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Durerea toracica acuta

Dr Andreeea Catarina Popescu


Etiologia durerii toracice acute
• Sindrom coronarian acut
• Trombembolism pulmonar
• Miocardita acuta
• Pericardita acuta
• Disectie acuta de aorta
• Pneumotorax
• Pneumonie
• Ruptura de esofag
• Boala ulceroasa
• Colecistita acuta
• Fracturi costale
• Traumatism toracic
• mediastinita
Etiologii amenintatoare de viata

• sindrom coronarian acut,


• disectia acuta de aorta,
• trombembolism pulmonar,
• tamponada cardiaca,
• ruptura de esofag
Elemente ajutatoare in diagnosticul
etiologic al durerii toracice acute
• Anamneza (caracterul durerii, circumstantele de aparitie, factori
agravanti, factori care amelioreaza durerea, durata, ritmicitatea)
• Antecedente personale fiziologice
• Antecedente personale patologice
• Examen clinic
• ECG
• Teste de laborator troponina, Ddimeri
• Ecocardiografia
• Examen CT spiral cu contrast
• Teste de efort (ECG sau imagistice)
• Radiografia cardiopulmonara
• Ecografia abdominala
• Angiografia coronariana prin tomografie computerizata
• Rezonanata magnetica cardiaca
Algoritm pentru diagnosticul/excluderea etiologiei
amenintatoare de viata a durerii toracice
Durerea toracica

sindrom coronarian acut


disectia de aorta
trombembolism pulmonar
boala coronariana stabila
miocardita cardiomiopatia hipertrofica
pericardita stenoza aortica
regurgitare aortica
anevrism de aorta
Diagnostic diferential
sindrom coronarian acut

infarct miocardic cu supradenivelare ST

infarct miocardic acut fara supradenivelare ST

angina instabila
Diagnosticul diferential
Anamneza
Examen clinic
Descrierea durerii
inspectie
caracter,
palpare
intensitate
percutie
localizare
auscultatie Investigatii
iradiere
Troponina
durata
ECG
factori provocatori
Test ECG de efort
factori calmanti
Ecocardiografia, de stress
Antecedente heredocolaterale
coronarografie
Antecedente personale
CT torace
CT coronare
Radiografia cord pulmon
RM cardiac
Durerea toracica
Angina
• Retrosternal, precordial

• iradiere in mandibula, brate, coate

• Apasare

• Apare la efort si la emotii

• Cedeaza la intreruperea efortului si dupa NTG

• Transpiratii

• Caracter constant
Durerea toracica
Disectia de aorta
• Durere violenta
• Interscapulovertebral
• Sincopa
• Senzatie de moarte iminenta

Trombembolism pulmonar
• Dispnee
• Sincopa
Durerea toracica
Pericardita
• Durere accentuata de inspir
• Iradiere in umar
ESC Guidelines for the management of acute coronary syndromes in patients
presenting without persistent ST-segment elevation Eur Heart J 2015
Electrocardiograma
Criterii pentru supradenivelare ST
Supradenivelare ST masurata in punctul J, in cel putin 2 derivatii contigue

≥ 0,1mV in orice derivatii cu exceptia V2-V3

In V2-V3

≥ 0,2mV la barbati ≥ 40 ani si

≥ 0,25mV la barbati < 40 ani;

In V2-V3
≥ 0,15mV la femei.

BRS major nou aparut

La pacientii cu infarct inferior se recomanda si inregistrarea derivatiilor V3R

si V4R – pentru diagnsoticul infarctului de VD


Modificari ECG ce impun angioplastie coronariana
de urgenta la pacienti cu simptome
Bloc de ramura
Criterii pentru diagnosticul STEMI in BRS
•Supradenivelari ST concordante>1mm in derivatii cu QRS pozitiv
•Subdenivelari concordnte ≥ 1mm in V1-V3
•Supradenivelari discordante ≥ 5mm in derivatii in care complexul
QRS e negativ
Prezenta BRD poate face dificil diagnosticul de STEMI

Ritm de pacemaker
Aceleasi criterii ca in cazul BRS
Infarct miocardic posterior
Subdenivelare izolata ST ≥ 0,5mm in V1-V2 si supradenivelare de ST
≥ 0,5mm in V7-V9
Ischemia determinata de ocluzia de trunchi al coronarei stangi
sau boala multivasculara
Subdenivelare de ST ≥ 1mm in 8 sau maimulte derivatii impreuna cu
supradenivelare ST in aVR si/sau V1 sugereaza ocluzie de trunchi
sau echivalenta – boala trivasculara severa
Criterii pentru sindrom coronarian acut fara
supradenivelare de ST

Subdenivelare ST orizontala sau descendenta

≥ 0,05mV in 2 derivatii contigue

sau

T negativ ≥ 0,1mV in 2 derivatii contigue cu R


proeminent sau R/S>1
Electrocardiograma
Troponina

Crestere si descrestere a troponinei

Troponine cu specificitate crescuta


2015 ESC Guidelines for the management of acute coronary syndromes in patients
presenting without persistent ST-segment elevation. European Heart Journal (2016) 37, 267–315
2015 ESC Guidelines for the management of acute coronary syndromes in patients
presenting without persistent ST-segment elevation. European Heart Journal (2016) 37, 267–315
Ecocardiografia
criteriu diagnostic de infarct - tulburare de cinetica nou
aparuta (hipo sau akinezie)
Diagnostic diferential - comorbiditati

In practica
La cei cu modificari ECG diagnostice – confirmare si examinare pentru
comorbiditati
La cei fara modificari ECG diagnostice – tulburarea de cinetica nou aparuta –
criteriu diagnostic

tulburarea de cinetica parietala poate lipsi


• la cei cu hipertrofie
• la cei cu unde T negative
Lang et al.

