Cardiovascular case for - HOME - Bradford VTS



Case scenario: Part 165-year-old male, currently pain-free but experienced chest pain in the previous 12 hours John, 65 years old, presents to your GP branch surgery at 0830. He reports that he had chest pain last night, which woke him from his sleep. The pain started at around 0200. He thinks it lasted about 20–25 minutes. He reports that he felt sweaty during the pain. He did not want to bother anyone so he rested and the pain eased. He reports that it was very painful and therefore wanted to see you to get it checked. He is currently not in any pain, although he feels quite tired. Medical history He has been a smoker for 40 years. On average, he has around 10 cigarettes a day. He has no past medical history of chest pain, ischemic heart disease or heart failure.Questions:What are your differential diagnoses, remember to think laterally?As the GP, should you suspect acute coronary syndrome (ACS)? What is ACS?What immediate management should you offer whilst patient is in surgery? Should all patients be given oxygen? Other monitoring? You do not have an ECG machine at your branch surgery. Should you refer him to hospital? If so, how urgently? Part 2.Presentation to A&E On admission at 1030 John’s heart rate is 75 bpm and his blood pressure is 127/80 mmHg. Tropinin T 0.02 Creatinine 0.9 mg/dL. Questions Which blood tests should be done?When should you repeat the troponin?Part 3.ECG: there is no regional ST elevation or presumed left bundle branch block (LBBB) and no ST-segment depression or deep T wave inversion suggestive of a non-ST-segment-elevation myocardial infarction (NSTEMI) or stable angina.Admission to medical admissions ward 12 hours after symptom onset the troponin T is 0.15 ug/L. QuestionCan you diagnose ACS? If so, why?What early management should you offer this patient?ANSWERS Chest pain - acute or worseningDiagnosisEvidence?Angina (new or unstable)Suggested by: central pain ± radiating to jaw and either arm (left usually). Intermittent, brought on by exertion, relieved by rest or nitrates, and lasting <30 minutes. May be associated with transient ST depression or T inversions or, rarely, ST elevation.?Confirmed by: no troponin rise after 12 hours (excludes MI). Stress test showing inducible ischemiaST-elevation myocardial infarction (STEMI)Suggested by: central chest pain ± radiating to jaw and either arm (left usually). Continuous, usually over 30 minutes, not relieved by rest or nitrates?Confirmed by: ST elevation 1 mm in limb leads or 2 mm in chest leads on serial ECGs (this is regarded as sufficient evidence to treat with thrombolysis). Raised troponin indicates episode of muscle necrosis up to 2 weeks before. Raised troponin may not be present in the first 4 hours after the onset of chest pain.Non-ST elevation myocardial infarction (NSTEMI)Suggested by: central chest pain ± radiating to jaw and either arm (left usually). Continuous, usually over 30 minutes, not relieved by rest or nitrates?Confirmed by: elevated troponin after 12 hours. T-wave and ST-segment changes but no ST elevation on serial ECGsEsophagitis and oesophageal spasmSuggested by: past episodes of pain when supine, after food. Relieved by antacids?Confirmed by: no increase in troponin after 12 hours and no ST-segment changes on ECG. Improvement with antacids. Esophagitis on endoscopyPulmonary embolus (arising from leg DVT, silent pelvic vein thrombosis, right atrial thrombus)Suggested by: central chest pain, also abrupt shortness of breath, cyanosis, tachycardia, loud second sound in pulmonary area, associated deep vein thrombosis, (DVT) or risk factors such as cancer, recent surgery, immobility?Confirmed by: V/Q scan with mismatched ventilation and perfusion, spiral (helical) CT (CT-pulmonary angiogram) showing clot in pulmonary arteryPneumothoraxSuggested by: abrupt pain in center or side of chest with abrupt breathlessness. Resonance to percussion over site?Confirmed by: expiration CXR showing dark field with loss of lung markings outside sharp line containing lung tissueDissecting thoracic aortic aneurysmSuggested by: ‘tearing pain often radiating to back and not responsive to analgesia, abnormal or absent peripheral pulses, early diastolic murmur, low blood pressure, and wide mediastinum on CXR?Confirmed by: loss of single clear lumen on CT scan or MRIChest wall pain (e.g.costochondritis and Tietze’s syndrome, strained muscle or rib injury)Suggested by: chest pain and localized tenderness of chest wall or chest pain on twisting of neck or thoracic cage?Confirmed by: no rise in troponin after 12 hours, and no ST-segment changes or T-wave