The document describes several patient cases presenting with chest pain. The first case is a 45-year-old man with a history of angioplasty who presents with chest pain on walking. The second case is a 55-year-old man with chest pain while sitting. The third case is a 63-year-old man with chest pain while gardening. The fourth case is a 65-year-old woman with sudden chest pain. The fifth case is a 60-year-old man with severe chest pain for 2 hours. The document then discusses diagnoses, risk factors, management, and treatment for acute coronary syndromes.
This document discusses the early management of suspected myocardial infarction (MI). It outlines key risk factors for cardiac events and recommendations for stabilizing, diagnosing, and treating patients presenting with chest pain. Diagnostic steps include electrocardiograms (EKGs), cardiac enzyme levels, and potentially angiography. Treatment involves aspirin, nitrates, anticoagulants, and potentially thrombolytics or angioplasty depending on the situation. Goals are to promptly diagnose and treat to reduce mortality from MI.
1. This document discusses several scenarios involving patients experiencing potential heart attacks and the appropriate emergency response, including ECG diagnosis and management plans.
2. Per NHS QIS standards, the goal is to minimize time from ECG to balloon (PPCI) or needle (thrombolysis). If PPCI isn't possible within 40 minutes, thrombolysis may be administered instead.
3. One scenario details a patient receiving thrombolysis more than 90 minutes after symptoms due to long transport time, who then underwent PPCI at the hospital with first balloon inflation 23 minutes later, meeting NHS standards.
1. The document discusses a case of a 40-year-old male who visited a clinic with a history of drug abuse and had a blood pressure reading of 160/95.
2. A diagnosis of hypertension cannot officially be made at this time based on a single high blood pressure reading, and the average of 3 or more properly measured readings over weeks to months is needed.
3. Risk factors for hypertension include excess sodium intake, alcohol, energy drinks, genetics, obesity, diabetes, and lack of exercise. Treatment reduces risks of stroke, heart attack, and heart failure.
A 65-year-old male presented with chest pain and was diagnosed with acute myocardial infarction. Lab results showed abnormal CBC and troponin levels, and echocardiogram revealed blockage of the LAD artery. He was treated with medications to relieve symptoms, prevent blood clots and complications. Over 9 days in the ICU and ward, his vitals stabilized and he was discharged on medications including aspirin, clopidogrel and atorvastatin to prevent future cardiac events.
This document provides an overview of arrhythmias that may present in the intensive care unit (ICU) with a focus on atrial fibrillation, wide complex tachycardia, bradycardia, and supraventricular tachycardia. It discusses approaches to determining whether arrhythmias require rate or rhythm control and outlines treatment strategies including pharmacological and electrical cardioversion. Guidelines for determining the need for anticoagulation based on a patient's CHADS2-VASc score are also reviewed.
A 35-year-old female was admitted with swelling of the legs for 6 months, breathlessness for 4 months, and decreased urine output for 1 month. On examination, she had swollen joints, facial puffiness, elevated jugular venous pressure, and tender hepatomegaly. Investigations showed features of heart failure, interstitial lung disease, and a positive ANA and anti-U1RNP antibody. She was diagnosed with dilated cardiomyopathy and cardiac failure secondary to an overlap connective tissue disease syndrome.
This document provides guidance on the early management of suspected myocardial infarction (MI). It outlines key risk factors, clinical presentations, diagnostic approaches including EKG and imaging, and treatment strategies including reperfusion therapies, anticoagulation, beta blockers, ACE inhibitors, and lipid management. The management of MI focuses on prompt pain relief, risk factor modification, and multi-drug therapies to reduce mortality.
The following powerpoint presentation is about the current AF guidelines, prepared by Dr Jawad Siraj, who is a final year resident as Cardiology Unit, PGMI, LRH, Peshawar
This document discusses the early management of suspected myocardial infarction (MI). It outlines key risk factors for cardiac events and recommendations for stabilizing, diagnosing, and treating patients presenting with chest pain. Diagnostic steps include electrocardiograms (EKGs), cardiac enzyme levels, and potentially angiography. Treatment involves aspirin, nitrates, anticoagulants, and potentially thrombolytics or angioplasty depending on the situation. Goals are to promptly diagnose and treat to reduce mortality from MI.
1. This document discusses several scenarios involving patients experiencing potential heart attacks and the appropriate emergency response, including ECG diagnosis and management plans.
2. Per NHS QIS standards, the goal is to minimize time from ECG to balloon (PPCI) or needle (thrombolysis). If PPCI isn't possible within 40 minutes, thrombolysis may be administered instead.
3. One scenario details a patient receiving thrombolysis more than 90 minutes after symptoms due to long transport time, who then underwent PPCI at the hospital with first balloon inflation 23 minutes later, meeting NHS standards.
1. The document discusses a case of a 40-year-old male who visited a clinic with a history of drug abuse and had a blood pressure reading of 160/95.
2. A diagnosis of hypertension cannot officially be made at this time based on a single high blood pressure reading, and the average of 3 or more properly measured readings over weeks to months is needed.
3. Risk factors for hypertension include excess sodium intake, alcohol, energy drinks, genetics, obesity, diabetes, and lack of exercise. Treatment reduces risks of stroke, heart attack, and heart failure.
A 65-year-old male presented with chest pain and was diagnosed with acute myocardial infarction. Lab results showed abnormal CBC and troponin levels, and echocardiogram revealed blockage of the LAD artery. He was treated with medications to relieve symptoms, prevent blood clots and complications. Over 9 days in the ICU and ward, his vitals stabilized and he was discharged on medications including aspirin, clopidogrel and atorvastatin to prevent future cardiac events.
This document provides an overview of arrhythmias that may present in the intensive care unit (ICU) with a focus on atrial fibrillation, wide complex tachycardia, bradycardia, and supraventricular tachycardia. It discusses approaches to determining whether arrhythmias require rate or rhythm control and outlines treatment strategies including pharmacological and electrical cardioversion. Guidelines for determining the need for anticoagulation based on a patient's CHADS2-VASc score are also reviewed.
A 35-year-old female was admitted with swelling of the legs for 6 months, breathlessness for 4 months, and decreased urine output for 1 month. On examination, she had swollen joints, facial puffiness, elevated jugular venous pressure, and tender hepatomegaly. Investigations showed features of heart failure, interstitial lung disease, and a positive ANA and anti-U1RNP antibody. She was diagnosed with dilated cardiomyopathy and cardiac failure secondary to an overlap connective tissue disease syndrome.
This document provides guidance on the early management of suspected myocardial infarction (MI). It outlines key risk factors, clinical presentations, diagnostic approaches including EKG and imaging, and treatment strategies including reperfusion therapies, anticoagulation, beta blockers, ACE inhibitors, and lipid management. The management of MI focuses on prompt pain relief, risk factor modification, and multi-drug therapies to reduce mortality.
The following powerpoint presentation is about the current AF guidelines, prepared by Dr Jawad Siraj, who is a final year resident as Cardiology Unit, PGMI, LRH, Peshawar
Acute coronary syndrome management by RxVichuZ! ;)RxVichuZ
This is my 99th powerpoint...
Deals with ACS(Acute coronary syndrome), its clinical features, and management strategies, based on standard guidelines and literatures.
Brugada Syndrome was first described in 1992 and is characterized by ST-segment elevation in the right precordial leads and risk of sudden cardiac death. It is caused by mutations that result in loss of function of the cardiac sodium channel. Diagnosis requires a type 1 ECG pattern with coved ST elevation of ≥2 mm in ≥1 right precordial lead, either spontaneously or after sodium channel blocker administration. Implantable cardioverter defibrillator placement is the primary treatment for those who experience symptoms or induced arrhythmias due to high risk of sudden death. Lifestyle modifications and sodium channel blockers like quinidine may also be used for prevention and treatment of arrhythmias.
