AKUTNI KORONARNI SINDROM-AKSDoc. Dr Vladimir Miloradovi

AKS / Definicija

Angina koja se javlja sve uestalije, dueg trajanja, jaeg intenziteta, odnosna angina koja se javlja u miru.

Atherothrombosis: Main Cause of Major Ischemic (Vascular) EventsAtherothrombosis is characterized by a sudden (unpredictable) atherosclerotic plaque disruption (rupture or erosion) leading to platelet activation and thrombus formation

Atherothrombosis is the underlying condition that results in events leading to myocardial infarction, ischemic stroke, and vascular death

Plaque rupture1Plaque erosion21. Falk E et al. Circulation 1995; 92: 65771. 2. Arbustini E et al. Heart 1999; 82: 269272

Atherothrombosis is characterized by an unpredictable, sudden disruption (rupture or erosion/fissure) of an atherosclerotic plaque, which leads to platelet activation and thrombus formation.

The left hand image illustrates the rapid progression of atherothrombosis, showing a disrupted coronary plaque with occlusive thrombosis superimposed.1

The right hand image shows plaque erosion with an acute coronary thrombosis.2

Atherothrombosis is the underlying condition that results in events leading to myocardial infarction, ischemic stroke, and vascular death. Cardiovascular, cerebrovascular and peripheral vascular disease (also known as peripheral arterial disease) are part of a continuum of diseases with the common underlying pathophysiology of atherothrombosis.

References1. Falk E et al. Circulation 1995; 92: 657671. 2. Arbustini E et al. Heart 1999; 82: 269272.

AKS - Klinika slika I Simptomi : bol u grudima ( KKD 6-8 ), trajanja do 30 min.,nedostatak vazduha, opta malaksalost, munina, slab odgovor na ling NTGII Znaci : uplaenog izgleda, bledi, oroeni hladnim znojem, ruke na grudnom kou, hipotenzivni, auskultatorno izuzetno retko prisitni III i IV ton kao i sistolni um na vrhu.

AKS Dijagnoza(laboratorija)

Enzimski profil eliske nekroze ( CPK, CK Mb, AST, LDH, Troponin, Mioglobin ) negativan.

AKS Dijagnoza(EKG)

AKS Dijagnoza( EHO )

AKS Dijagnostika (selektivna koronarografija)

AIM - Etiopatogeneza

AIM - Definicija

Infarktom miokarda nazivamo nekrozu miokarda uzrokovanu naglim smanjenjem ili potpunim prekidom koronarnog protoka.

AIM - EpidemiologijaU SAD pod slikom naprasne srane smrti umire godinje 500.000, 25% je uzrokovano AIM.Zemlje EU belee pad incidence AIM od 30%Prema SZO neposredni uzrok 19 000.000 smrtnih sluajeva godinjeMortalitet od KV bolesti u SRB 54-56%

AIM - Patofiziologija

AIM Klinika slikaSimptomi : anginozni bol traje due od 30 min. Ne prestaje na ling NTG, ( KKD 9-10), esto karakteristine propagacije, munina, gaenje povraanje, guenje, izrazita opta malaksalost, omaglica, strah od neposredne smrti.Znaci : uznemireni, bledi, oroeni hladnim znojem, cijanotini, najee nemirni u postelji, trljaju kou u predelu grudne kosti, telesna temperatura umereno poveana, puls ubrzan, mogua bradikardija, hiper/hipotenzivni, tonovi tihi, ponekad III i IV ton, tranzitorni holosistolni um na vrhu, ponekad prisutna staza na pluima ( Killip I-IV ).

AIM Dijagnoza : laboratorijaEnzimski profil eliske nekroze pozitivan.

CK pojavljuje se u cirkulaciji u okviru prvih 4-8 h, max koncentracija nakon 24h, prisutan do 72h.LDH raste u prvih 48h, vraa se u normalni okvir u roku od 7-14 dana (nespecifian).Troponin ( T i I ), pojavljuju se u cirkulaciji u prva 3h, perzistiraju u cirkulaciji 7-10 dana ( I ), odnosno 10-14 dana ( T ) nakon AIM.Mioglobin se pojavljuje 1-4h, moe se detektovati u urinu, ali poseduje manju specifinost, samo kao komplementarna laboratoriska analiza.Ostali markeri : SGOT (AST), hFABP, MLC, MHC, GPNN.

