Transcript Ffiltvis arteriis hipertenzia filtvis tuberkuloziT

Ffiltvis arteriis hipertenzia filtvis tuberkuloziT daavadebul pacientebSi
m. mesxi, q. barbaqaZe, m. kikviZe,
r. marSaniSvili, l. miqiaSvili
“samSabaToba”, 15.06.10
Ffiltvis arteriis hipertenzia
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Pph aris hemodinamikuri da paTofiziologiuri mdgomareoba, rac ganisazRvreba rogorc filtvis arteriaSi wnevis momateba
vwy.sv-is 25 mm-ze metad (mosvenebisas), gazomili marjvena parkuWis kaTeterizaciiT.
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filtvis arteriis hipertenzia moicavs daavadebaTa mTel speqtrs, romelTac axasiaTebs filtvis arteriaSi wnevis momateba,
saSualod CasunTqvisas – vwy.sv 25 mm, xolo amosunTqvisas 30 mm-ze metad (pulmonuri venuri wnevis an sxva
respiraciuli an emboliuri daavadebebis ararsebobis SemTxvevaSi).
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fah xasiaTdeba filtvis arteriis sisxlZarRvebis rezistentulobis progresuli matebiT, multifaqtoruli vazokonstriqciiT da
sisxlZarRvebis remodelirebiT, rasac, sabolood mohyveba marjvenaparkuWovani ukmarisoba da sikvdili.
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aranamkurnalevi pacientebis sicocxlis xangrZlivoba diagnostirebis Semdeg saSualod 2,8 weliwadia.
Ffah-is tipuri simptomatika
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qoSini umniSvnelo datvirTvis Semdeg;
tkivili gulmkerdis areSi;
sinkope;
SeSupeba, asciti
pacientebis umetesoba eqims gvian mimarTavs da maT ukve aReniSnebaT fah-is
mZime forma
Ffizikaluri gamokvlevis dros SeiZleba gamovlindes:
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fa sarqvelebis daxurvis maRali toni
marjvenaparkuWovani saZgeri (epigastruli pulsacia);
trikuspiduli regurgitaciis Suili (sistoluri Suili mkerdis Zvlis marcxena kidis qvemo nawilSi);
filtvis arteriis sarqvlis ukmarisobis Suili
(diastoluri Suili mkerdis Zvlis marcxena kidesTan);
sauRle venebis gadavseba (rac centraluri venuri wnevis momatebaze miuTiTebs);
periferiuli SeSupeba;
hepatomegalia;
hepatoiuguluri refluqsi;
asciti;
cianozi;
“dolis joxisebri” TiTebi.
Ffah klasifikacia:
etiologiis mixedviT
• a) pirveladi, romelc ar aris dakavSirebuli arc erT cnobil mizezTan;
• b) meoradi, romelsac ganapirobebs cnobili avadmyofobebi an mdgomareobebi
lokalizaciis mixedviT;
• a) prekapilaruli – ganpirobebulia filtvis arteriebSi sisxlis mimoqcevis mimarT winaaRmdegobis gazrdiT;
• b) postkapilaruli – rasac ukavSireben marcxena gulis mxriv ganxorcielebul zewolas (retrogradul wnevas)
da/an filtvis venebis winaaRmdegobis gazrdas.
Ffah klasifikacia
mimdinareobis mixedviT:
• a) mwvave (mag. mwvave Tromboemboliis an mozrdilebSi sunTqvis moSlis mwvave sindromis dros )
• b) qronikuli – TiTqmis yvela danarCen SemTxvevaSi
histologiuri cvlilebebis mixedviT:
• a) pleqsiformuli dazianeba, rac xasiaTdeba mediis fokusuri gaglejiT, anevrizmuli dilataciiT da sabolood
intimis ujredebis arxebisgan rTuli proliferaciuli warmonaqmnis CamoyalibebiT
• b) Trombozuli dazianeba, rac xasiaTdeba sisxlZarRvTSida TrombozebiT
Ffah funqciuri klasifikacia NYHA mixedviT saSualebas gvaZlevs
davadginoT
a) ramdenadaa SesaZlebeli mocemuli pacientis mkurnaloba;
b) prognozi. aSS janmrTelobis erovnuli institutis mier dadgenilia, rom avadmyofTa sicocxlis saSualo
xangrZliobaa:
I fk – 6 weli
II fk – 3 weli
III fk – 1,8 weli
IV fk – 6 Tve
Ffah funqciuri klasifikacia NYHA mixedviT:
• IFfunqciuri klasi : avadmyofs Civilebis ara aqvs
• II klasi – pacientebi aqtiur yoveldRiur cxovrebas ewevian, magram iRlebian varjiSis an mZime fizikuri
samuSaos Sesrulebis dros;
• III klasi – avadmyofebs uWirT yoveldRiuri saqmianoba; mag. Cacma, banaoba, sakvebis momzadeba;
• IV klasi – avadmyofebs ewyebT qoSini umniSvnelo fizikuri datvirTvis an mosvenebis drosac.
