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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.

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Presentación del tema: "J.R.G. JUANATEY C.H.U.Santiago José Ramón González-Juantey Hospital Clínico Universitario. Santiago de Compostela El Dolor Torácico en Urgencias."— Transcripción de la presentación:

1 J.R.G. JUANATEY C.H.U.Santiago José Ramón González-Juantey Hospital Clínico Universitario. Santiago de Compostela El Dolor Torácico en Urgencias

2 J.R.G. JUANATEY C.H.U.Santiago ISCHEMIC SYNDROMES AntithromboticTherapyThrombolysis / PCI ECG:UnstableAnginaNon-Q wave MI StableAngina Q wave MIPlaquerupture ST elevation MI UA / Non STE MI Cannon CP J T Thrombolysis 1996

3 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

4 J.R.G. JUANATEY C.H.U.Santiago What is Acute Cardiovascular Care? HOSPITAL Cardiología Atención pre- hospitalaria URGENCIAS UCIC: Unidad Cuidados Intensivos Cardiacos UC: Unidad Coronaria UCIC UC

5 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

6 J.R.G. JUANATEY C.H.U.Santiago Síntomas clave de cardiopatía Dolor precordial Disnea Síncope Palpitaciones Muerte súbita

7 J.R.G. JUANATEY C.H.U.Santiago 1- DOLOR o malestar precordial Donde: Precordial (boca- ombligo)Donde: Precordial (boca- ombligo) Calidad: opresivoCalidad: opresivo Intensidad: variableIntensidad: variable Aparición: bruscaAparición: brusca Irradiado: brazos, mandíbulaIrradiado: brazos, mandíbula Desencadenado: esfuerzo, nadaDesencadenado: esfuerzo, nada Duración: minutos, horas (no dias)Duración: minutos, horas (no dias) Alivio: reposo, NTGAlivio: reposo, NTG Otros síntomas: disnea, mareo, sudorOtros síntomas: disnea, mareo, sudor

8 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

9 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

10 J.R.G. JUANATEY C.H.U.Santiago minutes hours days - years ACUTE CORONARY OCLUSION ECG EVOLUTIVE CHANGES ST Q Q T QS T Bayes de Luna. Clinical Electrocard 1993

11 J.R.G. JUANATEY C.H.U.Santiago IAM inferior 24h 1h

12 J.R.G. JUANATEY C.H.U.Santiago Anterior AMI. I II III aVR aVL aVF V1V1V1V1 V2V2V2V2 V3V3V3V3 V4V4V4V4 V5V5V5V5 V6V6V6V6 I II III aVR aVL aVF V1V1V1V1 V2V2V2V2 V3V3V3V3 V4V4V4V4 V5V5V5V5 V6V6V6V6 2 febr 4 febr ECG CHANGES and EVOLUTION

13 J.R.G. JUANATEY C.H.U.Santiago Anterior AMI. I II III aVR aVL aVF V1V1V1V1 V2V2V2V2 V3V3V3V3 V4V4V4V4 V5V5V5V5 V6V6V6V6 A B ECG CHANGES and EVOLUTION

14 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 V1V1V1V1 V2V2V2V2 V3V3V3V3 V4V4V4V4 V5V5V5V5 V6V6V6V6

15 CARDIOPATIA ISQUEMICA.- I Wu AH et al. Clin Chem 1999;45: CK-MB poco específica 2 Troponina, muy específica (de miocardio) 1 Mioglobina, la que se normaliza antes Dias post IAM Múltiplos de valor normal Límite normal Analítica. Marcadores de daño miocárdico 1 2 3

16 J.R.G. JUANATEY C.H.U.Santiago REPERFUSIONChest Pain Unit 3 Medical Treatment 1 Clinical Evaluation 2 Diagnosis / Risk assessment ACS unclear (Rule out ACS) Quality of chest pain Probability of CAD Physical examination ECG (ST?) STEMI NSTE ACS No ACS 4 Invasive Strategy 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-ischemic therapy Antiplatelet therapy Anticoagulation Emergent <2 hours Urgent 2-24 hours Early hours No / Elective 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-ischemic therapy Antiplatelet therapy Anticoagulation Emergent <2 hours Urgent 2-24 hours Early hours No / Elective

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

18 PTCA + STENT ST elevation MI

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

20 CARDIOPATIA ISQUEMICA.- I Supplemental oxygen should be administered to patients with arterial oxygen desaturation (SaO 2 < 90%). It is reasonable to administer supplemental oxygen to all patients with uncomplicated STEMI during the first 6 hours. Oxygen

21 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

22 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

23 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.

24 CARDIOPATIA ISQUEMICA.- I Aspirin/Clopidogrel/Prasugrel/Ticagrelor 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.

25 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-Blockers

26 CARDIOPATIA ISQUEMICA.- I Ischemia/Reperfusion Injury -acute inflammatory response -apoptosis -platelet-neutrofil aggregates (no-reflow)

27 CARDIOPATIA ISQUEMICA.- I

28 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

29 CARDIOPATIA ISQUEMICA.- I


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