李麗君急性胸痛

1、Chest pain,Differential diagnosis of chest pain以急性胸痛主訴就診，你應(yīng)考慮那些可能診斷？,Li - Jun Li Department of Emergency MedicineSecond Hospital,胸痛鑒別的重要性,胸痛(chest pain)指原發(fā)于胸部或由軀體其他部位放射到胸部的疼痛。原因多樣，程度不一，且不一定與疾病的部位和嚴(yán)重程度相一致。由于解剖、生理和心

2、理因素的相互影響，牽扯痛、應(yīng)激反應(yīng)及心理暗示等機(jī)制的作用，使得許多嚴(yán)重疾病被誤以為普通疾病，而相反情況也時(shí)有發(fā)生。有些可能發(fā)生猝死的疾病如ACS、主動(dòng)脈夾層、肺動(dòng)脈主干栓塞等與某些非致命性疾病如食管疾病、肺部疾病甚至出疹前的帶狀皰疹等，同樣可有胸痛或胸背部不適。以急性胸痛、胸部不適為主訴來醫(yī)院急診的患者十分常見。雖然沒有準(zhǔn)確的統(tǒng)計(jì)資料，但在我國(guó)大中城市的三級(jí)甲等醫(yī)院急診科，估計(jì)這類患者約占5-10%。胸痛作為多種疾病的首發(fā)癥狀，其中

3、隱匿著一些致命性疾病, 除最常見的急性冠脈綜合征（ACS）外，還有近幾年被逐步重視的急性肺栓塞（PE）、主動(dòng)脈夾層等，它們都具有發(fā)病急，病情變化快，死亡率高的特點(diǎn)；而早期快速診斷，及時(shí)治療，可以顯著改善預(yù)后。雖然這些疾病僅占胸痛病人的1/4左右，但由于醫(yī)務(wù)人員受專業(yè)知識(shí)和檢測(cè)手段的限制不能將其迅速準(zhǔn)確甄別，使得一些具有嚴(yán)重疾病的胸痛患者混于一般病人，延誤了救治時(shí)間，甚至造成嚴(yán)重后果。及時(shí)正確地識(shí)別和診治各種胸痛有著非常重要的臨床意義。

4、,重點(diǎn),認(rèn)識(shí)心絞痛的不典型癥狀區(qū)分心源性與非心源性胸痛，即鑒別有生命威脅的、需要緊急救治的疾病 。警惕誤診：急性心肌缺血，急性肺栓塞，動(dòng)脈夾層。區(qū)分抗凝與不能抗凝的疾?。罕热纾杭毙孕募」Ｋ琅c主動(dòng)脈夾層的識(shí)別,思考病例,病例1 男，56歲，彎腰抱起小孩突然左側(cè)胸背部痛，不劇烈，持續(xù)1小時(shí)到西安市某三甲醫(yī)院就診。心電圖大致正常，胸部X片示肺紋理加重，血白細(xì)胞和中性粒細(xì)胞略增高，血壓160/90mmHg,高血壓病史3-4年，間斷服用

5、降壓藥。該院醫(yī)生診斷肺部感染、高血壓病，抗感染和降血壓治療半月，因上樓梯右下肢痛而再次就診。？病例2 男，氣短、胸痛、呼吸困難2周，當(dāng)?shù)蒯t(yī)院診斷缺血性心臟病，心衰，治療無效，且咳血3天主訴急診入我院?；颊叨俗粑?，全身紫紺，大汗，血壓90/40mmHg，心率150次/分。？,,,,Causes of chest pain,,需要寬視野！ 避免窄思維！,首先區(qū)分,Some are life-threatenin

6、g and require prompt diagnosis and treatment whereas others are more benign. 鑒別有生命威脅的、需要緊急救治的疾病。Differentiation: cardiac and non – cardiac chest pain. 鑒別心源性（如急性心肌梗死，動(dòng)脈夾層）和非心源性胸痛。,Why do we differentiate cardiac and non

7、– cardiac chest pain?,,Why?,為什么鑒別心源性和非心源性胸痛？,The reason to differentiate Cardiac and non-caardiac chest pain,thrombolysis is indicated in acute myocardial infarction, pulmonary embolus; thrombolysis is contraindicated

8、in pericarditis and dissection of the thoracic aorta.急性心肌梗死、急性大面積肺栓塞需要緊急血管再通、抗凝抗血小板及溶栓等。心包炎和動(dòng)脈夾層是溶栓、抗凝抗血小板禁忌癥。血栓性疾病有治療時(shí)間窗。急性動(dòng)脈夾層有極高的死亡率。,Characteristic of chest pain心源性和非心源性胸痛特征,Distinguishing characteristic of car

9、diac and non-cardiac chest pain,心源性和非心源性胸痛特征,心源性 非心源性疼痛 沉重，壓榨， 鈍痛，刀割樣，銳痛部位 中心部位 左乳房下 放射到左臂、頸、牙，誘因 用力，精神因素，寒冷， 體位變動(dòng)，觸痛,,,,,,心絞痛癥狀-典型與不典型 -2007A

