RU2649572C1 - Method of treatment of patients with acute myocardial infarction with massive thrombosis of the infarct-related coronary artery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to cardiology. Emergency coronary angiography is performed, and when an acute occlusion of the coronary artery is detected and a thrombus length of more than 3 artery diameters is present, antiplatelet therapy comprising itegrylin with heparin or bivalirudin is performed. Then, after 1 day, control angiography is performed and stenting of hemodynamically significant residual stenosis is performed. In special case, when an absence of TIMI-2-3 blood flow in an infarct-related coronary artery is detected on an emergency coronary angiography, a partial destruction of the thrombus by a conductor with an undisclosed coronary balloon is performed, restore the blood flow to TIMI-2-3.

EFFECT: method allows to shorten the term of the patient in the intensive care unit and the general period of hospitalization, to prevent the phenomenon of no-reflow.

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Description

The invention relates to medicine, specifically to cardiology.

According to current clinical guidelines, percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) is the most effective treatment and should be used in as many patients as possible. Moreover, the performance of PCI is recommended regardless of the nature of the thrombus in a heart attack-related coronary artery. As a complication of PCI in AMI, the no-reflow phenomenon often arises. This is a sharp slowdown in the rate of antegrade blood flow or its absence while removing an obvious obstacle to blood flow in a heart attack-related coronary artery, that is, a blockage of the microvasculature and, accordingly, a violation of myocardial perfusion [1]. According to the literature, depending on the diagnostic method for this phenomenon, its frequency can reach 50% when performing primary PCI [2]. This phenomenon can develop with AMI with and without ST elevation. The development of the no-reflow phenomenon dramatically exacerbates the course of myocardial infarction and significantly worsens the prognosis for the patient’s life [3]. One of the main mechanisms for the development of this phenomenon is microembolization of the distal bed during mechanical destruction of a blood clot in a heart-attached coronary artery [4]. The installation of a conventional coronary stent in the presence of massive thrombosis does not eliminate the risk of the development of the no-reflow phenomenon, since soft thrombotic masses protrude into the stent lumen. At the same time, the risk of acute stent occlusion is increased as a result of a combination of initial thrombosis and the subsequent absence of blood flow as a manifestation of the no-reflow phenomenon.

A known method of treating patients with acute myocardial infarction with massive thrombosis of a heart attack-related coronary artery, which consists in the use of platelet receptor inhibitors IIb / IIIa during stenting [5].

This method is the closest to the claimed technical essence and the achieved result and is adopted as a prototype.

The disadvantage of this prototype method is the low efficiency in the prevention of the no-reflow phenomenon.

The objective of the invention is the prevention of the phenomenon of no-reflow with percutaneous coronary intervention.

The problem is solved in that in case of emergency PCI in case of detection of an occlusive intracoronary thrombus, the thrombus is partially destroyed by a conductor with an undisclosed coronary balloon in order to achieve TIMI-2-3 blood flow, and if a massive coronary thrombus is detected (the length of the thrombosis is more than 3 diameters arteries) the intervention stops and continues antithrombotic therapy: double antiplatelet therapy in combination with integrin and heparin or with one bivalirudin. If TIMI-2-3 blood flow is already detected on emergency coronary angiography in the presence of a massive coronary thrombus (the length of the thrombosis is more than 3 diameters of the artery), stenting is also postponed for 1 day. The patient is returned to the intensive care unit and continued similar antithrombotic therapy. After 1 day, patients undergo control angiography and stenting of hemodynamically significant residual stenosis. With complete thrombus lysis and the presence of residual stenosis <50%, stenting is not performed.

What is new is that in the presence of a massive coronary thrombus (the length of the thrombosis is more than 3 diameters of the artery), stenting is postponed for 1 day. The maximum possible antithrombotic therapy - double antiplatelet therapy in combination with integrin and heparin or with one bivalirudin - provides not only thrombus lysis, but prevents coronary artery reocclusion. Performing control angiography and stenting 1 day after the initial PCI, and not later, reduces the time spent by the patient in the intensive care unit and the total hospital stay. Stenting of a myocardial coronary artery in the absence of massive thrombosis provides the prevention of the no-reflow phenomenon. Complete lysis of the thrombus on the background of combined antithrombotic therapy allows us to assess the real size of the atherosclerotic plaque and to refrain from stenting in the case of residual stenosis <50%.

Distinctive features showed in the inventive combination of new properties that are not explicitly derived from the prior art in this field and are not obvious to a specialist.

An identical set of features was not found in the patent and medical literature.

The proposed method can be used in clinical practice for the treatment of patients with acute myocardial infarction with massive thrombosis of a heart attack-associated coronary artery to improve the quality of treatment.

Thus, the proposed method as an invention meets the conditions of patentability: "novelty", "inventive step", "industrial applicability".

Clinical example No. 1

Patient R., 64 years old, was admitted to the emergency cardiology department on 05/18/2016 at 12:59 by transfer from the district hospital with complaints of recurrent anginal pains for 2 days, which were pre-hospitalized with iv administration of morphine. In addition, in the district hospital, the patient has already received a loading dose of aspirin and ticagrelor, as well as carvedilol, lisinopril, rosuvastatin and heparin. In the anamnesis: a hypertension, therapy accepts irregularly and smoking since 16 years. At the time of admission, the state of moderate severity. Light lip cyanosis. The breath is hard, clean. NPV 16 in 1 min. Heart sounds are muffled, rhythmic 73 beats in 1 min. HELL = 143/80 mm Hg The abdomen is soft, b / w. No peripheral edema.

