Differential diagnosis diagnosis in in Differential acute cardiac cardiac care care acute Astrid Apor Semmelweis Egyetem Kardiológiai Tanszék Cardiovascularis Centrum 2008. 06. 19. 1 acute vascular emergencies acute coronary syndrome acute arrhythmias Cardiac emergencies acute depression of myocard. contractility 2008. 06. 19. acute valvular emergencies acute pericardial diseases 2 Symptoms of of acute acute Symptoms cardiac diseases diseases cardiac Chest pain Dyspnea, diaphoresis Marked weakness Nausea, emesis Palpitation Anxiety Dizziness, acute confusion, syncope 2008. 06. 19. 3 Principal causes causes of of acute acute Principal chest pain pain chest Acute coronary syndrome (ACS) Aortic dissection Pulmonary embolism (PE) Acute pleurisy Stable angina pectoris (AP) Pericarditis, myocarditis Valvular heart disease Hypertrophic cardiomyopathy (HCMP) Gastroesophageal reflux/spasm (GERD) Musculosceletal disorders 2008. 06. 19. 4 2008. 06. 19. 5 Acute thoracic thoracic vascular vascular Acute catastrophes catastrophes Acute aortic syndrome 2008. 06. 19. Pulmonary embolism 6 Acute aortic aortic syndrome syndrome Acute (AAS) (AAS) AD= aortic dissection PAU= penetrating ulcer IMH= intramural haematoma AD PAU IMH aneurysm ± leak, rupture trauma transection Vilacosta I et all. Acute aortic syndrome. Heart 2001,85:365-8. 2008. 06. 19. 7 Clinical symptoms symptoms and and Clinical signs of of aortic aortic dissection dissection signs Migratory, tearing, ripping sharp chest pain (resolves, reoccurs) Malperfusion syndromes: syncope, neurologic deficit limb/visceral/spinal cord ischemia Shock: tamponade, hemorrhagic shock Cardiac failure: aortic regurgitation, myocardial ischemia Hoarseness, dysphagia, SVC syndrome 2008. 06. 19. 8 Echo signs signs of of acute acute aortic aortic Echo dissection dissection Dissection membrane/flap, dilation Double lumen with different flow pattern Entry/reentry sites Aortic root/valve abnormality, regurgitation (dilation, bicuspid valve, flap prolapse) Pericardial effusion Obstruction/dissection of coronary vessels 2008. 06. 19. 9 Aortic dissection dissection Aortic 2008. 06. 19. 10 Questions to to be be answered answered Questions in aortic aortic dissection dissection in Is the ascending aorta involved? Pericardial effusion? Immediate surgery Pathology of aortic anulus, mechanism of aortic regurgitation? Surgical strategy Are coronary ostia endangered? Surgical strategy 2008. 06. 19. 12 Aortic Intramural Intramural Aortic Hematoma (IMH) (IMH) Hematoma Blood within aortic media (rupture of vasa vasorum) Aortic pain, fluid extravasates, malperfusion syndromes Tomographic imaging diagnosis (TEE, CT, CMR) Biomarkers: smooth muscle heavy chain protein? Acute phase reactants: WBC, CRP, D-dimer, fibrinogen 2008. 06. 19. 13 Natural history history Natural of IMH IMH of rupture pseudoaneurysm AD aneurysm aortic wall pathology absorption 2008. 06. 19. 06. 19. B van der2008. Loo et all, Heart 2003;89:928 IMH PAU 14 Therapy Therapy acute chest pain cardiac and non-vascular causes excluded consider AAS TEE, CT evidence of high risk profile + type-A: surgery 2008. 06. 19. Ahmad F, et all Postgrad.Med. J. 2006;82;305-312 − + medical treatment elective repair type-B: EVAR 15 2008. 06. 19. 16 2008. 06. 19. 17 Integrated echo echo approach approach Integrated of PE PE of PE 2008. 06. 19. 