1. The document discusses acute coronary syndrome and its pathophysiology including plaque rupture and thrombosis leading to dynamic obstruction.
2. It summarizes several studies on outcomes of invasive versus conservative treatment strategies for acute coronary syndrome patients, finding reduced mortality and myocardial infarction with invasive approaches.
3. Biomarkers like troponin and homocysteine are discussed as risk factors for adverse outcomes in acute coronary syndrome.
This document provides an overview of electrocardiogram (EKG) interpretation for physician assistants. It lists the steps to reading an EKG, analyzes normal electrical progression, relates coronary vessel anatomy to EKG findings, and recognizes common rhythms and life-threatening conditions. Key aspects of the EKG like rate, rhythm, intervals and waves are defined. Common abnormalities indicating conditions like ischemia, hypertrophy, enlargement and electrolyte imbalances are described. Example EKG readings from patient cases are provided and interpreted. Resources for further EKG education are listed at the end.
This patient was admitted to the hospital for breathlessness, wheezing, and cough. They have a history of hypertension and type 2 diabetes for 20 years. On examination, their blood pressure was elevated and they showed signs of heart failure. Laboratory tests showed elevated blood glucose and kidney dysfunction. The patient was diagnosed with heart failure due to hypertrophic cardiomyopathy, hypertension, and type 2 diabetes with chronic kidney disease. Over the hospital stay, their symptoms improved with treatment including diuretics, insulin, and blood pressure medications. They were discharged with medications and lifestyle counseling to control their conditions.
A 45-year-old male patient presented with a chief complaint of chest pain for one week along with giddiness and palpitations. On examination, he was found to have pedal edema, elevated blood pressure, and abnormal echocardiogram and ECG results. Lab work showed anemia, elevated CK-MB, and abnormal lipid levels. He was diagnosed with inferior wall myocardial infarction, dyslipidemia, hypertension, depression, and anemia. His treatment plan included medications to treat these conditions like aspirin, clopidogrel, atorvastatin, enalapril, ferrous sulfate, alprazolam, and cefotaxime. Counseling was provided on medication
The document discusses various biomarkers used in the diagnosis and management of heart failure. It states that natriuretic peptides like BNP and NT-proBNP are the most widely used biomarkers for heart failure as they are accurate for establishing diagnosis, determining severity, and predicting prognosis. It describes the release and function of these peptides. It also mentions other biomarkers like cardiac troponins, inflammatory markers, neurohormonal factors, and matrix proteins that provide additional information on myocardial injury, inflammation, neurohormonal activation, and remodeling in heart failure. A multimarker approach may help better classify and risk stratify heart failure.
- The patient is a 60-year-old male who presented to the clinic with severe chest pain for 3 hours. Tests showed ST elevation on ECG and positive troponin levels, indicating ST elevation myocardial infarction (STEMI).
- The patient has a history of hypertension and hyperlipidemia. Echo showed no blood flow to part of the myocardium.
- The initial treatment plan included aspirin, clopidogrel, metoprolol, atorvastatin, lisinopril, ranitidine, morphine, and glyceryl trinitrate as needed for pain. Long-term medication and lifestyle changes were also recommended.
Atrial fibrillation in advanced heart failure role of rate controldrucsamal
1) Treating atrial fibrillation in patients with advanced heart failure remains a challenge due to the risks of both rate and rhythm control strategies.
2) Rate control is preferred over rhythm control, though strict heart rate targets may not be necessary, and beta blockers provide less clear benefit for rate control in AF patients with heart failure compared to those in sinus rhythm.
3) Antiarrhythmic drugs for rhythm control have been shown to increase risks of death and hospitalization, so non-pharmacological approaches and newer agents are being explored.
Case Presentation on STROKE (Subarachnoid Hemorrhage)nayanadiv
A 45-year old female presented with generalized tiredness, drowsiness, confusion and seizures. Lab tests and CT scan revealed early hydrocephalus, a suspicious lesion in the fourth ventricle, and subarachnoid hemorrhage due to aneurysm rupture. She was admitted to the neuro ICU and started on treatments including dexamethasone, nimodipine, pantoprazole, paracetamol, fosphenytoin, mannitol and ondansetron to relieve symptoms, repair the bleeding vessel, prevent complications and recurrence. The pharmacist provided counseling on disease, drugs, lifestyle modifications and points to the physician regarding monitoring and potential drug interactions.
This document summarizes the case of a 44-year-old male patient admitted to the hospital with seizures, vomiting, decreased appetite, and weakness in his limbs. Lab results found increased creatinine, BUN, and decreased chloride levels. A CT scan found no abnormalities in the brain but soft tissue swelling in the frontal region. Based on the subjective and objective patient data, the patient was diagnosed with a cerebrovascular accident, hypertension, and stage 4 chronic kidney disease. The treatment plan focused on rehabilitation, medication, monitoring the patient's condition, and counseling on lifestyle changes and managing the disease.
The document presents a case report of a 56-year-old male patient admitted with a venous ulcer on his left lower leg complicated by congestive heart failure, type 2 diabetes mellitus, hypertension, and acute kidney injury. The patient's medical history and examination findings are documented over a hospital stay involving monitoring of vital signs and lab tests, along with management of his conditions through pharmacotherapy and procedures.
1) Sexual activity can generally be resumed safely after an acute myocardial infarction (MI) for patients at low risk, with clearance from a cardiologist for those at intermediate or high risk.
2) Sexual intercourse requires a moderate physical exertion equivalent to 2-4 metabolic equivalents, which causes a temporary increase in heart rate and blood pressure.
3) Erectile dysfunction is common after an MI but can often be treated safely with phosphodiesterase type 5 inhibitors like sildenafil, though their use requires caution with nitrates which are contraindicated.
A 42-year old male patient presented with symptoms of right-sided body weakness, slurred speech, and loss of consciousness. He was diagnosed with a hemorrhagic stroke caused by a left capsulaganglionic bleed based on his MRI results. He was treated with medications to control blood pressure and prevent further complications. Through physical therapy and treatment, the patient's symptoms improved and he was discharged upon being able to follow commands and having normal vital signs.
This document provides guidelines for the management of atrial fibrillation. It defines different types of AF and recommends use of the CHA2DS2-VASc score to assess stroke risk and determine need for oral anticoagulation. It recommends rate control with beta blockers, non-DHP calcium channel blockers, or digoxin. It provides recommendations for cardioversion and antiarrhythmic medications for rhythm control. It also provides AF management guidelines for specific patient groups such as those with heart failure, pulmonary disease, or hyperthyroidism.
This document discusses the management of atrial fibrillation (AF). It outlines the goals of management which are to prevent stroke, cardiomyopathy, relieve symptoms, and improve survival. The main strategies for management are rate control, rhythm control, and prevention of thromboembolism. Rate control is recommended for all AF patients using medications, while rhythm control is only recommended for selected patients. Risk stratification is important for determining anticoagulation and cardioversion approaches. Electrical and pharmacological cardioversion can be used to restore normal sinus rhythm but have varying success rates depending on the duration and chronicity of AF.
Brugada Syndrome is a genetic disorder characterized by abnormal ECG patterns and increased risk of ventricular arrhythmias. It is caused by mutations in genes encoding sodium channels. Typical ECG findings include ST elevation in leads V1-V3. Risk factors include spontaneous type 1 ECG pattern, family history of sudden cardiac death, and inducible arrhythmias on electrophysiology study. Diagnosis requires type 1 ECG pattern plus symptoms or family history of events.
