ACİL SERVİSE GÖĞÜS AĞRISI İLE BAŞVURAN HASTALARIN AKUT KORONER SENDROM ORANLARININ DEĞERLENDİRİLMESİ

Öz

Göğüs ağrısı GA şikâyeti, acil servislere AS başvuruların en sık nedenlerinden birisidir. Göğüs ağrısı şikayeti ile başvuran olgularda erken müdahale edilmeyi gerektiren akut koroner sendrom AKS tanısını koymak her zaman mümkün olmayabilir. Bazı hasta grubunda tanıya gidilmesi için hastaların klinik veya Elektokardiyografik EKG olarak izlemi gerekmektedir. Çalışmamızın amacı; Acil Servise tipik yada atipik Göğüs Ağrısı şikâyetiyle başvuran ve iskemik göğüs ağrısı olduğu düşünülen hastaların AKS oranlarının değerlendirilmesidir. AS’e, GA şikâyeti ile başvuran onsekiz yaş üstü ve nontravmatik tüm hastalar çalışmaya alındı. Çalışmaya dahil olmama kriterlerine ise;Travma hastaları,18 yaş altı hastalar, GA tariflemeyen hastalar, ST elavasyon myokart infarktüsü STEMI olan hastalar, kendi isteğiyle çalşmadan ayrılan hastalar, çalışmaya katılmayı kabul etmeyen hastalar, izleminde veri toplama formunda eksiklik olan hastalardan oluşmaktadır. Hastaların Çalışmaya 411 hasta alındı. Çalışmaya alınan hastaların 240’ı erkek %58,4 , 171’i %41,6 kadındı. Hastaların 314’ü %76,4 65 yaş ve altı iken, 97’si %23,6 65 yaş üstünde bulundu. Çalışmaya alınan hastaların 266’ında %73,3 KAH için en az bir risk faktörü varken, 71 hastada %26,7 birden fazla risk faktörü bulundu. Atipik semptomlarla başvuran hastalarda Akut Koroner Sendrom oranı %6,9 olarak saptandı. AKS’lu hastaların ilk geliş EKG’leri %53,9’u normal iken takip EKG'lerinde %16,9’unun EKG’sinde değişiklik saptandı. Tipik göğüs ağrısı olanlardaki AKS varlığı ve EKG değişikliği oranları atipik göğüs ağrısı olanlardaki AKS varlığı ve EKG değişikliği oranlarından yüksek olarak gözlendi p

Anahtar Kelimeler

• akut koroner sendrom,EKG,troponin,anjina pektoris,acil tıp

EVALUATING THE ACUTE CORONARY SYNDROME RATES OF THE PATIENTS WHO APPLY TO EMERGENCY SERVICE WITH CHEST PAIN

Öz

Chest Pain CP is one of the most frequent complaints observed in Emergency Services ES . It may not always be possible to diagnose the Acute Coronary Syndrome ACS , which requires immediate intervention in cases with CP. It is necessary that a clinical or Electrocardiographic ECG observation is performed in some patient groups to be able to diagnose the disease accurately. The purpose of this study is evaluating the ACS rates of the patients who apply to the Emergency Service with typical or atypical Chest Pain and who are considered to have ischemic chest pain. The patients who were non-traumatic and over 18 years of age who applied to the ES with CP complaints were included in the study. The criteria for not being included in the study were; being trauma patients, patients who were below the age of 18, patients whose APs were not defined; patients with ST Elevation Myocardia Infarct STEMI , patients who left the study with their own will, patients who did not want to participate in the study, and patients whose data collection forms had missing points in terms of observations. Doctor’s opinions on the complaints of the patients were determined as Typical Chest Pain or Atypical Chest Pain. The troponin and ECG follow-up of the patients were performed. The patients who were diagnosed according to the high troponin levels and ECG change were evaluated. The patients were examined in terms of gender, age, complaints for applying to the emergency service, background characteristics, TIMI risk factors, latest diagnoses, and the prognostic accuracy of the TIMI risk score. 411 patients were included in the study. 240 of the patients who participated in the study were male 58,4% , and 171 were female 41,6% . 314 of the patients 76,4% were at or below the age of 65, and 97 of them 23,6% were over the age of 65. 266 of the patients 73,3% had at least one risk factor for Coronary Artery Disease CAD , and 71 of them 26,7% had more than one risk factor. The Acute Coronary Syndrome ACS rate in the patients who applied with atypical symptoms was determined as 6,9%. The ECGs of the patients with ACS at the arrival were normal in 53,9%; however, changes were observed in the follow-up ECGs as 16,9%. The ACS existence and ECG change rates of the patients with Typical Chest Pain were observed as being higher than the ACS existence and ECG change rates of the patients with Atypical Chest Pain p

