1. DIFFERENTIAL DIAGNOSIS OF CHEST PAIN. COURSE MYOCARDIAL INFARCTION
DIFFERENTIAL DIAGNOSIS OF CHEST PAIN. COURSE MYOCARDIAL INFARCTION. TACTICS GPS. PRINCIPLES OF PREVENTION AND TREATMENT.
Professor A.G. Gadaev

2. Chest pain is one of the major symptoms of many diseases.
Cohn JK, Cohn PF. Chest pain. Circulation 2002
According to studies, 25% of chest pain koronogennogo origin (CHD).

3. Although the possible causes of chest pain are many,
until an accurate diagnosis of any chest
pain should be seen a doctor like pain presumably
cardiogenic origin.

4. How to determine the cause?
What kind of pain is cardiac, what - no?

5. However, GPs have :
When the problem of the patient "chest pain" is necessary as soon as possible to assess its severity.
First of all, avoid the most dangerous diseases that threaten the patient's life
Myocardial
Infarctionspontaneous
pneumothoraxPATEDissecting
aneurysm of the aorta
require immediate diagnosis
Just removing them, you should look for other causes of chest pain

6. Evaluation of the depth of this syndrome
The most important characteristics for the differential diagnosis of chest pain are
estimated duration
Evaluation of the depth of this syndrome
Analysis of precipitating factors
The circumstances of pain relief
localization
Some other specific signs

7. What kind of pain is koronogennoy what - no?
The pain is localized mostly in the retrosternal area
The specific duration of pain
Irradiation to the neck,back - interscapulum and left side of the body
It is strong enough,burning, pressing.
May be accompanied by shortness of breath
Linked to physical or emotional stress.
It may take afternitroglycerin
KORONOGENNAYA CHEST PAIN

8. Stenokardicheskie pain
These pains occur on the background of myocardial ischemia, when there is no correlation between myocardial oxygen demand and delivery

9. Characteristics of pain stenokardicheskie character
Normal localization of the sternum and to the left of the sternumIrradiation: the left shoulder, the inner surface of the left hand from the armpit to 4-5 fingers
Chest pain, usually caused by stress and physical activity, taking place in rest or nitroglycerin
Characterized by intermittent episodes of pain (from a few seconds to 30 minutes) going completely without residual discomfort.
Patients often do not say "pain"They use keywords such as "burning", "contraction", "pressure", "heartburn" "discomfort" (considered equivalents)

11. The nature of the cause of pain stenokardicheskie
Atherosclerosis of the coronary vessels 
Spasm of the coronary vessels.
Obstruction of the coronary vessels (embolism, congenital anomalies, arteritis, delamination of the arteries)
Severe myocardial hypertrophy
The increased need for myocardial metabolism: hyperthyroidism, anemia, paroxysmal tachycardia

12. KORONOGENNOY THE MOST FREQUENT CAUSE OF CHEST PAIN IS -        
ISCHEMIC HEART DISEASE(CHD)
It is important to keep in mind that only about 40-50% of all CHD know they have the disease, and receive appropriate treatment, while 50-60% of cases of the disease remains unrecognized.

13. Pathologic substrate of atherosclerotic coronary artery disease is narrowing of the coronary arteries
ischemia
damage
necrosis
rate
atherosclerosis
atherosclerosis,
thrombosis

14. Classification of coronary artery disease
Sudden cardiac death
2. Angina:
2.1. Stable angina (4 PK)        
2.2. Unstable angina:
New-onset angina
Progressive exertional angina
Spontaneous (special) angina
Early post-infarction angina
Early postoperative angina
3. Silent myocardial ischemia
4. myocardial infarction         
With Q-wave         
Non-Q wave
5. Myocardial infarction
6. Cardiac arrhythmias (indicating shape)
7. Congestive heart failure (specifying step and FC)

15. Risk factors (RF) Unrecoverable FR Paul (mostly male) Age
(more than 44 years for men and over 55 for women)
Genetic predisposition to disease
(MI or sudden cardiac death at the age ofup to 55 years for male relatives orunder the age of 65 years with relatives in the female line)

16. arterial hypertension
smoking
diabetes mellitus
Disposable FR

17. Occasional discomfort in the chest, resulting from myocardial ischemia.
Transient symptoms (1-20 min)
Pain predictable and renewable
The frequency of attacks is constant over time does not change
CHD. stable angina
Physical activity or episodes of emotional stress can trigger an attack.
Rest or medications such as nitroglycerin, remove the attack (the effect of which can be pre-assumed with high probability).
The cause is fixed, stenosing atherosclerotic lesions of the coronary arteries.

