Файловый архив студентов. Файловый архив студентов.
1330 вузов, 5508 предметов.
/ Регистрация
FAQ Обратная связь Вопросы и предложения
Добавил:
kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Ростовский Государственный Медицинский Университет
Предмет:
Медицина общая
Файл:

Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

.pdf
Скачиваний:
0
Добавлен:
15.09.2026
Размер:
12 Мб
Скачать
☆
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
ECG—lookforthepresenceofST-segmentandTwavechanges,pathologicalQwaves,andnew LBBB:
Perform serial ECGsor considerusing additional leadsifinitial ECGsare non-diagnostic, e.g.posteriorMI.
AnormalECGdoesnotruleoutACS. Bloods—cardiac troponins, urea and electrolytes (U&E), full blood count (FBC), glycated haemoglobin(HbA1c),andlipidprofile(Table1.2) ChestX-ray—lookforpulmonaryoedema(seeChapter2)ornon-ACScausesofchestpain Echocardiogram:
Bedside echocardiography can detectnew regional wall motion abnormalities or non-ACS
causesofchestpain.
Table1.2BloodsinACS
Cardiac troponins
Beawarethatmultipletroponinassaysexistwithdifferentsensitivitiesandnormalranges.Interpret anyresultsinlinewithlocalguidelines
U&E Renaldiseaseisariskfactorforischaemicheartdisease
KnowledgeofrenalfunctionisrequiredwhenprescribingACStreatments
FBC Anaemiamayexacerbatechestpainandisarelativecontraindicationforantithrombotictherapy
HbA1c Diabetesisariskfactorforischaemicheartdisease
Lipidprofile Hyperlipidaemiaisariskfactorforischaemicheartdisease
Management
Acutemanagement
Painmanagement:
Useintravenous (IV) opioids,e.g.diamorphine1–5mgIV or morphinesulphate5–10mg IV,
titratedtoeffect.Alsoofferanantiemetic,e.g.metoclopramide10mgIV
Givesublingual glyceryl trinitrate(GTN)ifblood pressure allows (systolic blood pressure
>100mmHg)oraGTNinfusionifpaincontinues Antiplatelettherapy:
Aspirin300mgloadingdoseunlessknownallergy Oxygen:
Donotgiveoxygenunlessoxygensaturations<94%onroomair Hyperglycaemia:
Keepglucoselevels<11mmol/L.Useavariablerateinsulininfusionifrequired Monitoring:
All patients with ACS should have regular pulse, blood pressure, heart rhythm, oxygen
saturation,andpainmonitoring.
https://t.me/med1917
•
•
•
•
•
•
•
•
•
•
•
•
•
STEMI
Allpatients with STEMI shouldbediscussed withcardiologyimmediately as theymay requireemergencyprimaryPCIorfibrinolysis—seeBox1.1.
Box1.1ACSreperfusionstrategy
PatientswithSTEMIshouldbeconsideredforangiographywithfollow-onPCIif:
Presentation is within 12 hours of symptom onset and PCI can be delivered within 120 minutes Presentationwas>12hoursago,butthereisongoingevidenceofischaemiaorcardiogenic
shock Ifangiographycannotbedeliveredwithin120minutes,offerfibrinolysisinstead If anECGshows residualSTelevation60–90minutesfollowingfibrinolysis, offerimmediate coronaryangiography If there is recurrent myocardial ischaemia following successful fibrinolysis, consider angiographyandPCI.
Source:datafromNICENG185.
STEMIwithprimaryPCI
Addprasugrel(orticagrelor)alongsideaspirinunless:
Age>75yearswithahighbleedingrisk(considerclopidogrelinstead)
Patientalreadytakinganoralanticoagulant(giveclopidogrelinstead) Drug-elutingstentsarerecommended Ifmultivesseldiseaseisfound,itmaybeelectedtoperformPCIforallthediseasedvesselsand notjustthevesselthatisthoughttohavecausedtheSTEMI.
STEMIwithoutprimaryPCI
Addticagrelor(orprasugrel)alongsideaspirinunless:
Bleedingriskishigh(addclopidogreloruseaspirinalone).
NSTEMI
https://t.me/med1917
•
•
•
•
•
•
•
•
•
•
◦
◦
•
◦ ◦
•
•
•
•
•
•
•
•
Antithrombintherapy:
Fondaparinux 2.5mg subcutaneously (SC) to those without a high bleeding risk unless
immediatecoronaryangiographyisplanned
Unfractionatedheparinispreferredifsignificantrenalimpairment PerformGlobalRegistryofAcuteCoronaryEvents(GRACE)score(predicts6-monthmortality):
Offercoronaryangiographyassoonaspossibleifclinicallyunstable
Offer coronary angiography within72 hours to patients with a predicted 6-month mortality
>3%
Consider coronary angiography for patients with a predicted 6-month mortality ≤3% and
subsequentischaemia
Consider conservative management for patients with a predicted 6-month mortality ≤3%
withoutischaemia Antiplatelettherapy:
Inpatientsundergoingangiography:
Add either ticagrelor (or prasugrel) alongside aspirin if not already taking an oral anticoagulant Addclopidogrelalongsideaspirinifalreadytakinganoralanticoagulant
Inpatientsnotundergoingangiography:
Addticagrelor(orprasugrel)alongsideaspirinunlesshighbleedingrisk Ifbleedingriskishigh,addclopidogrelalongsideaspirinoruseaspirinalone
Drug-elutingstentsarepreferred.
