Acute coronary syndrome
Concept the acute coronary syndrome (ACS) experts of ACC/AHA and ESC designate "group of the states developing at acute ischemia of a myocardium" (fig). The Construction Department usually (but not always) is prichinno connected with atherosclerotic defeat of coronary arteries, often caused by process of destruction of an atherosclerotic plaque with the subsequent cascade of the pathological processes reducing a coronary blood stream.
Nomenclature of an acute coronary syndrome. Patients with an acute coronary syndrome can have a ST segment elevation on an ECG. or not to have it. Most of patients with an acute coronary syndrome with a ST segment elevation in the subsequent have a myocardial infarction with Q tooth (a wide arrow), the smaller part can have a myocardial infarction without Q tooth (a narrow arrow). Persons with an acute coronary syndrome without elevation of ST can have either unstable stenocardia, or a myocardial infarction without Q tooth (wide shooters), only the small part of them has a myocardial infarction with Q tooth (a narrow arrow) (it is adapted from ACC/AHA, 2000,2004).
In tables 1. and 2. approaches to an assessment of complaints and the anamnesis, and also recommendation about performance of an ECG, echocardiography and an assessment of biochemical cardial markers at persons with an acute coronary syndrome are provided. Allocation of various options of an acute coronary syndrome in clinic is based on characteristics of an ECG and levels of biochemical markers of a necrosis of a myocardium (a kreatinfosfokinaz of CK-MB, a troponina of TPT and Tnl). Existence of IM ST "↑" is established in the presence of again arisen elevation of the ST segment beginning from J point on> 0.2 mV in assignments of V1-V3 and> 0.1 mV in other assignments. Biochemical markers of cardial damage at patients with IM ST "↑" in an acute phase are raised. At persons without ST segment elevation in the presence of again arisen ST segment depression> 0.1 mV in two or more adjacent assignments or inversion of a tooth of T> 0.1 mV in assignments where there is a dominance of a tooth of R, state existence of NANOSECOND/IM ST "-". Existence of a myocardial infarction with a tooth of Q is established at identification of again arisen tooth Q any durations in assignments of V1-V3 or> 0.03 with in assignments of I, II, aVL, aVF, V4-V6.
Table 1. Approaches to an assessment of complaints and the anamnesis at an acute coronary syndrome (ANA is adapted IZASS/. 2000.2004) 1. COMPLAINTS: • Thorax pain or the expressed pain in epigastriums, not traumatic by origin, with existence of the features typical for ischemia of a myocardium or a myocardial infarction: the retrosternal squeezing or gripping pain; heavy feeling, prelums, "hoop", constraint, burning, dull ache; inexplicable feelings of "lump", difficulty of a proglatyvaniye, eructation, pain in an anticardium; distribution of pain to a neck, jaw, shoulders, back, one or both hands, feeling of "numbness" of these areas • + asthma; • + nausea and/or vomiting • + perspiration 2. ANAMNESIS. At the initial stage it is necessary to collect quickly and precisely the following data on the patient (collecting the anamnesis should not slow down the beginning of urgentny medical actions): • existence in the past of the episodes of stenocardia postponed a myocardial infarction, procedures of revascularization (angioplasty, stenting, shunting); • reception of nitroglycerine for elimination of discomfort in a thorax; • existence of risk factors of coronary heart disease (smoking, lipidemia, arterial hypertension, diabetes mellitus, raniy beginning of vascular defeats in the family anamnesis 3. SEPARATE GROUPS OF PATIENTS: • women more often in comparison with men can have atypical options of symptoms (including atypical thorax pain); • patients with a diabetes mellitus can have atypical symptomatology (owing to vegetative dysfunction); • elderly patients can have quite often such atypical manifestations as generalized general weakness, syncopes, changes of consciousness, insultny symptomatology
Table 2. Recommendations about performance of an ECG, echocardiography and an assessment of biochemical cardial markers at persons with an acute coronary syndrome (it is adapted from ACC/AHA-2000.2004. ESC-2003). • The ECG in 12 assignments should be registered immediately (within 10 minutes) at suspicion on an acute coronary syndrome at patients both with remaining, and with already eliminated discomfort in a thorax (a class I. level of proofs C) • Biochemical markers of cardial damage have to be measured at all patients where there is a suspicion on an acute coronary syndrome. Cardio-specific troponina are preferable, and if it is possible, their measurement has to be taken at all patients. Also measurement of a kreatiikinaza (CK-MB) is acceptable. At the persons having negative takes of measurement of cardial markers during the first 6 h after the beginning of symptomatology, one more measurement has to be taken in terms from 6 to 12 h (for example, in 9 h after emergence of symptoms) (a class I, level of proofs C) • Performance of a two-dimensional echocardiography for the purpose of identification of other possible reasons of pain in a thorax (acute stratification of an aorta, an exudate in a pericardium, a thromboembolism of a pulmonary artery (a class I, level of proofs C) • At suspicion on an acute coronary syndrome it is not necessary to estimate levels of the general kreatiikinaza (SK without MB), aminotransferases, lactate dehydrogenases (class III)