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IM - ISCHEMIC HEART DISEASES

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tonystep1's version from 2017-08-25 09:50

ISCHEMIC HEART DISEASE Differential diagnosis and distinguishing clinical features

Question Answer
Stable Angina PectorisChest pain or substernal pressure sensation // Lasts less than 10 to 15 minutes (usually 1 to 5 minutes) // Brought on by exertion or emotion // Resting ECG usually normal
Unstable Angina Pectorischronic angina with increasing frequency, duration, or intensity of chest pain // new-onset angina that is severe and worsening // angina at rest // negative cardiac enzymes
Variant (Prinzmetal's) AnginaEpisodes of angina occur at rest and are associated with ventricular dysrhythmias // Hallmark is transient S-T segment elevation (not depression) on ECG during chest pain
Myocardial Infarction (MI)Intense substernal pressure sensation; often described as "crushing" and "an elephant standing on my chest >30mins // Radiation to neck, jaw, arms, or back, commonly to the left side // S-T segment elevation indicates transmural injury and can be diagnostic of an acute infarct // elevated cardiac enzymes
PericarditisOften severe and pleuritic association with breathing // Pain is positional: It is aggravated by lying supine, coughing, swallowing, and deep inspiration. // Pain is relieved by sitting up and leaning forward // Pericardia! friction rub // Diffuse S-T elevation and PR depression
Aortic dissectionSevere, tearing/ripping/stabbing pain, either in the anterior or back of the chest (often the interscapular region) // Pulse or BP asymmetry between limbs // Diaphoresis // CXR shows widened mediastinum (>8 mm on AP view) .
pulmonary embolismPleuritic chest pain // Dyspnea // A normal V/Q scan virtually rules out or negative d-dimer // Virchow's triad (hemodynamic changes , endothelial injury, hypercoagulability)
pneumothoraxIpsilateral chest pain, usually sudden in onset // Decreased breath sounds over the affected side // Decreased or absent tactile fremitus on affected side // CXR line demarcating free air (hyperlucent with no pulmonary vascular markings) in the pleural space
gastroesophageal reflux diseaseHeartburn, dyspepsia // Retrosternal pain/burning shortly after eating (especially after large meals) // Exacerbated by lying down after meals // Regurgitation
diffuse esophageal spasmchest pain that may radiate to the jaw, arms, and back. // Dysphagia is common // Esophageal manometry shows simultaneous, multiphasic, repetitive contractions that occur after a swallow; sphincter response is normal // Upper GI barium swallow ("corkscrew esophagus")-in 50%
peptic ulcer diseaseEpigastric pain Aching or gnawing in nature // Nocturnal symptoms and the effect of food on symptoms are variable // Biopsy: histologic evaluation of endoscopic biopsy is gold standard // Urease detection via urea breath test is the most convenient test (sensitivity and specificity >95%)
esophageal rupturePain of variable location, commonly in the lower anterior chest or upper abdomen // Vomiting // Subcutaneous emphysema // Water-soluble contrast esophagogram shows contrast leak (arrowheads) and normal esophageal lumen
costochondritisChest wall pain with a history of repeated minor trauma or unaccustomed activity (eg, painting, moving furniture) is common // Exacerbated by trunk movement, deep inspiration, and/or exertion // Lessens with decreased movement, quiet breathing, or change of position // The second through the fifth costochondral junctions typically are tender.
rib fracture history of trauma // complain of pain on inspiration and dyspnea. // tenderness on palpation, crepitus, and chest wall deformity are common findings // With flail chest, the detached segment of the chest wall is pulled into the chest cavity during inspiration and pushed outward during expiration
herpes zosterCutaneous findings that typically appear unilaterally, stopping abruptly at the midline of the limit of sensory coverage of the involved dermatome // Vesicular involution: Vesicles initially are clear but eventually cloud, rupture, crust, and involuted
vascular thoracic outlet syndromepatients who perform vigorous overhead arm activity such as throwing // patients may report color changes of their affected upper extremity, claudication, or diffuse arm or hand pain (including the forearm) // if venous obstruction present patients may present with upper extremity swelling, venous distention, or diffuse arm or hand pain (including the forearm)
panic attacksa period of intense fear in which 4 of 13 defined symptoms develop abruptly and peak rapidly less than 10 minutes from symptom onset. // Palpitations, pounding heart, or accelerated heart rate // Trembling or shaking // During the episode, patients have the urge to flee or escape and have a sense of impending doom
Cocaine useMydriasis, headache, bruxism, nausea, vomiting, vertigo, nonintentional tremor (eg, twitching of small muscles, especially facial and finger), tics, preconvulsive movements, and pseudohallucinations // Possible increase in blood pressure (BP), slowed or increased pulse rate (possibly with ventricular ectopy), and pallor // Urine toxicology positive for 60hrs to 22 days
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Diagnosis of CAD

