ɍɇɂȼEɊɁɂɌȿɌ ɍ ɄɊȺȽɍȳȿȼɐɍ ɎȺɄɍɅɌȿɌ ɆȿȾɂɐɂɇɋɄɂɏ ɇȺɍɄȺ Ⱦɪ Ɇɢɥɟɧɤɨ Ɋɨɫɢћ ɍɌɂɐȺȳ ɉɊȿɌɏɈȾɇȿ ɉȿɊɄɍɌȺɇȿ ɄɈɊɈɇȺɊɇȿ ɂɇɌȿɊȼȿɇɐɂȳȿ ɇȺ ɂɋɏɈȾ ɏɂɊɍɊɒɄȿ ɊȿȼȺɋɄɍɅȺɊɂɁȺɐɂȳȿ ɆɂɈɄȺɊȾȺ ɞɨɤɬɨɪɫɤɚ ɞɢɫɟɪɬɚɰɢјɚ Ɇɟɧɬɨɪ: ɉɪɨɮ. ɞɪ ɋɜɟɬɨɡɚɪ ɇɢћɢɧ Ʉɪɚɝɭјɟɜɚɰ, 2014. ɝɨɞɢɧɟ 1 I ʢʑOʓ 5 1 ɄτɊτɇAɊɇA ɂɋɏEMɂJɋɄA ȻτɅEɋT 6 2 ɊȺɋɉɊɈɋɌɊȺȵȿɇɈɋɌ ɂ ɁɇȺɑȺȳ ɄȺɊȾɂɈȼȺɋɄɍɅȺɊɇɂɏ ȻɈɅȿɋɌɂ 7 3 ɎAɄTτɊɂ ɊɂɁɂɄA ɁA ɇAɋTAɇAɄ ɄτɊτɇAɊɇE ɂɋɏEMɂJɋɄE ȻτɅEɋTɂ 9 4 ɉȺɌɈȺɇȺɌɈɆɂȳȺ ɂ ɉAɌτɎɂɁɂτɅτȽɂJA ɄτɊτɇAɊɇE ɂɋɏEɆɂJEɋɄE ȻτɅEɋɌɂ 10 5 ɉɊEȼEɇɐɂJA ɂ ɅEɑEȵE ɄτɊτɇAɊɇE ɂɋɏEMɂJɋɄE ȻτɅEɋTɂ 11 6 ɂɋɏEɆɂJɋɄτ ɂ ɊȿɉȿɊɎɍɁɂɈɇɈ ɈɒɌȿȶȿȵȿ 14 7 ɏɂɊɍɊɒɄɈ Ʌȿɑȿȵȿ ɄτɊτɇAɊɇE ɂɋɏEMɂJɋɄE ȻτɅEɋTI 19 8 ɊȿȼȺɋɄɍɅȺɊɂɁȺɐɂȳȺ ɆɂɈɄȺɊȾȺ ɉȿɊɄɍɌȺɇɈɆ ɄɈɊɈɇȺɊɇɈɆ ɂɇɌȿɊȼȿɇɐɂȳɈɆ 23 9 ɍɉɈɊȿȾɇȺ ȺɇȺɅɂɁȺ ɏɂɊɍɊɒɄɈȽ ɅȿɑȿȵȺ ɍ ɈȾɇɈɋɍ ɇȺ ɉȿɊɄɍɌȺɇɍ ɂɇɌȿɊȼȿɇɐɂȳɍ 28 9.1 ɋɌɍȾɂȳȿ ɄɈȳȿ ɍɉɈɊȿЂɍȳɍ ɂɁɈɅɈȼȺɇɂ PCI ɂ ɏɂɊɍɊɒɄɍ ɊȿȼȺɋɄɍɅȺɊɂɁȺɐɂȳɍ ɆɂɈɄȺɊȾȺ (CABG) 29 9.2 ɋɌɍȾɂȳȿ ɄɈȳȿ ɋɍ ɎɈɊɆɂɊȺɇȿ ȾȺ Ȼɂ ɍɉɈɊȿȾɂɅȿ ɉȿɊɄɍɌȺɇȿ ɄɈɊɈɇȺɊɇȿ ɂɇɌȿɊȼȿɇɐɂȳȿ ɋȺ ɋɌȿɇɌɈɆ ɂ ɏɂɊɍɊɒɄɍ ɊȿȼȺɋɄɍȺɅɊɂɁȺɐɂȳɍ ɆɂɈɄȺɊȾȺ 35 9.3 ɋɌɍȾɂȳȿ ɄɈȳȿ ɍɉɈɊȿЂɍȳɍ ɉȿɊɄɍɌȺɇȿ ɄɈɊɈɇȺɊɇȿ ɂɇɌȿɊȼȿɇɐɂȳȿ ɋȺ ɅȿɄɈɆ ɈȻɅɈɀȿɇɂɆ ɋɌȿɇɌɈɆ ɂ ɏɂɊɍɊɒɄɂ ɁȻɊɂɇɍɌȿ ɉȺɐɂȳȿɇȺɌȿ 40 2 II ʥʗʻʔʑʗ ʗʠʡʟʏʕʗʑʏʼʏ 43 III ʟʏʓʜʔ ʤʗʞʝʡʔʖʔ 44 1 ɇɍɅɌȺ ɏɂɉɈɌȿɁȺ 44 2 ɇɍɅɌȺ ɏɂɉɈɌȿɁȺ 44 3 ɇɍɅɌȺ ɏɂɉɈɌȿɁȺ 44 4 ɇɍɅɌȺ ɏɂɉɈɌȿɁȺ 44 IV ʛʔʡʝʓʝʚʝʒʗЈʏ ʟʏʓʏ ʗ ʞʚʏʜ ʟʏʓʏ 45 1 ȼɊɋɌȺ ɋɌɍȾɂȳȿ 45 2 ɉɈɉɍɅȺɐɂȳȺ ɄɈȳȺ ɋȿ ɂɋɌɊȺɀɍȳȿ 45 3 ɍɁɈɊɄɈȼȺȵȿ 46 4 ȼȺɊɂȳȺȻɅȿ ɄɈȳȿ ɋɍ ɆȿɊȿɇȿ ɍ ɋɌɍȾɂȳɂ 47 4.1 ɇȿɁȺȼɂɋɇȿ ȼȺɊɂȳȺȻɅȿ 47 4.2 ɁȻɍȵɍȳɍȶȿ ȼȺɊɂȳȺȻɅȿ 47 4.3 ɁȺȼɂɋɇȿ ȼȺɊɂȳȺȻɅȿ 47 V ʠʡʏʡʗʠʡʗʦʙʏ ʝʐʟʏʓʏ ʞʝʓʏʡʏʙʏ 49 VI ʟʔʖʢʚʡʏʡʗ 50 1 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɉɊȿɆȺ ɈɋɇɈȼɇɂɆ ɈȻȿɅȿɀȳɂɆȺ 50 1.1 ɍɄɍɉȺɇ ȻɊɈȳ ɉȺɐɂȳȿɇȺɌȺ 50 1.2 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɉɈ ɉɈɅɍ 51 1.3 ɋɌAɊτɋɇA ɋɌɊɍɄɌɍɊA ɉAɐɂJEɇAɌA 52 3 1.4 ɋɌɊɍɄɌɍɊA ɉAɐɂJEɇAɌA ɍ τȾɇτɋɍ ɇA ɎAɄɌτɊE ɊɂɁɂɄA 53 1.5 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ɈɑȿɄɂȼȺɇɂ ɈɉȿɊȺɌɂȼɇɂ ɊɂɁɂɄ ɍ ȽɊɍɉɂ CABG 55 1.6 ɉɈɅɇȺ ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ȽɊɍɉɂ CABG 56 1.7 ɋɌȺɊɈɋɇȺ ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ȽɊɍɉɂ CABG 57 1.8 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ɎȺɄɌɈɊȿ ɊɂɁɂɄȺ ɂɁ ȽɊɍɉȿ CABG 58 1.9 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ɉɊȿɈɉȿɊȺɌɂȼɇɍ ɌȿɊȺɉɂȳɍ ɍ ȽɊɍɉɂ CABG 59 1.10 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ɇɂȼɈ ɈɑȿɄɂȼȺɇɈȽ ɈɉȿɊȺɌɂȼɇɈȽ ɊɂɁɂɄȺ EUROSCORE ɍ ȽɊɍɉɂ ɋȺ ɉɊȿɌɏɈȾɇɈɆ PCI 60 1.11 ɉɈɅɇȺ ɋɌɊɍɄɌɍɊȺ ɍ ȽɊɍɉɂ ɉȺɐɂȳȿɇȺɌȺ ɋȺ ɉɊȿɌɏɈȾɇɂɆ PCI 62 1.12 ɋɌȺɊɈɋɇȺ ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ȽɊɍɉɂ ɋȺ ɉɊȿɌɏɈȾɇɂɆ PCI 63 1.13 ɋɌɊɍɄɌɍɊA ɉAɐɂJEɇAɌA ɍ τȾɇτɋɍ ɇA ɎAɄɌτɊE ɊɂɁɂɄA ɁA ɊAɁȼτJ ɄτɊτɇAɊɇE ȻτɅEɋɌɂ ɍ ȽɊɍɉɂ ɉAɐɂJEɇAɌA ɋA ɉɊEɌɏτȾɇɂɆ ЈCI 64 1.14 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ɉɊȿɈɉȿɊȺɌɂȼɇɍ ɌȿɊȺɉɂȳɍ ɍ ȽɊɍɉɂ ɋȺ ɉɊȿɌɏɈȾɇɈɆ PCI 65 1.15 ɍɉɈɊȿȾɇȺ ȺɇȺɅɂɁȺ ɉȺɐɂȳȿɇȺɌȺ ɂɁ ɈȻȿ ȽɊɍɉȿ ɉɈ ȼɊȿȾɇɈɋɌɂɆȺ ɈɑȿɄɂȼȺɇɈȽ ɈɉȿɊȺɌɂȼɇɈȽ ɊɂɁɂɄȺ ɉɈ EUROSCOR-U 66 1.16 ɍɉɈɊȿȾɇȺ ȺɇȺɅɂɁȺ ɉɊȿɈɉȿɊȺɌɂȼɇȿ ɌȿɊȺɉɂȳȿ ɍ ɈȻȿ ȽɊɍɉȿ ɉȺɐɂȳȿɇȺɌȺ 67 1.17 ɍɉɈɊȿȾɇȺ ȺɇȺɅɂɁȺ ɎȺɄɌɈɊȺ ɊɂɁɂɄȺ ɍ ɈȻȿ ȽɊɍɉȿ 69 2 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɉɊȿɆȺ ȻɊɈȳɍ, ȼɊɋɌɂ ɂ ɆȿɋɌɍ ЈCI 72 4 2.1 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɉɈ ȻɊɈȳɍ ɂɆɉɅȺɇɌɂɊȺɇɂɏ ɋɌȿɇɌɈȼȺ ɍ ȽɊɍɉɂ ɋȺ ɉɊȿɌɏɈȾɇɈɆ PCI 72 2.2 ȻɊɈȳ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ȼɊɋɌɍ ɂɆɉɅȺɇɌɂɊȺɇɈȽ ɋɌȿɇɌȺ ɍ ȽɊɍɉɂ ɋȺ ɉɊȿɌɏɈȾɇɈɆ PCI 73 2.3 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ɆȿɋɌɈ ɈɌȼȺɊȺȵȺ ȺɊɌȿɊɂȳȿ ɍ ȽɊɍɉɂ ɉɊȿɌɏɈȾɇȿ PCI 74 3 ɉȿɊɂɈɉȿɊȺɌɂȼɇɂ ɇȺɅȺɁɂ ɉɈ ȽɊɍɉȺɆȺ 76 3.1 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɉɈ ȻɊɈȳɍ ȻȺȳɉȺɋȿȼȺ ɍ ȽɊɍɉɂ ȻȿɁ ɉɊȿɌɏɈȾɇȿ PCI 76 3.2 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɉɈ ȻɊɈȳɍ ȻȺȳɉȺɋȿȼȺ ɍ ȽɊɍɉɂ ɋȺ ɉɊȿɌɏɈȾɇɈɆ PCI 77 3.3 ɍɉɈɊȿȾɇɂ ɉɊɂɄȺɁ Ⱦɍɀɂɇȿ ɌɊȺȳȺȵȺ ɋɊɑȺɇɈȽ ɁȺɋɌɈȳȺ ɂ Ⱦɍɀɂɇȿ ɉɍɆɉȿ ɁȺ ȿɄɋɌɊȺɄɈɊɉɈɊȺɅɇɍ ɐɂɊɄɍɅȺɐɂȳɍ ɍ ɈȻȿ ȽɊɍɉȿ 78 4 ɉȿɊɂɈɉȿɊȺɌɂȼɇȿ ɂ ɉɈɋɌɈɉȿɊȺɌɂȼɇȿ ɄɈɆɉɅɂɄȺɐɂȳȿ ɉɈ ȽɊɍɉȺɆȺ 80 4.1 ɉȿɊɂɈɉȿɊȺɌɂȼɇɂ ɂɇɎȺɊɄɌ ɆɂɈɄȺɊȾȺ 81 4.2 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ɉɈȳȺȼȴɂȼȺȵȿ ɋɍɉɊȺȼȿɇɌɊɂɄɍɅȺɊɇɂɏ ȿɄɋɌɊȺɋɂɋɌɈɅȺ (ЋЏEЋ) 82 4.3 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ɉɈɋɌɈɉȿɊȺɌɂȼɇɈ ɉɈȳȺȼȴɂȼȺȵȿ ȼȿɇɌɊɂɄɍɅȺɊɇɂɏ ȿɄɋɌɊȺɋɂɋɌɈɅȺ (VES) 84 4.4 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ɉɈɋɌɈɉȿɊȺɌɂȼɇɈ ɄɊȼȺȼȴȿȵȿ ɂ ɊȿȼɂɁɂȳɍ ɏȿɆɈɋɌȺɁȿ 86 4.5 ɄȺɊȾɂɈɉɍɅɆɈɇȺɅɇȺ ɊȿȺɇɂɆȺɐɂȳȺ 87 4.6 ɋȼȿ ɄɈɆɉɅɂɄȺɐɂȳȿ ɄɈȾ ɉȺɐɂȳȿɇȺɌȺ ɍ ȽɊɍɉɂ ɋȺ ɉɊȿɌɏɈȾɇɈɆ PCI 89 4.7 ɋȼȿ ɄɈɆɉɅɂɄȺɐɂȳȿ ɍ ȽɊɍɉɂ ȻȿɁ ɉɊȿɌɏɈȾɇȿ PCI 90 5 4.8 ɍɉɈɊȿȾɇɂ ɉɊɂɄȺɁ ɉȿɊɂɈɉȿɊȺɌɂȼɇɂɏ ɂ ɉɈɋɌɈɉȿɊȺɌɂȼɇɂɏ ɄɈɆɉɅɂɄȺɐɂȳȺ ɍ ɈȻȿ ȽɊɍɉȿ 91 5 ȾɍɀɂɇȺ ɌɊȺȳȺȵȺ ɅȿɑȿȵȺ ɉȺɐɂȳȿɇȺɌȺ ɂ ɋɆɊɌɇɂ ɂɋɏɈȾ 92 5.1 ɈȾɇɈɋ ɉȺɐɂȳȿɇȺɌȺ ɍ ɁȺȼɂɋɇɈɋɌɂ ɈȾ ɁȺȾɊɀȺȼȺȵȺ ɍ ȳȿȾɂɇɂɐɂ ɂɇɌȿɁɂȼɇȿ ɇȿȽȿ 92 5.2 ɈȾɇɈɋ ɉȺɐɂȳȿɇȺɌȺ ɍ ɁȺȼɂɋɇɈɋɌɂ ɈȾ ɁȺȾɊɀȺȼȺȵȺ ɍ ȻɈɅɇɂɐɂ ɉɈ ȽɊɍɉȺɆȺ 94 5.3 ɋɆɊɌɇɂ ɂɋɏɈȾ ɉɈ ȽɊɍɉȺɆȺ 95 VII ʓʗʠʙʢʠʗJA 97 1 ɆȿɏȺɇɂɁȺɆ ɇȿȽȺɌɂȼɇɈȽ ɍɌɂɐȺȳȺ ɉɊȿɌɏɈȾɇȿ ЈCI ɋȺ ɋɌȿɇɌɈɆ ɇȺ CABG 102 VIII ʖʏʙʻʢʦʏʙ 106 IX ʙʚʗʜʗʦʙʔ ʗʛʞʚʗʙʏʥʗЈʔ ʗ ʛʝʒʢʽʜʝʠʡʗ ʓʏʻʔʒ ʗʠʡʟʏʕʗʑʏʼʏ 107 X ʚʗʡʔʟʏʡʢʟʏ 109 6 I ɍȼOȾ ɍɩɪɤШɫ ɫɜɢɦ ɧКɭɱɧɢɦ ɞШɤКɡɢɦК ɢ ɫɦɟɪɧɢɰɚɦɚ ɡК ɥОɱОʃО ɤШɪШɧКɪɧО КɪɬОɪɢУɫɤО ɛШɥОɫɬɢ, ɤШУɢ ɭɤКɡɭУɭ ɧК ɩɪОɞɧШɫɬ ɯɢɪɭɪɲɤО ɪОɜКɫɤɭɥКɪɢɡКɰɢУО ɦɢШɤКɪɞК CABG, ɧКɪШɱɢɬШ ɤШɞ ɩКɰɢУОɧКɬК ɫК ɜɢɲОɫɭɞШɜɧШɦ ɤШɪШɧКɪɧШɦ ɛШɥОɲʄɭ, ɞШɥКɡɢ ɞШ ОɤɫɩШɧОɧɰɢУКɥɧШɝ ɪКɫɬК ɭ ɩОɪɤɭɬКɧШУ ɤШɪШɧКɪɧШУ ɢɧɬОɪɜОɧɰɢУɢ ЈCI ɫК ɫɬОɧɬШɦ. ɋК ɬОɯɧШɥШɲɤɢɦ ɪКɡɜШУОɦ ɢ ɧКɝШɦɢɥКɧɢɦ ɢɫɤɭɫɬɜШɦ ɬШɤШɦ ɝШɞɢɧК, ɢɧɞɢɤКɰɢУО ɡК PCI ɫɭ ɫО ɩɪШɲɢɪɢɥО ɢ ɤКШ ɬКɤɜО,ɩɪШɰОɞɭɪО PCI ɫК ɫɬОɧɬШɦ ɤШɞ ɩКɰɢУОɧКɬК ɫК ɜɢɲОɫɭɞШɜɧШɦ ɤШɪШɧКɪɧШɦ ɛШɥОɲʄɭ ɫɭ ɫɜО ɜɢɲО ɡКɫɬɭɩʂОɧО. ɍ ШɜШУ ɬКɤШɡɜКɧШУ “ɫɬОɧɬ-Оɪɢ”, ɩКɰɢУОɧɬɢ ɫК ɤШɪШɧКɪɧШɦ КɪɬОɪɢУɫɤШɦ ɛШɥОɲʄɭ ɢ ɨɫɧɨɜɧɨɦ ɢɧɞɢɤКɰɢУШɦ ɡК CABG,ɩɚɰɢʁɟɧɬɢ ɫО ɫɜО ɜɢɲО ɢɧɞɢɤɭУɭ ɡК PCI ɤКШ ɢɧɢɰɢУКɥɧК КɥɬОɪɧКɬɢɜК ɩɪО ɯɢɪɭɪɲɤШɝ ɬɪОɬɦКɧК. ɇОɤО ɫɬɭɞɢУО ɫɭ ɩШɤКɡКɥО ɫɬШɩɭ ɪОɫɬОɧШɡК ɭ ɪКɫɩШɧɭ Шɞ 20% ɞШ 40% ɩШɫɥО PCI ɫК ɫɬОɧɬШɦ, ɫК ɩШɬɪОɛШɦ ɡК ɪОɢɧɬОɪɜОɧɰɢʁɨɦ ɡɛШɝ ɩШɧКɜʂКɧɢɯ ɫɢɦɩɬШɦК. ɍ ɩɨɫɥɟɞʃɟ ɜɪОɦО ɫО ɫɜО ɜɢɲО ɤɨɦɟɧɬɚɪɢɲɟ ɢ ɞɢɫɤɭɬɭʁɟ ɨ ɬɨɦɟ ɞК ɥɢ je ɩɪОɬɯШɞɧК PCI ɫК ɫɬОɧɬШɦ ɮКɤɬШɪ ɪɢɡɢɤК ɫК ɧОɝКɬɢɜɧɢɦ ɭɬɢɰКУОɦ ɧК ɢɫɯШɞ ɯɢɪɭɪɲɤО ɪОɜКɫɤɭɥКɪɢɡКɰɢУО ɦɢШɤКɪɞК ɩШɫɥО ɫɬОɧɬК. ɁɧКɱКУКɧ ɢɧɮɥКɦКɬШɪɧɢ ɩɪШɰОɫ ɢ ОɧɞШɬОɥɢУКɥɧК ɮɭɧɤɰɢШɧКɥɧК КɛɧШɪɦКɥɧШɫɬ ɭ ɤШɪШɧКɪɧɢɦ КɪɬОɪɢУКɦК УО ɩШɜОɡКɧК ɫК ɩОɪɤɭɬКɧШɦ ɤШɪШɧКɪɧШɦ ɢɧɬОɪɜОɧɰɢУШɦ ɫК ɫɬОɧɬШɦ К ɩШɝШɬШɜɭ ɤШɞК ɫО ɤШɪɢɫɬɢ ɞɪɭɝ-Оɥɭɬɢɧɝ ɫɬОɧɬ (ɥɟɤɨɦ ɨɛɥɨɠɟɧ ɫɬɟɧɬ). ɂ ɩɨɪɟɞ ɫɜɢɯ ɫɬɭɞɢʁɚ 7 ɢ ɩɪɚʄɟʃɚ, ɩɪКɜɢ ɤɥɢɧɢɱɤɢ ɭɬɢɰКУ ɩɪɢɫɭɫɬɜК ɫɬОɧɬК ɧК ɤШɪШɧКɪɧɭ КɪɬОɪɢУɭ ɢ ɢɫɯШɞ ɯɢɪɭɪɲɤО ɪОɜКɫɤɭɥКɪɢɡКɰɢУО ɩШɫɥО ɫɬОɧɬК УШɲ ɭɜОɤ ɧɢУО ɞШɤКɡКɧ ɢ ɞШ ɫКɞК УО УШɲ ɭɜОɤ ɤШɧɬɪШɜОɪɡК. Ƚɥɚɜɧɢ ɱɢɧɢɥɚɰ ɤШУɢ ɦШɠО ɞК ɭɬɢɱО ɧК ɦОʃКʃО ɫɦɟɪɧɢɰɚ ɭ ɥɟɱɟʃɭ ɤɨɪɨɧɚɪɧɟ ɢɫɯɟɦɢʁɫɤɟ ɛɨɥɟɫɬɢ ʁɟ ʁɨɲ ɭɜɟɤ ɦɨɪɬɚɥɢɬɟɬ. τɫɧШɜɧɢ ɡКɞКɬКɤ ШɜО ɞɢɫОɪɬКɰɢУО УО ɞК ɩɪШɰОɧɢ ɭɬɢɰКУ ɩɪОɬɯШɞɧШɝ PCI ɫК ɫɬОɧɬШɦ ɧК ɢɫɯШɞ ɯɢɪɭɪɲɤО ɪОɜКɫɤɭɥКɪɢɡКɰɢУО ɢ ɞК ɢɫɩɢɬК ɞК ɥɢ ɩɪОɬɯШɞɧɢ PCI ɫК ɫɬОɧɬШɦ ɩɪОɞɫɬКɜʂК ШɞɪОђОɧɢ ɪɢɡɢɤШ-ɮКɤɬШɪ. 1 ɄOɊOɇAɊɇA ɂɋɏEMɂJɋɄA ȻOɅEɋT Ʉoɪoɧaɪɧa ɢɫɯeɦɢjɫɤa ɛoɥeɫɬ oɡɧaɱaɜa ɢɫɯeɦɢjɭ ɦɢoɤaɪɞa ɭɫɥeɞ ɧeaɞeɤɜaɬɧoɝ ɢɥɢ ɫɦaʃeɧoɝ ɩɪoɬoɤa ɤɪɜɢ ɤɪoɡ ɤoɪoɧaɪɧe aɪɬeɪɢje ɩɪɢ ɧoɪɦaɥɧoj ɢɥɢ ɩoɜeʄaɧoj ɩoɬɪeɛɢ ɦɢoɤaɪɞa ɡa ɤɢɫeoɧɢɤoɦ. ɍ ɩoɫɥeɞʃe ɞɜe ɞeɰeɧɢje ɩoɫɬɢɝɧɭɬ je ɡɧaɱajaɧ ɧaɩɪeɞaɤ ɭ ɛoɪɛɢ ɩɪoɬɢɜ ɤoɪoɧaɪɧe ɛoɥeɫɬɢ ɫɪɰa (CHD) ɤКɤШ ɧa ɩoʂɭ ɩɪОɜОɧɰɢУО ɬКɤШ ɢ ɥeɱeʃa. ɂɩaɤ, CHD ɢ ɞaʂe ɡaɭɡɢɦa ɩɪɜo ɦeɫɬo ɧa ɥɢɫɬɢ ɭɡɪoɤa ɩɪeɭɪaʃeɧe ɫɦɪɬɢ ɭ ɧКɲШУ ɡОɦʂɢ . CHD ɫe ɦaɧɢɮeɫɬɭje ɤɪoɡ ɫɩeɤɬaɪ ɤɥɢɧɢɱɤɢɯ ɨɛɥɢɤɚ: oɞ ɫɬaɛɢɥɧe aɧɝɢɧe, aɤɭɬɧoɝ ɢɧɮaɪɤɬa ɦɢoɤaɪɞa (AMI), ɫɪɱaɧe ɢɧɫɭɮɢɰɢeɧɰɢje (HF), aɪɢɬɦɢja ɢ ɢɡɧeɧaɞɧe ɫɪɱaɧe ɫɦɪɬɢ (ɋɐȾ). Ʌoɤaɰɢja, ɫɬeɩeɧ ɢ ɩɪɢɪoɞa ɥɟɡɢʁɚ ɤɨɪɨɧɚɪɧɢɯ ɚɪɬɟɪɢʁɚ oɞɪeђɭjɭ ɤɥɢɧɢɱɤɭ ɫɥɢɤɭ ɤɨɞ ɩaɰɢjeɧaɬa. ɇaɜeɞeɧɢ ɮaɤɬoɪɢ oɞɪeђɭjɭ ɤɪajʃɢ ɜɢɞ ɢɧɞɢɜɢɞɭaɥɧoɝ ɥeɱeʃa. 8 ɉaɰɢjeɧɬɢɦa ɫa ɫɬaɛɢɥɧoɦ aɧɝɢɧoɦ, ɫɢɦɩɬoɦɢ ɦoɝɭ ɛɢɬɢ ɤoɧɬɪoɥɢɫaɧɢ ɮaɪɦaɤoɥoɲɤɢ. Ʉoɞ ɩКɰɢУОɧКɬК ɫК ɧОɫɬɛɢɥɧШɦ КɧɝɢɧШɦ ɪeɜaɫɤɭɥaɪɢɡaɰɢja ɦɢoɤaɪɞa oɫɬaje ɝɥaɜɧa ɬeɪaɩɢjɫɤa oɩɰɢja. Ʉaɫɧɢje, ɭɡɧaɩɪeɞoɜaɥa CHD ɬɪeɬɢɪaɧa ɥeɤoɜɢɦa ɤoɞ ɦɧoɝɢɯ ɩaɰɢjeɧaɬa ɫa ɫɬaɛɢɥɧoɦ aɧɝɢɧoɦ ɡaɯɬeɜaʄe ɪeɜaɫɤɭɥaɪɢɡaɰɢjɭ ɦɢoɤaɪɞa. ɂɡ ɬoɝ ɪaɡɥoɝa ɪeɜaɫɤɭɥaɪɢɡaɰɢja ɦɢoɤaɪɞa ɡaɭɡɢɦa ɡɧaɱajɧo ɦeɫɬo ɭ ɥeɱeʃɭ ɫɪɱaɧɢɯ ɛoɥeɫɧɢɤa. 2 ɊȺɋɉɊɈɋɌɊȺȵȿɇɈɋɌ ɂ ɁɇȺɑȺȳ ɄȺɊȾɂɈȼȺɋɄɍɅȺɊɇɂɏ ȻɈɅȿɋɌɂ Ʉɚɪɞɢɨɜɚɫɤɭɥɚɪɧɟ ɛɨɥɟɫɬɢ, ɛɨɥɟɫɬɢ ɫɪɰɚ ɢ ɤɪɜɧɢɯ ɫɭɞɨɜɚ, ɞɟɰɟɧɢʁɚɦɚ ɭɧɚɡɚɞ ɩɪɟɞɫɬɚɜʂɚʁɭ ɜɨɞɟʄɢ ɭɡɪɨɤ ɩɪɟɜɪɟɦɟɧɟ ɫɦɪɬɢ ɭ ɫɜɟɬɭ. ɉɪɟɦɚ ɩɨɞɚɰɢɦɚ ɋɜɟɬɫɤɟ ɡɞɪɚɜɫɬɜɟɧɟ ɨɪɝɚɧɢɡɚɰɢʁɟ (WHO) ɨɞ 2008. ɝɨɞɢɧɟ, ɨɞ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɢɯ ɛɨɥɟɫɬɢ ɝɨɞɢɲʃɟ ɭɦɪɟ ɨɤɨ 17,3 ɦɢɥɢɨɧɚ ʂɭɞɢ, ɲɬɨ ʁɟ ɨɤɨ 30% ɭɤɭɩɧɨɝ ɫɜɟɬɫɤɨɝ ɦɨɪɬɚɥɢɬɟɬɚ. Ɍɟɧɞɟɰɢʁɚ ʁɟ ɞɚ ɫɟ ɭ ɜɢɫɨɤɨɪɚɡɜɢʁɟɧɢɦ ɡɟɦʂɚɦɚ ɫɬɨɩɚ ɦɨɪɬɚɥɢɬɟɥɚ ɨɞ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɢɯ ɛɨɥɟɫɬɢ ɫɦɚʃɭʁɟ, ɞɨɤ ɫɟ ɭ ɫɪɟɞʃɟ ɢ ɧɢɫɤɨɪɚɡɜɢʁɟɧɢɦ ɡɟɦʂɚɦɚ ɫɬɨɩɚ ɦɨɪɬɚɥɢɬɟɬɚ ɡɧɚɱɚʁɧɨ ɩɨɜɟʄɚɜɚ, ɬɟ ɞɨɫɬɢɠɟ ɢ ɞɨ 80% ɢ ɩɨɞʁɟɞɧɚɤɨ ʁɟ ɡɚɫɬɭɩʂɟɧɚ ɢ ɤɨɞ ɦɭɲɤɚɪɚɰɚ ɢ ɤɨɞ ɠɟɧɚ. ɉɪɨɰɟʃɭʁɟ ɫɟ ɞɚ ʄɟ ɞɨ 2030. ɝɨɞɢɧɟ ɛɨɥɟɫɬɢ ɫɪɰɚ ɢ ɤɪɜɧɢɯ ɫɭɞɨɜɚ ɩɨɫɬɚɬɢ ʁɟɞɚɧ ɨɞ ɜɨɞɟʄɢɯ ɭɡɪɨɤɚ ɫɦɪɬɢ ɭ ɫɜɟɬɭ, ɧɚɪɨɱɢɬɨ ɭ ɧɟɪɚɡɜɢʁɟɧɢɦ ɡɟɦʂɚɦɚ, ɞɚ ʄɟ ɨɞ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɢɯ ɛɨɥɟɫɬɢ ɭɦɢɪɚɬɢ ɨɤɨ 23 ɦɢɥɨɧɚ ʂɭɞɢ ɝɨɞɢɲʃɟ1. 9 Ȼɨɥɟɫɬɢ ɫɪɰɚ ɢ ɤɪɜɧɢɯ ɫɭɞɨɜɚ ɫɭ ɜɨɞɟʄɢ ɭɡɪɨɤ ɫɦɪɬɢ ɢ ɭ ȿɜɪɨɩɢ. ɋɜɚɤɟ ɝɨɞɢɧɟ ɨɤɨ 4 ɦɢɥɢɨɧɚ ʂɭɞɢ ɭɦɪɟ ɨɞ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɢɯ ɛɨɥɟɫɬɢ, ɲɬɨ ʁɟ ɨɤɨ 47% ɭɤɭɩɧɨɝ ɦɨɪɬɚɥɢɬɟɬɚ ɭ ȿɜɪɨɩɢ. Ʉɚɪɞɢɨɜɚɫɤɭɥɚɪɧɟ ɛɨɥɟɫɬɢ ɫɭ ɬɚɤɨђɟ ɝɥɚɜɧɢ ɭɡɪɨɤ ɫɦɪɬɢ ɢ ɭ ȿɜɪɨɩɫɤɨʁ ɭɧɢʁɢ ɝɞɟ ɩɪɢɛɥɢɠɧɨ 1,9 ɦɢɥɢɨɧɚ ʂɭɞɢ ɭɦɪɟ ɝɨɞɢɲʃɟ2. Ɂɧɚɱɚʁɧɨ ɜɟʄɚ ɫɬɨɩɚ ɦɨɪɬɚɥɢɬɟɬɚ ʁɟ ɭ ɡɟɦʂɚɦɚ ɢɫɬɨɱɧɟ ȿɜɪɨɩɟ ɭ ɨɞɧɨɫɭ ɧɚ ɡɟɦʂɟ ɡɚɩɚɞɧɟ ȿɜɪɨɩɟ. Ɍɨ ʁɟ ɫɜɟ ɩɨɫɥɟɞɢɰɚ ɫɬɚɥɧɨɝ ɩɨɛɨʂɲɚɜɚʂɚ ɫɨɰɢɨ-ɟɤɨɧɨɦɫɤɨɝ ɫɬɚɬɭɫɚ ɫɬɚɧɨɜɧɢɲɬɜɚ ɪɚɡɜɢʁɟɧɢɯ ɡɟɦɚʂɚ, ɫɬɚɥɧɟ ɩɪɨɦɨɰɢʁɟ ɡɞɪɚɜɨɝ ɧɚɱɢɧɚ ɠɢɜɨɬɚ, ɤɚɨ ɢ ɩɨɜɟʄɚɧɟ ɫɜɟɫɬɢ ɨ ɡɞɪɚɜɟɫɬɜɟɧɨʁ ɡɚɲɬɢɬɢ ɫɬɚɧɨɜɧɢɲɬɜɚ3. ȼɨɞɟʄɢ ɭɡɪɨɤ ɭɦɢɪɚʃɚ ɭ ɧɚɲɨʁ ɡɟɦʂɢ ʁɟ ɢɞɟɧɬɢɱɚɧ ɤɚɨ ɢ ɭ ȿɜɪɨɩɢ. ɉɪɟɦɚ ɩɨɞɚɰɢɦɚ ɂɧɫɬɢɬɭɬɚ ɡɚ ʁɚɜɧɨ ɡɞɪɚɜʂɟ ɋɪɛɢʁɟ „ Ⱦɪ Ɇɢɥɚɧ ȳɨɜɚɧɨɜɢʄ Ȼɚɬɭɬ“, ɭ 2012. ɝɨɞɢɧɢ ɜɨɞɟʄɢ ɭɡɪɨɤ ɫɦɪɬɢ ɭ ɋɪɛɢʁɢ ɫɭ ɤɚɪɞɢɨɜɚɫɤɭɥɚɧɟ ɛɨɥɟɫɬɢ. Ȼɪɨʁ ɭɦɪɥɢɯ ʁɟ ɢɡɧɨɫɢɨ 54972, ɲɬɨ ɩɪɟɞɫɬɚɜʂɚ ɨɤɨ 53,7% ɨɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɭɦɪɥɢɯ ʂɭɞɢ. Ɉɞ ɫɜɢɯ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɢɯ ɛɨɥɟɫɬɢ ɧɚʁɡɚɫɬɭɩʂɟɧɢʁɟ ɫɭ ɰɟɪɟɛɪɨɜɚɫɤɭɥɚɪɧɟ ɛɨɥɟɫɬɢ ɫɚ 26,2%, ɡɚɬɢɦ ɫɥɟɞɟ ɢɫɯɟɦɢʁɫɤɟ ɛɨɥɟɫɬɢ ɫɪɰɚ ɫɚ 19,2%, ɯɢɩɟɪɬɟɧɡɢɜɧɟ ɛɨɥɟɫɬɢ ɫɪɰɚ ɫɚ 7,4%, ɚ ɨɫɬɚɥɟ ɛɨɥɟɫɬɢ ɫɪɰɚ ɢ ɫɢɫɬɟɦɚ ɤɪɜɨɬɨɤɚ ɫɚ 47,1%4. ɋɜɟ ɨɜɨ ʁɟ ɩɨɫɥɟɞɢɰɚ ɫɦɚʃɟɧɟ ɮɢɡɢɱɤɟ ɚɤɬɢɜɧɨɫɬɢ, ɥɨɲɢɯ ɧɚɜɢɤɚ ɭ ɢɫɯɪɚɧɢ ɢ ɤɨɧɡɭɦɢɪɚʃɚ ɚɥɤɨɯɨɥɚ ɢ ɰɢɝɪɚɪɟɬɚ. 10 3 ɎAɄTOɊɂ ɊɂɁɂɄA ɁA ɇAɋTAɇAɄ ɄOɊOɇAɊɇE ɂɋɏEMɂJɋɄE ȻOɅEɋTɂ ɉojaɦ "ɮaɤɬoɪ ɪɢɡɢɤК" ɫО ɱОɫɬШ ɤШɪɢɫɬɢ ɞК ШɩɢɲО oɧe ɤaɪaɤɬeɪɢɫɢɬɢɤe ɤoje ɫɭ ɧaђeɧe ɤoɞ ɡɞɪaɜɢɯ ɩojeɞɢɧaɰa, a ɡa ɤoje je ɭɬɜɪђeɧo ɭ eɩɢɞeɦɢoɥoɲɤɢɦ ɫɬɭɞɢjaɦa ɞa ɫɭ ɩoɜeɡaɧɢ ɫa ɧaɤɧaɞɧoɦ ɩojaɜoɦ ɛoɥeɫɬɢ, ɭ oɜoɦ ɫɥɭɱajɭ ɤШɪШɧКɪɧО ɢɫɯОɦɢУɫɤО ɛШɥОɫɬɢ. ɍ ɭɠeɦ ɫɦɢɫɥɭ ɪeɱɢ, ɩojaɦ ɮaɤɬoɪa ɪɢɡɢɤa oɛɭɯɜaɬa ɩɪoɦeʃɢɜe ɢ ɧeɩɪoɦeʃɢɜe ɤaɪaɤɬeɪɢɫɬɢɤe ɫɜaɤoɝ ɩojeɞɢɧɰК5. JeɞКɧ Шɞ ШɫɧШɜɧɢɯ ɰɢʂОɜК ɋɜОɬɫɤО ɡɞɪКɜɫɬɜОɧО ɨɪɝКɧɢɡКɰɢУО (ɋɁɈ) je ɫɦКʃОʃО ɛɪɡШ ɧКɩɪОɞɭУɭʄО ОɩɢɞОɦɢУО ɤКɪɞɢШɜКɫɤɭɥКɪɧɢɯ ШɛШʂОʃК, ɤКШ ɢ ОɮɢɤКɫɧК ɤШɧɬɪШɥК ɪɢɡɢɱɧɢɯ ɮКɤɬШɪК ɤШУɢ ɞШɜШɞО ɞШ ʃО. τɫɧШɜɧК ɫɬɪКɬОɝɢУК УО ɭ ɫɩɪОɱКɜКʃɭ ɤКШ ɢ ɭ ШɞɥКɝКʃɭ ɩɪШɰОɫК КɬОɪШɫɤɥОɪШɡО К ɫКɦɢɦ ɬɢɦ ɢ ɫɩɪОɱКɜКʃО ɭ ɦКɧɢɮОɫɬКɰɢУɢ ɤШɪШɧКɪɧО ɢɫɯОɦɢУɫɤО ɛШɥОɫɬɢ. ɉШɡɧКɬШ УО ɞК ШɞɪОђОɧО ɛШɥОɫɬɢ, ɫɬКʃК ɢ ɧКɜɢɤО, ШɞɧШɫɧШ ɮКɤɬШɪɢ ɪɢɡɢɤК ɡК ɪКɡɜШУ ɤШɪШɧКɪɧО ɢɫɯОɦɢУɫɤО ɛШɥОɫɬɢ ɭɛɪɡКɜКУɭ КɬОɪШɫɤɥОɪШɡɭ ɢ ɩШɜОʄКɜКУɭ ʃОɧɭ ɭɱОɫɬКɥШɫɬ. ɎКɤɬШɪɢ ɪɢɡɢɤК ɫО ɝɪɭɩɢɲɭ ɩɪОɦК ɡɧКɱКУɭ ɧК ɜОɥɢɤО, ɡКɬɢɦ ɧК ɩɪОɞɢɫɩШɧɢɪКУɭʄО ɢ ɧК ɭɫɥШɜɧО ɮКɤɬШɪО6. ɍɞɪɭɠɢɜКʃОɦ ɞɜК ɢɥɢ ɜɢɲО ɮКɤɬШɪК ɪɢɡɢɤК ʃɢɯШɜ ɭɬɢɰКУ ɧК ɩШУКɜɭ ɤШɪШɧКɪɧО ɢɫɯОɦɢУɫɤО ɛШɥОɫɬɢ ɫО ɬКɞК ɧО ɫКɛɢɪК ɧОɝШ ɦɧШɠɢ, ШɞɧШɫɧШ ɦɭɥɬɢɩɥɢɰɢɪК7. ɉɪОɩШɡɧКɜКʃО ɮКɤɬШɪК ɪɢɡɢɤК ɤШɞ ШɫШɛК ɤШɞ ɤШУɢɯ УШɲ ɭɜОɤ ɧɢУО ɧКɫɬɭɩɢɥК ɛШɥОɫɬ, ɤКШ ɢ ɫɩɪОɱКɜКʃО ɪКɡɜШУК ɛШɥОɫɬɢ ɩɪШɦОɧШɦ ɧКɜɢɤК ɤШУО ɩɪОɞɫɬКɜʂКУɭ ɪɢɡɢɤ ɡК ʃОɧ ɧКɫɬКɧКɤ, ɩɪОɞɫɬКɜʂКУɭ ɝɥКɜɧО ɦОɪО ɩɪɢɦКɪɧО ɩɪОɜОɧɰɢУО ɋɜОɬɫɤО ɡɞɪКɜɫɬɜОɧО ШɪɝКɧɢɡКɰɢУО. 11 ȼОШɦК УО ɜКɠɧШ ɞК ɫО Ш ɫɜКɤШɦ ɮКɤɬШɪɭ ɪɢɡɢɤК ɩШУОɞɢɧКɱɧШ ɜШɞɢ ɪКɱɭɧК К ɩШɫОɛɧШ ɭɤШɥɢɤШ ɩШɫɬШУɢ ɜОʄɢ ɛɪШУ ɬɢɯ ɮКɤɬШɪК. ɋɜО ɮКɤɬШɪО ɪɢɡɢɤК ɬɪɟɛɚ ɬɪОɬɢɪКɬɢ ɧК ШɞɝШɜКɪКУɭʄɢ ɧКɱɢɧ ɩɪО ɩШУКɜО К ɩШɝШɬШɜɭ ɭ ɬШɤɭ ɦКɧɢɮОɫɬКɰɢУО ɛШɥОɫɬɢ8. 4 ɉȺɌɈȺɇȺɌɈɆɂȳȺ ɂ ɉAɌOɎɂɁɂOɅOȽɂJA ɄOɊOɇAɊɇE ɂɋɏEɆɂJEɋɄE ȻOɅEɋɌɂ Ʉɨɪɨɧɚɪɧɚ ɢɫɯɟɦɢʁɫɤɚ ɛɨɥɟɫɬ ɩɪɟɞɫɬɚɜʂɚ ɩɚɬɨɥɨɲɤɨ ɫɬɚʃɟ ɭ ɤɨʁɟɦ ɩɪɨɝɪɟɫɢʁɚ ɚɬɟɪɨɫɤɥɟɪɨɡɟ ɭ ɤɨɪɨɧɚɪɧɨʁ ɚɪɬɟɪɢʁɢ ɫɦɚʃɭʁɟ ɩɪɨɬɨɤ ɤɪɜɢ ɭ ɫɪɱɚɧɨɦ ɦɢɲɢʄɭ. Ɋɚɧɚ ɩɚɬɨɝɟɧɟɡɚ ɫɟ ɤɚɪɚɤɬɟɪɢɲɟ ɟɧɞɨɬɟɥɢʁɚɥɧɨɦ ɞɢɫɮɭɧɤɰɢʁɨɦ, ɜɚɫɤɭɥɚɪɧɨɦ ɢɧɮɥɚɦɚɰɢʁɨɦ ɢ ɮɨɪɦɢɪɚʃɟɦ ɥɢɩɢɞɚ, ɤɚɥɰɢʁɭɦɚ ɢ ʄɟɥɢʁɫɤɢɯ ɨɬɩɚɞɚɤɚ ɭ ɢɧɬɢɦɚɥɧɨɦ ɞɟɥɭ ɡɢɞɚ ɤɨɪɨɧɚɪɧɟ ɚɪɬɟɪɢʁɟ9,10. Ɂɚ ɜɪɟɦɟ ɩɨɡɢɬɢɜɧɨɝ ɪɟɦɨɞɟɥɨɜɚʃɚ ɮɢɛɪɨɡɧɚ ɩɥɨɱɚ ɚɪɬɟɪɢʁɫɤɨɝ ɡɢɞɚ ɢɦɚ ɬɟɧɞɟɧɰɢʁɭ ɪɚɡɜɢʁɚʃɚ ɜɚɧ ɥɭɦɟɧɚ ɢ ɭ ɩɨɱɟɬɤɭ ɧɟ ɞɨɜɨɞɢ ɞɨ ɨɩɫɬɪɭɤɰɢʁɟ ɫɚɦɨɝ ɥɭɦɟɧɚ. ɋɚ ɞɚʂɢɦ ɪɚɡɜɢʁɚʃɟɦ ɚɬɟɪɨɫɤɥɟɪɨɡɟ ɞɨɥɚɡɢ ɞɨ ɧɚɩɪɟɞɨɜɚʃɚ ɩɥɚɤɚ ɭɧɭɬɚɪ ɥɭɦɟɧɚ ɚ ɫɚɦɢɦ ɬɢɦ ɢ ɞɨ ɫɦɚʃɟʃɚ ɞɢʁɚɦɟɬɪɚ ɚɪɬɟɪɢʁɟ, ɤɚɨ ɢ ɪɟɞɭɤɰɢʁɟ ɩɪɨɬɨɤɚ ɤɪɜɢ ɤɪɨɡ ɤɨɪɨɧɚɪɧɭ ɚɪɬɟɪɢʁɭ11. Ɋɭɩɬɭɪa ɢɥɢ eɪoɡɢja ɮɢɛɪoɡɧe ɤaɩe ɩɥaɤa ɢɡɥaɠe ɫe ɰɢɪɤɭɥɢɲɭʄɢɦ ɬɪШɦɛШɰɢɬɢɦК ɢ ɮКɤɬШɪɢɦК ɤШКɝɭɥaɰɢje, ɫɭɛeɧɞoɬeɥɧoɦ ɤoɥaɝeɧɭ ɢ ȼoɧ ȼɢɥeɛɪaɧɞoɜoɦ ɮaɤɬoɪɭ, ɲɬo ɞoɜoɞɢ ɞo aɝɪeɝaɰɢje ɬɪoɦɛoɰɢɬa ɢ ɪaɡɥɢɱɢɬoɝ ɫɬeɩeɧa ɤoɪoɧaɪɧe ɬɪoɦɛoɡe, ɤoɪoɧaɪɧoɝ ɜaɡoɫɩaɡɦa ɢ ɞɢɫɬaɥɧe ɬɪШɦɛШɰɢɬɧО ɦɢɤɪШОɦɛШɥɢɡКɰɢУО . 12 5 ɉɊEȼEɇɐɂJA ɂ ɅEɑEȵE ɄOɊOɇAɊɇE ɂɋɏEMɂJɋɄE ȻOɅEɋTɂ ɍ ɩɪɟɜɟɧɰɢʁɢ ɤɨɪɨɧɚɪɧɟ ɢɫɯɟɦɢʁɫɤɟ ɛɨɥɟɫɬɢ ɫɟ ɢɧɫɢɫɬɢɪɚ ɧɚ ɢɫɩɢɬɢɜɚʃɭ ɩɪɢɫɭɫɬɜɚ ɪɢɡɢɤɚ, ʁɟɪ ɨɧɢ ɩɨɬɟɧɰɢɪɚʁɭ ʁɟɞɚɧ ɞɪɭɝɨɝ ɢ ɡɧɚɬɧɨ ɩɨɜɟʄɚɜɚʁɭ ɪɢɡɢɤ ɡɚ ɩɨʁɚɜɭ ɤɨɪɨɧɚɪɧɟ ɛɨɥɟɫɬɢ ɢ ɞɪɭɝɢɯ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɢɯ ɨɛɨʂɟʃɚ. ɉɪɢɫɭɫɬɜɨ ɜɢɲɟ ɮɚɤɬɨɪɚ ɪɢɡɢɤɚ ɨɛɢɱɧɨ ɞɨɩɪɢɧɨɫɢ ɚɪɬɟɪɢɨɫɤɥɟɪɨɡɢ, ɤɨʁɚ ɭɡɪɨɤɭʁɟ ɤɨɪɨɧɚɪɧɭ ɛɨɥɟɫɬ. ɉɨɲɬɨ ɩɪɨɰɟɫ ɚɪɬɟɪɨɫɤɥɟɪɨɡɟ ɦɨɠɟ ɩɨɱɟɬɢ ʁɨɲ ɭ ɪɚɧɨɦ ɞɟɬɢʃɫɬɜɭ, ɦɟɪɟ ɩɪɟɜɟɧɰɢʁɟ ɬɪɟɛɚ ɫɩɪɨɜɨɞɢɬɢ ɬɨɤɨɦ ɰɟɥɨɝ ɠɢɜɨɬɚ. ɍɤɭɩɧɢ ɝoɞɢɲʃɢ ɬɪoɲɤoɜɢ ɤШУО ɭ EɜɪШɩɫɤШУ ɍɧɢjɢ ɭɡɪoɤɭjɭ ɤaɪɞɢoɜaɫɤɭɥaɪɧe ɛoɥeɫɬɢ ɢɡɧoɫe 192 ɦɢɥɢjaɪɞe eɜɪa. Oɞ ɬoɝa oɤo 57% ɱɢɧО ɬɪШɲɤШɜɢ ɥОɱОʃК, 21% ɝɭɛɢɰɢ ɭ ɩɪoɞɭɤɬɢɜɧoɫɬɢ ɢ 22% ɧeɮoɪɦaɥɧa ɧeɝa oɛoɥeɥɢɯ8. ɇajɜeʄɢ ɭɞeo ɭ ɬɪoɲɤoɜɢɦa ɢɦa ɤoɪoɧaɪɧa ɢɫɯeɦɢjɫɤa ɛoɥeɫɬ ɢ ɰeɪeɛɪoɜaɫɤɭɥaɪɧa ɛoɥeɫɬ. Ⱦaɤɥe, ɢɫɯeɦɢjɫɤa ɛoɥeɫɬ ɫɪɰa ɩɪeɞɫɬaɜʂa ɧe ɫaɦo ɦeɞɢɰɢɧɫɤɢ ɜeʄ ɢ oɡɛɢʂaɧ eɤoɧoɦɫɤɢ ɢ ɫoɰɢjaɥɧɢ ɩɪoɛɥeɦ. ɍ ɞɢjaɝɧoɫɬɢɰɢ ɢ ɥeɱeʃɭ ɤoɪoɧaɪɧe ɢɫɯeɦɢjɫɤe ɛoɥeɫɬɢ ɩɪɢɦeʃɭjɭ ɫe ɢɧoɜaɬɢɜɧa ɢ ɱeɫɬo ɪeɜoɥɭɰɢoɧaɪɧa ɬeɯɧoɥoɲɤa ɪeɲeʃa. ɍ ɬɪeɬɦaɧɭ oɜe ɛoɥeɫɬɢ ɤoɪɢɫɬe ɫe ɧajɦoɞeɪɧɢje ɧeɢɧɜaɡɢɜɧe ɢ ɢɧɜaɡɢɜɧe ɦeɬoɞe ɞɢjaɝɧoɫɬɢɤe, ɫaɜɪeɦeɧe ɮaɪɦaɤoɬeɪaɩɢjɫɤe ɮoɪɦɭɥe, ɤao ɢ ɢɧɬeɪɜeɧɬɧa ɤaɪɞɢoɥoɝɢja ɢ ɤaɪɞɢoɯɢɪɭɪɝɢja. Meɞɢɤaɦeɧɬoɡɧɢ ɬɪeɬɦaɧ je ɞɢɡajɧɢɪaɧ ɜɢɲeɫɦeɪɧo. ɉɪɜОɧɫɬɜОɧШ УО ɭɫɦОɪОɧ ɩɪeɦa ɩoɡɢɬɢɜɧoj ɦoɞɢɮɢɤaɰɢjɢ ɮaɤɬoɪa ɪɢɡɢɤa ɡa ɧaɫɬaɧaɤ ɤoɪoɧaɪɧe 13 ɢɫɯeɦɢjɫɤe ɛoɥeɫɬɢ, ɡКɬɢɦ ɤК ɭɦКʃОʃɭ ɫɭɛУОɤɬɢɜɧɢɯ ɬОɝШɛК ɢ ɩoɛoʂɲaʃe ɪaɞɧe ɫɩoɫoɛɧoɫɬɢ ɢ ɤɜaɥɢɬeɬa ɠɢɜШɬК. ɎКɪɦКɤШɬОɪКɩɢjɫɤɢ ɬɪОɬɦКɧ ɭɫɦОɪОɧ УО ɤa ɩɪeɜeɧɰɢjɢ ɩɪШɝɪОɫɢУО ɛШɥОɫɬɢ ɢ ɩojaɜe ɧeɠeʂeɧɢɯ ɞoɝaђaja ɭ ɫɦɢɫɥɭ ɬɪajɧoɝ oɲɬeʄeʃa ɦɢoɤaɪɞa ɢɥɢ ɧaɝɥe ɫɪɱaɧe ɫɦɪɬɢ. ɇajɜaɠɧɢjɢ ОɮОɤКɬ ШɜШɝ ɜɢɞК ɥОɱОʃК УО ɞoɛɢjaʃe ɜɪeɦeɧa ɞo ɢɧɬeɪɜeɧɬɧe ɩeɪɤɭɬaɧe ɩɪoɰeɞɭɪe ɢɥɢ oɩeɪaɰɢje, ɭɡ ɫɬaɥɧe ɩɪoɰeɧe ɞejɫɬɜa ɦeɞɢɤaɦeɧɬoɡɧe ɬeɪaɩɢje ɧa oɫɧoɜɭ ɫɭɛjeɤɬɢɜɧɢɯ ɢ oɛjeɤɬɢɜɧɢɯ ɦeɪɢɥa ɢ ʃeɧo ɩɪɢɥaɝoђaɜaʃe ɤɥɢɧɢɱɤoɦ ɫɬaʃɭ. „Ɋeɜaɫɤɭɥaɪɢɡaɰɢja ɦɢoɤaɪɞК” ɤoja ɫe oɞɧoɫɢ ɧa ɩoɧoɜɧo ɭɫɩoɫɬaɜʂaʃe ɩɪoɤɪɜʂeɧoɫɬɢ ɢɫɯeɦɢɱɧoɝ ɦɢoɤaɪɞa oɫɬɜaɪɭje ɫe ɭɡ ɩoɦoʄ ɬɪɢ oɫɧoɜɧe ɦeɬoɞe:  Ȼɚʁɩɚɫ ɤШɪШɧКɪɧО КɪɬОɪɢУО ɝɪКɮɬШɦ (CABG)  ɉОɪɤɭɬКɧК ɤШɪШɧКɪɧК ɢɧɬОɪɜОɧɰɢУК (ЈCI)  TɪШɦɛШɥɢɬɢɱɧК ɬОɪКɩɢУК (ɩɪɢɦОʃɢɜК ɤШɞ ɩКɰɢУОɧКɬК ɫК Кɤɭɬɧɢɦ ɢɧɮКɪɤɬШɦ ɦɢШɤКɪɞК ɤКɞК ɩɪɢɦКɪɧО ɩОɪɤɭɬКɧО ɤШɪШɧКɪɧО ɢɧɬОɪɜОɧɰɢУО ɧɢɫɭ ɞШɫɬɭɩɧО). Ȼɚʁɩɚɫ ɤШɪШɧКɪɧО КɪɬОɪɢУО ɝɪКɮɬШɦ (CABG) УО ɯɢɪɭɪɲɤК ɦeɬoɞa ɪeɜaɫɤɭɥaɪɢɡaɰɢje ɦɢɨɤɚɪɞɚ ɩɪɢ ɤojoj ɫe ɤɪɜɧɢ ɫɭɞoɜɢ (ɜОɧО ɢ/ɢɥɢ КɪɬОɪɢУО) ɭɡɟɬɢ ɢɡ ɞɪɭɝɢɯ ɞeɥoɜa ɬeɥa ɩɪeɫaђɭjɭ ɩɪoɤɫɢɦaɥɧo (ɚɨɪɬɚ ɧɚʁɱɟɲʄɟ) ɢ ɞɢɫɬaɥɧo ɨɞ ɦɟɫɬɚ ɥɟɡɢʁɟ ɧa ɛШɥОɫɧɨʁ ɤoɪoɧaɪɧɨʁ aɪɬeɪɢjɢ, ɤaɤo ɛɢ ɫe ɭɫɩoɫɬaɜɢɥa ɩoɧoɜɧa ɩɪoɤɪɜʂeɧoɫɬ ɢɫɯeɦɢɱɧoɝ ɦɢoɤaɪɞa. CABG ɡaɯɬeɜa oɬɜoɪeɧɭ ɬoɪaɤoɬoɦɢjɭ ɢ oɛaɜʂa ɫe ɭ oɩɲɬoj aɧeɫɬeɡɢjɢ. ɍ ɩoɫɥeɞʃe ɞɜe ɞeɰeɧɢje ɩaɰɢjeɧɬɢ ɩɪeɬɯoɞɧo ɫɦaɬɪaɧɢ ɩoɝoɞɧɢɦ ɡa CABG ɫɜe ɱeɲʄe ɫɟ ɪeɜaɫɤɭɥaɪɢɡɭjɭ ɩɭɬeɦ PCI. Meђɭɬɢɦ, CABG oɫɬaje ɜoɞeʄa ɩɪoɰeɞɭɪa ɭ ɤoɪoɧaɪɧoj 14 ɪeɜaɫɤɭɥaɪɢɡaɰɢjɢ ɩaɰɢjeɧaɬa ɫa oɡɛɢʂɧɢɦ ɢ ɤoɦɩɥeɤɫɧɢɦ ɤoɪoɧaɪɧɢɦ oɛoɥeʃeɦ ɤoje ɢɯ ɤɜaɥɢɮɢɤɭje ɧeɩoɝoɞɧɢɦ ɡa PCI. ɋɬaʃe ɢ ɩɪoɝɪeɫɢja ɤoɪoɧaɪɧoɝ aɬeɪoɫɤɥeɪoɬɫɤoɝ ɩɥaɤa oɞɪeђɭje ɤɥɢɧɢɱɤɭ ɫɥɢɤɭ ɢ ɫɬɪaɬeɝɢjɭ ɩɪeɞɫɬojeʄe ɪeɜaɫɤɭɥaɪɢɡaɰɢje ɦɢoɤaɪɞa. Aɬeɪoɫɤɥeɪoɬɫɤɢ ɩɥaɤ ɤojɢ ɭɝɪoɠaɜК > 70% ɥɭɦeɧa ɫɦaɬɪa ɫe ɡɧaɱajɧoɦ ɫɬeɧoɡoɦ ɢ ɧajɱeɲʄe ɭɝɪoɠaɜa ɦɢoɤaɪɞɧɢ ɩɪoɬoɤ ɲɬo ɡaɯɬeɜa ɧeɤɢ oɞ oɛɥɢɤa ɪeɜaɫɤɭɥaɪɢɡaɰɢje. Oɜaɤɜe ɥeɡɢje ɦoɝɭ ɞa ɛɭɞɭ ɩoɞɜɪɝɧɭɬe ɢɥɢ PCI ɢɥɢ CABG. Ɂɧaɱajɧe ɥeɡɢje ɭ ɜɢɲe oɞ ɞɜe eɩɢɤaɪɞɢjaɧe ɤoɪoɧaɪɧe aɪɬeɪɢje ɢɥɢ ɥОɡɢУО ɤШУО ɫО ШɞɧШɫО ɧК ɩɪШɦОɧО ɧК ɝɥКɜɧШɦ ɫɬКɛɥɭ ɦШɝɭ ɫО ɭɝɥɚɜɧɨɦ ɪОɲКɜКɬɢ ɫК CABG. ɅОɡɢУО ɤШУО ɫɭ ɥШɤКɥɢɡШɜКɧО ɧКУɜɢɲО ɧК ɞɜОɦК ɤШɪШɧКɪɧɢɦ КɪɬОɪɢУКɦɚ ɫК ɩШɜШʂɧШɦ КɧКɬШɦɢУШɦ ɩШɞɜɪɝКɜКУɭ ɫО ɫК ЈCI. ɉeɪɤɭɬaɧa ɤoɪoɧaɪɧa ɢɧɬeɪɜeɧɰɢja (PCI) je ɢɧɬeɪɜeɧɬɧɢ ɩoɫɬɭɩaɤ ɭ ɤojeɦ ɫe oɛoɥeɥa ɫɭɠeɧa ɤoɪoɧaɪɧa aɪɬeɪɢja oɬɜaɪa ɩeɪɤɭɬaɧo ɭɡ ɩoɦoʄ ɤaɬeɬeɪa ɢ ɛaɥoɧa. ɍ ɜeʄɢɧɢ ɫɥɭɱajeɜa ɢɧɬɪaɤШɪШɧКɪɧɢ ɫɬОɧɬ ɫО ɭɜШɞɢ ɧК ɦОɫɬШ aɧɝɢoɩɥaɫɬɢɱɧoɝ ɛaɥoɧa, ɲɬo oɞɪɠaɜa ɩɪoɯoɞɧoɫɬ ɥɭɦeɧa. PCI je ɩoɫɬao ɞoɦɢɧaɧɬaɧ ɩoɫɬɭɩaɤ ɡa ɤoɪoɧaɪɧɭ ɪeɜaɫɤɭɥaɪɢɡaɰɢjɭ ɤoɞ ɩaɰɢjeɧaɬa ɫa ɫɬaɛɢɥɧoɦ ɢ ɧeɫɬaɛɢɥɧoɦ ɤШɪШɧКɪɧШɦ ɛШɥОɲʄɭ. Ʉoɞ aɤɭɬɧe ɪɭɩɬɭɪe ɩɥaɤa ɫa ɬɪШɦɛШɰɢɬɧɢɦ ɧКɝШɦɢɥКɜКʃОɦ ɢ ɩШɬɩɭɧШɦ oɛɥɢɬОɪКɰɢУШɦ ɤШɪШɧКɪɧО КɪɬОɪɢУО oɛaɜʂa ɫe ɯɢɬɧa PCI ɞa ɛɢ ɫe aɪɬeɪɢja oɬɜoɪɢɥa . Oɜa ɩɪoɰeɞɭɪa ɧaɡɢɜa ɫe ɩɪɢɦaɪɧa ɉɐɂ. Aɥɬeɪɧaɬɢɜɧo ɭɤoɥɢɤo ɩɪɢɦaɪɧa PCI ɧɢje ɞoɫɬɭɩɧa ɩɪɢɛeɝaɜa ɫe ɮaɪɦaɤoɥoɲɤoj ɬɪoɦɛoɥɢɡɢ aɤɭɬɧe ɬɪoɦɛoɡe. 15 Oɞ ɩɪɜoɝ oɩɢɫa ɤoɪoɧaɪɧe aɧɝɢoɩɥaɫɬɢɤe Aɧɞɪeaɫa Ƚɪüɧɬɡɢɝa (1977), ɩoɫɬɭɩaɤ je ɡɧaɱajɧo ɦoɞɢɮɢɤoɜaɧ. Teɯɧɢɱɤɢ ɧaɩɪeɞaɤ ɡajeɞɧo ɫa ɭɩoɬɪeɛoɦ ɤoɪoɧaɪɧɢɯ ɫɬeɧɬoɜa ɢ ɩoɦoʄɧe ɬeɪaɩɢje ɦeɞɢɤaɦeɧɬɢɦa ɪeɡɭɥɬoɜaɥɢ ɫɭ ɜeɥɢɤШɦ ɫɬoɩoɦ ɭɫɩeɯa ɫaɦoɝ ɩoɫɬɭɩɤa ɢ ɧɢɫɤШɦ ɫɬШɩШɦ ɪОɫɬОɧШɡО. ȾКɧКɫ ɫО ɩШɫɬɭɩɤɭ ЈCI ɭɫɩeɲɧo ɩoɞɜɪɝaɜajɭ ɢ ɩaɰɢjeɧɬɢ ɡɪeɥɢje ɠɢɜoɬɧe ɞoɛɢ, ɤao ɢ ɫɥoɠeɧɢje ɜɢɲОɫɭɞШɜɧО ɥeɡɢje. 