Acute coronary syndrome: emergency care,treatment, recommendations

Update: October 2018 Under the term “acute coronary syndrome”
implies a very life-threatening emergency. AT
in this case, blood flow through one of the arteries feeding the heart,
decreases so much that a larger or smaller portion of the myocardium or
ceases to perform its function normally, or completely dies.
The diagnosis is valid only during the first day of development.
states, while doctors differentiate
нестабильная стенокардия или это – начало инфаркта myocardium. AT это
At the same time (while diagnostics is being carried out), cardiologists are doing everything
possible measures to restore the patency of the damaged
arteries.

Acute coronary syndrome requires emergency care.
If we are talking about myocardial infarction, it is only during the first (from
appearance of initial symptoms) 90 minutes may even enter
препарат, который растворит тромб в питающей сердце arteries. After
90 minutes, doctors can only help the body in every possible way to reduce
area of ​​the dying off site, maintain basic life
function and try to avoid complications. Therefore, developed
suddenly a heartache when it does not go away for several
minutes of rest, even if this symptom appeared for the first time, requires
call an ambulance immediately. Do not be afraid to appear
alarmist and seek medical help, because with each
minute irreversible changes in the myocardium accumulate.

Next we look at what symptoms, other than heart pain,
You need to pay attention to what you need to do before the arrival of the ambulance.
We will also tell about who is more likely to develop acute
coronary syndrome.

A bit more about terminology.

AT настоящее время под острым коронарным синдромом подразумевают
two conditions manifested by similar symptoms:

Unstable angina

Unstable angina – a condition in which the background
physical exertion or dormancy pain appears behind the sternum, having
pressing, burning or constricting. Such pain gives in
jaw, left hand, left scapula. Can she manifest and pain
in the stomach, nausea.

Unstable angina is said to have these symptoms or:

  • only arose (that is, before the person performed the load without
    heart pain, shortness of breath or unpleasant sensations in the abdomen);
  • began to occur with less stress;
  • become stronger or last longer;
  • began to appear alone.

AT основе нестабильной стенокардии – сужение или спазм просвета
greater or smaller arteries, feeding, respectively, larger or
меньший участок myocardium. Withчем это сужение должно быть более 50%
from the diameter of the artery in this area, or an obstacle in the way of blood
(it is almost always atherosclerotic plaque) is not
fixed, and fluctuates with blood flow, then more, then less
blocking the artery.

Myocardial infarction

острый коронарный синдромMyocardial infarction – без подъема
ST segment or with the rise of this segment (it is possible to determine
ECG only). It occurs when more than 70% of the diameter is covered.
arteries, as well as in the case of “flown away” plaque, thrombus or
drops of fat plugged the artery in one place or another.

Acute coronary syndrome without ST elevation is or
unstable angina, or a heart attack without raising this segment.
At the stage before hospitalization in the cardiology hospital these 2
states do not differentiate – for this there are no necessary conditions and
instrumentation. If the STI segment is visible on the ECG, you can
diagnose acute myocardial infarction.

From what will be the type of disease – with the rise of ST or without
него – и зависит лечение острого coronary syndrome.

If on ЭКГ уже сразу видно образование глубокого
(“Infarction”) Q wave, a diagnosis of “Q-myocardial infarction” is made, and
не острый коронарный syndrome. it говорит о том, что поражена
major branch of the coronary artery, and the center of the dying myocardium
quite large (large focal myocardial infarction). Such a disease
occurs with complete blockage of a large branch of the coronary artery
dense thrombotic mass.

When to suspect acute coronary syndrome

The alarm needs to be beaten if you or your relative shows
The following complaints:

  • Боль за грудиной, распространение которой
    show a fist, and not a finger (that is, a large area hurts).
    The pain is burning, baking, strong. Not necessarily defined on the left,
    но can локализоваться посредине или с правой стороны грудины.
    Gives to the left side of the body: half of the lower jaw, arm, shoulder,
    neck, back. Its intensity does not change depending on the position
    body, but can (this is typical for ST-elevation syndrome)
    there are several bouts of such pain, between which there is
    several practically painless “gaps”. She doesn’t
    removed by nitroglycerin or similar preparations. To pain
    присоединяется страх, на теле выступает пот, can быть тошнота или
    vomiting.
  • Одышка, которая зачастую сопровождается
    feeling short of breath. If this symptom develops as
    a sign of pulmonary edema, then suffocation increases, a cough appears, can
    cough up pink frothy sputum.
  • Нарушения ритма, которые ощущаются как перебои
    in the work of the heart, discomfort in the chest, sharp tremors of the heart
    o ribs, pauses between heartbeats. As a result of such
    irregular contractions in the worst case very quickly
    loss of consciousness, at best – a headache develops,
    dizziness.
  • Боль can ощущаться в верхних отделах живота и
    сопровождаться послаблением стула, тошнотой, рвотой
    ,
    which does not bring relief. It is also accompanied by fear
    sometimes a feeling of palpitations, irregular contraction
    heart, dyspnea.
  • AT некоторых случаях острый коронарный синдром can
    начинаться с потери сознания
    .
  • There is a variant of the course of acute coronary syndrome,
    проявляющийся головокружениями, рвотой, тошнотой,
    in rare cases – focal symptoms (face asymmetry,
    paralysis, paresis, trouble swallowing, and so on).

