RU2641851C2 - Method for care of patients with acute coronary syndrome under conditions of medical institution with specialized department of percutaneous coronary interventions - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: emergency coronary angiography is performed: for patients diagnosed with acute coronary syndrome without ST segment elevation, if at least one of the "high risk factors" is detected; for patients with acute coronary syndrome with ST segment elevation, who did not undergo thrombolytic therapy at the prehospital stage; for patients with acute coronary syndrome with ST segment elevation, who underwent thrombolytic therapy, but it was not effective. Coronary angiography is urgently performed for 3-6 h: for patients with acute coronary syndrome without ST segment elevation, in the absence of "high-risk factors", in the absence of troponin I level elevation, with a GRACE score>140; for patients with acute coronary syndrome with ST segment elevation, if the effect of the thrombolytic therapy on prehospital stage is revealed. Coronarography is performed in a delayed manner for 24 hours for patients diagnosed with acute coronary syndrome without ST segment elevation, in the absence of "high risk factors", in the absence of troponin I level increase, with a GRACE score>108<140, if one of the factors exists; for patients with acute coronary syndrome without ST segment elevation, in the absence of "high-risk factors", in the absence of troponin I increase, with a GRACE score>108<140, in the absence of one of the factors. Coronarography is not performed: for patients with acute coronary syndrome without ST segment elevation, in the absence of "high risk factors", in the absence of troponin I increase, with a GRACE score of <108.

EFFECT: method allows to reduce hospital lethality and risk of haemorrhagic complications, and allows to make a decision in a short time about the timeliness and urgency of coronary angiography and intermittent coronary intervention according to its results.

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Description

The invention relates to medicine, namely to cardiology, endovascular diagnostic methods, and can be widely used for the treatment of patients with acute coronary syndrome, in particular, in a medical institution with a specialized department (center) of percutaneous coronary interventions (PCI).

Currently developed national recommendations for the diagnosis and treatment of patients with acute myocardial infarction with ST segment elevation of the ECG (see Journal of Cardiovascular Therapy and Prevention. 2007. 6 (8). Appendix 1), Recommendations of the European Society of Cardiology for the treatment of acute coronary syndrome without persistent ST segment elevation (see http://docviewer.yandex.ru/?url=yaserp%3A%2F%2Fcardiperm.ru%2Fdocs%2F1801121.pdf&c=559cbaee051//), Recommendations of the European Society of Cardiology for the treatment of myocardial infarction stable rise of the ST segment (see http://www.rpcardio.ru/pdf_articles/2009/5/RPC_2009_5_a rt12_recomendation.pdf), Russian recommendations for the diagnosis and treatment of patients with acute myocardial infarction with ST segment elevation of the electrocardiogram (see http://webmed.irkutsk.ru/doc/pdf/miest.pdf) refer to only one of the options for acute coronary syndrome - with or without elevation of the ST segment. In addition, well-known techniques do not take into account the specifics of the existing patient routing and the work of regional vascular centers and offer universal technical approaches for acute coronary syndrome.

The prior art discloses an algorithm for selecting patients with acute coronary syndrome to perform emergency invasive diagnostic and therapeutic procedures, selected as the closest analogue, which consists in identifying patients with a diagnosis of acute coronary syndrome without raising the ST segment of very high risk factors and / or stratifying the risk of developing the nearest negative outcomes on the GRACE scale and, based on the data obtained, the decision on the need and urgency of coronary angiography and, as a result, The cost-effectiveness of coronary artery disease according to its results, while the presence of very high risk factors for ischemic events in the patient is the basis for emergency coronary angiography, a GRACE score of> 140 is the basis for early coronary angiography, a GRACE score of <140, but > 108 in patients who do not have one of the other high-risk factors, serves as the basis for late coronary angiography, and a GRACE score of <108 indicates that there is no need for coronary angiography, while very high risk factors include: the presence of ongoing or recurring myocardial ischemia, any negative dynamics of the ST segment in dynamics, the presence of deep depression of the ST segment in lead V2-V4, indicating continued transmural damage to the posterior parts of the left ventricular myocardium, instability hemodynamics, the presence of life-threatening ventricular arrhythmias, other high-risk factors include: diabetes mellitus, recently (6 months) performed percutaneous coronary artery confusion, recent coronary artery bypass grafting, renal failure (estimated glomerular filtration rate less than 60 ml / min / 1.73 m ³ ), decreased left ventricular function (ejection fraction <40%), and patients diagnosed with acute coronary syndrome with segment elevation ST consisting in establishing the fact of the presence or absence of a pre-hospital TLT for the patient and evaluating the effectiveness of its delivery and, depending on the data obtained, making a decision on the urgency of coronary angiography and the need for following its performance by ChKB according to its results, while the basis for an emergency referral of a patient to coronarography is the lack of pre-hospital TLT or the lack of effectiveness from its conduct, and the basis for more delayed coronary angiography is the effect of its conduct, while anticoagulant and antiplatelet therapy is carried out until the beginning of coronary angiography, after its completion and after the implementation of the ChKB, performed if there are indications for its performance according to the results of coronary raffia (see www.cardio.by/files/lekcii/algoritm1.pdf// and www.cardio.by/files/lekcii/algoritm2.pdf//).

The purpose of this well-known technique is to determine the treatment strategy (emergency invasive, early invasive, delayed invasive or conservative strategy). At the same time, for patients diagnosed with acute coronary syndrome without ST segment elevation, a decision on a particular treatment strategy is made after determining the risk stratification according to the GRACE scale, which allows assessing the risk of developing the nearest (during hospital treatment) negative cardiovascular outcomes (death, myocardial infarction ) subject to the selection of a conservative treatment strategy, or after analyzing the presence of very high risk factors for ischemic events or the presence or absence of other high risk criteria. For patients diagnosed with acute coronary syndrome with ST segment elevation according to a known technique, it is recommended to consider the strategy of interventional revascularization as preferred.

Schemes of anticoagulant and antiplatelet therapy for patients with these diagnoses consist in the appointment of anticoagulant and antiplatelet drugs before coronary angiography and PCI (percutaneous coronary intervention), according to its results and in the postoperative period.

However, the known technique provides for significant time intervals from the patient’s admission to a medical institution until the patient undergoes coronary angiography, respectively, emergency - during the first 2 hours, early - within 24 hours and late (delayed) - during the first 72 hours from the patient’s arrival the hospital.

In addition, the known technique when deciding on the appointment of patients with a diagnosis of acute coronary syndrome without raising the ST segment to perform emergency coronary angiography and subsequent revascularization does not take into account a number of criteria of very high risk, such as the presence of early post-infarction angina pectoris or elevated troponin I prior to its study in the calculation GRACE scoring, which leads to the fact that patients with these criteria are not promptly performed emergency coronary angiography and, accordingly, ChKB according to its Performan. In addition, the well-known technique does not include factors such as myocardial infarction or a history of cerebrovascular accident, verified atherosclerosis in other arterial pools, but includes early post-infarction angina pectoris, which, in turn, also leads to a number of other high-risk factors. the fact that patients who have these criteria are not timely performed coronary angiography and, accordingly, PCI according to its results.

