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Linee guida SCA. The 12-lead ECG is central to the diagnostic and triage pathway for ACS and provides important prognostic informations.

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linee guida sca
Linee guida SCA
  • The 12-lead ECG is central to the diagnostic and triage pathway for ACS and provides important prognostic informations.
  • Patients with symptoms that may represent ACS … should be referred to a facility that allows evaluation by a physician and the recording of a 12-lead ECG and biomarker determination
  • A 12-lead ECG should be performed and shown to an experienced emergency physician as soon as possible after ED arrival
morfologia iniziale ecg
MORFOLOGIA INIZIALE ECG
  • SENZA SOPRALIVELLAMENTO ST
  • ECG non diagnostico o Normale
  • T negativa (> 1 mm)
  • Sottolivellamento ST (>0.5 mm isolato o con inversione T)
  • CON SOPRALIVELLAMENTO ST
  • Sopralivellamento ST (>0.5 mm in due derivazioni contigue)
  • Sopralivellamento ST + sottolivellamento ST
  • BBS di nuovo riscontro
morfologia iniziale
MORFOLOGIA INIZIALE

ASPETTI ATIPICI e CONFONDENTI

Ipertrofia VS

Bassi Voltaggi

Blocco di branca

Pace maker

WPW

“Patients with ECG coufounder … have relatively higher mortality”

Savonitto et Al JAMA 2005

ecg non diagnostico
ECG NON DIAGNOSTICO
    • If the initial ECG is not diagnostic but the patient remains symptomatic and there is high clinical suspicion for ACS:
  • Serial ECGs, initially at 15- to 30-min intervals, should be performed to detect the potential for development of ST-segment elevation or depression.
  • It is reasonable to obtain supplemental ECG leads V7 through V9 in patients whose initial ECG is not diagnostic to rule out MI due to left circumflex occlusion.
  • A normal ECG does not completely exclude ACS
ecg non diagnostico 2
ECG non diagnostico (2)
  • Serial or continuous ECGs increase diagnostic sensitivity,although the yield is greater with serial cardiac biomarkermeasurements
  • Approximately 4% of MI patients show ST elevationisolated to the posterior chest leads V7 through V9 Posterior ST elevation is diagnostically important because it qualifies the patient for reperfusion therapy as a STEMIpatient
  • A normal ECG does not completely excludeACS:

1% to 6% of such patients prove to have had anNSTEMI, and at least 4% will be found to have UA

aspetti ecg tipici
Aspetti ECG Tipici
  • T NEGATIVA ISOLATA : 19% CORONARIE INDENNI O LIEVI LESIONI
  • SOTTOLIVELLAMENTO ST : MALATTIA DEI 36% TRE VASI
  • SOPRALIVELLAMENTO ST : MAGGIORANZA 1 VASO

GUSTO II b, Savonitto et Al JAMA 1999

analisi quantitativa st sopralivellato
ANALISI QUANTITATIVAST SOPRALIVELLATO

ELEVATA FC

DURATA QRS (>80 MS)

ST INFERIORE IN PREGRESSO IMA

NUMERO DI DERIVAZIONI

SOMMA ASSOLUTA DEVIAZIONE ST (>20 mm)

SOMMA ST IN DD INFERIORI

Hathaway et Al, JAMA 1998

analisi quantitativa non st elevation
ANALISI QUANTITATIVA NON ST ELEVATION

MINIMAL ST ELEVATION + SOTTOLIVELLAMENTO ST

ST SEGMENT DEPRESSION + INVERSIONE T

ENTITA’ ST SOTTOLIVELLATO:

NUMERO DI DERIVAZIONI CON ST ALTERATO

SOMMA CUMULATIVA DI SOTTOLIVELLAMENTO ST

somma sottolivellamento st
Somma Sottolivellamento ST

GUSTO II b, Savonitto et Al Eur H J 2005

quantitative nste
QUANTITATIVE NSTE

Kaul et al J Am Coll Cardiol 2003

quantitative st deviation grace
Quantitative ST deviation: GRACE

CUMULATIVE ST DEVIATION

Yan et Al, Am J Cardiol 2008

analisi quantitativa st
Analisi Quantitativa ST

Although more severe ST deviation is a marker of increase short- and long- term mortality …. after adjustment for clinically important predictors (risk factors and biomarkers), quantitative ST deviationdoes not provide incremental prognostic value beyond simple dichotomous evaluation for the presence of ST deviation..