Ffah – is diagnozi
anamnezi:
gansakuTrebuli mniSvneloba eZleva fah-is SesaZlo mizezebis dadgenas (mogzauroba an cxovreba
Sistosomatozis endemur kerebSi, memkvidreoba da sxv.)
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aucilebeli sabaziso gamokvlevebi:
• a) gulmkerdis rentgenografia,
• b) ekg
• g) eqokg
miRebuli Sedegebis gaanalizebis Semdeg gadavdivarT kvlevis Semdgom etapebze
rentgenodiagnostika
klasikur cvlilebebi (pacienti daavadebulia fah-iT) vxedavT:
a) fa-s gamodrekas,
b) perferiul hipovaskularizacias,
g) marjvena parkuWis hipertrofias ise, rom gverdiT proeqciaSi retrosternuli are amovsebulia.
Eekg diagnostika
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Eekg gvaZlevs gasaRebs imis gasagebad Tu rogor icvleba ekg fah momatebasTan erTad :
a) RerZis marjvniv gadaxra;
b)Mmarjvena winagulis gaganiereba;
g) hisis konis marjvena fexis nawilobrivi an sruli blokada:
d) marjvena parkuWis hipertrofia gadatvirTviT.
Eeqokardiografia
Mmarjvena parkuWis kaTeterizacia
mpk aucilebelia:
• marjvena winagulsa da parkuWSi fa wnevis WeSmariti maCveneblebis dasadgenad;
• marjvena parkuWis funqciuri mdgomareobis dasadgenad;
• mwvave vazodilataciuri testis Casatareblad, risTvisac klinikebSi gamoiyeneba xanmokle moqmedebis
vazodilatatori-azotis oqsidi, prostaciklini da adenozini;
• zogadi mdgomareobisa da prognozis Sesafaseblad;
• mkurnalobis taqtikis SesamuSaveblad.
Ffah-is klinikuri klasifikacia
(2003 w. venecia)
pulmonuri hipertenzia da masTan asocirebuli paTologiebi
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1. filtvis arteriuli hipertenzia;
1.1 idiopaTiuri fah
1.2 ojaxuri fah
1.3 sisxlRarRvTa kolagenuri daavadebebi
1.4 filtvis Tandayolili sistemuri Suntebi
1.5 portuli hipertenzia
1.5 aiv-infeqcia/Sidsi
1.6 wamlebi da toqsinebi
1.7. sxva SemTxvevebi (glikogenis Senaxvis paTologiebi, memkvidruli hemoragiuli teleangieqtazia, hemoglobinopaTia,
mieloproliferaciuli daavadebebi)
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2. filtvis venuri hipertenzia;
2.1 marcxena winagulovani an parkuWovani paTologiebi
2.2 marcxenamxrivi sarqvlovani paTologiebi
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3. hipoqsemiasTan dakavSirebuli fah
3.1 filtvis qronikuli obstruqciuli daavadebebi
3.2 intersticiuli daavadebebi
3.3 Ramis apnoe
3.4 did simaRleze xangrZlivi yofna
3.5 alveoluri hipoventilaciis SemTxvevebi
• 4. qronikul Trombo - da/an emboliur darRvevebTan dakavSirebuli fah
4.1 filtvebis proqsimuli arteriebis Tromboemboliuri obstruqcia
4.2 filtvebis distaluri arteriebis Tromboemboliuri onstruqcia
4.3 pulmonuri embolizmi (simsivne, parazitebi, ucxo sxeulebi)
• 5. sxvadasxva: sarkoizodi, histiocitozi, limfangiomatozi, zewola filtvebis sisxlZarRvebze (adenopaTia, simsivne,
fibrozuli mediastiniti)
ph – ganaxlebuli klinikuri klasifikacia
(dana pointi 2008 weli)
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1. fah -1.1 idiopaTiuri
1.2 Tandayolili
1.2.1 BMPR2 - Zvlis morfogenetikuri proteinis meore tipis receptori
1.2.2 ALK1, endoglini (Tandayolili hemoragiuli teleangieqtaziebiT, an mis gareSe)
1.2.3 ucnobi etiologiis
1.3 wamlebiT d toqsinebiT gamowveuli
1.4 asocirebuli fah
1.4.1 SemaerTebeli qsovilis daavadebebi
1.4.2 aiv-infeqcia/Sidsi
1.4.3 portuli hipertenzia
1.4.4 gulis Tandayolili daavadebebi
1.4.5 Sistosomatozi
1.4.6 qronikuli hemolizuri anemia
1.5 persistuli ph axalSobilebSi