Background: Cardiovascular Diseases (CVD) are the highest-incidence cause of death and morbidity in patients with type 2 Diabetic (T2DM). The natriuretic peptide is important in controlling blood pressure and salt water balance. Both corin and furin are involved in cleave Pro-Atrial Natriuretic Peptide (ANP) and Pro-BNP (Brian Natriuretic Peptide) into their active forms (ANP and BNP). Recently, studied showed that furin and corin defects could contribute to CVDs.
Methods: This study includes 360 subjects divided into three groups; 120 healthy subjects as controls (Gr I); 120 T2DM patients with no medical history of CVD (Gr II) and 120 T2DM patients confirmed diagnosis of CVD (Gr III). All groups were matched for age and gender. All subjects were investigated for biochemical markers, serum corin and furin levels were determined By ELISA techniques.
Palpitations In The Young Patients: Another False Alarm?ahvc0858
This document discusses palpitations in young adults. It begins by introducing the speakers and describing the services provided at AHVC, including general cardiology, interventional procedures, and electrophysiology. It then discusses common causes of palpitations like supraventricular tachycardia, outlines four case studies of patients presenting with palpitations, and debunks myths about palpitations always being benign or due to anxiety. The document emphasizes that arrhythmias in young patients should be properly evaluated.
Cut End-to-End eDiscovery Time in Half: Leveraging the CloudDruva
Today legal hold data requests expand far beyond traditional email server requirements. Last year alone, 62% of requests included data from mobile devices and 37% from cloud application services. As the data volumes increase, Legal and IT teams can no longer continue to rely on legacy eDiscovery processes that are both inefficient and costly.
Our experts discussed how the latest generation of eDiscovery solutions, using native-cloud technologies, are dramatically reducing both data collection and ingestion times, while significantly increasing the speed and efficiencies of the analysis and review process. Hear how legal and IT teams can:
* Extend data collection to endpoints and cloud apps to centrally collect, preserve and classify information
* Increase transparency for senior lawyers and corporate counsel through automated real-time metrics
* Achieve cloud-to-cloud data transfer to reduce the risk of data spoliation while removing the need for physical collection and shipping
By moving your eDiscovery process to the cloud, IT can quickly respond to their legal department’s inquiries, and legal teams gain faster data ingestion times along with high speed processing, analysis, and review.
To view the webcast: http://pages2.druva.com/eDiscovery-in-Cloud_On-Demand.html
The document discusses how CBT utilizes a BPO platform and resources to set concrete goals and monitor integration progress in real time. It then summarizes the key aspects of a discovery workshop process, noting that it is important to include process owners. The workshop is designed to map current processes and identify problems using industry best practices. Finally, the document outlines a banking eProcurement project that centralized purchasing on a custom web application, resulting in over $650,000 in savings annually through reduced costs and inventory management.
Acute coronary syndrome management by RxVichuZ! ;)RxVichuZ
This is my 99th powerpoint...
Deals with ACS(Acute coronary syndrome), its clinical features, and management strategies, based on standard guidelines and literatures.
Brugada Syndrome was first described in 1992 and is characterized by ST-segment elevation in the right precordial leads and risk of sudden cardiac death. It is caused by mutations that result in loss of function of the cardiac sodium channel. Diagnosis requires a type 1 ECG pattern with coved ST elevation of ≥2 mm in ≥1 right precordial lead, either spontaneously or after sodium channel blocker administration. Implantable cardioverter defibrillator placement is the primary treatment for those who experience symptoms or induced arrhythmias due to high risk of sudden death. Lifestyle modifications and sodium channel blockers like quinidine may also be used for prevention and treatment of arrhythmias.
1. The document discusses acute coronary syndrome and its pathophysiology including plaque rupture and thrombosis leading to dynamic obstruction.
2. It summarizes several studies on outcomes of invasive versus conservative treatment strategies for acute coronary syndrome patients, finding reduced mortality and myocardial infarction with invasive approaches.
3. Biomarkers like troponin and homocysteine are discussed as risk factors for adverse outcomes in acute coronary syndrome.
This document provides an overview of electrocardiogram (EKG) interpretation for physician assistants. It lists the steps to reading an EKG, analyzes normal electrical progression, relates coronary vessel anatomy to EKG findings, and recognizes common rhythms and life-threatening conditions. Key aspects of the EKG like rate, rhythm, intervals and waves are defined. Common abnormalities indicating conditions like ischemia, hypertrophy, enlargement and electrolyte imbalances are described. Example EKG readings from patient cases are provided and interpreted. Resources for further EKG education are listed at the end.
This patient was admitted to the hospital for breathlessness, wheezing, and cough. They have a history of hypertension and type 2 diabetes for 20 years. On examination, their blood pressure was elevated and they showed signs of heart failure. Laboratory tests showed elevated blood glucose and kidney dysfunction. The patient was diagnosed with heart failure due to hypertrophic cardiomyopathy, hypertension, and type 2 diabetes with chronic kidney disease. Over the hospital stay, their symptoms improved with treatment including diuretics, insulin, and blood pressure medications. They were discharged with medications and lifestyle counseling to control their conditions.
A 45-year-old male patient presented with a chief complaint of chest pain for one week along with giddiness and palpitations. On examination, he was found to have pedal edema, elevated blood pressure, and abnormal echocardiogram and ECG results. Lab work showed anemia, elevated CK-MB, and abnormal lipid levels. He was diagnosed with inferior wall myocardial infarction, dyslipidemia, hypertension, depression, and anemia. His treatment plan included medications to treat these conditions like aspirin, clopidogrel, atorvastatin, enalapril, ferrous sulfate, alprazolam, and cefotaxime. Counseling was provided on medication
The document discusses various biomarkers used in the diagnosis and management of heart failure. It states that natriuretic peptides like BNP and NT-proBNP are the most widely used biomarkers for heart failure as they are accurate for establishing diagnosis, determining severity, and predicting prognosis. It describes the release and function of these peptides. It also mentions other biomarkers like cardiac troponins, inflammatory markers, neurohormonal factors, and matrix proteins that provide additional information on myocardial injury, inflammation, neurohormonal activation, and remodeling in heart failure. A multimarker approach may help better classify and risk stratify heart failure.
- The patient is a 60-year-old male who presented to the clinic with severe chest pain for 3 hours. Tests showed ST elevation on ECG and positive troponin levels, indicating ST elevation myocardial infarction (STEMI).
- The patient has a history of hypertension and hyperlipidemia. Echo showed no blood flow to part of the myocardium.
- The initial treatment plan included aspirin, clopidogrel, metoprolol, atorvastatin, lisinopril, ranitidine, morphine, and glyceryl trinitrate as needed for pain. Long-term medication and lifestyle changes were also recommended.
Atrial fibrillation in advanced heart failure role of rate controldrucsamal
1) Treating atrial fibrillation in patients with advanced heart failure remains a challenge due to the risks of both rate and rhythm control strategies.
2) Rate control is preferred over rhythm control, though strict heart rate targets may not be necessary, and beta blockers provide less clear benefit for rate control in AF patients with heart failure compared to those in sinus rhythm.
3) Antiarrhythmic drugs for rhythm control have been shown to increase risks of death and hospitalization, so non-pharmacological approaches and newer agents are being explored.
Case Presentation on STROKE (Subarachnoid Hemorrhage)nayanadiv
A 45-year old female presented with generalized tiredness, drowsiness, confusion and seizures. Lab tests and CT scan revealed early hydrocephalus, a suspicious lesion in the fourth ventricle, and subarachnoid hemorrhage due to aneurysm rupture. She was admitted to the neuro ICU and started on treatments including dexamethasone, nimodipine, pantoprazole, paracetamol, fosphenytoin, mannitol and ondansetron to relieve symptoms, repair the bleeding vessel, prevent complications and recurrence. The pharmacist provided counseling on disease, drugs, lifestyle modifications and points to the physician regarding monitoring and potential drug interactions.
