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1
arteriuli hipertenzia
klinikuri praqtikis erovnuli rekomendacia
(gaidlaini)
2
klinikuri praqtikis erovnuli rekomendacia (gaidlaini)
`arteriuli hipertenzia~ miRebulia klinikuri praqtikis
erovnuli rekomendaciebis (gaidlainebi) da daavadebaTa
marTvis saxelmwifo standartebis (protokolebi) SemuSavebis,
Sefasebis da danergvis erovnuli sabWos 2006 wlis 21
noembris #2 sxdomaze da damtkicebulia saqarTvelos Sromis,
janmrTelobisa da socialuri dacvis ministris 2007 wlis 27
agvistos # 265/o brZanebiT.
3
arteriuli hipertenzia
arteriuli hipertenzia warmoadgens gulis, Tavis tvinis da Tirkmelebis
sisxlZarRvovani daavadebebis ganviTarebis umTavres risk-faqtors orive
sqesis, sxvadasxva asakis da rasobrivi jgufebisaTvis. swored es
daavadebebi gvevlinebian sikvdilis ZiriTad mizezad saerTo
sikvdilobis struqturaSi. amave dros, STambeWdavia arteriuli
hipertenziis gavrcelebis masStabi msoflioSi. igi aris udidesi
arainfeqciuri pandemia kacobriobis istoriaSi. farTomasStabiani
multicentruli kvlevebiT dadasturebulia, rom arteriuli
hipertenziis adeqvaturi kontroli (arteriuli wnevis samizne donis
miRweva) amcirebs populaciur doneze Tavis tvinis insultisa da gulis
koronaruli daavadebis ganviTarebas da am daavadebaTa mizeziT
ganpirobebuli sikvdilobis risks. hipertenziis efeqturi kontroli
uzrunvelyofs sicocxlis xangrZlivobis realur zrdas dasavleT
evropis qveynebsa da aSS-Si. kontrolis es sistema warmoadgens
aRniSnuli miznebis misaRwevad yvelaze ufro xarj-efeqturi
mkurnalobis strategias.
saqarTveloSi arteriuli hipertenziis problemis Seswavlas gaaCnia
xangrZlivi istoria, mdidari tradicia da gamocdileba. gasuli saukunis
40-ian wlebSi akad. mixeil winamZRvriSvilis mier SemuSavda
“hipertoniuli daavadebis” klasifikacia. aRniSnuli klasifikacia
gulisxmobda daavadebis mimdinareobis variantebis (prehipertonia da
reversibeluri) analizs da e.w. “SeuRlebuli” anu Tanmxlebi
daavadebebis klinikur mniSvnelobas. sayuradReboa, rom winamZRvriSvilma
SemoiRo termini “prehipertonia” da daavadebis es faruli premorbiduli
mdgomareoba asaxa klasifikaciur struqturaSi. aRniSnuli, ukve maSin
iZleoda daavadebis riskis gansazRvris SesaZleblobas da mkurnalobis
Cvenebebis gamomuSavebas. prehipertonia (prehipertenzia), romelic 50-ian
wlebSi didi debatebisa da kritikis sagani gaxldaT, dRes
gaTvaliswinebulia aSS-is JNC-7-is klasifikaciis struqturaSi. iseve,
rogorc JNC-7-Si, mixeil winamZRvriSvilic 60 wlis win amtkicebda am
mdgomareobis mqone pacientebis xangrZlivi meTvalyureobis
aucileblobas. dRes ukve cnobilia, rom dawyebuli 115/75 mm.vwy.sv.-dan
arteriuli wnevis mateba yoveli 20/10 mm.vwy.sv.-iT, aormagebs
kardiovaskuluri garTulebebis ganviTarebis risks. ZiriTadi principi,
romliTac unda ixelmZRvanelos praqtikosma eqimma, mdgomareobs
momatebuli arteriuli wnevis daqveiTebaSi optimalur samizne donemde.
swored am strategiam Zireulad unda gamoasworos hipertenziis
kontrolTan dakavSirebuli situacia.
gansakuTrebul mniSvnelobas iZens eqimsa da pacients Soris
partnioruli urTierTobis damyarebis aucilebloba, igi ar unda darCes
mxolod mcdelobad. idealuri daniSnulebebic ki, pacientebis mier
Sesruldeba mxolod im SemTxvevaSi, Tu eqimi SeZlebs aamaRlos
pacientis motivacia mkurnalobisadmi. es erT-erTi mTavari faqtori
gaxlavT hipertenziis efeqturi kontrolisa.
winamdebare gaidlaini warmoadgens hipertenziis sferoSi dReisaTvis
yvelaze avtoritetuli saerTaSoriso organizaciebis rekomendaciebis
4
adaptirebul versias (JNC 7, ESH-ESC-2003 da ESH updates). man mniSvnelovnad
unda Seuwyos xeli arteriuli hipertenziis kontrolis sistemis Seqmnas
da gaaumjobesos pirveladi jandacvis rgolebis, saswrafo daxmarebis
samsaxuris, sadazRvevo medicinis da Sromis eqspertizis samedicino
momsaxurebis xarisxi.
profesori beJan winamZRvriSvili
akad. m. winamZRvriSvilis sax.
kardiologiis institutis direqtori
saqarTvelos hipertenziis Semswavleli
sazogadoebis prezidenti
5
daavadebis definicia, sinonimebi, terminologia
arteriul hipertenziad iTvleba sistoluri wneva 140 mm.vwy.sv. da meti an
diastoluri wneva 90 mm.vwy.sv. da meti.
arteriuli hipertenziis SemTxvevaTa umetesobaSi (90-95%-ze meti) ver
vlindeba hipertenziis gamomwvevi mizezi da amas pirveladi, esenciuri an
idiopaTiuri hipertenzia ewodeba. adre CvenSi mas hipertonul daavadebas
uwodebdnen. rodesac arteriuli hipertenzia viTardeba raime specifiuri
gamomwvevi mizezis Sedegad, mas meoradi anu simptomuri hipertenzia
ewodeba.
epidemiologia
arteriuli hipertenzia warmoadgens yvelaze farTod gavrcelebul gul-
sisxlZarRvTa daavadebas da amave dros, igi sxva gul-sisxlZarRvTa
daavadebebis ganviTarebis umTavresi risk-faqtoria. arteriul wnevasa da
kardiovaskuluri SemTxvevebis ganviTarebis risks Soris damokidebuleba
aris mkafio, uwyveti da sxva risk-faqtorebisagan damoukidebeli.
ekonomikurad ganviTarebuli qveynebis mozrdil mosaxleobaSi misi
gamovlenis sixSire daaxloebiT 20%-ia. hipertenzia aris yvelaze xSiri
pirveladi diagnozi msoflios bevri qveynisaTvis. janmrTelobis
msoflio organizaciis SefasebiT (WHO 2002), mTeli msoflios masStabiT
arteriuli hipertenzia daaxloebiT 1 miliard adamians aReniSneba da
yovelwliurad masTan dakavSirebulia daaxloebiT 7 milion sikvdilze
meti [252].
saqarTveloSi ukanaskneli 20 wlis ganmavlobaSi Catarebuli
epidemiologiuri kvlevebis monacemebi adastureben, rom arteriuli
hipertenzia warmoadgens yvelaze metad gavrcelebul daavadebas qarTul
populaciaSi.
akad. m. winamZRvriSvilis sax. kardiologiis instituts gaaCnia
unikaluri SesaZlebloba arteriuli hipertenziis gavrcelebis 60
wliani dinamikis Sefasebisa mozrdili mosaxleobis (18 wlis zemoT)
reprezentatul jgufebSi (1950w. araorganizebuli populacia 7,2%,
organizebuli populacia 10,5%; 1980w. 16,6% da 25,1%; 1999w. 37,2% da 32,7%;
2005 w. 43,2% da 45,7%).
jandacvis msoflio organizaciis 2005w. angariSSi (The European Health Raport. 2005), 2002 wlis monacemebiT, saqarTveloSi arteriuli
hipertenziis xvedriTi wili sikvdilobis mizezTa Soris aris 48,8%.
qveynis oficialuri statistikuri monacemebiT, hipertonuli daavadebis
gavrcelebis dinamika 1998-2004 ww. negatiuria (daavadebianoba Sesabamisad
1628,8 da 3108,2; avadoba 446,3 – 801,9; janmrTelobis dacva 2003, 2004).
1996w. hipertenziis respublikuri centrisa da aSS daavadebaTa
kontrolis centris erToblivi kvleviT aWaraSi (xelmZRvaneli b.
winamZRvriSvili da s. miuziki) arteriuli hipertenziis gavrceleba
mozrdil mosaxleobaSi (18 wlis zemoT) – baTumi, qeda, xulo – 26,9%.
2001 w. 5 wliani dinamika igive kontigentSi (kardiologiis institutis
profilaqtikuri kardiologiis ganyofileba) – 49,8%. (epidemiologiuri
biuletini 1996w. noember-dekemberi; 2004).
6
arteriuli hipertenziis gavrcelebis Seswavlis mizniT, viskonsinis
samedicino kolejis (aSS), miluokis janmrTelobis treiningis
saerTaSoriso centrisa (aSS) da eqsperimentuli da klinikuri Terapiis
samecniero-kvleviTi institutis (xelmZRvaneli akad. n. yifSiZe) mier 1996
wels Catarebuli erToblivi kvleviT qalaqis populaciaSi (q. Tbilisis
didubis raioni), arteriuli hipertenziis gavrceleba 40-70w. asakis
individebSi 59,9% (qalebi 59,1% da mamakacebi 62,0%) da soflis
populaciaSi (duSeTis raioni) 40,5% (qalebi 42,0% da mamakacebi 37,5%)
iyo.
The Republic of Georgia High Blood Pressure Control Program. Ethnicity and Disease, 2006; 16[suppl 2]:S2-62–66). Barbakadze V., Koblianidze L., Kipshidze N., Grim CE, Grim CM, Tavill F.
saqarTveloSi amJamad hipertenziis gavrcelebis sxva monacemebi ar
arsebobs.
bolo wlebSi saerTaSoriso standartebiT Catarebuli kvlevebis
safuZvelze SesaZloa vivaraudoT, rom qveynis masStabiT arteriuli
hipertenzia aReniSneba 600 000 pirze mets.
etiopaTogenezi
esenciuri hipertenziis etiopaTogenezi multifaqtorulia da mas
safuZvlad udevs arteriuli wnevis regulaciis darRveva, romelSic
CarTulia erTmaneTTan dakavSirebuli neirohumoruli da ujredul-
molekuluri faqtorebi. fiziologiurad arteriuli wnevis sidides
ganapirobebs ori faqtori, gulis wuTmoculoba da sisxlZarRvTa
periferiuli winaaRmdegoba (upiratesad rezistiul doneze). sqema #1-
Si mocemulia im darRvevaTa erToblioba, romlebic gavlenas axdens am
ZiriTad komponentebze da erTmaneTTan urTierTqmedebiT iwvevs
hipertenzias. calkeuli pacientebisaTvis am darRvevaTa tipi da simZime
gansxvavebulia.
7
ნატრიუმის ჭარბი მიღება
სიმსუქნე ნეფრონების რიცხვის შემცირება
სტრესი გენეტიკური ალტერაცია
ენდოთელური ფაქტორები
ნატრიუმის შეკავება თირკმელებში
ფილტრაციის ზედაპირის შემცირება
სიმპათიკური სისტემის ჰიპერტონუსი
რენინ-ანგიოტენზინის სიჭარბე
უჯრედის მემბრანული ცვლილებები
ჰიპერ-ინსულინემია
სტრუქტურული ჰიპერტროფია
ფუნქციური კონსტრიქცია
კუმშვადობა პრედატვირთვა
ვენო-კონსტრიქცია
სითხის მოცულობა
ავტორეგულაცია
ჰიპერტენზია = გულის გაზრდილი წუთმოცულობა და/ან გაზრდილი პერიფერიული წინააღმდეგობა
sqema #1
8
klinikuri simptomatika
uxSiresad gaurTulebeli hipertenzia mimdinareobs asimptomurad.
pacients ara aqvs gaTviTcnobierebuli mosalodneli kardiovaskuluri
riskis Sesaxeb. simptomebi romlebic Tan axlavs hipertenzias: Tavis
tkivili, xmauri yurebSi, Tavbrusxveva, saerTo sisuste, gulis friali.
magram zemoT aRniSnuli simptomebi SeiZleba Segvxdes igive sixSiriT
normotenziul populaciaSic. ufro metic, bevri simptomi, romelic
Tan axlavs hipertenzias Tavis warmoSobiT aris fsiqogenuri. Tavis
tkivilic ki, romelic didi xnis ganmavlobaSi ganixileboda rogorc
hipertenziis yvelaze xSiri simptomi, sust korelaciaSia arteriuli
wnevis sididesTan.
arteriuli wnevis klasifikacia
ganixileba arteriuli wnevis 3 kategoria:
1. normuli;
2. prehipertenzia:
a. I stadia
b. II stadia
3. hipertenzia.
antihipertenziuli mkurnalobis daniSvnis sabaziso kriteriumad
ganixileba wnevis matebis xarisxi da mowodebulia yvela hipertenziuli
piris (I da II stadiis) mkurnaloba.
unda aRiniSnos, rom prehipertenzia ar aris daavadebis kategoria. is
moicavs im individebs, romlebic arian arteriuli hipertenziis
ganviTarebis maRali riskis qveS da Sesabamisad saWiroeben cxovrebis
wesis Secvlas. metic, Tu prehipertenziis mqone pirebs aqvT diabeti an
Tirkmlis qronikuli daavadebebi da cxovrebis wesis warmatebuli
Secvla ver uzrunvelyofs wnevis 130/80 mm.vwy.sv.-ze qvemoT daqveiTebas,
unda Catardes medikamenturi mkurnaloba. wnevis am kategoriis mqone
pirebSi cxovrebis jansaRi wesis adreul danergvas SeuZlia wnevis
Semcireba, asakTan erTad wnevis hipertenziul donemde progresirebis
Seneleba an hipertenziis Tavidan acileba.
arteriuli wnevis klasifikacia 18 wlis da ufrosi asakis mozrdilebisaTvis
arteriuli wnevis kategoria
sistoluri wneva
(mm.vwy.sv.) da/an
diastoluri wneva
(mm.vwy.sv.)
normaluri < 120 da < 80 prehipertenzia 120-139 an 80-89
hipertenzia:
hipertenziis I stadia 140-159 an 90-99 hipertenziis II stadia ≥ 160 an ≥ 100
9
** damyarebulia ofisSi ori an meti vizitis dros dadasturebul wnevis maRal
cifrebze. TiTo vizitis dros mxedvelobaSi miiReba ori an meti gazomvis saSualo.
*** rodesac sistoluri da diastoluri wnevebi sxvadasxva kategoriebSi xvdeba,
mxedvelobaSi miiReba ufro maRali kategoria (mag, Tu arteriuli wnevis cifrebi
aris 162/94 mm.vwy.sv., am SemTxvevaSi piri miekuTvneba hipertenziis II stadias).
**** mdgomareoba, roca sistoluri wneva 140 mm.vwy.sv. da metia, xolo diastoluri
wneva naklebia 90 mm.vwy.sv.-ze, iTvleba izolirebul sistolur hipertenziad.
izolirebuli sistoluri hipertenziis dros stadiis mikuTvneba xdeba sistoluri
wnevis donis mixedviT. mag, arteriuli wnevis cifrebis 170/82 mm.vwy.sv. SemTxvevaSi,
piri miekuTvneba hipertenziis II stadias.
meoradi hipertenziis mizezebi (identificirebadi mizezebi)
hipertenziis gamomwvevi mizezebis dasadgenad SesaZloa saWiro gaxdes
damatebiTi sadiagnostiko RonisZiebebi. im SemTxvevebSi rodesac:
1. pacientis asaki, fizikaluri gamokvleva, hipertenziis simZime da/an
sawyisi laboratoriuli monacemebi migvaniSnebs hipertenziis
mizezebze;
2. arteriuli hipertenzia cudad eqvemdebareba medikamentur
mkurnalobas;
3. kargad kontrolirebuli hipertenziis SemTxvevaSi arteriuli wneva
gaurkveveli mizeziT izrdeba;
4. hipertenzia uecrad iwyeba.
meoradi hipertenziis sadiagnostiko testebi
diagnozi Ddiagnostikuri testebi Tirkmlis qronikuli daavadeba GFR-is Sefaseba aortis koarqtacia CT angiografia kuSingis sindromi da sxva mdgomareobebiT
gamowveuli glukokortikoidebis siWarbe,
qronikuli steroiduli Terapia
anamnezi, deqsametazonis supresiis testi
medikamenturi anamnezi, medikamenturi skriningi
feoqromocitoma 24sT-ian SardSi metanefrinisa da
normetanefrinis gansazRvra
pirveladi aldosteronizmi da sxva
mizeziT gamowveuli
mineralokortikoidebis siWarbe
24sT-ian SardSi aldosteronis donis an
sxva mineralokortikoidebis donis
gansazRvra.
renovaskularuli hipertenzia doplereqokardiografia,
magnitorezonansuli angiografia
Zilis apnea Zilis dros saturaciis gansazRvra
Tiroiduli/paraTiroiduli daavadeba TSH da Sratis PTH-is gansazRvra GFR-glomerularuli filtraciis siCqare
CT- kompiuteruli tomografia
TSH-Tiroidmastimulirebeli hormoni PTH-paraTiroiduli hormoni
10
feoqromocitoma unda vivaraudoT im pacientebSi, visac aReniSneba
labiluri an paroqsizmuli saxis hipertenzia, rasac Tan axlavs Tavis
tkivili, guliscemis SegrZneba, sifermkrTale, oflianoba.
aortis koarqtacias axasiaTebs arteriuli wnevis Semcireba qvemo
kidurebze, dagvianebuli pulsacia barZayis arteriaze.
simsuqne torsis midamoSi, tolerantoba glukozis mimarT da striebi
miuTiTebs kuSingis sindromze.
laboratoriuli kvlevebidan sayuradReboa araprovocirebadi
hipokalemia (pirveladi aldosteronizmi), hiperkalcemia
(hiperparaTireoidizmi), maRali kreatinini an Sardis Secvlili analizi
(Tirkmlis parenqimuli dazianeba).
