IV-47 Accidents coronaires aigus

IV#47&ACCIDENTS&CORONAIRES&AIGUS&
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1!
Accidents&coronaires&aigus&&
dont&l’infarctus&du&myocarde&
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1. Généralités&:&
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"#$%&!'()!*+'!nécrose&myocardique&ischémique!),*-./+)!/*!0,1+(!2!-02!%*!03,-/4%'5!%*'!6!$71+)'44*8)1,+!
94*)/$'!%'!$7/88,4)!(/+:*1+!/4);41'$5!%;8/((/+)!$'(!8,((191$1);(!%'!(*88$;/+-'!-,$$/);4/$'<!=#'()!*+'!*4:'+-'!
0;%1-/$'5!$#.,(81)/$1(/)1,+!'+!*+1);!%'!(,1+(!1+)'+(1>(!-/4%1,$,:1?*'(!'()!1+%1(8'+(/9$'<!!
"'!84,+,()1-!@1)/$!%;8'+%!%'!$/!(*4@'+*'!%'!)4,*9$'(!%*!43).0'!')!%'!$#;)'+%*'!%'!$/!+;-4,('<!!
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• Epidémiologie&:&
A B4;@/$'+-'!C!120&000&cas/an&!
A 12&000&décès&par&an&!1ere&cause&de&décès&en&France!
A DE!EEE!8/)1'+)(!(,+)!.,(81)/$1(;(!-./?*'!/++;'!
A &,4)/$1);!%'!FG!/@/+)!FE!/+(!')!/*:0'+)'!/@'-!$7H:'!
A IEG!%'(!%;-J(!/441@'+)!%/+(!$/!K'4'!.'*4'<!
A "7.,00'!'()!),*-.;!%/+(!2LM!%'(!-/(5!:;+;4/$'0'+)!6!8/4)14!%'!NN!/+(!
A =.'O!$/!>'00'5!DEG!%'(!-/(!/441@'+)!/84J(!FN!/+(!
A P/+(!NG!%'(!-/(5!$'(!(*Q')(!,+)!'+)4'!2E!')!IE!/+(!
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• Facteurs&de&risque&:&
A R/9/:1(0'!
A P1/9J)'!
A SRT!
A T+,0/$1'!%*!0;)/9,$1(0'!$181%1?*'!
A U9;(1);!/9%,01+/$'!')!4;:10'!/$10'+)/14'!
A V)4'((!8(3-.,$,:1?*'!
A B1$$*$'!
A V;%'+)/41);!
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1.1 &&&&Ancienne&définition&de&l’IdM&:&
P'8*1(!8'*5!$/!(,-1;);!'*4,8;'++'!%'!-/4%1,$,:1'!')!$'!-,$$J:'!/0;41-/1+!%'!-/4%1,$,:1'!,+)!4'%;>1+1!%'!
0/+1J4'!-,+('+(*'$$'!$#1+>/4-)*(!%*!03,-/4%'<!!
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W$$'!/!8,*4!9*)!%'!4'%;>1+14!$/!+,)1,+!%'!+;-4,('!-'$$*$/14'!:4H-'!+,)/00'+)!6!$#/88,4)!%'(!-41)J4'(!91,$,:1?*'(!
X)4,8,+1+'Y!')!%'(!84,:4J(!'+!10/:'41'!X;-.,:4/8.1'!')!(-1+)1:4/8.1'Y5!%'!()4/)1>1'4!$'!41(?*'!')!%'!%;>1+14!$'(!
()4/);:1'(!).;4/8'*)1?*'(<!!
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T1+(15!),*)'!;$;@/)1,+!'+O30/)1?*'!%'!$/!)4,8,+1+'!);0,1:+'!%#*+'!+;-4,('!-'$$*$/14'5!/0'+/+)!6!
%;81()'4!*+!+,094'!(*8;41'*4!%#ZP&<![+'!;$;@/)1,+!*+1?*'0'+)!%'!$/!)4,8,+1+'!X(/+(!W=\!;@,-/)'*4Y!8'40')!