AIM - Dijagnoza : EKGAkutna faza sa elevacijom spojnice u II, III i aVF

AIM Dijagnoza : EKG Lokalizacija Prednji Anteroseptalni Dijafragmalni (inferiorni)LateralniVisoki lateralni(pars alta)Posteriorni(zadnji)Desna komora

EKG odvodiI, aVL, V1-V6 (Q, ST )V1-V3 (Q, ST )II, III, aVF (Q, ST )I, aVL, V4-V6 (Q, ST )I, aVL (Q, ST )V1-V3 ( R, ST )V4R ( ST )

AIM Dijagnoza : EHO

AIM Dijagnoza : SPECT

AIM Dijagnoza : SPECT

AIM - Dijagnoza

CT - 64 slice

MRI

AIM Diferencijalna dijagnoza

Disekantna aneurizma aorte

Perikarditis

Pluna embolija

AIM Dijagnoza (SK)

AIM- Komplikacije Predkomorski poremeaji sranog ritmasin. tahikardijasin. bradikardijaatrijalne ekstrasistoleatrijalna tahikardija i flaternodalni ritamKomorski poremeaji sranog ritma

- ventrikularne ekstrasistole- ventrikularna tahikardija- ventrikularna fibrilacija

AIM - Komplikacije

Atrioventrikularni ( AV blok gr. I, II i III ).Interventrikularni ( BLG i BDG).

AIM-komplikacije:AV blok gr III sa polimorfnom VT

AIM-Komplikacije : sustained VT

AIM-Komplikacije : asistolija srca

AIM-Komplikacije : VF

AIM-KOMPLIKACIJE : SRANA INSUFICIJENCIJA(SI)

AIM - Terapija

AIM - Terapija

Klasina Th : bola, poremeaja sranog ritma, rastereenja miokarda pasivna zatita miokarda, spreavanje procesa remodelovanja leve komore.

AIM Terapija : standardnaMorfijum 2-4 mgO2 2-3l /minHeparin visoko, niskomolekularni ( 5ooo i.j. bolus + 20.000 i.j. u 500ml NaCl i.v.) , Enoxiparin 30mg i.v. Bolus + 1mg/kg s.cAspirin 75 325 mg/dan NTG ( amp Nirmin 15-25mg u 5oo ml NaCl)Beta blok. ( amp. Presolol a 5mg I +I +I, tbl.Presolo a 100mg 2x1)Xilocain 2% bolus 80 120 mg i.v. Bolus + 500mg u 500 ml NaClACE inhibitori ( kaptopril, cilazapril, enalapril, kvinalapril, ramipril, od min do max konc.)

AIM Terapija : noviteti(promising)Clopidogrel Plavix a 75 mg/danStatini ( Atorvastatin, simvastatin, fluvastatin, max konc. do 80 mg/dan )GP IIb /IIIa ( apciximab-ReoPro, tirofiban-Agrastat )HirudinNova antiinflamatorna Th. ?

Atherothrombosis is characterized by an unpredictable, sudden disruption (rupture or erosion/fissure) of an atherosclerotic plaque, which leads to platelet activation and thrombus formation.

The left hand image illustrates the rapid progression of atherothrombosis, showing a disrupted coronary plaque with occlusive thrombosis superimposed.1

The right hand image shows plaque erosion with an acute coronary thrombosis.2

Atherothrombosis is the underlying condition that results in events leading to myocardial infarction, ischemic stroke, and vascular death. Cardiovascular, cerebrovascular and peripheral vascular disease (also known as peripheral arterial disease) are part of a continuum of diseases with the common underlying pathophysiology of atherothrombosis.

References1. Falk E et al. Circulation 1995; 92: 657671. 2. Arbustini E et al. Heart 1999; 82: 269272.