The medical accompaniment of patients with acute coronary pathology by a known method provides the same schemes for all types of acute coronary syndrome and the irrational use of expensive drugs that affect blood thinning, which is not always justified.

In addition, the well-known methodology in the form as set out requires careful analysis before deciding on the need and urgency of coronary angiography and, accordingly, the need for PCI for its results, which cannot but affect, firstly, the decision making time and secondly, does not exclude the possibility of making the wrong decision.

All this cannot but affect hospital mortality among patients with acute coronary pathology due to the untimely conduct of invasive reperfusion therapy and its adequate medical support, and the risk of hemorrhagic complications (especially in the conditions of routine use of femoral arterial access).

Thus, the technical result to which the claimed invention is directed is to create a method that allows to reduce the time intervals from the patient’s admission to a medical institution to coronary angiography for different stages of acute coronary syndrome and the risk of ischemic events, which allows for timely reperfusion treatment, which is significantly reduces hospital mortality and the risk of hemorrhagic complications, and also allows the rational use of expensive drugs that affect blood thinning.

An additional technical result of the claimed methodology is its development in the form of a flowchart that is simple and understandable, allowing in a short time to decide on the timeliness and urgency of coronary angiography and ChKB according to its results.

Thus, the technical result to be solved by the claimed invention is to create a method that allows to reduce the time intervals from the patient’s admission to a medical institution before coronary angiography, to take into account the course and risk level of ischemic events of acute coronary syndrome and the degree of urgency of coronary angiography and subsequent PCI allowing to ensure timely reperfusion treatment, a method that eliminates the possibility of potential noy risks and possible complications when performing coronary angiography, a method to apply adequate medical support coronary intervention procedures with regard to the need and urgency of their implementation, which greatly reduces hospital mortality and the risk of hemorrhagic complications. In addition, the creation of a method that allows the rational use of expensive drugs that affect blood thinning.

An additional technical result of the claimed methodology is its development in the form of a flowchart, simple and understandable, which allows in a short time to decide on the timeliness and urgency of coronary angiography and PCI according to its results.

The specified technical result is achieved by the fact that in the selection method for coronary angiography of patients with acute coronary syndrome in a medical institution having a specialized department for percutaneous coronary interventions, including selecting patients for coronary angiography, according to the invention

carry out emergency coronarography

patients diagnosed with acute coronary syndrome without ST segment elevation, if at least one of the “high risk factors” is identified:

- religious pain syndrome or its equivalent, which continues from the prehospital stage or recurs upon further observation;

- any negative dynamics of the ST segment in dynamics;

- the presence of deep depression of the ST segment in lead V2-V4, indicating continued transmural damage to the posterior portions of the left ventricular myocardium;

- hemodynamic instability;

- the presence of life-threatening ventricular arrhythmias;

- the presence of early post-infarction angina;

patients diagnosed with acute coronary syndrome without ST segment elevation, in the absence of the above “high risk factors”, but with an increase in troponin I;

patients diagnosed with acute coronary syndrome with ST-segment elevation who did not undergo thrombolytic therapy at the prehospital stage, while the treatment includes

at the prehospital stage:

- aspirin 250 mg;

- ticagrelor 180 mg once or clopidogrel 600 mg orally;

- heparin 70-100 IU / kg, intravenous bolus;

after coronary angiography, in the absence of indications for PCI:

- aspirin 125 mg daily;

- plug-in 75 mg daily;

- heparin intravenously drip 12 IU / kg / h for 24-48 hours, or clexane 1 mg / kg 4 hours after UFH every 12 hours, or Arikstra 2.5 mg subcutaneously 1 time per day for 8 days,

after coronary angiography and subsequent PCI:

- aspirin 125 mg;

- ticagrelor 90 mg 2 times a day or if there are contraindications: Plavix 75 mg daily;

- heparin intravenously drip 12 U / kg / h lasting 24-48 hours or clexane 1 mg / kg 4 hours after UFH every 12 hours,

carry out emergency coronarography

patients diagnosed with acute coronary syndrome with ST-segment elevation, who underwent thrombolytic therapy, but who have no effect from it, the therapy includes

at the prehospital stage:

- aspirin 250 mg;

- clopidogrel 600 mg orally;

- heparin 70-100 PIECES / kg, but not more than 4000 PIECES, by intravenous bolus,

after coronarography, in the absence of indications for PCI:

- aspirin 125 mg daily;

- plug-in 75 mg daily;

- heparin intravenously drip 12 IU / kg / h for 24-48 hours, or clexane 1 mg / kg 4 hours after UFH every 12 hours, or Arikstra 2.5 mg subcutaneously 1 time per day for 8 days,

after coronary angiography and subsequent PCI:

- aspirin 125 mg daily;

- Plavix 75 mg daily;

- heparin intravenously drip 12 U / kg / h lasting 24-48 hours or clexane 1 mg / kg 4 hours after UFH every 12 hours,

carry out coronary angiography urgently for 3-6 hours

patients diagnosed with acute coronary syndrome without ST segment elevation, in the absence of "high risk factors", in the absence of an increase in troponin I, with a GRACE score of> 140, the therapy includes

at the prehospital stage:

- aspirin 250 mg;

- ticagrelor 180 mg once or clopidogrel 600 mg orally;

- heparin 70-100 PIECES / kg, but not more than 5000 PIECES, by an intravenous bolus;

after coronary angiography, in the absence of indications for PCI:

- aspirin 125 mg daily;

- plug-in 75 mg daily;

- intravenous heparin 12 U / kg / h for 24-48 hours, or clexane 1 mg / kg 4 hours after UFH every 12 hours, or Arikstra 2.5 mg subcutaneously 1 time per day for 8 days,

after coronary angiography and subsequent PCI:

- aspirin 125 mg;

- ticagrelor 90 mg 2 times a day or if there are contraindications: Plavix 75 mg daily;

- heparin intravenously drip 12 U / kg / h lasting 24-48 hours or clexane 1 mg / kg 4 hours after UFH every 12 hours,

carry out coronary angiography urgently for 3-6 hours

patients diagnosed with acute coronary syndrome with ST segment elevation, when the effect of the thrombolytic therapy at the prehospital stage is identified, the treatment includes

at the prehospital stage:

- aspirin 250 mg;

- clopidogrel 300 mg orally;

- heparin 60-70 U / kg bolus,

after coronary angiography, in the absence of indications for PCI:

- aspirin 125 mg;

- plug-in 75 mg daily;

