medsovetМедицинский СоветMeditsinskiy sovet = Medical Council2079-701X2658-5790REMEDIUM GROUP Ltd.10.21518/ms2023-326medsovet-7807Research ArticleХИРУРГИЯSURGERYПольза и риски реваскуляризации у пациента с ишемической болезнью сердца старческого возраста: есть ли оптимальный выбор?Benefits and risks of revascularization in senile coronary artery disease patients: is there any optimal choice?https://orcid.org/0009-0009-5664-8766РахимиН. А.RakhimiN. A.

Рахими Навид Ахмад - аспирант кафедры интервенционной кардиологии и кардиореабилитации факультета дополнительного профессионального образования.

117997, Москва, ул. Островитянова, д. 1

Nawid Ahmad Rakhimi - Postgraduate Student of Department of Interventional Cardiology and Cardiac Rehabilitation, Faculty of Additional Professional Education.

1, Ostrovityanov St., Moscow, 117997

rahimi.2024@mail.ruhttps://orcid.org/0000-0003-4918-3795КонстантиноваЕ. В.KonstantinovaE. V.

Константинова Екатерина Владимировна - доктор медицинских наук, доцент кафедры факультетской терапии имени академика А.И. Нестерова, профессор кафедры интервенционной кардиологии и кардиореабилитации, РНИМУ имени Н.И. Пирогова; врач-кардиолог, ГКБ №1 имени Н.И. Пирогова.

117997, Москва, ул. Островитянова, д. 1; 119049, Москва, Ленинский проспект, д. 8

Ekaterina V. Konstantinova - Dr. Sci. (Med.), Associate Professor of Academician A.I. Nesterov Department of Intermediate Level Therapy, Professor of Department of Interventional Cardiology and Cardiac Rehabilitation, Pirogov RNRMU; Cardiologist, CCH No. 1 named after N.I. Pirogov.

1, Ostrovityanov St., Moscow, 117997; 8, Lenin Ave., Moscow, 119049

katekons@mail.ruhttps://orcid.org/0009-0006-3655-1586ВеликоцкийА. А.VelikotskiyA. A.

Великоцкий Антон Александрович - врач-рентгенхирург.

119049, Москва, Ленинский проспект, д. 8

Anton A. Velikotskiy - X-Ray Surgeon.

8, Lenin Ave., Moscow, 119049

vel_aa@mail.ruhttps://orcid.org/0009-0007-4694-6140ПлощенковЕ. В.PloshchenkovE. V.

Площенков Евгений Валерьевич - заведующий отделением рентгенхирургических методов диагностики и лечения.

119049, Москва, Ленинский проспект, д. 8

Evgeniy V. Ploshchenkov - Head of Department of X-ray Surgical Diagnostic Methods and Treatment.

8, Lenin Ave., Moscow, 119049

Jenya-09@inbox.ruhttps://orcid.org/0000-0003-4140-5058СветловаО. Н.SvetlovaO. N.

Светлова Ольга Николаевна - врач-кардиолог.

119049, Москва, Ленинский проспект, д. 8

Olga N. Svetlova – Cardiologist.

8, Lenin Ave., Moscow, 119049

svetolga@ro.ruhttps://orcid.org/0000-0001-9981-5952НестеровА. П.NesterovА. P.

Нестеров Алексей Петрович - кандидат медицинских наук, заместитель главного врача по терапевтической помощи, ГКБ №1 имени Н.И. Пирогова; доцент кафедры интервенционной кардиологии и кардиореабилитации факультета дополнительного профессионального образования, РНИМУ имени Н.И. Пирогова.

117997, Москва, ул. Островитянова, д. 1; 119049, Москва, Ленинский проспект, д. 8

Alexey P. Nesterov - Cand. Sci. (Med.), Deputy Chief Medical Officer for Therapeutic Care, CCH No. 1 named after N.I. Pirogov; Associate Professor of Department of Interventional Cardiology and Cardiac Rehabilitation, Faculty of Additional Professional Education, Pirogov RNRMU.