6 ɂɋɏEɆɂJɋɄO ɂ ɊȿɉȿɊɎɍɁɂɈɇɈ ɈɒɌȿȶȿȵȿ ɋɦaʃeɧa ɩɪoɤɪɜʂeɧoɫɬ ɦɢoɤaɪɞa ɪeɡɭɥɬɭje ɢɫɯeɦɢjɫɤɢɦ oɲɬeʄeʃeɦ. Tɢɩɢɱɧa ɢɫɯeɦɢjɫɤa ɞeɲaɜaʃa ɫe ɦoɝɭ ɩɪɢɦeɬɢɬɢ ɤaɤo ɭ ɬoɤɭ aɤɭɬɧoɝ ɢɧɮaɪɤɬa ɦɢoɤaɪɞa, ɬaɤo ɢ ɤoɞ ɩeɪɤɭɬaɧe ɤoɪoɧaɪɧe ɢɧɬeɪɜeɧɰɢje ɢ ɭ ɬoɤɭ oɩeɪaɰɢje ɫɪɰa. ɇɢɜo ɢɫɯeɦɢjɫɤe ɲɬeɬe ɤojɭ ɬɪɩɢ ɬɤɢɜo ɦɢoɤaɪɞa ɡaɜɢɫɢ oɞ ɬɪajaʃa ɢɫɯeɦɢje, ɦɢoɤaɪɞa ɡaɯɜaʄeɧoɝ ɢɫɯeɦɢjoɦ ɢ ɩɪɢɫɭɫɬɜa ɢɥɢ ɨɞɫɭɫɬɜɚ ɤoɥaɬeɪaɥɧoɝ ɫɧaɛɞeɜaʃa ɦɢoɤaɪɞa ɤɪɜʂɭ. ɇa ʄeɥɢjɫɤoɦ ɧɢɜoɭ, ɭ ɬoɤɭ ɢɫɯeɦɢje, ɫɦaʃeʃe ɤɢɫeoɧɢɤa ɪeɡɭɥɬɭje ɫɦaʃeɧoɦ oɤɫɢɞaɬɢɜɧoɦ ɮoɫɮoɪɢɥaɰɢjoɦ ɢ ɩoɫɥeɞɢɱɧo ɭɦaʃeɧɢɦ ɧɢɜoɢɦa aɞeɧoɡɢɧ ɬɪɢ-ɮoɫɮaɬa (ATɉ). ɇeɞoɫɬaɬaɤ ATɉ-a ɭɬɢɱe ɧa joɧɫɤe ɤaɧaɥe ʄeɥɢjɫɤe ɦeɦɛɪaɧe ɲɬo ɞoɜoɞɢ ɞo aɤɭɦɭɥaɰɢje ɧaɬɪɢjɭɦa (Na+) ɢ ɜoɞe, ɚ ɝɭɛɢɬɚɤ ɤaɥɢjɭɦa (Ʉ+) ɭ ʄeɥɢjaɦa, ɲɬɨ ɢɡɚɡɢɜɚ ɩɪoɝɪeɫɢɜɧɨ ɛɭɛɪɟʃɟ ʄeɥɢja. Aɤɬɢɜaɰɢja aɧaeɪoɛɧɢɯ ɝɥɢɤoɥɢɬɢɱɤɢɯ ɩɭɬeɜa ɪaɞɢ ɤoɦɩeɧɡaɰɢje ɦaʃɤa ɝeɧeɪɢɫaʃa eɧeɪɝɢje ɤɪoɡ ɪeɫɩɢɪaɬoɪɧɢ ɥaɧaɰ ɪeɡɭɥɬɭje ɢɧɬɪaʄeɥɢjɫɤoɦ 16 aɰɢɞoɡoɦ ɡɛoɝ aɤɭɦɭɥaɰɢje ɥaɤɬaɬa. To ɞoɜoɞɢ ɞo aɤɬɢɜaɰɢje ɪaɡɦeʃɢɜaɱa ɧaɬɪɢjɭɦ-ɜoɞoɧɢɤa (Na+H+) ɲɬo ɪeɡɭɥɬɭje ɞoɞaɬɧoɦ ʄeɥɢjɫɤoɦ aɤɭɦɭɥaɰɢjoɦ Na+. Ⱦoɞaɬɧo, aɤɭɦɭɥaɰɢja ɦaɫɧɢɯ ɤɢɫeɥɢɯ ɦeɬaɛoɥɢɬa ɤɪoɡ ɥɢɩoɥɢɡɭ ɞoɜoɞɢ ɞo ɩɪoɝɪeɫɢɜɧoɝ oɲɬeʄeʃa ɫɬɪɭɤɬɭɪe ʄeɥɢjɫɤe ɦeɦɛɪaɧe ɢ ɮɭɧɤɰɢje12. Ɋaɡɦeʃɢɜaɱ ɧaɬɪɢjɭɦ-ɤaɥɰɢjɭɦa (Na+/Ca2+) jeɞaɧ ʁɟ oɞ ɧajɜaɠɧɢjɢɯ ʄeɥɢjɫɤɢɯ ɦeɯaɧɢɡaɦa ɡa ɭɤɥaʃaʃe Ca2+ ɤojɢ ɭɤɥaʃa jeɞaɧ joɧ ɤaɥɰɢjɭɦa ɢ ɭɜoɞɢ ɬɪɢ joɧa Na+. Ʉao oɞɝoɜoɪ ɧa ɜɢɫoɤ ɧɢɜo ɢɧɬɪaʄeɥɢjɫɤoɝ Na+, ɞeɥɭje ɫe ɭ ɫɭɩɪoɬɧoɦ ɫɦeɪɭ ɞa ɫe oɞɪɠɢ ɯoɦeoɫɬaɡa ɧaɬɪɢjɭɦa aɥɢ ɪeɡɭɥɬɭje ɩoɜeʄaʃeɦ ɢɧɬɪaɰeɥɭɥaɪɧe aɤɭɦɭɥaɰɢje Ca2+. ɉɪoɞɢɪaʃe Ca2+ ɭ ʄeɥɢjɭ ɫe ɬaɤoђe oɞɜɢja ɩɭɬeɦ ɞɢɪeɤɬɧɢɯ Na2+ ɤaɧaɥa ɢ ɤɪoɡ oɫɥoɛaђaʃe Ca2+ ɢɡ ʄeɥɢjɫɤoɝ ɫaɪɤoɩɥaɡɦaɬɫɤoɝ ɪeɬɢɤɭɥɭɦa ɭ ɬoɤɭ ɢɫɯeɦɢjɫɤe ɩoɜɪeɞe13. ɉɪeɥaɡaɤ ɫa ɪeɜeɪɡɢɛɢɥɧoɝ ɧa ɢɪeɜeɪɡɢɛɢɥɧo oɲɬeʄeʃe ɩoɱɢʃe ɧeɪeɝɭɥɢɫaɧoɦ aɤɭɦɭɥaɰɢjoɦ Ca2+, ɡa ɲɬa je ɬaɤoђe ɤaɪaɤɬeɪɢɫɬɢɱaɧ ɪaɡɜoj ɬeɲɤoɝ ɞeɮeɤɬa ɩɪoɩɭɫɧoɫɬɢ ɦeɦɛɪaɧe14. ɇɢɜoɢ ɦɢɬoɯoɧɞɪɢjɫɤe ɦaɬɪɢɰe Ca2+ ɫe ɬaɤoђe ɩoɜeʄaɜajɭ ɞoɤ ɭɧɢɩoɪɬeɪ Ca2+ ɭ ɦɢɬoɯoɧɞɪɢjɫɤoj ɦeɦɛɪaɧɢ ɞeɥɭje ɤao ɤaɧaɥ ɤɪoɡ ɤojɢ eɤɫɬɪa-ɦɢɬoɯoɧɞɪɢjɫɤɢ ɢɧɬɪaʄeɥɢjɫɤɢ Ca2+ ɭɥaɡɢ ɭ ɦɢɬoɯoɧɞɪɢjɫɤɭ ɦaɬɪɢɰɭ. To ɞoɜoɞɢ ɞo ɩɪeoɩɬeɪeʄeʃa Ca2+ ɫa ɝɭɛɢɬɤoɦ eɥeɤɬɢɱɧe ɩoɬeɧɰɢjaɥɧe ɪaɡɥɢɤe ɞɭɠ ɦeɦɛɪaɧe ɚ ɬɨ ɜoɞɢ ɤa oɲɬeʄeʃɭ ɦɢɬoɯoɧɞɪɢja15. Ʉɥaɫɢɱɧa ɧeɤɪoɬɢɱɧa ʄeɥɢjɫɤa ɫɦɪɬ ɧaɫɬaje oɬɢɰaʃeɦ ʄeɥɢjɫɤɢɯ oɪɝaɧeɥa ɢ ɩoɫɥeɞɢɱɧɢɦ eɤɫɬɪɭɞɢɪaʃeɦ ʄeɥɢjɫɤoɝ ɫaɞɪɠaja ɭ eɤɫɬɪaʄeɥɢjɫɤɭ ɦaɬɪɢɰɭ ɡɛoɝ ɪɭɩɬɭɪe ɩɥaɡɦe ʄeɥɢjɫɤe ɦeɦɛɪaɧe. ɍ ɤɥɢɧɢɱɤoj ɩɪaɤɫɢ ɩɪaɜo ɢɫɯeɦɢjɫɤo oɲɬeʄeʃe ɤoje ɞoɜoɞɢ ɞo ɧeɤɪoɡe ʄeɥɢja ɦɢoɤaɪɞa (ɢɧɮaɪɤɬa) ɦoɠe ɞa ɫe ɞoɝoɞɢ ɭ ɬoɤɭ ɧeɥeɱeɧoɝ ɢɧɮaɪɤɬa ɦɢoɤaɪɞa ɢɥɢ ɬɢɯoɝ ɢɧɮaɪɤɬa ɦɢoɤaɪɞa. ɍ ɬoɤɭ eɥeɤɬɢɜɧɢɯ ɤoɪoɧaɪɧɢɯ 17 ɢɧɬeɪɜeɧɰɢja ɧa ɩaɰɢjeɧɬɢɦa ɩeɪɢ-ɩɪoɰeɞɭɪaɥɧa ɦɢɤɪo-eɦɛoɥɢja, ɞeɥa aɬeɪoɫɤɥeɪoɬɢɱɧoɝ ɩɥaɤa, joɲ ʁɟ jeɞaɧ oɞ ɫɥɭɱajeɜa ɝɞe ɦoɠe ɞoʄɢ ɞo ɧeɤɪoɬɢɱɧe ʄeɥɢjɫɤe ɫɦɪɬɢ. Meђɭɬɢɦ, ɭ ɜeʄɢɧɢ ɫɥɭɱajeɜa ɢɫɯeɦɢjɫɤɢ ɦɢoɤaɪɞ ɫe ɞoɩɭʃaɜa ɫoɩɫɬɜeɧɢɦ ɞoɬoɤoɦ ɤɪɜɢ, ɬeɪaɩeɭɬɫɤɢ ɢɥɢ ɫɩoɧɬaɧoɦ ɪeɜaɫɤɭɥaɪɢɡaɰɢjoɦ. OɜaɤɜК „ɪeɩeɪɮɭɡɢУК”, ɪaɡɭɦʂɢɜo, ɫɩɪeɱaɜa ɞaʂe ɢɫɯeɦɢjɫɤo oɲɬeʄeʃe ʄeɥɢja, ɦaɞa ɦoɠe ɢ ɞa ɢɧɢɰɢɪa ɫeɪɢjɭ ɞoɝaђaja ɭɧɭɬaɪ ʄeɥɢje ɤoja ɜoɞɢ ɤa oɲɬeʄeʃɭ ɦɢoɤaɪɞa, ɚ ɬɨ ʁɟ „ɪeɩeɪɮɭɡɢoɧo oɲɬeʄeʃe”. ɉoɪeɞ ɧeɤɪoɬɢɱɧe ʄeɥɢjɫɤe ɫɦɪɬɢ, ɩoɫɬoje joɲ ɞɜa ɧaɱɢɧa ɧa ɤoja ɦoɠe ɞa ɧaɫɬɭɩɢ ʄeɥɢjɫɤa ɫɦɪɬ ɭɫɥeɞ ɢɫɯeɦɢjɫɤoɝ oɲɬeʄeʃa: aɩoɩɬoɡa ɢ aɭɬoɮaɝɢja. Ⱥɩɨɩɬɨɡɚ (ɝɪɱ. απόπIJωıις ɨɡɧɚɱɚɜɚ ɨɩɚɞɚʃɟ) ɨɛɥɢɤ ʁɟ ɩɪɨɝɪɚɦɢɪɚɧɟ ʄɟɥɢʁɫɤɟ ɫɦɪɬɢ ɤɨʁɚ ɫɟ ʁɚɜʂɚ ɭ ɮɢɡɢɨɥɨɲɤɢɦ ɢ ɩɚɬɨɥɨɲɤɢɦ ɩɪɨɰɟɫɢɦɚ ɭ ɨɪɝɚɧɢɡɦɭ. Aɩoɩɬoɡa ɦoɠe ɞa ɛɭɞe ɢɧɢɰɢɪaɧa oɫɥoɛaђaʃeɦ ɰɢɬoɯɪoɦa ɐ ɢɡ oɲɬeʄeɧe ɦɢɬoɯoɧɞɪɢje ɢɥɢ ɤɪoɡ ɜeɡɢɜaʃe ɪeɰeɩɬoɪa ɫɦɪɬɢ ɤojɢ ɬɪaɧɫɦɢɬɭje aɩoɩɬoɬɢɱɧɢ ɫɢɝɧaɥ ɭɧɭɬaɪ ʄeɥɢje. ȶeɥɢjɫɤa ɫɦɪɬ ɤoja ɧaɫɬaje oɜaɤɜɢɦ ɦeɯaɧɢɡɦoɦ ɞoɝaђa ɫe, ɭɝɥaɜɧoɦ, ɭ ɜɢɞɭ ɫɤɭɩʂaʃa, ɤoɧɞeɧɡaɰɢje, ɦaɪɝɢɧaɰɢje ɯɪoɦaɬɢɧa ɢ ɩɭɩʂeʃa ɩɥaɡɦe ɦeɦɛɪaɧe16. ɂɫɯeɦɢja ɬaɤoђe ɦoɠe ɞa ɢɡaɡoɜe ɬɪeʄɢ ɧaɱɢɧ oɞɭɦɢɪaʃa ʄeɥɢje ɤɪoɡ aɭɬoɮaɝɢjɭ, ɢɧɬɪaʄeɥɢjɫɤɢ ɮeɧoɦeɧ ɩɪɢ ɤojeɦ ʄeɥɢja ɜaɪɢ ɫoɩɫɬɜeɧɢ ɫaɞɪɠaj. Ɂɧaʃe o ɦeɯaɧɢɡɦɢɦa oɜaɤɜe ʄeɥɢjɫɤe ɫɦɪɬɢ je joɲ ɭɜɢjeɤ oɝɪaɧɢɱeɧo, aɥɢ oɧo ɩoɞɪaɡɭɦeɜa aɤɬɢɜaɰɢjɭ ɩɪoɬeoɥɢɬɢɱɤoɝ ɥɢɡoɡoɦaɥɧoɝ eɧɡɢɦa,ɤao oɞɝoɜoɪ ɧa aɤɭɦɭɥaɰɢjɭ ɥaɤɬaɬa ɢ ɩɪoɬoɧa ɭ ʄeɥɢjɢ. ɂaɤo ɫe ɫɦaɬɪa ɞa jeɞaɧ ɧaɱɢɧ ʄeɥɢjɫɤe ɫɦɪɬɢ ɢɫɤʂɭɱɭje ɞɪɭɝɢ, ɭ ɩɪaɤɫɢ ɫe jaɜʂa ɡɧaɱajɧo ɩɪeɤɥaɩaʃe ɦeђɭ ʃɢɦa, ɬaɤo ɞa ɢɧɞɢɜɢɞɭaɥɧe ʄeɥɢje ɦoɝɭ ɞa ɩoɤaɡɭjɭ ɤaɪaɤɬeɪɢɫɬɢɤe ɜɢɲe oɞ jeɞɧoɝ ɦeɯaɧɢɡɦa ɢɫɬoɜɪeɦeɧo16. 18 Ɋeɩeɪɮɭɡɢja ɢɫɯeɦɢjɫɤoɝ ɫɪɱaɧoɝ ɦɢɲɢʄa ɞoɩɪɢɧoɫɢ ɩɪeɜeɧɰɢjɢ ɞaʂeɝ ɢɫɯeɦɢjɫɤoɝ oɲɬeʄeʃa ʄeɥɢja ɤoje ɫɭ ɩoɞɜɪɝɧɭɬe aɩɫoɥɭɬɧoj ɢɫɯeɦɢjɢ ɦɢoɤaɪɞa. Meђɭɬɢɦ, ɩɪɢ ɢɡɧeɧaɞɧoj ɪeɩeɪɮɭɡɢjɢ ʄeɥɢje ɦɢoɤaɪɞa ɤoje ɫɭ ɩɪeɬɪɩeɥe ɪaɡɥɢɱɢɬe ɧɢɜoe ɢɫɯeɦɢjɫɤoɝ oɲɬeʄeʃa ɩoɤɪeʄɭ ɫeɪɢjɭ ɞoɝaђaja ɭɧɭɬaɪ ʄeɥɢje ɤojɢ ɦoɝɭ ɞa ɞoɜeɞɭ ɞo ɞaʂeɝ oɲɬeʄeʃa. Oɜaj ɮeɧoɦeɧ ɩoɜɪeɞe ɢɥɢ ɫɦɪɬɢ ʄeɥɢja ɦɢoɤaɪɞa ɭɡɪoɤoɜaɧ ɧaɝɥɢɦ ɩoɧoɜɧɢɦ ɭɫɩoɫɬaɜʂaʃeɦ ɩeɪɮɭɡɢje ɭ ɢɫɯeɦɢjɫɤoɦ ɦɢoɤaɪɞɭ ɩoɡɧaɬ je ɤКШ „ɥeɬaɥɧo ɪeɩeɪɮɭɡɢoɧo oɲɬeʄeʃО”. τɧo oɫɥɢɤaɜa oɛɢɦ ɡaɯɜaʄeɧoɫɬɢ ɫɪɱaɧoɝ ɦɢɲɢʄa ɢɧɮaɪɤɬoɦ. Ɋeɩeɪɮɭɡɢja ɦɢoɤaɪɞa ɦoɠe ɞa ɞoɜeɞe ɢ ɞo ɞɪɭɝɢɯ ɤɥɢɧɢɱɤɢɯ ɦaɧɢɮeɫɬaɰɢja ɩoɪeɞ ɥeɬaɥɧoɝ ɪeɩeɪɮɭɡɢoɧoɝ oɲɬeʄeʃa, ɬo ɫɭ ɭɝɥaɜɧoɦ ɢɡɧeɧaɞaɧ ɢɧɮaɪɤɬ ɢ ɪeɩeɪɮɭɡɢoɧe aɪɢɬɦɢje. Ⱦa ɛɢ ɞoɲɥo ɞo ɫɦɪɬoɧoɫɧoɝ ɪeɩeɪɮɭɡɢoɧoɝ oɲɬeʄeʃa, ɫaɦa ɢɫɯeɦɢja ɧe ɫɦe ɞa ɩɪoɭɡɪoɤɭje ɢɪeɜeɪɡɢɛɢɥɧo oɲɬeʄeʃe. ɂɡ oɜoɝa ɫe ɦoɠe ɢɡɜɭʄɢ ɡaɤʂɭɱaɤ ɞa ɫɭ ɢɫɯeɦɢjɫɤe ɩɪoɦeɧe ɧa ɧɢɜoɭ ʄeɥɢja ɧeoɩɯoɞaɧ ɩɪeɞɭɫɥoɜ ɡa ɥeɬaɥɧo ɪeɩeɪɮɭɡɢoɧo oɲɬeʄeʃe, aɥɢ ɧe ɢ ɫaɦ ɩo ɫeɛɢ ɞoɜoʂaɧ ɭɡɪoɤ ʄeɥɢjɫɤe ɫɦɪɬɢ17. ɇaɠaɥoɫɬ, ɭ ɫɥɭɱajɭ ɪeɩeɪɮɭɡɢoɧe ɢɫɯeɦɢje ɬeɯɧɢɱɤɢ je ɧeɦoɝɭʄe ɩɪoɰeɧɢɬɢ ɦaɧɢɮeɫɬaɰɢje ɢɪeɜeɪɡɢɛɢɥɧoɝ oɲɬeʄeʃa ɭ oɞɪeђeɧoɦ ɞeɥɭ ɦɢoɤaɪɞa ɩɪe ɢ ɩoɫɥe ɪeɩeɪɮɭɡɢje. Taɤoђe je ɧeɦoɝɭʄe oɞɪeɞɢɬɢ ɫaɦo aɧaɥɢɡaɦa ɧaɩɪeɞɭjɭʄeɝ ɪeɩeɪɮɭɡɢoɧoɝ oɲɬeʄeʃa ɦɢoɤaɪɞa ɞa ɥɢ je ɭɡɪoɤ ʄeɥɢjɫɤe ɫɦɪɬɢ ɢɫɤʂɭɱɢɜo ɢɫɯeɦɢjɫɤoɝ ɩoɪeɤɥa ɢɥɢ je ɪeɩeɪɮɭɡɢoɧɢ17. Jeɞɢɧɢ ɢɧɞɢɪeɤɬaɧ ɧaɱɢɧ ɞoɧoɲeʃa ɬaɤɜoɝ ɡaɤʂɭɱɤa jeɫɬe ɢɫɩɢɬɢɜaʃe ɞa ɥɢ ɦoɞɢɮɢɤaɰɢja ɭɫɥoɜa ɪeɩeɪɮɭɡɢje ɦoɠe ɞa ɫɩɪeɱɢ ʄeɥɢjɫɤɭ ɫɦɪɬ ɞo ɤoje ɛɢ ɭ ɫɭɩɪoɬɧoɦ ɞoɲɥo. Ⱦaɧaɫ je ɞoɛɪo ɩoɡɧaɬo ɞa ɦoɞɢɮɢɤaɰɢja ɭɫɥoɜa ɪeɩeɪɮɭɡɢje ɡaɢɫɬa ɩɪɭɠa ɧɢɜo ɡaɲɬɢɬe. 19 ȶeɥɢjɫɤɢ ɦeɯaɧɢɡɦɢ ɭɤʂɭɱeɧɢ ɭ ɪeɩeɪɮɭɡɢoɧa oɲɬeʄeʃa ɫɭ ɞoɛɪo ɪaɡjaɲʃeɧɢ ɬoɤoɦ ɧɢɡa ɝoɞɢɧa ɛɪojɧɢɯ ɢɫɬɪaɠɢɜaʃa ɤoja ɫɭ ɞeɬaʂɧo ɫaɝɥeɞaɥɢ Yeɥɥoɧ ɢ ɏaɭɫeɧɥoy 18 ɢ ɉɢɩeɪ ɢ ɞɪ. 17. Meɯaɧɢɡɦɢ ɪeɩeɪɮɭɡɢoɧoɝ oɲɬeʄeʃa ɩoɞɪaɡɭɦeɜajɭ: a) ɧaɝɥo ɢɧɬɪaʄeɥɢjɫɤo ɩɪeoɩɬeɪeʄeʃe ɤaɥɰɢjɭɦoɦ ɤoje ɞoɜoɞɢ ɞo ɯɢɩeɪɤoɧɬɪaɤɬɭɪe ɦɢoɰɢɬa, ɛ) oɤɫɢɞaɬɢɜɧɢ ɫɬɪeɫ, ɰ) ɪaɩɢɞɧɭ ɪeɫɬaɭɪaɰɢjɭ ɮɢɡɢoɥoɲɤe PH ɜɪeɞɧoɫɬɢ ɢɡ aɰɢɞoɡɧoɝ ɦɢʂea ɢ ɞ) aɤɬɢɜaɰɢje ɢɧɮɥaɦaɬoɪɧɢɯ ɤaɫɤaɞa, oɞ ɤojɢɯ ɫɜɢ ɞoɩɪɢɧoɫe ɧeɤɪoɡɢ ɦɢoɤaɪɞa ɢɧɞɭɤoɜaɧɨɦ ɪeɩeɪɮɭɡɢjoɦ ɢɥɢ aɩoɩɬoɬɢɱɧoɦ ɫɦɪʄɭ. ɋɪɱaɧɢ ɦɢoɰɢɬɢ ɬɪoɲe oɝɪoɦɧɭ ɤoɥɢɱɢɧe eɧeɪɝɢje. Ⱦa ɛɢ ɫe ɩɪɢɥaɝoɞɢɥe ɩoɬɪeɛaɦa, ʄeɥɢje ɞoɡɜoʂaɜajɭ ɜeɥɢɤɭ ɝɭɫɬɢɧɭ ɦɢɬoɯoɧɞɪɢja. Tɪaɧɡɢɰɢoɧa ɩoɪa ɩɪoɩɭɫɬʂɢɜaoɫɬɢ ɦɢɬoɯoɧɞɪɢja (mPTP) ɩɪɢɜɥaɱɢ ɫɜe ɜɢɲe ɩaɠʃe ɡɛoɝ ɫɜoje ɭɥoɝe ɭ ɦeɞɢjaɰɢjɢ ɪeɩeɪɮɭɡɢoɧɢɯ oɲɬeʄeʃa. ɍɧɭɬɪaɲʃa ɦeɦɛɪaɧa ɦɢɬoɯoɧɞɪɢja ɤoja je oɞɝoɜoɪɧa ɡa oɞɪɠaɜaʃe ɩoɬeɧɰɢjaɥa ɦɢɬoɯoɞɪɢjɫɤe ɬɪaɧɫɦeɦɛɪaɧe je ɭ ɧoɪɦaɥɧɢɦ ɭɫɥoɜɢɦa ɧeɩɪoɩɭɫɧa ɡa joɧe ɢ ɞɪɭɝe ɦoɥeɤɭɥe. Ɋaɫɢɩaʃe eɥeɤɬɪɢɱɧoɝ ɩoɬeɧɰɢjaɥa ɤɪoɡ ɦeɦɛɪaɧɭ ɧaɡɜaɧo je „ɬɪaɧɡɢɰɢja ɩɪoɩɭɫɧoɫɬɢ”, ɲɬo je ɩɪoɰeɫ ɤojɢ ɫe ɫɦaɬɪa ɩoɫɪeɞoɜaɧɢɦ ɤɪoɡ mPTP. ɂaɤo ɫaɫɬaɜ ɤoɦɩoɧeɧaɬa ɩɪoɬeɢɧa oɫɬaje ɧeɩoɡɧaɬ, ɮoɪɦɢɪaʃe ɩoɪa ɫɬɜaɪa ɧeɫeɥeɤɬɢɜaɧ ɤaɧaɥ ɢɡɦeђɭ ɭɧɭɬɪaɲʃɢɯ ɦeɦɛɪaɧa ɦɢɬoɯoɧɞɪɢja ɢ ɫaɪɤoɩɥaɡɦe. Ɋeɡɭɥɬaɬ je ɝɭɛɢɬaɤ eɥeɤɬɪoɯeɦɢjɫɤoɝ ɝɪaɞɢjeɧɬa, oɫɥoɛaђaʃe ɪeaɤɬɢɜɧɢɯ ɜɪɫɬa ɤɢɫeoɧɢɤa (ROS) ɢ ɮoɪɦɢɪaʃe aɩoɩɬoɡoɦa. ɉɪeoɩɬeɪeʄeʃe ɤaɥɰɢjɭɦoɦ, ɪaɩɢɞɧa ɧoɪɦaɥɢɡaɰɢja Ph ɜɪeɞɧoɫɬɢ ɢ oɤɫɢɞaɰɢoɧɢ ɫɬɪeɫ ɫɭ ɩoɡɧaɬɢ oɤɢɞaɱɢ mPTP. ɇeɫɩeɰɢɮɢɱɧɢ ɜɢɫoɤoɩɪoɩɭɫɬʂɢɜɢ mPTP ɞoɜoɞɢ ɞo ɪaɡɞɜajaʃa oɤɫɢɞaɬɢɜɧe ɮoɫɮoɪɢɥaɰɢje ɢ ɩoɫɥeɞɢɱɧoɝ ATɉ ɩɪaɠʃeʃa, oɬɢɰaʃa ɦɢɬoɯoɧɞɪɢja ɢ ɝɭɛɢɬɤa ɢɧɬeɝɪɢɬeɬa ʄeɥɢje15,19. ɉɪoaɩoɩɬoɬɢɱɧɢ ɩɭɬ aɤɬɢɜaɰɢje 20 oɫɥoɛaђaʃeɦ ɰɢɬoɯɪoɦa ɐ ɢɡ ɭɧɭɬɪaɲʃe ɦeɦɛɪaɧe ɦɢɬoɯoɧɞɪɢja ɬaɤoђe ɞoɩɪɢɧoɫɢ ʄeɥɢjɫɤoj ɫɦɪɬɢ. ɋa ɰeɧɬɪaɥɧoɦ ɭɥoɝoɦ ɭ ɪeɩeɪɮɭɡɢoɧoɦ oɲɬeʄeʃɭ, ɢɧɯɢɛɢɰɢja mPTP ɫe ɢɫɬaɤɥa ɤao ɩɪɢɦaɪɧɢ ɰɢʂ ɩɪɢ ɫɩɪeɱaɜaʃɭ ɪeɩeɪɮɭɡɢoɧoɝ oɲɬeʄeʃa. ɍ ɤɥɢɧɢɱɤoj ɩɪaɤɫɢ ɧeɢɡɜoɞʂɢɜo je ɥeɬaɥɧo ɪeɩeɪɮɭɡɢoɧo oɲɬeʄeʃe ɛeɡ ɢɫɯeɦɢjɫɤoɝ oɲɬeʄeʃa. ɉoɫɥeɞɢɱɧo, ɜeʄɢɧa ɫɥɭɱajeɜa ɪeɩeɪɮɭɡɢoɧoɝ oɲɬeʄeʃa ɦɢoɤaɪɞa ɛɢ ɢɦaɥa ɪaɡɥɢɱɢɬe ɫɬeɩeɧe ɢɫɯeɦɢjɫɤoɝ oɲɬeʄeʃa. ɇeɤɢ oɞ ɤɥaɫɢɱɧɢɯ ɫɥɭɱajeɜa ɢɫɯeɦɢjɫɤo-ɪeɩeɪɮɭɡɢoɧɢɯ oɲɬeʄeʃa ɫa ɤojɢɦa ɫe ɫɭɫɪeʄeɦo ɭ ɥeɱeʃɭ ɫɪɰa ɩoɞɪaɡɭɦeɜajɭ aɤɭɬɧɭ ɬɪɚɧɡɢɬɨɪɧɭ ɋT eɥeɜaɰɢjɭ ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ ɩoɞɜɪɝɧɭɬɢɦ ɩɪɢɦaɪɧoj ɩeɪɤɭɬaɧoj ɢɧɬeɪɜeɧɰɢjɢ ɢɥɢ ɬɪoɦɛoɥɢɡɢ, ɚ ɩɨɧɟɤɚɞ ɢ ɭ ɤaɪɞɢoɯɢɪɭɪɲɤɢɦ ɢɧɬeɪɜeɧɰɢjaɦa ɤoje ɩoɞɪaɡɭɦeɜajɭ ɤaɪɞɢoɩɥeɝɢɱɧɢ ɡaɫɬoj. Ƚoɞɢɧaɦa, ɧajɜeʄɢ ɩɪɢoɪɢɬeɬ ɭ ɡɛɪɢʃaɜaʃɭ aɤɭɬɧoɝ Mɂ je ɛɢɥa ɪeɫɬoɪaɰɢja ɫɧaɛɞeɜaʃa ɤɪɜʂɭ. To je ɞoɜeɥo ɞo ɛɪɡɨɝ ɪaɡɜoja ɧaɩɪeɞɧɢjɢɯ ɦeɞɢɰɢɧɫɤɢɯ ɢ ɢɧɬɟɪɜɟɧɬɧɢɯ ɬeɯɧɢɤa ɭ ɰɢʂɭ ɛɪɡɨɝ ɭɫɩɨɫɬɚɜʂɚʃɚ ɩɟɪɮɭɡɢʁɟ ɪaɞɢ ɫɦɚʃɟʃɚ ɢɫɯeɦɢjɫɤoɝ oɲɬeʄeʃa. ɍ ɤaɪɞɢoɯɢɪɭɪɭɪɲɤoɦ oɤɪɭɠeʃɭ, ɧaɝɥaɫaɤ je ɫɬaɜʂeɧ ɧa ɫɤɪɚʄɟʃɟ ɜɪeɦeɧa ɤaɪɞɢoɩɥeɝɢɱɧoɝ ɚɪɟɫɬɚ ɭɡ ɭɧaɩɪeђɢɜaʃe ɯɢɪɭɪɲɤɢɯ ɬeɯɧɢɤa ɤaɤo ɛɢ ɫe ɫɦaʃɢɥo ɢɫɯeɦɢjɫɤo oɲɬeʄeʃe ɫɪɰa. Ɉ ɨɜɨɦɟ ɫɭ ɞɨɫɬɚ ɢɡɜɟɲɬɚɜɚɥɢ Marry at al.20 ɭ ɫɜɨʁɢɦ ɪɚɞɨɜɢɦɚ. 21 7 ɏɂɊɍɊɒɄɈ Ʌȿɑȿȵȿ ɄOɊOɇAɊɇE ɂɋɏEMɂJɋɄE ȻOɅEɋTI Ⱦɭɝɨ ɫɟ ɬɪɚɝɚɥɨ ɡɚ ɧɚʁɛɨʂɢɦ ɧɚɱɢɧɨɦ ɡɚ ɡɛɪɢʃɚɜɚʃɟ ɢɫɯɟɦɢɱɧɨɝ ɫɪɱɚɧɨɝ ɦɢɲɢʄɚ. Ɉɫɧɨɜɧɢ ɰɢʂ ʁɟ ɛɢɨ ɞɚ ɫɟ ɩɨɜɟʄɚ ɩɟɪɮɭɡɢʁɚ ɨɲɬɟʄɟɧɨɝ ɦɢɨɤɚɪɞɚ. Ⱦɨ ɩɪɜɟ ɩɨɥɨɜɢɧɟ ɞɜɚɞɟɫɟɬɨɝ ɜɟɤɚ ɛɢɥɨ ʁɟ ɞɨɫɬɚ ɧɟɭɫɩɟɥɢɯ ɩɨɤɭɲɚʁɚ ɢɧɞɢɪɟɤɬɧɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɦɢɨɤɚɪɞɚ 21-25. ȼɟɥɢɤɢ ɛɪɨʁ ɨɜɢɯ ɩɪɨɰɟɞɭɪɚ ʁɟ ɩɪɢɦɟʃɢɜɚɧ ɢ ɢɦɩɥɟɦɟɧɬɢɪɚɧ ɭ ɫɬɚɧɞɚɪɞɧɭ ɯɢɪɭɪɝɢʁɭ ɬɨɝ ɜɪɟɦɟɧɚ ɚ ʁɟɞɢɧɚ ɤɨʁɚ ɫɟ ɡɚɞɪɠɚɥɚ ɞɭɝɢ ɧɢɡ ɝɨɞɢɧɚ ɛɢɥɚ ʁɟ ɢɧɞɢɪɟɤɬɧɚ ɢɧɬɪɚɦɢɨɤɚɪɞɧɚ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɚ, ɢ ɬɨ ɢɦɩɥɚɧɬɚɰɢʁɨɦ ɭɧɭɬɪɚɲʃɟ ɝɪɭɞɧɟ ɚɪɬɟɪɢʁɟ 26. Ɉɜɚ ȼɢɧɟɛɟɪɝ-ɨɜɚ ɦɟɬɨɞɚ, ɛɢɥɚ ʁɟ ɧɚʁɩɪɢɡɧɚɬɢʁɚ ɢ ɫɚ ɧɚʁɛɨʂɢɦ ɪɟɡɭɥɚɬɚɬɢɦɚ ɤɪɚʁɟɦ ɲɟɡɞɟɫɬɢɯ ɝɨɞɢɧɚ. ɍɜɨђɟʃɟɦ ɫɟɥɟɤɬɢɜɧɟ ɚɧɝɢɨɝɪɚɮɢʁɟ ɤɨɪɨɧɚɪɧɢɯ ɚɪɬɟɪɢʁɚ 1958. ɝɨɞɢɧɟ27, ɤɨʁɭ ʁɟ ɞɪ ɋɨɧɟɫ ɫɚ Ʉɥɢɜɥɟɧɞ Ʉɥɢɧɢɤɟ ɢɦɩɥɟɦɟɧɬɢɪɚɨ ɩɪɜɢ ɩɭɬ ɧɚ ɞɟɱɚɤɭ ɨɞ 26 ɝɨɞɢɧɚ, ɨɦɨɝɭʄɢɥɨ ʁɟ ɯɢɪɭɪɡɢɦɚ ɦɧɨɝɨ ɥɚɤɲɢ ɢ ɫɢɝɭɪɧɢʁɢ ɩɪɢɫɬɭɩ ɥɟɡɢʁɢ ɤɨɪɨɧɚɪɧɟ ɚɪɬɟɪɢʁɟ. ɋɟɥɟɤɬɢɜɧɚ ɚɧɝɢɨɝɪɚɮɢʁɚ ɞɚʁɟ ɬɚɱɧɭ ɢɧɞɟɬɢɮɢɤɚɰɢʁɭ ɦɟɫɬɚ ɧɚ ɤɨɦɟ ɫɟ ɧɚɥɚɡɢ ɥɟɡɢʁɚ ɤɚɨ ɢ ɩɨɞɫɬɪɟɤ ɞɚ ɩɨɱɧɟ ɪɚɡɜɢʁɚʃɟ ɞɢɪɟɤɬɧɟ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɝɪɚɮɬɨɜɢɦɚ. Ʉɨɪɨɧɚɪɧɚ ɚɧɝɢɨɝɪɚɮɢʁɚ ʁɟ, ɬɚɤɨђɟ, ɩɨɤɚɡɚɥɚ ɢ ɟɮɢɤɚɫɧɨɫɬ ȼɢɧɟɛɟɪɝ-ɨɜɟ ɨɩɟɪɚɰɢʁɟ ɤɨʁɚ ʁɟ ɭ ɬɨ ɜɪɟɦɟ ɛɢɥɚ ɢ ɧɚʁɡɚɫɬɭɩʂɟɧɢʁɚ ɢɧɬɟɪɜɟɧɰɢʁɚ ɢ ɤɨʁɚ ɫɟ ɡɚɞɪɠɚɥɚ ɤɚɨ ɬɚɤɜɚ ɞɨ ɩɨɱɟɬɤɚ ɫɟɞɚɦɞɟɫɟɬɢɯ ɝɨɞɢɧɚ 20.ɜɟɤɚ. ɏɢɪɭɪɲɤɚ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɚ ɦɢɨɤɚɪɞɚ ʁɟ ɩɨɱɟɥɚ ɞɚ ɫɟ ɩɪɢɦɟʃɭʁɟ ɭ ɤɥɢɧɢɱɤɨʁ ɩɪɚɤɫɢ ɨɞ ɞɪɭɝɟ ɩɨɥɨɜɢɧɟ ɞɜɚɞɟɫɟɬɨɝ ɜɟɤɚ 28-30. 22 ȼɚɫɢɥɢ ɂ.Ʉɨɥɟɫɨɜ ɛɢɨ ʁɟ ɩɪɜɢ ɯɢɪɭɪɝ ɤɨʁɢ ʁɟ 25.ɮɟɛɪɭɚɪɚ 1964 ɩɨɫɥɟ ɨɩɫɟɠɧɟ ɫɬɭɞɢʁɟ ɧɚ ɩɫɢɦɚ, ɭɪɚɞɢɨ ɩɪɜɭ ɭɫɩɟɲɧɭ ɯɢɪɭɪɲɤɭ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɭ ɩɪɟɞʃɟ ɫɢɥɚɡɧɟ ɚɪɬɟɪɢʁɟ ɫɚ ɭɧɭɬɪɚɲʃɨɦ ɝɪɭɞɧɨɦ ɚɪɬɟɪɢʁɨɦ. ɉɪɢɫɬɭɩ ɫɪɰɭ ɛɢɨ ʁɟ ɤɪɨɡ ɥɟɜɭ ɬɨɪɚɤɨɬɨɦɢʁɭ ɧɚ ɤɭɰɚʁɭʄɟɦ ɫɪɰɭ ɫɚ ɤɨɪɢɲʄɟʃɟɦ ɫɬɟɩɥɟɪɚ 31. ɍ ɩɟɪɢɨɞɭ ɨɞ 25. ɮɟɛɪɭɚɪɚ 1964. ɞɨ 9. ɦɚʁɚ 1967. ɝɨɞɢɧɟ ɞɟɩɚɪɬɦɚɧ ɡɚ ɯɢɪɭɪɝɢʁɭ, ɤɨʁɢɦ ʁɟ ɭɩɪɚɜʂɚɨ ȼɚɫɢɥɢ ɂ. Ʉɨɥɟɫɨɜ,ɛɢɥɨ ʁɟ ʁɟɞɢɧɨ ɦɟɫɬɨ ɭ ɫɜɟɬɭ ɧɚ ɤɨɦɟ ɫɭ ɫɟ ɢɡɜɨɞɢɥɟ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɦɢɨɤɚɪɞɚ ɝɪɚɮɬɨɜɢɦɚ32,33. Ɉɞ 1967. ɝɨɞɢɧɟ ɧɚ Ʉɥɢɜɥɟɧɞ ɤɥɢɧɢɰɢ, Ɋɟɧɟ Ɏɚɜɚɥɨɪɨ ɩɨɱɢʃɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɭ ɦɢɨɤɚɪɞɚ ɭɡ ɩɨɦɨʄ ɜɟɧɫɤɢɯ ɝɪɚɮɬɨɜɚ. Ʉɨɪɢɫɬɢɨ ʁɟ ɜɟɧɭ ɫɚɮɟɧɭ ɥɟɜɟ ɢ ɞɟɫɧɟ ɧɨɝɟ. ɍ ɩɨɱɟɬɤɭ ɨɫɧɨɜɧɚ ɬɟɯɧɢɤɚ ɦɭ ʁɟ ɛɢɥɚ ɢɧɬɟɪɩɨɡɢɰɢʁɚ ɜɟɧɟ ɢɡɧɚɞ ɢ ɢɫɩɨɞ ɩɥɚɤɚ ɞɟɫɧɟ ɤɨɪɨɧɚɪɧɟ ɚɪɬɟɪɢʁɟ ɞɚ ɛɢ, ɤɚɫɧɢʁɟ, ɫɜɨʁɭ ɬɟɯɧɢɤɭ ɭɧɚɩɪɟɞɢɨ ɭ ɬɟɯɧɢɤɭ ɤɨʁɚ ɫɟ ɢ ɞɚɧɚɫ ɤɨɪɢɫɬɢ: ɚɨɪɬɨ-ɤɨɪɨɧɚɪɧɢ ɛɚʁɩɚɫ34. Ɂɚ 18 ɦɟɫɟɰɢ Ɏɚɜɚɥɨɪɨ ʁɟ ɨɩɟɪɢɫɚɨ 155 ɩɚɰɢʁɟɧɚɬɚ ɢ ɩɨɤɚɡɚɨ ɞɚ ɯɢɪɭɪɲɤɚ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɚ ɦɢɨɤɚɪɞɚ, ɤɨɪɢɫɬɟʄɢ ɜɟɧɫɤɟ ɝɪɚɮɬɨɜɟ ɭɡ ɤɥɚɫɢɱɧɭ ɫɬɟɪɧɨɬɨɦɢʁɭ ɢ ɫɬɚɜʂɚʃɟ ɩɚɰɢʁɟɧɬɚ ɧɚ ɟɤɫɬɪɚɤɨɪɩɨɪɚɥɧɭ ɰɢɪɤɭɥɚɰɢʁɭ, ɦɨɠɟ ɛɢɬɢ ɫɢɝɭɪɧɚ ɦɟɬɨɞɚ ɫɚ ɞɨɛɪɢɦ ɪɟɡɭɥɬɚɬɢɦɚ. Ɍɪɟɛɚɥɨ ɛɢ ɧɚɩɨɦɟɧɭɬɢ Ƚɚɪɪɟɬɚ(Garett) ɢ ɋɚɛɢɫɬɨɧɚ(Sabiston) ɤɨʁɢ ɫɟ ɜɨɞɟ ɭ ɱɥɚɧɰɢɦɚ35,36 ɞɚ ɫɭ ɩɪɜɢ ɯɢɪɭɪɡɢ ɤɨʁɢ ɫɭ ɩɨɱɟɥɢ ɞɚ ɪɚɞɟ ɫɚ ɜɟɧɫɤɢɦ ɝɪɚɮɬɨɜɢɦɚ 1962.ɢ 1964.ɝɨɞɢɧɟ, ɚɥɢ ɡɛɨɝ ɧɟ ɩɪɢɞɚɜɚʃɭ ɡɧɚɱɚʁɚ ɢ ɧɟ ɨɛʁɚɜʂɢɜɚʃɭ ɪɚɞɨɜɚ (ɨɛʁɚɜɢɥɢ ɫɭ ɬɟɤ 1973.ɝɨɞɢɧɟ), ɢɫɬɨɪɢʁɫɤɚ ɫɥɚɜɚ ɩɪɢɩɚɥɚ ʁɟ ɞɪɭɝɨɦɟ. 23 ɋɟɞɚɦɞɟɫɟɬɟ ɝɨɞɢɧɟ ɩɪɟɞɫɬɚɜʂɚʁɭ ɝɨɞɢɧɟ ɜɟɥɢɤɨɝ ɪɚɡɜɢɬɤɚ ɞɢɪɟɤɬɧɟ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɫɚ ɩɪɨɲɢɪɢɜɚʃɟɦ ɢɧɞɢɤɚɰɢʁɚ ɧɚ ɩɚɰɢʁɟɧɬɟ ɫɚ ɜɢɲɟɫɭɞɨɜɧɨɦ ɛɨɥɟɲʄɭ, ɤɚɨ ɢ ɧɨɜɭ ɟɪɭ ɦɨɞɟɪɧɟ ɤɚɪɞɢɨɯɢɪɭɪɝɢʁɟ. ɂɡɦɟђɭ ɫɟɞɚɦɞɟɫɟɬɢɯ ɢ ɨɫɚɦɞɟɫɟɬɢɯ ɝɨɞɢɧɚ ɩɪɨɲɥɨɝ ɜɟɤɚ, ɪɚђɟɧ ʁɟ ɜɟɥɢɤɢ ɛɪɨʁ ɩɪɨɫɩɟɤɬɢɜɧɢɯ, ɪɚɧɞɨɦɢɡɢɪɚɧɢɯ ɫɬɭɞɢʁɚ, ɤɨʁɟ ɫɭ ɢɦɚɥɟ ɡɚ ɰɢʂ ɞɚ ɩɨɤɚɠɭ ɤɜɚɥɢɬɟɬ ɢ ɭɫɩɟɲɧɨɫɬ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɦɢɨɤɚɪɞɚ ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɬɟɲɤɨɦ ɤɨɪɨɧɚɪɧɨɦ ɛɨɥɟɲʄɭ 37-42. ȳɭɫɭɮ ɢ ɫɚɪɚɞɧɢɰɢ ɭ ɫɜɨʁɨʁ ɦɟɬɚ-ɚɧɚɥɢɡɢ ɤɨʁɚ ʁɟ ɫɚɞɪɠɚɥɚ ɬɪɢ ɜɟɥɢɤɟ ɦɭɥɬɢɰɟɧɬɪɢɱɧɟ ɫɬɭɞɢʁɟ, ɫɩɪɨɜɟɞɟɧɟ ɨɞ 1972. ɞɨ 1984. ɝɨɞɢɧɟ ɡɚɤʂɭɱɢɨ ʁɟ ɞɚ ɯɢɪɭɪɲɤɨ ɡɛɪɢʃɚɜɚʃɟ ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɬɪɨɫɭɞɨɜɧɨɦ ɛɨɥɟɲʄɭ ɤɨɪɨɧɚɪɧɢɯ ɚɪɬɟɪɢʁɚ, ɤɚɨ ɢ ɫɚ ɫɬɟɧɨɡɨɦ ɝɥɚɜɧɨɝ ɥɟɜɨɝ ɤɨɪɨɧɚɪɧɨɝ ɫɬɚɛɥɚ ɧɚ ɩɟɬɨɝɨɞɢɲʃɟɦ ɢ ɞɟɫɟɬɨɝɨɞɢɲʃɟɦ ɩɪɚʄɟʃɭ ɢɦɚ ɜɟɥɢɤɢ ɛɟɧɟɮɢɬ ɤɚɨ ɢɧɢɰɢʁɚɥɧɢ ɬɪɟɬɦɚɧ 43. Ɋɚɡɜɢʁɚʃɟɦ ɧɨɜɢɯ ɬɟɯɧɨɥɨɝɢʁɚ ɨɫɚɦɞɟɫɟɬɢɯ ɝɨɞɢɧɚ, ɩɨɱɟɥɚ ʁɟ ɩɪɢɦɟɧɚ ɧɨɜɢɯ ɭɪɟђɚʁɚ ɤɨʁɢ ɫɭ ɨɦɨɝɭʄɚɜɚɥɢ ɯɢɪɭɪɲɤɭ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɭ ɦɢɨɤɚɪɞɚ ɛɟɡ ɤɨɪɢɲʄɟʃɚ ɩɭɦɩɟ ɡɚ ɟɤɫɬɪɚɤɨɪɩɨɪɚɥɧɭ ɰɢɪɤɭɥɚɰɢʁɭ. Ɍɚɤɜɢ ɭɪɟђɚʁɢ ɫɭ ɨɦɨɝɭʄɚɜɚɥɢ ɞɚ ɫɟ ɭɪɚɞɢ ɨɩɟɪɚɰɢʁɚ ɧɚ ɤɭɰɚʁɭʄɟɦ ɫɪɰɭ ɦɚʃɟ ɚɝɪɟɫɢɜɧɨ ɢ ɫɚ ɦɚʃɢɦ ɦɨɪɛɢɞɢɬɟɬɨɦ 44-48. Ʉɨɪɢɲʄɟʃɟɦ ɨɜɢɯ ɬɟɯɧɨɥɨɝɢʁɚ, ɤɚɨ ɢ ɪɟɡɜɨʁ ɬɟɯɧɨɥɨɝɢʁɟ ɞɟɜɟɞɟɫɟɬɢɯ, ɩɨɱɟɥɚ ʁɟ ɧɨɜɚ ɟɪɚ ɭ ɤɚɪɞɢɨɯɢɪɭɪɝɢʁɢ, ʁɟɞɚɧ ɧɨɜɢ ɤɨɧɰɟɩɬ ɭ ɡɛɪɢʃɚɜɚʃɭ ɤɚɪɞɢɨɯɢɪɭɪɲɤɨɝ ɩɚɰɢʁɟɧɬɚ, ɟɪɚ “ɦɢɧɢɦɚɥɧɨ ɢɧɜɚɡɢɜɧɟ ɯɢɪɭɪɝɢʁɟ” 21-27 . ɇɨɜɢ ɤɨɰɟɩɬ ɦɢɧɢɦɚɥɧɨ ɢɧɜɚɡɢɜɧɟ ɯɢɪɭɪɝɢʁɟ ʁɟ ɭɤʂɭɱɢɜɚɨ ɤɚɤɨ ɤɚɪɞɢɨɚɧɟɫɬɟɡɢʁɭ, ɯɢɪɭɪɲɤɭ ɢɧɰɢɡɢʁɭ ɛɟɡ ɤɚɪɞɢʁɚɥɧɨɝ ɚɪɟɫɬɚ, ɬɚɤɨ ɢ ɩɨɫɬɨɩɟɪɚɬɢɜɧɨ ɩɪɚʄɟʃɟ ɩɚɰɢʁɟɧɚɬɚ. Ɉɫɧɨɜɧɢ ɰɢʂ ɨɜɨɝ ɤɨɧɰɟɩɬɚ ɛɢɨ ʁɟ ɞɚ 24 ɪɟɞɭɤɭʁɟ ɯɢɪɭɪɲɤɭ ɬɪɚɭɦɭ, ɦɨɪɛɢɞɢɬɟɬ ɢ ɦɨɪɬɚɥɢɬɟɬ, ɤɚɨ ɢ ɞɚ ɫɦɚʃɢ ɛɨɪɚɜɚɤ ɭ ɛɨɥɧɢɰɢ. ɍ ɢɫɬɨ ɜɪɟɦɟ, ɨɜɢɦ ɤɨɧɰɟɩɬɨɦ, ɠɟɥɟɥɨ ɫɟ ɞɚ ɫɟ ɤɜɚɥɢɬɟɬ ɨɩɟɪɚɰɢʁɚ ɡɚɞɪɠɢ ɧɚ ɢɫɬɨɦ ɧɢɜɨɭ ɤɚɨ ɢ ɤɨɞ ɤɨɧɜɟɧɰɢɨɧɟ ɯɢɪɭɪɝɢʁɟ, ɢ ɞɚ ɫɟ ɩɚɰɢʁɟɧɬɢ ɲɬɨ ɩɪɟ ɜɪɚɬɟ ɧɚ ɫɜɨʁɟ ɪɟɞɨɜɧɟ ɚɤɬɢɜɧɨɫɬɢ 27-30,49. ɇɟɞɚɜɧɨ, ɪɚɡɜɢʁɚʃɟɦ ɧɨɜɢɯ ɤɨɧɰɟɩɚɬɚ ɤɚɪɞɢɨɯɢɪɭɪɝɢʁɟ ɩɨɱɢʃɟ ɞɚ ɫɟ ɪɚɡɜɢʁɚ ɢ ɪɨɛɨɬɢɤ ɯɢɪɭɪɝɢʁɚ 35,36,50. Ɉɫɧɨɜɧɢ ɰɢʂ ʁɟ ɞɚ ɫɟ ɫɦɚʃɢ ɯɢɪɭɪɲɤɚ ɬɪɚɭɦɚ ɢ ɩɨɫɩɟɲɢ ɩɪɟɰɢɡɧɨɫɬ ɭ ɢɡɜɨђɟʃɭ ɯɢɪɭɪɲɤɢɯ ɚɧɚɫɬɨɦɨɡɚ ɭ ɤɨɪɨɧɚɪɧɨʁ ɯɢɪɭɪɝɢʁɢ 51. Ɉɜɚ ɬɟɯɧɨɥɨɝɢʁɚ ɪɨɛɨɬɢɤ ɯɢɪɭɪɝɢʁɟ ɫɟ ʁɨɲ ɭɜɟɤ ɪɚɡɜɢʁɚ, ɜɟɨɦɚ ʁɟ ɫɤɭɩɚ ɚ ɫɚɦɢɦ ɬɢɦ ɨɦɨɝɭʄɟɧɚ ɡɚ ɩɪɢɦɟɧɭ ɫɚɦɨ ɭ ɜɟɥɢɤɢɦ ɦɟɞɢɰɢɧɫɤɢɦ ɰɟɧɬɪɢɦɚ. Ɉɜɨ ʁɟ ɧɨɜɢ ɤɨɧɰɟɩɬ ɯɢɪɭɪɝɢʁɟ ɝɞɟ ɯɢɪɭɪɝ ɧɢʁɟ ɭ ɞɢɪɟɤɬɧɨɦ ɤɨɧɬɚɤɬɭ ɫɚ ɩɚɰɢʁɟɧɬɨɦ ɜɟʄ ɭ ɢɧɞɢɪɟɤɬɧɨɦ ɝɞɟ ɩɪɟɤɨ ɦɨɧɢɬɨɪɚ ɢ ɤɨɦɚɧɞɧɟ ɬɚɛɥɟ ɭɩɪɚɜʂɚ ɪɭɱɢɰɚɦɚ ɪɨɛɨɬɚ ɤɨʁɢ ɫɭ ɩɪɟɤɨ ɩɨɪɬɨɜɚ ɩɨɜɟɡɚɧɢ ɫɚ ɩɚɰɢʁɟɧɬɨɦ. ɇɢʁɟ ɩɪɢɦɟʃɟɧɚ ɡɚ ɫɜɟ ɤɚɪɞɢɨɯɢɪɭɪɲɤɟ ɢɧɞɢɤɚɰɢʁɟ ɜɟʄ ɫɚɦɨ ɤɨɞ ɰɢʂɚɧɢɯ ɫɥɭɱɚʁɟɜɚ. 8 ɊȿȼȺɋɄɍɅȺɊɂɁȺɐɂȳȺ ɆɂɈɄȺɊȾȺ ɉȿɊɄɍɌȺɇɈɆ ɄɈɊɈɇȺɊɇɈɆ ɂɇɌȿɊȼȿɇɐɂȳɈɆ ɇɟɦɚɱɤɢ ɤɚɪɞɢɨɥɨɝ Aɧɞɪeaɫ Ɋoɥaɧɞ Ƚɪɭɧɬɡɢɝ(A.Gruntzig) ʁɟ ɩɪɜɢ ɱɨɜɟɤ ɤɨʁɢ ʁɟ ɭɪɚɞɢɨ ɛɚɥɨɧ ɞɢɥɚɬɚɰɢʁɭ ɧɚ ɫɭɠɟɧɨʁ ɤɨɪɨɧɚɪɧɨʁ ɚɪɬɟɪɢʁɢ ɤɚɨ ɩɚɧɞɚɦ ɯɢɪɭɪɲɤɨʁ ɤɨɪɨɧɚɪɧɨʁ ɪɟɜɚɫɤɭɥɚɪɢɡɰɢʁɢ52. Ɉɜɨɦ ɢɧɬɟɪɜɟɧɰɢʁɨɦ, ɤɨʁɭ ʁɟ ɭɪɚɞɢɨ 1977.ɝɨɞɢɧɟ ɧɚ ɛɭɞɧɨɦ ɱɨɜɟɤɭ ɭ ɐɢɪɢɯɭ, Ƚɪɭɧɬɡɢɝ ʁɟ ɡɚɩɨɱɟɨ ɧɨɜɭ ɟɪɭ ɭ ɡɛɪɢʃɚɜɚʃɭ ɤɨɪɨɧɚɪɧɟ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ. 25 ɍ ɩɨɱɟɬɤɭ, ɨɜɨɦ ɢɧɬɟɪɜɟɧɰɢʁɨɦ, ɛɢɥɚ ʁɟ ɡɛɪɢʃɚɜɚɧɚ ɫɚɦɨ ʁɟɞɧɚ ɥɟɡɢʁɚ, ʁɟɞɚɧ ɤɪɜɧɢ ɫɭɞ. Ƚɨɞɢɧɚɦɚ, ɢɧɬɟɪɜɟɧɰɢʁɚ ɫɟ ɩɪɨɲɢɪɢɥɚ ɧɚ ɞɜɚ ɩɚ ɢ ɜɢɲɟ ɤɪɜɧɢɯ ɫɭɞɨɜɚ. ɉɪɜɟ ɫɬɭɞɢʁɟ ɤɨʁɟ ɫɭ ɩɪɚɬɢɥɟ ɩɟɪɤɭɬɚɧɭ ɚɧɝɢɨɩɥɚɫɬɢɤɭ ɭɤɚɡɢɜɚɥɟ ɫɭ ɞɚ ʁɟ 23% ɩɚɰɢʁɟɧɚɬɚ ɨɛɨɥɟɥɢɯ ɨɞ ɜɢɲɟɫɭɞɨɜɧɟ ɛɨɥɟɫɬɢ ɞɨɛɢɥɨ ɬɭ ɢɧɬɟɪɜɟɧɰɢʁɭ.Ɍɚʁ ɛɪɨʁ ɫɟ ɩɨɜɟʄɚɨ ɧɚ 53 % ɭ ɫɥɟɞɟʄɢɦ ɫɬɭɞɢʁɚɦɚ. Ɍɚɤɨ ɞɚ ʁɟ ɢ ɛɪɨʁ ɡɚɯɜɚʄɟɧɢɯ ɫɭɞɨɜɚ ɩɟɪɤɭɬɚɧɨɦ ɚɧɝɢɨɩɥɚɫɬɢɤɨɦ ɩɨɪɚɫɬɚɨ ɫɚ 1.9 ɧɚ 2.7 53 ɤɪɜɧɚ ɫɭɞɚ. Ʉɚɨ ɩɨɫɥɟɞɢɰɚ ɩɨɜɟʄɚʃɚ ɛɪɨʁɚ ɩɟɪɤɭɬɚɧɢɯ ɛɚɥɨɧ ɚɧɝɢɨɩɥɚɫɬɢɤɚ ɦɟђɭ ɩɚɰɢʁɟɧɬɢɦɚ ɫɚ ɜɢɲɟɫɭɞɨɜɧɨɦ ɛɨɥɟɲʄɭ ɩɨʁɚɜɢɥɟ ɫɭ ɫɟ ɪɚɧɞɨɦɢɡɢɪɚɧɟ ɫɬɭɞɢʁɟ ɤɨʁɟ ɭɩɨɪɟђɭʁɭ ɯɢɪɭɪɲɤɨ ɡɛɪɢʃɚɜɚʃɟ ɫɚ ɩɟɪɤɭɬɚɧɢɦ ɛɚɥɨɧ ɚɧɝɢɨɩɥɚɫɬɢɤɚɦɚ. Ɉɞ 1986. ɞɨ 1992. ɝɨɞ. ɩɨɫɬɨʁɚɥɨ ʁɟ ɩɟɬ ɜɟɥɢɤɢɯ ɦɭɥɬɢɰɟɧɬɪɢɱɧɢɯ ɪɚɧɞɨɦɢɡɢɪɚɧɢɯ ɫɬɭɞɢʁɚ ɤɨʁɟ ɭɩɨɪɟђɭʁɭ ɯɢɪɭɪɭɲɤɨ ɡɛɪɢʃɚɜɚʃɟ ɫɚ ɩɟɪɤɭɬɚɧɨɦ ɚɧɝɢɨɩɥɚɫɬɢɤɨɦ 54-58 . ɍɩɪɤɨɫ ɫɜɢɦ ɨɝɪɧɢɱɟʃɢɦɚ, ɧɢʁɟ ɩɨɫɬɨʁɚɥɨ ɫɢɝɧɢɮɢɤɚɧɬɧɟ ɪɚɡɥɢɤɟ ɭ ɦɨɪɬɚɥɢɬɟɬɭ ɢ ɢɧɰɢɞɟɧɰɢ ɢɧɮɚɪɤɬɚ ɦɢɨɤɚɪɞɚ ɢɡɦɟђɭ ɨɜɚ ɞɜɚ ɩɪɢɫɬɭɩɚ ɭ ɥɟɱɟʃɭ ɜɢɲɟɫɭɞɨɜɧɟ ɤɨɪɨɧɚɪɧɟ ɛɨɥɟɫɬɢ. Ɇɟђɭɬɢɦ, ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ ɬɪɟɬɢɪɚɧɢɦ ɩɟɪɤɭɬɚɧɨɦ ɤɨɪɨɧɚɪɧɨɦ ɚɧɝɢɨɩɥɚɫɬɢɤɨɦ, ɭ ɩɟɪɢɨɞɭ ɨɞ ʁɟɞɧɟ ɞɨ ɩɟɬ ɝɨɞɢɧɚ, ɨɞ 30 % ɞɨ 60 % ɩɚɰɢʁɟɧɚɬɚ ɨɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɫɟ ɩɪɢʁɚɜɢɥɨ ɧɚ ɧɨɜɭ ɚɧɝɢɨɩɥɚɫɬɢɤɭ ɢɥɢ ɯɢɪɭɪɝɢʁɭ ɡɛɨɝ ɧɨɜɨ ɧɚɫɬɚɥɢɯ ɫɢɦɩɬɨɦɚ, ɪɟɤɭɪɟɧɬɧɟ ɩɨɜɪɟɞɟ ɢɥɢ ɩɨɧɨɜɧɢɯ ɚɧɝɢɧɨɡɧɢɯ ɬɟɝɨɛɚ. Ɇɟђɭ ɯɢɪɭɪɲɤɢɦ ɩɚɰɢʁɟɧɬɢɦɚ ɭ ɢɫɬɨɦ ɩɟɪɢɨɞɭ ɫɚɦɨ ɫɟ ɨɞ 2% ɞɨ 13 % ɨɛɪɚɬɢɥɨ ɡɚ ɩɨɧɨɜɧɭ ɢɧɬɟɪɜɟɧɰɢʁɭ 59. ɍ ɰɢʂɭ ɞɚ ɫɟ ɫɦɚʃɟ ɚɤɭɬɧɟ ɤɨɦɩɥɢɤɚɰɢʁɟ ɢ ɪɚɧɟ ɪɟɫɬɟɧɨɡɟ ɫɚ ɠɟʂɨɦ ɞɚ ɫɟ ɩɨɩɪɚɜɟ ɪɟɡɭɥɬɚɬɢ ɩɟɪɤɭɬɚɧɟ ɤɨɪɨɧɚɪɧɟ ɚɧɝɢɨɩɥɚɫɬɢɤɟ, ɪɚђɚɥɟ ɫɭ ɫɟ ɢ ɧɨɜɟ ɦɟɬɨɞɟ, ɢɧɬɟɪɜɟɧɬɧɟ ɬɟɯɧɢɤɟ. ɇɚʁɜɢɲɟ ɩɭɛɥɢɤɨɜɚɧɚ ɢ ɧɚʁɪɚɡɜɢʁɟɧɢʁɟ ɢɧɬɟɪɜɟɧɬɧɚ ɬɟɯɧɢɤɚ ɛɢɥɚ ʁɟ ɢɦɩɥɟɦɟɧɬɚɰɢʁɚ ɫɬɟɧɬɚ ɭ ɤɨɪɨɧɚɪɧɨʁ ɚɪɬɟɪɢʁɢ 60. Ʉɨɪɢɲʄɟʃɟɦ ɫɬɟɧɬɚ ɭ ɤɨɪɨɧɚɪɧɨʁ ɚɪɬɟɪɢʁɢ ɩɪɨɰɟɧɚɬ ɚɤɭɬɧɢɯ ɤɨɦɩɥɢɤɚɰɢʁɚ ɢ ɪɟɫɬɟɧɨɡɚ ɞɢɥɚɬɢɪɚɧɢɯ ɫɟɝɦɟɧɚɬɚ ɤɥɚɫɢɱɧɨɦ ɩɟɪɤɭɬɚɧɨɦ ɚɧɝɢɨɩɥɚɫɬɢɤɨɦ ɛɢɨ ʁɟ ɫɢɝɧɢɮɢɤɚɧɬɨ ɪɟɞɭɤɨɜɚɧ. ɍɡ ɤɨɪɢɲʄɟʃɟ ɫɬɟɧɬɚ ɩɪɨɦɟɧɢɥɢ ɫɭ ɫɟ ɢ ɫɬɚɜɨɜɢ ɨ ɤɨɪɢɲʄɟʃɭ ɚɧɬɢɤɨɚɝɭɥɚɧɬɧɢɯ ɥɟɤɨɜɚ ɤɨʁɢ ɫɭ ɡɚɦɟʃɟɧɢ ɚɧɬɢɚɝɪɟɝɚɰɢɨɧɢɦ. ɋɜɟ ɨɜɨ ɤɚɨ ɢ ɢɦɩɥɟɦɟɧɬɚɰɢʁɚ ɫɬɟɧɬɚ ɩɨɞ ɜɟɥɢɤɢɦ ɩɪɢɬɢɫɤɨɦ ɭ ʁɟɞɢɧɢɰɢ ɜɪɟɦɟɧɚ, 26 ɞɨɜɟɥɨ ʁɟ ɞɨ ɫɦɚʃɟʃɚ ɤɨɦɩɥɢɤɚɰɢʁɚ, ɤɚɨ ɢ ɬɪɟɧɭɬɧɨɝ ɩɨɛɨʂɲɚʃɚ ɫɬɚʃɚ ɩɚɰɢʁɟɧɬɚ 61-63. Ɉɞ 2002.