Veauthier Brian, Sievers Karlynn, Hornecker Jaime
University of Wyoming Family Medicine Residency, 1522 East A Street, Casper, WY 82601.
FP Essent. 2015 Oct;437:17-22.
Patients with chest pain who present to emergency departments have a significantly higher incidence of acute coronary syndrome (ACS) than patients with chest pain presenting to outpatient settings, so emergency department clinicians should have a lower threshold for considering ACS as an etiology. Evaluating patients with suspected ACS in the emergency department involves obtaining a history, physical examination, electrocardiograms (ECGs), and cardiac troponin measurements in conjunction with risk calculators. These parameters cannot be used individually because, for example, a normal ECG result does not exclude ACS and troponin levels can be elevated in many conditions. All patients with suspected ACS should receive aspirin, if not contraindicated, as soon as possible. Those with an ST-segment elevation myocardial infarction (STEMI) or those without STEMI who are in unstable condition should be triaged to undergo reperfusion therapy, typically via percutaneous coronary intervention (PCI), within 120 minutes of first medical contact. If that time limit cannot be met because the patient must be transferred to a PCI-capable facility, fibrinolytic therapy should be initiated within 30 minutes of presentation if STEMI is present. (Fibrinolytic therapy is contraindicated for myocardial infarction without STEMI.) Patients also should receive nitroglycerin to relieve angina and beta blockers if not contraindicated.
与前往门诊就诊的胸痛患者相比，前往急诊科就诊的胸痛患者急性冠状动脉综合征（ACS）的发病率显著更高，因此急诊科临床医生应降低将ACS视为病因的阈值。在急诊科评估疑似ACS的患者包括获取病史、进行体格检查、心电图（ECG）检查以及结合风险计算器进行心肌肌钙蛋白检测。这些参数不能单独使用，因为例如正常的ECG结果并不能排除ACS，并且在许多情况下肌钙蛋白水平可能会升高。所有疑似ACS的患者如果没有禁忌证，应尽快服用阿司匹林。那些患有ST段抬高型心肌梗死（STEMI）或病情不稳定的非STEMI患者应在首次医疗接触后120分钟内接受分诊以进行再灌注治疗，通常通过经皮冠状动脉介入治疗（PCI）。如果由于患者必须转至具备PCI能力的机构而无法达到该时间限制，若存在STEMI，应在就诊后30分钟内启动纤溶治疗。（非STEMI型心肌梗死禁忌使用纤溶治疗。）患者还应服用硝酸甘油以缓解心绞痛，若无禁忌证还应服用β受体阻滞剂。
