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"lead": "Заболевание, характеризующееся первичным избирательным поражением миокарда",
"description": "<p>Кардиомиопатия - это <span style=\"background-color: transparent; font-family: Verdana; font-size: 7pt; white-space: pre-wrap;\">заболевание миокарда неизвестной этиологии, основными признаками которой являются кардиомегалия (увеличение размеров сердца) и/или сердечная недостаточность.</span></p>\r\n<p><span style=\"background-color: transparent; font-family: Verdana; font-size: 7pt; white-space: pre-wrap;\"> </span></p>",
"etiology": "<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Существует три группы основных причин развития первичной кардиомиопатии: врожденная, смешанная, и приобретенная. К вторичным относятся кардиомиопатии вследствие какого-либо заболевания.</span></p>\r\n<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Врождённая патология сердца развивается вследствие нарушения закладки тканей миокарда во время эмбриогенеза. Причин очень много, начиная от вредных привычек будущей матери и заканчивая стрессами и неправильным питанием. Также известны кардиомиопатии беременных и воспалительные кардиомиопатии, которые по существу можно назвать миокардитом.</span></p>\r\n<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">К вторичным формам относятся следующие виды:</span></p>\r\n<p> </p>\r\n<ul style=\"margin-top: 0; margin-bottom: 0; padding-inline-start: 48px;\">\r\n<li style=\"list-style-type: disc; font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Кардиомиопатия накопленная или инфильтративная. Для нее характерно накопление между клетками или в клетках патологических включений.</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Токсическая кардиомиопатия.</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Эндокринная кардиомиопатия (метаболическая кардиомиопатия, дисметаболическая кардиомиопатия) возникает вследствие нарушения обмена веществ в сердечной мышце.</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Алиментарная кардиомиопатия образуется в результате нарушения питания, а в частности при длительных диетах с ограничением мясных продуктов или голодании.</span></p>\r\n</li>\r\n</ul>",
"pathogenesis": "<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">В основе ишемической кардиомиопатии лежит нарушение кровоснабжения миокарда, которое запускает цепочку патологических реакций: некроза, фиброза, активации тканевой ренин-ангиотензиновой системы. Важную роль играет механизм прекондиционирования, который заключается в многократных эпизодах ишемии с реперфузией сердечной мышцы. Частое повторение такого процесса активирует АТФ-зависимые насосы и увеличивает порог ишемического повреждения.</span></p>\r\n<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Морфологически при кардиомиопатии на фоне ИБС наблюдается увеличение массы сердца до 500-700 г и тотальное расширение его полостей. При этом наблюдается диспропорциональное истончение стенки левого желудочка, очаги крупноочагового фиброза сердечной мышцы. Характерно обширное атеросклеротическое поражение коронарных сосудов, участки артериальных стенозов и окклюзии, кальцификация в начальных отделах аорты.</span></p>",
"diagnostics": "<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Обследование начинается с подробного опроса пациента – сбора анамнестических данных. Это необходимо для установления первопричины патологии. Далее следует тщательная аускультация (выслушивание) сердечных тонов и шумов, после чего больного направляют на проведение инструментальных и лабораторных исследований. Основными из них являются:</span></p>\r\n<ul style=\"margin-top: 0; margin-bottom: 0; padding-inline-start: 48px;\">\r\n<li style=\"list-style-type: disc; font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 7pt; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Клинический и биохимический анализы крови, мочи. С их помощью оценивается функциональное состояние сосудов, печени, почек. Также помогает выявить первопричину болезни генетическая диагностика.