1, Ostrovityanov St., Moscow, 117997; 8, Lenin Ave., Moscow, 119049

drcor@mail.ruРоссийский национальный исследовательский медицинский университет имени Н.И. ПироговаРоссияPirogov Russian National Research Medical UniversityRussian FederationРоссийский национальный исследовательский медицинский университет имени Н.И. Пирогова; Городская клиническая больница №1 имени Н.И. ПироговаРоссияPirogov Russian National Research Medical University; City Clinical Hospital No. 1 named after N.I. PirogovRussian FederationГородская клиническая больница №1 имени Н.И. ПироговаРоссияCity Clinical Hospital No. 1 named after N.I. PirogovRussian Federation202321102023016108116Copyright © Рахими Н.А., Константинова Е.В., Великоцкий А.А., Площенков Е.В., Светлова О.Н., Нестеров А.П., 20232023Рахими Н.А., Константинова Е.В., Великоцкий А.А., Площенков Е.В., Светлова О.Н., Нестеров А.П.Rakhimi N.A., Konstantinova E.V., Velikotskiy A.A., Ploshchenkov E.V., Svetlova O.N., Nesterov А.P.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.med-sovet.pro/jour/article/view/7807

В последние годы наблюдается увеличение в популяции пациентов с ишемической болезнью сердца числа пожилых больных. У пациентов пожилого и особенно старческого возраста типично имеется коморбидная патология, многососудистое поражение коронарных артерий, их кальцификация, что затрудняет лечение. Данные доказательной медицины, позволяющие однозначно выбрать оптимальную тактику ведения пожилого пациента, не совсем убедительны до настоящего времени, поскольку крупные рандомизированные клинические исследования включают не очень значительный процент пациентов данного возраста, исключая пациентов с тяжелыми сопутствующими заболеваниями. В представленном случае у пациента 80 лет с выраженным кальцинозом и многососудистым поражением коронарных артерий выполнение второго этапа чрескожного коронарного вмешательства осложнилось рецидивирующей диссекцией передней межжелудочковой артерии, тромбозом стента ствола левой коронарной артерии, что потребовало имплантации 8 стентов и введения блокаторов IIb/IIIa рецепторов тромбоцитов с последующей клинической картиной возникшего желудочнокишечного кровотечения. В представленном клиническом случае с одной стороны имелись факторы риска развития ишемических событий и тромбоза стента, с другой – риски развития геморрагических осложнений. Важной особенностью представленного случая была вынужденная необходимость имплантации большого количества стентов, что само по себе является фактором риска развития рестеноза. При обсуждении данного случая затрагиваются различные вопросы, включая выбор оптимальной тактики ведения пациента 80 лет с многососудистым поражением коронарных артерий. Геморрагические риски в описанном случае также были высокими. Врачам необходимо было принимать непростые решения, чтобы достичь оптимального баланса между возможной пользой и риском. С целью совершенствования ведения пациентов пожилого возраста представляется необходимым не только дальнейшее проведение исследований, но и накопление и обсуждение клинических данных.

There has been an increase in the population of elderly patients with coronary artery disease (CAD) in recent years. Elderly and, especially, senile patients typically have comorbid conditions, multivessel coronary artery disease and coronary calcification, which make treatment more challenging. The available data from evidence-based medicine is not enough to determine the best treatment strategies for elderly patients, because large randomized clinical trials usually do not include elderly individuals with severe comorbidities. In the presented case, an 80-year-old patient with severe calcification and multivessel coronary artery disease experienced recurrent dissection of the left anterior descending artery (LAD) and stent thrombosis of the left main coronary artery (LMCA) during the second phase of percutaneous coronary intervention, which required the implantation of 8 stents and administration of glycoprotein IIb/IIIa inhibitors, leading to the clinical manifestation of gastrointestinal bleeding. An important feature of the presented case was the necessity to implant a large number of stents, which is a risk factor for restenosis. Various issues are discussed in this case, including the choice of optimal management strategy for an 80-year-old patient with multivessel coronary artery disease. Physicians had to make difficult decisions to achieve a balance between potential benefit and risk. In order to improve the management of elderly patients, further research is needed, as well as the accumulation and discussion of clinical data.

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The authors declare that there are no conflicts of interest present.