Μαθήματα Καρδιολογίας σε παθολόγους Στεφανιαία Νόσος Από την Διάγνωση στην απόφαση Σταύρος Γαβριηλίδης Ομότιμος Καθηγητής Πανεπιστημίου ΠΡΠ 22/1/12
Στεφανιαίας Νόσος: Διάγνωση Αρχή Τέλος
Στεφανιαία Νόσος
Στεφανιαίας Νόσος: Κλινικές εκδηλώσεις Ασυμπτωματική Χρόνια σταθερή στηθάγχη Οξέα στεφανιαία σύνδρομα Ασταθής στηθάγχη Οξύ έμφραγμα μυοκαρδίου Καρδιακή ανεπάρκεια Αιφνίδιος θάνατος
Ασυμπτωματική ΣΝ Διάγνωση:Τυχαία Διερεύνηση: Αξιολόγηση παραγόντων κινδύνου, ΗΚΓ, Ηχω, ΔΚ;
Health Risk Continuum and Graded Exercise Testing Consider the following two people, both of whom had a + GXT ( d ST-segments) Healthy Increased Health Risk Gender: female Gender: male Family History: negative Family History: father died of MI at 42 Age: 17 Age: 70 TC: 146 TC: 310 HDL-C 69 HDL-C 29 LDL-C 92 LDL-C 191 BP: 114 / 76 BP: 156 / 96 Smoking: never Smoking 150 pack years Peak VO 2 : 52 ml / kg / min Peak VO 2 : 22 ml / kg / min Diabetes: never Diabetes: Type 1 since age 23 Exercise habits: 3x / week for 50 min. Exercise habits: none ST- segments and Hemodynamics of GXT ST-segments and Hemodynamics of GXT Upsloping depression noted only at peak downsloping depression noted at low exercise resolved within 15 seconds of workload - persisted 8 minutes after exercise exercise termination termination BP 174 / 84 at peak exercise BP 118 / 72 10 min. post exercise (Most likely a False + test) BP 246 / 110 at peak exercise BP 208 / 102 10 min. post exercise (Most likely a True + test)
Ασυμπτωματική Στεφανιαία Νόσος: Απόφαση Ελεγχος παραγόντων κινδύνου Αποφυγή - Διακοπή καπνίσματος Έλεγχος βάρους σώματος Άσκηση
Χρόνια σταθερή στηθάγχη Blood Flow 25 50 75 100%
Χρόνια σταθερή στηθάγχη Διάγνωση:Ιστορικό Διερεύνηση: Αξιολόγηση παραγόντων κινδύνου, ΗΚΓ, Ηχω, ΔΚ; Σπινθηρογράφημα μυοκαρδίου Απόφαση Συντηρητική αγωγή; Ασπιρίνη, κλοπιδογρέλη, νιτρώδη, β αποκλειστές, ανταγωνιστές του μυοκαρδίου, Α- ΜΕΑ, Ραντολαζινη (Ranexa), Ivabradine, στατίνες Αγγειοπλαστική; Εγχείρηση παρακάμψεως των στεφανιαίων αρτηριών;
The Courage Trial - Optimal Medical Therapy with or without PCI for Stable Coronary Disease William E. Boden, M.D.,and others, NEJM april 12, 2007. Conclusions As an initial management strategy in patients with stable coronary artery disease, the addition of PCI to optimal medical therapy reduced the prevalence of angina, it did not reduce long term rates of death, nonfatal myocardial infarction, and hospitalization for acute coronary syndromes.
Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology, 2006 1. PCI is an effective treatment and is indicated for patients with angina not satisfactorily controlled by medical treatment 2. Restenosis continues to be a problem, 3. There is no evidence that PCI reduces the risk of death in patients with stable angina compared with medical or surgical therapy. CABG is highly effective in 1. relieving the symptoms of stable angina and 2. reduces the risk of death over longterm follow-up in particular subgroups of patients, such as those with LM stem stenosis, proximal LAD stenosis, and three-vessel disease, especially if LV function is impaired.