This document summarizes the case of a 44-year-old male patient admitted to the hospital with seizures, vomiting, decreased appetite, and weakness in his limbs. Lab results found increased creatinine, BUN, and decreased chloride levels. A CT scan found no abnormalities in the brain but soft tissue swelling in the frontal region. Based on the subjective and objective patient data, the patient was diagnosed with a cerebrovascular accident, hypertension, and stage 4 chronic kidney disease. The treatment plan focused on rehabilitation, medication, monitoring the patient's condition, and counseling on lifestyle changes and managing the disease.
The document presents a case report of a 56-year-old male patient admitted with a venous ulcer on his left lower leg complicated by congestive heart failure, type 2 diabetes mellitus, hypertension, and acute kidney injury. The patient's medical history and examination findings are documented over a hospital stay involving monitoring of vital signs and lab tests, along with management of his conditions through pharmacotherapy and procedures.
1) Sexual activity can generally be resumed safely after an acute myocardial infarction (MI) for patients at low risk, with clearance from a cardiologist for those at intermediate or high risk.
2) Sexual intercourse requires a moderate physical exertion equivalent to 2-4 metabolic equivalents, which causes a temporary increase in heart rate and blood pressure.
3) Erectile dysfunction is common after an MI but can often be treated safely with phosphodiesterase type 5 inhibitors like sildenafil, though their use requires caution with nitrates which are contraindicated.
A 42-year old male patient presented with symptoms of right-sided body weakness, slurred speech, and loss of consciousness. He was diagnosed with a hemorrhagic stroke caused by a left capsulaganglionic bleed based on his MRI results. He was treated with medications to control blood pressure and prevent further complications. Through physical therapy and treatment, the patient's symptoms improved and he was discharged upon being able to follow commands and having normal vital signs.
This document provides guidelines for the management of atrial fibrillation. It defines different types of AF and recommends use of the CHA2DS2-VASc score to assess stroke risk and determine need for oral anticoagulation. It recommends rate control with beta blockers, non-DHP calcium channel blockers, or digoxin. It provides recommendations for cardioversion and antiarrhythmic medications for rhythm control. It also provides AF management guidelines for specific patient groups such as those with heart failure, pulmonary disease, or hyperthyroidism.
This document discusses the management of atrial fibrillation (AF). It outlines the goals of management which are to prevent stroke, cardiomyopathy, relieve symptoms, and improve survival. The main strategies for management are rate control, rhythm control, and prevention of thromboembolism. Rate control is recommended for all AF patients using medications, while rhythm control is only recommended for selected patients. Risk stratification is important for determining anticoagulation and cardioversion approaches. Electrical and pharmacological cardioversion can be used to restore normal sinus rhythm but have varying success rates depending on the duration and chronicity of AF.
Brugada Syndrome is a genetic disorder characterized by abnormal ECG patterns and increased risk of ventricular arrhythmias. It is caused by mutations in genes encoding sodium channels. Typical ECG findings include ST elevation in leads V1-V3. Risk factors include spontaneous type 1 ECG pattern, family history of sudden cardiac death, and inducible arrhythmias on electrophysiology study. Diagnosis requires type 1 ECG pattern plus symptoms or family history of events.
Background: Cardiovascular Diseases (CVD) are the highest-incidence cause of death and morbidity in patients with type 2 Diabetic (T2DM). The natriuretic peptide is important in controlling blood pressure and salt water balance. Both corin and furin are involved in cleave Pro-Atrial Natriuretic Peptide (ANP) and Pro-BNP (Brian Natriuretic Peptide) into their active forms (ANP and BNP). Recently, studied showed that furin and corin defects could contribute to CVDs.
Methods: This study includes 360 subjects divided into three groups; 120 healthy subjects as controls (Gr I); 120 T2DM patients with no medical history of CVD (Gr II) and 120 T2DM patients confirmed diagnosis of CVD (Gr III). All groups were matched for age and gender. All subjects were investigated for biochemical markers, serum corin and furin levels were determined By ELISA techniques.
Palpitations In The Young Patients: Another False Alarm?ahvc0858
This document discusses palpitations in young adults. It begins by introducing the speakers and describing the services provided at AHVC, including general cardiology, interventional procedures, and electrophysiology. It then discusses common causes of palpitations like supraventricular tachycardia, outlines four case studies of patients presenting with palpitations, and debunks myths about palpitations always being benign or due to anxiety. The document emphasizes that arrhythmias in young patients should be properly evaluated.
Cut End-to-End eDiscovery Time in Half: Leveraging the CloudDruva
Today legal hold data requests expand far beyond traditional email server requirements. Last year alone, 62% of requests included data from mobile devices and 37% from cloud application services. As the data volumes increase, Legal and IT teams can no longer continue to rely on legacy eDiscovery processes that are both inefficient and costly.
Our experts discussed how the latest generation of eDiscovery solutions, using native-cloud technologies, are dramatically reducing both data collection and ingestion times, while significantly increasing the speed and efficiencies of the analysis and review process. Hear how legal and IT teams can:
* Extend data collection to endpoints and cloud apps to centrally collect, preserve and classify information
* Increase transparency for senior lawyers and corporate counsel through automated real-time metrics
* Achieve cloud-to-cloud data transfer to reduce the risk of data spoliation while removing the need for physical collection and shipping
By moving your eDiscovery process to the cloud, IT can quickly respond to their legal department’s inquiries, and legal teams gain faster data ingestion times along with high speed processing, analysis, and review.
To view the webcast: http://pages2.druva.com/eDiscovery-in-Cloud_On-Demand.html
The document discusses how CBT utilizes a BPO platform and resources to set concrete goals and monitor integration progress in real time. It then summarizes the key aspects of a discovery workshop process, noting that it is important to include process owners. The workshop is designed to map current processes and identify problems using industry best practices. Finally, the document outlines a banking eProcurement project that centralized purchasing on a custom web application, resulting in over $650,000 in savings annually through reduced costs and inventory management.
This document summarizes a webinar about eDiscovery and privacy laws in the US and UK. It discusses the differences between the broad discovery process in the US compared to the more limited process in the UK. It also outlines the key principles of the UK Data Protection Act, including the requirements for processing and transferring personal data. Finally, it discusses some of the challenges of cross-border data transfers and litigation between different jurisdictions with varying privacy laws.
1) The document discusses the surgical approach and procedure for cortical mastoidectomy. Key steps include raising skin and periosteal flaps, drilling along anatomical landmarks like the sigmoid sinus and facial nerve to identify structures, and widening the aditus and performing a posterior tympanotomy to access the mesotympanum.
2) Post-operative care involves drain removal within 48 hours and dry dressing of the ear. Potential complications discussed are persistent deafness, facial nerve injury, CSF leak, hemorrhage and infection.
3) The patient is advised restricted activity for 3 weeks followed by a gradual return to normal activity over 4 weeks, and to keep the operation site dry.
Retail es el negocio que ha ganado ventas de doble dígito con RFID al poder hacer inventarios físicos todos los días en segundos o minutos, dependiendo de la solución. Encuentra más información aqui.
Here are the answers to the 5-point quiz on the DASH diet:
1. DASH stands for Dietary Approaches to Stop Hypertension.
2. The two versions of the DASH diet are based on the amount of sodium intake. The standard DASH diet allows up to 2,300 mg of sodium per day, while the lower sodium DASH diet allows up to 1,500 mg per day.