ɝɨɞɢɧɟ ɪɚɡɜɢʁɚʃɟɦ ɧɨɜɟ ɜɪɫɬɟ ɫɬɟɧɬɚ DES ( drug eluting stent ), ɞɨɲɥɨ ʁɟ ɞɨ ʁɨɲ ɜɟʄɟɝ ɫɦɚʃɟʃɚ ɪɟɫɬɟɧɨɡɚ ɩɨɫɥɟ ɢɦɩɥɟɦɟɧɬɚɰɢʁɟ ɫɬɟɧɬɚ. Ɉɜɚʁ ɫɬɟɧɬ ʁɟ ɨɛɥɨɠɟɧ (ɥɟɤɨɦ) ɫɭɩɫɬɚɧɰɨɦ ɤɨʁɚ ɞɨɜɨɞɢ ɞɨ ɢɧɯɢɛɢɰɢʁɟ ɧɟɨɢɧɬɢɦɚɥɧɟ ɯɢɩɟɪɩɥɚɡɢʁɟ 64,65. Ɋɚɡɜɢʁɚʃɟɦ ɧɨɜɢɯ ɜɪɫɬɚ ɫɬɟɧɬɨɜɚ ɪɚђɚʁɭ ɫɟ ɢ ɧɨɜɢ ɩɪɨɛɥɟɦɢ. ɇɚɢɦɟ, ɫɜɟ ɫɭ ɱɟɲʄɟ ɛɢɜɚɥɟ ɬɪɨɦɛɨɡɟ ɢɧɬɪɚɤɨɪɨɧɚɪɧɢɯ ɫɬɟɧɬɨɜɚ, ɩɚ ʁɟ ɦɨɪɚɥɨ ɞɚ ɫɟ ɩɪɨɦɟɧɢ ɢ ɫɬɪɚɬɟɝɢʁɚ ɭ ɞɚɜɚʃɭ ɚɧɬɢɚɝɪɟɝɚɰɢɨɧɢɯ ɥɟɤɨɜɚ. Ɉɞ ɞɨɫɚɞɚɲʃɟ ʁɟɞɧɟ ɩɪɟɲɥɨ ɫɟ ɧɚ ɞɜɨʁɧɭ ɚɧɬɢɚɝɪɟɝɚɰɢɨɧɭ ɬɟɪɚɩɢʁɭ. ȼɪɟɦɟɧɨɦ ɢ ɫɬɢɰɚʃɟɦ ɧɨɜɢɯ ɢɫɤɭɫɬɚɜɚ, ɫɜɢ ɨɜɢ ɩɪɨɛɥɟɦɢ ɫɭ ɩɪɟɜɚɡɢɥɚɠɟɧɢ ɢ ɪɟɡɭɥɬɚɬɢ ɫɭ ɛɢɜɚɥɢ ɫɜɟ ɛɨʂɢ ɢ ɛɨʂɢ 66-68. ɋɜɚ ɨɜɚ ɭɧɚɩɪɟђɟʃɚ ɢ ɞɨɫɬɢɝɧɭʄɚ ɭ ɪɚɡɜɨʁɭ ɫɬɟɧɬɨɜɚ ɤɚɨ ɢ ɜɟɥɢɤɨ ɢɫɤɭɫɬɜɨ ɭ ɩɟɪɤɭɬɚɧɨʁ ɢɦɩɥɟɦɟɧɬɚɰɢʁɢ ɫɬɟɧɬɨɜɚ ɫɚ ɰɢʂɟɦ ɡɛɪɢʃɚɜɚʃɚ ɫɭɠɟʃɚ ɤɨɪɨɧɚɪɧɟ ɚɪɬɟɪɢʁɟ, ɭɤɚɡɭʁɭ ɞɚ ʁɟ ɨɜɚ ɦɟɬɨɞɚ ɫɜɟ ɦɚʃɟ ɢɧɜɚɡɢɜɧɚ, ɫɢɝɭɪɧɢʁɚ ɤɚɨ ɢ ɞɚ ɫɭ ɪɟɡɭɥɬɚɬɢ ɢɦɩɥɟɦɟɧɬɚɰɢʁɟ ɫɬɟɧɬɚ ɜɟɨɦɚ ɫɥɢɱɧɢ ɫɚ ɪɟɡɭɥɬɚɬɢɦɚ ɯɢɪɭɪɭɲɤɨɝ ɡɛɪɢʃɚɜɚʃɚ ɤɨɪɨɧɚɪɧɟ ɚɪɬɟɪɢʁɟ 69. ɇɟɤɨɥɢɤɨ ɪɚɧɞɨɦɢɡɢɪɚɧɢɯ ɫɬɭɞɢʁɚ ʁɟ ɭɩɨɪɟђɢɜɚɥɨ ɩɟɪɤɭɬɚɧɭ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɭ ɫɬɟɧɬɨɦ (ɫɚ ɢɥɢ ɛɟɡ ɥɟɤɚ ɨɛɥɨɠɟɧɢɦ ɫɬɟɧɬɨɦ) ɫɚ ɯɢɪɭɪɲɤɨɦ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɨɦ . ɍɩɪɤɨɫ ɢɡɜɚɧɪɟɞɧɨɦ ɧɚɩɪɟɬɤɭ ɩɟɪɤɭɬɚɧɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɦɢɨɤɚɪɞɚ ɫɬɟɧɬɨɦ, ɢ ɯɢɪɭɝɢʁɚ ɫɟ ɝɨɞɢɧɚɦɚ ɫɜɟ ɜɢɲɟ ɪɚɡɜɢʁɚɥɚ ɬɚɤɨ ɞɚ ɨɜɟ ɫɬɭɞɢʁɟ ɩɨɤɚɡɭʁɭ ɞɚ ɩɚɰɢʁɟɧɬɢ ɫɚ ɞɢɮɭɡɧɨɦ ɜɢɲɟɫɭɞɨɜɧɨɦ ɤɨɪɨɧɚɪɧɨɦ ɛɨɥɟɲʄɭ ʁɨɲ ɭɜɟɤ ɢɦɚʁɭ ɜɟʄɢ ɛɟɧɟɮɢɬ ɨɞ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ. Ɉɜɟ ɩɪɟɞɧɨɫɬɢ ɫɟ ɨɞɧɨɫɟ ɭɝɥɚɜɧɨɦ ɧɚ ɦɚʃɢ ɛɪɨʁ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɢɯ ɞɨɝɚђɚʁɚ , ɤɚɨ ɢ ɞɚ ʁɟ ɛɟɧɟɮɢɬ ɨɞ ɯɢɪɭɪɲɤɟ ɪɟɚɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɜɟʄɢ ɭɤɨɥɢɤɨ ʁɟ ɛɨɥɟɫɬ ɤɨɪɨɧɚɪɧɢɯ ɫɭɞɨɜɚ ɜɟʄɚ. ɍɩɨɪɟђɢɜɚђɟɦ ɨɜɚ ɞɜɚ ɩɪɢɫɬɭɩɚ ,ɛɟɧɟɮɢɬ ɨɞ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɪɚɫɬɟ ɢɚɤɨ ʁɟ ɩɪɚʄɟʃɟ ( follow up ) ɩɚɰɢʁɟɧɚɬɚ ɞɭɠɟ 30-35,103,104. 27 ɑɚɤ ɢ ɞɚɧɚɫ, ɬɟɠɢɧɚ ɛɨɥɟɫɬɢ ɤɨɪɨɧɚɪɧɢɯ ɚɪɬɟɪɢʁɚ ɫɟ ɦɨɠɟ ɤɥɚɫɢɮɢɤɨɜɚɬɢ ɤɚɨ ɥɟɡɢʁɚ ɝɥɚɜɧɨɝ ɫɬɚɛɥɚ ɫɚ ʁɟɞɧɨɫɭɞɨɜɧɨɦ, ɞɜɨɫɭɞɨɜɧɨɦ ɢɥɢ ɬɪɨɫɭɞɨɜɧɨɦ ɛɨɥɟɫɬɢ ɫɚ ɢɥɢ ɛɟɡ ɭɝɪɨɠɚɜɚʃɚ ɩɪɟɞʃɟ ɫɢɥɚɡɧɟ ɤɨɪɨɧɚɪɧɟ ɚɪɬɟɪɢʁɟ 70-73. Ɉɜɚ ɤɥɚɫɢɮɢɤɚɰɢʁɚ ɬɟɠɢɧɟ ɛɨɥɟɫɬɢ ɤɨɪɨɧɚɪɧɢɯ ɚɪɬɟɪɢʁɚ ʁɟ ɞɨɜɨђɟɧɚ ɭ ɩɢɬɚʃɟ ɡɛɨɝ ʃɟɧɟ ʁɟɞɧɨɫɬɚɜɧɨɫɬɢ, ɤɚɨ ɢ ɞɚ ɧɟɞɨɜɨʂɧɨ ɢɧɞɟɧɬɢɮɢɤɭʁɟ ɢɧɬɟɧɡɢɬɟɬ ɤɨɪɨɧɚɪɧɟ ɚɪɬɟɪɢʁɫɤɟ ɛɨɥɟɫɬɢ. Ⱦɨɜɨђɟɧɚ ʁɟ ɭ ɩɢɬɚʃɟ ɢ ʃɟɧɚ ɦɨɝɭʄɧɨɫɬ ɞɚ ɪɚɡɝɪɚɧɢɱɢ ɤɨʁɢ ɩɚɰɢʁɟɧɬɢ ɦɨɝɭ ɞɚ ɫɟ ɬɪɟɬɢɪɚʁɭ ɯɢɪɭɪɲɤɢɦ ɚ ɤɨʁɢ ɩɟɪɤɭɬɚɧɢɦ ɩɪɢɫɬɭɩɨɦ. ɍ ɫɤɨɪɢʁɟ ɜɪɟɦɟ, ɧɚɩɪɚɜʂɟɧɟ ɫɭ ɧɨɜɢʁɟ ɤɥɚɫɢɮɢɤɚɰɢʁɟ ɤɨʁɟ ɫɭ ɧɚɦ ɭ ɦɧɨɝɨɦɟ ɩɨɦɨɝɥe ɞɚ ɪɚɡɥɭɱɢɦɨ ɤɨʁɢ ɩɚɰɢʁɟɧɬɢ ɢɦɚʁɭ ɜɟʄɢ ɛɟɧɟɮɢɬ ɨɞ ɩɟɪɤɭɬɚɧɟ ɤɨɪɨɧɚɪɧɟ ɫɬɟɧɬ ɚɧɝɢɨɩɥɚɫɬɢɤɟ ɚ ɤɨʁɢ ɨɞ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ. ȳɟɞɧɚ ɨɞ ɧɚʁɢɫɬɚɤɧɭɬɢʁɢɯ ɧɨɜɢʁɢɯ ɫɬɭɞɢʁɚ ʁɟ “ЋвЧtКб sМШrО” ɫɬɭɞɢʁɚ. Ɉɜɚ ɫɬɭɞɢʁɚ ɭɩɨɪɟђɭʁɟ ɩɟɪɤɭɬɚɧɟ ɤɨɪɨɧɚɪɧɟ ɢɧɬɟɪɜɟɧɰɢʁɟ ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɜɢɲɟɫɭɞɨɜɧɢɦ ɩɪɨɦɟɧɚɦɚ ɤɚɨ ɢ ɫɚ ɫɭɠɟʃɟɦ ɥɟɜɨɝ ɝɥɚɜɧɨɝ ɫɬɚɛɥɚ ɫɚ ɩɚɰɢʁɟɧɬɢɦɚ ɤɨʁɢ ɫɭ ɯɢɪɭɪɲɤɢ ɡɛɪɢɧɭɬɢ. ɋɬɭɞɢʁɚ ʁɟ ɪɚɡɜɢʁɟɧɚ ɭ ɏɨɥɚɧɞɢʁɢ ɨɞ ɜɨɞɟʄe ɝɪɭɩɟ ɫɬɪɭɱʃɚɤɚ ɢɡ “TШrКбМОЧtОr”. ɋɤɨɪɨɜɚʃɟ ʁɟ ɢɡɜɟɞɟɧɨ ɢɡ ɜɟʄ ɩɨɫɬɨʁɟʄɢɯ ɤɥɚɫɢɮɢɤɚɰɢʁɚ, ɤɨʁɟ ɫɭ ɭɤʂɭɱɢɜɚɥɟ “AЦОrТМКЧ HОКrt AssШМТКtТШЧ”, ȺɏȺ ɤɥɚɫɢɮɢɤɚɰɢʁɭ ɫɟɝɦɟɧɚɬɚ ɤɨɪɨɧɚɪɧɨɝ ɫɬɚɛɥɚ, American College of Cardiology (ACC)/AHA ɤɥɚɫɢɮɢɤɚɰɢɨɧɢ ɫɢɫɬɟɦ ɥɟɡɢʁɚ, ɤɥɚɫɢɮɢɤɚɰɢɨɧɢ ɫɢɫɬɟɦ ɬɨɬɚɥɧɟ ɨɤɥɭɡɢʁɟ, ɡɚɬɢɦ ɤɥɚɫɢɮɢɤɚɰɢɨɧɢ ɫɢɫɬɟɦ ɛɢɮɭɪɤɚɰɢɨɧɢɯ ɥɟɡɢʁɚ ɢ ɦɧɨɝɢɯ ɞɪɭɝɢɯ . “ЋвЧtКб” ɫɬɭɞɢʁɚ ɤɚɨ ɪɚɧɝɢɪɚʁɭʄɢ ɚɥɚɬ ɡɚ ɤɥɚɫɢɮɢɤɨɜʃɟ ɬɟɠɢɧɟ ɛɨɥɟɫɬɢ ɤɨɪɨɧɚɪɧɢɯ ɤɪɜɧɢɯ ɫɭɞɨɜɚ ʁɟ ɩɪɜɢ ɩɭɬ ɩɭɛɥɢɤɨɜɚɧɚ 2005. ɝɨɞɢɧɟ 74. “ЋвЧtКб sМШrО” ʁɟ ɡɛɢɪ ɩɨɟɧɚ ɞɨɞɟʂɟɧ ɫɜɚɤɨʁ ɩɨʁɟɞɢɧɚɱɧɨʁ ɥɟɡɢʁɢ ɢɞɟɧɬɢɮɢɤɨɜɚɧɨʁ ɭ ɤɨɪɨɧɚɪɧɨɦ ɫɬɚɛɥɭ ɫɚ ɜɢɲɟ ɨɞ >50% ɫɭɠɟʃɚ ɤɪɜɧɨɝ ɫɭɞɚ ɤɨʁɢ ʁɟ ɞɢʁɚɦɟɬɪɚ ɜɟʄɟɝ ɨɞ >1.5ɦɦ. 28 Ʉɨɪɨɧɚɪɧɨ ɫɬɚɛɥɨ ʁɟ ɩɨɞɟʂɟɧɨ ɧɚ 16 ɫɟɝɦɟɧɚɬɚ ɩɨ ȺɏȺ ɤɥɚɫɢɮɢɤɚɰɢʁɢ (ɫɥɢɤɚ 1). ɋɥɢɤɚ 1. ɋɜɚɤɢ ɫɟɝɦɟɧɬ ɞɨɛɢʁɚ ɨɰɟɧɭ 1 ɢɥɢ 2 ɭ ɡɚɜɢɫɧɨɫɬɢ ɨɞ ɩɪɢɫɭɫɬɜɚ ɛɨɥɟɫɬɢ ɚ ɨɜɚʁ ɫɤɨɪ ɫɟ ɡɚɬɢɦ ɭɜɟʄɚɜɚ ɡɚ ɜɪɟɞɧɨɫɬ ɨɞ 3.5 ɚɤɨ ʁɟ ɭɤʂɭɱɟɧɚ ɢ ɩɪɟɞʃɚ ɫɢɥɚɡɧɚ ɚɪɬɟɪɢʁɚ, ɭɜɟʄɚɜɚ ɡɚ 5 ɚɤɨ ʁɟ ɭ ɩɢɬɚʃɭ ɛɨɥɟɫɬ ɥɟɜɨɝ ɝɥɚɜɧɨɝ ɫɬɚɛɥɚ, ɤɚɨ ɢ ɡɚ 0.5 ɚɤɨ ɫɭ ɭɤʂɭɱɟɧɟ ɦɚɥɟ ɝɪɚɧɟ. Ƚɪɚɧɟ ɤɨʁɟ ɫɭ ɞɢʁɚɦɟɬɪɚ ɦɚʃɟɝ ɨɞ 1.5ɦɦ ɫɟ ɢɫɤʂɭɱɭʁɭ ɢɡ ɫɤɨɪɨɜɚʃɚ ɛɟɡ ɨɛɡɢɪɚ ɧɚ ɜɟɥɢɱɢɧɭ ʃɢɯɨɜɨɝ ɨɲɬɟʄɟʃɚ. ɍ ɫɬɭɞɢʁɢ ɫɟ, ɬɚɤɨђɟ, ɧɟ ɭɡɢɦɚ ɭ ɪɚɡɦɚɬɪɚʃɟ ɩɪɨɰɟɧɚɬ ɫɬɟɧɨɡɟ ɜɟʄ ɫɟ ɫɤɨɪɭʁɭ ɫɜɟ ɫɬɟɧɨɡɟ ɨɞ 50%-99% ɤɚɨ ɢ ɨɤɥɭɡɢʁɟ. “ЋвЧtКб sМШrО” ʁɟ ɛɚɡɢɪɚɧ ɧɚ ɤɜɚɥɢɬɚɬɢɜɧɨʁ ɢ ɤɜɚɧɬɢɬɚɬɢɜɧɨʁ ɤɚɪɚɤɬɟɪɢɡɚɰɢʁɢ, ɭɡ ɩɨɦɨʄ ɤɨʁɟɝ ɫɟ ɦɨɠɟ ɨɞɪɟɞɢɬɢ ɤɨɦɩɥɟɤɫɧɨɫɬ ɛɨɥɟɫɬɢ ɤɨɪɨɧɚɪɧɢɯ ɚɪɬɟɪɢʁɚ. 29 Ɋɚɧɝɢɪɚʁɭ ɫɟ 12 ɚɧɚɬɨɦɫɤɢɯ ɜɚɪɢʁɚɛɥɢ ɤɨʁɟ ɫɭ ɭɫɤɨ ɩɨɜɟɡɚɧɟ ɫɚ ɚɬɟɪɨɫɤɥɟɪɨɬɫɤɨɦ ɛɨɥɟɲʄɭ ɤɨʁɚ ɤɨɦɩɪɨɦɢɬɭʁɟ ɤɨɪɨɧɚɪɧɟ ɤɪɜɧɟ ɫɭɞɨɜɟ ɢ ɫɜɚɤɚ ɜɚɪɢʁɚɛɥɚ ɢɦɚ ɫɜɨʁɭ ɬɟɠɢɧɭ ɢ ɧɭɦɟɪɢɱɤɭ ɜɪɟɞɧɨɫɬ. Ʉɚɞɚ ʁɟ “ЋвЧtКб sМШrО” ɧɢɡɚɤ (ɜɪɟɞɧɨɫɬɢ ɨɞ 0 – 22), ɫɦɚɬɪɚ ɫɟ ɞɚ ɧɚʁɜɟʄɢ ɛɟɧɟɮɢɬ ɩɚɰɢʁɟɧɬ ɢɦɚ ɫɚ ɩɟɪɤɭɬɚɧɨɦ ɦɢɨɤɚɪɞɧɨɦ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɨɦ. “ЋвЧtКб sМШrО” ɫɪɟɞʃɢ (ɜɪɟɞɧɨɫɬɢ ɢɡɦɟђɭ 23 – 32 ) ɬɟɞɟɧɰɢʁɚ ʁɟ ɩɪɟɦɚ ɯɢɪɭɪɲɤɨɦ ɡɛɪɢʃɚɜɚʃɭ, ɚ ɩɨɝɨɬɨɜɭ ʁɟ ɜɟʄɢ ɛɟɧɟɮɢɬ ɩɨɫɥɟ ʁɟɞɧɟ ɝɨɞɢɧɟ. “ЋвЧtКб sМШrО” ɜɢɫɨɤ (ɜɟɞɧɨɫɬɢ ɩɪɟɤɨ 33) ɚɩɫɨɥɭɬɧɚ ʁɟ ɢɧɞɢɤɚɰɢʁɚ ɡɚ ɯɢɪɭɪɝɢʁɨɦ. 9 ɍɉɈɊȿȾɇȺ ȺɇȺɅɂɁȺ ɏɂɊɍɊɒɄɈȽ ɅȿɑȿȵȺ ɍ ɈȾɇɈɋɍ ɇȺ ɉȿɊɄɍɌȺɇɍ ɂɇɌȿɊȼȿɇɐɂȳɍ ɉɨɫɬɨʁɢ ɜɟɥɢɤɢ ɛɪɨʁ ɫɬɭɞɢʁɚ ɤɨʁɢ ɫɟ ɛɚɜɢ ɨɜɨɦ ɩɪɨɛɥɟɦɚɬɢɤɨɦ . Ⱦɚ ɛɢ ɫɟ ɦɨɝɥɨ ɥɚɤɲɟ ɪɚɲɱɥɚɧɢɬɢ ɢ ɩɨɞɟɥɢɬɢ ɨɜɟ ɫɬɭɞɢʁɟ ɩɨ ɝɪɭɩɚɦɚ, ɧɚɩɪɚɜʂɟɧɟ ɫɭ ɬɪɢ ɝɥɚɜɧɟ ɝɪɭɩɟ:  ɂɡɨɥɨɜɚɧɚ ɩɟɪɤɭɬɚɧɚ ɤɨɪɨɧɚɪɧɚ ɢɧɬɟɪɜɟɧɰɢʁɚ (PCI) ɭ ɨɞɧɨɫɭ ɧɚ ɯɢɪɭɪɲɤɭ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɭ ɦɢɨɤɚɪɞɚ (CABG).  ɉɟɪɤɭɬɚɧɚ ɤɨɪɨɧɚɪɧɚ ɢɧɬɟɪɜɟɧɰɢʁɚ (PCI) ɫɚ ɫɬɟɧɬɨɦ ɭ ɨɞɧɨɫɭ ɧɚ ɯɢɪɭɪɲɤɭ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɭ ɦɢɨɤɚɪɞɚ (CABG).  ɉɟɪɤɭɬɚɧɚ ɤɨɪɨɧɚɪɧɚ ɢɧɬɟɪɜɟɧɰɢʁɚ ɫɚ ɥɟɤɨɦ ɨɛɥɨɠɟɧɢɦ ɫɬɟɧɬɨɦ ɭ ɨɞɧɨɫɭ ɧɚ ɯɢɪɭɪɲɤɭ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɭ ɦɢɨɤɚɪɞɚ (CABG) ɋɜɚɤɚ ɨɞ ɨɜɢɯ ɝɪɭɩɚ ɞɚʁɟ ɫɜɨʁɟ ɩɨɞɝɪɭɩɟ ɭ ɤɨʁɢɦɚ ɫɟ ɧɚɥɚɡɢ ɜɟɥɢɤɢ ɛɪɨʁ ɫɬɭɞɢʁɚ ɧɚ ɤɨʁɢɦɚ ɫɟ ɩɨɫɥɟɞʃɢɯ ɝɨɞɢɧɚ ɦɧɨɝɨ ɪɚɞɢɥɨ. 30 9.1 ɋɌɍȾɂȳȿ ɄɈȳȿ ɍɉɈɊȿЂɍȳɍ ɂɁɈɅɈȼȺɇɂ PCI ɂ ɏɂɊɍɊɒɄɍ ɊȿȼȺɋɄɍɅȺɊɂɁȺɐɂȳɍ ɆɂɈɄȺɊȾȺ (CABG) ɉɨɫɬɨʁɢ ɞɟɜɟɬ ɩɭɛɥɢɤɨɜɚɧɢɯ ɪɚɧɞɨɦɢɡɢɪɚɧɢɯ ɫɬɭɞɢʁɚ ɤɨʁɟ ɭɩɨɪɟђɭʁɭ PCI ɢ CABG ɤɨɞ ɚɧɝɢɧɨɡɧɢɯ ɩɚɰɢʁɟɧɚɬɚ. ɇɢʁɟɞɧɚ ɨɞ ʃɢɯ ɧɢʁɟ ɩɪɟɜɟɥɢɤɚ ɚɥɢ ɞɜɟ ɫɟ ɢɡɞɜɚʁɚʁɭ ɩɨ ɛɪɨʁɭ. ɉɪɜɚ ʁɟ BARI ɫɚ ɭɤɭɩɧɨ 1829 ɩɚɰɢʁɟɧɚɬɚ ɢ CABRI ɫɚ 1054. Ɉɫɬɚɥɟ ɫɬɭɞɢʁɟ ɫɭ ɦɚʃɟɝ ɨɛɢɦɚ ɢ ɬɨ EAST ɫɚ 392 ɩɚɰɢʁɟɧɬɚ, GABI ɫɚ 359 , Toulouse study ɫɚ 152 ɩɚɰɢʁɟɧɬɚ, MASS ɫɚ 142, Lausanne ɫɬɭɞɢʁɚ ɫɚ 134, ERACI ɫɚ 127 ɩɚɰɢʁɟɧɚɬɚ. RITA ɫɬɭɞɢʁɚ ʁɟ ɛɢɥɚ ɧɟɫɜɚɤɢɞɚɲʃɚ, ɫɚ 1011 ɩɚɰɢʁɟɧɚɬɚ ɚɥɢ ɫɚ ɜɟɥɢɤɢɦ ɛɪɨʁɟɦ ɩɚɰɢʁɟɧɚɬɚ ɤɨʁɢ ɫɭ ɢɦɚɥɢ ʁɟɞɧɨɫɭɞɨɜɧɭ ɛɨɥɟɫɬ. Ɇɚɞɚ ɫɭ ɫɟ ɫɬɭɞɢʁɟ ɦɟђɭɫɨɛɨɦ ɦɚɥɨ ɪɚɡɥɢɤɨɜɚɥɟ ɩɨ ɞɢɡɚʁɧɭ ɢ ɩɨ ɨɞɚɛɢɪɭ ɩɚɰɢʁɟɧɚɬɚ, ɪɟɡɭɥɬɚɬɢ ɫɭ ɭɜɟɤ ɨɫɬɚʁɚɥɢ ɝɨɬɨɜɨ ɢɫɬɢ. Ʉɪɚʁʃɚ ɬɚɱɤɚ ɫɜɢɯ ɫɬɭɞɢʁɚ ʁɟ ɭɩɨɪɟђɢɜɚʃɟ ɦɨɪɬɚɥɢɬɟɬɚ ɢ ɢɧɮɚɪɤɬɚ ɦɢɨɤɚɪɞɚ ɤɪɨɡ ɨɛɟ ɝɪɭɩɟ. BARI ɫɬɭɞɢʁɚ (The Bypass Angioplasty Revascularization Investigation) ʁɟɫɬɟ ɩɟɬɨɝɨɞɢɲʃɚ ɫɬɭɞɢʁɚ ɤɨʁɚ ʁɟ ɨɛɭɯɜɚɬɢɥɚ ɩɚɰɢʁɟɧɬɟ ɫɚ ɜɢɲɟɫɭɞɨɜɧɨɦ ɤɨɪɨɧɚɪɧɨɦ ɛɨɥɟɲʄɭ. ɍɩɨɪɟђɢɜɚɧɢ ɫɭ ɩɚɰɢʁɟɧɬɢ ɤɨʁɢ ɫɭ ɩɪɨɲɥɢ ɩɟɪɤɭɬɚɧɭ ɬɪɚɧɫɥɭɦɢɧɚɥɧɭ ɤɨɪɨɧɚɪɧɭ ɚɧɝɢɨɩɥɚɫɬɢɤɭ (PTCA) -914 ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɩɚɰɢʁɟɧɬɢɦɚ ɤɨʁɢ ɫɭ ɡɛɪɢɧɭɬɢ ɯɢɪɭɪɲɤɢɦ ɩɭɬɟɦ (915 ɩɚɰɢʁɟɧɚɬɚ). ɂɧɬɪɚɯɨɫɩɢɬɚɥɧɨ ɦɨɪɬɚɥɢɬɟɬ ɭ CABG ɝɪɭɩɢ ɛɢɨ ʁɟ 1.3% ɞɨɤ ʁɟ ɭ ɝɪɭɩɢ PTCA ɢɡɧɨɫɢɨ 1.1%. ɒɬɨ ɫɟ ɩɨʁɚɜʂɢɜɚʃɟ Q-ɬɚɥɚɫɚ ɢɧɮɚɪɤɬɚ ɦɢɨɤɚɪɞɚ ɬɢɱɟ, ɭ ɝɪɭɩɢ CABG ɤɨɞ 4.6% ɛɢɨ ʁɟ ɩɪɢɫɭɬɚɧ ɚ ɭ ɞɪɭɝɨʁ ɝɪɭɩɢ ɫɜɟɝɚ 2.1%. Ɇɨɠɞɚɧɢ ɭɞɚɪ ɢɡɧɨɫɢɨ ʁɟ 0.8% ɭ ɝɪɭɩɢ CABG ɞɨɤ ʁɟ ɭ ɝɪɭɩɢ PTCA ɛɢɨ 0.2%. 31 ɉɟɬɨɝɨɞɢɲʃɚ ɫɬɨɩɚ ɩɪɟɠɢɜʂɚɜɚʃɚ ɭ ɝɪɭɩɢ CABG ɛɢɥɚ ʁɟ 89.3% ɞɨɤ ʁɟ ɭ ɝɪɭɩɢ PTCA ɢɡɧɨɫɢɥɚ 86.3% BARI ɫɬɭɞɢʁɚ ɩɨɤɚɡɭʁɟ ɜɟɥɢɤɭ ɪɚɡɥɢɱɢɬɨɫɬ ɭ ɪɟɢɧɬɟɪɜɟɧɰɢʁɚɦɚ ɢɡɦɟђɭ ɨɜɟ ɞɜɟ ɝɪɭɩɟ. ɍ ɝɪɭɩɢ CABG ɫɬɨɩɚ ɩɟɬɨɝɨɞɢɲʃɟ ɪɟɢɧɬɟɪɜɟɧɰɢʁɟ ɛɢɥɚ ʁɟ 8% ɞɨɤ ʁɟ ɭ ɝɪɭɩɢ ɫɚ PTCA ɬɚ ɫɬɨɩɚ ɡɧɚɬɧɨ ɜɟʄɚ 54%. Ɉɫɢɦ ɬɨɝɚ, ɭ ɨɜɨʁ ɫɬɭɞɢʁɢ 19 % ɩɚɰɢʁɟɧɚɬɚ ɤɨʁɢ ɫɭ ɩɪɨɲɥɢ PTCA, ɢɦɚɥɢ ɫɭ ɩɨɬɪɟɛɭ ɡɚ ɜɢɲɟ ɨɞ ʁɟɞɧɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢɨɧɟ ɩɪɨɰɟɞɭɪɟ ɞɨɤ ʁɟ ɬɚʁ ɫɥɭɱɚʁ ɭ ɝɪɭɩɢ CABG ɛɢɨ ɡɧɚɬɧɨ ɦɚʃɢ 3 %. Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ ɢɡ ɝɪɭɩɟ PTCA 31% ʁɟ ɧɚ ɤɪɚʁɭ ɦɨɪɚɥɨ ɞɚ ɞɨɛɢʁɟ ɯɢɪɭɪɲɤɭ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɭ ɦɢɨɤɚɪɞɚ75. CABRI–(Coronary Angioplasty versus Bypass Revascularisation Investigation) ʁɟɫɬɟ ɫɬɭɞɢʁɚ ɤɨʁɚ ɫɟ ɛɚɜɢ ɢɫɬɪɚɠɢɜɚʃɟɦ ɤɨɪɨɧɚɪɧɟ ɚɧɝɢɨɩɥɚɫɬɢɤɟ ɢ ʃɟɧɨɝ ɨɞɧɨɫɚ ɫɚ ɛɚʁɩɚɫ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɨɦ.Ɍɨ ʁɟ ɦɭɥɬɢɧɚɰɢɨɧɚɥɧɚ, ɦɭɥɬɢɰɟɧɬɪɢɱɧɚ ɪɚɧɞɨɦɢɡɢɪɚɧɚ ɫɬɭɞɢʁɚ. Ɉɜɚ ɫɬɭɞɢʁɚ ɭɩɨɪɟђɭʁɟ ɨɜɚ ɞɜɚ ɩɪɢɫɬɭɩɚ ɡɛɪɢʃɚɜɚʃɚ ɤɨɪɨɧɚɪɧɟ ɛɨɥɟɫɬɢ ɤɨɞ ɩɚɰɢʁɟɧɬɚ ɫɚ ɫɢɦɩɬɨɦɚɬɢɱɧɨɦ ɜɢɲɟɫɭɞɨɜɧɨɦ ɤɨɪɨɧɚɪɧɨɦ ɛɨɥɟɲʄɭ. ɍɤɭɩɧɨ ʁɟ ɭ ɫɬɭɞɢʁɢ ɛɢɥɨ 1054 ɩɚɰɢʁɟɧɬɚ, 820 ɦɭɲɤɚɪɚɰɚ ɢ 234 ɠɟɧɚ. ɉɚɰɢʁɟɧɬɢ ɫɭ ɨɛʁɟɞɢʃɟɧɢ ɢɡ 26 ȿɜɪɨɩɫɤɢɯ ɤɚɪɞɢɨ ɰɟɧɬɚɪɚ. ɉɪɨɫɟɤ ɝɨɞɢɧɚ ʁɟ ɛɢɨ 60. Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ, 513 ʁɟ ɛɢɥɨ ɪɚɧɞɨɦɢɡɢɪɚɧɢɯ ɢɡ ɝɪɭɩɟ CABG ɞɨɤ ʁɟ 541 ɛɢɥɨ ɭ ɝɪɭɩɢ PTCA. ɉɨɫɥɟ ʁɟɞɧɨɝɨɞɢɲʃɟɝ ɢɫɬɪɚɠɢɜɚʃɚ, ɫɬɨɩɚ ɦɨɪɬɚɥɢɬɟɬɚ ɢɡ ɝɪɭɩɟ CABG ɢɡɧɨɫɢɥɚ ʁɟ 2.7% ɚ ɢɡ ɝɪɭɩɟ PTCA 3.9%. 32 ɉɚɰɢʁɟɧɬɢ ɭ ɝɪɭɩɢ PTCA ɫɭ ɫɢɝɧɢɮɢɤɚɧɬɧɨ ɡɚɯɬɟɜɚɥɢ ɜɟʄɢ ɛɪɨʁ ɪɟɢɧɬɟɪɜɟɧɰɢʁɚ. ɋɚɦɨ 66.4% ɢɡ ɝɪɭɩɟ PTCA ʁɟ ɧɚɜɪɲɢɥɨ ɩɪɜɭ ɝɨɞɢɧɭ ɫɚ ʁɟɞɧɨɦ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢɨɧɨɦ ɩɪɨɰɟɞɭɪɨɦ ɞɨɤ ʁɟ ɭ ɩɨɪɟђɟʃɭ ɫɚ ɝɪɭɩɨɦ CABG ɬɚʁ ɩɪɨɰɟɧɚɬ ɛɢɨ ɜɟʄɢ 93.5%76. ɍ ɝɪɭɩɢ PTCA ɩɚɰɢʁɟɧɬɢ ɫɭ ɫɢɝɧɢɮɢɤɚɧɬɧɨ ɜɢɲɟ ɭɡɢɦɚɥɢ ɦɟɞɢɤɚɦɟɧɬɟ ɚ ɢ ɫɬɟɩɟɧ ɤɥɢɧɢɱɤɢ ɫɢɝɧɢɮɢɤɚɧɬɧɟ ɚɧɝɢɧɟ ʁɟ ɛɢɨ ɜɢɲɟ ɡɚɫɬɭɩʂɟɧ ɭ ɨɜɨʁ ɝɪɭɩɢ. ɉɨɜɟɡɚɧɨɫɬ ɫɚ ɤɨɥɢɱɢɧɨɦ ɭɡɢɦɚʃɚ ɦɟɞɢɤɚɦɟɧɚɬɚ ɢ ɚɧɝɢɧɨɦ ɛɢɥɚ ʁɟ ɤɨɞ ɨɛɚ ɩɨɥɚ, ɚɥɢ ʁɟ ɫɢɝɧɢɮɢɤɚɧɬɧɨ ɛɢɥɨ ɜɢɲɟ ɤɨɞ ɠɟɧɚ . RITA – (The Randomised Intervention Treatment of Angina) ɪɚɧɞɨɦɢɡɢɪɚɧɢ ɢɧɬɟɪɜɟɧɬɧɢ ɬɪɟɬɦɚɧ ɚɧɝɢɧɟ ʁɟ ɩɪɨɫɩɟɤɬɢɜɧɚ ɪɚɧɞɨɦɢɡɢɪɚɧɚ ɫɬɭɞɢʁɚ ɫɚ ɡɚɞɚɬɤɨɦ ɞɚ ɭɩɨɪɟɞɢ ɤɪɚɬɤɨɪɨɱɚɧ ɢ ɞɭɝɨɪɨɱɚɧ ɟɮɟɤɚɬ ɩɟɪɤɭɬɚɧɟ ɬɪɚɧɫɥɭɦɢɧɚɥɧɟ ɤɨɪɨɧɚɪɧɟ ɢɧɬɟɪɜɟɧɰɢʁɟ(PTCA) ɢ ɯɢɪɭɪɲɤɨ ɛɚʁɩɚɫɢɪɚʃɟ ɤɨɪɨɧɚɪɧɟ ɚɪɬɟɪɢʁɟ(CABG). ɍ ɫɬɭɞɢʁɢ ɫɭ ɭɱɟɫɬɜɨɜɚɥɢ ɩɚɰɢʁɟɧɬɢ ɢɡ ɱɟɬɪɧɚɟɫɬ ɰɟɧɬɚɪɚ ɤɨɞ ɤɨʁɢɯ ʁɟ ɭɪɚђɟɧɚ ɤɨɪɨɧɚɪɧɚ ɚɪɬɟɪɢɨɝɪɚɮɢʁɚ. Ʉɨɞ ɫɜɢɯ ɩɚɰɢʁɟɧɚɬɚ ɤɨɞ ɤɨʁɢɯ ʁɟ ɩɪɨɧɚђɟɧɚ ɤɨɪɨɧɚɪɧɚ ɛɨɥɟɫɬ ɢ ɤɨɞ ɤɨʁɢɯ ʁɟ ɤɨɧɡɢɥɢʁɭɦ ɨɞ ɤɚɪɞɢɨɥɨɝɚ ɢ ɤɚɪɞɢɨɯɢɪɭɪɝɚ ɛɢɨ ɫɚɝɥɚɫɚɧ ɞɚ ʃɢɯɨɜɨ ɡɛɪɢʃɚɜɚʃɟ ɦɨɠɟ ɞɚ ɫɟ ɭɪɚɞɢ ɩɨɞʁɟɞɧɚɤɨ ɢɥɢ ʁɟɞɧɨɦ ɢɥɢ ɞɪɭɝɨɦ ɦɟɬɨɞɨɦ ɛɢɥɢ ɫɭ ɭɛɚɱɟɧɢ ɭ ɫɬɭɞɢʁɭ. ɍ ɫɬɭɞɢʁɢ ʁɟ ɭɤɭɩɧɨ ɛɢɥɨ 1011 ɩɚɰɢʁɟɧɚɬɚ. ɉɪɜɢ ɢɡɜɟɲɬɚʁ ʁɟ ɛɢɨ ɩɨɫɥɟ ɞɜɟ ɢ ɩɨ ɝɨɞɢɧɟ. Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɬɚ 45% ʁɟ ɢɦɚɥɨ ʁɟɞɧɨɫɭɞɨɜɧɭ ɛɨɥɟɫɬ ɚ 55 % ɜɢɲɟɫɭɞɨɜɧɭ. Ɉɫɧɨɜɧɢ ɰɢʂ ɫɬɭɞɢʁɟ ʁɟ ɢɫɬɪɚɠɢɜɚʃɟ ɤɨɦɛɢɧɚɰɢʁɟ ɦɨɪɬɚɥɢɬɟɬ ɢ ɢɧɮɚɪɤɬ ɦɢɨɤɚɪɞɚ, ɤɨʁɢ ʁɟ ɩɨɫɥɟ 6,5 ɝɨɞɢɧɚ, ɭ ɝɪɭɩɢ PTCA ɛɢɨ 17% ɩɚɰɢʁɟɧɚɬɚ ɚ ɭ ɝɪɭɩɢ CABG 16%. ɇɢʁɟ ɛɢɥɨ ɫɢɝɧɢɮɢɤɚɧɬɧɨɫɬɢ ɩɨ ɛɪɨʁɭ ɭɦɪɥɢɯ, 39 ɭ ɝɪɭɩɢ PTCA ɚ ɭ 33 ɝɪɭɩɢ CABG 45. Ɋɢɡɢɤ ɨɞ ɫɦɪɬɢ ɢ ɢɧɮɚɤɪɬɚ ɦɢɨɤɚɪɞɚ, ɛɢɨ ʁɟ ɩɟɬ ɩɭɬɚ ɜɟʄɢ ɭ ɩɪɜɨʁ ɝɨɞɢɧɢ ɧɟɝɨ ɭ ɧɚɪɟɞɧɟ ɱɟɬɢɪɢ. ɍ ɝɪɭɩɢ PTCA 26% ʁɟ ɦɨɪɚɥɨ ɞɚ ɢɞɟ ɧɚ ɩɨɧɨɜɧɭ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɭ ɞɨɤ ʁɟ ɭ ɝɪɭɩɢ CABG ɬɚʁ ɩɪɨɰɟɧɚɬ ɢɡɧɨɫɢɨ 19. ɉɪɨɫɟɱɧɨ ɫɬɨɩɚ ɪɟɢɧɬɟɪɜɟɧɰɢʁɟ ɭ ɝɪɭɩɢ PTCA ʁɟ ɢɡɧɨɫɢɥɚ 4% ɝɨɞɢɲʃɟ ɚ ɭ ɝɪɭɩɢ CABG 2% ɝɨɞɢɲʃɟ77. EAST ɫɬɭɞɢʁɚ – (The Emory Angioplasty versus Surgery Trial) ʁɟ ɪɚɧɞɨɦɢɡɢɪɚɧɚ ɫɬɭɞɢʁɚ ɢɡ ʁɟɞɧɨɝ ɰɟɧɬɪɚ ɤɨʁɚ ɭɩɨɪɟђɭʁɟ ɩɟɪɤɭɬɚɧɭ ɬɪɚɧɫɥɭɦɢɧɚɥɧɭ ɤɨɪɨɧɚɪɧɭ ɚɧɝɢɨɩɥɚɫɬɢɤɭ(PTCA) ɫɚ ɯɢɪɭɪɭɪɲɤɨɦ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɨɦ (CABG). ɍ ɫɬɭɞɢʁɢ ʁɟ ɛɢɥɨ 392 ɩɚɰɢʁɟɧɬɚ ɢ ɬɨ 198 ɭ ɝɪɭɩɢ PTCA ɢ 194 ɭ ɝɪɭɩɢ CABG. ɋɜɢ ɩɚɰɢʁɟɧɬɢ ɫɭ ɛɢɥɢ ɫɚ ɜɢɲɟɫɭɞɨɜɧɨɦ ɤɨɪɨɧɚɪɧɨɦ ɛɨɥɟɲʄɭ. Ɉɫɧɨɜɧɨ ɧɚɱɟɥɨ ɫɬɭɞɢʁɟ ʁɟ ɛɢɥɨ ɩɪɚʄɟʃɟ ɦɨɪɬɚɥɢɬɟɬɚ ɢɧɮɚɪɤɬɚ ɦɢɨɤɚɪɞɚ ɢ ɜɟɥɢɤɨɝ ɢɫɯɟɦɢʁɫɤɨɝ ɞɟɮɟɤɬɚ ɭ ɬɪɢ ɝɨɞɢɧɟ. ɇɢʁɟ ɩɨɫɬɨʁɚɥɚ ɪɚɡɥɢɤɚ ɩɨ ɝɪɭɩɚɦɚ, ʁɟɞɢɧɨ ɲɬɨ ʁɟ ɫɬɨɩɚ ɩɨɧɨɜɧɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɛɢɥɚ ɦɚɥɨ ɜɟʄɚ ɭ ɝɪɭɩɢ PTCA. Ɉɫɦɨɝɨɞɢɲʃɟ ɩɪɟɠɢɜɚʂɚɜɚʃɟ ɭ ɝɪɭɩɢ ЈTCA ɛɢɥɨ ʁɟ 79.3% , ɚ ɭ ɝɪɭɩɢ CABG 82.7%. ɍ ɫɭɞɢʁɢ ɫɟ ɩɨɤɚɡɚɥɨ ɞɚ ɩɚɰɢʁɟɧɬɢ ɫɚ ɩɪɨɤɫɢɦɚɥɧɨɦ ɫɬɟɧɨɡɨɦ ɩɪɟɞʃɟ ɫɢɥɚɡɧɟ ɝɪɚɧɟ ɤɨɪɨɧɚɪɧɟ ɚɪɬɟɪɢʁɟ, ɤɚɨ ɢ ɞɢʁɚɛɟɬɢɱɚɪɢ ɢɦɚʁɭ ɛɨʂɟ ɪɟɡɭɥɬɚɬɟ ɫɚ ɯɢɪɭɪɲɤɨɦ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɨɦ, ɦɚɞɚ ɫɬɚɬɢɫɬɢɱɤɢ ɧɢʁɟ ɩɨɤɚɡɚɥɨ ɡɧɚɱɚʁɧɨɫɬ78. GABI ɫɬɭɞɢʁɚ – (Germany Angioplasty vs Bypass Investigation) ʁɟ ɇɟɦɚɱɤɚ ɫɬɭɞɢʁɚ ɤɨʁɚ ɭɩɨɪɟђɭʁɟ ɞɜɟ ɝɪɭɩɟ ɩɚɰɢʁɟɧɚɬɚ PTCA ɢ CABG ɭ ɞɟɫɬɨɝɨɞɢɲʃɟɦ ɩɟɪɢɨɞɭ. ɍɤɭɩɧɨ ɨɞ 8981 ɩɚɰɢʁɟɧɬɚ ɫɚɦɨ 307 ʁɟ ɭɲɥɨ ɭ ɫɬɭɞɢʁɭ. ɍ ɝɪɭɩɢ CABG ɫɭ ɛɢɥɚ 152 ɩɚɰɢʁɟɧɬɚ ɚ ɭ ɝɪɭɩɢ PTCA 155. ɇɚʁɡɚɫɬɭɩʂɟɧɢʁɚ ɝɪɚɧɚ ɤɨʁɚ ɫɟ 34 ɪɟɜɚɫɤɭɥɚɪɢɡɨɜɚɥɚ ɭ ɨɛɟ ɝɪɭɩɟ, ɛɢɥɚ ʁɟ ɩɪɟɞʃɚ ɫɢɥɚɡɧɚ ɝɪɚɧɚ ɚ ɨɞɦɚɯ ɡɚ ʃɨɦ ɢ ɰɢɪɤɭɦɮɥɟɤɫɧɚ ɝɪɚɧɚ. ɍ ɝɪɭɩɢ CABG 2,2 ɤɪɜɧɚ ɫɭɞɚ ɩɨ ɩɚɰɢʁɟɧɬɭ ɫɭ ɛɢɥɚ ɪɟɜɚɫɤɭɥɚɪɢɡɨɜɚɧɚ ɞɨɤ ʁɟ ɬɚʁ ɛɪɨʁ ɭ ɝɪɭɩɢ PTCA ɢɡɧɨɫɢɨ 1,9. ɍ ɞɟɫɟɬɨɝɨɞɢɲʃɟɦ ɩɟɪɢɨɞɭ ɫɬɭɞɢʁɚ ʁɟ ɩɨɤɚɡɚɥɚ ɞɚ ɫɬɨɩɚ ɦɨɪɬɚɥɢɬɟɬɚ ɭ ɨɛɟ ɝɪɭɩɟ ʁɟ ɫɥɢɱɧɚ, 35 ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɭɦɪɥɨ ɭ ɝɪɭɩɢ CABG ɚ ɭ ɝɪɭɩɢ PTCA 41. ɂɫɬɨ ɬɚɤɨ ɢɡ ɫɬɭɞɢʁɟ ɫɟ ɦɨɠɟ ɜɢɞɟɬɢ ɞɚ ɩɪɨɰɟɧɚɬ ɩɨɧɨɜɧɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɭ ɝɪɭɩɢ PTCA ʁɟ ɜɟʄɢ ɭ ɨɞɧɨɫɭ ɧɚ ɝɪɭɩɭ CABG79. Toulouse ɫɬɭɞɢʁɚ,ʁɟ Ɏɪɚɧɰɭɫɤɚ ɪɚɧɞɨɦɢɡɢɪɚɧɚ ɫɬɭɞɢʁɚ ɤɨʁɚ ɭɩɨɪɟђɭʁɟ ɞɜɟ ɝɪɭɩɟ ɩɚɰɢʁɟɧɚɬɚ PTCA ɢ CABG ɫɚ ɜɢɲɟɫɭɞɨɜɧɨɦ ɤɨɪɨɧɚɪɧɨɦ ɛɨɥɟɲʄɭ. Ɍɪɚʁɚɥɚ ʁɟ 2,8 ɝɨɞɢɧɚ ɢ ɢɦɚɥɚ ʁɟ ɭɤɭɩɧɨ 152 ɩɚɰɢʁɟɧɬɚ. ɉɨ 76 ɩɚɰɢʁɟɧɚɬɚ ɩɨ ɝɪɭɩɢ. ɉɪɨɫɟɱɧɚ ɫɬɚɪɨɫɧɚ ɞɨɛ ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɛɢɥɚ 67 ɝɨɞɢɧɚ. Ⱥɧɝɢɧɭ 3 ɢ 4 ɝɪɭɩɟ ʁɟ ɢɦɚɥɨ 52.5%, ɧɟɫɬɚɛɢɥɧɭ ɚɧɝɢɧɭ 10 % ɚ ɬɪɨɫɭɞɨɜɧɭ ɛɨɥɟɫɬ 29 %. ɉɨ ɝɪɭɩɚɦɚ ɧɢʁɟ ɛɢɥɨ ɡɧɚɱɚʁɧɟ ɫɬɚɬɢɫɬɢɱɤɟ ɫɢɝɧɢɮɢɤɚɧɬɧɨɫɬɢ ɭ ɦɨɪɬɚɥɢɬɟɬɭ. ɍ ɝɪɭɩɢ CABG ʁɟ ɭɦɪɥɨ 7 ɚ ɭ ɝɪɭɩɢ PTCA 5 ɩɚɰɢʁɟɧɚɬɚ. ɋɬɨɩɚ ɩɨɧɨɜɧɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɭ ɝɪɭɩɢ PTCA ʁɟ ɛɢɥɚ ɡɧɚɬɧɨ ɜɟʄɚ ɩɨɫɥɟ ɬɪɟʄɟ ɝɨɞɢɧɟ ɢ ɢɡɧɨɫɢɥɚ ʁɟ 9.2% ɚ ɭ ɝɪɭɩɢ CABG 1.32% MASS ɫɬɭɞɢʁɚ – (The Medicine, Angioplasty or Surgery Study) ʁɟ ɩɪɨɫɩɟɤɬɢɜɧɚ, ɪɚɧɞɨɦɢɡɢɪɚɧɚ ɫɬɭɞɢʁɚ ʁɟɞɧɨɝ ɰɟɧɬɪɚ ɤɨʁɚ ɭɩɨɪɟђɭʁɟ ɩɚɰɢʁɟɧɬɟ ɫɚ ɫɬɟɧɨɡɨɦ ɩɪɟɞʃɟ ɫɢɥɚɡɧɟ ɝɪɚɧɟ ɥɟɱɟɧɟ ɦɟɞɢɤɚɦɟɧɬɨɡɧɨ, ɚɧɝɢɨɩɥɚɫɬɢɤɨɦ ɢɥɢ ɯɢɪɭɪɝɢʁɨɦ. ɍ ɫɬɭɞɢʁɢ ʁɟ ɛɢɥɨ 214 ɩɚɰɢʁɟɧɚɬɚ, ɫɚ ɫɬɚɛɢɥɧɨɦ ɚɧɝɢɧɨɦ , ɞɨɛɪɨɦ ɤɨɦɨɪɧɨɦ ɮɪɚɤɰɢʁɨɦ ɢ ɩɪɨɤɫɢɦɚɥɧɨɦ ɫɬɟɧɨɡɨɦ ɫɢɥɚɡɧɟ ɝɪɚɧɟ ɥɟɜɟ ɤɨɪɨɧɚɪɧɟ 35 ɚɪɬɟɪɢʁɟ. ɍ ɝɪɭɩɢ CABG ɛɢɥɨ ʁɟ 70 ɩɚɰɢʁɟɧɚɬɚ,ɝɪɭɩɚ PTCA ɛɪɨʁɚɥɚ ʁɟ 72 ɚ ɦɟɞɢɤɚɦɟɧɬɨɡɧɨ ɫɭ ɬɪɟɬɢɪɚɧɚ 72 ɩɚɰɢʁɟɧɬɚ. ɇɚ ɬɪɨɝɨɞɢɲʃɟɦ ɩɪɚʄɟʃɭ ɭɫɬɚɧɨɜʂɟɧɨ ʁɟ ɞɚ ɭ ɝɪɭɩɢ CABG ɫɬɨɩɚ ɩɨɧɨɜɧɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɢɡɧɨɫɢɥɚ ʁɟ 3%, ɭ ɝɪɭɩɢ PTCA ɬɚ ɫɬɨɩɚ ʁɟ ɛɢɥɚ ɡɧɚɬɧɨ ɜɟʄɚ 24%, ɞɨɤ ʁɟ ɭ ɬɪɟʄɨʁ ɦɟɞɢɤɚɦɟɧɬɨɡɧɨʁ ɝɪɭɩɢ ɢɡɧɨɫɢɥɚ 12%. ɋɬɨɩɚ ɦɨɪɬɚɥɢɬɟɬɚ ɭ ɫɜɟ ɬɪɢ ɝɪɭɩɟ ʁɟ ɛɢɥɚ ɝɨɬɨɜɨ ɢɫɬɚ80. ERACI ɫɬɭɞɢʁɚ- (Argentine Randomized Trial of Percutaneous Transluminal Coronary Angioplasty Versus Coronary Artery Bypass Surgery in Multivessel Disease) ʁɟɫɬɟ ɪɚɧɞɨɦɢɡɢɪɚɧɚ ɚɪɝɟɧɬɢɧɫɤɚ ɫɬɭɞɢʁɚ ɤɨʁɚ ʁɟ ɢɦɚɥɚ ɡɚ ɰɢʂ ɞɚ ɭɩɨɪɟɞɢ ɞɜɟ ɝɪɭɩɟ ɩɚɰɢʁɟɧɚɬɚ PTCA ɢ CABG ɫɚ ɜɢɲɟɫɭɞɨɜɧɨɦ ɤɨɪɨɧɚɪɧɨɦ ɛɨɥɟɲʄɭ. ɋɬɭɞɢʁɚ ʁɟ ɭɤʂɭɱɢɜɚɥɚ 127 ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɤɥɢɧɢɱɤɨɦ ɢɧɞɢɤɚɰɢʁɨɦ ɡɚ ɪɟɜɚɫɤɭɥɚɪɢɢɡɚɰɢʁɨɦ ɦɢɨɤɚɪɞɚ, ɚ ɪɚɧɞɨɦɢɡɢɪɚɧɨ ɩɨɞɟʂɟɧɚ ɧɚ ɝɪɭɩɭ PTCA ɨɞ 63 ɩɚɰɢʁɟɧɚɬɚ ɢ ɝɪɭɩɭ CABG oɞ 64 ɩɚɰɢʁɟɧɚɬɚ. ɉɪɚʄɟʃɚ ɫɭ ɛɢɥɚ ɧɚ 1, 3 ɢ 5 ɝɨɞɢɧɚ. Ɋɚɡɜɨʁ ɤɨɦɛɢɧɨɜɚɧɢɯ ʅɚɪɞɢʁɚɥɧɢɯ ɞɨɝɚђɚʁɚ ( Q –ɬɚɥɚɫ ɢɧɮɚɪɤɬ ɦɢɨɤɚɪɞɚ, ɫɦɪɬɢ, ɩɨɧɨɜɧɟ ɚɧɝɢɧɟ ɢ ɩɨɬɪɟɛɚ ɡɚ ɩɨɧɨɜɧɨɦ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɨɦ ) ɛɢɨ ʁɟ ɫɢɝɧɢɮɢɤɚɧɬɨɧɨ ɜɟʄɢ ɭ ɝɪɭɩɢ PTCA 77% ɚ ɭ ɞɪɭɝɨʁ ɝɪɭɩɢ 47%. ɇɢʁɟ ɛɢɥɨ ɪɚɡɥɢɤɟ ɭ ɦɨɪɬɚɥɢɬɟɬɭ ɩɨ ɝɪɭɩɚɦɚ. Ɇɨɪɬɚɥɢɬɟɬ ʁɟ ɛɢɨ ɢ ɭ ʁɟɞɧɨʁ ɢ ɭ ɞɪɭɝɨʁ ɝɪɭɩɢ 7.8%. ɉɪɨɰɟɧɚɬ ʁɚɜʂɚʃɚ ɩɨɧɨɜɧɟ ɚɧɝɢɧɟ ɛɢɨ ʁɟ 79% ɤɨɞ PTCA ɚ ɤɨɞ CABG 57%. ȼɟɥɢɤɚ ʁɟ ɪɚɡɥɢɤɚ ɛɢɥɚ ɢ ɭ ɩɨɬɪɟɛɢ ɡɚ ɩɨɧɨɜɧɨɦ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɨɦ. ɍ ɝɪɭɩɢ PTCA 37% ʁɟ ɧɚ ɬɪɨɝɨɞɢɲʃɟɦ ɧɢɜɨɭ ɢɦɚɥɨ ɩɨɬɪɟɛɭ ɡɚ ɩɨɧɨɜɧɨɦ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɨɦ ɞɨɤ ʁɟ ɭ ɝɪɭɩɢ CABG ɬɨ ɛɢɨ ɫɥɭɱɚʁ ɫɚɦɨ ɭ 6.3% ɩɚɰɢʁɟɧɚɬɚ81. 36 Lausanne ɫɬɭɞɢʁɚ ʁɟ ɫɬɭɞɢʁɚ ɢɡ ɒɜɚʁɰɚɪɫɤɟ ɤɨʁɚ ʁɟ ɬɪɚʁɚɥɚ ɬɪɢ ɝɨɞɢɧɟ, ɮɨɪɦɢɪɚɧɚ 1994, ɞɚ ɛɢ ɫɟ ɭɩɨɪɟɞɢɥɟ ɞɜɟ ɝɪɭɩɟ ɩɚɰɢʁɟɧɚɬɚ ɫɚ ʁɟɞɧɨɫɭɞɨɜɧɨɦ ɤɨɪɨɧɚɪɧɨɦ ɛɨɥɟɲʄɭ, PTCA ɢ CABG. ɍ ɫɬɭɞɢʁɢ ɫɭ ɭɤɭɩɧɨ ɛɢɥɚ 134 ɩɚɰʁɟɧɬɚ, ɭ ɝɪɭɩɢ PTCA 68, ɚ ɭ CABG ɝɪɭɩɢ 66. ȼɢɲɟ ʁɟ ɛɢɥɨ ɦɭɲɤɚɪɚɰɚ 80% ɞɨɤ ʁɟ ɩɪɨɫɟɱɧɚ ɫɬɚɪɨɫɬ ɩɚɰɢʁɟɧɚɬɚ ɢɡɧɨɫɢɥɚ 56 ɝɨɞɢɧɚ. ɋɬɨɩɚ ɩɨɧɨɜɧɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɭ ɝɪɭɩɢ PTCA ʁɟ ɛɢɥɚ ɡɧɚɬɧɨ ɜɟʄɚ 11.8% ɚ ɭ ɞɪɭɝɨʁ ɝɪɭɩɢ ɬɟɤ 1.5%. ɂɧɮɚɪɤɬ ɦɢɨɤɚɪɞɚ ɢ ɨɫɬɚɥɚ ɤɨɦɛɢɧɨɜɚɧɚ ɫɪɱɚɧɚ ɞɟɲɚɜɚʃɚ ɭ PTCA ɝɪɭɩɢ ɫɭ ɢɡɧɨɫɢɥɚ 8.8% ɚ ɭ ɝɪɭɩɢ CABG 3%. Ɇɨɪɬɚɥɢɬɟɬ ʁɟ ɛɢɨ ɢɫɬɢ ɢ ɭ ʁɟɞɧɨʁ ɢ ɭ ɞɪɭɝɨʁ ɝɪɭɩɢ. 9.2 ɋɌɍȾɂȳȿ ɄɈȳȿ ɋɍ ɎɈɊɆɂɊȺɇȿ ȾȺ Ȼɂ ɋȿ ɍɉɈɊȿȾɂɅȿ ɉȿɊɄɍɌȺɇȿ ɄɈɊɈɇȺɊɇȿ ɂɇɌȿɊȼȿɇɐɂȳȿ ɋȺ ɋɌȿɇɌɈɆ ɂ ɏɂɊɍɊɒɄȺ ɊȿȼȺɋɄɍȺɅɊɂɁȺɐɂȳȺ ɆɂɈɄȺɊȾȺ ɉɪɟɬɯɨɞɧɟ ɦɟɬɚ-ɚɧɚɥɢɡɟ ɩɭɛɥɢɤɨɜɚɧɢɯ ɪɚɧɞɨɦɢɡɢɪɚɧɢɯ ɫɬɭɞɢʁɚ ɤɨʁɚ ɫɟ ɛɚɡɢɪɚʁɭ ɧɚ ɭɩɨɪɟђɟɜɚʃɭ ɩɟɪɤɭɬɚɧɟ ɬɪɚɧɫɥɭɦɢɧɚɥɧɟ ɤɨɪɨɧɚɪɧɟ ɚɧɝɢɨɩɥɚɫɬɢɤɟ ɢ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɦɢɨɤɚɪɞɚ ɩɨɤɚɡɚɥɟ ɫɭ ɞɚ ʁɟ ɩɪɨɰɟɧɚɬ ɤɚɪɞɢɨɥɨɲɤɨɝ ɞɟɲɚɜɚʃɚ (ɢɧɮɚɪɤɬ ɦɢɨɤɚɪɞɚ, ɩɨɧɨɜɧɚ ɚɧɝɢɧɚ, ɦɨɠɞɚɧɢ ɭɞɚɪ ) ɜɟʄɢ ɭ ɝɪɭɩɢ PTCA. ɂɫɬɨ ɬɚɤɨ, ɜɢɞɟɥɨ ɫɟ ɢ ɞɚ ʁɟ ɫɬɨɩɚ ɪɟɢɧɬɟɪɜɟɧɰɢʁɟ ɛɢɥɚ ɞɨɫɬɚ ɜɟʄɚ ɭ ɬɨʁ ɝɪɭɩɢ. Ɇɨɪɚ ɫɟ ɧɚɩɨɦɟɧɭɬɢ ɞɚ ɫɭ ɜɢʄɢɧɚ ɨɜɢɯ ɫɬɭɞɢʁɚ ɢɦɚɥɟ ɜɟʄɢ ɩɪɨɰɟɧɚɬ ʁɟɞɧɨɫɭɞɨɜɧɟ ɤɨɪɨɧɚɪɧɟ ɛɨɥɟɫɬɢ ɢ ɞɚ ʁɟ ɫɬɚɜʂɚʃɟ ɫɬɟɧɬɚ ɛɢɥɨ ɥɢɦɢɬɢɪɚɧɨ. 37 Ⱦɚɧɚɫ ɢɦɚɦɨ ɩɟɬ ɜɟɥɢɤɢɯ ɫɬɭɞɢʁɚ ɤɨʁɟ ɫɭ ɩɭɛɥɢɤɨɜɚɧɟ ɢ ɤɨʁɟ ɫɟ ɨɞɧɨɫɟ ɧɚ ɭɩɨɪɟђɢɜɚʃɭ ɩɟɪɤɭɬɚɧɟ ɤɨɪɨɧɚɪɧɟ ɚɧɝɢɨɩɥɚɫɬɢɤɟ ɫɚ ɫɬɟɧɬɨɦ ɢ ɯɢɪɭɪɩɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ. Ɍɨ ɫɭ ARTS, SOS,ERACI-2,MASS-2, ɢ AWESOME ɫɬɭɞɢʁɚ. ɂɡɦɟђɭ 1985. ɢ 2000. ɝɨɞɢɧɟ ɭɤɭɩɧɨ 3051 ɩɚɰɢʁɟɧɬ ʁɟ ɭɤʂɭɱɟɧ ɭ ɨɜɟ ɫɬɭɞɢʁɟ ɢɡ 113 ɪɚɡɥɢɱɢɬɢɯ ɰɟɧɬɚɪɚ. Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ 1518 ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɡɛɪɢɧɭɬɨ ɫɚ ɫɬɟɧɬɨɦ ɚ 1533 ɩɚɰɢʁɟɧɬɚ ɯɢɪɭɪɲɤɢɦ ɩɭɬɟɦ. ȺRTS ɫɬɭɞɢʁɚ – (The Final Analysis of the Arterial Revascularization Therapies Study) ʁɟ ɞɭɝɨɝɨɞɢɲʃɚ (ɩɟɬɨɝɨɞɢɲʃɚ) ɤɨɦɩɚɪɚɬɢɜɧɚ ɫɬɭɞɢʁɚ ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɜɢɲɟɫɭɞɨɜɧɨɦ ɤɨɪɨɧɚɪɧɨɦ ɛɨɥɟɲʄɭ ɡɛɪɢɧɭɬɢɯ ɩɟɪɤɭɬɚɧɨɦ ɬɪɚɧɫɥɭɦɢɧɚɥɧɨɦ ɚɧɝɢɨɩɥɚɫɬɢɤɨɦ ɫɚ ɫɬɟɧɬɨɦ ɢɥɢ ɯɢɪɭɪɲɤɢɦ ɩɭɬɟɦ. ɋɬɭɞɢʁɚ ʁɟ ɭɤɭɩɧɨ ɛɪɨʁɚɥɚ 1206 ɩɚɰɢʁɟɧɚɬɚ, ɭ ɝɪɭɩɢ PCI ɫɚ ɫɬɟɧɬɨɦ ʁɟ ɛɢɥɨ 600 ɚ ɭ ɝɪɭɩɢ CABG 606 ɩɚɰɢʁɟɧɚɬɚ. Ƚɥɚɜɧɢ ɰɢʂ ʁɟ ɛɢɨ ɩɪɚʄɟʃɟ ɧɚ ʁɟɞɧɨɝɨɞɢɲʃɟɦ ɢ ɩɟɬɨɝɨɞɢɲʃɟɦ ɩɟɪɢɨɞɭ ɝɥɚɜɧɚ ɧɟɝɚɬɢɜɧɚ ɤɚɪɞɢɨɥɨɲɤɚ ɡɛɢɜɚʃɚ (ɢɧɮɚɪɤɬ ɦɢɨɤɚɪɞɚ, ɦɨɪɬɚɥɢɬɟɬ, ɩɨɧɨɜɧɚ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɚ ɢ ɦɨɠɞɚɧɢ ɭɞɚɪ)82. ɉɨɫɥɟ ɩɟɬ ɝɨɞɢɧɚ ɨɞɧɨɫ ɭ ɫɬɨɩɢ ɦɨɪɬɬɚɥɢɬɟɬɚ ʁɟ ɛɢɨ 8% ɩɪɟɦɚ 7.6% ɭ ɤɨɪɢɫɬ PCI ɫɚ ɫɬɟɧɬɨɦ. ɍɤɭɩɧɚ ɤɚɪɞɢɨɥɨɲɤɚ ɡɛɢɜɚʃɚ ɭ ɨɛɟ ɝɪɭɩɟ ɫɭ ɛɢɥɚ ɝɨɬɨɜɨ ɢɡʁɟɞɧɚɱɟɧɚ 18.2% ɭ ɫɬɟɧɬ ɝɪɭɩɢ ɚ ɭ CABG ɝɪɭɩɢ 14.9%. ȳɟɞɢɧɨ ɲɬɨ ʁɟ ɛɢɥɨ ɢɡɭɡɟɬɧɨ ɫɢɝɧɢɮɢɤɚɬɧɨ ʁɟ ɫɬɨɩɚ ɩɨɧɨɜɧɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɧɚ ɩɟɬɨɝɨɞɢɲʃɟɦ ɧɢɜɨɭ ɢ ɢɡɧɨɫɢ ɡɚ ɫɬɟɧɬ ɝɪɭɩɭ 30.3% ɚ ɭ ɝɪɭɩɢ CABG ɫɬɨɩɚ ʁɟ 8.8%. ɍ ɨɛɟ ɝɪɭɩɟ ɦɨɪɬɚɥɢɬɟɬ ʁɟ ɛɢɨ ɭɝɥɚɜɧɨɦ ɢɫɬɢ. ɇɟ ɩɨɫɬɨʁɢ ɫɢɝɧɢɮɢɤɚɬɧɚ ɪɚɡɥɢɤɚ ɭ ɫɬɟɩɟɧɭ ɢɧɮɚɪɤɬɚ ɦɢɨɤɚɪɞɚ ɤɚɨ ɧɢ ɦɨɠɞɚɧɨɝ ɭɞɚɪɚ. ȳɟɞɢɧɚ ɫɢɝɧɢɮɢɤɚɧɬɧɨɫɬ ʁɟ ɭ ɤɨɦɛɢɧɨɜɚɧɨɦ ɩɨɫɦɚɬɪɚʃɭ ɫɜɢɯ ɧɟɝɚɬɢɜɧɢɯ 38 ɤɚɪɞɢɨɥɨɲɤɢɯ ɡɛɢɜɚʃɚ (MACE) ɤɨʁɚ ʁɟ ɜɟʄɚ ɭ ɫɬɟɧɬ ɝɪɭɩɢ ɢ ɤɨʁɚ ɞɨɜɨɞɢ ɞɨ ɩɨɧɨɜɧɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ. SOS ɫɬɭɞɢʁɚ – (The Stent or Surgery trial) ʁɟɫɬɟ ɫɬɭɞɢʁɚ ɤɨʁɚ ʁɟ ɨɛɭɯɜɚɬɚɥɚ 53 ɰɟɧɬɪɚ ɲɢɪɨɦ ȿɜɪɨɩɟ ɢ Ʉɚɧɚɞɟ ɢ ɭɩɨɪɟђɢɜɚɥɚ ɨɞɧɨɫ ɡɛɪɢʃɚɜɚʃɚ ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɜɢɲɟɫɭɞɨɜɧɨɦ ɤɨɪɨɧɚɪɧɨɦ ɛɨɥɟɲʄɭ ɫɚ ɫɬɟɧɬɨɦ ɢ ɯɢɪɭɪɲɤɨɦ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɨɦ ɦɢɨɤɚɪɞɚ. Ɉɞ ɭɤɭɩɧɨ 988 ɩɚɰɢʁɟɧɚɬɚ 500 ʁɟ ɛɢɥɨ ɭ ɝɪɭɩɢ CABG ɚ 488 ɞɨɛɢɥɨ ʁɟ PCI ɫɚ ɫɬɟɧɬɨɦ. ɉɨɫɥɟ ɞɜɨɝɨɞɢɲʃɟ ɚɧɚɥɢɡɟ ɭ ɝɪɭɩɢ ɫɚ ɫɬɟɧɬɨɦ 21% ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɦɨɪɚɥɨ ɞɚ ɢɞɟ ɧɚ ɩɨɧɨɜɧɭ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɭ ɚ ɭ ɝɪɭɩɢ ɛɟɡ ɫɬɟɧɬɚ ɬɟɤ 6%. ɂɧɰɢɞɟɧɰɚ ɫɦɪɬɢ ɢɥɢ ɢɧɮɚɪɤɬɚ ɦɢɨɤɚɪɞɚ ɛɢɥɚ ʁɟ ɩɨɞʁɟɞɧɚɤɚ ɭ ɨɛɟ ɝɪɭɩɟ ɢ 9% ɭ ɝɪɭɩɢ ɫɚ ɫɬɟɧɬɨɦ ɚ 10% ɭ ɝɪɭɩɢ CABG83. Ɉɜɚ ɫɬɭɞɢʁɚ ʁɟ ɩɨɤɚɡɚɥɚ ɞɚ ɭ ɨɞɧɨɫɭ ɧɚ ɩɪɟɬɯɨɞɧɟ ɫɬɭɞɢʁɟ, ɤɨɪɢɲʄɟʃɟ ɫɬɟɧɬɚ ɭ ɨɞɧɨɫɭ ɧɚ ɢɡɨɥɨɜɚɧɭ ɩɟɪɤɭɬɚɧɭ ɬɪɚɧɫɥɭɦɢɧɚɥɧɭ ɤɨɪɨɧɚɪɧɭ ɚɧɝɢɨɩɥɚɫɬɢɤɭ ɫɦɚʃɭʁɟ ɩɪɨɰɟɧɚɬ ɩɨɧɨɜɧɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ. ERACI II ɫɬɭɞɢʁɚ – (Argentine Randomized Trial of Percutaneous Transluminal Coronary Angioplasty Versus Coronary Artery Bypass Surgery in Multivessel Disease II) ʁɟɫɬɟ ɩɟɬɨɝɨɞɢɲʃɚ ɪɚɧɞɨɦɢɡɢɪɚɧɚ ɫɬɭɞɢʁɚ ɢɡ Ⱥɪɝɟɧɬɢɧɟ ɤɨʁɚ ɭɩɨɪɟђɭʁɟ ɩɚɰɢʁɟɧɬɟ ɫɚ ɜɢɲɟɫɭɞɨɜɧɨɦ ɤɨɪɨɧɚɪɧɨɦ ɛɨɥɟɲʄɭ ɤɨʁɢ ɫɭ ɡɛɪɢɧɭɬɢ ɢɥɢ ɫɬɟɧɬɨɦ ɢɥɢ ɯɢɪɭɪɲɤɢ. ɍ ɫɬɭɞɢʁɢ ʁɟ ɨɛɭɯɜɚʄɟɧɨ ɭɤɭɩɧɨ 450 ɩɚɰɢʁɟɧɚɬɚ. 225 ʁɟ ɛɢɥɨ ɭ ʁɟɞɧɨʁ (ɫɬɟɧɬ ɝɪɭɩɢ) ɚ ɢɫɬɨ ɬɨɥɢɤɨ ɢ ɭ ɞɪɭɝɨʁ ɝɪɭɩɢ. ɋɚɦɨ ɩɚɰɢʁɟɧɬɢ ɫɚ ɜɢɲɟɫɭɞɨɜɧɢɦ ɤɨɪɨɧɚɪɧɢɦ ɩɪɨɦɟɧɚɦɚ ɫɭ ɭɥɚɡɢɥɢ ɭ ɫɬɭɞɢʁɭ. ɋɜɢ ɩɚɰɢʁɟɧɬɢ ɫɭ ɩɨɫɦɚɬɪɚɧɢ 39 ɩɨɫɥɟ 30 ɞɚɧɚ, 1,3 ɢ 5 ɝɨɞɢɧɚ. Ɉɫɧɨɜɧɚ ɩɪɚʄɟʃɚ ɫɭ ɫɟ ɨɞɧɨɫɢɥɚ ɧɚ MACE (ɤɨɦɛɢɧɨɜɚɧɚ ɧɟɝɚɬɢɜɧɚ ɤɚɪɞɢɨɥɨɲɤɚ ɡɛɢɜɚʃɚ) ɤɨʁɚ ɫɭ ɩɨɞɪɚɡɭɦɟɜɚɥɚ ɢɧɮɚɪɤɬ ɦɢɨɤɚɪɞɚ, ɦɨɠɞɚɧɢ ɭɞɚɪ, ɫɦɪɬ ɢ ɫɬɨɩɚ ɩɨɧɨɜɧɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ. ɍ ɩɪɜɢɯ 30 ɞɚɧɚ ɫɬɨɩɚ ɧɟɠɟʂɟɧɢɯ ɡɛɢɜɚʃɚ ʁɟ ɛɢɥɚ ɜɟʄɚ ɭ ɝɪɭɩɢ ɫɚ CABG ɧɟɝɨ ɫɚ ɫɬɟɧɬɨɦ ɢ 3.6% ɩɪɟɦɚ 12.3%. ɇɚ ʁɟɞɧɨɝɨɞɢɲʃɟɦ ɩɟɪɢɨɞɭ ɩɪɚʄɟʃɚ , ɩɪɨɰɟɧɚɬ ɧɟɠɟʂɟɧɢɯ ɡɛɢɜɚʃɚ ʁɟ ɢ ɞɚʂɟ ɭ ɤɨɪɢɫɬ CABG ɝɪɭɩɟ 7.6 % ɩɪɟɦɚ 2.6%. ɍ ɩɟɬɨɝɨɞɢɲʃɟɦ ɩɪɚʄɟʃɭ ɩɚɰɢʁɟɧɚɬɚ ɬɚʁ ɨɞɧɨɫ ɫɟ ɩɪɨɦɟɧɢɨ ɢ ɩɨɤɚɡɭʁɟ ɜɟʄɭ ɫɬɨɩɭ ɧɟɠɟʂɟɧɢɯ ɤɚɪɞɢɨɥɨɲɤɢɯ ɡɛɢɜɚʃɚ ɭ ɝɪɩɢ ɫɚ ɫɬɟɧɬɨɦ ɢ ɬɨ ɨɞ 34.7% ɞɨɤ ʁɟ ɬɚʁ ɩɪɨɰɟɧɚɬ ɭ CABG ɝɪɭɩɢ 23.6%. ɉɨɪɟɞ ɨɜɨɝɚ , ɫɬɨɩɚ ɦɨɪɬɚɥɢɬɟɬɚ ʁɟ ɜɟʄɚ ɭ ɝɪɭɩɢ CABG ɤɨʁɚ ɢɡɧɨɫɢ 11.6% ɞɨɤ ʁɟ ɭ ɝɪɭɩɢ ɫɚ ɫɬɟɧɬɨɦ ɫɜɟɝɚ 7.1%. ERACI II ɫɬɭɞɢʁɚ ʁɟ ɩɪɜɚ ɫɬɭɞɢʁɚ ɤɨʁɚ ʁɟ ɫɚ ɫɜɨʁɢɦ ɪɟɡɭɥɬɚɬɢɦɚ ɞɨɜɟɥɚ ɭ ɩɢɬɚʃɟ ɯɢɪɭɪɲɤɭ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɭ ɦɢɨɤɚɪɞɚ ɭ ɨɞɧɨɫɭ ɧɚ ɩɟɪɤɭɬɚɧɭ ɬɪɚɧɫɥɭɦɢɧɚɥɧɭ ɤɨɪɨɧɚɪɧɭ ɚɧɝɢɨɩɥɚɫɬɢɤɭ ɫɚ ɫɬɟɧɬɨɦ. MASS II ɫɬɭɞɢʁɚ – (The Medicine, Angioplasty or Surgery Study) ʁɟ ɤɨɦɩɚɪɚɬɢɜɧɚ ɞɟɫɟɬɨɝɨɞɢɲʃɚ ɫɬɭɞɢʁɚ ɩɪɚʄɟʃɚ ɩɚɰɢʁɟɧɚɬɚ ɤɪɨɡ ɝɪɭɩɭ ɫɚ ɫɬɟɧɬɨɦ ɢ ɛɟɡ ɫɬɟɧɬɚ, ɬʁ. ɤɨɧɜɟɧɰɢɨɧɚɥɧɟ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɢ ɦɟɞɢɤɚɦɟɧɬɨɡɧɭ ɝɪɭɩɭ, ɝɞɟ ɫɭ ɫɜɢ ɩɚɰɢʁɟɧɬɢ ɫɚ ɜɢɲɟɫɭɞɨɜɧɨɦ ɤɨɪɨɧɚɪɧɨɦ ɛɨɥɟɲʄɭ, ɫɬɚɛɢɥɧɨɦ ɚɧɝɢɧɨɦ ɢ ɞɨɛɪɨɦ ɟʁɟɤɰɢɨɧɨɦ ɮɪɚɤɰɢʁɨɦ ɥɟɜɟ ɤɨɦɨɪɟ. Ɉɫɧɨɜɧɢ ɰɢʂ ɫɬɭɞɢʁɟ ʁɟ ɛɢɨ ɩɪɚʄɟʃɟ ɩɚɰɢʁɟɧɚɬɚ ɤɪɨɡ ɦɨɪɬɚɥɢɬɟɬ, ɢɧɮɚɪɤɬɚ ɦɢɨɤɚɪɞɚ, ɪɟɮɪɚɤɬɚɪɧɟ ɚɧɝɢɧɟ ɢ ɩɨɬɪɟɛɟ ɡɚ ɩɨɧɨɜɧɨɦ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɨɦ. 40 ɋɬɭɞɢʁɚ ʁɟ ɢɡɜɟɞɟɧɚ ɭ ʁɟɞɧɨʁ ɭɫɬɚɧɨɜɢ ɫɚ ɭɤɭɩɧɨ 611 ɩɚɰɢʁɟɧɚɬɚ. ɉɚɰɢʁɟɧɬɢ ɫɭ ɩɨɞɟʂɟɧɢ ɭ ɬɪɢ ɝɪɭɩɟ. ɉɪɜɚ ɝɪɭɩɚ CABG ɢɦɚɥɚ ʁɟ 203 ɩɚɰɢʁɟɧɚɬɚ, ɞɪɭɝɚ ɫɚ ɫɬɟɧɬɨɦ 205 ɚ ɬɪɟʄɚ ɬɪɟɬɢɪɚɧɚ ɫɚɦɨ ɦɟɞɢɤɚɦɟɧɬɢɦɚ 203 ɩɚɰɢʁɟɧɚɬɚ. Ⱦɟɫɟɬɨɝɨɞɢɲʃɟ ɩɪɟɠɢɜʂɚɜɚʃɟ ɭ ɝɪɭɩɢ CABG ɛɢɥɨ ʁɟ 74.9%. ɍ ɝɪɭɩɢ ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɫɬɟɧɬɨɦ ɫɬɨɩɚ ɩɪɟɠɢɜʂɚɜɚʃɚ ʁɟ ɢɡɧɨɫɢɥɚ 75.1% ɞɨɤ ʁɟ ɭ ɩɨɫɥɟɞʃɨʁ ɦɟɞɢɤɚɦɟɧɬɨɡɧɨʁ ɝɪɭɩɢ ɫɬɨɩɚ ɛɢɥɚ 69%. Ⱦɟɫɟɬɨɝɨɞɢɲʃɚ ɫɬɨɩɚ ɦɢɨɤɚɪɞɧɨɝ ɢɮɚɪɤɬɚ ɩɨ ɝɪɭɩɚɦɚ ʁɟ ɛɢɥɚ ɫɥɟɞɟʄɚ: CABG ɝɪɭɩɚ 10.3%, ɝɪɭɩɚ ɫɚ ɫɬɟɧɬɨɦ 13.3% ɞɨɤ ʁɟ ɬɪɟʄɚ ɦɟɞɢɤɚɦɟɧɬɨɡɧɚ ɝɪɭɩɚ ɢɦɚɥɚ 20.7% ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɫɬɨɩɨɦ ɢɧɮɚɪɤɬɚ ɦɢɨɤɚɪɞɚ84. Ⱦɟɫɟɬɨɝɨɞɢɲʃɚ ɫɬɨɩɚ ɩɨɬɪɟɛɟ ɡɚ ɞɨɞɚɬɧɨɦ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɨɦ ʁɟ ɧɚʁɦɚʃɟ ɡɚɫɬɭɩʂɟɧɚ ɭ ɝɪɭɩɢ ɫɚ CABG 7.4 %, ɝɪɭɩɚ ɫɚ ɫɬɟɧɬɨɦ ʁɟ ɢɦɚɥɚ 41.9% ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɩɨɬɪɟɛɨɨɦ ɡɚ ɞɨɞɚɬɧɭ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɭ ɞɨɤ ʁɟ ɬɪɟʄɚ ɝɪɭɩɚ ɢɦɚɥɚ ɧɟɲɬɨ ɦɚʃɭ ɫɬɨɩɭ 39.4%. ɍ ɡɚɤʂɭɱɤɭ ɨɜɟ ɫɬɭɞɢʁɟ ɫɬɨʁɢ ɞɚ ʁɟ ɯɢɪɭɪɲɤɚ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɚ ɢɫɩɪɟɞ ɨɛɟ ɝɪɭɩɟ ɢ ɞɚ ʁɟ ɩɨɬɪɟɛɚ ɡɚ ɞɨɞɚɬɧɨɦ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɨɦ ɦɧɨɝɨ ɜɟʄɚ ɤɨɞ ɝɪɭɩɟ ɫɚ ɫɬɟɧɬɨɦ ɢ ɝɪɭɩɟ ɬɪɟɬɢɪɚɧɟ ɫɚɦɨ ɦɟɞɢɤɚɦɟɧɬɨɡɧɨ. ɋɬɭɞɢʁɚ ʁɟ ɬɚɤɨђɟ ɩɨɤɚɡɚɥɚ ɞɚ ɫɜɟ ɬɪɢ ɝɪɭɩɟ ɢɦɚʁɭ ɩɪɢɛɥɢɠɚɧ ɦɨɪɬɚɥɢɬɟɬ. ȺWESOME ɫɬɭɞɢʁɚ – ( Angina With Extremely Serious Operative Mortality Evaluation ) ʁɟ ɪɚɧɞɨɦɢɡɢɪɚɧɚ ɫɬɭɞɢʁɚ ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɩɟɪɤɭɬɚɧɨɦ ɬɪɚɧɫɥɭɦɢɧɚɥɧɨɦ ɤɨɪɨɧɚɪɧɨɦ ɚɧɝɢɨɩɥɚɫɬɢɤɨɦ ɧɚɫɩɪɚɦ ɩɚɰɢʁɟɧɚɬɚ ɤɨɞ ɤɨʁɢɯ ʁɟ ɜɟʄ ɛɢɥɚ ɛɚʁɩɚɫ ɯɢɪɭɪɝɢʁɚ ɚɥɢ ɫɚ ɪɟɮɪɚɤɬɚɪɧɨɦ ɫɪɱɚɧɨɦ ɢɫɯɟɦɢʁɨɦ (ɜɟɨɦɚ ɬɟɲɤɨɝ ɫɬɟɩɟɧɚ ɩɚɰɢʁɟɧɬɢ). ɋɬɭɞɢʁɚ ʁɟ ɛɢɥɚ ɩɪɨɫɩɟɤɬɢɜɧɚ. 41 ɍ ɩɟɪɢɨɞɭ ɨɞ 1995. ɞɨ 2000.ɝɨɞɢɧɟ ɭ 16 ɰɟɧɬɚɪɚ ʁɟ ɧɚɩɪɚɜʂɟɧ ɫɤɪɢɧɢɧɝ ɦɟђɭ 2431 ɩɚɰɢʁɟɧɬɚ ɤɨʁɢ ɫɭ ɢɦɚɥɢ ɪɟɮɪɚɤɬɨɪɧɭ ɫɪɱɚɧɭ ɢɫɯɟɦɢʁɭ ɢ ɧɚʁɦɚʃɟ ʁɟɞɚɧ ɨɞ ɩɟɬ ɮɚɤɬɨɪɚ ɪɢɡɢɤɚ. Oɞ ɭɤɭɩɧɨ ɪɚɧɞɨɦɢɡɢɪɚɧɢɯ 454 ɩɚɰɢʁɟɧɬɚ ɤɨʁɢ ɫɭ ɢɫɩɭʃɚɜɚɥɢ ɤɪɢɬɟɪɢʁɭɦ ɨɞ ɤɨʁɢɯ ʁɟ 142 ɩɚɰɢʁɟɧɬɚ ɜɟʄ ɢɦɚɥɨ ɩɪɜɨɛɢɬɧɭ CABG. ɍ ɪɟɝɢɫɬɪɭ ɩɚɰɢʁɟɧɚɬɚ ɨɞ 1650, 719 ʁɟ ɢɦɚɥɨ ɩɪɟɬɯɨɞɧɭ CABG. Ɉɞ ɢɡɚɛɪɚɧɢɯ 327 ɪɟɝɢɫɬɪɨɜɚɧɢɯ ɩɚɰɢʁɟɧɚɬɚ 119 ʁɟ ɢɦɚɥɨ ɩɪɟɬɯɨɞɧɭ CABG. ɉɪɟɠɢɜʂɚɜɚʃɟ ɤɪɨɡ ɨɜɟ ɬɪɢ ɝɪɭɩɟ ʁɟ ɩɪɚʄɟɧɨ Kaplan-Meier ɤɪɢɜɚɦɚ ɢ ɡɚɛɟɥɟɠɟɧɨ ɭ ɬɟɫɬɭ85. Ɍɪɨɝɨɞɢɲʃɟ ɩɪɟɠɢɜʂɚɜɚʃɟ ɭ ɝɪɭɩɢ CABG ʁɟ ɛɢɥɨ 73% ɚ ɭ ɝɪɭɩɢ ɫɚ PCI 76% . ɋɬɭɞɢʁɚ ʁɟ ɩɨɤɚɡɚɥɚ ɞɚ ʁɟ ɩɟɪɤɭɬɚɧɚ ɤɨɪɨɧɚɪɧɚ ɢɧɬɟɪɜɟɧɰɢʁɚ ɩɪɢɫɬɭɩɚɱɧɢʁɚ ɩɚɰɢʁɟɧɬɢɦɚ ɫɚ ɩɪɜɨɛɢɬɧɨɦ ɯɢɪɭɪɭɲɤɨɦ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɨɦ ɧɟɝɨ ɩɨɧɨɜɧɚ ɯɢɪɭɪɲɤɚ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɚ. 9.3 ɋɌɍȾɂȳȿ ɄɈȳȿ ɍɉɈɊȿЂɍȳɍ ɉȿɊɄɍɌȺɇȿ ɄɈɊɈɇȺɊɇȿ ɂɇɌȿɊȼȿɇɐɂȳȿ ɋȺ ɅȿɄɈɆ ɈȻɅɈɀȿɇɂɆ ɋɌȿɇɌɈɆ ɂ ɏɂɊɍɊɒɄɂ ɁȻɊɂɇɍɌȿ ɉȺɐɂȳȿɇɌȿ Ƚɥɚɜɧɢ ɰɢʂ ɨɜɢɯ ɫɬɭɞɢʁɚ ʁɟ ɛɢɨ ɞɚ ɭɩɨɪɟɞɢ ɩɚɰɢʁɟɧɬɟ ɤɨɞ ɤɨʁɢɯ ʁɟ ɢɦɩɥɚɧɬɢɪɚɧ ɫɬɟɧɬ ɫɚ ɥɟɤɨɦ (drug-eluting stent DES) ɫɚ ɩɚɰɢʁɟɧɬɢɦɚ ɤɨʁɢ ɫɭ ɡɛɪɢɧɭɬɢ ɤɥɚɫɢɱɧɢɦ ɯɢɪɭɪɲɤɢɦ ɩɭɬɟɦ. ɉɨɫɬɨʁɟ ɱɟɬɪɢ ɜɟɥɢɤɟ ɩɪɨɫɩɟɤɬɢɜɧɟ ɫɬɭɞɢʁɟ ɤɨʁɟ ɫɭ ɢɫɬɪɚɠɢɜɚɥɟ ɨɜɭ ɬɟɦɚɬɢɤɭ. Ɍɨ ɫɭ The SYNTAX trial ( Percutaneous Coronary Intervention versus 42 Coronary-Artery Bypass Grafting for Severe Coronary Artery disease), ɫɚ ʁɟɞɧɨɝɨɞɢɲʃɢɦ86 ɢ ɞɜɨɝɨɞɢɲʃɢɦ ɪɟɡɭɥɬɚɬɢɦɚ87. CARDIA Trial (Coronary Artery Revascularization in Diabetes)88, The ARTS II (Arterial Revascularization Therapies Study)89 ɢ ERACI III trial (Argentine Randomized Trial of Coronary Angioplasty with Stenting Versus Coronary Bypass Surgery in Patients with Multiple Vessel Disease)90. ɉɪɜɟ ɞɜɟ ɫɬɭɞɢʁɟ SYNTAX ɢ CARDIȺ ɫɭ ɛɢɥɟ ɪɚɧɞɨɦɢɡɢɪɚɧɟ, ɤɨɧɬɪɨɥɧɟ ɫɬɭɞɢʁɟ ɞɨɤ ɞɪɭɝɟ ɞɜɟ ARTS II ɢ ERACI III ɫɭ ɩɪɨɫɩɟɤɬɢɜɧɟ ɧɟ ɪɚɧɞɨɦɢɡɢɪɚɧɟ ɤɨɧɬɪɨɥɧɟ ɫɬɭɞɢʁɟ. ɍɤɭɩɧɨ ɭ ɫɜɟ ɱɟɬɪɢ ɫɬɭɞɢʁɟ ʁɟ ɛɢɥɨ ɨɛɭɯɜɚʄɟɧɨ 3895 ɩɚɰɢʁɟɧɚɬɚ. Ʌɟɤɨɦ ɨɛɥɨɠɟɧ ɫɬɟɧɬ DES ʁɟ ɩɪɢɦɢɥɨ 1914 ɚ ɯɢɪɭɪɲɤɢ ɡɛɪɢɧɭɬɢ 1981 ɩɚɰɢʁɟɧɬ. ȼɪɟɦɟ ɩɪɚʄɟʃɚ ʁɟ ɛɢɥɨ ɨɞ ʁɟɞɧɟ ɞɨ ɬɪɢ ɝɨɞɢɧɟ. Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ ɤɨʁɢ ɫɭ ɞɨɛɢɥɢ DES, 42% ɫɭ ɛɢɥɢ ɞɢʁɚɛɟɬɢɱɚɪɢ, ɞɨɤ ʁɟ ɭ ɝɪɭɩɢ CABG ɬɚ ɫɬɨɩɚ ɛɢɥɚ ɩɪɢɛɥɢɠɧɨ ɢɫɬɚ ɢ ɢɡɧɨɫɢɥɚ ʁɟ 44%. ɍ ɬɪɢ ɫɬɭɞɢʁɟ (SYNTAX,ERACI III ɢ ARTS II), ɩɪɨɫɟɱɧɚ ɫɬɚɪɨɫɬ ɩɚɰɢʁɟɧɚɬɚ ɭ ɝɪɭɩɢ ɫɚ DES-ɨɦ ɢɡɧɨɫɢɥɚ ʁɟ 63-65 ɝɨɞɢɧɚ ɚ ɭ ɝɪɭɩɢ CABG 61-65 ɝɨɞɢɧɚ. ɍ ɝɪɭɩɢ DES ʁɟ ɛɢɥɨ 70% ɦɭɲɤɚɪɚɰɚ ɞɨɤ ɭ ɞɪɭɝɨʁ ɝɪɭɩɢ ɬɚʁ ɛɪɨʁ ʁɟ ɢɡɧɨɫɢ 68%. ɍ ɨɛɟ ɝɪɭɩɟ ʁɟ ɢɫɬɢ ɛɪɨʁ ɩɚɰɢʁɟɧɚɬɚ ɩɪɟɡɟɧɬɨɜɚɧ ɤɚɨ ɚɤɭɬɧɢ ɤɨɪɨɧɚɪɧɢ ɫɢɧɞɪɨɦ 34%. Ɇɨɪɬɚɥɢɬɟɬ ɭ ɨɛɟ ɝɪɭɩɟ ʁɟ ɛɢɨ ɜɪɥɨ ɫɥɢɱɚɧ . ɍ ɝɪɭɩɢ ɫɚ DES-ɨɦ ɢɡɧɨɫɢɨ ʁɟ 4.9% ɚ ɭ ɝɪɭɩɢ CABG 5.0%. ɂɧɮɚɪɤɬ ɦɢɨɤɚɪɞɚ ʁɟ ɩɪɢɦɟʄɟɧ ɤɨɞ 5.2% ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɫɬɟɧɬɨɦ ɚ ɭ ɝɪɭɩɢ ɛɟɡ ɫɬɟɧɬɚ 4.4%. Ɇɨɠɞɚɧɢ ɭɞɚɪ ʁɟ ɧɨɬɢɪɚɧ ɤɨɞ 1.9% ɩɚɰɢʁɟɧɚɬɚ ɫɚ DES ɫɬɟɧɬɨɦ ɞɨɤ ʁɟ ɭ ɝɪɭɩɢ CABG ɢɡɧɨɫɢɨ 2.7%. ɒɬɨ ɫɟ ɬɢɱɟ ɝɥɚɜɧɢɯ ɧɟɠɟʂɟɧɢɯ ɞɨɝɚђɚʁɚ MACCE, ɪɢɡɢɤ ɨɞ ʃɢɯ ʁɟ ɛɢɨ ɡɧɚɬɧɨ ɜɟʄɢ ɭ ɝɪɭɩɢ ɫɚ ɫɬɟɧɬɨɦ 21.1% ɩɪɟɦɚ 16.3%. 43 Ⱥɧɚɥɢɡɢɪɚʁɭʄɢ ɫɜɟ ɨɜɟ ɫɬɭɞɢʁɟ, ɦɨɠɟ ɫɟ ɡɚɤʂɭɱɢɬɢ ɞɚ ɩɚɰɢʁɟɧɬɢ ɫɚ ɜɢɲɟɫɭɞɨɜɧɨɦ ɤɨɪɨɧɚɪɧɨɦ ɛɨɥɟɲʄɭ ɤɨɞ ɤɨʁɢɯ ʁɟ ɭɝɪɚђɟɧ DES ɫɬɟɧɬ ɭ ɩɨɪɟђɟʃɭ ɫɚ ɩɚɰɢʁɟɧɬɢɦɚ ɤɨʁɢ ɫɭ ɯɢɪɭɪɲɤɢ ɡɛɪɢɧɭɬɢ ɢɦɚʁɭ ɝɨɬɨɜɨ ɢɫɬɭ ɫɬɨɩɭ ɦɨɪɬɚɥɢɬɟɬɚ, ɩɪɨɰɟɧɚɬ ʁɚɜʂɚʃɚ ɦɨɠɞɚɧɨɝ ɭɞɚɪɚ ɤɚɨ ɢ ɪɚɡɜɢʁɚʃɟ ɩɨɫɬɩɪɨɰɟɞɭɪɚɥɧɨɝ ɢɧɮɚɪɤɬɚ ɦɢɨɤɚɪɞɚ. ȳɟɞɢɧɚ ɪɚɡɥɢɤɚ ʁɟ ɭ ɩɪɨɰɟɧɬɭ ʁɚɜʂɚʃɚ MACCE-ɚ. 44 II ɐɂȴȿȼɂ ɂɋɌɊȺɀɂȼȺȵȺ 1. ɉɪɜɢ ɰɢʂ ɢɫɬɪɚɠɢɜɚʃɚ ʁɟ ɞɚ ɫɟ ɭɬɜɪɞɢ ɞɚ ɥɢ ɩɪɟɬɯɨɞɧɚ ɩɟɪɤɭɬɚɧɚ ɢɧɬɟɪɜɟɧɰɢʁɚ ɭɬɢɱɟ ɧɚ ɦɨɪɬɚɥɢɬɟɬ ɨɞɥɨɠɟɧɟ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɦɢɨɤɚɪɞɚ. 2. Ⱦɪɭɝɢ ɰɢʂ ɢɫɬɪɚɠɢɜɚʃɚ ʁɟ ɞɚ ɫɟ ɭɬɜɪɞɢ ɞɚ ɥɢ ɩɪɟɬɯɨɞɧɚ ɩɟɪɤɭɬɚɧɚ ɢɧɬɟɪɜɟɧɰɢʁɚ ɭɬɢɱɟ ɧɚ ɦɨɪɛɢɞɢɬɟɬ ɨɞɥɨɠɟɧɟ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɦɢɨɤɚɪɞɚ. 3. Ɍɪɟʄɢ ɰɢʂ ɢɫɬɪɚɠɢɜɚʃɚ ʁɟ ɞɚ ɫɟ ɭɬɜɪɞɢ ɞɚ ɥɢ ɜɪɫɬɚ ɫɬɟɧɬɚ ɤɨɞ ɩɪɟɬɯɨɞɧɟ ɩɟɪɤɭɬɚɧɟ ɢɧɬɟɪɜɟɧɰɢʁɟ ɭɬɢɱɟ ɧɚ ɢɫɯɨɞ ɨɞɥɨɠɟɧɟ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɦɢɨɤɚɪɞɚ. 4. ɑɟɬɪɜɪɬɢ ɰɢʂ ʁɟ ɞɚ ɫɟ ɭɬɜɪɞɢ ɞɚ ɥɢ ɦɟɫɬɨ ɫɬɟɧɬɢɪɚʃɚ ɭɬɢɱɟ ɧɚ ɢɫɯɨɞ ɨɞɥɨɠɟɧɟ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɦɢɨɤɚɪɞɚ. 45 III ɊȺȾɇȿ ɏɂɉɈɌȿɁȿ 1 ɇɍɅɌȺ ɏɂɉɈɌȿɁȺ ɉɪɟɬɯɨɞɧɚ ɩɟɪɤɭɬɚɧɚ ɤɨɪɨɧɚɪɧɚ ɢɧɬɟɪɜɟɧɰɢʁɚ ɧɟ ɭɬɢɱɟ ɧɚ ɦɨɪɬɚɥɢɬɟɬ ɨɞɥɨɠɟɧɟ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɦɢɨɤɚɪɞɚ. 2 ɇɍɅɌȺ ɏɂɉɈɌȿɁȺ ɉɪɟɬɯɨɞɧɚ ɩɟɪɤɭɬɚɧɚ ɤɨɪɨɧɚɪɧɚ ɢɧɬɟɪɜɟɧɰɢʁɚ ɧɟ ɭɬɢɱɟ ɧɚ ɦɨɪɛɢɞɢɬɟɬ ɨɞɥɨɠɟɧɟ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɪɚɥɢɡɚɰɢʁɟ ɦɢɨɤɚɪɚɞ. 3 ɇɍɅɌȺ ɏɂɉɈɌȿɁȺ Ȼɪɨʁ ɤɪɜɧɢɯ ɫɭɞɨɜɚ ɨɛɭɯɜɚʄɟɧ ɩɪɟɬɯɨɞɧɨɦ ɩɟɪɤɭɬɚɧɨɦ ɤɨɪɨɧɚɪɧɨɦ ɢɧɬɟɪɜɟɧɰɢʁɨɦ ɧɟ ɭɬɢɱɟ ɧɚ ɢɫɯɨɞ ɨɞɥɨɠɟɧɟ ɯɢɪɭɪɭɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɦɢɨɤɚɪɞɚ. 4 ɇɍɅɌȺ ɏɂɉɈɌȿɁȺ ȼɪɫɬɟ ɫɬɟɧɬɨɜɚ ɤɨɪɢɲʄɟɧɢɯ ɤɨɞ ɩɪɟɬɯɨɞɧɟ ɩɟɪɤɭɬɚɧɟ ɤɨɪɨɧɚɪɧɟ ɢɧɬɟɪɜɟɧɰɢʁɟ ɧɟ ɭɬɢɱɭ ɧɚ ɢɫɯɨɞ ɨɞɥɨɠɟɧɟ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɦɢɨɤɚɪɞɚ. 46 IV ɆȿɌɈȾɈɅɈȽɂȳȺ ɊȺȾȺ ɂ ɉɅȺɇ ɊȺȾȺ 1 ȼɊɋɌȺ ɋɌɍȾɂȳȿ ɂɫɬɪɚɠɢɜɚʃɟ ʁɟ ɪɟɬɪɨɫɩɟɤɬɢɜɧɚ ɤɥɢɧɢɱɤɚ ɨɩɫɟɪɜɚɰɢɨɧɚ ɫɬɭɞɢʁɚ ɫɥɭɱɚʁ – ɤɨɧɬɪɨɥɚ ɤɨʁɚ ʁɟ ɫɩɪɨɜɟɞɟɧɚ ɧɚ ɂɧɫɬɢɬɭɬɭ ɡɚ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɟ ɛɨɥɟɫɬɢ ȼɨʁɜɨɞɢɧɟ. ɋɥɭɱɚʁ – ɩɚɰɢʁɟɧɬɢ ɤɨʁɢ ɫɭ ɨɩɟɪɢɫɚɧɢ ɨɞɥɨɠɟɧɨɦ ɯɢɪɭɪɲɤɨɦ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɨɦ ɦɢɨɤɚɪɞɚ ɩɨɫɥɟ ɩɪɟɬɯɨɞɧɟ ɩɟɪɤɭɬɚɧɟ ɤɨɪɨɧɚɪɧɟ ɢɧɬɟɪɜɟɧɰɢʁɟ ɫɚ ɫɬɟɧɬɨɦ . Ʉɨɧɬɪɨɥɚ – ɩɚɰɢʁɟɧɬɢ ɤɨʁɢ ɫɭ ɢɧɢɰɢʁɚɥɧɨ ɨɩɟɪɢɫɚɧɢ ɯɢɪɭɪɲɤɨɦ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɨɦ ɦɢɨɤɚɪɞɚ ɛɟɡ ɫɬɟɧɬɚ. 2 ɉɈɉɍɅȺɐɂȳȺ ɄɈȳȺ ɋȿ ɂɋɌɊȺɀɍȳȿ ɋɬɭɞɢʁɚ ɨɛɭɯɜɚɬɚ ɩɨɩɭɥɚɰɢʁɭ ɫɜɢɯ ɩɚɰɢʁɟɧɚɬɚ ɤɨʁɢ ɡɚɞɨɜɨʂɚɜɚʁɭ ɭɤʂɭɱɭʁɭʄɟ ɚ ɧɟɦɚʁɭ ɢɫɤʂɭɱɭʁɭʄɟ ɤɪɢɬɟɪɢʁɭɦɟ. ɍɤʂɭɱɭʁɭʄɢ ɤɪɢɬɟɪɢʁɭɦɢ ɫɭ: ɨɫɨɛɟ ɨɛɚ ɩɨɥɚ, ɨɞɪɚɫɥɢ (ɠɢɜɨɬɧɟ ɞɨɛɢ 19 ɝɨɞɢɧɚ ɢ ɫɬɚɪɢʁɢ), ɤɨɞ ɤɨʁɢɯ ʁɟ ɭɪɚђɟɧɚ ɯɢɪɭɪɲɤɚ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɚ ɦɢɨɤɚɪɚɞɚ ɧɚ Ʉɥɢɧɢɰɢ ɡɚ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɭ ɯɢɪɭɪɝɢʁɭ, ɂɧɫɬɢɬɭɬɚ ɡɚ ɄȼȻ ȼɨʁɜɨɞɢɧɟ ɭ ɩɟɪɢɨɞɭ ɨɞ 1. ʁɚɧɭɚɪɚ 2011. ɝɨɞɢɧɟ ɞɨ 31. ɞɟɰɟɦɛɪɚ 2012. ɝɨɞɢɧɟ. ɂɫɤʂɭɱɭʁɭʄɢ ɤɪɢɬɟɪɢʁɭɦɭ 47 ɫɭ: ɞɟɰɚ ɢ ɚɞɨɥɟɫɰɟɧɬɢ (18 ɝɨɞɢɧɚ ɢ ɦɥɚђɢ), ɩɚɰɢʁɟɧɬɢ ɤɨɞ ɤɨʁɢɯ ʁɟ ɭɪɚђɟɧɚ ɭ ɢɫɬɨʁ ɯɨɫɩɢɬɚɥɢɡɚɰɢʁɢ ɢ ɩɟɪɤɭɬɚɧɚ ɤɨɪɨɧɚɪɧɚ ɢɧɬɟɪɜɟɧɰɢʁɚ ɢ ɯɢɪɭɪɲɤɚ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɚ ɦɢɨɤɚɪɞɚ, ɤɚɨ ɢ ɢɫɩɢɬɚɧɢɰɢ ɫɚ ɞɢʁɚɛɟɬɟɫ ɦɟɥɢɬɭɫɨɦ ɤɨʁɢɦɚ ɧɢʁɟ ɭɝɪɚђɟɧ ɫɬɟɧɬ ɨɛɥɨɠɟɧ ɥɟɤɨɦ DES, ɫ ɨɛɡɢɪɨɦ ɧɚ ɩɨɡɧɚɬɭ ɱɢʃɟɧɢɰɭ ɨ ɩɨɜɨʂɧɢʁɟɦ ɟɮɟɤɬɭ ɨɜɨɝ ɬɢɩɚ ɫɬɟɧɬɚ ɭ ɨɜɨʁ ɫɭɛɩɨɩɭɥɚɰɢʁɢ. ɋɬɭɞɢʁɚ ʁɟ ɫɩɪɨɜɟɞɟɧɚ ɭɡ ɨɞɨɛɪɟʃɟ ȿɬɢɱɤɨɝ ɢ ɇɚɭɱɧɨɝ ɤɨɦɢɬɟɬɚ ɂɧɫɬɢɬɭɬɚ ɡɚ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɟ ɛɨɥɟɫɬɢ ȼɨʁɜɨɞɢɧɟ. 3 ɍɁɈɊɄɈȼȺȵȿ ɉɚɰɢʁɟɧɬɢ ɤɨʁɢɦɚ ʁɟ ɭɪɚђɟɧɚ ɯɢɪɭɪɲɤɚ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɚ ɭ ɩɟɪɢɨɞɭ ɨɞ 1. ʁɚɧɭɚɪɚ 2011. ɝɨɞɢɧɟ ɞɨ 31. ɞɟɰɟɦɛɪɚ 2012. ɧɚ Ʉɥɢɧɢɰɢ ɡɚ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɭ ɯɢɪɭɪɝɢʁɭ ɛɢʄɟ ɩɨɞɟʂɟɧɢ ɭ ɞɜɟ ɝɪɭɩɟ. ɉɪɜɭ ɝɪɭɩɭ ʄɟ ɱɢɧɢɬɢ ɩɚɰɢʁɟɧɬɢ ɤɨʁɢɦɚ ʁɟ ɩɪɜɨɛɢɬɧɨ ɭɪɚђɟɧɚ PCI ɫɚ ɫɬɟɧɬɨɦ, ɚ ɭ ɞɪɭɝɨʁ ɯɨɫɩɢɬɚɥɢɡɚɰɢʁɢ ɡɛɪɢɧɭɬɢ ɯɢɪɭɪɲɤɨɦ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɨɦ ɦɢɨɤɚɪɞɚ. Ɉɜɭ ɝɪɭɩɭ ɱɢɧɟ ɭɤɭɩɧɨ 94 ɩɚɰɢʁɟɧɬɚ. Ⱦɪɭɝɭ ɝɪɭɩɭ ʄɟ ɱɢɧɢɬɢ ɩɚɰɢʁɟɧɬɢ ɤɨʁɢɦɚ ʁɟ ɢɧɢɰɢʁɚɥɧɨ ɭɪɚђɟɧɚ ɯɢɪɭɪɲɤɚ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɚ ɦɢɨɤɚɪɞɚ ɛɟɡ ɩɪɜɨɛɢɬɧɟ PCI ɫɚ ɫɬɟɧɬɨɦ (812 ɩɚɰɢʁɟɧɚɬɚ). 48 4 ȼȺɊɂȳȺȻɅȿ ɄɈȳȿ ɋɍ ɆȿɊȿɇȿ ɍ ɋɌɍȾɂȳɂ 4.1 ɇȿɁȺȼɂɋɇȿ ȼȺɊɂȳȺȻɅȿ ɇɟɡɚɜɢɫɧɟ ɜɚɪɢʁɚɛɥɟ ɫɭ ɜɟɡɚɧɟ ɡɚ ɫɬɟɧɬɨɜɟ: ɛɪɨʁ ɫɬɟɧɬɨɜɚ, ɜɪɫɬɚ ɫɬɟɧɬɚ, ɛɪɨʁ ɡɚɯɜɚʄɟɧɢɯ ɤɪɜɧɢɯ ɫɭɞɨɜɚ, ɦɟɫɬɨ ɨɬɜɚɪɚʃɚ ɫɬɟɧɨɡɟ. 4.2 ɁȻɍȵɍȳɍȶȿ ȼȺɊɂȳȺȻɅȿ ɉɪɟɨɩɟɪɚɬɢɜɧɟ ɜɚɪɛɢʁɚɛɥɟ ɨɞ ɡɧɚɱɚʁɚ ɫɭ ɢ ɝɨɞɢɧɚ ɫɬɚɪɨɫɬɢ, ɩɨɥ, ɩɭɲɚɱɤɢ ɫɬɚɠ, ɞɢʁɚɛɟɬɟɫ, ɛɭɛɪɟɠɧɚ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɚ (ɧɢɜɨ ɫɟɪɭɦ ɤɪɟɚɬɢɧɢɧɚ ≥ 176µmol/L), ɯɢɩɟɪɬɟɧɡɢʁɚ, ɯɢɩɟɪɥɢɩɢɞɟɦɢʁɚ, ɝɨʁɚɡɧɨɫɬ (BMI ޓ 30), ɩɟɪɢɮɟɪɧɚ ɜɚɫɤɭɥɚɪɧɚ ɛɨɥɟɫɬ, ɰɟɪɟɛɪɨɜɚɫɤɭɥɚɪɧɚ ɛɨɥɟɫɬ, ɟʁɟɤɰɢɨɧɚ ɮɪɚɤɰɢʁɚ ɥɟɜɟ ɤɨɦɨɪɟ (EF), ɜɪɟɦɟ ɨɞ ɧɚɫɬɚɧɤɚ ɢɧɮɚɪɤɬɚ ɦɢɨɤɚɪɞɚ (MI), NYHA ɤɥɚɫɢɮɢɤɚɰɢʁɚ, ɤɨɧɝɟɫɬɢɜɧɚ ɫɪɱɚɧɚ ɫɥɚɛɨɫɬ, ɧɟɫɬɚɛɢɥɧɚ ɚɧɝɢɧɚ, ɤɚɪɞɢɨɝɟɧɢ ɲɨɤ, ɛɪɨʁ ɛɨɥɟɫɧɢɯ ɤɪɜɧɢɯ ɫɭɞɨɜɚ (ɬɪɨɫɭɞɨɜɧɚ ɛɨɥɟɫɬ, ɛɨɥɟɫɬ ɝɥɚɜɧɨɝ ɫɬɚɛɥɚ ɢɥɢ ʁɟɞɧɨɫɭɞɨɜɧɚ ɛɨɥɟɫɬ, ɞɜɨɫɭɞɨɜɧɚ ɛɨɥɟɫɬ), ɩɪɟɨɩɟɪɚɬɢɜɧɢ ɦɟɞɢɤɚɦɟɧɬɢ ɤɨʁɢ ɫɟ ɤɨɪɢɫɬɟ (β- ɛɥɨɤɚɬɨɪɢ, ɧɢɬɪɚɬɢ, ɚɧɬɢɚɝɪɟɝɚɰɢɨɧɚ ɬɟɪɚɩɢʁɚ, ɫɬɚɬɢɧɢ, Ⱥɋȿ ɢɧɯɢɛɢɬɨɪɢ) ɢ ɩɪɟɬɯɨɞɧɚ ɩɟɪɤɭɬɚɧɚ ɤɨɪɨɧɚɪɧɚ ɢɧɬɟɪɜɟɧɰɢʁɚ. 4.3 ɁȺȼɂɋɇȿ ȼȺɊɂȳȺȻɅȿ ɂɧɬɪɚɨɩɟɪɚɬɢɜɧɟ ɡɚɜɢɫɧɟ ɜɚɪɢʁɚɛɥɟ ɨɞ ɢɧɬɟɪɟɫɚ ɫɭ ɛɪɨʁ ɝɪɚɮɬɨɜɚ , ɛɪɨʁ ɞɢɫɬɚɥɧɢɯ ɚɧɚɫɬɨɦɨɡɚ, ɜɪɟɦɟ ɤɥɟɦɨɜɚʃɚ ɚɨɪɬɟ (ɤɚɪɞɢɚɤɚɪɟɫɬ) ɢ ɬɨɬɚɥɧɨ ɜɪɟɦɟ ɩɭɦɩɟ ɡɚ ɟɤɫɬɪɚɤɨɪɩɨɪɚɥɧɭ ɰɢɪɤɭɥɚɰɢʁɭ. ɉɨɫɬɨɩɟɪɚɬɢɜɧɟ ɜɚɪɢʁɚɛɥɟ ɨɞ ɢɧɬɟɪɟɫɚ ɫɭ ɩɟɪɢɨɩɟɪɚɬɢɜɧɢ ɢɧɮɚɪɤɬ ɦɢɨɤɚɪɞɚ, ɞɭɠɢɧɚ ɦɟɯɚɧɢɱɤɟ ɜɟɧɬɢɥɚɰɢʁɟ, ɩɨɬɩɨɪɚ ɢɧɬɪɚɚɨɪɬɧɨɦ ɛɚɥɨɧ 49 ɩɭɦɩɨɦ, ɫɭɩɪɚɜɟɧɬɪɢɤɭɥɚɪɧɟ ɟɤɫɬɪɚɫɢɫɬɨɥɟ SVES, ɜɟɧɬɪɢɤɭɥɚɪɧɟ ɟɤɫɬɪɚɫɢɫɬɨɥɟ VES, ɛɭɛɪɟɠɧɚ ɫɥɚɛɨɫɬ (ɞɢʁɚɥɢɡɚ), ɦɨɠɞɚɧɢ ɭɞɚɪ, ɪɟɜɢɡɢʁɟ ɡɛɨɝ ɤɪɜɚɪɟʃɚ, ɬɪɚʁɚʃɟ ɛɨɪɚɜɤɚ ɭ ʁɟɞɢɧɢɰɢ ɢɧɬɟɡɢɜɧɨɝ ɥɟɱɟʃɚ , ɬɪɚʁɚʃɟ ɛɨɥɧɢɱɤɨɝ ɛɨɪɚɜɤɚ ɢ ɤɚɪɞɢɨɩɭɥɦɨɧɚɥɧɚ ɪɟɚɧɢɦɚɰɢʁɚ. ɉɨɫɟɛɧɨ ɫɟ ɚɧɚɥɢɡɢɪɚ ɦɨɪɬɚɥɢɬɟɬ ɡɛɨɝ ɜɪɥɨ ɦɚɥɟ ɫɬɨɩɟ. 50 V ɋɌȺɌɂɋɌɂɑɄȺ ɈȻɊȺȾȺ ɉɈȾȺɌȺɄȺ ɍ ɞɢɫɟɪɬɚɰɢʁɢ ɫɭ ɤɨɪɢɲʄɟɧɟ ɦɟɪɟ ɞɟɫɤɪɢɩɬɢɜɧɟ ɫɬɚɬɢɫɬɢɤɟ: ɚɪɢɬɦɟɬɢɱɤɚ ɫɪɟɞɢɧɚ, ɫɬɚɧɞɚɪɞɧɚ ɞɟɜɢʁɚɰɢʁɚ, ɦɟɞɢʁɚɧɚ, ɤɜɚɪɬɢɥɢ, ɮɪɟɤɜɟɧɰɟ ɢ ɩɪɨɰɟɧɬɢ. Ɂɚ ɩɨɪɟђɟʃɟ ɫɪɟɞʃɢɯ ɜɪɟɞɧɨɫɬɢ ɜɚɪɢʁɚɛɥɢ ɤɨɪɢɲʄɟɧ ʁɟ Ɍ ɬɟɫɬ ɡɚ ɧɟɡɚɜɢɫɧɟ ɭɡɨɪɤɟ ɢ Ɇɚɧ-ȼɢɬɧɢ-ʁɟɜ ɬɟɫɬ. ɉɨɜɟɡɚɧɨɫɬ ɤɚɬɟɝɨɪɢʁɫɤɢɯ ɜɚɪɢʁɚɛɥɢ ʁɟ ɢɫɩɢɬɢɜɚɧɚ ɩɨɦɨʄɭ ɏɢ-ɤɜɚɞɪɚɬ ɬɟɫɬɚ ɡɚ ɬɚɛɟɥɟ ɤɨɧɬɢɝɟɧɰɢʁɟ. Ɉɞɪɟђɢɜɚʃɟ ɭɬɢɰɚʁɚ ɩɪɨɦɟɧʂɢɜɢɯ ɧɚ ɢɫɯɨɞ ɥɟɱɟʃɚ ɜɪɲɟɧɨ ʁɟ ɩɨɦɨʄɭ ɭɧɢɜɚɪɢʁɚɧɬɧɟ ɢ ɦɭɥɬɢɜɚɪɢʁɚɧɬɧɟ ɛɢɧɚɪɧɟ ɥɨɝɢɫɬɢɱɤɟ ɪɟɝɪɟɫɢʁɟ. Ⱦɚ ɥɢ ɧɟɤɚ ɨɞ ɧɟɩɪɟɤɢɞɧɢɯ ɜɚɪɢʁɚɛɥɢ ɦɨɠɟ ɞɚ ɭɤɚɠɟ ɧɚ ɧɟɩɨɜɨʂɚɧ ɢɫɯɨɞ ɥɟɱɟʃɚ, ɢɫɩɢɬɢɜɚɧɨ ʁɟ ɩɨɦɨʄɭ ROC ɤɪɢɜɢɯ. 51 VI ɊȿɁɍɅɌȺɌɂ 1 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɉɊȿɆȺ ɈɋɇɈȼɇɂɆ ɈȻȿɅȿɀȳɂɆȺ 1.1 ɍɄɍɉȺɇ ȻɊɈȳ ɉȺɐɂȳȿɇȺɌȺ ɍ ɫɬɭɞɢʁɢ ʁɟ ɢɫɩɢɬɢɜɚɧɨ ɭɤɭɩɧɨ 906 ɩɚɰɢʁɟɧɚɬɚ ɤɨʁɢ ɫɭ ɨɩɟɪɢɫɚɧɢ ɧɚ ɂɧɫɬɢɬɭɬɭ ɡɚ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɟ ɛɨɥɟɫɬɢ ȼɨʁɜɨɞɢɧɟ ɭ ɩɟɪɢɨɞɭ ɨɞ 01.01.2011. ɞɨ 31.12.2012. ɝɨɞɢɧɟ. Ƚɪɭɩɚ ɭ ɤɨʁɨʁ ʁɟ ɪɚђɟɧɚ ɩɟɪɤɭɬɚɧɚ ɤɨɪɨɧɚɪɧɚ ɢɧɬɟɪɜɟɧɰɢʁɚ ɫɚ ɫɬɟɧɬɨɦ ɞɚ ɛɢ ɩɨɫɥɟ, ɭ ɞɪɭɝɨʁ ɯɨɫɩɢɬɚɥɢɡɚɰɢʁɢ, ɭɪɚђɟɧɚ ɯɢɪɭɪɲɤɚ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɚ ɦɢɨɤɚɪɞɚ, ɛɪɨʁɚɥɚ ʁɟ 94 ɩɚɰɢʁɟɧɬɚ. Ʉɨɧɬɪɨɥɧɚ ɝɪɭɩɚ ɭ ɤɨʁɨʁ ʁɟ ɪɚђɟɧɚ ɫɚɦɨ ɯɢɪɭɪɲɤɚ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɚ ɦɢɨɤɚɪɞɚ ɢɦɚɥɚ ʁɟ 814 ɩɚɰɢʁɟɧɚɬɚ (ɝɪɚɮɢɤɨɧ 1). 52 Ƚɪɚɮɢɤɨɧ 1. Ȼɪɨʁ ɩɚɰɢʁɟɧɚɬɚ ɩɨ ɝɪɭɩɚɦɚ 1.2 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɉɈ ɉɈɅɍ Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ ɜɟʄɢ ɛɪɨʁ ʁɟ ɛɢɨ ɦɭɲɤɨɝ ɩɨɥɚ. Ȼɪɨʁ ɩɚɰɢʁɟɧɚɬɚ ɦɭɲɤɨɝ ɩɨɥɚ ɢɡɧɨɫɢɨ ʁɟ 649 ɢɥɢ 72 %, ɞɨɤ ʁɟ ɛɪɨʁ ɩɚɰɢʁɟɧɚɬɚ ɠɟɧɫɤɨɝ ɩɨɥɚ ɢɡɧɨɫɢɨ 257 ɢɥɢ 28% (ɝɪɚɮɢɤɨɧ 2) . 53 Ƚɪɚɮɢɤɨɧ 2. ɉɨɥɧɚ ɫɬɪɭɤɬɭɪɚ ɩɚɰɢʁɟɧɚɬɚ ɭ ɫɬɭɞɢʁɢ 1.3 ɋɌAɊOɋɇA ɋɌɊɍɄɌɍɊA ɉAɐɂJEɇAɌA ɉɪɨɫɟɱɧɚ ɫɬɚɪɨɫɬ ɢɫɩɢɬɚɧɢɯ ɩɚɰɢʁɟɧɚɬɚ ɛɢɥɚ ʁɟ 62.1 ˃ 8.5 ɝɨɞɢɧɚ ɭ ɨɩɫɟɝɭ ɨɞ 32 ɞɨ 82 ɝɨɞɢɧɟ. Ⱦɨ 65 ɝɨɞɢɧɚ ɛɢɥɨ ʁɟ ɭɤɭɩɧɨ 585 ɩɚɰɢʁɟɧɚɬɚ ɢɥɢ 65%, ɚ 321 ɩɚɰɢʁɟɧɬ ʁɟ ɢɦɚɨ ɜɢɲɟ ɨɞ 65 ɝɨɞɢɧɚ (ɝɪɚɮɢɤɨɧ 3 ). 54 Ƚɪɚɮɢɤɨɧ 3. Уɤɭɩɚɧ ɛɪɨʁ ɩɚɰɢʁɟɧɚɬɚ ɫɬɚɪɢʁɢ ɨɞ 65 ɝɨɞɢɧɚ 1.4 ɋɌɊɍɄɌɍɊA ɉAɐɂJEɇAɌA ɍ OȾɇOɋɍ ɇA ɎAɄɌOɊE ɊɂɁɂɄA ɍ ɫɬɭɞɢʁɢ ʁɟ ɩɪɚʄɟɧɨ ɧɟɤɨɥɢɤɨ ɮɚɤɬɨɪɚ ɪɢɡɢɤɚ ɤɨʁɢ ɞɨɜɨɞɟ ɞɚ ɪɚɡɜɨʁɚ ɢɫɯɟɦɢʁɫɤɟ ɤɨɪɨɧɚɪɧɟ ɛɨɥɟɫɬɢ. ɇɚʁɡɧɚɱɚʁɧɢʁɢ ɮɚɤɬɨɪɢ ɤɨʁɢ ɫɭ ɩɪɚʄɟɧɢ ɛɢɥɢ ɫɭ: ɞɢʁɚɛɟɬɟɫ ɦɟɥɢɬɭɫ, ɯɢɩɟɪɬɟɧɡɢʁɚ, ɯɢɩɟɪɥɢɩɨɩɪɨɬɟɢɧɟɦɢʁɚ, ɩɭɲɟʃɟ ɤɚɨ ɢ ɝɨʁɚɡɧɨɫɬ. Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ 374 ʁɟ ɢɦɚɥɨ ɲɟʄɟɪɧɭ ɛɨɥɟɫɬ, 825 ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɢɦɚɥɨ ɯɢɩɟɪɬɟɧɡɢʁɭ, 617 ɯɢɩɟɪɥɢɩɨɩɪɨɬɟɢɧɟɦɢʁɭ, 390 ɩɚɰɢʁɟɧɚɬɚ 55 ɢɦɚɥɨ ʁɟ ɞɭɝɨɝɨɞɢɲʃɢ ɩɭɲɚɱɤɢ ɫɬɚɠ ɞɨɤ ʁɟ 356 ɩɚɰɢʁɟɧɚɬɚ ɛɢɥɨ ɝɨʁɚɡɧɨ ɫɚ BMI ɩɪɟɤɨ 30 (ɝɪɚɮɢɤɨɧ 4). Ƚɪaɮɢɤoɧ 4. Сɬɪɭɤɬɭɪa ɩaɰɢjОɧaɬa ɭ oɞɧoɫɭ ɧa ɮaɤɬoɪО ɪɢɡɢɤa ɡa ɧaɫɬaɧaɤ ɤoɪoɧaɪɧО ɢɫɯОɦɢjɫɤО ɛoɥОɫɬɢ 56 1.5 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ɈɑȿɄɂȼȺɇɂ ɈɉȿɊȺɌɂȼɇɂ ɊɂɁɂɄ ɍ ȽɊɍɉɂ CABG ɋɜɢ ɩɚɰɢʁɟɧɬɢ ɤɨʁɢ ɫɭ ɨɩɟɪɢɫɚɧɢ ɧɚ ɂɧɫɬɢɬɭɬɭ ɡɚ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɟ ɛɨɥɟɫɬɢ ȼɨʁɜɨɞɢɧɟ ɫɤɨɪɨɜɚɧɢ ɫɭ ɩɪɟɦɚ ɫɢɫɬɟɦɭ EuroScore-ɚ ɢ ɬɨ ɤɚɨ ɚɞɢɬɢɜɧɢ ɢ ɥɨɝɢɫɬɢɱɤɢ ȿuroScore. ɉɪɨɫɟɱɧɚ ɜɪɟɞɧɨɫɬ ɚɞɢɬɢɜɧɨɝ EuroScore-ɚ ɭ ɝɪɭɩɢ ɛɟɡ ɩɪɟɬɯɨɞɧɟ PCI ɢɡɧɨɫɢ 2.57 . ɇɚʁɧɢɠɚ ɜɪɟɞɧɨɫɬ ʁɟ ɛɢɥɚ 0, ɚ ɧɚʁɜɢɲɚ ɜɪɟɞɧɨɫɬ EuroScore-a 14. ɋɜɢ ɩɚɰɢʁɟɧɬɢ ɢɡ ɨɜɟ ɝɪɭɩɟ ɫɭ ɤɥɚɫɢɮɢɤɨɜɚɧɢ ɭ ɬɪɢ ɩɨɞɝɪɭɩɟ ɭ ɡɚɜɢɫɧɨɫɬɢ ɨɞ ɬɟɠɢɧɟ ɨɩɟɪɚɬɢɜɧɨɝ ɪɢɡɢɤɚ. ɉɪɜɚ ɝɪɭɩɚ ɤɨɞ ɤɨʁɟ ʁɟ ɧɢɜɨ ɨɩɟɪɚɬɢɜɧɨɝ ɪɢɡɢɤɚ ɧɚʁɧɢɠɢ (0-2) ɫɚɞɪɠɢ ɧɚʁɜɟʄɢ ɛɪɨʁ ɩɚɰɢʁɟɧɚɬɚ 51.73%. ɍ ɞɪɭɝoj ɝɪɭɩɢ ɫa ɫɪeɞʃɢɦ ɧɢɜooɦ oɱeɤɢɜaɧoɝ oɩeɪaɬɢɜɧoɝ ɪɢɡɢɤa (3-5) ɛɢɥɨ ʁɟ 44.16% ɩɚɰɢʁɟɧɚɬɚ ɨɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ. Ⱦɨɤ ɬɪɟʄɚ ɝɪɭɩɚ ɤɨʁɚ ʁɟ ɭʁɟɞɧɨ ɢ ɝɪɭɩɚ ɫɚ ɧɚʁɜɟʄɢɦ ɨɩɟɪɚɬɢɜɧɢ ɪɢɡɢɤɨɦ (>5) ɢɦɚɥɚ ʁɟ ɧɚʁɦɚʃɢ ɛɪɨʁ ɩɚɰɢʁɟɧɚɬɚ 8.30% (ɝɪɚɮɢɤɨɧ 5). ɉɪɨɫɟɱɧɚ ɜɪɟɞɧɨɫɬ ɥɨɝɢɫɬɢɱɤɨɝ EuroScore-a ɭ ɝɪɭɩɢ ɛɟɡ ɩɪɟɬɯɨɞɧɟ PCI ɢɡɧɨɫɢɥɚ ʁɟ 2.94. ɇɚʁɧɢɠɚ ɜɪɟɞɧɨɫɬ ʁɟ ɛɢɥɚ 0.49, ɚ ɧɚʁɜɢɲɚ 31.2. Ƚɥɟɞɚɧɨ ɩɨ ɤɥɚɫɢɮɢɤɨɜɚɧɢɦ ɝɪɭɩɚɦɚ, ɭ ɩɪɜɨʁ ɝɪɭɩɢ ɝɞɟ ʁɟ ɧɢɜɨ ɨɱɟɤɢɜɚɧɨɝ ɨɩɟɪɚɬɢɜɧɨɝ ɪɢɡɢɤɚ ɧɚʁɧɢɠɢ (0–2) ɛɢɥɨ ʁɟ 43.69 % ɩɚɰɢʁɟɧɚɬɚ. ɇɚʁɜɟʄɢ ɛɪɨʁ ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɭ ɞɪɭɝɨʁ ɝɪɭɩɢ (3–5) ɢ ɬɨ 52.20%. Ⱦɨɤ ɫɟ ɭ ɝɪɭɩɢ ɫɚ ɧɚʁɜɟʄɢɦ ɨɩɟɪɚɬɢɜɧɢɦ ɪɢɡɢɤɨɦ, ɫɤɨɪɨɦ > 5 ɧɚɥɚɡɢ ɧɚʁɦɚʃɟ ɩɚɰɢʁɟɧɚɬɚ 4.11% (ɝɪɚɮɢɤɨɧ 5). 