Unstable angina non ST elevation myocardial infarction physical examination

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Patient Information

Overview

Classification

Pathophysiology

Unstable Angina
Non-ST Elevation Myocardial Infarction

Differentiating Unstable Angina/Non-ST Elevation Myocardial Infarction from other Disorders

Epidemiology and Demographics

Risk Stratification

Natural History, Complications and Prognosis

Special Groups

Women
Heart Failure and Cardiogenic Shock
Perioperative NSTE-ACS Related to Noncardiac Surgery
Stress (Takotsubo) Cardiomyopathy
Diabetes Mellitus
Post CABG Patients
Older Adults
Chronic Kidney Disease
Angiographically Normal Coronary Arteries
Variant (Prinzmetal's) Angina
Substance Abuse
Cardiovascular "Syndrome X"

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Blood Studies
Biomarkers

Electrocardiogram

Chest X Ray

Echocardiography

Coronary Angiography

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Immediate Management

Anti-Ischemic and Analgesic Therapy

Cholesterol Management

Antitplatelet Therapy

Antiplatelet therapy recommendations
Aspirin
Thienopyridines
Glycoprotein IIb/IIIa Inhibitor

Anticoagulant Therapy

Additional Management Considerations for Antiplatelet and Anticoagulant Therapy

Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS

Mechanical Reperfusion

Initial Conservative Versus Initial Invasive Strategies
PCI
CABG

Complications of Bleeding and Transfusion

Discharge Care

Medical Regimen
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Long-Term Medical Therapy and Secondary Prevention

ICD implantation within 40 days of myocardial infarction

ICD within 90 days of revascularization

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Case #1

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Patients with suspected acute coronary syndrome must be evaluated rapidly. The objectives of the initial evaluation are first to identify signs of immediate life-threatening instability, and then to ensure that the patient is moved rapidly to the most appropriate setting for the level of care needed, based on diagnostic criteria and an estimation of the need for intervention.

Physical Examination

Vital Signs

  • In the evaluation of a patient presenting with ACS, hypotension (systolic blood pressure <100 mm Hg), tachycardia (pulse >100) and bradycardia (pulse <60 bpm) indicate that the patient is at higher risk.
  • As with the assessment of all patients, other abnormal vital signs such as hypoxia, tachypnea (RR >19), hypothermia (T <95 F) or fever (T >100.3 F) should raise concern, although they are not specifically suggestive of ACS.
  • If aortic dissection is considered in the differential diagnosis, blood pressure should be checked in both arms (>20 mm Hg differential is suggestive of aortic dissection).

Appearance of the Patient

Eyes

Ear, Nose and Throat

  • The ears and nose are typically not the focus of a physical exam for ACS.
  • However, the examination of the buccal mucosa can help to determine a patient's volume status, as can the examination of the right internal jugular vein pulsations (JVP).
  • A JVP which is elevated greater than 4 cm above the sternal angle (9 cm above the right atrium) is considered elevated and reflects elevated right atrial pressure.

Heart

Lungs

Abdomen

  • The abdominal exam is typically not the focus of a physical exam for ACS.
  • However, a finding of a expansile, pulsatile mass in the upper abdomen suggests an aortic aneurysm and requires further urgent evaluation.

Extremities

  • Assess the lower extremities for edema, suggestive of heart failure.
  • It is also important to palpate the radial, femoral and pedal pulses.
  • Unequal radial pulses are suggestive of aortic dissection.
  • Weak pedal pulses are suggestive of peripheral vascular disease.
  • Femoral pulses are important to document in the event that cardiac catheterization is necessary.

Neurologic

  • The neurological examination is typically not the focus of a physical exam for ACS.
  • However, mental status at the time of the initial assessment should be documented for future reference, should the patient's mental status deteriorate during the period of observation.
  • Also, headache in the context of chest pain and severe hypertension (i.e., SBP > 210 mm/Hg or a DBP > 120 mm/Hg) would support a diagnosis of hypertensive emergency as a cause for ACS.

References

  1. Anderson JL, Adams CD, Antman EM; et al. (2007). "ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine". JACC. 50 (7): e1–e157. PMID 17692738. Text "doi:10.1016/j.jacc.2007.02.013 " ignored (help); Unknown parameter |month= ignored (help)

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