Anahtar Kelimeler

• acute coronary syndrome,ECG,troponin,angina pectoris,emergency medicine

Kaynakça

1. ) Green GB, Hill PM. Cardiovascular disease: Approach to chest pain and possible myocardial ischemia. In; Emergency Medicine: A Comprehensive Study Guide, 5th ed. Tintinalli JE, Kelen GD, Stapczynski JS (eds). North Carolina: McGraw-Hill, 1999;341-51.
2. ) Weingarten SR, Ermann B, Riedinger MS. Selecting the best triage rule for patients hospitalized with chest pain. Am J Med 1989; 87(5): 494.
3. ) Sönmez Demiryoğuran N, Topaçoğlu H., Karcıoğlu Ö. Nonspesifik Göğüs Ağrılı Hastalarda Anksiyete Bozukluğu. DEÜ Tıp Fakültesi Derg. 2005; 19(2): 127–32.
4. ) O’Rourke RA, Shaver JA, Silverman ME. Hikaye, Fizik Muayene ve Oskültasyon. In; Hurst’s The Heart, 10. baskı,Türkçe. Fuster V, Alexander RW, O’Rourke RA (eds) (çeviri ed: Yılmaz Y, Sahinbas E) McGraw-Hill 2002;193
5. ) Solinas L, Raucci R, Terrazzino S et al. Prevalence, clinical characteristics, resource utilization and outcome of patients with acute chest pain in the emergency department. A multicenter, prospective, observational study in north-eastern Italy. Ital Heart J 2003; 4(5): 24.
6. ) Eslick GD, Fass R. Noncardiac chest pain: Evaluation and treatment. Gastroenterol Clin North Am 2003; 32(2): 52.
7. ) Karlson BW, Wiklund I, Bengston A, Herlitz J. Prognosis and symptoms one year after discharge from the emergency department in patients with acute chest pain. Chest 1994; 105(5): 1442-7.
8. ) Hollander JE. Cardiovascular disease: Acute Coronary Syndromes: Unstable Angina, Myocardial Ischemia, and Infarction. In; Tintinalli JE, Kelen GD, Stapczynski JS (eds). Emergency Medicine; A Comprehensive Study Guide; 5th ed. North Carolina: McGraw-Hill; 1999:pp –366

