2022年ACC急性胸痛专家共识十大要点.docx

2022年ACC急性胸痛专家共识十大要点2022美国心脏病学会的这份急性胸痛专家共识体现了以高敏肌钙蛋白检测为中心的临床决策路径（CDP）,但没有涉及到如何治疗，其内容主要有以下10个要点：1、心电图仍然是评估胸痛的最佳初始检查手段，因其快速、廉价并能提供关键的诊断和预后信息。建议进急诊室后10分钟内完成心电图检查，对高度怀疑ACS的患者应短时间（没有讲具体几分钟）后进行心电图复查。STEMIorSTEMIequiva1.ent*4Manageasper2013ACCF/AHASTEMIguide1.ineT-、 IschemicST-segmentdepressionorT-waveinversion ST-segmente1.evationinaVRwithmu1.ti1.eadST-depression We1.1.en,sSignManageasper2014AHA/ACCNSTE-ACSguide1.ineOtherfindingsconcerningforacuteischemiaorinfarction*4 Emergentcardio1.ogyconsu1.tation Performseria1.ECGsovershortinterva1.s,EmergentechocardiogramNonischemicECGEnterCDP图1、初始心电图评估STEM1.equiva1.entsPosteriorSTEMICriteria： Horizonta1.ST-segmentdepressioninVrV3 DominantR-wave(RSratio>1)InV2 UprightTwavesinanterior1.eads ProminentandbroadR-wave(>30ms)Conedby： ST-segmente1.evationof0.5mminat1.east1of1.eadsV7-V91.eftbund1.ebranchb1.ockOfventricu1.arpacedrhythmwithSgarbossaCriteriaAtota1.score3pointsisrequired： ConcordantST-segmente1.evation三1mmin1.eadswithapositiveQRScomp1.ex(Spoints) ConcordantST-segmentdepression1mmin1.eadsV-Vj(3points) DiscordantST-segmente1.evation-*5mmin1.eadswithanegativeQRScomp1.ex(2points)IfthereisdiscordantST-segmente1.evation5mm.considerST/Sratio<-O.251.eftbund1.ebranchb1.ockorventricu1.arpacedrhythmwithSmith-modifiedSgarbossaCriteriaPositiveifanyofthefo1.1.owingarepresent： ConcordantST-segmente1.evationof1mmin1.eadswithapositiveQRScomp1.ex ConcordantST-segmentdepressionof1mmInV1-V1 ST-segmente1.evationattheJ*point,re1.ativetotheQRSonset,isat1.east1mmandhasanamp1.itudeofat1.east25%oftheprecedingSwaveDeWinterSign Ta1.1.,prominent,symmetrica1.Twavesarisingfromups1.opingST-segmentdepression>1mmattheJpointintheprecordia1.1.eads 0.5-1mmST-segmente1.evationmaybeseenin1.eadaVRHyperacuteTwavesBroad,asymmetric,peakedTwavesmaybeseenrtyinSTEMISerU1.ECGsoververyshortinterva1.sareusefu1.toassessforprogressiontoSTEMIECGndingsConSiStentwithacute/SUbaCUtemyocardia1.ischemiaWRSi-segmente1.evationMostoftencausedbydiffusesubendocardia1.ischemiaandusua1.1.yoccursinthesettingofsignificant1.eftmaincoronaryarteryormu1.tivesse1.coronaryarterydisease STsegmete1.evationinaVRW1.mm Mu1.ti1.eadST-segmentdepressionin1.eadsI.II.Va1.and/orV4-V6 AbsenceofcontiguousST-segmente1.evationinother1.eadsST-segmentdepressionHorizonta1.ordowns1.opingST-segmentdepression工0.5mmattheJpointin2ormorecontiguous1.eadsissuggestiveofmyocardia1.ischemiaWe(1.en'ssyndromeQiniCdIsyndromecharacterizedby： Biphasicordeep1.yinvertedandsymmetricTwavesin1.eadsV?andVj(mayextendtoV«) Recentangina AbsenceofQwavesIrwertedTwavesMaybeseeninischemia(subacute)orinfarction(maybefixedandssociatedwithQwaves)incontinuous1.eadsFIND1.NGCRITERIAVyp1.acedat1.eftposterioraxary1.ineinsamep1.aneasV&V8PbCedatthetipofthe1.eftscapu1.a；Vep1.acedinthe1.eftparaspna1.reg）inthesamep1.aneasV6.aVR-augmentedvectorright；ECG-dec”OeafdOgram；STEMI-STdevatJonmyocardia1.infarction.表1、提示缺血的心电图表现2、对于疑似ACS但心电图无法诊断的患者，应考虑紧急经胸心超评估室壁运动。3、高敏肌钙蛋白检测应与快速CDP结合使用。对于大多数急诊胸痛患者，这些路径允许在1-2小时内安全排除（“排除”）心肌梗死，从而促进低风险患者的快速处置和出院。ITAB1.E2IQinica1.DecisionPathwaysWithHs-cTnApproachCriteriaforRu1.eOutAdvantagesDisadvantages03hSing1.ehscTn<99thpercenti1.eUR1.ifsymptoms>6handnowPdinfreeORIf<6hofsymptoms,O-and3htroponin1.essthanthe99thpercenti1.eUR1.Uses99thpercenti1.eUR1.cutoffssimi1.artoconventiona1.troponin,whichisfami1.iartoc1.iniciansConceptua1.1.ysimp1.erVa1.idated1.owersensitivityandNPV.andfewerpatientsru1.edoutcomparedwithotherpathways0-h(sing1.e0-hru1.eoutforcTbe1.ow1.oQorImmediateru1.eoutof1.ow-riskpatientsApp1.iesto<50%ofpatientsdraw)anoptimizedcutoff(eg.hscT1.<5ng1.)TakesadvantageofsensitivityofhscTnNotsuitab1.eforpatientspresentingear1.yQ1hru1.eoutUsebase1.ine(0-h)andde1.tava1.uesat1htoassignpatientstotheru1.eout.observation,orabnorma1.groupsTakesadvantageofbetterassaysensitivityandprecisionAvoidsinherentprob1.emswith99thpercenti1.eUR1.va1.ueRUIeSouta1.argeproportionofpatientsComp1.exa1.gorithmTimingofb1.ooddrawsveryimportantMaymiss1.ate-presentingM1.onthe"f1.at"portionofadec1.iningtroponintrendQ2-hru1.eoutIdentica1.approachto0/1-hru1.eoutexceptde1.taassessedt2hTakesadvantageofhighersensitivityandpre-dstonofassayMorepractica1.forsomecentersthatcannotroutine1.yobtain1-hsamp1.esBetterforer1.ypresentersthan0/1-ha1.gorithm1.ongertimetoru1.eoutthan0/1-ha1.gorithmEqua1.1.ycomp1.exas0/1-ha1.gorithmMaymiss1.ate-presentingM1.onthe"f1.at"portionofadec1.iningtroponintrendNotva1.idatedinRCT$High-STEACSM1.Kru1.edoutdinitia1.hscT1.<5ng/1.orhs-cTT<6ng/1.Of>3hfromsymptomonset)orifchangefrominitia1.to3-hhs-cTnis<3ng/1.andremansbdowsex-speciftc99thperceteUR1.Ukesadvantageofbettersensitivityandpre-dsioofasaySafetyandefficacyva1.idatedinrandomizedcontro