</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 7pt; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">ЭКГ. Регистрируется электрическая активность миокарда в момент исследования, отображаясь на кардиограмме характерными признаками КМП.</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 7pt; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Холтеровское мониторирование ЭКГ. Оценивается степень нарушений ритма.</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 7pt; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Рентгенография грудной клетки. Подтверждает увеличение сердца в размерах.</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 7pt; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Эхокардиография (УЗИ сердца). Метод позволяет узнать точные размеры сердечных камер, их функциональную активность.</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 7pt; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Коронарография. Показана при постоянных приступах стенокардии.</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 7pt; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">МРТ. Проводится перед оперативным вмешательством.</span></p>\r\n</li>\r\n</ul>",
"treatment": "<p align=\"justify\">Специфическая терапия кардиомиопатий отсутствует, поэтому все лечебные мероприятия имеют целью предотвращение несовместимых с жизнью осложнений. Лечение кардиомиопатий в стабильной фазе амбулаторное, при участии кардиолога; периодическая плановая госпитализация в отделение кардиологии показана пациентам с тяжелой сердечной недостаточностью, экстренная – в случаях развития некупируемых пароксизмов тахикардии, желудочковой экстрасистолии, мерцательной аритмии, тромбоэмболий, отека легких.</p>\r\n<p align=\"justify\">Пациентам с кардиомиопатиями необходимо снижение физической активности, соблюдение диеты с ограниченным потреблением животных жиров и соли, исключение вредных окружающих факторов и привычек. Эти мероприятия существенно снижают нагрузку на сердечную мышцу и замедляют прогрессирование сердечной недостаточности.</p>\r\n<p align=\"justify\">При кардиомиопатиях целесообразно назначение диуретиков для уменьшения легочного и системного венозного застоя. При нарушениях сократимости и насосной функции миокарда применяются сердечные гликозиды. Для коррекции сердечного ритма показано назначение противоаритмических препаратов. Предотвратить тромбоэмболические осложнения позволяет использование антикоагулянтов и антиагрегантов в лечении пациентов с кардиомиопатиями.</p>\r\n<p align=\"justify\">В исключительно тяжелых случаях проводят хирургическое лечение кардиомиопатий: септальную миотомию (резекцию гипертрофированного участка межжелудочковой перегородки) с протезированием митрального клапана либо трансплантацию сердца.</p>\r\n<p>Летальность при ГКМП зависит от формы заболевания и возраста пациента. Прогноз хуже у молодых больных в отсутствие оперативного лечения. Смертность достигает 50 % в год от желудочковых нарушений ритма. Прогноз благоприятный у пациентов успешно перенесших оперативное вмешательство. Второй механизм смерти — застойная сердечная недостаточность, как правило у пациентов средней и старшей возрастной категории.</p>",
