Chest pain, Pulmonary embolism,

Chest pain, Acute coronary syndrome, Pulmonary embolism, Aortic dissection Dr. Szabó Zoltán Definitions • Acute coronary syndrome is defined as myoc...
Author: Harvey Gilmore
2 downloads 2 Views 7MB Size
Chest pain, Acute coronary syndrome, Pulmonary embolism, Aortic dissection Dr. Szabó Zoltán

Definitions • Acute coronary syndrome is defined as myocardial ischemia due to myocardial infarction (NSTEMI or STEMI) or unstable angina • Unstable angina is defined as angina at rest, new onset exertional angina (8.5 mmol/L)

Poulter N et al., 1993

Diagnostic tools • 12-lead ECG • Echocardiography • Stress test • Holter ECG • Event recorder • Myocardial scintigraphy • Coronary CT • Coronarography • Electrophysiological testing

Diagnosis • Clinical symptoms • Chest pain • Heart failure • Circulatory shock

• Electrocardiography

• ST segment abnormalities • Acute left bundle branch block

• Laboratory parameters

• cTroponin • CK • other (myoglobin, GOT, LDH, BNP, hs CRP)

• Echocardiography

• Negative predictive value

Angina Pectoris • Episode of chest pain or pressure due to insufficient artery flow of oxygenated blood. • Myocardial 02 demand exceeds 02 supply. CAD is the most common cause. • One coronary artery branch becomes completely occluded; therefore, 02 is not perfused to the myocardium, resulting in transient ischemia and subsequent retrosternal pain.

Angina Pectoris Precipitating Factors: Warning Sign for MI Clinical Signs & Symptoms: do not occur until lumen is 75% narrowed. Sternal pain: mild to severe. May be described as heavy, squeezing, pressing, burning, crushing or aching. Onset sudden or gradual. May radiate to L. shoulder and arm. Radiates less commonly to R. shoulder, neck, jaw. Pt may have weakness/numbness of wrist, arm, hands. pain usually short duration and relieved by removal precipitating factors,rest or NTG. Can be gradual (CAD) or sudden(vasospasm) Associated Symptoms: dyspnea, N & V, tachycardia, palpitations, fatigue, diaphoresis, pallor, weakness, syncope, factors

Types of Angina •



• •

Stable: There is a stable pattern of onset, duration and

intensity of sx, pain is triggered by a predictable degree of exertion or emotion. Variant Angina (Prinzmetal's) Cyclical, may occur at rest. Ventricular arrhythmia, brady arrhythmia and conduction disturbances occur. Syncope associated with arrhythmia may occur Nocturnal Angina only at night. Possible associated with REM sleep. Unstable Angina AKA Pre infarction angina Pain is more intense, lasts longer

Angina equivalent symptoms • Fatigue • Dyspnea • Palpitation

Physical examination • Inspection • • • • • • • • •

Fear Dyspnea Sweating Jaundice Xanthomas, xanthelasmas Distension of the jugular veins Cyanosis Edema Abnormal pulses

Diagnosis • Clinical symptoms • Chest pain • Heart failure • Circulatory shock

• Electrocardiography

• ST segment abnormalities • Acute left bundle branch block

• Laboratory parameters

• cTroponin • CK • other (myoglobin, GOT, LDH, BNP, hs CRP)

• Echocardiography

• Negative predictive value

AMI és elektrokardiográfia

Elevation •1mm •V1-3 2 mms Depression •Horizontal •Ascending •Descending

Anterior STEMI

Inferior STEMI

Anteroseptal STEMI

Posterior STEMI

Lateral STEMI

Left Bundle Branch Block • QRS>120 msec • V1-2 depolarization is dominantely negative • I, aVL: pozitive depolarization • Secondary ST changes • Discordant T waves

Diagnosis • Clinical symptoms • Chest pain • Heart failure • Circulatory shock

• Electrocardiography

• ST segment abnormalities • Acute left bundle branch block

• Laboratory parameters

• cTroponin • CK • other (myoglobin, GOT, LDH, BNP, hs CRP)

• Echocardiography

• Negative predictive value

Diagnosztika Az említett diagnosztikus kritériumokon alapul 1. Necroenzimemelkedés: Troponin I v. T vagy CK-MB + egy az alábbiak közül 2. Típusos tünetek patológiás Q-hullám kialakulása ST-eleváció ( >20 perc) vagy depresszió coronariaintervenció A fizikális vizsgálatnak kicsi a jelentősége, aspecifikus: tachycardia, néha inferior AMI-ban bradycardia, hypotonia, S4 hang. Szövődményei: pericarditis (napok): dörzszörej septumruptúra, papilláris izom dysfunkció-ruptúra: systolés zörej, sokk, pulmonális pangás Járulékos vizsgálatok: echocardiographia, mellkas rtg