Tirkmlis parenqimuli dazianeba, asocirebuli hipertenziasTan
umeteswilad gamowveulia, qronikuli glomerulonefritiT,
polikistoziT da hipertenziuli nefroskleroziT. es mizezebi SeiZleba
dadgindes klinikuri da damatebiTi laboratoriuli kvlevebiT.
magaliTad: Tirkmlis eqoskopiuri kvleviT SesaZlebelia polikistozis
dadgena. Tirkmlis arteriebis stenozi da Sesabamisad renovaskularuli
hipertenzia unda vivaraudoT Semdeg SemTxvevebSi:
1. hipertenziis gamovlena 30 wlis asakamde, gansakuTrebiT im
SemTxvevebSi, rodesac pacients ar aReniSneba datvirTuli ojaxuri
anamnezi an mniSvnelovani hipertenzia viTardeba 55 wlis Semdgom;
2. abdominuri Suili;
3. mzardi hipertenzia;
4. warsulSi kontrolirebuli hipertenzia, magram amJamad rezistentuli
hipertenzia;
5. ganmeorebiTi filtvebis SeSupeba;
6. gaurkveveli etiologiis Tirkmlis ukmarisoba, gansakuTrebiT im
SemTxvevaSi Tu ar aris proteinuria an SardSi ar aRiniSneba
paTologiuri naleqi;
7. Tirkmlis mwvave ukmarisoba, ganviTarebuli agf inhibitorebiT da a.r. blokerebiT mkurnalobiT, Tirkmlis arteriis ormxrivi stenozis an
hipovolemiis pirobebSi.
pacientebSi, romelTac SesaZlebelia hqondeT, renovaskularuli genezis
hipertenzia, arainvaziuri gamokvlevis meTodebi moicavs agf
inhibitorebiT gaZlierebul Tirkmlis skanirebas, doplerul kvlevas,
magnitur-rezonansul angiografias.
miuxedavad imisa rom Tirkmlis arteriebis angiografia aRiarebulia,
rogorc oqros standarti Tirkmlis arteriebis anatomiis
SeswavlisaTvis, diagnostikisaTvis mainc ar aris rekomendebuli mxolod
misi gamoyeneba, procedurasTan asocirebuli didi riskis gamo.
intervenciis dros angiografia unda ganxorcieldes kontrastis
SezRuduli raodenobiT, raTa dadgindes stenozis arseboba da
Tirkmlis arteriebis anatomia.
11
mkacri Cvenebebi
hipertenzia SesaZlebelia sxvadasxva klinikur mdgomareobebTan iyos
asocirebuli. aseTi mdgomareobebia: gulis ukmarisoba, Tirkmlis
qronikuli ukmarisoba, ganmeorebiTi insultebi, gulis iSemiuri
daavadeba, diabeti. aseT SemTxvevebSi mkurnaloba warmatebuli unda iyos
orive mimarTulebiT: rogorc sisxlis wnevis daqveiTebis, aseve
asocirebuli klinikuri mdgomareobis mimarTulebiT.
Progress (perindopriliT dacva ganmeorebiTi insultebisagan) kvlevis
mixedviT ganmeorebiTi insultis sixSire Semcirebul iqna Tiazidis
damatebiT agf inhibitorebiT bazalur Terapiaze.
arteriuli wnevis klasifikacia da menejmenti mozrdilebSi
arteriuli
wnevis (BP) klasifikacia
sistoluri
arteriuli
wneva (SBP) (mm/vwy.sv)
diastoluri
arteriuli
wneva (DBP) (mm/vwy/sv)
cxovrebis
stilis
modifikacia
sawyisi medikamenturi
mkurnaloba
mkacri
Cvenebis
gareSe
mkacri
CvenebiT
Nnormaluri <120 D<80 mizanSewo-
nilia
ar saWiroebs
antihipertenz
iul
mkurnalobas
Aar saWiroebs
prehipertenzia 120—139 Aan 80-89 diax
saWiroebs
mkurnalo
bas
hipertenziis I
stadia
140-159
A
an 90-99
diax umetesad
Tiaziduri
diuretikebi
an agfi, arb, bb, kab Aan maTi
kombinaciaN
medikamentebi
mkacri
Cvenebebisas
sxva
antihipertenz
iuli wamlebi:
(diuretikebi,
agfi, arb, bb,
kab.
saWiroebis
SemTxvevaSi)
hipertenziis II
stadia
≥160 ≥100 diax ori
medikamentis
kombinacia
(Tiaziduri
diuretiki da
agfi, arb, bb,
kab.)
12
cxrili #1
sxvadasxva jgufis medikamentebis gamoyeneba mkacri Cvenebebisas
mkacri
Cvenebebi
rekomendebuli medikamentebi klinikuri kvlevebi
diuretiki
bb
agfi
arb
kab
aldos.antag
gulis
ukmarisoba
+
+
+
+
+
ACC/AHA gulis
ukmarisobis gaidlaini
miokardiumis
infarqtis
Semdgomi
periodi
+
+
+
ACC/AHA – Post MI gaidlaini
koronaruli
daavadebis
arsebobis
maRali riski
+
+
+
+
ALLHAT,HOPE, ANBP, LIFE CONVINCE
diabeti
+
+
+
+
+
NKF-ADA gaidlaini
Tirkmlis
qronikuli
daavadeba
+
+
NFK gaidlaini,
RENAAL,IDNT,REIN,AASK
ganmeorebiTi
insultis
prevencia
+
+
PPROGRESS
arteriuli wnevis gazomva
arteriuli wnevis gazomvis oqros standarts warmoadgens kaTeteris
saSualebiT pirdapiri intraarteriuli gazomva, romelic klinikur
praqtikaSi iSviaTad gamoiyeneba. arteriuli wnevis kontrolis ZiriTad
meTods wnevis gazomvis arapirdapiri, auskultaciuri meTodi
warmoadgens. igi advilad Sesrulebadobis gamo farTod gamoiyeneba
rogorc samedicino personalis, aseve mosaxleobis mier.
arteriuli wnevis gazomva medicinaSi yvelaze xSirad gamoyenebuli
proceduraa. sakmarisia aRiniSnos, rom eqims Tavisi samedicino karieris
manZilze ramdenime aTasjer mouwevs arteriuli wnevis gazomva da amis
safuZvelze gadawyvetilebis miReba. wnevis mxolod zusti da sarwmuno
gazomva warmoadgens arteriuli wnevis saTanado kontrolis safuZvels.
pacients da mTlianad sazogadoebas mxolod maSin SeuZlia miiRos
sargebeli da mniSvnelovnad Semcirdes arteriuli hipertenziiT
gamowveuli avadoba da sikvdiloba, Tu arteriuli wnevis gazomva
klinikur praqtikaSi maqsimaluri sizustiT moxdeba.
arteriuli wnevis gazomva auskultaciuri meTodiT unda moxdes
teqnikurad gamarTuli instrumentiT, sul cota orjer TiTo vizitisas.
pacienti gazomvamde aranakleb 5 wT-is ganmavlobaSi unda iyos
13
mosvenebul mdgomareobaSi. sistoluri arteriuli wneva Seesabameba
korotkovis I fazas da ganisazRvreba rogorc ori regularuli
dartymidan pirveli. diastolur arteriul wnevas Seesabameba
korotkovis V fazis dasawyisi, roca aRiniSneba tonebis sruli gaqroba.
arteriuli wnevis dafiqsireba xdeba 2 mm.vwy.sv. intervalebiT da
Canaweric Sesabamisi keTdeba. eqimma pacients sityvierad unda acnobos da
dauweros gazomili wnevis cifrebi da samizne wneva.
periodulad naCvenebia pacientis wnevis gazomva fexze mdgom
mdgomareobaSi, gansakuTrebiT im SemTxvevebSi, roca pacients aqvs
orTostatikuri hipotenziis ganviTarebis riski (xanSiSesuli pirebi,
axali medikamentis daniSvna an wamlis dozis cvlilebebi, pacientis mier
fexze adgomisas Sesabamisi simptomebis aRniSvna).
dawvrilebiT arteriuli wnevis sworad gazomvis Sesaxeb ixileT protokolSi.
arteriuli wnevis ambulatoriuli monitoringi
arteriuli wnevis ambulatoriuli monitoringi (ABPM) gvaZlevs
informacias arteriuli wnevis cvalebadobis Sesaxeb Zilis dros da
dRis ganmavlobaSi. igi mniSvnelovania:
samizne organoebis dazianebis ararsebobisas “TeTri xalaTis
hipertenziis” gamovlenis mizniT;
sxvadasxva medikamentis mimarT rezistentobis ganviTarebis
aRmoCenis mizniT;
antihipertenziuli medikamentebiT ganpirobebuli hipotenziis
simptomebis, epizoduri hipotenziisa da avtonomiuri disfunqciebis
aRmoCenis mizniT.
Cveulebriv arteriuli wneva Ramis ganmavlobaSi mcirdeba 10-20%-iT. im
pirebs, romelTac wnevis es fiziologiuri Semcireba ar aReniSnebaT,
kardiovaskuluri daavadebebis ganviTarebis ufro maRali riski
aReniSnebaT.
arteriuli wnevis ambulatoriuli monitoringiT miRebuli monacemebiT,
arahipertenziulad aris miCneuli wnevis done sifxizleSi naklebi 135/85
mm.vwy.sv.-ze da Zilis dros naklebi 120/75 mm.vwy.sv.-ze.
arteriuli wnevis TviTkontroli
arteriuli wnevis TviTkontrols (pacientis an misi axloblebis mier
arteriuli wnevis saxlSi an samsaxurSi gazomvas) aqvs mTeli rigi
dadebiTi mxareebi:
Tavisufalia situaciuri matebisgan - e.w. “TeTri xalaTis
hipertenzia”, anu roca pacientis wneva maRalia mxolod maSin,
rodesac is samedicino personalis mier an maTi TandaswrebiT
izomeba;
pacients warmodgenas uqmnis antihipertenziuli medikamentis
adeqvaturi moqmedebis Sesaxeb;
14
cvlis pacientis ganwyobas mkurnalobis mimarT, kerZod aumjobesebs
pacientis mkurnalobisadmi erTgulebas (pacientebi naklebad anebeben
Tavs mkurnalobas);
potenciurad amcirebs mkurnalobis Rirebulebas.
Tumca, pacientisTvis, an misi ojaxis wevrebisTvis metad mniSvnelovania
arteriuli wnevis zustad da sworad gazomvis swavleba, sazomi
aparatebis sizustis regularulad Semowmeba da eqimTan mudmivi
kontaqtis SenarCuneba.
saxlSi gazomvis pirobebSi wnevis cifrebi meti an toli 135/85 mm.vwy.sv.-
ze miCneulia hipertenziad.
pacientTa Sefaseba
hipertenziul pacientTa Sefasebas aqvs 3 mizani:
1. Sefasdes cxovrebis wesi da gamovlindes sxva kardiovaskuluri
risk-faqtorebi da Tanmxlebi darRvevebi, romelTac SeuZliaT
daamZimon prognozi da Secvalon mkurnalobis taqtika (cxrili
#2);
2. maRali arteriuli wnevis gamomwvevi mizezebis identificireba;
3. samizne organoebis dazianebis da sxva kardiovaskuluri
daavadebebis arsebobis albaTobis gansazRvra.
pacientis Sefaseba xdeba Semdegi monacemebiT: samedicino anamnezi,
fizikaluri gamokvlevebi, rutinuli laboratoriuli kvlevebi da sxva
diagnostikuri procedurebi. fizikaluri gamokvleva unda moicavdes:
arteriuli wnevis saTanado kontrols orive zemo kidurze, Tvalis
fskeris Semowmebas, sxeulis masis indeqsis gamoTvlas (BMI) (agreTve
sasurvelia welis garSemowerilobis gansazRvra), karotidebis, muclis
aortis da barZayis arteriis auskultacias, farisebri jirkvlis
palpacias; filtvebisa da gulis srul gamokvlevas; abdominur
gasinjvas, Tirkmelebis gadidebis da aortis paTologiuri pulsaciis
aRmoCenis mizniT. qvemo kidurebis palpacias SeSupebisa da pulsaciis
Sefasebis mizniT, agreTve nevrologiur Sefasebas.
15
cxrili #2
kardiovaskularuli risk-faqtorebi
mizezebi
mTavari/didi risk-faqtorebi
hipertenzia
sigaretis moweva
simsuqne (sxeulis masis indeqsi ≥30kg/m2 fizikuri aqtivoba
dislipidemia
Saqriani diabeti
mikroalbuminuria an glomeru-
luri filtraciis siCqare <60 ml/wT
asaki ( >55 mamakaci, > 65 qali)
ojaxuri istoria, anamnezSi kardiovaskuluri daavadeba (mamakaci<55 welze da
qali <65
samizne organoebis dazianeba
guli
• marcxena parkuWis hipertrofia
• stenokardia an gadatanili miokardiumis infarqti.
• gadatanili koronaruli revaskularizacia
• gulis ukmarisoba
Tavis tvini
• insulti an Tavis tvinSi sisxlis mimoqcevis gardamavali moSla
• demencia
Tirkmlis qronikuli ukmarisoba
periferiuli arteriebis daavadeba
retinopaTia
meoradi hipertenziis mizezebi
Zilis apnoe
medikamentiT gamowveuli sruli an nawilobrivi mizezebi
qronikuli Tirkmlis ukmarisoba
pirveladi aldosteronizmi
Tirkmlis sisxlZarRvovani paTologia
qronikuli steroiduli Terapia da kuSingis sindromi
feoqromocitoma
aortis koarqtacia
farisebri da paraTiroiduli daavadebebi.
obstruqciuli uropaTia
16
laboratoriuli kvlevebi da sxva diagnostikuri RonisZiebebi
antihipertenziuli mkurnalobis dawyebamde, rekomendebulia rutinuli
laboratoriuli kvlevebis Catareba, romelic moicavs ekg-s, Sardis
saerTo analizs, sisxlSi glukozisa da hematokritis, Sratis kaliumis,
kreatininis (an Sesabamisi glomeruluri filtraciis sixSiris (GFR)), kalciumis lipiduri speqtris (kvebidan 9-12sT-is Semdgom), romelic
moicavs m.s.l., d.s.l., trigliceridebis gansazRvras. damatebiTi
analizebi moicavs SardSi albuminisa da albumini/kreatininis
Sefardebis gansazRvras.
damatebiTi testebis gamoyeneba ar aris naCvenebi Tu wnevis kontroli
miRweulia.
testebi rekomendebulia im SemTxvevaSi, Tu wnevis kontrolis miRweva
ver xerxdeba da rutinuli testebi migvaniSnebs meorad hipertenziaze.
mkurnalobis sqema
samizne wneva
antihipertenziuli mkurnalobis mizania kardiovaskuluri da Tirkmlis
daavadebebiT gamowveuli avadobisa da sikvdilobis Semcireba.
hipertenziul pirebSi gansakuTrebiT 50 wels zeviT, pirveli rigis
amocanaa sistoluri wnevis kontrolis miRweva.
samizne arteriuli wnevad miCneulia <140/90 mm.vwy.sv-ze, radgan am
SemTxvevaSi mcirdeba kardiovaskuluri daavadebebis ganviTarebis
albaToba.
pacientebSi romelTac aqvT Saqriani diabeti an Tirkmlis qronikuli
ukmarisoba samizne wnevaa <130/80 mm.vwy/sv.-ze.
cxovrebis wesis Secvla
jansaRi cxovrebis wesi yvela adamianisTvis aris hipertenziis
mniSvnelovani prevencia. mas aseve gansakuTrebuli mniSvneloba eniWeba
hipertenziuli pirebis mkurnalobaSi. cxovrebis jansaRi wesi moicavs:
1. wonis Semcirebas maTSi visac Warbi wona aqvs;
2. regularul fizikur varjiSs (swrafi siaruli sufTa haerze minimum
30 wuTi kviris umetes dReebSi);
3. dietur kvebas anu kaliumiT da kalciumiT mdidari (xili, bostneuli,
dabalcximiani rZis produqtebi) da natriumiT Raribi sakvebis miRebas.
natriumis dRiuri miReba unda Semcirdes 100 mmolamde (2,4 grami
natriumi, rac Seesabameba 4 gram sufris marils);
4. alkoholis moxmarebis Semcirebas 30 mililitramde dReSi eTanolze
gadaangariSebiT mamakacebSi da 15 mililitramde qalebsa da dabali
wonis pirebSi.
17
dietis principebi mocemulia #3 cxrilSi, romelic Seiqmna kvleva
DASH-is (dietis principebi hipertenziis prevenciis da mkurnalobisTvis)
safuZvelze.
jansaRi cxovrebis wesi amcirebs arteriul wnevas, axdens hipertenziis
prevencias an anelebs mis ganviTarebas, aseve aZlierebs
antihipertenziuli medikamentebis efeqturobas da amcirebs
kardiovaskuluri daavadebebis ganviTarebis risks: magaliTad DASH-is
mixedviT garkvel pirebSi, sakvebSi natriumis SezRudvas 1600 mg-mde (66
mmoli, rac Seesabameba 4g sufris marils) aqvs igive efeqti, rac erTi
antihipertenziuli medikamentiT mkurnalobas. jansaRi cxovrebis wesis
ori an meti RonisZiebis kombinaciiT SesaZlebelia saukeTeso Sedegebis
miRweva.
medikamenturi mkurnaloba
hipertenziis samkurnalod gamoiyeneba sxvadasxva jgufis medikamentebi.
cxrili #4 da #5 moicavs yvelaze xSirad gamoyenebad
antihipertenziuli medikamentebs.
hipertenziul pirTa daaxloebiT or mesamedSi samizne arteriuli wnevis
miRweva xerxdeba ori an meti antihipertenziuli preparatis saSualebiT.
pacientTa mxolod erT mesamedSia SesaZlebeli efeqturi mkurnaloba
erTi medikamentis saSualebiT. magaliTad, kvleva (ALLHAT)-is mixedviT
pacientebis mxolod 30%-s hqonda arteriuli wneva kargad
gakontrolebuli erTi antihipertenziuli preparatiT. danarCen
pacientebs sWirdebodaT ori an meti medikamenti. 1967 wlidan kvlevebiT
aRiarebulia Tiaziduri diuretikebi, rogorc antihipertenziuli
mkurnalobis bazisi. diuretikebi mniSvnelovnad amcireben hipertenziiT
gamowveul kardiovaskuluri garTulebebis sixSires. diuretikebi
mraval medikamentTan kombinaciaSi aZliereben antihipertenziul efeqts
da gamoirCevian siiafiT sxva antihipertenziul medikamentebTan
SedarebiT. miuxedavad am monacemebisa maT jer kidev ver hpoves jerovani
gamoyeneba.
bevri kvleviT dadasturebulia, rom maRali wnevis mkurnaloba (agf inhibitorebiT, a.r. blokerebiT, beta blokerebiT, kalciumis arxebis
antagonistebiT) aseve amcirebs hipertenziis garTulebebis sixSires. hipertenziul pacientTa umravlesobaSi Tiaziduri tipis diuretikebi
unda iqnas gamoyenebuli mkurnalobis sawyis stadiaze marto an
kombinaciaSi sxva (agf inhibitorebiT, a.r. blokerebiT, beta blokerebiT,
kalciumis arxebis antagonistebiT) medikamentebTan erTad. sxva
antihipertenziuli preparatebis gamoyenebis Cveneba mocemulia #1
cxrilSi. medikamentis autanlobis an ukuCvenebis SemTxvevaSi
rekomendebulia sxva jgufis preparatebi.
