Il paziente con dolore toracico acuto. Come orientare la diagnosi sulla strada verso il laboratorio di Emodinamica o verso un area a bassa intensità

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Transcription:

Il paziente con dolore toracico acuto. Come orientare la diagnosi sulla strada verso il laboratorio di Emodinamica o verso un area a bassa intensità Andrea Barbieri Azienda Ospedaliero-Universitaria di Modena

Immediate invasive strategy in ACS 1. Lessons from STEMI services 2. Applying the lessons of STEMI services to NSTEMI?

Immediate invasive strategy in ACS 1. Lessons from STEMI services 2. Applying the lessons of STEMI services to NSTEMI?

Eur Heart J 2018;39:119-177

Emerg Med Clin N Am 2006;24:91 111

Mayo Clin Proc 2015;90:1614-1622

Mayo Clin Proc 2015;90:1614-1622

Mayo Clin Proc 2015;90:1614-1622

ECG findings for hyperkaliemia Emerg Med Clin North Am 2006;24:91 111

ECG criteria for LV hypertrophy Emerg Med Clin North Am 2006;24:91 111

Classic STEMI ECG diagnostic criteria Am Heart J 2010;160:995-1003

Incidence of TIMI 0/1 grade flow in trials of NSTEMI Am Heart J 2009;158:706-12

STEMI-equivalent Eur Heart J 2018;39:119-177

ECG criteria for LBBB Emerg Med Clin North Am 2006;24:91 111

LM coronary occlusion pattern Am Heart J 2010;160:995-1003

Am Heart J 2009;158:706-12

Am Heart J 2009;158:706-12

Physicians ECG Interpretation accuracy by specialty and experience J Am Heart Assoc 2013;2:e000268

Int J Cardiol 2014;172:e91-3

Classification of Cath Lab activation Am Heart J 2010;160:995-1003

ECG criteria for benign early repolarization Emerg Med Clin North Am 2006;24:91 111

ECG criteria for myopericarditis Emerg Med Clin North Am 2006;24:91 111

Eur Heart J 2018;39:119-177

Eur Heart J 2018;39:119-177

Immediate invasive strategy in ACS 1. Lessons from STEMI services 2. Applying the lessons of STEMI services to NSTEMI?

GRACE Registry. Nat Clin Pract Cardiovasc Med 2008;5:580-9

NSTEMI risk criteria: 24/7 vs 7/7 services

N Engl J Med 2009; 360:2165-75

N Engl J Med 2009; 360:2165-75

N Engl J Med 2009;360:2165-75

Home About Web Version Help Contact Us GRACE 2.0 Risk Calculator The GRACE 2.0 ACS Risk Calculator implements the revised GRACE algorithms for predicting death or death/myocardial infarction following an initial acute coronary syndrome (ACS). WHAT'S NEW IN 2.0? - "Mini-GRACE" algorithm (for use when serum creatinine and Killip class may not be available) - New 1- and 3-year calculations - New calculations provide probabilities directly, bypassing scores - Population histograms with high-, medium- and low-risk markers - The GRACE 2.0 ACS Risk Calculator app has been defined as a medical device under the Medical Device Directive (MDD) 93/42/EEC and has been CE-marked to indicate compliance with the Directive DOWNLOAD THE MOBILE APP USE THE CALCULATOR ONLINE WEB VERSION http://www.gracescore.org/website/default.aspx?returnurl=%2f

Home About Web Version Help Contact Us Calculator 1. INPUT DATA > 2. DEATH / DEATH MI RESULTS Age ( years ) Heart rate ( bpm ) Systolic blood pressure ( mmhg ) CHF ( Killip class ) ST-segment deviation Cardiac arrest at admission Elevated troponin* * Or other necrosis cardiac biomarkers Diuretic usage 1 1 Creatinine ( mg dl / μmol L ) Renal failure RESET CALCULATE http://www.gracescore.org/website/default.aspx?returnurl=%2f

Home About Web Version Help Contact Us Calculator 1. INPUT DATA > 2. DEATH / DEATH MI RESULTS Death Time % Risk (Score) Histograms In hospital 8.8 Not available Number of patients by risk group for 1-year death 29% 6 months 16 (144) Not available 1 year 29 GRAPH 3 years 44 GRAPH Death/MI Time % Risk Histograms 1 year 37 GRAPH Area plot: distribution (log scale) of risk based on the entire GRACE population of 102,341 patients. EDIT INPUT NEW CALCULATION Line: risk of death or death/mi Vertical bar: individual risk of death or death/mi green = low, yellow = intermediate, red = high http://www.gracescore.org/website/default.aspx?returnurl=%2f

Acute Versus Subacute Angioplasty in Patients With NON-ST-Elevation Myocardial Infarction (NONSTEMI) The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. ClinicalTrials.gov Identifier: NCT01638806 Recruitment Status! : Terminated (slow recuritment) First Posted! : July 12, 2012 Last Update Posted! : October 4, 2017 https:// clinicaltrials.gov/ct2/show/nct01638806. [Accessed 27 March 2018]

87% ACS 74% culprit lesion 64% underwent coronary revascularization (median 2.4 days early) Hospitalization reduced by 16% Eur Heart J Acute Cardiovasc Care 2017;6:490-499

Eur Heart J 2016;37:267 315

J Am Heart Assoc 2014;3:e000473

Conclusive remarks: 24/7 services 1. STEMI 2. Very high-risk NSTEMI 3. High-risk NSTEMI? 4. Rapid triage decision with emergency echocardiography to rule-in or rule-out differential diagnoses

Echocardiography to rule-in and rule-out ACS and differential diagnoses: caveats 1. H24 emergency echocardiography service 2. Level C: lack of outcome studies (refine the triage/ assist in clinical decision-making)

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