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1. * filtvismieri venur - okluziuri daavadebebi da/an filtvis kapilaruli hemangiomatozi
• 2. ph – marcxena gulis daavadebebis dros
2.1 sistoluri disfunqcia
2.2 diastoluri disfunqcia
2.3 sarqvlovani paTologia
• 3. ph – filtvebis daavadebebis da/an hipoqsiis gamo
3.1 filtvebis qronikuli obstruqciuli daavadebebi
3.2 filtvebis intersticiis daavadebebi
3.3 filtvebis sxva obstruqciul-restriqciuli daavadebebi
3.4 Ramis apnoe
3.5 alveolebis hipoventilaciuri moSlilobebi
3.6 simaRlis daavadeba
3.7 ganviTarebis mankebi
• 4. qronikuli TromboemboliT gamowveuli ph
• 5. ph gaurkveveli da/an multiformuli meqanizmebiT gamowveuli
5.1 hematologiuri moSlilobebi – mieloproliferaciuli daavadeba, spleneqtomia
5.2 sistemuri daavadebebi – sarkoidozi, filtvebis langerhansis ujredovani histiocitozi,
limfangioleiomiomatozi, neirofibromatozi, vaskulitebi
5.3 metabolizmis moSlasTan SeWiduli paTologiebi – glikogenis dagrovebis paTologia, goSes
daavadeba, farisebri jirkvlis daavadebebi
5.4 sxva : simsivnuri obstruqciebi, fibrozuli mediastiniti, dializze myofi qronikuli Tirkmlis
ukmarisobiT Sepyrobili pacientebSi ganviTarebuli fah.
Ffah-is mkurnaloba
• prostaciklinTromboqsanebi (epoprostenoli, treprostinili, iloprosti);
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• azotis oqsidi da cikluri guanozinmonofosfatis da endoTelin-receptorebis (1,2) blokeri ( bozestani);
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• fosfodisteraza-5-inhibitori (sildenafili – gamoiyeneba calkec da prostaciklinebTan kombinaciaSic.
• Ggeneraluri sqema: digoqsini, diuretikebi, Jangbadi, antikoagulantebi
• kab
naSromis miznebi:
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fah-is sixSire tuberkuloziT daavadebul pacientebSi;
fah mimdinareobis Taviseburebani;
fah simZimisa da tuberkulozis formebis urTierTkavSiri;
dignostikis SesaZleblobebi;
mkurnalobis SesaZleblobebi da Taviseburebani;
rekomendaciis SemuSaveba
Kkvlevis meTodebi
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Seswavlil iqna 386 avadmyofis istoria;
mamakaci – 309, qali – 77;
asaki : 18-dan 75 wlamde;
gaanalizda ekg, eqokg, rentgenologiuri cvlilebebi, spirometriis monacemebi, Tanmxlebi
daavadebebi da garTulebani, Seswavlil iqna mkurnalobis sqemebi;
• gamoiyo fah-iT garTulebuli SemTxvevebi
• monacemebi damuSavda programiT EPI-INFO
Ddiagnostirebuli fah
sul 386 pacienti
386
134 (34,7 %) SemTxveva - fah
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39 (10,1%) – mZime fah
386 SemTxveva
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63 (16,3%) gardacvlili
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21 (33,3%) gardacvalebis mizezi - fah
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• 1. sul 366
• 2. 140 (36%) rezistentuli tuberkulozis SemTxveva
• 3. 34 MDR-TB
• 4. 21 MDR-TB + mZime fah
ekg cvlilebebi:
• I – RerZis deviaciebi – 309 (80%) SemTxveva;
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II – hisis konis marjvena fexis arasruli blokada – 193 (50%)
III – hisis marjvena fexis sruli blokada – 12 (3,1%);
IV – marjvena parkuWis hipertrofia – 75 (19,4%)
V – marjvena winagulis hipertrofia – 77 (19,8%)
VI – aritmia – 21 (5,7%)
FFfah-is I da II fk-is SemTxvevebSi Catarebuli
mkurnaloba
• Jangbadi – erTeul SemTxvevebSi;
• Kkalciumis arxebis blokerebi – ZiriTadad verapamili xangrZilvad, doziT – 80-160 mg dReRameSi, ramdenime
SemTxvevaSi – ufro mcire 40 – 60 mg an ufro maRali 240 mg sadReRamiso doziT.
