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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.

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Linee guida SCA

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  1. 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

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. Somma Sottolivellamento ST GUSTO II b, Savonitto et Al Eur H J 2005

  10. QUANTITATIVE NSTE Kaul et al J Am Coll Cardiol 2003

  11. Quantitative ST deviation: GRACE CUMULATIVE ST DEVIATION Yan et Al, Am J Cardiol 2008

  12. 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

  13. ICTUS TRIAL Windausen et Al, J Electrocardiol 2007

  14. 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

  15. 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,

  16. 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

  17. Sopralivellamento ST AVR

  18. ST depression + T inversion V4-V6 Gusto II B, Atar et AL Am J Cardiol 2007

  19. Sottolivellamento ST + T negativa V4-V6

  20. 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)

  21. 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

  22. CONCLUSIONI (3) ASPETTI QUANTITATIVI E MORFOLOGIE PARTICOLARI POSSONO FAR SOSPETTARE UNA CORONAROPATIA SEVERA E PERTANTO MODIFICARE L’ITER DIAGNOSTICO E TERAPEUTICO

  23. CONCLUSIONI (4) I DATI ECG DI UN PAZIENTE CON SOSPETTA SCA DEVONO SEMPRE ESSERE INSERITI NEL CONTESTO DI UNA VALUTAZIONE MULTIPARAMETRICA

  24. 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

  25. 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

  26. Somma Sottolivellamento ST Kaul et al J Am Coll Cardiol 2003 GUSTO II b, Savonitto et Al Eur H J 2005

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