j.r.g. juanatey c.h.u.santiago josé ramón gonzález-juantey hospital clínico universitario....
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J.R.G. JUANATEY C.H.U.Santiago
José Ramón González-Juantey
Hospital Clínico Universitario. Santiago de Compostela
El Dolor Torácico en Urgencias
J.R.G. JUANATEY C.H.U.Santiago
ISCHEMIC SYNDROMES
AntithromboticTherapy
Thrombolysis/ PCI
ECG:
UnstableAngina
Non-Qwave MI
StableAngina
Q waveMI
Plaquerupture
ST elevation MIUA / Non STE MICannon CPJ T Thrombolysis 1996
J.R.G. JUANATEY C.H.U.Santiago
SUSPECTED ISCHEMIC CHEST PAIN IN ED
1- Bed rest &Immediate clinical evaluation
3- ECG in ≤ 10 minutes- Correctly read- Ask if in doubt
4- Decisions
EARLY RISK STRATIFICATION. FAST TRACK
J.R.G. JUANATEY C.H.U.Santiago
What is Acute Cardiovascular Care?
HOSPITAL
Cardiología
Ate
nció
n p
re-
hosp
itala
ria
UR
GEN
CIA
S
UCIC: Unidad Cuidados Intensivos CardiacosUC: Unidad Coronaria
UCIC
UC
J.R.G. JUANATEY C.H.U.Santiago
DIAGNOSTICO
1- Clínica
2- ECG
3- Encimas (marcadores séricos de daño miocárdico)
4- Pruebas detección isquemia
5- Coronariografia
6- Otras
J.R.G. JUANATEY C.H.U.Santiago
Síntomas clave de cardiopatía
Dolor precordial
Disnea
Síncope
PalpitacionesMuer
te s
úbita
J.R.G. JUANATEY C.H.U.Santiago
1- DOLOR o malestar precordial
• Donde: Precordial (boca- ombligo)• Calidad: opresivo
• Intensidad: variable• Aparición: brusca
• Irradiado: brazos, mandíbula• Desencadenado: esfuerzo, nada
• Duración: minutos, horas (no dias)• Alivio: reposo, NTG
• Otros síntomas: disnea, mareo, sudor
J.R.G. JUANATEY C.H.U.Santiago
Gastroesophageal reflux (GERD) and spasm
Chest-wall pain
Pleurisy
Peptic ulcer disease
Panic attack
Cervical disc or neuropathic pain
Biliary or pancreatic pain
Somatization and psychogenic pain disorder
ED Evaluation of Patients With STEMI
Differential Diagnosis of STEMI: Other Noncardiac
J.R.G. JUANATEY C.H.U.Santiago
CARACTERISTICAS SUGESTIVAS DE DOLOR TORACICO NO ISQUEMICO
•CARACTERISTICAS•- Pinchazos, difuso en todo el torax•- ”cuchillo clavado”•LOCALIZACION•- Area Inframamaria izq.•- Hemitorax izquierdo•DURACION•- Segundos o días
• PROVOCACION• - Agrava con respiración
• - Reproduce con la presión
• - Provocado con movimientos del cuerpo
• ALIVIO• - Comida o antiacidos• - Cambios de postura
J.R.G. JUANATEY C.H.U.Santiago
minutes
hours
days - years
ACUTE CORONARY OCLUSIONECG EVOLUTIVE CHANGES
ST Q QT
QST
Bayes de Luna. Clinical Electrocard 1993
J.R.G. JUANATEY C.H.U.Santiago
IAM inferior 24h1h
J.R.G. JUANATEY C.H.U.Santiago
Anterior AMI.
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
2 febr 4 febr
ECG CHANGES and EVOLUTION
J.R.G. JUANATEY C.H.U.Santiago
Anterior AMI.
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
A B
ECG CHANGES and EVOLUTION
J.R.G. JUANATEY C.H.U.Santiago
Hombre, 53 años,Dolor torácico Sin dolor torácico
NTG s.l.
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
CARDIOPATIA ISQUEMICA.- I
Wu AH et al. Clin Chem 1999;45:1104.