18
cxrili #3
cxovrebis wesis srulyofa hipertenziis mkurnalobis mizniT
modifikacia
rekomendaciebi
sistoluri
arteriuli wnevis
maCveneblebi
wonis Semcireba
N
sxeulis masis normalizacia
(sxeulis masis ineqsi 18,5-24,5 kg/m)
5-20 mm/vwy.sv wonis Semcirebisas
K
kveba DASH-is dietis
mixedviT
gulisxmobs xiliT, bostneuliT
mdidar da najeri cximebiT Rarib
dietas
8-14 mm/vwysv.
sakvebSi sufris marilis
raodenobis SezRudva
100 mmolamde dReSi, rac Seesabameba
6 gram sufris marils
2-8 mm/vwysv.
F
fizikuri aqtivoba
regularuli aerobikuli fizikuri
aqtiuroba, rogoric aris swrafi
siaruli (30wT mainc dReSi, kviris
umetes dReebSi)
4-6 mm/vwysv.
alkoholis miRebis
SezRudva
alkoholis SezRudva araumetes 2-
jer miRebisa (1 oz an 30 ml eTanoli,
24 oz ludi, 10 oz Rvino, 3 oz viski). yoveldRe mamakacTa umravlesobaSi
da araumetes erTi miRebisa qalebSi
da mcire wonis pirebSi.
2-4 mm/vwysv.
DASH – dieturi midgoma hipertoniis mkurnalobisaTvis.
OZ – 37 mililitri
19
cxrili #4
peroraluri antihipertenziuli medikamentebi
jgufi
Mmedikamentebi
dozireba
mg/dReSi
dRiuri
jeradoba
Tiaziduri Sardmdenebi qlorTiazidi
qlortalidoni
hidroqlorTiazidi
poliTiazidi
indapamidi
metolazoni
125-500
12,5-25
12,5-50
2-4
1,25-2,5
0,5-1.0
1-2
1
1
1
1
1
maryuJze moqmedi Sardmdeni
bumetanidi
furosemidi
torsemidi
0,5-2
20-80
2,5-10
2
2
1
kaliumSemnaxveli
Sardmdeni
amiloridi
triamtereni
5-10
50-100
1-2
1-2
aldosteronis receptoris blokerebi eplerenoni
spironolaqtoni
50-100
25-50
1
1
beta-blokerebi atenololi
bisoprololi
metaprololi
nadololi
propranololi
gaxangrZlivebuli
moqmedebis propranololi
Timololi
25-100
2,5-10
50-100
40-120
40-160
60-180
20-40
1
1
1-2
1
2
1
2
beta-blokatorebi+simpa-
tomimetikebi
acebutololi
pindololi
200-800
10-40
2
2
kombinirebuli alfa da beta blokerebi karvediloli
labetaloli
12,5-50
200-800
2
2
Aagf inhibitorebi
benazeprili
kaptoprili
enalaprili
fozinoprili
lizinoprili
perindoprili
moeqsiprili
qvinaprili
ramiprili
trandolaprili
10-40
25-100
5-40
10-40
10-40
4-8
7,5-30
10-80
2,5-20
1-4
1
1
1-2
1
1
1
1
1
1
1
angiotenzin receptorebis blokerebi
kanvesartani
eprosartani
irbesartani
losartani
olmesartani
telmisartani
valsartani
8-32
400-800
150-300
25-100
20-40
20-80
80-320
1
1-2
1
1-2
1
1
1-2
20
Kkalciumi arxebis
blokerebi(aradihidripiridinis jgufis)
dilTiazemi(xangrZlivi
moqmadebis)
verapamili(xanmokle
moqmedebis)
verapamili(xangrZlivi
moqmedebis)
verapmili
180-420
80-320
120-480
120-360
1
2
1-2
1
Kkalciumis rxebis
blokerebi(dihidripiridinis jgufis ) amlodipini
Ffelodipini
isradipini
nikardipini
nifedipini(xangrZlivi
moqmedebis)
nisoldipini
2,5-10
2,5-20
2,5-10
60-120
30-60
10-40
1
1
2
2
1
1
alfa1 blokerebi
doqsazozini
prazozini
terazozini
1-16
2-20
1-20
1
2-3
1-2
centraluri moqmedebis alfa 2-is
agonistebi da sxva centraluri
moqmedebis medikamenetebi
klonidini
klonidinis plastiri
meTildofa
rezerpini
guanfacini
0,1-0,8
0,1-0,3
250-100
0,1-0,25
0,5-2,0
2
1-xel
kviraSi
2
1
1
P
pirdapiri moqmedebis vazodilatatorebi
hidralazini
minoqsidili
25-100
2,5-80
2
1-2
21
cxrili #5
hipertenziis samkurnalo kombinirebuli medikamentebi
kombinaciis tipebi
Sereuli dozebis kombinacia, mg-Si
agfi da kab amlodipini-benazeprili (2.5/10, 5/10, 5/20, 10/20)
enalaprili-fenodipini (5/5)
trandolaprili-verapamili (2/180, 1/240, 2/240, 4/240)
agfi da Sardmdeni
benazeprili-hidroqlorTiazidi (5/6.25, 10/12.5, 20/12.5, 20/25)
kaptopril-hidroqlorTiazidi (25/15, 25/25, 50/15, 50/25)
enalapril-hidroqlorTiazidi (5/12.5, 10/25)
fosinopril-hidroqlorTiazidi (10/12.5, 20/12.5)
lizinopril-hidroqlorTiazidi (10/12.5, 20/12.5, 20/25)
moeqsipril-hidroqlorTiazidi (7.5/12.5, 15/25)
qvinapril-hidroqlorTiazidi (10/12.5, 20/12.5, 20/25)
arb da Sardmdeni kandersartan-hidroqlorTiazidi (16/12.5, 32/12.5)
eprosartan-hidroqlorTiazidi (600/12.5, 600/25)
irbesartan-hidroqlorTiazidi (150/12.5, 300/12.5)
losartan-hidroqlorTiazidi (50/12.5, 100/25)
olmesartan-hidroqlorTiazidi (20/12.5, 40/12.5, 40/25)
telmisartan-hidroqlorTiazidi (40/12.5, 80/12.5)
valsartan-hidroqlorTiazidi (80/12.5, 160/12.5, 160/25)
bb da Sardmdeni atenolol-qlortalidoni (50/25, 100/25)
bisoprolol-hidroqlorTiazidi (2.5/6.25, 5/6.25, 10/6.25)
metoprolol-hidroqlortiazidi (50/25, 100/25)
propranololi-hidroqlorTiazidi (40/25,80/25)
Timolol-hidroqlorTiazidi (10/25)
centraluri
moqmedebis
medikamentebi da
Sardmdenebi
meTildopa-hidroqlorTiazidi (250/15, 250/25, 500/30, 500/50)
rezerpin-qlortalidoni (0.125/25, 0.25/50)
rezerpin-qlorTiazidi (0.125/250, 0.25/500)
rezerpin-hidroqlorTiazidi (0.125/25, 0.125/50)
Sardmdeni da
Sardmdeni amiloridi-hidroqlorTiazidi (5/50)
spironolaqtoni-hidroqlorTiazidi (25/25, 50/50)
triamteren-hidroqlorTiazidi (37.5/25, 75/50)
arteriuli wnevis kontrolis miRweva pacientebSi
hipertenziul pacientTa umravlesobas esaWiroeba ori an meti
antihipertenziuli medikamenti samizne arteriuli wnevis misaRwevad.
rodesac erTi preparetis adeqvaturi dozis miRebis Sedegad ver
xerxdeba wnevis kontroli, maSin saWiroa sxva jgufis medikamentis
damateba. Tu arteriuli wneva samiznes aRemateba 20/10mm/vwy.sv.–iT, maSin
sasurvelia mkurnalobis gagrZeleba erTdroulad ori preparatiT,
romliTac miiRweva arteriuli wnevis ukeTesi kontroli. Ggarkveul
SemTxvevebSi saWiroa sifrTxilis gamoCena xandazmul, diabetiT
daavadebul pacientebSi, romelTac aReniSnebaT autonomiuri disfunqcia
- SesaZlo orTostatiuli hipotenziis ganviTarebis gamo. generuli
medikamentebis an maTi kombinaciebis gamoyeneba mkveTrad amcirebs
mkurnalobis Rirebulebas.
22
Semdgomi monitoringi da meTvalyureoba
pacientTa umravlesobam antihipertenziuli mkurnalobis dawyebidan,
erTi Tvis intervaliT an samizne arteriuli wnevis miRwevamde unda
gaiaros Semdgomi Semowmeba. meore stadiis hipertenziisa da Tanmxlebi
daavadebis mqone pacientebisaTvis saWiroa ufro xSiri vizitebi. plazmis
kaliumis da kreatininis kontroli unda ganxorcieldes aranakleb
orjer weliwadSi. samizne wnevis miRwevis Semdeg momdevno vizitebi
SeiZleba ganxorcieldes 3 – 6 Tvis intervaliT. Tanmxlebi daavadebebis,
magaliTad gulis ukmarisobis da diabetis dros aucilebeli vizitebis
sixSire izrdeba. paralelurad unda mimdinareobdes sxva
kardiovaskuluri risk-faqtorebis koreqcia. aspirinis dabali doziT
mkurnaloba naCvenebia samizne wnevis miRwevis Semdeg, radganac
arakontrolirebadi hipertenziis dros arsebobs hemoragiuli insultis
ganviTarebis riski.
cxovrebis wesis Secvla
samizne arteriuli wneva ar aris miRweuli < 140/90 (diabetisa da Tirkmlis
qroniruli ukmarisobis dros <1 30/80 mm/vwy/sv)
sawyisi medikamenturi Terapia
mkacri Cvenebis gareSe mkacri CvenebiT
hipertenziis II
stadia
(SBP ≥160 an DBP≥100mmvwy/sv) ori medikamentis
kombinacia
(uxSiresad
Tiaziduri
diuretikebi da agfi,arb,bb,kab).
medikamentebi mkacri
Cvenebis
samkurnalod
(ix. cxrili #1)
sxva
antihipertenziuli
saSualebebi(diureti
kebi,agfi,arb,bb,kab) saWiroebis mixedviT
samizne wneva miuRwevelia
hipertenziis
I stadia
(SBP 140-159; an DBP 90-99mmvwy/sv) SemTxvevaTa
umravlesobaSi
Tiaziduri
diuretikebi, aseve
Agfi,arb,bb,kab an maTi kombinaciebi
medikamenturi Terapiis Secvla (medikamentebis damateba an dozebis Secvla
arteriuli wnevis daregulirebamde). kardiologis konsultacia.
23
hipertenziis marTva gansakuTrebul SemTxvevebSi
gulis iSemiuri daavadeba
pacientebi arteriuli hipertenziiT, imyofebian mzardi riskis jgufSi
miokardiumis infarqtis an sxva koronaruli paTologiis ganviTarebis
TvalsazrisiT, aseve ufro maRali riskis qveS miokardiumis infarqtiT
gamowveuli sikvdilis TvalsazrisiT. hipertenziiT daavadebulebSi
miokardiumis JangbadiT momarageba SeiZleba SezRuduli iyos Tanmxlebi
k.a.d.-is gamo, maSin roca Jangbadze moTxovnileba gazrdilia, erTis
mxriv gazrdili periferiuli winaaRmdegoba da meores mxriv marcxena
parkuWis hipertrofiis gamo. pacientebSi k.a.d.-iT rogorc sistoluri
aseve diastoluri wnevis SemcirebiT miokardiumis Jangbadze
moTxovnileba da Sesabamisad kardiovaskuluri garTulebebis riski
qveiTdeba. am jgufis pacientebSi antihipertenziuli mkurnalobis
erTerTi mniSvnelovani aspeqti aris koronaruli riskis zrda dabali
diastoluri wnevis pirobebSi. magaliTad: SHEP kvleviT diastoluri
wnevis Semcireba 55-60 mm/vwy.sv-is qveviT asocirebuli iyo mzard
kardiovaskulur garTulebebTan, maT Soris miokardiumis mwvave
infarqtTan, TumcaRa igive kavSiri ar iyo dadgenili sistoluri wnevis
agresiuli daqveiTebis SemTxvevaSi. da bolos, hipertenziis agresiuli
mkurnalobiT, gacilebiT meti garTulebebis Tavidan acileba SeiZleba,
vidre warmoqmna.
stabiluri stenokardia da munji iSemia
am pacientebSi mkurnalobis mizania miokardiumis infarqtis da
sikvdilis prevencia, aseve stenokardiis simptomebis Semcireba.
betablokerebi, rogorc sawyisi Terapia gamoiyeneba yvela SemTxvevaSi Tu
ar aris ukuCveneba. betablokerebi amcireben arteriul wnevas,
stenokardiis simptomebs, sikvdilianobas, gulis wuTmoculobasa da
gulis SekumSvaTa sixSires. Semcirebuli inotropizmi da SekumSvaTa
sixSire amcirebs miokardiumis moTxovnilebas Jangbadze. mkurnaloba
aseve moicavs: glukozis kontrols, lipidebis donis daqveiTebas,
antiagregacias, varjiSs, wonis Semcirebas Warbwonian pacientebSi da
Tambaqos moxmarebis Sewyvetas.
Tu ki arteriuli wnevisa da stenokardiis simptomebis kontroli ver
xerxdeba mxolod betablokeriT, an Tu betablokeri ukunaCvenebia
(magaliTad iseT SemTxvevebSi, rogoric aris sasunTqi gzebis mZime
obstruqciuli paTologia, periferiuli arteriebis daavadeba, maRali
xarisxis atrioventrikuluri blokada, sinusis kvanZis sisustis
sindromi), mizanSewonilia xangrZlivmoqmedi dihidropiridinebis an
aradihidropiridinis tipis kalciumis arxebis blokerebis gamoyeneba.
kalciumis arxebis blokerebi amcireben periferiul winaaRmdegobas, rac
Tavis mxriv amcirebs marcxena parkuWis kedlis daWimulobas. kalciumis
arxebis blokerebi aseve amcireben winaaRmdegobas koronarul
arteriebSi da Sesabamisad aumjobeseben poststenozur koronarul
perfuzias. aradihidropiridinuli kalciumis arxebis blokerebi aseve
amcireben gulis SekumSvaTa sixSires, betablokerebTan kombinaciaSi
24
SeuZliaT gamoiwvion mZime bradikardia an maRali xarisxis blokada. im
SemTxvevaSi Tu stenokardia an arteriuli wneva ver kontrolirdeba am
orkomponentiani reJimiT, SesaZlebelia daematos nitrati, magram
aucilebelia didi sifrTxilis gamoCena im pacientebSi, romlebic iReben
fosfodiesTerazas 5-is inhibitorebs (sildenafils - viagra). A
pacientebSi arteriuli hipertenziiT da stabiluri stenokardiiT ar
gamoiyeneba xanmokle moqmedebis kalciumis arxebis blokerebi (mag.
nifedipini), radgan isini zrdian sikvdilianobas.
gulis ukmarisoba
gulis ukmarisobis sindromi, vlindeba im SemTxvevaSi, rodesac guli ver
uzrunvelyofs periferiuli qsovilebis perfuzias da metaboluri
moTxovnilebebis dasakmayofileblad adeqvaturi sisxlis nakadis
miwodebas. gulis ukmarisobiT pacientebis 40-50%-s SeiZleba hqondeT
SenarCunebuli sistoluri funqcia. aseT pacientebs metad savaraudoa
hqondeT hipertenzia, marcxena parkuWis hipertrofia da izolirebuli
diastoluri disfunqcia. am jgufs ufro xSirad ganekuTvnebian qalebi.
sxvadasxva neirohumoraluri sistemebi, gansakuTrebiT renin-angiotenzin-
aldosteronisa da simpaTikuri nervuli sistema SeiZleba gaaqtiurdes
marcxena parkuWis disfunqciisas, magram aseT aqtivacias SeiZleba mohyves
paTologiuri remodelireba, SemdgomSi marcxena parkuWis dilatacia da
daqveiTebuli kumSvadi funqcia. marcxena parkuWis disfunqciis
progresireba SeiZleba Senelebul iqnas agfi, bb-iT da diuretikebiT.
hipertenzia win uswrebs gulis ukmarisobis ganviTarebas daaxloebiT
90% pacientebSi da 2-3-jer zrdis gulis ukmarisobis ganviTarebis risks.
amerikis SeerTebul StatebSi, SemTxvevaTa 2/3-Si gulis ukmarisobis
mizezs warmoadgens koronaruli arteriebis daavadeba. ukanaskneli 50
wlis ganmavlobaSi gulis ukmarisobis sixSire ar Secvlila mamakacebSi,
xolo qalebSi SeimCneva klebis tendencia. gulis ukmarisobiT
hospitalizaciis sixSire TiTqmis gaormagda bolo 20 weliwadSi. amis
mizezs warmoadgens mkurnalobis gaumjobeseba da sicocxlis
xangrZlivobis gazrda. gulis ukmarisobis gamo hospitalisazaciis
SemTxvevebi savaraudod gaizrdeba CvenTanac momavalSic da es tendencia
dakavSirebulia sicocxlis xangrZlivobis zrdasTan.
ACC/AHA gaidlainebi xelsayrelia gulis ukmarisobis marTvisTvis.
A stadiis jgufSi, es aris I (NYHA), maTTvis visac aqvT gulis
ukmarisobis ganviTarebis maRali riski, magram marcxena parkuWis
kumSvadobis daqveiTeba ar aReniSnebaT, mkurnaloba gulisxmobs risk-
faqtorebis marTvas: arteriuli wnevis, hiperqolesterinemiis,
hiperglikemiis kontrols. Aam stadiaze maRali kardiovaskuluri riskis
mqone pacientebSi mizanSewonilia agf inhibitorebis gamoyeneba. ALHHAT-is safuZvelze gamoiTqva varaudi, Tiaziduri jgufis diuretikebis
mizanSewonilobaze daavadebis progresis SesaCereblad.
B stadia gulis ukmarisoba (NYHA) - I; marcxena parkuWis kumSvadi
funqciis daqveiTeba EF<40%-ze, sxvamxriv usimptomo pacientebSi, maTTvis
rekomendirebulia agf inhibitorebi da beta blokerebi.
