home
about the project
Medical news
For authors
Licensed books on medicine
<< Previous Next >>

Clinical protocol for providing medical care to patients with acute coronary syndrome without ST segment elevation (MI without Q wave and unstable angina)

Heading for ICD-10: 120-122.

Signs and criteria for diagnosing the disease

Acute coronary syndrome is a group of symptoms and signs that make it possible to suspect acute myocardial infarction or unstable angina pectoris.

The term "acute coronary syndrome" is used at the first contact with patients as a preliminary diagnosis. Acute coronary syndrome with persistent elevation of the ST segment on an ECG and without it is isolated. The first in most cases transforms into acute MI with tooth 0 on the ECG, the second into acute MI without tooth 0 or unstable angina (final clinical diagnoses).

Acute myocardial infarction is necrosis of any mass of the myocardium due to acute prolonged ischemia. Unstable angina pectoris is acute myocardial ischemia, the severity and duration of which is insufficient for the development of myocardial necrosis.

Acute myocardial infarction without elevation of the BT segment / without tooth 0 differs from unstable angina by an increase in the level of biochemical markers of myocardial necrosis in the blood.

The clinical diagnostic criteria for acute coronary syndrome should be considered:

- protracted (more than 20 min) anginal pain at rest;

- angina pectoris at least III FC (according to the classification of the Canadian Association of Cardiology, 1976), which arose for the first time (during the previous 28 days);

- progressive angina pectoris at least III FC.

ECG criteria for acute coronary syndrome are horizontal depression of the ST segment and / or “coronary” negative T wave. It is also possible that these changes are absent on the ECG.

The biochemical criterion for acute coronary syndrome is an increase with a subsequent decrease in the dynamics of the level of cardiospecific enzymes (CPK, CF-fraction of CPK, troponins T and I) in blood plasma. In conflicting cases, this criterion is crucial for diagnosis.

Conditions in which medical care should be provided

Patients with acute coronary syndrome should urgently be hospitalized in a specialized heart attack (or in the absence of a cardiology) unit, preferably in an intensive care, treatment and resuscitation unit. After stabilization, patients are discharged for outpatient treatment under the supervision of a cardiologist.

Diagnostic program

Mandatory studies

1. Collection of complaints and medical history.

2. Clinical examination.

3. Measurement of blood pressure (on both hands).

4. ECG in 12 leads in dynamics.

5. Laboratory examination (general analysis of blood and urine, CPK in dynamics 3 times, it is desirable to determine the MV fraction of CPK or Troponins T or I, if necessary, in the dynamics 2 times, AlAT, AsAT, potassium, sodium, bilirubin, creatinine, total cholesterol, TG, blood glucose).

6. Echocardiography.

7. Stress test (VEM or treadmill (treadmill)) with stabilization and no contraindications.

8. Coronoventriculography in the absence of stabilization of the patient's condition against the background of adequate drug therapy for 48 hours or the presence of contraindications for stress tests.

Additional research

1. APTT (in the treatment of unfractionated heparin).

2. Chest x-ray.

Treatment program

List and scope of compulsory medical services

1. Acetylsalicylic acid.

2. Thienopyridine derivatives.

3. Unfractionated heparin (intravenously drip for at least 1-2 days followed by subcutaneous administration), low molecular weight heparins or fondaparinux subcutaneously to all patients. The duration of therapy is 2-5 days, and while maintaining the clinical signs of ischemia and longer

4. Blockers of p-adrenergic receptors without internal sympathomimetic activity.

5. Statins are indicated for all patients. Patients with total blood cholesterol <4.5 mmol / l and / or LDL cholesterol <2.5 mmol / l - by decision of the doctor.

6. ACE inhibitors (according to indications), with their intolerance - ARB I (angiotensin receptor blockers).

7. Nitrates in the presence of angina pectoris and / or signs of myocardial ischemia. Alternatively, sydnimines can be used.

8. Blockers of calcium channels. Diltiazem and verapamil should be used to treat patients who have contraindications to p-adrenergic blockers, and in patients with variant angina (in the absence of heart failure with LV systolic dysfunction). Long-acting dihydropyridines can be used with the purpose of antihypertensive and additional antianginal effects only together with p-adrenergic blockers. Short-acting dihydropyridine derivatives are contraindicated.