3 CK-MB poco específica
2 Troponina, muy específica (de miocardio)
1 Mioglobina, la que se normaliza antes
Dias post IAM
Mú
ltip
los
de
va
lor
no
rma
l
Límite normal
0 1 2 3 4 5 6 7 8
1
2
5
10
20
50
3- Analítica. Marcadores de daño miocárdico
1
23
J.R.G. JUANATEY C.H.U.Santiago
REPERFUSION
Chest Pain Unit
3Medical
Treatment
1Clinical
Evaluation
2Diagnosis /
Risk assessment
ACS unclear(Rule out ACS)
• Quality of chest pain
• Probability of CAD
• Physical examination
• ECG (↑ST?)
STEMI
NSTE ACS
No ACS
4InvasiveStrategy
• Serial ECGs• Serial troponin• Lab tests (Hb, Crea
Clea…)• Ischemic risk score(i.e. GRACE)
• Bleeding risk score(i.e. CRUSADE)
• Imaging techniques results (optional)
Anti-ischemictherapy
Antiplatelettherapy
Anticoagulation
Emergent<2 hours
Urgent2-24 hours
Early24-72 hours
No /Elective
J.R.G. JUANATEY C.H.U.Santiago
J.R.G. JUANATEY C.H.U.Santiago
PTCA +STENT
ST elevation MI
J.R.G. JUANATEY C.H.U.Santiago
CARDIOPATIA ISQUEMICA.- I
Supplemental oxygen should be
administered to patients with arterial oxygen
desaturation (SaO2 < 90%).
It is reasonable to administer supplemental oxygen to all patients with uncomplicated STEMI during the first 6 hours.
OxygenIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
CARDIOPATIA ISQUEMICA.- I
Patients with ongoing ischemic discomfort should receive sublingual NTG (0.4 mg) every 5 minutes for a total of 3 doses, after which an assessment should be made about the need for intravenous NTG.
Intravenous NTG is indicated for relief of ongoing ischemic
discomfort that responds to nitrate therapy, control of
hypertension, or management of pulmonary congestion.
Nitroglycerin
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
CARDIOPATIA ISQUEMICA.- I
Nitrates should not be administered to patients with:
Nitrates should not be administered to patients who have received a phosphodiesterase inhibitor for erectile dysfunction within the last 24 hours (48 hours for tadalafil).
• systolic pressure < 90 mm Hg or ≥ to 30 mm Hg below baseline
• severe bradycardia (< 50 bpm)• tachycardia (> 100 bpm) or• suspected RV infarction.
Nitroglycerin
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
CARDIOPATIA ISQUEMICA.- I
Analgesia
Morphine sulfate (2 to 4 mg intravenously with
increments of 2 to 8 mg intravenously
repeated at 5 to 15 minute intervals) is the
analgesic of choice for management of pain
associated with STEMI.
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
CARDIOPATIA ISQUEMICA.- I
Aspirin/Clopidogrel/Prasugrel/TicagrelorIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
Aspirin should be chewed by patients who
have not taken aspirin before presentation
with STEMI. The initial dose should be 162
mg (Level of Evidence: A) to 325 mg (Level
of Evidence: C)
Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations.
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
CARDIOPATIA ISQUEMICA.- I
Oral beta-blocker therapy should be administered
promptly to those patients without a contraindication,
irrespective of concomitant fibrinolytic therapy or
performance of primary PCI.
It is reasonable to administer intravenous beta-
blockers promptly to STEMI patients without
contraindications, especially if a tachyarrhythmia or
hypertension is present.
Beta-BlockersIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
CARDIOPATIA ISQUEMICA.- I
Ischemia/Reperfusion Injury Ischemia/Reperfusion Injury
-acute inflammatory response-apoptosis -platelet-neutrofil aggregates (no-reflow)
CARDIOPATIA ISQUEMICA.- I
CARDIOPATIA ISQUEMICA.- I
Other Pharmacological Measures
Angiotensin converting enzyme (ACE)
inhibitors
Angiotensin receptor blockers (ARB)
Aldosterone blockers
Glucose control
Magnesium
Calcium channel blockers
Inhibition of the renin -angiotensin -aldosterone system
CARDIOPATIA ISQUEMICA.- I
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