%#1%'+)1>1'4!*+!:4,*8'!%'!8/)1'+)!6!./*)!41(?*'!%#;@J+'0'+)(!-/4%1,@/(-*$/14'(5!?*1!)14'!9;+;>1-'!%'(!
).;4/8'*)1?*'(!0,%'4+'(!]!.;8/41+'(!%'!9/(!8,1%(!0,$;-*$/14'5!+,*@'/*^!/:'+)(!/+)1A8$/?*'))/14'(!')!()4/);:1'!
84;-,-'!%'!4'@/(-*$/41(/)1,+<!!
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• Ancienne&définition&de&l'infarctus&du&myocarde&:&&
=$/((1?*'0'+)5!$'!%1/:+,()1-!%'!$#ZP&!4'8,('!(*4!$/!84;('+-'!%#/*!0,1+(!%'*^!%'(!)4,1(!-41)J4'(!%;>1+1(!8/4!
$#U4:/+1(/)1,+!&,+%1/$'!%'!$/!V/+);!XU&VY!]!!
A *+'!%,*$'*4!).,4/-1?*'!%'!8$*(!%'!ME!01+*)'(5!!
A %'(!0,%1>1-/)1,+(!;$'-)4,-/4%1,:4/8.1?*'(!/@'-!(*(A%;-/$/:'!%*!(':0'+)!VR!!

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2!
A $/!$19;4/)1,+!8/4!$'!03,-/4%'!%#'+O30'(!')!%'!84,);1+'(!%'!$#/88/4'1$!-,+)4/-)1$'<!!
='(!-41)J4'(!(,+)!)4J(!4'()41-)1>(!')!+'!8'40'))'+)!8/(!$'!%1/:+,()1-!%'!),*(!$'(!1+>/4-)*(<!V'*$'!$/!0,%1>1-/)1,+!%'(!
0/4?*'*4(!91,$,:1?*'(5!);0,1+(!%'!$/!+;-4,('!-'$$*$/14'!8'40')!/$,4(!%#/>>140'4!$'!%1/:+,()1-<!!
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1.2 &&&&Nouvelle&définition&de&l'IdM&:!!
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U+!8/4$'!0/1+)'+/+)!%'!Syndrome&Coronarien&Aigu&]!!
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U+!4':4,*8'!/-)*'$$'0'+)!(,*(!$'!+,0!%'!V3+%4,0'!-,4,+/14'!/1:*!XV=TY!$'(!;@J+'0'+)(!-$1+1?*'0'+)!
;@,-/)'*4(!X%,*$'*4!/+:1+'*('!+'!-;%/+)!8/(!/*^!+1)4;(Y!(*1@/+)(!]!!
A L’infarctus&du&myocarde&complet!XP,*$'*4!_5!W=\!_!')!0/4?*'*4(!_Y!/@'-!(*(A%;-/$/:'!VR!
A L'infarctus&du&myocarde&sans&onde&Q!XP,*$'*4!_5!W=\!A!0/1(!0/4?*'*4(!_Y!(/+(!(*(A%;-/$/:'!VR!!
A Le&syndrome&de&menace&ou&angor&instable!XP,*$'*4!_5!W=\!A5!0/4?*'*4(!A!0/1(!6!(*1@4'!(*4!2I!.'*4'(Y!!
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SCA&
Douleur&
ECG&
Marqueurs&
IdM&complet&
+&
+&
+&
IdM&sans&Q&
+&
#&
+&
Angor&instable&
+&
#&
#&(suivre&24h)&
!&
1.3 &&Définition&de&l'angor&instable&:&&
Z(-.;01'!03,-/4%1?*'!(;@J4'!)4/+(1),14'!:;+;4/$'0'+)!8/4!*+'!4*8)*4'!%'!8$/?*'!/).;4,0/)'*('!
-,08$1?*;'!%#*+'!).4,09,('!-,4,+/41'++'!8/4)1'$$'0'+)!,--$*(1@'!')!/::4/@;'!8/4!%'(!8.;+,0J+'(!