Troponin

Diagnosis • Clinical symptoms • Chest pain • Heart failure • Circulatory shock

• Electrocardiography

• ST segment abnormalities • Acute left bundle branch block

• Laboratory parameters

• cTroponin • CK • other (myoglobin, GOT, LDH, BNP, hs CRP)

• Echocardiography

• Negative predictive value

AMI-Echocardiographia

Reperfusion therapy-STEMI

Thrombolysis

PCI

Reperfúziós therapy is indicated within 12 hours from the beginning of chest pain, furtheromere in the case of ST elevation and novel LBBB

Fibrinolysis (tPA) alteplase, tenecteplase

Absolute Contraindications to Thrombolysis • •

Any previous history of hemorrhagic stroke

History of stroke, dementia, or central nervous system damage within 1 year •

Head trauma or brain surgery within 6 months •

Known intracranial neoplasm

• • • • •

Suspected aortic dissection Internal bleeding within 6 weeks

Active bleeding or known bleeding disorder

Major surgery, trauma, or bleeding within 3 weeks

Traumatic cardiopulmonary resuscitation within 3 weeks

Relative Contraindications to Thrombolysis •

Oral anticoagulant therapy •



Pregnancy or within 1 week postpartum •



Acute pancreatitis

Active peptic ulceration

Transient ischemic attack within 6 months •

• •

Infective endocarditis

Active cavitating pulmonary tuberculosis •

Advanced liver disease •



Dementia

Intracardiac thrombi

Uncontrolled hypertension (systolic blood pressure >180 mm Hg, diastolic blood pressure >110 mm Hg) •

Puncture of noncompressible blood vessel within 2 weeks

PCI vs. Thrombolysis

Date of download: 1/21/2014

Copyright © The American College of Cardiology. All rights reserved. J Am Coll Cardiol. 2010;55(2):102-110. doi:10.1016/j.jacc.2009.08.007

PCI

Primary Percutaneous Coronaria Intervention

A primer PCI-t minél gyorsabban javasolt elvégezni, megcélozva, hogy az első orvosi kontaktus – balloon időt 120 percen belül tartsuk, illetve 2 ó-n belüli nagy (ált. anterior) STEMI esetében 90 percen belül. Egyébként fibrinolízis a választandó terápia!

Nem javasolt: panaszmentes betegnél 24 ó után (lezajlott AMI)

Coronarography

PCI: guide wire, ballon catheters, stents

Mguard stent

Drugs • ASA • NTG (consider MSO4 if pain not relieved) • Beta Blocker • Heparin/LMWH • ACE-I • +/-Clopidogrel (based on possibility of CABG) • IIBIIIA • Statin • Activate the Cath Lab!!!

Treatment of ACS; Aspirin • Aspirin is an antiplatelet agent that initiates the irreversible inhibition of cyclooxygenase, thereby preventing platelet production of thromboxane A2 and decreasing platelet aggregation • Administration of ASA in ACS reduces cardiac endpoints

ACC/AHA Guidelines for Aspirin Therapy

• Aspirin should be given in a dose of 75-325 mg/day to all patients with ACS unless there is a contraindication (in which case, clopidogrel should be given)

Nitrates 1. Nitrates decrease myocardial 02 demand via peripheral vasodilation and reverse coronary artery spasm thus increase 02 supply to myocardial tissue. 2. Understanding how Nitrates Work: peripheral vasodilation results in: -decreased 02 demand -decreased venous return to heart -decreased ventricular filling which results in decreased wall tension and thus -decreased 02 demand

NTG Forms • SL (Nitromint) • Lingual Sprays - similar to SL in use (Nitrolingual)

• Sustained release capsules/tablets (Nitromint retard) • Transdermal Patch (Nitro-Dur)

• IV (Nitro-Pohl)

ACC/AHA Guidelines for Heparin Therapy

• All patients with acute coronary syndromes should be treated with a combination of ASA (325 mg/day) and heparin (bolus followed by continuous infusion with goal of PTT 1-2.5X control) or ASA and low molecular weight heparin unless one of the drugs is contraindicated

Peiotropic effects of statins

Renin Angiotensin Aldosterone System

Beta Blockers

COPERNICUS study

Beta blocker 100 90 80

Survival %

Carvedilol

70

N = 2289 III-IV NYHA

p=0.00014 35% RR

60

Placebo

50 0 NEJM 2001;344:1651

4

8

12

16

months

20

24

28

US-CARVEDILOL

Béta-blocker 1.0

Carvedilol (n=696)

0.9

Survival %

p