The list and scope of medical services of an additional choice

1. For anesthesia, with an insufficient effect of nitrates and p-adrenergic blockers, non-narcotic and narcotic analgesics.

2. With an increase in blood pressure - antihypertensive therapy.

3. With recurrent myocardial ischemia - surgical myocardial revascularization. The indication and choice of the method of revascularization are determined by the nature of the damage to the coronary arteries according to coronary ventriculography.

Characterization of the final expected

treatment result

The disappearance of angina pectoris and stabilization of hemodynamics.

Treatment duration

Mandatory inpatient treatment lasting 7-10 days.
Extension of treatment time is possible in the presence of complications: refractory unstable angina, heart failure, severe arrhythmias and blockages.

Treatment Quality Criteria

The absence of clinical and ECG signs of myocardial ischemia. The absence of signs of high risk according to stress tests (ischemic depression of the ST segment> 2 mm, exercise tolerance less than 5 METS (metabolic equivalents), 75 W or with general operation <22 kJ, decreased SBP during exercise).

Possible side effects and complications

Possible side effects of drugs according to their pharmacological properties. For example, adequate antithrombotic therapy can cause bleeding.

Outpatient recommendations

Patients should be on follow-up at the place of residence throughout life. An annual mandatory examination is necessary, if necessary, examination and correction of therapy.

Dietary and Restriction Requirements

Patients should receive a diet with a restriction of salt to 6 g / day, animal fats and products containing cholesterol. A diet enriched with omega-3 polyunsaturated fatty acids (sea fish) is recommended. With overweight, the calorie content of food is limited.

In the presence of bad habits - refusal from smoking, restriction of alcohol consumption.

Requirements for the regime of work, rest, rehabilitation

Temporary limited dosed physical activity and exercise therapy are recommended under the supervision of specialists. It is not recommended to stay in direct sunlight, hypothermia and overheating. Rehabilitation is indicated on an outpatient basis or in suburban specialized sanatoriums (in the absence of contraindications).

Patients are subject to rehabilitation treatment in the rehabilitation cardiology departments of local sanatoriums in accordance with the established procedure of referral (order of the Ministry of Health No. 206 of 12.30.1992). Transfer of patients to a specialized department of sanatoriums is carried out after performing the following level of physical activity - dosed walking per 1000 m in 1-2 doses and climbing 17-22 steps.

When referring to the sanatorium stage of rehabilitation, one should be guided by the functional preparation of the patient to perform the indicated level of motor activity, and not by the time of the occurrence of MI or unstable angina. With inadequate performance of the motor regimen, a test with physical activity on a bicycle ergometer or coronary angiography is necessary, after which the question of the need for surgical intervention is decided.

Indications for the spa phase

1. Patients with primary or repeated MI, with satisfactory fulfillment of the required level of physical activity.

2. Patients who have suffered unstable angina pectoris provided that the necessary level of physical activity is adequately performed.

3. After CABG surgery, resection of aneurysm, stenting of coronary vessels or surgical interventions for cardiac arrhythmias not earlier than 15-18 days after surgery (without postoperative complications).

4. The presence of such complications and concomitant diseases in patients at the time of their referral to the sanatorium is allowed:

CH not higher than stage IIA;

¦ normo-or bradyarrhythmic form of constant atrial fibrillation;

• single or frequent (not polytopic, not group and not early (I on T)) extrasystole;

• AU-blockade not higher than I degree;

¦ heart aneurysm with circulatory failure not higher than I degree;

¦ hypertension with controlled blood pressure and a crisis-free course;

• type II diabetes mellitus (compensated or subcompensated).

Contraindications for the sanatorium phase of treatment

1. General contraindications that exclude the referral of patients to the sanatorium (acute infectious diseases, sexually transmitted diseases, mental illnesses, blood diseases

in the acute stage and stage of exacerbation, malignant neoplasms, concomitant diseases in the stage of decompensation or exacerbation, etc.).

