junetion-SeerTeba).
amdenad warmodgenil suraTSi#2 (ST segmentisa da T kbilis morfologia) naCvenebia
ST segmentisa da T kbilis morfologiur
cvlilebaTa 8 ti pi, saidanac aRsaniSnavia,
rom:
-cdoma zemoT ST segmentisa da T kbilis
cvlilebebTa erTad ti pi 2-3 ar dagviregistrirebia, garda ti pi I-sa(vagotonuri ti pi)
da isic 10 wlis zemoT, sxva asakSi iSviaTad.
- cdoma qvemoT ST segmentisa taqikardiuli ti pis (Vti pi) gvxvdeboda 0-3wlamde
asakSi, xolo hi pertonuli ti pis iSviaTad
da mainc 5wlis zemoT.
A amdenad, ST segmentisa da T kbilis morfologiuri cvlilebani princi pSi janmrTel
bavSvebSi ar gvxvdeba, Tu ar gaviTvaliswinebT
gardamaval asaks da riTmis mkveTr cvlilebebs bradikardiisa da taqikardiis saxiT.
Uupriania, rodesac vixilavT ekg-ze ST segmentisa da T kbilis cvlilebebs, aqve ar ganvixiloT QT intervalis gaxangrZliveba da
parkuWTa naadrevi repolarizaciis sindromi, miTumetes, rodesac bavSvTa asakzea saubari.
SedarebiT damaxasiaTebeli sindromi ekgze aris Senelebuli repolarizaciis sindromi(Q_T intervalis gaxangrZliveba), rac
eleqtruli sistolis xangrZlivobis matebas
asaxavs. Ees cvlilebebi periodulad emTxveva
parkuWovani
taqikardiis, parkuWTa
TrTolvis da asistoliis Setevebs, rac klinikurad vlindeba sisustiT, TavbrusxveviT,
zogjer sinkopeTi an krunCxviT. Q_T intervalis
gaxangrZlivebis
mizezi
ucnobia.
Aautopsiur masalazec ver i poves calsaxa
paTomorfologiuri substrati, rac sikvdilis mizezi gaxda.
literaturaSi Q_T intervalis gaxangrZlivebis ori variantia aRwerili: 1) siyruiTjervel-lange-nilsenis sindromi(Gervell A.
Lange-Nielson F 1957) da 2) siyruis gareSe – romano-uordis sindromi(Romano C Word O. 1963).
dRes maT erT sindromad ganixilaven Q_T intervalis gaxangrZlivebis sindromi.
Q_T intervalis gaxangrZliveba registrirdeba periodulad – SeiZleba gaqres da
isev gamoCdes. Mmisi Semokleba normamde mkurnalobis gareSe iSviaTi da droebiTia. arcTu
2010 weli
15
iSviaTad aRiniSneba repolarizaciis procesis darRvevis sxva niSnebic T kbilis amplitudis momateba an Semcireba, misi formis(orfazianoba, wvetianoba, gaxleCa, inversia)Ocvlileba, U kbilis momateba. rogorc Q_T
intervalis, ise T da U kbilebis forma da xangrZlivoba SeiZleba varirebdes. Aam sindromebis damaxasiaTebeli niSnebi memkvidreobiTac gadaecema –pirveli varianti autosomurrecesiulia, meore –autosomur-dominanturi.
Cven vakvirdebodiT bavSvebs, romelTac
hqondaT Q_T intervalis gaxangrZliveba siyruis da gonebis dakargvis gareSe(hqondaT
mxolod Tavbrusxveva). Kkliniko-instrumentulma kvlevam ver gamoavlina gulSi mimdinare raime paTologiuri procesi.
Q_T intervalis gaxangrZlivebis sindromi SeiZleba iyos agreTve miokardiumis funqciuri dazianebis gamovlineba gulis sxvadasxva paTologiis dros(revmokarditi, infeqciuri miokarditi, gulis manki, mitraluri sarqvlis prolafsi, eleqtrolituri
cvlilebebis darRveva da sxva). aseT SemTxvevaSi paTologiuri procesis CaqrobasTan
erTad eleqtruli sistolis xangrZlivoba
normalizdeba. Yyvela bavSvs, romelsac aqvs
ati piurad mimdinare epilepsia an sinkopes
Setevebi, unda iqnes gamokvleuli Q_T intervalis gaxangrZlivebis sindromis gamosaricxad.
ekg-ze parkuWovani kompleqsis damamTavrebeli nawilis Tavisebur cvlilebebs ewodeba parkuWTa adreuli repolarizaciis sindromi (pars). igi gvxvdeba 1,5-2% sixSiriT, zogierTi mas normad miiCnevs (Abakumov S.A.1979,
Phillips J. 1976 da sxva). Aam sindromisaTvis damaxasiaTebelia izoxazidan ST segmentis awevis
xarisxi 0,5-dan 6mm-mde meryeobs da izomeba 4
segmentis yvelaze dabali wertilidan izoxazamde. aRniSnuli cvlilebebi xSirad aRiniSneba gulmkerdis ganxrebSi(V2-V4).
Ppars-is damaxasiaTebel Taviseburebad
iTvleba ST segmentis amowevis SenarCuneba
wlebis manZilze miuxedavad ekg suraTis polimorfizmisa da labilobisa, asakTan erTad xdeba ST segmentis Semcireba(Kamvacha I.
At all 1976). am sindromis dros xSiria diagnostikis siZneleebi, misi paTologiisgan(gid,
mwvave perikarditi, vegetatiuri da endokrinuli moSliloba) diferencirebis TvalsazrisiT. iwyeben fizikuri datvirTvis sinjs,
paTologiis ararsebobis SemTxvevaSi xdeba
segmentis izoeleqtrul xazze dabruneba da
uaryofiTi T kbili xdeba dadebiTi. uaryofiTi T kbilis inversiac qreba kaliumis da inderalis sinjebis dros, rac cvlilebebis
funqiur xasiaTze miuTiTebs. Ppars bavSvebSi
,fdidsf rfhlbjkjubf
16
sakmarisad xSiria, gansakuTrebiT
pubertatul da prepubertatul periodSi vegetodistoniis niSnebis fonze.
Ppars-is niSnebi bavSvebSi ufro xSirad
gvxdeba II,III, aVF, V2, V3, V5,V6 ganxrebSi, iSviaTad I da aVL, V2, V6 ganxrebSi. Ggamonaklisis
saxiT mxolod standartul, an mxolod gulmkerdis ganxrebSi. Yyvelaze ufro gamoxatuli ST segmentis aweva aRiniSneba V2-V3 ganxrebSi ST segmentis varirebis 0,5-2mm-is farglebSi.
rogorc Cvenma dakvirvebebma aCvena parkuWTa adreuli repolarizaciis sindromi
arc Tu iSviaTad emTxveva P_Q intervalis
Semcirebas(<0,12c), igi registrirdeba bradikardiisa(SemTxvevaTa1/4) da gamoxatuli sinusuri ariTmiis fonze.
yovelive zemoaRniSnulidan gamomdinare,,parkuWTa adreuli repolarizaciis sindromi”-s diagnozi, rogorc normaluri ekg-s
varianti, moiTxovs did sifrTxiles da gamarTlebulia sruli kompleqsuri klinikuri kvlevisa da dinamikaSi ekg monacemebis
arsebobis SemTxvevaSi, Semdgom Seswavlas moiTxovs agreTve am sindromis klinikuri TavisTavadoba, im SemTxvevaSi roca daavadebis
fonze vlindeba sindromis klinikuri niSnebi, Cndeba safuZveli es sindromi ganvixiloT
rogorc paTologiis gamovlineba Tu sindromis niSnebi rCeba xangrZlivad, miuxedavad
paTologiuri procesis Cacxromisa, maSin igi
SeiZleba CaiTvalos janmrTeli organizmis
individualur ekg-ul Taviseburebad. udavoa, rom bavSvebSi pars-is genezi Semdgom
kvlevas saWiroebs.
maSasadame, Cvens mier Catarebuli gamokvlevebis Sedegebi adastureben, rom bavSvTa
asakSi ST segmentisa da T kbilis cvlilebani sxvadasxva asakobriv jgufebSi moiTxovs
individualurad ganxilviT midgomas, rac
bavSvTa kardiologiidan siberemde mis Semdgom Rrma klinikur informaciis matareblad
unda darCes.
Tavi II ST segmentisa da T kbilis monacemebi gulis zogierT daavadebaTa dros
bavSvebSi (NeHb-is ganxrebis gamoyenebis
prespeqtiva pediatriaSi.
Cvens mier zemoaRniSnuli daavadebebis
dros Seswavlil iqna ST segmentis cvlilebebi. igi yvelaze xSirad gvxvdeboda ararevmatiuli karditis(65 Semtxveva), revmatoiduli
arTritis saxsrovani formis(50 SemTxveva) da
miokardiodistrofiebis(47 SemTxveva) dros,
naklebad – tonzilogenuri kardiopaTiis(10SemTxveva) dros, xolo revmatiuli arTritis saxsrovani formis, vegetosisxlZarRvovani distoniis da revmatoiduli artritis saxsrovani formis dros gvxvdeboda erTeul SemTxvevebSi. parkuWebis adreuli repolarizaciis fenomeni ZiriTadad damaxasiaTebeli iyo vegetosisxlZarRvovani distoniis mqone pacientebisaTvis(65 SemTxveva), SedarebiT dabali maCvenebeli aRiniSna revmatoiduli artritis saxsrovani formisa da
tonzilogenuri kardiopaTiis dros(Sesabamisad 22 da 15 SemTxveva). Aararevmatiuli karditis, mitraluri sarqvelis prolafsis da
distrofiebis dros parkuWebis adreuli repolarizaciis fenomeni ar dafiqsirebula.
IV ti pis gamovlinebebi aRiniSna ufro
xSirad revmatiuli arTritis saxsrovan-visceraluri formis dros (17 SemTxveva), SedarebiT naklebad ki ararevmatiuli karditis
da miokardiodistrofiis dros, erTeuli
cxrili #2
ST segmentisa da T kbilis cvlilebaTa tipebi gulis zogierTi anTebiTi da
araanTebiTi daavadebebis dros
tipebi
r/a-is
r/a-is
Ararevmasaxsrovani saxsrovantoiduli
forma
visceraluri karditi
forma
Tonzilomitraluri v.s.d.
genuri
sarqvlis
kardiopaTia prolafsi
miokardio- jami
distrofia
I
22
3
--
15
--
65
--
105
II
--
2
10
--
--
--
--
12
III
--
--
3
--
--
--
--
3
IV
2
17
8
--
--
--
7
34
V
--
22
30
10
1
2
40
105
VI
--
2
3
--
--
--
--
5
VII
--
3
5
--
--
--
--
8
VII
--
4
6
--
--
--
--
10
2010 weli
,fdidsf rfhlbjkjubf
SemTxvevebi aRiniSna revmatiuli arTritis
saxsrovani formis dros (2 SemTxveva)
zemoaRniSnulis analizisasa davrwmundiT, rom aucileblobas warmoadgenda ST
segmentisa da T kbilis morfologiur
cvlilebaTa erTian konteqstSi ganxilva.
cxrili #-2 -Si naTlad Cans maTi SesaZlo
8 sxvadasxva ti pis gamoxatuleba da cvlilebani, romlebic klinicistebisagan zust
analizs moiTxoven. kerZod, I ti pi ufro
xSirad gvxvdeboda vegetosisxlZarRvovani
distoniis dros (65 SemTxveva), SedarebiT
naklebad _ revmatiuli arTritis saxsrovani formis (22 SemTxveva) da tonzilogenuri
kardiopaTiis dros (15 SemTxveva) revmatiuli arTritis saxsrovan-viscelaruli formis dros I ti pis cvlilebebi ar aRiniSneboda.
II ti pi gamoxatuli iyo mxolod 12 SemTxvevaSi, aqedan 10 iyo ararevmatiuli karditi
da 2 revmatiuli arTritis saxsrovan-vinceraluri forma. danarCeni daavadebebis dros
II ti pis cvlilebebi ar dafiqsirebula. rac
Seexeba III ti ps igi xvdeboda mxolod ararevmatiuli karditis dros.
sakvlev avadmyofebSi SedarebiT meti iyo
V ti pis cvlilebebi, igi revmatoiduli arTritis saxsrovani formis garda yvelgan
gvxvdeboda.
kerZod: revmatoiduli arTritis saxsrovan-visceraluri formis dros aReniSna 22
SemTxvevaSi. Aararevmatiuli karditis dros
30 SemTxvevaSi, tonzilogenuri kardiopaTiis
dros sixSire SedarebiT dabali iyo (10 SemTxveva). Yvelaze maRali maCvenebeli ki dafiqsirda miokardiodistrofiis dros (40 SemTxveva) mitraluri sarqvelis prolafsis da
vegetosisxlZarRvovani distoniis dros V
ti pis gamovlineba atarebda erTeul xasiaTs.
sakvlev kontigentSi SedarebiT naklebad
iyo warmodgenili VI, VII da VIII ti pi, ZiriTadad revmatoiduli arTritis saxsrovanvisceraluri formis da Aararevmatiuli karditis dros. kerZod, revmatoiduli arTritis
saxsrovan-visceraluri formis dros VI ti pi aRiniSna 2 SemTxvevaSi, xolo ararevmatiuli karditis dros 3 SemTxvevaSi. VII ti pi
revmatoiduli arTritis saxsrovan-visceraluri formis dros Segvxvda 3 SemTxvevaSi,
xolo ararevmatiuli karditis dros 5 SemTxvevaSi. miaxloebuli iyo Sedegi VIII ti pTan dakavSirebiTac. Sesabamisad 4 da 6 SemTxveva.
Cveni monacemebis saboloo interpretaciamde aucileblad migvaCnia ST segmentisa da
2010 weli
17
T kbilis cvlilebaTa mimoxilviTi analizi
normisa da paTologiis zRvarze.
Uunda aRiniSnos, rom dadgenilia periferiul ganxrebSi ST intervalis 1mm-iT cdoma
Seesabameba 400 000miokardiuli boWkos dazianebas(gulmkerdis ganxrebSi ki 4000-s). Aam
monacemebis(Schaeffer H. Haas H. 1962) gaTvaliswinebiT saWiroa da aucilebelia ufro
meti yuradreba daeTmos ST-T umniSvnelo
darRvevebsac, romlebic aRiniSneba standartul da monopolarul ganxrebSi, radgan es
cvlilebebi SeiZleba iyos ufro mniSvnelovani, vidre iSemiis ufro intensiuri gamovlinebebi gulmkerdis ganxrebSi. Mmravali
statistikuri monacemebis Tanaxmad msubuqi
eleqtrokardiografiuli darRvevebi warmoadgenen koronaruli riskis aSkara faqtorebs(Ross S.R. 1970) zogierTi gamokvlevis Tanaxmas mamakacebs Soris sikvdilianoba dabali, dakbiluli mcired uaryofiTi T kbiliT
2-jer metia, vidre sakontrolo jgufSi(Freidberg H.D.1069), rac miuTiTebs, rom msgavsi darRvevebis SemTxvevaSi aucilebelia vawarmooT damatebiTi gamokvlevebi am cvlilebebis mniSvnelobis dasadgenad.
ST intervalis da T kbilis patara cvlilebebi eleqtrokardiografiaSi interpretaciisaTvis yvelaze rTuli sferoa. Aamitom
ioli ar aris ST-T darRvevebis mniSvnelobis
gansazRvra iSemiuri kardiopaTiis adreuli
diagnostirebis mizniT. am TvalsazrisiT, STT cvlilebebis interpretaciis mniSvnelovan
kriteriums warmoadgens am darRvevaTa,,lokalizacia” da maTi SeTanxmebuli evolucia
sxvadasxva ganxrebSi. repolarizaciis,,meoradi” aSliloba(daRmavali, Senelebuli, progresirebadi, st intervaliT da arasimetriuli uaryofiTi T kbiliT) SeiZleba gamoCndes I, II da marcxena gulmkerdismier ganxrebSi(maqsimaluri I da V6 ganxrebSi) an II,
III da wina gulmkerdismier ganxrebSi(maqsimaluri III da V1 ganxrebSi) da romelic
warmoadgens sxvadasxva ganxrebSi TandaTanobiT evolucias V1-Si maqsimaluri uaryofiTobidan meoradi T kbilis amplituda marcxena gulmkerdis ganxraSi an Sesabamisi
tranziciis zonaSi progresulad unda mcirdebodes. Tumca aseT pirobebSi, agreTve,,iuveniluri” T kbilis SemTxvevaSi, aranormaluria, rom TII ufro uaryofiTi iyos vidre T1,
T3, TVs an V4 ufro uaryofiTi vidre TV6 da
sxva. radgan aseTi darRvevebi mxolod maSin
dgeba, roca adgilobrivi,,pirveladi” ganapirobebs T kbilis uaryofiTobis cdomas. agreTve ST_T umniSvnelo cvlilebebis dros
gaumarTlebelia momdevno gulmkerdis ganx-
18
rebSi dadebiTi T kbilis amplitudis mkveTri Semcireba, im SemTxvevaSic ki, roca Sesabamisi T kbilebi QRS kompleqsis maqsimaluri
kbilis 1/20-s ver aRweven. aseTi mdgomareobis
dros aucilebelia yuradReba mivaqcioT
iseT SemTxvevebs, roca T kbilis amplituda
V1 da V6 ganxrebSi naklebia TV3-is da TV4is jamis naxevarze an TV5<TV4/2 uaryofiTi
ganrTxmuli TV3-is SemTxvevaSi. Ggamokvlevis
Tanaxmad msgavsi aspeqtebi xSirad aRiniSneba
organuli kardiopaTiebis dros.
T kbilis da ST intervalis sxva morfologiuri Taviseburebebis analizi agreTve
SesaZleblobas iZleva moxdes organuli dazianebebis diferencireba ST_T umniSvnelo
cvlilebebisagan. migvaCnia, rom T kbilis aSkara simetriuloba da mzardi uaryofiToba V1 da V4 ganxrebSi warmoadgens niSans,
romelic met yuradRebas saWiroebs, vidre
12mm-ze meti amplitudis minesotis kodSi aRniSnuli T kbili.
simetriuli wvetiani T kbilebi xSirad
warmoadgenen subendokardiuluri iSemiis
gamovlinebas(Lepeschkin E.1957), romelic uxSiresad iSemiuri kardiopaTiis dasawyisia. miTumetes, rom normalur pirobebSic ki endokardiumi warmoadgens zonas, sadac sisxlis
nakadi da O02-is wneva SedarebiT(epikardiumTan) dabalia. Uumtkivneulo iSemiuri kardiopaTiis dros ST-T zogierTi mcire darRvevis mniSvnelobis dadgena rTulia paTologiuri cvlilebebis difuzuri xasiaTis gamo.
Aaseve gvxvdeba ST_T difuzuri darRvevebi,
romlebic upirates lokalizacias gansazRvrul arxebSi ar gvaZleven. maTi arsebobisas
da sxva sarwmuno asocirebuli niSnebis
araasebobisas umtkivneulo iSemiuri kardiopaTiis diagnozis dadgena did sifrTxiles moiTxovs, gansakuTrebiT xandazmulebSi
da Zalian axalgazrda asakSi, romelSic dabalia riskis faqtoris da iSemiuri kardi paTiis arsebobis sarwmunooba.
Aaqve unda gvaxsovdes mravali eqstrakardialuri mizezi, romlebic iwveven ekg-ze
sxvadasxva darRvevebs da romlebic arTuleben diagnostirebas, kerZod: ST-T cvlilebebi qalebSi menstrtualuri ciklis da saSvilosnos fobromis dros, dabalvoltaJiani
T kbili hi persimpatikotonur mdgomareobaSi,
taqikardiiT mimdinare mousvenrobis dros,
maRalvoltaJiani T kbili da ST intervali
cdomiT zemoT(,,aRmavali ti pis”) adreuli
repolarizaciis dros, dakbiluli, gaormagebuli T kbili cns-is dazianebis da vegetatiuri labilobis dros da sxva. amasTan ST intervalTan SedarebiT T kbilis didi cvale-
,fdidsf rfhlbjkjubf
badobis gamo vegetatiurad aramdgrad avadmyofebSi orTostatiuli sinjis da fizikuri datvirtvis dros darRvevebi ST nawilSi
SeiZleba ufro mniSvnelovani iyos, vidre T
kbilis amplitudis da mimarTulebis cvlileba.
Aamdenad, ST segmentisa da T kbilis morfologiuri parametrebi gulis zogierTi zemoT
ganxiluli anTebiTi da araanTebiTi daavadebebis dros mkveTrad gamoxatuli cvlilebebiT xasiaTdeba da aucilebel pirobas warmoadgens maTi ti paJebis gansaRvris Semdgom
damatebiTi informaciis miReba koronarul
sisxlis mimoqcevaze ekg-s sxvadasxva maCvenebelTa gansazRvriT(TV6+TV5..... da a. S)
Cvens mier, rogorc avRniSneT warmoebuli iyo ekg-li gamokvleva 12 Cveulebriv da
damatebiT 3 NeHb(A,D,I) ganxrebSi, sadac vvaraudobdiT, rom NeHb-is ganxrebSi unda migveRo mniSvnelovani korelaciuri informaciebi. Cveni masalis analizisas aRmoCnda
Semdegi saintereso Sedegebi, romlebic
mniSvnelovan adgils daiWers bavSvTa kardiologiaSi.
Cvens kvlevebSi Cans ST segmentis cvlilebasTan dakavSirebuli korelaciuri indeqsebi; kerZod, R kbili 12 standartul ganxraSi
da misi korelacia S-Tan NeHb-is 3 ganxraSi.
maTiMmonacemebi gviCvenebs, rom am SemTxvevaSi korelaciuri indeqsebi dabalia da 3,827s ar aRemateba.
S
V1 ------- NeHb
R
D ---- 7,974
A ---- 6,401
S
V2 ------- NeHb
R
D ---- 6,942
A ---- 5,517
S
V6 ------- NeHb
A ---- 5,320
R
rogorc vxedavT saSualo maCvenebeli 6dan 7-mde meryeobs, rac maRali ara aris da
mxolod tendenciaze miuTiTebs.
SromaSi asaxulia monacemebi, romlebic
miuTiTebs korelaciaze R kbilebs Soris 12
standartul ganxrasa da NeHb-is ganxrebs
Soris. aq SedarebiT met ganxraSi dafiqsirda korelaciuri indeqsis momateba magram
maCveneblebi mniSvnelovnad maRali ar aris,
kerZod:
2010 weli
,fdidsf rfhlbjkjubf
R
II st ------------
Nehb
D ---- 6,393
R
R
III st ------------
Nehb
D ---- 7,296
19
sxva ganxrebSi monacemebi mniSvnelovnad
dabalia, aRniSnul maCveneblebTan SedarebiT,
romlebic aSkara tendenciaze miuTiTeben.
mniSvnelovania ST segmentis ST-sTan korelacia 12 standartul da Nehb-s 3 ganxraSi
(D,A,I). aq monacemebi ufro mniSvnelovani da
mravalferovania, kerZod :
R
ST
II st ------------
R
AAVF ------------
ST
Nehb
A ----- 9,377
I ------ 10,143
D ---- 6,829
ST
R
AVF ------------
Nehb
I ------ 10,492
ST
R
AV1 ------------
D ----- 8,065
Nehb
Nehb
D ---- 5,098
R
ST
V2 ------------
Nehb
ST
D ----- 10,704
A ----- 10,553
R
AV3 ------------
Nehb
D ---- 5,112
ST
V3 ------------
R
Nehb
ST
A
R
V4 ------------
Nehb
A ---- 5,995
R
A
T
V2 ------------
Nehb
A ---- 8,411
Nehb
A ---- 8,345
Nehb
D ---- 8,065
T
T
V3 ------------
T
T
V6 ------------
T
2010 weli
A ----- 9, 358
ST
V4 ------------
Nehb
ST
rogorc cxedavT aqac adgili aqvs mxolod tendecias matebisaken.
analisi gviCvenebs S kbilis korelacias S
kbilTan 12 standartul da Nehb-is (D,A,I)
ganxrebs Soris. maCveneblebi am SemTxvevaSi
dabalia da korelacia ar aRiniSneba.
sxva monacemebi warmodgenilia T kbilis T
kbilTan korelacia yvela standartul da
Nehb-is ganxrebSi. aq SedarebiT maRali korelaciuri indeqsebi aRiniSna vilsonis ganxrebSi,
kerZod:
D ----- 11,662
D ----- 14,461
A ----- 11,491
ST
V5 ------------
Nehb
ST
D ----- 14,232
A ----- 9, 668
ST
V6 ------------
ST
Nehb
D ----- 14,046
A ----- 10,279
rogorc vxedavT korelaciuri indeqsebi
maRalia (saSualod > 10-ze), gansakuTrebiT
V5 - V6 da Sesabamisad Nehb-s D-ur ganxrebSi (>14-ze), V4-Si SedarebiT maRali iyo korelaciuri indeqsi Nehb-s A-sTan (11,491) xolo
Nehb-s I-Tan korelaciis indeqsi SedarebiT
maRali iyo AVF- ganxraSi (10,492).
zemoaRniSnuli monacemebi, gansakuTrebiT R
da S kbilebTan dakavSirebiT, mozrdilTa analogia, Tumca korelaciuri indeqsebi ase dawvrilebiT pediatriaSi dRemde ganxiluli ar
yofila. Amdenad, unda iTqvas, rom Nehb-is ganxrebi mniSvnelovan informacias iZlevian bavSvTa asakSi da isini aseve mniSvnelovan rols
Seasruleben bavSvTa kardiologiis ganviTa-
20
rebaSi, rogorc samkurnalo, aseve sareabilitacio da daavadebaTa prevenciis etapze.
daskvnebi:
ST segmentisa da T kbilis monacemebi janmrTel bavSvebSi xasiaTdebian asakobrivi TaviseburebebiT:
bavSvTa asakSi SesaZlebelia ganisazRvros T kbilis depresiuloba:
_ I standartul ganxraSi (1 Tvis asakis
garda);
_ II standartul ganxraSi (yvela asakobriv jgufSi);
_ AVF ganxraSi (0-3 wlamde);
_ V4 – ganxraSi (6-15 wlamde asakobriv
jgufSi);
_ V5 – V6 ganxrebSi (yvela asakobriv
jgufSi) es ukanaskneli warmoadgens, rogorc
dRenakl, ise droul axalSobilTa kardiologiaSi wamyvan sadiagnostiko kriteriumebs, romlebic mniSvnelovania, rogorc dasawyisSi daavadebisaTvis da rac mTavaria,
reabilitaciis periodSi, ukve mozrdilTa
gul-sisxlZarRvTa sistemis daavadebaTa
prevenciisaTvis.
janmrTel bavSvebSi ST segmentis cToma
izoeleqtrul xazs zemoT yvela asakobriv
,fdidsf rfhlbjkjubf
jgufSi gvxvdeba, magram ar cdeba 1 mm-s, xolo izoeleqtrul xazs qvemoT V5 – V6 ganxrebs garda maqsimaluri 1 mm-mdea;
ST segmentisa da T kbilis morfologiuri
cvlilebani unda ganixilebodes erTian konteqstSi SemuSavebuli 8 ti pidan erTis gansazRvriT, rogorc janmrTel, aseve daavadebul bavSvTa kontigentSi;
bavSvTa asakSi ST segmentisa da T kbilis
cvlilebani sxvadasxva asakobriv jgufSi
moiTxovs individualurad ganxilviT midgomas, rac bavSvTa kardiologiidan siberemde
mis Semdgom Rrma klinikur informaciis matareblad unda darCes;
NeHb-is ganxrebi mniSvnelovan informacias aZleven rogorc janmrTel, aseve daavadebul bavSvTa kontigentSi da isini aseve mniSvnelovan rols Seasruleben bavSvTa kardiologiis ganviTarebaSi, rogorc samkurnalo,
aseve sareabilitacio da daavadebaTa prevenciis etapebze maTi asakisda miuxedavad.
amrigad, droulad diagnostirebuli ST
segmentisa da T kbilis mciredi gadaxrebic
ki umniSvnelovanesia aramarto pediatriuli
asakis, aramed didi kardiologiis prevenciuli sakiTxebis gadawyvetaSi.
sur. 1
sur. 2
2010 weli
,fdidsf rfhlbjkjubf
ganxra
1 Tve
maqs.
min.
3
-1
6,5
0
3
-1
-3
-1,5
2,5
-2
3,5
1
1
-6
5,5
-5,5
5
-4
5
-1
5
1,5
6
1
4,25
-1,5
1,75
-4
4,25
-1,5
I
II
III
AVR
AVL
AVF
V1
V2
V3
V4
V5
V6
D
A
I
mm
0-2 weli 3-5 weli 6-10 weli 10-15
weli
1
1
1
1
0,5
0,5
0,5
0,5
1
1
1
1
0,5
0,5
0,5
0,5
2
2
2
2
1
1
1
1
2
2
2
2
4
4
4
4
3
3
3
3
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1 Tve
I
II
III
AVR
AVL
AVF
V1
V2
V3
V4
V5
V6
A
D
I
asaki
0-2 weli
maqs.
min.
4,5
1
6,5
1,5
4,5
-2
-4,5
-3
3
-1
3
1
1
-6
3
-5
3
-3
5,5
-2
6
1,5
5
2
3
-1
2
-3,5
3
-1
Asaki
3-5 weli
maqs.
min.
5
1,5
7
1,5
5
1,5
-5
-3,5
3,5
-2
4,5
-1
-1
-5,5
3
-3,5
4
-4
12
-1
8
2
6
2,5
4,25
-2,5
1,25
-3,8
4,25
-2,5
1 Tve
1
0,5
1
0,5
2
1
2
4
3
2
2
1
1
1
1
5,05
2,525
5,05
2,525
10,1
5,05
10,1
20,2
15,15
10,1
10,1
5,05
5,05
5,05
5,05
6-10 weli
maqs.
min.
5
2
5,5
1,5
3
1,5
-6
-3
4,5
-3
3,5
-1,5
-1
-5
5
-5,5
8
-5,5
10
1
9
2,5
7,5
2
5,75
-3,5
1,75
-4
5,75
-3,5
21
10-15 weli
maqs.
min.
5,5
2
7
1,5
4,5
1,5
-5
-3
4,5
1,5
5
-1
-1
-5,5
6
-7
7
-6
11
1
10,5
2
7,5
2
6
-3,5
1,75
-3,5
6
-3,5
S (mm2)
0-2 weli 3-5 weli 6-10 weli
5,375
2,6875
5,375
2,6875
10,75
5,375
10,75
21,5
16,125
10,75
10,75
5,375
5,375
5,375
5,375
4,95
2,475
4,95
2,475
9,9
4,95
9,9
19,8
14,85
9,9
9,9
4,95
4,95
4,95
4,95
5,875
2,9375
5,875
2,9375
11,75
5,875
11,75
23,5
17,625
11,75
11,75
5,875
5,875
5,875
5,875
10-15 weli
6,725
3,3625
6,725
3,3625
13,45
6,725
13,45
26,9
20,175
13,45
13,45
6,725
6,725
6,725
6,725
1 Tve
QT1saS."
ST (mm)
QRSsaS."
0-2 weli 3-5 weli 6-10 weli 10-15
weli
14,6
15,75
16,9
18,75
20,45
5,05
5,375
4,95
5,875
6,725
4,5
5
7
7
7
ST=QT1-QRS
0,02''=1mm
SST=ST->xST|
x
cxrili
Mme3e cxrilSi mocemulia T
kbilis maqsimaluri da minimaluri simaRle e.k.g.-s 15 ganxraSi
- 12 Cveulebrivi da 3
NeHb-is janmrTel bavSvTa
sxvadasxva asakobriv jgufebSi; T kbilis farTobi ganisazRvreba Semdegi formuliT.
S=2/3*a*h,
Mm
1 Tve
I
II
III
AVR
AVL
AVF
V1
V2
V3
V4
V5
V6
A
D
I
2010 weli
# 3-4
sadac a aris sigane, xolo
h simaRle. Sesabamisad diagramebi ##1-16 asaxaven T kbilis maqsimalur da minimalur farTs mm2, e.k.g.-s ganxraSi - janmrTel bavSvTa sxvadasxva asakobriv jgufebSi;
me-4e da me-5e cxrilSi mo-
0-2
3-5
6-10
10-15
1
weli
weli
weli
weli
-0,8
-0,8
-0,8
-0,8
-0,8
-0,5
-0,5
-0,5
-0,5
-0,5
-1
-1
-1
-1
-1
-1
-1
-1
-1
-1
-1
-1
-1
-1
-1
-1
-1
-1
-1
-1
-2
-2
-2
-2
-2
-3
-3
-3
-3
-3
-3
-3
-3
-3
-3
-2
-2
-2
-2
-2
0
0
0
0
0
0
0
0
0
0
-1
-1
-1
-1
-1
-1
-1
-1
-1
-1
-1
-1
-1
-1
-1
cemulia ST segmentis maqsimaluri cdoma izoeleqtruli
xazis zemoT da qvemoT (mm-iT
da mm2-iT). ST kbilis farTobi ganisazRvreba
Semdegi
formuliT.
ST=QT1-QRS
SST=ST->xST|
diagramebi ##16-22 asaxaven ST segmentis farTs aRniSnul umetes ganxrebSi.
cxrilebSi kargad Cans
TiToeul ganxrebSi T kbilis
maqsimaluri simaRleebi, aseve
minimaluris minimaluri da
maqsimaluri simaRleebi.
rac Seexeba naxazebsa da
diagramebs, isini saSualebas
iZlevian bavSvTa asakSi asakis
da miuxedavad ganisazRvros
depresiuli kbilebis arseboba
I standartul ganxraSi - pirveli asakobrivi jgufis garda.
II standartul ganxraSi yvela
asakobriv jgufSi AVF-Si da
V1-Si pirvel or asakobriv
jgufSi. V4-Si bolo 2 asakobriv jgufSi, V5 da V6-Si yvela
asakobriv jgufebSi, es ukanaskneli ki warmoadgens dRenaklul bavSvTa kardiologiis
wamyvan sadiagnostiko kriteriumebs, romelic mniSvnelovania rogorc daavadebaTa mkurnalobis dasawyisSi, ise misi dinamikis Sesafaseblad - prognozirebisaTvis da rac mTavaria reabilitaciis periodSi
gss-s daavadebaTa prevenciisaTvis ukve mozrdilTa asakSi.
cxrili
# 5
2
S(mm )
0-2
3-5
6-10
weli
weli
-4,04
-4,3
-3,96
-2,525 -2,6875 -2,475
-5,05 -5,375
-4,95
-5,05 -5,375
-4,95
-5,05 -5,375
-4,95
-5,05 -5,375
-4,95
-10,1 -10,75
-9,9
-15,15 -16,125 -14,85
-15,15 -16,125 -14,85
-10,1 -10,75
-9,9
0
0
0
0
0
0
-5,05 -5,375
-4,95
-5,05 -5,375
-4,95
-5,05 -5,375
-4,95
Tve
weli
-4,7
-2,9375
-5,875
-5,875
-5,875
-5,875
-11,75
-17,625
-17,625
-11,75
0
0
-5,875
-5,875
-5,875
10-15 weli
-5,38
-3,3625
-6,725
-6,725
-6,725
-6,725
-13,45
-20,175
-20,175
-13,45
0
0
-6,725
-6,725
-6,725
22
,fdidsf rfhlbjkjubf
2010 weli
,fdidsf rfhlbjkjubf
23
diagramebi 16-22
2010 weli
24
,fdidsf rfhlbjkjubf
QT intervalis Tanamedrove problemebi
bavSvTa da mozardTa kardiologiaSi
termini, gulis uecari sikvdilis sindromi, miRebulia sikvdilis SemTxvevebis aRsaniSnavad pirebSi, romelTaFfizikuri da fsiqiuri mdgomareoba aqamde stabiluri iyo.
sikvdili dgeba daavadebis mwvave gamovlinebidan 1sT-Si,klinikuri niSnebis ararsebobis
fonze.
,,gus’’ mizezis da meqanizmis Seswavla aqtualur problemas warmoadgens mTels
msoflioSi. maRali riskis jgufs ganekuTvnebian pacientebi mwv. miokardiumis infarqtiT, gulis ukmarisobiT, ariTmiebiT.
,,gus’’ sixSire Seadgens bavSvTa sikvdilianobis 5%-s(1,5-8,0 100000-ze yovelwliurad). sxva
monacemebiT, yovelwliurad 5000-dan 7000-mde
garegnulad janmrTeli bavSvi iRupeba uecrad, xolo mozrdilebSi SemTxvevaTa ricxvi
3-5 mln-s Seadgens. 1999w monacemebiT,,gus”
1000 bavSvze Seadgens:G
germania-0,78,
aSS-0,77,
ruseTi-0,43,
SvedeTi-0,45,
italia-1.
ukrainaSi 2008w oqtomber-noemberSi bavSvebSi uecari sikvdilis 6 SemTxveva dafiqsirda.,,gus’’ SemTxvevebis ricxvi bavSvebSi (anu,,sikvdili akvanSi’’) aSS-Si yovelwliurad
500-700
Seadgens.
axalgazrdebSi ,,gus’’
fiqsirdeba: 20%-Si sportuli aqtivobis
dros, 30%-Si Zilis dros, 50%-Si sxvadasxva
SemTxvevebSi sifxizlisas. garegnulad TiTqosda janmrTeli bavSvis uecari sikvdilis
SemTxvevaSi autopsiis Sedegad miRebuli mwiri monacemebi gviCvenebs, rom sikvdilis mizezi aris an ariTmogenuli, an apnoes Sedegi.
80%-Si mizezia parkuWebis fibrilacia. hi poTeza, rom ,,gus’’ bavSvebSi SesaZloa iyos gulis ariTmiis Sedegi, dadasturda Shwartz et al.
gamokvlevebiT. maT Seiswavles ekg 34442
axalSobilSi da daadgines, rom gulis uecari sikvdili bavSvebSi mniSvnelovnad asocirdeba QTKDintervalis paTologiur gaxangrZlivebasTan. bavSvTa uecari sikvdilis
sindromsa da QTEintervalis gaxangrZlivebas Soris kavSiris arsebobaze diskusia 30
welze metxans grZeldeboda. L.a. Freed, D. Levi,
R. A. Livine et al.D5-24%,,gus’’SemTxvevas xsnian
mitraluri sarqvlis prolafsiT, xolo m.s.p.iT avadmyofebSi maRali riskis jgufs miakuTvneben pacientebs, romelTac aReniSnebaT
sinkope, QT
intervalis gaxangrZliveba,
parkuWovani taqiariTmia, ojaxur anamnezSi
uecari sikvdilis SemTxvevebi.