(8/()1?*'(5!1+>$/00/),14'(<!!
=$1+1?*'0'+)5!,+!,9('4@'!]!!
A =41('!/1:*`!%#/+:,4!+'!-;%/+)!8/(!6!$/!)41+1)41+'!')L,*!/*!4'8,(!!
A T::4/@/)1,+!%#*+!/+:,4!-,++*!]!-41('!8$*(!>4;?*'+)'(5!8$*(!84,$,+:;'!')L,*!8$*(!>4;?*'+)'(!!
A T+:,4!%'!4'8,(!,*!%'(!'>>,4)(!)4J(!0,%;4;(<!!
A T+:,4!:4/@'!%'!+,@,<!!
Angor&stable&
Angor&instable&
P,*$'*4(!).,4/-1?*'(!/88/4/1((/+)!à&l’effort!
P,*$'*4(!).,4/-1?*'(!/88/4/1((/+)!au&repos!
B/(!%7/+,0/$1'!;$'-)41?*'!
T+,0/$1'(!;$'-)41?*'(!01+'*4'(!]!VR!a!
X%;84'((1,+!VR5!1+@'4(1,+!RY!
=bB![V!;$'@;'!
V1:+'!91,$,:1?*'!]!)4,8,+1+'(!+,40/$'(!
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1.4 !!!!!Marqueurs,&diagnostic&et&CAT&:&&
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Le&dosage&des&troponines&est&devenu&le&dosage&de&référence.&&
='$/!/!'+)4/1+;!*+'!+,*@'$$'!%;>1+1)1,+!%'!$#ZP&!]!R,*)'!;$;@/)1,+!%#*+!0/4?*'*4!91,-.101?*'!X___!
)4,8,+1+'(Y!%/+(!*+!-,+)'^)'!%#1(-.;01'!03,-/4%1?*'!@,14'!%'!%,*$'*4!).4,4/-1?*'!/)381?*'!%,1)!c)4'!
%;(,40/1(!-,+(1%;4;!-,00'!*+!1+>/4-)*(!%*!03,-/4%'d!<!!

IV#47&ACCIDENTS&CORONAIRES&AIGUS&
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3!
• En&pratique&hospitalière&:&
T!8/4)14!%'(!;$;0'+)(!-$1+1?*'(!X%,*$'*4!/+:1+'*('!84;('+)'Y5!91,-.101?*'(!X/*:0'+)/)1,+!%'!$/!)4,8,+1+'Y!')!
;$'-)41?*'!X(*(!%;-/$/:'!84;-,-'!%'!VRY!,+!8'*)!%1()1+:*'4!2!/))1)*%'(!X.,4(!-,08$1-/)1,+!-,00'!UTB5!Re5!')-!<<Y!!
A V*(!%;-/$/:'!84;-,-'!%'!VR!XD!6!K2!.'*4'(Y!(1:+'!$#,--$*(1,+!),)/$'!]!1$!108,('!*+!:'()'!%'!
4'8'4>*(1,+!'+!*4:'+-'!8/4!).4,09,$3('!,*!/+:1,8$/()1'!!
A T9('+-'!%'!(*(!%;-/$/:'!84;-,-'!%'!VR!X,--$*(1,+!8/4)1'$$'5!(8/(0'Y!]!)4/1)'0'+)!0;%1-/$!'+![VZ!
-/4%1,$,:1?*'!/((,-1/+)!:;+;4/$'0'+)!%;41@;(!+1)4;(5!9c)/9$,?*/+)(!')!/+)1).,09,)1?*'(!
XT(8141+'!_!SfB&Y<!P/+(!*+!%'*^1J0'!)'08(5!$'!8/)1'+)!8,*44/!c)4'!;@/$*;!8/4!-,4,+/4,:4/8.1'5!
;84'*@'!%#'>>,4)5!(-1+)1:4/8.1'!03,-/4%1?*'<!!