changes serially on ECG. Response to rest and analgesicsAlso consider GI causes.2. As the GP, should you suspect acute coronary syndrome (ACS)? What is ACS?The term 'acute coronary syndrome' (ACS) covers a range of disorders, including a heart attack (myocardial infarction) and unstable angina, that are caused by the same underlying problem. Unstable angina occurs when the blood clot causes a reduced blood flow but not a total blockage. This means that the heart muscle supplied by the affected artery does not die (infarct).The underlying problem is a sudden reduction of blood flow to part of the heart muscle. This is usually caused by a blood clot that forms on a patch of atheroma within a coronary artery (which is described below).The types of problems range from unstable angina to an actual myocardial infarction. In unstable angina a blood clot causes reduced blood flow but not a total blockage. Therefore, the heart muscle supplied by the affected artery does not die (infarct). The location of the blockage, the length of time that blood flow is blocked and the amount of damage that occurs determine the type of ACS.3. What immediate management should you offer whilst patient is in surgery? Should all patients be given oxygen? Other monitoring?pain relief (GTN and/or an intravenous opioid) a single loading dose of 300 mg aspirin unless the person is allergic. Send a written record with the person if given before arriving at hospital. a resting 12-lead ECG. If the person is referred, send the results to the hospital before they arrive, if possible other therapeutic interventions as necessary pulse oximetry, ideally before hospital admission. Offer oxygen: if oxygen saturation (SpO2) is less than 94% with no risk of hypercapnic respiratory failure. Aim for SpO2 of 94–98% to people with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure. Aim for SpO2 of 88–92% until blood gas analysis is available. Monitoring. Include: exacerbations of pain and/or other symptoms pulse and blood pressure heart rhythm oxygen saturation by pulse oximetry repeated resting 12-lead ECGs checking pain relief is effective. Decide how often this should be done.5. Which blood tests should be done?Blood glucose, lipid profiles, and urea and electrolyte levels?— to review the person's cardiovascular risk profile. See the CKS?topic on?CVD risk assessment and management.Full blood count?— to check for anaemia which may be exacerbating stable angina.Thyroid function tests?— to check for thyroid disease. See the CKS?topics on?Hyperthyroidism?and?Hypothyroidism.Liver function tests and amylase?— to check for cholecystitis and pancreatitis. See the CKS?topics on?Pancreatitis - chronic?and?Cholecystitis - acute.C-reactive protein or erythrocyte sedimentation rate (ESR)?— for evidence of infection or inflammation. See the CKS?topics on?Chest infections - adult,?Polymyalgia rheumatica, and?Osteoarthritis.Chest X-ray?— to look for signs of heart failure and pulmonary pathology (including pleural effusion, lobar collapse, lung cancer). For more information, see the CKS?topics on?Heart failure - chronic?and?Lung and pleural cancers - recognition and referral.When should you repeat the troponin?rsCan you diagnose ACS? If so, why?Diagnosis of ACS can be made by: Detection of rise and/or fall of cardiac biomarkers (preferably troponin) with at least one value above the 99th percentile of the upper reference limit (yes troponin T was 0.15 ug/L. For the purpose of this case study, above 0.03 ug/L is considered to suggest myocardial ischaemia. Considering your local upper reference limit, is 0.15 ug/L suggestive of myocardial ischemia?), together with evidence of myocardial ischaemia with at least one of the following: symptoms of ischaemia – chest pain lasting longer than 15 minutes and sweatiness with the pain ECG changes indicative of new ischaemia (new ST-T changes or new LBBB) development of pathological Q wave changes in the ECG imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.What early management should you offer this patient?Offer a single loading dose of 300 mg aspirin and continue aspirin indefinitely. Offer fondaparinux to patients without a high bleeding risk unless angiography is planned within 24 hours. Offer unfractionated heparin if angiography is likely within 24 hours. Carefully consider choice and dose of antithrombin for patients with a high bleeding risk (see box 11) consider unfractionated heparin, with dose adjusted to clotting function, if creatinine > 265 micromoles per litre. Question 1.11: What risk assessments ................
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