Кардиоэмболический инсульт: классификация причин и стратегии профилактики

В лекции отражены многообразие кардиоэмболического инсульта (КЭИ), гетерогенность источников эмболии и неоднородность морфологических характеристик эмболического субстрата. Подчеркивается, что определение индивидуальной тактики вторичной профилактики базируется на верификации конкретных кардиальных причин инсульта, для удобства стратифицированных как патология камер, клапанов сердца и варианты парадоксальной эмболии. Показано, что ведущей патологией камер сердца, ассоциированной с КЭИ, служат неклапанная фибрилляция предсердий и тромбоз левого желудочка, а основой профилактики инсульта при данной патологии является пероральная антикоагулянтная терапия с помощью прямых оральных антикоагулянтов либо антагонистов витамина К (варфарин). Основными видами патологии клапанов сердца являются протезированные клапаны и ревматический митральный стеноз. В этом случае основой вторичной профилактики также служит пероральная антикоагулянтная терапия. При отсутствии необходимости назначать антикоагулянты (в основном при патологии естественных клапанов сердца) препаратом выбора является ацетилсалициловая кислота. При инфекционном эндокардите базисными стратегиями профилактики являются антибактериальная терапия и хирургические вмешательства. Хирургическая тактика также остается основной для профилактики КЭИ при опухолях левых отделов сердца. Все шире в повседневную практику интервенционной медицины с целью профилактики ишемического инсульта внедряются транскатетерное закрытие открытого овального окна и окклюзия ушка левого предсердия. Взвешенный индивидуальный подход к пациенту, целенаправленное кардиологическое обследование, комплексный анализ клинико-инструментальных данных и обоснованное использование средств, доказавших свою эффективность и безопасность в рамках основных стратегий профилактики инсульта, закладывают основы действенной профилактики КЭИ.

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