2. CH above the PA stage.

3. Angina pectoris IV FC.

4. Severe cardiac arrhythmias and conduction disturbances (paroxysms of atrial fibrillation and flutter or paroxysmal tachycardia with an attack frequency of more than 2 times a month, polytopic, early and group extrasystole, AV block II-III stage, three-beam block).

5. Stage III hypertension with uncorrected blood pressure, crisis course and significant impaired renal function.

6. Recurrent thromboembolic complications.

7. Diabetes mellitus decompensated or with severe course.

8. The impossibility of further expansion of the motor regime due to other reasons.
<< Previous Next >>
= Skip to textbook content =

Clinical protocol for providing medical care to patients with acute coronary syndrome without ST segment elevation (MI without Q wave and unstable angina)

  1. Clinical protocol for providing medical care to patients with acute coronary syndrome with ST segment elevation (MI with Q wave)
    ICD-10 rubric: I21-I22 Symptoms and criteria for diagnosing the disease Acute coronary syndrome with persistent ST elevation in most cases precedes acute myocardial infarction with Q wave. Acute myocardial infarction is necrosis of any myocardial mass due to acute prolonged ischemia. Clinical diagnostic criteria should be considered: - protracted (more than 20 min) anginal pain at rest; - the presence of typical
  2. Tactics of percutaneous coronary intervention in acute coronary syndrome without ST segment elevation
    Recently published reviews indicate that percutaneous coronary interventions are performed in less than 50% of patients with acute coronary syndrome without ST elevation (GRACE (Global Registry of Acute Coronary Events), CRUSADE (Coronary Revascularization UltraSound Angioplasty DEvice trial)). Proponents of drug treatment for patients with unstable angina and myocardial infarction without ST segment elevation
  3. Determining the risk of rapid disease progression in acute coronary syndrome without ST segment elevation
    The importance of dividing patients with unstable angina and myocardial infarction without ST segment elevation into high and low risk groups for complications is justified by the fact that the clear advantage of performing early coronary angiography and, if necessary, percutaneous coronary intervention is determined only in patients at high risk for complications. In the recommendations of the European Cardiology
  4. Clinical protocol for providing medical care to patients with coronary heart disease: stable angina pectoris I-II FC
    ICD-10 rubric: 120.8 Symptoms and criteria for diagnosing the disease Stable angina pectoris is characterized by the appearance of anginal attacks during physical exertion. FC angina pectoris is determined by the level of load at which signs of ischemia occur. Attacks of angina pectoris I FC occur with significant physical exertion. When conducting tests with dosed physical activity
  5. Clinical protocol for providing medical care to patients with coronary heart disease: stable angina of exertion III-IV FC
    ICD-10 heading: W.8. Signs and criteria for diagnosing the disease With stable angina pectoris, the appearance of anginal attacks during physical and emotional stress is noted. Angina pectoris FC is determined by the load level at which signs of ischemia appear. With III FC, angina attacks occur during normal physical exertion. With IV FC, angina attacks are provoked
  6. Clinical protocol for providing medical care to patients with acute pericarditis, chronic constrictive pericarditis
    ICD-10 heading: I30, I32 Conditions under which medical care should be provided Patients with acute pericarditis are subject to inpatient treatment at the place of residence, and if there is evidence, they should be referred for surgical treatment to the appropriate specialized institutions. Patients with constrictive pericarditis should be referred for surgical treatment to the appropriate specialized
  7. ACUTE CORONARY SYNDROME WITHOUT SUSTAINABLE ST SEGMENT ELEVATION
    ACUTE CORONARY SYNDROME WITHOUT SUSTAINABLE SEGMENT ELEVATION
  8. Percutaneous coronary interventions in acute coronary syndrome without ST elevation
    Percutaneous coronary interventions in acute coronary syndrome without segment elevation
  9. Clinical protocol for providing medical care to patients with dyslipidemia
    Conditions under which medical care should be provided All patients with identified dyslipidemia, including patients with ischemic heart disease and equivalents of ischemic heart disease (with peripheral atherosclerosis, cerebral artery atherosclerosis, aortic aneurysm, patients with diabetes mellitus), as well as asymptomatic patients with dyslipidemia should be examined and treated at the place of residence. The survey may be conducted in
