Please enable JavaScript.

Coggle requires JavaScript to display documents.

(Introduction and Epidemiology, Clinical Features, Diagnosis and…

- - - - Defined by myocardial necrosis evident from elevation of cardiac biomarkers
      - Classified by ECG into STEMI or NSTEMI
    - - Clinical diagnosis defined by chest pain or equivalent from inadequate myocardial perfusion
      - Characteristics: new onset or occurring with greater frequency less activity or at rest
      - ECG: no pathologic ST-segment elevation
      - Cardiac biomarkers: no elevation
      - Risk: eventual myocardial damage absent recognition and treatment
- - - - Pain outside chest: epigastrium neck jaw shoulders arms
      - No chest pain experienced or pain migrated away from chest at evaluation
      - AMI without chest pain: diagnostic and treatment delays with in-hospital mortality >2 times higher than those with chest pain
    - - Retrosternal left anterior chest crushing squeezing tightness or pressure
      - Exacerbated by exertion and relieved by rest
      - Duration patterns
        
        Anginal pain: 2-10 minutes
        
        Unstable angina pain: 10-30 minutes
        
        AMI pain: >30 minutes
      - Associated classic features: radiation to arms neck or jaw diaphoresis dyspnea nausea vomiting
    - - Characteristics: lasting for seconds constant pain lasting 12-24 hours or more without waxing/waned intensity pain worsened by specific body movements/positions
      - Uncommon in ACS but cannot exclude it: stabbing well-localized positional pleuritic
      - Multicenter Chest Pain Study: 22% of AMI patients described pain as sharp or stabbing
      - Higher frequency groups: women racial minorities diabetics elderly patients with psychiatric disease or altered mental status
      - Cultural differences: term sharp may mean severe rather than knife-like in some cultures
      - Pre- and early menopausal women features: pain unrelated to exercise pain not relieved by rest or nitroglycerin pain relieved by antacids palpitations without chest pain chief complaint of fatigue
      - Sex-based associated symptoms: nausea emesis jaw/neck/back pain more common in women diaphoresis more common in men
    - - Non-chest pain presentation rate in MI: 47% in one large public hospital study
      - Equivalent symptoms: dyspnea at rest or exertion nausea lightheadedness generalized weakness acute mental status changes diaphoresis shoulder/arm/jaw discomfort
      - Risk of dyspnea: 4-fold increased risk of sudden cardiac death compared to asymptomatic patients 2-fold compared to classic angina
      - Epigastric or upper abdominal discomfort: raises ACS suspicion especially in age >50 or known CAD (routine ECG recommended for abdominal pain in these groups)
      - New palpitations: ischemia increases automaticity and irritability triggering dysrhythmias tachycardia increases oxygen demand
    - - Major CAD risk factors: age >40 male or postmenopausal female hypertension tobacco use hypercholesterolemia diabetes truncal obesity family history sedentary lifestyle
      - Cocaine use: associated with AMI in young people with minimal/no CAD chronic use accelerates atherosclerosis ED cocaine-associated acute chest pain has low rate of adverse outcomes
      - HIV infection and HAART: accelerates atherosclerosis
      - Diagnostic value of risk factors: useful for population risk prediction less useful for diagnosing ACS presence/absence in individual patient
      - Previous cardiac history: identify prior chest pain echocardiography stress testing coronary angiography revascularization (stent or CABG)
  - - - Tachycardia mechanism: increased sympathetic tone and decreased left ventricular stroke volume
      - Bradycardia mechanism: ischemia/infarction of conduction system or altered sympathetic/parasympathetic activation of SA/AV nodes
    - - Heart sounds: S1 or S4 gallop diminished S1 paradoxically split S2
      - New murmurs: AMI with chordae tendineae rupture or aortic root dissection
      - Lung sounds: crackles from ischemia-induced congestive heart failure
  - - - Abnormal vital signs
      - ECG findings of ischemia or injury
      - History of prior coronary artery disease
      - Multiple atherosclerotic risk factors
      - Abrupt new or severe chest pain or dyspnea
    - - Initiate cardiac monitoring
      - Establish IV access
      - Obtain ECG ideally within 10 minutes of arrival
      - Identify and treat immediate life needs (airway breathing circulation)
      - Measure vital signs promptly and at regular intervals
      - Administer oxygen if ambient saturation <94%
    - - ACS
      - Aortic dissection
      - Pulmonary embolism
      - Severe pneumonia
      - Esophageal rupture
      - Symptom parameters: onset timing severity radiation character
      - Modifying factors: alleviating and exacerbating factors
      - Associated symptoms: diaphoresis dyspnea nausea vomiting palpitations dizziness
    - - Inspection: prior surgical incisions chest wall deformities symmetric respiratory rise and fall
      - Palpation: tenderness masses crepitus
      - Auscultation: consolidation pneumothorax murmurs gallops friction rubs
      - Imaging: chest radiograph to identify immediate life-threatening processes
  - - - Radiation to right arm or shoulder: Positive Likelihood Ratio 2.31
      - Radiation to both arms or shoulders: Positive Likelihood Ratio 2.58
      - Associated with exertion: Odds Ratio 2.81
      - Radiation to left arm: Positive Likelihood Ratio 1.36
      - Associated with diaphoresis: Odds Ratio 1.50
      - Associated with nausea or vomiting: Odds Ratio 0.89
      - Described as pressure/squeezing: Odds Ratio 1.52