25
C stadia gulis ukmarisoba II-III (NYHA); marcxena parkuWis disfunqciis Tanaarseboba da manifestirebuli simptomebi. aseTi pacientebisaTvis
naCvenebia agf inhibitoris betablokerebis gamoyeneba. aldosteronis
antagonistebic SeiZleba Rirebuli iyos am situaciaSi. maryuJovani
Sardmdenebi aucilebelia zedmeti moculobis sakontrolod, Tumca ar
arsebobs imis mtkiceba, rom diuretikebs SeuZliaT daavadebis progresis
prevencia da amasTan Warbi gamoyenebisas iwveven kreatininis donis
matebas.
D stadia, gulis ukmarisoba IV (NYHA); pacientebi saWiroeben igive
mkurnalobas rasac C stadiis dros plus mkurnalobas inotropebiT,
implantirebuli defibrilatoriT, biventrikuluri peismekeriT,
meqanikuri “asist-devaisiT” an gulis transplantaciiT.
pacientebSi, romlebSic agf inhibitorebis gamoyeneba ver xerxdeba
SesaZlebelia a.r.b.-is gamoyeneba. gulis ukmarisobis dros
rekomendebulia beta-blokerebis gamoyenebac, radganac klinikurma
kvlevebma aCvena maTi gamoyenebis SemTxvevaSi avadobis da sikvdilianobis
Semcireba, agreTve gulis ukmarisobis simptomebis gaumjobeseba (ix.
cxrili #1).
marcxena parkuWovani mZime disfunqciis (stadia C) (NYHA III-IV) mkurnalobaSi efeqturia aldosteronis antagonistebis damateba. kvleva (RALES)-is mixedviT standartul Terapiaze damatebuli spironolaqtoni
dabali doziT (12,5-25mg/dReSi) amcirebs sikvdilianobas 34%-iT, im
pirebSi, romelTac EF≤40%-ze. aldosteronis antagonistis gamoyenebisas
hiperkalemiis (radganac pacientebis umravlesoba Rebulobs agf
inhibitors an a.r. blokers) Tavidan acilebis mizniT maTi miReba unda
SeizRudos im pacientebSi romelTac kreatinini >2,5mg/dl. maTi
gamoyenebis paralelurad unda xdebodes sisxlSi kaliumis donis
kontroli.
pacientebSi gulis ukmarisobiT arteriuli wnevis sasurveli done ar
aris mkacrad gansaRvruli, Tumca sistoluri arteriuli wnevis
Semcireba yovelTvis dadebiTad moqmedebs am situaciebSi, aris kvlevebi
romelTa mixedviT pacientebSi arteriuli hipertenziiT da gulis
ukmarisobiT sistoluri wnevis Semcireba sasurvelia <100 mmvcx/sv-isa.
miuxedavad dabalsarwmuno klinikuri kvlevebisa digoqsini kvlav
gamoiyeneba pacientebSi gulis ukmarisobiT. kvlevaSi Dig digoqsini ar amcirebda sikvdilianobas NYHA II-III pacientebSi, romlebic iRebdnen agf
inhibitorebs da diuretikebs, magram Seamcira gulis ukmarisobis
simptomebi da hospitalizaciis sixSire.
diabeti da hipertenzia
pacientebs arteriuli hipertenziiT da diabetiT aqvT maRali riski
ganuviTardeT kardiovaskuluri garTulebebi, insulti, Tirkmlis
qronikuli ukmarisoba, diabeturi nefropaTia. Kkvlevam (UKPDS) aCvena, rom sistoluri wnevis yoveli 10-iT Semcireba iwvevs diabetdamokidebuli
garTulebebis 13%-iT, miokardiumis infarqtis 11%-iT, nefropaTiis
retinopaTiis mikrovaskularuli garTulebebis 13%-iT Semcirebas.
26
Semdegma kvlevebma: (UKPDS, HOT, SHEP, LIFE, ALLHAT ,HOPE study) cxadad aCvena, rom wnevis adeqvaturi kontroli aumjobesebs kardiovaskuluri
garTulebebis gamosavals, gansakuTrebiT insultis gamosavals.
diabetian pacientebSi Tirkmlis qronikuli paTologia iTvleba
diagnostirebulad Tu pacients aReniSneba mZime albuminuria
(>300mg/dReSi an kreatinini SardSi >200 mg/gr.) an Tirkmlis ukmarisoba
(glumeruli filtraciis siCqare < 60ml/wuTSi rac Seesabameba plazmaSi
kreatinins >1.5mg/dl kacebSi da >1.3 mg/dl qalebSi)
JNC7-is rekomendaciebi Seesabameba, amerikis diabetis asociaciis
gaidlains, romlis mixedviTac arteriuli wneva diabetian pacientebSi ar
unda aRematebodes 130/80mm/Hg-s. klinikuri kvlevebiT dadgenilia, rom
pacientebSi I an II tipis diabetiT da arteriuli hipertenziiT efeqturia
Semdegi jgufis medikamentebi: Tiaziduri tipis Sardmdenebi, beta
blokerebi, kalci antagonistebi, agf inhibitorebi, a.r. blokerebi.
pacientebSi diabetiT da arteriuli hipertenziiT samizne wnevis
misaRwevad rogorc wesi saWiroa ori an meti medikamentis kombinacia.
pacientebSi diabetiT da arteriuli hipertenziiT efeqturia Tiaziduri
tipis Sardmdenebis gamoyeneba marto an kombinaciaSi. ALHAT kvlevam aCvena, rom am pacientebSi dawyebulma mkurnalobam qlortalidoniT,
gulis koronaruli daavadebis da miokardiumis infarqtis fataluri
gamosavali Seamcira imave xarisxiT, rogorc mkurnalobam
lizinopriliTa da amlodipiniT. yuradRebis sagans warmoadgens is
tendencia, rom Sardmdenebi auareseben hiperglikemias, magram es efeqti
mcirea da ar iwvevs ufro met kardiovaskulur garTulebebs vidre
sxva klasis antihipertenziuli medikamentebi.
agf inhibitorebi aseve mniSvnelovan komponents warmoadgens diabetiT da
arteriuli hipertenziiT daavadebuli pacientebis mkurnalobis sqemaSi.
es jgufi SeiZleba gamoyenebuli iqnas marto, magram ufro efeqturia
TiazidebTan kombinaciaSi. ADA rekomendacias uwevs agf inhibitorebs
diabetis mqone >55 welze asakis maRali kardiovaskuluri riskis
pacientebSi da beta-blokerebs diagnostirebuli koronaruli arteriebis
daavadebebis SemTxvevaSi.
beta-blokerebi, gansakuTrebiT beta-1 seleqtiuri _ efeqturia diabetiT
daavadebul pacientebSi, rogorc nawili multikomponenturi Terapiis,
magram maTi gamoyeneba monoTerapiis saxiT dRemde davis sagans
warmoadgens. kvleva LIFE-is mixedviT beta-blokerebi a.r. blokerebTan
SedarebiT nakleb efeqturia insultis prevenciis mizniT. beta
blokerebma SeiZleba gamoiwvios insulinisadmi mgrZnobelobis
gauareseba da hipoglikemiis epinefringamowveuli simptomebis SeniRbva,
es problemebi Cveulebriv advilad koregirdeba da ar aris Bbeta
blokerebis daniSvnis absoluturi ukuCveneba.
kalciumis arxebis blokerebi aseve SeiZleba gamoyenebul iyos diabetian
pacientebSi, rogorc kombinirebuli Terapiis nawili. kvlevebiT
dadginda, rom isini amcireben kardiovaskulur garTulebebs diabetiT
daavadebul pacientebSi. kvleva ALHAT-is mixedviT amlodipini iyo
iseTive efeqturi, rogorc qlorTalidoni, garda gulis ukmarisobis
qvejgufisa, sadac qlortalidonis upiratesoba iyo aSkara.
27
Tirkmlis qronikuli daavadeba
sicocxlis mesame - meoTxe dekadidan Tirkmlis eqskretoruli funqcia
iwyebs gauaresebas da meeqvse dekadisTvis glumeruli filtraciis
siCqare mcirdeba 1-2ml-iT/wT yovelwliurad. asakdamokidebuli Tirkmlis
funqciis gauareseba pirdapirproporciul kavSirSia arteriuli wnevis
sididesTan. magaliTad cudad gakontrolebuli arteriuli wnevis
SemTxvevaSi gauareseba mimdinareobs oTxjer ufro swrafad. gauaresebis
tempma SeiZleba gamoiwvios iseTi xarisxis Tirkmlis ukmarisoba, rom
aucilebeli gaxdes dializi an transplantacia.
Tirkmlis qronikuli daavadeba gulisxmobs:
1. eqskretoruli funqciis Semcirebas – glomeruli filtraciis siCqare
(GFR) <60ml/wT/ yovel 1,73m2-ze (romelic daaxloebiT Seesabameba
kretinins > 1,5mg/dl kacebSi da >1,3mg/dl qalebSi. Aan
2. albuminurias (>300mg/dReSi).
kardiovaskuluri daavadebebi aris sikvdilis uxSiresi mizezi aseT
pacientebSi, Tavis mxriv Tirkmlis qronikuli daavadeba aris
kardiovaskuluri paTologiis ganviTarebis damoukidebeli risk-faqtori.
magaliTad Tu glomeruli filtraciis siCqare aris <60 ml/wT-Si
kardiovaskuluri sikvdilianobis riski aris 16%-iT meti. Tu glumeruli
filtraciis siCqare <30 ml/wT-Si sikvdilianoba aris 30%-iT meti.
pacientebSi arteriuli hipertenziiT da Tirkmlis qronikuli daavadebiT
samizne arteriuli wnevaa <130/80 mm/vwysv. am miznis misaRwevad rogorc
wesi saWiroa ori an meti antihipertenziuli medikamenti. mkurnalobaSi
arCevis preparatebia agf inhibitorebi da a.r. blokerebi SardmdenebTan
kombinaciaSi. umeteswilad upiratesoba eZleva maryuJze moqmed
Sardmdenebs. Aagf inhibitorebiT da a.r. blokerebiT mkurnalobisas
dasaSvebia sawyisi kreatininis donis mateba 35%-iT da es ar warmoadgens
am preparatebis Sewyvetis Cvenebas.
pacientebi cerebrovaskuluri daavadebebiT
mwvave insultebis dros arteriuli wnevis mkveTri daqveiTebiT riski da
gamosavali aris cudi, arteriuli wnevis kontroli saSualo farglebSi
(daaxloebiT 160/110mm/vwy.sv.) mizanSewonilia manam sanam mdgomareobis
stabilizacia da gaumjobeseba ar moxdeba. ganmeorebiTi insultebis
sixSire mcirdeba agf inhibitorebisa da Tiaziduri tipis Sardmdenebis
gamoyenebiT.
klinikuri garTulebebis riski cerebrovaskuluri daavadebebisas,
moicavs: iSemiur insults, hemoragiul insults da demencias. yvelaze
xSirad iSemiuri insulti viTardeba prehipertenziul an hipertenziis
pirveli stadiis pacientebSi. iSemiuri da hemoragiuli insultis sixSire
mkveTrad klebulobs arteriuli wnevis kargi kontrolis SemTxvevaSi.
dResdReobiT ar aris gamovlenili romelime medikamentis mkafio
upiratesoba insultis prevenciisTvis. kvleva LIFE-is mixedviT
losartani ufro efeqturia vidre atnololi insultis prevenciisTvis.
kvleva ALLHAT-is mixedviT Tiaziduri tipis Sardmdenebi da
dihidropiridinuli tipis kalciumis arxebis blokerebi ufro efeqturia
28
vidre agf inhibitorebi insultis prevenciisTvis. amave kvlevis mixedviT
qlortalidoni da amlodipini gacilebiT efeqturad amcirebdnen
arteriul wnevas vidre lozartani. Kkvleva PPROGRESS-is mixedviT
indapamidis da perindoprilis kombinaciam gamoiwvia insultis sixSiris
43%-iT Semcireba.
arteriuli wnevis marTva mwvave insultis dros dRemde kamaTis sagans
warmoadgens. mwvave insultis dros xSiria mkveTrad momatebuli
arteriuli wneva, rac rigi avtorebis azriT fiziologiuri
kompensatoruli pasuxia Tavis tvinSi iSemiuri ubnebis perfuziis
gasaumjobeseblad. klinikuri mdgomareobis stabilizaciamde ar aris
rekomendebuli arteriuli wnevis swrafi daqveiTeba. amerikis insultis
asociaciis mixedviT pacientebSi insultiT da sistoluri wneviT
>220mm/vws an diastoluri wneviT 120-140 mm/vws, wnevis daqveiTeba unda
ganxorcieldes frTxilad araumetes 10-15%-iT. pacientebSi insultiT da
diastoluri wneviT >140-mm/vwy.sv-ze dawyebul unda iqnas natriumis
nitroprusidis infuzia wnevis 10-15 %-iT Sesamcireblad.
iSemiuri insultis dros Trombolizisis Catarebis ukuCvenebaa -
sistoluri arteriuli wneva > 185 mm/vwy.sv-ze an diastoluri arteriuli
wneva > 110 mm/vwy.sv-ze. Trombolizuri Terapiis dawyebis Semdeg saWiroa
arteriuli wnevis mkacri monitoringi gansakuTrebiT pirveli 24 saaTis
ganmavlobaSi. sistoluri arteriuli wneva >180 mm/vwysv.-ze da
diastoluri > 105 mm/vwy.sv.-ze saWiroebs agresiul intravenur
mkurnalobas intracerebruli sisxldenebis Tavidan acilebis mizniT.
simsuqne da metaboluri sindromi
metaboluri sindromi warmoadgens Semdeg kardiovaskulur risk-
faqtorTa erTobliobas: hipertenzia, abdominuri simsuqne, dislipidemia
da insulinis mimarT rezistentoba. metaboluri sindromis
diagnostirebisTvis aucilebelia sami an meti qvemoT CamoTvlili risk-
faqtorebis Tanxvedra:
1. cximovani qsovilis Warbi ganviTareba muclis midamoSi
(garSemoweriloba >102sm mamakacebSi; an > 88sm qalebSi);
2. arteriuli wneva ≥130/85mm/vwy.sv; 3. glukoza uzmod ≥110mg/dl;
4. trigliceridebi ≥150 mg/dl;
5. maRali simkvrivis lipoproteini <40 mg/dl kacebSi da <50 mg/dl
qalebSi.
mamakacebSi, romelTac aReniSnebaT metaboluri sindromiT fataluri
koronaruli paTologiis riski izrdeba oTxjer, kardiovaskuluri
garTulebebis da zogadad sikvdilis riski izrdeba orjer da diabetis
ganviTarebis ki 5-9 jer.
mkurnaloba moicavs Semdeg ZiriTad momentebs: wonis Semcireba,
arteriuli hipertenziis kargi kontroli, lipiduri speqtris
gamosworeba, cxovrebis wesis Secvla _ jansaRi kveba da fizikuri
varjiSi.
29
simsuqne (BMI≥30kg/m2 sxeulis masis indeqsi BMI =wona [kilogramebSi] / (simaRle [metrebSi])²) aris risk-faqtori hipertenziisa da
kardiovaskuluri daavadebebis ganviTarebis. sxeulis masis indeqsis
Secvla (dabruneba normaSi) unda moxdes Semdegi RonisZiebebiT:
maqsimalurad Canacvldes cxovrebis jdomiTi wesi fizikuri aqtivobiT
(siaruli, velosipediT seirnoba, tenisi, fexburTi da sxva). unda
Semcirdes: sakvebi ulufebis zoma, maRalkaloriuli sasmelis moxmareba.
marcxena parkuWis hipertrofia (LVH)
marcxena parkuWis masis zrda damaxasiaTebelia marcxena parkuWis
hipertrofiis yvela tipisTvis. aTletebSi ganviTarebuli marcxena
parkuWis hipertrofiisTvis (V) damaxasiaTebelia normaluri an
gazrdili sistoluri funqcia, gazrdili saboloo distoluri
moculoba da elongirebuli miofibrilebi. Hhipertrofiis am tips
uwodeben eqscentrul hipertrofias. Aarteriuli hipertenziis Sedegad
viTardeba koncentruli hipertrofia, romlisTvisac damaxasiaTebelia
miofibrilebis cirkumferencialuri hipertrofia normaluri an
gazrdili kontraqtiloba, kedlis sisqis gazrda, normaluri an
Semcirebuli saboloo diastoluri moculoba da gauaresebuli
relaqsacia. umkurnalebel an cudad namkurnaleb pacientebSi marcxena
parkuWis hipertrofia aris mTavari ris-kfaqtori dilataciuri
kardiomiopaTiis da gulis ukmarisobis ganviTarebis. marcxena parkuWis
hipertrofiis diagnostirebis yvelaze sensitiuri meTodebia: ekg da
eqokardioskopia. gansakuTrebiT sensitiuri meTodia eqokardioskopia,
radgan ekg kriteriumebis mixedviT xSiria cru dadebiTi diagnozi.
pacientebs marcxena parkuWis hipertrofiiT aqvT orjer maRali riski
kardiovaskuluri garTulebebis da sikvdilis. kvlevebiT
dadasturebulia, rom marcxena parkuWis hipertrofiis regresi amcirebs
kardiovaskuluri garTulebebis risks. Mmarcxena parkuWis hipertrofiis
regresi miiRweva Semdegi RonisZiebebiT: wonis Semcireba, sufris
marilis moxmarebis Semcireba, arteriuli wnevis kargi kontroli. am
mizniT gamoiyeneba yvela ZiriTadi jgufis antihipertenziuli preparati.
periferiuli arteriebis daavadeba
arteriuli hipertenzia, diabeti da Tambaqo aris mTavari risk-faqtorebi
periferiuli arteriebis daavadebis ganviTarebisTvis. simptomuri
periferiuli arteriebis daavadeba asocirebulia kardiovaskuluri
garTulebebis maRal riskTan. am jgufis pacientebSi arteriuli
hipertenziis samkurnalod SeiZleba gamoyenebul iqnas yvela ZiriTadi
antihipertenziuli jgufis preparatebi, maT Soris beta blokerebic,
radgan kvlevebma aCvena rom isini mcirediT auareseben xangamoSvebiT
koWlobas. Sesabamisad maTi gamoyeneba SesaZlebelia im pacientebSi, visac
aqvT periferiuli arteriebis daavadeba, gansakuTrebiT, Tu maT
aReniSnebaT koronaruli arteriebis daavadeba da/an gulis ukmarisoba.
unda aRiniSnos, rom mxolod antihipertenziuli mkurnaloba ar aris
sakmarisi periferiuli arteriebis daavadebiT gamowveuli simptomebis
gasaqrobad. Aucilebelia Semdegi RonisZiebebi: Tambaqos moxmarebis
Sewyveta, idealuri wonis miRweva, datvirTvis specialuri programis
30
gamoyeneba, samizne arteriuli wnevis miRweva, lipiduri profilis
gamosworeba (d.s.l. <100 mg/dl), diabetis prevencia an kontroli,
antiagregaciuli mkurnaloba (aspirini, klopirogeli an orive), ganixile
cilostazolis gamoyenebis aucilebloba Tu mxolod fizikuri
datvirTvis programa ar aris sakmarisi.
izolirebuli sistoluri hipertenzia
JNC-VI- isa da WHO/ISH mixedviT, izolirebuli sistoluri hipertenzia
gansazRvreba, rogorc: sistoluri sisxlis wneva ≥ 140 mm.vwy.sv. da
diastoluri sisxlis wneva < 90 mm.vwy.sv.
izolirebuli sistoluri hipertenziis (ISH) sxvadasxva xarisxebi
gansazRvreba Semdegnairad:
I xarisxi:
jgufSida mosazRvre
II xarisxi:
III xarisxi
sistoluri arteriuli wneva < 160 mm vwy sv.
sistoluri arteriuli wneva < 150 mm vwy sv.
sistoluri arteriuli wneva < 180 mm vwy sv.
sistoluri arteriuli wneva ≥ 180 mm vwy sv.
asakTan dakavSirebuli sisxlZarRvovani da neirohumoruli cvlilebebi
mniSvnelovani faqtorebia, romelTac mivyavarT hipertenziis da kerZod,
izolirebuli sistoluri hipertenziis ganviTarebamde. asakTan erTad
izrdeba kolagenis, ujredgare matriqsis cilebis, ZiriTadi nivTierebis
da elastinis raodenoba, rac kavSirSia sisxlZarRvTa struqturul da
funqciur cvlilebebTan, Sesabamisad uaresdeba arteriuli damyolobac.
es cvlilebebi iwvevs sisxlZarRvTa intimisa da mediis struqturul da
meqanikur cvlilebebs. kalciumi ukavSirdeba elastins, Sedegad mediis
aradiferencirebuli kunTovani ujredebi ganicdian proliferacias da
elastikuri membranis gavliT migrireben intimaSi. SemaerTebeli
qsovilis proliferacia iwvevs intimis gasqelebasa da fibrozs, izrdeba
sisxlZarRvTa rigiduloba kumSvadobis mniSvnelovani SemcirebiT.