3. The DASH diet emphasizes eating foods rich in potassium, calcium, and magnesium such as fruits, vegetables, low-fat dairy products, and whole grains. These key nutrients help lower blood pressure.
4. False. The DASH diet does not recommend consumption of caffeine-filled products
Java Wisata Bandung,sebagai travel terbaik dan terpercaya di Indonesia dapat membantu perjalanan anda.Kami menyediakan Paket Wisata Flores Murah 7 Hari 6 Malam
The document discusses the DASH diet plan for reducing hypertension. It provides information on hypertension prevalence, blood pressure goals, and how high blood pressure affects the body. The DASH diet is highlighted as an effective non-pharmacological approach to treating hypertension through its focus on fruits, vegetables, whole grains, and low-fat dairy while limiting sodium, red meat, and sugar. Weight loss through diet and exercise is also emphasized as important for reducing hypertension risk factors like obesity.
The DASH diet is a dietary pattern promoted by the U.S. National Heart, Lung, and Blood Institute to prevent and control hypertension. It emphasizes fruits, vegetables, whole grains, and low-fat dairy foods; includes meat, fish, poultry, nuts and beans; and limits sugar-sweetened foods and beverages, red meat, and added fats. Studies show the DASH diet lowers blood pressure and cholesterol and reduces the risk of heart disease, stroke, diabetes and some cancers. The DASH diet recommends consuming fruits, vegetables, whole grains, fish, poultry, nuts, seeds, and low-fat dairy products while limiting fats, red meat, sweets and sugar
This document provides 3 rough sketches for magazine advert ancillaries and evaluates them. The authors' favorite sketch is the third one, which incorporates a wide range of skills through an impactful picture collage theme that could be extended across other materials. The first sketch is considered the worst as it lacks originality and challenges few skills while also being visually boring.
Este documento presenta un resumen de dos artículos académicos relacionados con el uso de tecnologías Web 2.0 en la educación. El primer artículo examina el conocimiento y adopción de estas herramientas entre educadores empresariales en Nigeria, mientras que el segundo identifica beneficios, barreras y mejores prácticas de enseñanza con Web 2.0. Ambos artículos concluyen que estas tecnologías tienen el potencial de mejorar la interacción e involucramiento de los estudiantes, aunque se necesita más
This document discusses chemiluminescence, including its principles, instrumentation, and applications. It describes how chemiluminescence occurs through excited molecule species that emit light upon returning to ground state. Common techniques are fluorescence and phosphorescence. The document outlines criteria for successful chemiluminescent reactions and examples like luminol-peroxidase and luciferin-luciferase reactions. Detection methods like photomultiplier tubes and applications in immunoassays, DNA detection, food analysis, and clinical utilities are summarized.
The document discusses various Gothic architectural styles from the 15th century, including Gothic Flemish, Gothic Catalan civil, and Gothic Flemish civil styles. Specific examples mentioned include Salisbury Cathedral in England, Lincoln Cathedral, and the church of San Juan de los Reyes in Guadalajara, Spain.
Actividad 4; bloque 1. bullying por Desirée Manzano AragüezDESIREE MANZANO
El documento habla sobre el bullying o acoso escolar. Define bullying como un tipo de maltrato físico, verbal o psicológico que ocurre entre estudiantes de forma repetida. Describe los roles principales como la víctima, el agresor y el espectador. También detalla las formas de bullying, consecuencias y conductas típicas de cada rol, así como los contextos y teorías explicativas del fenómeno. Finalmente, enfatiza la importancia de la prevención e intervención en las escuelas.
O documento discute reações de eliminação, onde um próton e um grupo abandonador são removidos para formar uma ligação dupla. Existem dois mecanismos possíveis para eliminação - E1 e E2. A reação E2 segue cinética de segunda ordem e envolve um estado de transição concertado, enquanto E1 é gradual. A estereoquímica e regioquímica das reações de eliminação são também discutidas.
A 63-year-old man presented to the emergency department with shortness of breath, chest pain, and lightheadedness. He had a history of smoking and alcohol use. On examination, he was pale, diaphoretic, and had distended jugular veins. Tests showed signs of pulmonary embolism including reduced oxygen levels and elevated D-dimer and cardiac markers. A CT scan confirmed multiple pulmonary embolisms. He was treated with oxygen supplementation, analgesics, and low molecular weight heparin to prevent further clot propagation.
A 75-year-old diabetic male presented with chest pain and other symptoms of acute coronary syndrome. The most probable diagnosis is myocardial infarction. Relevant investigations include ECG, biochemical markers like CK-MB and troponin, and echocardiogram. Management involves medical therapy in emergency, possible fibrinolysis or PCI, and long term preventative treatment. Complications can include heart failure, cardiogenic shock, arrhythmias if not properly managed.
This document provides an overview of cardiology topics including basic physiology, common investigations, conditions like hypertension, angina, heart failure, and procedures. It discusses evaluation of patients presenting with chest pain or shortness of breath and management of acute coronary syndromes, arrhythmias, valve diseases and more. Investigations covered include ECG, echocardiogram, stress testing and scores for predicting patient risk. Treatment focuses on lifestyle changes, medications, procedures like angiography or ablation.
A 60-year-old man presented with chest pain and was found to have risk factors for coronary artery disease including a previous myocardial infarction and diabetes. Diagnostic testing showed elevated biomarkers and ECG changes consistent with an acute myocardial infarction. The goals of treatment were to restore blood flow to the heart with percutaneous coronary intervention, reduce ischemia and complications with medications, and modify risk factors to prevent future events.
This document provides guidance on interpreting chest radiographs from Kristopher Maday, a physician assistant. It lists steps for reading chest x-rays, recognizes common pathologies, and focuses the assessment based on history and physical exam rather than trying to interpret like a radiologist. Examples are then provided of chest x-ray findings from patient cases with relevant history, physical exam findings, and radiographic impressions. Resources for further radiograph interpretation education are included at the end.
Acute coronary syndrome in emergency departmentrigomontejo
This document discusses acute coronary syndrome, including unstable angina, NSTEMI, and STEMI. It outlines the risk factors, symptoms, diagnosis, and management of these conditions. For STEMI specifically, it describes evaluating patients for fibrinolysis or PCI based on time of presentation, contraindications, and cardiac status. Key treatments discussed include aspirin, oxygen, nitrates, beta blockers, ACE inhibitors, and anti-platelet medications to reduce mortality and complications from myocardial infarction.
The document discusses the diagnosis and management of non-ST elevation acute coronary syndromes (NSTE ACS), including defining NSTE ACS, assessing risk through patient history, physical exam, and investigations, and providing medical therapy including antiplatelet agents, anticoagulants, and risk factor modification. It also addresses evaluating specific patient cases presenting with chest pain and evaluating treatment options.
- A 54-year-old man presented with crushing chest pain and difficulty breathing.
- An ECG showed ST-elevation consistent with an acute anterior wall myocardial infarction (STEMI).
- Initial management included fibrinolytic therapy (e.g. streptokinase) within 12 hours of symptom onset to reperfuse the occluded coronary artery and reduce mortality.
principles of preoperative evaluation and preparation.pptxMahmood Hasan Taha
The importance of preoperative assessment and evaluation to prepare the patient to surgical procedure is directly proportional with the degree of successful of any surgical procedure.
So, good preoperative assessment and evolution is necessary to avoid the morbidity and mortality that expected to the surgical procedures.