18. IBS.Nestabilnye angina.
Symptoms lasting more than 20 minutes correspond to pain at rest and are an indication of unstable angina.
It may also manifest symptoms of changes in a patient with previously diagnosed coronary heart disease in the form of increased frequency of angina attacks, an increase in the duration of seizures or emergence of resistance to the symptoms previously successfully stop attacks of drugs, such as nitroglycerin, β-blockers or calcium channel blockers.
Patients with first-episode symptoms typical of myocardial ischaemia (up to 1 month).
IBS.Nestabilnye angina.

19. Variant angina or Prinzmetal angina.
It is the consequence of coronary artery spasm alone against the minimal intensity of coronary heart disease.
Sometimes the attack can be removed physical exercise.

20. Unstable angina should be regarded as a harbinger of acute myocardial infarction and, therefore, this condition requires urgent directions to the hospital.
Remember!

21. ECG at rest in a quarter of patients with angina - no pathology.
ECG signs
Key Points
ECG at rest in a quarter of patients with angina - no pathology.
During the attack recorded segment depression, ST, negative or pointed or high T waves, various arrhythmias and conduction.
Sometimes-segment elevation ST, which may indicate an acute myocardial infarction or vasospasm.

22. T wave changes in a patient with angina pectoris.
Negative teeth in the left breastleads.

23. acute coronarysyndrome (ACS)
ACS - a period (24 hours) with new-onset angina to long flowing strokes ("intermediate" state) that does not pass after taking nitroglycerin, with an unknown outcome, with the possible development macrofocal myocardial infarction or sudden death, as well as to the progression of pain, even in alone. ?

24. ACS classification of ACS Without persistent elevationST segment
With persistent elevationST segment

25. myocardial infarction
This is a limited necrosis of the heart muscle, resulting from increased myocardial oxygen demand and insufficient blood supply to the myocardium.

26. A sense of "cola" or press "heavy fire" in the sternum
manifestations of MI
Pressing, compressing, do not remove the pain by nitroglycerine, prolonged chest pain (30 minutes or longer) with irradia-tion
A sense of "cola" or press "heavy fire" in the sternum
The presence of cold clammy sweat

27. Atypical variants of acute myocardial infarction
arrhythmic
Accompanied by acute cardiac rhythm and conduction and the absence of typical pain
asthmatic
Proceeds on the type of cardiac asthma or pulmonary edema
abdominal
Develops at the posterolateral basal infarction, accompanied by pain in the epigastric region, nausea, vomiting, not bringing relief from flatulence, paresis of the gastrointestinal tract
cerebrovascular
Accompanied coronary and cerebral vascular thrombosis as blocked, resulting in the development of clinical signs of syncope or stroke
Besimptomnaya or malosimptomno
It often occurs in the elderly and patients with diabetes, determined by chance when removing or ECG signs of the Tax Code. Patients can not accurately determine the timing of myocardial infarction

28. Myocardial infarction with Q wave
Violation of the coronary circulation in MI leads to the formation of the three zones of pathological changes: necrosis are located around the site of the ischemic damage and ischemia

30. For myocardial infarction with Q wave is characterized by phasic flow
prodromal stage
At this time, there are signs of unstable angina
The acute stage
up to 2 hours after the onset of MI

31. lasts from 2 hours to 14 days
The acute stage.
lasts from 2 hours to 14 days
subacute stage
1-3 days weeks
stage scarring
1-3 weeks - 3 months

32. Myocardial infarction without Q-wave
Myocardial infarction without Q wave is characterized by the development of the heart muscle netransmuralnyh necrosis, localized subendocardial or intramural.
The most common ECG signs of non-Q wave myocardial infarction are
Segment offset RS-T contours below
A variety of pathological changes of the T wave (most negative symmetrical and pointed coronary T wave)
The emergence of these changes on an electrocardiogram after a long and intense pain attack and save them for 2-5 weeks

34. Complications of myocardial infarction
early complications
rhythm disorders
Acute heart failure
Thromboembolic complications
Tromboendokardit
cardiogenic shock
reflex type
arrhythmic type
true
unresponsiveness type
Acute cardiac aneurysm ruptures internal and external attack