Sesabamisad mcirdeba arteriuli damyoloba da iklebs msxvili
arteriebis e.w. “windkessel function”. sistoluri arteriuli wnevis
araproporciuli zrda iwvevs pulsuri wnevisa da pulsuri talRis
siCqaris zrdas, rac ganpirobebulia periferiaze wneviTi talRis
adreuli arekvliT. Sesabamisad, 60 wels gadaSorebul pirebSi sisxlis
sistoluri wneva imatebs, maSin, roca diastoluri wneva ucvlelia an
Semcirebuli. izolirebuli sistoluri hipertenziis dros aRiniSneba
gulis wuTmoculobis, dartymiTi moculobis, sisxlZarRvSida
moculobis, Tirkmlis sisxlis mimoqcevisa da plazmis reninis
aqtivobis Semcireba, marcxena parkuWis masis, mocirkulire
kateqolaminebis (kerZod, noradrenalinis), da saerTo periferiuli
sisxlZarRvovani rezistentobis zrdis fonze. aseve mcirdeba
baroreceptorebis mgrZnobeloba sisxlis wnevis cvlilebebis mimarT,
rac ganpirobebulia sisxlis wnevis maRali variabelobiT.
31
izolirebuli sistoluri hipertenziis ukanasknel gansazRvrebaze
dayrdnobiT (≥140/<90 mm vwy sv), arsebobs mwiri informacia izolirebuli
sistoluri hipertenziis gavrcelebis Sesaxeb. asakTan erTad aRiniSneba
izolirebuli sistoluri hipertenziis (Zveli gansazRvreba)
gavrcelebis zrda (cxrili #6). is warmoadgens hipertenziis yvelaze
metad gavrcelebul tips asakovanTa Soris. 60 wels gadaSorebul,
aranamkurnalebi hipertenziis mqone pirebs Soris, izolirebuli
sistoluri hipertenzia warmoadgens hipertenziis yvelaze metad
gavrcelebul formas.
cxrili #6
izolirebuli sistoluri hipertenziis gavrceleba
(Zveli gansazRvreba, ≥160/<90 mm.vwy.sv)
asaki (%)
50
60
70
80+
0.8
5.0
8-12.6
23-25
Framingham Study–is (aseve Zveli gansazRvrebis gamoyenebiT) 24-wlian
kumulaciur monacemebze dayrdnobiT, izolirebuli sistoluri
hipertenziis arseboba maRalia rogorc 65 wels gadaSorebul qalebSi
(533/1000), ise mamakacebSi (418/1000). 65 wels gadaSorebulTa Soris,
izolirebuli sistoluri hipertenzia diagnostirda, rogorc
hipertenziis yvelaze metad gavrcelebuli tipi (57.4%-kacebSi, 65.1%-
qalebSi). zogierTma kvlevam gamoavlina kardio- an cerebrovaskuluri
daavadebebis ganviTarebisa da sikvdilobis gazrdili riski pacientebSi
izolirebuli sistoluri hipertenziiT. izolirebuli sistoluri
hipertenzia orjer da metad zrdis kardiovaskulur avadobasa da yvela
mizeziT ganpirobebul sikvdilobas, xolo kardiovaskulur sikvdilobas
– samjer. MRFIT kvleveaSi, romelSic CarTuli iyo 316 099 mamakaci,
gamovlinda sistoluri wnevis ukeTesi prediqtoruli mniSvneloba
diastolurTan SedarebiT. izolirebuli sistoluri hipertenziis mqone
aranamkurnaleb pacientebSi gamovlinda koncentraciuli remodelirebis
32
tipis marcxena parkuWis hipertrofiis farTo gavrceleba, rac cudi
kardiovaskuluri prognozis mimaniSnebelia.
Catarebuli randomizebuli klinikuri kvlevebi avlens izolirebuli
sistoluri hipertenziis mkurnalobis mniSvnelovan sargeblianobas. Systolic Hypertension in the Elderly Program (SHEP) kvleva iyo pirveli, romelSic
4716 pacientis magaliTze gamovlinda qlortalidoniT (saWiroebis
SemTxvevaSi atenololis da rezerpinis damatebiT) antihipertenziuli
mkurnalobis dadebiTi gavlena kardiovaskulur avadobasa da
sikvdilobaze. Aarafataluri insultis SemTxvevaTa raodenoba Semcirda
37%-iT, arafataluri miokardiumis infarqtis – 33%-iT da marcxena
parkuWis ukmarisobis – 54%-iT. AaRiniSna mkveTri tendencia
tranzitoruli iSemiuri Setevebis (25%-iT), saerTo sikvdilobis (13%-iT),
kardiovaskuluri (20%-iT), cerebrovaskuluri (29%-iT) da koronaruli
(20%-iT) sikvdilobis Semcirebis mxriv. kvlevis farglebSi aseve
gamovlinda SardmJavas damoukidebeli prediqtoruli mniSvneloba
izolirebuli sistoluri hipertenziis mqone pacientebisaTvis.
pacientebSi SardmJavas maRali SemcvelobiT, diuretikebze damyarebuli
mkurnaloba iseTive efeqturi iyo, rogorc pacientebSi SardmJavas
dabali doniT. The Systolic Hypertension in Europe (Syst-Eur) iyo pirveli udidesi
kvleva (romelSic CarTuli iyo izolirebuli sistoluri hipertenziis
mqone 4695 pacienti), romelic mieZRvna gaxangrZlivebuli moqmedebis
kalciumis antagonistis, nitrendipinis (saWiroebis SemTxvevaSi
enalaprilis da/an hidroqlorTiazidis damatebiT) efeqturobis
Seswavlas avadobasa da sikvdilobis riskze. Syst-Eur kvlevaSi
gamovlinda insultebis saerTo raodenobis 42%-iani da sisxlZarRvovani
demenciis ganviTarebis 50%-iani Semcireba, rac ar aRiniSna
qlortalidonis miRebaze damyarebuli SHEP kvlevis dros, Tumca
gamoTqmuli iqna mosazreba dihidropiridinuli jgufis kalciumis
antagonistis, nitrendipinis neiroproteqtoruli efeqtis arsebobis
Sesaxeb. Syst-China kvlevam ganamtkica Sexeduleba izolirebuli
sistoluri hipertenziis mqone pacientebze nitrendipinis dadebiTi
gavlenis arsebobis Sesaxeb, rameTu kvlevis procesSi gamovlinda
insultis saerTo raodenobis 38%-iani, insultiT avadobis 58%-iani,
yvela saxis sikvdilobis 39%-iani, kardiovaskuluri sikvdilobis 39%-
iani, fataluri da arafataluri kardiovaskuluri movlenebis 37%-iani
Semcireba. INSIGHT kvlevis jgufSida analizma gamoavlina, rom
izolirebuli sistoluri hipertenziis mqone pacientebi Cveulebriv
hipertenziasTan SedarebiT ukeT eqvemdebarebodnen gaxangrZlivebuli
moqmedebis nifedipiniT mkurnalobas da mniSvnelovnad naklebi
raodenobiT pacienti saWiroebda meore preparatis damatebas. Staessen-is meta-analizma aCvena, rom aqtiuri mkurnaloba amcirebs saerTo
sikvdilobas 13%-iT, kardiovaskulur sikvdilobas 18%-iT, yvela saxis
kardiovaskuluri garTulebebis ganviTarebas 26%-iT, insultebis
ganviTarebas 30%-iT da koronaruli movlenebis ganviTarebas 23%-iT.
absoluturi sargebeli gamovlinda upiratesad mamakacebSi, 70 wels
gadaSorebul pacientebSi, gadatanili kardiovaskuluri garTulebebisa
da farTo pulsuri wnevis mqone individebSi. aRniSnuli mkurnalobis
prevenciuli efeqti koronarul movlenebTan SedarebiT ufro Zlierad
insultTan mimarTebaSi gamovlinda.
33
sisxlis wnevis Semcirebisa da kardiovaskuluri garTulebebis
prevenciis TvalsazrisiT Catarebulma, medikamentTa efeqturobis
Sesafasebelma kvlevebma gamoavlina beta-blokerebTan SedarebiT
Tiaziddamokidebuli mkurnalobis upiratesoba. izolirebuli
sistoluri hipertenziis mqone pacientebze Catarebulma bolo drois
kvlevebma, romelic moicavda agf-inhibitorebsa da angiotenzin AT1 receptorebis antagonistebs, aseve gamoavlina arteriuli wnevis ukeTesi
kontrolis saSualeba.
izolirebuli sistoluri hipertenziis mqone pacientebisaTvis pirveli
donis mkurnaloba aris cxovrebis stilis Secvla (fizikuri aqtivoba,
marilis moxmarebis SezRudva, Warbi wonis mqone pacientebSi sxeulis
masis Semcireba, Tambaqos moxmarebis Sewyveta). rekomendebuli sisto-
luri wnevis SenarCuneba samizne doneze, kerZod ≤ 140 mm vwy sv
(garkveuli periodis ganmavlobaSi SesaZlebelia 160 mm vwy sv-ze naklebi
cifrebis SenarCunebac). Tu cxovrebis stilis Secvla ar iZleva sisto-
luri wnevis samizne donis miRwevis saSualebas, sisxlis wnevis
kontrolis misaRwevad rekomendebulia medikamenturi mkurnaloba.
izolirebuli sistoluri hipertenziis mqone pacientebisaTvis,
diuretikebi da gaxangrZlivebuli moqmedebis dihidropiridinuli tipis
kalciumis antagonistebi miCneulia mkurnalobis pirveli rigis
medikamentebad. garda aRniSnuli medikamentebisa, izolirebuli sisto-
luri hipertenziis samkurnalod aranakleb efeqtur medikamentebad
iTvleba agf-inhibitorebi da angiotenzin AT1 receptorebis antago-
nistebi. zogierTi mimdinare kvleva iZleva imeds, rom gamovlindes
medikamentebis SesaZlo axali damatebiTi efeqtebi da axali
medikamentebi problemis gadaWris mizniT.
orTostatikuri hipotenzia
normaSi fexze dgomisas sistoluri arteriuli wneva mcirediT
klebulobs da diastoluri wneva mcirediT matulobs. orTostatikuri
hipotenzia diagnostirdeba Tu wamodgomisas sistoluri arteriuli
wneva qveiTdeba > 20 mm/vwy.sv. an diastoluri wneva qveiTdeba > 10
mm/vwy.sv. orTostatikuri hipotenzia gansakuTrebiT xSiria xanSiSesul,
diabetiT daavadebul pacientebSi. Aarsebobs pirdapiri korelacia
orTostatikur hipotenziis simZimesa da sikvdilobas Soris.
orTostatikuri hipotenziis mizezebia: hipovolemia, baroreceptorebis
disfunqcia, avtonomiuri disfunqcia, sxvadasxva venodilatatorebi
(alfa blokerebi, beta-alfa blokerebi). nitratebma da diuretikebma
SeiZleba gaaZlieron orTostatikuri hipotenzia. xanSiSesul pacientTa
mkurnalobisas klinicistebs yovelTvis unda axsovdeT orTostatikuri
hipotenziis ganviTarebis riskis Sesaxeb da ar gamoeparoT misi
simptomebi (wamodgomisas Tavbrusxveva, wonasworobis dakargva, sisuste).
Sesabamisad aucilebelia periodulad wnevis gazomva wolisas da
dgomisas yvela pacientSi 50 wlis zemoT.
34
hipertenzia qalebSi
araorsul qalebSi
arsebobs arteriuli wnevis seqsualuri dimorfizmi, rac gamoixateba
dabal arteriul wnevaSi mozardi asakis qalebSi mamakacebTan SedarebiT
da piriqiT, sicocxlis meeqvse dekadidan qalebs aReniSnebaT ufro
maRali sistoluri arteriuli wneva, vidre mamakacebs. diastoluri
arteriuli wneva qalebSi ufro dabalia vidre mamakacebSi miuxedavad
asakisa. Sesabamisad adreul mozard asakSi hipertenzia naklebad xSiria
qalebSi, vidre mamakacebSi. Tumca sicocxlis mexuTe dekadidan qalebSi
arteriuli hipertenzia gvxvdeba igive an ufro meti sixSiriT vidre
mamakacebSi
menopauza da arteriuli wneva
menopauzis gavlena arteriul wnevaze davis sagans warmoadgens. erTma
nawilma kvlevebisa ver daadastura axdens Tu ara gavlenas menopauza
arteriul wnevaze, maSin rodesac kvlevebis meore nawilma aCvena
arteriuli wnevis mniSvnelovani zrda postmenopauzur qalebSi.
oraluri kontracefcia da arteriuli wneva
qalebis umravlesobas, romlebic iyeneben oralur kontracefcias
aReniSnebaT arteriuli wnevis mcired, magram SesamCnevad mateba, xolo
maT mcire procents ki ewyebaT mniSvnelovani hipertenzia. erT-erTi
kvlevis mixedviT qalebi, romlebic xSirad iyeneben kontraceptivebs
imyofebian ufro maRal risk-jgufSi arteriuli hipertenziis
ganviTarebis, vidre qalebi, romlebic oralur kontraceptivebs ar
xmaroben. sxvadasxva kvlevebma aCvena, rom oraluri kontraceptivebis
moxmarebis Sewyvetis mere arteriuli wneva 3 TveSi ubrundeba sawyis
dones.
kontraceptivebiT Terapiisas rekomendebulia arteriuli wnevis
regularuli monitoringi. kontraceptivis miRebis xangrZlivoba unda
SeizRudos eqvs Tvemde, raTa moxdes mdgomareobis xelaxali Sefaseba.
kontraceptivebiT gamowveuli hipertenziis dros unda Sewydes am
preparatebis miReba. gamonaklis SemTxvevebSi (Tu sxva kontraceptiuli
meTodebi ar aris xelsayreli) kombinirebuli unda iyos
antihipertenziul TerapiasTan.
antihipertenziuli mkurnalobis SerCevis principebi qalebSi
antihipertenziuli mkurnalobis daniSvnisas qalebSi unda
gaviTvaliswinoT, ramodenime specifikuri sakiTxi.
agf blokerebi, a.r. blokerebi ukunaCvenebia orsulebSi an im pirebSi,
romlebic SeiZleba iyvnen fexmZimed, nayofis anomaliebis ganviTarebis
Tavidan asacileblad. ramdenime antihepertenziuli medikamenti
specifiuria sqesis mimarT. magaliTad: kvleva TOMHS-is, mixedviT, qalebs
orjer meti gverdiTi efeqtebi aReniSnebaT, vidre mamakacebs. qalebs
35
ufro xSirad aReniSnebaT diuretikebiT gamowveuli hiponatremia, xolo
mamakacebs podagra. hipokalemia ufro xSiria qalebSi, romlebic
mkurnaloben diuretikebiT. agf inhibitorebiT gamowveuli xvela orjer
ufro xSiria qalebSi, vidre mamakacebSi. qalebSi ufro xSiria
kalciumis arxebis blokerebiT gamowveuli periferiuli SeSupeba da
minoqsidiliT gamowveuli hirsutizmi.
orsulTa hipertenzia
orsulTa hipertenzia dedis, nayofis da neonataluri avadobisa da
sikvdilobis mniSvnelovani mizezia, rogorc ganviTarebad, aseve
ganviTarebul qveynebSi. orsulobis meore trimestrSi aRiniSneba
arteriuli wnevis fiziologiuri daqveiTeba da Sesabamisad, arteriuli
wneva daaxloebiT 15 mm.vwy.sv.-iT (saSualod) naklebia orsulobamdel
donesTan SedarebiT. mesame trimestrSi arteriuli wneva ubrundeba
orsulobamdel dones da SeiZleba gadaaWarbos mas.
dReisaTvis ar arsebobs orsulTa hipertenziis unificirebuli
gansazRvreba. Zveli gansazRvreba eyrdnoboda meore trimestrSi
arteriuli wnevis matebis sidides pirveli trimestris sabaziso
maCveneblTan an orsulobamdel donesTan SedarebiT; dReisaTvis
upiratesoba arteriuli wnevis absolutur doneze (sistoluri
arteriuli wneva (saw) > 140 mm vwy sv an/da diastoluri arteriuli wneva
(daw) ≥90 mm vwy sv) damyarebul gansazRvrebas eniWeba.
