Myocardial ischaemia, dyspnoeic and sudden cardiac death Flashcards
Treatments NSTEACS according to risk stratification
High: aggressive medical management AND coronary angiography AND revascularisation
Medium: further observation and risk stratification then restratification into high or low risk
Low: discharge on upgraded medical therapy WITH urgent cardiac follow up
What acute coronary syndrome does not have confirmed myonecrosis?
Unstable angina
Medications that cause cough (2)
ACE inhibitors
Beta blockers
What patients are likely to present without chest pain (who have acute coronary syndrome)?
Diabetics
Elderly (delerium and fatigue common)
Pain is absent in ~ 20% patients
May be complicated by cardiac failure, arrhythmias and shock.
WWWTK acute dyspnoea + no fever
chest pain?
No - wheezing?
Yes - pleuritic?
Physical exam: inspection of head and neck of dyspnoeic patient (5)
1 nasal flaring
2 pursed lip breathing
3 mouth vs nose breathing
4 evidence of trauma
5 tracheal position
Patient Hx - MI likelihood decreased if presenting with (4):
Pleuritic chest pain
Produced by palpation
Sharp or stabbing pain
Position chest pain
What investigations should be performed early for presentation of chest pain?
ECG and blood tests specifically for myonecrosis (troponin)
List factors involved in the risk stratification of NSTEACS
clinical features, complications, age, number of risk factors, high risk background including diabetics and renal failure, elevated troponins and ECG changes
Patient Hx - MI likelihood increased if presenting with (4):
SOCRATES
- radiating pain
Sweating
Nausea/vomiting
History of MI
ECG evolution during MI (5)
1 ST elevation
2 R drops and Q develops
3 T wave inversion and Q wave begins
4 ST normalizes and T wave inverted
5 ST and T normal, Q persists
Dx acute dyspnoea + fever
pneumonia
Relevant past MHx for dyspnoeic patient
Lung & heart disease and severity
GIT as well as causes of anaemia
Hx thromboembolism
Hx malignancy
Hx rheumatic disease
DDX acute dyspnoea + no fever + pleuritic chest pain (3)
Spontaneous pneumothorax
PE
Pericarditis
Medications that cause interstitial lung disease (4)
Amiodarone
Hydralazine
Bleomycine
Methotrexate
What is the typical presentation of ACS?
chest pain
Besides diagnostic value, what else is troponin good for?
Prognostic indicator
- pt. with elevated troponin but normal CK and CK-MB levels = develop adverse outcome
- the higher the troponin, the poorer the higher risk of adverse event
Medication Hx for ACS (6)?
Nitrates, beta blockers, aspirin, ACE inhibitors
Drugs for:
hypertension hypercholesterolaemia
Important DDX for troponin elevation? (6)
MI
Chronic or acute renal dysfunction
Hypertensive crisis
Tachy- or bradyarrhythmias
PE
Myocarditis
First thing to differentiate in symptom presentation of dyspnoea
acute vs chronic
STEMI symptom onset - time before hospital presentation - AND intervention
<1hr - PCI within 1hr otherwise fibrinolysis
1-3hrs - PCI within 90min otherwise fibrinolysis
3-12hrs - PCI within 90min (onsite) or 2hr (offsite) otherwise fibrinolysis
Categories in the assessment of severity of dyspnoea
Class I
- disease present bu no dyspnoea or only on exertion
Class II
- dyspnoea on moderate exercise
Class III
- dyspnoea on minimal exercise
Class IV
- dyspnoea at light rest
DDX acute dyspnoea + no fever + no chest pain + wheeze (4)
asthma
anaphylaxis
aspiration
COPD
ECG criteria (mm for leads) for diagnosis of acute STEMI (<40M, >40M and F all ages)
ST elevation…
<40 male
- V2/V3: >2.5mm
- all other leads: >1mm
> 40 male
- V2/V3: >2mm
- all other leads: >1mm
All ages female
- V2/V3: >1.5mm
- all other leads: >1mm
List 3 non cardiorespiratory causes of dyspnoea
Psychogenic
Acidosis
Hypothalamic lesion
Primary investigation of dyspnoeic patient (4)
Vitals - all, SaO2 required on pts presenting with respiratory distress
GCS
BSL on known diabetics and pts on steroids
ECG if cardiac involvement suspected
Define stable angina
Acute pain resulting from an increased demand for oxygen and a decreased ability to provide it.
- fixed stenosis
Chest pain is usually short lived (<10 min), provoked by exercise and relieved by rest and/or glycerol nitrate (GTN).