"prevention": "<p>Первичная профилактика направлена на предупреждение развития кардиомиопатии. С этой целью рекомендуется соблюдать следующие рекомендации, позволяющие снизить воздействие факторов риска возникновения этого патологического состояния:</p>\r\n<ul>\r\n<li>отказ от употребления высоких доз алкоголя;</li>\r\n<li>ограничение контакта с профессиональными вредностями, токсическими материалами;</li>\r\n<li>использование средств индивидуальной защиты на производстве;</li>\r\n<li>сбалансированное питание с достаточным содержанием белка, витаминов группы В, селена, карнитина;</li>\r\n<li>предупреждение развития метаболических расстройств, например, сахарного диабета;</li>\r\n<li>предупреждение и своевременное лечение вирусных инфекций;</li>\r\n<li>адекватное лечение воспалительных заболеваний сердечной стенки;</li>\r\n<li>планирование и профессиональное ведение беременности.</li>\r\n</ul>\r\n<p>К сожалению, встречаются идиопатические формы кардиомиопатиии, причина развития которых не установлена. Не существует методов профилактики возникновения и наследственной кардиомиопатии. Остается лишь добавить, что лицам с генетической предрасположенностью к данной патологии следует особенно тщательно соблюдать рекомендации по первичной профилактике. Родственники больных кардиомиопатией должны наблюдаться у кардиолога и регулярно выполнять УЗИ сердца.</p>\r\n<p>Вторичная профилактика</p>\r\n<p>Мероприятия вторичной профилактики кардиомиопатии направлены на предупреждение прогрессирования данного заболевания, а также препятствуют возникновению осложнений. Кроме того пациентам с таким диагнозом следует снизить риск развития заболевания, которые могут значительно ухудшить течение кардиомиопатии. Прежде всего, это профилактика ишемической болезни сердца и артериальной гипертензии.</p>\r\n<p>К методам вторичной профилактики кардиомиопатии относят следующее:</p>\r\n<ul>\r\n<li>отказ от занятий спортом и тяжелым физическим трудом. Таким пациентам показана регулярная легкая физическая нагрузка;</li>\r\n<li>регулярное наблюдение у специалиста;</li>\r\n<li>регулярное выполнение ЭхоКГ;</li>\r\n<li>проведение регулярной антибиотикопрофилактики инфекционного эндокардита дает возможность значительно снизить риск развития этого опасного состояния;</li>\r\n<li>регулярный прием препаратов, назначенных специалистом. Обычно терапия таких больных включает использование диуретиков, антикоагулянтов, антигипертензивных средств и антиаритмиков;</li>\r\n<li>хирургическое лечение некоторых разновидностей кардиомиопатии является эффективным методом улучшения качества жизни пациентов с таким диагнозом. Так протезирование митрального клапана, удаление сосочковых мышц и части межжелудочковой перегородки при гипертрофической кардиомиопатиии дает возможность на долгие годы нормализовать внутрисердечную гемодинамику;</li>\r\n<li>полный отказ от курения и приема алкоголя;</li>\r\n<li>установка электрокардиостимулятора может быть показана некоторым больным с кардиомиопатией с целью предупреждения развития жизнеугрожающих аритмий;</li>\r\n<li>борьба с избыточной массой тела;</li>\r\n<li>снижение потребления соли;</li>\r\n<li>избегание стрессовых ситуаций;</li>\r\n<li>нормализация режима труда и отдыха;</li>\r\n<li>регулярный контроль уровня холестерина и сахара крови;</li>\r\n<li>отказ от самолечения.</li>\r\n</ul>\r\n<p>Проведение грамотной первичной и вторичной профилактики кардиомиопатии дает возможность предупредить развитие и прогрессирование этого заболевания.</p>",
"clinical_picture": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Долгое время болезнь протекает бессимптомно, проявляя себя только изредка недомоганием и дискомфортом за грудиной. Человек может узнать о своем заболевании случайно – во время прохождения в целях профилактики электрокардиографии или ультразвукового исследования сердца.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">При значительном изменении сердечного аппарата больной жалуется на следующие патологические признаки:</span></p>\r\n<p> </p>\r\n<ul style=\"margin-top: 0; margin-bottom: 0; padding-inline-start: 48px;\">\r\n<li style=\"list-style-type: disc; font-size: 6.999999999999999pt; font-family: Verdana; color: #092148; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">одышка и удушье при интенсивных нагрузках, стрессе;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.999999999999999pt; font-family: Verdana; color: #092148; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">бледно-синюшный