Lang et al. Recommendations for Cardiac Chamber Quantification


by Echocardiography in Adults: An Update from the American Society of
Echocardiography and the European Association of Cardiovascular Imaging
European Heart Journal – Cardiovascular Imaging (2015) 16, 233–271
The Use of Echocardiography in Certified Chest Pain Units:
Results from the German Chest Pain Unit Registry.
Breuckmann F1, Hochadel M, Voigtländer T, Haude M,
Schmitt C, Münzel T, Giannitsis E, Mudra H, Heusch G,
Schumacher B, Barth S, Schuler G, Hailer B, Walther D, Senges J.

TTE did not delay door-to-balloon times


About two thirds of the patients admitted to certified CPUs received TTE evaluation,
with the highest rates being in ACS patients, and thereby providing diagnostic
information supporting or refuting further invasive management

Cardiology. 2016 Feb 25;134(2):75-83


J Echocardiogr. 2015 Oct 26. [Epub ahead of print]
Point-of-care echocardiography for aortic dissection, pulmonary
embolism and acute coronary syndrome in patients with killer chest
pain: EASY screening focused on the assessment of effusion, aorta,
ventricular size and shape and ventricular asynergy.
Nishigami K1
evaluation of cardiac disease in the emergency room

EASY screening - consists of the assessment of effusion in the pericardial space, aortic
abnormalities, the size and shape of the ventricles and asynergy of the left ventricle.

Aortic dissection is suggested by positive findings for effusion and/or abnormal aortic
findings.
Pulmonary embolism is suggested by a dilated right ventricle and a D-shaped left
ventricle in the short-axis view.
Acute coronary syndrome is suggested by asynergy of left ventricular wall motion.

EASY screening may facilitate the assessment of aortic dissection, pulmonary


embolism and acute coronary syndrome in patients presenting to the emergency room
with killer chest pain.
Diagnostic
Infarct miocardic – trombembolism pulmonar

ECG modificari unda T


Troponina pozitiva
Ecocardiografia sugestiva pentru TEP
Confirmare - CT spiral cu substanta de contrast
Caz disectie
Infarct miocardic – disectia de aorta

• ECG subdenivelari orizontale ST


• Troponina pozitiva
• ecocardiografia TT
• confirmare - TEE sau CT torace cu substanta
de contrast
Traumatism toracic cu
disectie de crosa
Tamponada cardiaca
Takotsubo
Troponina I 30,9ng/ml,
CK 679U/L,
CKMB 86U/L,
VSH 9mm/h
Postcontrast tardiv
Infarct miocardic – miocardita

• ECG
• Troponina
• ecocardiografia
• coronarografia – doar prezenta trombului
intracoronarian
• RM cardiac
Importanţa problemei

simptome cardiace acute


Infarct miocardic acut
+
modificări ECG
+ Terapie de reperfuzie
creştere a troponinei
10% din cazuri
coronare angiografic normale
Importanţa problemei

coronare angiografic normale

Boala coronariană
miocardită
nesemnificativă TakoTsubo
• Placă instabilă complicată
• Embolie
• Spasm
• Ocluzie prin flush a unui ram
Coronarografia

• valoare are în cazul în care se găseşte tromb,


ocluzie, stenoza critică, disecţie coronariană

• la cei cu coronare normale angiografic


suspiciunea de miocardită este mai mare
totuşi nu se poate exclude infarctul prin spasm
coronarian, embolie coronariană
Heart 2011;97:1312e1318. doi:10.1136/hrt.2010.204818

In patients presenting with chest pain, ECG


changes, raised troponin and apparently
culprit-free coronary angiograms, CMR
frequently contributes to important
diagnoses (including missed MI) and may
become an important component of
diagnostic pathways in heart attack centres
Infarct miocardic acut cu
supradenivelare de ST
Situatii de urgenta

Diagnosticul de infarct si tratamentul de reperfuzie

Complicatii
Aritmii ventriculare
Aritmii supraventriculare
Blocuri atrioventriculare
Insuficienta cardiaca acuta, edem pulmonar acut, soc cardiogen
Tamponada cardiaca
Defectul septal ventricular
Regurgitarea mitrala acuta
Sindroame coronariene acute
fara supradenivelare de ST
Criterii de risc foarte inalt la pacientii cu sindrom
coronarian acut fara supradenivelare de ST

coronarografia este indicata in urmatoarele 2h, in vederea


angioplastiei
• Instabilitate hemodinamica sau soc cardiogen
• Durere toracica recurenta sau persistent, rezistenta la
tratamentul medical
• Aritmie amenintatoare de viata sau stop cardiac
• Complicatii mecanice
• Insuficienta cardiaca acuta
• Modificari ST, T recurente, dinamice, supradenivelare de ST
intermitenta
 
Criterii de risc inalt la pacientii cu sindrom
coronarian acut fara supradenivelare de ST
Va efectua coronarografia in urmatoarele 24h

• Crestere sau scadere a troponinei compatibila


cu infarct
• Modificari dinamice ST, T (simptomatice sau
silentioase)
• Scor GRACE >140
 
Criterii de risc intermediar la pacientii cu sindrom
coronarian acut fara supradenivelare de ST
necesita coronarografie in 24-72 h

• Diabet zaharat
• Insuficienta renala (eGRF<60mL/1,73m2)
• LVEF <40% sau insuficienta cardiaca congestive
• Angina precoce postinfarct
Disectia acuta de aorta