Cardiology an der RCSI-Medical University Of Bahrain | Karteikarten & Zusammenfassungen

Lernmaterialien für Cardiology an der RCSI-Medical University of Bahrain

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DEFINITION OF A TYPE 1 MYOCARDIAL
INFARCTION

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TESTE DEIN WISSEN

Detection of a rise and/ or fall of Troponin with at least one value
above the 99th percentile upper reference limit (URL) and with at

least one of the following:
 Symptoms of acute myocardial ischemia (central crushing
chest pain for several minutes)
 New Ischemic ECG changes
 Development of pathological Q waves
 Imaging evidence of new loss of viable myocardium or new
regional wall motion abnormality
 Identification of a coronary thrombus by angiography or
autopsy

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TESTE DEIN WISSEN

Common description of ACS pain

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Vise-like,


Constricting,


Crushing weight and / or pressure

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How do you clinically diagnose ACS? 

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Electrocardiographic changes suggestive of acute myocardial ischemia: 
- New ST Elevation at the J-point in two contiguous leads with the cut-off points: ≥1mm in all other leads except V2-V3 where the - following cut-off points apply: ≥2mm in men ≥ 40 years; ≥ 2.5mm in men <40 years, or ≥ 1.5mm in women regardless of age. 
- ST depression and T Wave changes are defined as new horizontal or down-sloping ST depression ≥ 0.5mm in two contiguous leads and / or T Wave inversion> 1mm in two contiguous leads with prominent R wave or R / S ratio> 1

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TESTE DEIN WISSEN

Pathophysiology/Aetiology of ACS

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5 different types of myocardial infarction: 

• Type 1 Myocardial Infarction (MI) is an acute event caused by atherosclerotic plaque disruption 

• Type 2 MI is an elevated troponine with evidence of an imbalance between myocardial oxygen supply and demand, which is unrelated to coronary athero thrombosis. Examples include severe anemia, hypotension, and respiratory failure 

• Type 3 MI is diagnosed on autopsy when patients have sudden cardiac death with symptoms suggestive of myocardial ischemia, with associated ECG changes,

• Type 4 MI is related to percutaneous coronary intervention where there is a significant troponin rise (x5 ULN) secondary to the procedure with associated evidence of myocardial ischemia 

• Type 5 MI is related to coronary artery bypass grafting (CABG) where there is a significant troponin rise (x10 ULN) with associated evidence of myocardial ischemia

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Epidemiology of ACS

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- The relative incidence of STEMI is decreasing, whilst the incidence of NSTEMI is increasing

- The inpatient mortality rate is higher with STEMI varying between 4-12%

ACS occurs 3-4 times more often in men than in women <60, but after the age of 75, women represent the majority of patients with ACS

The inpatient mortality rate is higher with STEMI varying between 4-12%

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Aortic Dissection

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 Acute onset 

 Described as tearing sensation 

 Radiates to the back - intra scapular 

 Radio-radial delay 

 LR arm BP difference (> 20mmHg) 

 ECG can occasionally demonstrate ST elevation if the cusp of the coronary artery is involved, causing a simultaneous STEMI 

 Elevated troponin 

 Elevated D-Dimer 

 CT Aortogram is the diagnostic test of choice

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TESTE DEIN WISSEN

Risk factors of ACS

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• Prior history of ACS 
• Family history (1st degree relative <55 in males and <65 in females) 
• Smoking 
• Sex 
• Hypercholesterolemia 
• Hypertension 
• Diabetes mellitus 
• Obesity

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Myocarditis

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 Often there is a viral prodrome with a more gradual onset 

 Younger population 

 No radiation 

 Pyrexic 

 Non-specific ECG changes 

 Elevated WCC, CRP 

 Elevated troponin 

 Echo may show regional wall motion abnormalities of the left ventricle. 

 Cardiac magnetic resonance imaging shows myocardial edema

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Pericarditis

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 Often there is a viral prodrome with a more gradual onset 

 Younger population 

 Aggravated by lying flat, relieved by sitting forward 

 No radiation 

 Global ST elevation characteristic (Saddle ST changes) and PR Depression 

 Elevated WCC, CRP 

 Normal or mildly elevated troponin 

 Echo can occasionally show a small pericardial effusion

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Pulmonary Embolism

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 Acute onset dyspnoea with associated chest pain  Can present with syncope or pre syncope 

 Associated with malignancy, OCP, immobilization

 Unilateral lower limb edema 

 ECG - most common finding is sinus tachycardia, rarely “S1Q3T3” suggestive of right heart strain 

 Wells score - can help calculate probability 

 CTPA is the diagnostic test of choice if high index of suspicion

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Ddx of ACS

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• Pericarditis

• Myocarditis

• Pulmonary Embolism

• Aortic Dissection

• Musculoskeletal pain

• Atypical pneumonia/ Pleurisy

• Oesophageal spasm /GORD

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Symptoms of ACS

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- Chest pain

- Feelings of heart racing / increased awareness of heart beating

- Feeling weak / dizzy 

- Nausea and diaphoresis      
- Shortness of breath 

- Exercise related chest pain

- Swelling of the legs and difficulty in lying flat / increased breathlessness

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Q:

DEFINITION OF A TYPE 1 MYOCARDIAL
INFARCTION

A:

Detection of a rise and/ or fall of Troponin with at least one value
above the 99th percentile upper reference limit (URL) and with at

least one of the following:
 Symptoms of acute myocardial ischemia (central crushing
chest pain for several minutes)
 New Ischemic ECG changes
 Development of pathological Q waves
 Imaging evidence of new loss of viable myocardium or new
regional wall motion abnormality
 Identification of a coronary thrombus by angiography or
autopsy

Q:

Common description of ACS pain

A:

Vise-like,


Constricting,


Crushing weight and / or pressure

Q:

How do you clinically diagnose ACS? 

A:

Electrocardiographic changes suggestive of acute myocardial ischemia: 
- New ST Elevation at the J-point in two contiguous leads with the cut-off points: ≥1mm in all other leads except V2-V3 where the - following cut-off points apply: ≥2mm in men ≥ 40 years; ≥ 2.5mm in men <40 years, or ≥ 1.5mm in women regardless of age. 
- ST depression and T Wave changes are defined as new horizontal or down-sloping ST depression ≥ 0.5mm in two contiguous leads and / or T Wave inversion> 1mm in two contiguous leads with prominent R wave or R / S ratio> 1

Q:

Pathophysiology/Aetiology of ACS

A:

5 different types of myocardial infarction: 

• Type 1 Myocardial Infarction (MI) is an acute event caused by atherosclerotic plaque disruption 

• Type 2 MI is an elevated troponine with evidence of an imbalance between myocardial oxygen supply and demand, which is unrelated to coronary athero thrombosis. Examples include severe anemia, hypotension, and respiratory failure 

• Type 3 MI is diagnosed on autopsy when patients have sudden cardiac death with symptoms suggestive of myocardial ischemia, with associated ECG changes,

• Type 4 MI is related to percutaneous coronary intervention where there is a significant troponin rise (x5 ULN) secondary to the procedure with associated evidence of myocardial ischemia 

• Type 5 MI is related to coronary artery bypass grafting (CABG) where there is a significant troponin rise (x10 ULN) with associated evidence of myocardial ischemia

Q:

Epidemiology of ACS

A:

- The relative incidence of STEMI is decreasing, whilst the incidence of NSTEMI is increasing

- The inpatient mortality rate is higher with STEMI varying between 4-12%

ACS occurs 3-4 times more often in men than in women <60, but after the age of 75, women represent the majority of patients with ACS

The inpatient mortality rate is higher with STEMI varying between 4-12%

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Q:

Aortic Dissection

A:

 Acute onset 

 Described as tearing sensation 

 Radiates to the back - intra scapular 

 Radio-radial delay 

 LR arm BP difference (> 20mmHg) 

 ECG can occasionally demonstrate ST elevation if the cusp of the coronary artery is involved, causing a simultaneous STEMI 

 Elevated troponin 

 Elevated D-Dimer 

 CT Aortogram is the diagnostic test of choice

Q:

Risk factors of ACS

A:

• Prior history of ACS 
• Family history (1st degree relative <55 in males and <65 in females) 
• Smoking 
• Sex 
• Hypercholesterolemia 
• Hypertension 
• Diabetes mellitus 
• Obesity

Q:

Myocarditis

A:

 Often there is a viral prodrome with a more gradual onset 

 Younger population 

 No radiation 

 Pyrexic 

 Non-specific ECG changes 

 Elevated WCC, CRP 

 Elevated troponin 

 Echo may show regional wall motion abnormalities of the left ventricle. 

 Cardiac magnetic resonance imaging shows myocardial edema

Q:

Pericarditis

A:

 Often there is a viral prodrome with a more gradual onset 

 Younger population 

 Aggravated by lying flat, relieved by sitting forward 

 No radiation 

 Global ST elevation characteristic (Saddle ST changes) and PR Depression 

 Elevated WCC, CRP 

 Normal or mildly elevated troponin 

 Echo can occasionally show a small pericardial effusion

Q:

Pulmonary Embolism

A:

 Acute onset dyspnoea with associated chest pain  Can present with syncope or pre syncope 

 Associated with malignancy, OCP, immobilization

 Unilateral lower limb edema 

 ECG - most common finding is sinus tachycardia, rarely “S1Q3T3” suggestive of right heart strain 

 Wells score - can help calculate probability 

 CTPA is the diagnostic test of choice if high index of suspicion

Q:

Ddx of ACS

A:

• Pericarditis

• Myocarditis

• Pulmonary Embolism

• Aortic Dissection

• Musculoskeletal pain

• Atypical pneumonia/ Pleurisy

• Oesophageal spasm /GORD

Q:

Symptoms of ACS

A:

- Chest pain

- Feelings of heart racing / increased awareness of heart beating

- Feeling weak / dizzy 

- Nausea and diaphoresis      
- Shortness of breath 

- Exercise related chest pain

- Swelling of the legs and difficulty in lying flat / increased breathlessness

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