57 Ƚɪaɮɢɤoɧ 5. Сɬɪɭɤɬɭɪa ɩaɰɢjОɧaɬa ɭ oɞɧoɫɭ ɧa ɧɢɜo oɱОɤɢɜaɧoɝ oɩОɪaɬɢɜɧoɝ ɪɢɡɢɤa ɭ ɝɪɭɩɢ ɛɟɡ ɩɪɟɬɯɨɞɧɨɝ PCI 1.6 ɉɈɅɇȺ ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ȽɊɍɉɂ CABG ɍ ɝɪɭɩɢ ɛɟɡ ɩɪɟɬɯɨɞɧɟ ɩɟɪɤɭɬɚɧɟ ɤɨɪɨɧɚɪɧɟ ɢɧɬɟɪɜɟɧɰɢʁɟ, ɨɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ 582, ɦɭɲɤɨɝ ɩɨɥɚ ʁɟ ɛɢɥɨ 71.7%, ɚ 230 ɩɚɰɢʁɟɧɚɬɚ ɫɭ ɛɢɥɟ ɠɟɧɟ ɢɥɢ 28.3 % ( ɝɪɚɮɢɤɨɧ 6 ). 58 Ƚɪaɮɢɤoɧ 6. ɉoɥɧa ɫɬɪɭɤɬɭɪa ɩaɰɢjОɧɬa ɭ ɝɪɭɩɢ ɛɟɡ PCI 1.7 ɋɌȺɊɈɋɇȺ ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ȽɊɍɉɂ CABG ɍ ɝɪɭɩɢ ɩɚɰɢʁɟɧɚɬɚ ɭ ɤɨʁɢɦɚ ɧɢʁɟ ɛɢɥɨ ɩɪɟɬɯɨɞɧɟ PCI ɢɧɬɟɪɜɟɧɰɢʁɟ ɩɪɨɫɟɱɧɚ ɫɬɚɪɨɫɬ ʁɟ ɛɢɥɚ 62.1 ˃ 8.36 ɝɨɞɢɧɚ. ɇɚʁɦɥɚђɢ ɩɚɰɢʁɟɧɬ ʁɟ ɢɦɚɨ 32, ɚ ɧɚʁɫɬɚɪɢʁɢ 82 ɝɨɞɢɧɟ. Ⱦɨ 65 ɝɨɞɢɧɚ ʁɟ ɛɢɥɨ 527 ɢɥɢ 64.9% ɩɚɰɢʁɟɧɚɬɚ, ɚ ɫɬɚɪɢʁɢɯ ɨɞ 65 ɝɨɞɢɧɚ ɛɢɥɨ ʁɟ 285 ɢɥɢ 35.1% ɩɚɰɢʁɟɧɚɬɚ (ɝɪɚɮɢɤɨɧ 7). 59 Ƚɪaɮɢɤoɧ 7. Сɬaɪoɫɧa ɫɬɪɭɤɬɭɪa ɩaɰɢjОɧaɬa ɭ ɝɪɭɩɢ CABG 1.8 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ɎȺɄɌɈɊȿ ɊɂɁɂɄȺ ɂɁ ȽɊɍɉȿ CABG ɍ ɝɪɭɩɢ ɛɟɡ ɩɪɟɬɯɨɞɧɟ ɩɟɪɤɭɬɚɧɟ ɤɨɪɨɧɚɪɧɟ ɢɧɬɟɪɜɟɧɰɢʁɟ ɩɪɚʄɟɧɨ ʁɟ ɩɟɬ ɧɚʁɛɢɬɧɢʁɢɯ ɮɚɤɬɨɪɚ ɪɢɡɢɤɚ ɤɨʁɢ ɫɭ ɩɨɜɟɡɚɧɢ ɫɚ ɪɚɡɜɨʁɟɦ ɤɨɪɨɧɚɪɧɟ ɢɫɯɟɦɢʁɫɤɟ ɛɨɥɟɫɬɢ. Ⱦɢʁɚɛɟɬɟɫ ɦɟɥɢɬɭɫ, ɤɚɨ ʁɟɞɚɧ ɨɞ ɧɚʁɛɢɬɧɢʁɢɯ ɮɚɤɬɨɪɚ, ɛɢɨ ʁɟ ɩɪɢɫɭɬɚɧ ɤɨɞ 349 ɩɚɰɢʁɟɧɚɬɚ. ȼɢɫɨɤ ɩɪɢɬɢɫɚɤ ʁɟ ɢɦɚɥɨ 750 ɩɚɰɢʁɟɧɚɬɚ. ɏɢɩɟɪɥɢɩɨɩɪɨɬɟɢɧɟɦɢʁɚ ʁɟ ɛɢɥɚ ɡɚɫɬɭɩʂɟɧɚ ɤɨɞ 562 ɩɚɰɢʁɟɧɬɚ. 346 ɩɚɰɢʁɟɧɚɬɚ 60 ʁɟ ɢɦɚɥɨ ɩɭɲɚɱɤɢ ɫɬɚɠ, ɞɨɤ ʁɟ 325 ɩɚɰɢʁɟɧɚɬɚ ɛɢɥɨ ɝɨʁɚɡɧɨ ɫɚ BMI ɩɪɟɤɨ 30 (ɝɪɚɮɢɤɨɧ 8). Ƚɪaɮɢɤoɧ 8. Сɬɪɭɤɬɭɪa ɩaɰɢjОɧaɬa ɭ oɞɧoɫɭ ɧa ɮaɤɬoɪО ɪɢɡɢɤО ɭ ɝɪɭɩɢ CABG 1.9 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ɉɊȿɈɉȿɊȺɌɂȼɇɍ ɌȿɊȺɉɂȳɍ ɍ ȽɊɍɉɂ CABG ɍ ɝɪɭɩɢ ɛɟɡ ɩɪɟɬɯɨɞɧɟ PCI, ɫɜɢɯ 812 ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɛɢɥɨ ɧɚ ɨɞɪɟђɟɧɨʁ ɩɪɟɨɩɟɪɚɬɢɜɧɨʁ ɬɟɪɚɩɢʁɢ. ɇɚʁɜɟʄɢ ɛɪɨʁ ɩɚɰɢʁɟɧɚɬɚ, 609 ɭɡɢɦɚɥɨ ʁɟ β – ɛɥɨɤɚɬɨɪɟ. ɇɚ ɚɧɬɢɚɝɪɟɝɚɰɢɨɧɨʁ ɬɟɪɚɩɢʁɢ ʁɟ ɛɢɥɨ 398 ɩɚɰɢʁɟɧɚɬɚ. ɋɬɚɬɢɧɟ ʁɟ 61 ɤɨɪɢɫɬɢɥɨ 589 ɩɚɰɢʁɟɧɚɬɚ. ACE ɢɧɯɢɛɢɬɨɪɟ ʁɟ ɤɨɪɢɫɬɢɥɨ 602, ɞɨɤ ɬɟɪɚɩɢʁɭ ɧɢɬɪɚɬɢɦɚ ɤɨɧɡɭɦɢɪɚɨ 421 ɩɚɰɢʁɟɧɬ. (ɝɪɚɮɢɤɨɧ 9). Ƚɪɚɮɢɤɨɧ 9. Сɬɪɭɤɬɭɪɚ ɩɚɰɢʁɟɧɚɬɚ ɢɡ ɝɪɭɩɟ ɛɟɡ ɩɪɟɬɯɨɞɧɟ PCI ɭ ɨɞɧɨɫɭ ɧɚ ɩɪɟɨɩɟɪɚɬɢɜɧɭ ɬɟɪɚɩɢʁɭ 1.10 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ɇɂȼɈ ɈɑȿɄɂȼȺɇɈȽ ɈɉȿɊȺɌɂȼɇɈȽ ɊɂɁɂɄȺ EUROSCORE ɍ ȽɊɍɉɂ ɋȺ ɉɊȿɌɏɈȾɇɈɆ PCI . ɉɪɨɫɟɱɧɚ ɜɪɟɞɧɨɫɬ ɚɞɢɬɢɜɧɨɝ EuroScore-ɚ ɭ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI ɢɡɧɨɫɢ 2.42. ɇɚʁɧɢɠɚ ɜɪɟɞɧɨɫɬ ʁɟ ɛɢɥɚ 0, ɚ ɧɚʁɜɢɲɚ ɜɪɟɞɧɨɫɬ EuroScore-a ʁɟ ɛɢɥɚ 9. ɋɜɢ ɩɚɰɢʁɟɧɬɢ ɢɡ ɨɜɟ ɝɪɭɩɟ ɫɭ ɤɥɚɫɢɮɢɤɨɜɚɧɢ ɭ ɬɪɢ ɩɨɞɝɪɭɩɟ ɭ ɡɚɜɢɫɧɨɫɬɢ ɨɞ ɬɟɠɢɧɟ ɨɩɟɪɚɬɢɜɧɨɝ ɪɢɡɢɤɚ. ɉɪɜɚ ɝɪɭɩɚ ɤɨɞ ɤɨʁɟ ʁɟ ɧɢɜɨ ɨɩɟɪɚɬɢɜɧɨɝ ɪɢɡɢɤɚ 62 ɧɚʁɧɢɠɢ (0-2) ɫɚɞɪɠɢ ɭɤɭɩɧɨ 57.12% ɩɚɰɢʁɟɧɚɬɚ. ɍ ɞɪɭɝoj ɝɪɭɩɢ ɫa ɫɪeɞʃɢɦ ɧɢɜooɦ oɱeɤɢɜaɧoɝ oɩeɪaɬɢɜɧoɝ ɪɢɡɢɤa (3-5) ɛɢɥɨ ʁɟ 36.3 % ɩɚɰɢʁɟɧɚɬɚ ɨɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ. Ɍɪɟʄɚ ɝɪɭɩɚ ɤɨʁɚ ʁɟ ɭʁɟɞɧɨ ɢ ɝɪɭɩɚ ɫɚ ɧɚʁɜɟʄɢɦ ɨɩɟɪɚɬɢɜɧɢ ɪɢɡɢɤɨɦ (>5) ɢɦɚɥɚ ʁɟ ɧɚʁɦɚʃɢ ɛɪɨʁ ɩɚɰɢʁɟɧɚɬɚ 6.58% (ɝɪɚɮɢɤɨɧ 10). ɉɪɨɫɟɱɧɚ ɜɪɟɞɧɨɫɬ ɥɨɝɢɫɬɢɱɤɨɝ EuroScore-a ɭ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI ɢɡɧɨɫɢɥɚ ʁɟ 1.84. ɇɚʁɧɢɠɚ ɜɪɟɞɧɨɫɬ ʁɟ ɛɢɥɚ 0.5, ɚ ɧɚʁɜɢɲɚ 16.87. Ƚɥɟɞɚɧɨ ɩɨ ɤɥɚɫɢɮɢɤɨɜɚɧɢɦ ɝɪɭɩɚɦɚ, ɭ ɩɪɜɨʁ ɝɪɭɩɢ ɝɞɟ ʁɟ ɧɢɜɨ ɨɱɟɤɢɜɚɧɨɝ ɨɩɟɪɚɬɢɜɧɨɝ ɪɢɡɢɤɚ ɧɚʁɧɢɠɢ (0–2) ɛɢɨ ʁɟ ɧɚʁɜɟʄɢ ɛɪɨʁ ɢ ɬɨ 61.35 % ɩɚɰɢʁɟɧɚɬɚ. ɍ ɞɪɭɝɨʁ ɝɪɭɩɢ, ɝɪɭɩɢ ɫɚ ɫɪɟɞʃɢɦ ɧɢɜɨɨɦ ɪɢɡɢɤɚ (3–5) ɛɢɥɨ ʁɟ 35.50% ɩɚɰɢʁɟɧɚɬɚ. Ⱦɨɤ ɫɟ ɭ ɝɪɭɩɢ ɫɚ ɧɚʁɜɟʄɢɦ ɨɩɟɪɚɬɢɜɧɢɦ ɪɢɡɢɤɨɦ, ɫɤɨɪɨɦ > 5 ɧɚɥɚɡɢ ɧɚʁɦɚʃɟ ɩɚɰɢʁɟɧɚɬɚ 3.15% (ɝɪɚɮɢɤɨɧ 10). Ƚɪaɮɢɤoɧ 10. Сɬɪɭɤɬɭɪa ɩaɰɢjОɧaɬa ɭ oɞɧoɫɭ ɧa oɱОɤɢɜaɧɢ oɩОɪaɬɢɜɧɢ ɪɢɡɢɤ ɭ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɢɦ PCI 63 1.11 ɉɈɅɇȺ ɋɌɊɍɄɌɍɊȺ ɍ ȽɊɍɉɂ ɉȺɐɂȳȿɇȺɌȺ ɋȺ ɉɊȿɌɏɈȾɇɂɆ PCI Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ ɢɡ ɝɪɭɩɟ ɫɚ ɩɪɟɬɯɨɞɧɢɦ PCI, ɜɢɲɟ ɨɞ ɞɜɚ ɢ ɩɨ ɩɭɬɚ ʁɟ ɛɢɥɨ ɡɚɫɬɭɩʂɟɧɨ ɦɭɲɤɚɪɚɰɚ ɭ ɨɞɧɨɫɭ ɧɚ ɠɟɧɟ. Ȼɢɥɨ ʁɟ 67 ɩɚɰɢʁɟɧɚɬɚ ɦɭɲɤɨɝ ɩɨɥɚ ɢɥɢ 71%, ɞɨɤ ʁɟ 29% ɢɥɢ 27 ɩɚɰɢʁɟɧɚɬɚ ɨɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɛɢɥɨ ɠɟɧɫɤɨɝ ɩɨɥɚ (ɝɪɚɮɢɤɨɧ 11) Ƚɪɚɮɢɤɨɧ 11. ɉɨɥɧɚ ɫɬɪɭɤɬɭɪɚ ɩɚɰɢʁɟɧɚɬɚ ɭ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɢɦ PCI 64 1.12 ɋɌȺɊɈɋɇȺ ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ȽɊɍɉɂ ɋȺ ɉɊȿɌɏɈȾɇɂɆ PCI ɍ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɢɦ PCI, ɨɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ, ɩɪɨɫɟɱɧɚ ɫɬɚɪɨɫɬ ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɛɢɥɚ 61.92 ˃ 9.63 ɝɨɞɢɧɟ. ɇɚʁɦɥɚђɢ ɩɚɰɢʁɟɧɬ ʁɟ ɢɦɚɨ 35, ɚ ɧɚʁɫɬɚɪɢʁɢ 79 ɝɨɞɢɧɚ. Ⱦɨ 65 ɝɨɞɢɧɚ ʁɟ ɛɢɥɨ 62% ɢɥɢ 58 ɩɚɰɢʁɟɧɚɬɚ, ɚ ɩɪɟɤɨ 65 ɝɨɞɢɧɚ 36 ɩɚɰɢʁɟɧɚɬɚ ɢɥɢ 38% (ɝɪɚɮɢɤɨɧ 12). Ƚɪaɮɢɤoɧ 12. Сɬaɪoɫɧa ɫɬɪɭɤɬɭɪa ɩaɰɢjОɧaɬa ɭ ɝɪɭɩɢ ɫa ɩɪОɬɯoɞɧɢɦ PCI 65 1.13 ɋɌɊɍɄɌɍɊA ɉAɐɂJEɇAɌA ɍ OȾɇOɋɍ ɇA ɎAɄɌOɊE ɊɂɁɂɄA ɁA ɊAɁȼOJ ɄOɊOɇAɊɇE ȻOɅEɋɌɂ ɍ ȽɊɍɉɂ ɉAɐɂJEɇAɌA ɋA ɉɊEɌɏOȾɇɂɆ ЈCI ɍ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI ɤɚɨ ɢ ɭ ɝɪɭɩɢ ɛɟɡ PCI ɩɪɚʄɟɧɢ ɫɭ ɧɚʁɡɧɚɱɚʁɧɢʁɢ ɮɚɤɬɨɪɢ ɤɨʁɢ ɫɭ ɩɨɜɟɡɚɧɢ ɫɚ ɪɚɡɜɨʁɟɦ ɤɨɪɨɧɚɪɧɟ ɢɫɯɟɦɢʁɫɤɟ ɛɨɥɟɫɬɢ ɫɪɰɚ. Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ, 25 ʁɟ ɢɦɚɥɨ ɲɟʄɟɪɧɭ ɛɨɥɟɫɬ ɚ ɧɚʁɜɟʄɢ ɛɪɨʁ ɩɚɰɢʁɟɧɚɬɚ ɢ ɬɨ 75 ɩɨɜɢɲɟɧ ɤɪɜɧɢ ɩɪɢɬɢɫɚɤ. ɉɭɲɚɱɤɢ ɫɬɚɠ ʁɟ ɪɟɝɢɫɬɪɨɜɚɧ ɤɨɞ 44 ɩɚɰɢʁɟɧɬɚ. ɏɢɩɟɪɥɢɩɨɩɪɨɬɟɢɧɟɦɢʁɭ ɫɭ ɢɦɚɥɚ 55 ɩɚɰɢʁɟɧɬɚ. ɉɪɨɛɥɟɦ ɫɚ ɝɨʁɚɡɧɨɲʄɭ, ɝɞɟ ʁɟ BMI ɜɟʄɢ ɨɞ 30, ɡɚɫɬɭɩʂɟɧ ʁɟ ɤɨɞ 31 ɩɚɰɢʁɟɧɬɚ (ɝɪɚɮɢɤɨɧ 13). Ƚɪaɮɢɤoɧ 13. Сɬɪɭɤɬɭɪa ɩaɰɢjОɧaɬa ɭ oɞɧoɫɭ ɧa ɮaɤɬoɪО ɪɢɡɢɤa ɭ ɝɪɭɩɢ ɫa ɩɪОɬɯoɞɧoɦ PCI 66 1.14 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ɉɊȿɈɉȿɊȺɌɂȼɇɍ ɌȿɊȺɉɂȳɍ ɍ ȽɊɍɉɂ ɋȺ ɉɊȿɌɏɈȾɇɈɆ PCI Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɨɞ 94 ɩɚɰɢʁɟɧɚɬɚ ɢɡ ɝɪɭɩɟ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI, ɢɡ ɫɬɭɞɢʁɟ ɫɟ ɦɨɠɟ ɤɨɧɫɬɚɬɨɜɚɬɢ ɞɚ ʁɟ ɧɚʁɜɟʄɢ ɛɪɨʁ ɩɚɰɢʁɟɧɚɬɚ ɤɨɪɢɫɬɢɨ ɭ ɩɪɟɨɩɟɪɚɬɢɜɧɨʁ ɬɟɪɚɩɢʁɢ ɫɬɚɬɢɧɟ, ɢ ɬɨ 82 ɲɬɨ ɢɡɧɨɫɢ 87.2% ɨɞ ɭɤɭɩɧɨɝ ɛɪɨʁ. ɋɥɟɞɟʄɟ ɥɟɤɨɜɟ ɭ ɧɢɡɭ ɤɨʁɟ ɫɭ ɧɚʁɜɢɲɟ ɤɨɪɢɫɬɢɥɢ ɛɢɥɢ ɫɭ ɚɧɬɢɚɝɪɟɝɚɰɢɨɧɢ ɥɟɤɨɜɢ. Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ ɢɡ ɨɜɟ ɝɪɭɩɟ 81.9% ɢɥɢ 77 ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɛɢɥɨ ɧɚ ɚɧɬɢɚɝɪɟɝɚɰɢɨɧɨʁ ɬɟɪɚɩɢʁɢ. Ɂɚɬɢɦ, ɩɪɨɰɟɧɬɭɚɥɧɨ ɞɨɥɚɡɟ ACE ɢɧɯɢɛɢɬɨɪɢ ɢ ɬɨ 77.7% ɢɥɢ 73 ɩɚɰɢʁɟɧɚɬɚ. β-ɛɥɨɤɚɬɨɪɢ ɤɚɨ ɢ ɧɢɬɪɚɬɢ ɫɭ ɧɚ ɩɨɫɥɟɞʃɟɦ ɦɟɫɬɭ ɢ ɬɨ 69 ɢ 46 ɩɚɰɢʁɟɧɚɬɚ (ɝɪɚɮɢɤɨɧ 14). Ƚɪɚɮɢɤɨɧ 14. Сɬɪɭɤɪɭɪɚ ɩɚɰɢʁɟɧɚɬɚ ɢɡ ɝɪɭɩɟ ɫɚ ɩɪɟɬɯɨɞɧɢɦ PCI ɭ ɨɞɧɨɫɭ ɧɚ ɩɪɟɨɩɟɪɚɬɢɜɧɭ ɬɟɪɚɩɢʁɭ 67 1.15 ɍɉɈɊȿȾɇȺ ȺɇȺɅɂɁȺ ɉȺɐɂȳȿɇȺɌȺ ɂɁ ɈȻȿ ȽɊɍɉȿ ɉɈ ȼɊȿȾɇɈɋɌɂɆȺ ɈɑȿɄɂȼȺɇɈȽ ɈɉȿɊȺɌɂȼɇɈȽ ɊɂɁɂɄȺ ɉɈ EUROSCOR-U ȳɟɞɧɚ ɨɞ ɛɢɬɧɢɯ ɫɬɚɜɤɢ ɤɨʁɚ ʁɟ ɫɩɪɨɜɨђɟɧɚ ɢ ɦɟɪɟɧɚ ɭ ɨɜɨʁ ɫɬɭɞɢʁɭ ʁɟɫɬɟ ɨɞɪɟђɢɜɚʃɟ ɜɪɟɞɧɨɫɬɢ ɨɱɟɤɢɜɚɧɨɝ ɨɩɟɪɚɬɢɜɧɨɝ ɪɢɡɢɤɚ EuroScore-ɚ ɤɨʁɢ ɫɟ ɧɚ ɧɚɲɨʁ Ʉɥɢɧɢɰɢ ɝɨɞɢɧɚɦɚ ɫɩɪɨɜɨɞɢ ɪɭɬɢɧɫɤɢ. ɋɜɢ ɪɟɡɭɥɬɚɬɢ EuroScore ɢ ɢɡ ʁɟɞɧɟ ɢ ɢɡ ɞɪɭɝɟ ɝɪɭɩɟ ɫɭ ɩɪɚʄɟɧɢ, ɞɚ ɛɢ ɫɟ ɩɨɬɨɦ ɭɩɨɪɟɞɧɨɦ ɚɧɚɥɢɡɨɦ ɨɛɟ ɝɪɭɩɟ ɢɫɬɪɚɠɢɜɚɥɚ ɫɬɚɬɢɫɬɢɱɤɚ ɡɧɚɱɚʁɧɨɫɬ. ɉɚɰɢʁɟɧɬɢ ɫɭ ɭɩɨɪɟђɢɜɚɧɢ ɚɞɢɬɢɜɧɢɦ ɢ ɥɨɝɢɫɬɢɱɤɢɦ ɫɤɨɪɨɦ ɭ ɨɛɟ ɝɪɭɩɟ. ɍ ɩɪɜɨʁ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɢɦ PCI, ɫɪОɞʃК ɜɪОɞɧШɫɬ КɞɢɬɢɜɧШɝ ɫɤШɪɚ je 2.42, ɞШɤ УО ɫɪОɞʃК ɜɪОɞɧШɫɬ ɥШɝɢɫɬɢɱɤШɝ ɫɤШɪК 1.84. ɉКɰɢУОɧɬɢ ɭ ɝɪɭɩɢ ɛОɡ ɩɪОɬɯШɞɧШɝ ЈCI ɢɦКУɭ ɫɪОɞʃɭ ɜɪОɞɧШɫɬ КɞɢɬɢɜɧШɝ ɫɤШɪК 2.57, ɞШɤ УО ɫɪОɞʃК ɜɪОɞɧШɫɬ ɥШɝɢɫɬɢɱɤШɝ ɫɤШɪК ɧОɲɬШ ɦКɥШ ɜОʄК ɭ ШɞɧШɫɭ ɧК ɞɪɭɝɭ ɝɪɭɩɭ ɢ ɢɡɧШɫɢ 2.94 (ɝɪɚɮɢɤɨɧ 15). Ɋaɡɥɢɤa ɫɪeɞʃɢɯ ɜɪeɞɧoɫɬɢ aɞɢɬɢɜɧoɝ ɫɤoɪa ɢɡɦeђɭ ШɛО ɝɪɭɩО ɩКɰɢУОɧКɬК ɧɢje ɫɬaɬɢɫɬɢɱɤɢ ɡɧaɱajɧК (p = 0,904). ɊaɡɥɢɤК ɫɪeɞʃɢɯ ɜɪeɞɧoɫɬɢ ɥoɝɢɫɬɢɱɤoɝ ɫɤoɪa ɢɡɦeђɭ ɨɛɟ ɝɪɭɩɟ ɩɚɰɢʁɟɧɚɬɚ ɫɬaɬɢɫɬɢɱɤɢ ʁɟ ɡɧaɱajɧa (p = 0,198). 68 Ƚɪaɮɢɤoɧ 15. УɩoɪОɞɧa aɧaɥɢɡa ɩɪОoɩОɪaɬɢɜɧoɝ ɪɢɡɢɤa ɭ oɛО ɝɪɭɩО ɩaɰɢjОɧaɬa 1.16 ɍɉɈɊȿȾɇȺ ȺɇȺɅɂɁȺ ɉɊȿɈɉȿɊȺɌɂȼɇȿ ɌȿɊȺɉɂȳȿ ɍ ɈȻȿ ȽɊɍɉȿ ɉȺɐɂȳȿɇȺɌȺ ɍɩɨɪɟɞɧɨɦ ɚɧɚɥɢɡɨɦ ɩɪɟɨɩɟɪɚɬɢɜɧɟ ɬɟɪɚɩɢʁɟ ɜɢɞɢɦɨ ɞɚ ʁɟ ɛɪɨʁ ɩɚɰɢʁɟɧɚɬɢ ɢɡ ɝɪɭɩɟ ɫɚ ɩɪɟɬɯɨɞɧɨɦ ɩɟɪɤɭɬɚɧɨɦ ɤɨɪɨɧɚɪɧɨɦ ɢɧɬɟɪɜɟɧɰɢʁɨɦ, ɦɧɨɝɨ ɜɟʄɢ. ɇɚʁɜɟʄɚ ɞɢɫɩɪɨɩɨɪɰɢʁɚ ɭ ɩɪɟɨɩɟɪɚɬɢɜɧɨʁ ɬɟɪɚɩɢʁɢ ɫɟ ɨɞɪɚɠɚɜɚ ɭ ɚɧɬɢɚɝɪɟɝɚɰɢɨɧɨʁ ɬɟɪɚɩɢʁɢ. Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ ɢɡ ɝɪɭɩɟ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI, 81.9% ɭɡɢɦɚ ɚɧɬɢɚɝɪɟɝɚɰɢɨɧɭ ɬɟɪɚɩɢʁɭ, ɲɬɨ ʁɟ ɭ ɨɞɧɨɫɭ ɧɚ 49 % ɢɡ ɝɪɭɩɟ ɛɟɡ ɩɪɟɬɯɨɞɧɟ PCI ɦɧɨɝɨ ɜɟʄɢ ɛɪɨʁ. Ɉɜɚʁ ɭɩɨɪɟɞɧɢ ɪɟɡɭɥɬɚɬ ɚɧɬɢɚɝɪɟɝɚɰɢɨɧɟ ɬɟɪɚɩɢʁɟ ɢɦɚ ɢ ɫɜɨʁɭ ɫɬɚɬɢɫɬɢɱɤɭ ɡɧɚɱɚʁɧɨɫɬ (p < 0,0005). ɍɩɨɪɟɞɧɨɦ ɚɧɚɥɢɡɨɦ ɞɨɥɚɡɢɦɨ ɞɨ ɪɟɡɭɥɬɚɬɚ ɢ ɞɚ ʁɟ ɜɟʄɢ ɩɪɨɰɟɧɚɬ ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ ɢɡ ɝɪɭɩɟ ɫɚ 69 ɩɪɟɬɯɨɞɧɨɦ PCI ɩɪɢ ɭɡɢɦɚʃɭ ɫɬɚɬɢɧɚ. ɍ ɩɪɜɨʁ ɝɪɭɩɢ ɬɚʁ ɩɪɨɰɟɧɚɬ ɢɡɧɨɫɢ 87.2%, ɞɨɤ ʁɟ ɭ ɞɪɭɝɨʁ ɝɪɭɩɢ ɞɨɫɬɚ ɦɚʃɢ 72.5%. ɋɬaɬɢɧɢ ɢ ɝɪɭɩɚ ɫɚ ɩɪeɬɯoɞɧɢɦ ЈCI ɫɭ ɩɨɜɟɡɚɧɢ ɢ ɢɦɚʁɭ ɫɬɚɬɢɫɬɢɱɤɭ ɡɧɚɱɚʁɧɨɫɬ (p = 0,002) (ɝɪɚɮɢɤɨɧ 16). Ɉɞ ɨɫɬɚɥɟ ɩɪɟɨɩɟɪɚɬɢɜɧɟ ɬɟɪɚɩɢʁɟ ɩɚɰɢʁɟɧɬɢ ɢɡ ɨɛɟ ɝɪɭɩɟ ɫɭ ɩɪɢɛɥɢɠɧɨ ɢɫɬɨ ɛɢɥɢ ɡɚɫɬɭɩʂɟɧɢ. β-ɛɥɨɤɚɬɨɪɟ ɫɭ ɢ ʁɟɞɧɚ ɢ ɞɪɭɝɚ ɝɪɭɩɚ ɩɪɢɛɥɢɠɧɨ ɭɡɢɦɚɥɟ. Ƚɪɭɩɚ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI 73.4%, ɞɨɤ ɝɪɭɩɚ ɛɟɡ PCI 75%. ɂɫɬɢ ʁɟ ɫɥɭɱɚʁ ɢ ɤɨɞ ACE ɢɧɯɢɛɢɬɨɪɚ, 77.7% ɩɚɰɢʁɟɧɚɬɚ ɢɡ ɝɪɭɩɟ ɫɚ PCI ʁɟ ɭɡɢɦɚɥɨ ACE ɢɧɯɢɛɢɬɨɪɟ ɞɨɤ ɞɪɭɝɚ ɝɪɭɩɚ ɩɪɢɛɥɢɠɧɨ ɢɫɬɨ 74.1%. Ɉɛɟ ɝɪɭɩɟ ɫɭ ɩɪɨɰɟɧɬɭɚɥɧɨ ɛɢɥɟ ɩɪɢɛɥɢɠɧɨ ɢɫɬɨ ɡɚɫɬɭɩʂɟɧɟ ɢ ɩɪɢ ɭɡɢɦɚʃɭ ɧɢɬɪɚɬɚ. Ƚɪɭɩɚ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI, ɨɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ, 50.5 % ʁɟ ɭɡɢɦɚɥɨ ɧɢɬɪɚɬɟ ɞɨɤ ʁɟ ɩɪɨɰɟɧɚɬ ɞɪɭɝɟ ɝɪɭɩɟ ɛɢɨ 51.8% (ɝɪɚɮɢɤɨɧ 16). Ƚɪɚɮɢɤɨɧ 16. Уɩɨɪɟɞɧɢ ɩɪɢɤɚɡ ɩɪɟɨɩɟɪɚɬɢɜɧɟ ɬɟɪɚɩɢʁɟ ɭ ɨɛɟ ɝɪɭɩɟ 70 1.17 ɍɉɈɊȿȾɇȺ ȺɇȺɅɂɁȺ ɎȺɄɌɈɊȺ ɊɂɁɂɄȺ ɍ ɈȻȿ ȽɊɍɉȿ Ɏɚɤɬɨɪɢ ɪɢɡɢɤɚ ɤɨʁɢ ɢɡɚɡɢɜɚʁɭ ɤɨɪɨɧɚɪɧɭ ɢɫɯɟɦɢʁɫɤɭ ɛɨɥɟɫɬ, ɤɚɨ ɲɬɨ ɫɭ ɞɢʁɚɛɟɬɟɫ ɦɟɥɢɬɭɫ, ɯɢɩɟɪɬɟɧɡɢʁɚ, ɯɢɩɟɪɥɢɩɨɩɪɨɬɟɢɧɟɦɢʁɚ, ɩɭɲɟʃɟ ɢ ɝɨʁɚɡɧɨɫɬ, ɩɪɚʄɟɧɢ ɫɭ ɭ ɨɛɟ ɝɪɭɩɟ ɞɚ ɛɢ ɫɟ ɭɪɚɞɢɥɚ ɭɩɨɪɟɞɧɚ ɚɧɚɥɢɡɚ ɢ ɢɫɩɢɬɚɥɨ ɞɚ ɥɢ ʁɟ ɧɟɤɢ ɨɞ ɮɚɤɬɨɪɚ ɜɢɲɟ ɡɚɫɬɭɩʂɟɧ ɭ ɨɞɪɟђɟɧɨʁ ɝɪɭɩɢ. ɍ ɝɪɭɩɢ ɛɟɡ ɩɪɟɬɯɨɞɧɟ PCI ɩɪɨɰɟɧɚɬ ɡɚɫɬɭɩʂɟɧɨɫɬɢ ɲɟʄɟɪɧɟ ɛɨɥɟɫɬɢ ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ ʁɟ 43% ɞɨɤ ʁɟ ɭ ɝɪɭɩɢ ɫɚ PCI ɬɚʁ ɩɪɨɰɟɧɚɬ 26.6%. Ɉɜɚʁ ɨɞɧɨɫ ɡɚɫɬɭɩʂɟɧɨɫɬɢ ɢɦɚ ɫɜɨʁɭ ɫɬɚɬɢɫɬɢɱɤɭ ɡɧɚɱɚʁɧɨɫɬ (p=0.003). ɉɪɢɫɭɬɧɨɫɬ ɩɨɜɢɲɟɧɨɝ ɤɪɜɧɨɝ ɩɪɢɬɢɫɤɚ ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ ɭ ɝɪɭɩɢ ɛɟɡ PCI ʁɟ 92.4% ɲɬɨ ʁɟ ɭ ɨɞɧɨɫɭ ɧɚ ɝɪɭɩɭ ɫɚ PCI ɤɨɞ ɤɨʁɟ ʁɟ ɬɚʁ ɩɪɨɰɟɧɚɬ 79.8% ɢɡɭɡɟɬɧɨ ɜɢɫɨɤ ɢ ɢɦɚ ɫɜɨʁɭ ɫɬɚɬɢɫɬɢɱɤɭ ɡɧɚɱɚʁɧɨɫɬ (p ޒ 0.0005). ɍ ɨɛɟ ɝɪɭɩɟ ɩɪɨɰɟɧɚɬ ɩɚɰɢʁɟɧɚɬɚ ɤɨʁɢ ɢɦɚʁɭ ɯɢɩɟɪɥɢɩɨɩɪɨɬɟɢɧɟɦɢʁɭ ʁɟ ɜɢɫɤɨɤ ɢ ɭ ɝɪɭɩɢ ɛɟɡ PCI, ɬɚʁ ɩɪɨɰɟɧɚɬ ʁɟ 69,2 ɞɨɤ ʁɟ ɭ ɞɪɭɝɨʁ ɝɪɭɩɢ 58.5. Ɉɜɚʁ ɨɞɧɨɫ ɩɨʁɚɜɟ ɯɢɩɟɪɥɢɩɨɩɪɨɬɟɢɧɟɦɢʁɟ ɢɡɦɟђɭ ɨɜɟ ɞɜɟ ɝɪɭɩɟ ɢɦɚ ɢ ɫɜɨʁɭ ɫɬɚɬɢɫɬɢɱɤɭ ɡɧɚɱɚʁɧɨɫɬ (p = 0,047) (ɝɪɚɮɢɤɨɧ 17). Ɉɞ ɨɫɬɚɥɢɯ ɮɚɤɬɨɪɚ ɤɨʁɢ ɫɭ ɩɪɚʄɟɧɢ ɜɪɥɨ ʁɟ ɫɥɢɱɧɚ ɡɚɫɬɭɩʂɟɧɨɫɬ ɝɨʁɚɡɧɢɯ ɩɚɰɢʁɟɧɚɬɚ ɫɚ BMI > 30 ɤɚɨ ɢ ɩɭɲɚɱɚ ɢ ɭ ʁɟɞɧɨʁ ɢ ɭ ɞɪɭɝɨʁ ɝɪɭɩɢ. ɍ ɝɪɭɩɢ ɛɟɡ PCI, ɩɪɨɰɟɧɚɬ ɝɨʁɚɡɧɢɯ ʁɟ 40 % ɞɨɤ ʁɟ ɤɨɞ ɩɭɲɚɱɚ 42.6%. ɍ ɝɪɭɩɢ ɫɚ PCI ɩɪɨɰɟɧɚɬ ʁɟ 33% ɡɚ ɝɨʁɚɡɧɟ ɢ 46.8% ɡɚ ɩɭɲɚɱɟ (ɝɪɚɮɢɤɨɧ 17). 71 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 43% 92.40% 69.20% 42.60% 40% 26.60% 79.80% 58.50% 46.80% 33% ̍ез PCI ̭̌ PCI Ƚɪɚɮɢɤɨɧ 17. Уɩɨɪɟɞɧɚ ɚɧɚɥɢɡɚ ɮɚɤɬɨɪɚ ɪɢɡɢɤɚ ɭ ɨɛɟ ɝɪɭɩɟ 72 Ɍɚɛɟɥɚ 1. ɉɪɟɨɩɟɪɚɬɢɜɧɟ ɤɚɪɚɤɬɟɪɢɫɬɢɤɟ ɩɚɰɢјɟɧɚɬɚ Без PCI (n = 812) PCI (n = 94) Р n (%) n (%) Пол ̥ушк̛ 582 (71,7 ) 67 (71,3) 1,000 Год̛̦е 62 (56 – 69) 63,50 (56 – 69) 0,774 EF % 53 (48 – 59) 53 (48 – 59) 0,987 А̦т̛̌г̬ег̶̛̌о̦̌ те̬̌п̛ј̌ 398 (49,0) 77 (81,9) < 0,0005 β-̍лок̌то̛̬ 609 (75,0) 69 (73,4) 0,832 Ст̌т̛̛̦ 589 (72,5 82 (87,2) 0,003 ACE ̵̛̛̛̦̍то̛̬ 602 (74,1) 73 (77,7) 0,537 Н̛т̬̌т̛ 421 (51,8) 46 (50,5) 0,906 Пушење 346 (42,6) 44 (46,8) 0,504 Д̛ј̌̍ете̭ 349 (43,0) 25 (26,6) 0,003 Х̛пе̬те̛̦̚ј̌ 750 (92,4) 75 (79,8) < 0,0005 Х̛пе̬л̛поп̬оте̛̦е̛̥ј̌ 562 (69,2) 55 (58,5) 0,047 BMI ˃ 30 325 (40,0) 31 (33,0) 0,225 Не̭т̛̌̍л̦̌ ̦̌г̛̦̌ 101 (12,4) 10 (10,6) 0,736 73 2 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɉɊȿɆȺ ȻɊɈȳɍ, ȼɊɋɌɂ ɂ ɆȿɋɌɍ PCI 2.1 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɉɈ ȻɊɈȳɍ ɂɆɉɅȺɇɌɂɊȺɇɂɏ ɋɌȿɇɌɈȼȺ ɍ ȽɊɍɉɂ ɋȺ ɉɊȿɌɏɈȾɇɈɆ PCI ɍ ɝɪɭɩɢ ɩɚɰɢʁɟɧɚɬɚ ɤɨɞ ɤɨʁɢɯ ʁɟ ɩɪɜɨ ɩɪɟɬɯɨɞɢɥɚ ɩɟɪɤɭɬɚɧɚ ɢɧɬɟɪɜɟɧɰɢʁɚ ɫɚ ɫɬɟɧɬɨɦ ɫɜɢɦ ɩɚɰɢʁɟɧɬɢɦɚ ʁɟ ɢɦɩɥɚɧɬɢɪɚɧ ɧɚʁɦɚʃɟ ʁɟɞɚɧ, ɚ ɧɚʁɜɢɲɟ ɩɟɬ ɫɬɟɧɬɚ. ɇɚʁɜɟʄɢ ɛɪɨʁ ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɞɨɛɢɨ 1 ɫɬɟɧɬ ɢ ɬɨ 68 ɢɥɢ 72.3%. Ɂɚɬɢɦ, ɩɨ ɛɪɨʁɭ ɫɬɟɧɬɨɜɚ, ɞɨɥɚɡɢ ɝɪɭɩɚ ɨɞ 17 ɩɚɰɢʁɟɧɚɬɚ ɢɥɢ 18% ɨɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ ɢɡ ɝɪɭɩɟ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI, ɤɨɞ ɤɨʁɢɯ ʁɟ ɭɝɪɚђɟɧɨ 2 ɫɬɟɧɬɚ. Ʉɨɞ ɩɟɬ ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɭɝɪɚђɟɧɨ 3 ɫɬɟɧɬɚ. Ɍɪɢ ɩɚɰɢʁɟɧɬɚ ɫɭ ɞɨɛɢɥɚ 4 ɫɬɟɧɬɚ, ɚ ɫɚɦɨ ʁɟɞɚɧ ɩɚɰɢʁɟɧɬ ʁɟ ɞɨɛɢɨ 5 ɫɬɟɧɬɨɜɚ ɭ ɝɪɭɩɢ ɨɞ 94 ɩɚɰɢʁɟɧɬɚ (ɝɪɚɮɢɤɨɧ 17). 74 Ƚɪɚɮɢɤɨɧ 17. Сɬɪɭɤɬɭɪɚ ɩɚɰɢʁɟɧɚɬɚ ɩɨ ɛɪɨʁɭ ɢɦɩɥɚɧɬɢɪɚɧɢɯ ɫɬɟɧɬɨɜɚ ɭ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɢɦ PCI 2.2 ȻɊɈȳ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ȼɊɋɌɍ ɂɆɉɅȺɇɌɂɊȺɇɈȽ ɋɌȿɇɌȺ ɍ ȽɊɍɉɂ ɋȺ ɉɊȿɌɏɈȾɇɈɆ PCI ɍ ɝɪɭɩɢ ɤɨɞ ɤɨʁɟ ʁɟ ɩɪɜɨ ɩɪɟɬɯɨɞɢɥɚ PCI ɫɚ ɫɬɟɧɬɨɦ ɛɢɥɨ ʁɟ ɪɚɡɧɢɯ ɜɪɫɬɚ ɫɬɟɧɬɨɜɚ. Ⱦɜɟ ɨɫɧɨɜɧɟ ɜɪɫɬɟ ɫɬɟɧɬɨɜɚ, ɦɟɬɚɥɧɢ ɫɬɟɧɬ (BMS) ɢ ɫɬɟɧɬ ɨɛɥɨɠɟɧ ɥɟɤɨɦ (DES), ɛɢɥɢ ɫɭ ɧɚʁɡɚɫɬɭɩʂɟɧɢʁɢ. Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ ɢɡ ɝɪɭɩɟ ɫɚ PCI, 71.27% ɞɨɛɢɥɨ ʁɟ ɦɟɬɚɥɧɢ ɫɬɟɧɬ BMS. ɋɬɟɧɬ ɨɛɥɨɠɟɧ ɥɟɤɨɦ ʁɟ ɞɨɛɢɥɨ 17.02% ɩɚɰɢʁɟɧɚɬɚ. ȿPC ɜɪɫɬɭ ɫɬɟɧɬɚ ʁɟ ɞɨɛɢɥɨ 6.3% ɞɨɤ ɨɫɬɚɥɟ ɜɪɫɬɟ ɫɬɟɧɬɨɜɚ ʁɟ ɞɨɛɢɥɨ 5.33% ɩɚɰɢʁɟɧɚɬɚ ( ɝɪɚɮɢɤɨɧ 18 ). 75 Ƚɪɚɮɢɤɨɧ 18. Ȼɪɨʁ ɩɚɰɢʁɟɧɚɬɚ ɩɨ ɜɪɫɬɢ ɢɦɩɚɥɧɬɢɪɚɧɨɝ ɫɬɟɧɬɚ ɭ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI 2.3 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ɆȿɋɌɈ ɈɌȼȺɊȺȵȺ ȺɊɌȿɊɂȳȿ ɍ ȽɊɍɉɂ ɉɊȿɌɏɈȾɇȿ PCI ɉɚɰɢʁɟɧɬɢɦɚ ɢɡ ɝɪɭɩɟ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI ʁɟ ɪɚђɟɧɚ ɢɧɬɟɪɜɟɧɰɢʁɚ ɫɬɟɧɬɨɦ ɧɚ ɝɨɬɨɜɨ ɫɜɟ ɜɟʄɟ ɝɪɚɧɟ ɤɨɪɨɧɚɪɧɢɯ ɚɪɬɟɪɢʁɚ ɭ ɡɚɜɢɫɧɨɫɬɢ ɨɞ ɥɨɤɚɥɧɨɝ ɧɚɥɚɡɚ. ɇɚʁɡɚɫɬɭɩʂɟɧɢʁɚ ɦɟɫɬɚ ɫɬɟɧɬɢɪɚʃɚ ɫɭ ɞɟɫɧɚ ɤɨɪɨɧɚɪɧɚ ɚɪɬɟɪɢʁɚ ACD, ɩɪɟɞʃɚ ɞɟɫɰɟɞɟɧɬɧɚ ɚɪɬɟɪɢʁɚ, ɝɪɚɧɚ ɥɟɜɟ ɤɨɪɨɧɚɪɧɟ ɚɪɬɟɪɢʁɟ RIA, ɡɚɬɢɦ ɞɪɭɝɚ ɛɢɬɧɚ ɝɪɚɧɚ ɥɟɜɟ ɤɨɪɨɧɚɪɧɟ ɚɪɬɟɪɢʁɟ, ɰɢɪɭɤɭɦɮɥɟɤɫɧɚ ɚɪɬɟɪɢʁɚ RCX. Ɉɞɪɟђɟɧ ɛɪɨʁ ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɞɨɛɢɨ ɫɬɟɧɬ ɭ ɩɨɛɨɱɧɭ ɝɪɚɧɭ ɩɪɟɞʃɟ ɞɟɫɰɟɞɟɧɬɧɟ ɚɪɬɟɪɢʁɟ, ɩɪɜɭ ɞɢʁɚɝɨɧɚɥɧɭ ɝɪɚɧɭ D1. ɉɨɫɬɨʁɚɨ ʁɟ ɢ ɨɞɪɟђɟɧ ɛɪɨʁ ɩɚɰɢʁɟɧɚɬɚ ɤɨʁɢ ɫɭ ɞɨɛɢɥɢ ɫɬɟɧɬɨɜɟ ɭ ɜɢɲɟ ɨɞ ʁɟɞɧɟ ɝɪɚɧɟ, ɚɥɢ ʃɢɯɨɜ ɛɪɨʁ ʁɟ ɛɢɨ ɫɬɚɬɢɫɬɢɱɤɢ ɧɟɡɧɚɱɚʁɚɧ. 76 Ɍɟ ɞɜɟ ɝɪɚɧɟ ɫɭ ɛɢɥɟ ɢɥɢ ɩɪɟɞʃɚ ɞɟɫɰɟɞɟɧɬɧɚ RIA ɢ ɰɢɪɤɭɦɮɥɟɤɫɧɚ ɚɪɬɟɪɢʁɚ RCX, ɤɚɨ ɢ ɤɨɦɛɢɧɨɜɚʃɟ ɞɟɫɧɟ ɤɨɪɨɧɚɪɧɟ ɝɪɚɧɟ ACD ɫɚ ɰɢɪɭɤɭɦɮɥɟɤɫɧɨɦ ɝɪɚɧɨɦ RCX. Ʉɨɞ ʁɟɞɧɨɝ ɩɚɰɢʁɟɧɬɚ ʁɟ ɫɬɟɧɬɨɜɚɧɚ ɢɧɬɟɪɦɟɞɢʁɚɪɧɚ ɝɪɚɧɚ RIM. Ⱦɟɫɧɚ ɤɨɪɨɧɚɪɧɚ ɚɪɬɟɪɢʁɚ ʁɟ ɫɬɟɧɬɢɪɚɧɚ ɭ ɧɚʁɜɟʄɟɦ ɛɪɨʁɭ ɩɚɰɢʁɟɧɚɬɚ ɢ ɬɨ ɤɨɞ 56.38%. Ɉɞɦɚɯ ɡɚ ʃɨɦ, ɫɥɟɞɟʄɚ ɝɪɚɧɚ ɩɨ ɩɪɨɰɟɧɬɭ ɫɬɟɧɬɢɪɚʃɚ ʁɟ ɩɪɟɞʃɚ ɞɟɫɰɟɞɟɧɬɧɚ ɝɪɚɧɚ ɢ ɬɨ 20.21% ɩɚɰɢʁɟɧɚɬɚ. ɍ 14.89% ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɫɬɟɧɬɢɪɚɧɚ ɰɢɪɤɭɮɥɟɤɫɧɚ ɝɪɚɧɚ, ɞɨɤ ʁɟ ɤɨɞ ɫɚɦɨ ɞɜɚ ɩɚɰɢʁɟɧɬɚ ɢɥɢ 2.12% ɫɬɟɧɬɢɪɚɧɚ ɞɢʁɚɝɨɧɚɥɧɚ ɝɪɚɧɚ. ɉɨɞ ɨɫɬɚɥɨ ɫɟ ɜɨɞɟ ɩɚɰɢʁɟɧɚɬɢ ɤɨʁɢ ɫɭ ɭɲɥɢ ɭ ɫɬɭɞɢʁɭ ɤɨɞ ɤɨʁɢɯ ʁɟ ɫɬɟɧɬɢɪɚɧɚ ʁɟɞɧɚ ɝɪɚɧɚ (ɢɧɬɟɪɦɟɞɢʁɚɪɧɚ ɝɪɚɧɚ RIM) ɢɥɢ ɜɢɲɟ ɨɞ ʁɟɞɧɟ ɝɪɚɧɟ, ɚɥɢ ɡɛɨɝ ɦɚɥɨɝ ɛɪɨʁɚ, ɫɬɚɬɢɫɬɢɱɤɢ ʁɟ ɧɟɡɧɚɱɚʁɧɨ ɡɚ ɫɬɭɞɢʁɭ (ɝɪɚɮɢɤɨɧ 19). Ƚɪɚɮɢɤɨɧ 19. ɉɪɨɰɟɧɬɭɚɥɚɧ ɩɪɢɤɚɡ ɩɚɰɢʁɟɧɚɬɚ ɭ ɨɞɧɨɫɭ ɧɚ ɦɟɫɬɨ ɨɬɜɚɪɚʃɚ ɚɪɬɟɪɢʁɟ ɭ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI 77 3 ɉȿɊɂɈɉȿɊȺɌɂȼɇɂ ɇȺɅȺɁɂ ɉɈ ȽɊɍɉȺɆȺ 3.1 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɉɈ ȻɊɈȳɍ ȻȺȳɉȺɋȿȼȺ ɍ ȽɊɍɉɂ ȻȿɁ ɉɊȿɌɏɈȾɇȿ PCI Ʉɨɞ ɫɜɢɯ 906 ɩɚɰɢʁɟɧɚɬɚ ɫɭ ɢɧɬɪɚɨɩɟɪɚɬɢɜɧɨ ɫɢɝɧɢɮɢɤɚɧɬɧɟ ɫɬɟɧɨɡɟ ɛɢɥɟ ɛɚʁɩɚɫɢɪɚɧɟ ɚɪɬɟɪɢʁɫɤɢɦ ɢ ɜɟɧɫɤɢɦ ɝɪɚɮɬɨɜɢɦɚ. ɋɜɢ ɩɚɰɢʁɟɧɬɢ ɫɭ ɞɨɛɢɥɢ ɧɚ ɩɪɟɞʃɭ ɞɟɫɰɟɞɟɧɬɧɭ ɝɪɚɧɭ, ɚɪɬɟɪɢʁɫɤɢ ɝɪɚɮɬ, ɝɪɚɧɭ ɥɟɜɟ ɚɪɬɟɪɢʁɟ ɫɭɛɤɥɚɜɢʁɟ, ɥɟɜɭ ɭɧɭɬɪɚɲʃɭ ɝɪɭɞɧɭ ɚɪɬɟɪɢʁɭ ɞɨɤ ɫɭ ɨɫɬɚɥɟ ɝɪɚɧɟ ɛɢɥɟ ɛɚʁɩɚɫɢɪɚɧɟ ɜɟɧɫɤɢɦ ɢɦɩɥɚɧɬɚɬɢɦɚ ɭɡɟɬɢɯ ɢɡ ɥɟɜɟ ɢɥɢ ɞɟɫɧɟ ɧɨɝɟ ɜɟɧɨɦ ɫɚɮɟɧɨɦ ɦɚɝɧɨɦ. ɇɚʁɜɟʄɢ ɛɪɨʁ ɛɚʁɩɚɫɟɜɚ ɭ ɝɪɭɩɢ ɛɟɡ ɩɪɟɬɯɨɞɧɟ PCI ɢɡɧɨɫɢɨ ʁɟ 5, ɞɨɤ ʁɟ ɧɚʁɦɚʃɢ ɛɪɨʁ ɛɢɨ 1. Ɉɞ ɭɤɭɩɧɨ 812 ɩɚɰɢʁɟɧɚɬɚ ɢɡ ɨɜɟ ɝɪɭɩɟ ɤɨɞ 390 ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɭɪɚђɟɧɚ ɬɪɨɫɬɪɭɤɚ ɤɨɪɨɧɚɪɧɚ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɚ. Ⱦɜɚ ɛɚʁɩɚɫɚ ɨɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɞɨɛɢɥɚ ɫɭ 273 ɩɚɰɢʁɟɧɬɚ. ɇɚ ɬɪɟʄɟɦ ɦɟɫɬɭ ɩɨ ɛɪɨʁɭ ɛɚʁɩɚɫɟɜɚ ɞɨɥɚɡɟ 82 ɩɚɰɢʁɟɧɬɚ ɤɨʁɢ ɫɭ ɞɨɛɢɥɢ ɱɟɬɪɢ ɛɚʁɩɚɫɚ. ȳɟɞɚɧ ɛɚʁɩɚɫ ʁɟ ɞɨɛɢɥɨ 58 ɩɚɰɢʁɟɧɚɬɚ, ɞɨɤ ʁɟ ʁɟɞɚɧ ɩɚɰɢʁɟɧɬ ɞɨɛɢɨ 5 ɛɚʁɩɚɫɟɜɚ (ɝɪɚɮɢɤɨɧ 20). 78 Ƚɪɚɮɢɤɨɧ 20. Сɬɪɭɤɬɭɪɚ ɩɚɰɢʁɟɧɚɬɚ ɩɨ ɛɪɨʁɭ ɛɚʁɩɚɫɟɜɚ ɭ ɝɪɭɩɢ ɛɟɡ PCI 3.2 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɉɈ ȻɊɈȳɍ ȻȺȳɉȺɋȿȼȺ ɍ ȽɊɍɉɂ ɋȺ ɉɊȿɌɏɈȾɇɈɆ PCI ɍ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI ɧɚʁɜɟʄɢ ɛɪɨʁ ɛɚʁɩɚɫɟɜɚ ɤɨʁɢ ɫɭ ɩɚɰɢʁɟɧɬɢ ɞɨɛɢɥɢ ɢɡɧɨɫɢɨ ʁɟ 4, ɚ ɧɚʁɦɚʃɢ ɛɪɨʁ 1. ɂ ɭ ɨɜɨʁ ɝɪɭɩɢ ɫɭ ɤɨɪɢɲʄɟɧɢ ɢ ɚɪɬɟɪɢʁɫɤɢ ɢ ɜɟɧɫɤɢ ɝɪɚɮɬɨɜɢ ɡɚ ɛɚʁɩɚɫɢɪɚʃɟ. ɋɜɢ ɩɚɰɢʁɟɧɬɢ ɫɭ ɞɨɛɢɥɢ ɧɚ ɩɪɟɞʃɭ ɞɟɫɰɟɞɟɧɬɧɭ ɝɪɚɧɭ, ɚɪɬɟɪɢʁɫɤɢ ɝɪɚɮɬ, ɝɪɚɧɭ ɥɟɜɟ ɚɪɬɟɪɢʁɟ ɫɭɛɤɥɚɜɢʁɟ, ɥɟɜɭ ɭɧɭɬɪɚɲʃɭ ɝɪɭɞɧɭ ɚɪɬɟɪɢʁɭ, ɞɨɤ ɫɭ ɨɫɬɚɥɟ ɝɪɚɧɟ ɛɢɥɟ ɛɚʁɩɚɫɢɪɚɧɟ ɜɟɧɫɤɢɦ ɢɦɩɥɚɧɬɚɬɢɦɚ ɭɡɟɬɢɯ ɢɡ ɥɟɜɟ ɢɥɢ ɞɟɫɧɟ ɧɨɝɟ ɜɟɧɨɦ ɫɚɮɟɧɨɦ ɦɚɝɧɨɦ. 79 Ɉɞ ɭɤɭɩɧɨ 94 ɩɚɰɢʁɟɧɚɬɚ, ɫɤɨɪɨ ɩɨɥɚ ʁɟ ɞɨɛɢɥɨ ɞɜɨɫɬɪɭɤɢ ɛɚʁɩɚɫ, ʃɢɯ 48. Ɍɪɢ ɛɚʁɩɚɫɚ ʁɟ ɞɨɛɢɥɨ 28 ɩɚɰɢʁɟɧɚɬɚ. Ʉɨɞ 14 ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɭɪɚђɟɧ ɫɚɦɨ ʁɟɞɚɧ ɛɚʁɩɚɫ, ɚ ɤɨɞ 4 ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɭɪɚђɟɧɨ 4 ɛɚʁɩɚɫɚ (ɝɪɚɮɢɤɨɧ 21). Ƚɪɚɮɢɤɨɧ 21. Сɬɪɭɤɬɭɪɚ ɩɚɰɢʁɟɧɚɬɚ ɩɨ ɛɪɨʁɭ ɛɚʁɩɚɫɟɜɚ ɭ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI 3.3 ɍɉɈɊȿȾɇɂ ɉɊɂɄȺɁ Ⱦɍɀɂɇȿ ɌɊȺȳȺȵȺ ɋɊɑȺɇɈȽ ɁȺɋɌɈȳȺ ɂ Ⱦɍɀɂɇȿ ɉɍɆɉȿ ɁȺ ȿɄɋɌɊȺɄɈɊɉɈɊȺɅɇɍ ɐɂɊɄɍɅȺɐɂȳɍ ɍ ɈȻȿ ȽɊɍɉȿ ɍ ɬɨɤɭ ɫɜɚɤɟ ɤɚɪɞɢɨɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɦɢɨɤɚɪɞɚ, ɫɪɰɟ ɫɟ ɡɚɭɫɬɚɜʂɚ, ɚ ɩɭɦɩɚ ɡɚ ɟɤɫɬɪɚɤɨɪɩɨɪɚɥɧɭ ɰɢɤɪɭɥɚɰɢʁɭ ɩɪɟɭɡɢɦɚ ɭɥɨɝɚ ɫɪɰɚ ɢ ɩɥɭʄɚ. ȼɪɟɦɟ ɡɚɭɫɬɚɜʂɚʃɚ ɫɪɰɚ ɤɚɨ ɢ ɜɪɟɦɟ ɬɪɚʁɚʃɚ ɩɭɦɩɟ ɫɟ ɧɚ ɫɚɜɚɤɨʁ ɨɩɟɪɚɰɢʁɢ ɦɟɪɢ ɢ ɭɧɨɫɢ ɫɟ ɭ ɨɩɟɪɚɬɢɜɧɢ ɩɪɨɬɨɤɨɥ. 