胸痛PPT医学ppt课件英文版

1、Approach to Chest PainLevente Batizy, DOSeptember 15, 2005.Chest Pain5% of ED visits5 million pts/yrAccurate diagnosis remains a challenge.Chest PainVisceralOften referred Aching, heaviness, discomfortDifficult to localize painSomaticSharp, easily localized.Chest Pain DefinitionsAcute Chest Pain:Acu

2、te - sudden or recent onset (usually within minutes to hours), presenting typically 24 hrsChest - thorax midaxillary to midaxillary line, xiphoid to suprasternum notchPain noxious uncomfortable sensationAche or discomfort.Initial ApproachTriageChest painSignificant abnormal pulseAbnormal blood press

3、ureDyspneaThese pts need IV, O2, Monitor, ECG.Initial ApproachEvaluation: AirwayBreathingCirculationVital SignsFocused examCardiac, pulmonary, vascular.Initial ApproachHistory:Character of painPresence of associated symptomsCardiopulmonary historyPain intensity, 0-10 pain.Initial ApproachSecondary e

4、xam:HistoryQuality, radiation/migration, severity, onset, duration, frequency, progression and provoking or relieving factors of painRisk factorsPhysical examReview old records/ekgs.Categorizing Chest PainChest Wall PainSharp, Precisely localizedReproducible: Palpation, movementPleuritic or Respirat

5、ory CPSomatic pain, SharpWorse with breathing/coughingVisceral CPPoorly localized, aching, heaviness.Causes Table 49-1Chest wallCostosternal syndCostochrondritisPrecordial catch syndSlipping Rib SyndXiphodyniaRadicular SyndIntercostal NerveFibromyalgiaPleuriticPulmonary EmbolismPneumoniaSpontaneous

6、pneumoPericarditisPleurisy.Causes Table 49-13.Visceral Pain:Typical Exertional AnginaAtypical AnginaUnstable AnginaAcute Myocardial Infarction (AMI)Aortic DissectionPericarditisEsophageal Reflux or spasmEsophageal RuptureMitral Valve Prolapse.Categorizing Chest Pain Assessment of Risk FactorsCAD:Cig

7、arette SmokingDiabetesHypertensionHypercholesterolemiaFamily History.Categorizing Chest Pain Assessment of Risk FactorsAortic Dissection:Middle AgedMaleHypertensionMarfan Syndrome.Categorizing Chest Pain Assessment of Risk FactorsPulmonary EmbolismHypercoagulable DiathesisMalignancyRecent Immobiliza

8、tionRecent Surgery.Chest pain incidentals ACSAMI Rare under 30 y/o except with cocaine useGI cocktail may cause relief even in AMI Nitroglycerin can cause relief of esophagus spasm, biliary colic, and AMINSAIDS can be analgesic for all types of pain.Atypical Chest PainDyspnea at rest, DOEDiscomfort:

9、 shoulder, jaw, armNausea, Epigastric painLightheadedness, Generalized weaknessMS changesDiaphoresisAtypicals usually inDM, females, non-white, elderly, altered MS pts.Differential DxAcute Coronary Syndrome (ACS)ACS = AMI or Unstable AnginaVisceral chest pain ptsAMI 15% UA 25-30%.Differential DxAcut

10、e Coronary Syndrome (ACS)ECG is the most useful testIncidenceSignificant ST elevation = 80% are AMIST depression/T wave inversion = 20% are AMINo change 20 min, severeAssociated Sx: Dyspnea, Diaphoresis, NauseaMay even be Reproducible.Differential Dx ACSExertional Angina:Episodic pain, 20 minHigh ri

11、sk of AMI.Differential Dx ACSPulmonary Embolism:Atypical, presenting with any combination of:Chest Pain, Dyspnea, Syncope, Shock, HypoxiaFever, cough, hemoptosisPain is often pleuralReproducible with breathing, palpationClassic presentaion:Sharp pain, DyspneaTachypnea, tachycardia, hypoxemia.Differe

12、ntial Dx ACSAortic Dissection:Risk Factors Atherosclerosis, HTN (uncontrolled), Coarctation of Aorta, Bicuspid Aortic Valve, Aortic Stenosis, Marfan Syn, Ehlers-Danlos Syn, PregnancyPain midline Substernal CP, tearing, ripping, searing, radiating to interscapular area Pain Above AND Below DiaphragmO

