Phác đồ 1 giờ trong chẩn đoán và điều trị nhồi máu cơ tim cấp

Phác Đồ Giờ Chẩn Đoán Và Loại Trừ Nhồi Máu Cơ Tim Cấp Với Troponin T Siêu Nhạy The one-hour algorithm to rule-out and rule-in of Acute Myocardial Infarction with cardiac Troponin T-high sensitive PGS TS Trần Văn Huy FACC FESC Phó Chủ Tịch Phân Hội THA VN, Trưởng Khoa TM BV Tỉnh Khánh Hòa Giảng Viên Thỉnh Giảng ĐHYD Huế, ĐHTN Test early Treat right Save lives Có bật khuyến cáo chẩn đoán NMCT cấp 2015? Khuyến Cáo ESC 9/2015 NSTEAMI Initial assessment of patients with suspected acute coronary syndromes ESC GUIDELINES NSTAMI European Heart Journal Advance Access published August 29, 2015 Khuyến cáo ESC 2015 chẩn đoán, phân tầng nguy vai trò troponin bệnh nhân nghi ngờ hội chứng mạch vành ST không chênh Recommendations Class Level Ref.c It is recommended to base diagnosis and initial short-term ischaemic and bleeding risk stratification on a combination of clinical history, symptoms, vital signs, other physical findings, ECG and laboratory results I A 28,109–112 A rapid rule-out and rule-in protocol at h and h is recommended if a high-sensitivity cardiac troponin test with a validated h/1 h algorithm is available Additional testing after 3–6 h is indicated if the first two troponin measurements are not conclusive and the clinical condition is still suggestive of ACS I B 30–34, 36, 39, 51–55 It is recommended to use established risk scores for prognosis estimation I B 84,94,106 Diagnosis and risk stratification ESC GUIDELINES NSTAMI European Heart Journal Advance Access published August 29, 2015 h/3 h rule-out algorithm of non-ST-elevation acute coronary syndromes using high-sensitivity cardiac troponin assays ESC GUIDELINES NSTAMI European Heart Journal Advance Access published August 29, 2015 Phác đồ rule-in rule out h/1 h hs-cTn bệnh nhân nghi ngờ NMCT không ST chênh lên (NSTEMI) ESC GUIDELINES NSTAMI European Heart Journal Advance Access published August 29, 2015 Chứng cho phác đồ 0-1h hs cTn? 14 nghiên cứu phác đồ 0-1h, hs cTnT 10/14 • APACE (Advantageous Predictors of Acute Coronary Syndrome Evaluation ) 2012 • TRAPID-AMI (High sensitivity cardiac Troponin T assay for RAPID rule-out of Acute Myocardial Infarction) is a Roche-sponsored clinical trial presented at the meeting ESC 2014 • APACE : 2015 The “APACE revalidation” study.(Prospective validation of a 1-hour algorithm to rule-out and rule-in acute myocardial infarction using a high-sensitivity cardiac troponin T assay) Reichlin T et al., CMAJ 2015, April • 1-h algorithm for hs-cTnI Rubini Gimenez M et al., Am J Med 2015, Mar 31 Acute myocardial infarction (AMI) Time is life Each year over million people have an AMI worldwide1 AMI is a life-threatening condition STEMI mortality: (1 year) This is a race against the clock where every minute counts ≈9% NSTEMI mortality: ≈ 11.6 % (1 year) Every 30 minutes of delay between symptoms and treatment increases the relative risk of 1-year mortality by 7.5% in patients with AMI2 White and Chew (2008) Lancet 372:570-584 De Luca et al (2004) Circulation 109:1223-1225 Time is life Is a safe AMI diagnosis possible in a shorter time? • Serial blood samples at variable time intervals are required for the diagnosis of AMI and to differentiate acute from chronic cardiac disease1 • 2011 ESC guidelines recommend, in conjunction with full clinical assessment including 12–lead ECG, either a 6-9 hours observation time with conventional cTn tests or hours ruleout protocol using high sensitivity Troponin1 Conventional troponin tests High sensitivity troponin tests1 2 Faster rule-in Faster rule-out Reduce time to diagnosis Possible ? Hamm et al (2011) Eur Heart J 32:2999–3054 Time since admission (hours) Faster appropriate therapy Reduced ED crowding cTn: Cardiac troponin; ECG: Electrocardiogram; ED: Emergency department; ESC: European Society of Cardiology Phác đồ 0-1h cTnT chẩn đoán & loại trừ NMCTC The APACE study: a 1-hour cTnT-hs algorithm Advantageous Predictors of Acute Coronary Syndrome Evaluation  A pilot study with 436 patients presenting at the ED