Transcript differential diagnosis of chest pain. course myocardial infarction

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DIFFERENTIAL DIAGNOSIS OF CHEST PAIN. COURSE
MYOCARDIAL INFARCTION. TACTICS GPS.
PRINCIPLES OF PREVENTION AND TREATMENT.
Professor A.G. Gadaev
Chest pain is one of the major symptoms of many
diseases.
Skletno-muscleneurogenic changes
Psychogenic
Heart disease
4%
31%
25%
40%
Diseases of the abdominal
cavity and mediastinum
According to studies, 25% of chest pain koronogennogo
origin (CHD).
Cohn JK, Cohn PF. Chest pain. Circulation 2002
Although the possible causes of chest pain are many,
until an accurate diagnosis of any chest
pain should be seen a doctor like pain presumably
cardiogenic origin.
How to
determine the
cause?
What kind of pain is cardiac,
what - no?
However, GPs have :
When the problem of the patient "chest pain" is
necessary as soon as possible to assess its severity.
First of all, avoid the most dangerous
diseases that threaten the patient's life
require
immediate
diagnosis
Just removing them, you should
look for other causes of chest pain
The most important characteristics for the
differential diagnosis of chest pain are
estimated
duration
Analysis of
precipitating
factors
localization
The
circumstances
of pain relief
Evaluation of
the depth of
this syndrome
Some other
specific signs
What kind of pain is koronogennoy what - no?
KORONOGENNAY
A CHEST PAIN
Irradiation to the neck,back
- interscapulum and left
side of the body
* Stenokardicheskie pain
* These pains occur on the background of myocardial ischemia,
when there is no correlation between myocardial oxygen
demand and delivery
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Characteristics of pain stenokardicheskie
character
Chest pain, usually caused by stress and physical
activity, taking place in rest or nitroglycerin
Normal localization of the sternum and to the left of the
sternumIrradiation: the left shoulder, the inner surface of the left
hand from the armpit to 4-5 fingers
Characterized by intermittent episodes of pain (from
a few seconds to 30 minutes) going completely
without residual discomfort.
Patients often do not say "pain"They use
keywords such as "burning", "contraction",
"pressure", "heartburn" "discomfort"
(considered equivalents)
* The nature of the cause of pain
stenokardicheskie
* Atherosclerosis of the coronary vessels
* Spasm of the coronary vessels.
* Obstruction of the coronary vessels (embolism,
congenital anomalies, arteritis, delamination of the
arteries)
* Severe myocardial hypertrophy
* The increased need for myocardial metabolism:
hyperthyroidism, anemia, paroxysmal tachycardia
KORONOGENNOY
THE
MOST
FREQUENT CAUSE OF CHEST PAIN IS ISCHEMIC HEART DISEASE(CHD)
Pathologic substrate of atherosclerotic
coronary artery disease is narrowing of
the coronary arteries
ischemia
rate
atherosclerosis
atherosclerosis,
thrombosis
damage
necrosis
Classification of coronary artery
disease
1. Sudden cardiac death
2. 2. Angina:
2.1. Stable angina (4 PK)
2.2. Unstable angina:
New-onset angina
Progressive exertional angina
Spontaneous (special) angina
Early post-infarction angina
Early postoperative angina
3. Silent myocardial ischemia
4. myocardial infarction
- With Q-wave
- Non-Q wave
5. Myocardial infarction
6. Cardiac arrhythmias (indicating shape)
7. Congestive heart failure (specifying step and FC)
Risk factors (RF)
Unrecoverable FR
Paul
(mostly male)
•
Age
(more than 44 years for men and over 55 for women)
•
Genetic predisposition to disease
(MI or sudden cardiac death at the age ofup to 55 years
for male relatives orunder the age of 65 years with
relatives in the female line)
•
Disposable FR
 smoking
 diabetes mellitus
 arterial
hypertension
CHD. stable
angina
Occasional discomfort in the chest, resulting from
myocardial ischemia.
Transient symptoms (1-20 min)
Pain predictable and renewable
The frequency of attacks is constant over time does not
change
Physical activity or episodes of emotional stress can
trigger an attack.
Rest or medications such as nitroglycerin, remove the
attack (the effect of which can be pre-assumed with high
probability).