A Z$!'()!/-)*'$$'0'+)!4'-,00/+%;!8/4!$#T0'41-/+!=,$$':'!,>!=/4%1,$,:1'!XT==Y!')!$#T0'41-/+!S'/4)!
T((,-1/)1,+!XTSTY!%#/((,-1'4!%*!=$,81%,:4'$!/*!)4/1)'0'+)!()/+%/4%!8/4!$#/(8141+'!-.'O!),*(!$'(!
8/)1'+)(!?*#1$(!(,1'+)!)4/1);(!0;%1-/$'0'+)!,*!-.14*4:1-/$'0'+)<!!
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• SCA&:&un&continuum&physiopathologique&:&
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Angor&stable&&&&&SCA&non&ST&+&&&&SCA&avec&ST&+&
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2. Physiopathologie&:&
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"#!ZP&!'()!$/!-,+(;?*'+-'!%#*+'!occlusion&coronaire&aiguë<!!
P/+(!8$*(!%'!gEG!%'(!-/(5!1$!'()!('-,+%/14'!6!*+'!thrombose&coronaire&occlusive!84,@,?*;'!8/4!$/!
>1((*4/)1,+!%#*+'!8$/?*'!%#/).;4,0'!'+!:;+;4/$!8'*!();+,(/+)'<!!
='))'!>1((*4/)1,+!(#/--,08/:+'!%'!$/!01('!'+!-,+)/-)!/@'-!$'!(/+:!-14-*$/+)!%#;$;0'+)(!>,4)'0'+)!
84,/::4;:/+)(!')!84,-,/:*$/+)(!-,+)'+*(!%/+(!$/!$;(1,+!/).;4,0/)'*('5!/@'-!/-)1@/)1,+!')!/:4;:/)1,+!
8$/?*'))/14'!8*1(!>,40/)1,+!%#*+!-/1$$,)!,9$1);4/+)<!"/!>,40/)1,+!%'!).4,09*(!'()!>/-1$1);'!(#1$!'^1()'!*+'!
/+,0/$1'!/-?*1('!X)/9/-5!.38'4>1941+,:;+;01'!4;/-)1,++'$$'!<<<<!Y!,*!:;+;)1?*'!%'(!(3()J0'(!%'!$/!-,/:*$/)1,+!')!
%'!$/!).4,09,$3('!8.3(1,$,:1?*'<!!
W+!$#/9('+-'!%'!-14-*$/)1,+!-,$$/);4/$'!%'!(*88$;/+-'5!$#,--$*(1,+!-,4,+/14'!'+)4/h+'!*+'!1(-.;01'!/1:*`!
;@,$*/+)!6!8/4)14!%'!$/!DJ0'!.'*4'!@'4(!$/!+;-4,('!-'$$*$/14'!/+,^1?*'<!='))'!+;-4,('!(#;)'+%!%'(!-,*-.'(!(,*(A
'+%,-/4%1?*'(!@'4(!$'(!-,*-.'(!;81-/4%1?*'(<!"/!$101)/)1,+!%'!$/!+;-4,('!'()!,9)'+*'!8/4!$/!%;(,9()4*-)1,+!%'!
$#/4)J4'!-,4,+/14'!4'(8,+(/9$'!%'!$#1+>/4-)*(<!!
"#1(-.;01'!03,-/4%1?*'!'()!6!$#,41:1+'!%'!troubles&du&rythme&cardiaque&graves!X)/-.3-/4%1'!')!(*4),*)!
>1941$$/)1,+!@'+)41-*$/14'Y5!'^8$1?*/+)!$/!>4;?*'+-'!%'!$/!mort&subite<!!
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&Le&facteur&temps&est&donc&décisif&dans&la&prise&en&charge&de&l'IDM&=&URGENCE&MEDICALE&
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"/!0,4)!%'(!-'$$*$'(!03,-/4%1?*'(!'()!6!$#,41:1+'!%'!$/!$19;4/)1,+!%/+(!$/!-14-*$/)1,+!%#'+O30'(!')!%'!84,);1+'(!