18 Role of of TTE TTE in in PE PE Role Thrombi in transit PASP mobile thrombi pulm. ejection pattern 60/60 sign IVC dilatation collapsibility RV strain McConnells sign 2008. 06. 19. 19 Clinical symptoms symptoms and and signs signs Clinical of pulmonary pulmonary embolism embolism of Tachypnea, dyspnea Chest pain (pleuritic) Tachycardia Collapse, shock Swelling of lower extremity Venous jugular distension 2008. 06. 19. 20 Pulmonary embolism embolism Pulmonary 2008. 06. 19. 21 Pulmonary embolism embolism Pulmonary 2008. 06. 19. 22 Diagnostic algorythm algorythm in in Diagnostic pulmonary embolism embolism pulmonary Unexplained haemodynamic instability, shock APE unlikely consider other diagnosis Emergency TTE, D-dimer APE probable TEE, VUS Helical CT 2008. 06. 19. APE confirmed embolectomy thrombolysis APE confirmed highly probable start agressive therapy APE confirmed start agressive therapy 23 Acute diseases diseases of of the the pericardium pericardium Acute Pericarditis Tamponade 2008. 06. 19. 24 Pericarditis Pericarditis -PR segment depression -diffuse ST segment elevation -absence of reciprocal ST segment depression -T wave flattening, inversion 2008. 06. 19. 25 Tamponade Tamponade 2008. 06. 19. 26 Tamponade Tamponade 2008. 06. 19. 27 Tamponád Tamponád 2008. 06. 19. 28 Tamponade Tamponade Phase I Phase II/A Phase II/B Phase III Pressure PP=RAP PP=RAP=RV P PP=RAP=RVP PP=RAP=RVP= PCWP Flow CO CO CO CO Echo features RV collapse RA late diast.collapse in exspiration Tr. inflow resp. variation RV collapse in exsp. and insp. RA coll.:1/3RR Mitr. inflow var. RA, RV collapse, septal shift Mitr. inflow var. Clinical signs mild/mod. hypotension mild/mod tachycardia mild/mod. tachypnoe Puls.parad.≤20 Hgmm / no Hypotension Tachycardia Tachypnoe puls.parad.≥20 Hgmm Electrical altern. Tamponade echo echo signs signs Tamponade Echolucent space (global/loculatated), partial organization, fibrin strands, solid masses… Swinging heart RA/RV diastolic collapse LA/LV diastolic collapse (postsurgical) IVC plethora Abnormal ventricular septal motion Tricuspid/Mitral flow velocity resp. variationÇ Aortic/Pulmonary flow velocity resp. variationÇ HV, SVC exp. diastolic flow reversal 2008. 06. 19. 30 Indication for for urgent urgent Indication pericardiocentesis pericardiocentesis 1. haemodynamic compromise with moderate/large pericardial effusion 2. electrical alternans on ECG 3. swinging heart on echo 4. low pressure tamponade if doesn’t resolve after fluid replenishment 2008. 06. 19. 31 ACS: acute acute coronary coronary ACS: syndromes syndromes Unstable angina pectoris non-ST segment elevation myoc. inf. ST segment elevation myoc. inf. 2008. 06. 19. chest pain ECG Troponin-T, I Echocardiography coronary angiography 32 Role of of echo echo in in AMI AMI Role Diagnosis Functional infarct size Infarct related artery Functional assessment (systolic, diastolic) Viability Complications of AMI Prognosis Effects of therapy 2008. 06. 19. 33 Diagnosis Diagnosis Detectable dyssynergy: Coron.flow ≤ 50% Ischemia ≥ 20% of the wall Ischemia ≥ 6% of LV mass 2008. 06. 19. 34 Hypokinesis,, akinesis akinesis,, Hypokinesis dyskinesis dyskinesis 2008. 06. 19. 35 Acute AMI Myocarditis Anginal/ischemic attack Cardiomyopathy LBBB Regional dyssynergy Chronic ischemia Scar Infarct related related artery artery Infarct 2008. 06. 19. 37 Functional infarction infarction size size Functional Necrosis zone Ischemic stunned zone Hybernated myocardium Dysfuntional zone from previous AMI 2008. 