orsulTa hipertenziis klasifikacia
orsulTa hipertenzia moicavs Semdeg formebs:
• orsulobamde arsebuli hipertenzia arTulebs orsulobaTa 1-5%-s da
ganisazRvreba, rogorc arteriuli wneva ≥140/90 mm vwy sv, romelic win
uswrebs orsulobas an viTardeba orsulobis meoce kviramde;
Cveulebriv rCeba mSobiarobis Semdeg 42 dReze met xans da SeiZleba
Tan axldes proteinuria;
• gestaciuri hipertenzia ganisazRvreba, rogorc orsulobiT
gamowveuli hipertenzia proteinuriis gareSe. gestaciur hipertenzias
mniSvnelovan proteinuriasTan erTad (>300 mg/l an >500 mg/24 sT an +2
da meti testis Cxirze) preeklamfsia ewodeba. gestaciuri hipertenzia
viTardeba oci kviris orsulobis Semdeg da xasiaTdeba organoebis
perfuziis gauaresebiT;
• gestaciuri hipertenzia da proteinuriiT garTulebuli orsulobamde
arsebuli hipertenzia. aRniSnuli Seesabameba adre arsebul termins -
“preeklamfsiiT garTulebuli qronikuli hipertenzia”. igi xasiaTdeba
orsulobis meoce kviris Semdeg proteinuriiT Tanxlebuli
arteriuli wnevis mkveTri zrdiT (cilis eqskreciasTan ≥3 g/dReSi 24 saaTian SardSi);
• antenatalurad araklasificirebuli hipertenzia ganisazRvreba,
rogorc orsulobis meoce kviris Semdeg pirveladad gamovlenili
hipertenzia sistemuri gamovlinebebiT an maT gareSe. ganmeorebiTi
36
Sefaseba aucilebelia mSobiarobidan 42 dRis Semdeg. Tu am
droisaTvis hipertenzia aRar aRiniSneba, mdgomareoba Sefasdeba
rogorc gestaciuri hipertenzia (proteinuriiT an mis gareSe). Tu
hipertenzia rCeba, mdgomareoba Sefasdeba rogorc orsulobamde
arsebuli hipertenzia.
rekomendebuli laboratoriuli gamokvlevebi
orsulobisas ganviTarebulma hipertenziam da masTan asocirebulma
darRvevebma, kerZod gestaciurma hipertenziam proteinuriiT an mis
gareSe, SeiZleba gamoiwvios hematologiuri, Tirkmlisa da RviZlis
funqciuri maCveneblebis cvlilebebi da uaryofiTi gavlena moaxdinos
dedisa da nayofis gamosavalze. orsulobisas hipertenziuli
pacientebis monitoringisaTvis rekomendirebuli ZiriTadi
laboratoriuli gamokvlevebi mocemulia cxrili #7-Si.
cxrili #7
orsulTa hipertenziis mqone pacientebis monitoringisaTvis
rekomendebuli ZiriTadi laboratoriuli gamokvlevebi
hemoglobini da
hematokriti
hemokoncentracia gestaciuri hipertenziis diagnozis (proteinuriiT an mis
gareSe) safuZvlia da miuTiTebs mdgomareobis simZimeze. Zalian mZime
SemTxvavevebSi aRniSnuli maCvenebeli SeiZleba dabali iyos, rac
hemoliziTaa ganpirobebuli.
Trombocitebi
aRiniSneba Trombocitopenia < 100.000X 1099//ll,, rraacc SSeessaaZZlleebbeelliiaa mmcciirree
ssiissxxllZZaarrRRvveebbSSii mmiiss mmooxxmmaarreebbaazzee mmiiuuTTiiTTeebbddeess.. mmaaCCvveenneebbeellii kkoorreelliirreebbss
ssiimmZZiimmeessTTaann ddaa ggaannssaazzRRvvrraavvss mmSSoobbiiaarroobbiiss SSeemmddggoomm ppeerriiooddSSii
ggaammoojjaannmmrrTTeelleebbiiss tteemmppss..
ast da alt
sisxlSi
momatebuli maCvenebeli miuTiTebs procesSi RviZlis CarTvaze. SemdgomSi
maTi mateba mdgomareobis damZimebaze miuTiTebs.
ldh sisxlSi
momatebuli done procesSi RviZlis CarTvasa da hemolizze miuTiTebs.
SeiZleba asaxavdes mdgomareobis simZimes da gansazRvravdes mSobiarobis
Semdgom gamojanmrTelebis potencials.
proteinuria (24
saaTiani Sardis
SegrovebiT)
proteinuriis Sesafasebeli standartuli meTodia. Tu proteinuriis done
metia 2 g/dReSi, aucilebelia intensiuri monitoringis ganxorcieleba. im
SemTxvevaSi, Tu is aRemateba 3 g/dReSi, unda daisvas mSobiarobis
daCqarebis sakiTxi.
Sardis analizi
testis CxiriT proteinuriis gansazRvra xasiaTdeba cru-pozitiuri da
cru-negatiuri Sedegebis mniSvnelovani sixSiriT. dadebiTi Sedegis
SemTxvevaSi (≥1), proteinuriis dasadastureblad saWiroa 24 saaTiani
Sardis kvleva. uaryofiTi Sedegi ar gamoricxavs proteinurias,
gansakuTrebiT daw ≥ 90 mm vwy sv SemTxvevaSi.
SardmJava
sisxlSi
momatebuli done gvexmareba gestaciuri hipertenziis diferencialur
diagnozSi da SeiZleba asaxavdes mdgomareobis simZimes.
kreatinini
sisxlSi
done qveiTdeba orsulobisas. momatebuli done hipertenziis simZimis
xarisxis zdaze miuTiTebs; mizanSewonilia kreatininis 24 saaTiani
klirensis gansazRvra.
aasstt –– aassppaarrtt aammiinnoottrraannssffeerraazzaa;;
aalltt -- aallaanniinn aammiinnoottrraannssffeerraazzaa;;
llddhh –– llaaqqttaattddeehhiiddrrooggeennaazzaa;;
ddaaww –– ddiiaassttoolluurrii aarrtteerriiuullii wwnneevvaa..
37
orsulTa hipertenziis mkurnaloba
pacientebs, romelTac orsulobamde aReniSnebodaT msubuqi an saSualo
simZimis arteriuli hipertenzia(140-179/90-109 mm vwy sv) da ar gaaCniaT
Tirkmlis funqciis darRvevebi, ar saWiroeben medikamentur Carevas,
radgan ar arsebobs imis mtkicebuleba, rom farmakologiuri mkurnaloba
neonataluri gamosavlis gaumjobesebas iwvevs. SefardebiTi riski
pacientTa am kontigentSi SedarebiT dabalia.
B
orsulTa hipertenziis aramedikamenturi mkurnaloba da profilaqtika
aramedikamenturi marTvis sakiTxi unda daisvas im SemTxvevaSi, roca
orsulebs aReniSnebaT saw 140-149 mm. vwy.sv. an daw 90-99 mm.vwy.sv, an orive
erTad. mkurnalobis tipi ganisazRvreba arteriuli wnevis doniT,
gestaciuri asakiT, dedisa da nayofis mdgomareobiT; da moicavs mWidro
zedamxedvelobas, aqtivobis SezRudvas da xSirSemTxvevaSi, woliT reJims
marcxena lateralur poziciaSi.
aseTi pacientebisaTvis rekomendebulia dieta marilis SezRudviT.
kalciumis preparatebis (2 g/dReSi), Tevzis qonisa da dabali doziT
acetilsalicilis mJavas miRebam ver dadasturda efeqturoba
gestaciuri hipertenziis, gansakuTrebiT preeklamfsiis riskis Semcirebis
TvalsazrisiT. im qalebSi, romlebsac anamnezSi aReniSnebaT adreuli
preeklamfsia (<28 kvira), aspirinis dabali dozebiT profilaqtikuri
daniSvna mizanSewonilia. orsulobis periodSi arteriuli wnevis
daqveiTebisaTvis wonis dakleba rekomendirebuli ar aris, rameTu wonis
daklebam SeiZleba gamoiwvios axalSobilis dabali wona da Seaferxos
bavSvis zrda (dedis dietaze yofnis SemTxvevaSi).
sakamaTo rCeba qronikuli hipertenziis mqone orsul qalebSi
antihipertenziuli medikamentebis mudmivi miRebis saWiroebis sakiTxi.
arsebobs erTiani azri imis Sesaxeb, rom orsulobisas mZime hipertenziis
medikamenturi mkurnaloba aucilebeli, efeqturi da sasargebloa.
hipertenziis SedarebiT msubuqi formebis mkurnalobis Sesaxeb ki
gansxvavebuli mosazrebebi arsebobs. marTalia, artriuli wnevis
daqveiTeba dedisTvis SeiZleba sasargeblo iyos, magram aman SeiZleba
gaauaresos uteroplacenturi perfuzia da Sesabamisad nayofis
ganviTareba.
orsulTa hipertenziis farmakologiuri mkurnaloba
miuxedavad imisa, rom orsulTa hipertenziis mkurnalobis mizani
dedismxrivi riskis Semcirebaa, SerCeuli preparatebi misaRebi unda iyos
nayofisTvisac.
orsulebSi, romelTac aReniSnebaT: gestaciuri hipertenzia proteinuriis
gareSe an arsebuli hipertenzia 28 kviris orsulobamde, gestaciuri
hipertenzia da proteinuria an simptomebiT mimdinare orsulobis
nebismieri periodi, arsebuli hipertenzia da samizne organos dazianeba,
gestaciuri hipertenzia garTulebuli arsebuli hipertenziiT, -
mkurnalobis dawyebis zRurblia saw - 140 mm.vwy.sv. da daw – 90 mm.vwy.sv.
38
sxva SemTxvevaSi Carevis zRurbli saw - 150 mm.vwy.sv da daw – 95
mm.vwy.sv.-aa.
orsulebSi saw ≥170 mm vwy sv an daw ≥110 mm vwy sv unda CaiTvalos
gadaudebel mdgomareobad da aucilebelia hospitalizacia.
SesaZlebelia farmakologiuri mkurnaloba intravenuri
labetaloliT, peroraluri meTildofaTi an nifedipiniT. intravenuri
hidralazini aRar ganixileba arCevis preparatad, ramdenadac misi
gamoyeneba sxva medikamentebTan SedarebiT ufro met perinatalur
gverdiT movlenebTan asocirdeba;
hipertenziis naklebad mZime formisas arCevis medikamentebia
meTildofa, labetaloli, kalciumis antagonistebi da beta-
blokatorebi. amasTan, kalciumis antagonisti ar unda dainiSnos
magniumis sulfatTan erTad (hipotenziis riski; potenciuri
sinergizmis gamo);
orsulobisas ar SeiZleba angiotenzinis gardamqneli fermentis (agf)
inhibitorebis da angiotenzi II antagonistebis gamoyeneba;
preeklamfsiis SemTxvevaSi Semcirebulia plazmis moculoba. aqedan
gamomdinare, Tu saxeze ar aris oliguria, SardmdenebiT mkurnaloba
araadeqvaturia;
eklamfsiis prevenciisa da krunCxvebis mkurnalobaSi efeqturia
magniumis sulfatis intravenuri ineqcia;
naadrevi mSobiarobis gamowveva saWiroa im SemTxvevebSi, Tu aRiniSneba
proteinuriisa da gestaciuri hipertenziis iseTi garTulebebi,
rogoricaa mxedvelobis gauareseba, koagulaciuri darRvevebi an
nayofis distresi.
hipotenziuri preparatebi orsulebSi
orsulebs, romelTac aReniSnebodaT orsulobamdeli periodis
hipertenzia, unda ganagrZon daniSnuli hipotenziuri medikamentebis
miReba, garda agf-inhibitorebisa da angiotenzin II antagonistebisa.
arsebuli hipertenziis mqone qalebma, romelTa daw ≥100 mm.vwy.sv. (an daw <100 mm.vwy.sv. da aReniSnebaT samizne organoebis dazianeba an/da
Tirkmlis paTologiis arseboba) da mwvave hipertenziisas (daw ≥105 mm.vwy,sv.) rekomendirebulia miiRon Semdegi preparatebi:
39
centraluri alfa
agonistebi meTildofa arCevis preparatia
beta-blokatorebi atenololi da metaprololi uvnebeli da efeqturia orsulobis
mogvianebiT periodSi
alfa/beta-
blokatorebi
labetalols aqvs meTildofas msgavsi moqmedeba; mZimed mimdinare
hipertenziis SemTxvevaSi unda dainiSnos intravenurad
kalciumis arxebis
blokatorebi
arteriuli hipertenziis dros, gadaudebel situaciebSi unda
dainiSnos peroralurad nifedipini, an intravenurad isradipini. am
jgufis preparatebis daniSvnam magniumis sulfatTan, potenciurad
sinergistuli moqmedebis gamo SeiZleba gamoiwvios hipotonia
agf-inhibitorebi,
angiotenzin II
antagonistebi
preparatebis miRebam SeiZleba gamoiwvios nayofis dazianeba da
sikvdili, ris gamoc isini ukunaCvenebia orsulebSi
Sardmdenebi
Sardmdenebi rekomendebulia qronikuli hipertenziis mqone qalebSi
Tu isini daniSnuli iyo gestaciamde, an pacientebSi, romelTac
aReniSnebaT gaZlierebuli mgrZnobeloba marilis mimarT. am jgufis
preparatebi ar aris rekomendirebuli pre-eklamfsiis dros
pirdapiri
vazodilatatorebi hidralazini iniSneba upiratesad parenteralurad
hipertenzia laqtaciis dros
ZuZuTi kveba ar zrdis dedis arteriul wnevas. meZuZuri dedis mier
miRebuli yvela antihipertenziuli preparati xvdeba rZeSi. maTi
umravlesobis koncentracia Zalian dabalia, garda propranololisa da
nifedipinisa, romelTa koncentracia dedis rZeSi plazmuri
koncentraciis sidides utoldeba.
hipertenzia bavSvebsa da mozardebSi
bavSvebsa da mozardebSi arteriuli hipertenzia ganisazRvreba rogorc
ramodenime ganmeorebiTi gazomviT miRebuli maRali arteriuli wnevis
cifrebi - asakis, sqesis da simaRliT gaTvaliswinebulis 95 persintili
an meti. bavSvebSi hipertenziis SemTxvevaSi eqimma aucileblad unda
ifiqros meorad hipertenziaze da klinikuri monacemebis safuZvelze
daiwyos Sesabamisi gamokvlevebi. mozardebSi arteriuli hipertenzia
xSirad asocirebulia simsuqnesTan, mjdomare cxovrebis wesTan,
hipertenziis da sxva kardiovaskuluri garTulebebis ojaxur anamnezTan.
arteriuli hipertenziis mkurnalobisas farmakologiuri Terapia
aucilebeli xdeba, roca misi marTva ver xerxdeba mxolod cxovrebis
wesis SecvliT. antihipertenziuli medikamentebi igivea, rac mozrdili
asakis pacientTaTvis, mxolod doza aris mcire da amavdroulad unda
dainiSnos didi sifrTxiliT. Aagf inhibitorebi da a.r. blokerebi ar gamoiyeneba orsul da seqsualurad aqtiur gogonebSi, romelTac
dafexmZimebis riski aqvT. gaurTulebeli hipertenziis pirobebSi, bavSvebi
ar unda SeizRudon fizikuri aqtivobis mxriv, radganac xangrZlivi
40
varjiSi aqveiTebs arteriul wnevas. bavSvebSi mkacrad ikrZaleba
anaboluri steroidebis gamoyeneba.
hipertenziis gadaudebeli da saswrafo SemTxvevebis mkurnaloba
hipertenziis gadaudebeli SemTxvevebi ganisazRvreba, rogorc arteriuli
wnevis (aw) Zlieri mateba samizne organoebis mwvave dazianebis
arsebobisas. mwvave koronaruli sindromi, aortis ganSrevebadi
anevrizma, filtvebis mwvave SeSupeba, hipertenziuli encefalopaTia,
Tavis tvinis mwvave infarqti an intracerebruli sisxlCaqceva da
eklamfsia aris is klinikuri mdgomareobebi, rodesac saWiroa aw
dauyovnebeli daqveiTeba, raTa Tavidan iqnes acilebuli samizne
organoebis dazianebis progresireba (cxrili #8).
hipertenziis saswrafo SemTxvevebi aris aw Zlieri mateba (>180/120 mm.
vwy.sv) samizne organoebis mwvave dazianebis gareSe. hipertenziis
saswrafo SemTxvevebis dros aw Cveulebriv unda daqveiTdes oralurad
misaRebi medikamentebiT, ambulatoriuli meTvalyureobis qveS.
pirveladi Sefaseba
pirveladi Sefasebis kritikuli nawilia pacientebisaTvis
damaxasiaTebeli triada: anamnezis dawvrilebiTi Segroveba
(gansakuTrebuli yuradReba unda mieqces hipertenziis da samizne
organoebis dazianebis arsebobas), zusti fizikaluri gasinjva (moicavs
ofTalmoskopiasac) da SerCeviTi laboratoriuli gamokvlevebi,
rogoricaa Sardis analizi, kreatinini, Sardovana, eleqtrolitebi da
sisxlis saerTo analizi.