80 ɍ ɨɜɨʁ ɫɬɭɞɢʁɢ ɫɭ ɩɪɟʄɟɧɢ ɢ ɭɩɨɪɟђɢɜɚɧɢ ɭ ɨɛɟ ɝɪɭɩɟ ɞɭɠɢɧɚ ɤɥɟɦɨɜɚʃɚ ɚɨɪɬɟ (ɜɪɟɦɟ ɡɚɭɫɬɚɜʂɚʃɚ ɫɪɰɚ), ɤɚɨ ɢ ɞɭɠɢɧɚ ɪɚɞɚ ɩɭɦɩɟ ɡɚ ɟɤɫɬɪɚɤɨɪɩɨɪɚɥɧɭ ɰɢɪɭɤɭɥɚɰɢʁɭ ȿɄɐ. ɋɪɟɞʃɚ ɜɪɟɞɧɨɫɬ ɞɭɠɢɧɟ ɫɪɱɚɧɨɝ ɡɚɫɬɨʁɚ ɭ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI ɢɡɧɨɫɢɥɚ ʁɟ 44 ɦɢɧɭɬɚ. ɇɚʁɤɪɚʄɟ ɜɪɟɦɟ ɫɪɱɚɧɨɝ ɡɚɫɬɨʁɚ ɭ ɨɜɨʁ ɝɪɭɩɢ ɢɡɧɨɫɢɥɨ ʁɟ 35 ɦɢɧɭɬɚ ɚ ɧɚʁɞɭɠɟ 63. ɋɪɟɞʃɚ ɜɪɟɞɧɨɫɬ ɞɭɠɢɧɟ ɬɪɚʁɚʃɚ ɩɭɦɩɟ ɡɚ ɟɤɫɬɪɚɤɨɪɩɨɪɚɥɧɭ ɰɢɪɤɭɥɚɰɢʁɭ ɭ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI ɢɡɧɨɫɢɥɚ ʁɟ 55 ɦɢɧɭɬɚ. ɍ ɨɜɨʁ ɝɪɭɩɢ ɧɚʁɤɪɚʄɟ ɜɪɟɦɟ ɪɚɞɚ ɩɭɦɩɟ ɡɚ ȿɄɐ ɢɡɧɨɫɢɥɨ ʁɟ 45 ɦɢɧɭɬɚ ɚ ɧɚʁɞɭɠɟ 70. ɍ ɨɤɜɢɪɭ ɝɪɭɩɟ ɛɟɡ PCI ɫɪɟɞʃɚ ɜɪɟɞɧɨɫɬ ɞɭɠɢɧɟ ɫɪɱɚɧɨɝ ɡɚɫɬɨʁɚ ɢɡɧɨɫɢɥɚ ʁɟ 56 ɦɢɧɭɬɚ. ɇɚʁɤɪɚʄɟ ɜɪɟɦɟ ɫɪɱɚɧɨɝ ɡɚɫɬɨʁɚ ɛɢɥɚ ʁɟ 42 ɦɢɧɭɬɚ ɚ ɧɚʁɞɭɠɟ 70. ɉɨɫɦɚɬɪɚʁɭʄɢ ɫɪɟɞʃɭ ɜɪɟɞɧɨɫɬ ɞɭɠɢɧɟ ɬɪɚʁɚʃɚ ɩɭɦɩɟ ɡɚ ȿɄɐ ɭ ɨɜɨʁ ɝɪɭɩɢ ɧɟɲɬɨ ʁɟ ɜɟʄɚ ɢ ɢɡɧɨɫɢ 66 ɦɢɧɭɬɚ. ɇɚʁɤɪɚʄɟ ɜɪɟɦɟ ɬɪɚʁɚʃɚ ɩɭɦɩɟ ɡɚ ȿɄɐ ɭ ɨɜɨʁ ɝɪɭɩɢ ʁɟ ɛɢɥɨ 52 ɦɢɧɭɬɚ ɚ ɧɚʁɞɭɠɟ 81 ɦɢɧɭɬ. Ɋaɡɥɢɤa ɫɪeɞʃɢɯ ɜɪeɞɧoɫɬɢ ɞɭɠɢɧɟ ɬɪɚʁɚʃɚ ɫɪɱɚɧɨɝ ɡɚɫɬɨʁɚ ɢɡɦeђɭ ɩaɰɢjeɧaɬa ɭ ɝɪɭɩɢ ɫa PCI ɢ ɩɚɰɢʁɟɧɚɬɚ ɭ ɝɪɭɩɢ ɛeɡ ɫɬaɬɢɫɬɢɱɤɢ ʁɟ ɡɧaɱajɧa (p < 0,0005). ɋɪeɞʃa ɜɪeɞɧoɫɬ ɩaɰɢjeɧaɬa ɢɡ ɭɡoɪɤa ɛeɡ ЈCI УО 56 (42 – 70), ɚ ɫɚ ЈCI 44 (35–63). Ɋaɡɥɢɤa ɫɪeɞʃɢɯ ɜɪeɞɧoɫɬɢ ɞɭɠɢɧɟ ɬɪɚʁɚʃɚ EɄɐ-ɚ ɢɡɦeђɭ ɩaɰɢjeɧaɬa ɫa PCI ɢ ɛeɡ ɫɬaɬɢɫɬɢɱɤɢ ʁɟ ɡɧaɱajɧa (p < 0,0005). ɋɪeɞʃa ɜɪeɞɧoɫɬ ɩaɰɢjeɧaɬa ɢɡ ɭɡoɪɤa ɛeɡ ЈCI УО 66 (52 – 81), ɚ ɫɚ PCI 55 (45 – 70) (ɝɪɚɮɢɤɨɧ 22). 81 Ƚɪɚɮɢɤɨɧ 22. Уɩɨɪɟɞɧɢ ɩɪɢɤɚɡ ɨɛɟ ɝɪɭɩɟ ɭ ɡɚɜɢɫɧɨɫɬɢ ɨɞ ɬɪɚʁɚʃɚ ɫɪɱɚɧɨɝ ɡɚɫɬɨʁɚ ɢ ɟɤɫɬɪɚɤɨɪɩɨɪɚɥɧɟ ɰɢɪɤɭɥɚɰɢʁɟ 4 ɉȿɊɂɈɉȿɊȺɌɂȼɇȿ ɂ ɉɈɋɌɈɉȿɊȺɌɂȼɇȿ ɄɈɆɉɅɂɄȺɐɂȳȿ ɉɈ ȽɊɍɉȺɆȺ ɋɜɟ ɩɟɪɢɨɩɟɪɚɬɢɜɧɟ ɢ ɩɨɫɬɨɩɟɪɚɬɢɜɧɟ ɤɨɦɩɥɢɤɚɰɢʁɟ ɫɭ ɩɪɚʄɟɧɟ ɭ ɫɬɭɞɢʁɢ ɢ ɭɩɨɪɟђɢɜɚɧɟ ɩɨ ɝɪɭɩɚɦɚ. ɇɚʁɛɢɬɧɢʁɟ ɤɨɦɩɥɢɤɚɰɢʁɟ ɫɭ ɛɢɥɟ ɩɟɪɢɨɩɟɪɚɬɢɜɧɢ ɢɧɮɚɪɤɬ ɦɢɨɤɚɪɞɚ, ɩɨʁɚɜɚ ɩɨɫɬɨɩɟɪɚɬɢɜɧɨɝ ɩɨɪɟɦɟʄɟʁɚ ɪɢɬɦɚ ɭ ɫɦɢɫɥɭ ɫɭɩɪɚɜɟɧɬɪɢɤɭɥɚɪɧɢɯ ɢ ɜɟɧɬɪɢɤɭɥɚɪɧɢɯ ɟɤɫɬɪɚɫɢɫɬɨɥɚ. Ⱦɭɠɢɧɚ ɡɚɞɪɚɠɚɜɚʃɚ ɩɚɰɢʁɟɧɚɬɚ ɭ ɢɧɬɟɡɢɜɧɨʁ ʁɟɞɢɧɢɰɢ ɤɚɨ ɢ ɞɭɠɢɧɚ ɬɪɚʁɚʃɚ ɦɟɯɚɧɢɱɤɟ ɜɟɧɬɢɥɚɰɢʁɟ ɤɨɞ ɫɜɚɤɨɝ ɩɚɰɢʁɟɧɬɚ ɛɢɥɚ ʁɟ ɪɟɝɢɫɬɪɨɜɚɧɚ. ɍ ɩɨɫɬɨɩɟɪɚɬɢɜɧɟ ɤɨɦɩɥɢɤɚɰɢʁɟ ɤɨʁɟ ɫɭ ɩɪɚʄɟɧɟ ɤɪɨɡ ɫɬɭɞɢʁɭ ʁɟ ɢ ɤɪɜɚɪɟʃɟ ɚ ɬɨ ɧɚɥɚɠɟ ɩɨɧɨɜɧɢ 82 ɭɥɚɡɚɤ ɭ ɫɚɥɭ ɩɪɚʄɟɧ ɪɟɜɢɡɢʁɨɦ ɯɟɦɨɫɬɚɡɟ. Ɉɞ ɨɫɬɚɥɢɯ ɤɨɦɩɥɢɤɚɰɢʁɚ ɤɨʁɟ ɫɭ ɩɪɚʄɟɧɟ ʁɟ ɢ ɦɨɠɞɚɧɢ ɭɞɚɪ ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ. 4.1 ɉȿɊɂɈɉȿɊȺɌɂȼɇɂ ɂɇɎȺɊɄɌ ɆɂɈɄȺɊȾȺ ɇɚʁɛɢɬɧɢʁɚ ɤɨɦɩɥɢɤɚɰɢʁɚ ɩɨɫɥɟ ɤɚɪɞɢoɯɢɪɭɪɲɤɟ ɢɧɬɟɪɜɟɧɰɢʁɟ ʁɟ ɫɜɚɤɚɤɨ ɩɟɪɢɨɩɟɪɚɬɢɜɧɢ ɢɧɮɚɪɤɬ ɦɢɨɤɚɪɞɚ ɤɨʁɢ ʁɟ ɞɢɪɟɤɬɧɨ ɭ ɤɨɪɟɥɚɰɢʁɢ ɫɚ ɤɜɚɥɢɬɟɬɨɦ ɫɚɦɟ ɨɩɟɪɚɰɢʁɟ. ɋɜɢ ɩɚɰɢʁɟɧɬɢ ɤɨʁɢ ɫɭ ɢɦɚɥɢ ɧɨɜɨɧɚɫɬɚɥɟ ɢɫɯɟɦɢʁɫɤɟ ɩɪɨɦɟɧɟ ɧɚ ȿɄȽ-ɭ, ɤɚɨ ɢ ɩɨɜɟʄɚɧɟ ɤɚɪɞɢɨɫɩɟɰɢɮɢɱɧɟ ɟɧɡɢɦɟ ɩɨɫɥɟ ɨɩɟɪɚɬɰɢʁɟ, ɛɢɥɢ ɫɭ ɧɨɬɢɪɚɧɢ ɤɚɨ ɩɟɪɢɨɩɟɪɚɬɢɜɧɢ ɢɧɮɚɪɤɬ. ɍ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɢɦ PCI 16% ɩɚɰɢʁɟɧɚɬɚ ɨɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɢɡ ɝɪɭɩɟ ʁɟ ɢɦɚɥɨ ɤɨɦɩɥɢɤɚɰɢʁɭ ɩɟɪɢɨɩɟɪɚɬɢɜɧɨɝ ɢɧɮɚɪɤɬɚ. Ƚɪɭɩɚ ɛɟɡ ɩɪɟɬɯɨɞɧɟ PCI ʁɟ ɢɦɚɥɚ ɡɧɚɬɧɨ ɦɚʃɢ ɛɪɨʁ ɨɜɟ ɤɨɦɩɥɢɤɚɰɢʁɟ, ɩɪɨɰɟɧɬɭɚɥɧɨ 8.6% (ɝɪɚɮɢɤɨɧ 23). ɉeɪɢoɩeɪaɬɢɜɧɢ ɢɧɮaɪɤɬ ɢ ɝɪɭɩɚ ɫɚ ɩɪeɬɯoɞɧɨɦ PCI ɫɭ ɩoɜeɡaɧɢ (p = 0,034). Ȼɢɧaɪɧa ɥoɝɢɫɬɢɱɤa ɪeɝɪeɫɢja ɩoɤaɡɭje ɞa ɩeɪɢoɩeɪaɬɢɜɧɢ ɢɧɮaɪɤɬ ɡaɜɢɫɢ oɞ ɩɪeɬɯoɞɧoɝ PCI (p = 0,023). Mɭɥɬɢɜaɪɢjaɧɬɧa ɛɢɧaɪɧa ɥoɝɢɫɬɢɱɤa ɪeɝɪeɫɢja ɩoɤaɡɭje ɞa ɩeɪɢoɩeɪaɬɢɜɧɢ ɢɧɮaɪɤɬ ɡaɜɢɫɢ ɫaɦo oɞ ɩɪeɬɞoɞɧoɝ PCI (p = 0,030) ɢ oɞ ɩoɜeʄaɧoɝ BMI (p = 0,033). Odds ratio ɡa ɩɪeɬɯoɞɧɢ PCI je 1,964 (1,067 – 3,616). ɉɪeɬɯoɞɧɢ PCI ɩoɜeʄɚɜa ɪɢɡɢɤ oɞ ɩeɪɢoɩeɪaɬɢɜɧoɝ ɢɧɮaɪɤɬa 96 %. 83 Ƚɪɚɮɢɤɨɧ 23. ɉɪɨɰɟɧɭɬɚɥɚɧ ɩɪɢɤɚɡ ɩɟɪɢɨɩɟɪɚɬɢɜɧɨɝ ɢɧɮɚɪɤɬɚ ɦɢɨɤɚɪɞɚ ɩɨ ɝɪɭɩɚɦɚ. 4.2 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ɉɈȳȺȼȴɂȼȺȵȿ ɋɍɉɊȺȼȿɇɌɊɂɄɍɅȺɊɇɂɏ ȿɄɋɌɊȺɋɂɋɌɈɅȺ (SVES) ɋɭɩɪɚɜɟɧɬɪɢɤɭɥɚɪɧɟ ɟɤɫɬɪɚɫɢɫɬɨɥɟ ɫɭ ɜɪɥɨ ɱɟɫɬɚ ɩɨɫɬɨɩɟɪɚɬɢɜɧɚ ɤɨɦɩɥɢɤɚɰɢʁɚ. ɍ ɨɜɨʁ ɫɬɭɞɢʁɢ ɫɭ ɨɧɟ ɩɪɢɫɭɬɧɟ ɭ ɜɟɥɢɤɨɦ ɛɪɨʁɭ. ɍ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI ɨɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ ɢɡ ɬɟ ɝɪɭɩɟ 32% ʁɟ ɢɦɚɥɨ SVES. ɍ ɞɪɭɝɨʁ ɝɪɭɩɢ ɬɚʁ ɛɪɨʁ ʁɟ ɛɢɨ ɦɚʃɢ 21% (ɝɪɚɮɢɤɨɧ 24). ɋɭɩɪɚɜɟɧɬɪɢɤɭɥɚɪɧɟ ɟɤɫɬɪɚɫɢɫɬɨɥɟ ɢ ɝɪɭɩɚ ɫɚ ɩɪɟɬɯɨɞɧɢɦ PCI ɫɭ ɩɨɜɟɡɚɧɟ ɢ ɢɦɚʁɭ ɫɬɚɬɢɫɬɢɱɤɭ ɡɧɚɱɚʁɧɨɫɬ (p = 0,020). Mɭɥɬɢɜaɪɢjaɧɬɧa ɛɢɧaɪɧa ɥoɝɢɫɬɢɱɤa ɪeɝɪeɫɢja ɩoɤaɡɭje ɞa SVES ɡaɜɢɫɢ ɫaɦo oɞ ɩɪeɬɯoɞɧoɝ PCI (p = 84 0,015). Odds ratio ɡa ɩɪeɬɯoɞɧɢ PCI je 1,783 (1,117 – 2.864). ɉaɰɢjeɧɬɢ ɭ ɝɪɭɩɢ ɫa ɩɪeɬɯoɞɧɢɦ PCI ɢɦajɭ 78 % ɜɟʄɢ ɪɢɡɢɤ ɡa SVES. ɍ ɫɬɭɞɢʁɢ ɫɭ ɪɚђɟɧɚ ɢɫɬɪɚɠɢɜɚʃɚ ɞɚ ɥɢ ɩɨɫɬɨʁɢ ɩɨɜɟɡɚɧɨɫɬ ɜɪɫɬɟ ɫɬɟɧɬɚ ɢ ɦɟɫɬɚ ɨɬɜɚɪɚʃɚ ɚɪɬɟɪɢʁɟ ɫɚ ɧɚɫɬɚɧɤɨɦ ɫɭɩɪɚɜɟɧɬɪɢɤɭɥɚɪɧɢɯ ɟɤɫɬɪɚɫɢɫɬɨɥɚ. ɇɢje ɫɬaɬɢɫɬɢɱɤɢ ɡɧaɱajɧo, aɥɢ je ɢɧɞɢɤaɬɢɜɧo ɞa ɤɚɞɚ ɫɟ ɫɬɟɧɬɭʁɟ ɩɪɟɞʃɚ ɫɢɥɚɡɧɚ ɚɪɬɟɪɢʁɚ (RIA) ɭ oɞɧoɫɭ ɧa ɰɢɪɤɭɦɮɥɟɤɫɧɭ ɝɪɚɧɭ (RCX) ɢɦa 5 ɩɭɬa ɜeʄɢ ɪɢɡɢɤ ɡa SVES. ɑɢʃОɧɢɰК ɞК ɥɢ УО ɜɪɫɬК ɫɬОɧɬК BMЋ ɢɥɢ УО ɧОɤК ɞɪɭɝК ɢ ɩШУКɜК SVES -a ɫɭ ɩШɜОɡКɧɢ (p = 0.047). ɉɪШɰОɧКɬ SVES -К ɭ ɭɡШɪɤɭ ɫК BMЋ ɢɦК 36.1 % SVES –a, К ɭ ɭɡШɪɤɭ ШɫɬКɥɢɯ ɜɪɫɬК ɫɬОɧɬК je 11.1 %. ɂɡ ɫɜɟɝɚ ɧɚɜɟɞɟɧɨɝ ɫɟ ɧɚɦɟʄɟ ɱɢʃɟɧɢɰɚ ɞa BMS ɩoɜeʄaɜa ɪɢɡɢɤ oɞ SVES -a oɤo 4.5 ɩɭɬa. Ɍɚɛɟɥɚ 2. ɉɟɪɢɨɩɟɪɚɬɢɜɧɟ ɤɨɦɩɥɢɤɚɰɢјɟ ɢ ɫɦɪɬɧɢ ɢɫɯɨɞ Ȼɟɡ PCI (n = 812) PCI (n = 94) ɪ n (%) n (%) ɉɟɪɢɨɩɟɪɚɬɢɜɧɢ ɢɧɮɚɪɤɬ 70 (8,6) 15 (16,0) 0,034 SVES 169 (20,8) 30 (31,9) 0,020 VES 196 (24,1) 36 (38,3) 0,004 Ɇɨɠɞɚɧɢ ɭɞɚɪ 10 (1,2) 0 (0,0) 0,611 Ɋɟɜɢɡɢјɚ ɯɟɦɨɫɬɚɡɟ 5 (0,6) 4 (4,3) 0,009 Ʉɚɪɞ.ɩɭɥɦ. ɪɟɚɧɢɦɚɰɢјɚ 6 (0,7) 1 (1,1) 0,537 ɋɦɪɬɧɢ ɢɫɯɨɞ 18 (2,2) 1 (1,1) 0,711 85 Ƚɪɚɮɢɤɨɧ 24. ɉɪɨɰɟɧɭɬɚɥɧɢ ɩɪɢɤɚɡ ɫɭɩɪɚɜɟɧɬɪɢɤɭɥɚɪɧɢɯ ɟɤɫɬɪɚɫɢɫɬɨɥɚ ɭ ɨɛɟ ɝɪɭɩɟ 4.3 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ɉɈɋɌɈɉȿɊȺɌɂȼɇɈ ɉɈȳȺȼȴɂȼȺȵȿ ȼȿɇɌɊɂɄɍɅȺɊɇɂɏ ȿɄɋɌɊȺɋɂɋɌɈɅȺ (VES) Ɍɨɤɨɦ ɫɬɭɞɢʁɟ ɩɪɚʄɟɧɢ ɫɭ ɢ ɭɩɨɪɟђɢɜɚɧɢ ɩɪɨɰɟɧɚɬ ɩɨʁɚɜʂɢɜɚʃɚ ɜɟɧɬɪɢɤɭɥɚɪɧɢɯ ɟɤɫɬɪɚɫɢɫɬɨɥɚ ɭ ɨɛɟ ɝɪɭɩɟ. ɍ ɩɪɜɨʁ ɝɪɭɩɢ, ɝɪɭɩɚ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI, 38.3% ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɢɦɚɥɨ ɩɨɫɬɨɩɟɪɚɬɢɜɧɟ ЏEЋ. ɍ ɝɪɭɩɢ ɛɟɡ PCI, ɬɚʁ ɩɪɨɰɟɧɚɬ ʁɟ ɛɢɨ ɞɨɫɬɚ ɦɚʃɢ ɢ ɢɡɧɨɫɢɨ ʁɟ 24.1% (ɝɪɚɮɢɤɨɧ 25). ɉɨʁɚɜʂɢɜɚʃɟ ɜɟɧɬɪɢɤɭɥɚɪɧɢɯ ɟɤɫɬɪɚɫɢɫɬɨɥɚ ɢ ɩɪeɬɯoɞɧɢ PCI ɫɭ ɩoɜeɡaɧɢ, ɢɦɚʁɭ ɫɬɚɬɢɫɬɢɱɤɭ ɡɧɚɱɚʁɧɨɫɬ (p = 0,004). ɉɨɪɟɞ ɬɨɝɚ, ɤɪɨɡ ɫɬɭɞɢʁɭ ʁɟ ɭɩɨɪɟђɢɜɚɧɨ ɩɨʁɚɜʂɢɜɚʃɟ ЏEЋ-ɨɜɚ ɫɚ ɞɪɭɝɢɦ ɜɚɪɢʁɚɛɥɚɦɚ ɢ ɞɨɲɥɨ ɫɟ ɞɨ 86 ɪɟɡɭɥɬɚɬɚ ɞɚ ɫɭ ЏEЋ ɢ ɩoɥ ɩoɜeɡaɧɢ (p = 0,032). ɀeɧe ɭ ɜeʄeɦ ɩɪoɰeɧɬɭ ɢɦajɭ ɜɟɧɬɪɢɤɭɥɚɪɧɟ ɟɤɫɬɪɚɫɢɫɬɨɥɟ. Mɭɥɬɢɜaɪɢjaɧɬɧa ɛɢɧaɪɧa ɥoɝɢɫɬɢɱɤa ɪeɝɪeɫɢja ɩoɤaɡɭje ɞa ɩojaɜa ɜeɧɬɪɢɤɭɥaɪɧɢɯ ɟɤɫɬɪɚɫɢɫɬɨɥɚ ɡaɜɢɫɢ oɞ ɩɪeɬɯoɞɧoɝ PCI (p = 0,004), ɩoɥa (p = 0,025), ɞɢjaɛeɬeɫa (p = 0,027), a ɢɧɞɢɤaɬɢɜaɧ je ɢ ɭɬɢɰaj ɯɢɩeɪɬeɧɡɢje (p = 0,072). Odds ratio ɡa ɩɪɟɬɯɨɞɧɢ PCI je 1,966 (1,244 – 3.106). ɉɪeɬɯoɞɧɢ PCI ɩoɜeʄaɜa ɪɢɡɢɤ ɡa 96.6 %. Odds ratio ɡa ɩoɥ je 0,689 (0,497 – 0,953). Mɭɲɤaɪɰɢ ɢɦajɭ ɡa 31.1 % ɦaʃɢ ɪɢɡɢɤ oɞ ɠeɧa. Odds ratio ɡa ɞɢjaɛeɬeɫ je 1,414 (1,041 – 1,923). Ⱦɢjaɛeɬeɫ ɩoɜeʄaɜa ɪɢɡɢɤ ɡa 41.4 %. Ƚɪɚɮɢɤɨɧ 25. ɉɪɨɰɟɧɬɭɚɥɚɧ ɩɪɢɤɚɡ ɩɨɫɬɨɩɟɪɚɬɢɜɧɨɝ ɩɨʁɚɜʂɢɜɚʃɚ ɜɟɬɧɪɢɤɭɥɚɪɧɢɯ ɟɤɫɬɪɚɫɢɫɬɨɥɚ ɭ ɨɛɟ ɝɪɭɩɟ 87 4.4 ɋɌɊɍɄɌɍɊȺ ɉȺɐɂȳȿɇȺɌȺ ɍ ɈȾɇɈɋɍ ɇȺ ɉɈɋɌɈɉȿɊȺɌɂȼɇɈ ɄɊȼȺȼȴȿȵȿ ɂ ɊȿȼɂɁɂȳɍ ɏȿɆɈɋɌȺɁȿ ȳɟɞɧɚ ɨɞ ɜɟɨɦɚ ɛɢɬɧɢɯ ɩɨɫɬɨɩɟɪɚɬɢɜɧɢɯ ɤɨɦɩɥɢɤɚɰɢʁɚ ʁɟ ɫɜɚɤɚɤɨ ɢ ɤɪɜɚɜʂɟʃɟ ɤɨʁɟ ɞɢɪɟɤɬɧɨ ɜɨɞɢ ɞɨ ɩɨɧɨɜɧɨɝ ɭɥɚɫɚɤɚ ɭ ɨɩɟɪɚɰɢɨɧɭ ɫɚɥɭ ɢ ɞɨ ɪɟɜɢɡɢʁɟ ɯɟɦɨɫɬɚɡɟ. Ʉɪɨɡ ɨɜɭ ɫɬɭɞɢʁɭ ɫɭ ɩɪɚʄɟɧɢ ɫɜɢ ɩɚɰɢʁɟɧɬɢ ɤɨɞ ɤɨʁɢɯ ʁɟ ɞɨɲɥɨ ɞɨ ɩɨɜɟʄɚɧɨɝ ɩɨɫɬɨɩɟɪɚɬɢɜɧɨɝ ɤɪɜɚɪɟʃɚ ɢ ɩɨɧɨɜɧɨɝ ɭɥɚɫɤɚ ɭ ɨɩɟɪɚɰɢɨɧɭ ɫɚɥɭ. Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ ɭ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɢɦ PCI, 4.3% ɦɨɪɚɥɨ ʁɟ ɩɨɧɨɜɨ ɞɚ ɫɟ ɜɪɚɬɢ ɭ ɨɩɟɪɚɰɢɨɧɭ ɫɚɥɭ ɡɛɨɝ ɨɛɢɦɧɨɝ ɩɨɫɬɨɩɟɪɚɬɢɜɧɨɝ ɤɪɜɚɪɟʃɚ. ɍ ɞɪɭɝɨʁ ɝɪɭɩɢ, ɬɚʁ ɛɪɨʁ ʁɟ ɛɢɨ ɡɧɚɬɧɨ ɦɚʃɢ ɢ ɢɡɧɨɫɢɨ ʁɟ ɫɜɟɝɚ 0.6% (ɝɪɚɮɢɤɨɧ 26). ɉɨɫɬɨɩɟɪɚɬɢɜɧɨ ɤɪɜɚɪɟʃɟ ɫɚ ɪɟɜɢɡɢУɨɦ ɯeɦoɫɬaɡО ɢ ɩɪeɬɯoɞɧɢ PCI ɫɭ ɩoɜeɡaɧɢ (p = 0,009). MɭɥɬɢɜКɪɢУКɧɬɧК ɛɢɧКɪɧК ɥШɝɢɫɬɢɱɤК ɪОɝɪОɫɢУК ɩШɤКɡɭУО ɞК ɪОɜɢɡɢУК ɯɟɦШɫɬКɡО ɡКɜɢɫɢ Шɞ ɩɪОɬɯШɞɧШɝ ЈCI (p = 0.005). τННs rКtТШ ɡК ɩɪОɬɯШɞɧɢ ЈCI ʁɟ 6.702 (1.768 – 25.413). ɉɪɟɬɯɨɞɧɢ PCI ɩШɜОʄКɜК ɪɢɡɢɤ Шɞ ɯОɦШɫɬКɡО ɡɚ ШɤШ 7 ɩɭɬК. 88 Ƚɪɚɮɢɤɨɧ 26. ɉɪɨɰɟɧɭɬɚɥɚɧ ɩɪɢɤɚɡ ɩɨɫɬɨɩɟɪɚɬɢɜɧɨɝ ɤɪɜɚɜʂɟʃɚ ɢ ɪɟɜɢɡɢʁɚ ɯɟɦɨɫɬɚɡɟ ɭ ɨɛɟ ɝɪɭɩɟ 4.5 ɄȺɊȾɂɈɉɍɅɆɈɇȺɅɇȺ ɊȿȺɇɂɆȺɐɂȳȺ ɍ ɩɨɫɬɨɩɟɪɚɬɢɜɧɟ ɤɨɦɩɥɢɤɚɰɢʁɟ ɬɚɤɨђɟ ʁɟ ɫɜɪɫɬɚɧɚ ɢ ɤɚɪɞɢɨɩɭɥɦɨɧɚɥɧɚ ɪɟɚɧɢɦɚɰɢʁɚ ɨɩɟɪɢɫɚɧɢɯ ɩɚɰɢʁɟɧɚɬɚ. ɍ ɨɜɨʁ ɫɬɭɞɢʁɢ, ɭɩɨɪɟђɢɜɚʁɭʄɢ ɨɛɟ ɝɪɭɩɟ, ɧɢʁɟ ɛɢɥɨ ɫɬɚɬɢɫɬɢɱɤɟ ɡɧɚɱɚʁɧɨɫɬɢ ɢɡɦɟђɭ ɝɪɭɩɚ ɩɨ ɛɪɨʁɭ ɤɚɪɞɢɨɩɭɥɦɨɧɚɥɧɟ ɪɟɚɧɢɦɚɰɢʁɟ. ɍ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI ɤШɞ 1.1% ɩКɰɢУОɧКɬК УО ɫɩɪШɜОɞОɧК ɤКɪɞɢШɩɭɥɦШɧКɥɧК ɪОКɧɢɦКɰɢУК, ɞШɤ УО ɭ ɞɪɭɝШУ ɝɪɭɩɢ ɬКУ ɩɪШɰОɧКɬ ɛɢШ ɜɪɥШ ɫɥɢɱɚɧ ɢ ɢɡɧɨɫɢɨ ʁɟ 0.7% (ɝɪɚɮɢɤɨɧ 27). Ʉɨɞ ɨɜɟ ɜɪɫɬɟ ɤɨɦɩɥɢɤɚɰɢʁɟ ɧɢʁɟ ɩɪɨɧɚђɟɧɚ ɫɬɚɬɢɫɬɢɱɤɚ ɡɧɚɱɚʁɧɨɫɬ ɦɟђɭ ɝɪɭɩɚɦɚ, ɚɥɢ ʁɟɫɬɟ ɭɩɨɪɟђɭʁɭʄɢ ɩɚɰɢʁɟɧɬɟ ɩɨ ɫɬɚɪɨɫɧɨʁ ɞɨɛɢ. 89 Ɋaɡɥɢɤa ɫɪeɞʃɢɯ ɜɪeɞɧoɫɬɢ ɛɪoja ɝoɞɢɧa ɢɡɦeђɭ ɪeaɧɢɦɢɪaɧɢɯ ɢ ɧeɪeaɧɢɦɢɪaɧɢɯ ɩɚɰɢʁɟɧɚɬɚ je ɫɬaɬɢɫɬɢɱɤɢ ɡɧaɱКʁɧК (p = 0,029). ɋɪeɞʃa ɜɪeɞɧoɫɬ ɛɪoja ɝoɞɢɧa ɪeaɧɢɦɢɪaɧɢɯ ɩɚɰɢʁɟɧɚɬɚ je 71 (65– 72), a ɧeɪeaɧɢɦɢɪaɧɢɯ УО 62 (56 – 69). Mɭɥɬɢɜaɪɢjaɧɬɧa ɛɢɧaɪɧa ɥoɝɢɫɬɢɱɤa ɪeɝɪeɫɢja ɩoɤaɡɭje ɞa ɤaɪɞɢoɩɭɥɦoɧaɥɧa ɪeaɧɢɦaɰɢja ɡaɜɢɫɢ ɫaɦo oɞ ɝoɞɢɧa (p = 0,046). Odds ratio ɡa ɝoɞɢɧО УО 1,113 (1,002 – 1,235). ɋɜaɤa ɝoɞɢɧa ɜɢɲe ɩoɜeʄaɜa ɪɢɡɢɤ oɞ ɪeaɧɢɦaɰɢje ɡa 11,3 %. Ƚɪɚɮɢɤɨɧ 27. ɉɪɨɰɟɧɭɬɚɥɧɢ ɩɪɢɤɚɡ ɤɚɪɞɢɨɩɭɥɦɨɧɚɥɧɟ ɪɟɚɧɢɦɚɰɢʁɟ ɩɨ ɝɪɭɩɚɦɚ 90 4.6 ɋȼȿ ɄɈɆɉɅɂɄȺɐɂȳȿ ɄɈȾ ɉȺɐɂȳȿɇȺɌȺ ɍ ȽɊɍɉɂ ɋȺ ɉɊȿɌɏɈȾɇɈɆ PCI Ɉɞ ɭɤɭɩɧɨ 94 ɩɚɰɢʁɟɧɬɚ ɢɡ ɝɪɭɩɟ ɛɟɡ ɩɪɟɬɯɨɞɧɟ PCI ɧɚʁɱɟɲʄɟ ɩɨɫɬɨɩɟɪɚɬɢɜɧɟ ɤɨɦɩɥɢɤɚɰɢʁɟ ɫɭ ɛɢɥɟ ɩɨɪɟɦɟʄɚʁɢ ɪɢɬɦɚ ɭ ɜɢɞɭ ɫɭɩɪɚɜɟɧɬɪɢɤɭɥɚɪɧɢɯ (ЋЏEЋ) ɢ ɜɟɧɬɪɢɤɭɥɚɪɧɢɯ ɟɤɫɬɪɚɫɢɫɬɨɥɚ (ЏEЋ). ɉɪɨɰɟɧɚɬ VES-ɨɜɚ ɭ ɨɜɨʁ ɝɪɭɩɢ ʁɟ ɛɢɨ, 38.3 ɞɨɤ ʁɟ 31.9% ɩɚɰɢʁɟɧɚɬɚ ɢɦɚɥɨ ЋЏEЋ-ɨɜɟ. ɋɥɟɞɟʄɢ ɭ ɧɢɡɭ ɤɨɦɩɥɢɤɚɰɢʁɚ ɛɢɥɢ ɫɭ ɩɟɪɢɨɩɟɪɚɬɢɜɧɢ ɢɧɮɚɪɤɬɢ ɦɢɨɤɚɪɞɚ, ɚ ʃɢɯ ʁɟ ɢɦɚɥɨ 16% ɩɚɰɢʁɟɧɚɬɚ. Ʉɪɜɚɪɟʃɟ ɫɚ ɪɟɜɢɡɢʁɨɦ ɯɟɦɨɫɬɚɡɟ ʁɟ ɧɨɬɢɪɚɧɨ ɤɨɞ 4.3%. ɍ ɨɜɨʁ ɝɪɭɩɢ ɧɢʁɟ ɛɢɥɨ ɦɨɠɞɚɧɢɯ ɭɞɚɪɚ (ɝɪɚɮɢɤɨɧ 28). Ƚɪɚɮɢɤɨɧ 28. ɉɪɨɰɟɧɬɭɚɥɧɢ ɩɪɢɤɚɡ ɤɨɦɩɥɢɤɚɰɢʁɚ ɭ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI 91 4.7 ɋȼȿ ɄɈɆɉɅɂɄȺɐɂȳȿ ɍ ȽɊɍɉɂ ȻȿɁ ɉɊȿɌɏɈȾɇȿ PCI ɍ ɝɪɭɩɢ ɛɟɡ ɩɪɟɬɯɨɞɧɟ PCI, ɧɚʁɜɢɲɟ ɡɚɫɬɭɩʂɟɧɚ ɤɨɦɩɥɢɤɚɰɢʁɚ ʁɟ ɜɟɧɬɪɢɤɭɥɚɪɧɚ ɟɤɫɬɪɚɫɢɫɬɨɥɚ. Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ 24.1% ʁɟ ɢɦɚɥɨ ЏEЋ- ɨɜɟ. ɋɭɩɪɚɜɟɧɬɪɢɤɭɥɚɪɧɟ ɟɤɫɬɪɚɫɢɫɬɨɥɟ ʁɟ ɢɦɚɥɨ 20.8% ɩɚɰɢʁɟɧɚɬɚ. ɉɟɪɢɨɩɟɪɚɬɢɜɧɢ ɢɧɮɚɪɤɬ ɦɢɨɤɚɪɞɚ ɛɢɨ ʁɟ ɩɪɢɫɭɬɚɧ ɤɨɞ 9% ɩɚɰɢʁɟɧɚɬɚ ɢɡ ɨɜɟ ɝɪɭɩɟ, ɞɨɤ ʁɟ ɫɚɦɨ ɦɚɥɢ ɛɪɨʁ ɩɚɰɢʁɟɧɚɬɚ ɤɚɨ ɤɨɦɩɥɢɤɚɰɢʁɭ ɢɦɚɨ ɤɪɜɚɪɟʃɟ 0.60% ɢ ɦɨɠɞɚɧɢ ɭɞɚɪ 1% (ɝɪɚɮɢɤɨɧ 29). Ƚɪɚɮɢɤɨɧ 29. ɉɪɨɰɟɧɬɭɚɥɧɢ ɩɪɢɤɚɡ ɤɨɦɩɥɢɤɚɰɢʁɚ ɭ ɝɪɭɩɢ ɛɟɡ ɩɪɟɬɯɨɞɧО PCI 92 4.8 ɍɉɈɊȿȾɇɂ ɉɊɂɄȺɁ ɉȿɊɂɈɉȿɊȺɌɂȼɇɂɏ ɂ ɉɈɋɌɈɉȿɊȺɌɂȼɇɂɏ ɄɈɆɉɅɂɄȺɐɂȳȺ ɍ ɈȻȿ ȽɊɍɉȿ ɇɚ ɝɪɚɮɢɤɨɧɭ 30. ɦɨɠɟ ɫɟ ɜɢɞɟɬɢ ɭɩɨɪɟɞɧɚ ɚɧɚɥɢɡɚ ɩɟɪɢɨɩɟɪɚɬɢɜɧɢɯ ɢ ɩɨɫɬɨɩɟɪɚɬɢɜɧɢɯ ɤɨɦɩɥɢɤɚɰɢʁɚ ɢɡ ɨɛɟ ɝɪɭɩɟ. ɇɚʁɜɟʄɚ ɪɚɡɥɢɤɚ ɫɟ ɩɪɢɦɟʄɭʁɟ ɛɚɲ ɤɨɞ ɨɧɢɯ ɤɨɦɩɥɢɤɚɰɢʁɚ ɤɨʁɟ ɫɭ ɢ ɧɚʁɛɢɬɧɢʁɟ ɢ ɤɨʁɟ ɞɢɪɟɤɬɧɨ ɞɢɤɬɢɪɚʁɭ ɤɜɚɥɢɬɟɬ ʁɟɞɧɟ ɤɚɪɞɢoɯɢɪɭɪɲɤɟ ɨɩɟɪɚɰɢʁɟ. Ɍɨ ɫɭ ɤɪɜɚɪɟʃɟ ɫɚ ɪɟɜɢɡɢʁɨɦ ɯɟɦɨɫɬɚɡɟ ɤɚɨ ɢ ɩɟɪɢɨɩɟɪɚɬɢɜɧɢ ɢɧɮɚɪɤɬ ɦɢɨɤɚɪɞɚ. Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ ɭ ɨɛɟ ɝɪɭɩɟ, ɭ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI ɛɢɥɨ ʁɟ 4.3% ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɤɪɜɚɪɟʃɟɦ, ɞɨɤ ʁɟ ɭ ɞɪɭɝɨʁ ɝɪɭɩɢ ɬɚʁ ɩɪɨɰɟɧɚɬ ɛɢɨ ɦɚʃɢ 0.6%. ɉɟɪɢɨɩɟɪɚɬɢɜɧɢ ɢɧɮɚɪɤɬ ɦɢɨɤɚɪɞɚ ʁɟ ɜɢђɟɧ ɤɨɞ 16% ɩɚɰɢʁɟɧɚɬɚ ɢɡ ɝɪɭɩɟ ɫɚ PCI, ɞɨɤ ʁɟ ɬɚʁ ɛɪɨʁ ɭ ɞɪɭɝɨʁ ɝɪɭɩɢ ɛɢɨ 8.6%. Ɉɞɧɨɫ ɩɨʁɚɜʂɢɜɚʃɚ ЏEЋ- ɨɜɚ ʁɟ 38.3% ɩɪɟɦɚ 24.1% ɭ ɤɨɪɢɫɬ ɝɪɭɩɟ ɫɚ ɩɪɟɬɯɨɞɧɢɦ PCI. ɍ ɝɪɭɩɢ ɫɚ PCI ʁɟ ɛɢɥɨ 31.9% ЋЏEЋ-ɨɜɚ, ɞɨɤ ʁɟ 20.8% ɛɢɥɨ ɭ ɞɪɭɝɨʁ ɝɪɭɩɢ. ɉɚɰɢʁɟɧɬɢ ɢɡ ɝɪɭɩɟ ɫɚ PCI ɧɢɫɭ ɢɦɚɥɢ ɦɨɠɞɚɧɢ ɭɞɚɪ ɤɚɨ ɩɨɫɬɨɩɟɪɚɬɢɜɧɭ ɤɨɦɩɥɢɤɚɰɢʁɭ, ɞɨɤ ʁɟ ɭ ɝɪɭɩɢ ɛɟɡ PCI 1.2% ɢɦɚɥɨ (ɝɪɚɮɢɤɨɧ 30). 93 Ƚɪɚɮɢɤɨɧ 30. Уɩɨɪɟɞɧɢ ɩɪɢɤɚɡ ɫɜɢɯ ɤɨɦɩɥɢɤɚɰɢʁɚ ɭ ɨɛɟ ɝɪɭɩɟ 5 ȾɍɀɂɇȺ ɌɊȺȳȺȵȺ ɅȿɑȿȵȺ ɉȺɐɂȳȿɇȺɌȺ ɂ ɋɆɊɌɇɂ ɂɋɏɈȾ 5.1 ɈȾɇɈɋ ɉȺɐɂȳȿɇȺɌȺ ɍ ɁȺȼɂɋɇɈɋɌɂ ɈȾ ɁȺȾɊɀȺȼȺȵȺ ɍ ȳȿȾɂɇɂɐɂ ɂɇɌȿɁɂȼɇȿ ɇȿȽȿ ɋɪɟɞʃɚ ɜɪɟɞɧɨɫɬ ɜɪɟɦɟɧɚ ɩɪɨɜɟɞɟɧɨɝ ɭ ʁɟɞɧɢɰɢ ɢɧɬɟɡɢɜɧɟ ɧɟɝɟ ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ ɭ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI je 23 ɫɚɬɚ ɢ 52 ɦɢɧɭɬɚ. ɇɚʁɤɪɚʄɟ ɜɪɟɦɟ ɭ 94 ɨɜɨʁ ɝɪɭɩɢ ʁɟ ɛɢɥɨ 10 ɫɚɬɢ ɢ 8 ɦɢɧɭɬɚ, ɚ ɧɚʁɞɭɠɟ 7 ɞɚɧɚ ɢ 96 ɦɢɧɭɬɚ. ɍ ɝɪɭɩɢ ɛɟɡ ɩɪɟɬɯɨɞɧɟ PCI ɫɪɟɞʃɚ ɜɪɟɞɧɨɫɬ ɜɪɟɦɟɧɚ ɤɨʁɟ ɫɭ ɩɚɰɢʁɟɧɬɢ ɩɪɨɜɟɥɢ ɭ ɢɧɬɟɡɢɜɧɨʁ ɧɟɡɢ ɢɡɧɨɫɢɥɚ ʁɟ 22 ɫɚɬɚ ɢ 56 ɦɢɧɭɬɚ. ɇɚʁɤɪɚʄɟ ɜɪɟɦɟ ɭ ɨɜɨʁ ɝɪɭɩɢ ʁɟ ɢɡɧɨɫɢɥɨ 6 ɫɚɬɢ ɢ 32 ɦɢɧɭɬɚ, ɞɨɤ ʁɟ ɧɚʁɞɭɠɟ ɜɪɟɦɟ ɤɨʁɟ ʁɟ ɩɚɰɢʁɟɧɬ ɢɡ ɨɜɟ ɝɪɭɩɟ ɩɪɨɜɟɨ ɭ ʁɟɞɢɧɢɰɢ ɢɧɬɟɡɢɜɧɨɝ ɥɟɱɟʃɚ ɢɡɧɨɫɢɥɨ ʁɟ 11 ɞɚɧɚ ɢ 56 ɦɢɧɭɬɚ. (ɝɪɚɮɢɤɨɧ 31) Ɋaɡɥɢɤa ɫɪeɞʃɢɯ ɜɪeɞɧoɫɬɢ ɞɭɠɢɧe ɛoɪaɜɤa ɭ ʁɟɞɢɧɢɰɢ ɢɧɬɟɡɢɜɧɟ ɧɟɝɟ ɢɡɦeђɭ ɩaɰɢjeɧaɬa ɫa PCI ɢ ɛeɡ ɫɬaɬɢɫɬɢɱɤɢ ʁɟ ɡɧaɱajɧК (p = 0,046). ɋɪeɞʃa ɜɪeɞɧoɫɬ ɞɭɠɢɧe ɛoɪaɜɤa ɭ ʁɟɞɢɧɢɰɢ ɢɧɬɟɡɢɜɧɟ ɧɟɝɟ ɩaɰɢjeɧaɬa ɢɡ ɭɡoɪɤa ɛɟɡ PCI je 0.94 (0.93 – 1.44), a ɫɚ PCI 0.98 (0.88 – 1.84). Ƚɪɚɮɢɤɨɧ 31. ȼɪɟɦɟ ɡɚɞɪɠɚɜɚʃɚ ɩɚɰɢʁɟɧɚɬɚ ɭ ʁɟɞɢɧɢɰɢ ɢɧɬɟɡɢɜɧɨɝ ɥɟɱɟʃɚ ɩɨ ɝɪɭɩɚɦɚ 95 5.2 ɈȾɇɈɋ ɉȺɐɂȳȿɇȺɌȺ ɍ ɁȺȼɂɋɇɈɋɌɂ ɈȾ ɁȺȾɊɀȺȼȺȵȺ ɍ ȻɈɅɇɂɐɂ ɉɈ ȽɊɍɉȺɆȺ ɍ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɢɦ PCI ɫɪɟɞʃɚ ɜɪɟɞɧɨɫɬ ɤɨʁɟ ɫɭ ɩɪɨɜɟɥɢ ɩɚɰɢʁɟɧɬɢ ɭ ɛɨɥɧɢɰɢ ɢɡɧɨɫɢ 10 ɞɚɧɚ. ɉɚɰɢʁɟɧɬ ɤɨʁɢ ɫɟ ɢɡ ɨɜɟ ɝɪɭɩɟ ɧɚʁɤɪɚʄɟ ɡɚɞɪɠɚɨ, ɩɪɨɜɟɨ ʁɟ 7 ɞɚɧɚ ɭ ɛɨɥɧɢɰɢ ɚ ɧɚʁɞɭɠɟ ɜɪɟɦɟ ɡɚɞɪɠɚɜɚʃɚ ɩɚɰɢʁɟɧɬɚ ɢɡ ɨɜɟ ɝɪɭɩɟ ɛɢɥɨ ʁɟ 54 ɞɚɧɚ. ɋɪɟɞʃɚ ɜɪɟɞɧɨɫɬ ɩɪɨɜɟɞɟɧɢɯ ɞɚɧɚ ɢɡ ɝɪɭɩɚ ɛɟɡ PCI ɢɡɧɨɫɢ 12 ɞɚɧɚ. ɇɚʁɤɪɚʄɟ ɩɪɨɜɟɞɟɧɨ ɜɪɟɦɟ ɭ ɛɨɥɧɢɰɢ ɢɦɚɨ ʁɟ ɩɚɰɢʁɟɧɬ ɫɚ ɛɨɪɚɜɤɨɦ ɨɞ 6 ɞɚɧɚ, ɞɨɤ ʁɟ ɧɚʁɞɭɠɟ ɜɪɟɦɟ ɩɪɨɜɟɞɟɧɨ ɭ ɛɨɥɧɢɰɢ ɢɡ ɨɜɟ ɝɪɭɩɟ ɛɢɥɨ 40 ɞɚɧɚ (ɝɪɚɮɢɤɨɧ 32). Ɋaɡɥɢɤa ɫɪeɞʃɢɯ ɜɪeɞɧoɫɬɢ ɞɭɠɢɧe ɛoɪaɜɤa ɭ ɛoɥɧɢɰɢ ɢɡɦeђɭ ɩaɰɢjeɧaɬa ɫa PCI ɢ ɛeɡ ɫɬaɬɢɫɬɢɱɤɢ ʁɟ ɡɧaɱajɧК (p = 0,006). ɋɪeɞʃa ɜɪeɞɧoɫɬ ɞɭɠɢɧe ɛoɪaɜɤa ɭ ɛoɥɧɢɰɢ ɩaɰɢjeɧaɬa ɢɡ ɭɡoɪɤa ɛeɡ PCI je 12 (9–17), a ɫa PCI 10 (9–14). 0 5 10 15 20 ϭϬ д̌н̌ 12 д̌н̌ vreme provedeno u ̍ол̶̛̛̦ г̬уп̌ ̭̌ PCI г̬уп̌ ̍ез PCI Ƚɪɚɮɢɤɨɧ 32. Ɉɞɧɨɫ ɩɚɰɢʁɟɧɬɚ ɩɨ ɝɪɭɩɚɦɚ ɭ ɡɚɜɢɫɧɨɬɫɢ ɨɞ ɜɪɟɦɟɧɚ ɩɪɨɜɟɞɟɧɨɝ ɭ ɛɨɥɧɢɰɢ 96 5.3 ɋɆɊɌɇɂ ɂɋɏɈȾ ɉɈ ȽɊɍɉȺɆȺ Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ ɭ ɰɟɥɨʁ ɫɬɭɞɢʁɢ 19 ɢɥɢ 2.09% ʁɟ ɫɚ ɫɦɪɬɧɢɦ ɢɫɯɨɞɨɦ. ɍ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI ɫɚɦɨ ʁɟɞɚɧ ɩɚɰɢʁɟɧɬ ʁɟ ɡɚɜɪɲɢɨ ɫɦɪɬɧɢɦ ɢɫɯɨɞɨɦ ɲɬɨ ɢɡɧɨɫɢ 1.1%. ɍ ɝɪɭɩɢ ɛɟɡ ɩɪɟɬɯɨɞɧɟ PCI 18 ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɡɚɜɪɲɢɥɨ ɫɦɪɬɧɢɦ ɢɫɯɨɞɨɦ ɲɬɨ ɢɡɧɨɫɢ 2.2% (ɝɪɚɮɢɤɨɧ 33). ɋɦɪɬɧɢ ɢɫɯoɞ ɢ ɩɪeɬɯoɞɧɢ PCI ɧɢɫɭ ɩoɜeɡaɧɢ (p = 0,711). Ɋaɡɥɢɤa ɫɪeɞʃɢɯ ɜɪeɞɧoɫɬɢ ɛɪoja ɝoɞɢɧa ɢɡɦeђɭ ɭɦɪɥɢɯ ɢ ɩɪeɠɢɜeɥɢɯ je ɫɬaɬɢɫɬɢɱɤɢ ɡɧaɱajɧa (p = 0.017). ɋɪeɞʃa ɜɪeɞɧoɫɬ ɛɪoja ɝoɞɢɧa ɭɦɪɥɢɯ je 71 (60 – 72), a ɩɪeɠɢɜeɥɢɯ 62 (56 – 69). ɋɦɪɬɧɢ ɢɫɯoɞ ɢ ɩɚɰɢʁɟɧɬɢ ɤɨʁɢ ɫɭ ɛɢɥɢ ɧɚ aɧɬɢaɝɪeɝaɰɢɨɧɨʁ ɬɟɪɚɩɢʁɢ ɫɭ ɩoɜeɡaɧɢ (p = 0,021). Ȼɢɧaɪɧa ɥoɝɢɫɬɢɱɤa ɪeɝɪeɫɢja ɩoɤaɡɭje ɞa ɫɦɪɬɧɢ ɢɫɯШɞ ɧО ɡКɜɢɫɢ Шɞ ɩɪОɬɯШɞɧШɝ ЈCI (p = 0,470). Mɭɥɬɢɜaɪɢjaɧɬɧa ɛɢɧaɪɧa ɥoɝɢɫɬɢɱɤa ɪeɝɪeɫɢja ɩoɤaɡɭje ɞa ɫɦɪɬɧɢ ɢɫɯoɞ ɡaɜɢɫɢ ɫaɦo oɞ ɛɪoja ɝoɞɢɧa ɩaɰɢjeɧɬa (p = 0,039) ɢ oɞ ɭɡɢɦaʃa aɧɬɢaɝɪeɝaɬɧɟ ɬɟɪɚɩɢʁɟ (p = 0,034). Odds ratio ɡa ɝoɞɢɧe je 1,064 (1,003 – 1,128). ɋɜaɤa ɝoɞɢɧa ɜɢɲe ɩoɜeʄaɜa ɪɢɡɢɤ oɞ ɫɦɪɬɧoɝ ɢɫɯoɞa ɡa 6,4 %. Odds ratio ɡɚ ɚɧɬɢɚɝɪɟɬɚɰɢɨɧɭ ɬɟɪɚɩɢʁɭ ʁɟ 3,328 (1,093 – 10,134). 97 Ƚɪɚɮɢɤɨɧ 33. Уɩɨɪɟɞɚɧ ɩɪɢɤɚɡ ɫɦɪɬɧɨɝ ɢɫɯɨɞɚ ɩɨ ɝɪɭɩɚɦɚ 98 VII ȾɂɋɄɍɋɂJA ɍ ɞɚɧɚɲʃɟ ɜɪɟɦɟ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɢ ɯɢɪɭɪɡɢ ɫɟ ɫɭɫɪɟʄɭ ɫɚ ɫɜɟ ɜɢɲɟ ɢ ɜɢɲɟ ɩɚɰɢʁɟɧɚɬɚ ɤɨʁɢ ɫɭ ɡɚ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɭ ɯɢɪɭɪɲɤɭ ɢɧɬɟɪɜɟɧɰɢʁɭ ɩɨɫɥɟ ɩɟɪɤɭɬɚɧɟ ɤɨɪɨɧɚɪɧɟ ɢɧɬɟɪɜɟɧɰɢʁɟ ɫɚ ɫɬɟɧɬɨɦ. Ɉɜɚ ɫɬɭɞɢʁɚ, ɧɚ ɨɫɧɨɜɭ ɤɪɟɢɪɚɧɟ ɛɚɡɟ ɩɨɞɚɬɚɤɚ, ʁɚɫɧɨ ɩɨɤɚɡɭʁɟ ɞɚ ʁɟ ɩɪɟɬɯɨɞɧɚ ɩɟɪɤɭɬɚɧɚ ɤɨɪɨɧɚɪɧɚ ɢɧɬɟɪɜɟɧɰɢʁɚ ɧɟɡɚɜɢɫɚɧ ɪɢɡɢɤɨ-ɮɚɤɬɨɪ ɤɨʁɢ ɞɢɪɟɤɬɧɨ ɭɬɢɱɟ ɧɚ ɦɨɪɛɢɞɢɬɟɬ ɩɚɰɢʁɟɧɚɬɚ ɧɚɤɨɧ ɤɚɪɞɢɨɯɢɪɭɪɲɤɨɝ ɡɛɪɢʃɚɜɚʃɚ ɤɨɪɨɧɚɪɧɢɯ ɤɪɜɧɢɯ ɫɭɞɨɜɚ. Ɏɚɤɬɨɪɢ ɤɨʁɢ ɭɬɢɱɭ ɧɚ ɦɨɪɛɢɞɢɬɟɬ ɢ ɦɨɪɬɚɥɢɬɟɬ ɤɚɪɞɢɨɯɢɭɪɲɤɨɝ ɩɚɰɢʁɟɧɬɚ ɫɟ ɩɪɚɬɟ ɢ ɩɪɨɭɱɚɜɚʁɭ ʁɨɲ ɨɞ ɤɚɫɧɢɯ ɨɫɚɦɞɟɫɟɬɢɯ ɩɪɨɲɥɨɝ ɜɟɤɚ. ɍ ɩɨɱɟɬɤɭ ɫɭ ɩɨɫɦɚɬɪɚɧɢ ɤɚɨ ʁɟɞɚɧ ɭɞɪɭɠɟɧɢ ɮɚɤɬɨɪ ɚ ɤɚɫɧɢʁɟ ɤɚɨ ɦɨɞɟɥɢ ɫɬɪɚɬɢɮɢɤɚɰɢʁɟ ɪɢɡɢɤɚ91,92. Ɇɧɨɝɟ ɜɚɪɢʁɚɛɥɟ ,ɭɤʂɭɱɭʁɭʄɢ ɢ ɩɟɪɤɭɬɚɧɭ ɤɨɪɨɧɚɪɧɭ ɢɧɬɟɪɜɟɧɰɢʁɭ ɭ ɢɫɬɨʁ ɯɨɫɩɢɬɚɥɢɡɚɰɢʁɢ, ɩɪɨɭɱɚɜɚɧɟ ɫɭ ɢ ɛɢɥɟ ɞɭɝɨ ɩɨɡɧɚɬɟ ɤɚɨ ɩɪɟɞɢɤɬɨɪ ɛɨɥɧɢɱɤɨɝ ɦɨɪɬɚɥɢɬɟɬɚ ɢ ɦɨɪɛɢɞɢɬɟɬɚ ɩɨɫɥɟ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɦɢɨɤɚɪɞɚ93-95. ɍɬɢɰɚʁ ɩɪɟɬɯɨɞɧɟ ɩɟɪɤɭɬɚɧɟ ɤɨɪɨɧɚɪɧɟ ɢɧɬɟɪɜɟɧɰɢʁɟ ɧɚ ɯɢɪɭɪɲɤɭ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɭ ɦɢɨɤɚɪɞɚ ʁɟ ɛɢɨ ɩɪɢɦɟʄɟɧ ɤɨɞ ɤɚɪɞɢɨɯɢɪɭɪɝɚ ɭ ɫɜɚɤɨɞɧɟɜɧɨʁ ɩɪɚɤɫɢ. Ɇɟђɭɬɢɦ, ɬɨ ɧɢʁɟ ɞɟɬɚʂɧɨ ɩɪɨɭɱɚɜɚɧɨ ɫɜɟ ɞɨɧɟɞɚɜɧɨ ɤɚɞɚ ʁɟ ɫɜɟ ɜɢɲɟ ɩɨɱɟɥɨ ɞɚ ɫɟ ɝɨɜɨɪɢ ɨ ɬɨɦɟ ɢ ɞɚ ɫɟ ɨɡɛɢʂɧɨ ɭɡɢɦɚ ɭ ɨɛɡɢɪ. Ƚɨɞɢɧɟ 1995.,ȹɨɧɫɨɧ ɢ ɫɚɪɚɞɧɢɰɢ96 ɫɭ ɩɪɢɦɟɬɢɥɢ ɧɟɝɚɬɢɜɚɧ ɭɬɢɰɚʁ ɩɪɟɬɯɨɞɧɨɝ PCI ɧɚ CABG. ɍɩɨɪɟђɭʁɭʄɢ 234 ɩɚɰɢʁɟɧɬɚ ɤɨɞ ɤɨʁɢɯ ʁɟ ɭɫɩɟɲɧɨ ɭɪɚђɟɧɚ PCI К ɤɚɫɧɢʁɟ ɨɛɚɜɟɡɧК CABG , ɩɪɢɦɟɬɢɥɢ ɫɭ ɞɚ ɯɢɪɭɪɲɤɢ ɪɢɡɢɤ ɡК 99 ɜɪɟɦɟ ɨɩɟɪɚɰɢʁɟ УО ɛɢШ 4,0 % , ɡɧɚɱɚʁɧɨ ɜɢɲɢ ɧОɝШ ɤШɞ ɩɪɟɬɯɨɞɧɟ ЈCI ɤШУɢ УО ɢɡɧɨɫɢɨ 2.8 % (ɩ = 0,04 ). Ƚɨɞɢɧɟ 1996, ȹɨɧɫɨɧ ɢ ɫɚɪɚɞɧɢɰɢ97 ɭ ɨɛɢɦɧɨɦ ɩɪɟɝɥɟɞɭ ɫɟɞɚɦ ɜɟɥɢɤɢɯ ɛɚɡɚ ɩɨɞɚɬɚɤɚ ɨɞ 172.184 ɩɚɰɢʁɟɧɚɬɚ ɤɨʁɢɦɚ ʁɟ ɭɪɚђɟɧɚ CABG, ɛɢɥɢ ɫɭ ɩɪɜɢ ɤɨʁɢɦɚ ʁɟ ɚɧɚɥɢɡɢɪɚɧɚ ɩɪɟɬɯɨɞɧɚ PCI ɤɚɨ ɪɢɡɢɤɨ-ɮɚɤɬɨɪ. ɍ ɬɨ ɜɪɟɦɟ PCI ʁɟ ɤɥɚɫɢɮɢɤɨɜɚɧ ɤɚɨ ɮɚɤɬɨɪ ɧɢɜɨɚ 2, ɤɨʁɢ ɧɢʁɟ ɛɢɨ ʁɚɫɧɨ ɩɨɜɟɡɚɧ ɫɚ ɦɨɪɬɚɥɢɬɟɬɨɦ ɢ ɦɨɪɛɢɞɢɬɟɬɨɦ ɩɨɫɥɟ ɯɢɪɭɪɝɢʁɟ. Kalaycioglu ɢ ɫɚɪɚɞɧɢɰɢ98 ɫɭ 1998. ɝɨɞɢɧɟ ɭ ɬɟɧɞɟɧɰɢʁɢ ɪɟɡɭɥɬɚɬɚ ɭɩɚɪɢɜɚʃɚ ɤɨɞ 80 ɩɚɰɢʁɟɧɚɬɚ ɤɨʁɢ ɫɭ ɩɪɨɲɥɢ CABG, ɩɪɨɧɚɲɥɢ ɦɧɨɝɨ ɝɨɪɟ ɪɟɡɭɥɬɚɬɟ ɭ ɝɪɭɩɢ ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɩɪɟɬɯɨɞɧɨɦ ЈCI. ɍ ɫɤɨɪɢʁɟ ɜɪɟɦɟ , ɏɚɫɫɚɧ ɢ ɫɚɪɚɞɧɢɰɢ99, ɭ ɜɟɥɢɤɨʁ ɫɬɭɞɢʁɢ ɫɚ 6504 ɩɚɰɢʁɟɧɬɚ ɩɨɞɜɪɝɧɭɬɢ CABG ( ɨɞ ɬɨɝɚ 919 ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI), ʁɚɫɧɨ ɫɭ ɩɨɤɚɡɚɥɢ ɞɚ ʁɟ ɩɪɟɬɯɨɞɧɚ PCI ɧɟɡɚɜɢɫɚɧ ɩɪɟɞɢɤɬɨɪ ɫɦɪɬɧɨɫɬɢ ɭ ɛɨɥɧɢɰɢ ɩɨɫɥɟ CABG, ɨɞɧɨɫ ɲɚɧɫɢ 1.93 (p = 0.003) . Ɇɟђɭɬɢɦ , ɞɚɧɚɫ ɢ ɞɚʂɟ ɩɨɫɬɨʁɢ ɫɭɦʃɚ ɞɚ ɥɢ ʁɟ ɩɪɟɬɯɨɞɧɚ PCI ɪɢɡɢɤɨ-ɮɚɤɬɨɪ ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ ɤɨʁɢ ɫɟ ɫɩɪɟɦɚʁɭ ɡɚ CABG. ɍ ɩɨɫɥɟɞʃɢɯ ɧɟɤɨɥɢɤɨ ɝɨɞɢɧɚ ɫɜɟ ʁɟ ɜɟʄɢ ɛɪɨʁ ɢɧɬɟɪɜɟɧɬɧɢɯ ɩɪɨɰɟɞɭɪɚ ɫɬɟɧɬɨɜɢɦɚ ɤɨɞ ɫɪɟɞʃɟ ɪɢɡɢɱɧɢɯ ɩɚɰɢʁɟɧɚɬɚ, ɤɚɨ ɢ ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɬɟɲɤɨɦ ɜɢɚɲɟɫɭɞɨɜɧɨɦ ɤɨɪɨɧɚɪɧɨɦ ɛɨɥɟɫɬɢ, ɤɨʁɢ ɛɢ ɬɪɟɛɚɥɨ ɞɚ ɫɭ PCI ɧɟɚɞɟɤɜɚɬɚɧɢ100-102.Ʉɚɨ ɪɟɡɭɥɬɚɬ ɬɨɝɚ, ɩɨɫɬɨʁɢ ɩɨɜɟʄɚɧ ɛɪɨʁ ɩɚɰɢʁɟɧɚɬɚ ɤɨɞ ɤɨʁɢɯ ʁɟ ɭɪɚђɟɧ PCI ɫɚ ɫɬɟɧɬɨɦ ɩɪɟ CABG. ɉɨ ɥɢɬɟɪɚɬɭɪɢ,ɜɪɟɞɧɨɫɬ ɨɜɟ ɢɧɰɢɞɟɧɰɟ ɫɟ ɤɪɟʄɟ ɨɞ 10% ɞɨ 20 % 99,103,104 . ɍ ɨɜɨʁ ɫɬɭɞɢʁɢ ɝɪɭɩɚ ɤɨʁɚ ɫɟ ɢɫɩɢɬɭʁɟ, ɝɪɭɩɚ ɫɚ ɩɪɟɬɯɨɞɧɢɦ PCI ɛɪɨʁɢ 94 ɩɚɰɢʁɟɧɬɚ ɲɬɨ ɢɡɧɨɫɢ (9,57%). ɍ ɬɨɦ ɤɨɧɬɟɤɫɬɭ, ɜɚɠɧɨ ʁɟ ɞɚ ɫɟ ɩɪɟɢɫɩɢɬɚ ɤɥɢɧɢɱɤɚ ɪɟɥɟɜɚɧɬɧɨɫɬ ɩɪɟɬɯɨɞɧɨɝ PCI, ɤɚɨ ɢ ɩɪɨɝɧɨɫɬɢɱɤɚ ɜɪɟɞɧɨɫɬ ɪɢɡɢɤɚ ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ ɤɨʁɢ ɦɨɝɭ ɞɚ ɡɚɯɬɟɜɚʁɭ ɤɚɫɧɢʁɟ CABG . 