  10. Clinical protocol for providing medical care to patients with HCMP
    ICD-10 heading: 142.1 Conditions under which medical care should be provided Patients are subject to outpatient examination and treatment at the place of residence. Examination can be carried out in district clinics, and if necessary, additional examinations - in city cardiology dispensaries and diagnostic centers. If there is evidence, patients are subject to surgery
  11. Clinical protocol for providing medical care to patients with NDC
    ICD-10 heading: F45.3 Conditions under which medical care should be provided Patients are subject to outpatient examination and treatment at the place of residence. Examination can be carried out in district clinics, and if necessary, additional examinations - in city cardiology dispensaries and diagnostic centers. Diagnostic program Mandatory research Gathering complaints and
  12. Clinical protocol for the provision of medical care to patients with myocarditis
    ICD-10 rubric: Ш, Ш, Ш.4 Conditions under which medical care should be provided Features of examination and treatment depend on the prevalence and course of myocarditis. Patients with focal myocarditis are subject to outpatient examination and treatment at the place of residence. The examination can be carried out in district clinics, and if necessary, additional examinations - in urban
  13. Clinical protocol for providing medical care to patients with DCMP
    ICD-10 heading: M2.0 Conditions under which medical care should be provided Patients with DCMP are subject to outpatient examination and treatment at the place of residence. Examination can be carried out in district clinics, and if necessary, additional examinations - in city cardiology dispensaries and diagnostic centers. With the progression of HF, treatment in cardiac
  14. Clinical protocol for providing medical care to patients with infectious endocarditis
    ICD-10 heading: B3.0 Conditions under which medical care should be provided Patients with infectious endocarditis are subject to inpatient treatment at the place of residence. If there are indications, patients should be referred for surgical treatment to the appropriate specialized institutions. Diagnostic program Mandatory research 1. Collection of complaints and medical history. 2. Clinical examination.
  15. Clinical protocol for providing medical care to patients with supraventricular tachycardia
    ICD-10 heading: I47.1. Signs and criteria for diagnosing the disease. Have a paroxysmal nature, sudden onset and end. In most cases, a regular rhythm with slight frequency fluctuations. Heart rate 100-250 beats / min, usually 140-220 beats / min. Ventricular contractions correspond to atrial contractions or less in the presence of AV block. The Q – R – S complexes are narrow, but for
  16. Clinical protocol for providing medical care to patients with atrial fibrillation (flutter)
    M-KB-10 heading: 148 Symptoms of the diagnosis of the disease Atrial fibrillation and flutter - supraventricular arrhythmias, which are characterized by uncoordinated atrial activity with impaired mechanical function. These forms are distinguished: 1. The first paroxysm that arose. 2. Paroxysmal (rhythm is restored independently for 48 hours). 3. Persistent
  17. Clinical protocol for providing medical care to patients with ventricular arrhythmias
    Heading for ICD-10: 149.3; 147.0; 147.2 Symptoms and criteria for diagnosing the disease Premature ventricular contraction or ventricular extrasystole is a complex that occurs in the ectopic ventricular focus and is premature in relation to the main rhythm (Table 2.1). Table 2.1 Clinical and morphological classification of ventricular arrhythmias {foto338}
  18. Clinical protocol for providing medical care to patients with extrasystolic arrhythmia and parasystole
    Headings on ICD-10: M9.1; M9.2; M9.4 Signs and criteria for diagnosing the disease Extrasystole - a violation of the heart rhythm, which is caused by premature excitation of the myocardium of the whole heart or its parts. Localization distinguishes: ¦ supraventricular (sinus, atrial, from the AV connection); ¦ ventricular extrasystoles. Parasystole - rhythm disturbance due to autonomic
  19. Coronarographic morphology of atherosclerotic lesions in acute coronary syndrome without ST segment elevation
    The development of acute coronary syndrome is directly related to the complicated “growth of the atherosclerotic plaque, which is accompanied by the formation of blood clots of various sizes and localization with respect to the structure of the plaque. The morphological composition of stable atherosclerotic plaques may vary in the ratio of structures that contribute to its stabilization or destabilization. With enough
Medical portal "MedguideBook" © 2014-2019
info@medicine-guidebook.com