Tu saeWvoa simptomuri hipertenziis arseboba, saWiroa sisxlSi
gamokvleul iqnas reninis, aldosteronis da kateqolaminebis
Semcveloba. yvela avadmyofs mizanSewonilia Cautardes
eleqtrokardiografia da gulmkerdis rentgenologiuri gamokvleva
(cxrili #9).
arsebuli gaidlainebis mixedviT, arteriuli wneva unda gaizomos mjdo-
mare da vertikalur poziciebSi. Tu aRiniSneba xelebs Soris aw mniSvne-
lovani sxvaoba, eWvi unda iqnas mitanili aortis ganSrevebaze.
gadaudebeli daxmarebis ganyofilebebSi unda Catardes aw zusti
monitorireba.
hipertenziis gadaudebeli SemTxvevebis mkurnaloba
avadmyofebi unda moTavsdnen intensiuri Terapiis palataSi klinikuri
meTvalyureobisa da aw xangrZlivi monitorirebis mizniT. umravles Sem-
TxvevebSi upiratesoba eniWeba parenteraluri medikamentebiT agresiul
mkurnalobas, risi mizanic aris aw nawilobrivi daqveiTeba (da ara
normalizacia), pirveli wuTebidan erTi an ori saaTis ganmavlobaSi 20-
25%-iT, Semdeg saWiroa aw frTxili daqveiTeba. aw swrafi daqveiTeba
41
misaRebia hipertenziis gadaudebeli SemTxvevebis umetesobisas,
cerebrovaskuluri SemTxvevebis garda, rodesac mizanSewonilia ufro
frTxili midgoma. aw mkveTri daqveiTeba potenciurad saSiSia iseTi
SesaZlo iSemiuri garTulebebis gamo, rogoricaa miokardiumis mwvave
infarqti da Tavis tvinis insulti. hipertenziis gadaudebeli
SemTxvevebis dros gamoiyeneba parenteraluri medikamentebi (cxrili
#10). pirveli rigis antihipertenziuli medikamentebis SerCeva unda
moxdes pacientis sruli klinikuri mdgomareobis gaTvaliswinebiT.
hipertenziis gansakuTrebuli specifikuri SemTxvevebi
avadmyofebSi mwvave koronaruli sindromiT aw mniSvnelovani mateba ar
aris iSviaTi. im pacientebSi, romlebsac hemodinamikurad dadasturebuli
ara aqvT koronaruli arteriebis daavadebebi, aw mniSvnelovanma matebam
SesaZloa Tavis mxriv gamoiwvios miokardiumis iSemia marcxena parkuWis
kedlis daWimulobis da miokardiumis Jangbadze moTxovnilebis mniSvne-
lovani zrdis Sedegad. aseT SemTxvevebSi sawyisi medikamentebia
nitroglicerini da nitroprusidi beta-blokerebTan kombinaciaSi
(labetaloli, metaprololi, esmololi an atenololi), rac daaqveiTebs
aw da guliscemis sixSires da Sesabamisad iklebs miokadiumis mier
Jangbadis moxmarebac.
marcxena parkuWis mwvave ukmarisobis dros aw unda gakontroldes swra-
fad. arCevis preparatebia intravenuri nitroglicerini an nitroprusidi
maryuJovan SardmdenebTan kombinaciaSi, moculobiTi gadaZabvis
kontrolisaTvis.
pacientebSi aortis ganSrevebiT da hipertenziiT aw kontroli
gadamwyvetia. mkurnaloba unda daiwyos dauyovnebliv da sistoluri aw
daqveiTdes swrafad 100 mm.vwy.sv-ze qveviT. idealurma medikamentma unda
daaqveiTos aramarto wneva, aramed Seamciros guliscemis sixSire, Sekum-
Svadoba da aortis kedlis daWimuloba. es SeiZleba ganxorcieldes
beta-blokeris da vazodilatatoris, rogoricaa nitroprusidi an
nitoglicerinis kombinaciis intravenuri SeyvaniT.
feoqromocitomis dros krizis marTva xdeba intravenuri alfa-
blokeriT, rogoricaa fentolamini, Semdgom beta-blokeris Tanmxlebi
gadasxmiT; SesaZloa daematos nitroprusidi.
pacientebSi feoqromocitomiT beta-blokerebi yovelTvis unda SeuRldes
alfa-blokerebTan. beta-receptorebis inhibireba iwvevs vazodilatirebis
stimulirebas, rac Tavidan aicilebs aw matebas alfa-adrenerguli vazo-
konstriqciis pirobebSi. monoTerapia labetaloliT axdens alfa da
beta blokadas. Tavis tvinSi mwvave sisxlCaqcevis mqone avadmyofebSi
antihipertenziuli mkurnaloba jer kidev sakamaToa. Tavis tvinis
iSemiuri ubnebSi iTrguneba sisxlis nakadis autoregulacia da aw
daqveiTeba amcirebs sisxlis miwodebas iSemiur ubnebSi, rasac mosdevs
infarqtis zomebis zrda.
amgvarad, iSemiuri insultis dros antihipertenziuli mkurnaloba
rekomendirebulia mxolod Tu aw cifrebi aris 220/120 mm.vwy.sv-ze maRali
(an saSualo aw >140 mm.vwy.sv) da aw unda daqveiTdes sawyis monacemebTan
SedarebiT 10-15%-iT. mkurnaloba unda daiwyos intravenuri
42
labetaloliT da Tu saWiroa nitrogliceriniT an nitroprusidiT.
pacientebSi mwvave sisxlCaqceviT, romelTac utardebaT Trombolizisi,
aw unda SenarCundes 185/110 mm.vwy.sv-ze qveviT.
pirveladi intracerebraluri sisxlCaqcevis dros mkurnaloba unda
daiwyos, Tu aw cifrebi aris 180/105 mm.vwy.sv-ze meti.
mwvave postoperaciuli hipertenzia ar aris iSviaTi, gansakuTrebiT
kardioTorakaluri, vaskuluri, Tavis, kisris da neiroqirurgiuli ope-
raciebis Semdeg. arakardiuli qirurgiis umetes SemTxvevebSi ar aris
SeTanxmeba im zRurblze, rodesac unda daiwyos mkurnaloba da am
SemTxvevSi mxedvelobaSi unda iqnes miReebuli avadmyofebis ZiriTadi aw,
qirurgiuli proceduris tipi da asocirebuli klinikuri mdgomareobebi.
misaRebia aw cifrebis SenarCuneba operaciamdeli monacemebis 20%-is
farglebSi. kardioTorakaluri qirurgiis SemTxvevebSi riski matulobs.
aw cifrebis postoperaciuli matebis SemTxvevaSi aw unda iyos 140/90
mm.vwy.sv-ze qveviT. arteriuli wnevis kontrolis mizniT gamoyenebuli
unda iqnas labetaloli (da sxva beta-blokerebi), nitroprusidi,
nitroglicerini an fenildopami intravenurad.
hipertenziis saswrafo SemTxvevebis mkurnaloba
mZime hipertenziiT avadmyofTa umravlesobaSi samizne organoebis
dazianebis niSnebi Cveulebriv ar aris. aseT avadmyofebSi aw unda
daqveiTdes TandaTanobiT 24-48 saaTis ganmavlobaSi. es xSirad
xorcieldeba oraluri medikamentebiT, stacionarSi moTavsebis gareSe
da ambulatoriuli meTvalyureobis qveS. klinikuri gaumjobeseba
SesaZlebelia wamlebis miRebidan pirvel ramdenime saaTSi, aw unda
daqveiTdes TandaTanobiT. asimptomur pacientebSi, romlebsac ara aqvT
samizne organoebis aSkara mwvave dazianeba, aw swrafi daqveiTeba ar aris
mizanSewonili da piriqiT aw mkveTrma dawevam SeiZleba ufro meti ziani
miayenos. cxrili #11-Si mocemulia hipertenziis saswrafo SemTxvevebis
dros rekomendirebuli oraluri medikamentebi. Tavidanve
antihipertenziuli medikamentebis kombinaciis gamoyeneba zrdis aw
daqveiTebis efeqturobis albaTobas.
sublingualuri nifedipiniT aw daqveiTebis xarisxi inducirdeba, risi
arc winaswarmetyveleba da arc kontroli ar aris SesaZlebeli da
amitomac es preparati ar aris rekomendirebuli.
daskvnebi
aw mZime elevaciis dos samizne organoebis mwvave dazianebis
identificirebisaTvis gadamwyvetia dauyovnebeli, da zusti moqmedebis
dawyeba.
pirveladi gamokvlevis Sedegebze dayrdnobiT, mkurnaloba unda
daiwyos gadaudebeli daxmarebis ganyofilebaSi parenteruli an
oraluri medikamentebiT. aw unda daqveiTdes swrafad, magram Tavidan
unda aviciloT mkveTri daqveiTeba, vinaidan SemTxvevaTa
umravlesobaSi aw daqveiTeba da ara normalizacia aris mkurnalobis
mizani.
43
cxrili #8
hipertenziis gadaudebeli SemTxvevebi
hipertenziuli encefalopaTia
Zlieri hipertenzia asocirdeba samizne organoebis mwvave dazianebasTan
- mwvave koronaruli sindromi
- filtvebis SeSupeba
- aortis mwvave ganSreveba
- intracerebraluri sisxlCaqceva, subaraqnoiduli sisxlCaqceva
- Tavis tvinis mwvave infarqti
- mwvave an swrafad progresirebadi Tirkmlis ukmarisoba
Zlieri hipertenzia ganviTarebuli iSemiuri insultis dros Catarebuli
Trombolizisis Semdeg
krizi feoqromocitomis dros
uillian-Barre-s sindromi zurgis tvinis dazianeba
medikamentebi, romlebsac ukavSirdeba hipertenzia (simpaTomimeturi saSualebebi,
fentiklidini, fenilproponolamini, dieTilamini, ciklosporini)
eklamfsia
postoperaciuli sisxldena
gvirgvinovani arteriebis Suntirebis Semdgomi hipertenzia
cxrili #9
diagnostikuri gamokvlevebi
sisxlis wnevis ganmeorebiTi gazomvebi (pirveli gazomva orive mxarze)
klinikuri istoria da saeqimo gasinjva
- karsiovaskuluri
- cns
- Tvalis fskeri
seleqciuri laboratoriuli kvlevebi
- Sardis analizi, kreatinini, Sardovana, eleqtrolitebi da sisxlis saerTo analizi
- Tu simptomur hipertenziazea eWvi, plazmaSi reninis, aldosteronis da
kateqolaminebis aqtivobis dadgena
eleqtrokardiograma
gulmkerdis rentgenologiuri gamokvleva
Semdgomi kvlevebi (ukavSirdeba klinikur suraTs)
- eqokardiografia (TTE, TE) - Tavis tvinis C T an MRI - abdominuri ultrasonografia
- Torako, abdominuri C T an MRI - vaskuluri ultrabgeriTi gamokvleva
44
cxrili #10
hipertenziis gadaudebeli mdgomareobisaTvis saWiro medikamentebi
medikamenti doza sawyisi xangrZlivoba gverdiTi movlenebi
Sodium Nitroprussiate
0,25 – 10
mg/kg/wT dauyovnebeli 1 - 2 wT. hipotenzia, Rebineba,
cianaturi toqsiuroba
Labetalol 20 – 80 mg.
nakadiT;
1 – 2 mg/wT
wveTovnad
5 – 10 wT. 2 – 6 sT. gulisreva, Rebineba,
gulis blokada,
bronqospazmi
Glyceryl trinitrato
5 – 100 µg/wT 1 - 3 wT. 5 – 15 wT. Tavis tkivili, Rebineba
Enalaprilat 1,25 – 5,0 mg.
nakadurad
15 wT. 4 – 6 sT. hipotenzia, Tirkmlis
ukmarisoba, angioedema
Furosemde 40 – 60 mg 5 wT. 2sT. hipotenzia
Fenoldopam 0,1 – 0,6
µg/kg/wT 5 – 10 wT. 10 – 15 wT. hipotenzia, Tavis
tkivili
Nicardipine 2 – 10 mg/sT 5 – 10 wT. 2 – 4 sT. refleqsuri taqikardia,
saxis siwiTle
Hydralazine 10 20 mg.
nakadurad
10 wT. 2 – 6 sT. refleqsuri taqikardia
Phentolamine 5 – 10 mg/wT 1 – 2 wT. 3 – 5 wT. refleqsuri taqikardia
Urapidil 25 – 50 mg.
nakadurad
3 – 4 wT. 8 – 12 sT. sedacia
45
cxrili #11
hipertenziis saswrafo SemTxvevebis samkurnalo medikamentebi
medikamenti doza pikis dro naxevardaSlis
periodi
gverdiTi movlenebi
Captopril 12,5 – 25 mg.
p/o 15 - 60 wT. 1,5 sT. pacientebSi Tirkmlis
arteriis stenoziT
Tirkmlis ukmarisoba
labetalol 200 – 400 mg.
p/o 20 – 120 wT. 2,5 – 8 sT bronqospazmi,
miokardiumis
SekumSvadobis
daqveiTeba, AV blokada,
gulis da RviZlis
enzimebis elevacia
furosemide 25 – 50 mg.
p/o1 –2 sT. 0,5 – 1,1 sT. moculobis daqveiTeba
Amlodipine 5 – 10 mg.
p/o 1 – 6 sT. 30 – 50 sT. Tavis tkivili,
taqikardia, saxis
siwiTle, periferiuli
SeSupebebi
Felodipine 5 – 10 mg.
p/o 2 – 5 sT. 11 – 16 sT. Tavis tkivili,
taqikardia, saxis
siwiTle, periferiuli
SeSupebebi
Isradipine 5 – 10 mg.
p/o 1 – 1,5 sT. 8 – 16 sT. Tavis tkivili,
taqikardia, saxis
siwiTle, periferiuli
SeSupebebi
Prazosin 1 – 2 mg.
p/o 1 – 2 sT. 2 – 4 sT. sinkope (pirveli doza),
TrTolva, taqikardia,
orTostatuli
hipotenzia
damatebiTi mosazrebebi antihipertenziuli medikamentebis
arCevis Sesaxeb
antihipertenziul medikamentebs aqvT sasargeblo da gverdiTi efeqtebi
sxva Tanmxlebi paTologiebis arsebobisas.
sasargeblo efeqtebi
Tiaziduri tipis diuretikebi sasargebloa Tanmxlebi osteoporozis
dros. Bbeta blokerebis gamoyeneba sasargebloa winagulovani
taqikardiis/fibrilaciis, Sakikis, Tireotoqsikozis, tremoris sawyisi
stadiis an winasaoperacio hiperternziis mkurnalobis dros. kalciumis
arxebis blokerebis gamoyeneba mizanSewonilia reinos sindromisa da
zogierTi ariTmiis Tanaarsebobisas. alfablokerebi ki prostatis
adenomis dros.
46
gverdiTi efeqtebi
Tiaziduri tipis diuretikebi, sifrTxiliT gamoiyeneba, im pacientebSi
visac aqvT podagra, visac anamnezSi aReniSneba hiponatremia. beta
blokerebi ukunaCvenebia im pacientebSi, visac aqvT asTma, sasunTqi gzebis
daavadebebi, meore da mesame xarisxis blokada. agfi da a.r.b. winaaRmdegnaCvenebia fexmZime qalebSi. agfi agreTve ar gamoiyeneba im
pacientebSi visac anamnezSi aReniSnebaT angioedema. aldosteronis
antagonistebma da kaliumis Semnaxvelma diuretikebma SeiZleba
gamoiwvion hiperkalemia da ukunaCvenebia im pacientebSi visac plazmaSi
kaliumis done aqvT> 5,0ml.eq/l-ze.
rezistentuli hipertenzia
hipertenzia jer kidev rCeba janmrTelobis udides problemad, romelic
moicavs 60 wels gadaSorebuli mosaxleobis daaxloebiT 30%-s.
hipertenziul pacientTa 10% rezistentulia mkurnalobis mimarT.
rezistentuli hipertenzia ganisazRvreba, rogorc nebismier asakobriv
jgufSi sami an meti gansxvavebuli antihipertenziuli agentis
erTdrouli gamoyenebis miuxedavad arteriuli wnevis 140/90 mm.vwy.sv.-ze
metad daqveiTebis SeuZlebloba.
refraqteruli hipertenziis sistomaturi Sefaseba klinikis pirobebSi
aucilebelia procesSi CarTuli faqtorebisa da meqanizmebis
identificirebis mizniT. Yakovlevitch-ma da Black-ma gamoavlines
suboptimaluri medikamenturi reJimi, rogorc yvelaze gavrcelebuli
faqtori (43%), romelic mohyveba medikamenturi mkurnalobis mimarT
tolerantobis darRvevas (22%), damyolobis ararsebobasa (10%) da
meoradi hipertenzias (11%). meoradi hipertenziis gavrcelebis done
msgavsia Anderson-is (10%) da Desforges-is (11%) angariSebSi. meoradi
hipertenziis mizezebis moZiebamde, romelic moicavs ZviradRirebul
kvlevis meTodebs, unda moxdes medikamenturi reJimis Sesabamisobis,
medikamentebis SesaZlo urTierTqmedebis, alkoholis da medikamentebis
erTdrouli miRebis, medikamenturi reJimis darRvevis,
fsevdohipertenziis, TeTri xalaTis/ofisis hipertenziis, siTxis
Sekavebis, simsuqnis an Zilis apnoes sindromis gulmodgine gamokvleva-
Sefaseba. am faqtorebis eliminaciis Semdeg, WeSmaritad refraqteruli
hipertenzia aRiniSneba mxolod hipertenziis mqone saerTo populaciis
5%-Si. metad gavrcelebuli egzogenuri substanciebi/medikamentebi,
romlebic xels uSlian hipertenziis kontrols, aris NSAIDS, alkoholi,
malxeni medikamentebi, oraluri kontraceptivebi da fsiqotropuli
medikamentebi.AamasTan, arsebobs farTo individSida variabeloba
medikamentebis efeqturobis mxriv, rac xSirad SeuZlebels xdis sisxlis
wnevis kontrols. pacientis damyoloba udavod didi komponentia
sisxlis wnevis warmatebuli kontrolis misaRwevad. sisxlis wnevis
kontrolis SeuZlebloba SemTxvevaTa 50%-Si Tan axlavs medikamenturi
reJimis darRvevas, e.w. fsevdorefraqteroba.
fsevdohipertenzia ganisazRvreba rogorc mdgomareoba, romlis drosac
manJetSida wneva Seusabamod maRalia sisxlZarRvSida wnevasTan
47
SedarebiT, rac ganpirobebulia sisxlZarRvTa sixistiT. iTvleba, rom
fsevdohipertenzia metad gavrcelebulia asakovanTa Soris.
miuxedavad imisa, rom “TeTri xalaTis hipertenzia” (izolirebuli
ofisis an klinikuri hipertenzia) da “TeTri xalaTis efeqti”
ganisazRvra oTxmocdaaTiani wlebis dasawyisSi, rezistentuli
hipertenziis mqone pacientebSi. am movlenis irgvliv SezRuduli
raodenobiT kvlevebia Catarebuli. cota xnis win gamoqveynebul Brown et al kvlevaSi, arteriuli wnevis 24-saaTiani ambulatoriuli monitorirebis
monacemebis mixedviT, gamoxatuli rezistentuli hipertenziis mqone
yoveli 10 pacientidan 2-3-s aReniSneba kontrolirebuli sisxlis wneva.
plazmis moculobis siWarbe, romelic SesaZlebelia gazomil iqnas L125
radioaqtiurad moniSnuli albuminiT, damaxasiaTebelia pacientebisaTvis
rezistentuli hipertenziiT. es pacientebi kargad eqvemdebarebian
diuretikebs. populaciuri kvlevebi avlenen xazovan kavSirs marilis
moxmarebasa da sisxlis wnevas Soris. Warb natriums SeuZlia Seasustos
agf-inhibitorebis da diuretikebis efeqti, amdenad sakvebi marilis
moxmarebis SezRudva aucilebelia rezistentuli hipertenziis mqone
yvela pacientisaTvis.
fremingemis kvlevis Sedegebi aCveneben sxeulis masis indeqsis (>25-30 kg/m2) da rezistentuli hipertenziis kavSirs. sxeulis masis yoveli 10%-
iT mateba asocirdeba sistoluri wnevis 6,5 mm-ian matebasTan. sxeulis
masis Semcireba rekomendebuli unda iyos yvela hipertenziis mqone
pacientisTvis. aseve gamovlinda mniSvnelovani kavSiri Zilis apnoesa da
hipertenzias Soris. bolo drois naSromebi aCveneben, rom rezistentuli
hipertenziis mqone pacientebisTvis damaxasiaTebelia Zilis apnoes
sindromi da Tumca meqanizmi ucnobia, naCvenebia mkurnaloba haeris
nazaluri mudmivi dadebiTi wneviT, romelic iwvevs sisxlis wnevis
Semcirebas.
am mavne faqtorebis eliminaciis da Seqcevadobis Semdeg, SeiZleba
ganxilul iqnas meoradi mizezebi. bolo wlebis kvlevebi aCveneben, rom
hiperaldosteronizmi aris metad damaxasiaTebeli meoradi mizezi (8-32%),
romelsac mivyavarT Tirkmlis ukmarisobisa da Tirkmlis arteriis
stenozis ganviTarebamde. pacientebSi dabali renin-rezistentuli
hipertenziiT, aldosteronizmis skriningi aucilebelia. pirveladi
hiperaldosteronizmi kargad eqvemdebareba Sesabamis mkurnalobas
(qirurgiuls an medikamenturs). renovaskuluri daavadebisas
revaskularizacia aRadgens Tirkmlis funqcias, magram sisxlis wnevis
kontroli limitirebulia. Tirkmlis ukmarisobis mkurnaloba tardeba
etiologiis mixedviT.
