j.r.g. juanatey c.h.u.santiago josé ramón gonzález-juantey hospital clínico universitario....

J.R.G. JUANATEY C.H.U.Santiago

José Ramón González-Juantey

Hospital Clínico Universitario. Santiago de Compostela

El Dolor Torácico en Urgencias


ISCHEMIC SYNDROMES

AntithromboticTherapy

Thrombolysis/ PCI

ECG:

UnstableAngina

Non-Qwave MI

StableAngina

Q waveMI

Plaquerupture

ST elevation MIUA / Non STE MICannon CPJ T Thrombolysis 1996


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


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


DIAGNOSTICO

1- Clínica

2- ECG

3- Encimas (marcadores séricos de daño miocárdico)

4- Pruebas detección isquemia

5- Coronariografia

6- Otras


Síntomas clave de cardiopatía

Dolor precordial

Disnea

Síncope

PalpitacionesMuer

te s

úbita


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


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


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


minutes

hours

days - years

ACUTE CORONARY OCLUSIONECG EVOLUTIVE CHANGES

ST Q QT

QST

Bayes de Luna. Clinical Electrocard 1993


IAM inferior 24h1h


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


Anterior AMI.

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

A B

ECG CHANGES and EVOLUTION


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


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


PTCA +STENT

ST elevation MI


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


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




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




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.



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.



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



Ischemia/Reperfusion Injury Ischemia/Reperfusion Injury

-acute inflammatory response-apoptosis -platelet-neutrofil aggregates (no-reflow)


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

j.r.g. juanatey c.h.u.santiago josé ramón gonzález-juantey hospital clínico universitario....

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