Linee guida SCA

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Linee guida SCA

• The 12-lead ECG is central to the diagnostic and
  triage pathway for ACS and provides important
  prognostic informations.
• Patients with symptoms that may represent ACS
  should be referred to a facility that allows
  evaluation by a physician and the recording of a
  12-lead ECG and biomarker determination
• A 12-lead ECG should be performed and shown to an
  experienced emergency physician as soon as
  possible after ED arrival

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MORFOLOGIA INIZIALE ECG

• SENZA SOPRALIVELLAMENTO ST
• ECG non diagnostico o Normale
• T negativa (gt 1 mm)
• Sottolivellamento ST (gt0.5 mm isolato o con
  inversione T)
• CON SOPRALIVELLAMENTO ST
• Sopralivellamento ST (gt0.5 mm in due derivazioni
  contigue)
• Sopralivellamento ST sottolivellamento ST
• BBS di nuovo riscontro

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MORFOLOGIA INIZIALE
ASPETTI ATIPICI e CONFONDENTI Ipertrofia
VS Bassi Voltaggi Blocco di branca Pace
maker WPW Patients with ECG coufounder have
relatively higher mortality Savonitto et Al JAMA
2005
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ECG NON DIAGNOSTICO

• If the initial ECG is not diagnostic but the
  patient remains symptomatic and there is high
  clinical suspicion for ACS
• Serial ECGs, initially at 15- to 30-min
  intervals, should be performed to detect the
  potential for development of ST-segment elevation
  or depression.
• It is reasonable to obtain supplemental ECG
  leads V7 through V9 in patients whose initial ECG
  is not diagnostic to rule out MI due to left
  circumflex occlusion.
• A normal ECG does not completely exclude ACS

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ECG non diagnostico (2)

• Serial or continuous ECGs increase diagnostic
  sensitivity,although the yield is greater with
  serial cardiac biomarkermeasurements
• Approximately 4 of MI patients show ST
  elevationisolated to the posterior chest leads
  V7 through V9 Posterior ST elevation is
  diagnostically important because it qualifies the
  patient for reperfusion therapy as a
  STEMIpatient
• A normal ECG does not completely excludeACS
• 1 to 6 of such patients prove to have had
  anNSTEMI, and at least 4 will be found to have
  UA

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Aspetti ECG Tipici

• T NEGATIVA ISOLATA 19 CORONARIE INDENNI O
  LIEVI LESIONI
• SOTTOLIVELLAMENTO ST MALATTIA DEI 36 TRE VASI
• SOPRALIVELLAMENTO ST MAGGIORANZA 1 VASO

GUSTO II b, Savonitto et Al JAMA 1999
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ANALISI QUANTITATIVAST SOPRALIVELLATO
ELEVATA FC DURATA QRS (gt80 MS) ST INFERIORE IN
PREGRESSO IMA NUMERO DI DERIVAZIONI SOMMA
ASSOLUTA DEVIAZIONE ST (gt20 mm) SOMMA ST IN DD
INFERIORI
Hathaway et Al, JAMA 1998
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ANALISI QUANTITATIVA NON ST ELEVATION
MINIMAL ST ELEVATION SOTTOLIVELLAMENTO ST ST
SEGMENT DEPRESSION INVERSIONE T ENTITA ST
SOTTOLIVELLATO NUMERO DI DERIVAZIONI CON ST
ALTERATO SOMMA CUMULATIVA DI SOTTOLIVELLAMENTO ST
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Somma Sottolivellamento ST
GUSTO II b, Savonitto et Al Eur H J 2005
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QUANTITATIVE NSTE
Kaul et al J Am Coll Cardiol 2003
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Quantitative ST deviation GRACE
CUMULATIVE ST DEVIATION
Yan et Al, Am J Cardiol 2008
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Analisi Quantitativa ST
Although more severe ST deviation is a marker
of increase short- and long- term mortality .
after adjustment for clinically important
predictors (risk factors and biomarkers),
quantitative ST deviation does not provide
incremental prognostic value beyond simple
dichotomous evaluation for the presence of ST
deviation.. ..in contradistinction to the
clinical trial population, quantitative ST
deviation analysis has null incremental
prognostic value beyond a validated
comprehensive risk stratification
strategy Yan et Al, Am J Cardiol 2008
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ICTUS TRIAL
Windausen et Al, J Electrocardiol 2007
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IMPLICAZIONE TERAPIA
Patients with ST deviation gt 1 mm more often
fail on medical therapy, more often experience a
spontaneous MI after discharge when angiography
was not performed during initial
hospitalization Windausen et Al, J
Electrocardiol 2007
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ST aVR
In addition to ST depression in other leads,
greater than 1 mm ST aVR may be a simple marker
for severe CAD in patients with NSTE-ACS
GRACE, Yan et Al Am Heart J 2007,
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Implicazioni terapeutiche 2
Prompt identification of patients with LM or
3-VD is of clinical rilevance. GP IIB-IIIA
inhibitors may substitute for clopidogrel.,
coronary angiography may be expedited in
anticipation of the potential need for surgical
revascularization
Yan et Al Am Heart J 2007
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Sopralivellamento ST AVR
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ST depression T inversion V4-V6
Gusto II B, Atar et AL Am J Cardiol 2007
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Sottolivellamento ST T negativa V4-V6
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UNA SEMPLICE CLASSIFICAZIONE QUALITATIVA DELLECG
DI INGRESSO CONSENTE DI PORRE
DIAGNOSIEFFETTUARE UNA INIZIALE ED AFFIDABILE
STRATIFICAZIONE PROGNOSTICA AVVIARE IL PAZIENTE
ALLA PIU OPPORTUNA TERAPIA
CONCLUSIONI (1)
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CONCLUSIONI (2)
IN PRESENZA DI ECG NORMALE O FATTORI CONFONDENTI
LA INTERPRETAZIONE ECG UTILIZZARE ALTRI
PARAMETRI DI DIAGNOSI UN ECG NORMALE NON
ESCLUDE UNA SCA I PAZIENTI CON ECG MALE
INTERPRETABILE SPESSO HANNO PROGNOSI SEVERA
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CONCLUSIONI (3)
ASPETTI QUANTITATIVI E MORFOLOGIE PARTICOLARI
POSSONO FAR SOSPETTARE UNA CORONAROPATIA
SEVERA E PERTANTO MODIFICARE LITER DIAGNOSTICO
E TERAPEUTICO
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CONCLUSIONI (4)
I DATI ECG DI UN PAZIENTE CON SOSPETTA SCA
DEVONO SEMPRE ESSERE INSERITI NEL CONTESTO DI UNA
VALUTAZIONE MULTIPARAMETRICA
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PROGNOSI
PROGNOSI 30 GG E SEI MESI MORTE E REINFARTO T
NEGATIVA 5.5 8.1 ST SOTTOLIVELLATO 10.5 15.4
ST SOPRALIVELLATO 9.4 12.3 ST
12.4 15.7
GUSTO II B, Savonitto et Al JAMA 1999
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ECG RTI
Both ST and TnT are effective markers of
risk, TnT appears to be superior to ST in
assisting decision regarding theraphy
Kaul et al J Am Coll Cardiol 2003
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Somma Sottolivellamento ST
Kaul et al J Am Coll Cardiol 2003
GUSTO II b, Savonitto et Al Eur H J 2005