‼️تنطیمات دستگاه: باید روی سرعت 25mm/sec و ولتاژ 10mm/mv باشه.
• ECG
- قراره دربارهnonstemi و unstable angina صحبت کنیم که بهشون NSTEACS میگن. چرا اینارو با هم میارن؟ چون تا نتیجه تروپ بیاد طول میکشه پس براساس بالین بیمار تصمیم گیری میشه و اقدامات اولیه برای هردو یکسانه.
▪️Among patients considered to have angina, there are three presentations of angina that suggest an ACS
-Rest angina, which is usually more than 20 min in duration
-New onset angina that markedly limits physical activity
-Increasing angina that is more frequent, longer in duration, or occurs with less exertion than previous angina
▪️Initial tests for suspected NSTEACS
ECG, history and physical examination, troponin and other laboratory
values (ie, electrolyte panel, kidney function, complete blood count), and chest radiography, clinical risk (modified HEART Score)
▫️In patients with suspected NSTEACS, we suggest the modified HEART Score
*History
-Highly suspicious (e.g., classic angina: substernal, exertional, relieved by rest/nitroglycerin), 2 points
-Mixed features (some cardiac suspicion), 1 point
-Non-specific, unlikely cardiac, 0 point
*ECG
-If the ECG shows ST-segment depression, 2 points;
-if nonspecific changes are present, 1 point;
-otherwise, 0 points.
*Age
-If age is ≥65 years, 2 points;
-45 to 64 years, 1 point;
-otherwise, 0 points.
*Risk factors
-If the patient has ≥3 atherosclerotic risk factors, 2 points;
-if 1 or 2 risk factors, 1
point;
-otherwise, 0 points
*Atherosclerotic risk factors include hypertension, body mass index >30
kg/m2, current or prior tobacco use, diabetes mellitus, family history of coronary artery disease.
▫️High risk≥4 points
▪️Approach in high-risk patients
1️⃣ Ischemic ECG changes
Patients with ST-depression ≥1 mm in two contiguous leads or T-wave inversion in a pattern
consistent with ischemia should be observed in the hospital for management of suspected NSTEMI (Invasive angiography)
2️⃣ Known coronary artery disease
In patients with a history of CAD (eg, prior MI, prior stenting or coronary artery bypass graft surgery,
≥70 percent obstruction on prior imaging) who have a history suspicious for NSTEACS but no ECG
evidence of ischemia, additional evaluation for CAD is typically required (imaging scheduled within 72 hours of discharge, and evaluation by a cardiologist within 72 hours of discharge)
3️⃣ Modified HEART Score ≥4 points
In patients in whom there is a high clinical suspicion for ACS based on symptoms and risk factors, it
is appropriate to obtain troponin values at time zero and three hours for a conventional cTn assay. If troponin testing does not resolve the high clinical suspicion for ACS, additional troponin values (ie, at six hours) or prolonged
observation with or without a stress or anatomic test for obstructive CAD are reasonable options.
▪️Approaches in lower-risk patients
*For most patients with suspected NSTEACS who present within 3 to 12 hours after symptom onset and who have no history of CAD and either a normal ECG or nonspecific ECG changes,
*It is reasonable to use the modified HEART Pathway at centers with sensitive troponin assays.
▫️Modified HEART Pathway
In patients with a modified HEART score of 0 to 3 points, we obtain two sensitive troponin values at zero
hours and three hours later.
*Two normal troponin values: Further evaluation (eg, stress testing) for ACS is generally not indicated.
*Any elevated troponin value:
the diagnosis of myocardial injury is confirmed and, in the presence of ACS symptoms and absence of chronic troponin elevation, the provisional diagnosis of NSTEMI is
established.
Conditions in which troponin may be chronically elevated include heart failure and chronic kidney
disease.
*Increase in troponin values within normal limits: In patients whose second troponin value is
normal but rises toward the boundary of the upper limit of normal, it is reasonable to obtain a third troponin value in another hour (ie, three hours after presentation).