perugia 21 novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not...
TRANSCRIPT
![Page 1: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/1.jpg)
Casi clinici controversi in medicinad’Urgenza: Dolore Toracico
Perugia 21 Novembre 2019
Simone Vanni, MD, PhDDirettore SOC Medicina d’Urgenza
Ospedale San Giuseppe Empoli
![Page 2: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/2.jpg)
>40000 accessi/aa Età media 59±20 aa
(nel periodo 2017-2019 5710 pts al DEA Empoli)
18.7% ricoverati
67.5% dei pz viene dimessocon diagnosi sintomatologica
Riaccessi imprevisti (<72h)
1% a livello regionale, 0.65% per il DEA Empoli
Epidemiologia(in Toscana)
Tempo di permanenza PS
%
0-3h 7.9
4-6h 54.8
7-12h 20.8
13-24h 10.0
>24h 6.5
Mortalità nei pz dimessi
0.09% a 7gg0.36% a 30gg
![Page 3: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/3.jpg)
Caso Clinico 1 (19/11/2019)
• TM, maschio 52 anni, ore 6:30 del mattino• Dolore epigastrico interscapolare che si irradia
posteriormente da dopo cena. • 2 mesi fa per sintomatologia simile eseguita
valutazione in PS, con esecuzione di TC torace-addome con mdc per sospetta sindrome aorticaacuta, esclusa.
• 10 giorni fa nuovo episodio di dolore epigastrico, violento, sensibile a inibitori di pompa, programmata EGDS, non ancora eseguita
![Page 4: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/4.jpg)
Caso Clinico 1
• ore 7:00: PA 120/65, fc 110, sat 96%, TC 37,5• Codice 3• vigile sofferente, non deficit di lato• Torace Mv presente, non rumori aggiunti• Toni cardiaci ritmici, pause libere.• addome trattabile, dolorabilità in epigastrio-
ipocondio destro, con irradiazione interscapolare• Blumberg negativo.
![Page 5: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/5.jpg)
• In caso di alterazioni ECG compatibile con STEMI o stemi-like, rapida attivazione del cardiologo di guardia
• Screening del dolore toracico con intervallo 0-3h (in caso di HEART score ≥5, eventuale estensione in caso di dolore fortemente suggestivo previa valutazione cardiologica)
• HEART score ≥7 necessità di test da sforzo pre-dimissione
• HEART score =4, eventuale completamento diagnostico in regime ambulatoriale
• Rx torace è eseguita a giudizio del medico curante per DD di patologie polmonari/SCC
Triage
![Page 6: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/6.jpg)
ECG
![Page 7: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/7.jpg)
Esami ematici
• Creat: 0.79 mg/dl• GB: 16.040, 77.8% neutrofili• Hb:14.9• ALT 65, AST 46• LDH 274, Proteina CR 13.42*• amilasi pancreatica: 14 U/L
Troponina I hs: 3.7 pg/ml (2.3-19.8)
![Page 8: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/8.jpg)
HEART Score• Sviluppato nel 2008 per pazienti
con dolore toracico in PS• 5 parametri cui viene assegnato
un punteggio (score totale 0-10) • Il tasso di eventi aumenta in
modo significativo con l’aumentare dello score
• Facile da applicare • Buon valore predittivo sia per
pazienti ad alto che a basso rischio (migliore rispetto al TIMI e GRACE per stratificare pz indifferenziati al DEA)BASSO 0-
3MACE 1 6%
INTERMEDIO 4-6
MACE 16,6%
ALTO 7-10
MACE 50 1%
![Page 9: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/9.jpg)
HEART Score• History 1• ECG 0• Age 1• Risk factors 1• Troponin 0
• Score 3
BASSO 0-3
MACE 1 6%
INTERMEDIO 4-6
MACE 16,6%
ALTO 7-10
MACE 50 1%
![Page 10: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/10.jpg)
Eco addome
• Fegato megalico....la colecisti sembra rilevareun iniziale ispessimento parietale....
• Si segnala velatura seno costo frenico sin come per versamento pleurico lieve
![Page 11: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/11.jpg)
Ecografia clinica
![Page 12: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/12.jpg)
Ecografia clinica
![Page 13: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/13.jpg)
![Page 14: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/14.jpg)
Ecografia
• La consensus ANMCO-SIMEU 2016 ritiene l’ecografia bedside imprescindibile per DIAGNOSI DIFFERENZIALE e inquadramento delle cause cardiovascolari soprattutto in caso di instabillità emodinamica.