35. Chronic cardiac aneurysm
Complications of myocardial infarction
late complications
Dressler's syndrome
Chronic cardiac aneurysm
HSN

36. tactics GP Early diagnosis of the underlying cause
Implementation of preventive measures, as well as necessary medical treatment in conjunction with specialists
Consulting a specialist according to the characteristics of the GP qualifying(I or II category)
Clinical supervision and rehabilitation(IV category)

37. Early diagnosis of the underlying cause (disease)
objectiveinspection
history
Laboratory and instrumentalresearch
(III category)

38. First of all, avoid the most dangerous state
In the presence of the patient chest pain doctor must solve the following problem
First of all, avoid the most dangerous state
Or rule out the presence of cardiac pain koronogennoy

39. An objective examination
In a study of patients complaining of pain in the chest:
Skin: pallor / cyanosis, presence of lesions (typical for shingles pain can mimic nature stenokardicheskie)
Inspection of the neck: pulsation vessels or swollen veins
Pulse on the radial and femoral arteries, blood pressure and temperature.
Palpate the chest and spinous processes of the vertebrae. Identify local pain, fractures, the symptoms of diseases of the spine.
Percussion of the chest to exclude pneumothorax.
Lower extremities - exclude deep vein thrombosis (PE) swelling of the ankles - CH

40. Auscultation of the heart and lungs:
-absence of breathing and voice tremor - pneumothorax,
-pleural friction rub (pericardium) - pleurisy,
pericarditisrales in the lower lung - heart failure,
-systolic murmur at the apex - mitral valve prolapse,
-diastolic murmur over the aorta - delamination of the ascending aorta.
Palpation of the abdomen - epigastric pain? (gall bladder, stomach, duodenum).

41. 2. strategy GP I category II category Stable angina, coronary artery
Diagnosis and management in a hovercraft or joint venture
I category
II category
Early diagnosis and referral to a specialist or to hospital
Stable angina, coronary artery
Disease FC 1 and 2
Stable angina, coronary artery
disease FC 1 and 2
unstable angina ACS
myocardial infarction

42. Advice on healthy living
Principles of management and follow-up of patientswith coronary artery disease in a hovercraft or a family health center
Advice on healthy living
Learning the principles of patient self-
Monitoring blood sugar levels
Monitoring the level of lipids in the blood
ECG monitoring and control of blood pressure
Monitoring mass index / body
Psychological support
Timely diagnosis and prevention of complications
Control of the effects of pharmacotherapy
Control of the effects of pharmacotherapyPeriodic clinical examinations

43. Lifestyle changes:
Convince the patient of the need for smoking cessation
estriction of the use of alcohol and 20 mg in terms of pure alcohol per day

44. Eating healthy foods - milk-vegetable, fruit and vegetables.
Regular physical activity.

45. Obesity - a body mass index of 25 kg / m
When talking with patients should include information about the state of his health, the possible complications, the risk of death, behavior at an attack of angina pectoris.

46. Nitroglycerin 1 tablet sublingually (about 3 h 15 min)
Drug lecheniepri attack of angina pectoris
Nitroglycerin 1 tablet sublingually (about 3 h 15 min)
If the attack persists for 20 minutes - then think about AMI

48. Before carrying the load - nitroglycerin under the tongue
Prevention of angina attacks
Before carrying the load - nitroglycerin under the tongue
To treat conditions that may lead to attack: AG, CH, arrhythmias, and prevent heavy loads, emotional stress, and exposure to cold.
Long-acting nitrates, nitrosorbid mg orally 1 tablet 1-2 times a day or isosorbide mononitrate mg 2 times.
Beta-Blockers
calcium antagonists
statins

49. Prophylaxis
Activities aimed at increasing the educational level of the population, building people install on a healthy lifestyle and creating the conditions for its implementation.
Refusal of bad habits
Balanced diet
Adherence to rest
Prevention of inactivity
Prevention of stress
Prevention of obesity and its treatmentcorrection dislipedemii
Primary prevention

50. Routine inspection and tonometry
Fight with identified risk factors of hypertension among the population;
- Taking on the "D" records of newly diagnosed patients;
Patients treated hypertensive drugs of proven efficacy, with group and individual selection of doses, while respecting the continuity and duration of antihypertensive drugs.
Maintaining target blood pressure
Maintaining the quality of life.
secondary prevention

51. tertiary prevention
Prevention of complications-
Prevention of diabetes and hypertension-
Psychological support