This document discusses the nursing management of a 52-year-old woman presenting with fatigue, nausea, and chest discomfort diagnosed with an acute myocardial infarction (AMI). It outlines her assessment, including vital signs and ECG findings consistent with AMI. It then reviews AMI pathophysiology, diagnostic testing, signs and symptoms, and appropriate medications and treatments including aspirin, nitroglycerine, oxygen, morphine, heparin, clopidogrel, beta blockers, and ACE inhibitors. It discusses nursing diagnoses and guidelines for monitoring, preventing complications, managing pain and anxiety, and providing patient education on diet, activity, medications and risk factor modification.
Nusing Management of CAD Symposia (English) presented at Hôpital Sacré Coeur in Milot, Haiti.
CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
Stroke is the 2nd leading death associated disorder. It is also known as cerebrovascular disorder mainly caused by high blood cholesterol levels or rupture of cerebral arteries.
Mr. CP, an auto mechanic with a history of diabetes, hypertension, hyperlipidemia, and stents, presented with gastritis and a gastric ulcer. He had been taking various medications including aspirin, Plavix, statins, and diabetes medications. Two weeks prior he developed melena and was found to have the gastric ulcer. His exam and labs were normal. The document discusses pulmonary embolism including risk factors, pathophysiology, clinical presentation, diagnostic workup using Wells criteria and CT, and treatment with anticoagulation, IVC filters, or thrombolytics. Mr. CP was initially treated with anticoagulation for his pulmonary embolism.
This document presents a case study of a 70-year-old woman who presented with progressive shortness of breath over 4 hours. Upon examination, she was found to be in severe respiratory distress. Tests revealed signs of a heart attack and congestive heart failure. She was diagnosed with a ST-elevation myocardial infarction and treated with oxygen, medications, and supportive care in the intensive care unit. Her condition gradually improved and she was discharged after 6 days with a full recovery.
Rashed presented to the emergency room with chest pain and other symptoms of an acute coronary syndrome. He had multiple risk factors for coronary artery disease such as diabetes, smoking, hypertension, and obesity. Electrocardiogram showed ST-segment elevation consistent with ST-elevation myocardial infarction (STEMI). Treatment for STEMI focuses on rapidly restoring blood flow to the blocked artery through either fibrinolytic therapy or primary percutaneous coronary intervention in order to limit damage to heart muscle. Complications of a heart attack can include arrhythmias, heart failure, cardiogenic shock, and mechanical issues with the heart. Timely reperfusion is important for salvaging heart tissue in STEMI patients.
This document summarizes the diagnosis and management of coronary artery disease. It discusses chronic stable angina and acute coronary syndromes like unstable angina and STEMI. It covers the signs, symptoms, investigations like ECG and biomarkers, and treatments for STEMI like antiplatelet therapy, thrombolysis, angioplasty and CABG. It also discusses the treatment of NSTEMI and unstable angina, including antiplatelet and anticoagulation therapies as well as risk factor modification. Finally, it provides recommendations for the primary prevention of coronary artery disease in patients with diabetes.
Rheumatic fever is quite common in developing countries and it has well known cardiac complications. So it's very important to know rheumatic fever, hopefully, this presentation will fill the needs. If you think it's helpful then share it.
Myocardial infarction occurs when blood flow to the heart is obstructed, causing death of heart muscle tissue. It is usually caused by atherosclerosis leading to coronary artery occlusion. Risk factors include conditions like diabetes, smoking, high cholesterol, and family history. Symptoms include chest pain and potential complications are arrhythmias, heart failure, or cardiac rupture. Diagnosis involves cardiac enzyme and troponin levels, electrocardiogram, and other imaging tests. Treatment focuses on restoring blood flow, reducing risk factors, managing pain and symptoms, and monitoring for complications.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
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Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
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Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
2. 45 year old man comes to your clinic
for routine follow up. He gives history
of chest pain on walking 500 meters
on foot. There is no history of
dyspnea, orthopnea. He smokes 2
cigarettes per day. He has got history
of angioplasty of left anterior
descending artery 5 years back.
3. He is type 2 diabetic and hypertesive
taking lisinopril and glimepiride 2 mg
daily.
His pulse is 90/minute, B.P
145/90mmHg, R/R 14/minute, Temp.
98F°
Rest of examination is normal.
What is your diagnosis?
4.
5. 55 years old male presents in
emergency department with
central chest pain radiating to
left arm for last 20 minutes
while sitting in his study room.
6. He gives h/o chest pain on
walking 1000 steps for last 2
years for which he is talking
aspirin 75mg, clopidogrel 75gm,
simvastatin 40mg and triglyceryl
spray as needed.
What is your diagnosis?
7.
8. 63 years old man known case
of ischemic heart disease
present in emergency with c/o
chest pain for last 10 minutes
while working in his garden. It
is accompanied by cold
sweating and palpitations.
9. Pulse 96/-, B.P
160/110mmHg, temp. 98F°,
R/R 18/minute ECG in shown
below.
Cardiac enzymes are normal.
10.
11.
12. 65 years old female developed
sudden central chest pain
radiating to her left arm not
relieved by nitrates. It is
associated with cold sweating
and sinking of heart.
13. Pulse 100/minute, B.P
160/100mmHg, Temp. 98F°, R/R
15/minute.
Rest of examination is normal.
ECG is shown below.
Cardiac Enzymes are raised.
Trop T is positive.
14.
15.
16. 60 years old male presented
with sudden severe cental
chest pain for last 2 hours
associated with cold sweating
and sinking of heart not
relieved by rest or sublingual
nitrates.
17. Pulse 90/min, B.P 180/90 mmHg,
Temp 98F°, R/R 16/min
JVP is raised.
Resp examination shows bibasilar fine
cackles.
ECG is shown below.
Cardiac enzymes are raised.
Trop T is positive.
18.
19.
20. Unstable Angina
Non-ST-Segment Elevation MI (NSTEMI)
ST-Segment Elevation MI (STEMI)
21. NON- MODIFIABLE
Age
SEX
FAMILY HISTORY-----Event in 1st degree
relative
<55 Male
<65 Female
23. Ethnic-Specific Values for Waist Circumference
Ethnic Group Waist Circumference
Japanese
Men >85 cm (33.5 in)
Women >90 cm (35 in)
South Asians and Chinese
Men >90 cm (35 in)
Women >80 cm (31.5 in)
Europeans
Men >94 cm (37 in)
Women >80 cm (31.5 in)
24. Unstable
Angina STEMINSTEMI
Non occlusive
thrombus
Non specific
ECG
Normal cardiac
enzymes
Occluding thrombus
sufficient to cause
tissue damage & mild
myocardial necrosis
ST depression +/-
T wave inversion on
ECG
Elevated cardiac
enzymes
Complete thrombus
occlusion
ST elevations on
ECG or new LBBB
Elevated cardiac
enzymes
More severe
symptoms
25. Stable angina:
Reproducibly by exercise or emotion,
stress and relieved within 15-20 min by
rest or sublingual nitroglycerine
Unstable angina
(A) occurs at rest or mild exertion, usually
lasts more than 30 min
(B) new onset( within 1 month)
(C ) crescendo type
26. Criteria.
H/o prolonged chest discomfort or angina
equivalent > 30 min.
Presence of more than 1 mm ST- elevation in
2 consecutive chest leads or 2mm elevation
in limb leads.
Presence of elevated cardiac biomarkers.
New onset left bundle branch block
27. • Chest pain resembles angina.
• But lasts more than 30 minutes
• It is more intense, not relieved by rest or
sublingual nitrates.
• Accompanied by dyspnoea, nausea vomiting,
fatigue, syncope and cold sweating.
• It may present as extreme exhaustion.
• Impending fear of death
• It may occur without chest pain in
hypertensive, diabetic elderly, or post
operative patients.
28. PHYSICAL EXAMINATION
Patients usually appear restless and in
distress.
Tend to lie still.