Οξέα στεφανιαία σύνδρομα Διάγνωση 1.Το έμφραγμα του μυοκαρδίου με ανύψωση στου ST διαστήματος (STEMI), 2.Το έμφραγμα του μυοκαρδίου χωρίς ανύψωση στου ST διαστήματος (ΝSTEMI) 3. Την ασταθή στηθάγχη (UA) και 4. Τον αιφνίδιο καρδιακό θάνατο
Διάγνωση Definition of Myocardial Infarction WHO Criteria 2 out of 3 Characteristics Typical Symptoms Enzyme Rise and Fall ECG Pattern Involving Development of Q-waves *Circulation 1979 9903mo01, 2
Διερεύνηση
Evolution of ECG changes in acute MI
Απόφαση Symptom Recognition Call to Medical System PreHospital ED Cath Lab Increasing Loss of Myocytes Delay in Initiation of Reperfusion Therapy
Άμεση και ασφαλής μεταφορά
Οδηγίες ACC/AHA Ινωδόλυση Έγκαιρη προσέλευση (<3h από την εμφάν. των συμπτωμάτων και καθυστέρηση εργαστηρίου) Απουσία αιματηρής στρατηγικής (απουσία εργαστ., μη έμπειρο προσωπικό, μη προσπέλαση αγγείων) Καθυστέρηση αιματηρής στρατηγικής (door-to-balloon)-(door-to needle)>1 hr; med to balloon >90) Αιματηρή στρατηγική Έμπειρο εργαστήριο με Κ/Χ κάλυψη med contact to ballon <90 min Υψηλού κινδύνου STEMI (καρδιογενές shock, killip class>3) Αντένδειξη ινοδωλυτικών (αυξημένη αιμορραγία, ενδοκράνιος αιμορραγία) Καθυστερημένη προσέλευση (>3hrs) Αμφίβολη διάγνωση
Major Contraindications To the Use of Thrombolytic Therapy Any previous history of hemorrhagic stroke History of stroke, dementia, or central nervous system damage within 1 year Head trauma or brain surgery within 6 months Known intracranial neoplasm Suspected aortic dissection Internal bleeding within 6 weeks Active bleeding or known bleeding disorder Major surgery, trauma, or bleeding within 6 weeks Traumatic cardiopulmonary resuscitation within 3 weeks
Απόφαση ACS : medical vs invasive treatment Outcomes in patients with acute non-q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators. Boden WE, et al N Engl J Med 1998 Oct 8;339(15):1091. CONCLUSIONS: 1. Most patients with non-q-wave myocardial infarction do not benefit from routine, early invasive management consisting of coronary angiography and revascularization. 2. A conservative, ischemia-guided initial approach is both safe and effective.
Revascularization for NSTE-ACS relieves symptoms, shortens hospital stay, and improves prognosis. The indications and timing for myocardial revascularization and choice of preferred approach (PCI or CABG) depend on many factors including the patient s condition, the presence of risk features, co-morbidities, and the extent and severity of the lesions as identified by coronary angiography. Timing of angiography and intervention 1. Should be based on patient risk profile (<2h Έως 72 h) 2. Coronary angiography should be performed if the results are positive for reversible ischaemia.
AHA/ACC STEMI Guideline Recommendations Acute Therapy Aspirin Clopidogrel -Blocker ACE Inhibitor Heparin (UFH or LMWH) GP IIb-IIIa Inhibitor Receiving PCI Discharge Therapy Aspirin Clopidogrel -Blocker ACE Inhibitor Statin Smoking Cessation Cardiac Rehab.J Am Coll Cardiol. 2004 STRIVE TM
Dressler s Syndrome It is characterized by fever, pericarditis with friction rub, pericardial effusion, pleurisy, pleural effusions, pulmonary infiltrates, and joint pains.
Arrhythmias and conduction disturbances in the acute phase Διάγνωση Arrhythmias and conduction disturbances are common during the early hours after myocardial infarction. (within 11 +5 days) 28% for new-onset atrial fibrillation, 13% for non-sustained ventricular tachycardia, 10% for high-degree atrioventricular block ( 30 beats per minute lasting for 8 s), 7% for sinus bradycardia ( 30 beats per minute lasting for 8 s), 5% for sinus arrest ( 5 s), 3% for sustained ventricular tachycardia, and 3% for ventricular fibrillation. The longterm prognostic significance of early (,48 h) VF or sustained ventricular tachycardia (VT) in patients with acute myocardial infarction is still controversial.
Arrhythmias after the early reperfusion period may be a manifestation of a serious underlying condition, such as 1. continuing myocardial ischaemia, 2. pump failure, 3. altered autonomic tone, 4. hypoxia, and electrolyte- (e.g. hypokalaemia) and acid-base disturbances, High-degree atrioventricular block was a more powerful predictor of cardiac death than tachyarrhythmias in patients with left ventricular ejection fraction,40% after myocardial infarction.