Cheer up also should be increased or frequent pain for
the sternum, about which a person knows that his
angina pectoris, aggravated dyspnea and fatigue. In a few days
or weeks after that, 2/3 of people develop acute coronary
syndrome.

A particularly high risk of developing acute cardiac syndrome in
such people:

  • smokers;
  • persons with excess weight;
  • alcohol abusers;
  • lovers of salty dishes;
  • leading a sedentary lifestyle;
  • coffee lovers;
  • having a lipid metabolism disorder (for example, high levels
    cholesterol, LDL or VLDL in the blood test for lipidogram);
  • diagnosed with atherosclerosis;
  • with an established diagnosis of unstable angina;
  • if in one of the coronary arteries (which feed the heart)
    atherosclerotic plaques identified;
  • who have already suffered myocardial infarction;
  • Lovers have chocolate.

First aid

Assistance needs to start at home. In this first
the action must be the ambulance call. Further algorithm
following:

  1. It is necessary to lay a person on the bed, on the back, but with the head
    and shoulders should be raised, making an angle of 30-40 with the torso
    degrees
  2. Clothes and a belt need to be unbuttoned so that a person’s breath is nothing
    not embarrassed.
  3. If there is no evidence of pulmonary edema, give the person 2-3 tablets.
    Aspirin (Aspécarda, Aspeter, Cardiomagnyl,
    �”Aspirin-Cardio”) or “Clopidogrel” (i.e. 160-325 mg
    aspirin). They need to chew. So the probability increases
    dissolution of the thrombus, which (by itself, or layered on
    atherosclerotic plaque) blocked the lumen of one of the arteries,
    nourishing heart.
  4. Open the windows or windows (if necessary, a person needs to be
    cover): this way more oxygen will flow to the patient.
  5. If blood pressure is more than 90/60 mmHg, give
    man 1 tablet of nitroglycerin under the tongue (this drug
    dilates the vessels that feed the heart). Re-give nitroglycerin
    You can give another 2 times, with an interval of 5-10 minutes. Even if after
    1-3-fold reception of the person was better, the pain was gone, refuse
    from hospitalization is impossible in any case!
  6. If before that a person took drugs from the group
    beta blockers (Anaprilin, Metoprolol, Atenolol, Corvitol,
    �”Bisoprolol”), after aspirin, he needs to give 1 tablet of this
    drug. It will reduce myocardial oxygen demand, giving
    he has the opportunity to recover. Note! Beta blocker
    can be given if blood pressure is greater than 110/70 mm Hg, and
    pulse often 60 beats per minute.
  7. If a person takes antiarrhythmic drugs (for example,
    �”Aritmil” or “Cordaron”), and he feels a rhythm disturbance, you need
    take this pill. In parallel, the patient himself should begin
    cough deeply and strongly before the arrival of the ambulance.
  8. All the time before the arrival of “ambulance” you need to be close to
    man, watching his condition. If the patient is conscious and
    feels a sense of fear, panic, it needs to be reassured, but not
    отпаивать валерианой-пустырником (can понадобиться реанимация, и
    полный желудок can только помешать), а успокаивать словами.
  9. For convulsions, a person nearby should help.
    provide airway. To do this,
    taking the corners of the lower jaw and the area under the chin, move
    lower jaw so that the lower teeth are ahead of the upper ones. Of
    such a situation, you can do artificial respiration mouth to nose, if
    spontaneous breathing was gone.
  10. If the person has stopped breathing, check the pulse on the neck (from two
    sides of the Adam’s apple), and if there is no pulse, proceed to perform
    resuscitation: 30 direct pressure hands on
    the lower part of the sternum (to move the bone down), then – 2
    breath in the nose or mouth. The lower jaw at the same time you need to keep
    the area under the chin so that the lower teeth are in front
    top.
  11. Find ECG films and drugs that the patient takes to
    show them to the medical staff. They will not need this first.
    turn, but it will be necessary.

What should ambulance doctors do

Medical care for acute coronary syndrome begins with
simultaneous actions:

  • обеспечения жизненно важных функций. For this is served
    oxygen: if breathing is independent, then through the nasal cannulas,
    if breathing is absent, tracheal intubation is performed and
    artificial ventilation. If blood pressure is critical
    low, begin to inject into the vein special drugs that will be his
    raise;
  • параллельной регистрации электрокардиограммы. By her
    See if there is a ST rise or not. If there is a rise, then if not
    the possibility of rapid delivery of the patient in a specialized
    cardiological hospital (provided sufficient
    staffing of the departing crew), may begin to conduct
    thrombolysis (thrombus dissolution) in conditions outside the hospital. With
    lack of ST elevation, when the likelihood that a blocked artery
    the thrombus is “fresh”, which can be dissolved, the patient is taken to
    cardiological or multidisciplinary hospital where there is a department
    resuscitation.
  • устранения болевого синдрома. For этого вводят
    narcotic or non-narcotic pain medications;
  • in parallel, with the help of rapid tests (strips, where
    a drop of blood is dripping and they show a negative result or
    положительный) определяется уровень тропонинов
    – маркеров
    myocardial necrosis. Normal troponin levels should be
    negative.
  • if there are no signs of bleeding, inject under the skin
    антикоагулянты
    : «Клексан», «Гепарин», «Фраксипарин» или
    others;
  • if necessary, intravenous drip injected
    «Нитроглицерин» или «Ofокет»
    ;
  • can быть также начато введение внутривенных
    бета-блокаторов
    , уменьшающих потребность миокарда в
    oxygen.

