อพญ ขวัญศิริ นราจีนรณ ส าหรับ...
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อ.พญ. ขวญัศิร ินราจนีรณ
ส าหรบันิสติแพทยเ์วชปฏบิตัิ
ปีการศกึษา 2561
Complication of MI Clinical CHF
shock
Echo early detected
IABP, ECMO
Ventricular septal rubture
Papillary muscle rubture
Free wall rubture
Ischemic chest pain in ED GOAL
rapid identification of patients with STEMI
Rule out other life-threatening causes
Exclusion of alternative causes of non-ischemic chest pain
stratification of patients with acute coronary ischemia into low- and high-risk groups
2014 AHA/ACC Guideline for the Management of Patients WithNon–ST-Elevation Acute Coronary Syndromes
What case the should do ECG?
2014 AHA/ACC Guideline for the Management of Patients WithNon–ST-Elevation Acute Coronary Syndromes
Angina equivalent
***เขยีนpain score, BP ดว้ย
*SERIAL EKG 12 lead next 15 min*SERIAL EKG 12 lead when recurrence chest pain*Compare with previous EKGถา้ไมม่EีKGเก่า ก็ท าของใหมใ่หเ้ป็นของเก่าโดยการserial EKGอกีเช่นเคย ควรท า EKG ในเครื่องเดยีวกนัเท่านัน้ เคยท า position ไหนควรท า position นัน้
T h i r d u n i v e r s a l d e f i n i t i o n o f m y o c a r d i a l
i n f a r c t i o n E S C 2 0 1 2
T h i r d u n i v e r s a l d e f i n i t i o n o f m y o c a r d i a l
i n f a r c t i o n E S C 2 0 1 2
ESC 3rd universal definition MI
Myocardial infarct = Myocardial necrosis + Clinical myocardial ischemia
T h i r d u n i v e r s a l d e f i n i t i o n o f m y o c a r d i a l
i n f a r c t i o n E S C 2 0 1 2
0 h/3 h rule-out algorithm of NSTEMISerial testing 3 hr
5-fold of ULNMarco Roffi, et al. 2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-
segment elevation. European Heart Journal: doi:10.1093/eurheartj/ehv320.
0 h/3 h rule-out algorithm of NSTEMI
T < 14 ng/L T > 14 ng/L
value >14 ng/L + increase > 7 ng/L
valu
e >
70 n
g/L
+ cl
inic
al
pre
sen
tati
on
value >14 ng/L + increase>20% of initial value
Adapted from Marco Roffi, et al. 2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-segment elevation. European Heart Journal: doi:10.1093/eurheartj/ehv320.
Recommendations to measure hsTroponin T
Marco Roffi, et al. 2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-segment elevation. European Heart Journal: doi:10.1093/eurheartj/ehv320.
0 h/1 h rule-in and rule-out algorithms to the emergency department
P.10Marco Roffi, et al. 2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-
segment elevation. European Heart Journal: doi:10.1093/eurheartj/ehv320.
Key messagesSafe and effective AMI rule-in and rule-out in 1 hour
Reliable
results of
cTnT-hs with
many
references
supported
Algorithm
safety
confirmed by
30d-
mortality of
the patients
rule-out
(0.1%) and
high NPV
(>99.1-100%)
cTnT-hs 1-h
performs
well for
early AMI
rule-out and
rule-in
And reduces
diagnosis
time to 1h in
76-78% of
acute chest
pain patients
cTnT-hs
validates the
use of hs-cTn
with a
recommended
delta change
>99.1%NPV
30 day
mortality
More
patientsMore rule-
in/out
1h
cTnT-
hs
cTnT-
hs
diagnosed
in
1 hour
76-78%
GRACE : Predict inhospital death, death at 6 month
TIMI : predict 14 day death, MI, revascularization
For risk stratification and for guide treatment strategy
If GRACE score ≥ 109 (moderate – severe) invasive strategy PCI in 72 hr
If TIMI score ≥ 3(moderate – severe) invasive strategy PCI in 72 hr
On the monitor….
Marco Roffi, et al. 2015 ESC guidelines for the management of ACSin patients presenting without persistent ST-segment elevation. European Heart Journal
Electrocardiographic Monitoring in Adults
Rafael Ortega, M.D., et.al N Engl J Med 2015; 372:e11
Electrocardiographic Monitoring in Adults
Rafael Ortega, M.D., et.al N Engl J Med 2015; 372:e11
Case Male 58 y HT, smoking
CC : chest pain at rest 30 min PTA (16:30)
แสบหนา้อกขณะน่ังคยุกบัญาต ิ แน่นหนักๆ กลางหนา้อก กนิยา
เคลอืบกระเพาะแลว้ดขีึน้
Came to ER Chula 17:00 (30 min after C/P)
BP 158/84 mmHg PR 68/min, regular RR 18/min
PE: WNL , no CHF, no murmur
1st EKG Time 17:20 (20 min after) at OPD Room No.9
F/U EKG Time 18:24 (80 min.after) at OPD Room No.9, Dx STEMI
Case 3 Male 58 y C/P 30 min PTA Timeline
16:30 Chest pain
17:00 ER Chula
17:20 1st EKG
18:24 2nd EKG
18:25 consult fellow cardio
18:35 set primary PCI
18:55 arrived to cath lab
CAG DVD (95% distal RCA, 55 % prox LCX)
19:10 1st device (p-PCI to RCA)
Pitfall 3.1Screening miss HX มาดว้ยแสบหนา้อก กนิยาเคลอืบกพ.มานึกวา่เป็นGIเลยส่งหอ้งNo.9
3.2 R3 med miss dx EKG inferiorwall STEMI Txแบบdyspepsiaรอlab
3.3 F/U EKG นาน80min ท าอกีทSีTยก
ชดัเจน