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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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:
• 01.00 am: progressive severe thoracic pain radiating to left arm
• Orthopnoea
• 112Medical emergency team
• Other CV risk factors:
• Hyperlipidaemia
• Obesity
• Sudden death of father at 50 y
ACCA Masterclass 2017
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
ACCA Masterclass 2017
FMC in patient with chest pain
ACCA toolkit 2015
ECG 08.05 am
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ACCA Masterclass 2017
1. ER: Patient with chest pain, 08.28 am
ACCA toolkit 2015
Further strategy?
• Further stabilisation, diagnostics in ER?
• Direct transfer to cathlab?
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2. ER: dyspnoea, orthopnoea
ACCA Masterclass 2017ACCA toolkit 2015
Chest X-ray 08.32 am
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Furosemide 40mg IV (MET)
Quick look echo
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?
ACCA toolkit 2015
ACCA Masterclass 2017
CONGESTION - +
HYPO _PERFU S +IOn
ESC guidelines AHF 2015
ACCA Masterclass 2017ACCA toolkit 2015
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 2017Sedation, Intubation
Invasive strategy: Timing, antithrombotic R/ andaccess
• Timing?• Antiplatelet?
• None
• ASA mono
• DAPT
• Anticoagulation?• None
• UFH
• LMWH
• Fondaparinux
• Bivalirudin
• Access?
ACCA Masterclass 2017
ACCA Masterclass 2017ACCA toolkit-ESC guidelines NSTE-ACS2015
Timing
ACCA Masterclass 2017ACCA toolkit 2015
Ischemic risk
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Bleeding risk
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High ischemic and high bleeding riskKD and shock state
UFH 5000 IU bolus
ASA 200mg IV
ACCA Masterclass 2017ESC guidelines NSTE-ACS 2015
Coronary angiography 09.20 am
ACCA Masterclass 2017
Shock, peripheral VC:Femoral access
ACCA Masterclass 2017
CT angiography 09.50 am
ESC guidelines Aortic dis. 2014
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
THANK YOU
ACCA Masterclass 2017
Sofie Gevaert
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