อ.พญ. ขวญัศิร ินราจนีรณ

ส าหรบันิสติแพทยเ์วชปฏบิตัิ

ปีการศกึษา 2561

Complication of MI Clinical CHF

shock

Echo early detected

IABP, ECMO

Ventricular septal rubture

Papillary muscle rubture

Free wall rubture

Ischemic chest pain in ED GOAL

rapid identification of patients with STEMI

Rule out other life-threatening causes

Exclusion of alternative causes of non-ischemic chest pain

stratification of patients with acute coronary ischemia into low- and high-risk groups

2014 AHA/ACC Guideline for the Management of Patients WithNon–ST-Elevation Acute Coronary Syndromes

What case the should do ECG?

2014 AHA/ACC Guideline for the Management of Patients WithNon–ST-Elevation Acute Coronary Syndromes

Angina equivalent

***เขยีนpain score, BP ดว้ย

*SERIAL EKG 12 lead next 15 min*SERIAL EKG 12 lead when recurrence chest pain*Compare with previous EKGถา้ไมม่EีKGเก่า ก็ท าของใหมใ่หเ้ป็นของเก่าโดยการserial EKGอกีเช่นเคย ควรท า EKG ในเครื่องเดยีวกนัเท่านัน้ เคยท า position ไหนควรท า position นัน้

T h i r d u n i v e r s a l d e f i n i t i o n o f m y o c a r d i a l

i n f a r c t i o n E S C 2 0 1 2

T h i r d u n i v e r s a l d e f i n i t i o n o f m y o c a r d i a l

i n f a r c t i o n E S C 2 0 1 2

ESC 3rd universal definition MI

Myocardial infarct = Myocardial necrosis + Clinical myocardial ischemia

T h i r d u n i v e r s a l d e f i n i t i o n o f m y o c a r d i a l

i n f a r c t i o n E S C 2 0 1 2

0 h/3 h rule-out algorithm of NSTEMISerial testing 3 hr

5-fold of ULNMarco Roffi, et al. 2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-

segment elevation. European Heart Journal: doi:10.1093/eurheartj/ehv320.

0 h/3 h rule-out algorithm of NSTEMI

T < 14 ng/L T > 14 ng/L

value >14 ng/L + increase > 7 ng/L

valu

e >

70 n

g/L

+ cl

inic

al

pre

sen

tati

on

value >14 ng/L + increase>20% of initial value

Adapted from Marco Roffi, et al. 2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-segment elevation. European Heart Journal: doi:10.1093/eurheartj/ehv320.

Recommendations to measure hsTroponin T

Marco Roffi, et al. 2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-segment elevation. European Heart Journal: doi:10.1093/eurheartj/ehv320.

0 h/1 h rule-in and rule-out algorithms to the emergency department

P.10Marco Roffi, et al. 2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-

segment elevation. European Heart Journal: doi:10.1093/eurheartj/ehv320.

Key messagesSafe and effective AMI rule-in and rule-out in 1 hour

Reliable

results of

cTnT-hs with

many

references

supported

Algorithm

safety

confirmed by

30d-

mortality of

the patients

rule-out

(0.1%) and

high NPV

(>99.1-100%)

cTnT-hs 1-h

performs

well for

early AMI

rule-out and

rule-in

And reduces

diagnosis

time to 1h in

76-78% of

acute chest

pain patients

cTnT-hs

validates the

use of hs-cTn

with a

recommended

delta change

>99.1%NPV

30 day

mortality

More

patientsMore rule-

in/out

1h

cTnT-

hs

cTnT-

hs

diagnosed

in

1 hour

76-78%

GRACE : Predict inhospital death, death at 6 month

TIMI : predict 14 day death, MI, revascularization

For risk stratification and for guide treatment strategy

If GRACE score ≥ 109 (moderate – severe) invasive strategy PCI in 72 hr

If TIMI score ≥ 3(moderate – severe) invasive strategy PCI in 72 hr

On the monitor….

Marco Roffi, et al. 2015 ESC guidelines for the management of ACSin patients presenting without persistent ST-segment elevation. European Heart Journal

Electrocardiographic Monitoring in Adults

Rafael Ortega, M.D., et.al N Engl J Med 2015; 372:e11

Electrocardiographic Monitoring in Adults

Rafael Ortega, M.D., et.al N Engl J Med 2015; 372:e11

Case Male 58 y HT, smoking

CC : chest pain at rest 30 min PTA (16:30)

แสบหนา้อกขณะน่ังคยุกบัญาต ิ แน่นหนักๆ กลางหนา้อก กนิยา

เคลอืบกระเพาะแลว้ดขีึน้

Came to ER Chula 17:00 (30 min after C/P)

BP 158/84 mmHg PR 68/min, regular RR 18/min

PE: WNL , no CHF, no murmur

1st EKG Time 17:20 (20 min after) at OPD Room No.9

F/U EKG Time 18:24 (80 min.after) at OPD Room No.9, Dx STEMI

Case 3 Male 58 y C/P 30 min PTA Timeline

16:30 Chest pain

17:00 ER Chula

17:20 1st EKG

18:24 2nd EKG

18:25 consult fellow cardio

18:35 set primary PCI

18:55 arrived to cath lab

CAG DVD (95% distal RCA, 55 % prox LCX)

19:10 1st device (p-PCI to RCA)

Pitfall 3.1Screening miss HX มาดว้ยแสบหนา้อก กนิยาเคลอืบกพ.มานึกวา่เป็นGIเลยส่งหอ้งNo.9

3.2 R3 med miss dx EKG inferiorwall STEMI Txแบบdyspepsiaรอlab

3.3 F/U EKG นาน80min ท าอกีทSีTยก

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