      - Similar to previous ischemia: Odds Ratio 3.35
    - - Described as pleuritic: Odds Ratio 0.5
      - Described as worse with movement: Odds Ratio 0.69
      - Described as sharp: Odds Ratio 0.42
      - Tender chest wall: Odds Ratio 0.2
      - Radiation to abdomen: Odds Ratio 0.34
      - Not associated with exertion: Odds Ratio 0.8
- - - - Symptoms: sharp pleuritic chest pain dyspnea hypoxemia syncope shock cough hemoptysis fever leg swelling/pain chest wall tenderness
      - Physical exam: tachypnea tachycardia hypoxemia
      - Risk factors: recent surgery trauma prolonged immobility active cancer estrogen therapy/birth control combined with smoking procoagulant syndromes prior PE/DVT
      - Decision tools: Wells score Revised Geneva score PERC rule
      - D-dimer: sensitive ELISA excludes PE in stable low-to-intermediate risk (Geneva score 0-10) limited value in high risk
      - Prognostic biomarker: elevated troponin indicates ventricular dysfunction and higher risk of death/complications
      - ECG: nonspecific most common is sinus tachycardia
      - Imaging: chest radiograph usually nonspecific CT pulmonary angiography is test of choice
    - - Pain character: ripping or tearing sensation sudden onset maximal at onset radiation to interscapular back migrating above/below diaphragm
      - Secondary symptoms: stroke findings AMI limb ischemia from arterial branch occlusion
      - Risk factors: male sex age >50 poorly controlled hypertension cocaine/amphetamine use bicuspid aortic valve prior aortic valve replacement Marfan syndrome Ehlers-Danlos syndrome pregnancy
      - Physical exam: unilateral pulse deficit in carotid radial or femoral artery (likelihood ratio 31) focal neurologic deficits in 16%
      - Diagnostic testing: normal chest radiograph or normal D-dimer lowers likelihood but cannot exclude ECG changes in 40-50% elevated troponin associated with increased mortality CT aortogram or TEE when suspected
    - - High-risk populations: elderly immunocompromised multiple comorbidities
      - Symptoms: sharp or pleuritic chest pain fever cough sputum production hypoxemia
      - Physical exam: decreased breath sounds rales bronchial breath sounds
      - Imaging: chest radiograph confirms diagnosis
    - - History: sudden-onset sharp substernal chest pain following forceful vomiting
      - Exam: ill-appearing tachycardic febrile dyspneic diaphoretic neck/chest subcutaneous emphysema Hamman's crunch (audible crepitus varying with heartbeat)
      - Imaging: chest radiograph shows pleural effusion (left > right) pneumothorax pneumomediastinum pneumoperitoneum subcutaneous air CT with oral water-soluble contrast for confirmation
    - - Symptoms: sudden-onset sharp pleuritic chest pain with dyspnea
      - Patient profile: tall slender males risk factors include smoking asthma COPD
      - Complication: 1-3% develop tension pneumothorax
      - Exam: decreased breath sounds hyperresonance on ipsilateral side diagnosed by chest radiography
    - - Pain character: sharp severe constant substernal pain radiating to back neck shoulders worsened by lying flat/inspiration relieved by sitting up/leaning forward
      - Exam: pericardial friction rub (most specific)
      - ECG: diffuse ST-segment elevation with PR depression
    - - Symptoms: sharp chest pain palpitations fatigue anxiety dyspnea unrelated to exertion
      - Exam: mid-systolic click on auscultation
    - - Characteristics: sharp highly localized positional pain reproducible by light-to-moderate palpation or movements
      - Costochondritis (Tietze's syndrome): inflammation of costal cartilages or sternal articulations
      - Xiphodynia: inflammation of xiphoid process reproduced by light palpation
      - Precordial catch syndrome (Texidor twinge): short lancinating pain in bunches lasting 1-2 minutes near cardiac apex associated with inspiration/inactivity
      - Pleurisy: inflammation of parietal pleura causing sharp pleuritic pain
    - - Gastritis and GERD: burning or gnawing pain in lower chest acidic taste lessened by antacids exacerbated by recumbency
      - Peptic Ulcer Disease: postprandial dull boring epigastric pain awakening from sleep duodenal relieved by food gastric exacerbated by food
      - Pancreatitis and Biliary Disease: RUQ or epigastric pain/tenderness can cause chest pain
      - Esophageal Spasm: sudden dull or tight substernal pain triggered by hot/cold liquids or large bolus relieved by nitroglycerin
    - - Diagnostic criteria: recurrent panic attacks with >=4 symptoms (chest pain dyspnea palpitations diaphoresis nausea tremor choking dizziness fear of dying paresthesias chills hot flashes)
      - Epidemiology: 25% of ED chest pain patients meet panic disorder criteria 9% with panic disorder are diagnosed with ACS at discharge
      - Management rule: diagnosis of exclusion or co-diagnosis with ACS
- - - - Localization: complexed with actin/myosin and in myocyte cytoplasm
      - Mechanism: myocyte membrane disruption leaks cTn into peripheral blood
      - Role: biomarker of choice due to high sensitivity and near-complete cardiac specificity
      - Non-ischemic causes: contusion procedures heart failure aortic dissection valve disease HCM dysrhythmias apical ballooning rhabdomyolysis pulmonary hypertension PE stroke infiltrative/inflammatory diseases drug toxicity sepsis burns extreme exertion
      - AMI Diagnostic Criteria: gradual rise and fall above 99th percentile (upper reference limit) PLUS ischemic symptoms OR acute ECG changes OR new regional wall motion abnormality/loss of myocardium
      - Obsolete markers: myoglobin and CK-MB are obsolete
      - Isoforms: cTnI and cTnT
        