- heparin intravenously drip 12 IU / kg / h for 24-48 hours, or clexane 1 mg / kg 4 hours after UFH every 12 hours, or Arikstra 2.5 mg subcutaneously 1 time per day for 8 days,

after coronary angiography and subsequent PCI:

- aspirin 125 mg;

- Plavix 75 mg daily;

- intravenous heparin 12 U / kg / h for 24-48 hours or clexane 1 mg / kg 4 hours after UFH every 12 hours (for patients older than 75 years 0.75 mg / kg 2 times a day),

coronary angiography is carried out deferred for 24 hours

patients with a diagnosis of acute coronary syndrome without ST segment elevation, in the absence of “high risk factors”, in the absence of an increase in troponin I, with a GRACE score of> 108, but <140, if one of the factors is present:

- diabetes;

- a myocardial infarction or a history of cerebrovascular accident;

- verified atherosclerosis in other arterial pools;

- Percutaneous coronary intervention performed during the previous 6 months;

- performed coronary bypass surgery within the previous 6 months;

- renal failure at a glomerular filtration rate <60 ml / min / 1.73 m ² ;

- a decrease in left ventricular function with an ejection fraction <40%,

this includes

at the prehospital stage:

- aspirin 250 mg;

- ticagrelor 180 mg once or clopidogrel 600 mg orally;

- heparin 70-100 PIECES / kg, but not more than 5000 PIECES, by intravenous bolus,

after coronary angiography, in the absence of indications for PCI:

- aspirin 125 mg daily;

- plug-in 75 mg daily;

- heparin intravenously drip 12 IU / kg / h for 24-48 hours, or clexane 1 mg / kg 4 hours after UFH every 12 hours, or Arikstra 2.5 mg subcutaneously 1 time per day for 8 days,

after coronary angiography and subsequent PCI:

- aspirin 125 mg;

- ticagrelor 90 mg 2 times a day or if there are contraindications: Plavix 75 mg daily;

- heparin intravenously drip 12 U / kg / h lasting 24-48 hours or clexane 1 mg / kg 4 hours after UFH every 12 hours,

coronarography is not performed

patients with a diagnosis of acute coronary syndrome without ST segment elevation, in the absence of "high risk factors", in the absence of an increase in troponin I, with a GRACE score of> 108, but <140, in the absence of one of the factors:

- diabetes;

- a myocardial infarction or a history of cerebrovascular accident;

- verified atherosclerosis in other arterial pools;

- Percutaneous coronary intervention performed during the previous 6 months;

- performed coronary bypass surgery within the previous 6 months;

- renal failure at a glomerular filtration rate <60 ml / min / 1.73 m ² ;

- a decrease in left ventricular function with an ejection fraction <40%,

patients diagnosed with acute coronary syndrome without ST segment elevation, in the absence of "high risk factors", in the absence of an increase in troponin I, with a GRACE score of <108, the therapy includes

at the prehospital stage:

- aspirin 250 mg;

- ticagrelor 180 mg once or clopidogrel 300 mg orally;

- heparin 70-100 PIECES / kg, but not more than 5000 PIECES, by intravenous bolus,

the next day:

- aspirin 125 mg daily;

- ticagrelor 90 mg 2 times a day or plug-in 75 mg daily;

after 4 hours from the moment of the alleged first administration of heparin, the following are administered to patients:

- intravenous heparin 12 U / kg / h for 24-48 hours, or clexane 1 mg / kg 4 hours after UFH every 12 hours, or Arikstra 2.5 mg subcutaneously 1 time per day for 8 days.

The applicant has experimentally established that it is the combination of the above features that allows you to achieve the specified technical result.

The claimed methodology revised the time intervals from admission to coronary angiography for different stages of acute coronary syndrome and the risk of ischemic events. In a number of clinical situations, the reduction of these intervals for the work of the regional vascular center is of strategic importance: early establishment of a clinical diagnosis, provision of timely and complete medication and reperfusion treatment, rational use of the hospital bed fund of resuscitation and cardiology departments in an intensive flow of patients. In addition, it was additionally experimentally established that the inclusion of a number of criteria in one or another list of risk factors also allows timely provision of medical assistance to a number of patients. Based on the algorithm for selecting patients for coronary angiography, 4 protocols of medical support (antiplatelet agents and anticoagulants) have been developed, the effectiveness of which has also been confirmed by numerous experiments.

The claimed methodology does not contradict the current recommendations.

The possibility of presenting the inventive methodology in the form of a flow chart (Fig. 1) eliminates the waste of time in deciding on the timeliness of the patient to perform coronary angiography and PCI according to its results. It is understandable, simple and accordingly excludes the adoption of the wrong decision.

The inventive method is as follows.

Patients diagnosed with acute coronary syndrome without ST segment elevation.

Upon admission to a medical facility, a patient with this diagnosis evaluates very high risk factors.

The factors of very high risk in the claimed methodology include:

1. Anginous pain syndrome or its equivalent, which continues from the prehospital stage or recurs upon further observation.

2. Any negative dynamics of the ST segment in the dynamics (deepening depression or the appearance of elevation).

3. The presence of deep depression of the ST segment in leads V2-V4, indicating continued transmural damage to the posterior parts of the left ventricular myocardium.

4. Hemodynamic instability.

5. The presence of life-threatening ventricular arrhythmias.

6. Early post-infarction angina pectoris.

If the patient has the above factors, a decision is made to urgently carry out coronary angiography to the patient, which is performed by directing him immediately from the receiving ward.

Medical support for the patient is carried out according to Protocol No. 3.

If the patient does not have the above-mentioned factors of very high risk, he will be examined for the level of troponin I. If an increase in the level of troponin is detected, a decision is made to urgently perform the coronarography on the patient, to which he is also sent immediately from the receiving bed. Drug support is carried out according to Protocol No. 3. If the patient does not have an elevated level of troponin I, he is performed risk stratification according to the GRACE scale. In the case of obtaining a patient’s score of> 140, a decision is made on urgent (within 6 hours) coronary angiography. Drug maintenance is carried out according to protocol No. 3. With a score of> 108, but <140, the patient analyzes the presence of one of the other high-risk factors, which include:

1. Diabetes mellitus.

2. Myocardial infarction or a history of cerebrovascular accident.

3. Verified atherosclerosis in other arterial pools,

4. Recently performed percutaneous coronary intervention (6 months).

5. Recently performed coronary bypass surgery (6 months).

6. Renal failure (estimated glomerular filtration rate <60 ml / min / 1.73 m ² )

7. Decreased left ventricular function (ejection fraction <40%).

And if this patient has one of the other high-risk factors, a decision is made to refer the patient to non-urgent (delayed, late) coronary angiography, which can be performed within 24 hours from the moment of his admission to a medical institution. Drug support is carried out according to Protocol No. 3. And if he does not have these other high-risk factors, they decide on the patient's absence of indications for coronary angiography. Drug support is carried out according to Protocol No. 4. With a GRACE score of <108, a decision is made about the absence of indications for the patient to perform coronary angiography. Medical support according to Protocol No. 4.

