Феномен no-reflow и реперфузионное повреждение миокарда: механизмы и методы лечения

В настоящее время одним из ключевых методов лечения пациентов с инфарктом миокарда с подъемом сегмента ST является как можно более быстрое, полное и устойчивое восстановление кровотока в инфарктсвязанной артерии. Однако в ряде случаев добиться адекватной реперфузии миокарда не удается, несмотря на восстановление коронарного кровотока. Данный феномен получил название “no-reflow”, или «синдром невосстановленного коронарного кровотока». В связи с отсутствием единого подхода к диагностике no-reflow его встречаемость варьируется в широких пределах – от 2 до 44 %. Недостижение адекватной перфузии миокарда приводит к более высокой летальности – от 7,4 до 30,3 %, а также к более агрессивному ремоделированию миокарда. Длительное время одним из ведущих механизмов считалась дистальная эмболия при чрескожном коронарном вмешательстве. Однако рутинное использование защитных устройств не показало выраженного влияния на исход и прогноз, хотя и является оправданным в отдельных клинических ситуациях. Существенную роль играет непосредственно ишемическое повреждение за счет перегрузки кардиомиоцитов ионами кальция, клеточного отека, некроза и апоптоза, что значительно усугубляется при реперфузии миокарда и формирует обструкцию на уровне микроциркуляторного русла. Все больше данных накапливается об иммуноопосредованном повреждении посредством активации клеточного иммунитета, интенсивного воспаления и тромбоза in situ. Несмотря на успехи экспериментов на животных, клиническое применение отдельных групп препаратов показало неоднозначный результат. Согласно последним рекомендациям Европейского общества кардиологов и Европейской ассоциации кардиоторакальных хирургов (European Society of Cardiology / European Association for Cardio-Thoracic Surgery, ESC / EACTS) от 2018 г. в случае no-reflow рекомендовано использование ингибиторов GPIIb / IIIa-рецепторов тромбоцитов. Кроме того, согласно данным литературы перспективным кажется применение никорандила и нитропруссида натрия, а также антагонистов интерлейкина 1β. В качестве немедикаментозной терапии заслуживает внимания селективная интракоронарная гипотермия, показавшая свою эффективность и безопасность в пилотном исследовании. На сегодняшний день ясно, что феномен no-reflow является проявлением сложного каскада реакций, включающих ишемическое, реперфузионное и иммунное повреждение, а также дистальную эмболию. Учитывая его весомый вклад в частоту неблагоприятных исходов и поздних осложнений, кажется необходимым введение единого подхода к диагностике, профилактике и лечению, что требует проведения качественных клинических исследований.

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