8$*(!,*!0,1+(!(8;-1>1?*'(!%*!03,-/4%'!?*1!(,+)!6!$/!9/('!%*!%1/:+,()1-!91,$,:1?*'<!!
!
"'(!/*)4'(!0;-/+1(0'(!6!$#,41:1+'!%#*+!1+>/4-)*(!(,+)!9'/*-,*8!8$*(!4/4'(!]!!
A (8/(0'!-,4,+/14'!
A '09,$1'!-,4,+/14'!
A %1(('-)1,+!-,4,+/14'<!!
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!!!W=\!VR!_!
R4,8,+1+'!_!

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4!
3. Diagnostic&:& …EN&URGENCE&!!!&
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3.1 !!!Clinique&:&
• La&douleur&:&
A Rétrosternale&constrictive5!'+!9/44'!X_!1+)'+('!?*'!T+:,4Y!
A T@'-&irradiation&-'4@1-/$'!')!L,*!brachiale&gauche!
A T+:,1((/+)'!X('+(/)1,+!%'!0,4)!(*91)'Y!
A B4,$,+:;'!Xi!ME01+Y!
A b;(1()/+)'!6!$7/%01+1()4/)1,+!%'!%;41@;(!+1)4;(!(*9$1+:*/*^!
!
• Autres&signes&:&
A &/$/1('!:;+;4/$!/@'-!8H$'*4!
A b'>4,1%1(('0'+)!%'(!'^)4;01);(!
A V*'*4(!/9,+%/+)'(!
A V1:+'(!%1:'()1>(!Xj5eY!
A R/-.3-/4%1'5!S38,)'+(1,+5!>1J@4'!
!
• Formes&indolores&!!&:&
A 2EG!%'(!Z%&!
A j,)/00'+)!-.'O!$'(!(*Q')(!H:;(!')!$'(!%1/9;)1?*'(!
A P;-,*@'4)!6!$7,--/(1,+!%7'^/0'+!>,4)*1)!,*!$,4(!%'!-,08$1-/)1,+(!XZ=5!)/-.3-/4%1'!@'+)41-*$/14'!
,*!Te=Y!
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3.2 &&&&ECG…&&&en&URGENCE&!!!&:&
&
• \4/+%'(!ondes&T!8,(1)1@'(5!8,1+)*'(!')!
)4/+(1),14'(!
!ZV=SW&ZW!!(,*(A'+%,-/4%1?*'!X(1:+'!84;-,-'5!
8/(!)Q!%;)'-);Y!
!
• V*(!%;-/$/:'!%*!segment&ST!')!,+%'!'+!%k0'!%'!B/4%''!
!"WVZUj!
!
• Onde&Q,&84,>,+%'!')!$/4:'!
!jW=bUVW!(entre&la&3eme&et&la&12eme&heure)&
!
• Z+@'4(1,+!%'!l’onde&T&X+;:/)1@'Y!@'4(!lKN!
!
"#;$'-)4,-/4%1,:4/00'!'()!84/)1?*;!'+!*4:'+-'!')!/>>140'!$'!%1/:+,()1-<!!
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"'(!84'01'4(!(1:+'(!;$'-)41?*'(!(,+)!$/!84;('+-'!%'!:4/+%'(!,+%'(!R!8,(1)1@'(5!8,1+)*'(!')!)4/+(1),14'(!
%*'(!6!"#1(-.;01'!(,*(A'+%,-/4%1?*'!X(1:+'(!84;-,-'(!')!)4/+(1),14'(5!8/(!),*Q,*4(!'+4':1()4;(Y<!B*1(!)4J(!
4/81%'0'+)!/88/4/h)!*+!(*(A%;-/$/:'!%*!(':0'+)!VR!'+:$,9/+)!$#,+%'!R!4;/$1(/+)!$#,+%'!%'!B/4%''<!"#,+%'!m!
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!
!
T& & &&&&&&ST&&&&&&&Q&

IV#47&ACCIDENTS&CORONAIRES&AIGUS&
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5!