The cause is fixed,
stenosing
atherosclerotic
lesions of the
coronary arteries.
IBS.Nestabilnye angina.
Symptoms lasting more than
20 minutes correspond to pain
at rest and are an indication of
unstable angina.
Patients with first-episode
symptoms typical of myocardial
ischaemia (up to 1 month).
It may also manifest symptoms of changes in a patient with previously
diagnosed coronary heart disease in the form of increased frequency of angina
attacks, an increase in the duration of seizures or emergence of resistance to
the symptoms previously successfully stop attacks of drugs, such as
nitroglycerin, β-blockers or calcium channel blockers.
Variant angina or Prinzmetal angina.
It is the consequence of
coronary artery spasm alone
against the minimal intensity of
coronary heart disease.
Sometimes the attack can be
removed physical exercise.
Remember!
Unstable angina should be regarded as a
harbinger of acute myocardial infarction and,
therefore, this condition requires urgent
directions to the hospital.
ECG signs
ECG at rest in a quarter
of patients with angina
- no pathology.
During the attack
recorded segment
depression, ST, negative
or pointed or high T
waves, various
arrhythmias and
conduction.
Key Points
Sometimes-segment
elevation ST, which may
indicate an acute
myocardial infarction or
vasospasm.
T wave changes in a patient with angina pectoris.
Negative teeth in the left breastleads.
ACS - a period (24 hours) with new-onset angina to long
flowing strokes ("intermediate" state) that does not pass
after taking nitroglycerin, with an unknown outcome,
with the possible development macrofocal myocardial
infarction or sudden death, as well as to the progression
of pain, even in alone.
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CLASSIFICATION OF
ACS
ACS
With
persistent
elevationST
segment
Without
persistent
elevationST
segment
myocardial infarction
This is a limited necrosis of the
heart muscle, resulting from
increased myocardial oxygen
demand and insufficient blood
supply to the myocardium.
manifestations of MI
Pressing, compressing, do not remove the pain by
nitroglycerine, prolonged chest pain (30 minutes
or longer) with irradia-tion .......
A sense of "cola" or press "heavy fire" in the sternum
The presence of cold clammy sweat
Atypical variants of acute myocardial infarction
asthmatic
Proceeds on the type of cardiac asthma or pulmonary edema
arrhythmic
Accompanied by acute cardiac rhythm and conduction and the
absence of typical pain
abdominal
cerebrovascular
Besimptomnaya or
malosimptomno
Develops at the posterolateral basal infarction, accompanied by
pain in the epigastric region, nausea, vomiting, not bringing
relief from flatulence, paresis of the gastrointestinal tract
Accompanied coronary and cerebral vascular thrombosis as
blocked, resulting in the development of clinical signs of
syncope or stroke
It often occurs in the elderly and patients with diabetes,
determined by chance when removing or ECG signs of the Tax
Code. Patients can not accurately determine the timing of
myocardial infarction
Myocardial infarction with Q wave
Violation of the coronary circulation in MI leads to the formation of
the three zones of pathological changes: necrosis are located around
the site of the ischemic damage and ischemia
For myocardial infarction with Q wave is characterized by phasic flow
prodromal stage
The acute stage
At this time, there are
signs of unstable angina
up to 2 hours
after the onset of
MI
The acute stage.
subacute stage
stage scarring
lasts from 2 hours to 14
days
1-3 days - 1-3 weeks
1-3 weeks - 3
months
Myocardial infarction without Q-wave
Myocardial infarction without Q wave is characterized by the development of the heart
muscle netransmuralnyh necrosis, localized subendocardial or intramural.
