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Right upper portion of the heart right ventricular outflow tract

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Right upper portion of the heart right ventricular outflow tract

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  1. خانم 39 ساله با سوزش معده به اورژانس مراجعه می کند، بیمار چندین ماه است که از این درد و درد قفسه سینه رنج می برد. ایشان به توصیه پزشک خانواده آنتی اسید برای چندین هفته استفاده نموده است که بهبودی حاصل ننموده است. امروز بیمار دچار سوزش معده و احساس تنگی نفس بدنبال ورزش نموده است.بیمار در معاینه نکته خاصی به جزء تاکیکاردی خفیف نداشته. • سابقه مولتیپل اسکلروزیس را می دهد که دارو مصرف نمی کند

  2. Right upper portion of the heart • right ventricular outflow tract • basal portion of the interventricular septum • Lead aVR is electrically opposite to the left-sided leads I, II, aVL and V4-6

  3. Predictive Value of STE in aVR • In the context of widespread ST depression + symptoms of myocardial ischaemia:

  4. اقدام مناسب در این بیمار چیست؟

  5. Community Preparedness and System Goalsfor Reperfusion Therapy Class I • All communities should create and maintain a regional system of STEMI care that includes assessment and continuous quality improvement of EMS and hospital based activities. Performance can be facilitated by participating in programs such as Mission: Lifeline and the D2B Alliance (Level of Evidence: B) • Performance of a 12-lead ECG by EMS personnel at the site of first medical contact (FMC) is recommended in patients with symptoms consistent with STEMI. (Level of Evidence: B)

  6. Class I • Reperfusion therapy should be administered to all eligible patients with STEMI with symptom onset within the prior 12 hours. (Level of Evidence: A) • Primary PCI is the recommended method of reperfusion when it can be performed in a timely fashion by experienced operators. (Level of Evidence: A) • EMS transport directly to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI, with an ideal FMC-to-device time system goal of 90 minutes or less (Level of Evidence: B)

  7. Immediate transfer to a PCI-capable hospital for primary PCI is the recommended triage strategy or patients with STEMI who initially arrive at or are transported to a non–PCI- capable hospital, with an FMC-to-device time system goal of 120 minutes or less. (Level of Evidence: B)

  8. patients presenting to a non–PCI-capable hospital • 1) The time from onset of symptoms • 2) The risk of complications related to STEMI • 3) The risk of bleeding with fibrinolysis • 4) The presence of shock or severe HF • 5) The time required for transfer to a PCI-capable hospital

  9. In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI at non–PCI- capable hospitals when the anticipated FMC-to-device time at a PCI-capable hospital exceeds 120 minutes because of unavoidable delays. (Level of Evidence: B) • When fibrinolytic therapy is indicated or chosen as the primary reperfusion strategy, it should be administered within 30 minutes of hospital arrival. (Level of Evidence: B)

  10. Class IIa • Reperfusion therapy is reasonable for patients with STEMI and symptom onset within the prior 12 to 24 hours who have clinical and/or ECG evidence of ongoing ischemia. Primary PCI is the preferred strategy in this population. (Level of Evidence: B)

  11. Evaluation and Management of Patients WithSTEMI and Out-of-Hospital Cardiac Arrest • Therapeutic hypothermia should be started as soonas possible in • comatose patients with STEMI and • out-of-hospital cardiac arrest caused by VF or pulseless VT not asystole

  12. Class I • Immediate angiography and PCI • should be performed in resuscitated out-of-hospital cardiac arrest patients whose initial ECG shows STEMI

  13. اندیکاسیون primary PCI in STEMI چیست؟

  14. Reperfusion at a PCI-Capable Hospital

  15. بیمار قبل از اعزام جهت انجام PCI نیازمند چه اقدام درمانی می باشد؟

  16. Adjunctive Antithrombotic Therapy for Primary PCI

  17. Reperfusion at a Non–PCI-Capable Hospital

  18. Choice of Fibrinolytic Agent

  19. Contraindications and Cautions for Fibrinolytic Therapy in STEMI

  20. Contraindications and Cautions for Fibrinolytic Therapy in STEMI

  21. Assessment of Reperfusion After Fibrinolysis • The relatively sudden and complete relief of chest pain coupled with 70% ST resolution (in the index lead showing the greatest degree of elevation on presentation) is highly suggestive of restoration of normal myocardial blood flow • Lack of resolution of ST elevation by at least 50% in the worst lead at 60 to 90 minutes should prompt strong consideration of a decision to proceed with immediate coronary angiography and “rescue” PCI

  22. اندیکاسیون های انجام PCI بعد ازتجویز فیبرولیزین چیست؟

  23. Transfer to a PCI-Capable Hospital AfterFibrinolytic Therapy

  24. Routine Medical Therapies • Beta Blockers • ACE Inhibitors or ARB • Lipid Management • Nitroglycerin • Morphine

  25. Bleeding Complications

  26. Treatment of ICH • all antiplatelet and anticoagulant therapy should be stopped • Brain imaging with emergency neurological and neurosurgical consultation is required • Consideration can be given to the use of protamine, fresh frozen plasma, prothrombin complex concentrates, activated factor VII, and platelets as indicated.

  27. پروتکل PCI در بیمارستان رسول اکرم(ص) • اطلاع به اتند قلب • فعال سازی تیم PCI • درمان دارویی • اعضای تیم انتقال بیمار به آنژیوگرافی

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