Physical exam: general inspection of dyspnoeic patient (5)
1 level of consciousness
2 level of anxiety
3 speech
4 skin colour
5 body position
DDX chronic dyspnoea + no cough (5)
Pulmonary hypertension
Cardiomyopthay
Deconditioning
Anaemia
Neuromuscular disease
List causes of type II MI (5)
1 Artherosclerosis
2 Vasospasm
3 Microvascular dysfunction
4 Non-artherosclerotic coronary dissection
5 Oxygen supply/demand imabalance alone
Define dyspnoea
Subjective feeling of breathlessness or effort in breathing.
Multidimensional, not a single sensation.
1 work/effort
2 tightness
3 air hunger
List some alternate causes of chest pain to cardiac
Psychogenic
Reflux
Musculoskeletal
Respiratory
Vascular
Abdominal
Neurological
List 3 types of chest pain
Chest wall
Pleuritic
Visceral
DDX acute dyspnoea + no fever + no chest pain + no wheeze (2)
acidosis
respiratory muscle weakness
List 4 categories of respiratory disease responsible for dyspnoea and an example for each
1 airways disease - asthma, COPD
2 parenchymal disease - interstitial lung disease
3 pulmonary circulation - PE
4 chest wall and pleura - pneumothorax
DDX chronic dyspnoea + cough + wheeze (2)
Asthma
Chronic obstructive pulmonary disease
DDX acute dyspnoea + no fever + non pleuritic chest pain (2)
Myocardial ischaemia
Pericardial effusion / cardiac tamponade
How to assess severity of dyspnoea
Amount of exertion to generate dyspnoea
- distance walked
- number of steps that can be climbed
- duration
- variability (progressive deterioration / fluctuation)
Medications that cause wheeze (4)
Beta blockers
Aspirin and NSAIDs
Morphine
Tamoxifen
Past medical Hx ACS
Hx of angina, MI or other cardiac disease
Risk factors in young patient (<65yo)?
Hx angioplasties, coronary artery bypass, previous thrombolysis?
Diabetes mellitus or chronic renal failure?
List 3 main systems/conditions responsible for dyspnoea
Cardiac
Respiratory
Anaemia
Signs in dypsnoeic patient requiring immediate treatment (7)
1 Evidence of airway obstruction or compromise
2 Severe respiratory effort and marked accessory muscle use
3 Tachypnoea > 30, single words only
4 Pallor or cyanosis
5 Hypoxia despite oxygen therapy
6 Decreased air entry
7 Altered level of consciousness
Differentiate MI type I and II.
I - plaque rupture or thrombus
II - oxygen supply/demand imbalance
Typical vs atypical pain symptoms?
Typical = chest pain - radiating pain, sweating, nausea, SOB
Atypical = chest pain - not central (jaw/arms) - burning quality, lethargy, delerium
What diagnosis results from non ST elevated acute coronary syndrome + confirmed myonecrosis?
nonSTEMI
How long within arrival time should an ECG be performed on presentation with chest pain?
10 minutes
Medications that cause PE (2)
Oestrogens
Tamoxifen
List 3 conditions present under the umbrella term acute coronary syndrome
1 Unstable angina
2 STEMI
3 nonSTEMI
Troponin elevation timeline?
Delayed by 4-6 hours
ACS treatment
Revascularization = reperfusion
- percutaneous coronary intervention
- fibrinolysis
What does pulse oximetry measure?
Amount of Hb bound with oxygen
DDX chronic dyspnoea + cough + no wheeze (4)
Interstitial lung disease
Malignancy
Chronic pneumonia
Pleural effusion
What differentiates nonSTEMI and unstable angina?
Myonecrosis confirmed = rise/fall troponin
ECG can be similar
Initial management of NSTEACS presentations
All patients with NSTEACS should be given aspirin, unless contraindicated
Risk stratification: high, medium, low
Define unstable angina
Pain that occurs when the heart doesn’t receive enough oxygen. Unpredictable symptoms occurring during exertion and at rest.
- dynamic stenosis
Chest pain is prolonged or atypical presentation of known angina without ECG or laboratory findings of MI.
What is ECG able to differentiate between and allow for what immediate treatment?
STEMI vs NSTEACS
Immediate reperfusion
Adjunctive treatments of STEMI
Antiplatelets
Anticoagulants
Direct thrombin inhibitors
Oxygen
Nitrates
Antiemetics
Analgesics
DDX of patient with dyspnoea…
1 central chest pain
2 pleuritic chest pain
central - AMI, acute pulmonary edoema
pleuritic - PE, pneumothorax, pleural disease
List 5 cardiac conditions leading to dyspnoea
LV failure
Ischaemia
Valvular disease
Cardiomyopathy
Pericardial effusion