13、ften assoc. with stroke, AMI, limb ischemia .Differential Dx ACSSpontaneous Pneumothorax:Risks: Sudden Change in barometric pressureSmokers, COPD, Idiopathic Bleb DZPain: sudden, sharp, pleuritic chest pain, and dyspnea Dx:Absence of breath sounds ipsilaterallyHyper resonance to percussionCXR Dx sim

14、ple pneumo.Differential Dx ACSEsophageal Rupture (Boerhaave Syn):Life-threateningSubsternal, sharp CPSudden onset after forceful vomitingDyspneic, diaphoretic, and ill-appearingCXR: Normal, SQ air, Pleural Effusions, Pneumothorax, pneumoperitoneum, pneumomediastinum Water Soluble Contrast Study .Dif

15、ferential Dx ACSAcute Pericarditis:Acute, sharp, severe, constant, substernal CPRadiation to back, neck, shouldersWorse with lying down and inspirationRelief with leaning forwardFRICTION RUBEKG: ST segment elev., T wave inversion, or PR depression.Differential Dx ACSPneumonia:Sharp and PleuriticFeve

16、r, cough, hypoxiaRales, decreased breath sounds, etc.CXR .Differential Dx ACSMitral Valve Prolapse:Women MenDiscomfort at restAssoc. Sx:Dizziness, Hyperventilation, Anxiety, Depression, Palpitations, Fatigue, SVT, Ventricular DysrhythmiaTx: Beta-Adrenergic BlockersDx: Echo.Differential Dx ACSMusculo

17、skeletal/Chest Wall Disorders:LOCALIZED, Sharp, positional CPReproducibleTypes Costochondritis, Tietze SyndromeXiphodynia.Differential Dx ACSGI Disorders: GERD/dyspepsia burning, gnawing low CPAcidic tasteRecumbent position increases painRelief per antacidsCAREFUL, can also help in ACS.Differential

18、Dx ACSEsophageal Spasm:Sudden onset, dull, tight, gripping Hot or cold liquidsLarge food bolusResponds to NTG.Differential Dx ACSPeptic Ulcer Disease:Gastric:Postprandial, dull, boring painMidepigastric, may awake pt.Duodenal Ulcer:Relieved after eatingSymptomatic Tx: antacidsDDx: Pancreatitis and B

19、iliary tract Dz.Differential Dx ACSPanic Disorder:Recurrent, Unexpected panic Including at least 4 SX:Palpitations, diaphoresis, tremor, dyspnea, choking, CP, nausea, dizziness, derealization, or depersonalization, fear of losing control or dying, paresthesias, chills, hot flashesRule out substance

20、abuse.Testing for ACSEKGsSerum MarkersImaging studies.Testing for ACS - EKGAHA Guidlines:Any pt with Ischemic type pain is to have an EKG done within 10 minutes of arrival.This is to be handed directly to the physician.Testing for ACS - EKGAMI PT EKGs:50% = ST elevation 1mm in 2 contiguous leads20-3

21、0% = new ST seg. changes or T wave inversion10-20% = ST depression and T wave inversions Similar to previous EKGs10% nonspecific changes1-5% will have NORMAL initial EKG.Testing for ACS - EKGPositive predictive values:New ST elevation = AMI 80%New ST depression & T wave inversion = AMI 20%, 14-43% U

22、AAcute CP, preexisting ST depression & T wave inv. = AMI 4%, 21-48% UA.Testing for ACS - Serum MarkersCreatine Kinase, an intracellular enzyme involved in transferring phosphate grps from ATP to creatine in Cardiac & skeletal muscle and brainCK-BB = brainCK-MM = skeletalCK-MB = cardiac .Testing for

23、ACS - Serum MarkersCK elevates 4-8 hours after coronary Art. OcclusionPeaks = 12 to 24 hoursNml = 3 to 4 daysCK-MBDetectable 4-8 hrsPeak = before 24 hrsNml = in 48hrsCK-MB normally can be 5% of total CK (Rapid Index).Testing for ACS - Serum MarkersCommon Causes of CK-MB Elevation:UA, ACSInflammatory