цвет лица и кончиков пальцев на фоне одышки;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.999999999999999pt; font-family: Verdana; color: #092148; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">отечность голеней, лодыжек, стоп;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.999999999999999pt; font-family: Verdana; color: #092148; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">головные боли с эпизодами головокружения;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.999999999999999pt; font-family: Verdana; color: #092148; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">давящие боли в области сердца, сопровождающиеся онемением левой половины туловища;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.999999999999999pt; font-family: Verdana; color: #092148; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">ощущение перебоев в работе сердца или частого сердцебиения;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.999999999999999pt; font-family: Verdana; color: #092148; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">необъяснимая выраженная слабость;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.999999999999999pt; font-family: Verdana; color: #092148; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">эпизоды потери сознания.</span></p>\r\n</li>\r\n</ul>",
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},
"code": "R42",
"name": "Приступ головокружения и нарушение устойчивости",
"icd_name": "Головокружение и нарушение устойчивости",
"gender": 0,
"age_min": 0,
"age_max": 100,
"cause": [
3,
0
],
"periodicity": 1,
"slug": "r42_pristup_golovokruzheniya_i_narushenie_ustoychivosti",
"lead": "патологическое состояние, проявляющееся в ощущении вращения либо окружающих предметов вокруг человека, либо самого человека вокруг собственной оси",
"description": "",
"etiology": "<p>Причинами головокружения могут быть повреждение ядер вестибулярного нерва в продолговатом мозге, повреждение периферических волокон вестибулярного нерва, наличие патологического процесса в вестибулярных рецепторах. <a href=\"/symptom/golovokruzhenie/\" title=\"Перейти на страницу симптома Головокружение\">Головокружение</a> также является симптомом болезни Меньера, опухолей задней черепной ямки, невротических состояний.</p>",
"pathogenesis": "<p>А. Вестибулярное <a href=\"/symptom/golovokruzhenie/\" title=\"Перейти на страницу симптома Головокружение\">головокружение</a> (истинное <a href=\"/symptom/golovokruzhenie/\" title=\"Перейти на страницу симптома Головокружение\">головокружение</a>, вертиго) обычно обусловлено поражением периферического или центрального отдела вестибулярной системы. Оно проявляется иллюзией движения собственного тела или окружающих предметов. При этом возникают ощущения вращения, <a href=\"/symptom/narushenie_koordinacii/\" title=\"Перейти на страницу симптома Нарушение координации\">падения</a>, наклона или раскачивания. Острое <a href=\"/symptom/golovokruzhenie/\" title=\"Перейти на страницу симптома Головокружение\">головокружение</a> часто сопровождается вегетативными симптомами (тошнотой, рвотой, повышенным потоотделением), чувством страха, нарушением равновесия и нистагмом (последний иногда приводит к нечеткости зрения).</p>\r\n<p>Б. <a href=\"/symptom/obmorok/\" title=\"Перейти на страницу симптома Обморок\">Обморок</a> и предобморочное состояние. Этими терминами обозначают временную потерю сознания или ощущение приближающейся потери сознания. В предобморочном состоянии часто наблюдаются <a href=\"/symptom/potlivost/\" title=\"Перейти на страницу симптома Потливость\">повышенное потоотделение</a>, <a href=\"/symptom/toshnota/\" title=\"Перейти на страницу симптома Тошнота\">тошнота</a>, чувство страха и потемнение в глазах. Непосредственная причина обморока - <a href=\"/symptom/golovokruzhenie/\" title=\"Перейти на страницу симптома Головокружение\">падение</a> мозгового кровотока ниже уровня, необходимого для обеспечения мозга глюкозой и кислородом. <a href=\"/symptom/obmorok/\" title=\"Перейти на страницу симптома Обморок\">Обморок</a> и предобморочное состояние обычно развиваются на фоне артериальной гипотонии, заболеваний сердца или вследствие вегетативных реакций, и тактика при этих состояниях совершенно иная, чем при вестибулярном головокружении.