10、HA/ACC急性冠脈綜合癥指南,典型心絞痛部位：胸骨中下部位胸痛性質(zhì)：壓榨性、壓迫、緊縮、沉重感；放射：頸部、下頜、肩、背、單臂或雙臂。不典型伴隨胸部不適或不能解釋的消化不良、燒心、惡心、和或嘔吐。持續(xù)氣短。虛弱、頭暈、輕微頭痛、意識(shí)喪失。胸膜炎痛（呼吸或咳嗽時(shí)銳痛）。非創(chuàng)傷性胸痛或嚴(yán)重上腹部痛。單獨(dú)的上或下腹痛，指尖痛，非常短暫的痛（幾秒或更短）。,Past medical history will give you

11、clue to diagnosis 既往病史提供診斷線索,A history ischeamic heart disease; 心臟病史A history of peptic ulcer disease or or non-steroidal anti-inflammatory drugs; 潰瘍病史或者非甾類藥物使用史。Recent operations-cardiothoracic surgery may be complic

12、ated by Dressler’s syndurme, mediastinitis, ischaemic heart disease or pulmonary embolus(PE); 最近心胸手術(shù)史者有可能伴隨縱隔炎，缺血性心臟病，肺拴塞。Pericaarditis may be preceded by a prodromal viral illness;先前病毒感染已有心包炎。 Pulmonary embalus may be

13、 preceded by a period of inactivity (e.g. a recent operation, illness, or long jourmey); 肺栓塞可能伴隨不活動(dòng)，手術(shù)，等。Hyptertension is risk for both ischeamic heart disease and dissection of the thoracic aorta. 高血壓是缺血性心臟病，動(dòng)脈夾層的危險(xiǎn)因素

14、。,提示疾病的征象,Signs of shock (e.g. pallor, sweating)---indicate myocardial infarction, dissecting aorta, pulmonary embolus;休克征象（蒼白、出汗）：心梗、動(dòng)脈夾層、肺拴塞Laboured breathing--may indicate myocardial infarction leading to left ventri

15、cular failure or a pulmonary cause;呼吸困難：心衰或肺部原因Signs of vomiting--suggests myocardial infarction or on oesophageal cause;嘔吐：提示心?；蚴车涝駽oughing---suggests left ventricular failure, pneumonia.心衰或肺部原因,Investigation檢查,Test

16、 檢查,,Diagnosis 診斷,,動(dòng)脈血?dú)?嚴(yán)重低氧血癥提示：肺拴塞、左心衰、肺炎,心肌酶,可能在心梗最初4小時(shí)內(nèi)正常，但CK-MB將增加,,ECG,如果正常除外心梗，但是在急性期需要?jiǎng)討B(tài)觀察,,胸片,寬縱隔提示動(dòng)脈夾層；可以顯示胸腔積液，肺實(shí)變,,B超/CT,懷疑有動(dòng)脈夾層立即作B超/CT,,First-line tests to exclude a chest pain emergency 急診胸痛一線檢查,胸痛的危險(xiǎn)分層

17、 ---心電圖及缺血性胸痛患者危險(xiǎn)程度的可能性,高危組（＞1） 有心肌梗死病史，致命性心律失常 暈厥，已診斷冠心病 確定為冠心病 伴有癥狀的ST改變 前壁導(dǎo)聯(lián)T波明顯改變,中危組（=1） 青年人心絞痛 老年人可能心絞痛 可能有心絞痛 糖尿病和另外3個(gè)危險(xiǎn)因素 ST壓低＜或=1mm，R波直立,低危組（＜1） 可疑心絞痛 1個(gè)危險(xiǎn)因素、無糖尿病 T波倒置＜1mm 正常心電圖， T波倒置＞或=1mm,胸痛

18、的危險(xiǎn)分層 ---可疑缺血性胸痛患者近期死亡和非致命性心梗的危險(xiǎn)性,高危組： 胸痛＞20分鐘，休息不緩解 與缺血有關(guān)的肺水腫 ST或R波降低 合并高血壓 靜息心絞痛半暈厥 ST＞1mm 肌鈣蛋白增高,中危組 胸痛＞20分鐘，已緩解 中度可能的冠心病 靜息心絞痛＞20分鐘 1個(gè)危險(xiǎn)因素，但非糖尿病 年齡＞65歲 心絞痛和T波動(dòng)態(tài)改變 病理性Q波或多個(gè)導(dǎo)聯(lián)ST壓低壓低＜1mm,低危組 胸痛的頻率、時(shí)間

19、 程度增加 活動(dòng)耐量降低 2周至2個(gè)月內(nèi)新發(fā)心絞痛 心電圖無改變,Algorithm for investigation of chest pain,,,At rest,,Worse on exertion,,Consider pulmonary embolus in all patients,Chest pain,,,,Worse on inspiration,,Not worse on inspiration,,Inves

