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1、急性胸急性胸痛的快速诊断与甄别痛的快速诊断与甄别Prompt diagnosis Prompt diagnosis and differentiation of acute chest painand differentiation of acute chest pain福建医科大学附属协和医院心内科 Cardiology, Union Hospital, Fujian Medical University 福建省冠心病研究所 Provincial Institute of Coronary Disease, Fujian19551986L CHEN MD PhD FACC FESC1Pain
2、, it has been said, is one of “natures earliest signs of morbidity”. Few will deny that it stands preeminent among all the sensory experiences by which human judge the existence of disease within themselves. There are relatively few maladies that do not have their painful phases and in many of them
3、pain is characteristic without which diagnosis must always be in doubt. By Raymond D AdamsChest pain, as a pain, is beyond the pain. Chest pain is not necessarily painful sensation, numerous vocabularies used to descript such a feeling, for instances, chest distress, tightness, breathless and so on.
4、 As one of commonest clinical symptoms, chest pain relates itself to numerous somatic or mental diseases, ranging from minor to major illnesses, or evenly life-threatening or lethal diseases. By Lianglong ChenAbout chest painL CHEN MD PhD FACC FESC2Question 1Have you ever experienced chest pain? If
5、any, please describe your personal feeling.L CHEN MD PhD FACC FESC3How to properly descript chest painBasic clinical presentations of ABCDEArea (location, size, radiation)Beginning and ending (trigger/relief) Character (pain, tightness, distress)Degree (mild/severe)Duration (short/long)Exacerbation
6、(causes/inducer)Episode inducerAccompanying symptoms and signs of BBCBreathing affectionBrain affectionCardiac affection基本临床特征部位（位置、范围、放射）起止（触发与缓解）性质（疼痛、胸闷、压迫）程度（轻中重）时间（短或长）加重（原因与诱因）诱因（用力或应激)伴随症状体征对心脏的影响对呼吸的影响对脑部的影响L CHEN MD PhD FACC FESC4急性胸痛Acute chest pain (ACP)L CHEN MD PhD FACC FESC5At least 50
7、 illnesses will cause chest pain.Emergency ACP accounts for 25% emergency volume, among which 50% are of cardiovascular causes (e.g. ACS, PE, AAS, HF). Patients suspected with cardiogenic ACP transported by EMS were finally diagnosed as AMI , UA and non-cardiogenic diseases with proportion of one th
8、ird, respectively.Outpatient Commonest reasons of patients clinical visiting. A vast of diseases that cause ACP include cardio- and non-cardio- genesis. ACP：complex etiologiesL CHEN MD PhD FACC FESC63S+3S危急胸痛：快速临床诊断三步法3-Strategy/Steps for Rapid Triage Acute Critical Chest PainL CHEN MD PhD FACC FESC
9、7Broader consideration of ACP causesAcute critical chest pain (ACCP)? Cardiogenic ACCP?Myo-cardiogenic ACCP?3-Stretagies123L CHEN MD PhD FACC FESC8L CHEN MD PhD FACC FESC9从较宽的临床角度考虑急性胸痛病因Broader clinical consideration of ACP causesACP胸腔脏器疾病胸腔疾病胸膜疾病胸腔疾病肺部疾病肺实质病肺血管病纵隔脏器疾病心脏疾病血管疾病食管疾病非胸腔脏器病胸壁疾病皮肌神经病骨关节
10、疾病胸外疾病腹部疾病全身疾病Strategy 1L CHEN MD PhD FACC FESC10甄别急性胸痛病因：是否危急性Figure out the causes： Acute Critical Chest Pain (ACCP) or notACCP心脏性疾病心包心肌瓣膜主动脉疾病主动脉夹层肺动脉疾病肺动脉栓塞胸肺部疾病胸腔积液气胸病因：确定或不确定，多数不能确定临床：危机状态，如低血压或休克、呼吸困难、低氧血症诊断：迅速诊断，快速决策极为重要手段：临床、化验、心电图、影像学Strategy 2aACCPCardiogenicACSAMDVHDNon-cardiogenicAASAPE
11、TPT鉴别危急胸痛病因: 是否心源性Figure out the causes of acute critical chest pain：cardiogenic or notACS = acute coronary syndrome; AMD = acute myocarditis or myo-pericarditis; VHD = valvular heart disease; AAS = acute aortic syndrome; APE = acute pulmonary embolism; TPT = tension pneumothoraxStrategy 2bL CHEN MD
12、 PhD FACC FESC11ACPMyocardial ischemiaSTEACS/ STEMINSTEACS/ NSTEMIUANon-myocardial ischemiaAAS: AAD/IMHAPETNT鉴别急性胸痛病因：是否心肌缺血性Figure out the causes of acute chest pain: myocardial ischemia or notSTEACS/STEMI = ST elevation acute coronary syndrome/myocardial infarction; NSTEACS/NSTEMI = non-ST elevati
13、on acute coronary syndrome/myocardial infarction; UA = unstable angina; AAS = acute aortic syndrome; AAD = acute aortic dissection; IMH = aortic intramural hematoma; APE = acute pulmonary embolism; TNT = tension pneumothoraxStrategy 3L CHEN MD PhD FACC FESC12L CHEN MD PhD FACC FESC13急性胸痛：可能是需快速处置的临床
14、危机状况 ACP: a clinical crisis probably requiring urgent managementLife-threateningParadoxical treatmentNarrowed trx windowCausing PH disputesTime = lifePrompt diagnosis = saving lifeHow to promptly diax, difx and trx ？Commonest ACPs 1.Acute coronary syndrome(ACS)Unstable angina（UA）STEACS(STEMI)NSTEACS
15、(NSTEMI)2.Acute pulmonary artery embolism (APE)3.Acute aortic syndrome(AAD)4.Acute fulminant myocarditis(AFM)5.Tension pneumothorax (TNT)6.Heart breakL CHEN MD PhD FACC FESC14危急胸痛的诊断与鉴别ACCP diagnosis 29(16):1966-74 Eur Heart J. 2008 Nov;29(22):2713-22 NEJM。2009，Aug;27（9）361:858-867 L CHEN MD PhD FAC
16、C FESC22L CHEN MD PhD FACC FESC23生物标记物：Hs-cTnBiomarkers: Hs-cTn敏感性(sensitivity)特异性(specificity)便捷性(accessibility)损伤释放时间（releasing time）标本处理时间（blood handling time）仪器检测时间（detecting time）Prompt?ECG的重要性relevance of ECGPrompt, simple, accessibleQualitative, quantitative, localizationClassification, triage and decision-making快速、简单、易及定性、定位、定量分型、分流、治疗L CHEN MD PhD FACC FESC24For ACCP patien