Treatmentafterstabilization
Patienteducation
SeeChapter115fordrivingrestrictionsfollowingACS
Lifestyleadvice
Allpatientsshouldbeofferedacardiacrehabilitationprogramme Offersmokingcessationsupport Providelifestyleadvice:
EncourageaMediterranean-stylediet
20–30minutes/dayofexercise
Weightmanagement
Moderationofalcoholintake.
Pharmacologicaltherapy
https://t.me/med1917
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Angiotensin-converting enzyme inhibitor (ACE; e.g. ramipril 5mg) or angiotensin receptor blocker(ARB;e.g.valsartan20mgBD)ifintolerant:
Titratetothemaximumtolerateddoseandcontinuelong-term
Checkrenalfunction,electrolytes,andbloodpressurepriortostarting,after1–2weeksand
thenannuallyifstable Dualantiplatelettherapy(lifelong aspirin75mg plusasecond antiplateletagentas previously specifiedfor12months) Beta-blocker(e.g.bisoprolol2.5mg),oncehaemodynamicallystable:
Continuelong-termifreducedleftventricularejectionfraction
Considerstoppingafter12monthsinpatientswithpreservedleftventricularejectionfraction
Calcium channel blockers (e.g. diltiazem or verapamil) may be used ifbeta-blockers are
contraindicated Statin(e.g.atorvastatin80mg) Forpatientswhohavesymptomsand/orsignsofheartfailurewithreducedleftventricularejection fraction,initiatetreatmentwithanaldosteroneantagonist(e.g.spironolactone25mg).
Testingpriortodischarge
Perform anechocardiogram(toassessleftventricularfunction)forall patientswhohavehadan MI.ConsiderperformingforpatientswithUA ConsiderischaemiatestinginNSTEMIpatientswhohavebeenmanagedconservatively Patients withreduced leftventricular ejection fractionshould be considered foran implantable cardioverterdefibrillatorpriortodischarge CheckHbA1clevelsandfastingglucose(≥4daysafteronsetofACS)foranypatientswhowere hyperglycaemicbutwithoutknowndiabetes:
Patients with hyperglycaemia are at ↑ risk for developing type 2 diabetes and should be
monitoredannually.
Furtherreading
1.European SocietyofCardiology(2020). 2020ESCGuidelinesforthemanagementofacutecoronary syndromes in patients presenting without persistent ST-segment elevation. Available at:
https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-Coronary-Syndromes-ACS­in-patients-presenting-without-persistent-ST-segm
2.EuropeanSocietyofCardiology(2017).2017ESC/EACTSGuidelinesforthemanagementofvalvular heartdisease.Availableat:https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-
Myocardial-Infarction-in-patients-presenting-with-ST-segment-elevation-Ma
https://t.me/med1917
•
•
•
•
•
•
Chapter2
Acuteheartfailure
Guideline: NICE CG187 (Acute heart failure: diagnosis and
management):https://www.nice.org.uk/guidance/cg187
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Acuteheartfailure is a medicalemergencyand ariseswhen cardiacoutputcannot meet therequirementsofthebody.Inadults,itisusuallyaconsequenceofmyocardialdamage, valvulardysfunction,and/orarrhythmias.Forchronicheartfailure,seeChapter5.
Diagnosis
History
Patientswithacuteheartfailuremaypresentwith:
Shortnessofbreathonexertionoratrest Paroxysmalnocturnaldyspnoea Productivecough Orthopnoea Worseningperipheraloedema Generalizedlethargy.
Examination
https://t.me/med1917
SystematicallyexaminethepatientusinganABCDEapproach.Onexamination,youmay findthefollowing(Table2.1):
Table2.1Acuteheartfailureexaminationfindings
B Cyanosis
Bibasalcoarsecrepitations
C RaisedJVP(Box2.1)
Coolperipheries Prolongedcapillaryrefilltime AddedS3heartsound—‘gallop’rhythm Irregularlyirregularpulse(atrialfibrillation(AF)) Conjunctivalpallor(anaemia)
E Pittingoedema
Box2.1JVP
Ifyoucan’tfindtheJVP,sitthepatientupata45°angleandcheckbelowtheearlobe.
Investigations
Investigations aim to demonstrate acute heart failure, and rule out common causes for decompensation, e.g. infection, acute cardiac events, arrhythmias, and malignant hypertension.