20、tigate for angina(ECG, angiogram),,Raised ST segment,,,Consider MI,,ST depression T wave inversion T wave flatening,,Widespread concave ST elevation,,Consider unstable angina,investigate futher,,pericarditis,,Pleu

21、risy secondary to pneumonia, pneumothorax, poumonary embolus, Dressler’s syndrom,,,,Central pain,,Musculoskeletaloesophagitis,,lateral,,MusculoskeletalShingles(herpes zoster),Dressler’s syndrome,Pulmonary embolus,

22、肺栓塞,Pulmonary embolus,Pulmonary emboli may present as acute chest pain in an ill patients or as intermittent chest pain in a relatively well patient. For this reason it is crucial to suspect PE in all patients who have c

23、hest pain that is not typically anginal!,Symptoms and signs of PE,The pain of a PE may be pleuritic or tight in nature and may be located anywhere in the chest. It may be accompanied by the following symptoms and signs

24、: Dyspnoea; Dry cough or haemoptysis; Hypotension and sweating; Sudden collapse with syncope. A sense of “impending doom” or profound anxiety.,Electrocardiography of PE,S

25、inus tachycardia (or atrial fibrillation). Ventricular tachyarrhythmias or sinus rhythm with electromechanical dissociationTall P waves in lead II (right atrial dilatation).Right axis deviation and right bundle branch

26、block.S wave in lead I, Q wave in lead III, and invented T wave in lead III ( SI QIII pattern seen only with very large PE).,,,Dissection of the thoracic aorta主動(dòng)脈夾層,Predisposing factors,HypertensionBicuspid aortic val

27、vePregnancyMarfan等Connective tissue disease-SLE等Men>womenMiddle age,主動(dòng)脈夾層發(fā)病率、死亡率,發(fā)病率：每百萬人口五至三十人之間，男性高于女性。死亡率：急性夾層不治療，48小時(shí)內(nèi)死亡率約36-72%，一周內(nèi)死亡率62-91%；院內(nèi)保守治療，其平均死亡率也高達(dá)27.4%；夾層累及重要血管分支引起臟器缺血，其死亡率更高。,Pathophysiology,Da

28、mage to the media and high introluminal pressure causing an intimal tear;Blood enters and dissencts the luminal plane of the media creating a fals lumen.,Stanford classification,Type A----all dissections involving the a

29、scending aorta;Type B----all dissection not involving the ascending aorta.,Symptoms,Central tearing chest pain radiating to the back;Further complications as the dissection involves branches of the aorta:Coronary ost

30、ia----myocardial infarction;Carotid or spinal arteries----hemiplegia, dysphasia, or paraplegia;Mesenteric arteries-----abdominal pain.,Signs,shocked, cyanosed, sweating;Blood pressure and pulses differ between extremi

31、ties： Aortic regurgitation; Cardiac tamponade; Cardiac failure.,Investigation,CXR----widened mediastinum +/- fluid in costophrenic angle;ECG----may be ST elevation;CT/MRI----best inv

32、estigations, show aortic false lumen; Transoesophageal echo if available also very sensitive;Echocardiography----may show pericardial effusion if dissection extends proximally; tamponade may occur.,Summary,The importanc

33、e of this subject is that this situation represents a medical emergency requiring rapid diagnosis and treatment.It is necessary in this situation to distinguish between: MI; unstable angina; pericaditis; dissection of t

34、horacic aorta; PE; mediastinitis secondary to oesophageal tear; non-cardiac chest pain.,思考題和答案,1、當(dāng)遇到胸痛患者，首先鑒別什么？為什么？ 答：首先區(qū)分心源性和非心源性胸痛。因?yàn)樵谛脑葱孕赝丛蛑?，最常見的是致命的心肌梗死及?dòng)脈夾層。2、為什么鑒別心肌梗死和動(dòng)脈夾層非常重要？ 答：心肌梗死需要抗凝溶栓治療，動(dòng)脈夾層和心

35、包炎是禁忌癥。而且動(dòng)脈夾層撕裂往往波及冠脈而合并心肌梗死。3、心絞痛典型與不典型癥狀分別有哪些？ 答：心絞痛典型癥狀：疼痛性質(zhì)：沉重，壓榨。部位：中心部位，放射到頸部、下頜、牙、肩、背、單臂或雙臂。誘因：用力，精神因素及寒冷等。 心絞痛不典型癥狀：伴隨胸部不適或不能解釋的消化不良、燒心、惡心、和或嘔吐。持續(xù)氣短。虛弱、頭暈、輕微頭痛、意識(shí)喪失。胸膜炎痛（呼吸或咳嗽時(shí)銳痛）。非創(chuàng)傷性胸痛或嚴(yán)重上腹部痛。單獨(dú)的上或下腹痛，指尖痛，

36、非常短暫的痛（幾秒或更短）。,Reference of the lecture,Cardiology. Neil R. Grubb, David E. Newby. 2004 by Churchill Livingstone. Cardiology. Anjana Siva, Mark Noble. 1999 by mosby International Ltd. Emergency medicine--- a comprehens