ST-elevation in aVR and ST depression in all other leads ACCA - - PowerPoint PPT Presentation

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ST-elevation in aVR and ST depression in all other leads ACCA - - PowerPoint PPT Presentation

Jul 02, 2023 321 likes •574 views

A patient with chest pain and ST-elevation in aVR and ST depression in all other leads ACCA Masterclass 2017 Sofie Gevaert Mr LP, 55-years-old History: Hypertension, treated with Perindopril 5mg and Nebivolol 5mg Current:

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A patient with chest pain and ST-elevation in aVR and ST depression in all other leads

ACCA Masterclass 2017

Sofie Gevaert

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SLIDE 2

Mr LP, 55-years-old

  • History:
  • Hypertension, treated with Perindopril 5mg and Nebivolol 5mg
  • Current:
  • 01.00 am: progressive severe thoracic pain radiating to left arm
  • Orthopnoea
  • 112Medical emergency team
  • Other CV risk factors:
  • Hyperlipidaemia
  • Obesity
  • Sudden death of father at 50 y

ACCA Masterclass 2017

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SLIDE 3

MET 08.00 am: parameters, clinical exam

  • BP 142/72 mmHg, HR 160 bpm, regular, SaO2 88%, Resp R

27/min

  • Clammy, cold extremities
  • No jugular distension
  • No cardiac murmur
  • Bilateral crepitations
  • No peripheral edema

ACCA Masterclass 2017

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SLIDE 4

ACCA Masterclass 2017

FMC in patient with chest pain

ACCA toolkit 2015

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SLIDE 5

ECG 08.05 am

ACCA Masterclass 2017

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SLIDE 6

ACCA Masterclass 2017

  • 1. ER: Patient with chest pain, 08.28 am

ACCA toolkit 2015

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SLIDE 7

Further strategy?

  • Further stabilisation, diagnostics in ER?
  • Direct transfer to cathlab?

ACCA Masterclass 2017

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SLIDE 8
  • 2. ER: dyspnoea, orthopnoea

ACCA Masterclass 2017

ACCA toolkit 2015

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Chest X-ray 08.32 am

ACCA Masterclass 2017

Furosemide 40mg IV (MET)

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Quick look echo

ACCA Masterclass 2017

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?

ACCA toolkit 2015

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SLIDE 12

ACCA Masterclass 2017

CONGESTION

  • +

H Y P O _ P E R F U S + I O n ESC guidelines AHF 2015

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SLIDE 13

ACCA Masterclass 2017

ACCA toolkit 2015

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08.45 am

  • Ongoing chest pain despite high dose opioids
  • SaO2 90 despite FiO2 90%
  • Persisting respiratory failure despite initial measures
  • Troponin T 435 ng/L, creatinine 2.1 mg/dL (CKD-EPI 30 mL/min), Hct 42%
  • PH 7.24, PCO2 47mmHg, lactate 34.1 mg/dL (<11.3 mg/dL, =3.8mmol/L)

ACCA Masterclass 2017

Sedation, Intubation

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SLIDE 15

Invasive strategy: Timing, antithrombotic R/ and access

  • Timing?
  • Antiplatelet?
  • None
  • ASA mono
  • DAPT
  • Anticoagulation?
  • None
  • UFH
  • LMWH
  • Fondaparinux
  • Bivalirudin
  • Access?

ACCA Masterclass 2017

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SLIDE 16

ACCA Masterclass 2017

ACCA toolkit-ESC guidelines NSTE-ACS2015

Timing

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ACCA Masterclass 2017

ACCA toolkit 2015

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Ischemic risk

ACCA Masterclass 2017

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Bleeding risk

ACCA Masterclass 2017

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High ischemic and high bleeding risk KD and shock state

UFH 5000 IU bolus ASA 200mg IV

ACCA Masterclass 2017

ESC guidelines NSTE-ACS 2015

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Coronary angiography 09.20 am

ACCA Masterclass 2017

Shock, peripheral VC: Femoral access

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SLIDE 22

ACCA Masterclass 2017

CT angiography 09.50 am

ESC guidelines Aortic dis. 2014

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SLIDE 23

Type A dissection with dissection left main

  • Urgent surgery
  • Tear ascending aorta
  • Urgent surgery:Hemiarch

Sinotubular junction  proximal arch

  • Postoperative: stroke, AKI
  • Rehab program

ACCA Masterclass 2017

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SLIDE 24

THANK YOU

ACCA Masterclass 2017

Sofie Gevaert