Χειρισμός ασθενούς με προκάρδιο άλγος στα ΤΕΠ

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1 Χειρισμός ασθενούς με προκάρδιο άλγος στα ΤΕΠ Το υπερηχογράφηµα είναι απαραίτητο Κ. Αγγελη Παν. Καρδιολογική Κλινική Ιπποκρατειο Νοσοκομειο Αθηνων

2 Echocardiography in the Emergency Room Acute chest pain is one of the most common reasons for presentation to the Emergency Department (ED) accounting for approximately 7 million ED visits per year in the United States. The challenge for the clinician is to identify those patients with a serious cause of chest pain requiring intervention, particularly when acute coronary syndromes (ACSs) present with atypical symtoms, or diagnostic changes in the electrocardiogram(ecg) or cardiac enzyme markers are lacking.

3 Echocardiography in the Emergency Room Time is also of the essence when it comes to a patient with chest pain. Early treatment of myocardial injury and other serious diagnoses improves morbidity and mortality.

4 Echocardiography in the Emergency Room The diagnosis of myocardial infarction (MI) is generally based on patient history electrocardiographic findings and cardiac enzyme levels. Unfortunately these markers often take hours from symptoms onset to exceed the normal range and are note elevated in ACSs that are not associated with frank myocardial necrosis.

5 Echocardiography remains a first-line test and continues to provide valuable information on left ventricular and valvular function.

7 Echocardiography in the Emergency Room Depending on the particular cardiac marker, enzyme levels can also be elevated in the absence of ACS, depending on renal function and underlying disease process. Electrocardiographic changes are frequently nonspecific Given these limitations, echocardiography can be a useful adjunct in assessing the patient with chest pain

8 Goals of Echocardiography in Evaluation of Patients with Acute Chest Pain Diagnosis of Acute Coronary Syndrome Determination of coronary vascular territory involved Assessment of the area of myocardial at risk Evaluation of global ventricular function Exclusion of Other Causes of Chest Pain Aortic dissection Pericarditis (with effusion) Aortic stenosis Hypertrophic cardiomyopathy

9 The Ischaemic Cascade Rest Stress Perfusion abnormality Metabolic disorder Diastolic dysfunction Systolic dysfunction ECG alterations Anginal pain MCE, SPECT PET Stress echo ECG stress test Clinical syndrome

10 The miniaturization of echocardiography and the hand-held machine Contrast echocardiography TDI-2D strain, strain rate/cardiac mechanics 3D Echocardiography

11 MYOCARDIAL CONTRAST ECHOCARDIOGRAPHY

12 Perfusion-contraction mismatch (stunning) Moderate parallel reductions in perfusion and contraction (hibernation)

18 Echocardiographic parameters

19 The transmural control of infarction and regional wall thickening

20 Newer echocardiographic techniques

29 Ejection fraction and mortality

30 WMI and mortality

31 Cardiac Function + Perfusion patients with known or suspected CAD: likelihood of death or non-fatal MI we have already clinical + global function (EF) + regional function (WM) we go for myocardial perfusion on top Tsutsui JM et al., Circulation 112, 2005,

35 ECHOCARDIOGRAPHY TTE provides a rapid bedside assessment of wall motion and global left ventricular function and it excludes the presents of major complications. In the patient with an established myocardial infarction early evaluation of LV ejection fraction, diastolic function, regional wall motion and mitral regurgitation greatly assist with management.

36 Detecting complications of acute myocardial infarction Hemodynamic states Hypovolemia Right ventricle infarction Globally reduced LVcontractility Mechanical complications Papillary muscle ruptures and severe MR Ventricular septal rupture Free wall rupture and tamponate Other LV aneurysm Mural thrombus Pericardial effusion

38 ΨΕΥ ΟΑΝΕΥΡΥΣΜΑ ΚΟΡΥΦΗΣ

40 ACUTE MITRAL REGURGITATION

41 LV RUPTURE

42 LV THROMBUS

43 LV ANEURYSM

44 PSEUDOANEURYSM

45 Parietal and visceral pericardium

49 Πλευριτική και περικαρδιακή συλλογή

52 AORTIC DISSECTION

53 Dissection flap in the proximal descending thoracic aorta

64 Atherosclerosis of the aorta in patients with acute thoracic aortic dissection John Barbetseas, MD et al J CIRC TYPE (A) TYPE (B) P value In any segment, n (%) Ascending (n%) Aortic Arch (n%) Descending (n%) 43(67) 34(94) < (25) 36 (56) 43 (67) 19 (53) 31 (86) 34 (94) <0.005 <0.002 <0.001

65 Transesophageal echocardiography of the descending aorta

66 Transesophageal echocardiography of the descending aorta

67 Aortic dissection (AoD, AD) evaluation pathway. Copyright American Heart Association Rogers A M et al. Circulation 2011;123:

68 Τμήμα επειγόντων περιστατικών Τραύμα Υπόταση Shock ΣΗΜΑΝΤΙΚΟΣ Ο ΑΠΟΚΛΕΙΣΜΟΣ ΚΑΡΔΙΑΚΗΣ ΠΑΘΗΣΗΣ

69 Ασθενής μετά από ατύχημα με αυτοκίνητο, υπόταση και shock διοισοφάγειο ηχοκαρδιογράφημα αορτική ρήξη και ψευδοανεύρυσμα

70 Ασθενής με τραύμα από πυροβόλο όπλο, υπόταση και shock περικαρδιακή συλλογή που μοιάζει με νέφος, ενδεικτική αιμοπερικαρδίου από τραυματισμό του μυοκαρδίου ή των στεφανιαίων αρτηριών

71 Ασθενής μετά από τραυματισμό με μαχαίρι, υπόταση,shock και φύσημα στο προκάρδιο διοισοφάγειο ηχοκαρδιογράφημα επικοινωνία αριστερής κοιλίας αριστερού κόλπου λόγω διατιτραίνοντος τραύματος στην περιοχή

72 Conclusions Echocardiography provides key diagnostic and prognostic information All mechanical complications of AMI can be detectable by echocardiography Newer echocardiographic techniques allow a comprehensive assessment of global and regional LV function, myocardial perfusion, myocardial viability and can predict functional recovery after MI.

77 Η ευαισθησια του ΤΕΕ στην αναδειξη διαχωριστικου ανευρυσµατος ειναι Α. 100% Β. 65% Γ %. 50%

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