M
ariTmiuli darRvevebi, romlebic sicocxlisTvis saxifaToa xSiria axalSobilobis,
mozardTa da ufro gvian asakSic. maTi drouli gamovlena efeqturi prevenciuli Terapiis dawyebis saSualebas mogvcems. (sikvdils, romelic dakavSirebulia riTmis, an
gamtareblobis darRvevis Sedegad sisxlis
mimoqcevis uecar SeCerebasTan, uwodeben
ariTmiuls. aseTi sikvdilis dadgomis dro
ganisazRvreba
ara
sT_ebiT,
aramed
wT_ebiT.amrigad, uecari ariTmiuli sikvdili
dgeba ramodenime wT_Si da am dros gakveTisas ar gamovlindeba sicocxlesTan SeuTavsebeli morfologiuri cvlilebebi).
gamokvlevebma gviCvena, rom zogierTi
axalSobili QT intervalis gaxangrZlivebiT
sicocxlis pirvel kviras iRupeboda_uecari
sikvdilis sindromi axalSobilebSi. am fonze, zogierTma evropulma qveyanam,gul-sisxlZarRvTa sistemis skriningis programis
CarCoebSi, daiwyo ekg_saucileblobis ganxilva yvela axalSobilSi. (evropel kardiologTa kavSiri: Piter j. Shwarc, Artur Garson, Pola
Tomasa, Marko Stramba).
mocemuli Sromis mizans warmoadgens, SeviswavloT bavSvTa da mozardTa kardiologiaSi QT intervalis gaxangrZlivebis_rogorc uecari sikvdilis erT-erTi mizezis
arsi da misgan gamomdinare, ekg_s aucilebloba yvela axalSobilSi.
QT intervali _ aris manZili QRS kompleqsis dasawyisidan T kbilis bolomde. eleqtrofiziologiis mixedviT, is gamosaxavs
parkuWebis miokardis depolarizaciisa da
misi momdevno repolarizaciis process. xSirad am parametrs gulis eleqtrul sistolas uwodeben (Senelebuli repolarizaciis
sindromi,rac eleqtruli sistolis xangrZlivobis matebas asaxavs). es cvlilebebi periodulad emTxveva parkuWovani taqikardiis,
parkuWTa TrTolvis da asistoliis epizodebs.
paTogenezi ganpirobebulia gulis simpaTikuri inervaciis moSliT, ionuri arxebis
funqcionirebis paTologiiT. wamyvani roli
eniWeba genebis mutacias,romlebic kodireben natriumis da kaliumis ionebis transports ujreduli membranis gavliT.
2010 weli
,fdidsf rfhlbjkjubf
25
QT intervalis gaxangrZlivebisas izrdeba
riTmis fataluri darRvevis, aseve polimorfuli parkuWovani taqikardiis riski, rac
atarebs pacientis sicocxlisTvis saSiS xasiaTs.
aRwerilia QT intervalis gaxangrZlivebis ori forma:
bis simZimis kriteriumi. amasTanave, unda
gvaxsovdes, rom sikvdili SesaZloa dadges
sinkopes pirvelive SemTxvevisas. Setevebs Soris periodSi bavSvebi uCivian sisustes, Tavbrusxvevas, Tavis tkivils, uZilobas, simZimes
gulmkerdis areSi.
g. sporaduli formebi.
1. Tandayolili
(Seadgens 30%-s_Arking et al 2006. amave avtorebisgan iyo aRniSnuli sigrZis asociacia
NNOS 1AP genis variaciebTan 1q 23.3 qromosomul ubanze).
a. jervel_lange_nilsenis sindromi (Gervell
A.Lange -_Nielson F 1957) autosomur_recesiulia.
Tandayolili siyruiT. QT=440ml/wm. aRiniSneba sinkopes epizodebi da SesaZloa uecari
sikvdili.
b. romano_uordis sindromi (Romano C
word o. 1963). autosomur_dominanturia. (aRiniSneba QT intervalis gaxangrZlivebis
90%_Si.sixSirea 1:10000). ar mimdinareobs
siyruiT. bavSvebSi mkurnalobis ararsebobis SemTxvevaSi daavadebis pirveli simptomidan (sinkopes pirveli SemTxveva) 3_5wlis
Semdeg uecari sikvdilis riski aRwevs
32%_s da maqsimaluria pubertatul asakSi.avadmyofTa ojaxebSi riski maRalia klinikuri da ekg simptomebis ararsebobis SemTxvevaSic ki. romano_uordis sindromis
risk_faqtorebia:
gonebis dakargva anamnezSi da predsinkopealuri mdgomareoba. ekg –ze:parkuWovani
presistola, T kbilis alternacia, sinusuri
bradikardia, gulis riTmis darRveva, aseve
mamrobiTi sqesi.
ZiriTadi Civilia sinkopuri mdgomareoba
(sxvadasxva xangrZlivobis_1_2_dan 20 wT-mde),
romelic SesaZloa kavSirSi iyos emocionalur da fizikur stresTan da Tan sdevdes
uneblie Sardva da defekacia. sinkope ganpirobebulia parkuWTa polimorfuli taqikardiis ganviTarebiT (,,piruet’’_is ti pis) (,,torsades de pointes’’) (Tdp). aseve uwodeben_,,gulis baleti’’,,,qaoturi taqikardia’’,,,gulis Stormi’’,
rac Tavisi arsiT aris sisxlis mimoqcevis
SeCerebis sinonimi. Tdp_aramdgradi taqikardia, axasiaTebs recidivebi (ramodenime wm-Si
an wT-Si SesaZloa Seteva ganmeordes) da gadaizrdeba parkuWebis fibrilaciaSi (miekuTvneba sicocxlisTvis saSiS ariTmiebs). klinikur suraTSi SesaZlebelia tonur_klonuri krunCxvebis arsebobac, rac ganpirobebulia avTvisebiani ariTmiiT, ufro xSirad_parkuWovani taqikardiiT. sinkopes epizodis sixSire da raodenoba aris daavade-
2. SeZenili:
a. rigi preparatebis miRebis Sedegad. Centers for Disease Control end Prevention_is monacemebiT,aSS_Si yovelwliurad izrdeba,,gus’’ sixSire axalgazrdebSi. aris mosazreba, rom amaSi did rols asrulebs samkurnalo saSualebebis TviTneburi ada ukontrolo gamoyeneba, polifarmacia, preparatebis araswori
kombinacia da gaxangrZlivebuli mkurnaloba.es yovelive qmnis QT intervalis gaxangrZlivebis winapirobas.
magaliTad, rogorc kvlevebma aCvena, yvela centraluri moqmedebis samkurnalo saSualeba axangrZlivebs QT intervals, amitom fsiqiatriaSi mwvave problemaa medikamentur_inducirebuli QT intervalis gaxangrZlivebisa. 730 bavSvisa da mozardidan,
romlebic Rebulobdnen antidepresantebs
Terapiul dozebSi, QT intervalis gaxangrZliveba (QTc > 440ml/wm) Tan axlda: dezi praminomiT
mkurnalobas_30%,
imi praminomiT_16%. amitri ptiliniT_11%, klomi praminomiT_11%. aRwerilia QT intervalis gaxangrZlivebasTan asocirebuli,,gus’’ SemTxvevebi
pacientebSi, romlebic xangrZlivad iRebdnen
triciklur antidepresantebs. (i. n. limankina 2007)
_antiariTmiuli preparatebi:
I klasis: qinidini, dizopiramidi, prokainamidi (novokainamidi), hiluritmali.
III klasis: sotaloli, kordaroni, bretiliumi, dofetilidi, acetilprokainamidi.
IV klasis: bepridili.
sxva antiariTmiuli preparatebi: enkanidi,
aprinidini, azimilidi, klofiliumi, ibutilidi.
_preparatebi,
romlebic
gamoiyeneba
gul_sisxlZarRvTa daavadebebis samkurnalod: amiodaroni, dobutamini, dopamini, indapamidi, norepinefrini, qinidini, epinefrini,
efedrini.
_antihistaminuri preparatebi: astemizoli, terfanadini, ebastini, hidroqsizini.
_antibaqteriuli preparatebi: azitromicini, klaritromicini, levofloqsacini, ofloqsacini, ci profloqsacini, eriTromicini.
_fsiqonevrologiuri daavadebebis samkurnalo preparatebi: amitri ptilini, haloperi-
2010 weli
26
doli, droperidoli, imi pramidi, metadoni,
notri ptilini, Tizanidini da a.S.
_antivirusuli preparatebi: amantadini,
foskarneti.
_anti parazituli preparatebi: meflokvini, pentamidini, qlorokvini.
_kuW-nawlavis traqtis samkurnalo preparatebi: cizapridi, domperidini da a.S.
_respiratoruli daavadebebis samkurnalo
preparatebi: salbutamoli, salmeteroli,
terbutalini.
_diuretikebi: indapamidi.
_antifungaluri preparatebi: vosikonazoli, itrakonazoli, ketokonazoli, flukonazoli.
_sxvebi: alfuzosili, vardenafili, fsevdoefedrini, fenilefrini da a.S.
b. paTologiuri mdgomareobebi da daavadebebi, romelTa drosac SesaZlebelia moxdes QT intervalis gaxangrZliveba:
_nervuli anoreqsia.
_intrakranialuri da subaraqnoiduli
sisxlCaqcevebi (32% pacientSi).
_sruli AV blokada, sinusuri bradikardia.
_miokarditebi.
_kardiomiopaTiebi.
_hi poTireoidizmi.
_diabeturi neiropaTia.
_vercxliswyliT da organofosforuli
nivTierebebiT mowamvla.
_ciliT Raribi dieta.
_eleqtrolituri dararvevebi: hi pokalemia, hi pomagnemia, hi pokalcemia.
aseve, asaki (asakTan erTad matulobs),
sqesi (qalebSi ufro grZelia), dReRamis
dro.
QT intervalis cvlilebis ZiriTadi faqtorebidan gansakuTrebiT aRsaniSnavia gulis SekumSvaTa sixSire. damokidebuleba
arasworxazovani da ukuproporciulia. am
fenomenis pirveli mkvlevarebi iyvnen: Bazett
(1920), Friderici (1920), Hegglin & Holzmann(1937).
pediatriul
literaturaSi mocemulia
QT sigrZis gansazRvra da koreqcia Bazett
_is formuliT
sadac, Q QTc - QT intervalis koreqtirebuli sigrZea. RR - manZili mocemul da Semdgom QRS kompleqsebs Soris. gamoixateba
wm_ebSi.
QT intervalis gaxangrZliveba registrirdeba periodulad-SesaZloa gaqres da
,fdidsf rfhlbjkjubf
isev gamoCndes. zomieri sigrZis dasadgenad
minimum sami Tanmimdevruli QT da RR cikli
da regularuli riTmi unda iyos.
QT intervalis sazRvrebi normaSi:
300_430ml/wm-mamakacebSi;
300_450ml/wm_qalebSi.
Q
QT intervalis momateba >50ml/wm, mizezebis miuxedavad, iTvleba miokardis eleqtruli arastabilurobis kriteriumad. absoluturi gaxangrZliveba >500ml/wm, unda ganvixiloT rogorc Tdp_s saSiSroeba.
European Agency for the Evaluation of Medical
Products_gvTavazobs
QT intervalis gaxangrZlivebis Semdeg interpretacias:
norma
zRvruli
gaxangrZlivebuli
mamakacebi
< 430 ml/wm
430 - 450 ml/wm
> 450 ml/wm
qalebi
< 450 ml/wm
450 – 470 ml/wm
> 470 ml/wm
T kbilis alternacia_formis, polarobis,
amplitudis cvlileba mowmobs miokardis
eleqtrul arastabilurobas. QT intervalis
dispersia_QT intervalis maqsimalur da minimaluri monacemebis sxvaoba ekg_s 12 standartul ganxraSi.
QTd = QTmax – QTmin
normaSi QTd = 20-50 ml/wm
dispersiis momateba
mzaobas ariTmogenezze.
mowmobs miokardis
gamokvlevis sqema:
1. genetikuri testireba.
2. eleqtrolitebis donis gansazRvra sisxlSi.
3. ekg mosvenebisas.
4. daregistrirebuli parkuWovani taqikardia,,torsades de pointes’’ ti pis. (,,piruet’’ ti pi).
5. T kbilis alternacia.
6. T dakbiluli sam ganxraSi.
7. gulis SekumSvaTa dabali sixSire.
8. kardiointervalografia.
9. eqokardiografia.
10. gulis doplerografia.
11. gulis da koronaruli arteriis rentgenul-kompiuteruli tomografia da magnitur-rezonansuli tomografia.
P
mkurnaloba:
upirveles yovlisa, Tu es SesaZlebelia,
unda dadgindes etiologiuri faqtorebi,
romlebmac gamoiwvia QQT intervalis gaxangrZliveba. magaliTad, medikamentebis dozis
2010 weli
,fdidsf rfhlbjkjubf
Semcireba, an moxsna, romelTac SeuZliaT QT
intervalis gaxangrZliveba, an dispersia.
Ggulis ukmarisobis adeqvaturi mkurnaloba
da gulis mankebis SemTxvevaSi qirurgiuli
Careva, aseve migviyvans QT intervalis normalizaciamde. profilaqtikisa da mkurnalobis efeqtur saSualebad miCneulia beta
blokatorebi (efeqturia 90%-Si) da magniumis preparatebi. magram ukanaskneli gamokvlevebiT (Association of Long QT Syndrome Loci &
Lardiac Evants Among patients Treated With Beta
Blockers), aRmoCnda, rom pacientebs LQT2 da
LQT3 genoti pebiT, unarCundebaT kardialuri
movlenebi.
M
medikamentozuri Carevis uefeqtobis SemTxvevaSi, SesaZlebelia Catardes qirurgiuli procedura _ marcxenamxrivi simpaTikuri
denervacia, an Caidgas defibrilatori.
prognozi:
,,gus” SemTxvevis mqone pacientebis prognozuli SefasebisaTvis gamoiyeneba Thompson da
Mc Cullough-is Skala:
klinikuri maxasiaTeblebi
sistoluri aw > 90 mm/v.w.sv.
sistoluri aw < 90 mm/v.w.sv.
dro
cnobierebis
dakargvidan
moZraobis gamovlenamde < 25 wT.
dro
cnobierebis
dakargvidan
moZraobis gamovlenamde > 25 wT.
myesTa refleqsebis arseboba
komatozuri mdgomareoba
qulebi
1
spontanuri
1
spontanuri
1
3 qulis mqone pacientebSi, 89% SemTxvevaSi
xdeba cns-is funqciis aRdgena;
< 3 quliT pacientebSi gadarCenis Sansi
mcirea, qirurgiuli Carevis miuxedavadac ki;
xolo pacientebSi 0, 1 an 2 quliT da gamoxatuli anoqsiuri encefalopaTiiT, prognozi arakeTilsaimedoa, ar gamoiyeneba Terapiis invaziuri meTodebi.
uecari sikvdilis riski, QT intervalis
Tandayolili gaxangrZlivebisas,adeqvaturi
Terapiis ararsebobis SemTxvevaSi aRwevs
85%-s,amasTan bavSvebis 20% iRupeba gonebis
dakargvis pirveli SemTxvevidan 1 wlis ganmavlobaSi da naxevarze meti_sicocxlis pirvel aTwleulSi.
amrigad, problemis aqtualobidan gamomdinare, mizanSewonilad migvaCnia: ekg_s Catareba yvela axalSobilSi, rac xels Seuwyobs sindromis droulad gamovlenas. yvela bavSvs, romelsac aReniSneba ati purad
mimdinare epilepsia, an sinkope, aucilebelia
gamokvleul iqnas QT intervalis gaxangrZlivebis sindromis gamosaricxad. QT intervalis gaxangrZliveba, rogorc prediqtori
uecari sikvdilisa, iRebs medicinis proble2010 weli
27
mis masStabur xasiaTs. Tanamedrove eqimis
winaSe dgas rTuli problema preparatis
sworad SerCevisa efeqturobis da usafrTxoebis kriteriumebiT. aqedan gamomdinare,
saWiroa sifrTxiliT davniSnoT preparatebi, romlebic iwveven QT intervalis gaxangrZlivebas. QT intervalis monitoringi SesaZlebels gaxdis Tavidan aviciloT seriozuli kardiovaskularuli garTulebebi,
romlebic xSirad sicocxlesTan SeuTavsebelia.
gamoyenebuli literatura:
Frank N. Wilson, MD., at al. (1954). «Recommendations for Standardization of Electrocardiographic and
Vectorcardiographic Leads.». Circulation (10): 364-373.
Hegglin, R., M. Holzmann: QT-Dauer. Z.klin.Med. 132
(1937) 1
Bazett HC. (1920). «An analysis of the time-relations
of electrocardiograms.». Heart (7): 353-370.
Fridericia LS (1920). «The duration of systole in the
electrocardiogram of normal subjects and of patients with
heart disease.». Acta Medica Scandinavica (53): 469-486.
ICH E14. The clinical Evaluation of QT/QTc Interval
Prolongation and Proarrhythmic Potential for Non-arrhythmic Drugs. Step 4. 12 May 2005
Arking DE, Pfeufer A, Post W, Kao WH, NewtonCheh C, Ikeda M, West K, Kashuk C, Akyol M, Perz S,
Jalilzadeh S, Illig T, Gieger C, Guo CY, Larson MG,
Wichmann HE, Marbán E, O’Donnell CJ, Hirschhorn
JN, Kääb S, Spooner PM, Meitinger T, Chakravarti A
(June 2006). «A common genetic variant in the NOS1 regulator NOS1AP modulates cardiac repolarization». Nat.
Genet. 38 (6): 644–51. DOI:10.1038/ng1790. PMID
16648850.
QT INTERVAL, VARIATION IN - сводка генетических исследований на сайте OMIM.
И. Н. Лиманкина 2007– Синдром удлиненного
интервала QT и проблемы безопасности психофармакотерапии;
Л, М, Макаров - Причины преобретенного синдрома удлиненного интервала QT;
n. jobava 2004
P. Sidebotham, P. Fleming, Unexpected death in childhood. A handbook for practitioners. John Wiley & Sons,
2007, ISBN 9780470060957.
Н. П. Шабалов, Детские болезни, 5 изд. Том 1. —
СПб: Питер, 2002. ISBN 5-94723-451-3.
Сирс У., Сирс М.. Ваш малыш от рождения до двух
лет. — М.: Изд-во Эксмо, 2006. — 912 с.
Крэйг Г. Психология развития. — СПб.: Изд-во
«Питер», 2000. — 992 с.
Li DK, Willinger M, Petitti DB, Odouli R, Liu L,
Hoffman HJ. Use of a dummy (pacifier) during sleep and
risk of sudden infant death syndrome (SIDS): population
based case-control study. BMJ 2005.
28
,fdidsf rfhlbjkjubf
MITRAL VALVE PROLAPS
Resident ROSTOM AMIREJIBI
Mitral valve prolapse syndrome has been given many
names, including the systolic click murmur syndrome,
Barlow syndrome, billowing mitral cusp syndrome, myxomatous mitral valve, floppy valve syndrome, and redundant
cusp syndrome. It is a common but variable clinical syndrome that results from a diverse pathologenic mechanisms
of one or more portions of the mitral apparatus, the valve
leaflets, chordea tendineae, papillary muscle, and valve annulus. MVP usually associated with myxomatous degenaretion,
affect up to 2-3% of adults in industrialized countries, with a
2:1 female predominance.
The condition was first described by John Breleton
Barlow in 1966, and was subsequently termed mitral valve
prolapse by J. Michael Criley.
MVP has been observed in all ages.
Most frequenty non-classic mitral valve prolapse occurs
as a primary condition unassociated with other diseases.
Patients present with a mid-systolic click or clicks, mild billowing of non-thickened mitral valve leaflet, the mitral valve
leaflet coaptation point on the ventricle side of the mitral
annulus and no or minimal mitral regurgitation.
However, classic mitral valve prolapse has been reported
to be associated with many condition. It is characterized by
increased redundancy or thickening (myxomatous changes)
of varying portions of the mitral valve leaflets. There is surface fibrosis of the mitral valve leaflets, mitral annular dilatation, chordal redundancy and lengthening and fibrin deposits.
MVP occurs quite commonly inheritable disorders of connective tissue that increase the size of the mitral leaflets and
apparatus, including the Marfan syndrome, Ehlers-Danlos
syndrome, osteogenesis imperfects, Ebstein’s anomaly, atrial
septal defect and the Holt-Oram syndrome. Classic mitral
valve prolapse may be familial, non-familial. There appears
to be a high incidence of MVP in patients with asthenic habitus and a variety of congenital thoracic deformities, including
a straight back, a pectus excavatum and a shallow chest.
Secondary mitral valve prolapse can appear in coronary
artery disease due to a relative displacement of the ischemic
papillary muscle.
Functional mitral valve prolapse results from a disproportion of the mitral valve leaflets and chordate in relation to the
internal left ventricle dimension. A reduction or alteration in
left ventricular cavity size or shape may cause normal mitral
valve leaflets to move past the mitral valve annulus during
ventricular systole.
The myxomatous appearance of the leaflets in MVP is
due to a loss or dissolution of the normal dense
collagen fibers (fibrosa), with replacement and invasion
of a less sturdy type of connective tissue (spongiosa). The
leaflets, chordae tendineae, and annulus all may be affected
by myxomatous proliferation. The leaflets are thickened and
redundant, and the chordae tendineae become elongated.
Both mitral leaflets can be affected in MVP, but the posterior
leaflet is more commonly involved.
Myxomatous proliferation, although most commonly
affecting the mitral valve, is not limited to this valve but has
been described in the tricuspid, aortic, and pulmonic valves,
particularly in patients with Marfan syndrome, and may lead
to regurgitation of these valves.
Prolapse represents abnormal superior systolic displacement of the mitral valve leaflets; one or both of the leaflets
extend beyond the normal systolic coaptation point, allowing
MR to occur. During systole, individual scallops or an entire
leaflet may billow excessively into the left atrium. For severe
MR to be present, both leaflets must be affected or one leaflet
may be flail, such as in the case of a ruptured chordae
tendinea. The stress on the ballooning leaflets during ejection
may result in additional stretching of the valve tissue and
chordae. Thus, prolapse may be get greater prolapse.
Mitral valve prolapse is often diagnosed from the physical examination, when the classic auscultatory finding of a
mid-to-late systolic click and/or murmur is appreciated.
Alternatively, it may be incidentally diagnosed during routine
echocardiography or discovered when complications of
MVP manifest.
Most patients are asymptomatic. Symptomatic patients
with MVP are separated into 3 categories: (1) those with
symptoms related to autonomic dysfunction; (2) those with
symptoms related to the progression of mitral regurgitation;
and (3) those with symptoms that occur as a result of an associated complication (ie, stroke, endocarditis, or arrhythmia).
•
Symptoms related to autonomic dysfunction are
usually associated with genetically inherited MVP and
include the following:
o
Anxiety
o
Panic attacks
o
Arrhythmias
o
Exercise intolerance
o
Palpitations
o
Atypical chest pain
o
Fatigue
o
Orthostasis
o
Syncope or presyncope
o
Neuropsychiatric symptoms
•
Symptoms related to progression of mitral regurgitation include the following:
o
Fatigue
o
Dyspnea
o
Exercise intolerance
o
Orthopnea
o
Paroxysmal nocturnal dyspnea (PND)
o
Progressive signs of congestive heart failure (CHF)
•
ECG usually is normal, but can show nonspecific
ST-segment and T wave abnormalities especially in leads II,
III, aVF.
•
MVP is also commonly seen in patients with inheritable connective tissue disorders.
Clinical characteristics are typically benign in young
women, whereas men older than 50 years tend to have serious consequence of mitral regurgitation.
•
Common general physical features associated with
MVP include the following:
o
Asthenic body habitus
o
Low body weight or body mass index (BMI)
o
Straight-back syndrome
o
Scoliosis or kyphosis
o
Pectus excavatum
o
Hypermobility of the joints
o
Arm span greater than height (which may be indicative of Marfan syndrome)
•
The classic auscultatory finding is a mid-to-late sys2010 weli
,fdidsf rfhlbjkjubf
tolic click, which is present due to the leaflets prolapsing into
the left atrium resulting in tensing of the mitral valve apparatus. It may or may not be followed by a high-pitched, mid-tolate systolic murmur at the cardiac apex.
o
The midsystolic click can vary in intensity and timing, primarily depending on left ventricular volume.
o
End-diastolic volume can be reduced by performing
a Valsalva maneuver or by having the patient stand. These
maneuvers result in an early click, which is close to the first
heart sound, and a prolonged murmur. In the supine position,
especially with the legs raised for increased venous return,
left ventricular diastolic volume is increased, resulting in a
click later in systole and a shortened murmur.
•
Patients with MVP most frequently have symptoms
of autonomic dysfunction, including easy fatigability, dizziness, and atypical chest pain. This pain is perhaps related to
papillary muscle strain (ie, excessive pulling on the left ventricular wall with prolapsed leaflets in the left atrium).
Differential Diagnoses – Mitral regurgitation
Workup
•
Echocardiography
o
Findings
•
Classic MVP: The parasternal long-axis view
shows > 2 mm superior displacement of the mitral leaflets
into the left atrium during systole, with a leaflet thickness of
at least 5 mm.
•
Nonclassic MVP: Displacement is > 2 mm, with a
maximal leaflet thickness of < 5 mm.
•
Other: Other echocardiographic findings that
should be considered as criteria are leaflet thickening, redundancy, annular dilatation, and chordal elongation.
•
Contrast ventriculography: This study can also help
in defining MVP with or without mitral regurgitation.
However, with the advent of echocardiography, contrast ventriculography is rarely necessary.
•
Chest radiography: Radiographs may demonstrate
the progression from asymptomatic to chronic, severe mitral
regurgitation with the development of cardiomegaly secondary to left atrial and left ventricular dilatation and evidence of
heart failure.
Treatment
•
Asymptomatic patients with minimal disease
o
These patients should be strongly reassured of their
benign prognosis.
o
They should undergo initial echocardiography for
risk stratification. If no clinically significant mitral regurgitation and thin leaflets are observed, clinical examinations and
echocardiographic studies can be scheduled every 3-5 years.
o
These patients are encouraged to pursue a normal,
unrestricted lifestyle, including vigorous exercise.
•
Patients with symptoms of autonomic dysfunction
o
A trial of beta-blockers for symptomatic relief can
be recommended.
o
Abstinence from stimulants such as caffeine, alcohol, and cigarettes is also recommended. An ambulatory 24hour monitor may be useful to detect supraventricular and/or
ventricular arrhythmias.
•
Patients with evidence of or progression to severe
mitral regurgitation
o
Close follow-up and referral for surgical repair are
indicated early, before left ventricular dilatation and systolic
dysfunction develop.
o
Asymptomatic patients with moderate-to-severe
2010 weli
29
mitral regurgitation and left ventricular enlargement, especially those with atrial fibrillation and/or pulmonary hypertension, should undergo surgery before left ventricular function deteriorates.
o
If the physician is unsure if the patient is asymptomatic, a treadmill stress test for exercise tolerance can be performed. That is, have the patient demonstrate that he or she
can walk vigorously without symptoms.
•
Patients with MVP and neurologic findings
o
After atrial fibrillation and left atrial thrombus are
excluded, these patients should be given daily aspirin therapy at a dosage of 80-325 mg/d.
o
Cessation of smoking and oral contraceptive use to
prevent a hypercoagulable state should be recommended.
o
Warfarin should be used when patients older than
65 years have atrial fibrillation, especially if they have associated risk factors of a previous stroke or TIA, clinically significant valvular heart disease, hypertension, diabetes, left
atrial enlargement, or a history and/or findings of heart failure.
•
Patients with a mid-systolic click and late-systolic
mitral regurgitation murmur
o
Consider antibiotic prophylaxis in these patients,
including those with increased leaflet thickening or redundancy.
o
Antibiotic prophylaxis is not recommended for the
patient with an isolated mid-to-late systolic click without a
murmur, unless the echocardiogram demonstrates significant
leaflet redundancy and/or thickness.
Mitral valve prolapse associated with severe mitral regurgitation can be treated with repair or surgical replacement of
the mitral valve. Repair of the mitral valve is always preferable to replacement and should be performed by surgeons
that are skilled in the procedure. Current ACC/AHA guidelines suggest that early repair of mitral valve, performed in
centers of surgical excellence, should be considered even in
patients without symptoms of heart failure. Symptomatic
patients, those with evidence of diminished left ventricular
function or left ventricular dilatation need urgent attention.
1.
Hayek E, Gring CN, Griffin BP (2005). "Mitral
valve prolapse". Lancet 365 (9458): 507-18.
2.
Barlow JB, Bosman CK (February 1966).
"Aneurysmal protrusion of the posterior leaflet of the mitral
valve. An auscultatory-electrocardiographic syndrome". Am.
Heart J. 71 (2): 166–78.
3. Criley JM, Lewis KB, Humphries JO, Ross RS
(July 1966). “Prolapse of the mitral valve: clinical and cineangiocardiographic findings.” Br Heart J 28 (4): 488–96.
4.
Levy D, Savage D. (1987). "Prevalence and clinical features of mitral valve prolapse". Am Heart J 113 (5):
1281–90.
5.
Freed LA, Levy D, Levine RA, Larson MG, Evans
JC, Fuller DL, Lehman B, Benjamin EJ. (1999). "Prevalence
and clinical outcome of mitral-valve prolapse". N Engl J Med
341 (1): 1–7.
6.
Mitral Valve Prolapse at eMedicine.
7.
AJ Giannini, WA Price, RH Loiselle. Prevalence of
mitral valve prolapse in bipolar affective disorder. American
Journal of Psychiatry. 141:991-992,1984.
8.
Kolibash AJ (1988). "Progression of mitral regurgitation in patients with mitral valve prolapse". Herz 13 (5):
309–17.
9.
Tanser, Paul H. (March 2007).”Mitral Valve
Prolapse”. Merck. Retrieved 2007-07-11.
30
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USE OF BNP AND NT-PROBNP IN EARLY STAGE
DIAGNOSIS OF ATHLETE’S CARDIOVASCULAR
PATHOLOGIES: LITERATURE OVERVIEW.
ILIA NADAREISHVILI –
AIETI Highest Medical School
GEORGE CHAKHUNASHVILI MD, PhD. –
TSMU Pediatric Clinic Director Substitute
Brain natriuretic peptide (BNP), now known as B-type
natriuretic peptide(also BNP) or GC-B, is 32 amino acid
polypeptide secreted by the ventricles of the heart in
response to excessive stretching of heart muscle cells (cardiomyocytes). BNP, originally termed brain natriuretic
peptide, was discovered in 1988 from porcine brain by T.
Sudoh et al. in 1988, but it was soon discovered that the
highest concentration of the peptide is found in the atria,
with the total ventricular amount of BNP being even higher due to greater mass (Minamino et al.1988).
BNP is co-secreted along with the remaining part of
the prohormone, a 76 amino acid N-terminal fragment
(NT-proBNP) which is biologically inactive. BNP binds to
and activates the atrial natriuretic factor receptors
Natriuretic peptide receptor A/guanylate cyclase A NPRA,
or NPR1, and to a lesser extent NPRB, in a fashion similar to atrial natriuretic peptide (ANP) but with 10-fold
lower affinity. NRP1 is a single membrane-spanning
receptors with intrinsic guanylate cyclase activity. The
vast majority of natriuretic peptide-dependent effects are
mediated by elevations of intracellular cGMP concentrations. cGMP will then stimulate cGMP-dependent pro-tein
kinase (PKG) which will then induce smooth muscle
relaxation. This relaxation will decrease total periph-eral
resistance which will in turn decrease venous return to the
heart. The decrease in venous return to the heart will
reduce the preload and will result in the heart having to do
less work.
The physiologic actions of BNP are similar to ANP and
include increase in natriuresis, decrease in systemic vascular resistance and central venous pressure, inhibition of
renin and aldosterone production and of cardiac and vascular myocyte growth. Thus, the net effect of BNP and ANP
is a decrease in blood volume and a de-crease in cardiac
output.
The biological half-life of BNP, however, is twice as
long as that of ANP, and that of NT-proBNP is even longer,
making these peptides better targets than ANP for diagnostic blood testing. BNP accurately reflects cur-rent ventricular status. The half-life of NT-ProBNP is 1 to 2 hours vs.
20 minutes for BNP.
CLINICAL USE
The BNP assay has become one of the most important
blood tests in cardiology.
The BNP test as well as the NT-proBNP one have
already proved to be extremely useful in screening and
diag-nosis of Congestive Heart Failure, and in establishing
prognosis for heart failure patients. In addition, BNP helps
physicians to make decisions hospitalization and evaluate
effectiveness of therapy. A synthetic formula-tion of BNP
(nesiritide) is used to treat decompensated heart failure,
resulting in improved hemodynamics and symptoms.
There is also more and more evidence that the BNP test
may play a major role in critical care medicine, in : pulmonary embolism, cardio-renal syndrome, septic shock,
subarachnoid hemorrhage,
Cardiologic Pathologies: Congenital heart diseases,
cardiomyopathies, mitral regurgitation, aortic stenosis,
atrial fibrillation, acute coronary syndrome, myocardial
infarction, chronic stable angina, rheumatic fever, aortic
aneurism repair, cervical spine surgery,
Non-cardiologic pathologies: COPD, pulmonary
hypertension, fibrotic lung disease, oncology (radiotherapy),
B-type natriuretic peptide appears to be a reliable predictor of future cardiac and all-cause mortality in diabetic
patients. Bhalla et al. showed that combining BNP with
other tools like ICG can improve early diagnosis of heart
failure and advance prevention strategies. Utility of BNP
has also been explored in various settings like preeclampsia, shock and End Stage Renal Disease.
TEST FEATURES
Biostatistics:
Negative predictive value is 96%, so heart failure can
confidently be ruled out for patients in the normal range.
When BNP is over 100 pg per milliliter - sensitivity =
90% ; specificity = 76%
When BNP is over 50 pg per milliliter - sensitivity =
97% ; specificity = 62%
For patients with CHF, BNP values will generally be
above 100 pg per milliliter; however, a more conservative
interpretation of the BNP is that normal values are less than
50 pg per milliliter in order to achieve adequate sensitivity. There is a diagnostic ‘gray area’, often defined as
between 100 and 500 pg/mL, for which the test is considered inconclusive. Values above 500 pg/mL are generally
considered to be positive. This so called gray zone has
been addressed in several studies and using clinical history or other available simple tools can help make the diagnosis.
The effect or race and gender on value of BNP and its
utility in that context has been studied extensively
Results
BNP levels below 100 pg/mL indicate no heart failure
BNP levels of 100-300 suggest heart failure is present
BNP levels above 300 pg/mL indicate mild heart failure
BNP levels above 600 pg/mL indicate moderate heart
failure.
BNP levels above 900 pg/mL indicate severe heart failure.
3000 During Nesiritide Infusion
BNP levels rise with age. Mean BNP levels are:
26.2 pg/ml in those aged 55-64 years.
2010 weli
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31.0 pg/ml in those aged 65-74 years.
63.7 pg/ml in those aged 75 years and older.
Women without CHF tend to have higher BNP levels
than males of the same age.
A small difference was noted between the white and
black racial groups (area under the curve = 0.888 and
0.903, respectively). In patients presenting to the ED with
heart failure, the disconnect between perceived sever-ity of
CHF and severity as determined by BNP levels is most
pronounced in African Americans.
METHODS AND EQUIPMENT
A wide array of products now allows rapid measurement of BNP (or NT-proBNP) on a point-of-care or labora-tory basis. These products use whole blood or serum
samples and employ ELISA methods with photometric
readout. They differ mainly on points of hardware size,
CLIA-waived status, sample preparation, automation etc.
Usually, to test the BNP level, a small amount of blood
(in case of the Montgomery et al. study it was fifteen milliliters of venous blood) is taken and placed in a machine
that detects the level of BNP in blood. Blood thin-ner
EDTA is used to prevent blood from clotting. The test takes
about 15 minutes. Different machines can de-tect such low
concentrations as 5pg/ml.
We conclude that the BNP test is a quick, inexpensive
test which enhances current diagnostic assessment tools,
and enables doctors to make the correct diagnosis of heart
failure, prognosis and decisions regarding treatment.
Future research is evaluating the use of BNP test to determine its role in many other conditions for screening, diagnosis, prognosis and treatment strategy determination purposes.
Cardiac enlargement in athletes was first reported over
a century ago. But the debate whether this adaptation to
regular high intensity exercise training is a purely physiological condition or has pathological consequences continues to this day. We are uncomfortable with widely accepted view that athletic left ventricular hypertrophy is a purely physiological adaptation with no pathological consequences, for several reasons. Firstly, although sudden cardiac death in competitive athletes under the age of 35 years
is rare (according to the Minneapolis Heart Institute
Foundation, which tracks deaths of young athletes in a registry, about 125 athletes under 35 die in the U.S. each year,
mainly from cardiovascular problems), up to 18%of postmortems of athletes dying dur-ing sport suggest a condition which has been termed idiopathic left ventricular
hypertrophy, where no clear rea-son has been found for the
increase in left ventricular mass. Some studies were not
controlled for cardiovascular risk factors. The fact that left
ventricular hypertrophy caused by endurance training
regresses on cessation of regular exercise, merely confirms
that athletic left ventricular hypertrophy acts the same way
as other pathologi-cal conditions. Recent reports speculate
that structural adaptations to exercise, particularly of the
right ventricle (RV), may predispose to tachyarrhythmias
and sudden cardiac death.
At present, the risk of myocardial damage by
2010 weli
31
endurance exercise is under debate because of reports on
exercise-associated increases in cardiac biomarkers troponin and B-type natriuretic peptide. Based on the determination of cardiac troponin (cTnT), brain natriuretic peptide (BNP), and echocardiographic measurements, recent
inves-tigations have reported myocardial damage and
reversible cardiac dysfunction after prolonged endurance
exer-cise in apparently healthy subjects. Exercise-associated elevations of cardiac biomarkers can be present in elite
and in recreational athletes, especially after prolonged and
strenuous endurance exercise bouts (e.g., cycling, rowing,
marathon, ultra triathlon and cross-country skiing).
Athletic left ventricular hypertrophy does also occur in
people with other kind of strenuous activities. However, it
is still unclear if the exercise-associated appear-ance or
increase in cardiac biomarkers in obviously healthy athletes represents clinically significant cardiac in-sult or is
indeed part of the physiological response to endurance
exercise. In addition, elevations in cardiac bio-markers in
athletes after exercise may generate difficulties for clinicians in terms of differential diagnosis and may result in
inappropriate consequences.
