美国重症医学(FCCM)的基础教程急性冠脉综合征

MI1

AcuteCoronarySyndromes®ObjectivesIdentifypatientswithacutecoronarysyndromesOutlineacutemanagementofunstableangina,non-QwaveandQ-wavemyocardialinfarctionIdentifypatientswhoarecandidatesforrevascularizationinterventionsRecognizehigh-riskpatientsandearlycomplicationsofmyocardialinfarctionMI2

®AcuteCoronarySyndromesOverlappingclinicalconditionsUnstableanginaNon-Q-wavemyocardialinfarction(MI)Q-wave(ST-segmentelevation)myocardialinfarctionVariabledegreesofcoronaryarteryocclusionProcessofinflammation,plateletactivation/aggregation,thrombusformation,microembolizationMI3

®ChestPainAlgorithmPatientwithchestpain

History,physicalexamination,ECG,chestradiograph

MIwithST-segmentelevationpresent?

Yes

ToMI

algorithmNo

Unstableanginapresent

No

Consideralternativeevaluation

UnstableAnginaandNon-Q-WaveMyocardialInfarctionEvaluationandmanagementsimilarPreliminarydiagnosisClinicalsymptomsRiskfactorsElectrocardiogramCardiacenzymesAssessshort-termrisks

ChestPainAlgorithm Unstableanginapresent

Admit,monitorECG,O2

Aspirin Sublingualorspraynitroglycerin Intravenousnitroglycerin Heparin(unfractionated,lowmolecularweight)

-blocker

GPIIb/IIIainhibitor(high-riskpatients)

Symptomsrelieved?

Yes

Elective

evaluation No(nextslide)

ChestPainAlgorithm

Symptomsrelieved?

No

Adjustdoseofnitroglycerin,-blockerConsidercalciumchannelblocker

Symptomsrelieved?

Yes

Elective

evaluation No

Emergencyconsultation/transferCautionsNitroglycerinAvoiddecreaseinbloodpressure10%Adjustunfractionatedheparininfusion-blockercontraindicationsHeartrate<60beats/minModerate-severeheartfailureAtrioventricularblock>firstdegreeSystolicbloodpressure<100mmHgPeripheralhypoperfusionBronchospasticdiseaseQ-Wave(ST-segmentelevation)MyocardialInfarctionOcclusionofcoronaryarterybythrombusProgressionofnecrosiswithtimeDiagnosisClinicalsymptomsElectrocardiogramCardiacenzymesAdmit,O2

AspirinSublingual,sprayand/orivnitroglycerinMorphineHeparin(unfractionated,lowmolecularweight)

-blocker

Candidateforthrombolytic?

No

Emergencyconsultation/transferforprimaryPTCAQ-Wave(ST-segmentelevation)MyocardialInfarctionDefiniteIndicationsforThrombolyticTherapy

ConsistentClinicalSyndromeChestpain,newarrhythmia,unexplainedhypotensionorpulmonaryedemaDiagnosticECGSTelevation

1mmin

2contiguousleadsornewleftbundle-branchblockLessthan12hourssinceonsetofpainRelativeIndicationsforThrombolyticTherapy

ConsistentClinicalSyndromeChestpain,newarrhythmia,unexplainedhypotensionorpulmonaryedemaNondiagnosticECGLeftbundle-branchblockofunknownduration

AbsoluteContraindicationsforThrombolyticTherapy

HistoryofhemorrhagicstrokeStrokeorCVAwithin1yearAllergytotheagentSurgeryortraumainpast2wksKnownintracranialneoplasmSuspectedaorticdissectionActiveinternalbleeding

(exceptmenstruation)RelativeContraindicationsforThrombolyticTherapy

Severeuncontrolledhypertension(>180/110mmHg)HistoryofchronicseverehypertensionCVAorintracerebralpathology>1yragoCurrentanticoagulantuseRecenttrauma(within2-4weeks)AllergyorpriorexposuretostreptokinaseRelativeContraindicationsforThrombolyticTherapy

ActivepepticulcerdiseaseSignificanthepaticdysfunctionRecent(2-4weeks)internalbleedingBleedingdiathesisNoncompressiblearterialorcentral

venouspuncturePregnancyQ-Wave(ST-segmentelevation)MyocardialInfarction Candidateforthrombolytic?

No

Emergency

consultation/transfer Yes forprimaryPTCA

Thrombolyticagentgiven

ComplicationsofMI

Yes

Emergency

consultation/transfer No

ElectiveevaluationContinuingTherapyHeparininfusionafterthrombolysis(exceptafterstreptokinase)AspirindailyNitroglycerinfor24-48hours

-blockerunlesscontraindicatedAngiotensin-convertingenzyme(ACE)inhibitorwithinfirst24hoursCardiologyconsultationand/ortransferComplicationsofMyocardialInfarction

Heartfailure:SystolicBP>100mmHgVasodilatorsNitroglycerinNitroprussideInotropesDobutamineMilrinoneLoopdiureticsHeartfailure:SystolicBP<90mmHgVasopressorsinitiallyNorepinephrineDopamineInotropeswhenBPstableConsiderPTCAorintra-aorticballoonpumpCardiologyconsultationComplicationsofMyocardialInfarctionComplicationsofMyocardialInfarction

RecurrentischemiaorinfarctionFollowunstableanginaalgorithmCardiologyconsultationConsiderrepeatthrombolysiswithnon-streptokinaseagentAngioplastyorbypassComplicationsofMyocardialInfarction

ArrhythmiasProphylacticdrugsnotrecommen