9. ) Hecht HS, DeBord L, Sotomayor N, et al. Truly silent ischemia and the relationship of chest pain and ST segment changes to the amount of ischemic myocardium: 44 evaluation by supine bicycle stress echocardiography. J Am Coll Cardiol. 1994; (2):369–76.
10. ) Hamilton GC. Acute chest pain. In Emergency Medicine an approach to clinical problem-solving. Hamilton G, Sanders AB, Strange GR, Trott A (eds). WB Saunders Company; Philadelphia (3th ed) 1991,pp.173–
11. ) Braunwald E. Examination of the patient: The History. In: Braunwald E. eds; Heart Disease: A Textbook of Cardiovascular Medicine (5th ed.) Pennsylvania: W.B. Saunders Company 1997,pp.1–15.
12. ) Noeller T.P. Risk Stratification in Acute Coronary Syndromes. In; Hoekstra J.W. “Handbook of Cardiovascular Emergencies” Lippincott Williams & Wilkins, Philadelphia (2nd ed.) 2001; 111:118-20.
13. ) Van de Werf F, Ardissino D, Betriu A, Cokkinos DV, Falk E, Fox KAA, et al. Management of acute myocardial infarction inpatients presenting with ST-segment elevation The Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J 2003; 24(1): 28–66.
14. ) Biasucci LM. CDC/AHA Workshop on Markers of Inflammation and Cardiovascular Disease: Application to Clinical and Public Health Practice: clinical use of inflammatory markers in patients with cardiovascular diseases: a background paper. Circulation 2004; (25): 560-7.
15. ) Schindler TH, Nitzsche EU, Olschewski M, Magosaki N, Mix M, Prior JO et.al. Chronic inflammation and impaired coronary vasoreactivity in patients with coronary risk factors. Circulation. 2004; 110(9): 1069-75.
16. ) Tomai F, Crea F, Gaspardone A, Versaci F, Ghini AS, Chiariello L. et. al. Unstable angina and elevated C- reactive protein levels predict enhanced vasoreactivity ofthe culprit lesion. Circulation. 2001; 104(13): 1471-6.
17. ) Ross R. Atherosclerosis an inflammatory disease. N Engl J Med 1999; 340(2):115-126.
18. ) Eriksson S, Wittfooth S, Pettersson K. Present and future biochemical markers for detection of acute coronary syndrome. Crit Rev Clin Lab Sci ; 43(5-6):427-95. ) Spagnoli LG, Bonanno E, Sangiorgi G, Mauriello A.Role of inflammation in atherosclerosis. J Nucl Med. ; 48(11): 1800-15.
19. ) Davies MJ. The pathophysiology of acute coronary syndromes. Heart. 2000; 83(3): 361-6.
20. ) Schaar JA, Muller JE, Falk E, Virmani R, Fuster V, Serruys PW, et.al. Terminology for high-risk and vulnerable coronary artery plaques. Report of a meeting on the vulnerable plaque. Eur Heart J. 2004; (12): 1077-82.
21. ) Braunwald E. Unstable angina: an etiologic approach to management (editorial).Circulation 1998; 98(21): 22.
22. ) Lloyd-Jones D, Adams R, Carnethon M, ve ark. Heart disease and stroke statistics--2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2009; 119 (3): 480-6.
23. ) Theroux P, Fuster V. Acute coronary syndromes: unstable angina and non-Q-wave myocardial infarction. Circulation 1998; 97(12): 1195-206.
24. ) Davies MJ. The composition of coronary-artery plaques. The New England journal of medicine 1997; (18):1312-4.
25. ) Sampson J, Eliaser MJ. The diagnosis impending of acute coronary artery occlusion. Am Heart J 1937; 13(6): 86.
26. ) Feil H. Preliminary pain in coronary thrombosis. Am J Med Sci 1937;193(1):42-8.
27. ) Scanlon PJ, Nemickas R, Moran JF, ve ark. Accelerated angina pectoris. Clinical, hemodynamic, arteriographic, and therapeutic experience in 85 patients. Circulation 1973; 47(1): 19-26.
28. ) Vakil RJ. Preinfarction Syndrome-Management and Follow-Up. Am J Cardiol 1964; 14: 55-63.
29. ) Anderson JL, Adams CD, Antman EM, ve ark. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on
30. Practice Guidelines (Writing Committee to Revise the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions,and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Journal of the American College of Cardiology 2007; 50(7): e1-e157.
31. ) Antman E, Bassand JP, Klein W, Alpert JS, Thygesen K, Bassand JP. Myocardial infarction redefined-a consensus document of The Joint European Society of Cardiology/American College of Cardiology committee for the redefinition of myocardial infarction The Joint European Society of Cardiology/ American College of Cardiology Committee. J Am Coll Cardiol 2000; 36(3): 69.
32. ) Thygessen K, Alpert JS, Garson A, Bassand JP. Myocardial İnfarction redefined-Aconsensus document of the joint European Society of Cardiol / American College of Cardiology Comittee fot the redifinition of MI. J Am Coll Cardiol 2000; 36: 959-69.