Question Answer
If a patient with stable angina has normal resting ECG, what is the next step?Determine whether the patient is capable of performing treadmill exercise. If so, proceed to an exercise stress test
What are positive findings in an exercise stress ECG test?Exercise-induced ischemia results in subendocardial ischemia, producing ST segment depression. // Other positive findings include onset of heart failure or ventricular arrhythmia during exercise or hypotension.
What are positive findings in an exercise stress echocardiogram test?Performed before and immediately after exercise. Exercise-induced ischemia is evidenced by wall motion abnormalities (e.g., akinesis or dyskinesis) not present at rest.
If a patient has a positive stress test , what is the next step?patients with a positive test result should undergo cardiac catheterization
When is a pharmacological stress test indicated and how is it performed ?If the patient cannot exercise // IV adenosine, dipyramidole, or dobutamine can be used. The cardiac stress induced by these agents takes the place of exercise. This can be combined with an ECG, an echocardiogram, or nuclear perfusion imaging
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Management decisions (general guidelines)-Risk factor modification and aspirin are indicated in all patients. Manage patients according to overall risk:

Question Answer
Mild disease (normal EF, mild angina, single-vessel disease)Nitrates (for symptoms and as prophylaxis) and a /3-blocker are appropriate // Consider calcium channel blockers if symptoms continue despite nitrates and /3-blockers.
Moderate disease (normal EF, moderate angina, two-vessel disease)if medical regimen does not control symptoms then - consider coronary angiography to assess suitability for revascularization (either PTCA or CABG) .
Severe disease (decreased EF, severe angina, and three-vessel/left main or left anterior descending disease)Coronary angiography and consider for CABG
When is CABG indicated?Indicated in patients with left main disease, three-vessel disease with reduced left ventricular function, two-vessel disease with proximal LAD stenosis, or severe ischemia for palliation of symptoms
What is the management of Unstable Angina?Aspirin // Beta Blockers // Low Molecular weight heparin (Keep PTT at 2 to 2.5 times normal if using unfractionated heparin; PTT not followed with LMWH) // Nitrates are first-line therapy
What if medical management of Unstable Angina fails?If medical therapy fails to improve symptoms ancllor ECG changes indicative of ischemia persist after 48 hours, then proceed directly to catheterization/ revascularization.
What is the management of a patient with MI ?Admit patient to a cardiac monitored floor ( CCU) and establish IV access. Give supplemental oxygen and analgesics (nitrates, morphine) // Revascularization // Aspirin , Beta Blocker, ACE inhibitors , Statins , Nitrates , Morphine , Heparin
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ECG findings based on location of infarct

Question Answer
Anterior infarctS-T segment elevation in V1 -V4Iacute/active) // Q waves in leads V1 -V4 IIate change)
Posterior infarctLarge R wave in Vl and V2 S-T // segment depression in Vl and V2 // Upright and prominent T waves in Vl and V2
Lateral infarctQ waves in leads I and aVL I late change)
Inferior infarctQ waves in leads II, Ill, aVF I late change)
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CHF Clinical Features and Diagnosis

Question Answer
Symptoms of left-sided heart failureDyspnea // Orthopnea // Paroxysmal Nocturnal dyspnea // Nocturnal cough (non productive) // Diaphoresis and cool extremities(NYHA class IV)
Signs of left-sided heart failureDisplaced PMI (usually to the left) due to cardiomegaly // Pathologic S3 (ventricular gallop) // S4 // Crackles/rales at lung bases // Dullness to percussion and decreased tactile fremitus of lower lung fields caused by pleural effusion // Increased intensity of pulmonic component of second heart sound indicates pulmonary HTN (heard over left upper sternal border).
Symptoms/signs of right-sided heart failurePeripheral pitting edema // Nocturia // JVD // Hepatomegaly/hepatojugular reflex // Ascites // Right ventricular heave
Chest x-ray (CXR) findingsCardiomegaly // Kerley B lines are short horizontal lines near periphery of the lung near the costophrenic angles, and indicate pulmonary congestion secondary to dilatation of pulmonary lymphatic vessels. // Prominent interstitial markings // Pleural effusion
How can the Ejection Fraction be determined?Echocardiogram and Radionuclide ventriculography using technetium-99m
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CHF Treatment and Management

Question Answer
If patient presents with systolic dysfunctionSodium restriction: <4 g/day (initially) // Diuretics // ACE inhibitors (Monitor BP, potassium, BUN, and creatinine.) // {3-Blockers (Should be given to stable patients with mild to moderate CHF (class I, II, and III) unless there is a noncardiac contraindication)
If patient presents with diastolic dysfunctionDiastolic dysfunction: few therapeutic options available; patients are treated symptomatically
Mild CHF (NYHA Class I to II)Mild restriction of sodium intake (no-added-salt diet of <4 g sod i u m ) and physical activity // Start a loop diuretic if volume overload or pulmonary congestion is present // Use an ACE inhibitor as a first-line agent.
Mild to Moderate CHF (NYHA Class II to Ill)Start a diuretic (loop diuretic) and an ACE inhibitor // Add a {3-blocker if moderate disease (class II or I l l ) is present and the response to standard treatment is suboptimal
Moderate to Severe CHF (NYHA Class Ill to IV)Add digoxin (to loop diuretic and ACE inhibitor) // Note that digoxin may be added at any time for the relief of symptoms in patients with systolic dysfunction. (It does not improve mortality.) // In patients with class IV symptoms who are stil l symptomatic despite the above, adding spironolactone can be helpful.
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