Patients diagnosed with acute coronary syndrome with ST segment elevation.

Upon admission to a medical institution, it is determined whether the patient has received prehospital thrombolytic therapy (TLT). In the event that the patient did not receive pre-hospital TLT, a decision is made on the emergency performance of the coronary angiography, to which he is sent immediately from the emergency room. Medical support according to Protocol No. 3.

In the event that pre-hospital TLT was performed for the patient, but there is no effect from its implementation, a decision is made on the emergency implementation of the patient's coronary angiography, to which he is sent immediately from the emergency room. Medical support according to Protocol No. 2.

If the effect of the pre-hospital TLT is revealed, a decision is made on the delayed direction of the patient for coronary angiography (within 3-6 hours from the moment the patient arrives at the medical institution).

Drug support according to protocol No. 1.

On the day of monitoring the effectiveness of TLT, the initial ECG is compared with an ECG performed 60, 90, and 180 minutes after the start of the TLT. Performance criteria for TLT:

- cessation of pain;

- reduction of ST segment elevation by 50% or more in the lead with maximum initial elevation;

- the appearance of reperfusion arrhythmias - an accelerated idioventricular rhythm or a rhythm from the AV connection (not paroxysmal tachycardia).

Medical support according to Protocol No. 1 includes the following.

Before a patient enters a medical facility:

1. Chew aspirin 250 mg without enteric coating (1/2 tablet 500 mg).

2. Clopidogrel 300 mg orally; for patients older than 75 years - clopidogrel 75 mg.

3. Heparin 60-70 PIECES / kg, but not more than 4 thousand PIECES, by an intravenous bolus. If at the time of admission one of these appointments was not performed at the prehospital stage, it should be implemented in the regional vascular center immediately after hospitalization.

If within 6-24 hours the patient did not enter the X-ray, but CAG (coronary angiography or coronarography) is expected, then 4 hours after the time of the alleged first administration of Heparin, an anticoagulant should be administered.

Heparin at the rate of 12 U / kg / h (but not more than 1000 U / h) under the control of APTT (activated partial thromboplastin time). The first definition of APTT 3 hours after a bolus with subsequent correction (target APTT 50-70 seconds or 1.5-2 times higher than APTT control plasma);

or

clexane (enoxaparin) 1 mg / kg 4 hours after heparin every 12 hours (for patients older than 75 years, 0.75 mg / kg 2 times a day).

With GFR <30 ml / min / 1.73 m ² , regardless of age, the dose is reduced to 1 mg / kg subcutaneously 1 time per day.

The introduction of an anticoagulant continues until CAG. If clexane is made in anticipation of CAG, then heparin is not administered during PCI and there is no need for ABC control.

According to the CAG, 3 options are possible.

1. Completed by ChKB.

After the first hospital administration of an anticoagulant, avoid changing the drug.

If only prehospital heparin is administered, the choice of anticoagulant is determined based on the risk of bleeding, GFR (glomerular filtration rate), and the possibility of constant monitoring of APTT.

In the postoperative period, the patient is prescribed:

- aspirin 125 mg or its enteric analogues daily;

- Plavix 75 mg daily;

- one of 2 anticoagulants:

heparin intravenously drip 12 U / kg / h (but not more than 1000 U / h) lasting 24-48 hours under the control of APTT (target APTT 50-70 seconds or 1.5-2 times higher than APTT control plasma) or ABC (more 240 seconds), which are determined after 3, 6, 12, 24 hours (before reaching the target APTT) and 6 hours after changing the dose;

clexane (enoxaparin) 1 mg / kg 4 hours after UFH every 12 hours (for patients older than 75 years, 0.75 mg / kg 2 times a day).

With GFR <30 ml / min / 1.73 m ² , regardless of age, the dose is reduced to 1 mg / kg subcutaneously 1 time per day; lasting 24-48 hours.

At high risk of bleeding and a decrease in glomerular filtration rate (GFR), heparin is preferred.

2. ChKB was not carried out, at KAG a multivascular defeat.

3. ChKB was not performed, with CAG no significant pathology in the coronary arteries was found.

After coronary angiography is prescribed:

- aspirin 125 mg or its enteric analogues daily;

- plug-in 75 mg daily;

- one of 3 anticoagulants:

heparin intravenously drip 12 U / kg / h (but not more than 1000 U / h) lasting 24-48 hours under the control of APTT (target APTT 50-70 seconds or 1.5-2 times higher than APTT control plasma) or ABC (more 240 seconds), which are determined after 3, 6, 12, 24 hours (before reaching the target APTT) and 6 hours after changing the dose;

or clexane (enoxaparin) 1 mg / kg 4 hours after UFH every 12 hours (for patients older than 75 years, 0.75 mg / kg 2 times a day). With GFR <30 ml / min / 1.73 m ² , regardless of age, the dose is reduced to 1 mg / kg subcutaneously 1 time per day; duration up to 8 days;

or arikstra (fondaparinux) 2.5 mg subcutaneously 1 time per day for 8 days.

The choice of drug is based on 4 criteria: the risk of bleeding, glomerular filtration rate, age, the ability to control APTT with intravenous heparin infusion for 3 days.

Medical support under Protocol No. 2 includes the following.

Before a patient enters a medical facility:

1. Chew aspirin 250 mg without enteric coating (1/2 tablet 500 mg).

2. Clopidogrel 600 mg orally; for patients older than 75 years - clopidogrel 75 mg.

3. Heparin 70-100 PIECES / kg, but not more than 4 thousand PIECES, by an intravenous bolus.

If at the time of admission one of these appointments was not performed at the prehospital stage, it should be implemented in the regional vascular center immediately after hospitalization.

According to the CAG, 3 options are possible.

1. Completed by ChKB.

If heparin was administered (prehospital and during PCI), the choice of anticoagulant is determined based on the risk of bleeding, GFR, as well as the possibility of constant monitoring of APTT.

It is necessary to avoid changing the anticoagulant after its first administration in intensive care after PCI.

In the postoperative period appoint:

- aspirin 125 mg or its enteric analogues daily;

- Plavix 75 mg daily;

- one of 2 anticoagulants:

heparin intravenously drip 12 U / kg / h (but not more than 1000 U / h) lasting 24-48 hours under the control of APTT (target APTT 50-70 seconds or 1.5-2 times higher than APTT control plasma) or ABC (more 240 seconds), which are determined after 3, 6, 12, 24 hours (before reaching the target APTT) and 6 hours after changing the dose;

or clexane (enoxaparin) 1 mg / kg 4 hours after UFH every 12 hours (for patients older than 75 years, 0.75 mg / kg 2 times a day).

