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メモ 上野勝則心臓病診療アップデイト

●メモ 上野勝則心臓病診療アップデイト

●心筋梗塞は病歴で診断する
確定診断に、ECGもCKも不要
ST変わっていないからといってMI否定できない

●女性の心筋梗塞の症状
・前駆症状
普段と違う倦怠感、睡眠障害、息切れ、消化不良、不安
胸部症状は、28.7%のみ

・急性心筋梗塞時
息切れ、衰弱、普段と違う倦怠感、冷汗、めまい
胸部症状は、57%のみ

Circulation 108: 2619-2623, 2003

74歳とかでも!

●狭心症の胸痛は2〜10分
秒単位 or 時間単位であれば否定的
ニトロで速やかに回復

●心疾患随伴症状で 嘔気 を忘れない

●心外膜炎
臥位でしばしば増強する
僧帽筋への放散あれば可能性高い

●大動脈乖離
外傷性、高血圧、E-D syndrome, Mrfan syn
女性は妊娠中か出産前後に1/4発症
10%は胸痛ない
脳血管障害で運ばれてくることあり

●GERDの痛み
狭心症との判別難しいことあり
アルコール、アスピリン、食事で誘発
仰向けで増悪、明け方出現しやすい

●食道痙攣
ニトロで改善することあり、鑑別難しい

●過呼吸
しばしばST changeあり

●右肩への放散痛が、MIでもっともオッズ比高い

●動悸をタップで再現させると、かなり正確!

●静脈圧は、45度でみなくてよい。座位で、鎖骨上に静脈の拍動が見えるか

●新規のLBBBは即座に再還流

・トロポニンの結果は待つな
・心筋マーカー(CK-MB、トロポニン)の検査は1項目に絞れ

・左室圧充満してきても、肺うっ血出てくるまで12時間かかる

・MI初期診療
アスピリン160〜320mg(バイアスピリンは不可)
モルヒネ 4〜8mg 5〜15分ごとに痛み取れるまで。Max 3mg/kg(50kgで150mg)
呼吸抑制にはナロキサン
嘔気にはフェノチアジン

・ニトロ禁忌は
下壁梗塞、右室梗塞、SBP<90

・ヘパリン 初期量 60 U/kg(Max 4000 U)
維持量 12 U/kg/hr
再還流受けるなら、48時間まで(それ以上は出血のリスク高い)

・Clopidogrel 予後良好!
βブロッカーは禁忌でなければ24時間以内に必ず投与
ACE-I 禁忌でなければ必ず投与
ニトロ 狭心症や左心不全あれば
Ca blocker 投与すると死亡率悪化

・LVEF<40 なら必ずACE-I

・心不全が、入院後の予後不良の大半。聴診を

・Mgは2.0mmol/L以上に

●MI慢性期の治療
ACE-I、βブロッカー、アスピリン、スタチン

・胸部X線
右上部1/4は見えないはず

●右室梗塞
・ST上昇 U<V
・V4RのST上昇
→ 前負荷維持、右室後負荷を軽減、
→ 心房寝室 dual pacing、ドブタミン、再還流療法

・AVNRT AV nodal reentrant tachycardia
Aの興奮はVの興奮と同時におこるか、やや遅れる

・AVRT 
wide QRS
ワソラン禁忌!

・頚動脈洞マッサージ
AVNRT、AVRTは運がよければ停止する
AFL(flutter)、AT(Atrial tachycardia)は心房波がきれいに見える(AV block)
flutterだったら、Na channel brokerを先に入れると、1:1に! 先にβブロッカーかワソランでレートコントロールを

・VT
ショックなら電気的除細動
アミサリン
タイプわからなければワソラン禁忌

・Brugada
V2チェック

・Short QT syn
QT < 330
T高い(high Kと間違えやすい)

・失神
脳幹部の虚血でおこりうる、が、必ずほかの症状ある
失神のみで頭部CTは、まったくの無駄

・心房細動 急性期頻拍
インデラール 10mg(2A)を、1mg/1minで
または ワソラン1Aを点滴全開で

・レートコントロールは、βブロッカーまたはCa blocker

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