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Ffiltvis arteriis hipertenzia filtvis tuberkuloziT daavadebul pacientebSi

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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Ffiltvis arteriis hipertenzia filtvis tuberkuloziT daavadebul pacientebSi

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  1. FfiltvisarteriishipertenziafiltvistuberkuloziTdaavadebulpacientebSiFfiltvisarteriishipertenziafiltvistuberkuloziTdaavadebulpacientebSi m. mesxi, q. barbaqaZe, m. kikviZe, r. marSaniSvili, l. miqiaSvili “samSabaToba”, 15.06.10

  2. Ffiltvisarteriishipertenzia • PpharishemodinamikuridapaTofiziologiurimdgomareoba, racganisazRvrebarogorcfiltvisarteriaSiwnevismomatebavwy.sv-is 25 mm-zemetad (mosvenebisas), gazomilimarjvenaparkuWiskaTeterizaciiT. • filtvisarteriishipertenziamoicavsdaavadebaTamTelspeqtrs, romelTacaxasiaTebsfiltvisarteriaSiwnevismomateba, saSualodCasunTqvisas – vwy.sv 25 mm, xoloamosunTqvisas 30 mm-zemetad (pulmonurivenuriwnevis an sxvarespiraciuli an emboliuridaavadebebisararsebobisSemTxvevaSi). • fahxasiaTdebafiltvisarteriissisxlZarRvebisrezistentulobisprogresulimatebiT, multifaqtorulivazokonstriqciiTdasisxlZarRvebisremodelirebiT, rasac, saboloodmohyvebamarjvenaparkuWovaniukmarisobadasikvdili. • aranamkurnalevipacientebissicocxlisxangrZlivobadiagnostirebisSemdegsaSualod 2,8 weliwadia.

  3. Ffah-is tipurisimptomatika • qoSini umniSvnelo datvirTvis Semdeg; • tkivili gulmkerdis areSi; • sinkope; • SeSupeba, asciti pacientebis umetesoba eqims gvian mimarTavs da maT ukve aReniSnebaT fah-is mZime forma

  4. FfizikalurigamokvlevisdrosSeiZlebagamovlindes: • fasarqvelebisdaxurvismaRalitoni • marjvenaparkuWovanisaZgeri (epigastrulipulsacia); • trikuspiduliregurgitaciisSuili (sistoluriSuilimkerdisZvlismarcxenakidisqvemonawilSi); • filtvisarteriissarqvlisukmarisobisSuili (diastoluriSuilimkerdisZvlismarcxenakidesTan); • sauRlevenebisgadavseba (raccentralurivenuriwnevismomatebazemiuTiTebs); • periferiuliSeSupeba; • hepatomegalia; • hepatoiugulurirefluqsi; • asciti; • cianozi; • “dolisjoxisebri” TiTebi.

  5. Ffahklasifikacia: etiologiismixedviT • a) pirveladi, romelcararisdakavSirebuli arc erTcnobilmizezTan; • b) meoradi, romelsacganapirobebscnobiliavadmyofobebi an mdgomareobebi lokalizaciismixedviT; • a) prekapilaruli – ganpirobebuliafiltvisarteriebSisisxlismimoqcevismimarTwinaaRmdegobisgazrdiT; • b) postkapilaruli – rasacukavSirebenmarcxenagulismxrivganxorcielebulzewolas (retrogradulwnevas) da/an filtvisvenebiswinaaRmdegobisgazrdas.