• Le ultime linee guida ESC 2015 sulle SCA-NSTE assegnano all’ecocardiografia un ruolo essenziale nella diagnosi di ischemia miocardica acuta, in quanto eventuali alterazioni acute possono precedere le modificazioni dell’ECG e dei biomarcatori (classe II B).
• Le LG ESC STEMI 2017 indicano che in caso di instabilità emodinamica con diagnosi suggestiva per SCA, è indicata valutazione ecocardiografica, se questa non ritarda esecuzione della coronarografia (Classe I C)
![Page 15: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/15.jpg)
Caso Clinico 2 (6/11/2019)
• BL, Maschio, 49 anni• accede per dolore toracico retrosternale ,
poco dopo il risveglio, di circa 10 min.....• Al triage asintomatico, fumatore (1 pac),
familiarità per CAD.
![Page 16: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/16.jpg)
Caso Clinico 2
• BL, Maschio, 49 anni, ore 8:10• accede per dolore toracico retrosternale ,
poco dopo il risveglio, di circa 10 min.....• Al triage asintomatico, fumatore (1 pac),
familiarità per CAD.• PA 155/95, FC 80, sat 98%, FR 12, TC 36.6• Codice 3
![Page 17: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/17.jpg)
ECG
![Page 18: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/18.jpg)
HEART Score
• Hystory: 1• ECG: 0• Age : 1• Risk factor: 1• Troponin 0
• SCORE= 3
BASSO 0-3
MACE 1 6%
INTERMEDIO 4-6
MACE 16,6%
ALTO 7-10
MACE 50 1%
![Page 19: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/19.jpg)
Caso Clinico 2
• Rx torace : diffusa accentuazione dell’interstizio peribroncovasale in particolare in sede basale destra…
• Ore 11:26: lamenta nuovo dolore toracico che si modifica con gli atti respiratori ed il movimento. Agitato.
• Pa 150/85, sat 98%, FC 82.
![Page 20: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/20.jpg)
Caso Clinico 2
• ECG: negativo• Nuovo prelievo: ore 13:15
– 19.7 pg/ml: (vn 2.3-19.8)
• Flectadol ev+ceftriaxone ev• Richiesta valutazione cardiologica che richiede
nuovo dosaggio troponina
![Page 21: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/21.jpg)
HEART Score
• Hystory: 1• ECG: 0• Age : 1• Risk factor: 1• Troponin 0
• SCORE= 3
BASSO 0-3
MACE 1 6%
INTERMEDIO 4-6
MACE 16,6%
ALTO 7-10
MACE 50 1%
![Page 22: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/22.jpg)
![Page 23: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/23.jpg)
![Page 24: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/24.jpg)
Caso Clinico n 2
• Troponina ore 15:50 – 356 pg/ml
![Page 25: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/25.jpg)
![Page 26: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/26.jpg)
Caso clinico 2
• Richiesta ulteriore troponina che risulterà essere 918 pg/ml
• NSTEMI• Limitata asinergia setto medio anteriore e
posteriore con FE conservata• Coronarografia a il giorno seguente:
- Coronaropatia bivasale (CD, Cx)- stent multipli medicati- Brilique+ASA
Troponina picco: 5.161
![Page 27: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/27.jpg)
Cosa abbiamo imparato
• Utilità dell’ecografia bedside– ++ per la diagnosi differenziale– Valutazione della cinetica
• Esistenza dell’angina Instabile– Braunwald class III: rest angina <48 h.
• Necessità di interpretare i valori di troponinaHs che risultano essere un continuum– Sia per il NPV– Che per il PPV
![Page 28: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/28.jpg)
Bisogna metterci l’anima
“Come corpo ognuno è singolo,
come anima mai. “
Hermann Hesse
![Page 29: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/29.jpg)
Etiologies
![Page 30: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/30.jpg)
![Page 31: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/31.jpg)
Doloretoracico
1995
Impossibile trovare nel file la parte immagine con ID relazione rId2.
![Page 32: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/32.jpg)
ANMCO/SIMEU
![Page 33: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/33.jpg)
Clinica?
ESC 2015
![Page 34: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/34.jpg)
ESC guidelines
![Page 35: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/35.jpg)
![Page 36: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/36.jpg)
ECG: a chi?
ESC 2002
![Page 37: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/37.jpg)
ECG: a chi?
