胸痛1.留學生課程

1、 Song, Wei Professor, of Emergency medicine Director, Dept. of Emergency medicine Hainan Provincial Peoples Hospital海 南 省 急 救 中 心海南省人民醫(yī)院 急診科 宋 維 2014-11-25 Chest Pain: Cardiac or Not contentChest Pain -Introduction DefinitionsInitial ApproachHistoryPhysical ExaminationClinical FeaturesAncillary Test

2、ingDiagnosis1. Introduction The management of the patient with chest pain is a diagnostic and therapeutic challenge of critical importance Approximately 5% and 3% of all U.S.and China ED visits for chest pain but accurate diagnosis remains a challenge.2. Definitionsacute chest pain is pain of recent

3、 onset, typically 40 years old, male or postmenopausal female, hypertension, cigarette smoking, hypercholesterolemia, diabetes, truncal obesity, family history, sedentary lifestyle The patients medical record should be reviewed, and any previous ECGs should always be compared with current tracings 5

4、.Ischemic Equivalentsmany patients with ACS will not experience chest fort. In fact, MI patients entered into the National Registry of Myocardial Infarction , 33% did not have chest pain upon presentation to the hospital. Painless presentations are more common in women Although truly silent ischemia

5、 does also occur, ED physicians must always remain vigilant to recognize angina-equivalent symptoms. These may include one or any combination of the following: dyspnea at rest or exertion; shoulder, arm, or jaw fort; nausea; light-headedness; generalized weakness; acute changes in mental status; 6.P

6、hysical ExaminationThe physical examination of patients with the pain of ACS is often normal. Abnormalities in vital signs may include hyper- or hypotension, sinus tachycardia, or bradycardia. Tachycardia often results from increased sympathetic tone and decreased left ventricular stroke volume, alt

7、hough bradycardia may represent inferior wall ischemia. Patients with acute ischemia have a higher incidence of abnormal heart soundsClinical FeaturesTable 2 Important Causes of Acute Chest PainChest Wall PainPleuritic PainVisceral PainCostosternal syndromePulmonary embolismTypical exertional angina

8、Costochondritis (Tietze syndrome)PneumoniaAtypical (nonexertional) anginaSpontaneous pneumothoraxPrecordial catch syndromeUnstable anginaSlipping rib syndromePericarditisAcute myocardial infarctionXiphodyniaPleurisyRadicular syndromesAortic dissectionIntercostal nerve syndromesPericarditisEsophageal

9、 reflux or spasmFibromyalgiaEsophageal ruptureMitral valve prolapse7.Ancillary TestingECG and continuous ECG monitoringlaboratory testing and serial myocardial marker measurementsimaging studies (aids in detection and exclusion of a variety of other serious diagnoses i.e., pulmonary embolism, aortic

10、 dissection, etc.) a 12-lead ECG with a goal of within 10 minutes of ED arrival for all patients with chest fort or other symptoms About half (range, 13% to 69%) of patients with AMI have diagnostic changes on the initial ECG (new ST-segment elevation 1 mm in two contiguous leads), The positive pred

11、ictive value of different ECG patterns is well known. For new ST-segment elevation ( 1 mm in at least two contiguous leads), For new ST-segment depression and T-wave inversions, the positive predictive value is about 20% for AMI and between 14% and 43% for unstable angina. Serial ECGs over the initial 2 to 3 hours of the patients presentation will significantly increase the sensitivity of ECG for AMI diagnosisSerum Markers of Myocardial InjuryCardiac Troponins-troponin I and troponin TCreatine Kinase, Subunits, and MyoglobinB-type natriuretic peptide (BNP)