“WeSmariTad rezistentuli hipertenzia” SesaZlebelia diagnostirdes,
mxolod zemo aRniSnuli xelSemSleli faqtorebis eliminaciis Semdeg.
gaTvaliswinebul unda iqnas, rom meorad hipertenzias SeiZleba Tan
axldes mravali egzogenuri faqtori. rezistentuli hipertenziis
mkurnaloba moicavs egzogenuri faqtorebis eliminaciasa da mravali
medikamentis maqsimaluri tolerantuli (asatani) dozebis,
xangrZlivmomqmedi diuretikebis CaTvliT, gamoyenebas. Ouzan et al kvlevam
aCvena, rom sam- an oTxkomponentian medikamentur kombinaciaze
spironolaqtonis damateba rezistentuli hipertenziis mqone pacientebSi,
48
usafrTxoa da mniSvnelovnad amcirebs gamosayenebeli medikamentebis
raodenobas. es Sedegi moiTxovs Semdgom farTomasStabian
randomizrebul kvlevebs.
hipertenziis kontrolis gaumjobeseba
qceviTi modelebi adastureben, rom yvelaze frTxili klinicistis mier
gamowerili efeqturi mkurnalobac ki gaakontrolebs hipertenzias mxo-
lod im SemTxvevaSi, Tu pacienti motivirebulia medikamentis
daniSnulebis mixedviT misaRebad da janmrTelobisaTvis xelSemwyobi
cxovrebis wesis dasacavad. motivacia umjobesdeba, roca pacients aqvs
rwmena misi mkurnali eqimis mimarT. ukeTesi komunikacia aumjobesebs
gamosavals.
risi gakeTeba SeuZlia eqims
eqimsa da pacients Soris partnioruli urTierToba, romelic emyareba
rwmenas, pativiscemasa da pacientis ganaTlebis dones kavSirSia
pozitiur gamosavalTan. pacientebi eqimis kompetencias xSirad afaseben
pacientTan mopyrobis xelovnebiT da ara eqimis klinikuri codniT.
pacientis momsaxureba moicavs Zaldautanebel mopyrobas, lodinis
minimalur drosa da momsaxure personalis yuradRebian da Tavazian
damokidebulebas; yvela aRniSnuli cnobilia, rogorc pacientis
kmayofilebasa da rwmenaze zegavlenis mqone faqtori. klinicistebma
unda ganaxorcielon momsaxure personalis “treiningi”, raTa Seiqmnas
pozitiuri, interaqtiuli da TanagrZnobisunariani garemo. es gazrdis
pacientis komforts da survils miiRos monawileoba sakuTari
janmrTelobis marTvaSi.
klinikuri inertuloba/umoqmedoba
arsebobs klinicistTa farTo wre, romlebic axorcieleben hipertenziis
optimalur Terapias. medikamentTa titraciisa da kombinaciis ukmarisoba
da cxovrebis stilis arasakmarisi modifikacia, avlens klinikur
inertulobas, romelic daZlevas moiTxovs. gadawyvetilebis mxardaWeris
sistema erT-erTi yvelaze efeqturi gzaa, romelic mouwodebs eqims
gaaumjobesos mkurnaloba maSin, roca samizne wneva ar aris miRweuli.
pacientze orientirebuli qceviTi Carevebi, iseTi rogoricaa rCevis
micema/rekomendacia, aumjobesebs sisxlis wnevis kontrols. meddebma,
klinicistebma da farmacevtebma daadastures Tavisi efeqturi roli
sisxlis samizne wnevis miRwevis procesSi. klinicistebma periodulad
unda gadaamowmon sakuTari pacientebis monacemebi, Seafason xarisxi,
medikamenturi Carevisa da dasaxuli miznis miRwevis warmatebuloba.
49
janmrTelobis dacvis sxva specialistebis roli
eqimebma unda iTanamSromlon jandacvis sxva specialistebTan, raTa
zegavlena moaxdinon an gaaZlieron swavleba/instruqtaJi pacientis
cxovrebis stilisa da sisxlis wnevis kontrolis gasaumjobeseblad.
hipertenziis kontrolis gaumjobesebis procesSi CarTuli arian:
hipertenziis centrebi, profesionaluri jandacviTi departamentebi da
organizaciebi, farmacevtebi da sazogadoebis araprofesionali muSakebi.
sazogadoebrivi jandacvis muSakebi, meddebi da Temis muSakebi, aseve saWiroa maRali riskis populaciebSi skriningis, vizitis TariRis
Setyobinebis da pacientTa ganaTlebis mizniT. jandacvis sferoSi
momuSave yvela specialisti unda gaerTiandes sisxlis wnevis
kontrolis donis gasaumjobeseblad; yuradReba unda gamaxvildes
hipertenziis riskze, sistoluri da diastoluri sisxlis wnevis marTvis
mniSvnelobaze da samizne arteriuli wnevis miRwevis aucileblobaze.
aseve aucilebelia cxovrebis stilis modifikaciis swavleba,
medikamenturi mkurnaloba da rwmena mkurnalobis mimarT.
pacientTan dakavSirebuli faqtorebi
kulturuli gansxvavebani, rwmena da damokidebuleba sakuTari
janmrTelobis mimarT did zegavlenas axdens pacientTa poziciaze. eqimma
unda auxsnas mis pacients, rom terminebi “hipertenzia” da “maRali
sisxlis wneva” urTierTSemcvleli terminebia da arc erTi maTgani ar
miuTiTebs SemaSfoTebel, uimedo mdgomareobaze. pacients sWirdeba
rogorc motivaciis gazrda, ise specifikuri ganaTleba, romelic mas
daexmareba cxovrebis stilis Secvlasa da medikamentTa daniSnulebis
mixedviT miRebaSi, rac aucilebelia TviTSegrZnebis gaumjobesebisa da
riskis SemcirebisTvis.
miznis miRweva da qcevis cvlilebebi
eqimi da pacienti unda SeTanxmdnen samizne arteriuli wnevis doneze da
daadginon miznis misaRwevad saWiro dro. es yovelive unda aisaxos
sqematurad. eqimma unda daarwmunos pacienti, rom qceviTi cvlilebebi
pacientis pasuxismgeblobis sakiTxia. Tu pacientebi ganaxorcieleben
qceviT cvlilebebs, maT aReniSnebaT mniSvnelovani xarisxiT winsvla.
Tu Sedegi arasakmarisia, eqimma motivaciis gaZlierebis mizniT unda
gamoarkvios xelSemSleli faqtorebi e.w “barierebi”. Tu vizitis dros
arteriuli wneva aRemateba samizne dones, mkurnalobis grafikis
darRvevebi unda dafiqsirdes dokumenturad. saxlis pirobebSi
arteriuli wnevis gasazomi mowyobilobebis gamoyeneba mizanSewonilia.
eqimi valdebulia Seamowmos aRniSnuli mowyobilobebi (sazomi
aparatebi). es advilad ganxorcielebadia. pacientma wneva unda gaizomos
eqimis meTvalyureobis qveS. saxlSi gazomili arteriuli wnevis done 5
mm.vwy.sv.-Ti ufro naklebia e.w. “ofisis” wnevasTan SedarebiT. am faqtis
gaTvaliswineba aucilebelia im SemTxvevebSi, roca arteriuli wnevis
done samiznesTan axlosaa. pacientis keTilganwyoba jandacvis
samsaxuris warmomadgenlis mimarT, mkurnalobisadmi misi damyolobis
prediqtoria. yvela eqimma unda gamoiCinos dadebiTi, pacientze
50
orientirebuli mzrunveloba, raTa daakmayofilos pacienti da
daiTanxmos mkurnalobaze. zogierT pacientze orientirebulma qceviTma
Carevam, iseTma, rogoricaa rCeva/rekomendacia, gamoavlina sisxlis wnevis
kontrolis gaumjobeseba.
ekonomikuri sirTuleebi
efeqturi mkurnalobis xelSemSleli SesaZloa iyos medikamentis fasi.
pacientebi xSirad amtkiceben, rom cxovrebis stilis modifikacia DASH kvebiTi gegmis mixedviT Zviria, Tumca misi ganxorcieleba mwiri
biujetiTac ki SesaZlebelia. dieturi kvebiTi mkurnaloba aumjobesebs
janmrTelobas pacientebSi maRali qolesteriniT, diabetiT, simsuqniT,
da sxva qronikul daavadebaTa risk-faqtorebiT. pacients unda mieces
rekomendacia, rom cxovrebis stilis modifikaciaTa umravlesoba ufasoa
da SesaZloa fulis dazogvac ki (mag. Tambaqos moxmarebis Sewyveta da
alkoholis miRebis Semcireba). amasTan, cxovrebis stilis Secvlas
SeuZlia misaRebi medikamentebis ricxvis da Sesabamisad fasis da
dazRvevis Rirebulebis Semcireba. pacienti, romelic imyofeba DASH kvebiT gegmaze, saWiroebs nakleb medikaments da Sesabamisad zogavs
fuls. pacientma unda gaacnobieros mniSvnelovani gansxvaveba
medikamentis fassa da rekomendaciis dacvis fass Soris. medikamentis
fasi aris fulis raodenoba, romelic aucilebelia medikamentis
SesaZenad, xolo rekomendaciebis ugulebelyofis SemTxvevaSi uaresdeba
sicocxlis xarisxi, viTardeba garTulebebi, romelTa marTvac pacients
gacilebiT Zviri ujdeba.
saqarTvelos pirobebSi arteriuli hipertenziis kontrolis
optimizaciis SesaZleblobebis gansazRvris mizniT, 2000-2003 wlebSi
mcxeTa-mTianeTSi/miluokis pirveladi jandacvis partnioruli programis
farglebSi, romelic ganxorcielda amerikis saerTaSoriso jandacvis
kavSiris (AIHA) egidiT da aSS ganviTarebis saagentos (USAID)
mxardaWeriT, moxerxda programaSi monawile pacientebis hipertenziis
kontrolis maCveneblis 59%-mde gazrda. saqarTveloSi arsebul
pirveladi jandacvis qselze dayrdnobiT da hipertenziul pirTa
aqtiuri, Tanamedrove sqemaze dafuZnebuli anihipertenziuli
mkurnalobiT (hidroqlorTiazidi da atenololi), martivad da
SezRuduli resursebiT SesaZlebeli gaxda hipertenziis kontrolis
maCveneblebis swrafi da mkveTri gaumjobeseba programaSi CarTul
pirebSi.
The Republic of Georgia High Blood Pressure Control Program. Ethnicity and Disease, 2006; 16[suppl 2]:S2-62–66). Barbakadze V., Koblianidze L., Kipshidze N., Grim CE, Grim CM, Tavill F.
saqarTvelos hipertenziis Semswavleli sazogadoebis mier bolo 3 wlis
ganmavlobaSi gadaidga pirveli nabijebi qveyanaSi arteriuli
hipertenziis aradamakmayofilebeli kontrolis mizezebis dasadgenad.
farmakoepidemiologiuri kvlevebiT, am etapze gamovlenilia hipertenziis
marTvaSi zogierTi mniSvnelovani xarvezebi. ZiriTadad es gaxlavT,
antihipertenziuli medikamentebis xSiri cvla da wyvetiloba
mkurnalobaSi. aRniSnuli ganpirobebulia eqimsa da pacients Soris
51
partnioruli urTierTobis deficitiT, mkurnalobis mimarT pacientis
dabali motivaciiTa da Sesabamisad dabali damyolobiT mkurnalobaze,
mkurnalobis procesSi titraciuli reJimis darRvevebiTa da sabolood
preparatis samizne dozis miuRwevelobiT (klinikuri medicina 2004;
Кардиология СНГ 2004). populaciaSi hipertenziis kontrolis gaumjobesebis TvalsazrisiT
mniSvnelovania farmacevtuli kompaniebis aqtivoba. msoflioSi arsebul
mraval farmacevtul kompanias gaaCnia specialuri programa am
mimarTulebiT.
gaidlainis miRebis xerxi/wyaro
gaidlainis SemuSavebis meTodologia
winamdebare gaidlaini warmoadgens adaptirebul gaidlains.
“gaidlainebis miRebis xerxi/wyaro” aris “sxvadasxva gaidlainebis
Sejereba da adaptacia”.
alternatiuli gaidlaini ar arsebobs gamoyenebuli literatura
1. “aSS maRali arteriuli wnevis prevenciis, gamovlenis, Sefasebisa da
mkurnalobis gaerTianebuli nacionaluri komitetis me-7 moxseneba”;
2. “aSS maRali arteriuli wnevis prevenciis, gamovlenis, Sefasebisa da
mkurnalobis gaerTianebuli nacionaluri komitetis me-6 moxseneba”;
3. ESH-ESC-2003 da ESH updates 4. Manual of Cardiovascular Medicine (second Edition) editors BRIAN P. GRIFFIN. 5. ERIC J. TOPOL. 6. HEART DISEASE (A textbook of cardiovascular medicine) BRAUNWALD ZIPES LIBBY.
6th Edition.
avtorTa jgufi:
saqarTvelos hipertenziis Semswavleli sazogadoeba, saqarTvelos kardiologTa koleji da janmrTelobis servisis kvlevebis centri
⇒ prof. beJan winamZRvriSvili – akad. m. winamZRvriSvilis sax.
kardiologiis institutis direqtori, saqarTvelos hipertenziis
Semswavleli sazogadoebis prezidenti, evropis hipertenziis
sazogadoebis klinikuri hipertenziis specialistis programis
nacionaluri seleqtiuri komitetis Tavmjdomare;
52
⇒ levan yuraSvili – saqarTvelos kardiologTa kolejis vice-
prezidenti, joenis samedicino centri;
⇒ dali trapaiZe _ kardiologiis instituti, saqarTvelos
hipertenziis Semswavleli sazogadoebis arteriuli hipertenziis
kontrolis samuSao jgufis xelmZRvaneli;
⇒ vaxtang barbaqaZe – janmrTelobis servisis kvlevebis centri,
Terapiis erovnuli centri, m.m.k.;
⇒ giorgi kaWarava – saqarTvelos kardiologTa kolejis
prezidenti, joenis samedicino centri;
⇒ zaza mgalobliSvili _ saqarTvelos kardiologTa koleji,
joenis samedicino centri;
⇒ naTia axalaZe _ saqarTvelos kardiologTa koleji, joenis
samedicino centri;
⇒ nata gonjilaSvili _ saqarTvelos kardiologTa koleji,
joenis samedicino centri;
⇒ revaz TaTaraZe – jandacvis msoflio organizaciis programa
“CINDI”-s direqtori saqarTveloSi, saqarTvelos sazogadoebebis
kardiovaskuluri prevenciis gaerTianebuli komitetis
TavmJdomare, evropis hipertenziis sazogadoebis klinikuri
hipertenziis specialistis programis nacionaluri seleqtiuri
komitetis wevri. m.m.k.;
⇒ dodo kaWaxiZe – kardiologiis instituti, saqarTvelos
hipertenziis Semswavleli sazogadoebis vice-prezidenti, m.m.k.,
evropis hipertenziis sazogadoebis klinikuri hipertenziis
specialisti;
⇒ Tamar abesaZe – kardiologiis instituti, saqarTvelos
hipertenziis Semswavleli sazogadoebis arteriuli hipertenziis
kontrolis samuSao jgufi, evropis hipertenziis sazogadoebis
klinikuri hipertenziis specialisti;
⇒ ana rexviaSvili – saqarTvelos hipertenziis Semswavleli
sazogadoebis arteriuli hipertenziis kontrolis samuSao
jgufi;
⇒ nino lolaZe – kardiologiis instituti, saqarTvelos
hipertenziis Semswavleli sazogadoebis arteriuli wnevis
ambulatoriuli monitorirebis samuSao jgufi, m.m.k.;
⇒ giorgi papiaSvili – saqarTvelos kardiologTa koleji, joenis
samedicino centri;
⇒ konstantine liluaSvili _ m.m.k., Terapiis erovnuli centri,
janmrTelobis servisis kvlevebis centri (CHSR);
⇒ levan qoblianiZe _ Terapiis erovnuli centri, janmrTelobis
servisis kvlevebis centri (CHSR).
eqspertebi:
⇒ saojaxo medicinis profesionalTa kavSiri _ irina qarosaniZe;
53
⇒ saojaxo medicinis eqspertTa jgufi, romelic aerTianebs
Tbilissa da mcxeTaSi moqmedi eqvsi saojaxo medicinis
saswavlo centris warmomadgenlebs m.S. praqtikosi ojaxis
eqimebs da dawesebulebis xelmZRvanelebs (saojaxo medicinis
erovnuli saswavlo centri; Tbilisis saojaxo medicinis
saswavlo centri; saojaxo medicinis centri /#28 mozrdilTa
poliklinika; saaqcio sazogadoeba `vere XXI~; q. Tbilisis #1
samkurnalo-profilaqtikuri centri; mcxeTa-mTianeTis
regionuli saswavlo centri).
