Prise en charge du syndrome coronaire aigu (SCA)

 Diagnostic

Clinique & ECG

 Douleur angineuse continue et récente (plus de 20 minutes)

 ECG :

• Sus décalage de ST dans 2 dérivations adjacentes > 0.1mV dans les standards > 0.2mV dans les précordiales (consultez le simulateur ECG)
• images en miroir
• Sous décalage de ST dans 2 dérivations adjacentes
• ECG normal

 douleur trinitro-résistante

Importance de l’anamnèse

 ATCD personnels, terrain, facteurs de risque cardiovasculaire, circonstances de survenue

 Rechercher un diabète, une insuffisance rénale (facteurs de gravité).

Diagnostics différentiels

 péricardite, myocardite, dissection aortique, embolie pulmonaire, intoxication digitalique, intoxication au CO…

 BILAN PARACLINIQUE

Bilan de routine

 ECG 18 dérivations (à renouveler)
 Glycémie capillaire
 Monitorage Scope, PNI, SpO2

Bilan spécifique

 Hémostase (Groupe, NFS, plaquettes, TP, TCA)
 Myoglobine + Troponine (en cas de ST+ ne pas attendre les résultats pour entreprendre la recanalisation d’urgence).

NB : La troponine s’élève entre la quatrième et la sixième heure. Répéter le prélèvement +++

 Classification des SCA

 TRAITEMENT

Thérapeutique symptomatique

 Morphine titrée (en fonction de l’EVS) , anxiolytiques éventuels.
 Dérivés nitrés intra veineux (en respectant les contre indications) et en surveillant étroitement la PA la fonction ventriculaire droite.
 2 voies veineuses (G5% et Nacl) en garde veine.
 O2 si spo2 < 93% ou Killip > 1

Thérapeutique spécifique

 Références

 Long-term outcome of primary percutaneous coronary intervention vs prehospital and in-hospital thrombolysis for patients with ST-elevation myocardial infarction. Stenestrand U. et coll . JAMA. 2006 Oct 11 ;296(14):1749-56.
 Does time matter ? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients. Boersma E ; The Primary Coronary Angioplasty vs. Thrombolysis Group. Eur Heart J. 2006 Apr ;27(7):779-88.
 Management of acute myocardial infarction in patients presenting with ST-segment elevation - Task force ESC - Frans Van de Werf et coll. European Heart Journal 2003 : 24, 28-66
 A Comparison of Coronary Angioplasty with Fibrinolytic Therapy in Acute Myocardial Infarction. 2003 N Engl J Med 349:733-742
 Thrombolytic therapy vs primary percutaneous coronary intervention for myocardial infarction in patients presenting to hospitals without on-site cardiac surgery : a randomized controlled trial. JAMA 2002 ;287:1943-1951.
 Primary angioplasty versus prehospital fibrinolysis in acute myocardial infarction : a randomised study. Lancet 2002 ;360:825-829
 Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab, or unfractionated heparin : the ASSENT-3 randomised trial in acute myocardial infarction. Assessment of the Safety and Efficacy of a New Thrombolytic Regimen (ASSENT)-3 Investigators. Lancet. 2001 ;358:605-13.
 Mortality at 1 Year With Combination Platelet Glycoprotein IIb/IIIa Inhibition and Reduced-Dose Fibrinolytic Therapy vs Conventional Fibrinolytic Therapy for Acute Myocardial Infarction : GUSTO V Randomized Trial. JAMA (2002) 288 : 2130-2135
 Treatment of Acute Myocardial Infarction by Primary Coronary Angioplasty or Intravenous Thrombolysis in the ""Real World"" : One-Year Results From a Nationwide French Survey. Circulation 99 : 2639-2644
 DANAMI,Circulation 1997 ;96:748-755
 Does PTCA in acute myocardial infarction affect mortality and reinfarction rates ? A quantitative overview (meta-analysis) of the randomized clinical trials. Michels KB. et coll. Circulation. 1995 ;91:476-85.
 Coronary Stenting plus Platelet Glycoprotein IIb/IIIa Blockade Compared with Tissue Plasminogen Activator in Acute Myocardial Infarction. N Engl J Med 343 : 385-391
 The CAPTIM study. Lancet 2003 ; 361 : 700.
 Association of intravenous morphine use and outcomes in acute coronary syndromes : Results from the CRUSADE Quality Improvement Initiative. Trip J. Meine et coll. Am Heart J. 2005 Mar ;149 Volume 0, Number 0
 The task force for Percutaneous Coronary Interventions of the ESC mars 2005
 Correlation between the TIMI risk score and high-risk angiographic findings in non-ST-elevation acute coronary syndromes : observations from the Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) trial. Mega JL. et coll. Am Heart J. 2005 May ;149(5):846-50.
 Management of Acute Coronary Syndromes in patients presenting without persistent ST-segment elevation. Guidelines & Scientific Statements - European Heart Journal 23, 1809-1840 : 2002
 Effects of aspirin dose when used alone or in combination with clopidogrel in patients with acute coronary syndromes : observations from the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) study. Peters RJ et coll. Circulation. 2003 Oct 7 ;108(14):1682-7.
 Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. Yusuf S. et coll. N Engl J Med. 2001 Aug 16 ;345(7):494-502.
 Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. Antithrombotic Trialists’ Collaboration. BMJ. 2002 Jan 12 ;324(7329):71-86.
 Double-blind study of the safety of clopidogrel with and without a loading dose in combination with aspirin compared with ticlopidine in combination with aspirin after coronary stenting : the clopidogrel aspirin stent international cooperative study (CLASSICS). Bertrand ME et coll. Circulation. 2000 Aug 8 ;102(6):624-9.
 Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention : the PCI-CURE study. Mehta SR. et coll. Lancet. 2001 Aug 18 ;358(9281):527-33.
 Platelet glycoprotein IIb/IIIa inhibitors reduce mortality in diabetic patients with non-ST-segment-elevation acute coronary syndromes. Roffi M. et coll. Circulation. 2001 Dec 4 ;104(23):2767-71.
 Point-of-care measured platelet inhibition correlates with a reduced risk of an adverse cardiac event after percutaneous coronary intervention : results of the GOLD (AU-Assessing Ultegra) multicenter study. Steinhubl SR. et coll. Circulation. 2001 May 29 ;103(21):2572-8.
 Eptifibatide provides additional platelet inhibition in non-ST-elevation myocardial infarction patients already treated with aspirin and clopidogrel. Results of the platelet activity extinction in non-Q-wave myocardial infarction with aspirin, clopidogrel, and eptifibatide (PEACE) study. Dalby M. et coll. J Am Coll Cardiol. 2004 Jan 21 ;43(2):162-8.
 Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes : a meta-analysis of all major randomised clinical trials. Boersma E. Lancet. 2002 Jan 19 ;359(9302):189-98.
 Unfractionated heparin and low-molecular-weight heparin in acute coronary syndrome without ST elevation : a meta-analysis. Eikelboom JW. et coll. Lancet. 2000 Jun 3 ;355(9219):1936-42.
 A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group. Cohen M. et coll. N Engl J Med. 1997 Aug 14 ;337(7):447-52.
 Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) 11B trial. Antman EM. et coll. Circulation. 1999 Oct 12 ;100(15):1593-601.
 The SYNERGY trial : study design and rationale. SYNERGY Executive Committee. Superior Yield of the New strategy of Enoxaparin, Revascularization and GlYcoprotein IIb/IIIa inhibitors. Am Heart J. 2002 Jun ;143(6):952-60.