El Dolor Torácico en Urgencias
José Ramón González-Juantey
Hospital Clínico Universitario. Santiago de Compostela
J.R.G. JUANATEY
C.H.U.Santiago
Plaque
rupture
ISCHEMIC SYNDROMES
Stable
Angina
Unstable
Angina
Antithrombotic
Therapy
Non-Q
wave MI
Q wave
MI
Thrombolysis
/ PCI
ECG:
Cannon CP
J T Thrombolysis 1996
J.R.G. JUANATEY
C.H.U.Santiago
UA / Non STE MI
ST elevation MI
EARLY RISK STRATIFICATION. FAST TRACK
SUSPECTED ISCHEMIC CHEST PAIN IN ED
1- Bed rest &
Immediate clinical evaluation
3- ECG in ≤ 10 minutes
- Correctly read
- Ask if in doubt
4- Decisions
J.R.G. JUANATEY
C.H.U.Santiago
HOSPITAL
URGENCIAS
Atención prehospitalaria
What is Acute Cardiovascular Care?
Cardiología
UC
UCIC
UCIC: Unidad Cuidados Intensivos Cardiacos
UC: Unidad Coronaria
J.R.G. JUANATEY
C.H.U.Santiago
DIAGNOSTICO
1- Clínica
2- ECG
3- Encimas (marcadores séricos de daño miocárdico)
4- Pruebas detección isquemia
5- Coronariografia
6- Otras
J.R.G. JUANATEY
C.H.U.Santiago
Síntomas clave de cardiopatía
Dolor precordial
Disnea
Síncope
Palpitaciones
J.R.G. JUANATEY
C.H.U.Santiago
1- DOLOR o malestar precordial
• Donde: Precordial (boca- ombligo)
• Calidad: opresivo
• Intensidad: variable
• Aparición: brusca
• Irradiado: brazos, mandíbula
• Desencadenado: esfuerzo, nada
• Duración: minutos, horas (no dias)
• Alivio: reposo, NTG
• Otros síntomas: disnea, mareo, sudor
J.R.G. JUANATEY
C.H.U.Santiago
ED Evaluation of
Patients With STEMI
Differential Diagnosis of STEMI: Other Noncardiac
Gastroesophageal reflux
(GERD) and spasm
Chest-wall pain
Pleurisy
Peptic ulcer disease
Panic attack
J.R.G. JUANATEY
C.H.U.Santiago
Cervical disc or neuropathic pain
Biliary or pancreatic pain
Somatization and psychogenic
pain disorder
CARACTERISTICAS SUGESTIVAS DE
DOLOR TORACICO NO ISQUEMICO
•CARACTERISTICAS
•- Pinchazos, difuso en
todo el torax
•- ”cuchillo clavado”
•LOCALIZACION
•- Area Inframamaria izq.
•- Hemitorax izquierdo
•DURACION
•- Segundos o días
J.R.G. JUANATEY
C.H.U.Santiago
•PROVOCACION
•- Agrava con respiración
•- Reproduce con la
presión
•- Provocado con
movimientos del cuerpo
•ALIVIO
•- Comida o antiacidos
•- Cambios de postura
ACUTE CORONARY OCLUSION
ECG EVOLUTIVE CHANGES
ST
Q
Q
T
QS
T
minutes
hours
days - years
J.R.G. JUANATEY
C.H.U.Santiago
Bayes de Luna. Clinical Electrocard 1993
IAM inferior
J.R.G. JUANATEY
C.H.U.Santiago
1h
24h
ECG CHANGES and EVOLUTION
Anterior AMI.
I
2 febr
II
III
aVR
I
V1
V2
II
V1
4 febr
V2
V3
III
V3
V4
aVR
V4
V5
aVL
aVF
J.R.G. JUANATEY
C.H.U.Santiago
aVL
V5
aVF
V6
V6
ECG CHANGES and EVOLUTION
Anterior AMI.
B
A
I
V1
II
V2
III
V3
aVR
V4
aVL
V5
aVF
V6
J.R.G. JUANATEY
C.H.U.Santiago
Hombre, 53 años,
Dolor torácico
Sin dolor torácico
I
V1
NTG
s.l.
II
V2
III
V3
aVR
V4
V5
aVL
V6
aVF
J.R.G. JUANATEY
C.H.U.Santiago
CARDIOPATIA ISQUEMICA.- I
Múltiplos de valor normal
3- Analítica. Marcadores de daño miocárdico
3
50
3 CK-MB poco específica
2
20
2 Troponina, muy específica (de miocardio)
1
1 Mioglobina, la que se normaliza antes
10
5
2
Límite normal
1
0
1
2
3
4
5
6
Dias post IAM
Wu AH et al. Clin Chem 1999;45:1104.