Although the idea of using the BNP or NT-proBNP test
to assess athlete’s heart was suggest some years ago, the
present topic is still not studies well. It was noted by a
number of authors that strenuous exercise leads to a plasma BNP/NT-proBNP concentration increase. (Table # 1)
Some researches also shown, that the peptides’ concentration is also elevated in healthy control individuals after
physical exercise. Though the first such obser-vations and
hypotheses about the exact mechanism of this elevation
where done over a decade ago, there is still no commonly
accepted insight on this problem. Different researches try
to clear the meaning of these findings as well as explain
them theoretically and experimentally. Recent echocardiographic investigations have shown a reversible diastolic
and systolic dysfunction after long-lasting endurance
events in trained individuals. It can be speculated that this
exercise-induced myocardial dysfunction is pathogenetically responsible for an increase in BNP after such types of
exercise. Thus, there is a reasonable background to claim
for more information regard-ing the exercise-induced
myocardial stress reaction in athletes, particularly with the
third-generation assay for cTnT. Moreover, different exercise intensities and durations have to be considered. Aside
from the already men-tioned problem regarding the crossreactivity of the cTnT assay, an increase in postexercise
cTnT levels or the marked rise in BNP were mostly
observed after extreme ultra-endurance events. Although
the authors reported that the majority of subjects investigated were well-trained endurance athletes, the question
arises in how far any form of training can prepare the
human organism and particularly the heart for such forms
of exercise. In addition, some events took place under
extreme environmental conditions or high altitude, thereby
imposing additional cardiovascular stress.
Correct interpretation of the test could open new quick
and easy ways to diagnose and screen for heart diseases in
athletes. Some of the authors suggest that BNP/NT-
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32
proBNP tests can be very useful for differentiation between physiological and pathological cardiac hypertrophy.
Better knowledge of BNP behavior under physio-logical
conditions should be useful for proper assessment of load
in athletes as well as for correct interpretation of BNP
results after physical exercise..
Article
Effect of Professional
Exercises on BNP
(Sheikhani Shahin et al.)
Peptide
BNP
Elevation of serum NTNT-proBNP
proBNP after exercise is
an index of myocardial
damage or cytoprotective
reflection? (Faviou et al.)
GDF-15, endoglin and
NT-proBNP induction in
athletes participating in
an ultramarathon foot
race. (Tchou et al.)
NT-proBNP
Sports
Pre-Training
Concentration
Post-Training
Concentration
Football
26.3 +/- 12.9
48.5+/- 18.4
Volleyball
19.1+/-11.8
43.4+/- 30.6
Water Polo
9.5 +/- 2.1
12.4 +/- 4.3
Bodybuilding
12.0 +/- 5.9
15.7 +/- 5.6
pg/ml
pg/ml
-
-
58.37+/-19.48
22.93+/-10.22
ng/L
Ultramarathon
Foot Race
38.1+/-4.8 pg/ml 1280.6 +/- 259.0
pg/ml
Myocardial response to a Pro-BNP
triathlon in male athletes
evaluated by Doppler tissue imaging and biochemical parameters
(Leetmaa et al.)
Triathlon
7+/-2
27+/-21
pmol/L
pmol/L
Myocardial Stress after
Competitive Exercise in
Professional Road Cyclists (Koning et al)
Road Cycling
47.5+/-37.5
pg/ml
75.3 +/- 55.3
pg/ml
BNP
Magnitude, Reproduci- NT-proBNP
bility, and Association
With Baseline Cardiac
Function of Cardiac
Biomarker Release in
Long-Distance Runners
Aged ≥55 Years
(Sahlen et al.)
Running
42ng/L
191ng/L
Effect of Competitive
NT-proBNP
marathon cycling on
plasma NT-proBNP and
CTnT in healthy recreational cyclists (Neumayr et al.)
Road Cycling
28+/-21 ng/L
278 +/- 152 ng/L
Independent elevation
of NT proBNP and
cardiac troponins in endurance athletes after
prolonged strenuous
exercise (Scharhag et
al.)
Running marathon
Increased by:
200ng/L
Mountain bike
marathon
97ng/L
NT-proBNP
78ng/L
NT-proBNP
Predisposing factors
and consequences of
elevated biomarker levels in long-distance
runners aged >or=55
years
Running
53ng/L
121ng/L
Biochemical and func- BNP
tional abnormalities of
left and right ventricular
function following ultra-endurance exercise
Triathlon
12.2 etag/L
42.5 etag/L
(La Gerche et al.)
Article
Peptide
Sports
Before TrainPost-Training
ing
Concen- Concentration
tration
The impact of exercise dura- NT-proBNP Running
tion and intensity on the release of cardiac biomarkers
(Serrano-Ostariz et al.)
21-32 ng/L
38-67 ng/L
Effect of short-term maximal exercise on BNP plasma
levels in healthy individuals
(Krupicka et al.)
19.4+/-2.5
pg/ml
30.6+/-4.7
pg/ml
BNP
Bicycle Spiroergometry
Table #1| BNP test results before and after exercise, as
obtained by some authors. Note we do not add exercise
duration time and time past after the exercise, when the
blood samples were taken.
It’s interesting that at least one published work states
that the NT-proBNP test can be useful in senior endurance
runners screening. Sahlen et al. published two articles
related to the problem: “Predisposing factors and consequences of elevated biomarker levels in long-distance runners aged >or=55 years” (2009) and “Magnitude, re-producibility, and association with baseline cardiac function
of cardiac biomarker release in long-distance run-ners
aged > or =55 years” (2008). The aim of both studies was
to assess the magnitude and reproducibility of biomarker
release in athletes aged > or =55 years. One hundred
eighty-five participants where included (61.1 +/- 5 years;
29% women) at a 30-km cross-country race who were
self-reportedly in excellent health. Before and after the
race, the creatinine, N-terminal pro-brain natriuretic peptide (NT-proBNP), and troponin T were analyzed, and participation in the number of previous races and the race
duration were recorded. NT-proBNP increased from 53
ng/L (interquartile range 31 to 89) to 121 ng/L (interquartile range 79 to 184) and troponin T from undetectable to
0.01 microg/L (interquartile range 0.01 to 0.04). The independent predictors of a large NT-proBNP increase were
(1) greater levels present at baseline, (2) a greater increase
in creatinine (both p <0.001), (3) older age (p = 0.01), and
(4) a longer race duration (p <0.05). Troponin T elevation
was independently pre-dicted by (1) older age (p = 0.01),
(2) a greater increase in creatinine, and (3) participation in
fewer previous races (both p <0.05). Of the 15 runners
with an elevated (>194 ng/L) baseline NT-proBNP level
(8.1% of 185), 4 were found to have serious cardiovascular disease (2.2% of whole sample). Of these 4 patients, 1
died from sudden cardiac death within months after the
race. In conclusion, biomarker elevation occurs commonly in sen-ior runners. A high baseline NT-proBNP is predictive of a large release during exercise, suggesting that
the fac-tors that control the at rest levels also determine its
release with exertion. Troponin T elevation was seen in
less-experienced participants. A small group of very ill
runners were identified by NT-proBNP analysis. Longdistance runners aged > or =55 years released NT-proBNP
and troponin T in a reproducible fashion. The mag-nitude
of NT-proBNP release during the race was correlated
strongly with NT-proBNP baseline levels and was associated with left ventricular mass and age. These findings
may suggest a potential adverse effect of long-distance
running on cardiac function in certain participants in this
age group.
2010 weli
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Whether the observed elevation represents a physiological adaptation reaction or a pathology is not clear
yet. Here are some suggested hypotheses regarding this
question.
Among authors who claim the BNP/NT-proBNP elevation is a physiological response are J. Scharhag, A. Urhausen et al., who published the article titled “No difference in N-terminal pro-brain natriuretic peptide (NTproBNP) concentrations between endurance athletes with
athlete’s heart and healthy untrained controls” in 2004.
They still find that NT-proBNP and BNP tests can have
important value as a tool to differentiate between pathological and physiological cardiac hypertrophy. Ten triathlets, 5
road cyclists and 5 long distance runners (age, 28 (4) years;
height, 178(7) cm; weight, 69 (8) kg; heart volume, 14.5
(1.1) ml/kg; aerobic capacity VO2max, 68 (6) ml/min/kg;
endurance training volume per week, 17 (6) hours; training
history, 8 (4) years) and a control group of 20 healthy
untrained males (group C) (age, 26 (4) years; height, 179
(6) cm; weight, 73 (8) kg; heart volume, 10.9 (0.6) ml/kg;
VO2max, 42 (5) ml/min/kg) matched for age, weight and
height with no his-tory of physical activity were included
into the study. VO2max, CMR, and echocardiographic
parameters were determined as described previously.5
Diastolic function was determined by pulsed Doppler spectral recordings in the four chamber view at the tips of the
mitral leaflets and an E/A ratio > 1 was considered to be
normal.
As a result of the research, no difference was found in
diastolic or systolic function between groups. There was no
difference in NT-proBNP values between endurance athletes and untrained control subjects (p = 0.56); endurance
athletes, 24.7 pg/ml (10th, 25th, 75th, and 90th centiles:
9.9, 14.1, 37.3, and 49.4 pg/ml, respectively) and untrained
control subjects, 28.9 pg/ml (10th, 25th, 75th and 90th centiles: 14.1, 16.7, 32.5, and 41.2 pg/ml, respectively)
It was stated, that NT-proBNP represents BNP in an
equimolar manner. There was no difference between BNP
concentrations in a small group of eight cyclists and their
age matched controls. relation between LV mass and resting NT-proBNP concentration even when examining a
greater number of subjects was not found.
The authors discuss relation of their findings to those of
Montgomery at al. (which we will discuss next):
“Therefore, the present results do not support the findings
of Montgomery and colleagues, who observed an in-crease
in BNP concentrations in angiotensin converting enzyme
D-allele-positive healthy male British Army recruits with
an increase in LV mass after 10 weeks of intensive strength
and endurance training.3 As a marker of myocardial
growth,3 the raised BNP concentrations reported by
Montgomery might reflect acute cardiac stress and a beginning myocardial adaptation to the training stimulus (acute
effect), whereas in endurance ath-letes with a longer history of training, the myocardium might be already adapted to
endurance exercise bouts without further induction of relevant cardiomyocyte growth. Consequently, BNP concen2010 weli
33
trations do not remain elevated in endurance athletes with
athlete’s heart at rest (chronic effect).”
Scharhag et al. concluded, that repeated bouts of
endurance exercise do not chronically alter myocardial
integ-rity and that myocardial wall stress is not elevated in
endurance athletes with athlete’s heart. The results confirm
the assumption that the athlete’s heart represents a physiological hypertrophy to an increased volume load with-out
ventricular overload. Therefore, under resting conditions,
NT-proBNP (and BNP) might be a useful addi-tional tool
to differentiate between physiological and pathological
cardiac hypertrophy.
One of the first studies which pointed out, that BNP is
elevated after strenuous physical load was the one by
Montgomery et al. Although it was not focused on athletes,
but army recruits, it gave some first vision of the presented problem. And it was also one of the first research projects, which used the BNP test not to diagnose CHF, but to
describe the heart features related to the extremely strenuous long-term physical exercises.
Although the main aim of the project was determining
the genotype, which is the most associated with the LV
mass increase, it was there, where BNP test was used to
assess cardiologic features and functions related to extreme exercise, among such others as Electrocardiography
and Echocardiography.
“The study population comprised all 460 consecutive
males recruited to the Army Training Regiment Bassingbourn, UK, over a 9-month period. All were normotensive
and free of cardiovascular disease and underwent an identical 10-week period of intensive strength and endurance
training. At entry, height, weight, and the time taken to
complete a standard 1.5-mile run at maximal exertion were
recorded, and venous blood samples were drawn. On the
first day of training (pretraining data) and again 10 weeks
later (post-training data), BP (mean of three manual measurements after 5-minute supine rest, each 1 minute apart)
was documented, and transtho-racic echocardiography was
performed. In one random training cohort, blood was taken
for assay of BNP, and a 12-lead ECG recording was performed before and after training. Only subjects who completed training without interruption were included in follow-up.”
The results were:
One cohort of 84 participants was randomly selected at
entry for assay of plasma BNP, of whom 49 completed
training. Pretraining plasma BNP levels did not differ
between genotypes. Levels increased significantly with
training in the whole group (n=49; mean±SEM, 44.6±2.5
versus 66.4±4.7 pg/mL; P<.001), an effect strongly associated with ACE genotype ( for rise in BNP levels,P<.05).
Levels did not rise significantly for those of II genotype
(47.0±5.6 versus 58.4±6.3 pg/mL), rising significantly
only among those with 1 D allele (n=35; pretraining,
43.7±2.8 pg/mL; post-training,69.6±6.1 pg/mL; P<.0001).
The rise was greatest for those of DD genotype (mean rise,
34
11.5±6.3 versus 56.0±17.3 pg/mL for II versus DD genotype, respectively; P<.01). Post-training BNP levels, unlike
pretraining levels, were associated with ACE genotype
(DD>ID and DD>II; P<.001 for both comparisons).
The data obtained by Montgomery et al. strongly support the association of ACE genotype with LV growth, with
the rise in BNP levels with training being ACE genotype
dependent. Confounding factors (eg, cardiac dis-ease)
were eliminated.
The authors write: “Exercise has little influence on
plasma BNP concentration; all blood samples were taken
in the absence of recent exercise, and any such effect of
exercise is likely to be short-lived due to the very short
plasma half-life of BNP.” This was later observed by the
most researches of this topic. But the short-time eleva-tion
in BNP levels rose even more questions later.
On the basis of the above mentioned BNP test results as
well as electrocardiographic and echocardiography ones
(which we don’t add into our overview), the authors concluded that, exercise-induced LV growth in young males is
strongly associated with the ACE I/D polymorphism.
“Does Cardiac Morphology Predict Plasma Brain
Natriuretic Peptide Levels in Adolescent Athletes?” - the
ar-ticle by authors Nilsson, Womack and co-authors, who’s
research found that plasma BNP levels in healthy ado-lescent athletes have no correlation to body mass index or LV
mass, even when corrected for body surface area. Thirty
healthy male adolescent high school football players (16.0
± 1.1 years) were examined. Plasma BNP for this population was 11.9 ± 10.2 pg/mL. There was no correlation
between BNP and mean arterial pressure (r = -0.09, P =
0.64), body mass index (r = 0.11, P = 0.57), interventricular septal thickness (r = -0.15, P = 0.44), left ventricular
(LV) wall thickness (r = 0.00, P = 0.99), relative wall thickness (r = -0.04, P = 0.84), LV mass (r = 0.05, P = 0.79), or
LV mass index (r = 0.11, P = 0.55).
Other articles: “B-Type Natriuretic Peptide Is Related
to Left Ventricular Mass in Hypertensive Patients but Not
in Athletes” by Susana S. Almeida et al. and “Plasma Brain
Natriuretic Peptide In Endurance Trained Ado-lescents” by
Nilsson et al., does also find no relation between BNP levels and LVM in athletes.
Mechanism of exercise induces BNP/NT-proBNP level
elevation.
Despite the availability of some tens of published
works related to the problem we study, there is not clear
an-swer, what is the mechanism behind the BNP elevation.
Here is our overview of the article “Exercise-induced
increases in NT-proBNP are not related to the exerciseinduced immune response”, J. Scharhag, T. Meyer and others.
Fourteen cyclists and triathletes (mean (SD) age 25 (5)
years; height 180 (7) cm; weight 72 (9) kg; body fat 10.8
(2.5)%; heart volume 13.8 (1.7) ml/kg; VO2peak 67 (6)
ml/min/kg) represented the study population. Inflammatory and cardiovascular diseases were excluded by physical examinations, routine blood parameters, an electro-cardiogram at rest and during cycle ergometry, and an
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echocardiography at rest.
In randomised order, athletes had to perform three 4-h
constant load trials at an intensity of 70% of their indi-vidual anaerobic threshold on a 400 m track on three different
days, using different carbohydrate beverages (6% or 12%
carbohydrate or placebo; 50 ml fluid per kg body weight
for each trial). In all three trials (placebo, 6% carbohydrate,
12% carbohydrate), 13 of 14 athletes demonstrated an
exercise-induced increase in NT-proBNP concentrations,
with a significant effect over time (p<0.001). No difference
was found between trials for exercise-induced increases in
NT-proBNP concentrations.
It is known, that in cardiovascular patients, levels of
BNP and NT-proBNP are elevated due to a pathological
increase in myocardial wall stress and, in addition, have
been shown to be related to immune reactions.
Authors of the discussed article did not find significant correlations for increases between NT-proBNP and
IL-6 (r = 0.18; p = 0.25), CRP (R = 0.28; p = 0.12), leucocytes (R = 0.10; p = 0.54), neutro-phils (R = 0.13; p = 0.40),
monocytes (r = 0.05; p = 0.77), natural killer cells (R =
−0.18; p = 0.27), lactate (r = −0.02; p = 0.92), blood glucose
(r = −0.16; p = 0.32) or cortisol (r = 0.16; p = 0.32), or
between the exercise-induced increase in NT-proBNP and
the exercise heart rate at the end of exercise (r = 0.09; p =
0.60) or the heart volume (r = −0.42; p = 0.14). A significant relationship was found between the exercise-induced
increases in IL-6 and CRP (R = 0.68; p<0.001), and there
was a trend between blood glucose and IL-6 (r = −0.49; p
= 0.088).
The following text discusses the problem very well, so
we place it here closely to the original one:
Although prolonged exercise in the present study
induced a typical immune response (which could be
attenu-ated by CHO supplementation), and a typical
increase in NT-proBNP in healthy and well-trained
endurance ath-letes after 4 h of moderate but strenuous
exercise, no relationship between the exercise-induced
immune re-sponse and the increase in NT-proBNP could
be demonstrated. Therefore, exercise-induced increases in
NT-proBNP or BNP in healthy athletes must be differentiated from increases in cardiovascular patients with systemic inflammation.
First, it has to be noted that the exercise-induced
immune response in athletes is only transient and mild
com-pared with the chronic systemic inflammation in cardiovascular patients with heart failure, cardiac allograft rejection or other diseases. Although mean exercise-induced
concentrations in IL-6 reached about 5 pg/ml in the present
study, which is as high as resting values in patients with
worsening heart failure, resting values in ath-letes were
normal. Nevertheless, IL-6 has been shown to induce BNP
gene expression in cardiac myocytes in vitro, and it has
been assumed that the exercise-induced increase in IL-6
(which is produced by the contracting muscle to regulate
substrate delivery and to maintain the metabolic homeostasis for glycogen-depleted myo-cytes during exercise in
healthy athletes) is responsible for the exercise-induced
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release in BNP. However, in the present study, no relationship between the exercise-induced increase in IL-6 or other
exercise-induced im-mune reactions and the release in NTproBNP was found. Consequently, other reasons for the
exercise-induced release of BNP in healthy athletes have to
be considered.
Owing to the increase in cardiac work and arterial
blood pressure during exercise, elevated left ventricular
wall stress on cardiomyocytes could be one stimulus for
the exercise-induced increase in BNP release. In addition,
it has been shown that catecholamines induce an increase
in the gene expression and release of BNP in vitro and in
patients with sepsis. As epinephrine and norepinephrine
during 4 h of cycling at an intensity of 70% individ-ual
anaerobic threshold are elevated about 1.5 to 2-fold,
increases in catecholamines could further explain the exercise-induced increases in BNP or NT-proBNP in healthy
athletes.
In conclusion, the exercise-induced immune response
does not contribute to the exercise-induced increase in
BNP or NT-proBNP in healthy athletes, which therefore
has to be differentiated from (NT-pro)BNP elevations
modulated by pro-inflammatory cytokines in cardiovascular patients with systemic inflammation.
In an other article “Independent elevations of N-terminal pro-brain natriuretic peptide and cardiac troponins in
endurance athletes after prolonged strenuous exercise”,
Scharhag et al suggest, that the release of BNP during and
after exercise may not result from myocardial damage but
may have cytoprotective and growth-regulating effects.
This conclusion was made after the researches “examined
exercise-induced changes in NT-proBNP, cTnI, and cTnT
in 105 obviously healthy endurance athletes (40 +/- 8
years) before and after prolonged strenu-ous exercise.
Blood samples were taken before, 15 minutes, and 3 hours
after a marathon (n = 46), a 100-km run (n = 14), and a
mountain bike marathon (n = 45). RESULTS: Eighty-one
of 105 athletes exceeded the upper reference limit of NTproBNP (males/females 88:153 ng/L) after exercise. NTproBNP increased in all 3 events (P <.001) with the highest increase in the 100-km runners (median increase 200
ng/L; 25th/75th percentile 115/770 ng/L), which differed
from the increase in the marathon (97 ng/L; 36/254 ng/L)
or the mountain bike marathon (78 ng/L; 37/196 ng/L) (P
<.01). Cardiac troponin I exceeded 0.04 microg/L in 74%;
cTnT exceeded 0.01 microg/L in 47% of athletes after
exercise. NT-proBNP was not related to exercise-induced
increases in cTnI or cTnT, but correlated with exercise
time (r = 0.55, P <.001). “
In the article “Effect of Professional Exercises on Brain
Natriuretic Peptide”, H Sheikhani Shahin et al. (20 healthy
professional athletes were studied, test results are in table
1) suggest four possible mechanism of BNP concentration
rise. First it is “Myocardial Cell Injury”, as the increase in
BNP correlated to the elevation in cardiac Troponin-T after
the run and was interpreted as the result of exerciseinduced subclinical myocardial cell damage. Second version is – hemoconcentration, which is a result of exercise
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35
induced trans-capillary water passage. But as the authors
write themselves, due to a quick Hct correction but longer
BNP high levels, some other causes and factors should be
suggested. The third hypothesis is ACE gene polymorphism which we have already discussed under
Montgomery’s article overview. And the final possible
mechanism suggested by Ira-nian scientists is “Volumerelated stimulus”. The authors also have same theory as
that of Scharhag et al., that the elevation may represent a
cyto-protective mechanism.
La Gerche does also conclude that BNP rise is due to
myocardial damage (article “Biochemical and functional
abnormalities of left and right ventricular function following ultra-endurance exercise”). This study was aimed
to quantify the extent and duration of post-exercise cardiac injury with particular attention to right ventricular
(RV) dysfunction. The team tested 27 athletes (20 male, 7
female) one week before, immediately after, and one
week following an ultra-endurance triathlon. Tests
included cardiac troponin I (cTnI), B-type natri-uretic
peptide (BNP) and comprehensive echocardiographic
assessment. Results 26 athletes completed the race and
testing procedures. Post-race, cTnI was elevated in 15
athletes (56%) and the mean value for the entire co-hort
increased (0.17 vs 0.49microg/L, p<0.01). BNP rose in
every athlete and the mean increased significantly (12.2
vs 42.5 etag/L, p<0.001). Left ventricular ejection fraction (LVEF) was unchanged (60.4 vs 57.5%, p=0.09), but
integrated systolic strain decreased (16.9% vs 15.1%,
p<0.01). New regional wall motion abnor-malities developed in 7 athletes (27%) and LVEF was reduced in this
sub-group (57.8% vs 45.9%, p<0.001). RV function was
reduced in the entire cohort with decreases in fractional
area change (0.47 vs 0.39, p<0.01) and tricuspid annular
plane systolic excursion (21.7 vs 19.1mm, p<0.01). At
follow-up, all parameters returned to baseline except for
one athlete with persisting RV dysfunction. Conclusion
was made, that myocardial dam-age occurs during intense
ultra-endurance exercise and, in particular, there is a significant reduction in RV func-tion. Almost all abnormalities resolve within 1 week.
There are also other points of view. For example, the
article “Effects of a long-distance run on cardiac markers
in healthy athletes” by M. Leers et al. suggests that the
increase could be partially attributed to cardiac stress. The
transient increases in BNP, NT-pro-BNP and troponin T are
more likely to reflect myocardial stunning than cardiomyocyte damage. They also write, that the magnitude of the
increase in BNP could serve as a marker of the biological
age of the myocardium.
In their study 25 male and 2 female runners (age 34-64
years) who were running the Visй-Maastricht-Visй
marathon. Blood samples were drawn just before and
immediately after finishing the marathon. An additional
blood sample was collected 24 h later. As a result, running
the marathon led to a significant increase in cortisol. This
returned to baseline values 24 h after the marathon. There
was a slight increase in brain natriuretic peptide (BNP);
36
however, this was not statistically significant. On the contrary, the N-terminal fragment of BNP (NT-pro-BNP) was
significantly increased immediately after the run and was
normalized 24 h later in 26 out of 27 runners (96%). The
magnitude of the transient elevations in BNP and NT-proBNP increased with the age of the athletes. Furthermore, in
9 out of 27 runners there was a significant increase in troponin T. However, in all these runners this increase was
transient and troponin-T levels returned to baseline values
24 h after the marathon.
It is possible the elevation represents hypertrophic cardiomyopathy, as suggested by article “Athlete’s heart or
hypertrophic cardiomyopathy: Usefulness of N-Terminal
pro-Brain Natriuretic Peptide” by P. Godon, V. Griffet et al.
In Godon’s study, NT-proBNP levels were measured at
rest and after effort in trained athletes referred for sus-pectedly abnormal (≥ 13 mm) left ventricular hypertrophy.
Seventeen patients were included, 10 of whom were diagnosed with hypertrophic cardiomyopathy (group I) while
the other 7 presented typical signs of athlete’s heart (group
II). NT-proBNP levels did not significantly differ between
groups, whether at rest or after effort. NT-proBNP levels
were, however, significantly elevated in 3 subjects in group
I, while being consistently nor-mal in group II.
Authors conclude, that in active athletes presenting
with ambiguous left ventricular hypertrophy, abnormal
NT-proBNP levels indicate hypertrophic cardiomyopathy,
whereas normal values are inconclusive. The article makes
it obvious that the NT-proBNP test is extremely useful in
differentiation of athletes heart from hypertro-phic cardiomyopathy.
The article “Hypertrophic Cardiomyopathy vs. Athletes
Heart” by T. Cheng. also puts NT-proBNP test as one of the
most important tools for the two conditions differentiation.
A Greek/Swiss research based article “Growth-differentiation factor-15, endoglin and N-terminal pro-brain natriuretic peptide induction in athletes participating in an
ultramarathon foot race” by I. Tchou, A. Margeli, M.
Tsironi, Katerina Skenderi, I. Papassotiriou et al. states that
elevated circulating GDF-15, endoglin and NT-pro-BNP
levels reflect a transient endothelial dysfunction in these
athletes who participated in a foot race con-sisting of continuous, prolonged and brisk exercise. Here is a short
abstract data of their research, which repre-sents the base
for the conclusion made: “The actions of growth-differentiation factor (GDF)-15, endoglin and N-terminal pro-brain
natriuretic peptide (NT-pro-BNP) was investigated in 15
male athletes who participated in the ultradistance foot
race of the 246 km ‘Sparthathlon’. Measurements were
performed before (phase I), at the end of the race (phase II)
and 48 h post-race (phase III). GDF-15 and endoglin serum
concentrations were de-termined with enzyme-linked
immunosorbent assay and NT-pro-BNP plasma levels by
electrochemilumines-cence. GDF-15 levels were increased
from phase I (563.9 ± 57.1 pg ml−1) to phase II (2311.1 ±
462.3 pg ml−1) and decreased at phase III (862.0 ± 158.0
pg ml−1) (p < 0.0002). NT-pro-BNP levels followed a similar pattern to that of GDF-15 from 38.1 ± 4.8 pg ml−1 at
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phase I to 1280.6 ± 259.0 pg ml−1 at phase II and 89.8 ±
13.6 pg ml−1 at phase III (p < 0.0001) and at the same time
points, endoglin levels were 4.7 ± 0.2 ng ml−1 at phase I,
5.8 ± 0.2 ng ml−1 at phase II and 4.3 ± 0.2 ng ml−1 at
phase III (p < 0.002).”
Koning and co-workers wrote (article: “Myocardial
Stress after Competitive Exercise in Professional Road Cyclists”, also discussed earlier) that, strenuous endurance
exercise in professional road cyclists does not result in
structural myocardial damage. The rise in BNP in older
athletes may reflect a reversible, mainly diastolic left ventricular dysfunction. This needs to be confirmed by larger
trials including different intensities, sports, and age groups.
They examined 11 highly trained male professional road
cyclists (age 27 ± 4 yr; V̇O2peak 67 ± 5 mL•kg-1•min-1;
training workload 34,000 ± 2,500 km•yr-1). None of the
athletes showed pathological findings in the cardiac examination. CK (P < 0.01), CKMB (P < 0.05), and Myo (P <
0.01) were increased after the race. Normal postexercise
cTnT levels indicate that the increase in CK, CKMB, and
Myo was of noncardiac origin. In contrast, BNP rose significantly from 47.5 ± 37.5 to 75.3 ± 55.3 pg•mL-1 (P <
0.01). Pre- and postexercise values of BNP as well as the
individual exercise-induced increase in BNP were significantly correlated with age.
It was supposed that the increased BNP and cTnT levels represent cardiac fatigue and not myocardial damage
(“Effect of competitive marathon cycling on plasma N-terminal pro-brain natriuretic peptide and cardiac tro-ponin T
in healthy recreational cyclists”, Neumayr et al.). Neumayr
and his measured BNP and cTnT in recrea-tional cyclists
(n = 29) during the Otztal Radmarathon 2004. In all subjects, NT-pro-BNP significantly in-creased from 28 +/- 21
to 278 +/- 152 ng/L immediately after the race (p <0.001),
decreased again on the fol-lowing day, and returned to
baseline values 1 week later. The mean percentage increase
in NT-pro-BNP was 1,128 +/- 803%. CTnT, negative in all
subjects before the race, increased transiently in 13 athletes
(45%), with levels ranging from 0.043 to 0.224 mug/L in 8
of them (28%). One day after competition, cTnT had normalized in all athletes.
It becomes quite clear that the BNP and NT-proBNP
tests can be very useful in athletes heart assessment, but a
lot of further research is needed, as suggested by Scharhag,
Koning Kupricka, Almeida, Serrano-Ostariz, Legas-Arrese
and others in their articles.
Nounopoulos and others, recommend a routine checkup of plasma NT-proBNP before and after exercise as a
screening test, and state that elevated levels warrant further
evaluation.
Pagourelias also suggests that, BNP might be useful as
a pre-participation screening test in athletes, in his and his
co-authors recently published article “Brain natriuretic
peptide and the athlete’s heart: a pilot study”
The group of Greek scientists used an integrated M
mode, two-dimensional B mode and Doppler echocardiographical study and plasma BNP levels test to examine 25
strength athletes, 25 patients with established hyper-troph2010 weli
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ic cardiomyopathy (HCM) and 25 healthy volunteers.
Among athletes, BNP levels correlated negatively with the
total training time (r = −0.79, p = 0.002) and positively
with ejection fraction (r = 0.58, p = 0.049) and fractional
shortening (r = 0.57, p = 0.049). A BNP cut-off value of
11.8 pg/ml had 88% specificity and 74% negative predictive value for the exclusion of HCM.
As already mentioned, exercise-induced BNP increase
was shown to be significantly correlated with athletes’ age.
Some of the articles, such as the one by Leers et al. suggest
that NT-pro BNP can be used as a marker for biological age
of myocardium. At the same time some others, as
Krupicka’s article “Effect of short-term maxi-mal exercise
on BNP plasma levels in healthy individuals” did not find
any such correlation, putting this possi-ble usefulness
under question and need of further research.
Reports of BNP response to exercise in healthy control
individuals are also controversial and different mechanisms of BNP elevation where suggested (Krupicka et al.,
Scharhag et al.)
CONCLUSION: Having made a general overview of
the present problem and related literature, we consider that
the topic is quite important and it is necessary to conduct
further investigations. Of course not all related articles are
discussed in this text. You can find some of those not discussed but considered in our article in the literature list.
Sports medicine, particularly cardiology problems and a
new possibility of using BNP and NT-proBNP tests to
assess athletes heart made us decide to start our own original research program which is now being managed. We
propose a project of some stages, with possible developments according to results got in our original pilot study,
which considers testing 10 experienced rowers of the
Georgian national rowing team, before and after exercise,
as well as control group of healthy individuals. We decided to make BNP tests and not NT-proBNP as both are
shown to be elevated in the below mentioned articles, and
in our conditions it would be more suitable to test BNP and
not NT-proBNP. Further studies may consider different
sports activi-ties, age and exercise duration, as well as
comparing the results with echocardiography and electrocardiography data, as well as clinical histories, general
examination, capillaroscopy and possibly other assessment
methods.
LITERATURE
Introduction
Y. Ogawa, M Mukoyama et al. Brain natriuretic peptide
as a novel cardiac hormone in humans. Evidence for an
exquisite dual natriuretic peptide system, atrial natriuretic
peptide and brain natriuretic peptide. J Clin Invest. 1991
April; 87(4): 1402–1412.
T. Sudoh et al. A new natriuretic peptide in porcine
brain.Nature 1988;332:78-80.
Nobuyuki Yanagihara et al. Stimulatory effects of brain
natriuretic peptide on cyclic GMP accumulation and tyrosine hydroxylase activity in cultured bovine adrenal
medullary cells
2010 weli
37
Naunyn-Schmiedeberg’s Archives of Pharmacology
343, 289-295
CLINICAL USE
Bhalla MA, Chiang A et al. Prognostic role of B-type
natriuretic peptide levels in patients with type 2 diabetes
mellitus
Journal of the American College of Cardiology, Volume
44, Issue 5, 1 September 2004, Pages 1047-1052
Sheen V, Bhalla V, Tulua-Tata A, Bhalla MA, Weiss D,
Chiu A, Abdeen O, Mullaney S, Maisel A (February 2007).
“The use of B-type natriuretic peptide to assess volume
status in patients with end-stage renal disease”. Am. Heart
J. Volume 147, Issue 6, Pages 1078-1084
Resnik JL, Hong C, Resnik R, Kazanegra R, Beede J,
Bhalla V, Maisel A (August 2005). “Evaluation of B-type
natri-uretic peptide (BNP) levels in normal and preeclamptic women”. Am. J. Obstet. Gynecol. 193 (2): 450–4.
TEST FEATURES
Daniels LB, Bhalla V, et al.
B-type natriuretic peptide (BNP) levels and ethnic disparities in perceived severity of heart failure: results from
the Rapid Emergency Department Heart Failure Outpatient
Trial (REDHOT) multicenter study of BNP levels and
emergency de-partment decision making in patients presenting with shortness of breath.
J Card Fail. 2006 May;12(4):281-5.
Maisel AS, Clopton P et al
Impact of age, race, and sex on the ability of B-type
natriuretic peptide to aid in the emergency diagnosis of
heart failure: results from the Breathing Not Properly
(BNP) multinational study.
Am Heart J. 2004 Jun;147(6):1078-84.
Main Part:
Susana S. Almeida, Ana Azevedo, Alice Castro,
Fernando Friхes, Joгo Freitas, Antуnio Ferreira, Paulo
Bettencourt
B-Type Natriuretic Peptide Is Related to Left
Ventricular Mass in Hypertensive Patients but Not in
Athletes
Cardiology 2002;98:113-115
A Anastasakis, C Kotsiopoulou, A Rigopoulos, A
Theopistou, N Protonotarios,D Panagiotakos,
N Mammalis, CStefanadis
Similarities in the profile of cardiopulmonary exercise
testing between patients with hypertrophic cardiomyopathy and strength athletes
Heart 2005;91:1477-1478 doi:10.1136/hrt.2004.055053
Banfi G. ; Migliorini S. ; Dolci A. ; Noseda M. ;
Scapellato L. ; Franzini C.
B-type natriuretic peptide in athletes performing an
Olympic triathlon
Journal of sports medicine and physical fitness 2005,
vol. 45, no4, pp. 529-531
Banfi, Melzi D’Eril et al.
NT-proBNP concentrations in elite rugby players at rest
38
and after active and passive recovery following strenuous
training sessions
Clinical Chemical Laboratory Medicine. Volume 46,
Issue 2, Pages 247–249
Andre La Gerche, Kim Alexander Connelly, Don John
Mooney, Andrew Ian Macisaac, David Lloyd Prior
Biochemical and functional abnormalities of left and
right ventricular function following ultra-endurance exercise.
Heart. 2007 May 4
Patrick Godon, Vincent Griffet, Ulric Vinsonneau, Jean
Raymond Caignault, Jean Marc Prevosto, Gilles Quiniou
and Sylvain Guerard
Athlete’s heart or hypertrophic cardiomyopathy:
Usefulness of N-Terminal pro-Brain Natriuretic Peptide
Int J Cardiol in press.
Koning D.; Schumacher Y.; Heinrich L.; Schmid A. ;
Berg A.; Dickhuth H-H
Myocardial stress after competitive exercise in professional road cyclists
Medicine and science in sports and exercise 2003, vol.
35, no10, pp. 1679-1683
J Krupicka; T Janota; Z Kasalova; J
Effect of short-term maximal exercise on BNP plasma
levels in healthy individuals.
Hradec Physiological research / Academia Scientiarum
Bohemoslovaca 2009 Nov 20
Leers Mathie et al.
Effects of a long-distance run on cardiac markers in
healthy athletes
Clinical chemistry and laboratory medicine 2006, vol.
44, no8, pp. 999-1003
Leetmaa TH, Dam A, Glintborg D, Markenvard JD.
Myocardial response to a triathlon in male athletes
evaluated by Doppler tissue imaging and biochemical
parameters.
Scand J Med Sci Sports. 2008 Dec;18(6):698-705.
Christian Lцwbeerae, Astrid Seebergerb, Sven A.
Gustafssona, Frederic Bouvierc, Johan Hultingd
Serum cardiac troponin T, troponin I, plasma BNP and
left ventricular mass index in professional football players
Top of Form
J Sci Med Sport. 2007 Oct;10(5):291-6.
Hugh E. Montgomery; Peter Clarkson; Clare M.
Dollery et al.
Association of Angiotensin-Converting Enzyme Gene
I/D Polymorphism With Change in Left Ventricular Mass
in Re-sponse to Physical Training
Circulation. 1997;96:741-747.).
Neumayr G
Effect of competitive marathon cycling on plasma Nterminal pro-brain natriuretic peptide and cardiac troponin
T in healthy recreational cyclists.