  6. Ffahklasifikacia mimdinareobismixedviT: • a) mwvave (mag. mwvaveTromboemboliis an mozrdilebSisunTqvismoSlismwvavesindromisdros ) • b) qronikuli – TiTqmisyveladanarCenSemTxvevaSi histologiuricvlilebebismixedviT: • a) pleqsiformulidazianeba, racxasiaTdebamediisfokusurigaglejiT, anevrizmulidilataciiTdasaboloodintimisujredebisarxebisganrTuliproliferaciuliwarmonaqmnisCamoyalibebiT • b) Trombozulidazianeba, racxasiaTdebasisxlZarRvTSidaTrombozebiT

  7. FfahfunqciuriklasifikaciaNYHAmixedviTsaSualebasgvaZlevsdavadginoTFfahfunqciuriklasifikaciaNYHAmixedviTsaSualebasgvaZlevsdavadginoT 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

  8. Ffahfunqciuriklasifikacia 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.

  9. Ffah – is diagnozi anamnezi: gansakuTrebulimniSvnelobaeZlevafah-is SesaZlomizezebisdadgenas (mogzauroba an cxovrebaSistosomatozisendemurkerebSi, memkvidreobadasxv.) A aucilebelisabazisogamokvlevebi: • a) gulmkerdisrentgenografia, • b) ekg • g) eqokg miRebuliSedegebisgaanalizebisSemdeggadavdivarTkvlevisSemdgometapebze

  10. 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.

  11. Eekgdiagnostika 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.

  12. Eeqokardiografia

  13. MmarjvenaparkuWiskaTeterizacia mpkaucilebelia: • marjvenawinagulsadaparkuWSifawnevisWeSmaritimaCveneblebisdasadgenad; • marjvenaparkuWisfunqciurimdgomareobisdasadgenad; • mwvavevazodilataciuri testis Casatareblad, risTvisacklinikebSigamoiyenebaxanmoklemoqmedebisvazodilatatori-azotisoqsidi, prostaciklinidaadenozini; • zogadimdgomareobisadaprognozisSesafaseblad; • mkurnalobistaqtikisSesamuSaveblad.

  14. Ffah-is klinikuri klasifikacia(2003 w. venecia) pulmonuri hipertenzia da masTan asocirebuli paTologiebi • 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) • 2. filtvis venuri hipertenzia; 2.1 marcxena winagulovani an parkuWovani paTologiebi 2.2 marcxenamxrivi sarqvlovani paTologiebi

  15. 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)

  16. ph – ganaxlebuliklinikuriklasifikacia(danapointi 2008 weli) • 1. fah -1.1 idiopaTiuri 1.2 Tandayolili 1.2.1 BMPR2- Zvlismorfogenetikuriproteinismeoretipisreceptori 1.2.2 ALK1, endoglini(TandayolilihemoragiuliteleangieqtaziebiT, an misgareSe) 1.2.3 ucnobietiologiis 1.3 wamlebiT d toqsinebiTgamowveuli 1.4 asocirebulifah 1.4.1 SemaerTebeliqsovilisdaavadebebi 1.4.2 aiv-infeqcia/Sidsi 1.4.3 portulihipertenzia 1.4.4 gulisTandayolilidaavadebebi 1.4.5 Sistosomatozi 1.4.6 qronikulihemolizuri anemia 1.5 persistuli ph axalSobilebSi • 1. * filtvismierivenur - okluziuridaavadebebida/an filtviskapilarulihemangiomatozi

  17. 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

  18. 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.

  19. Ffah-is mkurnaloba • prostaciklinTromboqsanebi (epoprostenoli, treprostinili, iloprosti); A • azotis oqsidi da cikluri guanozinmonofosfatis da endoTelin-receptorebis (1,2) blokeri ( bozestani); F • fosfodisteraza-5-inhibitori (sildenafili – gamoiyeneba calkec da prostaciklinebTan kombinaciaSic. • Ggeneraluri sqema: digoqsini, diuretikebi, Jangbadi, antikoagulantebi • kab

  20. naSromismiznebi: • fah-is sixSire tuberkuloziT daavadebul pacientebSi; • fah mimdinareobis Taviseburebani; • fah simZimisa da tuberkulozis formebis urTierTkavSiri; • dignostikis SesaZleblobebi; • mkurnalobis SesaZleblobebi da Taviseburebani; • rekomendaciis SemuSaveba