7
8
1
Clinical
Evaluation
2
Diagnosis /
Risk assessment
STEMI
3
Medical
Treatment
4
Invasive
Strategy
REPERFUSION
Emergent
<2 hours
• Quality of
chest pain
• Probability
of CAD
• Physical
examination
• ECG (↑ST?)
NSTE ACS
• Serial ECGs
• Serial troponin
• Lab tests (Hb, Crea Clea…)
• Ischemic risk score
(i.e. GRACE)
• Bleeding risk score
(i.e. CRUSADE)
• Imaging techniques
results (optional)
ACS unclear
(Rule out ACS)
J.R.G. JUANATEY
C.H.U.Santiago
No ACS
Chest Pain
Unit
Anti-ischemic
therapy
Urgent
2-24 hours
Antiplatelet
therapy
Early
Anticoagulation
24-72 hours
No /
Elective
J.R.G. JUANATEY
C.H.U.Santiago
ST elevation MI
PTCA +
STENT
J.R.G. JUANATEY
C.H.U.Santiago
J.R.G. JUANATEY
C.H.U.Santiago
CARDIOPATIA ISQUEMICA.- I
Oxygen
II
IIa
IIa IIb
IIb III
III
Supplemental oxygen should be
administered to patients with arterial oxygen
desaturation (SaO2 < 90%).
I IIa IIb III
It is reasonable to administer supplemental
oxygen to all patients with uncomplicated
STEMI during the first 6 hours.
CARDIOPATIA ISQUEMICA.- I
Nitroglycerin
II
IIa
IIa IIb
IIb III
III
II
IIa
IIa IIb
IIb III
III
Patients with ongoing ischemic discomfort should receive
sublingual NTG (0.4 mg) every 5 minutes for a total of 3
doses, after which an assessment should be made about the
need for intravenous NTG.
Intravenous NTG is indicated for relief of ongoing ischemic
discomfort that responds to nitrate therapy, control of
hypertension, or management of pulmonary congestion.
CARDIOPATIA ISQUEMICA.- I
Nitroglycerin
II
IIa
IIa IIb
IIb III
III
Nitrates should not be administered to patients with:
• systolic pressure < 90 mm Hg or ≥ to 30
mm Hg below baseline
• severe bradycardia (< 50 bpm)
• tachycardia (> 100 bpm) or
• suspected RV infarction.
II
IIa
IIa IIb
IIb III
III
Nitrates should not be administered to patients who have
received a phosphodiesterase inhibitor for erectile
dysfunction within the last 24 hours (48
hours for tadalafil).
CARDIOPATIA ISQUEMICA.- I
Analgesia
II
IIa
IIa IIb
IIb III
III
Morphine sulfate (2 to 4 mg intravenously with
increments of 2 to 8 mg intravenously
repeated at 5 to 15 minute intervals) is the
analgesic of choice for management of pain
associated with STEMI.
CARDIOPATIA ISQUEMICA.- I
Aspirin/Clopidogrel/Prasugrel/Ticagrelor
II
IIa
IIa IIb
IIb III
III
Aspirin should be chewed by patients who
have not taken aspirin before presentation
II
IIa
IIa IIb
IIb III
III
with STEMI. The initial dose should be 162
mg (Level of Evidence: A) to 325 mg (Level
of Evidence: C)
Although some trials have used enteric-coated aspirin
for initial dosing, more rapid buccal absorption occurs
with non–enteric-coated formulations.
CARDIOPATIA ISQUEMICA.- I
Beta-Blockers
II
IIa
IIa IIb
IIb III
III
II
IIa
IIa IIb
IIb III
III
Oral beta-blocker therapy should be administered
promptly to those patients without a contraindication,
irrespective of concomitant fibrinolytic therapy or
performance of primary PCI.
It is reasonable to administer intravenous betablockers promptly to STEMI patients without
contraindications, especially if a tachyarrhythmia or
hypertension is present.
CARDIOPATIA ISQUEMICA.- I
Ischemia/Reperfusion Injury
-acute inflammatory response
-apoptosis
-platelet-neutrofil aggregates
(no-reflow)
CARDIOPATIA ISQUEMICA.STEMII
Before
Angio/PCI
After
Long-term
ASA
P2Y12 inhibitor
Anticoagulant
Clopidogrel
Prasugrel
Ticagrelor
UFH ?
1y
UFH/bival
Rivaroxaban
Very low dose
GPIIbIIIa inhibitor
Bail-out
CARDIOPATIA ISQUEMICA.- I
Other Pharmacological Measures
Inhibition of
the renin angiotensin aldosterone
system
Angiotensin converting enzyme (ACE)
inhibitors
Angiotensin receptor blockers (ARB)
Aldosterone blockers
Glucose control
Magnesium
Calcium channel blockers
CARDIOPATIA ISQUEMICA.- I