33. ) Canto JG, Fincher C, Kiefe CI, Allison JJ, Li Q, Funkhouser E, Centor RM, Selker HP, Weissman NW. Atypical presentations among Medicare beneficiaries with unstable angina pectoris. Am J Cardiol 2002; 90(3): –53.
34. ) Culic V, Eterovic D, Miric D, Silic N. Symptom presentation of acute myocardial infarction: influence of sex, age, and risk factors. Am Heart J 2002; 144(6): –7.
35. ) Lev EI, Battler A, Behar S, Porter A, Haim M, Boyko V, et al. Frequency, characteristics, and outcome of patients hospitalized with acute coronary syndromes with undetermined electrocardiographic patterns. Am J Cardiol ; 91(2): 224–7. ) van Domburg RT, van Miltenburg-van Zijl AJ, Veerhoek RJ, Simoons ML. Unstable angina: good long- term outcome after a complicated early course. J Am Coll Cardiol 1998; 31(7): 1534–9.
36. ) Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, et al. ACC/AHA 2002
37. Guideline Update for the Management of Patients With Chronic Stable Angina. URL: http://www.acc.org/clinical /guidelines/stable/update index.htm, Updated: 15 Nisan ) Braunwald E, Mark DB, Jones RH, Mark DB, Brown J, Brown L, et al: Unstable Angina: Diagnosis and Management. Clinical Practice Guideline No. 10 (amended). AHCPR Publication No. 94-0602. Rockville
38. MD: Agency for Health Care Policy and Research and the National Health, Lung and Blood İnstitute, Public Health Service, U.S. Department of Health and Human Services ) Gibbons RJ, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, et al. ACC/AHA 2002 Guideline update for the management of patients with unstable angina and non-ST segment elevation myocardial infarction-Summary article. A report of the American
39. College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2002: (7): 1366-74.
40. ) Bertrand ME, Simoons ML, Fox KA, Wallentin LC, Hamm CW, McFadden E, et al. Management of acute coronary syndromes in patients presenting without persistent STsegment elevation. The Task Force on the management of acute coronary syndromes of the European Society of Cardiology. Eur Heart J 2002; (23): 1809-40.
41. ) Boersma E, Pieper KS, Steyerberg EW, Wilcox RG, Chang WC, Lee KL, et al. Predictors of outcome in patients with acute coronary syndromes without persistent STsegment elevation. Results from an international trial of 9461 patients. The PURSUIT
42. Investigators. Circulation 2000; 101(22): 2557-67.
43. ) Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. ACC/AHA 2002 guideline update for the anagement of patients with chronic stable angina: a report of the American College of Cardiology/American
44. Heart Association Task Force on Practice Guidelines ) Holmes DR Jr, Berger BP, Hochman JS, Granger CB, Thompson TD, Califf RM, et al. Cardiogenic shock in patients with acute ischemic syndromes with and without STsegment elevation. Circulation 1999; 100(20): 2067
45. ) Diercks DB, Peacock WF, Hiestand BC, Chen AY, Pollack CV Jr, Kirk JD, et al. Frequency and consequences of recording an electrocardiogram. 10 min after arrival in an emergency room in non-ST-segment elevation acute coronary syndromes (from the CRUSADE Initiative). Am J Cardiol 2006; 97: 437–42.
46. ) Van de Werf F, Ardissino D, Betriu A, Cokkinos DV, Falk E, Fox KAA, et al. Management of acute myocardial infarction inpatients presenting with ST-segment elevation The Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J 2003; 24(1): 28–66.
47. ) Savonitto S, Ardissino D, Granger CB, Morando G, Prando MD, Mafrici A, et al. Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA 1999; 281(8): 707–13.
48. ) Cannon CP, McCabe CH, Stone PH, Rogers WJ, Schactman M, Thompson BW, et al. The electrocardiogram predicts one-year outcome of patients with unstable angina and non-Q wave myocardial infarction: results of the TIMI III Registry ECG Ancillary Study. Thrombolysis in Myocardial Ischemia. J Am Coll Cardiol 1997; 30(1): 133–40.
49. ) Holmvang L, Clemmensen P, Lindahl B, Lagerqvist B, Venge P, Wagner G, et al. Quantitative analysis of the admission electrocardiogram identifies patients with unstable coronary artery disease who benefit the most from early invasive treatment. J Am Coll Cardiol 2003; (6):905–15.
50. Hyde TA, French JK, Wong CK, Straznicky IT, Whitlock RM, White HD. Four-year survival of patients with acute coronary syndromes without ST-segment elevation and prognostic significance of 0.5-mm ST- segment depression. Am J Cardiol 1999; 84(4): 379–85.
51. ) Kaul P, Fu Y, Chang WC, Harrington RA, Wagner GS, Goodman SG, Granger CB, Moliterno DJ, Van de Werf F, Califf RM, Topol EJ, Armstrong PW. Prognostic value of ST segment depression in acute coronary syndromes: insights from PARAGON-A applied to GUSTO-IIb. PARAGON-A and GUSTO IIb Investigators. Platelet IIb/IIIa Antagonism for the Reduction of Acute Global Organization Network. J Am Coll Cardiol 2001; 38 (1): 6–
