胸痛诊断思路.ppt

胸痛诊断思路 丁荣晶 北京大学人民医院心脏中心 我国胸痛病因组成 急性胸痛诊断规范流程 ——摘自2010胸痛中心中国专家共识 识别高危患者 急性冠状动脉综合征（ACS） 肺栓塞 主动脉夹层 张力性气胸 ----等等 胸痛评估 是否存在威胁生命的症状和体征 突发晕厥或呼吸困难 血压90/60mmHg 心率100次/分 双肺罗音 胸痛评估 TIMI危险评分系统 GRACE危险评分系统 胸痛评估 缩短STEMI救治时间 及早识别和治疗致命性疾病 改善预后 2011年lancet发表 ECG,POCT,TIMI评分对30天MACE的预测价值 使用运动试验指导下一步检查 * 5% pt with low-risk treadmill score will be identified as high risk after imaging* those with known LV dysfunction should have cardiac catheterization Risk score Predicted average annual mortality Recommended treatment low 1% per year medical therapy intermediate 1% to 3% cardiac catheterization exercise imaging study high-risk score 3% per year cardiac catheterization 运动试验的 敏感性/ 特异性 SENS SPEC Exercise ECG 68% 77% Planar thallium 79% 73% SPECT 88% 77% Stress echo 76% 88% PET 91% 82% CTA 80-95% 70-90% 核素心肌显像的优势? – 临床价值 核素心肌显像提供 非常好的 阴性诊断价值。 核素心肌显像正常的患者每年发生心血管事件 1% Journal of the American College of Cardiology Vol. 53, No. 23, 2009:2201-2229 JACC 6/9/09 无症状* 患者的应用 Journal of the American College of Cardiology Vol. 53, No. 23, 2009:2201-2229 Appropriate Use Criteria – ACCF and most imaging professional societies in the US yes no 胸痛患者的应用 AHA/ASNC/ACCF JACC. 2009 “低危” – Davis Study评估急诊室胸痛低危患者常规运动试验的结果 血流动力学稳定 没有心律失常 通过体格检查、心电图或X线检查，没有急性心肺疾病证据 JACC 40:251-56 2002 Proportion of 1,000 patients with negative, positive and non diagnostic immediate exercise tests. Numbers within the bars indicate number of patients. JACC Vol. 40, No. 2, 2002 July 17, 2002:251–6 临床随访或进一步评估*? JACC Vol. 40, No. 2, 2002 July 17, 2002:251–6 No primary event occurred among the OBS patients discharged home from the OBS unit 低危* 胸痛患者平板运动试验的价值 No. Pts % Pos Neg PV Pos PV Adverse Events Tsakonis 28 17.8 100% ----- 0 Kerns et al 32 0 100% ----- 0 Lewis/Amsterdam 93 13.0 100% 46% 0 Gibler et al 782 1.2 99% 44% 0 Gibler et al 100 7 100% 0% 0 Zalenski et al 224 8 98% 16% 0 Polanczyk et al 276 24 98% 15% 0 Kirk et al 212 12.5 100% 57% 0 Amsterdam et al 1000 13 99% 33% 0 Amsterdam et al, JACC 05 AHA