- Am J Cardiol - 1-SEP-2005; 96(5): 732-5
Nilsson, Kurt J.; Womack, Michael S.; Pfeiffer, Ronald
P.; Bond, Laura
Plasma Brain Natriuretic Peptide In Endurance Trained
Adolescents:
,fdidsf rfhlbjkjubf
Medicine & Science in Sports & Exercise: May 2009 Volume 41 - Issue 5 - p 157
Serrano-Ostбriz, Legaz-Arrese, Terreros-Blanco,
Lуpez-Ramуn, Cremades-Arroyos, Бlvarez-Izquierdo,
Boscos-Terraz
Cardiac Biomarkers and Exercise Duration and
Intensity During a Cycle-Touring Event
Clinical Journal of Sport Medicine July 2009 – Volume
19 – Issue 4 – pp293-299
Serrano-Ostбriz E., Terreros-Blanco JL, Legaz-Arrese
A, George K, Shave R, Bocos-Terraz P, Izquierdo-Бlvarez
S, Bancalero JL, Echavarri JM, Quilez J, Aragonйs MT,
Carranza-Garcнa LE,
The impact of exercise duration and intensity on the
release of cardiac biomarkers.
Scand J Med Sci Sports. 2009 Nov 17.
E. D. Pagourelias, G. Giannoglou, E. Kouidi, G., A.
Karagiannis, V. G. Athyros, P. Geleris, D. P. Mikhailidis,
K. Efthimiadis, P. Zorou, K. Tziomalos.
Brain natriuretic peptide and the athlete’s heart: a pilot
study
International Journal of Clinical Practice Volume 64
Issue 4, Pages 511 - 517
J Scharhag, T Meyer, M Auracher, M Mьller, M
Herrmann, H Gabriel, W Herrmann, W Kindermann
Exercise-induced increases in NT-proBNP are not
related to the exercise-induced immune response
Br J Sports Med 2008;42:383-385
J Scharhag, K. George et al.
Exercise-Associated Increases in Cardiac Biomarkers
Medicine & Science in Sports & Exercise: August 2008
- Volume 40 - Issue 8 - pp 1408-1415
Scharhag J, Herrmann M, Urhausen A, Haschke M,
Herrmann W, Kindermann W.
Independent elevations of N-terminal pro-brain natriuretic peptide and cardiac troponins in endurance athletes
after pro-longed strenuous exercise.
Am Heart J. 2005 Dec;150(6):1128-34
J Scharhag, A Urhausen, M Herrmann, G Schneider, B
Kramann, W Herrmann, W Kindermann
No difference in N-terminal pro-brain natriuretic peptide (NT-proBNP) concentrations between endurance athletes with athlete’s heart and healthy untrained controls
Heart 2004;90:1055-1056 doi: 10.1136/hrt.2003.020420
H Sheikhani Shahin, MA Babaee Bigi, A Aslani, F
Daryanoosh
Effect of Professional Exercises on Brain Natriuretic
Peptide
/ www.icrj.ir
Isabelle Tchou, Alexandra Margeli, Maria Tsironi,
Katerina Skenderi, Marc Barnet, Christina KanakaGantenbein,,,Ioannis Papassotiriou, Photis Beris
Growth-differentiation factor-15, endoglin and N-terminal pro-brain natriuretic peptide induction in athletes
participating in an ultramarathon foot race
Biomarkers September 2009, Vol. 14, No. 6, Pages
418-422
2010 weli
,fdidsf rfhlbjkjubf
39
gul-sisxlZarRvTa sistemis funqciuri mdgomareoba
faruli vegetatiuri disfunqciisa da sisxlZarRvovani
hiperreaqtiulobis dros sportsmen bavSvebsa
da mozardebSi (diagnostikis, mkurnalobisa da
prevenciis sakiTxebi)
medicinis mecnierebaTa doqtori,
profesori- g. CaxunaSvili
asocirebuli profesori - i. doloZe
Tssu maZiebeli – T. gogatiSvili
aqtualoba: sportsmenTa uecari skvdili
kvlav rCeba medicinis gansakuTrebiT ki sportuli medicinis erT-erT mniSvnelovan
problemad. statistikuri analizi gviCvenebs,
rom sportsmenebSi uecari sikvdilis SemTxvevebis 80%-ze meti gamowveulia kardiuli mizezebiT.
sportSi araracionalurma (gadaWarbebulma fizikurma varjiSma) SesaZloa gamoiwvios organizmSi jer funqciuri, Semdeg ki
kardio-respiratorul sistemaSi organuli
xasiaTis paTologiuri cvlilebebi, miT umetes Tu sportsmenis organizms aqvs midrekileba daavadebisadmi.Ffizikuri varjiSi uaryofiTad moqmedebs gansakuTrebiT maSin, rodesac mis organozmSi paTologiuri procesi
farulad mimdinareobs.
sportsmenis paTologiis an paTologiis
wina mdgomareobis dadgena zogjer Zalze
rTulia, vinaidan organizmis maRali fizikuri muSaobis unaris gamo mas daavadebis SemTxvevaSic ki SeuZlia garkveuli periodis
manZilze mainc miiRos monawileoba sportul RonisZiebebSi. Aamitom, sportuli paTologiis diagnostika saWiroebs gaRrmavebuli klinikur da funqciuri gamokvlevebis
Catarebas. sportuli wvrTnis procesSi SesaZloa gamovavlinoT sportsmenebSi gulsisxlZarRvTa sistemis mxridan paTologiuri xasiaTis cvlilebebi. Aarc Tu iSviaTia
gulis mankis arseboba, (romelic upiratesad
gadatanili revmatiuli infeqciis Sedegia),
spotsmenTa gulis kunTis hi pertrofia (rac
Tavis mxriv SesaZloa iyos fiziologiuri
an paTologiuri xasiaTis).
Aaranaklebi mniSvneloba gaaCnia sportsmenTa gulis ritmis Seswavlas. sportsmeni,
romelsac sistematuri wvrTnis procesSi gamouvlindeba gulis muSaobis ritmis darRveva, aucileblad moiTxovs Rrma kvlevebis
Catarebas paTologiis gamosavlenad. sport2010 weli
smenTa gulis ritmis darRveva ganpirobebulia sportul wvrTnaSi didi fizikur datvirTvebiT, amitom es sakiTxi yovelTvis saWiroebs individualur midgomas.
sportuli paTologiis erT-erTi saxes
warmoadgens gulis kunTis gadaZabva, rac
aseve SeiZleba iyos ganpirobebuli intensiuri kunTuri muSaobiT (varjiSiT). gulis
kunTis gadaZabva SeiZleba iyos mwvave da
qronikuli. sportsmenebs igi ufro xSirad
marcxena parkuWis gadaZabvis saxiT uvlindebaT. am dros gulis kunTSi aRiniSneba
bioqimiuri procesebis darRveva, rac iwvevs
gulis kumSvadi funqciis daqveiTebas. klinikurad gadaZabul guls axasiaTebs fizikuri datvirTvis procesSi advilad daRla,
gul-sisxlZarRvTa sistemaze uaryofiTi reaqciis gamovlineba (magaliTad, hi potonuri
anu asTeniuri xasiaTis), gulis areSi CxvletiTi tkivili da sxva. Cveulebriv, gadaZabul gulis kunTSi darRveuli bioqimiuri
procesebi Seuqcevad xasiaTs atarebs. Aam
mizniT sakmarisia SeCerdes fizikuri datvirTva (varjiSi), rom TvalsaCinod gamoixatos gadaZabvis klinikuri niSnebis Semcireba. Aam SemTxvevaSi SesaZlebeliaGgulis
kunTis funqciuri cvlilebebi TandaTanobiT organulSi gadavides da procesma Seuqcevadi saxe miiRos. umniSvnelovanesia, zemoT CamoTvlili problemebi mimdinareobs
Tu ara faruli vegetatiuri disfunqciisa
da sisxlZarRvovani hi perreaqtiulobis
fonze da Tu mimdinareobs, rogoria Cveni
strategia mkurnalobasa Tu prevenciaze.
yo ve li ve ze moT T q mu li dan
ga mom di na re,
aucilebelia aRniSnuli sakiTxis Tanamedrove sportuli pediatriisadmi amoqmedeba.
sportSi moRvawe mozardebis fsiqo-fizikuri janmrTeloba moiTxovs mizandasaxul
saeqimo controls, raTa acilebuli iyos
mosalodneli organuli garTulebebi araracionaluri fizikuri datvirTvebis SemTxvevaSi, miT umetes, rom Tanamedrove monacemebiT, sportul seqciebSi gaerTianebulia
10000-ze meti bavSvi. Yyovelive es moiTxovs
mWidro profesiul TanamSromlobas prdi@__) otkb
40
atrbisa da sportuli medicinis specialistebis mxridan, raTa optimalur reJimSi
ganxorcieldes Tanamedrove wvrTnis procesebis marTva. Tanamedrove etapze sakiTxis
aqtualobam da misma argumentaciam, literaturaSi aseT konteqstSi arasrulyofilma monacemebma ganapiroba Cveni Sromis mizani da amocanebi.
gamokvlevis mizani
kvlevis mizans warmoadgens mozard sportsmenebSi (kalaTburTelebi) faruli vegetatiuri disfunqciisa da sisxlZarRvovani hi perreaqtiulobis drouli gamovlena, diagnostikis,prevenciisa da mkurnalobis sakiTxebis miznobrivi damuSavebisTvis.
samuSaos amocanebi:
mozard sportsmenTa Rrma klinikur-instrumentuli gamokvleva maTi wvrTnis sxvadasxva xangrZlivobis gaTvaliswinebiT (e.k.g,
kardio-intervalografia, eqoskopia, kapilaroskopia).
vegetatiuri reaqtiulobis gansazRvra, vegetatiuri disfunqciis gamovlena da maTi
darRvevis SemTxvevaSi faruli formebis adreuli dadgena.
Mmozard sportsmenebSi gulis funqciuri
mdgomareobis Sefaseba, romelTa eqoskopiuri parametrebi scildeba fiziologiur
normebs da maTi diferencirebuli ganxilva
sisxlZarRvovani hi perreqtiulobis konteqstSi.
orTostatiuri sinjis Sedagad gamowveul
swrafad mimdinare adaptaciur reaqciasa
(sxvadasxva
vegetatiur
mdgomareobaTa
dros) da zogad Sromisunarianobas Soris
urTierTkavSiris gamovlena; maTi dinamiuri
cvlilebebis gamovlena farmakologiur saSualebaTa (apiviti, apikori, api pulmo, apihepati) gamoyenebis fonze.
kvlevis masalisa da meTodebis SerCeva
(samuSaos sarwmunoobis uzrunvelsayofi meTodebis da meTodologiuri midgomis aRniSvniT, kvlevis savaraudo Rirebulebis miTiTebiT)
kvlevas daeqvemdebareba 125 sportsmeni vaJi 12-dan 18 wlamde, romlebic ganawildebian
V jgufad da TiToeulSi iqneba 25-25 bavSvi
da mozardi.
I jgufi – sportsmenebi, romelTa seqciaze wvrTnis xangrZlivoba Seadgens 1 wels
II jgufi – sportsmenebi, romelTa seqciaze wvrTnis xangrZlivoba Seadgens 2 wels
III jgufi – sportsmenebi, romelTa seqci@__) otkb
,fdidsf rfhlbjkjubf
aze wvrTnis xangrZlivoba Seadgens 3 wels
IV jgufi – sportsmenebi, romelTa seqciaze wvrTnis xangrZlivoba Seadgens 4 wels
V jgufi –warmodgenili ikneba janmrTeli mozardebiT
yvela mozardi miiRebs samkurnalo saSualebebs (api produqtebs) winaswar SemuSavebuli sqemebis mixedviT da gamokvleulni iqnebian klinikur – laboratoriuli da instrumentuli meTodebiT, kerZod:
eleqtrokardiografia 15 ganxraSi (12
standartuli da 3 NeHb –s)
kardio-intervalografia
doplereqokardiografia (marcxena parkuWebis struqturuli, funqciuri da hemodinamikis mdgomareobis Sesafaseblad.
Sesabamisi orTostatiuli sinjebi, swrafadadaptaciuri da zogadi Sromisunarianobis
dadgenisaTvis sistoluri, diastoluri wnevis gazomva da saSualo wnevis gamoTvla.
vegetatiuri reaqtiulobis gansazRvra
zemoaRniSnuli gamokvlevebi klinikur-laboratoriul monacemebTan erTad TiToeul
jgufs Cautardeba samkurnalo saSualebebis miRebamde da misi miRebis SemuSavebuli
sqemebis Semdeg (TiToeulisaTvis konkretuli dakvirvebis xangrZlivoba Seadgens 1
Tves) da Seivseba individualuri ruqa (ixileT danarTi #1).
miRebuli maCveneblebis sarwmunobis Sefaseba moxdeba stiudentis kriteriumiT (+),
xolo asociaciis koeficientis or Tvisobriv maCvenebels Soris - X2 kriteriumiT. SemTxveviT sidideebs Soris Sedareba moxdeba
Pearson –is korelaciis koeficientiT. gansxvaveba sarwmunoebaTa gamoiyeneba, Tu t > 1,96;
< 0,05 da X2 >3,84. maTematikuri uzrunvelyofa ganisazRvreba programiT pakets SPSS H 5 –is gamoyenebiT.
mecnieruli siaxle:
pirvelad mozard sportsmenebSi Seswavlili da amoxsnili iqneba pre- da postkapilaruli sistemis cvlilebaTa arsi sportuli wvrTnis sxavadasxva xangrZlivobis
fizikuri datviTvebisas da gaTvaliswinebuli iqneba vegetatiuri reaqtiuloba.
Teoriuli Rirebuleba
gamoyenebul iqneba kardiointervalografia, rogorc kvlevis Tanamedrove meTodi
kardialuri ritmis regulaciisa da organizmis adaptaciuri resursebis Sesafasebelad.
pirvelad iqneba dayenebuli sakiTxi ST
segmentis da T kbilis SemuSavebul cvlile2010 weli
,fdidsf rfhlbjkjubf
baTa 8 ti pidan konkretul SemTxvevaTa da
raodenobis gansazRvriT mozard sportsmenebSi (moWidaveebi,kalaTburTelebi,ragbistebi) wvrTnis sxvadasxva xangrZlivobis gaTvaliswinebiT..
pirvelad iqneba mowodebuli vegetatiuri
disfunqciisa da sisxlZarRvTa hi perraqtiulobis dadgenis aucilebloba mozard
sportsmenebSi.
praqtikuli Rirebuleba:
SemuSavebuli iqneba faruli vegetatiuri
disfunqciisa da sisxlZarRvovani hi perreaqtiulobis sadiagnostikoa kriteriumebi.
sicocxlisaTvis saxifaTo ritmis aRmocenebis riski vegetatiuri reaqtiulobis
sxvadasxva formebis dros.
mozard sportsmenebSi wvrTnis xangrZlivobis gaTvaliswinebiT samkurnalo saSualebebis (api produqciis) specifikuri sqemiT
gamoyenebis aucileblobis mizanSewoniloba.
amasTan erTad, rekomendacia miecema yovel
sportul seqcias, raTa yuradReba iqnas gamaxvilebuli gul-sisxlZarRvTa sistemis
adaptaciisa da morfologiuri parametrebis
kontrolze, sportsmenTa asakisa da pirveli sportuli staJis gaTvaliswinebiT.
kvlevis Sedegebi dainergeba saqarTvelos
Tssu-is sportuli medicinisa da samedicino
reabilitaciis, fizikuri medicinis departamentis saswavlo procesSi da iunor sportsmenTa wvrTnis procesSi sportklubebsa Tu
seqciebze.
amdenad, sakiTxis Seswavla Zalzed mniSvnelovania da muSaobis procesSi miRebuli
daskvnebi gamoqveyvebul iqneba TanmimdevrobiT.
programaSi citirebuli samecniero
literaturis nusxa:
sportuli medicina da kinezoTerapia.
Tbilisi, 2010weli. R. svaniSvili, z. kaxabriSvili
invalidTa kinezokoreqciis Taviseburebani. Tbilisi, 2008weli. i.doliZe, T. miqiaSvili
marcxena parkuWis sistolur-diatoluri
funqcia da parkuWTa repolarizaciis dispersia paTologiuri da adaptaciuri hi pertrofiebis dros.,,samkurnalo fizkultura
da sportuli medicina” 14.00.12 - avtoreferati. Tbilisi, 2006 weli. Tamar qiSmaria
klinikur-morfologiuri maCveneblebis
dinamika mozard sportsmenTa wvrTnisa da
reabilitaciis procesSi. 14.00.29 – pediatria.
Mmedicinis mecnierebaTa kandidatis samecni2010 weli
41
ero xarisxis mosapoveblad warmodgenili
disertaciis avtoreferati. Tbilisi, 2006 weli. xaTuna lasareiSvili
maRali kvalifikaciis moWidaveebis sawvrTno procesis marTva da Sromisunarianobis
gaumjobeseba funqciuri sinjebis, farmakologiuri saSualebebis da biologiurad aqtiuri kvebiTi danamatebis gamoyenebiT.,,samkurnalo fizkultura da sportuli medicina”. 14.00.12 – avtoreferati. Tbilisi, 2003
weli. 168 gverdi. zurab kaxabriSvili
sportsmenTa arteriuli wneva da fizikuri datvirTva. gamomcemloba,,saqrTvelos xarisxis marTvis universiteti”. Tbilisi, 2004
weli. 127 gverdi. Tamar svaniSvili
maRali kvalifikaciis moWidaveebis sawvrTo procesis samedicino safuZvlebi. Tbilisi, 2005 weli. zurab kaxabriSvili
sportsmenTa eleqtrokardiografia. Tbilisi, 1989 weli. d. tvilidiani, r. svaniSvili
saeqimo kontroli da samkurnalo fizikuri kultura. Tbilisi, 2003 weli. 480 gverdi. r. svaniSvili
bavSvTa asakSi zogierTi Tandayolili anTebadi da SeZenili araanTebadi daavadebebis
dros gul-sisxlZarRvTa sistemis klinikurinstrumentuli daxasiaTeba, maT mkurnalobaSi preparat GA – 40-is CarTvis SesaZleblobani. Mmedicinis mecnierebaTa kandidatis xarisxis mosapoveblad warmodgenili disertacia. Tbilisi, 2004 weli. n. jobava
Детская спортивная медицина. «Медицина».
Москва, 1991г. Под редакцией профессора С.Б.
Тихвинского, Профессора С.В. Хрущева
Cardiovascular system in the sports children
holding prevention arrangements against week
rings . G. Chakhunashvili, N. Jobava, D. Pruidze, D.
Tabutsadze, V. Kandelaki, M. Chichaidze. Pediatric
clinic of State Medical University Tbilisi, Georgia.
Profilactic Center for Mother and Child Tbilisi,
Georgia-Greece- Turkey 2008
Функциональные изменения сердца юных спортсменов: профилактика и коррекция. Медицинский
научный и учебно-методический журнал. Корнеева
И.Т., Поляков С.Д., НЦЗД РАМН, Москва 2005г.
Детская спортивная медицина. Андреева Т. Г.,
Феникс, Москва 2007 .
Pediatric Cardiology. Walter H. Johnson, James
H. Moller. ISBN-13: 9780781728782. 2001 y. 326 pages.
Pediatric Cardiology. Victoria Vetter, MD; Professor
of Pediatrics; The University of Pennsylvania School of
Medicine; Chief; Division of Cardiology; The Children’s
Hospital of Philadelphia, Philadelphia, PA., publication
date: FEB-2006 y. 384 pages.
@__) otkb
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42
persistiuli ovaluri
xvreli - Tanamedrove xedva
i.miminoSvili, g. ruxaZe
g. Jvanias saxelobis
pediatriuli klinika
persistiuli ovaluri xvreli (Patent
Foramen Ovale) PFO, cnobilia galenis droidan. pirvelad aRwerili iyo 1564 wels leonardo botalis mier. PFO gvxvdeba mozrdilTa populaciis 20-34%-Si, 30-80 wlamde
asakSi.
ovalur xvrels mniSvnelovani funqcia
akisria antenatalur periodSi nayofis sisxlismimoqcevaSi. misi saSualebiT JangbadiT
mdidari sisxli placentidan marjvena winagulis gavliT xvdeba sistemur sisxlismimoqcevaSi. dabadebis Semdeg is kargavs Tavis
funqcias. SemTxvevaTa 75%-Si ovaluri xvreli ixureba postnatalurad, rasac xels
uwyobs wnevis momateba marcxena winagulSi.
es procesi funqcionalurad dabadebisTanave
da anatomiurad ramdenime kviraSi da TveSi
sruldeba.
zogjer xdeba ovaluri xvrelis adreuli
daxurva antenatalur periodSi. am SemTxvevaSi gulis marjvena naxevari ganicdis hi pertrofias, xolo marcxena xdeba hi poplaziuri. am SemTxvevaSi sikvdili dgeba an an-
transezofagur da
@__) otkb
tenatalurad an maleve dabadebis Semdeg.
im SemTxvevaSi, Tu marjvena winagulis wneva gadaaWarbebs marcxenaSi arsebuls, venuri
sisxli moxvdeba sistemur sisxlismimoqcevaSi, rac SeiZleba gaxdes “paradoqsuli emboliis” mizezi. Jer kidev 1877 wels kopenheinma aRwera “paradoqsuli embolizmi” Ria
ovaluri xvrelis gamo. venuridan sistemur
sisxlismimoqcevaSi moxvedrilma emboliebma
SeiZleba gamoiwvios iseTi garTulebebi rogoricaa iSemiuri insulti, tranzitoruli
organzomilebian eqokardiogramaze aRiniSneba Ria ovaluri xvreli
2010 weli
,fdidsf rfhlbjkjubf
iSemiuri Seteva, Sakiki, dekompresiuli daavadeba, infarqti, embolia.
PFO SeiZleba Segvxvdes rogorc izolirebulad, aseve sxva anomaliebTan erTad.
uxSiresad persistiuli ovaluri xvreli
ar iwvevs garTulebebs. klinikurad mniSvnelovania didi zomis PFO.
2009 wlis pirvel naxevarSi droul axalSobilTa ganyofilebaSi fiqsirebulia Ria
ovaluri xvrelis 79 SemTxveva. aqedan 22 5mm
da meti zomis, erTi 7 mm, romlebic saWiroeben momavalSi dakvirvebas. 3 Tvis asakSi ganmeorebiTi kardioeqoskopiuri kvlevis Sedegad gairkva, rom mcire zomis Ria ovaluri
xvrelis 99% daxuruli iyo.
persistiuli ovaluri xvrelis mkurnaloba aris rogorc medikamentozuri, aseve qirurgiuli da intervenciuli.
prevencia moicavs iseTi procesebis Tavidan acilebas, romelic xels uwyobs marjvena winagulSi wnevis momatebas. magaliTad:
gaWinTva (aqedan gamomdinare Zalian sayuradReboa mSobiare qalis Ria ovaluri xvreli) simZimeebis aweva, Zlieri xvela. prevencia
aseve moicavs: Trombozebis profilaqtikas,
imobilizaciisa da hi perkoagulaciis dros
sifrTxiles.
daskvna: Ria ovaluri xvreli adreuli
asakis bavSvebSi ar warmoadgens paTologias,
magram mozrdil asakSi persistirebis SemTxveaSi is SeiZleba gaxdes fataluri Sedegis
an mZime garTulebebis mizezi. aqedan gamomdinare didi zomis ovaluri xvreli saWiroebs
dakvirvebas dinamikaSi.
literatura:
Petty GW, khandheria BK, Meissner I, et al.
Population-based study of the relationship between
patent foramen ovale and cerebrovascular ischemic
events. Mayo Clin
Proc. May 2006; 81(5):602-8.
Gupta V, Yesiibursa D, Huang WY, Aggarwal K,
Gupta V, Gomez C. Patent foramen ovale in a large population of ischemic stroke patients: diagno sis, age dis t ri bu ti on, gen der, and ra ce.
Echocardiography. Feb 2008:25(2):217-27.
Schwedt TJ, Demaerschalk BM, Dodick DW.
Patent foramen ovale and migraine: a quantitative
systematic
review.
Cephalalgia.
May
2008:28(5):531-40.
Telman G, Yalonetsky S, Kouperberg E, Sprecher E,
Lorber A, Yarnitsky D. Size of PFO and amount of microem2010 weli
43
bolic signals in patients with ischaemic stroke or TIA. Eur J
Neurol. Sep 2008:15(9):969-72.
Von Bardeleben RS, Ric h ter C, Otto J,
Himmrich L, et al. Long term fol low up af ter
percu ta ne o us clo su re of PFO in 357 pa ti ents
with pa ra do xi cal em bo lism: dif fe ren ce in oc c lu si on systems and in f lu en ce of at ri al sep tum
ane urysm. Int J Cardi ol. Aug 18 2008;
Majunke N, Baranowski A, Zimmermann W, et al.
A suture not always the ideal solution: Problrms encountered in developing a suture-based PFO closure technique. Catheter Cardiovasc interv. Oct 27
2008; 73(3):376-382.
Sievert H, Ruygrok P, Salkeld M, et al. Transcatheter closure of patent foramen ovale with radiofrequency:Acute and intermediate term results in 144
patients. Catheter Cardiovasc interv. Oct 27 2008;
73(3):368-373..
Messe SR, Silverman IE, Kizer JR, Homma S,
Zahn C, Gronseth G. Practice parameter: recurrent
stroke with patent foramen ovale and atrial septal
aneurysm: report of the Quality Standards Subcommittee of the American Academy of Neurology.
Neurology. Apr 13 2004; 62(7):1042-50.
Guntheroth WG, Schwaegler R, Trent E. Comparative roles of the atrial septal aneurysm versus
patent foramen ovale in systemic embolization
with inferences from neonatal studies. Am J Cardiol. Nov 15 2004; 94(10):1341-3.
Hanzel GS. Complications of patent foramen
ovale and atrial septal defect closure devices. J interv Cardiol. Apr 2006; 19(2):160-2.
RESUME:
Patent Foramen Ovale –
Contemporary View
I.MIMINOSHVILI, G.RUKHADZE
To review the Literature of “Patent
Foramen Ovale” giving to authoress to do
conclusion, that “Patent Foramen Ovale” in
early age of child`s is not pathology, but in
age of adults in case of persist it can be the
reason of fatal or heavy complication. Coming from the up mentioned big size of
“Patent Foramen Ovale” needs observation
in dynamic.
,fdidsf rfhlbjkjubf
44
medikamentebis arasasurveli reaqciis
monitoringis organizacia saqarTveloSi
rusudan
jaSi
klinikuri farmakologiis da racionaluri farmakoTerapiis kavSiriPRIMUM NON NOCERE
evromecnierebis saqarTvelos seqciis
farmakologiis departamenti
bolo aTwleulebis gamokvlevebma cxadyo, rom ama Tu im samedicino preparatis miRebiT gamowveuli daavadebebi da sikvdilianoba warmoadgens jandacvis seriozul problemas, romlis aRiareba mouxda ara mxolod
medikosebs, aramed mTel sazogadoebasac.
dadginda, rom aSS-Si wamalTa Tanamovlenebi sikvdilis gamomwvev garemoebaTa Soris meoTxe-meeqvse adgilzea. maTi mizeziT yovelwliurad aTasobiT pacienti iRupeba da aTiaTasobiT ki avaddeba. zogierTi qveyanis saavadmyofoebis procentuli monacemebiT wamlis arasasurveli reqciis zemoqmedebiT daavadebuli pacientebis raodenobaa—- norvegiaSi _ 11,5%, safrangeTSi _ 13,0%, did britaneTSi ki _ 16,0%
wamalTa Tanamovlenebis gamo pacientebis
janmrTelobisaTvis miyenebuli ziani garda
imisa, rom seriozul samedicino Carevas saWiroebs, aseve mZime finansur tvirTad awevs saavadmyofoebs. zogierT qveyanaSi medikamentebis Sedegad miRebuli klinikuri garTulebebis aRmosafxvrelad saavadmyofos biujetis
15 _20% ixarjeba.
garda aRniSnuli Tanamovlenebisa, samedicino preparatebTanaa dakavSirebuli iseTi
problemebic, rogoricaa: narkomania, wamlis
araswori moxmareba an daniSvna eqimis mier,
mowamvla da a.S.
premarketingul fazaSi SeuZlebelia preparatis moqmedebaze rogorc srulyofili informaciis miReba, ise yvela SesaZlo wamalTa Tanamovlenebis gamovlenac. amdenad, farmacevtuli produqcia bazarze gasvlis Semdegac saWiroebs dakvirvebasa da kontrols, raTa dadgindes cdis dros SeumCneveli, magram
zogjer Zalian saSiSi, arasasurveli Tanamovlenebi.
aqedan gamomdinare, mTeli msoflios masStabiT jandacvis muSakebs axali amocanis gadaWra daekisraT _ acnobon Sesabamis organizaciebs TavianT klinikur praqtikaSi gamovlenili ama Tu im medikamentis Tanamovlenis
Sesaxeb, amiT isini gadaarCenen rogorc Tavi-
anT, ise sxvaTa pacientebis sicocxlesac.
rogor SeiZleba wamalTa Tanamovlenebis
aRricxvam momavalSi mosalodneli tragediebi agvacilos
ramdenime aTwleuli dasWirda imis gagebas, rom aspirini azianebs kuW-nawlavis sistemas, analgini SeiZleba agranulocitozis mizezi gaxdes, fenacetinis xangrZlivma miRebam
ki SeiZleba Tirkmlis papilaruli nekrozi
gamoiwvios, aseve ramdenime welma ganvlo sanam fokomelias talidomidiT mkurnalobasTan daakavSirebdnen. swored talidomidiT
gamowveulma garTulebebma, SeerTebul StatebSi `talidomidis tragedia~ rom uwodes,
msoflios mraval qveyanas biZgi misca wamlebis kontrolis mizniT SeeqmnaT farmacevtuli produqciis saxelmwifo monitoringis
sistema. am sistemas daevala wamlis SesaZlo
arasasurveli reaqciebis adreul etapze gamovlena da prevenciuli zomebis gatareba
wamlismieri sikvdilianobisa da daavadebebis
Sesamcireblad.
am sistemis warmateba damokidebulia msoflios masStabiT jandacvis muSakTa TanamSromlobaze, raTa droulad gamovlindes medikamentebis saeWvo Tanamovlenebi, metadre
axal wamlebze.
mravali magaliTia imisa, rom medikosebis
mier gamoCenilma didma gamWriaxobam, sifxizlem da dakvirvebam gamoavlina araerTi preparatis paTologiuri an sicocxlisaTvis saSiSi reaqciebi da maT mier mowodebuli informaciis daxmarebiT moxda am preparatebis
moxmarebidan amoReba an maT gamoyenebaze
mkacri kontrolisa da SezRudvebis daweseba.
ratom aris saWiro medikamentebis arasasurveli reaqciis monitoringi saqarTveloSi
janmrTelobis msoflio organizaciis monacemebiT (janmo), ganviTarebad da gardamavali ekonomikis qveynebSi informacia wamalTa
gverdiTi movlenebis Sesaxeb Zalzed SezRudulia. amas emateba zogierT qveyanaSi medikamentebis yidva-gayidvis da maTi moxmarebis sakanonmdeblo bazis dauxvewaoba an ararseboba,
samedicino preparatebis gverdiTi movlenebis
ignorireba, falsificirebuli produqciiT
gajerebuli bazari, srulyofili informaciis uqonloba da aseve wamlebis gauazrebeli,
TviTneburi moxmareba _ yovelive es savsebiT
esadageba saqarTvelos mdgomareobas.
sxvadasxva qveyanaSi, zogjer erTi qveynis
farglebSi myof regionebSic ki, preparatebis
2010 weli
,fdidsf rfhlbjkjubf
Tanamovlenebis gamovlena gansxvavebul xasiaTs atarebs. regionebis mixedviT medikamentebis Tanamovlenebis diferencirebas ramdenime
obieqturma mizezma Seuwyo xeli:
gansxvavebulma daavadebebma da mkurnalobis meTodikam;
gansxvavebulma genetikam, kvebam da tradiciebma;
farmacevtuli produqciis warmoebis gansxvavebulma meTodma, rac preparatebis
xarisxsa da Sedgenilobaze aisaxeba;
gansxvavebulobam medikamentebis distribuciis pirobebSi, instruqciis, dozirebisa da xelmisawvdomobis CaTvliT;
tradiciuli da alternatiuli (mag., mcenareuli) wamlebis gamoyenebam, romlebsac SeuZliaT specifikuri toqsikologiuri problemebis gamowveva. miuxedavad
imisa, gamoiyenebian isini calke Tu sxva
wamlebTan kombinaciaSi.
monacemebs, romlebic mopovebulia erTi
qveynis sxvadasxva regionSi, Tanamovlenebis
droulad gamovlenisa da informirebis
TvalsazrisiT gadamwyveti mniSvneloba aqvs.
aseve maT SeuZliaT udidesi daxmareba gauwion farmacevtuli produqciis erovnuli regulaciis sistemis Seqmnasac.
aRsaniSnavia isic, rom erT romelime qveyanaSi (mag., wamlis mwarmoebel qveyanaSi) mopovebuli informacia SeiZleba ar iyos niSandoblivi
msoflios im regionebisaTvis, sadac sruliad
gansxvavebuli pirobebia. amitom erT regionSi
mopovebul monacemebs sainformacio Rirebuleba SeiZleba mxolod imave regionSi hqondes, maTi gamoyeneba sxva regionSi dauSvebelia.
efeqturi nacionaluri postmarketinguli
meTvalyureobis programa pirdapir aris damokidebuli jandacvis muSakTa aqtiurobaze.
maTTvis saukeTeso poziciaa _ yoveldRiur
praqtikaSi TiToeuli wamlis arasasurveli
reaqciis SemCnevisTanave acnobon farmacevtuli produqciis monitoringis centrebs, raTa
daicvan yoveli pacienti.
TiToeuli jandacvis muSakis (eqimebis, farmacevtebis, eqTnebis, stomatologebis da sxv.)
profesiuli movaleobaa, aRricxon wamlis
arasasurveli Tanamovlenebi da Sesabamis
centrebs dauyovnebliv Seatyobinos is im
SemTxvevaSic ki, Tu mxolod eWvobs wamalsa
da arasasurvel reaqcias Soris mizezSedegobriv kavSirze.
maSasadame, wamlebis monitorings, rogorc
mdare xarisxisa da falsificirebuli preparatebis Sesaxeb sruli informaciis mopovebis saSualebas udidesi mniSvneloba eniWeba
ama Tu im preparatze arasasurveli reaqciis
Sefasebis TvalsazrisiT. monitoringi aris
damatebiTi garantia, rom pacienti uzrunvelyofili iqneba usafrTxo da efeqturi prepa2010 weli
45
ratiT. medikamentebis arasasurveli reaqciis
monitoringis Sedegebs jandacvis muSakebisaTvis saganmanaTleblo mniSvnelobac aqvs.
saqarTveloSi amJamad ara gvaqvs statistikurad sarwmuno monacemebi wamlebis Tanamovlenebis Sesaxeb. Tumca, calkeuli kvlevebi cxadyofs, rom CvenTan situacia am mxriv sakmaod mZimea da wamlismieri daavadebebi da sikvdilianoba maT mier gamowveuli garTulebebiT iniRbeba.
Cvens qveyanaSi arsebuli epidsituaciis gamo kategoriul aucileblobas warmoadgens
wamalTa Tanamovlenebis kontrolis _ farmakozedamxedvelobis (Pharmacovigilance) sistemis amoqmedeba. saqarTveloSi jer kidev 1997
wlis 19 aprils parlamentis mier miRebul iqna kanoni “wamlisa da farmacevtuli saqmianobis Sesaxeb.” imave wlis 16 oqtombers jandacvis ministris brZanebiT saministros farmakologiis komitets daevala “samkurnalo
saSualebebis gverdiTi movlenebis monitoringis Sesaxeb“ – SeedginaT programa.
Cveni mizania saqarTvelosTvis specifikuri, mecnierulad dasabuTebuli wamalTa Tanamovlenebis kontrolis Pharmacovigilance _
farmakozedamxedvelobis sistemis amoqmedeba.
rasac safuZvlad daedeba janmos da ufsalis rekomendaciebi wamalTa Tanamovlenebis
menejmentis Sesaxeb.
evropuli rekomendaciebis mixedviT, farmakozedamxedvelobis danergva saqarTveloSi
xels Seuwyobs wamalTa gverdiTi movlenebis
gamovlenas, Sefasebas da prevencias.
ZiriTadi mizani miiRweva Semdeg konkretul amocanaTa gadaWris gziT:
axali, (aqamde ucnobi) wamalTa Tanamovlenebis da maTi urTierTqmedebis gamovlena.
seriozuli, (ukve cnobili) wamalTa Tanamovlenebis sixSiris matebis gamovlena.
wamalTa Tanamovlenebis risk-faqtorebis
identifikacia da im SesaZlo meqanizmebis
gamovlena, romelic safuZvlad udevs maT ganviTarebas.
wamalTa riskisa da sargeblis raodenobrivi aspeqtebis Sefaseba, rac aucilebelia
wamlis daniSnulebis gaumjobesebis da wamlis saxelmwifo regulirebisaTvis.
wamalTa uzrunvelyofis socialuri aspqetebis kvleva.
farmakozedamxedvelobis sakiTxebSi specialisti medikosebis momzadeba.
pacientebis codnis donis amaRleba, wamalTa Tanamovlenebis ganmsazRvrel risk-faqtorebsa da mosalodnel garTulebebTan dakavSirebiT.
monitoringis sawyis stadiaze yvela eWvi
wamalTa gverdiTi movlenebis Sesaxeb sasargeblo da mniSvnelovania, radgan dasawyisisaTvis saWiroa CamovayaliboT informirebis
kultura, romlis drosac nebiemieri eWvis Sem-
46
TxvevaSi Setyobineba medikamentebis arasasurveli reaqciis Sesaxeb unda gaigzavnos Sesabamis centrSi. zogjer eqimebs eSiniaT wamalTa
Tanamovlenebis Setyobineba, raTa eWvi ar Seitanon maT kompetenturobaSi an ar gaxdnen sasamarTlo garCevis sagani, zog eqims ar miaCnia medikamenti maTi warmoqmnis mizezad.