With GFR <30 ml / min / 1.73 m ² , regardless of age, the dose is reduced to 1 mg / kg subcutaneously 1 time per day; lasting 24-48 hours.

With a high risk of bleeding and a decrease in GFR, heparin is preferred.

2. ChKB was not carried out, at KAG a multivascular defeat.

3. ChKB was not performed, with CAG no significant pathology in the coronary arteries was found.

After coronary angiography is prescribed:

- aspirin 125 mg or its enteric analogues daily;

- plug-in 75 mg daily;

- one of 3 anticoagulants:

heparin intravenously drip 12 U / kg / h (but not more than 1000 U / h) lasting 24-48 hours under the control of APTT (target APTT 50-70 seconds or 1.5-2 times higher than APTT control plasma) or ABC (more 240 seconds), which are determined after 3, 6, 12, 24 hours (before reaching the target APTT) and 6 hours after changing the dose;

clexane (enoxaparin) 1 mg / kg 4 hours after UFH every 12 hours (for patients older than 75 years, 0.75 mg / kg 2 times a day).

With GFR <30 ml / min / 1.73 m ² , regardless of age, the dose is reduced to 1 mg / kg subcutaneously 1 time per day; duration up to 8 days;

Arikstra (fondaparinux) 2.5 mg subcutaneously 1 time per day for 8 days.

The choice of drug is based on 4 criteria: the risk of bleeding, glomerular filtration rate, age, the ability to control APTT with intravenous heparin infusion for 3 days.

Medical support according to Protocol No. 3 includes the following.

Before a patient enters a medical facility:

1. Chew aspirin 250 mg without enteric coating (1/2 tablet 500 mg).

2. Ticagrelor 180 mg once in the absence of contraindications.

In the presence of contraindications, clopidogrel 600 mg orally; for patients older than 75 years - clopidogrel 75 mg.

3. Heparin 70-100 PIECES / kg, but not more than 5 thousand PIECES, by an intravenous bolus.

If at the time of admission one of these appointments was not performed at the prehospital stage, it should be implemented in the regional vascular center immediately after hospitalization.

If within 4-24 hours the patient did not enter the X-ray, but CAG is expected, then after 4 hours from the time of the alleged first administration of Heparin, an anticoagulant should be administered.

Heparin at the rate of 12 PIECES / kg / h (but not more than 1000 PIECES / h) under the control of APTTV. The first definition of APTT 3 hours after a bolus followed by correction (target APTT 50-70 seconds or 1.5-2 times higher than APTT control plasma).

OR

Clexane (enoxaparin) 1 mg / kg 4 hours after heparin every 12 hours (for patients older than 75 years, 0.75 mg / kg 2 times a day).

With GFR <30 ml / min / 1.73 m ² , regardless of age, the dose is reduced to 1 mg / kg subcutaneously 1 time per day.

The introduction of an anticoagulant continues until CAG. If clexane is made in anticipation of CAG, then heparin is not administered during PCI and there is no need for ABC control.

According to the CAG, 3 options are possible.

1. Completed by ChKB.

If heparin was administered (prehospital and during PCI), the choice of anticoagulant is determined based on the risk of bleeding, GFR, as well as the possibility of constant monitoring of APTT.

Change of anticoagulant after its first administration in intensive care after PCI should be avoided.

In the postoperative period appoint:

- aspirin 125 mg or its enteric analogues daily;

- ticagrelor 90 mg 2 times a day in the absence of contraindications.

If there are contraindications: Plavix 75 mg daily;

- one of 2 anticoagulants:

heparin intravenously drip 12 U / kg / h (but not more than 1000 U / h) lasting 24-48 hours under the control of APTT (target APTT 50-70 seconds or 1.5-2 times higher than APTT control plasma) or ABC (more 240 seconds), which are determined after 3, 6, 12, 24 hours (before reaching the target APTT) and 6 hours after changing the dose;

or

clexane (enoxaparin) 1 mg / kg 4 hours after UFH every 12 hours (for patients older than 75 years, 0.75 mg / kg 2 times a day).

With GFR <30 ml / min / 1.73 m ² , regardless of age, the dose is reduced to 1 mg / kg subcutaneously 1 time per day; lasting 24-48 hours.

With a high risk of bleeding and a decrease in GFR, heparin is preferred.

2. ChKB was not carried out, at KAG a multivascular defeat.

3. ChKB was not performed, with CAG no significant pathology in the coronary arteries was found.

After coronary angiography is prescribed:

- aspirin 125 mg or its enteric analogues daily;

- plug-in 75 mg daily;

- one of 3 anticoagulants:

heparin intravenously drip 12 U / kg / h (but not more than 1000 U / h) lasting 24-48 hours under the control of APTT (target APTT 50-70 seconds or 1.5-2 times higher than APTT control plasma) or ABC (more 240 seconds), which are determined after 3, 6, 12, 24 hours (before reaching the target APTT) and 6 hours after changing the dose;

or

clexane (enoxaparin) 1 mg / kg 4 hours after UFH every 12 hours (for patients older than 75 years, 0.75 mg / kg 2 times a day).

With GFR <30 ml / min / 1.73 m ² , regardless of age, the dose is reduced to 1 mg / kg subcutaneously 1 time per day; duration up to 8 days;

or arikstra (fondaparinux) 2.5 mg subcutaneously 1 time per day for 8 days.

The choice of drug is based on 4 criteria: the risk of bleeding, glomerular filtration rate, age, the ability to control APTT with intravenous heparin infusion for 3 days.

Medical support according to Protocol No. 4 includes the following.

Before a patient enters a medical facility:

1. Chew aspirin 250 mg without enteric coating (1/2 tablet 500 mg).

2. Ticagrelor 180 mg once in the absence of contraindications.

In the presence of contraindications, clopidogrel 300 mg orally; for patients older than 75 years - clopidogrel 75 mg.

3. Heparin 70-100 PIECES / kg, but not more than 5 thousand PIECES, by an intravenous bolus.

If at the time of admission one of these appointments was not performed at the prehospital stage, it should be implemented in the regional vascular center immediately after hospitalization.

This Protocol is focused on the conservative tactics of treating acute coronary pathology, with subacute myocardial infarction without pain and the phenomena of acute heart failure; applicable for situations where CAG cannot be performed (the angiographic apparatus does not work, patient failure, allergy to a contrast medium, or other objective reason).

The next day:

- aspirin 125 mg or its enteric analogues daily;

- ticagrelor 90 mg 2 times a day in the absence of contraindications.

If there are contraindications:

- plugged 75 mg daily.

After 4 hours from the time of the alleged first administration of Heparin, one of the 3 anticoagulants must be administered:

heparin intravenously drip 12 U / kg / h (but not more than 1000 U / h) lasting 24-48 hours under the control of APTT (target APTT 50-70 seconds or 1.5-2 times higher than APTT control plasma) or ABC (more 240 seconds), which are determined after 3, 6, 12, 24 hours (before reaching the target APTT) and 6 hours after changing the dose;

or clexane (enoxaparin) 1 mg / kg 4 hours after UFH every 12 hours (for patients older than 75 years, 0.75 mg / kg 2 times a day).