Management of atrial fibrillation Απόφαση Acute rate control of atrial fibrillation 1. Intravenous beta-blockers or non-dihydropyridine CCB 2. Amiodarone or i.v. digitalis is indicated in case of rapid ventricular response in the presence of concomitant acute heart failure or hypotension. Cardioversion 1. Immediate electrical cardioversion 2. Intravenous amiodarone is indicated for conversion to sinus rhythm in stable patients I
Απόφαση Management of ventricular arrhythmias and conduction disturbances in the acute phase 1. Direct current cardioversion is indicated for sustainedvt andvf. 2. Sustained monomorphicvt that is recurrent or refractory to direct current cardioversion: i.v. amiodarone. Transvenous catheter pace termination 3. PolymorphicVT i.v. beta-blockere, i.v. amiodaroned 4. In cases of sinus bradycardia associated with hypotension, AV block II (Mobitz 2) or AV block III with bradycardia that causes hypotension or heart failure: intravenous atropine is indicated. temporary pacing is indicated in cases of failure to respond to atropine. I C - Management of ventricular arrhythmias and risk evaluation for sudden death on long term 1. Specialized electrophysiological evaluation of ICD implantation for secondary prevention of sudden cardiac death is indicated in patients with significant LV dysfunction, who suffer from haemodynamically unstable sustainedvt or who are resuscitated from VF occurring beyond the initial acute phase.
Στεφανιαία Νόσος:Καρδιακή ανεπάρκεια Απόφαση Eπί πλέον της βέλτιστης φαρμακευτικής αγωγής Επαναιμάτωση (PCI, GABAG) Αμφικοιλιακός βηματοδότης Εμφύτευση απινιδωτού Συσκευή υποβοήθησης αριστεράς κοιλίας Μεταμόσχευση καρδιάς
Recommendations for myocardial revascularization in patients with chronic HF and systolic LV dysfunction 1. CABG is recommended for patients with angina and significant left main stenosis, who are otherwise suitable for surgery and expected to survive >1 year with good functional status, to reduce the risk of premature death. I C 2. CABG is recommended for patients with angina and two- or three-vessel coronary disease, including a left anterior descending stenosis, who are otherwise suitable for surgery and expected to survive >1 year with good functional status, to reduce the risk of hospitalization for cardiovascular causes and the risk of premature death from cardiovascular causes. I B 191 3. Alternative to CABG: PCI may be considered asan alternative to CABG in the above categories of patients unsuitable for surgery. IIb C 4. CABG and PCI are NOT recommended in patients without angina AND without viable myocardium. III C
1. Ventricular reconstruction 2. Valvular surgery 1. Aortic stenosis, 1. transcatheter aortic valve replacement should be considered 2. Aortic regurgitation 3. Mitral regurgitation, Differentiating between primary and secondary mitral regurgitation is crucial 3. Heart transplantation
Patients to consider Heart transplantation: indications 1. End-stage heart failure with severe symptoms, a poor prognosis, and no remaining alternative treatment options 2. Motivated, well informed, and emotionally stable 3. Capable of complying with the intensive treatment required post operatively
Mechanical circulatory support (MCS) 1. Bridge to decision (BTD): 2. Bridge to candidacy (BTC): 3. Bridge to transplantation (BTT): 4. Bridge to recovery (BTR): 5. Destination therapy (DT):
Patients potentially eligible for implantation of a ventricular assist device Patients with >2 months of severe symptoms despite optimal medical and device therapy and more than one of the following: LVEF <25% and, if measured, peak VO2 < 12 ml/kg/min 3 HF hospitalizations in previous 12 months without an obvious precipitating cause Dependence on i.v. inotropic therapy Progressive end-organ dysfunction (worsening renal and/or hepatic function) due to reduced perfusion and not to inadequate ventricular filling pressure (PCWP 20 mm Hg and SBP 80 90 mmhg or CI 2 L/min/m2) Deteriorating right ventricular function
Devices Cardiac Resychronization Therapy the efficacy and safety of CRT remains unknown in certain groups of patients. 1. patients with a normal QRS duration but echocardiographic dyssynchrony? 2. patients with RBBB and IVCD? 3. patients in AF? Left Ventricular Aassist Devices the long-term efficacy and safety of LVADs as an alternative to heart transplantation or medical therapy remains uncertain
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