</p>\r\n<p>В. Нарушение равновесия характеризуется неустойчивостью, шаткой («пьяной») походкой, но не истинным головокружением. Причина этого состояния - поражения различных отделов нервной системы, обеспечивающих пространственную координацию. Однако больные с мозжечковыми, зрительными, экстрапирамидными и проприоцептивными расстройствами часто определяют ощущение неустойчивости как «<a href=\"/symptom/golovokruzhenie/\" title=\"Перейти на страницу симптома Головокружение\">головокружение</a>».</p>\r\n<p>Г. Неопределенные ощущения, часто описываемые как <a href=\"/symptom/golovokruzhenie/\" title=\"Перейти на страницу симптома Головокружение\">головокружение</a>, возникают при эмоциональных расстройствах, таких, как гипервентиляционный синдром, ипохондрический или истерический <a href=\"/symptom/nervoznost/\" title=\"Перейти на страницу симптома Нервозность\">невроз</a>, <a href=\"/symptom/depressiya/\" title=\"Перейти на страницу симптома Депрессия\">депрессия</a>. Больные обычно жалуются на «туман в голове», чувство легкого опьянения, дурноту или <a href=\"/symptom/strah/\" title=\"Перейти на страницу симптома Страх\">страх</a> <a href=\"/symptom/narushenie_koordinacii/\" title=\"Перейти на страницу симптома Нарушение координации\">падения</a>. Эти ощущения достаточно четко отличаются от ощущений при вестибулярном головокружении, обморочных состояниях и нарушениях равновесия. Поскольку любое <a href=\"/symptom/golovokruzhenie/\" title=\"Перейти на страницу симптома Головокружение\">головокружение</a>, независимо от его причины, может вызвать <a href=\"/symptom/trevozhnost/\" title=\"Перейти на страницу симптома Тревожность \">тревожность</a>, она не может служить доказательством психогенной природы заболевания.</p>\r\n<p>Д. Некоторые больные с жалобами на <a href=\"/symptom/golovokruzhenie/\" title=\"Перейти на страницу симптома Головокружение\">головокружение</a> затрудняются описать свои ощущения. В этом случае целесообразно провести провокационные пробы.</p>\r\n<p>1. Стандартный набор провокационных проб на <a href=\"/symptom/golovokruzhenie/\" title=\"Перейти на страницу симптома Головокружение\">головокружение</a> включает:</p>\r\n<p>а. Ортостатическую пробу.<br />б. Форсированную гипервентиляцию в течение 3 мин.<br />в. Резкие повороты во время ходьбы или круговое вращение в положении стоя.<br />г. Пробу Нилена-Барани на позиционное <a href=\"/symptom/golovokruzhenie/\" title=\"Перейти на страницу симптома Головокружение\">головокружение</a>.<br />д. Пробу Вальсальвы, которая усиливает <a href=\"/symptom/golovokruzhenie/\" title=\"Перейти на страницу симптома Головокружение\">головокружение</a>, обусловленное краниовертебральными аномалиями (например, синдромом Арнольда-Киари) или перилимфатической фистулой, а также вызывает предобморочное состояние у больных сердечно-сосудистыми заболеваниями.</p>\r\n<p>2. После каждой пробы необходимо спросить, напоминает ли возникшее <a href=\"/symptom/golovokruzhenie/\" title=\"Перейти на страницу симптома Головокружение\">головокружение</a> то ощущение, которое беспокоит больного. При ортостатической гипотонии, гипервентиляционном синдроме, позиционном головокружении и многих вестибулярных нарушениях результаты проб хорошо воспроизводятся, что позволяет получить важную диагностическую информацию.</p>",
"diagnostics": "<p>Проводится на основании жалоб, данных анамнеза, объективного осмотра.</p>",