With GFR <30 ml / min / 1.73 m ² , regardless of age, the dose is reduced to 1 mg / kg subcutaneously 1 time per day; duration up to 8 days;

or arikstra (fondaparinux) 2.5 mg subcutaneously 1 time per day for 8 days.

The choice of drug is based on 4 criteria: the risk of bleeding, glomerular filtration rate, age, the ability to control APTT with intravenous heparin infusion for 3 days.

The claimed method is presented in the form of a flowchart shown in FIG. one.

The inventive method is confirmed by clinical examples.

Clinical example with medical support according to Protocol No. 1.

Patient P., 70 years old, was delivered by an ambulance team with a diagnosis of acute coronary syndrome with ST segment elevation in the lower wall of the left ventricle 4 hours after the onset of the disease. At the time of admission, the patient had no complaints. An anginal attack arose sharply against the background of complete well-being without previous angina pectoris. After 1 hour, an SMP arrived, which established ischemic myocardial damage in the lower wall of the left ventricle (ST segment elevation of 5-6 mm with corresponding reciprocal depression).

At the prehospital stage, assistance was provided: nitrospray 1 dose; acetylsalicylic acid 250 mg, clopidogrel 300 mg, anaprilin 40 mg orally; morphine 1.0 ml and heparin 4000 units intravenously. Taking into account the transport inaccessibility of the ChKV center, the patient underwent thrombolytic therapy (TLT) with tenecteplase of 7 thousand units within the next 90 minutes from verification of acute myocardial ischemia.

In the emergency room, an ECG with positive dynamics - ST segment elevation decreased to 1-2 mm, the pain syndrome was stopped and did not recur, which indicates the effectiveness of the pre-hospital thrombolytic therapy. In accordance with the claimed method for selecting patients for CAG, tactics are considered in the right sector of the claimed flowchart shown in FIG. one:

1. ECG with ST segment elevation

2. Prehospital TLT

3. YES

4. Efficiency

5. YES

6. CAG after 3-6 hours from the onset of TLT, drug maintenance according to Protocol No. 1.

Pre-hospital medical care was provided to the patient in full.

After 4 hours from the onset of TLT, the patient was taken to an X-ray room, where a CAG was performed, on which critical stenosis of the right coronary artery was established. ChKB performed on the right coronary artery with restoration of blood circulation. In accordance with Protocol 1, after PCI, the patient received: thrombo-ACC 100 mg + Plavix 75 mg daily; Clexane 0.6 ml 2 times a day for 48 hours (weight 60 kg).

In satisfactory condition, the patient was discharged for outpatient aftercare.

Clinical example with medication under Protocol No. 2.

Patient Sh., 46 years old, was delivered by an ambulance team with a diagnosis of acute coronary syndrome with ST segment elevation in the lower wall of the left ventricle 5.5 hours after the onset of the disease. At the time of admission, the patient complained of pain behind the sternum of a pressing nature of moderate intensity, general weakness. He became acutely ill amid complete well-being without previous angina pectoris. At first, moderate discomfort appeared in the projection of the sternum for about 1 hour, which gradually intensified and after 2-2.5 hours reached pains of high intensity. Approximately 3 hours after the first symptoms, an SMP is caused, which established transmural ischemic myocardial damage in the lower wall of the left ventricle.

At the prehospital stage, assistance was provided: nitrospray 1 dose; acetylsalicylic acid 250 mg, clopidogrel 300 mg, anaprilin 40 mg orally; morphine 1.0 ml and heparin 4000 units intravenously. Taking into account the transport inaccessibility of the ChKV center, the patient underwent thrombolytic therapy (TLT) with tenecteplase of 7 thousand units within the next 90 minutes from verification of acute myocardial ischemia.

In the emergency room ECG without dynamics - ST segment elevation is preserved, which indicates the lack of effectiveness from the pre-hospital thrombolytic therapy (TLT). In accordance with the CAG patient selection scheme, tactics are considered in the right sector of the flowchart shown in FIG. one:

1. ECG with ST segment elevation

2. Prehospital TLT

3. YES

4. Efficiency

5. NO

6. CAG immediately from the emergency room, medical support according to Protocol No. 2.

Pre-hospital medical care was not provided to the patient in full - additionally clopidogrel 300 mg (total dose 600 mg).

Immediately from the emergency room, the patient was taken to the X-ray room, where a CAG was performed, on which acute occlusion of the right coronary artery was established. ChKB performed on the right coronary artery with restoration of blood circulation. In accordance with Protocol 2, after ChKB, the patient received: thrombo-ASS 100 mg + Plavix 75 mg daily; Clexane 0.8 ml 2 times a day for 48 hours (weight 80 kg).

In satisfactory condition, the patient was discharged for outpatient aftercare.

Clinical example No. 1 with medical support according to Protocol No. 3.

Patient K., 76 years old, was delivered by an ambulance team with a diagnosis of Acute Coronary Syndrome with ST segment elevation in the anterior wall of the left ventricle 2.5 hours after the onset of the disease. At the time of receipt of the complaint of discomfort behind the sternum. An anginal attack arose sharply against the background of complete well-being, a history of myocardial infarction 2 years ago, episodes of angina pectoris 1 functional class. Upon arrival, the SMP detected ischemic myocardial damage in the anterior wall of the left ventricle (ST segment elevation of 3-4 mm in the chest leads).

At the prehospital stage, assistance was provided: nitrospray 1 dose; acetylsalicylic acid 250 mg, clopidogrel 75 mg, anaprilin 40 mg orally; morphine 1.0 ml and heparin 5000 units intravenously. Given the transport accessibility of the ChKV center, TLT was not carried out.

In the emergency room ECG without dynamics - the ST segment elevation is preserved. In accordance with the CAG patient selection scheme, tactics are considered in the right sector of the flowchart shown in FIG. one:

1. ECG with ST segment elevation

2. Prehospital TLT

3. NO

4. CAG immediately from the emergency room, medical support according to Protocol No. 3.

Pre-hospital medical care was not provided to the patient in full. Additionally received 180 mg of ticagrelor (no contraindications).

The patient was taken from an emergency room to an X-ray room, where a CAG was performed, on which acute occlusion of the anterior descending branch (PNA) of the left coronary artery was established. ChKB performed on PNA with restoration of blood circulation. In accordance with Protocol No. 3 after PCI, the patient received:

thrombo ASS 100 mg + ticagrelor 90 mg 2 times a day daily; Clexane 0.6 ml 2 times a day for 48 hours (weight 80 kg, given the age older than 75 years - the dose is reduced by 25%).

