Patient né en 1971, consulte pour douleurs thoraciques le 18/01 Q1: Deux diagnostics possibles, lesquels ?

Patient né en 1971, consulte pour douleurs thoraciques le 18/01 Q2: apport de l’ECG ?

Adressé centre hospitalier: Pas d’anomalie clinique, douleur toujours présente, Pas de modification ECG Q3: Apport de la biologie ?

Adressé centre hospitalier: Q4: NSTEMI, arguments ?

Adressé centre hospitalier: Q5: Syndrome aortique aigu, arguments ?

Adressé centre hospitalier: Q6: Syndrome aortique aigu, comment faire le diagnostic ? Score sur 3 types d’éléments de risque + la biologie

Syndrome aortique aigu : algorithme

Transfert salle de cathétérisme ? Q7: quels délais pour ce type de patient ?

Transfert salle de cathétérisme Q8: Evaluation du risque ? Risque de décès/risque ischémique Risque de saignement majeur www.crusadebleedingscore.org

Transfert salle de cathétérisme Q9: quels traitements en urgence ?

Transfert salle de cathétérisme Q9: quels traitements anti thrombotiques en urgence ?

Coronarographie-angioplastie

5/7 des Indicateurs de qualité des soins (ACCA-ESC) Protocoles écrits entre SAMU/SMUR/cardio pour le transfert rapide et activation immédiate de salle de cathétérisme Domain of Care Quality Indicator 1) Center Organization Main QI: The centre should be part of a Network Organization with written protocols for rapid and efficient management covering the following points: Single emergency phone number for the patient to be connected to a medical system for triage Pre-hospital interpretation of ECG for diagnosis and decision for immediate transfer to a center with catheterization laboratory facilities Pre hospital activation of the catheterisation laboratory Direct access to catheterization laboratory, bypassing the emergency department Secondary QI (1): Routine assessment of relevant times to reperfusion for STEMI patients (i.e. times from “call to first medical contact”, “first medical contact to door”, “door to arterial access” and “door-in door-out” for centers without an on site catheterization laboratory). Secondary QI (2): The center should participate in a regular registry or program for quality assessment. 2) Reperfusion-Invasive Strategy Main QI (STEMI 1): Proportion of STEMI patients reperfused among eligible (onset of symptoms to diagnosis <12h) Main QI (STEMI 2): Proportion of patients with timely reperfusion. Timely is defined as: For patients treated with fibrinolysis: < 30 mins from diagnosis (FMC) to needle For patients treated with primary PCI and admitted to centres with catheterization laboratory facilities: < 60 mins from door to arterial access for reperfusion with PCI For transferred patients: < 30 mins from door-in-door to door-out Secondary QI (STEMI): Diagnosis (FMC) to arterial access time (absolute value) for reperfusion with PCI. Main QI (NSTEMI): The proportion patients with NSTEMI, and no contra-indication, who receive coronary angiography within 72 hours after admission. 3) In Hospital Risk Assessment Main QI (1): Proportion of patients with NSTEMI who have an ischaemic risk assessment using the GRACE risk score. The GRACE risk score should be assessed and the score’s numerical value recorded for all patients admitted with suspected NSTEMI. Main QI (2): Proportion of patients admitted with STEMI and NSTEMI who have a bleeding risk assessment using the CRUSADE bleeding score. The CRUSADE bleeding score should be assessed and the score’s numerical value recorded for all patients admitted with STEMI and NSTEMI. Main QI (3): Proportion of patients with STEMI and NSTEMI who have an assessment of left ventricular ejection fraction. Left ventricular ejection fraction should be assessed and the numerical value recorded for all patients admitted with STEMI and NSTEMI. 4) Anti thrombotics during Hospitalization Main QI (1): Proportion of patients with “adequate P2Y12 inhibition” defined as: number of patients discharged with prasugrel or ticagrelor or clopidogrel / patients eligible. Eligible is defined as follows: For ticagrelor: AMI patients without previous haemorrhagic stroke, high bleeding risk, fibrinolysis or oral anticoagulation For prasugrel: PCI treated AMI patients without previous haemorrhagic or ischaemic stroke, high bleeding risk (patients >75 years or <60 kg body weight are also considered as high bleeding risk), fibrinolysis or oral anticoagulation For clopidogrel: no indication for prasugrel or ticagrelor and no high bleeding risk  Main QI (2): Proportion of patients with NSTEMI and eGFR ≥ 20 ml/min who are not a candidate for an immediate (≤ 2 hours) invasive strategy, treated with fondaparinux. Secondary QI : Proportion of patients with AMI discharged on dual antiplatelet therapy / patients with AMI, without clear and documented contra-indication 5) Secondary Prevention-Discharge Treatment Main QI: Proportion of patients with AMI discharged on statins, unless contra indicated, at high intensity (defined as atorvastatin ≥40 mg or rosuvastatin ≥20 mg). Secondary QI (1): Proportion of patients with AMI and clinical evidence of heart failure or an LVEF ≤ 0.40 who are prescribed, before discharge, an ACEI (or ARBs if intolerant of ACEI) unless contraindicated. Secondary QI (2): Proportion of patients with AMI and clinical evidence of heart failure or an LVEF ≤ 0.40 who are prescribed, before discharge, β-Blockers, unless contraindicated. Temps de reperfusion: appel, arrivée, ECG qualifiant, arrivée cardio, ponction artérielle, ballon(stent) Evaluation du risque: noter valeur de GRACE et CRUSAGE et FEVG Choix du bon antiplaquettaire et du bon anticoagulant Choix du bon traitement de prévention