…..in contradistinction to the clinical trial population,… quantitative ST deviation analysis has null incremental prognostic value beyond a validated comprehensive risk stratification strategy…

Yan et Al, Am J Cardiol 2008

ictus trial
ICTUS TRIAL

Windausen et Al, J Electrocardiol 2007

implicazione terapia
IMPLICAZIONE TERAPIA

…Patients with ST deviation > 1 mm … more often fail on medical therapy, more often experience a spontaneous MI after discharge when angiography was not performed during initial hospitalization

Windausen et Al, J Electrocardiol 2007

st avr
ST aVR

In addition to ST depression in other leads, greater than 1 mm ST aVR may be a simple marker for severe CAD in patients with NSTE-ACS

GRACE, Yan et Al Am Heart J 2007,

implicazioni terapeutiche 2
Implicazioni terapeutiche 2

“Prompt identification of patients with LM or 3-VD is of clinical rilevance…. GP IIB-IIIA inhibitors may substitute for clopidogrel…., coronary angiography may be expedited in anticipation of the potential need for surgical revascularization”

Yan et Al Am Heart J 2007

st depression t inversion v4 v6
ST depression + T inversion V4-V6

Gusto II B, Atar et AL Am J Cardiol 2007

slide21

UNA SEMPLICE CLASSIFICAZIONE QUALITATIVA DELL’ECG DI INGRESSO CONSENTE DI :PORRE DIAGNOSIEFFETTUARE UNA INIZIALE ED AFFIDABILE STRATIFICAZIONE PROGNOSTICAAVVIARE IL PAZIENTE ALLA PIU’ OPPORTUNA TERAPIA

CONCLUSIONI (1)

conclusioni 2
CONCLUSIONI (2)

IN PRESENZA DI ECG NORMALE O FATTORI CONFONDENTI LA INTERPRETAZIONE ECG

UTILIZZARE ALTRI PARAMETRI DI DIAGNOSI

UN ECG NORMALE NON ESCLUDE UNA SCA

I PAZIENTI CON ECG MALE INTERPRETABILE SPESSO HANNO PROGNOSI SEVERA

conclusioni 3
CONCLUSIONI (3)

ASPETTI QUANTITATIVI E MORFOLOGIE PARTICOLARI

POSSONO FAR SOSPETTARE UNA CORONAROPATIA

SEVERA E PERTANTO MODIFICARE L’ITER

DIAGNOSTICO E TERAPEUTICO

conclusioni 4
CONCLUSIONI (4)

I DATI ECG DI UN PAZIENTE CON SOSPETTA SCA DEVONO SEMPRE ESSERE INSERITI NEL CONTESTO DI UNA VALUTAZIONE MULTIPARAMETRICA

prognosi
PROGNOSI

PROGNOSI 30 GG E SEI MESI MORTE E REINFARTO

T NEGATIVA 5.5 8.1

ST SOTTOLIVELLATO 10.5 15.4

ST SOPRALIVELLATO 9.4 12.3

ST + 12.4 15.7

GUSTO II B, Savonitto et Al JAMA 1999

ecg rti
ECG + RTI

“… Both ST and TnT are effective markers of risk, TnT appears to be superior to ST in assisting decision regarding theraphy”

Kaul et al J Am Coll Cardiol 2003

somma sottolivellamento st29
Somma Sottolivellamento ST

Kaul et al J Am Coll Cardiol 2003

GUSTO II b, Savonitto et Al Eur H J 2005