美国重症医学(FCCM)的基础教程急性冠脉综合征.ppt

MI MI 11 MI 1 Acute Coronary SyndromesAcute Coronary SyndromesMI MI 22 ObjectivesObjectives Identify patients with acute coronary syndromesIdentify patients with acute coronary syndromes Outline acute management of unstable angina,Outline acute management of unstable angina,non-Q wave and Q-wave myocardial infarctionnon-Q wave and Q-wave myocardial infarction Identify patients who are candidates for Identify patients who are candidates for revascularization revascularization interventionsinterventions Recognize high-risk patients and early Recognize high-risk patients and early complications of myocardial infarctioncomplications of myocardial infarctionMI 2 MI MI 33 Acute Coronary SyndromesAcute Coronary Syndromes Overlapping clinical conditionsOverlapping clinical conditions Unstable anginaUnstable angina Non-Q-wave myocardial infarction(MI)Non-Q-wave myocardial infarction(MI)Q-wave(ST-segment elevation)myocardial Q-wave(ST-segment elevation)myocardial infarctioninfarction Variable degrees of coronary artery occlusionVariable degrees of coronary artery occlusion Process of inflammation,platelet activation/Process of inflammation,platelet activation/aggregation,thrombus formation,aggregation,thrombus formation,microembolizationmicroembolizationMI 3 MI MI 44 Chest Pain AlgorithmChest Pain Algorithm Patient with chest pain Patient with chest pain History,physical examination,ECG,chest radiograph History,physical examination,ECG,chest radiograph MI with ST-segment elevation present?MI with ST-segment elevation present?Yes Yes To MI To MI algorithm algorithm No No Unstable angina present Unstable angina present NoNo Consider alternative evaluationConsider alternative evaluationMI MI 55 Unstable Angina and Non-Q-Unstable Angina and Non-Q-Wave Myocardial InfarctionWave Myocardial Infarction Evaluation and management similarEvaluation and management similar Preliminary diagnosisPreliminary diagnosis Clinical symptomsClinical symptoms Risk factorsRisk factors ElectrocardiogramElectrocardiogram Cardiac enzymesCardiac enzymes Assess short-term risksAssess short-term risksMI MI 66 Chest Pain AlgorithmChest Pain AlgorithmUnstable angina presentUnstable angina present Admit,monitor ECG,OAdmit,monitor ECG,O22 AspirinAspirin Sublingual or spray nitroglycerin Sublingual or spray nitroglycerin Intravenous nitroglycerinIntravenous nitroglycerinHeparin(Heparin(unfractionatedunfractionated,low molecular weight),low molecular weight)-blocker blocker GP GP IIbIIb/IIIa IIIa inhibitor(high-risk patients)inhibitor(high-risk patients)Symptoms relieved?Symptoms relieved?Yes Yes ElectiveElective evaluationevaluationNo(next slide)No(next slide)MI MI 77 Chest Pain AlgorithmChest Pain AlgorithmSymptoms relieved?Symptoms relieved?NoNo Adjust dose of nitroglycerin,Adjust dose of nitroglycerin,-blockerblocker Consider calcium channel Consider calcium channel blockerblocker Symptoms relieved?Symptoms relieved?Yes Yes Elective Elective evaluationevaluationNoNo Emergency consultation/transferEmergency consultation/transferMI MI 88 CautionsCautions NitroglycerinNitroglycerin Avoid decrease in blood pressure Avoid decrease in blood pressure 10%10%Adjust Adjust unfractionated unfractionated heparin infusionheparin infusion -blocker blocker contraindicationscontraindications Heart rate 60 beats/minHeart rate first degreeblock first degree Systolic blood pressure 100 mm HgSystolic blood pressure 180/110 mm Hg)(180/110 mm Hg)History of chronic severe hypertensionHistory of chronic severe hypertension CVA or CVA or intracerebral intracerebral pathology 1 pathology 1 yr yr agoago Current anticoagulant useCurrent anticoagulant use Recent trauma(within 2-4 weeks)Recent trauma(within 2-4 weeks)Allergy or prior exposure to Allergy or prior exposure to streptokinasestreptokinaseMI MI 1515 Relative Contraindications for Relative Contraindications for Thrombolytic TherapyThrombolytic Therapy Active peptic ulcer diseaseActive peptic ulcer disease Significant hepatic dysfunctionSignificant hepatic dysfunction Recent(2-4 weeks)internal bleedingRecent(2-4 weeks)internal bleeding Bleeding diathesisBleeding diathesis NoncompressibleNoncompressible arterial or central arterial or central venous puncturevenous puncture PregnancyPregnancyMI MI 1616 Q-Wave(ST-segment elevation)Q-Wave(ST-segment elevation)Myocardial InfarctionMyocardial InfarctionCandidate for Candidate for thrombolyticthrombolytic?No No Emergency Emergency consultation/transfer consultation/transferYesYes for primary PTCA for primary PTCA ThrombolyticThrombolytic agent given agent given Complications of MI Complications of MI Yes Yes Emergency Emergency consultation/transfer consultation/transferNoNo Elective evaluationElective evaluationMI MI 1717 Continuing TherapyContinuing Therapy Heparin infusion after Heparin infusion after thrombolysisthrombolysis (except after(except after streptokinasestreptokinase)Aspirin dailyAspirin daily Nitroglycerin for 24-48 hoursNitroglycerin for 24-48 hours -blockerblocker unless contraindicated unless contraindicated AngiotensinAngiotensin-converting enzyme(ACE)-converting enzyme(ACE)inhibitor within first 24 hoursinhibitor within first 24 hours Cardiology consultation and/or transferCardiology consultation and/or transferMI MI 1818 Complications of Myocardial Complications of Myocardial InfarctionInfarction Heart failure:Systolic BP 100 mm HgHeart failure:Systolic BP 100 mm Hg VasodilatorsVasodilators NitroglycerinNitroglycerin NitroprussideNitroprusside InotropesInotropes DobutamineDobutamine MilrinoneMilrinone Loop diureticsLoop diureticsMI MI 1919 Heart failure:Systolic BP 90 mm HgHeart failure:Systolic BP 90 mm Hg Vasopressors Vasopressors initiallyinitially NorepinephrineNorepinephrine DopamineDopamine Inotropes Inotropes when BP stablewhen BP stable Consider PTCA or intra-aortic balloon pumpConsider PTCA or intra-aortic balloon pump Cardiology consultationCardiology consultationComplications of Myocardial Complications of Myocardial InfarctionInfarctionMI MI 2020 Complications of Myocardial Complications of Myocardial InfarctionInfarction Recurrent Recurrent ischemiaischemia or infarction or infarction Follow unstable angina algorithmFollow unstable angina algorithm Cardiology consultationCardiology consultation Consider repeat thrombolysis with Consider repeat thrombolysis with non-non-streptokinasestreptokinase agent agent AngioplastyAngioplasty or bypass or bypassMI MI 2121 Complications of Myocardial Complications of Myocardial InfarctionInfarction ArrhythmiasArrhythmias Prophylactic drugs not Prophylactic drugs not recommendedrecommended Follow ACLS guidelinesFollow ACLS guidelinesMI MI 2222 Perioperative Perioperative Myocardial Myocardial InfarctionInfarction Peak occurrence on third postoperative dayPeak occurrence on third postoperative day May be painless or other pain may May be painless or other pain may obscure diagnosisobscure diagnosis New or worsening New or worsening arrhythmiasarrhythmias Pulmonary edemaPulmonary edema Thrombolysis may be contraindicatedThrombolysis may be contraindicated Consider primary PTCAConsider primary PTCAMI MI 2323 Key PointsKey Points