In satisfactory condition, the patient was discharged for outpatient aftercare.

Clinical example No. 2 with medical support according to Protocol No. 3.

Patient K., 66 years old, was delivered by an ambulance team with a diagnosis of Acute coronary syndrome without ST segment elevation 2 hours after the onset of the disease. At the time of receipt of complaints of chest pain of a pressing and constricting nature. An anginal attack arose sharply against the background of complete well-being. Upon arrival of the SMP ECG without acute coronary pathology.

At the prehospital stage, assistance was provided: nitrospray 1 dose; acetylsalicylic acid 250 mg, clopidogrel 300 mg, anaprilin 40 mg orally; morphine 1.0 ml twice + promedol 1 ml and heparin 5000 units intravenously. Given the absence of ischemic changes on the ECG, TLT was not performed.

In the emergency room ECG without dynamics - without acute coronary pathology. In accordance with the scheme for selecting patients for CAG, tactics are considered in the left sector:

1. ECG without ST segment elevation

2. Very high risk factors

3. YES (Sore throat)

4. CAG immediately from the emergency room, medical support according to Protocol No. 3.

Pre-hospital medical care was not provided to the patient in full. Additionally received 180 mg of ticagrelor (no contraindications).

The patient was taken from an emergency room to an X-ray room, where a CAG was performed, on which acute occlusion of the anterior descending branch (PNA) of the left coronary artery was established. ChKB performed on PNA with restoration of blood circulation. In accordance with Protocol No. 3 after PCI, the patient received:

thrombo ASS 100 mg + ticagrelor 90 mg 2 times a day daily; Clexane 0.8 ml 2 times a day for 48 hours (weight 80 kg).

In satisfactory condition, the patient was discharged for outpatient aftercare.

Clinical example No. 3 with medical support according to Protocol No. 3.

Patient L., 56 years old, was delivered by an ambulance team with a diagnosis of “Acute coronary syndrome without ST segment elevation” 6 hours after the onset of the disease in the evening of February 1, 2015. At the time of receipt, he had no complaints. An anginal attack arose sharply against the background of complete well-being lasting 10-15 minutes, stopped on its own. Upon arrival of the SMP ECG without acute coronary pathology.

At the prehospital stage, assistance was provided: nitrospray 1 dose; acetylsalicylic acid 250 mg, clopidogrel 300 mg, anaprilin 40 mg orally; heparin 5000 units intravenously. Given the absence of ischemic changes on the ECG, TLT was not performed.

In the emergency room ECG without dynamics - without acute coronary pathology. In accordance with the scheme for selecting patients for CAG, tactics are considered in the left sector:

1. ECG without ST segment elevation

2. Very high risk factors

3. NO

4. TROPONIN I. Given that 6 hours have passed from a sore throat, a laboratory study was conducted on troponin I

5. NO

6. GRACE scale

7. Item "108-140 points" (125 points)

8. One of the other high risk factors

9. YES (history of cerebrovascular accident)

10. CAG within 24 hours from the time of hospitalization

Pre-hospital medical care was not provided to the patient in full. Additionally received ticagrelor 180 mg (no contraindications).

The intensive care unit was delivered from the patient’s receiving room, where he was under observation, and treatment was also carried out:

- heparin by intravenous infusion of 1000 units / hour under the control of APTT;

- on the morning of February 2, 2015, thrombo ASS 100 mg + ticagrelor 90 mg.

6 hours after admission, a second blood test was performed for troponin I - negative.

12 hours after admission, a CAG was performed on which a multivascular lesion of the coronary arteries was established, which required planned coronary artery bypass grafting. In accordance with Protocol 3, after CAG, the patient received: ticagrelor 90 mg in the evening + heparin with an intravenous infusion of 1000 U / h under APTT control until the evening of February 3, 2015 (48 hours). From February 3, 2015, and until discharge, the patient received antiplatelet agents thrombo ASS 100 mg + ticagrelor 90 mg 2 times a day daily.

On the evening of February 3, 2015, the patient was transferred to the cardiology department, where he was diagnosed with unstable angina pectoris. Continued dual antiplatelet therapy.

In satisfactory condition, the patient was discharged for outpatient follow-up care and subsequent surgical treatment.

Clinical example with medical support according to Protocol No. 4.

Patient A., 60 years old, was delivered by an ambulance team with a diagnosis of Acute coronary syndrome without ST segment elevation 6 hours after the onset of the disease. At the time of receipt of complaints did not show. Muddy discomfort arose against the background of an increase in blood pressure to 180/100 mm Hg. lasting 10-15 minutes, stopped on their own. Upon arrival of the SMP ECG without acute coronary pathology.

At the prehospital stage, assistance was provided: nitrospray 1 dose; acetylsalicylic acid 250 mg, clopidogrel 300 mg, anaprilin 40 mg orally; heparin 5000 units intravenously. Given the absence of ischemic changes on the ECG, TLT was not performed.

In the emergency room ECG without dynamics - without acute coronary pathology. In accordance with the scheme for selecting patients for CAG, tactics are considered in the left sector:

1. ECG without ST segment elevation

2. Very high risk factors

3. NO

4. TROPONIN I. Given that 6 hours have passed from a sore throat, a laboratory study was conducted on troponin I

5. NO

6. GRACE scale

7. Point "less than 108" (105 points)

8. Conservative tactics shown

Pre-hospital medical care was not provided to the patient in full. Additionally received ticagrelor 180 mg (no contraindications).

The intensive care unit was delivered from the patient’s receiving room, where he was under observation, and treatment was also carried out:

- Arikstra 2.5 subcutaneously for 8 days;

- from the next day: thromboASS 100 mg + ticagrelor 90 mg 2 times a day.

6 hours after admission, a second blood test was performed for troponin I - negative.

The next day, the patient was transferred to the cardiology department, where he stayed for 8 days. Pain behind the sternum did not recur; double antiplatelet therapy + arikstra was carried out up to 8 days. Ischemic tests (Holter monitoring, bicycle ergometry) are negative. Indications for planned CAG no.

In satisfactory condition, the patient was discharged for outpatient aftercare.