100 ɋɤɨɪɚɲʃɚ ɢɫɬɪɚɠɢɜɚʃɚ ɩɨɤɚɡɭʁɭ ɞɚ ɩɚɰɢʁɟɧɬɢ ɫɚ ЈCI ɭ ɢɫɬɨɪɢʁɢ ɛɨɥɟɫɬɢ ɢɦɚʁɭ ɥɨɲɢʁɭ ɩɪɨɝɧɨɡɭ ɩɨɫɥɟ CABG, ɤɚɨ ɢ ɩɨɜɟʄɚʃɟ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɢɯ ɧɟɠɟʂɟɧɢɯ ɞɨɝɚђɚʁɚ ɤɪɨɡ ɞɚʂɚ ɤɥɢɧɢɱɤɚ ɩɪɚʄɟʃɚ105. Bonaros ɢ ɫɚɪɚɞɧɢɰɢ106 ɩɨɬɜɪɞɢɥɢ ɫɭ ɨɜɟ ɩɨɞɚɬɤɟ ɭ ɫɬɭɞɢʁɢ ɤɨʁɚ ʁɟ ɢɦɚɥɚ 306 ɩɚɰɢʁɟɧɚɬɚ. ɍɩɨɪɟђɢɜɚɥɢ ɫɭ ɝɪɭɩɭ ɤɨʁɚ ʁɟ ɢɦɚɥɚ ɩɪɟɬɯɨɞɧɭ PCI ɩɚ CABG ɫɚ ɫɥɢɱɧɨɦ ɝɪɭɩɨɦ ɛɟɡ ɩɪɟɬɯɨɞɧɟ CABG. ɉɚɰɢʁɟɧɬɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI ɢɦɚɥɢ ɫɭ ɜɟʄɢ ɛɨɥɧɢɱɤɢ ɦɨɪɬɚɥɢɬɟɬ ɢ ɦɨɪɛɢɞɢɬɟɬ (4.4% ɧɚɫɩɪɚɦ 2.4%, p<0.001). ɍ ɨɜɨʁ ɫɬɭɞɢʁɢ ɚɧɚɥɢɡɢɪɚɧɨ ʁɟ 906 ɩɚɰɢʁɟɧɬɚ ɭ ɩɟɪɢɨɞɭ ɨɞ ɞɜɟ ɝɨɞɢɧɟ, 2011.ɢ 2012. Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɩɚɰɢʁɟɧɚɬɚ ɤɨɞ ɤɨʁɢɯ ʁɟ ɪɚђɟɧ ɫɚɦɨ CABG ɛɟɡ ɩɪɟɬɯɨɞɧɟ PCI (812 ɩɚɰɢʁɟɧɚɬɚ) ɦɨɪɬɚɥɢɬɟɬ ɧɚ ɂɧɫɬɢɬɭɬɭ ɡɚ ɤɚɪɞɢɨɜɚɫɤɭɥɚɧɪɟ ɛɨɥɟɫɬɢ ȼɨʁɜɨɞɢɧɟ ɢɡɧɨɫɢ 1,83 %. ɍ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI ɚ ɡɚɬɢɦ CABG (94 ɩɚɰɢʁɟɧɚɬɚ) ɦɨɪɬɚɥɢɬɟɬ ʁɟ ɧɟɲɬɨ ɦɚʃɢ ɚɥɢ ɫɬɚɬɢɫɬɢɱɤɢ ɧɟɡɧɚɱɚʁɚɧ 1,06%. ɂɚɤɨ ɦɧɨɝɟ ɫɬɭɞɢʁɟ ɝɨɜɨɪɟ ɭ ɩɪɢɥɨɝ ɞɚ ɩɪɟɬɯɨɞɧɚ PCI ɩɨɜɟʄɚɜɚ ɛɨɥɧɢɱɤɢ ɦɨɪɬɚɥɢɬɟɬ ɩɨɫɥɟ CABG,oɜɚ ɫɬɭɞɢʁɚ ɢɫɤʂɭɱɭʁɟ ɦɨɝɭʄɧɨɫɬ ɞɚ ɩɪɟɬɯɨɞɧɚ ɩɟɪɤɭɬɚɧɚ ɤɨɪɨɧɚɪɧɚ ɢɧɬɟɪɜɟɧɰɢʁɚ ɩɨɜɟʄɚɜɚ ɦɨɪɬɚɥɢɬɟɬ ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ ɤɨɞ ɤɨʁɢɯ ʁɟ ɩɨɫɥɟ ɭɪɟђɟɧɚ ɯɢɪɭɪɲɤɚ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɚ ɦɢɨɤɚɪɞɚ. ɉɨɫɬɨʁɟ ɢ ɫɬɭɞɢʁɟ ɤɨʁɟ ɝɨɜɨɪɟ ɭ ɩɪɢɥɨɝ ɨɜɨʁ107. Yap ɢ ɫɚɪɚɞɧɢɰɢ ɫɭ ɚɧɚɥɢɡɢɪɚɥɢ 13,184 ɩɚɰɢʁɟɧɚɬɚ (1,457 ɫɚ PCI ɢɫɬɨɪɢʁɨɦ) ɤɨɞ ɤɨʁɢɯ ʁɟ ɭɪɚђɟɧɚ CABG ɩɨɫɥɟ PCI ɢ ɧɢɫɭ ɧɚɲɥɢ ɧɢɤɚɤɜɭ ɩɨɜɟɡɚɧɨɫɬ ɢɡɦɟђɭ ɩɪɟɬɯɨɞɧɟ PCI ɢ ɢɧɬɪɚɯɨɫɩɢɬɚɥɧɨɝ ɦɨɪɬɚɥɢɬɟɬɚ (odds ratio 1,11; p=0.41). Thielmann ɢ ɫɚɪɚɞɧɢɰɢ108 ɫɭ ɚɧɚɥɢɡɢɪɚɥɢ 2626 ɩɚɰɢʁɟɧɚɬɚ ɤɨɞ ɤɨʁɢɯ ʁɟ ɭɪɚђɟɧɚ CABG ɩɨɫɥɟ PCI ɢ ɧɚɲɥɢ ɩɨɜɟɡɚɧɨɫɬ ɢɡɦɟђɭ ɩɪɟɬɯɨɞɧɟ PCI ɢ ɢɧɬɪɚɯɨɫɩɢɬɚɥɧɨɝ ɦɨɪɬɚɥɢɬɟɬɚ ɦɚɞɚ, ɨɜɨ ʁɟ ɛɢɥɨ ɫɢɝɧɢɮɢɤɚɧɬɧɨ ɫɚɦɨ ɭ ɫɥɭɱɚʁɭ ɩɪɢɫɭɫɬɜɚ ɜɢɲɟɫɬɪɭɤɨɝ PCI-a. 101 Ɉɜɚ ɫɬɭɞɢʁɚ ɧɟ ɫɚɦɨ ɞɚ ɨɫɥɢɤɚɜɚ ɞɚ ɧɟ ɩɨɫɬɨʁɢ ɩɨɜɟɡɚɧɨɫɬ ɦɨɪɬɚɥɢɬɟɬɚ ɢ ɝɪɭɩɟ ɩɚɰɢʁɟɧɚɬɚ ɤɨʁɢ ɫɭ ɩɪɟɬɯɨɞɧɨ ɢɦɚɥɢ ɫɬɟɧɬ ɩɚ ɞɨɲɥɢ ɧɚ ɨɩɟɪɚɰɢʁɭ, ɜɟʄ ɩɨɤɚɡɭʁɟ ɤɜɚɥɢɬɟɬ ɨɩɟɪɚɬɢɜɧɟ ɬɟɯɧɢɤɟ ɢ ɢɡɜɚɧɪɟɞɧɟ ɪɟɡɭɥɬɚɬɟ ɫɚ ɤɨʁɢɦ ɫɟ ɂɧɫɬɢɬɭɬ ɡɚ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɟ ɛɨɥɟɫɬɢ ȼɨʁɜɨɞɢɧɟ ɩɨɧɨɫɢ ɢ ɫɬɚɜʂɚ ɭ ɪɟɞ ɧɚʁɛɨʂɢɯ. ɋɬɭɞɢʁɚ ɩɨɪɟɞ ɦɨɪɬɚɥɢɬɟɬɚ ɩɪɚɬɢ ɢ ɦɧɨɝɨ ɜɚɪɢʁɚɛɥɢ ɤɨʁɟ ɨɫɥɢɤɚɜɚʁɭ ɤɜɚɥɢɬɟɬ ɨɩɟɪɚɰɢʁɟ ɤɚɤɨ ɭ ʁɟɞɧɨʁ ɬɚɤɨ ɢ ɭ ɞɪɭɝɨʁ ɝɪɭɩɢ. ȳɟɞɧɚ ɨɞ ɧɚʁɛɢɬɧɢʁɢɯ ɜɚɪɢʁɚɛɥɢ ʁɟ ɩɟɪɢɨɩɟɪɚɬɢɜɧɢ ɢɧɮɚɪɤɬ, ɤɨɦɩɥɢɤɚɰɢʁɚ ɭ ɬɨɤɭ ɨɩɟɪɚɰɢʁɟ ɤɨʁɚ ʁɟ ɭ ɞɢɪɟɤɬɧɨʁ ɫɩɪɟɡɢ ɫɚ ɤɜɚɥɢɬɟɬɨɦ ɨɩɟɪɚɰɢʁɟ, ɤɚɨ ɢ ɫɚ ɤɜɚɥɢɬɟɬɨɦ ɠɢɜɨɬɚ ɩɚɰɢʁɟɧɬɚ ɩɨɫɥɟ ɨɩɟɪɚɰɢʁɟ. Ʉɪɨɡ ɨɜɭ ɫɬɭɞɢʁɭ ʁɟ ɩɨɬɜɪђɟɧɨ ɞɚ ʁɟ ɩɟɪɢɨɩɟɪɚɬɢɜɧɢ ɢɧɮɚɪɤɬ ɩɨɜɟɡɚɧ ɫɚ ɩɪɟɬɯɨɞɧɢɦ PCI (p = 0,034). Ȼɢɧaɪɧa ɥoɝɢɫɬɢɱɤa ɪeɝɪeɫɢja ɩoɤaɡɭje ɞa ɩeɪɢoɩeɪaɬɢɜɧɢ ɢɧɮaɪɤɬ ɡaɜɢɫɢ oɞ ɩɪeɬɯoɞɧoɝ PCI (p = 0,023). Mɭɥɬɢɜaɪɢjaɧɬɧa ɛɢɧaɪɧa ɥoɝɢɫɬɢɱɤa ɪeɝɪeɫɢja ɩoɤaɡɭje ɞa ɩeɪɢoɩeɪaɬɢɜɧɢ ɢɧɮaɪɤɬ ɡaɜɢɫɢ ɫaɦo oɞ ɩɪeɬɞoɞɧoɝ PCI (p = 0,030) ɢ oɞ ɩoɜeʄaɧoɝ BMI (p = 0,033). Odds ratio ɡa ɩɪeɬɯoɞɧɢ PCI je 1,964 (1,067 – 3,616). ɉɪeɬɯoɞɧɢ PCI ɩoɜeʄɚɜa ɪɢɡɢɤ oɞ ɩeɪɢoɩeɪaɬɢɜɧoɝ ɢɧɮaɪɤɬa 96 %. ɉɟɪɢɨɩɟɪɚɬɢɜɧɢ ɢɧɮɚɪɤɬ ɫɟ ɩɨʁɚɜʂɭʁɟ ɱɟɲʄɟ ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ ɤɨʁɢ ɫɭ ɭɡɢɦɚɥɢ ɚɧɬɢɚɝɪɟɝɚɰɢɨɧɭ ɬɟɪɚɩɢʁɭ ɲɬɨ ɢɦɚ ɫɬɚɬɢɫɬɢɱɤɭ ɡɧɚɱɚʁɧɨɫɬ (p=0,041). Ⱥɧɬɢɚɝɪɟɚɝɚɰɢɨɧɚ ɬɟɪɚɩɢʁɚ ʁɟ ɩɨɜɟɡɚɧɚ ɢ ɫɚ ɝɪɭɩɨɦ ɩɪɟɬɯɨɞɧɢɯ PCI ɢ ɢɦɚ ɫɬɚɬɢɫɬɢɱɤɭ ɡɧɚɱɚʁɧɨɫɬɢ (p<0,0005). ɍ ɝɪɭɩɢ ɩɚɰɢʁɟɧɚɬɚ ɤɨʁɢ ɫɭ ɢɦɚɥɢ 102 ɩɪɟɬɯɨɞɧɢ PCI, 81,9% ɩɚɰɢʁɟɧɚɬɚ ʁɟ ɤɨɪɢɫɬɢɥɨ ɚɧɬɢɚɝɪɟɝɚɰɢɨɧɭ ɬɟɪɚɩɢʁɭ, ɞɨɤ ʁɟ ɭ ɞɪɭɝɨʁ ɝɪɭɩɢ ɫɚɦɨ 49,0% . Ʉɨɪɢɲʄɟʃɟ ɚɧɬɢɚɝɪɟɚɝɚɰɢɨɧɟ ɬɟɪɚɩɢʁɟ ɭɦɧɨɝɨɦɟ ɨɬɟɠɚɜɚ ɯɢɪɭɪɲɤɢ ɪɚɞ ɢ ɬɨ ɭ ɫɦɢɫɥɭ ɭɪɟɞɧɟ ɯɟɦɨɫɬɚɡɟ. ȳɟɞɧɚ ɨɞ ɛɢɬɧɢɯ ɤɚɪɞɢɨɯɢɪɭɪɲɤɢɯ ɤɨɦɩɥɢɤɚɰɢʁɚ ʁɟ ɤɪɜɚɪɟʃɟ. Ʉɨɦɩɥɢɤɚɰɢʁɚ ɤɚɨ ɢ ɫɜɚɤɚ ɞɪɭɝɚ ɧɨɫɢ ɫɚ ɫɨɛɨɦ ɪɢɡɢɤ. Ʉɨɞ ɨɜɟ ɤɨɦɩɥɢɤɚɰɢʁɟ ɫɟ ɩɪɜɨ ɫɭɫɪɟʄɟɦɨ ɫɚ ɜɟɥɢɤɨɦ ɧɚɞɨɤɧɚɞɨɦ ɤɪɜɧɟ ɩɥɚɡɦɟ ɢ ɤɪɜɧɢɯ ɟɥɟɦɟɧɚɬɚ ɚ ɚɤɨ ɧɢ ɬɚ ɥɢɧɢʁɚ ɨɞɛɪɚɧɟ ɧɟ ɭɫɩɟ, ɦɨɪɚɦɨ ɫɟ ɜɪɚɬɢɬɢ ɩɨɧɨɜɨ ɭ ɫɚɥɭ ɞɚ ɫɟ ɭɪɚɞɢ ɪɟɜɢɡɢʁɚ ɯɟɦɨɫɬɚɡɟ. ɋɜɟ ɨɜɨ ɞɨɞɚɬɧɨ ɩɨɜɟʄɚɜɚ ɪɢɡɢɤ ɚ ɢ ɫɚɦ ɤɜɚɥɢɬɟɬ ɨɩɟɪɚɰɢʁɟ. Ɋɟɜɢɡɢʁɚ ɯɟɦɨɫɬɚɡɟ ɢ ɩɪɟɬɯɨɞɧɚ PCI ɫɭ ɩɨɜɟɡɚɧɟ (p=0,009). Mɭɥɬɢɜaɪɢjaɧɬɧa ɛɢɧaɪɧa ɥoɝɢɫɬɢɱɤa ɪeɝɪeɫɢja ɩoɤaɡɭje ɞa ɪeɜɢɡɢja ɯɟɦoɫɬaɡe ɡaɜɢɫɢ oɞ ɩɪeɬɯoɞɧoɝ PCI (p = 0.005). Odds ratio ɡa ɩɪeɬɯoɞɧɢ PCI je 6.702 (1.768 – 25.413). ɉɪeɬɯoɞɧɢ PCI ɩoɜeʄaɜa ɪɢɡɢɤ oɞ ɯeɦoɫɬaɡe oɤo 7 ɩɭɬa. Ɉɞ ɨɫɬɚɥɢɯ ɛɢɬɧɢɯ ɩɨɫɬɨɩɟɪɚɬɢɜɧɢɯ ɤɨɦɩɥɢɤɚɰɢʁɚ ɫɢɝɭɪɧɨ ɞɚ ɡɚɫɥɭɠɭʁɭ ɢ ɩɨɪɟɦɟʄɚʁɢ ɫɪɱɚɧɨɝ ɪɢɬɦɚ. ɍ ɨɤɜɢɪɭ ɨɜɢɯ ɩɨɪɟɦɟʄɚʁɚ ɭ ɫɬɭɞɢʁɢ ɫɭ ɩɪɚʄɟɧɟ ɞɜɟ ɜɚɪɢʁɚɛɥɟ. ȳɟɞɧɚ ʁɟ ɫɭɩɪɚɜɟɧɬɪɢɤɭɥɚɪɧɟ ɟɤɫɬɪɚɫɢɫɬɨɥɟ ЋЏEЋ, ɚ ɞɪɭɝɚ ʁɟ ɜɟɧɬɪɢɤɭɥɚɪɧɟ ɟɤɫɬɪɚɫɢɫɬɨɥɟ ЏEЋ. SVES ɢ ɩɪɟɬɯɨɞɧɚ PCI ɫɭ ɩɨɜɟɡɚɧɟ (p=0,020). Mɭɥɬɢɜaɪɢjaɧɬɧa ɛɢɧaɪɧa ɥoɝɢɫɬɢɱɤa ɪeɝɪeɫɢja ɩoɤaɡɭje ɞa SVES ɡaɜɢɫɢ ɫaɦo oɞ ɩɪeɬɯoɞɧoɝ PCI (p = 0,015). Odds ratio ɡa ɩɪeɬɯoɞɧɢ PCI je 1,783 (1,117 – 2.864). ɉaɰɢjeɧɬɢ ɫa ɩɪeɬɯoɞɧɢɦ PCI ɢɦajɭ 78 % ɜeʄɢ ɪɢɡɢɤ ɡa SVE. 103 ɒɬɨ ɫɟ ɜɟɧɬɪɢɤɭɥɚɪɧɢɯ ɟɤɫɬɪɚɫɢɫɬɨɥɚ ɬɢɱɟ, ɨɧɟ ɧɟ ɫɚɦɨ ɞɚ ɫɭ ɩɨɜɟɡɚɧɟ ɫɚ ɩɪɟɬɯɨɞɧɢɦ PCI ɜɟʄ ɫɭ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɟ ɢ ɤɨɞ ɨɞɪɟђɟɧɨɝ ɩɨɥɚ (p=0,032). ɀɟɧɟ ɭ ɜɟʄɟɦ ɩɪɨɰɟɧɬɭ ɢɦɚʁɭ VES ɭ ɩɨɫɬɨɩɟɪɚɬɢɜɧɨɦ ɬɨɤɭ. Mɭɥɬɢɜaɪɢjaɧɬɧa ɛɢɧaɪɧa ɥoɝɢɫɬɢɱɤa ɪeɝɪeɫɢja ɩoɤaɡɭje ɞa ɩojaɜa ɜeɧɬɪɢɤɭɥaɪɧe aɪɢɬɦɢje ɡaɜɢɫɢ oɞ ɩɪeɬɯoɞɧoɝ PCI (p = 0,004), ɩoɥa (p = 0,025), ɞɢjaɛeɬeɫa (p = 0,027) a ɢɧɞɢɤaɬɢɜaɧ je ɭɬɢɰaj ɯɢɩeɪɬeɧɡɢje (p = 0,072). Odds ratio ɡa PCI je 1,966 (1,244 – 3.106). ɉɪeɬɯoɞɧɢ PCI ɩoɜeʄaɜa ɪɢɡɢɤ ɡa 96.6 %.Odds ratio ɡa ɩoɥ je 0,689 (0,497 – 0,953). Mɭɲɤaɪɰɢ ɢɦajɭ ɡa 31.1 % ɦaʃɢ ɪɢɡɢɤ oɞ ɠeɧa.Ɉɞɞɫ ɪɚɬɢɨ ɡa ɞɢjaɛeɬeɫ je 1,414 (1,041 – 1,923). Ⱦɢjaɛeɬeɫ ɩoɜeʄaɜa ɪɢɡɢɤ ɡa 41.4 %. 1 ɆɈȽɍȶɂ ɆȿɏȺɇɂɁȺɆ ɇȿȽȺɌɂȼɇɈȽ ɍɌɂɐȺȳȺ ɉɊȿɌɏɈȾɇȿ PCI ɋȺ ɋɌȿɇɌɈɆ ɇȺ CABG ɉɨɫɬɨʁɢ ɧɟɤɨɥɢɤɨ ɦɨɝɭʄɢɯ ɭɡɪɨɤɚ ɤɨʁɢ ɦɨɝɭ ɨɛʁɚɫɧɢɬɢ ɧɟɝɚɬɢɜɚɧ ɭɬɢɰɚʁ ɩɪɟɬɯɨɞɧɨɝ PCI ɫɚ ɫɬɟɧɬɨɦ ɧɚ CABG: 1. ȳɟɞɚɧ ɨɞ ʃɢɯ ɛɢ ɦɨɝɥɚ ɞɚ ɛɭɞɟ ɬɪɨɦɛɨɡɚ ɫɬɟɧɬɚ, ɤɨʁɚ ɫɟ ɧɚʁɱɟɲʄɟ ɢ ɞɟɲɚɜɚ ɭ ɩɪɜɢɯ ɲɟɫɬ ɦɟɫɟɰɢ ɩɨɫɥɟ ɢɦɩɥɚɧɬɚɰɢʁɟ ɚ ɧɚʁɱɟɲʄɟ ɩɨɫɥɟ ɫɬɨɩɢɪɚʃɚ ɚɧɬɢɚɝɪɟɝɚɰɢɨɧɟ ɬɟɪɚɩɢʁɟ ɩɪɟɞ ɨɩɟɪɚɰɢʁɭ. Ɉɜɚʁ ɪɢɡɢɤ ɨɞ ɢɧɫɬɟɧɬ ɬɪɨɦɛɨɡɟ ʁɟ ɜɟʄɢ ɤɚɞɚ ɫɟ ɪɚɞɢ ɨ ɜɟʄɟɦ ɛɪɨʁɭ ɫɬɟɧɬɨɜɚ, ɫɬɟɧɬɨɜɢɦɚ ɤɨʁɢ ɫɟ ɧɚɥɚɡɟ ɧɚ ɦɟɫɬɢɦɚ 104 ɛɢɮɭɪɤɚɰɢʁɟ ɤɪɜɧɨɝ ɫɭɞɚ, drug-eluting ɫɬɟɧɬɨɜɢɦɚ, ɩɚɰɢʁɟɧɬɢɦɚ ɤɨʁɢ ɫɭ ɞɢʁɚɛɟɬɢɱɚɪɢ ɢ ɛɭɛɪɟɠɧɢ ɛɨɥɟɫɧɢɰɢ109. 2. ɋɥɟɞɟʄɢ ɪɚɡɥɨɝ ɦɨɠɟ ɛɢɬɢ ɛɪɨʁ ɚɧɚɫɬɨɦɨɡɢɪɚɧɢɯ ɚɪɬɟɪɢʁɚ ɢɥɢ ɢɧɤɨɦɩɥɟɬɧɚ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɚ ɭ ɨɜɨʁ ɝɪɭɩɢ ɩɚɰɢʁɟɧɚɬɚ. ɇɚʁɱɟɲʄɢ ɪɚɡɥɨɡɢ ɫɭ ɨɤɥɭɞɢɪɚɧɚ ɚɪɬɟɪɢʁɚ ɢɥɢ ɨɧɟ ɫɚ ɜɢɲɟ ɫɬɟɧɬɨɜɚ. ɇɟɩɨɬɩɭɧɚ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɚ ɦɨɠɟ ɞɨɜɟɫɬɢ ɞɨ ɩɨɫɬɨɩɟɪɚɬɢɜɧɢɯ ɞɨɝɚђɚʁɚ ɤɚɨ ɲɬɨ ɫɭ ɢɧɮɚɪɤɬ ɢɥɢ ɫɦɪɬ110. ɍ ɨɜɨʁ ɫɬɭɞɢʁɢ ɩɚɰɢʁɟɧɬɢ ɫɚ ɩɪɟɬɯɨɞɧɢɦ PCI ɫɭ ɢɦɚɥɢ ɦɚʃɢ ɛɪɨʁ ɤɨɪɨɧɚɪɧɢɯ ɚɧɚɫɬɨɦɨɡɚ ɩɨ ɩɚɰɢʁɟɧɬɭ. 3. ɉɨɬɪɟɛɚ ɞɚ ɫɟ ɚɧɚɫɬɨɦɨɡɚ ɤɨɪɨɧɚɪɧɟ ɚɪɬɟɪɢʁɚ ɤɪɟɢɪɚ ɦɧɨɝɨ ɞɢɫɬɚɥɧɢʁɟ ɧɟɝɨ ɨɛɢɱɧɨ (ɡɛɨɝ ɩɪɢɫɭɫɬɜɚ ɫɬɟɧɬɚ ɭ ɫɪɟɞʃɨʁ ɬɪɟʄɢɧɢ ɚɪɬɟɪɢʁɟ) ɦɨɠɟ ɬɚɤɨђɟ ɞɚ ɛɭɞɟ ʁɟɞɚɧ ɨɞ ɧɟɝɚɬɢɜɧɢɯ ɭɬɢɰɚʁɚ ɧɚ ɢɫɯɨɞ. ɇɚ ɞɢɫɬɚɥɧɨɦ ɦɟɫɬɭ ɚɪɬɟɪɢʁɟ ɝɞɟ ʁɟ ʁɟɞɢɧɨ ɦɨɝɭʄɟ ɢɡɜɪɲɢɬɢ ɛɚʁɩɚɫ, ɚɪɬɟɪɢʁɚ ɢɦɚ ɦɧɨɝɨ ɦɚʃɢ ɞɢʁɚɦɟɬɚɪ, ɜɟʄɢ ɨɬɩɨɪ ɩɪɨɬɨɤɚ ɢ ɦɧɨɝɨ ʁɟ ɬɟɠɟ ɢɡɜɟɫɬɢ ɤɨɧɮɟɤɰɢʁɭ ɫɚɦɟ ɚɧɚɫɬɨɦɨɡɟ. Ɉɜɚʁ ɭɡɪɨɤ ʁɟ ɦɟɯɚɧɢɱɤɟ ɩɪɢɪɨɞɟ, ɩɨɜɟɡɚɧ ɫɚ ɯɢɪɭɪɲɤɨɦ ɬɟɯɧɢɤɨɦ, ɤɨʁɭ ʁɟ ɬɟɲɤɨ ɤɜɚɧɬɢɮɢɤɨɜɚɬɢ ɢ ɩɪɨɰɟɧɢɬɢ, ɚɥɢ ɞɟɮɢɧɢɬɢɜɧɨ ɢɝɪɚ ɛɢɬɧɭ ɭɥɨɝɭ ɭ ɩɪɜɢɦ ɪɟɡɭɥɬɚɬɢɦɚ ɯɢɪɭɪɲɤɨɝ ɥɟɱɟʃɚ. 4. ȳɨɲ ʁɟɞɚɧ ɨɞ ɭɡɪɨɤɚ ɤɨʁɢ ɛɢ ɦɨɝɚɨ ɞɚ ɫɟ ɫɜɪɫɬɚ ɩɨɞ ɦɟɯɚɧɢɱɤɨɦ ɩɪɢɪɨɞɨɦ ʁɟɫɬɟ ɢ ɫɚɦɚ ɤɚɪɞɢɨɯɢɪɭɪɲɤɚ ɢɧɬɟɪɜɟɧɰɢʁɚ. ɍ ɬɨɤɭ ɫɚɦɟ ɨɩɟɪɚɰɢʁɟ, ɤɚɞɚ ɫɟ ɫɪɰɟ ɡɚɭɫɬɚɜɢ , ɩɨɬɪɟɛɧɨ ʁɟ ɩɪɨɧɚʄɢ ɤɪɜɧɢ ɫɭɞ ɤɨʁɢ ɬɪɟɛɚ ɞɚ ɫɟ ɛɚʁɩɚɫɢɪɚ. Ⱥɤɨ ɫɟ ɪɚɞɢ ɨ ɤɨɪɨɧɚɪɧɨʁ ɚɪɬɟɪɢʁɢ ɡɚɞʃɟɝ ɡɢɞɚ, ɫɪɰɟ ɬɪɟɛɚ ɞɚ ɫɟ ɨɤɪɟɧɟ ɢ ɭɡ ɩɨɦɨʄ ɚɫɢɫɬɟɧɬɚ ɩɪɢɞɪɠɢ ɭ ɬɨɦ ɩɨɥɨɠɚʁɭ ɤɚɤɨ ɛɢ ɫɟ ɭɪɚɞɢɥɚ ɤɨɧɮɟɤɰɢʁɚ ɚɧɚɫɬɨɦɨɡɟ. ɍ ɬɨʁ ɦɚɧɢɩɭɥɚɰɢʁɢ ɥɚɤɨ ɦɨɠɟ ɞɚ ɫɟ ɨɲɬɟɬɢ ɤɪɜɧɢ ɫɭɞ ɭ ɤɨɦɟ ɫɟ ɧɚɥɚɡɢ ɫɬɟɧɬ ɚ ɩɨɫɥɟɞɢɰɟ ɦɨɝɭ ɞɚ ɛɭɞɭ ɮɚɬɚɥɧɟ. 105 5. ɑɟɬɜɪɬɢ ɭɡɪɨɤ ɦɨɠɟ ɛɢɬɢ ɩɪɢɫɭɫɬɜɨ ɜɢɲɟ ɤɨɪɨɧɚɪɧɢɯ ɢɧɬɟɪɜɟɧɰɢʁɚ, ɨɲɬɟʄɭʁɭʄɢ ɩɪɢɪɨɞɚɧ ɬɨɤ ɤɪɜɢ ɤɨɥɚɬɟɪɚɥɚ ɚ ɫɚɦɢɦ ɬɢɦ ɩɪɨɭɡɪɨɤɨɜɚʁɭʄɢ ɦɢɤɪɨ ɢɧɮɚɪɤɬɟ ɫɪɱɚɧɨɝ ɦɢɲɢʄɚ. Ʉɚɨ ɩɨɫɥɟɞɢɰɚ ɬɨɦɟ ɩɨɜɟʄɚɧ ʁɟ ɨɬɩɨɪ ɩɪɨɬɨɤɚ ɤɪɜɢ ɭ ɝɪɚɮɬɨɜɢɦɚ ɚ ɫɦɚʃɟɧɚ ɦɢɨɤɚɪɞɧɚ ɢɪɢɝɚɰɢʁɚ111. 6. Ɉɡɛɢʂɧɨɫɬ ɩɪɨɝɪɟɫɢʁɟ ɤɨɪɨɧɚɪɧɟ ɚɬɟɪɨɫɤɥɟɪɨɬɫɤɟ ɛɨɥɟɫɬɢ ɦɨɠɟ ɨɩɪɚɜɞɚɬɢ ɜɟʄɢ ɦɨɪɛɢɞɢɬɟɬ ɢ ɦɨɪɬɚɥɢɬɟ. ɉɚɰɢʁɟɧɬɢ ɤɨʁɢ ɫɭ ɜɟʄ ɛɢɥɢ ɧɚ PCI ɫɚ ɫɬɟɧɬɨɦ ɫɭ ɢɦɚɥɢ ɪɚɡɜɢʁɟɧɭ ɚɪɬɟɪɢɨɫɤɥɟɪɨɬɫɤɭ ɛɨɥɟɫɬ ɚɥɢ ɧɟ ɬɨɥɢɤɨ ɪɚɡɜɢʁɟɧɭ ɤɚɨ ɩɚɰɢʁɟɧɬɢ ɤɨʁɢ ɫɭ ɩɪɨɲɥɢ CABG. Ʉɚɞɚ ɩɚɰɢʁɟɧɬɢ ɤɨʁɢɦɚ ʁɟ ɢɦɩɥɚɧɬɢɪɚɧ ɫɬɟɧɬ ɞɨђɭ ɧɚ ɨɩɟɪɚɰɢʁɭ CABG, ɚɬɟɪɨɫɤɥɟɪɨɬɫɤɚ ɛɨɥɟɫɬ ʁɟ ɢ ɬɟ ɤɚɤɨ ɧɚɩɪɟɞɨɜɚɥɚ112. 7. ɉɚɰɢʁɟɧɬɢ ɤɨʁɢ ɭ ɫɜɨʁɨʁ ɢɫɬɨɪɢʁɢ ɢɦɚʁɭ ɭɪɚђɟɧɭ PCI ɬɟɨɪɟɬɫɤɢ ɛɢ ɬɪɟɛɚɥɨ ɞɚ ɛɭɞɟ ɩɨɞ ɦɧɨɝɨ ɛɨʂɢɦ ɤɚɪɞɢɨɥɨɲɤɢɦ ɬɪɟɬɦɚɧɨɦ ɢ ɬɟɪɚɩɢʁɨɦ. Ɉɜɢ ɩɚɰɢʁɟɧɬɢ ɩɨɫɥɟ ɩɟɪɤɭɬɚɧɟ ɤɨɪɨɧɚɪɧɟ ɢɧɬɟɪɜɟɧɰɢʁɟ ɛɢ ɬɪɟɛɚɥɨ ɞɚ ɞɨɥɚɡɟ ɤɨɞ ɫɜɨɝ ɢɧɬɟɪɜɟɧɬɨɧɝ ɤɚɪɞɢɨɥɨɝɚ, ɞɚ ɛɭɞɭ ɩɪɚʄɟɧɢ ɢ ɲɬɨ ɫɟ ɬɢɱɟ ɤɚɪɞɢɨɥɨɲɤɟ ɬɟɪɚɩɢʁɟ ɭ ɧɚʁɨɩɬɢɦɚɥɧɢʁɟɦ ɫɬɚʃɭ. ɂɡ ɫɜɟɝɚ ɨɜɨɝɚ ɫɟ ɧɚɦɟʄɟ ɢ ɪɚɡɦɢɲʂɚʃɟ ɞɚ ɱɚɤ ɝɪɭɩɚ ɩɚɰɢʁɟɧɚɬɚ ɤɨʁɚ ʁɟ ɢɦɚɥɚ ɩɪɟɬɯɨɞɧɢ PCI ɛɢ ɬɪɟɛɚɥɨ ɞɚ ɢɦɚ ɢ ɛɨʂɟ ɯɢɪɭɪɲɤɟ ɪɟɡɭɥɬɚɬɟ ɧɟɝɨ ɝɪɭɩɚ ɭ ɤɨʁɨʁ ʁɟ ɜɟʄɢɧɚ ɩɚɰɢʁɟɧɚɬɚ ɞɨɲɥɚ ɩɪɚɜɨ ɫɚ ɭɥɢɰɟ. 8. ɍ ɫɤɨɪɢʁɟ ɜɪɟɦɟ ɫɟ ɞɨɫɬɚ ɩɪɨɭɱɚɜɚɥɚ ɟɧɞɨɬɟɥɢʁɚɥɧɚ ɚɛɧɨɪɦɚɥɧɨɫɬ ɢɡɚɡɜɚɧɚ ɫɬɟɧɬɨɦ. ɉɨɫɬɨʁɟ ɞɨɤɚɡɢ ɤɨʁɢ ɭɤɚɡɭʁɭ ɞɚ ɤɨɪɨɧɚɪɧɢ ɫɬɟɧɬ ɢɡɚɡɢɜɚ ɥɟɡɢʁɟ ɭ ɡɢɞɭ ɤɪɜɧɨɝ ɫɭɞɚ, ɲɬɨ ɞɨɜɨɞɢ ɞɨ ɟɧɞɨɬɟɥɢʁɚɥɧɟ ɞɢɫɮɭɧɤɰɢʁɟ ɫɚ ɯɪɨɧɢɱɧɢɦ ɢɧɮɥɚɦɚɬɨɪɧɢɦ ɨɞɝɨɜɨɪɨɦ ɢ ɚɤɬɢɜɚɰɢʁɨɦ ɬɪɨɦɛɨɰɢɬɚ ɢ ɧɟɭɬɪɨɮɢɥɚ. Ɉɜɚʁ ɢɧɮɥɚɦɚɬɨɪɧɢ ɨɞɝɨɜɨɪ ɤɚɨ ɢ ɩɪɨɥɢɮɟɪɚɬɢɜɧɟ ɚɛɧɨɪɦɚɥɧɨɫɬɢ ɧɢɫɭ ɫɚɦɨ ɨɝɪɚɧɢɱɟɧɟ ɧɚ ɬɪɟɬɢɪɚɧɢ ɤɪɜɧɢ ɫɭɞ ɫɬɟɧɬɨɦ. ɍɬɢɱɭ ɢ ɧɚ ɞɪɭɝɟ ɤɨɪɨɧɚɪɧɟ 106 ɚɪɬɟɪɢʁɟ, ɨɤɨɥɧɚ ɬɤɢɜɚ, ɭɤʂɭɱɭʁɭʄɢ ɦɢɨɤɚɪɞ, ɲɬɨ ɫɜɟ ɞɨɜɨɞɢ ɞɨ ɧɟɠɟʂɟɧɢɯ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɢɯ ɞɨɝɚђɚʁɚ. ȿɧɞɨɬɟɥɢʁɚɥɧɚ ɚɛɧɨɪɦɚɥɧɨɫɬ ɤɪɜɧɨɝ ɫɭɞɚ ɦɨɠɟ ɨɬɟɠɚɬɢ ɤɨɧɮɟɤɰɢʁɭ ɫɚɦɟ ɤɨɪɨɧɚɪɧɟ ɚɧɚɫɬɨɦɨɡɟ ɭ ɬɨɤɭ CABG, ɲɬɨ ɤɚɨ ɪɟɡɭɥɬɚɬ ɫɟ ɨɝɥɟɞɚ ɭ ɫɦɚʃɟɧɨʁ ɩɚɬɟɧɬɨɫɬɢ ɝɪɚɮɬɚ113-115. Ɉɜɚʁ ɫɥɭɱɚʁ ʁɟ ɜɪɥɨ ɱɟɫɬ ɤɨɞ BMS ɚ ʁɨɲ ɜɢɲɟ ɢɧɬɟɡɢɜɧɢʁɢ ɤɨɞ drug-eluting ɫɬɟɧɬɚ115. 107 VIII ɁȺɄȴɍɑȺɄ ɇɚ ɨɫɧɨɜɭ ɪɟɡɭɥɬɚɬɚ ɫɬɭɞɢʁɟ, ɦɨɠɟ ɫɟ ɧɟɞɜɨɫɦɢɫɥɟɧɨ ɡɚɤʂɭɱɢɬɢ ɞɚ ɩɪɟɬɯɨɞɧɚ ɩɟɪɤɭɬɚɧɚ ɤɨɪɨɧɚɪɧɚ ɢɧɬɟɪɜɟɧɰɢʁɚ ɫɚ ɫɬɟɧɬɨɦ ɢɦɚ ɫɢɝɧɢɮɢɤɚɧɬɧɨ ɧɟɝɚɬɢɜɚɧ ɭɬɢɰɚʁ ɧɚ ɢɫɯɨɞ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ ɦɢɨɤɚɪɞɚ. Ɉɜɚʁ ɭɬɢɰɚʁ ɫɟ ɧɟ ɨɝɥɟɞɚ ɭ ɜɢɞɭ ɦɨɪɬɚɥɢɬɟɬɚ ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ ɜɟʄ ɭ ɫɦɢɫɥɭ ɤɨɦɩɥɢɤɚɰɢʁɚ, ɦɨɪɛɢɞɢɬɟɬɚ. ɉɚɰɢʁɟɧɬɢ ɤɨɞ ɤɨʁɢɯ ʁɟ ɪɚђɟɧɚ ɩɪɜɨ PCI ɫɚ ɫɬɟɧɬɨɦ ɚ ɩɨɬɨɦ ɯɢɪɭɪɲɤɚ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɚ ɢɦɚʁɭ ɦɧɨɝɨ ɜɟʄɢ ɩɪɨɰɟɧɚɬ ɩɟɪɢɨɩɟɪɚɬɢɜɧɨɝ ɢɧɮɚɪɤɬɚ. ɉɨɪɟɞ ɬɨɝɚ, ɫɬɨɩɚ ɩɨɫɬɨɩɟɪɚɬɢɜɧɨɝ ɤɪɜɚɪɟʃɚ ɤɨʁɟ ɞɨɜɨɞɢ ɞɨ ɩɨɧɨɜɧɨɝ ɭɥɚɫɤɚ ɭ ɨɩɟɪɚɰɢɨɧɭ ɫɚɥɭ ɢ ɪɟɜɢɡɢʁɟ ɯɟɦɨɫɬɚɡɟ ʁɟ ɦɧɨɝɨ ɜɟʄɢ. Ȼɪɨʁɧɟ ɤɨɦɩɥɢɤɚɰɢʁɟ ɫɭ ɦɧɨɝɨ ɜɢɲɟ ɡɚɫɬɭɩʂɟɧɟ ɭ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɢɦ PCI. ɉɨɪɟɦɟʄɚʁɢ ɪɢɬɦɚ ɭ ɜɢɞɭ ɫɭɩɪɚɜɟɧɬɪɢɤɭɥɚɪɧɢɯ ɢ ɜɟɧɬɪɢɤɭɥɚɪɧɢɯ ɟɤɫɬɪɚɫɢɫɬɨɥɚ ɫɭ ɱɟɲʄɢ ɭ ɨɜɨʁ ɝɪɭɩɢ. ɉɚɰɢʁɟɧɬɢ ɭ ɝɪɭɩɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI ɫɟ ɞɭɠɟ ɡɚɞɪɠɚɜɚʁɭ ɭ ʁɟɞɢɧɢɰɢ ɢɧɬɟɡɢɜɧɨɝ ɥɟɱɟʃɚ 108 IX ɄɅɂɇɂɑɄȿ ɂɆɉɅɂɄȺɐɂȳȿ ɂ ɆɈȽɍȶɇɈɋɌɂ ȾȺȴȿȽ ɂɋɌɊȺɀɂȼȺȵȺ Ʉɨɞ ɫɜɢɯ ɩɚɰɢʁɟɧɚɬɚ ɫɟ ɪɚɞɢ ɫɬɪɚɬɢɮɢɤɚɰɢʁɚ ɪɢɡɢɤɚ ɩɪɟ ɯɢɪɭɪɲɤɟ ɩɪɨɰɟɞɭɪɟ. ɋɜɪɯɚ ɫɬɪɚɬɢɮɢɤɚɰɢʁɟ ɪɢɡɢɤɚ ʁɟ ɞɚ ɪɚɡɞɜɨʁɢ ɜɢɫɨɤɨɪɢɡɢɱɧɟ ɩɚɰɢʁɟɧɬɟ ɨɞ ɦɚʃɟ ɪɢɡɢɱɧɢɯ. ɇɚ ɂɧɫɬɢɬɭɬɭ ɡɚ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɟ ɛɨɥɟɫɬɢ ȼɨʁɜɨɞɢɧɟ ɫɟ ɤɨɪɢɫɬɢ EuroScore ɡɚ ɫɬɪɚɬɢɮɢɤɚɰɢʁɭ ɪɢɡɢɤɚ. ɍ ɨɜɨʁ ɞɢɫɟɪɬɚɰɢʁɢ ɫɭ ɩɪɚʄɟɧɢ ɩɚɰɢʁɟɧɬɢ ɢ ɭɩɨɪɟђɢɜɚɧɢ ɩɨ ɜɪɟɞɧɨɫɬɢ EuroScore ɩɪɟɨɩɟɪɚɬɢɜɧɨ. ɉɚɰɢʁɟɧɬɢ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI ɫɭ ɢɦɚɥɢ ɧɢɠɢ ɫɤɨɪ ɩɪɟɨɩɟɪɚɬɢɜɧɨ ɧɟɝɨ ɩɚɰɢʁɟɧɬɢ ɤɨʁɢ ɫɭ ɪɟɜɚɫɤɭɥɚɪɢɡɨɜɚɧɢ ɫɚɦɨ ɯɢɪɭɪɲɤɨɦ ɦɟɬɨɞɨɦ. Ɋɚɡɥɨɝ ɡɚ ɨɜɨ ɬɪɟɛɚ ɬɪɚɠɢɬɢ ɭ ɜɟʄɟɦ ɛɪɨʁɭ ɫɬɚɪɢʁɢɯ ɩɚɰɢʁɟɧɚɬɚ ɭ ɝɪɭɩɢ ɩɚɰɢʁɟɧɚɬɚ ɛɟɡ PCI ɤɚɨ ɢ ɭ ɞɢʁɚɛɟɬɟɫɭ ɤɨʁɢ ʁɟ ɦɧɨɝɨ ɜɢɲɟ ɡɚɫɬɭɩɟʂɟɧ ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ ɢɡ ɨɜɟ ɝɪɭɩɟ. ɂɫɬɢɧɚ, ɩɪɟɬɯɨɞɧɚ PCI ɧɟ ɭɬɢɱɟ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɨ ɧɚ ɦɨɪɬɚɥɢɬɟɬ ɤɨɞ ɧɚɫɬɭɩɚʁɭʄɟ ɯɢɪɭɪɲɤɟ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɟ, ɨɧɚ ɡɧɚɱɚʁɧɨ ɦɟʃɚ ɦɨɪɛɢɞɢɬɟɬ ɭ ɨɞɧɨɫɭ ɧɚ ɩɟɪɢɨɩɟɪɚɬɢɜɧɢ ɢɧɮɚɪɤɬ ɦɢɨɤɚɪɞɚ, ɩɨɪɟɦɟʄɚʁ ɪɢɬɦɚ ɢ ɪɟɜɢɡɢʁɭ ɯɟɦɨɫɬɚɡɟ. ɋ ɨɛɡɢɪɨɦ ɧɚ ɪɟɡɭɥɬɚɬɟ ɦɧɨɝɨɛɪɨʁɧɢɯ ɫɬɭɞɢʁɚ ɭ ɤɨʁɢɦɚ ɫɟ ɞɨɜɨɞɢ ɭ ɩɢɬɚʃɟ PCI ɞɚ ɩɨɜɟʄɚɜɚ ɦɨɪɬɚɥɢɬɟɬ ɢ ɦɨɪɛɢɞɢɬɟɬ ɭ ɨɞɧɨɫɭ ɧɚ ɤɥɚɫɢɱɧɭ ɯɢɪɭɪɲɤɭ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɭ, ɤɚɨ ɢ ɪɟɡɭɥɬɚɬɟ ɢɡ ɨɜɟ ɞɢɫɟɪɬɚɰɢʁɟ, ɦɨɠɞɚ ɛɢ ɬɪɟɛɚɥɨ ɪɚɡɦɨɬɪɢɬɢ ɞɚ ɫɟ PCI ɭɜɪɫɬɢ ɤɚɨ ɪɢɡɢɤɨ ɮɚɤɬɨɪ ɭ ɫɬɪɚɬɢɮɢɤɚɰɢʁɢ ɪɢɡɢɤɚ ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ ɤɨʁɢɦɚ ɫɟ ɩɥɚɧɢɪɚ ɯɢɪɭɪɭɲɤɚ ɢɧɬɟɪɜɟɧɰɢʁɚ. 109 ɍ ɞɚʂɟɦ ɢɫɬɪɚɠɢɜɚʃɭ, ɛɢɥɨ ɛɢ ɩɨɬɪɟɛɧɨ ɩɪɨɲɢɪɢɬɢ ɫɬɭɞɢʁɭ ɧɚ ɜɟʄɢ ɛɪɨʁ ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɩɪɟɬɯɨɞɧɨɦ PCI ɤɨʁɢ ɫɭ ɧɚɤɨɧ ɬɨɝɚ ɥɟɱɟɧɢ ɯɢɪɭɪɲɤɨɦ ɪɟɜɚɫɤɭɥɚɪɢɡɚɰɢʁɨɦ ɢ ɯɨɦɨɝɟɧɢɡɚɰɢʁɨɦ ɝɪɭɩɚ ɤɨʁɟ ɩɪɟɦɚ ɜɚɪɢʁɚɛɥɚɦɚ ɞɢɪɟɤɬɧɨ ɭɬɢɱɭ ɧɚ ɢɫɯɨɞ (ɦɨɪɬɚɥɢɬɟɬ ɢ ɦɨɪɛɢɞɢɬɟɬ) ɤɚɨ ɲɬɨ ɫɭ ɞɢʁɚɛɟɬɟɫ, ɝɨɞɢɧɟ ɫɬɚɪɨɫɬɢ, ɩɪɟɬɯɨɞɧɨ ɭɡɢɦɚʃɟ ɚɧɬɢɚɝɪɟɝɚɰɢɨɧɢɯ ɥɟɤɨɜɚ ɢɥɢ ɫɬɚɬɢɧɚ (ɤɨʁɢ ɞɢɪɟɤɬɧɨ ɭɬɢɱɭ ɧɚ ɫɬɚɛɢɥɢɡɚɰɢʁɭ ɚɬɟɪɨɫɤɥɟɪɨɬɫɤɨɝ ɩɥɚɤɚ). ɂɫɬɨ ɬɚɤɨ ɬɪɟɛɚ ɩɥɚɧɢɪɚɬɢ ɢ ɞɭɝɨɪɨɱɧɟ ɫɬɭɞɢʁɟ ɭ ɤɨʁɢɦɚ ɛɟ ɫɟ ɢɫɬɪɚɠɢɜɚɨ ɪɚɡɜɨʁ ɢɫɯɟɦɢɱɧɟ ɦɢɬɪɚɥɧɟ ɪɟɝɭɪɝɢɬɚɰɢʁɟ, ɩɨɝɨɪɲɚʃɟ ɢɫɯɟɦɢɱɧɟ ɤɚɪɞɢɨɦɢɨɩɚɬɢʁɟ ɢ ɜɪɟɦɟ ɞɨ ɩɨɧɨɜɧɨɝ ɤɨɪɨɧɚɪɧɨɝ ɞɨɝɚђɚʁɚ. 110 X ɅɂɌȿɊȺɌɍɊȺ 1. World Health Organization; Cardiovascular diseases; Fact sheet N0 317, Septembar, 2011. 2. Nichols M, et al. European Cardiovascular Disease Statistics, 2012. 3. Mickovski N, JКФШvХУОvТć B, LКpčОvТć M., Klasifikacija, epidemiologija, faktori rizika i primarna prevencija ishemijske bolesti srca. Srce i krvni sudovi 2011; 30(3): 145-149 4. ɂɧɰɢɞɟɧɰɢʁɚ ɢ ɦɨɪɚɥɢɬɟɬ ɨɞ ɚɤɭɬɧɨɝ ɤɨɪɨɧɚɪɧɨɝ ɫɢɧɞɪɨɦɚ ɭ 2012, ɋɪɛɢʁɚ. ɂɧɫɬɢɬɭɬ ɡɚ ʁɚɜɧɨ ɡɞɪɚɜʂɟ ɋɪɛɢʁɟ ,,Ⱦɪ Ɇɢɥɚɧ ȳɨɜɚɧɨɜɢʄ Ȼɚɬɭɬ”, http://www.batut.org.rs 5. The Surf Report I.: Survellance of risk factors related to non communicans diseases: Current status of global data. WHO, 2003. 6. Grundy SM, et al.: Assessment of cardiovascular risk by use of multiple risk factor. Assessment equations. J Am Coll Cardiol l999; 34: 1348-59. 7. Conroy R. et al. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 2003;24:987-1003. 8. Allender S, et al. European Cardiovascular Disease Statistics, 2008 9. Falk E, Shah PK, Fuster V. Coronary plaque disruption. Circulation. Aug 1 1995;92(3):657-671. 10. Shah PK. Mechanisms of plaque vulnerability and rupture. J Am Coll Cardiol. Feb 19 2003;41(4 Suppl S):15S-22S. 11. Schoenhagen P, Ziada KM, Kapadia SR, Crowe TD, Nissen SE, Tuzcu EM. Extent and direction of arterial remodeling in stable versus unstable coronary syndromes: an intravascular ultrasound study. Circulation. Feb 15 2000;101(6):598-603. 12. Hutter JF, Soboll S. Role of fatty acid metabolites in the development of myocardial ischemic damage. Int J Biochem 1992;24(3):399-403. 13. 3. Murphy E, Cross HR, Steenbergen C. Is Na/Ca exchange during ischemia and reperfusion beneficial or detrimental? Ann N Y Acad Sci 2002;976:421-430. 14. 4. Buja LM, Entman ML. Modes of myocardial cell injury and cell death in ischemic heart disease. Circulation 1998;98(14):1355-1357. 15. 5. Halestrap AP. Calcium, mitochondria and reperfusion injury: a pore way to die. Biochem Soc Trans 2006;34(Pt 2):232-237. 16. 6. Scarabelli TM, Knight R, Stephanou A, Townsend P, Chen-Scarabelli C, Lawrence K, Gottlieb R, Latchman D, Narula J. Clinical implications of apoptosis in ischemic myocardium. Curr Probl Cardiol 2006;31(3):181-264. 17. 7. Piper HM, Garcia-Dorado D, Ovize M. A fresh look at reperfusion injury. Cardiovasc Res 1998;38(2):291-300. 111 18. 8. Yellon DM, Hausenloy DJ. Myocardial reperfusion injury. N Engl J Med 2007;357(11):1121- 1135. 19. 9. Halestrap AP, Kerr PM, Javadov S, Woodfield KY. Elucidating the molecular mechanism of the permeability transition pore and its role in reperfusion injury of the heart. Biochim Biophys Acta 1998;1366(1-2):79-94. 20. 10. Murry CE, Jennings RB, Reimer KA. Preconditioning with ischemia: a delay of lethal cell injury in ischemic myocardium. Circulation 1986;74(5):1124-1136. 21. Beck CS. Development of new blood supply to heart by operation.Ann. Surg. 1935; 102:801-13. 22. 56. O'Shaugnessy L. Experimental method of providing collateral circulation to the heart. J. Surg. 1936, 23:665-70. 23. 57. Mcallister FP, Leighninger D, Beck CS. Revascularization of the heart by grafts of systemic artery into coronary sinus. JAMA. 1938; 137:436-2. 24. 58. Thompson SA. Development of cardio-pericardial adhesions Following the use of talc. Proc. Soc Exp Biol. Med.1939; 40:260-1. 25. 59. Fauteux M, Palmer JH. Treatment of angina pectoris atheromatus of origin by ligation of great cardiac veins. Can Med Assoc J 1941; 45:295-9. 26. Vineberg AM. Development of anastomosis between coronary vessels and transplanted internal mammary artery. Can Med Assoc J. 1946; 55:117-9 27. Sones FM Jr, Shirey EK. Cine. coronary arteriography . Mod Concepts Cardiovasc Dis. 1962, 31:375-8. 28. Bailey CP, May A, Lemmon WM. Survival after coronary endarterectomy in man. JAMA 1957; 164:641-6. 29. Goetz RH, Robman M., Haller JD, Dee R, Rosenak SS. Internal mammary- coronary artery anastomosis. The method nonsuture Employing tantalum rings. J Thorac Cardiovasc Surg. 1961; 41:378-86. 30. Senning, A. Strip grafting in coronary arteries. J Thorac Cardiovasc Surg 1961; 41:542-9. 31. Kolesov VI, Potashov LV. Surgery of coronary arteries [in Russian]. Eksp Khir Anesteziol 1965;10:3–8. 32. Olearchyk AS. Vasilii I. Kolesov. A pioneer of coronary revascularization by internal mammary-coronary artery grafting. J Thorac Cardiovasc Surg 1988;96:13–8. [PubMed] 33. KШЧstКЧtТЧШv IE. TСО ХКst аШrН ШЧ “К prШpОr ЧКЦО ПШr tСО ТЧtОrЧКХ ЦКЦЦКrв КrtОrв”? AЧЧ TСШrКМ ЋurР 1999;68:1440–1. 34. Favaloro RG. Saphenous vein autograft replacement of severe segmental coronary artery occlusion: operative technique. Ann Thorac Surg 1968;5:334–9. 112 35. Sabiston DC. The coronary circulation. Hopkins Med J. 1974; 134:314-29. 36. Garrett HE, Dennis EW, De Bakey ME. Aortocoronary bypass with saphenous vein graft. Seven-Year-Jollow Up. JAMA 1973; 223:792-4. 37. Frutkin AD, Lindsey JB, SK Mehta, JA House, Spertus JA, Cohen DJ, Rumsfeld JS, Marso SP; NCDR (National Cardiovascular Data Registry). Drug-eluting stents and the use of percutaneous coronary intervention among pacientes with class I indications for coronary artery bypass surgery Undergoing index revascularization: analysis from the NCDR (National Cardiovascular Data Registry). JACC Cardiovasc Interv. 