Eeqimebma aucilebelia Seiswavlon, ra da
rogor Seatyobinon. axali wamlebisaTvis
moTxovnaa umniSvnelo reaqciis Setyobinebac.
cnobili Zveli wamlebisaTvis mniSvnelovania
seriozuli da uCveulo reaqciebis Setyobineba, garkveuli reaqciis sixSiris mateba mniSvnelovani Setyobinebaa. agreTve ganxilul unda
iqnas wamalTa Tanamovlenebi tradiciul medicinaSi, gansakuTrebiT sainteresoa wamlebis
zedmeti miReba da narkomania, wamlebis gamoyeneba orsulobis (teratogenoba) da laqtaciis dros. agreTve mniSvnelovani informaciaa
wamlebis falsificireba da antibiotikebis
rezistentoba. Sefasebisas mniSvnelovania
toqsikologis kontroli-SemTxveviTi da winaswarganzraxuli zedmeti dozirebisas.
saavadmyofosa da eqimebs eqnebaT garantia, rom maTi monacemebi anonimuri iqneba, aseve konfidencialuri iqneba yvela publikacia.
klinikebi miiReben angariSs wamalTa Tanamovlenebis Sesaxeb.
medikamentebis arasasurveli reaqciis monitoringis gansaxorcieleblad mizanSewonilad migvaCnia evromecnierebis saqarTvelos seqciis
farmakologiis departamentTan da klinikuri
farmakologiis da racionaluri farmakoTerapiis kavSirTan erTad safuZveli Caeyaros farmakozedamxedvelobis (Pharmacovigilance) samecniero-saswavlo meToduri centris Seqmnas. rac
dagvexmareba saqarTvelos sxvadasxva regionSi farmakozedamxedvelobis menejmentSi.
Mmosalodneli Sedegebi da maTi mniSvneloba mecnierebis, ekonomikis da socialuri
sferosTvis.
,fdidsf rfhlbjkjubf
pirvelad saqarTveloSi ganisazRvreba wamalTa arasasurveli reaqciis realuri mdgomareoba. mTel qveyanaSi moxdeba farmakozedamxedvelobis integrireba klinikuri farmakologiis da farmaciis praqtikaSi, misi danergva pirvelad samedicino rgolSi. wamalTa arasasurveli reaqciis riskis Sesaxeb
codnis gaRrmaveba mosaxleobaSi. wamalTa
Tanamovlenebis Sesaxeb ganaTlebis donis
amaRleba - momaval eqimebs vaswavliT, rogor
da ra kriteriumebiT unda ganaxorcielon
preparatebis sasargeblo da arasasurveli
mxareebis mudmivi Sefaseba
farmakozedamxedvelobis arsi da meTodebi CairTveba medikosebis saswavlo programebSi, umaRles saswavleblebSi da postdi plomuri swavlebis saganmanaTleblo programebSi. Sedegebi gamoqveyndeba statiebis, meToduri rekimendaciebis saxiT, moxsendeba konferenciebsa da simpoziumebze.
farmakozedamxedvelobis sistemis danergviT gamovlenili monacemebiT da hi poTezebiT
wamlTa arasasurveli movlenebis meqanizmebisa da maTi sixSiris Semdgomi kvlevisaTvis
aspirantebma SeiZleba i povon TavianTi ideebis wyaro. eqimebs miecemaT meToduri saxelmZRvaneloebi, mkurnalobis sqemebi, standartebi, romlebic gamdidrebuli iqneba axali samkurnalo saSualebebis gamoyenebis sqemebiT,
rac xels Seuwyobs wamalTa arasasurveli
movlenebis adreul etapze aRmoCenasa da wamlismieri sikvdilobis Semcirebas, Sesabamisad Semcirdeba saxelmwifo biujetisa da pacientis piradi xarjebi.
miRebuli Sedegebi gaxdeba is obieqturi
safuZveli, razedac aigeba saqarTvelos jandacvis politika.
yovelive dagvexmareba mivaRwioT saboloo
mizans, ufro usafrTxo, efeqturi da iafi
gaxdes pacientis mkurnaloba saqarTveloSi.
ADVERSE DRUG REACTIONS
MONITORING IN GEORGIA
RUSUDAN G. JASHI MD. PHD
Georgian Society of Clinical Pharmacology and
Rational Pharmacotherapy
PRIMUM NON NOCERE
Department of Pharmacology Georgian
National Section of EuroScience
During the last decades it has been demonstrated by a number of studies that medicine morbidity
and mortality is one of the major health problems
which is beginning to be recognized by health professionals and the public. It has been estimated that
such adverse drug reactions (ADRs) are 4th to 6th
largest cause for mortality in the USA. They result in
the death of several thousands of patients each
year, and many more suffer from ADRs. The percentage of hospital admissions due to adverse drug
reactions in some countries is about or more than
10%: Norway 11.5%, France 13.0, UK 16.0%
2010 weli
,fdidsf rfhlbjkjubf
In addition suitable services to treat ADRs
impose a high financial burden on health care due to
the hospital care of patients with drug related problems. Some countries spend up to 15-20% of their
hospital budget dealing with drug complications.
Beside ADRs, medicine-related problems include
also drug abuse, misuse, poisoning, therapeutic
failure and medication errors.
Drug monitoring researches focusing on
adverse drug reactions, rationalization of drug
prescription and consumption, promotion of concept of essential drugs and precise reporting system are likely to be particularly cost-effective.
There is very limited information available on ADRs
in developing countries and countries in transition. However, one may expect that the situation is
worse rather than better. This problem is also
caused by a lack, in some countries, of legislation
and proper drug regulations, including ADR
reporting, a large number of substandard and
counterfeit products circulating in their markets, a
lack of independent information and the irrational
use of drugs that absolutely coincides with
Georgian situation. There are developed publications with this regard both for Georgian and international scientific editions.
We don t have statistically reliable data concerning ADRs in Georgia, but several studies confirm
that the situation is quite poor and sometimes morbidity and mortality is disguised by the name of
nosology ADR had caused. Due to existing in our
country epidemiological situation it is of urgent
necessity implementation of pharmacovigilance
system in our country.
WHO defines pharmacovigilance as the science
and activities relating to the detection, assessment,
understanding and prevention of adverse effects or
any other medicine_ related problem
Our aim is establish and maintain country specific, scientifically proved ADRs control system - the
system of Pharmacovigilance in Georgia, based on
WHO and Uppsala recommendations on ADR management .The pharmacovigilance system, established by the recommendations of European countries will improve the treatment of the patients and
will help to reveal, evaluate and prevent ADRs. Our
aim is establish and maintain country specific, scientifically proved ADRs control system - the system
of Pharmacovigilance in Georgia, based on WHO
and Uppsala recommendations on ADR management.
The main aim will be reached by resolving the
2010 weli
47
following problems: reveal new (not known) ADRs;
reveal the rising the incidence of (known) serious
ADRs; identify the risk-factors and reveal the mechanisms which cause ADRs; evaluate the quantitative indicators of the risk and benefit of drugs,
which is necessary for State regulation and
improvement of quality of prescriptions; search of
social aspects of drug provision; prepare specialists in the field of pharmacovigilance; patient education on ADR risk-factors and expected complications;
The major sources of information will patient s
medical record. Hospitals and physicians will be
guaranteed with the confidentiality of the data and
all publications. The clinics will receive the reports
on ADRs. The evaluation of questionnaires will be
carried out using methodologies, recommended by
WHO and tested in European countries, which are
simple for implementation, cheap and optimally
informative.
we reckon to create the center of
Pharmacovigilance Scientific-Research-Methodology
Center together with Department of Pharmacology
Georgian National Section of EuroScience and
Society Promotion of Clinical Pharmacology and
Rational Pharmacotherapy Primum non Nocere
(PNN) for the implementation of adverse drug reactions monitoring in Georgia.
For the first time in Georgian clinics it will be evaluated the real situation concerning ADRs. Data
derived from this may have greater relevance, educational value and will be used to increase awareness of medical society, medical students and the
population. Thus the potential users of results will be
health professionals and the population of Georgia.
This may encourage national regulatory decision-making to make National Center of Pharmacoviligance in
Georgia.
The management Pharmacoviligilance will be
studying in Medical Universities and during postgraduate education. The obtained data will inspire
graduate students to elaborate new ideas. The
physicians will be given methodological guidelines,
treatment protocols and standards, including
schemes of new drugs application. This will help to
reveal ADRs on early stages, decrease drug-caused
morbidity and mortality, and correspondingly
Governmental and individual expenditures will be
reduced.
It will promote achievement of the general goal
provide patients with safe, effective and affordable
treatment.
,fdidsf rfhlbjkjubf
48
“vamtkiceb” ———————————
Sps g. Jvanias sax. pediatriuli
klinikis direqtori d.fruiZe
bronquli asTmis Setevis
(gamwvavebis) marTva
(protokoli stacionaris eqimebisaTvis)
klinikuri protokoli eyrdnoba GINA-s (asTmis globaluri iniciativa)
2006 wlis versias.
bronquli
asTma
aris
sasunTqi gzebis qronikuli
anTebiTi daavadeba.
daavadebis
paTogenezSi
wamyvania alergia da sasunTqi gzebis hi perreaqtiuloba, rac bronqebis perioduli
da Seqcevadi spazmis mizezi
xdeba.
asTmis gamwvavebis (Setevis)
periodSi sxvadasxva maprovocirebeli faqtorebis zemoqmedebis gamo viTardeba sasunTqi gzebis (wvrili da saSualo
kalibris bronqebi) spazmi da
bronqebis
sanaTuris
lorwoTi daxSoba, ris gamoc adgili aqvs eqspiraciis Seferxebas. viTardeba sxvadasxva xarisxis hipoqsia, xvela, qoSini
da saerTo mgomareoba mZimdeba.
asTmis Setevis (gamwvavebis) marTva iTvaliswinebs
bronquli obs- truqciis da
masTan dakavSirebuli simptomebis moxsnas.
asTmis msubuqi (zogjer
saSualo simZimis) gamwvavebis marTva SesaZlebelia
binaze an hospitalis mimReb
da Terapiul ganyofilebebSi. saSuali simZimis (ufro
xSirad) da mZime Setevis (yovelTvis)Y marTva unda ganxorcieldes hospitalSi (upiratesad gadaudebeli daxmarebis departamentSi).
asTmis gamwvavebis marTva
ZiriTadad iTvaliswinebs:
asTmis Setevis simZimis
Sefasebas.
bronqospazmis
moxsnis
RonisZiebebis gatarebas.
Setevis Semdgomi periodis
marTvas
(rekomendaciebi
binaze Sesasruleblad)
ar aris yvela CamoTvlili
simptomis arseboba. sakmarisia
ramdenime maTganic.
SeniSvna:
cxrilSi gaTvaliswinebuli
cxrili 1.
asTmis Setevis simZimis Sefaseba
asTmis simZimis Sefasebis
kriteriumebi mocemulia #1
cxrilSi.
SeniSvna:
simZimis Sefasebisas saWiro
parametrebi
saSualo
mZime
siarulis dros
mozrdilebSi:
laparakis dros.
CvilebSi: susti
da xanmokle tirili. kveba gaZnelebulia.
yvela asakSi:
mosvenebul
mdgomareobaSi.
Cvili bavSvebi:
uars amboben
kvebaze.
SeuZlia wola
urCevnia ijdes
laparaki
cnobiereba
winadadebebiT
SesaZloa iyos
agzneba.
mokle frazebiT
Cveuebriv
agzne-bulia.
uWiravs iZulebiTi, mjdomare
da winwaxrili,
mdgomareoba
sityvebiT
Cveulebriv
agznebulia
sunTqvis
sixSire
sunTqvaSi
damatebiTi
kunTebis
monawileoba
da
retraqciebi
xixini
momatebuli
momatebuli
Cveulebriv ara
Cveulbriv
aris
xmamaRali.
pulsi(wuTSi)
zomieri.
xSirad
mxolod
amosunTqvisas.
< 100
paradoqsuli
pulsi
ar aris.
< 10 mm Hg.
SeiZleba iyos
12 _ 25 mm Hg.
bronqodilatatoriT sawyisi mkurnalobis Semdeg: PEF mosalodnelis an
personalurris %
PaO2 (haeriT
sunTqvis
pirobebSi)
> 80%
daaxloebiT:
60% _ 80%
sulxuTva
PaCO2
(haeriT
suntqvis
pirobebSi)
SaO2 (haerSi)
msubuqi
100 _ 120
momatebuli >
30
Cveulebriv
aris
Cveulebriv
xmamaRali.
> 120
mozrdilebSi
xSiria
>25 mm Hg.
bavSvebSi:
20 _40 mmHg
< 60% (mozrdilebSi).
sunTqvis
gaCerebis
safrTxe
goneba
dabinduli
an areuli
paradoqsuli
Torako-abdominuri
(qanqariseburi)
moZraoba.
ar ismis.
bradikardia.
misi ar arseboba miuTiTebs sasunTqi
kunTebis
gadaRlaze.
an mkurnalobaze pasuxi grZeldeba 2 saaTze
met xans.
normaluria da
gazomva Cveulebriv ar aris
saWiro.
> 60 mm Hg.
< 60 mm Hg.
SesaZlevelia
cianozis arsebboba.
< 45 mm Hg
< 45 mm Hg
> 95%
91% - 95%
> 45 mm Hg
SesaZlebelia
sunTqvis SeCereba.
< 90%
2010 weli
,fdidsf rfhlbjkjubf
ar aris bavSvTa asakis guliscemisa da
sunTqvis sixSiris asakobrivi normebi.
amasTan, mozrdil pacientTa pulsisa da
sunTqis sixSiris cvlileba asTmis Setevis
sxva-dasxva simZimis SemTxvevaSi mocemulia
ara normasTan procentuli cvlilebis,
aramed absoluturi ricxviTi mniSvnelobis
mixedviT. Cveni rekomendaciis mixedviT,
sunTqvisa da gulis cemis sixSire msubuqi
Setevis dros imatebs daaxloebiT 10%_15%iT. saSualo simZimis dros _ 20%_30%-iT da
mZime Setevis SemTxvevaSi _ 40%_ 50%-iT da
metad.
qvemoT mocemulia gulis cemisa da
sunTqvis sixSiris asakobri-vi normebi.
49
sqema 1.
asTmis gamwvavebis (Setevis) menejmenti gadaudebeli
daxmarebis ganyofilebaSi
sawyisi gamokvleva
x
anamnezi, fizikaluri gamokvleva (auskultacia, damxmare kunTebis monawileoba
sunTqvaSi, P, R, PEF an FEV1, 02-is saturacia, arteriuli sisxlis gazebi
x
x
x
Jagbadi, sanam saturacia ar iqneba > 90 (>95 bavSvebSi).
b2-agonisti 1 saaTis ganmavlobaSi.
sistemuri steroidebi. _ Tu ver miviReT swrafi gaumjobeseba an Tu pacienti
manamde iRebda k.s.-s peroralurad. an Tu Seteva mZimea.
sedacia arc erT SemTxvevaSi ara aris naCvenebi.
sawyisi mkurnaloba
x
SeafaseT mdgomareoba 1 saaTis Semdeg
fizikaluri kvleva. PEF. 02-saturacia da saWiroebis
mixedviT _ sxva testebi.
mZime Setevis kriteriumebi:
saSualo simZimis kriteriumebi:
PEF - normis an individualuri
normis 60%_80%-ia.
fizikaluri monacemebi: zomieri
simZimis simptomebi. sunTqvaSi monawileobs damxmare kunTebi.
x
x
sunTqvis sixSiris normebi mRviZare
bavSvisaTvis.
norma (wuTSi)
< 60
< 50
< 40
< 30
< 20
x
x
Jangbadi.
b2-agonisti + antiqolinerguli
preparatis inhalacia _ yovel 1
saaTSi.
oraluri k.s.
gaagrZeleT mkurnaloba 1_3 sT.,
Tu mdgomareoba umjobesdeba.
x
x
fatalurobis safrTxis risk-faqtorebis arseboba anamnezSi.
PEF < 60%.
fizikaluri kvleva: mZime simptomebi mosvenebul mdgomareobaSi.
gulmkerdis retraqcia.
mkurnalobis Sedegad mdgomareoba
ar umjobesdeba.
x
x
x
mkurnaloba:
asaki
2 Tvemde
2 _ 12 Tve
1 _ 5 weli
6 _ 8 weli
> 12 weli
x
mkurnaloba:
x
x
Jangbadi.
b2 + antiqolinerguli preparatis
inhalacia
sistemuri k.s.
intravenurad magnezia.
x
x
gadaamowmeT mdgomareoba 1 _ 2 saaTSi
pulsis sixSiris normebi mRviZare
bavSvebisaTvis.
asaki
2 _ 12 Tvemde
1 _ 2 weli
2 _ 8 weli
> 12 weli
norma (wuTSi)
< 160
< 120
< 80 – 90.
< 80
mdgomareobis Sefasebis Semdeg dauyovnebliv iwyeba medikamentozuri Terapia
im TanmimdevrobiT, romelic mocemulia #1
sqemaze. mkurnalobis dawyeba (garda Zalian
mZime mdgomareobisa) sasurvelia yovelTvis
Catardes gadaudebeli daxmarebis ganyofilebaSi. zogadi Terapiis ganyofilebaSi
asTmis Setevis menejmenti SeiZleba daiwyos
im SemTxvevaSi, Tu teqnikuri aRWurviloba
da samedicino persona-lis momzadebis
done saSualebas iZleba gamxorcieldes
Sesabamisi monitoringi da intervencia.
mZime Setevis dros mkurnaloba SeiZleba
daiwyos gadaudebeli Terapiis departamentSi. magram, Tu mkurnalobis Semdeg
mdgomareoba ar umjobesdeba (gaumjobesebis kriteriumebi mcemulia 1 sqemaze), pacienti unda gadayvanili iqnas intensiuri
Terapiis departamentSi.
intubaciasa da filtvis xelovnur ventilaciis saWiroeba fataluri Sedegis
riskis kriteriumia.
nebismieri ganyofileba, sadac asTmis
Setevis marTva xorciel-deba aRWurvili unda iyos pulsoqsimetriT, pik-floumetriT,
nebulaizeriT da Jangbadis miwodebis sistemiT.
I.Jangbadi. Jangbadi pacients miewodeba
nazaluri kanuliT, niRbiT an “Jangbadis kar2010 weli
kargi Sedegi 1 – 2 sT.
x
Sedegi SenarCunebulia preparatebis
bolo miRebidan 60
wT.-is ganmavlobaSi.
fizikaluri kvlevis maCveneblebi
normis farglebSia.
PEF > 70%.
02-is saturacia >
90% (bavSvebSi – 95)
x
x
x
Sedegi araa 1 _ 2
saaTSi.
arasruli Sedegi 1
– 2 saaTSi.
x
x
x
x
gadaiyvaneT g.d.g.-Si.
x
x
x
x
x
x
fatalurobis safrTxis risk-faqtorebi.
fizikalurad::
msubuqidan mZimemde simptomebi.
PEF < 60%.@
02-is saturacia
ar umjobesdeba.
Jangbadi.
b2-agonisti +
antiqolierguli
preparati.
sistemuri k.s.
magnezia intravenurad.
PEF,02-is saturaciis monitoringi.
x
x
x
x
fatalurobis safrTxis risk-faqtorebi.
fizikaluri
monacemebi mZimea.
gamoxatulia
SfoTva da/an
Zilianoba.
PEF < 30%
PCO2 > 45 mm Hg.
PO2 < 60 mm Hg.
gadaiyvaneT int. T. g.
x Jangbadi.
x
x
x
x
x
b2-agonisti + antiqolinerguli preparati.
intravenuri k.s.
ganixileT i.v b2-agonistis gamoyenebis
sakiTxi.
ganixileT i.v. Teofilinis gamoyenebis
sakiTxi.
SeiZleba saWiro
gaxdes intubacia
da f.x.v.G
mdgomareoba SeafaseT Tavidan, mokle droSi.
Sedegi ar aris (ixileT zemoT):
gauSviT binaze Tu:
x
x
PEF > 60 %.
SesaZlebelia peroraluri an sainhalacio preparatebiT mkurnaloba.
x
CaatareT intensiuri Terapia.
6 _ 12 sT. ganmavlobaSi Sedegi
arasrulia (ixileT zemoT).
x
Tu
6 _ 12 saaTSi mdgomareoba ar
umjbesdeba gadaiyvaneT intensiuri
Terapiis gan-yofilebaSi.
mkurnaloba binaze:
x
x
x
b2-agonistis inhalacia grZeldeba.
ufro xSirad ganixileba oraluri k.s. micemis sakiTxi.
ganixileT sainhalacio k.s.-is micemis sakiTxi.
pacientis ganaTleba:
x
x
x
wamlebis sworad miReba.
CamoayalibeT moqmedebis gegma.
SeadgineT pacientze Semdgomi
dakvirvebis gegma.
mdgomareoba gaumjobesda
,fdidsf rfhlbjkjubf
50
avis” saSualebiT (CvilebSi).
Jang-badi
pacients
eZleva
manam, saman saturacia ar iqneba > 90% (95% bavSvebSi).
II.swrafad moqmedi b2-agonistebi (ventolini). pirveli 1
sa-aTis ganmavlobaSi pacienti
akeTebs 2_4 inhalacias yovel
20 wuTSi. (1 inhalaciis dros
pacienti iRebs 100 mkg preparats) 1 saaTis Semdeg, msubuqi
Setevis SemTxvevaSi pacienti
akeTebs 2 dan 4 SesunTqvamde
yovel 3 _ 4 saaTSi. mZime Setevis dros 6 _ 10 SesunTqvas
yovel 1–2 saaTSi. mcire asakis
bavSvebSi, sadac SeuZlebelia
standartuli, wneviani mikroinhalatoris gamoyeneba, medikamentis misa-wodeblad gamoiyeneba speiseri. ventolinis inhalacia xorcieldeba Jangbadis
saturaciis da PEF-s maCveneblis monitoringis fonze.
nebulaizeris saSualebiT,
bavSvebSi 18 Tvis asakidan ventolinis
doza
Seadgenss
2,5_5,0 mg/24sT. mozrdilebSi maqsimaluri sadReRamisi doza
aris 40mg. nebulaizeriT miRebis SemTxvevaSi (preparati xsnaris saxiT mTavsebu-lia blisterSi) preparatis ganzaveba
Cveulebriv ar xdeba. Tumca ganzaveba SesaZlebelia mcire
raodenobiT
fiziologiur
xsnarSi.
b2-agonistis intravenuri
infuzia tardeba mxolod
gansakuTrebul SemTxvevaSi,
MmZime Setevis dros.
III. antiqolinerguli preparatebi. beroduali – dozirebuli aerozoli. 1 doza - 5 mkg.
sainhalacio xsnari – 200 ml.
20 wveTi _ 1,0 ml. dozirebuli
aerozoli gamoiyeneba 2 wlis
asakidan.
asTmis
Setevis
periodSi rekomendebulia erT
jerze 2 dozis SesunTqva. 5
wuTis Semdeg SesaZlebe- lia
kidev 2 dozis miReba. momdevno
2 dozis miReba SeiZleba 2
saaTis Semdeg. preparatis nebulaizeriT gamoyenebis SemTxvevaSi 6 wlamde asakSi gamoiyeneba xsnaris 1 wveTi/kg. 3-jer
dReSi. 6_14 wlis asakSi _ 10_20
wveTi 4 –jer dReSi. mZime
SemTxvevebSi doza SeiZleba
gasammagdes.
b) sistemuri kortikosteroidi. peroralurad an
intravenurad misaRebi k.s.
doza Seadgens 0,5 _ 1,0
mg/kg/24 saaTSi.
V. magniumis sulfati. ar
gamoiyeneba rutinulad. a) intravenirad – gamoiyeneba 1.
mozrdil pacientebSi Tu FEV1
aris normis an saukeTeso
individualuri maCveneblis
25%_30%. 2. mozrdilebsa da
bavSvebSi, rodesac asTmis
Seteva ar emorCileba sxva
saxis mkurnalobas 3. bavSvebSi, TuU mkurnalobis dawyebidan 1 saaTis Semdeg FEV1
< normis an saukeTeso individualuri maC-veneblis 60%-ze.
preparati, intravenurad gamoiyeneba 2,0 gr-is raodenobiT
yovel 20 wuTSi. preparatis
gverdiTi efeqtebidan gansakuTrebiT sayuradReboa sunTqvis centris daTrgunvis
SesaZlebloba.
IV. kortikosteroidebi.
a) sainhalacio k.s.
medikamenti
dabali diza (mg)
kontingeni
Beclomethasone
dipropionate
Budesonide
Fluticasone
Mometasone furoate
Triamcilone acetonide
mozrdili
200 _ 500
bavSvi
100-200
mozrdili
> 500_1000
saS. doza (mg)
bavSvi
>200_400
mozrdili
>1000_2000
maRali doza(mg)
bavSvi
>400
200 _ 400
100 _ 250
200 _ 400
100-200
100-200
100-200
> 400_800
> 250_500
> 400_800
>200_400
>200_500
>200_400
>800_1600
>500_1000
>800_1200
>400
>500
>400
400 _ 1000
400-800
>1000_2000
>8001200
> 2000
>1200
mwvave bronqioliti
(protokoli stacionaris eqimebisaTvis)
masala moamzada m.d. T. RonRaZem
dazianebiT (infiltraciuli SeSupeba, eqsudacia da bronqospazmi) da obstruqciiT.
protokoli gankuTvnilia: imunokompetenturi 4 kviridan 24 Tvemde asakis virusuli
warmoSobis bronqiolitiT daavadebuli Cvilebis samarTavad;
etiologia
bronqiolitis SemTxvevebis 90% dakavSirebulia respiraciul sincitiur virusTan (rsv).
bronqiolitis gamomwvevi sxva infeqciuri agentebia: paragripi, gripi B, eqovirusi, rinovirusi, adenovirusi, adamianis metapnevmovirusi.
protokoli ar aris gankuTvnili:
imunodeficitiT, bronqopulmonuri displaziiT, pankreasis cistofibroziT da tuberkuloziT daavadebuli pacientebis samarTavad.
definicia
mwvave bronqioliti Cvil bavSvTa sasunTqi
sistemis virusuli etiologiis epidemiuri
sezonuri daavadebaa, xasiaTdeba wvrili bronqebisa da bronqiolebis generalizebuli
epidemiologia.
mwvave bronqioliti 2 wlamde asakis
bavSvebSi qveda sasunTqi gzebis obstruqciis
yvelaze xSiri mizezia. bavSvebis 90%-s 2
wlamde asakSi gadaaqvs respiraciul sincitiuri virusuli infeqcia, maTgan mxolod 40%s emarTeba qveda sasunTqi gzebis obstruqcia.
hospitalis pirobebSi Cvil bavSvTa inficire2010 weli
,fdidsf rfhlbjkjubf
ba TiTqmis 100% aRwevs. daavadeba ufro xSiria dekember-martis TveebSi. rsv infeqcias ar
axasiaTebs xangrZlivi imuniteti, amitom SesaZlebelia reinfeqcia.
mwvave virusuli bronqiolitis sasargeblod
metyvelebs:
1 Tvidan 2 wlamde asaki;
daavadebis dawyeba kataruli movlenebiT
virusul infeqciasTan kontaqtis Semdeg;
respiraciuli distresi;
vizingi (asTmuri sunTqva) – gaZnelebuli xmauriani amosunTqva, romelic ar eqvemdebareba
bronqospazmolizur saSualebebs;
gulmkerdis Seberva da perkusiiT maRali
rezonansi (timpaniti);
difuzuri auskultaciuri monacemebi filtvebSi.
mwvave bronqiolits gamoricxavs:
gamoxatuli intoqsikacia;
asimetriuli perkusiuli da auskultaciuri
monacemebi.
daavadebis simptomebi da klinikuri niSnebi.
daavadeba iwyeba kataruli movlenebiT (riniti, mSrali zedapiruli xvela)
sxeulis temperatura mcired momatebuli an
normaluria.
rsv-iT gamowveuli infeqcia SeiZleba rinofaringitiT Semoifarglos. SemTxvevaTa mxolod
20%-40%-Si daavadebis dawyebidan 24-72 saaTSi
viTardeba bronqiolitis (qveda sasunTqi gzebis obstruqciis) klinikuri niSnebi.
zogadi mdgomareoba mZimdeba. vlindeba respiraciuli distresi: taqipnoe/ dispnoe, eqspiraciuli qoSini, vizingi (xmauriani eqspiracia),
retraqciebi (gulmkerdis qveda nawilis Cadreka, zogjer laviwqveSa areebis Cadreka), damxmare kunTebis monawileoba sunTqvaSi (cxviris
nestoebi, neknTaSua kunTebi). xvela zerelea.
mZime SemTxvevebSi aris mkvnesare sunTqva,
cianozi, cnobierebis Secvla, pacients ar
SeuZlia ZuZus wova an siTxis miReba, zogjer
aris Rebineba, kapilaruli avseba >3 wm.
obieqturad; gulmkerdi Seberilia, perkusiiT
maRali rezonansi (kolofiseburi xma, igive timpaniti). auskultaciiT – gaxangrZlivebuli
amosunTqva, nazi mstvinavi eqspiracia, difuzuri
wvrilbuStukovani sveli da krepituli xixini
(e.w. “sveli filtvi”).
daavadebis
mZime mimdinareobis
dros
auskultaciuri monacemebi Raribia.
daavadebis mZime mimdinareobis risk-faqtorebia:
asaki < 12 kviraze
dRenakluloba
gulis Tandayolili daavadebebi
bronqopulmonuri displazia
Tanmxlebi imunosupresiuli daavadeba
xelovnuri ventilacia
2010 weli
51
bavSvebi < 6 kviraze mravlobiTi Tandayolili anomaliebiT
metabolizmis darRvevebi
diagnostika.
bronqiolitis diagnozi da simZimis Sefaseba
efuZneba anamnezsa da fizikalur monacemebs.
laboratoriuli da radiologiuri kvlevis
rutinulad gamoyeneba ar aris rekomendebuli:
periferiuli sisxlis analizi naCvenebia:
1. hospitalizaciis
2. baqteriuli infeqciaze eWvis SemTxvevaSi.
periferiul sisxlSi specifiuri cvlilebebi
ar aris damaxasiaTebeli. SesaZlebelia adgili
hqondes zomier leikocitozs, an leikopenias
da mcired aCqarebul edss.
gulmkerdis radiografiuli kvlevis Cvenebaa:
1. hospitalizacia;
2. daavadebis klinikuri suraTis gauareseba
3. maRali riskis pacienti.
tipiur rentgenologiur niSnebad iTvleba:
gadaberili filtvebi, peribronqialuri infiltracia, zogjer wvrili ateleqtazis da konsolidaciis ubnebi. (konsolidacia anu infiltracia metyvelebs alveolebis dainteresebis
sasargeblod, rac virusul-baqteriuli asociaciiT unda aixsnas). diafragma daSvebulia
dabla, Suasayaris
zomebi
Semcirebulia.
SesaZlebelia segmenturi an wilis kolafsi.
rsv–s
antigenis
aRmoCena
cxvir-xaxis
CamonarecxSi (mgrZnobeloba 80-90%) ar cvlis
mkurnalobis taqtikas da Rirebulia mxolod
epidemiologiuri TvalsazrisiT.
hemoglobinis JangbadiT gajerebis maCvenebeli. saturacia <94% daavadebamde praqtikulad
janmrTel CvilebSi oqsigenoTerapiis Cvenebaa.
mwvave bronqiolitis marTva.
bronqioliti ZiriTadad TviTgankurnebadi
infeqciuri daavadebaa. hospitalizacia esaWiroeba pacientTa 1-5%-s. Tavdapirvelad unda
Sefasdes daavadebis simZime.
msubuqi
saSualo simZimis
sunTqvis sixSiris zRvruli maCveneblebi
da
airTa cvla damakmayofilebeli
da
ar aris an msubuqi retraqciebi
da
ar aris dehidrataciis niSnebi
sunTqvis sixSiris zRvruli maCveneblebi
da
zomierad gamoxatuli retraqciebi
an
gaxangrZlivebuli amosunTqva
da daqveiTebuli gazTa cvla
mZime
Zalian mZime
maRali riskis pacienti
an
sunTqvis sixSire >70/wuTSi
an
gamoxatuli retraqciebi
an
daqveiTebuli gazTa cvla
an
grunTingi
an
saturacia < 94%
an
dehidrataciis niSnebi
apnoes Seteva an sunTqvis gaCereba
an
cianozi oqsigenaciis fonze
an
mkveTrad gamoxatuli gazTa cvlis
darRveva
an
Sokis niSnebi
hospitalizaciis kriteriumebi:
mZime an Zalian mZime bronqioliti
oraluri kvebis problemebi
52
gamoxatuli intoqsikacia
cianozi, apnoes Setevebi
mkveTri taqi pnoe (sunTqvis sixSire >70
wuTSi)
asaki < 12 kviraze
dRenakluloba (hestaciuri asaki <34 kviraze);
Jangbadis saturacia spO2 <94%
dehidratacia (masis danakargi >5%)
aspiraciis faqti
gulmkerdis radiografiiT dadasturebuli ventilaciuri darRvevebi
fonuri daavadebebi: bronqopulmonuri
displazia, gulis manki, imunodeficiti, nervkunTovani paTologia
araadeqvaturi meTvalyureoba da movla
binis pirobebSi
intensiuri
Terapiis
ganyofilebaSi
moTavsebis kriteriumebi:
progresirebadi hi poqsemia da hi perkapnia
apnoes Setevebi
mZime respiraciuli distresi
mentaluri statusis gauareseba
daavadebis mimdinareoba, evolucia
obstruqciis kritikuli periodi 2-4 dRe
grZeldeba. ar arsebobs paralelizmi sawyisi
klinikuri niSnebis simZimesa da daavadebis
xangrZliobas Soris. obstruqcia
sul
grZeldeba 8-10 dRe, xvela SeiZleba gagrZeldes 15 dRemde.
bronqiolitis ganmeorebiTi epizodebi
pirveli 2 wlis ganmavlobaSi SesaZloa
bavSvTa 23-60%-Si. vizingis mesame epizodis
SemTxvevaSi unda gamoiricxos bronquli
asTma (20-25%-Si viTardeba), romlis risk-faqtorebia atopiuri anamnezi da garemo.
letaloba 1-4 %.
garTulebebi.
ti piuri baqteriuli garTulebebia: pnevmonia da Sua yuris anTeba. rsv-Tan asocirebul baqteriuli kolonizaciis 40-50%-is
mizezia: Haelmophilus influenza, Steptococccus pneumoniae , Moraxella catarrhalis.
6 Tvemde asakis hestaciuri asakiT <34 kviraze dRenaklebSi, gansakuTrebiT bronqopulmonuri displaziis an gulis mankebis fonze,
SesaZlebelia apnoes ganviTareba.
baqteriuli infeqciis kriteriumebia:
maRali cxeleba ³38,50C (aqsilaruli temperatura)
otalgia da otorea
lorwovan-Cirqovani bronquli sekreti
filtvSi radiologiuri kera
C-reaqtiuli cilis momateba (>50) da/an
polinuklearuli neitrofilebis mateba periferiul sisxlSi (>15000, CxirbirTviani
neitrofilebi 10%)
,fdidsf rfhlbjkjubf
Tundac erTi kriteriumis arseboba moiTxovs
pacientis
klinikuri
statusis
Tavidan Sefasebas da Sesabamisi gaidlainiT
monitorings.
letaloba 1-4 %. letalobis mizezia
progresuli
sunTqvis
ukmarisoba
da
garTulebebi (pnevmoToraqsi, pnevmomediastinumi, gulis ukmarisoba).
bronqiolitis marTvis ZiriTadi princi pebi:
I. adeqvaturi oqsigenaciis ganxorcieleba
SesaZlebelia:
qsovilebis
Jangbadze moTxovnilebis
SemcirebiT da Jangbadis parcialuri wnevis
gazrdiT
CasunTqul
haerSi.
amisaTvis
pacients unda SevuqmnaT mSvidi garemo, maqsimalurad SeizRudos mani pulaciebi da
xSirad ganiavdes oTaxi. Tu saturacia <94%,
naCvenebia datenianebuli JangbadiT oqsigenacia. helioqsi (helium-Jangbadi) mowodebulia
mwvave bronqiolitis mZime formebis dros
CPAP-iT.
bronqebis
gamavlobis
gaumjobesebiT.
bronqodilatatorebis rutinuli gamoyeneba
ar aris rekomendebuli. SeiZleba xanmokled
gaaumjobesos zogierTi klinikuri maCvenebeli, magram ar aqvs efeqti daavadebis mimdinareobasa da hospitalizaciis maCvenebelze.
pacientTa mxolod 50% pasuxobs dadebiTad Terapias beta 2-agonistebiT: epinefrini/adrenalini, albuteroli/salbutamoli.
2,25% racemiuli epinefrini gamoiyeneba
doziT 0,25-0,75ml (0,05ml/kg) ganzavebuli 3
ml.
fiziologiur
xsnarSi.
gamoyeneba
SeiZleba yovel 20 wuTSi.
L-adrenalinis (adrenalinis hidroqloridi) inhalaciuri gziT gamoyenebis SemTxvevaSi efeqti racemiuli epinefrinis analogiuria. ixmareba 1:1000 ganzavebis xsnaris
0,25-0,5 ml/kg, (4 wlamde asakSi maqsimaluri
dozaa 2,5 ml, 4 wlis zemoT - 5 ml). 1 wlamde
asakSi aucilebelia
ganzaveba
2,5 ml.
fiziologiur xsnarSi. 1 welze met asakSi
ixmareba ganuzaveblad,
bronqodilatatorebiT mkurnaloba moiTxovs aqtiur monitorings, raTa droulad
iqnes
SemCneuli
klinikuri
garTuleba
(taqikardia, hipertenzia). Tu am mkurnalobis
fonze ar aris klinikuri suraTis gaumjobeseba, ganixileT bronqodilatatorebis moxsnis
sakiTxi. nebulaizeriT Lepinefrinis (adrenalinis) gamoyeneba gamarTlebulia pasuxismgebel klinikur xelmZRvanelTan SeTanxmebis
safuZvelze. racemiuli epinefrini yvelaze
misaRebia.
bronqodilatatorad
no-Spis
gamoyeneba mizanSewonili ar aris.
kortikosteroidebis efeqti sakamaToa.
steroidebis
inhalaciuri gziT
micema
praqtikulad uefeqtoa, amitom budesonidi
2010 weli
,fdidsf rfhlbjkjubf
nebulaizeriT rutinulad ar
aris rekomendebuli bronqiolitis pirveli epizodis
menejmentSi, radgan ar iwvevs
SesaZlo recidivebis ricxvis Semcirebas. oraluri an
parenteraluri steroiduli
hormonebi
gamoiyeneba
mxolod
hospitalizebul
mZime kategoriis pacientebSi
nebulaizeroTerapia natriumis marilis hipertonuli
xsnariT (3%-iani) saSualo simZimis
bronqiolitis
dros
amcirebs
hospitalizaciis
xangrZliobas. zogjer hipertonuli xsnaris inhalacia
efeqturia
bronqodilatatorebis
(salbutamoli an
epinefrini) inhalaciis gareSec.
