急性胸痛的鑒別

1、急性胸痛的鑒別ACUTE CHEST PAIN,北京大學(xué)航天臨床醫(yī)學(xué)院王斌,,,一、胸痛的病因及發(fā)生機(jī)制,1. 病因,胸壁疾?。?皮膚、肌肉、肋間神經(jīng)、胸骨浸潤(rùn)心血管疾?。?心絞痛、心梗、心肌病、肺梗塞,呼吸系統(tǒng)疾?。?胸膜炎、腫瘤、氣胸、肺炎、肺癌縱膈疾?。?縱膈炎癥、膿腫、腫瘤其他：食管病變。,2. 胸痛的機(jī)制：,各種剌激因子（缺氧、炎癥、肌張力改變、癌浸潤(rùn)、組織壞死及理化因子）可剌激胸部的感覺神經(jīng)纖維產(chǎn)

2、生痛覺沖動(dòng)，并傳至大腦皮層的痛覺中樞引起胸痛。,胸痛的機(jī)制胸部感覺神經(jīng)纖維： 肋間神經(jīng)感覺纖維 交感神經(jīng)纖維 迷走神經(jīng)纖維 膈神經(jīng)感覺纖維,二、胸痛的分類,,分類1：,有生命危險(xiǎn)的胸痛嚴(yán)重的胸痛無生命危險(xiǎn)的胸痛,1. 具有生命危險(xiǎn)的胸痛,急性心肌梗死AMI不穩(wěn)定型心絞痛Unstable Angina肺動(dòng)脈栓塞PTE主動(dòng)脈夾層Aortic Dissection,2. 緊急情況,張力性氣胸心包炎Peri

3、carditis (尤其是心臟亞塞tamponade) 食管破裂Esophageal rupture,3. 無生命危險(xiǎn)的胸痛,心包炎Pericarditis食管反流或痙攣氣胸PTX ，胸膜炎 Pleuritis 消化道疾?。耗懩已?、胰腺炎G.B., P.U.D.,Pancreatitis骨骼肌疾病其它原因,分類2,心肌缺血性（冠心?。┓切募∪毖苑蝿?dòng)脈栓塞主動(dòng)脈夾層胸壁疾病消化道疾病,三、常見疾病胸痛的特點(diǎn),,

4、由于胸痛是一個(gè)癥狀，因此在臨床上應(yīng)高度重視病人胸痛的特點(diǎn)，甚至可以對(duì)50%或更多的病人提供診斷信息。,1. 冠心病心絞痛,胸痛特點(diǎn)部位：胸骨后、下頜、頸部、上肢、牙齒、背部持續(xù)時(shí)間：幾分鐘～十幾分鐘，一般短于30分鐘特點(diǎn)：壓迫性、擠壓感、緊縮感、燒灼感誘因：運(yùn)動(dòng)、情緒激動(dòng)、寒冷餐后緩解因素：休息、使用硝酸甘油疼痛類型 ：慢性穩(wěn)定型、初發(fā)型、惡化型、白天臥位型,1. 冠心病心絞痛,輔助檢查心電圖：靜息及運(yùn)動(dòng)放射性核素心肌灌

5、注顯像（可逆缺損）負(fù)荷超聲試驗(yàn)64排螺旋CT冠狀動(dòng)脈造影,2. 冠心病心肌梗死,胸痛特點(diǎn)部位 (胸骨后、下頜、頸部、上肢、牙齒、背部)時(shí)間：持續(xù)性特點(diǎn) (壓迫性、擠壓感、緊縮感、燒灼感)誘因 (運(yùn)動(dòng)、情緒激動(dòng)、寒冷餐后或無)常常不能緩解因素 (休息、使用硝酸甘油無效),2. 冠心病心肌梗死,輔助檢查心電圖：靜息及運(yùn)動(dòng)心肌酶,3. 肺動(dòng)脈栓塞,突然發(fā)生呼吸困難為主，與運(yùn)動(dòng)有關(guān)，嚴(yán)重的表現(xiàn)為持續(xù)的呼吸困難心動(dòng)過速、低血

6、壓胸痛癥狀較輕咳嗽、咯血較長(zhǎng)時(shí)間臥床病史,,輔助檢查心電圖心臟超聲放射性核素顯像64排CT肺動(dòng)脈造影,4. 主動(dòng)脈夾層,年齡較大，有高血壓病史突然發(fā)作后背部疼痛，劇烈，撕裂樣持續(xù)時(shí)間長(zhǎng)心電圖變化不明顯心肌酶無明顯升高,5. 氣胸,胸痛＋呼吸困難突然發(fā)生癥狀持續(xù)體格檢查患側(cè)呼吸運(yùn)動(dòng)及呼吸音減低患側(cè)語(yǔ)顫減弱叩診呈鼓音或過清音,6.胸膜炎/心包炎,尖銳刺痛可出現(xiàn)發(fā)熱等全身癥狀與深呼吸/心臟跳動(dòng)有關(guān)持續(xù)

7、時(shí)間較長(zhǎng)可有心電圖ST段抬高,7. 消化道疾病,多呈鈍痛，疼痛部位下胸部、上腹部持續(xù)性較長(zhǎng)，幾十分鐘至數(shù)小時(shí)與飲食有關(guān)與體位有關(guān)常常合并惡心、嘔吐、反酸等消化道癥狀一般沒有心電圖的改變,8. 胸壁骨骼肌疾病,持續(xù)性疼痛部位明確，胸壁局部可能與呼吸有關(guān)，與運(yùn)動(dòng)關(guān)系不大局部有壓痛,四、胸痛的診斷,胸痛的診斷？胸痛的類型？胸痛的處理,病例1,男性，70歲，既往有明確高血壓、冠心病史本次從外地來北京出差，車禍后出現(xiàn)持續(xù)左