84,>,+%'!')!$/4:'5!/>>140/+)!$/!+;-4,('5!/88/4/h)!'+)4'!$/!)4,1(1J0'!')!%,*O1J0'!.'*4'<!B/4!$/!(*1)'5!$#,+%'!R!
%'@1'+)!+;:/)1@'5!8,1+)*'!')!(30;)41?*'<!!
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R,*(!-'(!(1:+'(!;$'-)4,-/4%1,:4/8.1?*'(!(,+)!$,1+!%#c)4'!),*Q,*4(!/*((1!;@,-/)'*4(!')!%/+(!84J(!%'!2EG!
%'(!ZP&5!1$(!(,+)!%1(-4')(!@,14'!/9('+)(<!=#'()!$/!(*4@'1$$/+-'!91,$,:1?*'!?*1!8'40')!/$,4(!%'!8,4)'4!$'!%1/:+,()1-!
%#ZP&<!!
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3.3 !!!Pour&les&SCA&ST&+&:&
!
&
3.4 &&&&Marqueurs&biochimiques&:&
• Enzymes&X0/1+)'+/+)!obsolète!-/4!8'*!(8;-1>1?*'Y!]&
A TVTR!
A =n!')!=nA&f!
A "PS!
!
• Myoglobine&Xinutile!-/4!0,1+(!%;-1(1,++'$$'!?*'!$/!)4,8,+1+'Y!]!
A T88/4/h)!M.!/84J(!$/!+;-4,('!Xo!T*:0'+)'!2.!/84J(!$/!).4,09,$3('Y!
A j!C!gE!*:L"!
!
• Troponines&:&
o Structure&–&localisation&–&rôle&:!
 B4,);1+'(!-,+)4/-)1$'(!03,>1941$$/14'(!%*!0*(-$'!(?*'$'))1?*'!')!%*!03,-/4%'!
 R410J4'!>,40;!%'!M!(L*!]!Z5!R5!=!
A R+=!]!KpqP!a!>1^'!$'!=/__!')!0,%*$'!$7/-)1,+!%'!$/!R+Z!
A R+Z!]!2MqP!a!>1^'!$'!>1$/0'+)!%7/-)1+'!6!$/!R+=5!'08c-.'!$/!-,+)4/-)1,+!0*(-*$/14'!
'+!$7/9('+-'!%'!=/__!
A R+R!]!MFqP!a!$1'!$'!-,08$'^'!)4,8,+1+'!6!$/!)4,8,03,(1+'!
 "'(!)4,8,+1+'(!(,+)!4')4,*@;'(!%/+(!),*(!$'(!0*(-$'(!(,*(!%1>>;4'+)'(!1(,>,40'(!
 V'*$'!$'(!R+Z!')!R+R!(,+)!(8;-1>1?*'!%*!03,-/4%'!
 "/!R+R!8,((;%'!2!1(,>,40'(!-/4%1?*'(!')!$/!R+Z!*+'!('*$'!]!$/!TnIc&
 "'!8,,$!-3),(,$1?*'!%'!)4,8,+1+'!'()!$19;4;!4/81%'0'+)5!/$,4(!?*'!$/!>4/-)1,+!$1;'!'()!
4'$/4:*;'!8$(!Q,*4(!/84J(<!
!
o Méthodes&analytiques&:!
 R4,8,+1+'!Z!]!
A P,(/:'(!8/4!)'-.+1?*'(!100*+,'+O30/)1?*'(!%'!)38'!W"ZVT!(/+%r1-.!
A [)1$1(/)1,+!%7T-!0,+,-$,+/*^!8,*4!$/!R+Z-!AAAi!4;(*$)/)(!4/81%'!
A V8;-1>1?*'5!')!('+(19$'5!-/4%1,(8;-1>1?*'___!L!R+Z-!
A B$*(1'*4(!)4,*(('(!%1(8,+19$'(!a!B9!%'!()/+%/4%1(/)1,+!
 R4,8,+1+'!R!]!
A W"ZVT!')!'$'-)4,-.101$*01+'(-'+-'!