52. ) Nyman I, Areskog M, Areskog NH, Swahn E, Wallentin L. Very early risk stratificationnby electrocardiogram at rest in men with suspected unstable coronary heart disease. The RISC Study Group. J Intern Med 1993; 234(3): 293–301.
53. ) de Zwaan C, Bar FW, Janssen JH, Cheriex EC, Dassen WR, Brugada P, Penn OC, Wellens HJ. Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery.Am Heart J 1989; (3): 657–65.
54. ) McCarthy BD, Wong JB, Selker HP. Detecting acute cardiac ischemia in the emergency department: a review of the literature. J Gen Intern Med 1990; 5(4): 365–73.
55. ) Rouan GW, Lee TH, Cook EF, Brand DA, Weisberg MC, Goldman L. Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain Study). Am J Cardiol 1989; (18): 1087–92.
56. ) Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, et al. American College of Cardiology; American Heart Association. Committee on the Management of Patients With Unstable Angina. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction-summary article: a report of the American College of Cardiology/American Heart
57. Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol 2002; 40(7): 1366-74.
58. ) Aroney CN, Aylward P, Allan M, Kelly A, Chew D, Clune E. Acute Coronary Syndromes Working Group. Guidelines for the management of acute coronary syndromes 2006. MJA 2006; 184(8 supp): 8; 1-27.
59. ) Gök H,Akut koroner sendromların tanısında yeni biyokimyasal markerler. Türk Kardiyoloji Seminerleri, : 1; 20-32Tablo Jaffe AS, Babuin L, Apple FS. Biomarkers in acute cardiac disease. J Am Coll Cardiol 2006; 48(1):1–11.
60. ) Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol 2000; 36(3): 970-1006.
61. ) Bertrand ME, Simoons ML, Fox KAA, Wallentin LC, Hamm CW, McFadden E et.al.Task Force Report: Management of acute coronary syndromes in patients presenting without persistant ST-segment elevation.The Task Force on the manegement of Acute Coronary syndromes of European Society of Cardiology. Eur Heart J 2002; 23(23): 1809-40.
62. ) Kaplan KDR, Parker M, Przbylek J, Teagarden JR, lesch M. Intravenous nitroglycerin for the treatment of angina at rest unresponsive to nitrate therapy. Am J Cardiol 1983; 51(5): 694-8.
63. ) Oler S, Whooley MA, Oler J, Grady D. Adding heparin to aspirin reduces the incidence of myocardial infarction and death in patients with unstable angina. JAMA 1996; 276(10): 811-5.
64. ) CAPTURE Investigators. Randomized placebo- controlled trial of abciximab before and during coronary intervention in refractory unstable angina: The CAPTURE study. Lancet 2006; 368(9545): 1429-35.
65. ) Cohen M, Adams PC, Parry G, Xiong J, Chamberlein D, Wieczorek I et.al. and antitrombotic therapy in Acute Coronary Syndromes Research Group. Combination antirombotik therapy in unstable rest angina and non-Q wave infarction in non-prior aspirin users. Circulation ; 89(1): 81-8. ) PURSUIT Trial Investigators. Inhibition of platelet glycoprotein lib/Ilia with Eptifibatide in patients with acute coronary syndromes. Platelet glycoprotein lib/Ilia in Unstable angina: receptor supression Using Integrillin Therapy. N Eng J Med 1998; 339(7): 436-43.
66. ) Gazes PC, Mobley M, Faris HM ve ark. Preinfarctional(Unstable) angina –aprospective study- Ten year follow up. Circulation 1973; 48(2) : 331-7
67. ) Braunwald E. Unstable angina. A classification. Circulation 1989; 80(2): 410-4.
68. ) Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, et al. ACC/AHA guidelines for the management of patients with unstable angina and non– ST-segment elevation myocardial infarction: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Unstable Angina). Circulation 2000; 102(10): 1193-209.
69. ) Antman EM, Cohen M, Bernink PJ, ve ark. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA 2000;284(7):835-42.
70. ) Boersma E, Pieper KS, Steyerberg EW, et al. Predictors of outcome in patients with acute coronary syndromes without persistent ST54 segment elevation. Results from an international trial of 9461 patients. The PURSUIT Investigators. Circulation 2000; 101(22): 2557
71. ) Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA ; 284(7): 835-42. ) Gumina RJ, Wright RS, Kopecky SL, Miller WL, Williams BA, Reeder GS, et al. Strong predictive value of TIMI risk score analysis for in-hospital and long-term survival of patients with right ventricular infarction. Eur Heart J 2002; 23(21): 1678-8.