急性冠脉综合症的诊断与危险度分层（上）.pptVIP

Exercise, stress, or cold environment classically precipitates angina duration of symptoms typically 10 minutes, occasionally lasting up to 20 minutes usually improves within 2-5 minutes after rest or nitroglycerin Age over 40 male postmenopausal females family history cigarette smoking hypertension High cholesterol truncal obesity sedentary lifestyle diabetes previous cardiac hx Risk factors are modestly predictive of CAD is asymptomatic patients In the ER, risk factors are poor predictors of cardiac risk for MI or other ACS In males, only DM and family history are weakly predictive Cardiac risk factors are not predictive of ACS in female ER chest pain pts Not helpful in distinguishing pts with ACS from those with non cardiac etiologies Pts may appear deceptively will without distress or be uncomfortable, pale, cyanotic, and in respiratory distress. Bradycardic rhythms are more common with inferior wall MI in the setting of anterior wall MI, bradycardia or heart block is very poor prognostic sign Extremes of blood pressures are associated with worse prognosis S1 and S2 are often diminished due to poor myocardial contractility S3 is present in 15-20% of pts with AMI implies a failing myocardium S4 is common in pts with long standing HTN or myocardial dysfunction Presence of new systolic murmur is an ominous sign signifies papillary m. dysfunction, flail leaflet of mitral valve, or VSD 12 lead is single best test to identify pts with AMI upon presentation to ER Current guidelines state that the initial 12 lead ECG must be obtained and interpreted within 10 minutes of patient presentation Yet ECG has a relatively low sensitivity for detection of AMI In distributions previously described: ST elevation suggests acute transmural injury ST depression suggests subendocardial ischemia All inferior wall MI should have right sided ECG ST elevation in rV4 indicates right ventricular infarction a higher likelihood of cardiovascular complications increased mortality