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。胸痛的機(jī)制胸部感覺(jué)神經(jīng)纖維： 肋間神經(jīng)感覺(jué)纖維 交感神經(jīng)纖維 迷走神經(jīng)纖維 膈神經(jīng)感覺(jué)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(wú)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 Dissection3. 無(wú)生命危險(xiǎn)

2、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(jiàn)疾病胸痛的特點(diǎn)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)放射性核素心肌灌注

3、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(wú))常常不能緩解因素 (休息、使用硝酸甘油無(wú)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(guò)速、低血壓胸痛癥狀較輕咳嗽、咯血較長(zhǎng)時(shí)間臥床病史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(wú)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

4、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(guò)清音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(méi)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(lái)北京出差，車禍后出現(xiàn)持續(xù)左側(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(méi)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

5、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)心電圖：最重要未發(fā)作時(shí)發(fā)作時(shí)：假性正常化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;45:128Angiographic CorrelationCase Study from ChinaDissecting Aneurysm FlapFalse lumenFLPulmonary 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、

6、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(lái)檢查謝謝！TIMI Risk Score For UA/NSTEMI 7 Independent PredictorsAge 65 y 3 CAD Risk FactorsPrior Stenosis 50 % ST deviation 2 Anginal events 24 hASA in last 7 daysElev Cardiac Markers1.75 (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

7、 (1.20-1.96) 0.0011.74 (1.17-2.59) 0.0061.56 (1.21-1.99) 0.001 OR (95 CI) PRisk of Events in UA/NSTEMIPatient APatient BAge48 78CAD HxNoneDM, Incr Chol,HTNECGNo ST dev1.5 mm ST depASA useNoChronicTroponin I1.6 ng/ml0.00 ng/mlWhich pt. is at greater risk of Death + Cardiac Ischaemic Events in next 2

8、weeks ?TIMI Risk Score For UA/NSTEMITest Cohort-UFH Group TIMI 11B(N= 1957)EveNumber of Risk Factors4.317.332.029.313.03.4Ho3.56df8 P=0.89C Statistic = 0.6c2 trend P 0.001man et al JAMA 284 : 835, 200030 Day event ratesTroponinTp I (Oxford) Several kits 0.2ng/mlTp T (Roche) 0.1ng/mlPulmonary embolis

9、m, myocarditis, heart failure can elevateComplex mechanisms with renal insufficiencyPrognostic value of troponins ACS PhysiologyRuptureAtherosclerosisObstructionThrombosisLocal EffectsDistal EffectsMicrovascular InjuryLarge vessel InjuryThrombosisEmbolismVasospasm What does troponin tell us ?TimeRup

10、tureThrombosisOcclusionInjury(+) TroponinEmbolizationReperfusionInstabilityInfarction? Injury at some point in timeTherapy in ST elevation ACSPain relief/oxygenationArrhythmic/haemodynamic standbyReperfusion ASAP (aspirin, thrombolysis, primary PCI IIb/IIIa clopidogrel)Risk assessment for medium ter

11、mCardioprotection (beta-blockers, statins,ACEI)Therapy in non-ST elevation ACSPain relief (nitrates)Antiplatelet agents (aspirin:clopidogrel: IIb/IIIa antagonists)Antithrombotic agents (heparins)Cardioprotection (beta-blockers,ACEI,statin)Risk stratification and consider revacularisationIntervention

12、 in ACS: Pro and ConConTIMI IIBTIMI IIIBVANQWISHOASIS RegistrySWIFT(AVERT)ProIntuitive ReasoningInvaders SentimentsRITA 3FRISC 2Tactics/TIMI 180123456Time (months)048121620% PatientsCONSINVO.R 0.7895% CI (0.62, 0.97)p=0.02519.4%15.9%Primary Endpoint- TACTICSDeath, MI, Rehosp for ACS at 6 Months2220 patientsNo. Pts1o Endpoint Death/MI Death MI Rehosp ACS 111415.97.33.34.811.0110619.4 9.53.56.913.7P valueINV (%)CONS (%)0.780.740.930.670.78OR 0.025 0.050.740.0290.054TACICS Cardiac events at 6/12High Grade StenosisFilling DefectINTERHEART52 Countries 25000 s