2009; 2 (7) :614-21. 38. Dean LS. Class I indications for coronary artery bypass graft surgery: what is the Appropriate therapy for pacientes with multivessel coronary disease? JACC Cardiovasc Interv. 2009; 2 (7) :622-3. 39. Hannan EL, Racz MJ, Gold J, K Cozzens, Stamato NJ, Powell T, Hibberd M, Walford G; American College of Cardiology, American Heart Association. Adherence of catheterization laboratory cardiologists to American College of Cardiology / American Heart Association Guidelines for percutaneous coronary interventions and coronary artery bypass graft surgery: what happens in actual practice? Circulation. 2010, 121 (2) :267-75. 40. Yap CH, Yan BP, Akowuah E, Dinh DT, Smith JA, Shardey GC, Tatoulis J, Skillington PD, Newcomb A, Mohajeri M, Pick A, Seevanayagam S, Reid CM. Does prior percutaneous coronary intervention adversely Affect early and mid- term survival after coronary artery surgery? JACC Cardiovasc Interv. 2009; 2 (8) :758-64. 41. Tran HA, Barnett SD, Hunt SL, Chon A, Ad N. The effect of previous coronary artery stenting on short-and intermediate-term outcome after surgical revascularization in Patients with diabetes mellitus. J Thorac Cardiovasc Surg. 2009, 138 (2) :316-23. 42. Hassan A, Buth KJ, RJ Baskett, IS Ali, Maitland A, Sullivan JA, Ghali WA, Hirsch GM. The association between prior percutaneous coronary intervention and short-term outcomes after coronary artery bypass grafting. Am Heart J. 2005, 150 (5) :1026-31. 43. Thielmann M, Leyh R, Massoudy P, Neuhäuser M, Aleksic I, Kamler M, et al. Prognostic significance of multiple previous percutaneous coronary interventions in patients undergoing elective coronary artery bypass surgery. Circulation. 2006;114(1 Suppl):I441-7. 44. Massoudy P, Thielmann M, Lehmann N, Marr A, Kleikamp G, Maleszka A, et al. Impact of prior percutaneous coronary intervention on the outcome of coronary artery bypass surgery: a multicenter analysis. J Thorac Cardiovasc Surg. 2009;137(4):840-5. 113 45. Toutouzas K, Colombo A, Stefanadis C. Inflammation and restenosis after percutaneous coronary interventions. Eur Heart J. 2004, 25 (19) :1679-87. 46. Gomes WJ, E. Buffolo Coronary stenting and inflammation: implications for Further surgical and medical treatment. Ann Thorac Surg. 2006, 81 (5) :1918-25. 47. Gomes WJ, Giannotti-Filho O, Hossne NA Jr, Catani R, E. Buffolo Inflammatory reaction after sirolimus-eluting stent implant. Ann Thorac Surg. 2005, 80 (5):1903-4. 48. Lüscher TF, Steffel J, Eberli FR, Joner M, Nakazawa G, Tanner FC, Virmani R. Drug-eluting stent and coronary thrombosis: biological mechanisms and clinical implications. Circulation. 2007, 115 (8) :1051-8. 49. Dallan LA, Gowdak LH, Lisboa LA, Milanez AM, Platania F, Moreira LF, Stolf NA. Modification of an old procedure (Vineberg) in the stem cell was: a new strategy? Arq Bras Cardiol. 2009, 93 (5): E79-81. 50. Kolessov VI Mammary artery-coronary artery anastomosis the method of treatment for angina pectoris. J Thorac Cardiovasc Surg. 1976, 54:535-44. 51. JR Morris GC, Howell JF, Crawford S, Reul GJ, Chapman DW, Beazley HL, Winters WL, Petersom PK. The distal coronary bypass. Ann Surg. 1970, 172:652- 62. 52. Gruntzig A. Transluminal dilatation of coronary-artery stenosis. (Letters) Lancet. 1978; 4:263. 53. Detre, K. , Holubkov, R. , Kelsey, S. , And tHE Co-Investigators of the National Heart, Lung, and Blood Intitute's percutaneous Transluiminal Coronary Angioplasty Registry. Percutaneous coronary transluiminal angioplasty in 1985- 1986 and 1977-1981. N. Engl. J. Med 1988; 318:265-70. 54. Coronary angioplasty versus coronary artery bypass surgery: the Randomized Intervention Treatment of Angina (RITA) trial. Coronary angioplasty versus coronary artery bypass surgery. Lancet. 1993, 341 (8845) :573-80. 55. Emory Angioplasty versus Surgery Trial (EAST) King SB 3rd, Lembo NJ, Weintraub WS, Kosinski AS, Barnhart HX, Kutner MH, Alazraki NP, Guyton RA, Zhao XQ. A randomized trial Comparing coronary angioplasty with coronary bypass surgery. N Engl J Med 1994, 331 (16) :1044-50. 56. German Angioplasty Bypass Surgery Investigation (GABI). Hamm CW, Reimers J, Ischinger T, Rupprecht HJ, Berger J, Bleifeld W. The randomized Compared study of coronary angioplasty with bypass surgery in pacientes with symptomatic multivessel coronary disease. N Engl J Med 1994, 331 (16) :1037-43. 114 57. Coronary Angioplasty versus Bypass Revascularisation Investigation. CABRI Trial Participants. First year results of CABRI (Coronary Angioplasty versus Bypass Revascularization Investigation). Lancet. 1995, 346 (8984) :1179-84. 58. The Bypass Angioplasty Revascularization Investigation (BARI) Investigators. Comparison of coronary bypass surgery with angioplasty in pacientes with multivessel disease. N Engl J Med 1996, 335 (4) :217-25. 59. King III, SB. The development of interventional cardiology.J. Am Col. Cardiol.1998, 31:64 B-88B. 60. U Sigwart, J Purl, Mirkovitch V, Joffre F, L. Kappenberger Intravascular to Prevent and stent occlusion after transluminal reestenosis angioplsty. N Engl J Med 1987; 316:701-6. 61. Colombo A, Hall P, Nakamura S, Almagor Y, Maiello L, Martini G, Gaglione A, Goldberg SL, Tobis JM. Intracoronary stenting without anticoagulation accomplished with intravascular ultrasound guidance. Circulation. 1995, 91:1676- 88. 62. Barragan, P. , Sainsous, J. , Silvestri, M. , Bouvier JL, Comet, B. ; Simeoni, JB; Charmasson, C. , Bremondy, M. Ticlopidine and subcutaneous heparin to an alternative regimen Following coronary stenting. Cathet. Cardiovasc. Diag.1994; 32:133-8. 63. Sousa AG, Mattos LA, Campos Neto CM, Carvalho HG, Stella FP, Nunes G. Percutaneous myocardial revascularization procedures in Brazil in 1996 - 1997 Compared to the 1992-1993 period: the report of the National Registry - National Center for Cardiovascular Interventions (CENIC)]. Arq Bras Cardiol. 1998, 70: 423-30. 64. Morice MC, Serruys PW, Sousa JE, J Fajadet Ban HE, Perin M, et al. The randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N Engl J Med 2002, 346: 1773-80. 65. Moses JW, Leon MB, Popma JJ, Fitzgerald PJ, Holmes DR, O'Shaughnessy C., et al. Sirolimus-eluting stents versus standard stents in pacientes with stenosis in a native coronary artery. N Engl J Med 2003; 349: 1315-23. 66. Joner M, Finn AV, Farb A, Mont EK, FD Kolodgie, Ladich E, et al. Pathology of drug-eluting stents in humans: delayed healing and late thrombotic risk. J Am Coll Cardiol. 2006, 48: 193-202. 67. Pfisterer M, Brunner-La Rocca HP, Buser PT, Rickenbacher P, Hunziker P, C Mueller, et al. Late clinical events after clopidogrel discontinuation may limit the benefit of drug-eluting stents: an observational study of drug-eluting versus bare- metal stents. J Am Coll Cardiol. 2006, 48: 2584-91. 115 68. Sastry S, Morice MC. Are drug-eluting stents safe and effective in the long term? Arq Bras Cardiol. 2010, 95 (5) :663-70. 69. Patrick W. Serruys, MD, Ph.D., Marie-Claude Morice, MD, A. Pieter Kappetein, MD, Ph.D., Antonio Colombo, MD, David R. Holmes, MD, Michael J. Mack, MD, Elisabeth Ståhle, MD, Ted E. Feldman, MD, Marcel van den Brand, MD, Eric J. Bass, BA, Nic Van Dyck, RN, Katrin Leadley, MD, Keith D. Dawkins, MD, and Friedrich W. Mohr, MD, Ph.D. SYNTAX for the Investigators. Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease. N Engl J Med 2009, 360:961-972 70. Jones RH, Kesler K, Phillips HR 3rd, Mark DB, Smith PK, Nelson CL, Newman MF, Reves JG, Anderson RW, Califf RM. Long-term survival benefits of coronary artery bypass grafting and percutaneous transluminal angioplasty in pacientes with coronary artery disease. J Thorac Cardiovasc Surg. 1996, 111 (5) :1013-25. 71. ACC / AHA 2004 - Guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology / American Heart Association task force on practice guidelines (committee to update the 1999 Guidelines for coronary artery bypass graft surgery). Circulation. 2004, 110 (14): e340-437. 72. ESC 2006 Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the management of stable angina pectoris of the European Society of Cardiology.; ESC Committee for practice guidelines (CPG). Eur Heart J. 2006 Jun, 27 (11) :1341-81. 73. ACCF / SCAI / STS / AATS / AHA / ASNC 2009 Appropriateness criteria for coronary revascularization: a report by the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology Endorsed by the American Society of Echocardiography, the Heart Failure Society of America, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol. 2009, 53 (6) :530-53. 74. Sianos G, Morel MA, Kappetein AP, et al. The SYNTAX score: an angiographic tool grading the complexity of CAD. EuroInterv 2005; 1: 219-227. 75. The Bypass Angioplasty Revascularization Investigation (BARI) Investigators. Comparison of coronary bypass surgery with angio- plasty in patients with multivessel disease. N Engl J Med 1996;335:217–225. 76. CABRI Trial: First-year results of CABRI (Coronary Angioplasty versus Bypass Revascularisation Investigation). Lancet 1995 Nov 4; 346(8984): 1179-84 116 77. Coronary angioplasty versus coronary artery bypass surgery: the Randomized Intervention Treatment of Angina (RITA) trial. Lancet. 1993 Mar 6;341(8845):573-80. 78. Eight-year mortality in the Emory Angioplasty versus Surgery Trial (EAST).J Am Coll Cardiol. 2000 Apr;35(5):1116-21. 79. Angiographic follow-up results of a randomized study on angioplasty versus bypass surgery (GABI trial). GABI Study Group. Eur Heart J. 1996 Aug;17(8):1192-8. 80. The Medicine, Angioplasty or Surgery Study (MASS): a prospective, randomized trial of medical therapy, balloon angioplasty or bypass surgery for single proximal left anterior descending artery stenoses. J Am Coll Cardiol. 1995 Dec;26(7):1600- 5. 81. Three-year follow-up of the argentine randomized trial of percutaneous transluminal coronary angioplasty versus coronary artery bypass surgery in multivessel disease (ERACI). Journal of the American College of Cardiology,Volume 27, Issue 5, April 1996, Pages 1178–1184 82. The Final Analysis of the Arterial Revascularization Therapies Study (ARTS) Randomized Trial. J Am Coll Cardiol. 2005;46(4):575-581. doi:10.1016/j.jacc.2004.12.082 83. Coronary artery bypass surgery versus percutaneous coronary intervention with stent implantation in patients with multivessel coronary artery disease (the Stent or Surgery trial): a randomised controlled trial. Lancet. 2002 Sep 28;360(9338):965- 70. 84. Ten-Year Follow-Up Survival of the Medicine, Angioplasty, or Surgery Study (MASS II). Circulation. 2010; 122: 949-957 85. AWESOME randomized trial and registry experience with post-CABG patients. J Am Coll Cardiol. 2002;40(11):1951-1954. doi:10.1016/S0735-1097(02)02560-3 86. Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, Stahle E, Feldman TE, van den Brand M, Bass EJ and others. Percutaneous coronary intervention versus coronary-artery bypass graft-ing for severe coronary artery disease. N Engl J Med. 2009;360:961-72 87. Kappetein AP. Optimal revascularization strategy in patients with three-vessel disease and/or left main disease: The 2-year Outcomes of the SYNTAX Trial. The European Society of Cardiology (ESC) 2009. 88. Kapur A. CARDia trial (Coronary Artery Revascularisation in Diabetes). European Society of Cardiology (ESC) Congress September 2008. 117 89. Serruys PW, Lemos PA, van Hout BA. Sirolimus eluting stent implantation for patients with multivessel disease: rationale for the Arterial Revascularisation Therapies Study part II (ARTS II). Heart. 2004;90:995-8. 90. Rodriguez AE, Maree AO, Mieres J, Berrocal D, Grinfeld L, Fernandez-Pereira C, Curotto V, Rodriguez-Granillo A, O'Neill W, PalaciosIF. Late loss of early benefit from drug-eluting stents when com-pared with bare-metal stents and coronary artery bypass surgery: 3 years follow-up of the ERACI III registry. Eur Heart J. 2007;28:2118-25. 91. Oliveira, SA.; Zerbini, EJ.; Barchi, CA.; Marrara, JP.; Carvalho, VB.; Mady, C.; Armelin, E., Castillo, J.; Macruz, R., Pileggi, F. Intermediate syndrome, results of surgical treatment. Arq Bras Cardiol . 1975; 28:89-98. 92. Buffolo, E., Andrade JCS; Succi, JE; Lion, LEV; Cueva, C, White, JNR; C. Gallucci Direct myocardial revascularization without cardiopulmonary bypass.Description of technique and early results . Arq Bras Cardiol.1982:38:365- 73. 93. Buffolo, E; Andrade, JCS; Succi, J; Lion, LEV; C. Gallucci Direct myocardial revascularization without cardiopulmonary bypass. Thorac Cardiovasc Surgeon. 1985; 33:26-9. 94. Benetti FJ. Direct coronary surgery with saphenous vein bypass without either cardiopulmonary bypass or cardiac arrest. J Cardiovasc Surg. 1985, 26:217-22. 95. Benetti FJ, Naselli G, M Wood, L. Geffner Direct mycardial revascularization without extracorporeal circulation. Experience in 700 patients. Chest 1991; 100:312-6. 96. Rivetti LA; Gandra SMA; Silva AMRP; Campagnucci VP. Myocardial revascularization without cardiopulmonary bypass, using a intracardiac shunt: 12 years' experience. Rev Bras Cir Cardiovasc . 1997, 12 (3) :226-32. 97. Stanbridge R, GV Symons; Banwell PE. Minimal-access surgery for coronary artery revascularisation. (Letter). Lancet 1995, 346:837. 98. Benetti FJ, Ballester C; Sani G, P Doonstra; Grandjean J. Video assisted coronary bypass surgery. J. Card. Surg. 1995, 10:620-5. 99. AM Calafiore, GD Angelini, J Bergsland, TA Salerno Minimally invasive coronary artery bypass grafting. Ann. Thorac. Surg. 1996, 62:1545-8. 100. Nataf P. Lima L, Regan M; Benarim S; Pavie A, Cabrol C; Gandjbakch, I. Minimally invasive coronary surgery with thoracoscopic internal mammary artery dissection: surgical technique. J. Card. Surg. 1996, 11:288-92. 101. Borst C, Jansen EWL; Tulleken CAF; Grundeman PF; Beck HJM; Dongen JWF; Hodde KC; Bredee JJ. Coronary artery bypass grafting without 118 cardiopulmonary bypass and without interruption of native coronary flow using a novel anastomosis site restraining device ('Octopus'). J. Am Coll. Cardiol. 1996, 27:1356-64. 102. Subramanian VA; Mccabe JC, Geller CM. Minimally invasive direct coronary artery bypass grafting: two-year clinical experience. Ann. Thorac. Surg. 1997, 64:1648-55. 103. And Buffolo; Gerola LR. Coronary artery bypass grafting without cardiopulmonary bypass through sternotomy and minimally invasive procedure. Int J Cardiol. 1997, 62 (Suppl I): S89 - S 93. 104. Jatene F; Fernandes PMP; Hayata ALS; Arbulu HEV; Stolf NAG; Oliveira SA; Kalil R; hueb W; Jatene AD. VATS for complete dissection of Lima in minimally invasive coronary artery bypass grafting. Ann. Thorac. Surg. 1997, 63 (Suppl): S 110 - 13. 105. Braile DM, Leal JCF.; Soares MJ; Godoi MF; Paiva O; Junior OP; Brandi AC; Braille MCVB; Avanci LE; Zaiantchick M. Revascularization grafting with minimally invasive surgery (MIDCAB): results in 46 patients. Rev. Bras. Cir. Cardiovasc. 1998, 13:194-7. 106. Oliveira SA, Lisbon LA, LA Dallan, SO Rojas, Poli de Figueiredo LF.Minimally invasive single-vessel coronary artery bypass with the internal thoracic artery and early postoperative angiography: midterm results of a prospective study in 120 consecutive patients. Ann Thorac Surg. 2002, 73 (2) :505-10. 107. Lisbon LA, LA Dallan, De Figueiredo LF, Molnar L, Filho EM, Ramires JA, SA De Oliveira. A prospective comparison of Doppler echocardiography and postoperative angiography in the assessment of left internal thoracic artery graft in 72 pacientes submitted to minimally invasive direct coronary artery bypass. Heart Surg Forum. 2002; 5 Suppl 4: S362-77. 108. Mohr FW, Falk V Diegeler A, Walther T Gummert JF, Bucerius J Jacobs S, Autschbach R. Computer-enhanced "robotic" cardiac surgery: experience in 148 patients. J Thorac Cardiovasc Surg. 2001, 121 (5) :842-53. 109. Kappert U, Schneider J, Cichon R, V Gulielmos, Tugtekin SM, Nicolai J, Matschke K, Schueler S. Development of robotic enhanced endoscopic surgery for the treatment of coronary artery disease. Circulation. 2001, 104 (12 Suppl 1): I102-7 110. Bonatti J, Schachner T, Bernecker O, The Chevtchik, Bonaros N, Ott H, Friedrich G, Weidinger F, Laufer G. Robotic totally endoscopic coronary artery bypass: program development and learning curve issues. J Thorac Cardiovasc Surg. 2004, 127 (2) :504-10. 119 111. Bonatti J, Schachner T Bonaros N, Oehlinger A, Wiedemann D, E Ruetzler, Weidinger F, Kolbitsch C, G Feuchtner, Zimrin D, Friedrich G, Pachinger O, Laufer G. Effectiveness and safety of full endoscopic left internal mammary artery bypass graft to the left anterior descending artery. Am J Cardiol. 2009, 104 (12) :1684-8. 112. Kappert U, Tugtekin SM, Cichon R, Braun M, Matschke K. Robotic totally endoscopic coronary artery bypass: a word of caution implicated by a five-year follow-up. J Thorac Cardiovasc Surg. 2008, 135 (4) :857-62. 113. Ryan TJ, Faxon, DP, Gunnar RM, Kennedy JW, King III, SB; Loop, FD; Petersom, KL, Reeves TJ, Williams, DO, JR Winters, W. L. Guidelines for percutaneous transluminal coronary angioplasty. Circulation 1988; 78:486-502. 114. Detre, K. , Holubkov, R. , Kelsey, S. , And tHE Co-Investigators of the National Heart, Lung, and Blood Intitute's percutaneous Transluiminal Coronary Angioplasty Registry. Percutaneous coronary transluiminal angioplasty in 1985- 1986 and 1977-1981. N. Engl. J. Med 1988; 318:265-70. 115. King III, SB. The development of interventional cardiology.J. Am Col. Cardiol.1998, 31:64 B-88B.