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1、Approach to Chest PainLevente Batizy, DOSeptember 15, 2005. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Chest Pain 5% of ED visits 5 million pts/yr Accurate diagnosis remains a challenge. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Ches
2、t Pain Visceral Often referred Aching, heaviness, discomfort Difficult to localize pain Somatic Sharp, easily localized. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Chest Pain Definitions Acute Chest Pain: Acute - sudden or recent onset (usually within minutes to hour
3、s), presenting typically 24 hrs Chest - thorax midaxillary to midaxillary line, xiphoid to suprasternum notch Pain noxious uncomfortable sensation Ache or discomfort. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Initial Approach Triage Chest pain Significant abnormal p
4、ulse Abnormal blood pressure Dyspnea These pts need IV, O2, Monitor, ECG. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Initial Approach Evaluation: Airway Breathing Circulation Vital Signs Focused exam Cardiac, pulmonary, vascular. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人
5、单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Initial Approach History: Character of pain Presence of associated symptoms Cardiopulmonary history Pain intensity, 0-10 pain. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Initial Approach Secondary exam: History Quality, radiatio
6、n/migration, severity, onset, duration, frequency, progression and provoking or relieving factors of pain Risk factors Physical exam Review old records/ekgs. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Categorizing Chest PainChest Wall PainSharp, Precisely localizedRe
7、producible: Palpation, movementPleuritic or Respiratory CPSomatic pain, SharpWorse with breathing/coughingVisceral CPPoorly localized, aching, heaviness. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Causes Table 49-1Chest wallCostosternal syndCostochrondritisPrecordial
8、 catch syndSlipping Rib SyndXiphodyniaRadicular SyndIntercostal NerveFibromyalgiaPleuriticPulmonary EmbolismPneumoniaSpontaneous pneumoPericarditisPleurisy. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Causes Table 49-13.Visceral Pain:Typical Exertional AnginaAtypical
9、AnginaUnstable AnginaAcute Myocardial Infarction (AMI) Aortic Dissection Pericarditis Esophageal Reflux or spasm Esophageal Rupture Mitral Valve Prolapse. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Categorizing Chest Pain Assessment of Risk FactorsCAD:Cigarette Smoki
10、ngDiabetesHypertensionHypercholesterolemiaFamily History. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Categorizing Chest Pain Assessment of Risk FactorsAortic Dissection:Middle AgedMaleHypertensionMarfan Syndrome. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分
11、析现代农业示范工程设施红地球葡萄栽培培训材料Categorizing Chest Pain Assessment of Risk Factors Pulmonary Embolism Hypercoagulable Diathesis Malignancy Recent Immobilization Recent Surgery. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Chest pain incidentals ACS AMI Rare under 30 y/o except w
12、ith cocaine use GI cocktail may cause relief even in AMI Nitroglycerin can cause relief of esophagus spasm, biliary colic, and AMI NSAIDS can be analgesic for all types of pain. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Atypical Chest Pain Dyspnea at rest, DOE Disco
13、mfort: shoulder, jaw, arm Nausea, Epigastric pain Lightheadedness, Generalized weakness MS changes Diaphoresis Atypicals usually in DM, females, non-white, elderly, altered MS pts. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Differential DxAcute Coronary Syndrome (ACS
14、) ACS = AMI or Unstable Angina Visceral chest pain pts AMI 15% UA 25-30%. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Differential DxAcute Coronary Syndrome (ACS) ECG is the most useful test Incidence Significant ST elevation = 80% are AMI ST depression/T wave inversi
15、on = 20% are AMI No change 20 min, severe Associated Sx: Dyspnea, Diaphoresis, Nausea May even be Reproducible. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Differential Dx ACS Exertional Angina: Episodic pain, 20 min High risk of AMI. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事