• obstruqciis SemTxveva ar gvqonia, ramdenjerme mogvixda dozis Semcireba an preparatis moxsna art. hipotenziis
gamo. Tanmxlebi hipertenziis ramdenime (12) SemTxvevaSi pacientebi Rebulobdnen korinfars (10-20mg), amlodipins
(5-mg)
• sagule glikozidebi (digoqsini – 0,25mg dRiuri doziT, calke an vrapamilTan kombinaciaSi – gamoviyenebT II fk
SemTxvevebSi Tu taqikardias Tan axlda art. hipotenzia.
• Aage inhibitori – kaptoprili, enalaprili an perindoprili
( Sesabaisad 12,5-25, 5-10, 2-4 mg dRiuri doziT)
gamoyenebul iyo 34 avadmyofTan. 2 SemTxvevaSi moixsna xvelis gaZlierebis gamo
• Hheparini – 6 avadmyofTan, varfarini ar gamogviyenebia
Ffah III-IV fk-is SemTxvevebSi gamoyenebul iyo:
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Jangbadi – yvela SemTxvevaSi;
kab – evrapamili mcire dozebSi ( 40-60-80mg) 10 SemTxveva ( korinfari an amlodipini ar gvixmaria)
Sardmdenebi ( furosemidi, kaliumSemnaxveli diuretikebi) – yvela SemTxvevaSi;
Aage inhibitorebi – 4 SemTxvevaSi;
segule glikozidebi + evrapamili minimalur dozebSi – 26 SemTxvevaSi;
Hheparini – 8 SemTxvevaSi. (varfarini ar gamogviyenebia), ramdenime emTxvevaSi vixmareT
antiagregantebi (trentali, fludilati, kurantili).
• 8 SemTxvevaSi gamoyenebuli iyo amiodaroni (Tanmxlebi art. hipotenzia + aritmiebi, romelTa moxsna
ver moxerxda verapamiliT).
• TiTqmis yvela SemTxvevaSi viyenebdiT qsovilovani sunTqvis gamaumjobesebel saSualebebs,
antihipoqsantebs.
Mmkurnalobis Sedegebi:
• I-II fk SemTxvevebSi gaumjobeseba miviReT 15 % - Si;
• III-IV fk dros 39-dan 18 avadmyofi agrZelebs mkurnalobas mdgomareobis umniSvnelo
gaumjobesebiT;
• 21 avadmyofi gardaicvala
Ddaskvna
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fah tuberkuloziT daavadebulebSi sakmaod maRali siSiriT gvxvdeba;
mimdinareobs mZimed da xSirad mTavrdeba sikvdiliT;
mimdinareoba da simZime ganpirobebulia tuberkulozis simZimiT;
SeWidulia Rrma da Seuqcevad rentgenologiur cvlilebebTan;
SeWidulia rezistentul tuberkulozTan;
am jgufis pacientebis gamokvleva da mkurnaloba umZimes problemas qmnis
Pproblemuria pacientebis srulyofili Seswavla:
• teqnikuri da finansuri sirTuleebis gamo;
• pacientTa zogadi mZime mdgomareobis gamo iseTi gamokvlevis Catareba, rogoricaa marjvena
parkuWis kaTeterizacia da mwvave sisxlZarRvovani cda, II da IV fk-is avadmyofebisTvis, albaT
sruliad SeuZlebelia.
problemis mogvarebis gzebi:
• avadmyofTa drouli gamokvleva fah adreuli gamovlenis mizniT;
• aucilebelia eqokardiografia:
a) didi rentgenologiuri cvlilebebis SemTxvevaSi;
b) rezistentuli tuberkulozis dadgenis dros;
g) filtvebis garegani sunTqvis funqciis daqveiTebis SemTxvevaSi;
d) sunTqvis ukmarisobis gamovlenisTanave.
• specializebuli ganyofilebis Seqmna an palatis gamoyoba fah garTulebuli tuberkulozis
samkurnalod ( JangbadiT da medikamentebiT ukeT uzrunvelyofis, gadaudebeli daxmarebis
ukeT organizebis mizniT).