06. 19. 38 Haemodynamic parameters parameters Haemodynamic in the the evaluation evaluation of of in hypotension hypotension SV = stroke vol., CO = cardiac output RAP = right atrial pressure RVP = right ventricular pressure LAP = left atrial pressure (RRd-4(MI-Vmax)²) PCWP = pulm. capill. wedge pr. (1.25x(E/E’)+1.9 LVEDP = left ventr.end diast. pr. (RRs-4(AI-Vmin)²) PASP = pulm. art. syst. pressure (TI-Vmax) PAMP = pulm. art. mean pr. (PI-Vmax) PADP = pulm. art. diast. pr. (PI-Vmin) PVR = pulm. vasc. rez.(10xTI-Vmax/PulmVTI) 2008. 06. 19. 39 Complications of of AMI AMI Complications acute mitral regurg acute VSD DLVOTO free wall rupture pseudoaneurysm peric.effusion tamponade 2008. 06. 19. RV infarction thrombus aneurysm remodeling 40 Acute VSD VSD Acute 2008. 06. 19. 41 Acute VSD VSD Acute 2008. 06. 19. 42 Free wall wall rupture rupture Free free wall rupture Abrupt haemopericardium Constrained by pericardium tamponade pseudoaneurysm 2008. 06. 19. 43 Pseudoaneurysm Pseudoaneurysm 2008. 06. 19. 44 Pseudoaneurysm Pseudoaneurysm 2008. 06. 19. 45 2008. 06. 19. 46 LV thrombus thrombus LV 2008. 06. 19. 47 RV infarction infarction RV 2008. 06. 19. 48 RV infarction infarction RV Echo features RV/inferopost. dyssynergy/dilatation Paradox septum Tricusp. regurgitation PASP low Pulm. valve early opening 2008. 06. 19. Therapy Reperfusion therapy Volume loading Inotrop support Maintenance of AV synchrony 49 Dynamic left left ventricular ventricular Dynamic outflow tract tract obstruction obstruction outflow (DLVOTO) (DLVOTO) 2008. 06. 19. 50 Acute mitral mitral regurgitation regurgitation Acute Functional: papill. muscle reg. dyssynergy LV dilation, remodeling Flail: mitral chordal rupture 2008. 06. 19. Flail: papill. muscle partial/complete rupture 51 Acute functional functional MR MR Acute Papill.muscle dysfunction Ventr. wall dyssynergy LV dilation, sphericity Anular dilation Mitral leaflet tenting Malcoaptation Central/excentric Jet of regurgitation 2008. 06. 19. 52 Papillary muscle muscle rupture rupture Papillary 2008. 06. 19. 53 Papillary muscle rupture 2008. 06. 19. 54 Papillary muscle muscle rupture rupture Papillary 2008. 06. 19. 55 Papillary muscle muscle rupture rupture Papillary 2008. 06. 19. 56 Cardiogenic shock shock Cardiogenic 1. Establish rapid diagnosis of shock severe LV dysfunction mechanical complication RV infarction alternative cardiovasc. dg. (dissection, PE, valve disease…) alternative dg. (hypovolaemia, sepsis) 2. Assess effect of treatment 2008. 06. 19. 57 Acute valvular valvular lesions lesions Acute Acute aortic insufficiency (endocarditis, dissection, trauma) Acute mitral regurgitation (endocarditis, ischemia, degenerative processes, trauma…) Native valve obstruction Prosthetic valve dysfunction 2008. 06. 19. 58 Acute aortic aortic insufficiency insufficiency Acute Sudden volume load LVEDV↑ Non-compliant LV LVEDP↑ Pulmonary congestion 2008. 06. 19. 59 Infective endocarditis endocarditis Infective 2008. 06. 19. 60 Paravalvular leak leak Paravalvular 2008. 06. 19. 61 Acute prosthetic prosthetic valve valve Acute thrombosis thrombosis 2008. 06. 19. 62 Acute prosthetic prosthetic valve valve Acute thrombosis thrombosis 2008. 06. 19. 63 Acute native native valve valve Acute obstruction: LA myxoma myxoma obstruction : LA 2008. 06. 19. 64 Thank You You for for your your Thank attention!! attention 2008. 06. 19. 65