24、 Heart DzCardiomyopathiesShockCardiac Surgery/TraumaTraumaDermatomyositisMyopathic DisordersMuscular DystrophyExtreme ExerciseMalignant HyperthermiaReyes SyndromeRhabdomyolysisDelerium TremensEthanol Poisoning, chronic.Testing for ACS - Serum MarkersMyoglobin: Abnormal in 80 100% AMI pts Small prote

25、in in striated and cardiac muscle, released in cell disruptionIn AMI Rises within 3 hoursPeak at 4 to 9 hoursBaseline at 24 hoursExcept in trauma pts, renal pts, and cocaine users myoglobin can be as sensitive as CK-MB and Troponins.Testing for ACS - TroponinsMain regulatory protein of thin filament

26、 of myofibrils that regulate the Ca+ dependent ATP hydrolysis of actinomysin3 Subunits:Trop I = Inhibitory Subunit Myocardial SpecificElevation indicated worse prognosisTrop T = tropomyosin-binding subunitTrop C = calcium-binding subunit.Testing for ACS - TroponinsAMI:Cardiac Troponin I (cTnI) and c

27、TnT Elevates in 6 hrspeaks in 12 hRemain elevated for 7 to 10 daysHigher specificity than CK-MBControversy = Troponins are found to be elevated in Renal Failure pts without proof of ACS/AMI .Testing for ACS - Serum MarkersAMI on Initial EKG Markers not required for DxMarker changes may precede EKG C

28、hangeAMICK-MB initially elevated in 30-50% Serial CK-MB elevate in 6 hours in 80-96%.Testing for ACS - Serum MarkersUsing Myoglobin, CK-MB, and cTnI initially and at 3 hours = 90% of AMI pts diagnosed.Testing for ACS - Serum MarkersNew Bedside cardiac marker tests are now available with results in l

29、ess than 20 minutesOverall value of this remains to be determined.Testing for ACS Prognosis Categorization StrategyAMI = Immediate Revascularization candidateProbable acute Ischemia: High risk(Any of the following)Clinical InstabilityOngoing painPain at rest with ischemic EKG changesPositive cardiac

30、 marker(s)Positive perfusion imaging study.Testing for ACS Prognosis Categorization Strategy3. Possible acute Ischemia: Intermed. Risk:Hx suggestive of ischemia withRest pain, now resolved New onset of painCrescendo pattern of painIschemic pattern on EKG without CP.Testing for ACS Prognosis Categori

31、zation Strategy4.A. Probably NOT Ischemia: low riskRequires all of followingHx not strong for ischemiaEKG normal, unchanged from previous,or nonspecific changesNegative markers .Testing for ACS Prognosis Categorization Strategy4.B. Stable Angina Pectoris: low risk PxRequires all the following 2wk un

32、changed Sx pattern, Longstanding Sx with only mild change in exertional pain thresholdEKG normal, unchanged, nonspecific changesNegative initial myocardial markers.Testing for ACS Prognosis Categorization StrategyDefinitely not ischemia: very low risk for adverse eventsRequires AllClear objective ev

33、idence of nonischemic Sx etiologyECG normal, unchanged, nonspecificNegative Initial Markers.Testing for ACS - EchoNoninvasive, dynamic natureCan assess cardiac function, aortic dissection, pericardial pathology, valvular dz, possibly PENormal Echo during CP theoretically excludes ischemia, however f

34、alse positives and false negatives make it unreliable to rule out ACS.Testing for ACSStress Testing is used after observation of CP patients and negative work up for AMI yield pt low probability of CAD. This is used in low probability pts, but is not good in very low or moderate risk patients as the

35、 chance of false negatives increase.Testing for ACSPerfusion Imaging allows us to see the uptake and function of the cardiac muscle as the isotope is taken up by functioning muscle and not by damaged muscle.ACS - Patient ProtocolsInpatient Admission for Extended Observation and Definitive Diagnostic

36、s:Based on pts risk of short term morbidity and mortalityStep down careCHF, Prior CAD, Recurrent CP, new or presumed new ischemic EKG changes, + 1 Cardiac Marker Tele floorNormal EKG or unchanged, - Cardiac MarkersNonspecific Changes increase the risk.ACS ED ObservationsChest Pain Units have shown to be able to Discharge 82% of pts after set observation Serial Enzymes at 0, 3, 6, 9 hrsSerial EKGsFollowed by Echo and Stress test to rule out ACS.DispositionMiss rate of AMI = 2%C