胸痛的诊断与甄别

急性胸痛的快速诊断与甄别Prompt diagnosis and differentiation of acute chest pain,福建医科大学附属协和医院心内科Cardiology, Union Hospital, Fujian Medical University福建省冠心病研究所Provincial Institute of Coronary Disease, Fujian,L CHEN MD PhD FACC FESC,1,Pain, it has been said, is one of “natures earliest signs of morbidity”. Few will deny that it stands preeminent among all the sensory experiences by which human judge the existence of disease within themselves. There are relatively few maladies that do not have their painful phases and in many of them pain is characteristic without which diagnosis must always be in doubt. By Raymond D AdamsChest pain, as a pain, is beyond the pain. Chest pain is not necessarily painful sensation, numerous vocabularies used to descript such a feeling, for instances, chest distress, tightness, breathless and so on. As one of commonest clinical symptoms, chest pain relates itself to numerous somatic or mental diseases, ranging from minor to major illnesses, or evenly life-threatening or lethal diseases. By Lianglong Chen,About chest pain,L CHEN MD PhD FACC FESC,2,Question 1,Have you ever experienced chest pain?If any, please describe your personal feeling.,L CHEN MD PhD FACC FESC,3,How to properly descript chest pain,Basic clinical presentations of ABCDEArea (location, size, radiation)Beginning and ending (trigger/relief) Character (pain, tightness, distress)Degree (mild/severe)Duration (short/long)Exacerbation (causes/inducer)Episode inducerAccompanying symptoms and signs of BBCBreathing affectionBrain affectionCardiac affection,基本临床特征部位（位置、范围、放射）起止（触发与缓解）性质（疼痛、胸闷、压迫）程度（轻中重）时间（短或长）加重（原因与诱因）诱因（用力或应激)伴随症状体征对心脏的影响对呼吸的影响对脑部的影响,L CHEN MD PhD FACC FESC,4,急性胸痛,Acute chest pain (ACP),L CHEN MD PhD FACC FESC,5,At least 50 illnesses will cause chest pain.EmergencyACP accounts for 25% emergency volume, among which 50% are of cardiovascular causes (e.g. ACS, PE, AAS, HF).Patients suspected with cardiogenic ACP transported by EMS were finally diagnosed as AMI , UA and non-cardiogenic diseases with proportion of one third, respectively.Outpatient Commonest reasons of patients clinical visiting.A vast of diseases that cause ACP include cardio- and non-cardio-genesis.,ACP：complex etiologies,L CHEN MD PhD FACC FESC,6,3S+3S,危急胸痛：快速临床诊断三步法3-Strategy/Steps for Rapid Triage Acute Critical Chest Pain,L CHEN MD PhD FACC FESC,7,3-Stretagies,1,2,3,L CHEN MD PhD FACC FESC,8,L CHEN MD PhD FACC FESC,9,从较宽的临床角度考虑急性胸痛病因Broader clinical consideration of ACP causes,Strategy1,L CHEN MD PhD FACC FESC,10,甄别急性胸痛病因：是否危急性Figure out the causes： Acute Critical Chest Pain (ACCP) or not,病因：确定或不确定，多数不能确定临床：危机状态，如低血压或休克、呼吸困难、低氧血症诊断：迅速诊断，快速决策极为重要手段：临床、化验、心电图、影像学,Strategy2a,鉴别危急胸痛病因: 是否心源性Figure out the causes of acute critical chest pain：cardiogenic or not,ACS = acute coronary syndrome; AMD = acute myocarditis or myo-pericarditis; VHD = valvular heart disease; AAS = acute aortic syndrome; APE = acute pulmonary embolism; TPT = tension pneumothorax,Strategy2b,L CHEN MD PhD FACC FESC,11,鉴别急性胸痛病因：是否心肌缺血性Figure out the causes of acute chest pain: myocardial ischemia or not,STEACS/STEMI = ST elevation acute coronary syndrome/myocardial infarction; NSTEACS/NSTEMI = non-ST elevation acute coronary syndrome/myocardial infarction; UA = unstable angina; AAS = acute aortic syndrome; AAD = acute aortic dissection; IMH = aortic intramural hematoma; APE = acute pulmonary embolism; TNT = tension pneumothorax,Strategy3,L CHEN MD PhD FACC FESC,12,L CHEN MD PhD FACC FESC,13,急性胸痛：可能是需快速处置的临床危机状况ACP: a clinical crisis probably requiring urgent management,Life-threateningParadoxical treatmentNarrowed trx windowCausing PH disputesTime = lifePrompt diagnosis = saving life,How to promptly diax, difx and trx？,Commonest ACPs Acute coronary syndrome(ACS)Unstable angina（UA）STEACS(STEMI)NSTEACS(NSTEMI)Acute pulmonary artery embolism (APE)Acute aortic syndrome(AAD)Acute fulminant myocarditis(AFM)Tension pneumothorax (TNT)Heart break,L CHEN MD PhD FACC FESC,14,危急胸痛的诊断与鉴别ACCP diagnosis & differentiation,HistoryClinical manifestationLab testingECG,ImagingCT/AMR/AECHO,L CHEN MD PhD FACC FESC,15,第一步：临床表现,Step 1 Clinical manifestations,More detail to collect clinical data, more closer to the causes of ACCP,Basic clinical presentationArea (location, size, radiation)Beginning and ending (trigger/relief) Character (pain, tightness, distress)Degree (mild/severe)Duration (short/long)Exacerbation (causes/inducer)Episode inducerAccompanying symptoms and signsBreathing affectionBrain affectionCardiac affection,基本临床特征部位（位置、范围、放射）起止（触发与缓解）性质（疼痛、胸闷、压迫）程度（轻中重）时间（短或长）加重（原因与诱因）诱因（用力或应激)伴随症状体征对心脏的影响对呼吸的影响对脑部的影响,L CHEN MD PhD FACC FESC,16,L CHEN MD PhD FACC FESC,17,临床表现的重要性Relevance of clinical manifestation,最快捷(fast way)基本功(basic skill)被忽视(ignored)需重视(addressing),诊断第一线索First clue leading to final diagnosis,L CHEN MD PhD FACC FESC,18,ACCP(呼吸困难，低血压或休克)临床表现与诊断线索Seeking diagnostic clues for ACCP based on clinical presentations,临床表现的局限性limitation of clinical presentation,Patients with atypical presentations cant be correctly diagnosedDue to first impression, other causes of ACCP may be mis-diagnosed as ACS.Owing to complex etiology and presentations, ACCP is readily to be missed or misdiagnosed, resulting in missed trx or mistrx,多数ACCP患者发病过程、临床与心电图表现较典型，故较少误漏诊。然而，因急性冠脉综合征占ACCP病因首位，易使医生先入为见；ACCP的病因及临床表现多样复杂，可导致误诊漏诊、误治漏治。急诊环境及危急状况可干扰医生的临床判断，导致误诊漏诊、误治漏治。,L CHEN MD PhD FACC FESC,19,L CHEN MD PhD FACC FESC,20,第二步：生物标记物+ECG,Step 2 Biomarkers plus ECG,L CHEN MD PhD FACC FESC,21,生物标记物Biomarkers,快速鉴别缺血与非缺血性胸痛的新标记物,Eur Heart J. 2008 Aug;29(16):1966-74Eur Heart J. 2008 Nov;29(22):2713-22NEJM。