Transcript bol-grudi

The differential diagnosis of
chest pain. Features of
myocardial infarction. The
tactics of the SPM. The
principles of prevention and
treatment.
Associate Professor N.M. Nurillaeva
1. Consider the underlying causes
of chest pain
Give a complete picture of the
classification of the major risk
factors for coronary heart disease
2. To be able to carry out
differential diagnosis of coronary
artery disease by clinical,
laboratory and instrumental
parameters
The purpose of the lecture: to teach students modern
skilled differential diagnosis, treatment, prevention, pain
in the chest due to coronary heart disease, particularly
myocardial infarction in the prehospital and hospital
stages postgospitalnom
3. Determine the tactics of GPs in
ischemic heart disease
Able to recognize complications of
MI
4. Give an idea of ​the principles of
treatment, rehabilitation and
prevention of CHD in the
prehospital and hospital phase
postgospitalnom
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•
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Signs and symptoms
Ischaemic heart disease may be present with any of the
following problems:
Angina pectoris (chest pain on exertion, in cold weather or
emotional situations)
Acute chest pain: acute coronary syndrome, unstable
angina or myocardial infarction[3] ("heart attack", severe
chest pain unrelieved by rest associated with evidence of
acute heart damage)
Heart failure (difficulty in breathing or swelling of the
extremities due to weakness of the heart muscle)
Pathogenesis
• Main article: Coronary artery disease
• The disease process underlying most ischaemic heart disease is
atherosclerosis of the coronary arteries. The arteries become
"furred up" by fat-rich deposits in the vessel wall (plaques).
• Stable angina is due to inability to supply the myocardium (heart
muscle) with sufficient blood in situations of increased cardiac
output (such as exertion), and this pain of stable angina normally
resolves with rest or nitroglicerin (sublingual spray or tablet).
• Unstable angina, STEMI and NSTEMI are
attributed to "plaque rupture", where one of
the plaques gets weakened, develops a tear,
and forms an adherent blood clot that either
obstructs blood flow or floats further down
the blood vessel, causing obstruction there.
Risk Factors
Family history of coronary artery disease, diabetes, high blood pressure or atherosclerosis.
Smoking.
Poor nutrition, especially too much fat in theiet.
Previous heart attack or stroke.
Previous heart attack or stroke.
Overweight
Hypertension
Elevated cholesterol and/or low level of HDL (high-density lipoprotein).
Type A personality
• Diagnosis of angina is a clinical diagnosis based on a
characteristic complaint of chest discomfort or chest pain
brought on by exertion and relieved by rest. Confirmation may
be obtained by observing reversible ischemic changes
on ECG during an attack or by giving a test dose of sublingual
nitroglycerin that characteristically relieves the pain in 1 to 3
minutes. Certain tests may help determine the severity of
ischemia and the presence and extent of the coronary artery
disease. Diagnostic tests may include electrocardiogram
(measures electrical activity of the heart), echocardiogram
(measures sound waves), exercise-tolerance test, thallium stress
test, blood studies to measure total fat, cholesterol and
lipoproteins, X-rays of the chest and coronary angiogram
(cardiac catheterization).
• Signs and symptoms
• Ischaemic heart disease may be present with any of the following
problems:
• Angina pectoris (chest pain on exertion, in cold weather or emotional
situations)
• Acute chest pain: acute coronary syndrome, unstable angina or
myocardial infarction[3] ("heart attack", severe chest pain unrelieved
by rest associated with evidence of acute heart damage)
• Heart failure (difficulty in breathing or swelling of the extremities due
to weakness of the heart muscle)
Stable angina
• Main article: Angina pectoris
• In "stable" angina, chest pain with typical features
occurring at predictable levels of exertion, various
forms of cardiac stress tests may be used to induce
both symptoms and detect changes by way of
electrocardiography (using an ECG),
echocardiography (using ultrasound of the heart) or
scintigraphy (using uptake of radionuclide by the
heart muscle). If part of the heart seems to receive
an insufficient blood supply, coronary angiography
may be used to identify stenosis of the coronary
arteries and suitability for angioplasty or bypass
• Mechanism Of Action:
NO- Nitrc oxide GC- guanylyl cyclase c-GMP- Cyclic
GMP
Organic Nitrates stimulates the intracellular cyclicGMP, which, results in vascular smooth muscle
relaxation of both arterial and venous vasculature.
Increased venous pooling decreases left ventricular
pressure (preload) and arterial dilatation decreases
arterial resistance (afterload). Therefore, this
reduces cardiac oxygen demand by decreasing left
ventricular pressure and systemic vascular
resistance by dilating arteries. Additionally,
coronary artery dilation improves collateral flow to
ischemic regions.
Область ишемии
Область повреждения
Область инфаркта
Diagnosis of angina is a clinical
diagnosis based on a
characteristic complaint of
chest discomfort or chest pain
brought on by exertion and
relieved by rest. Confirmation
may be obtained by observing
reversible ischemic changes
on ECG during an attack or
by giving a test dose of
sublingual nitroglycerin that
characteristically relieves the
pain in 1 to 3 minutes.
MIOCARD INFARCTION
Acute chest pain
• Main articles: Acute coronary syndrome and myocardial infarction
• Diagnosis of acute coronary syndrome generally takes place in the
emergency department, where ECGs may be performed sequentially to
identify "evolving changes" (indicating ongoing damage to the heart
muscle). Diagnosis is clear-cut if ECGs show elevation of the "ST
segment", which in the context of severe typical chest pain is strongly
indicative of an acute myocardial infarction (MI); this is termed a STEM
(ST-elevation MI), and is treated as an emergency with either urgent
coronary angiography and percutaneous coronary intervention
(angioplasty with or without stent insertion) or with thrombolysis
("clot buster" medication), whichever is available. In the absence of STsegment elevation, heart damage is detected by cardiac markers
(blood tests that identify heart muscle damage). If there is evidence of
damage (infarction), the chest pain is attributed to a "non-ST elevation
MI" (NSTEMI).