II. adeqvaturi hidrataciis
uzrunvelyofa. siTxis kargva
perspiraciiT
taqi pnoes
fonze gaZlierebulia. siTxis
umetesi nawili bavSvma unda
miiRos peroralurad. Tu ar
aris dehidrataciis niSnebi,
sakmarisia
100MMmlL/kg
gaTvliT.KG Tu pacienti ar
svams
siTxes, ganixileba
nazogastruli
zondiT
siTxis miwodeba (frTxilad
–
aspiraciis
riski!).
moerideT hi perhidratacias.
Tu pacienti ver iRebs
siTxis
sadReRamiso
moTxovnilebas oralurad,
aqvs Zlieri qoSini (>70/wT),
respiraciuli
distresi,
apnoes epizodebi, kargavs
siTxes
RebinebiT,
igi
saWiroebs venur infuzias.
siTxis moTxovnileba (WHO)
sxeulis masa
<10 kg
10-19 kg
>20
sawvdomia mxolod ganviTarebul qveynebSi, Tumca zomierad efeqturia da misi gamoyeneba mxolod mZime SemTxvevebSi an riskis jgufis bavSvebSi xdeba.
montelukasti – leikotrienebis receptorebis antagonisti _ ar xsnis daavadebis
simptomebs.
antibiotikoTerapia rutinulad ar iniSneba. Tu Tavidan ver xerxdeba baqteriuli anTebis keris gamoricxva, antibaqteriuli saSualebebi iniSneba rentgenologiuri kvlevis Sedegebis
miRebamde, uxSiresad maTi
moxsna 2-3 dReSi xerxdeba.
antibiotikis daniSvna gamarTlebulia, roca aris:
Sereuli infeqciis riski;
Zlieri
intoqsikaciis
niSnebi
mZime respiraciuli distresi;
mZime hi poqsia.
poza Zilis dros – umjobesia zurgze sxeulis 300-iT
daxris da msubuqad ukan
gadaweuli Tavis pirobebSi.
zeda
sasunTqi
gzebis
gamavlobis aRdgenis mizniT
rekomendebulia fiziologiuri xsnaris wveTebis gamoyeneba.
garemo – Tambaqos pasiuri
SesunTqva damaZimebeli faqtoria da SeiZleba gaxdes
hospitalizaciis
mizezi.
oTaxis swori aeracia da
optimaluri
temperatura
(temperatura
ar
unda
0
aWarbebdes 19 C).
siTxis moTxovnileba ml/kg/dReSi
100-120 ml/kg-ze
90-120 ml/kg
50-90 ml/kg
adeqvaturi kveba. Cvilebi
III. damatebiTi rekomenda- xSirad uars amboben kvebaze,
aris aspiraciis, malnutriciis
ciebi.
antivirusuli Terapia rib- saSiSroeba. sasurvelia sakveavirinis aerozoliT. ribavi- bis miRebis xelSewyoba: nazorini sinTezuri nukleozidia, faringuli obstruqciis moxsromelic zRudavs virusis na kvebis win, sawovaris gamgamravlebas ujredSi. aeroz- sxvileba. saSualo simZimis
oloTerapia tardeba karvis pacientebSi rekomendebulia
patara
ulufebiT,
an ventilaciis pirobebSi kveba
dReSi 12-18 saaTis ganmavloba- maTTvis vinc uars acxadebs
Si 3-7 dRis manZilze. xelmi- kvebaze, rekomendebulia nazo2010 weli
53
gastraluri zondis Cadgma
kvebis da dekompresiis mizniT. mZime SemTxvevebSi xorcieldeba parenteruli kveba.K
intubacia da meqanikuri
ventilacia naCvenebia mZime
sunTqvis
ukmarisobis
da
apnoes dros.
stacionaridan
gaweris
kriteriumebi
klinikuri gaumjobeseba
adeqvaturi Jangbadis saturacia 1 dReze meti drois
ganmavlobaSi (oTaxis haerze
an stabiluri oqsigenacia
Jangbadis
miwodebisas
0,5l/wT-Si kanuliT )
sunTqvis sixSire <60
adeqvaturi
oraluri
rehidrataciis SesaZlebloba
6 Tvemde asakis bavSvebSi
24 saaTis ganmavlobaSi apnoe
ar dafiqsirebula.
6 Tveze meti asakis bavSvebSi – 48 saaTis ganmavlobaSi
ar dafiqsirebuli apnoe.
binaze
meTvalyureobis
SesaZlebloba
(jandacvis
pirveladi rgolis adeqvaturi muSaoba)
profilaqtika
6 Tvemde asaki Cvilebis
izolireba sazogadoebisagan
Semodgoma zamTris periodSi.
avadmyofis izolacia binaze an hospitalSi, saerTo
epidsawinaaRmdego RonisZiebebis gatareba – sagnebis sveli
wesiT, sadezinfeqcio xsnarebiT damuSaveba (SeiZleba 70%iani spirtiT damuSaveba).
xelis dabana sapniT da
wyliT aris pirveli, aucilebeli, mTavari RonisZieba efeqturi dacvisaTvis.
xelTaTmanis tareba efeqturia
xelis
dabanasTan
erTad, specialuri tansacmlis tareba ar aris aucilebeli.
pasiuri mwevelobis maqsimalurad Tavidan acileba.
sayovelTao vaqcina profilaqtika ar tardeba.
polivizumabi (Synagis) mowodebulia rsv imunoprofilaqtikisaTvis bronqopulmonuli displaziis mqone
bavSvebSi, dRenaklebSi <32 kvi-
,fdidsf rfhlbjkjubf
54
raze hestaciiT, gTm-s dros. aris usafrTxo,
efeqturi saSualeba. keTdeba 5 ineqcia 30 dRis
intervaliT. amcirebs garTulebebis risks,
sawol-dReebis ricxvs, rehospitalizacias.
Zviri imunoglobulinia, amitom ar aris xelmisawvdomi da ar gamoiyeneba rutinulad.
bronqiolitis marTvis strategia
msubuqi bronqioliti taqi pnoe, vizingi,
ar aris an aris msubuqi retraqcia, ar
aris dehidratacia
monitoringi
SesaZlebelia
saxlis
pirobebSi siTxeebiT datvirTva, ZuZuTi kvebis
gaaqtiureba oTaxis xSiri ganiaveba cxvirSi
fiziologiuri
xsnaris
CawveTeba
nebulaizeroTerapia hi pertonuli natriumis
- marilis (3%) da/an fiziologiuri
xsnariT
ganixileba
beta-2-agonistis
gamoyenebis saWiroeba.
saSualo simZimis taqi pnoe, zomierad
gamoxatuli retraqciebi da/an bronqioliti
gaxangrZlivebuli amosunTqva da daqveiTebuli gazTa cvla
saWiroebs hospitalizacias.
Jangbadis saturaciis monitoringi
cxvirSi fiziologiuri xsnaris CawveTeba
nebulaizeroTerapia hipertonuli natriumis
marilis (3%) da/an fiziologiuri xsnariT
ganixileba beta-2-agonistis an racepinefrinis
2,25% (0,05ml/kg, maqsimaluri doza 0,5 ml) 3 ml
fiziologiur an hipertonul marilis xsnarTan
erTad nebulaizeroTerapiis saWiroeba (klinikur xelmZRvanelTan SeTanxmebiT).
ganixileba
hormonoTerapiis
sakiTxi
(deqsametazoni 0,3 0,6 mg/kg, prednizoloni 1-2
mg/kg/dReSi 2-3 dRis ganmavlobaSi oralurad
an parenteralurad) ganixileba gulmkerdis
radiografiis Catareba siTxeebi, ZuZuTi kvebis gaaqtiureba
arisGgaumjobeseba – grZeldeba mkurnaloba
gauareseba _ ix. Mmwvave, mZime distresi
mZime bronqioliti maRali riskis pacienti, sunTqvis sixSire >70/wT,
mwvave, mZime distresi gamoxatuli retraqciebi, daqveiTebuli gazTa cvla, apnoe,
grunTingi, saturacia < 94% an dehidrataciis niSnebi
hospitalizacia
Jangbadis saturaciis monitoringi
oqsigenoTerapia
rehidratacia (oraluri Tu SeuZlia daleva an
parenteraluri, Tu ar SeuZlia daleva)
hematokritis da eleqtrolitebis monitoringi
gulmkerdis radiografia
nebulaizeroTerapia hi pertonuli natriumis marilis (3%) da/an fiziologiuri
xsnariT;
beta-2-agonisti, racepinefrini (adrenalini)
steroidi (deqsametazoni, prednizoloni
parenteralurad an sainhalacio budesonidi/pulmikorti) klinikur xelmZRvanelTan
SeTanxmebiT.
pediatriuli gastroezofaguri refluqsi
(protokoli stacionaris eqimebisaTvis)
masala moamzada m.d. c. farulavam
definicia.
gastroezofaguri refluqsi (ger) -kuWis SigTavsis uneblie regurgitaciaa saylapavSi, romelic zogjer am masis
gareT gamodevniT (wamoqafeba
an Rebineba) sruldeba. gastroezofaguri refluqsi fiziologiuri procesia, dRe-Ramis
ganmavlobaSi ramdenjerme meordeba da gvxvdeba janmrTeli bavSvebis da mozrdilebis
70%-Si. refluqsis epizodebi
Cveulebriv postprandialur
(kvebis Semdeg) periodSi, Zilis da vertikaluri poziciidan horizontalurSi gadasvlis dros fiqsirdeba, grZel-
deba 3 wuTamde,
asimptomuria
an umniSvnelo
simptomebiT vlindeba.
wamoqafeba – gastraluri
SigTavsis uneblie pasaJia
xorxsa da xaxaSi, romelic am
masis
gareT
gamodevniT
sruldeba. yoveldRe uvlindeba janmrTeli Cvilebis 3550%-s, ar aisaxeba zogad
mdgomareobaze, ar saWiroebs
mkurnalobas da 12-18 Tvemde
gaivlis.
Rebineba - kuWis da wvrili nawlavebis SigTavsis wneviT gamodevnaa piridan. gastroezofaguri refluqsi xSirad xdeba Rebinebis trigeri.
refluqsTan dakavSirebuli
Rebinebis mizezi savaraudoT
gastraluri SigTavsiT xaxis
receptorebis gaRizianebaa
gastroezofaguri refluqsuri daavadeba (gerd) - kuWis
SigTavsis saylapavSi gadasroliT gamowveuli Civilebi,
klinikuri simptomebi da/an
garTulebebia.
ger-is gerdSi gadazrdas
safuZvlad udevs kardiis
qronikuli ukmarisoba. amis
wamyvan mizezad bavSvebsa da
mozrdilebSi diafragmis saylapavis xvrelis Tiaqari iTvleba, sxva xelSemwyobi faqtorebia: kuWis dagvianebuli
dacla, SigTavsis gatutianebis problemebi, epiTelis regeneraciis darRveva, inervaci2010 weli
,fdidsf rfhlbjkjubf
is moSla, visceroptozi, zolinger-elisonis sindromiT
an hi perkalciemiiT gamowveuli gastrinis Warbi produqcia da hi peracidozi, medikamentebi da sxva.
klinikuri suraTi. gerd-is
universaluri simptomi ar arsebobs da klinikuri gamovlinebebi gansxvavebulia sxvadasxva asakobriv jgufSi.
gastroezofaguri refluqsuri daavadebis
simptomebi
morecidive regurgitacia RebinebiT
an mis gareSe
wonis kargva an cudi namati
gaRizianeba CvilebSi
ruminacia
gulZmarva/tkivili gulmkerdis areSi
hematemezisi
disfagia, odinofagia
vizingi
stridori
xvela. CaxleCili xma
mozardebsa da mozrdilebSi eWvis mitana SesaZlebelia
mxolod gulZmarvis safuZvelze, ufrosi asakis bavSvebSi yvelaze xSiri gamovlinebebia Rebineba, muclis tkivili da xvela. 1-5 wlis asakSi wamyvani Civilebia xvela da anoreqsia,
CvilebSi da adreuli asakis
bavSvebSi klinikuri simptomebi
araspecifiuria da gansxvavdeba mozrdilebisagan. xSiria: 1.
gaRizianeba, umizezo tirili,
kolikis msgavsi Setevebi; 2. cudi Zili, xSirad gaRviZeba, ZilSi tirili; 3. xSiri wamoqafeba
da Rebineba; 4.zurgis TaRiseburi gazneqa kvebis dros an
mis Semdeg; 5. boyini an kvebis
Semdeg amoqarvebis problemebi,
slokini; 6. gamonadeni cxviridan; 7. ylapvis problemebi, gadacdenis da moxrCobis epizodebi; 8. uari sakvebis miRebaze;
9. Ramis xvela, apnoe, morecidive respiraciuli daavadebebi
(asTma, bronqiti, pnevmonia, otiti, sinusiti); 10. amonasunTqi haeris da safenebis mJave suni.
Tu saxezea e.w.“gangaSis”
niSnebi, es eWvs badebs CamoTvlili simptomebis sxva etiologiaze da aucileblad saWiroebs kvlevas. “gangaSis” niSnebia: 1. Rebineba naRvlis minareviT; 2. sisxldena-kuWnawlavis traqtidan; 3. Seupovari an
Sadrevaniseburi Rebineba; 4.
Rebinebis sindromis gamovlena 6 Tvis asakis Semdeg; 5.
2010 weli
zrdaSi Seferxeba; 6. diarea an
yabzoba. 7. cxeleba; 8. leTargia; 9. hepatosplenomegalia; 10.
makro/mikrocefalia; 11. krunCxva; 12. muclis daWimva an Seberva; 13. dokumenturad dasabuTebuli an saeWvo genetikuri an metaboluri sindromi.
bavSvTa asakSi gerd-is diagnozi unda efuZnebodes diagnostikur testebs.
gastroezofaguri refluqsuri daavadebis
klinikuri gamovlinebebi
ezofagiti
saylapavis striqtura
baretis saylapavi
laringiti/faringiti
morecidive pnevmonia
anemia
minanqris erozia
anoreqsia
kisris distoniuri poza (sandiferis
sindromi)
apnoes epizodebi. ALTE
saylapavis intraluminaluri PH monitoringi. SesaZlebelia dafiqsirdes maRali
simJavis mqone refluqsis epizodebis sixSire da xangrZlioba. paTologiurad iTvleba xangrZlioba > 5 wT. RI <3%
iTvleba normad, RI 3-7% mosazRvre mdgomareobad, RI>7%
normidan gadaxrad.
kombinirebuli intraluminaluri impedans da PH monitoringi (PH/MII). informatiuli, magram bavSvebSi naklebad
Seswavlili testia.
ezofaguri manometria. fasdeba peristaltika, zeda da
qveda sfinqterebis wneva, saylapavis struqturebis koordinirebuli muSaoba ylapvis
dros. ar aris mgrZnobiare da
specifiuri testi, amitom mxolod masze dayrdnobiT gerdis diagnozis dasma ar aris
gamarTlebuli,
gastroenterologiuri
traqtis zeda segmentis endoskopia. gerd-Tan asocirebuli
makroskopuli cvlilebebia:
ezofagiti (50%), eroziebi,
wylulebi, striqtura, saylapavis diafragmis Tiaqari, metaplazia, poli pebi. msgavsi endoskopiuri suraTi ar aris
specifiuri mxolod refluqsezofagitisaTvis. normaluri
endoskopiuri suraTi ar gamoricxavs gerd-s. dazianebis
simZimis Sesafaseblad iyeneben
los-anJelesis klasifikacias,
55
romelic misaRebia bavSvTa
asakisaTvisac: I xarisxi – eriTema; II xarisxi – erTeuli
sigrZivi eroziebi; III xarisxi
– cirkularuli Serwymuli
eroziebi; IV xarisxi _ striqtura an baretis saylapavi. endoskopiis
diagnostikuri
mniSvneloba izrdeba bioptatis histologiuri SeswavliT.
magram refluqs –ezofagits,
erTi mxriv, axasiaTebs laqovani dazianeba, amitom SesaZlebelia aRebul masalaSi saerTod ar iyos cvlilebebi, meore mxriv: eozinofilia, papilebis dagrZeleba, bazaluri hi perplazia, ujredSorisi sivrceebis gafarToeba (spongiozi) ar aris damaxasiaTebeli
mxolod refluqs-ezofagitisaTvis, amitom am kvlevis specifiuroba da mgrZnobeloba
ar aris maRali.
rentgenokontrastuli
kvleva bariumiT. am paTologiis SemTxvevaSi ar aris specifiuri da arc maRali mgrZnobelobiT gamoirCeva. amitom igi
sadiagnostikod ar gamodgeba,
magram aucilebelia anatomiuri darRvevebis gamosaricxad.
radionuklearuli
scintigrafia. pacienti sakvebTan
erTad iRebs teqnecium
99-s da 1 saaTis xdeba saeWvo areebis skanireba (kuWi,
saylapavi
da
filtvebi).
mgrZnobeloba da specifiuroba maRalia, magram ar aris
rutinuli kvlevis meTodi. is
xels uwyobs postprandialuri refluqsis deteqcias (1 saaTi sakvebis miRebidan) miuxedavad simJavis xarisxisa, magram araefeqturia mogvianebiT
ganviTarebuli refluqsis dasafiqsireblad.
saylapavis da kuWis ultrasonografia. ar gamodgeba rutinul sadiagnostiko gamokvlevad bavSvebSi, radgan misi
SesaZleblobebi
CamorCeba
sxva testebisas. SesaZlebelia
siTxeebis gadaadgilebis deteqcia sakvebis miRebidan mokle periodSi. informatiulia
saylapavis diafragmis xvrelis Tiaqris, hisis kuTxesTan
gastroezofagaluri gadabmis
mimarTebis dasadgenad.
56
damatebiTi testebi: a) pepsinis aRmoCena yuridan gamonadenSi; b) laqtozis, glukozis, pepsinis, li pidebiT savse makrofagebis deteqcia
bronqoalveolur lavaJur siTxeSi; g) bilirubinis monitoringi saylapavSi duodenuri
SigTavsis pasaJis dasadastureblad. miRebuli
Sedegebi adasturebs gerd-is garkveul rols
yuris, sinusebis, zeda sasunTqi gzebis, filtvis
qronikuli daavadebebis etiologiaSi.
empiriuli antisekreciuli Terapia. ar gamodgeba gerd-is sadiagnostikod adreuli
asakis bavSvebSi.
gerd-is marTva
kvebis rekomendaciebi.
ger-is gamovlinebis sixSire erTnairia ZuZuTi da formuliT kvebaze myof CvilebSi,
refluqsis epizodebi ufro xanmoklea ZuZuTi kvebis dros.
kvebis moculobis Semcirebam SesaZloa uaryofiTi gavlena iqonios masis matebaze, gansakuTrebiT im CvilebSi, romlebsac isedac aradamakmayofilebeli namati aqvT. zogjer SesaZlebelia sakvebis kaloriulobis gazrdis xarjze moculobis da kvebis sixSiris Semcireba.
komerciuli AR formulebi amcireben xilul regurgitacias, rac momvlelebis damSvidebas iwvevs. magram refluqsis epizodebis
sixSire ar mcirdeba, Sesabamisad ar mcirdeba
garTulebebis riski.
Cvilebi, romlebic ar imateben an cudaT
imateben wonaSi saWiroeben nazogastralur an
nazoeiunalur kvebas. nazoeiunaluri kveba
gansakuTrebiT gamarTlebulia morecidive aspiraciuli pnevmoniis dros.
regurgitaciis da Rebinebis dasawyisi da
sixSire Zroxis rZis autanlobis SemTxvevaSi
Tavidan ar gansxvavdeba fiziologiuri gerisagan. diferencirebisaTvis rekomendebulia
formuliT kvebaze myofi Cvilebis 2-4 kviris
xangrZliobiT hidrolizebul an mJave formulaze gadayvana. eqskluziur ZuZuTi kvebaze
myofi CvilebisaTvis rekomendebulia dedis
racionidan Zroxis rZis da kvercxis amoReba.
soiis Semcveli formulebis gamoyenebis efeqturobis maCvenebeli kvlevebi ar Catarebula.
ufrosi asakis bavSvebSi da mozardebSi
specialuri SezRudvebi dietaSi ar aris, Tumca gamarTlebulia aikrZalos kofeinis Semcveli, Zalian cximiani da mware sakvebi, Sokoladi, alkoholi. rekomendebulia zedmeti wonis dakleba, gvian sakvebis miRebis SezRudva.
uSaqro saReWi rezinis daReWva Wamis Semdeg
amcirebs refluqss.
poziciuri Terapia.
mucelze Zili amcirebs refluqsis albaTobas. magram mucelze Zilis dros 10-jer da
gverdze Zilis dros 3-jer meti metia Cvilebis uecari sikvdilis riski. amitom mucelze
wola gamarTlebulia mxolod maSin, roca
Cvils RviZavs, an mxolod im CvilebisaTvis,
romelTac aqvT zeda sasunTqi gzebis anomaliebi da gerd-i maTTvis naklebad problemu-
,fdidsf rfhlbjkjubf
ria, vidre es anomalia. mucelze wola SesaZlebelia efeqturi da gamarTlebuli iyos 1
welze meti asakis bavSvebSi, romelTa Soris
uecari sikvdilis sindromis riski minimaluria. yvela sxva SemTxvevaSi gamarTlebulia
zurgze wola.
refluqsis sixSire erTnairia swor da Tavwamoweul pozaSi zurgze Zilis SemTxvevaSi.
marcxena mxares wolis dros refluqsi
naklebia, vidre marjvena gverdze wolis dros,
magram praqtikulad iseTive, rogorc mucelze
wolis dros. vinaidan gverdze wola arabunebrivia CvilisaTvis, amitom baliSiT amis
iZuleba ar aris rekomendebuli.
ufrosi asakis bavSvebisaTvis poza Zilis
dros ar aris ase aqtualuri, Tumca Tavwamoweuli da marcxena mxares wola xSirad aumjobesebs mdgomareobas.
medikamenturi mkurnaloba.
H2 histaminoreceptorebis antagonistebi.
ranitidinis (2mg/kg), cimetidinis (30-40 mg/kg), famotidinis an nizatidinis (10mg/kg) oraluri miReba 2-3-jer dRe-RameSi SemTxvevebis 50%-Si amcirebs klinikur gamovlinebebs da aumjobesebs saylapavis histologiur suraTs, gansakuTrebiT eroziuli gastritis dros. magram
xSiria SeCveva, rac dozis gazrdis da xangrZlivad gamoyenebis aucileblobas iwvevs. zogjer vlindeba gverdiTi efeqtebi: gaRizianeba,
Tavis tkivili,somnolencia. cimetidins axasiaTebs hepatotoqsiuri efeqti, ginekomastia.
protonis tumbos inhibitorebi. ufro efeqturia, vidre histaminoblokerebi: ar axasiaTebs SeCveva, amitom SesaZlebelia xangrZlivad gamoyeneba, miiReba mxolod 1-jer dReSi
uzmoze, amcirebs wnevas kuWSi 24 saaTis ganmavlobaSi, aCqarebs kuWis daclas da amcirebs
refluqsis albaTobas. aucilebloba, rom preparati kuWis simJavisgan daculi iyos damcavi
garsiT, zRudavs mis gamoyenebas pediatriul
praqtikaSi. xangrZlivi gamoyenebis SemTxvevaSi viTardeba hi pergastrinemia, rac zrdis parietuli ujredebis, enteroqromafinuli ujredebis hi perplaziis da jirkvlebis poli pozis risks da hi poqlorhidria romelic ganapirobebs arahospitaluri pnevmoniiT, gastroenteritiT, kandidoziT avadobas ufros
asakSi da wylulovani enterokolitiT avadobas dRenakl axalSobilebSi.
antacidebi. amcireben gulZmarvas da saylapavis dazianebis risks. maTi simptomurad
gamoyeneba iwvevs klinikuri Civilebis swraf
kupirebas. xangrZlivi da didi dozebiT xmarebis SemTxvevaSi aluminis Semcvel antacidebs
SesaZloa mohyves osteopenia, raqiti, mikrocituli anemia, neirotoqsiuroba, kalciumis karbonatis xangrZlivi gamoyenebisas ki aRwerilia triada: hi perkalcemia, alkalozi, Tirkmlis ukmarisoba. antacidebis miReba rekomendebulia kvebis win.
prokineturi Terapia. aCqarebs kuWis daclas, aumjobesebs saylapavis da nawlavis pe2010 weli
,fdidsf rfhlbjkjubf
ristaltikas, axdens RI-is mniSvnelovan reduqcias, magram SeuZlia QT intervalis gaxangrZliveba, ramac SesaZloa gazardos uecari sikvdilis sindromis riski, amitom misi xmareba
mkveTrad SeizRuda. gverdiTi efeqtebi akninebs prokineturi preparatebis mniSvnelobas,
amitom isini ar gamoiyeneba rutinulad.
amomfeni efeqtis mqone praparatebi. alginatebi da sukralfati amcireben klinikur gamovlinebebs, gamarTlebulia maTi simptomuri
gamoyeneba. am preparatebiT monoTerapia ar
aris sakmarisi eroziuli ezofagitis dros.
qirurgiuli mkurnaloba. nisenis fundoplikacia iwvevs refluqsis eliminacias, magram
ver asworebs gastroenterologiuri traqtis
motorikas. maRalia letalobis riski, SesaZloa adgili hqondes: antirefluqsur Terapiis, saylapavis dilataciis, ganmeorebiTi operaciis saWiroebas. operaciuli Careva gamarTlebulia, roca araefeqturia konservatuli Terapia, aris medikamentebze damokidebuleba an
gerd-is sicocxlisaTvis saSiSi garTulebebi.
gerd-is marTvis praqtikuli rekomendaciebi. praqtikosi eqimi pirvel rigSi unda gaerkves regurgitaciisa da Rebinebis mizezi geri, gerd-i Tu saerTod sxva darRveva.
gaurTulebeli morecidive regurgitacia
da Rebineba CvilebSi. anamnezisa da fizikaluri monacemebis Sefaseba “gangaSis” niSnebze yuradRebis gamaxvilebiT Cveulebriv sakmarisia ger-is klinikuri diagnozis dasasmelad. diagnostikuri testebis Catareba saWiro ar aris. regurgitaciis sixSire nel-nela
iklebs da 12-18 TvisaTvis gaivlis. Tu saxezea:
1. gerd-is niSnebi 2. “gangaSis niSnebi” 3. regurgitacia ar gaivlis 12-18 TvisaTvis, naCvenebia referali bavSvTa gastroenterologTan. Cveulebriv mSoblebis informireba da
damSvideba sakmarisia janmrTeli Cvilebis
samarTavad. tradiciulad mimarTaven dietis
modifikacias, kvebis sixSiris da moculobis
gakontrolebas, poziciur Terapias.
Cvili auxsneli tiriliT da/an tkiviliT
(kolika. refluqsi Cveulebriv ar aris gaRizianebis, umizezo tirilis da uZilobis mizezi. Tu sxva mizezi gamoiricxa, eqimma unda daamSvidos mSoblebi im imediT, rom TandaTan es
problema gaivlis. ganixileba sakiTxi gamokvlevebis Catarebis Sesaxeb (PH- metria an
PH/MII , endoskopia). zogjer iniSneba moklevadiani antisekreciuli mkurnaloba, Tumca gaumjobeseba SesaZloa spontanuradac moxdes.
18 Tveze meti asakis bavSvi morecidive regurgutaciiT da RebinebiT. am asakSi fiziologiuri refluqsi naklebad damaxasiaTebelia, amitom eqspertebis azriT saWiroa gamokvleva: endoskopia da/an PH/MII da bariumiT
rentgenokontrastuli kvleva struqturuli
anomaliebis gamosaricxad.
gulZmarva. gulZmarva mozardebsa da mozrdilebSi gerd-is wamyvani simptomia (81 %).
adreuli asakis bavSvebSi aseTi Civili ar
2010 weli
57
aris xSiri. rekomendebulia cxovrebis stilis cvlilebebi da farmakologiuri mkurnaloba. Cveulebriv iniSneba 2-4 kviriani antisekreciuli mkurnaloba. Tu ar aris gaumjobeseba, naCvenebia pediatr gastroenterologTan referali refluqs-ezofagitis gamosaricxad. Tu aris gaumjobeseba, kursi grZeldeba 2-3 Tvemde. vinaidan zogjer medikamentebis
moxsnas mosdevs recidivi, antisekreciuli medikamentebi nel-nela unda moixsnas.
refluqs-ezofagiti. gerd-is yvelaze xSiri
garTulebaa. Cumi (Rebinebis gareSe) refluqsi
ufro problemuria, radgan kuWis SigTavsi zeviT-qveviT gadaadgilebisas orjer azianebs
lorwovans. rekomendebulia 3 Tviani inicialuri Terapia omeprazoliT (1,4 mg/kg 1-jer dReSi sauzmemde 15-30 wuTiT adre). Tu 4 kviris Semdeg klinikuri simptomebi ar Semcirda, rekomendebulia dozis gazrda. endoskopiuri monitoringi ar aris aucilebeli, Tu ar aris: ati piuri an persistiuli simptomatika, an saylapavis
Seviwroeba. preparatis moxsna erTaSad ar SeiZleba, aman SesaZlebelia recidivi gamoiwvios.
dozis Semcireba unda gagrZelde 4 kvira. Tu
3-6 Tviani mkurnalobis ramdenime kursis Semdeg
situacia kvlav meordeba, es fasdeba rogorc
qronikuli gerd-i da ganixileba xangrZlivi
Terapiis an qirurgiuli Carevis sakiTxi.
baretis saylapavi. bavSvebSi iSviaTia (5%),
diagnozi ismeba bioptatis gamokvlevis safuZvelze. ti piuria epiTelis metaplazia. aris
adenokarcinomaSi evoluciis riski.
amitom qronikuli mZime gerd-is dros rekomendebulia endoskopiuri monitoringi yovel
3-5 welSi erTxel 20 wlis asakamde.
disfagia, odinofagia, uari sakvebis miRebaze. disfagia an odinofagia iSviaTad aris
asocirebulia gerd-Tan, amitom antirefluqsuri Terapia Cveulebriv mdgomareobis gamosworebas ar iZleva. disfagia ufro xSirad
asocirebulia piris Rrus da saylapavis anatomiur anomaliebTan da anTebiT paTologiasTan, nevrologiur da motorul darRvevebTan, fsiqiur problemebTan. odinofagia anu
mtkivneuli ylapva unda ganvasxvavoT gulZmarvisagan. marTalia is eroziuli ezofagitis drosac gvxvdeba, magram ufro xSirad misi mizezebia orofaringealuri anTeba, saylapavis wyluli, eozinofiluri ezofagiti, infeqciuri ezofagiti (kandidozi, perpesi, citomegalia), saylapavis motoruli darRvevebi. Tu
disfagias an odinofagias axlavs gerd-is
sxva simptomebic, naCvenebia endoskopia biofsiiT da empiriuli antisekreciuli Terapia.
uari sakvebis miRebaze da kvebis problemebi gulisxmobs: arakoordinirebul wovas da
ylapvas, gulze dadgomis da gadacdenis SegrZnebas, gaRizianebas Wamis dros. arc erTi
kvleva ar adasturebs am simptomebis kavSirs
gerd-Tan. arc antisekreciuli mkurnaloba iZleva efeqts. amitom aseT dros rekomendebulia bariumiT rentgenokontrastuli kvleva
58
sxva mizezebis identifikaciis mizniT (aqalazia, ucxo sxeuli, striqtura)
Cvilebis apnoe da uecari sikvdilis sindromi. Cvilebis umravlesobaSi ger-i ar aris
paTologiuri apnoes da ALTE-s (apnoe, kanis
feris cvlilebebi, kunTTa tonusis cvlileba, slokini, gadacdena, rac intervencias saWiroebs) mizezi, magram igi zrdis Cvilis uecari sikvdilis risks. gamarTlebulia kompleqsuri PH/MII da polisomnografiuli kvleva.
aseTi Cvilebis marTvis rekomendaciebi ar
aris SemuSavebuli. sakvebis Sesqeleba Teoriulad unda amcirebdes regurgitaciis risks.
farmakoTerapia ar aris efeqturi. ALTE—s
sixSire asakTan erTad mcirdeba mkurnalobis
gareSec. mxolod im SemTxvevaSi, roca adgili
aqvs regurgitaciasa da Rebinebas sifxizlis
dros da obstruqciul apnoes, gamarTlebulia antirefluqsuri Terapia an qirurgia.
sasunTqi gzebis dazianeba. mozardebsa da
mozrdil pacientebSi xSiria: CaxleCili xma,
qronikuli xvela, yelSi gaCxervis SegrZneba.
bavSvebSi gerd-i ufro xSirad morecidive
laringotraqeits iwvevs. refluqsTan dakavSirebuli laringoskopiuri cvlilebebia: eriTema, SeSupeba, marcvlovaneba, wyluli, granuloma,
qvafenilis suraTi. refluqsi SeiZleba asocirdebodes qronikul sinusitTan, Sua yuris anTebasTan da faringitTan. antirefluqsuri Terapia amcirebs zeda sasunTqi gzebis dazianebis
simptomebs. refluqsma SesaZlebelia gamoiwvios an daamZimos filtvis idiopaTiuri fibrozi.
klinicists uxdeba gadawyvetilebis miReba
konkretuli mdgomareobidan gamomdinare. antirefluqsuri Terapia amcirebs zeda sasunTqi gzebis dazianebis simptomebs. filtvis
funqciis mZime darRvevis SemTxvevaSi SesaZlebelia swori iyos antirefluqsuri qirurgiuli Careva filtvis Semdgomi dazianebis prevenciis mizniT. xolo Tu filtvis dazianeba
mZime ar aris, Terapiuli mkurnaloba Semdgomi dakvirvebiT ufro gamarTlebulia. nazoieunuluri kvebis efeqturoba SesaZlebelia antirefluqsuri qirurgiuli mkurnalobis prediqtorad gamodges.
,fdidsf rfhlbjkjubf
refluqss ZaluZs daamZimos asTmis mimdinareoba. Tavis mxriv asTmas SeuZlia gavlena
iqonios gerd-is simZimeze. Ramis vizingis mqone bavSvebs ufro xSirad aqvT gerd-i. mozrdilebSi protonis tumbos inhibitorebis kursis
Semdeg asTmis klinikuri gamovlinebebi iklebs.
msgavsi xelSesaxebi efeqti bavSvebSi ar dafiqsirebula, magram Znelad samarTavi asTmis marTvis dros es gaTvaliswinebuli unda iyos.
dentaluri erozia. gerd-s ukavSireben kbilebis minanqris lingvaluri zedapiris eroziebs. gamarTlebulia dadasturebuli gerdis mqone pacientebSi moxdes dentistis mier piris Rrus revizia.
sandiferis sindromi. Tavis distoniuri poza
igive spazmuri distonia gulisxmobs zurgis TaRiviT morkalvas da opistotonuss. es SesaZlebelia gamowveuli iyos saylapavis simJavis moxvedris fonze cTomili nervis gaRizianebasTan.
antirefluqsuri Terapia xSirad efeqturia.
mZime qronikuli gerd-is riskis jgufs Seadgenen bavSvebi:
gonebriv ganviTarebaSi CamorCeniT. naCvenebia
testebis Catareba da Terapiuli mkurnaloba.
qirurgiuli Terapia am jgufSi maRali letalobiT da naklebi efeqturobiT vlindeba.
anatomiuri defeqtebiT (saylapavis anomalia, diafragmis saylapavis xvrelis Tiaqari). am kontigentSi maRalia beretis saylapavis da adenokarcinomis riski amitom aris
rekomendacia maT 5 welSi erTxel CautardeT endoskopiuri kvleva.
simsuqniT
qronikuli respiraciuli daavadebebiT _
bronqopulmonuri displazia, idiopaTiuri intersticiuli fibrozi da cistofibrozi (27%).
gamarTlebulia am bavSvebis agresiuli antirefluqsuri mkurnaloba ezofagitis da adenokarcinomis gazrdili riskis gamo, Tumca fundoplikaciis Catareba ar aris rekomendebuli.
filtvis transplantacia. pulmeqtomia aZlierebs kuWisa da saylapavis motorul disfunqcias. am pacientebis letaluri gamosavlis wamyvani mizezi gerd-is garTulebebia.
dRenakluli axalSobili.
neonataluri pnevmonia
(protokoli stacionaris eqimebisaTvis)
masala moamzades m.d. i. favleniSvilma
da m.d. T. goTuam
letaloba: droul axalSobilebSi 20%.
dRenakl axalSobilebSi 50%-ze meti.
definicia: axalSobilTa pnevmonia filtvis anTebiTi procesia, romelic uxSiresad
sistemuri anTebiTi procesis, romelime neonataluri daavadebis an filtvis xelovnuri
ventilaciis fokaluri garTulebaa, Tumca
SeiZleba iyos damoukidebeli nozologiac.
sixSire: droul axalSobilebSi 1%. dRenakl axalSobilebSi 10%.
neonataluri sefsisi/pnevmonia Tu neonataluri pnevmonia?
janmrTelobis dacvis saerTaSoriso organizacia (WHO) ar ganasxvavebs neonatalur
pnevmonias sefsisis, baqteriemiis da saSarde
gzebis infeqciisgan, radganac maT aqvT msgavsi klinikuri gamovlineba da marTvis erTnairi strategia
2010 weli
,fdidsf rfhlbjkjubf
prenataluri risk-faqtorebi:
dausabuTebeli naadrevi mSobiaroba
sanayofe garsebis darRveva mSobiarobis
dawyebamde
xangrZlivi uwylo periodi (18 saaTze meti)
dedis cxeleba>38
saSvilosnos mtkivneuloba
cudi sunis mqone amnionuri siTxe
dedis Sard-sasqeso organoebis infeqcia
nayofis taqikardia
mekoniumi amnionur siTxeSi
dedis ganmeorebiTi saSarde gzebis infeqcia
SeniSvna:
mxedvelobaSi unda iqnas miRebuli orsulobis dros infeqciis skriningis Sedegebi (mag: sifilisi, gonorea, qlamidia, B jgufis streptokoki), aseve nebismieri mkurnaloba, romelic Catarda orsulobis dros
mSobiarobis dros Catarebuli antibiotikoTerapia amcirebs, magram ar xsnis postnataluri infeqciis risks
aRniSnuli risk-faqtorebis ararseboba ar
gamoricxavs pnevmonias
postnataluri risk-faqtorebi:
ventilaciaze myofi axalSobili,
haergamtari gzebis anomaliebi (qoanebis atrezia, traqeoezofaguri fistula, cisturi adenomatozuri malformacia da sxva)
prolongirebuli hospitalizacia
nevrologiuri darRvevebi, romlebsac axlavT gastrointestinuri SigTavsis aspiracia
mZime Tanmxlebi daavadeba
gamovlinebis drois mixedviT ganasxvaveben:
adreul pnevmonias (klinikuri gamovlineba
sicocxlis 1 kviraze) da
gvian pnevmonias (klinikuri gamovlineba sicocxlis 1 kviris Semdeg).