16、浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Differential Dx ACS Pulmonary Embolism: Atypical, presenting with any combination of: Chest Pain, Dyspnea, Syncope, Shock, Hypoxia Fever, cough, hemoptosis Pain is often pleural Reproducible with breathing, palpation Classic presentaion: Sharp pain, Dyspnea
17、 Tachypnea, tachycardia, hypoxemia. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Differential Dx ACS Aortic Dissection: Risk Factors Atherosclerosis, HTN (uncontrolled), Coarctation of Aorta, Bicuspid Aortic Valve, Aortic Stenosis, Marfan Syn, Ehlers-Danlos Syn, Pregna
18、ncy Pain midline Substernal CP, tearing, ripping, searing, radiating to interscapular area Pain Above AND Below Diaphragm Often assoc. with stroke, AMI, limb ischemia . .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Differential Dx ACS Spontaneous Pneumothorax: Risks: Su
19、dden Change in barometric pressure Smokers, COPD, Idiopathic Bleb DZ Pain: sudden, sharp, pleuritic chest pain, and dyspnea Dx: Absence of breath sounds ipsilaterally Hyper resonance to percussion CXR Dx simple pneumo. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Diffe
20、rential Dx ACS Esophageal Rupture (Boerhaave Syn): Life-threatening Substernal, sharp CP Sudden onset after forceful vomiting Dyspneic, diaphoretic, and ill-appearing CXR: Normal, SQ air, Pleural Effusions, Pneumothorax, pneumoperitoneum, pneumomediastinum Water Soluble Contrast Study . .常见心律失常心电图诊断
21、的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Differential Dx ACS Acute Pericarditis: Acute, sharp, severe, constant, substernal CP Radiation to back, neck, shoulders Worse with lying down and inspiration Relief with leaning forward FRICTION RUB EKG: ST segment elev., T wave invers
22、ion, or PR depression. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Differential Dx ACS Pneumonia: Sharp and Pleuritic Fever, cough, hypoxia Rales, decreased breath sounds, etc. CXR . .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Different
23、ial Dx ACS Mitral Valve Prolapse: Women Men Discomfort at rest Assoc. Sx: Dizziness, Hyperventilation, Anxiety, Depression, Palpitations, Fatigue, SVT, Ventricular Dysrhythmia Tx: Beta-Adrenergic Blockers Dx: Echo. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Different
24、ial Dx ACS Musculoskeletal/Chest Wall Disorders: LOCALIZED, Sharp, positional CP Reproducible Types Costochondritis, Tietze Syndrome Xiphodynia. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Differential Dx ACS GI Disorders: GERD/dyspepsia burning, gnawing low CP Acidic
25、 taste Recumbent position increases pain Relief per antacids CAREFUL, can also help in ACS. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Differential Dx ACS Esophageal Spasm: Sudden onset, dull, tight, gripping Hot or cold liquids Large food bolus Responds to NTG. .常见心
26、律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Differential Dx ACS Peptic Ulcer Disease: Gastric: Postprandial, dull, boring pain Midepigastric, may awake pt. Duodenal Ulcer: Relieved after eating Symptomatic Tx: antacids DDx: Pancreatitis and Biliary tract Dz. .常见心律失常心电图诊断的
27、误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Differential Dx ACS Panic 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, pa
28、resthesias, chills, hot flashes Rule out substance abuse. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS EKGs Serum Markers Imaging studies. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS - EKG AHA Guidlines: A
29、ny 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. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS - EKG AMI PT EKGs: 50% = ST elevation 1mm in 2 contiguous leads 20-30% = new
30、ST seg. changes or T wave inversion 10-20% = ST depression and T wave inversions Similar to previous EKGs 10% nonspecific changes 1-5% will have NORMAL initial EKG. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS - EKG Positive predictive values: New ST el
31、evation = AMI 80% New ST depression & T wave inversion = AMI 20%, 14-43% UA Acute CP, preexisting ST depression & T wave inv. = AMI 4%, 21-48% UA. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS - Serum Markers Creatine Kinase, an intracellular enzyme invo
32、lved in transferring phosphate grps from ATP to creatine in Cardiac & skeletal muscle and brain CK-BB = brain CK-MM = skeletal CK-MB = cardiac . .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS - Serum Markers CK elevates 4-8 hours after coronary Art. Occlu