Claims (106)

A method for the management of patients with acute coronary syndrome in a medical institution with a specialized department for percutaneous coronary interventions, including selecting patients for coronary angiography, characterized in that carry out emergency coronarography patients diagnosed with acute coronary syndrome without ST segment elevation, if at least one of the “high risk factors” is identified: - religious pain syndrome or its equivalent, which continues from the prehospital stage or recurs upon further observation; - any negative dynamics of the ST segment in dynamics; - the presence of deep depression of the ST segment in lead V2-V4, indicating continued transmural damage to the posterior portions of the left ventricular myocardium; - hemodynamic instability; - the presence of life-threatening ventricular arrhythmias; - the presence of early post-infarction angina; patients diagnosed with acute coronary syndrome without ST segment elevation, in the absence of the above “high risk factors”, but with an increase in troponin I; patients diagnosed with acute coronary syndrome with ST-segment elevation who did not undergo thrombolytic therapy at the prehospital stage, while the treatment includes at the prehospital stage: - aspirin 250 mg; - ticagrelor 180 mg once or clopidogrel 600 mg orally; - heparin 70-100 IU / kg, intravenous bolus; after coronary angiography, in the absence of indications for PCI:  - aspirin 125 mg daily; - plug-in 75 mg daily; - heparin intravenously drip 12 IU / kg / h for 24-48 hours, or clexane 1 mg / kg 4 hours after UFH every 12 hours, or Arikstra 2.5 mg subcutaneously 1 time per day for 8 days, after coronary angiography and subsequent PCI: - aspirin 125 mg; - ticagrelor 90 mg 2 times a day or if there are contraindications: Plavix 75 mg daily; - heparin intravenously drip 12 U / kg / h lasting 24-48 hours or clexane 1 mg / kg 4 hours after UFH every 12 hours, carry out emergency coronarography patients diagnosed with acute coronary syndrome with ST-segment elevation, who underwent thrombolytic therapy, but who have no effect from it, the therapy includes at the prehospital stage: - aspirin 250 mg; - clopidogrel 600 mg orally; - heparin 70-100 PIECES / kg, but not more than 4000 PIECES, by intravenous bolus, after coronarography, in the absence of indications for PCI:  - aspirin 125 mg daily; - plug-in 75 mg daily; - heparin intravenously drip 12 IU / kg / h for 24-48 hours, or clexane 1 mg / kg 4 hours after UFH every 12 hours, or Arikstra 2.5 mg subcutaneously 1 time per day for 8 days, after coronary angiography and subsequent PCI: - aspirin 125 mg daily; - Plavix 75 mg daily; - heparin intravenously drip 12 U / kg / h lasting 24-48 hours or clexane 1 mg / kg 4 hours after UFH every 12 hours, carry out coronarography urgently for 3-6 hours patients diagnosed with acute coronary syndrome without ST segment elevation, in the absence of "high risk factors", in the absence of an increase in troponin I, with a GRACE score of> 140, the therapy includes at the prehospital stage: - aspirin 250 mg; - ticagrelor 180 mg once or clopidogrel 600 mg orally; - heparin 70-100 PIECES / kg, but not more than 5000 PIECES, by an intravenous bolus; after coronary angiography, in the absence of indications for PCI: - aspirin 125 mg daily; - plug-in 75 mg daily; - intravenous heparin 12 U / kg / h for a duration of 24-48 hours, or clexane 1 mg / kg 4 hours after UFH every 12 hours, or Arikstra 2.5 mg subcutaneously 1 time per day for 8 days, after coronary angiography and subsequent PCI: - aspirin 125 mg; - ticagrelor 90 mg 2 times a day or if there are contraindications: Plavix 75 mg daily; - heparin intravenously drip 12 U / kg / h lasting 24-48 hours or clexane 1 mg / kg 4 hours after UFH every 12 hours, carry out coronary angiography urgently for 3-6 hours patients diagnosed with acute coronary syndrome with ST segment elevation, when the effect of the thrombolytic therapy at the prehospital stage is identified, the treatment includes at the prehospital stage: - aspirin 250 mg; - clopidogrel 300 mg orally; - heparin 60-70 U / kg bolus, after coronary angiography, in the absence of indications for PCI: - aspirin 125 mg; - plug-in 75 mg daily; - heparin intravenously drip 12 IU / kg / h for 24-48 hours, or clexane 1 mg / kg 4 hours after UFH every 12 hours, or Arikstra 2.5 mg subcutaneously 1 time per day for 8 days, after coronary angiography and subsequent PCI: - aspirin 125 mg; - Plavix 75 mg daily; - intravenous heparin 12 U / kg / h for 24-48 hours or clexane 1 mg / kg 4 hours after UFH every 12 hours (for patients older than 75 years 0.75 mg / kg 2 times a day), coronary angiography is carried out deferred for 24 hours patients with a diagnosis of acute coronary syndrome without ST segment elevation, in the absence of "high risk factors", in the absence of an increase in troponin I, with a GRACE score of> 108 <140, if one of the factors is present: - diabetes; - a myocardial infarction or a history of cerebrovascular accident; - verified atherosclerosis in other arterial pools; - Percutaneous coronary intervention performed during the previous 6 months; - performed coronary bypass surgery within the previous 6 months; - renal failure at a glomerular filtration rate <60 ml / min / 1.73 m ² ; - a decrease in left ventricular function with an ejection fraction <40%, this includes at the prehospital stage: - aspirin 250 mg; - ticagrelor 180 mg once or clopidogrel 600 mg orally; - heparin 70-100 PIECES / kg, but not more than 5000 PIECES, by intravenous bolus, after coronary angiography, in the absence of indications for PCI: - aspirin 125 mg daily; - plug-in 75 mg daily; - heparin intravenously drip 12 IU / kg / h for 24-48 hours, or clexane 1 mg / kg 4 hours after UFH every 12 hours, or Arikstra 2.5 mg subcutaneously 1 time per day for 8 days, after coronary angiography and subsequent PCI: - aspirin 125 mg; - ticagrelor 90 mg 2 times a day or if there are contraindications: Plavix 75 mg daily; - heparin intravenously drip 12 U / kg / h lasting 24-48 hours or clexane 1 mg / kg 4 hours after UFH every 12 hours, coronarography is not performed patients with a diagnosis of acute coronary syndrome without ST segment elevation, in the absence of “high risk factors”, in the absence of an increase in troponin I, with a GRACE score of> 108 <140, in the absence of one of the factors: - diabetes; - a myocardial infarction or a history of cerebrovascular accident; - verified atherosclerosis in other arterial pools; - Percutaneous coronary intervention performed during the previous 6 months; - performed coronary bypass surgery within the previous 6 months; - renal failure at a glomerular filtration rate <60 ml / min / 1.73 m ² ; - a decrease in left ventricular function with an ejection fraction <40%, patients diagnosed with acute coronary syndrome without ST segment elevation, in the absence of "high risk factors", in the absence of an increase in troponin I, with a GRACE score of <108, the therapy includes at the prehospital stage: - aspirin 250 mg; - ticagrelor 180 mg once or clopidogrel 300 mg orally; - heparin 70-100 PIECES / kg, but not more than 5000 PIECES, by intravenous bolus, the next day: - aspirin 125 mg daily; - ticagrelor 90 mg 2 times a day or plug-in 75 mg daily; 4 hours after the alleged first administration of heparin, the following are administered to patients: - intravenous heparin 12 U / kg / h for 24-48 hours, or clexane 1 mg / kg 4 hours after UFH every 12 hours, or Arikstra 2.5 mg subcutaneously 1 time per day for 8 days.

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