José Ramón González- Juantey Hospital Clínico Universitario. Santiago de Compostela

1. El Dolor Torácico en Urgencias José Ramón González-Juantey Hospital Clínico Universitario. Santiago de Compostela

2. Stable Angina Unstable Angina Non-Q wave MI Q wave MI Antithrombotic Therapy Thrombolysis / PCI Plaque rupture ISCHEMIC SYNDROMES ECG: ST elevation MI UA / Non STE MI Cannon CP J T Thrombolysis 1996

3. EARLY RISK STRATIFICATION. FAST TRACK SUSPECTED ISCHEMIC CHEST PAIN IN ED 1- Bed rest & Immediate clinical evaluation 3- ECG in ≤ 10 minutes - Correctly read - Ask if in doubt 4- Decisions

4. What is Acute Cardiovascular Care? HOSPITAL Atención pre-hospitalaria URGENCIAS Cardiología UC UCIC UCIC: Unidad Cuidados Intensivos Cardiacos UC: Unidad Coronaria

5. DIAGNOSTICO 1- Clínica 2- ECG 3- Encimas (marcadores séricos de daño miocárdico) 4- Pruebas detección isquemia 5- Coronariografia 6- Otras

6. Síntomas clave de cardiopatía Dolor precordial Disnea Síncope Palpitaciones Muerte súbita

7. 1- DOLOR o malestar precordial • Donde: Precordial (boca- ombligo) • Calidad: opresivo • Intensidad: variable • Aparición: brusca • Irradiado: brazos, mandíbula • Desencadenado: esfuerzo, nada • Duración: minutos, horas (no dias) • Alivio: reposo, NTG • Otrossíntomas: disnea, mareo, sudor

8. ED Evaluation of Patients With STEMI Differential Diagnosis of STEMI: Other Noncardiac Gastroesophageal reflux (GERD) and spasm Chest-wall pain Pleurisy Peptic ulcer disease Panic attack Cervical disc or neuropathic pain Biliary or pancreatic pain Somatization and psychogenic pain disorder

9. CARACTERISTICAS SUGESTIVAS DE DOLOR TORACICO NO ISQUEMICO • CARACTERISTICAS • - Pinchazos, difuso en todo el torax • - ”cuchilloclavado” • LOCALIZACION • - AreaInframamaria izq. • - Hemitorax izquierdo • DURACION • - Segundos o días • PROVOCACION • - Agrava con respiración • - Reproduce con la presión • - Provocado con movimientos del cuerpo • ALIVIO • - Comida o antiacidos • - Cambios de postura

10. ACUTE CORONARY OCLUSION ECG EVOLUTIVE CHANGES T T Q ST Q QS minutes hours days - years Bayes de Luna. Clinical Electrocard 1993

11. 24h 1h IAM inferior

12. ECG CHANGES and EVOLUTION Anterior AMI. I V1 V1 I 2 febr 4 febr II V2 II V2 III V3 III V3 V4 V4 aVR aVR V5 aVL aVL V5 V6 aVF aVF V6

13. ECG CHANGES and EVOLUTION Anterior AMI. B A I V1 II V2 III V3 aVR V4 aVL V5 aVF V6

14. Hombre, 53 años, Dolor torácico Sin dolor torácico I V1 II V2 III V3 NTG s.l. V4 aVR V5 aVL V6 aVF

15. 50 20 10 5 2 1 3- Analítica. Marcadores de daño miocárdico 3 3 CK-MB poco específica 2 Troponina, muy específica (de miocardio) 1 Mioglobina, la que se normaliza antes 2 1 Múltiplos de valor normal Límite normal 0 1 2 3 4 5 6 7 8 Dias post IAM Wu AH et al. Clin Chem 1999;45:1104.

16. 1 Clinical Evaluation 2 Diagnosis / Risk assessment 3 Medical Treatment 4 Invasive Strategy REPERFUSION STEMI Emergent <2 hours Emergent <2 hours • Serial ECGs • Serial troponin • Labtests (Hb, Crea Clea…) • Ischemicrisk score • (i.e. GRACE) • Bleedingrisk score • (i.e. CRUSADE) • Imagingtechniquesresults (optional) • Serial ECGs • Serial troponin • Labtests (Hb, Crea Clea…) • Ischemicrisk score • (i.e. GRACE) • Bleedingrisk score • (i.e. CRUSADE) • Imagingtechniquesresults (optional) • Quality of chest pain • Probability of CAD • Physical examination • ECG (↑ST?) Urgent 2-24 hours Urgent 2-24 hours Anti-ischemic therapy Antiplatelet therapy Anticoagulation Anti-ischemic therapy Antiplatelet therapy Anticoagulation NSTE ACS Early 24-72 hours Early 24-72 hours No / Elective No / Elective ACS unclear (Rule out ACS) Chest Pain Unit No ACS

18. ST elevation MI PTCA +STENT

20. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I Oxygen Supplemental oxygen should be administered to patients with arterial oxygen desaturation (SaO2 < 90%). It is reasonable to administer supplemental oxygen to all patients with uncomplicated STEMI during the first 6 hours.

21. Nitroglycerin Patients with ongoing ischemic discomfort should receive sublingual NTG (0.4 mg) every 5 minutes for a total of 3 doses, after which an assessment should be made about the need for intravenous NTG. Intravenous NTG is indicated for relief of ongoing ischemic discomfort that responds to nitrate therapy, control of hypertension, or management of pulmonary congestion.

22. Nitroglycerin Nitrates should not be administered to patients with: Nitrates should not be administered to patients who have received a phosphodiesterase inhibitor for erectile dysfunction within the last 24 hours (48 hours for tadalafil). • systolic pressure < 90 mm Hg or ≥ to 30 mm Hg below baseline • severe bradycardia (< 50 bpm) • tachycardia (> 100 bpm) or • suspected RV infarction.

23. Analgesia Morphine sulfate (2 to 4 mg intravenously with increments of 2 to 8 mg intravenously repeated at 5 to 15 minute intervals) is the analgesic of choice for management of pain associated with STEMI.

24. Aspirin/Clopidogrel/Prasugrel/Ticagrelor Aspirin should be chewed by patients who have not taken aspirin before presentation with STEMI. The initial dose should be 162 mg (Level of Evidence: A) to 325 mg (Level of Evidence: C) Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations.

25. Beta-Blockers Oral beta-blocker therapy should be administered promptly to those patients without a contraindication, irrespective of concomitant fibrinolytic therapy or performance of primary PCI. It is reasonable to administer intravenous beta-blockers promptly to STEMI patients without contraindications, especially if a tachyarrhythmia or hypertension is present.

26. Ischemia/Reperfusion Injury -acute inflammatory response-apoptosis -platelet-neutrofil aggregates (no-reflow)

28. Other Pharmacological Measures Angiotensin converting enzyme (ACE) inhibitors Angiotensin receptor blockers (ARB) Aldosterone blockers Glucose control Magnesium Calcium channel blockers Inhibition of the renin -angiotensin -aldosterone system