33、sion Peaks = 12 to 24 hours Nml = 3 to 4 days CK-MB Detectable 4-8 hrs Peak = before 24 hrs Nml = in 48hrs CK-MB normally can be 5% of total CK (Rapid Index). .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS - Serum Markers Common Causes of CK-MB Elevation:
34、 UA, ACS Inflammatory Heart Dz Cardiomyopathies Shock Cardiac Surgery/Trauma Trauma Dermatomyositis Myopathic Disorders Muscular Dystrophy Extreme Exercise Malignant Hyperthermia Reyes Syndrome Rhabdomyolysis Delerium Tremens Ethanol Poisoning, chronic. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险
35、法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS - Serum MarkersMyoglobin: Abnormal in 80 100% AMI pts Small protein in striated and cardiac muscle, released in cell disruption In AMI Rises within 3 hours Peak at 4 to 9 hours Baseline at 24 hours Except in trauma pts, renal pts, and cocaine users myogl
36、obin can be as sensitive as CK-MB and Troponins. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS - Troponins Main regulatory protein of thin filament of myofibrils that regulate the Ca+ dependent ATP hydrolysis of actinomysin 3 Subunits: Trop I = Inhibitor
37、y Subunit Myocardial Specific Elevation indicated worse prognosis Trop T = tropomyosin-binding subunit Trop C = calcium-binding subunit. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS - Troponins AMI:Cardiac Troponin I (cTnI) and cTnT Elevates in 6 hrs pe
38、aks in 12 h Remain elevated for 7 to 10 days Higher specificity than CK-MB Controversy = Troponins are found to be elevated in Renal Failure pts without proof of ACS/AMI . .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS - Serum Markers AMI on Initial EKG M
39、arkers not required for Dx Marker changes may precede EKG Change AMI CK-MB initially elevated in 30-50% Serial CK-MB elevate in 6 hours in 80-96%. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS - Serum Markers Using Myoglobin, CK-MB, and cTnI initially an
40、d at 3 hours = 90% of AMI pts diagnosed. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS - Serum Markers New Bedside cardiac marker tests are now available with results in less than 20 minutes Overall value of this remains to be determined. .常见心律失常心电图诊断的误区
41、诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料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 mark
42、er(s)Positive perfusion imaging study. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料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 p
43、ainIschemic pattern on EKG without CP. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS Prognosis Categorization Strategy4.A. Probably NOT Ischemia: low riskRequires all of followingHx not strong for ischemiaEKG normal, unchanged from previous,or nonspecifi
44、c changesNegative markers . .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS Prognosis Categorization Strategy4.B. Stable Angina Pectoris: low risk PxRequires all the following 2wk unchanged Sx pattern, Longstanding Sx with only mild change in exertional pa
45、in thresholdEKG normal, unchanged, nonspecific changesNegative initial myocardial markers. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS Prognosis Categorization StrategyDefinitely not ischemia: very low risk for adverse eventsRequires AllClear objective
46、 evidence of nonischemic Sx etiologyECG normal, unchanged, nonspecificNegative Initial Markers. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS - Echo Noninvasive, dynamic nature Can assess cardiac function, aortic dissection, pericardial pathology, valvul
47、ar dz, possibly PE Normal Echo during CP theoretically excludes ischemia, however false positives and false negatives make it unreliable to rule out ACS. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS Stress Testing is used after observation of CP patient
48、s 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 chance of false negatives increase. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Testing for ACS Perfusion
49、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. .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料ACS - Patient Protocols Inpatient Admission for Extended Observation and Defi
50、nitive Diagnostics: Based on pts risk of short term morbidity and mortality Step down care CHF, Prior CAD, Recurrent CP, new or presumed new ischemic EKG changes, + 1 Cardiac Marker Tele floor Normal EKG or unchanged, - Cardiac Markers Nonspecific Changes increase the risk. .常见心律失常心电图诊断的误区诺如病毒感染的防控知