2009，Aug;27（9）361:858-867,L CHEN MD PhD FACC FESC,22,L CHEN MD PhD FACC FESC,23,生物标记物：Hs-cTnBiomarkers: Hs-cTn,敏感性(sensitivity)特异性(specificity)便捷性(accessibility),损伤释放时间（releasing time）标本处理时间（blood handling time）仪器检测时间（detecting time）,Prompt?,ECG的重要性relevance of ECG,Prompt, simple, accessibleQualitative, quantitative, localizationClassification, triage and decision-making,快速、简单、易及定性、定位、定量分型、分流、治疗,L CHEN MD PhD FACC FESC,24,For ACCP patients, getting ECG tracing within 10 min, repeat 15-30 min for 6 times,L CHEN MD PhD FACC FESC,25,急性冠脉综合征临床分型Clinically practical classification for ACS,Early ACS classification based on ECG only,STEACS/STEMI心电图特征ECG features of STEACS/STEMI,Typical alterationsST elevationPathological Q-waveInversed T-waveDynamic changesHyper-acute phase: within hours, peaked T.Acute phase: after hours, ST elevation with decreased R-wave or pathological Q-waveSubacute phase: within 2 weeks, ST return to iso-electrical line, inverted T-waveChronic phase: after weeks and months, pathological Q-wave, coronary T-wave,特征改变ST弓背向上抬高病理性Q波T波倒置动态改变超急性改变：数小时内，T波高耸急性期改变：数小时后，ST弓背向上抬高、单向曲线，R波降低或病理Q波亚急性改变：自然病程数日-两周，ST段回落、T波倒置慢性期改变：数周-数月后，T波倒置对称,L CHEN MD PhD FACC FESC,26,NSTEACS/NSTEMI心电图特征ECG features of NSTEACS/NSTEMI,相邻2导联ST段压低1mm对称性T波倒置有或无病理性Q波上述改变动态变化,ST depression more than 1.0 mm in 2 contiguous leads.Symmetrically inverted T-wave.With or without pathological Q-waveDynamical changes,L CHEN MD PhD FACC FESC,27,ECG的局限性Limitations of ECG,胸痛患者如心电图完全正常也不能排除ACS可能性，因为1-6%的这类患者最终被证明患有心肌梗死（定义为NSTEM），而且至少有4%的患者被证明是不稳定心绞痛。ST段和T波变化时必须考虑其他可能的常见原因，如ST段抬高常见于左室室壁瘤、心包炎、心肌炎、变异性心绞痛、过早复极，应激性心肌病和W-P-W综合症等；而深倒T波见于中枢神经系统疾病和用三环类抗抑郁药或吩噻嗪类药物治疗患者。左旋支阻塞导致的急性心肌梗死可能出现非诊断性12导联心电图。约4%急性心肌梗死ST段抬高只出现在后壁导联V7-9。,Non-diagnosticFalse negativeFalse positivePseudo negativePseudo positive,L CHEN MD PhD FACC FESC,28,L CHEN MD PhD FACC FESC,29,第三步：影像学检查,Step 3 Imaging of ECHO, CTA, MRA,急诊床旁超声心动图,Emergent bedside echocardiography （EBE）,L CHEN MD PhD FACC FESC,30,EBE检诊的临床意义Relevance of EBE interrogation,As the miniaturization of instruments, echocardiography has become basic tool for emergent evaluation of cardiovascular diseases.Emergency bedside echocardiography (EBE) is great helpful for clinicians in risk stratification, clinical triage, decision-making and prompt intervention,随着超声诊断仪的小型化、低价化及临床培训的规范化和超声专业医师值班的常态化，超声心动图作为一种简便、准确、有效、易及的检诊手段而成为有相关症状患者心脏、大血管及邻近器官急诊评估不可或缺之基本工具。急诊床旁超声心动图(Emergency Bedside Echocardiography, EBE)获得的诊断信息可帮助临床医师进行危险分层、临床分流、治疗决策，并及时启动紧急治疗。,L CHEN MD PhD FACC FESC,31,L CHEN MD PhD FACC FESC,32,微小型仪器,轻便、简单、高效、易及便于急诊床边或院外如救护车、急救现场使用唯一的一线影像学检测手段,Vscan1357328mmGE Healthcare,床旁超声或急诊超声检诊流程Interrogation protocol for BEC/EBE,L CHEN MD PhD FACC FESC,33,EBE 可获得2个重要判断2 judgments afforded by EBE,Orientation to further diagx & trx,为进一步诊疗提供线索和方向,L CHEN MD PhD FACC FESC,34,EBE的临床价值,可及, Accessible床旁, Bed-side便捷,