Παύλος Στουγιάννος. Καρδιολόγος ΓΝΑ «Η ΕΛΠΙΣ»

Transcription

1 Επεμβατική Καρδιολογία. STEMI. Σύγχρονη θεώρηση Παύλος Στουγιάννος Καρδιολόγος ΓΝΑ «Η ΕΛΠΙΣ»

2 Criteria for acute myocardial infarction Thygesen K, et al. Third universal definition of myocardial infarction. European Heart Journal (2012) 33,

3 The classic manifestation of ischemia is angina, which is usually described as a heavy chest pressure or squeezing, a burning feeling, or difficulty breathing

4 Diagnosis of STEMI anterior-inferior

5 Definition of atypical presentation Hyun Kuk Kim and Myung Ho Jeong (2012). Acute Coronary Syndromes. Edited by Dr. Mariano Brizzio.

6 Silent STEMI 1. Nonfatal STEMI can be unrecognized by the patient and discovered only on subsequent routine electrocardiographic or postmortem examinations. 2. Of these unrecognized infarctions, approximately half are truly silent. 3. The other half of patients can recall an event characterized by symptoms compatible with acute infarction. 4. Unrecognized or silent infarction occurs more commonly in patients without antecedent angina pectoris and in patients with diabetes and hypertension. Feringa HH, Karagiannis SE, et al. Coron Artery Dis 18:571, 2007

7 Pain patterns with myocardial ischemia

8 Atypical descriptions of chest pain Pleuritic pain (i.e., sharp or knifelike pain brought on by respiratory movements or cough) Primary or sole location of discomfort in the middle or lower abdominal region Pain that may be localized at the tip of one finger, particularly over the left ventricular apex Pain reproduced with movement or palpation of the chest wall or arms Constant pain that persists for many hours Very brief episodes of pain that last a few seconds or less Pain that radiates into the lower extremities Anderson JL, et al. ACC/AHA Guidelines for the management of UA/NSTEMI. Circulation 116:e148, 2007

9 Atypical descriptions epigastric location When the pain of STEMI is epigastric in location and is associated with nausea and vomiting, the clinical picture can easily be confused with that of acute cholecystitis, gastritis, or peptic ulcer. More commonly in patients with inferior STEMI than in those with anterior STEMI. Occasionally, a patient complains of diarrhea or a violent urge to defecate during the acute phase of STEMI.

10 Atypical presentations of STEMI other symptoms 1. heart failure (i.e., dyspnea without pain beginning de novo or worsening of established failure) 2. CNS manifestations, resembling those of stroke, secondary to a sharp reduction in cardiac output in a patient with cerebral arteriosclerosis 3. apprehension and nervousness 4. sudden mania or psychosis 5. Syncope 6. overwhelming weakness 7. diaphoresis 8. acute indigestion and 9. peripheral embolization. Anderson JL, et al. ACC/AHA Guidelines for the management of UA/NSTEMI. Circulation 116:e148, 2007

11 Dominant symptom among patients with atypical presentation Insights From The Global Registry of Acute Coronary Events (GRACE) 95 hospitals located in 14 countries 20,881 patients with ACSs 1,763 (8.4%) presented with atypical symptoms Brieger D, et al. Chest. 2004;126: 461-9

12 Independent risk factor for atypical presentation Canto J.G, et al. JAMA. 2000;283:3223-9

13 Type of presentation by hospital admission diagnosis Percentages represent patients in whom the diagnosis of an ACS was not recognized at presentation Brieger D, et al. Chest. 2004;126: 461-9

14 Hospital Management: STEMI Brieger D, et al. Chest. 2004;126: 461-9

15 Hospital Outcomes Brieger D, et al. Chest. 2004;126: 461-9

16 In-hospital mortality rate in subgroups with ACSs according to presenting symptoms Brieger D, et al. Chest. 2004;126: 461-9

17 Adjusted OR plot for hospital mortality of typical vs atypical presentation Brieger D, et al. Chest. 2004;126: 461-9

18 Case #1 atypical presentation ACS 85 yrs- old man. Presented with syncope. Typical troponin rise

19 Case #1 Coronary angiography

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21 Criteria for ST Segment Elevation Thygesen K, et al. Third universal definition of myocardial infarction. European Heart Journal (2012) 33,

22 Electrocardiograms Showing Normal ST-Segment Elevation and Normal Variant Kyuhyun Wang, et al. N Engl J Med 2003;349:

23 Diagnosis of STEMI

24 Electrocardiographic diagnosis of evolving acute MI in the presence of LBBB Elena B. Sgarbossa, et al. N Engl J Med 1996;334:481-7

25 Electrocardiographic diagnosis of evolving acute MI in the presence of LBBB Elena B. Sgarbossa, et al. N Engl J Med 1996;334:481-7

26 Electrocardiographic diagnosis of evolving acute MI in the presence of LBBB Elena B. Sgarbossa, et al. N Engl J Med 1996;334:481-7

27 Diagnosis of STEMI - LBBB

28 Diagnosis of infero-lateral STEMI - LBBB 68yrs old female Primary PCI occl RCA

29 Diagnosis of anterior STEMI paced rhythm

30 Case #2 atypical presentation ACS 68 yrs- old man. Presented with angina. H/o PCI 4 yrs ago

31 Case #2 atypical presentation ACS 68 yrs- old man. Presented with angina. H/o PCI 4 yrs ago

32 Case #2 Coronary angiography

33 Case #3 atypical presentation ACS 42yrs- old man. Presented with atypical chest pain. Stress echo 4mo ago: no ischaemia Relief with iv nitrates Subtle TnI rise next morning

34 Case #3 coronary angiography 42yrs- old man. Presented with atypical chest pain. Stress echo 4mo ago: no ischaemia

35 Electrocardiograms Showing ST-Segment Elevation in Various Conditions Kyuhyun Wang, et al. N Engl J Med 2003;349:

36 Atypical symptoms or ECG findings of STEMI Take home messages STEMI occurs in patients with atypical symptoms or ECG findings with sufficient frequency. No single factor should be used to exclude the diagnosis of ACS. In particular, women, older persons, and individuals with diabetes may be more likely to report atypical symptoms. These patients represent a high-risk group. Emergency department and coronary care personnel need to have an increased awareness of this patient cohort, who should be provided with improved early diagnosis and better treatment options to reduce their significant morbidity and mortality.

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