"treatment": "<p>Патогенетическую терапию при головокружении проводят с учетом механизмов возникновения вестибулярного синдрома. При дисциркуляторных расстройствах назначают вазоактивные препараты, соответствующие типу ангиодистонии, антиагреганты и препараты, улучшающие микроциркуляцию. Специфическое лечение при системном головокружении известно лишь для ограниченного круга заболеваний. <a href=\"/symptom/golovokruzhenie/\" title=\"Перейти на страницу симптома Головокружение\">Головокружение</a> в рамках вертебробазилярной недостаточности требует назначения антиагрегантов (ацетилсалициловая кислота 75–330 мг/сут., тиклопедин 500 мг/сут.), а при нарастании симптоматики — антикоагулянтов. Эффективность противовирусных препаратов и глюкокортикоидов не доказана.</p>\r\n<p>Лечение приступов болезни Меньера симптоматическое. Наиболее эффективен бетагистин, который является ингибитором диаминоксидазы — фермента, инактивирующего гистамин. Стабилизируя образующийся в организме гистамин, бетагистин оказывает гистаминоподобное действие. Препарат эффективен при пероральном применении. Основными показаниями для применения являются болезнь Меньера, водянка лабиринта внутреннего уха, синдромы, характеризующиеся приступами головокружения, шумом в ушах, понижением слуха, тошнотой, рвотой. Препарат оказывает расслабляющее действие на прекапиллярные запирательные мышцы в системе микроциркуляции внутреннего уха, увеличивая таким образом приток крови к сосудистой полоске лабиринта. Снижает частоту и интенсивность головокружений, уменьшает <a href=\"/symptom/shum_v_ushah/\" title=\"Перейти на страницу симптома Шум в ушах\">шум в ушах</a>, улучшает слух в случае его снижения. Средняя суточная доза по 1 таблетке 3 раза в день. С осторожностью следует назначать препарат больным, имеющим в анамнезе язвенную болезнь желудка или двенадцатиперстной кишки. Бетагистин не показан при беременности, бронхиальной астме, наличии феохромоцитомы.</p>\r\n<p>Для профилактики назначают диету с пониженным содержанием соли и диуретики. Для симптоматического лечения системного головокружения применяют вестибулолитические средства, действующие на вестибулярные рецепторы либо на центральные вестибулярные структуры, главным образом вестибулярные ядра. К первым относятся антигистаминные препараты: меклозин назначают 12,5–25 мг внутрь 4 раза в сутки, прометазин — 25–50 мг внутрь 4–6 раз в сутки. Центральным вестибулолитическим эффектом обладают бензодиазепины: оксазепам — 10–15 мг внутрь 4 раза в сутки, диазепам — 5–10 мг внутрь, в/м или в/в 4–6 раз в сутки. Также применяют стимулятор гистаминовых рецепторов бетагистин — 8–16 мг внутрь 2–3 раза в сутки, антагонисты кальция (циннаризин 25–50 мг внутрь или в/м 4 раза в сутки, флунаризин 10 мг в сутки во второй половине дня).</p>\r\n<p>Эффективным средством для лечения головокружений является комбинированный препарат, содержащий 400 мг пирацетама и 25 мг циннаризина. Его назначают по 2 капсулы 3 раза в день в течение 3–6 недель.</p>\r\n<p>Для купирования тошноты и рвоты назначают прохлорперазин 5–10 мг внутрь или в/м 4 раза в сутки или метоклопрамид 5–50 мг внутрь, в/м или в/в 4–6 раз в сутки. Центральным вестибулолитическим и противорвотным действием обладает тиэтилперазин. Назначают 6,5 мг внутрь, ректально, п/к, в/м или в/в 1–3 раза в сутки. Эффективно сочетание антигистаминных препаратов и бензодиазепинов. Для уменьшения седативного эффекта вестибулолитических средств рекомендуется назначение метилфенидата гидрохлорида 5 мг внутрь 2 раза в сутки (в первой половине дня). Вестибулолитические средства следует назначать лишь при остром системном головокружении. Их прием должен быть максимально кратким, так как длительное применение замедляет процесс центральной компенсации дефекта.