The skin is cold and moist due to
sympathetic discharge.
Breathing may be labored and rapid.
Fine crackles, coarse crackles, or
rhonchi may be heard when
auscultating the lungs due to heart
failure.
29. Increased blood pressure
related to anxiety or a
decreased blood pressure
caused by heart failure.
The heart rate may vary from
bradycardia to tachycardia.
On auscultation, the first heart
sound may be diminished as a
result of decreased
contractility.
30. A fourth heart sound is heard in
almost all patients with MI, whereas a
third heart sound is detected in only
about 10% to 20% of patients due to
failure.
Transient systolic murmurs may be
heard due to papillary muscle
ischemia
After about 48 to 72 hours, many
patients acquire a pericardial friction
rub
31. • Patients with acute ST- elevation MI
are stratified into low and high risk
groups on the basis of their initial
physical examination.
1. Without pulmonary congestion or
shock. (Klipp I). Mortality rate < 5%.
2. Mild pulmonary congestion or
presence of S3(Klipp class II)
favourable prognosis.
32. 1. Pulmonary edema(Klipp Class III)
needs aggressive management.
2. Hypotensive patients with
evidence of shock(Klipp class IV)
80% mortality rate
33. 4 groups of investigation are
used.
ECG.
Cardiac biomarkers
Cardiac imaging.
Non specific indices of Tissue
necrosis and inflammation.
34. ECG CRITERA OF ACUTE MI
Pathological q wave
T wave inversion
Convex ST-elevation above 1 mm.
ECG CRITERA OF old MI
Pathological q wave
ST in baseline
T wave normal or inverted
Right ventricular MI(V 4 R)
35.
36. Tall R wave, ST segment
depression and t wave
inversions in V1 and V2
37. Q wave infarction means
infarction of full thickness
myocardium
Non Q wave infarction means
infarction of subendocardium
38.
39.
40.
41.
42.
43.
44.
45. Trop-T and Trop- I are raised after 3-12
hours of MI..>95% sensitivity and specificity
Peak at 2 days.
Elevated for 5-14 days.
CK-MB has sensitivity of 95 % when
measured within 24-36 hours after the onset
of chest pain. Increases within 3-4 hours of
chest pain. Peak at 24 hours. And returns to
base line at 48-72 hours.
47. • If MI not detected on ECG, then two dimensional
echocardiography is used which shows wall motion abnormalities
and aids in management and decision.
• It also shows RV infarction, ventricular aneurysm and pericardial
effusion.
• Myocardial perfusion imaging. Very sensitive but cann’t
distinguish acute infarct from chronic infarct thus not specific for
acute MI.
48. Radioneucleotide ventriculography. Tc
labelled RBCs are used which show wall
motion abnormalities.
MRI. Can be used. It detects MI accurately.
49. Immediate management.
The goal is to identify the patient for
reperfusion therapy.
IN IDEAL CONDITIONS Goal is door to needle
time of < 30 min and door to ballon time of
< 90 min.
Relieves ischemic pain, provide supplemental
oxygen, recognize and treat potential life
threatening complication.
50. 10/00medslides.com 50
ST elevation
12 h
Aspirin
Beta-blocker
Eligible for
fibrinolytic therapy
> 12 h
Fibrinolytic therapy
contraindicated
Not a candidate for
reperfusion therapy
Persistent
symptoms ?
Fibrinolytic therapy
Primary
PTCA or CABG
Other medical therapy:
ACE inhibitors
? Nitrates
Anticoagulants
Consider
Reperfusion
Therapy
No Yes
Modified from Antman EM. Atlas of Heart Disease, VIII; 1996
ST elevation
Aspirin
Beta-blocker
12 h > 12 h
Eligible for
fibrinolytic therapy
Fibrinolytic therapy
Fibrinolytic therapy
contraindicated
Primary
PTCA or CABG
Not a candidate for
reperfusion therapy
Other medical therapy:
ACE inhibitors
? Nitrates
Anticoagulants
Persistent
symptoms ?
No Yes
Consider
Reperfusion
Therapy
51. 10/00medslides.com 51
ST depression/T-wave inversion:
Suspected AMI
Heparin + Aspirin
Nitrates for recurrent angina
Assess Clinical Status
Continued observation
in hospital
Consideration of
stress testing
PCI
CABG
No
Yes
Antithrombins: LMWH - high-risk patients
Anti-Platelets: GpIIb/IIIa inhibitor
Patients without prior
beta-blocker therapy or
who are inadequately
treated on current dose
of beta-blocker
Persistnet symptoms in
patients with prior
beta-blocker therapy or
who cannot tolerate
beta-blockers
Establish adequate
beta-blockade
Add calcium antagonist
High-risk patient:
1. Recurrent ischemia
2. Depressed LV function
3. Widespread ECG changes
4. Prior MI
Clinical stability
Catheterization: Anatomy
suitable for revascularization
Medical
Therapy
Modified from Antman EM. Atlas of Heart Disease, VIII; 1996
ST depression/T-wave inversion:
Suspected AMI
Antithrombins: LMWH - high-risk patients
Anti-Platelets: GpIIb/IIIa inhibitorPatients without prior
beta-blocker therapy or
who are inadequately
treated on current dose
of beta-blocker
Establish adequate
beta-blockade
Add calcium antagonist
Persistnet symptoms in
patients with prior
beta-blocker therapy or
who cannot tolerate
beta-blockers
Assess Clinical Status
High-risk patient:
1. Recurrent ischemia
2. Depressed LV function
3. Widespread ECG changes
4. Prior MI
Catheterization: Anatomy
suitable for revascularization
Yes
PCI
CABG
Medical
Therapy
Clinical stability
Continued observation
in hospital
Consideration of
stress testing
Heparin + Aspirin
Nitrates for recurrent angina
No
52. IV CANULA
OXYGEN INHALATION
MORPHINE DERIVATIVES
NITROGLYCERINE SUBLINGUALLY
ORAL Asprin 300mg chew and swallow THEN
75mgd
Clopidogril. 300 bolus then 75mg/day
Anti-coagulation
UFH: initial bolus 60u/kg, maximum 5000u
followed by infusion of 12u/kg /hr.
maximum 1000u/hr to keep APTT of 1.5-2
times of control.
LWMH: (enoxaparin): 1mg/kg bid.
53. should be avoided in patients of hypotension.
Right ventricular MI, bradycardia < 50/ min.
Sublingual preparation used ,If pain still
continues then IV nitroglycerine
10microgram/ min should be initiated.
Dose adjustment may be performed every 5
min at 10 microgram/min until chest pain
resolves or heart rate increases or BP
decreases more than 10 %.
54. Cellular Mechanism of Vasodilatation
Nitrates Formation of
Nitric oxide (NO)
Activation of
Guanylate cyclase
Synthesis of
cyclic GMP
Relaxation of Vascular
smooth muscles
55. Effect of Nitrates :
Venodilatation Arteriolar
dilatation
Preload Afterload
Myocardial
Oxygen demand
2- Redistribution of coronary flow towards
subendocardium
3- Dilatation of coronary collateral vessels
1-
57. They reduce myocardial ischemia
and infarct size and myocardial
rupture.
IV metoprolol 5 mg can be
repeated every 5 min for 3 doses.
If tolerated then can be shifted to
oral medication 25-50 mg/ 6 -12
hrly.
60. Only indicated in highest risk UA/NSTEMI
patients (dynamic changes on EKG,
elevated biomarkers, electrical
instability) and/or in whom early PCI is
planned
Abciximab is the choice if early
angiography and PCI is planned
Tirofiban indicated when no PCI planned
61. Handle patient carefully while providing initial
care, starting I.V. infusion, obtaining baseline
vital signs, and attaching electrodes for
continuous ECG monitoring.
