Криптогенный инсульт. Часть 3: предсердная кардиопатия и скрытая фибрилляция предсердий

Предсердная кардиопатия (ПК) и скрытая фибрилляция предсердий (ФП) – потенциальные причины эмболического криптогенного инсульта (embolic stroke of undetermined source, ESUS), своевременная диагностика которых может существенно изменить направление вторичной профилактики и снизить риск повторной мозговой катастрофы. В статье обсуждаются клинические и радиологические маркеры кардиоэмболии, концепция предсердной кардиопатии, ее электрокардиографические, эхокардиографические и сывороточные маркеры, а также возможности медикаментозной профилактики повторного инсульта. Наиболее применимыми в ежедневной работе признаками ПК служат данные ЭКГ (конечная отрицательная часть зубца P в отведении V1 > 5000 μV х мс, наджелудочковые экстрасистолы и далекозашедшая межпредсердная блокада), 24-часового холтеровского мониторирования ЭКГ (≥ 480 наджелудочковых экстрасистол в сутки, пароксизмы наджелудочковой тахикардии ≥ 20 комплексов), трансторакальной (диаметр левого предсердия > 40 мм, индекс диаметра левого предсердия ≥ 3 см/м², индекс объема левого предсердия > 34 мл/м²) и чреспищеводной эхокардиографии (феномен спонтанного эхоконтрастирования, скорость кровотока в ушке ЛП < 20 см/с), а также концентрация NT-proBNP > 250 пг/мл. Целесообразно индивидуальное, междисциплинарное решение вопроса о назначении антикоагулянта при сочетании: (1) наличия структурных и функциональных маркеров ПК, (2) кардиоэмболического паттерна инфаркта мозга или окклюзии интракраниальной артерии по данным визуализации и (3) высокого тромбоэмболического риска и вероятности выявления ФП по оценочным шкалам (CHA2DS2-VASc, AF-ESUS и C2HEST). Наибольшую пользу от назначения антикоагулянтной терапии могут получить пациенты с повторным ESUS на фоне адекватной вторичной профилактики с выраженной ПК, типичным кардиоэмболическим визуализационным паттерном и высоким риском тромбоэмболических событий.

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