If there is no evidence of damage, the
term "unstable angina" is used. This
process usually necessitates admission
to hospital, and close observation on a
coronary care unit for possible
complications (such as cardiac
arrhythmias – irregularities in the heart
rate).
Depending on the risk assessment,
stress testing or angiography may be
used to identify and treat coronary
artery disease in patients who have
had an NSTEMI or unstable angina.
Coronary angiography
• Stable angina
• Main article: Angina pectoris
• In "stable" angina, chest pain with typical features
occurring at predictable levels of exertion, various
forms of cardiac stress tests may be used to induce
both symptoms and detect changes by way of
electrocardiography (using an ECG), echocardiography
(using ultrasound of the heart) or scintigraphy (using
uptake of radionuclide by the heart muscle). If part of
the heart seems to receive an insufficient blood
supply, coronary angiography may be used to identify
stenosis of the coronary arteries and suitability for
angioplasty or bypass surgery.
АКШ и стентирование
Interventions and Practices Considered
• Treatment of depression to improve mental health outcomes
• Angiotensin-converting enzyme (ACE) inhibitor therapy
• Angiotensin II receptor blocker (ARB) therapy
• Anticoagulant Therapy
• Antiplatelet therapy
– Aspirin Clopidogrel
• Antiplatelet therapy post stent placement
– Clopidogrel plus aspirin
– Delay of elective procedures requiring interruption of therapy
• Beta-blocker therapy
– Atenolol
– Bisoprolol
– Carvedilol
– Labetalol
– Metoprolol
– Propranolol
– Pindolol
• Calcium channel blocker therapy
• Lifestyle modification
– Diet therapy
– Dietary fat modification
– Smoking cessation
– Exercise
• Treating comorbid conditions
– Hypertension (target blood pressure)
– Lipid management (statin therapy)
• Interventions considered but not recommended include (1) unopposed
estrogen and estrogen and progestin combination therapy for the
prevention of cardiovascular events in postmenopausal women; (2)
screening for coronary artery disease by exercise stress testing, computed
tomography angiography, and coronary artery calcium scoring in
asymptomatic adults; and (3) dietary supplement therapy.
Prevention
• Some of the risks for heart disease that you CAN change are:
• Do not smoke or use tobacco.
• Get plenty of exercise -- at least 30 minutes a day, at least 5 days
a week (talk to your doctor first)
• Stay at a healthy weight. Try for a body mass index (BMI) of
between 18.5 and 24.9.
• Get checked and treated for depression.
• Women at high risk for heart disease should take omega-3 fatty
acid supplements.
• If you drink alcohol, limit yourself to no more than one drink a
day for women, and no more than two drinks a day for men.
Because alcohol in large amounts can be toxic to the heart, you may
be asked to limit your alcohol even more, or stop drinking it
completely.
• Good nutrition is important for your heart health and will control
some of your risk factors. See also: Heart disease and diet
Примерные формулировки диагноза:
1.
ИБС: стабильная стенокардия напряжения ФК II. ПИКС (2005 г.)
2.
ИБС: стабильная стенокардия напряжения ФК III. ГБ III стадии,
АГ I степени, риск 4 (очень высокий). Фон: СД 2 тип с повышенной
массой тела, средней степени тяжести
ИБС: острый коронарный синдром без подъема сегмента ST
3.
(если имеются отразить нарушения ритма и проводимости). Соп: Ожирение:
II степени
(далее с трансформацией в прогрессирующую стенокардию, потом в стабильную
стенокардию напряжения ФК III). ГБ III стадии, АГ II степени, риск 4
(очень высокий)
4.
5.
6.
ИБС: острый инфаркт миокарда с зубцом Q (от 7авг. 2007г.),
подострая стадия с нарушением ритма ЖЭС III кл. по Лауну.
Осл.: Отек легких (от 9 авг. 2007г.)
ИБС: острый инфаркт миокарда без зубца Q. Осл: Синд-ром
Дресслера (или ранняя постинфарктная стенокардия и т.д.)
(указать число). Соп: Ожирение III степени
ИБС: прогрессирующая стенокардия напряжения (далее
трансформация в стабильную стенокардию или ИМ). ГБ III
стадии, АГ I степени, риск 4 (очень высокий). Осл: НК IIА стадии (II
ФК по NYHA)
• Management
• In stable IHD, antianginal drugs may be used to reduce the rate of
occurrence and severity of angina attacks. Treatments for acute
coronary syndrome and established coronary artery disease is
discussed above in "diagnosis". Revascularization for acute coronary
syndrome has a significant mortality benefit.. Recent evidence
suggests that revascularization for stable ischaemic heart disease may
also confer a mortality benefit over medical therapy alone.[
• Treatment of coronary artery disease includes addressing
"modifiable" risk factors. This includes suppression of cholesterol
(usually with statins), even in those with statistically normal
cholesterol levels, control of blood pressure, blood sugars (if
diabetic), and regular exercise. Smokers are encouraged to stop
smoking. Diet plays a major role in the progression of coronary artery
disease and by making certain diet choices a person can drastically
change their chance of dying from it.[
• Epidemiology
• IHD is the leading cause of death for both men
and women in the US and other industrialized
countries. It may affect individuals at any age
but is most common in older individuals.
Males are affected more often than females
however the rates equalize between men and
women following menopause.