![Page 38: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/38.jpg)
NICE guidelines 2016• 1.2.1 Initial assessment and referral to hospital• 1.2.1.1 Check immediately whether people currently have
chest pain. If they are pain free, check when their last episode of pain was, particularly if they have had pain in the last 12 hours. [2010]
• 1.2.1.2 Determine whether the chest pain may be cardiacand therefore whether this guideline is relevant, by considering:
• the history of the chest pain• the presence of cardiovascular risk factors• history of ischaemic heart disease and any previous
treatment• previous investigations for chest pain. [2010]
![Page 39: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/39.jpg)
NICE guidelines• Initially assess people for any of the following symptoms,
which may indicate an ACS:• pain in the chest and/or other areas (for example, the
arms, back or jaw) lasting longer than 15 minutes• chest pain associated with nausea and vomiting, marked
sweating, breathlessness, or particularly a combination of these
• chest pain associated with haemodynamic instability• new onset chest pain, or abrupt deterioration in previously
stable angina, with recurrent chest pain occurringfrequently and with little or no exertion, and with episodesoften lasting longer than 15 minutes. [2010]
![Page 40: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/40.jpg)
NICE guidelines• 1.2.1.4 Do not use people's response to glyceryl trinitrate (GTN)
to make a diagnosis. [2010]• 1.2.1.5 Do not assess symptoms of an ACS differently in men
and women. Not all people with an ACS present with central chest pain as the predominant feature. [2010]
• 1.2.1.6 Do not assess symptoms of an ACS differently in ethnic groups. There are no major differences in symptoms of an ACS among different ethnic groups. [2010]
• 1.2.1.7 Refer people to hospital as an emergency if an ACS is suspected (see recommendation 1.2.1.3) and:
• they currently have chest pain or• they are currently pain free, but had chest pain in the last 12 hours,
and a resting 12-lead ECG is abnormal or not available. [2010]
![Page 41: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/41.jpg)
ESC guidelines
![Page 42: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/42.jpg)
NICE guidelines
• 1.2.5 Use of biochemical markers for diagnosisof an acute coronary syndrome
• 1.2.5.1 Do not use high-sensitivity troponin testsfor people in whom ACS is not suspected. [new 2016]
• 1.2.5.2 For people at high or moderate risk of MI (as indicated by a validated tool), perform high-sensitivity troponin tests as recommended in the NICE diagnostics guidance on myocardial infarction (DG15). [new 2016]
![Page 43: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/43.jpg)
Eco: a chi?
![Page 44: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/44.jpg)
Chi dimettere?
![Page 45: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/45.jpg)
Work-up diagnostico
![Page 46: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/46.jpg)
Linee guida ANMCO/SIMEU 2016
![Page 47: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/47.jpg)
The rational clinical examination. Is this patient havinga myocardial infarction?
JAMA 1998• When faced with a patient with acute chest pain, clinicians must
distinguish myocardial infarction (MI) from all other causes of acute chest pain.
• Despite advances in investigative modalities, a focused history and physical examination followed by an ECG remain the key tools for the diagnosis of MI.
• The most powerful features that increase the probability of MI, and their associated likelihood ratios (LRs), are new ST-segmentelevation (LR range, 5.7-53.9); new Q wave (LR range, 5.3-24.8); chest pain radiating to both the left and right arm simultaneously(LR, 7.1); presence of a third heart sound (LR, 3.2); and hypotension(LR, 3.1). The most powerful features that decrease the probabilityof MI are a normal ECG result (LR range, 0.1-0.3), pleuritic chestpain (LR, 0.2), chest pain reproduced by palpation (LR range, 0.2-0.4), sharp or stabbing chest pain (LR, 0.3), and positional chest pain(LR, 0.3).
Panju AA et al
![Page 48: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/48.jpg)
Does This Patient With Chest Pain Have Acute Coronary Syndrome? The Rational Clinical
Examination Systematic ReviewJAMA 2015
• About 10% of patients with acute chest pain are ultimatelydiagnosed with acute coronary syndrome (ACS). Early, accurate estimation of the probability of ACS ....ensure that high-risk patients are promptly treated.
• Among patients with suspected ACS presenting to emergency departments, the initial history, physicalexamination, and electrocardiogram alone did not confirmor exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores, which incorporate the first cardiac troponin, provided more diagnostic information.
• The most useful for identifying patients less likely to have ACS were the low-risk range HEART score (0-3) (LR, 0.20 [95% CI, 0.13-0.30]), low-risk range TIMI score (0-1) (LR, 0.31 [95% CI, 0.23-0.43]),
Fanaroff et al
![Page 49: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/49.jpg)
HEART validation
![Page 50: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/50.jpg)
Scores
![Page 51: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/51.jpg)
![Page 52: Perugia 21 Novembre 2019 - consultaumbria.com · examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores,](https://reader033.vdocuments.net/reader033/viewer/2022041804/5e537d8eba71a240a47e401b/html5/thumbnails/52.jpg)
Confronto scores