The most common ECG signs of non-Q wave
myocardial infarction are
Segment offset RS-T contours below
A variety of pathological changes of the T wave (most
negative symmetrical and pointed coronary T wave)
The emergence of these changes on an
electrocardiogram after a long and intense pain attack
and save them for 2-5 weeks
Complications of myocardial infarction
rhythm disorders
Acute cardiac aneurysm
ruptures internal and
external attack
Acute heart failure
early
complications
Tromboendokardit
Thromboembolic
complications
cardiogenic shock
reflex type
arrhythmic type
true
unresponsiveness
type
Complications of myocardial infarction
Chronic cardiac
aneurysm
Dressler's syndrome
late
complications
HSN
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Early diagnosis of the
underlying cause
Consulting a specialist
according to the
characteristics of the GP
qualifying(I or II category)
TACTICS GP
Implementation of
preventive measures, as
well as necessary medical
treatment in conjunction
with specialists
Clinical supervision and
rehabilitation(IV category)
* Early diagnosis of the underlying
cause (disease)
history
objectiveinspection
Laboratory and instrumentalresearch
(III category)
In the presence of the patient chest pain
doctor must solve the following problem
First of all, avoid the most dangerous state
Or rule out the presence of cardiac pain koronogennoy
An objective examination
In a study of patients complaining of pain in the chest:
Skin: pallor / cyanosis, presence of lesions (typical for
shingles pain can mimic nature stenokardicheskie)
Inspection of the neck: pulsation vessels or swollen veins
Pulse on the radial and femoral arteries, blood pressure
and temperature.
Palpate the chest and spinous processes of the vertebrae.
Identify local pain, fractures, the symptoms of diseases of
the spine.
Percussion of the chest to exclude pneumothorax.
Lower extremities - exclude deep vein thrombosis (PE)
swelling of the ankles - CH
Auscultation of the heart and lungs:
-absence of breathing and voice tremor pneumothorax,
-pleural friction rub (pericardium) - pleurisy,
pericarditisrales in the lower lung - heart
failure,
-systolic murmur at the apex - mitral valve
prolapse,
-diastolic murmur over the aorta delamination of the ascending aorta.
Palpation of the abdomen - epigastric pain?
(gall bladder, stomach, duodenum).
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2. strategy GP
I category
Diagnosis and management in a
hovercraft or joint venture
•Stable angina, coronary artery
•Disease FC 1 and 2
II category
Early diagnosis and referral to a
specialist or to hospital
•Stable angina, coronary artery
disease FC 1 and 2
•unstable angina ACS
•myocardial infarction
Principles of management and follow-up of patientswith coronary artery
disease in a hovercraft or a family health center
Advice on healthy living
Learning the principles of patient selfMonitoring blood sugar levels
Monitoring the level of lipids in the blood
ECG monitoring and control of blood pressure
Monitoring mass index / body
Psychological support
Timely diagnosis and prevention of complications
Control of the effects of pharmacotherapy
Control of the effects of pharmacotherapyPeriodic clinical examinations
*Lifestyle changes:
Convince the patient of
the need for smoking
cessation
estriction of the use of alcohol
and 20 mg in terms of pure
alcohol per day
Eating healthy foods - milkvegetable, fruit and vegetables.
Regular physical activity.
Obesity - a body mass index of 25 kg / m
When talking with patients should include information about the
state of his health, the possible complications, the risk of death,
behavior at an attack of angina pectoris.
Drug lecheniepri attack of angina pectoris
Nitroglycerin 1 tablet
sublingually (about 3 h 15 min)
If the attack persists for 20 minutes then think about AMI
Prevention of angina attacks
To treat conditions that may lead to attack: AG, CH, arrhythmias,
and prevent heavy loads, emotional stress, and exposure to cold.
Before carrying the load - nitroglycerin under the tongue
Long-acting nitrates, nitrosorbid 10-40 mg orally 1 tablet 1-2
times a day or isosorbide mononitrate 10-40 mg 2 times.
Beta-Blockers
calcium antagonists
statins
*Prophylaxis
Primary
prevention
Activities aimed at increasing the
educational level of the population,
building people install on a healthy
lifestyle and creating the conditions for
its implementation.
Refusal of bad habits
Balanced diet
Adherence to rest
Prevention of inactivity
Prevention of stress
Prevention of obesity and its
treatmentcorrection dislipedemii
secondary
prevention
Routine inspection and tonometry
Fight with identified risk factors of
hypertension among the population;
- Taking on the "D" records of newly
diagnosed patients;
Patients treated hypertensive drugs of
proven efficacy, with group and
individual selection of doses, while
respecting the continuity and duration
of antihypertensive drugs.
Maintaining target blood pressure
Maintaining the quality of life.
tertiary
prevention
- Prevention of complications- Prevention of diabetes and hypertension- Psychological support