  21. KkvlevismeTodebi • 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

  22. Ddiagnostirebulifah

  23. 1. sul 366 • 2. 140 (36%) rezistentuli tuberkulozis SemTxveva • 3. 34 MDR-TB • 4. 21 MDR-TB + mZime fah

  24. ekgcvlilebebi: • I – RerZis deviaciebi – 309 (80%) SemTxveva; • 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%)

  25. FFfah-is I da II fk-is SemTxvevebSiCatarebulimkurnaloba • Jangbadi– erTeulSemTxvevebSi; • Kkalciumisarxebisblokerebi– ZiriTadadverapamilixangrZilvad, doziT – 80-160 mg dReRameSi, ramdenimeSemTxvevaSi – ufromcire 40 – 60 mg an ufromaRali 240 mg sadReRamisodoziT. • obstruqciisSemTxvevaargvqonia, ramdenjermemogvixdadozisSemcireba an preparatismoxsna art. hipotenziisgamo. Tanmxlebihipertenziisramdenime (12) SemTxvevaSipacientebiRebulobdnenkorinfars(10-20mg), amlodipins (5-mg) • saguleglikozidebi(digoqsini – 0,25mg dRiuridoziT, calke an vrapamilTankombinaciaSi – gamoviyenebT II fkSemTxvevebSiTutaqikardias Tan axlda art. hipotenzia. • Aageinhibitori– kaptoprili, enalaprili an perindoprili ( Sesabaisad 12,5-25, 5-10, 2-4 mg dRiuridoziT) gamoyenebuliyo 34 avadmyofTan. 2 SemTxvevaSimoixsnaxvelisgaZlierebisgamo • Hheparini– 6 avadmyofTan, varfariniargamogviyenebia

  26. FfahIII-IV fk-is SemTxvevebSigamoyenebuliyo: • Jangbadi – yvelaSemTxvevaSi; • kab– evrapamilimciredozebSi ( 40-60-80mg) 10 SemTxveva ( korinfari an amlodipiniargvixmaria) • Sardmdenebi ( furosemidi, kaliumSemnaxvelidiuretikebi) – yvelaSemTxvevaSi; • Aageinhibitorebi – 4 SemTxvevaSi; • seguleglikozidebi + evrapamiliminimalurdozebSi– 26 SemTxvevaSi; • Hheparini– 8 SemTxvevaSi. (varfariniargamogviyenebia), ramdenimeemTxvevaSivixmareTantiagregantebi (trentali, fludilati, kurantili). • 8 SemTxvevaSigamoyenebuliiyoamiodaroni(Tanmxlebi art. hipotenzia+ aritmiebi, romelTamoxsnavermoxerxdaverapamiliT). • TiTqmisyvelaSemTxvevaSiviyenebdiTqsovilovanisunTqvisgamaumjobesebelsaSualebebs, antihipoqsantebs.

  27. MmkurnalobisSedegebi: • I-II fk SemTxvevebSi gaumjobeseba miviReT 15 % - Si; • III-IV fk dros 39-dan 18 avadmyofi agrZelebs mkurnalobas mdgomareobis umniSvnelo gaumjobesebiT; • 21 avadmyofi gardaicvala

  28. Ddaskvna • 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

  29. PproblemuriapacientebissrulyofiliSeswavla: • 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.

  30. problemismogvarebisgzebi: • avadmyofTadrouligamokvlevafahadreuligamovlenismizniT; • aucilebeliaeqokardiografia: a) didirentgenologiuricvlilebebisSemTxvevaSi; b) rezistentulituberkulozisdadgenisdros; g) filtvebisgareganisunTqvisfunqciisdaqveiTebisSemTxvevaSi; d) sunTqvisukmarisobisgamovlenisTanave. • specializebuliganyofilebisSeqmna an palatisgamoyobafahgarTulebulituberkulozissamkurnalod ( JangbadiTdamedikamentebiTukeTuzrunvelyofis, gadaudebelidaxmarebisukeTorganizebismizniT).

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