8、側(cè)胸痛，曾在某醫(yī)院急診室診斷為心絞痛，處理后不緩解外院心電圖：ST段輕度壓低,查體,胸壁沒有外傷左側(cè)呼吸運(yùn)動(dòng)減低左側(cè)呼吸音低，語(yǔ)顫減弱心電圖：QRS波群低電壓、ST段輕度壓低,下一步檢查？,鑒別：胸痛的特點(diǎn),胸痛：部位、性質(zhì)、持續(xù)時(shí)間、發(fā)作和緩解因素持續(xù)時(shí)間：幾分鐘～十幾分鐘發(fā)作和緩解的因素：是否與運(yùn)動(dòng)和情緒激動(dòng)有關(guān)是否與飽餐（＋運(yùn)動(dòng)）有關(guān),與心臟鑒別,心電圖有無ST段－T波改變動(dòng)態(tài)節(jié)段性心肌酶：肌鈣蛋白,心電圖

9、：最重要,,,,,,未發(fā)作時(shí),,,發(fā)作時(shí)：假性正?；?急性心肌梗死生化標(biāo)志,影像學(xué)檢查,超聲心動(dòng)圖64排 CT血管造影,JACC 2005;45:128,Angiographic Correlation,,Case Study from China,Dissecting Aneurysm Flap,False lumen,FL,Pulmonary Embolism,,,處理原則,按照類型和嚴(yán)重性急性心肌梗死、肺栓塞，心絞痛主動(dòng)脈

10、夾層氣胸其它：消化道疾病,基層醫(yī)院,缺血性服用阿司匹林、β受體阻滯劑、鎮(zhèn)靜高血壓、主動(dòng)脈夾層降壓、鎮(zhèn)靜其它疾病留下來檢查,,,謝謝！,,,TIMI Risk Score For UA/NSTEMI 7 Independent Predictors,Age > 65 y> 3 CAD Risk FactorsPrior Stenosis > 50 % ST deviation> 2 Angi

11、nal events < 24 hASA in last 7 daysElev Cardiac Markers,1.75 (1.35-2.25) < 0.0011.54 (1.16-2.06) 0.0031.70 (1.30-2.21) < 0.001 1.51 (1.13-2.02) 0.0051.53 (1.20-1.96) 0.0011.74

12、 (1.17-2.59) 0.0061.56 (1.21-1.99) < 0.001,OR (95 CI) P,Risk of Events in UA/NSTEMI,Patient APatient BAge48 78CAD HxNoneDM, Incr Chol,HTNECGNo ST dev1.5 mm ST

13、 depASA useNoChronicTroponin I1.6 ng/ml0.00 ng/ml,Which pt. is at greater risk of Death + Cardiac Ischaemic Events in next 2 weeks ?,TIMI Risk Score For UA/NSTEMITest Cohort--UFH Group TIMI 11B(N= 1957),Eve,

14、Number of Risk Factors,,4.3,17.3,32.0,29.3,13.0,3.4,Ho3.56df8 P=0.89C Statistic = 0.6c2 trend P <0.001,man et al JAMA 284 : 835, 2000,30 Day event rates,Troponin,Tp I (Oxford) Several kits < 0.2ng/mlTp T (Roch

15、e) < 0.1ng/mlPulmonary embolism, myocarditis, heart failure can elevateComplex mechanisms with renal insufficiency,Prognostic value of troponins,,,ACS Physiology,,,,,Rupture,Obstruction,,Thrombosis,,Local Effects,,D

16、istal Effects,,,,,,,What does troponin tell us ?,,,,,,Time,Rupture,,Thrombosis,,Occlusion,,Injury,,(+) Troponin,,,,Embolization,,,,,,,,Reperfusion,Instability,Infarction,,?,Injury at some point in time,,Therapy in ST ele

17、vation ACS,Pain relief/oxygenationArrhythmic/haemodynamic standbyReperfusion ASAP (aspirin, thrombolysis, primary PCI [IIb/IIIa] [clopidogrel])Risk assessment for medium termCardioprotection (beta-blockers, statins,A

18、CEI),Therapy in non-ST elevation ACS,Pain relief (nitrates)Antiplatelet agents (aspirin:clopidogrel: [IIb/IIIa antagonists])Antithrombotic agents (heparins)Cardioprotection (beta-blockers,[ACEI,statin])Risk stratific

19、ation and consider revacularisation,Intervention in ACS: Pro and Con,ConTIMI IIBTIMI IIIBVANQWISHOASIS RegistrySWIFT(AVERT),ProIntuitive ReasoningInvaders’ SentimentsRITA 3FRISC 2Tactics/TIMI 18,0,1,2,3,4,5,

20、6,Time (months),0,4,8,12,16,20,% Patients,Primary Endpoint- TACTICS,Death, MI, Rehosp for ACS at 6 Months,,2220 patients,,,,,,,,,,No. Pts1o Endpoint Death/MI Death MI Rehosp ACS,111415.97.33.34.811.0,110619.

21、4 9.53.56.913.7,P value,INV (%),CONS (%),0.780.740.930.670.78,OR,0.025 <0.050.740.0290.054,,TACICS – Cardiac events at 6/12,,,High Grade Stenosis,,Filling Defect,INTERHEART52 Countries 25000 subjects(L

22、ancet 2004; 362,937),Predictive ORSmoking2.87ApoB/ApoA13.25Diabetes2.37Hypertension1.91Psychosocial 2.67Obesity 1.62,ProtectiveORAlcohol0.91Reg exercise0.86Fruit/veg0.76,Over 90% e