Note! Transport the patient to and from the car
possible only in the supine position.

Even the absence of ECG changes in the background of complaints characteristic of
acute coronary syndrome, is an indication of hospitalization in
cardiology or intensive care unit
A hospital that has a cardiology department.

Inpatient treatment

Recommendations for acute coronary syndrome relate to
at the same time and further examination, and treatment:

  1. Against the background of the continuation of therapy, necessary to maintain vital
    important functions, re-ECG in 10 leads.
  2. Repeatedly, already (preferably) by a quantitative method, determine
    levels of troponins and other enzymes (MB-creatine phosphokinase, AST,
    myoglobin), which are additional markers of death
    myocardium.
  3. With подъеме сегмента ST, если нет противопоказаний, проводится
    thrombolysis procedure. Contraindications to thrombolysis are
    such states:

    • internal bleeding;
    • traumatic brain injury for less than 3 months
      back;
    • �“Top” pressure is higher than 180 mm Hg. or “lower” – above 110
      mmHg.;
    • suspicion of aortic dissection;
    • a stroke or brain tumor;
    • if a person has been taking anti-coagulant drugs for a long time
      (blood thinners);
    • if there was an injury or any (even laser correction) surgery in
      the next 6 weeks;
    • pregnancy;
    • exacerbation of peptic ulcer disease;
    • hemorrhagic eye disease;
    • the last stage of cancer of any localization, severe
      liver or kidney failure.
  4. With отсутствии подъема сегмента ST или его снижении, а также
    at inversion of teeth of T or again arisen blockade of the left leg of a bunch
    His issue of the need for thrombolysis is solved individually –
    according to the GRACE scale. It takes into account the age of the patient, the frequency of his
    heart rate, blood pressure, presence
    chronic heart failure. It also takes into account
    whether the cardiac arrest before admission, whether the ST was elevated, high
    troponins. Depending on the risk on this scale, cardiologists decide
    Is there any indication for a thrombus dissolving therapy?
  5. Markers of myocardial damage are determined every 6-8 hours in
    the first day regardless of whether the thrombolytic was performed
    therapy or not: they are judged on the dynamics of the process.
  6. Be sure to determine other indicators of the body:
    glucose, electrolyte, urea and creatinine levels, condition
    lipid metabolism. Chest radiography performed
    cavity to assess the state of the lungs and (indirectly) the heart. Held
    and ultrasound of the heart with dopplerography – to assess the blood supply
    heart and its current state, to give a forecast of the development of such
    complications like heart aneurysm.
  7. Strict bed rest – in the first 7 days, if the coronary
    синдром закончился развитием инфаркта myocardium. If has been installed
    diagnosis of unstable angina, a person is allowed to get up
    earlier – 3-4 days of illness.
  8. After suffering acute coronary syndrome to a human
    prescribe several drugs for continuous use. it
    inhibitors of the angiotensin-converting enzyme (“Enalapril”,
    �”Lisinopril”), statins, blood-thinning agents (“Prasugrel”,
    �”Clopidogrel”, “Aspirin-cardio”).
  9. With необходимости, для профилактики внезапной смерти,
    establish an artificial pacemaker (pacemaker).
  10. After some time (depending on the condition of the patient and
    nature of changes on the ECG), if there are no contraindications, is carried out
    such research as coronary angiography. it рентгенологический
    method when through a catheter being held through the femoral vessels in
    aorta, enter a contrast agent. It falls into the coronary
    arteries and stains them, so doctors can clearly see which
    permeability has every segment of the vascular path. If on
    there is a significant contraction at some site, it is possible
    additional procedures restoring the original diameter
    vessel.

Forecast

The overall mortality in acute coronary syndrome is
20–40%, with the majority of patients dying before
will be taken to hospital (many from such a fatal arrhythmia
as ventricular fibrillation). The fact that a person has a high
risk of death, can be said on such grounds:

  • a person over 60 years old;
  • his blood pressure has decreased;
  • heart palpitations have developed;
  • developed acute heart failure above class 1
    Kilip, that is, there are either only wet rales in the lungs, or already
    increased pressure in the pulmonary artery, or developed pulmonary edema,
    or developed a state of shock with a drop in blood pressure,
    a decrease in the amount of urine discharge, impaired consciousness;
  • a person suffers from diabetes;
  • heart attack developed along the front wall;
  • the person has already suffered a myocardial infarction.

Автор: Кривега Мария Салаватовна врач-реаниматолог

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