SeniSvna: uaxlesi monacemebiT, pnevmonia
adreulia, Tu klinikuri gamovlineba moxda
pirvel 48 saaTSi, xolo gviani, Tu 48 saaTis
Semdeg, radganac sefsisi/pnevmoniis 85%-Si
klinikuri simptomebi vlindeba pirvel 24
saaTSi, 5%-Si 24-48 saaTSi, Zalian iSviaTad 4872 saaTSi an ufro gvian.
inficirebis drois mixedviT ganasxvaveben:
Tandayolili transplacenturi pnevmonia:
saSvilosnosSiga pnevmonia
Tandayolili intranataluri pnevmonia
postnataluri:
nozokomuri pnevmonia
ventilator-asocirebuli pnevmonia
sazogadoebaSi asocirebuli pnevmonia
aspiraciuli pnevmonia
etiologia:
adreuli pnevmoniis etiologiuri struqtura:
Group B Streptococcus; Streptococcus agalactiae
Gram-negative enteric bacilli (mag.: E. coli)
Staphylococcus aureus
2010 weli
59
Streptococcus pneumonie
U. urealyticum (34 kviraze adre dabadebul
axalSobilebSi)
Mycobacterium tuberculosis
TORCH- infeqcia (Toxoplasma gondii, Rubella,
Cytomegalovirus, Herpes simplex virus, Treponema pallidum, Mumps, enterovirus,adenovirus).
Lysteria monocytogenes
Candida spp.
Aadreuli pnevmoniis dros infeqciis gavrcelebis gzebia: 1. tranplacenturi anu hematogenuri (dedidan nayofze) 2. saSvilosnosSiga (amnionuri siTxis aspiraciis gamo) 3. dabadebis
dros an Semdeg (dainficirebuli amnionuri
siTxis aspiraciis gamo). amnionuri siTxis garda aspirirebuli SeiZleba iyos sisxli, dedis
vaginaluri mikroorganizmebi da sxva
gviani pnevmoniis etiologiuri struqtura:
Chlamydia trachomatis
Respiratory syncytial virus
Parainfluenza virus
Klebsiella spp/
Serratia marcescens
Staph.aureus
Esch.coli
Entrobacter chloace
Citrobacer diversus
Bacillus cerius
Chlamydia trachomatis
Candida spp.
HIV
sazogadoebaSi asocirebuli pnevmoniis etiologiuri struqtura
asaki
0-20 dRe
3 kvira- 3 Tve
uxSiresi gamomwvevebi
SedarebiT iSviaTi gamomwvevebi
Bacteria:
Escherichia coli
Group B streptococci
Listeria monocytogenes
Bacteria:
Anaerobic organisms
Group D streptococci
Haemophilus influenzae
Streptococcus pneumoniae
Ureaplasma urealyticum
Viruses:
Cytomegalovirus
Herpes simplex virus
Bacteria:
Bacteria:
Chlamydia trachomatis
Bordetella pertussis
S. pneumoniae
H. influenzae type B and nontypeable
Viruses:
Moraxella catarrhalis
Adenovirus
Staphylococcus aureus
Influenza virus
U. urealyticum
Parainfluenza virus 1, 2, and 3 Viruses:
Respiratory syncytial virus
Cytomegalovirus
Rhinovirus
klinikuri gamovlinebebi.
neonataluri pnevmonia klinikuri gamovlinebebi mravalferovania. klinikuri simptomebi
araspecifiuria da uxSiresad rds-is simptomatikiT vlindeba. simptomebi SeiZleba iyos pulmonuri, sistemuri an lokaluri
pulmonuri simptomebi: rds-is klinikuri simptomatika:
persistiuli taqipnoe >60 wT (mgrZnobeloba60-89%)
gulmkerdis retraqcia (mgrZnobeloba 80%)
eqspiraciuli xmauriani sunTqva (mgrZnobeloba-60-89%)
cianozi
cxviris nestoTa berva
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60
SeniSvna: xvela axalSobilebSi ar aris ti piuri simptomi da 20%-ze nakleb
SemTxvevebSi gvxvdeba
xixini ar aris aucilebeli niSani
rds-is arainfeqciuri mizezebia:
respiraciuli distress sindromi
axalSobilTa tranzitoruli taqipnoe
mekoniumis aspiraciis sindromi
pulmonuri hemoragia
pnevmoToraqsi
gulis ukmarisoba an manki
pulmonuri hi poplazia
diafragmis Tiaqari
traqeoezofaguri fistula
cns-is defeqtebi
hematologiuri mizezebi
metaboluri darRvevebi
gastroezofaguri refluqsi da sxva
sistemuri simptomebi:
sefsisis an sxva infeqciuri daavadebis
klinika
arastabiluri temperatura
leTargia
sakvebze uari
Rebineba
kanze gamonayari
siyviTle dabadebisas an gaxangrZlivebuli
siyviTle
taqikardia
glukozis donis meryeoba
muclis Seberva
daqveiTebuli perfuzia
oliguria
lokaluri niSnebi:
koniunqtiviti
vezikuluri gamonayari an sxva
dazianebis niSnebi
uCveulo sekreti cxviridan
eriTema da sxva
lokaluri
nozokomuri pnevmonia vlindeba maRali riskis, gansakuTrebiT mcire masis da Zalian mcire
masis axalSobilebSi. dakavSirebulia axalSobilis ZiriTad daavadebasTan, neonataluri intensiuri Terapiisa da reanimaciis ganyofilebis multi_rezistentul florasTan, invaziur
monitoringTan da sxva teqnikur saSualebebTan. nozokomuri pnevmonias miekuTvneba ventilator-asocirebuli pnevmoniac, romlis marTvac xdeba Sesabamisi gaidlainiT.
nozokomuri pnevmonia umetesad generalizebuli infeqciis garTulebaa, misTvis damaxasiaTebelia:
apnoe da bradikardia
arastabiluri temperatura
muclis Seberva
kvebis autanloba
Soki
dvs
sunTqvis ukmarisoba
lokaluri kerebi (omfaliti, koniunqtiviti,
diarea, pnevmonia, bulozuri impetigo da sxva)
klinikuri gamovlinebebi gamomwvevis mixedviT SesaZlebelia garkveuli TaviseburebebiTac gamovlindes:
E.coli,Serratia marcescens, Enterobacter, Strept.pneumoniae
- pnevmatocele,
Citrobacter diversus - tvinis, filtvis abscesi
Bacillus cerius -manekrozebeli pnevmonia, ventilator-asocirebuli pnevmonia
Ureaplasma urealiticum – dRenaklulebSi zrdis
filtvis qronikul daavadebis
(bronq-filtvis displazia) risks
Tandayolili sifilisi asocirebulia mZime
pnevmonitTan da hi poqsemiasTan
(pneumonia alba)
qlamidiuri pnevmonia cnobilia, rogorc
,,afebriluri pnevmonia”.
antibiotikebiT mkurnalobis fonze persistirebadi simptomebis arsebobis
SemTxvevaSi unda gamoiricxos virusuli an
kandidozuri infeqcia.
difereciuli diagnozi. unda gatardes rdsiT mimdinare yvela pulmonur da arapulmonur
paTologiasTan. aucilebelia mxedvelobaSi viqonioT sxva problemebic, romlebic respiraciuli disfunqciiT viTardeba pirvel 24 saaTSi
alveolur-kapilaruli displazia
ariTmia
asfiqsia
bronqis gaoreba
gulmkerdis dazianeba an anomalia
qoanebis atrezia
qiloToraqsi
diafragmis eventracia
gulis gaCereba
intrakranialuri hemoragia
xorxis naprali
xorxis nervis dazianeba
ABCA3 genis mutacia (pasuxismgebelia surfaqtantis transportze)
nervkunTovani daavadebebi
diafragmis nervis dazianeba
sisxldena filtvidan
filtvis hi poplazia
filtvis limfangieqtazia
xerxemlis dazianeba
surfaqtantis B proteinis deficiti
taqikardiiT mimdinare mdgomareobebi
traqeoezofaguri fistula
medikamentis transplacenturi Seyvana
sisxlZarRvis kaTeterTan dakavSirebuli incidenti
sasunTqi gzebis sxva genezis obstruqcia
gulis sxva Tandayolili mankebi
metabolizmis sxva Tandayolili darRvevebi
sxva nerv-kunTovani daavadebebi
marTvis princi pebi. infeqciaze saeWvo, maT
Soris pnevmoniaze saeWvo yvela axalSobili, eqvemdebareba hospitalizacias. yvela axalSobili saSiSroebis niSnebiT aseve eqvemdebareba
hospitalizacias, radgan yvela saSiSroebis ni2010 weli
,fdidsf rfhlbjkjubf
Sani aris agreTve mZime baqteriuli infeqciis niSanic (sensituroba-100%, specifiuroba 92%).
saSiSroebis niSnebia:
ZuZus wovis SeuZlebloba
krunCxva
leTargia an cnobierebis dabindva
sunTqvis sixSire <30-ze wuTSi an apnoe
sunTqvis sixSire >60-ze wuTSi
xmauriani (mkvnesare) sunTqva
gulmkerdis retraqcia
centraluri cianozi
damatebiTi niSnebia:
muclis Zlieri Seberva
gamoxatuli siyviTle
gamokvlevis sqema:
skriningi sefsisze (leikocitozi an leikopenia, umwifari formebi >20%-ze, momatebuli C
reaqtiuli cila, momatebuli edsi)
sisxlis saerTo analizi
sisxlis airebi da mJava-tutovani wonasworoba
glukoza sisxlSi
hematokriti
gulmkerdis radiologiuri kvleva
kultura (sisxli, cerebrospinaluri siTxe,
plevris siTxe, traqeis aspirati)
SeniSvna:
1.Hpnevmoniis dros hi poqsemia aRiniSneba
77%-Si, magram 36%-Si hi poqsemia aReniSnebaT im
axalSobilebsac, romelTac ar aqvT pnevmonia.
hi poqsemia axlavs bevr neonatalur daavadebas, maT Soris filtvis paTologiasac.
2. apnoe aris xSiri, araspecifiuri pasuxi sefsiszec, hi poTermiasa da hi poglikemiazec.
3. hi poqsemiis klinikuri Sefaseba umeteswilad gamoiwvevs Secdomas.
4. gulmkerdis radiologia adasturebs klinikur diagnozs. ti piuria bilateraluri alveoluri daCrdilva haerovani bronqogramiT, Tumca SesaZlebelia iyos nodularuli an arasworkideebiani, araerTgvarovani, uxeSi infiltratebi an lobaruli an segmenturi konsolidacia. aRniSnuli cvlilebebi 48 saaTis ganmavlobaSi ar unda alagdes. ar aris gamoricxuli
normaluri radiologiuri suraTic.
5.Zalian Zneli gansasxvavebelia GBS –iT gamowveuli sefsisi, radganac rentgenograma rds
1-is msgavsia. am SemTxvevaSi gvexmareba gestaciuri asaki (dRenaklia Tu drouli, aris Tu ara
plevris gamonaJoni da sxva)
mkurnaloba:
antibaqteriuli Terapia
antibaqteriuli Terapia damokidebulia
pnevmoniis gamovlenis droze (adreulia pnevmonia Tu gviani), saeWvo an dadasturebul paTogenis tipze, daavadebis mimdinareobaze da sxva
faqtorebze.
adreuli
tardeba:
2010 weli
pnevmoniis
inicialuri
Terapia
61
penicilinis jgufis da aminoglikozidis an
penicilinis jgufis da cefotaqsimis kombinaciiT.
Tu sisxlidan an saintubacio milidan amoiTesa:
Coliforms – CEFOTAXIME + aminoglikozidi
Pseudomonas – Ticarcilin clavulanate, CEFTAZIDIME +
aminoglikozidi
Group B Streptococcus - penicilinis jgufi+aminoglikozidi
Staphylococcus aureus – penicilinis jgufi+aminoglikozidi
Tu kultura negatiuria:
axalSobili< 5 dReze penicilinis jgufi+aminoglikozidi
axalSobili > 5 dReze CEFOTAXIME +aminoglikozidi
nozokomuri infeqcia:
saWiroa antibiotikis SerCeva saavadmyofoSi gavrcelebuli infeqciisa da misi mgrZnobelobis gansazRvriT.
gviani nozokomuri pnevmoniis SemTxvevaSi SesaZlebelia sawyis TerapiaSi CarTul iqnas vankomicini + aminoglikozidi meticilin rezistentuli stafilokokze (MRSA) zemoqmedebisTvis.
sxva SemTxvevaSi gamoiyeneba karbapenemisa
da vankomicinis kombinacia
herpesuli etiologiis dros rekomendebulia intravenuri acikloviri
qlamidiiT, ureaplazmiT gamowveuli pnevmoniis gamowveuli pnevmoniis
dros _ makrolidebi
respiraciul sincitialuri virusiT gamowveuli pnevmoniis dros –
ribavirini
intraabdominaluri sefsisisa an NEC-s
dros damatebiT metronidazoli
Tu bavSvi (gansakuTrebiT dRenakluli) ar eqvemdebareba tradiciul
mkurnalobas, gamoricxeT sokovani septicemia.
saboloo antibiotikis SerCeva xdeba baqteriologiuri kvlevisa da mgrZnobelobis Sedegebis safuZvelze.
antibaqteriuli mkurnalobis garda aucilebelia:
2. respiraciuli daxmareba
3. hemodinamikis mowesrigeba
4. nutrientebis miwodeba
5. temperaturis kontroli
am problemebis marTva xdeba Sesabamisi gaidlainebiT.
,fdidsf rfhlbjkjubf
cbw!T!w!Ub!btb!ljt!nxwb!wf!bsb!ipt!qj!ub!mv!sj!qofw!np!oj!jt!nbs!U!wb
62
)qsp!up!lp!mj !tub!dj!p!ob!sjt!frj!nf!cj!tbU!wjt*
masala moamzada m.d. c. farulavam
1.daavadebis definicia. pnevmonia alveolebisa da terminaluri sasunTqi gzebis anTebaa gamowveuli infeqciuri
agentis filtvebSi inhalaciuri an hematogenuri gziT moxvedriT da axasiaTebs mwvave
respiraciuli simptomebi, intoqsikacia da gulmkerdis
rentgenogramaze filtvis parenqimis infiltraciis (konsolidaciis) niSnebi.
ganasxvaveben
lobalur
pnevmonias, bronqopnevmonias
da intersticiul pnevmonias.
2. daavadebis etiologiuri
struqtura.
arahospitaluri pnevmoniis
uxSiresi gamomwvevi 2 wlamde
asakSi virusebia, 1 -5 wlis asakis bavSvebSi baqteriuli gamomwvevebi sWarboben. virusebidan pnevmoniis uxSires mizezs warmoadgens RS virusi,
uxSiresi baqteriuli gamomwvevebi ki nebismier asakSi Streptococcus pneumoniae da B jgufis
Haemophilus influenza arian, Tumca
axalSobilebSi aseve xSiria B jgufis streptokokiT
da nawlavis CxiriT gamowveuli, xolo 6 Tvemde asakSi
Staph. aureus-iT gamowveuli
filtvebis anTeba.
ati piuri pnevmoniis etiologiuri faqtorebia axalSobilebsa da adreuli Cvilobis periodSi Mycoplasmahomini, Ureaplasma urealyticum, Chlamydia trachomatis
xolo 5 welze meti asakis
bavSvebSi Mycoplasma pneumoniae
da Chlamydia pneumonia.
hospitaluri
pnevmoniis
mizezi gram-uaryofiTi multirezistentuli
floraa
(Pseudomonas aeroginosa, Staph.
aureus, enterobaqteriebi).
imunodeficitis fonze pnevmonias klasikuri gamomwvevebis garda oportunistuli
flora iwvevs (herpesis jgufis virusebi, pnevmocista, mikozuri flora da sxva). pankre-
asis cistofibroziT daavadebulebSi pnevmoniis mizezi uxSiresad Staph. aureus, Pseudomonas
aeruginosa da B.cepacia xdeba. 3. daavadebis kriteriumebi
pnevmoniis
sasargeblod
metyvelebs:
respiraciuli simptomebi;
lokaluri perkusiuli da
auskultaciuri monacemebi;
rentgenologiuri cvlilebebi. pnevmonias gamoricxavs:
Sesabamisi klinikuri suraTis
da lokaluri paTologiuri
niSnebis ararseboba, rentgenologiurad
infiltraciis
ararseboba. 4. pnevmoniis simptomebi da niSnebi.
intoqsikaciis niSnebi: cxeleba, sisute, umadoba, Rebineba,
muclis tkivili, Tavis tkivili,
mialgia, arTralgia da sxva
respiraciuli simptomebi:
xvela
taqi pnoe (pnevmoniis erTerTi ZiriTadi sadiagnostiko
niSania. Tu sunTqvis sixSire
2 Tvemde asakSi tolia an >
60/wT, 2-12 Tve _ tolia an >
50/wT, 1-5 wlis asakSi tolia
an > 40/wT, 5 wlis zemoT tolia an > 30/wT, unda gamoricxos pnevmonia)
sunTqvis gaZneleba. mkvnesare sunTqva CvilebSi
gulmkerdis retraqcia (mZime pnevmoniis erT-erTi ZiriTadi
sadiagnostiko kriteriumia)
damxmare kunTebis monawileoba sunTqvaSi (cxviris
nestoebis daZabva, Tavis sinqronuli moZraoba, neknTaSua
kunTebis monawileoba)
lokaluri simptomatika:
perkusiuli xmis Sesusteba an moyrueba;
auskultaciiT Sesustebuli sunTqva an sunTqva ar
tardeba;
bronquli sunTqva;
krepitacia (an lokaluri
sveli wvrilbuStukovani xixini).
ti piuri pnevmoniis dros
yvela am niSnis erTdrouli
gamovlena ar aris aucilebeli. perkusiuli da auskulta-
pnevmoniis simZimis Sefaseba.
pnevmonia
x
x
taqipnoe
mZime pnevmonia
x
taqipnoe
Zalian mZime pnevmonia
x
taqipnoe
x
pnevmoniis
perkusiuli da
auskultaciuri lokaluri
niSnebi
x
gulmkerdis
retraqcia
x damxmare kunTebis monawileoba
sunTqvaSi
x
damxmare kunTebis
monawileoba sunTqvaSi
x xmauriani sunTqva (mkvnesare
x
xmauriani sunTqva
(mkvnesare sunTqva
CvilebSi)
pnevmoniis
x pnevmoniis perkusiuli da
auskultaciuri lokaluri niSnebi
perkutoruli da
auskultaciuri
lokaluri niSnebi da sul mcire erTi niSani
CamoTvlilidan:
x gulmkerdis retraqcia
sunTqva CvilebSi)
da sul mcire erTi
niSani CamoTvlilidan:
x
x
centraluri cianozi
ar SeuZlia miiRos
sakvebi an aqvs Rebineba
ZuZus, sakvebis an siTxis
miRebis Semdeg
x krunCxva, leTargia an
ugono mdgomareoba
2010 weli
,fdidsf rfhlbjkjubf
ciuri kriteriumebis mgrZnobeloba dabalia, amitom sadiagnostiko kriteriumebad upiratesoba eniWeba taqipnoes da
gulmkerdis retraqcias.
ati piuri pnevmoniis dros
dominirebs ararespiraciuli
Civilebi (mag. Tavis tkivili,
diarea, mialgia, arTralgia, agzneba da sxva), avadmyofs SesaZloa ar hqondes cxeleba
da/an ar axvelebdes, zogjer
aris gamonayari kansa da
lorwovanebze. kerovani simptomatika ar aris an aramkveTrad aris gamoxatuli;
rentgenologiuri monacemebi ar korelirebs Rarib
fizikalur monacemebTan.
ati piuri mimdinareoba axasiaTebs mikoplazmur, qlamidiur da virusul pnevmoniebs.
5. pnevmoniis simZimis Sefaseba.
pnevmoniis marTva SesaZlebelia binis pirobebSi, mZime
pnevmoniis dros aucilebelia
hospitalizacia, Zalian mZime
pnevmoniis dros pacienti Tavsdeba reanimaciisa da intensiuri Terapiis ganyofilebaSi.
6. hospitalizaciis Cvenebebi. pnevmoniis sadiagnostiko kriteriumebi da:
mZime an Zalian mZime pnevmonia
asaki < 3 Tveze
Seupovari Rebineba
krunCxvis epizodi aRniSnuli daavadebis dros
taqipnoe ( 5 wlamde asakSi >
70 wT, 5 wlis zemoT >50 wuTSi)
perioduli, xanmokle apnoe
dehidratacia
saturacia< 93%
araefeqturi mkurnaloba
binaze
araadeqvaturi meTvalyureoba da movla binis pirobebSi
fonuri daavadebebi (imunodeficiti, filtvis, gulis, cnsis qronikuli paTologia)
7. diagnostika gulmkerdis rentgenologiuri kvleva ar keTdeba rutinulad.
Tu saxezea pnevmoniis klasikuri niSnebi, diagnozi eWvs
ar iwvevs da Tu pnevmonia ar
fasdeba rogorc mZime an Zalian mZime, radiologiuri
kvleva aucilebeli ar aris.
2010 weli
rentgenonegatiuri pnevmonia
ar arsebobs. gulmkerdis
rentgenologiuri kvleva naCvenebia, Tu:
saxezea pnevmoniis urTierTgamomricxavi niSnebi;
eWvia garTulebebze;
ar aris saTanado pasuxi
mkurnalobaze;
4. 5 wlamde asakis pacients
aqvs ucnobi etiologiis cxeleba da maRali leikocitozi, miuxedavad imisa, gamoxatulia Tu ara respiraciuli
sistemis dazianebis niSnebi.
ganmeorebiTi
gulmkerdis
rentgenologiuri kvleva naCvenebia, Tu saxezea:
filtvis wilis kolafsi;
pnevmoniis mrgvali Crdili;
klinikuri simptomebis gaxangrZliveba;
4. garTulebebi (abscesi,
empiema, plevruli efuzia) periferiuli sisxlis analizi:
ar keTdeba rutinulad. Tu
saxezea pnevmoniis klasikuri niSnebi, diagnozi eWvs ar
iwvevs da Tu pnevmonia ar
fasdeba rogorc mZime an Zalian mZime, hematologiuri
kvleva aucilebeli ar aris.
baqteriuli pnevmoniis albaToba maRalia, Tu aris: maRali
leikocitozi (>15x109 /l) da
maRali febriliteti (>390C).
C-reaqtiuli cila. C –reaqtiuli cilis zomieri mateba ti piuria nebismieri genezis pnevmoniisaTvis. baqteriuli pnevmoniis albaToba maRalia, Tu is >50-ze.
puls-oqsimetria (Tu aris
amis SesaZlebloba) rekomendebulia Cautardes pnevmoniiT hospitalizebul yvela
pacients. Jangbadis saturacia <92%-ze aris oqsigenoTerapiis Cveneba.
damatebiT SesaZlebelia saWiro gaxdes Semdegi kvlevebi:
plevraluri
punqtatis
mikroskopuli da baqteriologiuri kvleva plevraluri
garTulebebis SemTxvevaSi.
sisxlis kultura _ mizanSewonilia mZime pnevmoniis,
araefeqturi mkurnalobis da
septiur procesze eWvis dros;
serologiuri kvleva _ rekomendebulia ati piuri pnev-
63
moniis an garTulebuli an
mZime pnevmoniis SemTxvevaSi;
ultrabgeriTi kvleva –
rekomendebulia plevraluri
efuziis
SemTxvevaSi
siTxis raodenobaze dinamikaSi dakvirvebis mizniT;
Sardovana da eleqtrolitebi – mZime pnevmoniis an dehidrataciis niSnebis SemTxvevaSi.
kompiuteruli tomografia
– mZime garTulebebis dros;
pulmonologis (ftiziatris) konsultacia – garTulebebis
an
araefeqturi
mkurnalobis SemTxvevaSi.
8.pnevmoniis garTulebebi.
Tu mkurnalobis fonze 48 saaTis Semdeg ar aris mdgomareobis
gaumjobeseba
an
mdgomareoba gauaresda, safiqrebelia
garTulebebis
arseboba: eqsudaciuri plevriti, abscesi, empiema, pnevmoToraqsi. garTulebaze eWvis
SemTxvevaSi rekomendebulia
radiologiuri kvlevis ganmeorebiT Catareba sasurvelia pirdapir da gverdiT
proeqciebSi.
9.reanimaciul ganyofilebaSi
moTavsebis/gadayvanis
kriteriumebi
Soki
Zalian mZime pnevmonia
60%-ze meti koncentraciis
Jangbadis miwodebisas saturacia <92%-ze
ganmeorebadi apnoe an gaiSviaTebuli, araregularuli
sunTqva
10.pnevmoniis mkurnaloba.
antibiotikoTerapia iwyeba I
rigis antibaqteriuli preparatebiT. antibiotikoTerapiis efeqturoba fasdeba 48
saaTis Semdeg. araefeqturobis SemTxvevaSi rekomendebulia II rigis preparatebze
gadasvla.
pnevmonia. mkurnaloba SesaZlebelia ambulatoriul
pirobebSi. stacionarSi moTavsebis
SemTxvevaSi mkurnalobis
taqtika ar icvleba. hospitalizacia ar aris parenteraluri antibiotikoTerapiis
Cveneba.
,fdidsf rfhlbjkjubf
64
asaki
5 wlamde
antibiotiki
I rigi
II rigi
5 welze
meti
penicilinis jgufi
an
daculi penicilini
(amoqsicilini + klavulanis
mJava an sulbaqtami)
cefalosporini (I an II
Taoba)
an
makrolidi
I rigi
II rigi
nebismier
asakSi
dasaxeleba
mxolod im
SemTxvevaSi,
roca
pacienti
ver iRebs
antibiotiks
oralurad,
gamoiyeneba
saineqcio
antibiotiki
makrolidi
cefalosporini (I an II
Taoba)
penicilinis jgufi
an
daculi penicilini
(amoqsicilini + klavulanis
mJava an sulbaqtami
administrirebis
gza.
oraluri
oraluri
oraluri
oraluri
i/m 3 dRe
Semdeg oraluri
antibiotiki
mkurnalobis
xangrZlioba
5-7 dRe
Tu 48 saaTis Semdeg
mkurnalobis
dawyebidan
mdgomareoba ar
umjobesdeba,
naCvenebia II rigis
antibiotikze
gadasvla
5-7 dRe
Tu 3 DdRis Semdeg
mkurnalobis
dawyebidan
mdgomareoba ar
umjobesdeba,
naCvenebia referali
stacionarSi.
5-7 dRe
Tu 3 DdRis Semdeg
mkurnalobis
dawyebidan
mdgomareoba ar
umjobesdeba,
naCvenebia referali
stacionarSi.
Tu 3 DdRis Semdeg
mkurnalobis
dawyebidan
mdgomareoba ar
umjobesdeba,
naCvenebia referali
stacionarSi.
mZime pnevmonia
asaki
5 wlamde
antibiotiki
I rigi
dasaxeleba
penicilinis jgufi
an
daculi penicilini
(amoqsicilini +
klavulanis mJava an
sulbaqtami)
administrirebis
gza.
mkurnalobis
xangrZlioba
i/m an i/v
minimum 3 dRe
sul 7 - 14 dRe
Tu 48 saaTis Semdeg
mkurnalobis
Tu aris
dawyebidan
gaumjobeseba,
mdgomareoba ar
grZeldeba
umjobesdeba,
oraluri
naCvenebia II rigis
antibiotikoTerapia antibiotikze
gadasvla
i/m an i/v
minimum 3 dRe
cefalosporini
an
cefalosporini+makrolidi
II rigi
5 welze
meti
I rigi
cefalosporini
an
cefalosporini+makrolidi
Tu aris
sul 7-14 dRe
gaumjobeseba,
grZeldeba
oraluri
antibiotikoTerapia
i/m an i/v
minimum 3 dRe
sul 7-14 dRe
Tu aris
gaumjobeseba,
grZeldeba
oraluri
antibiotikoTerapia
oqsigenoTerapiis
Cvenebe-
bi:
Jangbadis saturacia <92%
hopoqsemiis niSnebi: agzneba, centraluri
cianozi,
mkveTrad gamoxatuli retraqcia, taqi pnoe, mkvnesare
sunTqva Jangbadis miwodeba
umjobesia nazaluri kanuliT an kaTeteriT.
rehidrataciis Cvenebebi:
bavSvi ver iRebs siTxis
sadRe Ra mi so
moTxov ni le bas;
bavSvi kargavs siTxes perspiraciis an Rebinebis gamo
sadReRamiso moTxovnileba siTxeze
<10 kg _ 100-120 ml/kg
10-19 kg _ 90- 120 ml/kg
20kg > _ 50-90ml/kg
siTxis oraluri gziT micemas upiratesoba eniWeba
parenteralurTan SedarebiT.
intravenuri rehidrataciis SemTxvevaSi siTxis raodenoba ar unda aRematebodes
sadReRamiso moTxovnilebis
80%-s da xdebodes Sratis
eleqtrolitebis kontrolis
qveS.
temperaturis kontroli.
sicxis damwevi saSualebebis
gamoyeneba rekomendebulia
maRali temperaturis SemTxvevaSi (>38,5_39 0). I rigis anti piretuli saSualebaa acetaminofeni erTjeradi doza
10-15mg/kg. minimaluri intervali miRebebs Soris 6 saaTi.
II rigis anti piretuli saSualeba ibuprofeni. erTjeradi doza 5-10 mg/kg. minimaluri intervali miRebebs Soris
6-8 saaTi.
amosaxvelebeli saSualebebi. mwvave periodSi xvelis
damTrgunveli saSualebebi
ar
aris
rekomendebuli.
bronqospazmolizuri saSualebebi ar gamoiyeneba rutinulad. amosaxvelebeli saSualebebi da naxvelis gamaTxelebeli preparatebi ar
cvlis daavadebis mimdinareobasa da gamosavals. amo2010 weli
,fdidsf rfhlbjkjubf
65
Zalian mZime pnevmonia
asaki
5 wlamde
antibiotiki
I rigi
II rigi
administrirebis
gza.
mkurnalobis
xangrZlioba
1. penicilinis jgufi +
aminoglikozidi an
2.daculi penicilini +
aminoglikozidi an
3. cefalosporini (III Taoba)
i/m an i/v
minimum 5 dRe
sul 10-14 dRe
Tu aris
mniSvnelovani
gaumjobeseba 5
dRis Semdeg,
gagrZeldes
oraluri
amoqsicilini(10
dRe)+
parenteraluri
aminoglikozidi
(sul 10 dRe)
1.cefalosporini+makrolidi an
2.cefalosporini+vankomicini
i/m an i/v
minimum 5 dRe
dasaxeleba
5 welze
meti
nebismier
asakSi
nebismier
asakSi
I rigi
cefalosporini (III Taoba)
II rigi
1.cefalosporini + makrolidi
an
2.cefalosporini+vankomicini
stafilokokur
pnevmoniaze
eWvis
SemTxvevaSi
mxolod im
SemTxvevaSi,Tu
Catarebuli
mkurnaloba
araefeqturia
kloqsacilini+aminoglikozidi
an
oqsacilini+aminoglikozidi
an cefalosporini +
aminoglikozidi an vankomicini
i/m an i/v
minimum 5 dRe
sul 10-14 dRe
sul 10-14 dRe
Tu aris
sagrZnobi
gaumjobeseba,
naCvenebia
oralur
antibiotikze
gadasvla.
i/m an i/v
minimum 5 dRe
sul 10-14 dRe
Tu aris
sagrZnobi
gaumjobeseba,
naCvenebia
oralur
antibiotikze
gadasvla
i/m an i/v
minimum 5 dRe
sul 14-21 dRe
i/m an i/v
minimum 5 dRe
karbapenemebi an
IV Taobis cefalosporinebi
saxveleblebi sifrTxiliT
ixmareba
wlamde
asakSi
(bronqoobstruqciis riskis
gamo).
bronqoobstruqciis
SemTxvevaSi naCvenebia salbutamoli an epinefrini (nebulaizeriT).
11. monitoringi. mZime da
Zalian mZime pnevmoniis SemTxvevaSi aucilebelia Semdegi simptomebis monitoringi:
sunTqvis sixSire
guliscemis sixSire
gulmkerdis retraqcia
Jangbadis saturacia
oqsigenoTerapiis SemTxvevaSi monitoringi tardeba
yovel 3-4 saaTSi.
12. saavadmyofodan gaweris kriteriumebi:
siTxis adeqvaturi raodenobiT miReba
antibiotikoTerapiis binaze gagrZelebis SesaZlebloba
ubanze meTvalyureobis SesaZlebloba
mSoblebis Tanxmoba da
mzaoba gagrZeldes daniSnuli mkurnaloba binaze
virusuli krupis sindromis
(mwvave laringotraqeitis) marTva
(protokoli stacionaris eqimebisaTvis)
masala moamzada m.d. c. farulavam
krupi anu mwvave laringotraqeiti, zogjer laringotraqeobronqiti _ zeda sasunTqi gzebis obstruqciis wamyvani mizezia adreul asakSi. igi upiratesad viTardeba 6
Tvidan 6 wlamde asakSi (91%), pikuri asakia 12 weli. daavadeba 2-jer ufro xSiria biWebSi, vidre gogonebSi. krupis sindroms iwvevs:
virusebi. uxSiresi gamomwvevebia: paragri pis (74%), gri pis, wiTelas, ybayuras virusebi,
adenovirusi, rinovirusi, enterovirusebi. virusul krups axasiaTebs sezonuroba – xSiria zamTarsa da adreul gazafxulze.
baqteriebi. Corynebacterium Diptheriae sayovelTao imunizaciis fonze iSviaTad xdeba krupis mizezi. SesaZlebelia Mycoplasma pneumonia, Haemophilus influenza, Zalze iSviaTad Staphylococcus aureus-iT gamowveuli zeda sasunTqi
2010 weli
gzebis obstruqcia.
spazmuri krupi savaraudoT ukavSirdeba
alergiiT an fiziko-qimiuri
gamRizianeblebiT gamowveul angionevrozul SeSupebas, iSviaTad
hi pokalcemiiT gamowveul laringospazms.
virusuli krups adasturebs:
1. klinikuri triada: sunTqvis gaZneleba
(inspiraciuli stridori), myefavi xvela
da xmis tembris cvlilebebi
2. respiraciuli virusuli infeqciis niSnebi.
virusul krups gamoricxavs:
1. maRali cxeleba da intoqsikaciis sxva
niSnebi
2. nerwyvdena
3. stridoris ararseboba
4. eqspiraciuli xmianoba (vizingi)
5. asaki < 3 Tveze
6.iZulebiTi poza da ynosvis pozicia.
,fdidsf rfhlbjkjubf
66
klinikuri simptomatika
daavadeba iwyeba respiraciuli virusuli infeqciisaTvis damaxasiaTebeli kataruli movlenebiT (rinorea,
iSviaTi xvela, dabali temperatura). 12-72 saaTis Semdeg,
uxSiresad RamiT vlindeba
krupis klasikuri niSnebi:
myefavi xvela
gaZnelebuli
xmauriani
sunTqva (inspiraciuli stridori)
xmis CaxleCa srul afoniamde
amas emateba sxvadasxva
xarisxiT gamovlenili respiraciuli distresis niSnebi
(taqi pnoe, inspiraciuli retraqciebi, damxmare kunTebis
monawileoba sunTqvaSi, cianozi, agzneba an leTargia).