Bedside
ECGtoindicatepossiblecauseofheartfailuree.g.ST/Twavechanges(ACS;seeChapter
1), left ventricular hypertrophy (aortic stenosis or hypertension; see Chapter 3 or 6,
respectively),orarrhythmias(e.g.AF;seeChapter4)
Bloods
SeeTable2.2.
https://t.me/med1917
•
•
•
•
Table2.2Bloodsforacuteheartfailure
Test Indication
FBC Anaemiamayexacerbateheartfailure
U&E Renaldiseaseisbothariskfactorforheartfailureandapotential
consequence
HbA1candlipidprofile Diabetesmellitusandhyperlipidaemiaareriskfactorsforheartfailure
Thyroidfunctiontests(TFT) Thyroiddiseasemaycauseheartfailure
Liverfunctiontests(LFT) Liverdamagecanresultfromheartfailureandalcoholcancause
cardiomyopathy
B-typenatriureticpeptide(BNP)orN­terminalpro-B-typenatriureticpeptide (NT-proBNP)
Thesepeptidesaresecretedinresponsetoventricularwallstress.AF, age,andrenalfailuremaycauseelevatedlevels.Obesitymaybe associatedwithlowerlevels
BNP<100ng/LorNT-proBNP<300ng/Lsuggeststhatheartfailure isunlikely
Source:datafromNICECG187.
Imaging
ChestX-ray—posteroanteriorfilm(Fig.2.1) Transthoracicechocardiogram—performwithin48hoursto:
Measureseverityofsystolic/diastolicdysfunction Identifystructuralabnormalities,e.g.valvulardefects.
https://t.me/med1917
•
•
•
Fig.2.1 Chest X-ray showing ABCDE findings suggestive of acute heart failure. A, alveolar oedema (batwing perihilar shadowing); B, Kerley B lines; C, cardiomegaly (cardiothoracic ratio of>0.5);D, dilatedupperlobevessels;E,pleuraleffusions.
AdaptedfromWilkinsonIBetal(2017)‘OxfordHandbookofClinicalMedicine10e’OxfordUniversity Press:Oxford,withpermissionfromOxfordUniversityPress.
Management
Acutemanagement
Oxygenifrequiredtotargetsaturations>94%.Sittingthepatientupmayimproveoxygenation IV diuretics, unless hypoperfused, e.g. IV furosemide 40mg twice daily (BD). If already prescribeddiuretics,considerahigherdosage MonitorU&E,weight,andurineoutputdaily.Considerurinarycatheterization.
Second-lineoptions—discusswithasenior
https://t.me/med1917
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Nitratesarenotroutinelyindicatedandarecontraindicatedifthepatientishypotensive;however, theymaybe usefulifthepatientis extremelyunwell,hascoexistingmyocardialischaemia, or is hypertensive Inotropes or vasopressors should be considered in cardiogenic shock. Consider whether escalationtohigherdependencycareisappropriate Non-invasiveventilationisanoptionifthepatienthascardiogenicpulmonaryoedema,dyspnoea, or acidaemia. Invasive ventilation should be used if worsening respiratory failure, reduced consciousness,orexhaustiondespitetheabove-mentionedtreatments Considerrenalreplacementtherapyifdiuretictherapyisinadequate Opiatesarenotroutinelyindicatedbutmaybeusedunderspecialistguidance.
Treatmentafterstabilization
Allofthefollowingapplytopatientswithreducedleftventricularejectionfraction.
Beta-blockers(firstline)
Decreasemortality Continueunlessheartrate<50bpm,shock,orsecond/third-degreeheartblock Startorrestartwhenpatientisstableandmonitorfor48hours,e.g.bisoprolol2.5mgoncedaily (OD)(uptitrateastolerated) Sideeffects:bradycardia,hypotension.
ACEinhibitors(firstline)
Decreasemortality,e.g.ramipril2.5mgOD(uptitrateastolerated) Sideeffects:drycough,hypotension SecondlineifACEinhibitornottolerated:ARB,e.g.losartan12.5mgOD(uptitrateastolerated).
Aldosteronereceptorantagonists(firstline)
Decreasemortality,e.g.spironolactone25mgODoreplerenone25mgOD.
Monitor clinical observations, serum creatinine, and electrolyte levels closely after any changesintreatmentregimen.
Surgicalmanagement
Valve surgery: surgical repair or replacement or percutaneous valve intervention (e.g. transcatheteraorticvalveimplantation(TAVI))mayberequiredforthosewithacuteheartfailure secondarytovalvedisease Mechanicalcirculatorysupport:forpatientswithpotentiallyreversiblesevereacuteheartfailure or those who are candidates for transplantation. Specialist input ± transfer to tertiary centre required.
https://t.me/med1917
Furtherreading
1.RamrakhaP,HillJ(eds)(2012).Heartfailure.In:OxfordHandbookofCardiology,2nded(pp.367–
416). Oxford: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780199643219.003.0007
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана
Помощь Обратная связь Вопросы и предложения Пользовательское соглашение Политика конфиденциальности