Maintain oxygen saturation greater than 92%.
Administer oxygen by nasal cannula if
prescribed
62. Following agents are used as
fibrinolytic agents.
TPA
Streptokinase.
Tenecteplase.
Reteplase.
63. Thrombolytic therapy should be
considered in patients with ST-
elevation MI in 2 or more leads.
Effective if given within 12 hours but
not beyond 24 hours.
It is not indicated if symptoms have
resolved or the patient with ST-
depression.
64. Absolute.
• Intracranial hemorrhage
• Ischemic strokes within past year
• Head trauma
• Suspected Aortic dissection.
• Active internal bleed
• BP> 180/110
65. Allergy or previous use of streptokinase------ 5
days to 2 years
Active peptic ulcer disease
Internal bleed 2-4 weeks
Prolonged CPR > 10 min.
Major surgery < 2 weeks
Known bleeding diathesis
hemorrhagic ophthalmic condition (e.g.,
hemorrhagic diabetic retinopathy),
Severe menstrual bleeding.
Pregnancy
66. • Streptokinase.
• 1.5 million units IV over 60 min.
• Retiplase.
• IV bolus of 10 mg over 2 min followed by
another IV bolus of 10 mg over 30 min.
• Alteplase.
• IV bolus of 15 mg followed by a 0.75mg/kg
by IV infusion over 30 min. then 0.5 mg/kg
over 60 min. maximum dose of 100mg over
90 min.
67. Grade O: indicates complete occlusion.
Grade I: some penetration beyond the part of
obstruction but without penetration distal
part.
Grade II: perfusion of entire infarct vessel into
distal bed but flow is delayed.
Grade III: full perfusion of infarct vessel.
Fibrinolytic therapy reduces mortality in 50 %.
68. It is alternative to thrombolytic
therapy.
Used in patients in whom diagnosis is
in doubt.
Cardiogenic shock, increased bleeding
risk.
It should be considered when door to
baloon time is < 90 min.
69. • Primary PCI is preferred over thrombolysis in
patients < 75 years age and present with
cardiogenci shock within 36 hrs of MI. and PCI
can be performed within 18 hours of shock.
• Contraindications to fibrinolytic therapy.
• Increased risk of death or CHF.
• Underwent resent PCI.
• NOTE: emergency CABG is a high risk precedure
that should be considered if a patient has
cardiogenic shock and coronary vasculature is
not compatible for PCI or the procedure has
failed.
70. (PTCA) is an effective alternative to reestablish
blood flow to ischemic myocardium.
Primary PTCA is an invasive procedure in which
the infarct-related coronary artery is dilated
during the acute phase of an MI without prior
administration of thrombolytic agents
These complications can include retroperitoneal
or vascular hemorrhage, other evidence of
bleeding, early acute reocclusion, and late
restenosis.
71. Bed rest for 12 hrs.
Under supervision to upright position
sitting in a chair in 24 hours.
In absence of shock, hypotension, 2rd
day, can go to washroom on wheel
chair, can take shower or stand on the
sink.
End of 3rd day, activity is increased.
72. For 1st 4-12 hrs:
Clear fluids or NPO.
30% less of total calories , complex
carbohydrates should take 50% of
total calories.
Bowels:
Bed side comod should be used .
Diet rich in bulk, stool softners and
lexatives.
73. After medical therapy including thrombolysis:
Stress test: Is done to determine the
prognosis or functional capacity.
Stress test: Can be performed 4-6 days after
the MI. Can also be performed after hospital
discharge 2-3 weeks or late after discharge
3-6 weeks if the initial post infartction stress
test was sub maximal.
74. • The goal of secondary prevnetion is to produce a
favourable impact on the morbidity and mortality .
• Antiplatelet agents: Asprin 75- 325 mg/ day should
be used indefinitly.
• Clopidogril : 75 mg/day for a maximum of 9
months.
• Ace Inhibitors: reduce mortality and incidence of CHF.
• Treatment should be given indefinitely.
• Benefit is seen in patients with LV dysfunction,
ejection fraction less than 40 and all patients of MI.
• Beta blocker: Reduce cardiac events after MI, and
should be use indefinitly.
75. • B1 selective blokeres e.g Metoprolol 100mg BID,
atenolol 100mg daily, propranolol 80mg TID.
• Cholestrol treatment:
• With ACS and ST-elevation MI, it should be less
than 100mg/dl.
• Tobacco cessation
• Diet:
• A body mass index of < 25kg/m2 is desireable.
• Diabetes:
• Target HbA1C <7.
• Exercise:
• The goal is a minimum of 3-4 days per week of
30-60 min of activity in those who are physically
capable.
76. Routine office visits:
Every 4-12 months are suggested for the 1st
year.
81. • Post infarction ischemia:
• Nitrates. Beta blockers. Clopidogril.
Asprin.
• Arrythmias:
• Sinus bradycardia: Atropine 0.5-1 mg
IV.
82. Supraventricular tachyarrthmia:
IV beta blockers such as metoprolol 2.5-
5mg/hr.
IV diltiazim 5-15mg/hr if beta blockers are
contraindicated.
Digoxin 0.5mg as initial dose then 0.25mg
every 90 to 120 min.
amiodarone 150mg IV bolus.
Ventricular arrythmias:
1mg/kg bolus of lidocaine if the patient is
stable.
If not, then DC cardioversion at 100-200
jouls. IV amiodarone can be used.
84. Conduction disturbances:
• Ist degree heart block is the most
common and requires no treatment.
• 2nd degree block is usually of Mobitz
type I and requires treatment only if
symptomatic.
• Complete AV block occurs in 5% of
patiets and generally resolves but it
may persist for hours to several
weeks. And TPM is indicated in such
cases.
85. • Hypotension and shock:
• Patients with hypotension should be treated
with successive boluses of 100ml of normal
saline until PCWP reaches 15mm of Hg.
• Dopamine is the most appropriate for
the cardiogenic hypotension initiated at the
dose of 2-4mcg/kg/min.
• At low doses, < 5mcg it improves renal
blood flow.
• At intermediate dosages 2.5-10mcg, it
stimulates myocardial contractility and
above 10mcg it is a potent alpha 1
adrenergic agonist.
86. • It is associated with inferior wall
MI.
• Diagnosis is suggested by ST-
elevation in right sided anterior
chest leads particulary R wave in
V4 .
• Confirmed by echocardiography.
87. Rupture of papillary muscles or
interventricular septa usually occurs
3-7 days.
Detected by new systolic murmurs.
Confirmed by doppler
echocardiography
surgical intervention is mandatory.
88. • Complete rupture occurs in 1 % of
patients and results in immediate
death.
• It occurs 2-7 days post infarction.
• Involves anterior wall.
• Incomplete rupture recognized by
echocardiography, radioneucleotide
angiography.
• Early surgical repair is indicated.
89. • 10-20% of patients.
• Usually follows anterior wall infarction.
Recognized by persistent ST-
elevation beyond 4-8 weeks.
• They rarely rupture but associated
with arterial emboli, ventricular
arrythmias and CHF.
• Surgical resection may be performed.
90. Pericardium is involved in 50 % of infarction.
But pericarditis is often not clinically
significant.
Pericardial pain occurs 2-7 days, recognized by
its variation with position and respiration.
Improved by sitting.
Often no treatment is required but Asprin
650mg 4-6hrly will usually relieve the pain.
91. 1-12 weeks after infarction.
Autoimmune phenomenom.
Presents as pericarditis associated with
◦ Fever
◦ Leucocytosis
◦ pericardial or pleural effusion.