SesaZlebelia krupis simptomebi gamovlindes uecrad
Ramis saaTebSi respiraciuli
virusuli infeqciis niSnebis
gareSe an paralelurad.
mwvave laringotraqeitis
diagnostika da marTva.
krupis sindromis diagnostika SesaZlebelia mxolod
klinikuri niSnebis safuZvelze. virusuli krupis sadiagnostikod ar aris aucilebeli paraklinikuri kvlevebis
Catareba. unda Sefasdes:
pacientis zogadi mdgomareoba _ mousvenroba, mkveTrad gamoxatuli agzneba an
daTrgunva, leTargia. gonebis dabindva. cnobierebis
done korelirebs krupis simZimesTan.
respiraciuli distresis
niSnebi _ taqi pnoe, inspiraciuli retraqcia, damxmare kunTebis monawileoba sunTqvaSi, cianozi an mkveTri sifermkrTale. distresis niSnebi
mizanSewonilia
Sefasdes
bavSvis simSvidis dros. taqi pnoes xarisxi korelirebs
krupis simZimesTan. taqikardiis arseboba miuTiTebs hi poqsemiasa da acidozze.
gamokvlevebis Catareba rekomendebulia hospitalizaciis SemTxvevaSi da/an im SemTxvevaSi, Tu saWiroa diferencialuri diagnozi gatardes
obstruqciiT mimdinare sxva
daavadebebTan (mwvave epiglotiti, baqteriuli traqeiti,
ucxo sxeulis aspiracia, retrofaringealuri an peritonzilaruli abscesi, hi pokalcemiiT gamowveuli laringospazmi, angionevrozuli SeSupeba, anatomiuri defeqti).A
1. sisxlis saerTo analizi. rutinulad ar keTdeba,
radgan specifiuri cvlilebebi damaxasiaTebeli ar aris,
amasTan ar iZleva informacias etiologiuri agentis Sesaxeb, ar cvlis marTvis taqtikas; hemogramis gakeTeba mizanSewonilia
baqteriul
traqeitze, epiglotitze, abscesebze eWvis SemTxvevaSi;
2. xaxis daTvaliereba rutinulad ar aris saWiro da absoluturad usafrTxoa. xaxisa da xorxis daTvaliereba
retrofaringialuri abscesis
an epiglotitis gamoricxvis
mizniT rekomendebulia mxolod gadaudebeli Terapiis
ganyofilebaSi, radgan maRalia
apnoes ganviTarebis riski;
3. kisris rentgenografiuli kvleva rutinulad ar
tardeba. naCvenebia, roca eWvia sasunTqi gzebis ucxo
sxeulze, retrofaringealur
abscesze an epiglotitze.
mwvave
laringotraqeitis
dros pirdapir proeqciaSi
ti piuri niSania xorxis Seviwroeba uSualod xorxsarqvelis qveda nawilSi da
normaluri zomis xorxsarqveli, rac qmnis damaxasiaTebel “solis niSans”;
4. Jangbadis saturaciis maCvenebeli Zalze informatiulia
da mizanSewonilia ganesazRvros yvela hospitalizebul pacxrili #1
msubuqi
> stridori
datvirTvis dros
> retraqcia
datvirTvis dros
> aqtiuria,
interess iCens
garemos mimarT
> siTxes iRebs
cients, romelsac aqvs respiraciuli distresis niSnebi;
5. arteriuli gazebis gansazRvra
mizanSewonilia
mxolod mZime SemTxvevebSi.
hi poqsemiis da hi perkapniis
maCveneblebi korelirebs obstruqciis simZimesTan;
6. virusologiuri kvleva
(cxvir-xaxis Camonarecxi) ar
aris aucilebeli. wamyvani
etiologiuri agentebi cnobilia, miRebuli Sedegi ar
cvlis mkurnalobis taqtikas,
amasTan virusis deteqcia
mxolod 22 _ 38%-Si xerxdeba;
7. Tanamedrove sadiagnostiko saSualebebi virusuli
antigenis, antisxeulebis titris an genomis dasadgenad
(ELISA, PCR) iZleva swrafi
diagnostirebis saSualebas,
magram ZviradRirebulia da
rutinulad ar gamoiyeneba.
marTvis taqtikis SerCeva
xdeba sasunTqi gzebis obstruqciis xarisxis _ krupis
simZimis Sefasebis safuZvelze. (cxrili #1)
msubuqi xarisxis krupis
sindromi _ pacientis zogadi
mdgomareoba damakmayofilebelia, SeuZlia siTxis da
sakvebis miReba, TamaSobs,
iCens interess garemo faqtorebis mimarT. inspiraciuli retraqcia da stridori
vlindeba mxolod datvirTvis dros. msubuqi xarisxis
krupis marTva SesaZlebelia
binis pirobebSi.
saSualo simZimis krupis
sindromi _ stridori da inspiraciuli
retraqciebi
vlindeba mosvenebul mdgomareobaSic, aris taqikardia,
sasunTqi gzebis obstruqciis xarisxis
(krupis simZimis) Sefaseba
saSualo simZimis
mZime
> stridori mSvid
mdgomareobaSi
> gulmkerdis qveda
nawilis retraqcia
mSvid mdgomareobaSi
> SeSinebuli
gamometyveleba
> agzneba
> aqtiuria, interess
iCens garemos mimarT
> siTxes iRebs
>stridori mSvid
mdgomareobaSi
> gulmkerdis qveda
nawilis retraqcia
mSvid mdgomareobaSi
>gulmkerdis qveda
nawilis retraqcia
mSvid mdgomareobaSi
>Zlieri agzneba an
leTargia
> mkveTri
sifermkrTale
> sakvebs ver iRebs
da/an ver saubrobs
sicocxlisaTvis
saSiSi
> stridori mSvid
mdgomareobaSi an
stridori ar
vlindeba
> leTargia
> dabinduli
cnobiereba an ugono
mdgomareoba
>sustad gamoxatuli
sunTqviTi aqtioba
> munji filtvi
> totaluri cianozi
2010 weli
,fdidsf rfhlbjkjubf
magram
bavSvs
SeuZlia
siTxis da sakvebis miReba,
iCens interess garemo faqtorebis mimarT. SesaZlebelia iyos agzneba. agznebis
mateba miuTiTebs hi poqsiis
gaZlierebaze. msubuqi xarisxis krupis marTva SesaZlebelia binis pirobebSi.
mZime krupi _ Zlieri stridori mosvenebul mdgomareobaSi, mkveTrad gamoxatuli
retraqciebi, Secvlili cnobiereba (Zlieri agzneba, leTargia an gonebis dabindva).
aris taqikardia da cianozi.
mZime
obstruqciis
dros
aucilebelia hospitalizacia, SesaZloa saWiro gaxdes
intensiuri Terapia.
sicocxlisaTvis
saSiSi
krupi _ morecidive apnoe, bradikardia, kolafsi, Zlieri agzneba, auskultaciiT munji filtvis arseboba warmoadgens sicocxlisaTvis saSiS niSnebs
da saWiroebs dauyovnebliv
reanimaciul daxmarebas.
hospitalizaciis Cvenebebi:
obstruqciis sicocxlisaTvis saSiSi niSnebi, romlebic dauyovnebliv reanimaciuli RonisZiebebis Catarebas
saWiroeben:
araadeqvaturi Zilianoba
an Zlieri agzneba;
mkveTri cianozi an mkveTri sifermkrTale;
apnoe;
bradikardia;
kolafsi (hi potenzia);
munji filtvi auskultaciiT.
saSualo da mZime xarisxis krupi;
asaki < 6 Tveze;
intoqsikaciis niSnebi, rac
saeWvos xdis baqteriul daavadebebs;
oralurad
sakvebis
an
siTxis miRebis problemebi;
saturacia <92%
araefeqturi inicialuri
mkurnaloba binaze;
mZime obstruqciis epizodi
anamnezSi;
fonuri mdgomareobebi: gulis an filtvis qronikuli
daavadebebi, mZime nevrologiuri paTologia, daunis sindromi (sasunTqi gzebis anato2010 weli
67
miuri Taviseburebis gamo);
araadeqvaturi movla saxlis pirobebSi, satransporto
an sakomunikacio saSualebebis arqona.
hospitalizaciis maCvenebeli meryeobs 3-50%-mde.
mkurnalobis princi pebi.
(cxrili #2)
Jangbadze respiraciuli
moTxovnilebebis Sesamcireblad rekomendebulia mSvidi,
komfortuli garemos Seqmna,
radgan tirili, fizikuri
datvirTva aZlierebs obstruqcias, zrdis moTxovnilebas Jangbadze. umjobesia pacienti dedas hyavdes xelSi.
amave mosazrebiT rekomendebulia minimaluri laboratoriuli kvlevebi.
grili teniani haeri amcirebs SeSupebis xarisxs da
lorwovanis gamoSrobis safrTxes. ar aris rekomendebuli Tbili procedurebi: orTqliT inhalacia, Tbili abazanebi, Tbili sasmelebis miReba.
siTxiT uzrunvelyofa.
steroiduli preparatebi
arCevis preparatebia. steroidebiT mkurnaloba amcirebs
klinikuri simptomebis simZimes, sainhalacio adrenalinis
gamoyenebis aucileblobas,
hospitalizaciis da intensiuri daxmarebis ganyofilebaSi moTavsebis maCveneblebs,
hospitalizaciis xangrZliobas, intubaciis aucileblobas, aumjobesebs gamosavals.
oraluri
deqsametazoni
iseTive efeqturia, rogorc
parenteraluri an sainhalacio kortikosteroidi. pero-
raluri steroidis erTjeradi gamoyeneba uxSiresad sakmarisia. efeqti miiRweva 1-6
saaTSi. rekomendirebuli doza 0,15_0,3_0,6 mg/kg (erTjeradi doza) simZimis mixedviT
(maqsimaluri dasaSvebi doza
10 mg, romelic SeiZleba dainiSnos ertjeradad an gaiyos
3-4 miRebaze). ganmeorebiT micema SeiZleba 6 saaTSi. deqsametazonis tabletis doza
Zalian pataraa da cudi gemo
aqvs. ampula ufro koncentrirebulia (4mg/ml), amitom
dasaSvebia ampulis sirofTan Sereva da peroraluri
miReba. deqsametazonis alternativaa oraluri meTilprednizoloni an prednizoloni 1-2 mg/kg (2 wlamde 10 mg,
2 welze meti asakis bavSvebSi
20 mg). uxSiresad medikamentis erTi dozac sakmarisia.
Tu pacients aReniSneba
Rebineba an ver iRebs medicaments oralurad, rekomendebulia steroiduli preparatis parenteralurad daniSvna: prednizoloni 1-2mg/kg
(erTjeradi doza im an i/v.
inhalaciuri steroidoTerapia (budezonidi, pulmokorti) efeqturia, magram ufro Zviria da ar gamoiyeneba
rutinulad. budezonidis erTjeradi doza nebulaizeriT 2mg (2ml xsnari). ganmeoreba SeiZleba yovel 12 saaTSi 1mg-is odenobiT.
mZime obstruqciis dros
sastarto preparati adrenalinia. rekomendebulia adrenerguli agonistis (adrenalini, epinefrini) da steroidis erTdrouli gamoyeneba.
cxrili #2 mwvave laringotraqeitis marTva
msubuqi
binaze marTva
>oraluri
deqsametazoni 0,1-0,3
mg/kg
an
>aerozoli
kortikosteroidiT
an
>kortikosteroidi
parenteralurad
prednizoloni 1-2
mg/kg
saSualo simZimis
gadaudebeli
daxmarebis/Terapiuli
ganyofileba
>oraluri
deqsametazoni 0,3-0,6
mg/kg
an
>aerozoli
kortikosteroidiT
an
>prednizoloni
1-2
mg/kg parenteralurad
>komfortuli pozicia
>minimaluri Careva
>dakvirveba minimum 4
saaTis ganmavlobaSi
Sefaseba yovel
30wT-1 sT-Si
mZime
sicocxlisaTvis
saSiSi
intensiuri Terapiis
gadaudebeli
ganyofileba
daxmarebis
ganyofileba
>oqsigenoTerapia
> L-adrenalinis aerozoli 1 wlamde 2,5
ml+2,5 ml fiziologiuri xsnari
1 wlis zemoT 4-5ml ganuzaveblad
>kortikosteroidiT aerozoli
an
prednizoloni parenteralurad 1-2 mg/kg
>komfortuli pozicia
>minimaluri Careva
>guliscemis sixSiris Sefaseba yovel 5
wuTSi
>sasococxlo niSnebis Sefaseba yovel 15
wuTSi
,fdidsf rfhlbjkjubf
68
steroidebis da adrenalinis kombinirebulma Terapiam intubaciis aucilebloba mZime krupis dros Seamcira 3%-dan TiTqmis 0%-mde.
2,25% racemiuli epinefrini gamoiyeneba doziT 0,250,75ml (0,05ml/kg) ganzavebuli 3 ml. fiziologiur
xsnarSi. gamoyeneba SeiZleba
yovel 20 wuTSi
L-adrenalinis (adrenalinis hidroqloridi) inhalaciuri gziT gamoyenebis SemTxvevaSi efeqti racemiuli
epinefrinis analogiuria. ixmareba 1:1000 ganzavebis xsnaris 0,25-0,5 ml/kg, (4 wlamde
asakSi maqsimaluri dozaa 2,5
ml, 4 wlis zemoT - 5 ml). 1
wlamde asakSi aucilebelia
ganzaveba 2,5 ml. fiziologiur xsnarSi. 1 welze met asakSi ixmareba ganuzaveblad,
ganzaveba efeqts amcirebs.
efeqti grZeldeba 2 saaTi.
mZime SemTxvevaSi ganmeoreba
SesaZlebelia 2 saaTis Semdeg. (adrenalinis hidrotartratis 0,18% xsnari Seesabameba adrenalinis hidroqloridis 0,1 % xsnars).
nebulaizeroTerapia sasurvelia Catardes JangbadiT. adrenaliniT inhalaciis fonze gaumjobesebis miuxedavad dinamiuri meTvalyureoba rekomendebulia 3 saaTis ganmavlobaSi. adrenalinis gamoyeneba ar aris naCvenebi gulis mankebis, epiglotitis da baqteriuli traqe-
itis dros.
oqsigenoTerapiis Cvenebaa
mZime xarisxis krupi da/an saturacia <93%_ze. oqsigenoTerapiis reJimi ise unda
iyos SerCeuli, rom Jangbadis
saturaciis maCvenebeli iyos
> 93 %_ze.
datenianebuli haeri qmnis
meti komfortis SegrZnebas,
radgan aiolebs sekretis gamoyofas, amSvidebs bavSvsac
da mSobelsac, amitom gamarTlebulia
fiziologiuri
xsnariT nebulaizeroTerapia.
Tu datenianebuli haeri ar
moswons pacients, Zaldataneba ar aris gamarTlebuli.
endotraqealuri intubacia naCvenebia im SemTxvevaSi, rodesac Catarebuli Terapia ar iZleva gaumjobesebas. virusuli krupi iSviaTad saWiroebs intubacias.
steroidebis (prednizolonis) gamoyeneba grZeldeba
eqstubaciidan kidev 24 saaTis manZilze.
infuzuri Terapia Cveulebriv saWiro ar aris garda im
SemTxvevebisa, rodesac pacienti ver svams siTxes da aris
dehidrataciis saSiSroeba.
antibiotikebi rutinulad
ar aris rekomendebuli. antibiotikoTerapia gamarTlebulia im SemTxvevaSi, Tu: temperatura metia > 38 gradusze,
aris intoqsikacia, Cirqovani
naxveli, eWvi garTulebebze.
rekomendebulia penicilinis
jgufis antibaqteriuli sa-
Sualebebi an cefalosporinebi.
anti piretuli saSualebebi
gamarTlebulia maRali cxelebis dros (>38,5 gradusze).
monitoringi.
saSualo simZimis kriupis
dros monitorini xorcieldeba 0,5-1 sT-Si erTxel minimum 4 saaTis ganmavlobaSi.
mZime krupis da sicocxlisaTvis saSiSi obstruqciis
dros saWiroa uwyveti monitoringi. adrenalinis gamoyenebidan 5 wuTis Semdeg fasdeba guliscemis sixSire.
monitoringi
xorcieldeba
minimum 15 wuTSi erTxel da
grZeldeba minimum 3 saaTis
ganmavlobaSi.
monitoringis dros fasdeba:
klinikuri simptomebi_cnobiereba, sunTqvisa da guliscemis sixSire, stridoris arseboba, retraqciebi, damxmare kunTebis monawileoba sunTqvaSi.
Jangbadis saturacia
garTulebebi.
riski 15 %. uxSiresi garTulebebia otiti, baqteriuli traqeiti da pnevmonia.
stacionaridan
gaweris
kriteriumebi:
sasunTqi gzebis obstruqciis niSnebis ararseboba
mSoblebis mzaoba. mSoblebis esmiT daavadebis arsi
da saSiSroebis niSnebis gamoxatvis SemTxvevaSi stacionarSi dabrunebis aucilebloba
test-kiTxvari eqimebisaTvis
!@*$8 tbptyvtyuthbc rjvgktmcbc itvs[dtdfib
fh fqbybiyt,f5
f` fjhnbc ltmcnhgjpbwbf9
,` gfhrezsfijhbc ’ublbc ltatmnb9
u` vfh]dtyf gfhrezbc /bgthnhjabf9
8l` abkndbc fhnthbbc cntyjpb9
t` abkndbcvbthb /bgthntypbf8
!@*%8 afkjc nhbflfib fh itlbc5
f` abkndbc fhnthbbc cntyjpb9
,` obyfueksfijhbc ’ublbc ltatmnb9
8u` gfhrezsfijhbc ’ublbc ltatmnb9
l` vfh]dtyf gfhrezbc /bgthnhjabf8
!@*^8 afkjc ntnhflbc itvflutytkb rjvgjytynb fh fhbc5
f` abkndbc fhnthbbc cntyjpb9
,` gfhrezsfijhbc ’ublbc ltatmnb9
u` fjhnbc ltmcnhfgjpbwbf9
8l` vfhw[tyf gfhrezbc /bgthnhjabf8
!@**8 afkjc ntnhflfc fh f[fcbfst,c5
f` b’ekt,bsb vlt,fhtj,f9
,` wbfyjpbc itntdt,b9
u` abpbrehb ufydbsfht,fib xfvjhxtyf9
l` 3ljkbc ]j[bct,hb4 sbst,b9
8t` ecbvgnjvj vbvlbyfhtj,f8
2010 weli
,fdidsf rfhlbjkjubf
!@*(8 /bgjmcbehb ~mjibybcf lf wbfyjpbc` rhbpt,bc gfhjmcbpvbc vrehyfkj,bcfc afkjc ntnhflfc lhjc fh ufvjb.tyt,f5
f`,fdidbc lfodtyf gbhmdt vewtkpt vb,]tybkb
at[t,bs9
,` jmcbutysthfgbf9
u` ghjvtljkbc it.dfyf rfymdti9
l` fyfghbkbybc ~j,pblfybc` lfybidyf ! vu/ru
lqt-qfvtib9
8t` cfuekt ukbrjpblt,bc gfhtynthekb it.dfyf8
!@*)8 uekbc sfylf.jkbkb vfyrt,blfy hjvtkc f[fcbfst,c v.fhb wbfyjpb lf ktnfkj,bc
’fkpt vfqfkb vfxdtyt,tkb cbwjw[kbc gbhdtk
otkc0
f` afkjc ntnhflfc9
8,` vfubcnhfkehb cbc[k’fhqdt,bc nhfycgjpbwbfc9
u` vbnhfkehb cfhmdkbc sfylf.jkbk cntyjpc9
l` t,intbybc fyjvfkbfc8
!@(_8 vfubcnhfkehb cbc[k’fhqdt,bc nhfycgjpbwbbc lhjc lbfuyjcnbrehb vybidytkj,f
fhf fmdc5
f` ghjuhtcbht,fl wbfyjpc cbwjw[kbc gbhdtk rdbhfpt9
,` nfmbgyjtc9
u` uekbc itue,t,bs ervfhbcj,fc9
8l` iebkc9
t` ghjuhtcbht,fl rfhlbjvtufkbfc9
d` gjkbwbntvbfc8
!@(!8 vbnhfkehb cfhmdkbc sfylf.jkbk ervfhbcj,fc fh f[fcbfst,c5
f` gfycbcnjkehb e[tib iebkb9
8,` uekbc gbhdtkb njybc vrdtshb uf’kbtht,f9
u` vtpjlbfcnjkehb fy ghtcbcnjkehb iebkb vodthdfkpt9
l` vt-@ njybc fmwtynbht,f abkndbc fhnthbfpt8
!@(@8 tyljrfhlbfkeh ab,hjtkfcnjpc fh
f[fcbfst,c5
f` lffdflt,bc lfo.t,f evtntcfl ^ sdbc fcfrfvlt9
,` uekbc vfhw[tyfgfhrezjdfyb ervfhbcj,bc
ghjuhtcbht,f9
u` htynutyjuhfabbs rfhlbjvtufkbf7 cathjct,hb uekb9
8l` htynutyjcrjgbbs uekbc uf’kbtht,ekb
fy yjhvfkehb gekcfwbf9
t` v’bvt7 fhfrtsbkcfbvtlj ghjuyjpb8
!@(#8 mdtvjfqybiyekb tktmnhjrflbjuhfabekb vjyfwtvt,blfy vodfdt vbjrfhlbnc fh f[fcbfst,c5
2010 weli
69
f` QRS rjvgktmcbc djknf;bc lfmdtbst,f9
,` P-Q bynthdfkbc uf[fyuh’kbdt,f9
u` T r,bkbc bydthcbf9
l` S-T ctuvtynbc wljvf9
8t` gfsjkjubehb l r,bkb8
!@($8 f,hfvjd-ablkthbc bpjkbht,ek vbjrfhlbnc fh f[fcbfst,c5
f` rfhlbjvtufkbf9
,` jhrfhbfyb fy cfvrfhbfyb cfhmdtkt,bc itlfht,bsb ervfhbcj,f9
u` uekvrthlbc fhtib nrbdbkb7 hjvtkbw uflftwtvf c[dflfc[df vbvfhsekt,bs9
l` tktmnhjrfhlbjuhfvfpt hbnvbc c[dflfc[dfudfhb lfhqdtdf9
8t` vhfdkj,bsb jhv[hbdb byafhmnt,b abkndib9
d` uekbc ervfhbcj,f7 hjvtkbw rfhufl tmdtvlt,fht,f cfuekt ukbrjpblt,bs vrehyfkj,fc8
!@(%8 byatmwbeh tyljrfhlbnc fh f[fcbfst,c5
f` w[tkt,f9
,` pjuflb njmcbrjpb9
u` /tvjhfubekb cbylhjvb9
l` /tgfnjcgktyjvtufkbf9
t` shjv,jtv,jkbehb ufhsekt,t,b9
8d` rheyx[dbc gfhjmcbpvt,b8
!@(^8 byatmwbeh tyljrfhlbnc fh f[fcbfst,c5
f` pjvbthb fy vrdtshfl ufvj[fnekb rfhlbfkubf9
,` vbjrfhlbevbc tv,jkbehb byafhmnb9
u` ghjnjlbfcnjkehb fy cbcnjkehb iebkb7
gfsjkjubehb 6| njyb9
8l` htynutyjcrjgbbs uekbc gekcfwbbc vrdtshb itvwbht,f fy ufmhj,f9
t` tmjrfhlbjuhfabbs vbrhj,ekb dtutnfwbt,b vbnhfkeh cfhmdtkpt8
!@(*8 vihfk ~ab,hjpek` gthbrfhlbnc fh
f[fcbfst,c5
f` x[dktnbsb [fcbfsbc nrbdbkb uekbc fhtib9
,` mjibyb9
u` fecreknfwbbs gthbrfhlbevbc [f[eyb9
8l` rfhlbjvtufkbf9
t` efh.jabsb T r,bkb cnfylfhnek ufy[ht,ib8
!@((8 tmcelfwbeh gthbrfhlbnc fh f[fcbfst,c5
f` cf[bcf lf c[tekbc ptlf yfobkbc itiegt,f9
,` nfmbrfhlbf7 fhbnvbf7 gfhfljmcekb gekcb9
8u` fecreknfwbbs gthbrfhlbevbc [f[eyb9
l` fhnthbekb oytdbc lfmdtbst,f9
t` htynutyjkjubehfl uekbc gekcfwbbc lfmdtbst,f7 rfhlbjvtufkbf9
d` tktmnhjrfhlbjuhfvfpt djknf;bc lfmdtbst,f8
70
!@()8 mdtvjfqybiyekblfy tmcnhfcbcnjkbfcsfy lfrfdibht,bs hf fh fhbc cojhb0
f` ,fdidj,bc fcfrib tmcnhfcbcnjkbbc ufydbsfht,fib ofv.dfyb hjkb tybzt,f tmcnhfrfhlbfkeh7 ytdhjutyek vbptpt,c9
,` eahj [ibhfl tmcnhfcbcnjkbf ufvjdkbylt,f itvs[dtdbs ,fdidbc ufcby]dbcfc vodfdt htcgbhfwbekb byatmwbbc ajypt fy vbc itvltu9
8u` tmcnhfcbcnjkbbc vmjyt ,fdidt,b xfvjhxt,bfy abpbreh ufydbsfht,fib9
l` tmcnhfcbcnjkbf itb’kt,f ufvjdkbyltc
uekbc bctsb jhufyekb lffdflt,t,bc ajypt7
hjujhbwff rfhlbnb7 rfhlbjvbjgfsbf8
!@)_8 gfhrezptlf gfhjmcbpvek nfmbrfhlbfc
eahj [ibhfl bodtdc5
f` uekbc jhufyekb gfsjkjubf9
8,` ytbhjdtutnfnbehb lbc,fkfycb9
u` sbhtjnjmcbrjpb9
l` gytdvjybf9
t` sbhrvtkbc ervfhbcj,f8
!@)!8 gfhrezjdfy gfhjmcbpvek nfmbrfhlbfc
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8f` uekbc jhufyekb gfsjkjubf9
,` ytbhjdtutnfnbehb lbc,fkfycb9
u` abkndbc mhjybrekb lffdflt,f9
l` sbhtjnjmcbrjpb9
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!@)@8 obyfuekjdfy gfhjmcbpveh nfmbrfhlbfc
fh f[fcbfst,c5
f` itntdbc cohfab lfo.t,f lf fctdt cohfab
lfvsfdht,f9
,` uekbcwtvbc cb[ibht !(_-pt vtnb9
8u` itntdbc thsflthsb rkbybrehb ufvjdkbyt,ff nfmbrfhlbf9
l` uf[fyu’kbdt,ekvf itntdfv itb’kt,f ufvjbodbjc uekbc ervfhbcj,f8
,fdidsf rfhlbjkjubf
u` fhnthbekb cbcnjkehb /bgthnjybf lf,fkb lbfcnjkehb oytdbs9
l` vrdtshfl fmwtynbht,ekb 6 njyb9
t` vjhufy-tltvc-cnjmcbc itntdt,b8
!@)%8 evtntcfl hjvtkb vfyrbc lhjc dkbylt,f /bcbc rjybc vfh]dtyf njnbc fhfchekb ,kjrflf0
f` qbf fhnthbekb ~,jnfkjc` cflbyhbc itvs[dtdfib9
,` fjhnbc rjfhmnfwbbc lhjc9
u` abkndbc fhnthbbc cntyjpbc lhjc9
l` obyfueksfijhbc ’ublbc ltatmnbc itvs[dtdfib8
!@)^8 /bcbc rjybc vfhw[tyf njnbc chekb
,kjrflf .dtkfpt vtnfl f[fcbfst,c5
f` vbnhfkehb cfhmdkbc ervfhbcj,fc9
,` gfhrezsfijhbc ’ublbc ltatmnc8
8u` rfhlbjvbjgfsbfc9
l` abkndbc fhnthbbc cntyjpc9
t` fjhnbc cfhmdkt,bc ervfhbcj,fc8
!@)*8 ,tnf-flhtyj,kjrfnjht,c vbtresdyt,f5
f` flhtyfkbyb9
,` bpjkfyblb9
u` yjdjrfbyfvblb9
l` tsvjpbyb9
8t` fyfghbkbyb ~j,pblfyb`8
!@)(8 fyfghbkbybc ~j,pblfybc` lfybidyf ereyfxdtyt,bf5
f` cbyecehb nfmbrfhlbbc lhjc9
,` gfhjmcbpvekb nfmbrfhlbbc lhjc9
u` tmcnhfcbcnjkbbc itvs[dtdfib9
8l` chekb fy yfobkj,hbdb fnhbjdtynhbrekehb ,kjrflbc lhjc9
t` obyfuekt,bc shsjkdbcf lf wbvwbvbc itvs[dtdfib8
!@)#8 mdtvjfqybiyekb rkbybrehb ufvjdkbyt,t,blfy hjvtkbf ufycfresht,bs vybidytkjdfyb
gfhrezjdfyb gfhjmcbpvekb nfmbrfhlbbc lbfuyjcnbrfib0
f` dtutnfnbehb ufvjdkbyt,t,b9
,` mjibyb9
u` urbdbkb uekbc fhtib9
l` gekcbc uf[ibht,f lf uekbcwtvbc uf’kbtht,f9
8t` rbchbc dtyt,bc gekcfwbbc ufbidbfst,f fhnthbek gekcsfy itlfht,bs8
!@))8 ,fdidsf gbhdtkflb fhnthbekb /bgthntypbbc ufydbsfht,bc hbcr-afmnjht,c fh ufytresdyt,f5
f` vtvrdblhtj,bsb lfndbhsdf9
,` cbvcemyt9
u` ythdek-acbmbrehb uflf’f,df9
l` /bgjlbyfvbf9
t` ceahbc vfhbkbc zfh,fl vj[vfht,f9
8d` sbhtjnjmcbrjpb8
!@)$8 chek fnhbjdtynhbrekeh ,kjrflfc
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,` nfmbfhbnvbf9
!#__8 uekbc mhjybrekb ervfhbcj,bc .dtkfpt eahj flhtekb rkbybrehb ufvjdkbyt,ff5
8f` uekbc vj.het,bc cfpqdht,bc ufafhsjt,f9
,` mjibyb9
2010 weli
,fdidsf rfhlbjkjubf
u` nfmbrfhlbf9
l` wbfyjpb9
t` qdb’kbc itue,t,bsb uflblt,f9
d` cdtkb [b[byb abkndt,ib8
!#_!8 gthbathbek dfpjlbkfnfnjht,c vbtresdyt,f5
f` bpjkfyblb9
8,` ybnhjghecblb9
u` rjhlfhjyb9
l` rehfynbkb9
t` teatkbyb8
!#_@8 itvfthst,tkb mcjdbkbc lbaepeh lffdflt,t,c ~rjkfutyjpt,c` fh vbtresdyt,f5
f` htdvfnbpvb9
,` cbcntvehb obstkb vukehf9
u` lthvfnjvbjpbnb9
l` rdfy’jdfyb gthbfhnthbbnb9
t` crkthjlthvbf8
!#_#8 htdvfnbpvbc cflbfuyjcnbrj ’bhbsfl
~]jycbc` rhbnthbevt,c fh ufyresdyt,f5
f` rfhlbnb9
8,` fhshfkubf9
u` mjhtf9
l` rfymdtif htdvfnbekb rdfy’t,b9
t` ,tzlbct,hb thbstvf8
!#_$8 htdvfnbpvbc cflbfuyjcnbrj lfvfnt,bs
rhbnthbevt,c fh ufytresdyt,f5
f` w[tkt,f9
,` fhshfkubf9
8u` nfmbrfhlbf9
l` P-Q bynthdfkbc uf[fyu’kbdt,f9
t` tlc-bc vjvfnt,f9
d` 3C4 htfmnbekb wbkbc ufvjxtyf cbc[kib8
!#_%8 htdvfnbpvbc rkbybreh ufvjdkbyt,t,c
fh f[fcbfst,c5
f` vodfdt lfcfo.bcb9
,` vc[dbkb cf[cht,bc lfpbfyt,f9
u` rfhlbj-dfcrekehb cbylhjvb7 hjvtkbw
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8l` ’dkt,bc ltajhvfwbf lf fyrbkjpt,b9
t` vbjpbnb8
!#_^8 ,fdidj,bc fcfrib htdvjrfhlbnbc ajypt
.dtkfpt [ibhfl dbsfhlt,f5
f` vbjrfhlbjcrkthjpb9
,` fjhnbc cntyjpb9
u` fjhnbc cfhmdkbc ervfhbcj,f9
2010 weli
71
l` vbnhfkehb [dhtkbc cntyjpb9
8t` vbnhfkehb cfhmdkbc ervfhbcj,f8
!#_*8 vodfdt htdvfnbek gjkbfhshbnc fh
f[fcbfst,c5
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,` lfpbfyt,bc 3vahbyfdb4 [fcbfsb9
u` lfpbfyt,ek cf[cfhib vj’hfj,bc vrdtshb
itpqeldf9
l` rfybc cbobskt lf ufw[tkt,f7 gthbfhnbrekehb mcjdbkbc itiegt,f9
t` tmcelfwbf cf[chbc qheib9
8d` vrehyfkj,bc ufhtit fhshbnbc vjdktyt,b
fh mht,f8
!#_(8 htdvfnbpvbc itvs[dtdfib wtynhfkehb
ythdekb cbcntvbc lfpbfyt,f .dtkfpt [ibhfl ufvjdkbylt,f5
8f` vwbht mjhtbs9
,` htdvfnbekb tywtafkbnbs9
u` vtybyubnbs9
l` /bgjsfkfvehb cbylhjvbs8
!#_)8 htdvfnbek vwbht mjhtfc fh f[fcbfst,c5
f` tvjwbehb kf,bkj,f9
,` reyst,bc /bgjnjybf9
u` c[tekbcf lf rbleht,bc eyt,kbt vj’hfj,f9
8l` htdvfnbekb ghjwtcbc vfqfkb fmnbdj,f7
v’bvt vbjrfhlbnb9
t` vjhtwblbdt vbvlbyfhtj,f8
!#!_8 htdvfnbpvbc fmnbehb afpbc ,fpbceh
sthfgbfib fh ufvjb.tyt,f5
f` gtybwbkbyb9
,` fwtnbkcfkbwbkv;fdf ~fcgbhbyb`9
u` ,heatyb9
8l` wbrkjajcafvblb8
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f` vwbht mjhtbc vce,emb ajhvf9
,` uekbc lfpbfyt,bc ufvjdkbyt,bc fhfhct,j,f9
8u` gjkbcthjpbnb9
l` lffdflt,bc leyt fy kfntynehb vbvlbyfhtj,f8
!#!@8 hjujhbf ,bwbkbyghjabkfmnbrbc cmtvf
( okbc ,fdidbcsdbc7 hjvtkvfw uflfbnfyf gbhdtkflb htdvjrfhlbnb xfvj.fkb,t,ekb uekbc vfyrbc ybiyt,bs0
8f` ,bwbkby-% ljpbs ! @__ ___ ths8 $ rdbhfib
ths[tk eo.dtnfl % okbc ufyvfdkj,fib9
,` ,bwbkby-% ljpbs *%_ ___ ths8 @ rdbhfib
ths[tk eo.dtnfl # okbc ufyvfdkj,fib lf ,bwbkby-! ljpbs ^__ ___ ths8 sbsj bytmwbf rdbhfib
72
ths[tk ufpfa[ekbc lf itvjlujvbc sdtt,ib7 @
okbc ufyvfdkj,fib9
u` ,bwbkby-% ljpbs ! @__ ___ ths8 $ rdbhfib
ths[tk # okbc ufyvfdkj,fib9
l` ,bwbkby-# ljpbs ^__ ___ ths8 sbsj bytmwbf rdbhfib ths[tk7 ufpfa[ekbc lf itvjlujvbc sdtt,ib7 @ okbc ufyvfdkj,fib8
!#!#8 bedtybkeh htdvfnjbleh fhshbnc fh
f[fcbfst,c5
f` bynthvbcbekb [fcbfsbc w[tkt,f9
,` lbkbc it,jzbkj,f9
u` htdvfnjblehb rdfy’t,b9
l` # rdbhfpt vtnb [fyu’kbdj,bc fhshbnb9
t` ,ehcbnb fy ntyljcbyjdbnb9
8d` vbjpbnb8
!#!$8 bedtybkehb htdvfnjblekb fhshbnbc
itvs[dtdfib sdfkt,bc v[hbd hjvtkb lfpbfyt,ff
.dtkfpt vtnfl vybidytkjdfyb0
f` rfnfhfmnf9
8,` edtbnb9
u` mjhbjblbnb9
l` hmjdfyfc pjyhbct,hb lbcnhjabf9
t` ,flehf ufhcbc fihtdt,f8
!#!%8 bedtybkeh htdvfnjbleh fhshbnc fh
f[fcbfst,c5
f` tgbabpbehb jcntjgjhjpb9
,` cf[cht,bc yfghfkbc itdbohjdt,f9
8u` jcntjkbpb9
l` gthbfhnbrekehb mcjdbkbc ufcmtkt,f8
!#!^8 bedtybkehb htdvfnjblehb fhshbnbc
lbfuyjcnbrfib .dtkfpt eahj vybidytkjdfybf5
f` tlc-bc vjvfnt,f #% vv cs-ib vtnfl9
,` cbc[kib LE-e]htlt,bc ufvjdktyf9
u` cbc[kbc ihfnib O-fynbcnhtgnjkbpbybc
nbnhbc vjvfnt,f9
l` fynbc[tekt,bc vfqfkb nbnhb yfnbehb
lyv-bc vbvfhs9
t` cbc[kbc ihfnib htdvfnjblehb afmnjhbc
ufvjdkbyt,f8
!#!*8 cbcntvehb obstkb vukehf evtntcfl
edkbylt,fs5
f` crjkfvltkb fcfrbc ,bzt,c9
,` crjkfvltkb fcfrbc ujujyt,c9
8u` ujujyt,c ge,thnek gthbjlib9
l` ,bzt,c ge,thnek gthbjlib8
!#!(8 cbcntvehb obstkb vukehfc lbfuyjcnbreh rhbnthbevt,c fh ufytresdyt,f5
f` cf[tpt thbstvekb7 kfmjdfy-gfgekehb ufvjyf.fhb 3gtgtkfc4 cf[bs9
,fdidsf rfhlbjkjubf
,` htbyjc cbylhjvb9
u` fhshbnb ltajhvfwbbc ufhtit9
l` /tgfnjcgktyjvtufkbf9
t` /tvjkbpehb fytvbf7 ktbrjgtybf7 shjv,jgtybf8
!#!)8 cbcntvehb obstkb vukehfc lbfuyjcnbreh rhbnthbevt,c fh ufytresdyt,f5
f` gktdhbnb7 gthbrfhlbnb9
,` cbc[kib lblb hfjltyj,bs LE-e]htlt,b9
u` lqt-qfvtib #7% u-pt vtnb ghjntbyehbf9
8l` dfhcrdkfdbct,hb ntktfyubtmnfpbt,b rfycf lf kjhojdfy ufhct,pt9
t` ajnjctycb,bkbpfwbf8
!#@_8 ’dfk-reysjdfyb cbcntvbc lfpbfyt,t,blfy cbcntvek obstk vukehfc fh f[fcbfst,c5
f` vbuhfwbekb fhshfkubf lf fhshbnb9
,` egbhfntcfl odhbkb cf[cht,bc lfpbfyt,f9
8u` fyrbkjpb9
l` vbfkubf7 vbjpbnb8
!#@!8 vukehfcvbth ytahbnc fh f[fcbfst,c5
f` ghjntbyehbf9
,` vfrhj/tvfnehbf9
u` fhnthbekb /bgthntypbf9
l` /bgthfpjntvbf9
t` mhjybrekb vbvlbyfhtj,f htwblbdt,bs9
8d` lflt,bsb ghjuyjpb rjhnbrjcnthjblt,bs vrehyfkj,bc ajypt8
!#@@8 cbcntveh obstk vukehfc fh f[fcbfst,c5
f` lblb hfjltyj,bs LE-e]htlt,b cbc[kib9
8,` vfqfkb ktbrjwbnjpb9
u` fynbyerktehb fynbc[tekt,bc vfqfkb nbnhb cbc[kbc ihfnib9
l` /bgthghjntbytvbf7 0-ukj,ekbybc vjvfnt,f8
!#@#8 fhnthbekb oytdbc vfqfkb vfxdtyt,tkb
f[fcbfst,c5
f` htdvfnjblek fhshbnc9
,` lthvfnjvbjpbnc9
u` htdvfnbpvc9
8l` rdfy’jdfy gthbfhnthbbnc9
t` cbcntveh crkthjlthvbfc8
!#@$8 rdfy’jdfyb gthbfhnthbbnbc rfhlbyfkehb rkbybrehb ybifybf5
8f` cbc[k’fhqdsf ufcodhbd kjrfkbpt,ekb
rdfy’t,b ! cv-vlt lbfvtnhbs9
,` sbst,bc vodfdt vihfkb ufyuhtyf9
u` /tgfnjcgktyjvtufkbf9
l` ghjuhtcbht,flb cbufv[lht8
ufuh’tkt,f b[8 itvltu yjvthib
2010 weli