        Renal failure difference: cTnT elevation more common than cTnI
        
        Dialysis effect: cTnT increases post-dialysis cTnI decreases
      - High-Sensitivity Troponin Assays (Fifth-Generation)
        
        Upper reference limit range: 10 to 40 ng/L
        
        Analytical sensitivity: 10-fold higher than previous assays
        
        Sensitivity for AMI: 94-96% vs 85-90% for previous assays
        
        Early presentation (<3 hours): sensitivity 92-94% vs 76% for previous assays
        
        Trade-off: potential oversensitivity by detecting non-AMI cTn elevations
      - Prognostic Value: elevated cTn associated with increased risk of death or AMI at 30 days (Odds Ratio 3.4)
      - Testing Protocol: obtain in all suspected ACS single 4th-gen cTn identifies 80% within 2-3 hours two high-sensitivity cTn within 3 hours approaches 100% sensitivity single cTn safe only in select low-risk patients with constant symptoms >6-12 hours
    - - Specificity: non-specific to ischemia rises with any ventricular dysfunction
      - Prognostic value: elevated level predicts higher short-term mortality in ACS
    - - High-sensitivity C-reactive protein: aids long-term prediction not recommended for ED care
      - Investigational biomarkers not supported for ED chest pain evaluation: ischemia-modified albumin IL-6 VCAM ICAM E-selectin P-selectin PAPP-A myeloperoxidase copeptin H-FABP