</p>\r\n<p>При всех формах вестибулярного синдрома назначают лекарственные средства, снижающие возбудимость центральных и периферических отделов вестибулярного анализатора и подавляющие сопутствующие вегетативные реакции. Антигистаминные препараты применяют как для лечения, так и для профилактики головокружения. Назначают дифенгидрамин 2–3 раза в день внутрь (0,02–0,05 г), в свечах (0,01–0,02) или по 1 мл 1% раствора в мышцу; прометазин 2–3 раза в день внутрь (0,025 г) или по 2 мл 5% раствора в мышцу; дименгидринат по 50–100 мг внутрь 2–3 раза в день. Нейролептики подавляют возбудимость центральных вегетативных образований. При головокружении предпочтительнее назначать тиэтилперазин по 1 таблетке (0,0065 г) 1–2 раза в день внутрь, в свечах (0,0065 г) или по 1 мл в вену или мышцу; алимемазин внутрь по 0,005 г 2–4 раза в день; метоклопрамид по 0,01 г 2–3 раза в день внутрь или по 1–2 мл в мышцу или вену. При выраженных сопутствующих вегетативных реакциях назначают хлорпромазин, галоперидол, левомепромазин. При хроническим вестибулярном синдроме проводят этиотропную терапию, эффективны повторные курсы биостимуляторов (алоэ, ФИБС, стекловидное тело, апилак, кокарбоксилаза, витамины группы В) и ноотропные препараты.</p>\r\n<p>При лечении тяжелых пароксизмов больному внутримышечно вводят 2 мл тиэтилперазина или метоклопрамида, 1–2 мл диазепама, 1–2 мл дифенгидримина или прометазина, под кожу 0,5–1 мл платифиллина, дают внутрь 1 таблетку беллатаминала. При приступе болезни Меньера рекомендуется приложить грелку к ногам, на шейно-затылочную область — горчичник, внутримышечно вводят 1–2 мл тиэтилперазина и 2 мл метоклопрамида, 1 мл прометазина, в вену — 5 мл 0,5% раствора новокаина на 20 мл 40% раствора глюкозы, 40 мг фуросемида. При неэффективности этих мер вводят внутримышечно 1 мл аминазина, под кожу — 1 мл 0,1% раствора атропина сульфата и 1 мл 10% раствора кофеина-бензоата натрия.</p>\r\n<p>Вестибулярная <a href=\"/symptom/migren/\" title=\"Перейти на страницу симптома Мигрень\">мигрень</a> купируется при сочетании холинолитиков и альфа-адреноблокаторов, дифенина и транквилизаторов. Для межприступного лечения мигрени назначают курсы бета-блокаторов, антисеротониновые средства, антагонисты кальция. При головокружении, возникшем на фоне повышения ВЧД или отека лабиринта, применяют диуретики, ограничивают прием жидкости, назначают бессолевую диету. Больным, страдающим головокружением инфекционно-токсического генеза, проводят противовоспалительную, дегидратирующую и дезинтоксикационную терапию. При головокружении вследствие медикаментозной интоксикации отменяют или уменьшают дозу препарата, вызвавшего <a href=\"/symptom/golovokruzhenie/\" title=\"Перейти на страницу симптома Головокружение\">головокружение</a>, назначают дезинтоксикационную терапию, витамины и вазоактивные средства. При головокружении, вызванном эндогенной интоксикацией в случаях нарушения метаболизма, необходимы коррекция электролитов плазмы и КОС, дезинтоксикационная терапия, препараты витаминов. Психогенное <a href=\"/symptom/golovokruzhenie/\" title=\"Перейти на страницу симптома Головокружение\">головокружение</a> купируется психотропными средствами.</p>",
"prevention": "",
"clinical_picture": "<p>Приступ головокружения сопровождается чувством вращения окружающих предметов вокруг человека либо вращения самого человека вокруг собственной оси. Больные предъявляют жалобы на повышенную <a href=\"/symptom/potlivost/\" title=\"Перейти на страницу симптома потливость\">потливость</a>, тошноту, рвоту. В период приступа у больных отмечаются <a href=\"/symptom/tahikardiya/\" title=\"Перейти на страницу симптома Тахикардия\">тахикардия</a>, повышение артериального давления, а также <a href=\"/symptom/nistagm/\" title=\"Перейти на страницу симптома Нистагм\">нистагм</a> глаз. Различают ротаторный или диагональный <a href=\"/symptom/nistagm/\" title=\"Перейти на страницу симптома Нистагм\">нистагм</a>, а также вертикальный и горизонтальный <a href=\"/symptom/nistagm/\" title=\"Перейти на страницу симптома Нистагм\">нистагм</a>.</p>",
"image": null,
"image_alt": null,
"standard_type": 3,
"danger": 26,
"published": 1,
"parent": null,
"block_rubric": 192,
"standards": []
}
]
}