ECG: Sinus rhythm 76 beats per 1 min. Prongs QS III, aVF. ST segment depression up to 2 mm V2-V5.

The analysis revealed an increase in KFK-MV to 82 units / l (N to 25). Diagnosed with ischemic heart disease. Acute repeated myocardial infarction, unspecified localization. Postinfarction cardiosclerosis (of unknown age). The patient is directed to emergency PCI. Under the local infiltration anesthesia, the right femoral artery is punctured. Coronary angiography revealed occlusion of the right coronary artery with retrograde filling, cascading stenosis up to 70% in the anterior interventricular branch, and thrombotic occlusion of the proximal 1/3 envelope of the artery. PCI was performed in the form of mechanical recanalization of the envelope of an artery with an unopened balloon conductor, TIMI-2 blood flow was restored, and the size of the thrombus was determined to be> 3 diameters of the coronary artery. The catheter is removed, the introducer is left. Antithrombotic therapy continued: unfractionated heparin under the control of APTT, integlin, aspirin, ticagrelor. After a day, 05/19/2016 at 11:20 the patient underwent control angiography. Blood flow TIMI-3 without signs of thrombosis with residual stenosis of up to 75% was detected in the envelope of the artery. Direct stenting of this stenosis was performed with a Calypso stent 3.5 × 18 mm, without complications. The catheter and introducer were removed, the site of the femoral artery puncture was occluded by the AngioSeal device. In the future, the disease proceeded without complications and on 01.06.2016 the patient was discharged for outpatient treatment.

Clinical example No. 2

Patient P., 39 years old, was admitted to the Department of Emergency Cardiology, Clinics, Research Institute of Cardiology, Tomsk 05/29/16 as an ambulance with intense chest pain arising from physical exertion. The patient was admitted within 90 minutes from the appearance of complaints. The diagnosis of acute primary lower myocardial infarction was verified with an ST segment elevation from 05/29/16.

On examination, a normosthenic physique, BMI of 30.6 kg / m ² , the skin of normal humidity, no cyanosis. Vesicular breathing, wheezing is not heard, BH 16 per minute. The boundaries of relative cardiac dullness are not changed. Heart sounds are muffled, the rhythm is correct, the heart rate (HR) is 80 beats per 1 min, blood pressure is 160/80 mm Hg, the pulse on the radial arteries is of satisfactory quality, corresponds to heart rate. The abdomen is soft, painless, the liver is not enlarged. Pastosity of the legs.

On admission ECG: ST segment elevation in leads II, III, aVF, V6 up to 2 mm; reciprocal depression of the ST segment (up to 1.5-2.0 mm) in leads aVR, aVL, with V1-V3.

Coronary angiography revealed: the type of blood supply to the left, stenosis of the anterior descending artery in the proximal third to 30%, stenosis of the I diagonal artery 30%, I artery of the obtuse margin 60%, thrombosis of the right coronary artery in the middle third with thrombosis longer than 3 diameters of the artery with blood flow TIMI-3. The drug Angiox® (bivalirudin) was prescribed: a bolus of 0.75 mg / kg, followed by infusion of 1.75 mg / kg / hour, continued therapy with antiplatelet agents (aspirin + ticagrelor).

Over the next day, the patient was observed in the intensive care unit, the condition was stable, anginal pain did not recur. 05/30/16 the patient was re-taken to the angio block: residual stenosis of up to 75% of the right coronary artery was revealed, PCI was performed: a stent with antiproliferative coating “Resolute” 3.5 × 30 mm was installed, without complications.

The subsequent inpatient period was calm, the patient was discharged for outpatient observation with standard recommendations for therapy.

Proposed as an invention, the method was tested on 12 patients. In all patients, after daily antithrombotic therapy, the volumes of the intracoronary thrombus decreased, coronary artery reocclusion was not observed, and when performing stenting of residual stenosis, the no-reflow phenomenon was absent. Thus, this method allows to prevent the development of the no-reflow phenomenon in patients with massive thrombosis of a heart attack-associated coronary artery during PCI.

Literature

1. Abbo K.M., Dooris M., Glasier S. et al. Features and outcome of no-reflow after percutaneous coronary intervention. AJC. April 15, 1995 V. 75, Issue 12, P. 778-782.

2. Niccoli G., Burzotta F., Galiuto L. et al. Myocardial No-Reflow in Humans. J Am Coll Cardiol. 2009; 54: P. 281-292.

3. Ito H. No-reflow phenomenon and prognosis in patients with acute myocardial infarction. Nature Clinical Practice Cardiovascular Medicine 2006; 3: 499-506.

4. Rezkalla S.H., Kloner R.A. No-Reflow Phenomenon. Circulation. 2002; 105: 656-662.

5. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal. 2012. No. 33. P. 2569-2619.

Claims (2)

1. A method for the treatment of patients with acute myocardial infarction with massive thrombosis of a heart attack-associated coronary artery, including antithrombotic therapy and percutaneous coronary intervention (PCI), characterized in that emergency coronary angiography is performed and if acute coronary artery occlusion and a thrombus length of more than 3 are detected arterial diameters carry out antiplatelet therapy, including itegrilin with heparin or bivalirudin, then after 1 day control angiography is performed and a stent is performed hemodynamically significant residual stenosis. 2. The method according to p. 1, characterized in that if emergency blood flow TIMI-2-3 is detected on an emergency coronary angiography, the blood clot is partially destroyed by a conductor with an undisclosed coronary balloon, blood flow is restored to TIMI-2-3.