ADVANCED MEDICAL-SURGICAL NURSING I CASE SCENARIO THE CLIENT WITH CARDIOVASCULAR ALTERATIONS Prepared by: John Henry O. Valencia, RN, RM Master of Arts in Nursing Student
It is mid-morning in the medical ward where you work, and you are getting a new patient, M.A., a 60- year-old, retired businessman, is married and has 3 grown children. As you take his health history, he tells you that he began to feel palpitations and on and off chest discomfort about 10 days ago. He has hypertension and a 5-year history of angina pectoris. He is 59 and weighs 200 lb. He is sedentary and gets no routine exercise. During the past week, he has had more frequent episodes of midchest discomfort. During the week, he has also experienced increased fatigue. He states I just feel crappy most of the time. He tells you a cardiac catheterization done several years ago revealed 50% occlusion of the right coronary artery and 50% occlusion of the LAD artery. He also tells you that both his parents had CAD. He is taking NTG, amlodipine, metoprolol, lipitor and baby ASA.The MD writes his diagnosis as CAD, HPN.
At 1AM the following day, M.A. turns on his call light. When you respond, he is talking rapidly and pointing to the bathroom. His speech pattern indicates he is short of breath. You assist him to the bathroom and note that his skin feels clammy. While sitting on the commode he vomits. The resident MD comes and evaluates M.A.s condition. He orders Furosemide 40 mg. IV push STAT. M.A. continues to experience vomiting and diaphoresis inspite of medications and comfort measures. A STAT 12-lead ECG reveals ischemic changes indicating ACS. M.A. is ordered to be transferred to the CCU.
Five days later his condition is stabilized and M.A. is taken to OR for CABG x3. When he arrives from the OR, he has a Swan-Ganz catheter in place for hemodynamic monitoring and is intubated and put on a ventilator at FiO2 70. His ABG reading is: pH 7.36; PCO2 46 mmHg; PO2 61 mmHg; SaO2 85% with a Hgb 10.3mg/dL. Hemodynamic values show that the pressures within his heart and lungs are slightly elevated and that his cardiac output is low, indicating that the heart is not effectively pumping out the blood that is returned to it or that he is experiencing a little fluid overload. M.A. receives continuous IV infusions of Nitroprusside and Dobutamine. Close monitoring and intensive management of M.A.s condition is done. His condition improves and is transferred to the Telemetry unit. Five days later, he is now preparing for discharge.
INSTRUCTIONS: Identify the learning issues (at least 7) related to pathophysiology (Focus on CV) that you can draw out from this case. Prepare to discuss these issues with the class on Tuesday, September 23, 2014. Your written answer to your learning issues will be submitted next Tuesdays class.
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OLD AGE (60 YEARS OLD), OBESITY (97KGS OR 200LBS) AND SEDENTARY LIFESTYLE
Nonspecific Injury to endothelial lining
Desquamation of endothelial lining
Activation of tissue inflammatory response
Release of pro-inflammatory cytokines (MCP-1, TNF-, Interleukins, CRP and Serum Amyloid A)
Interleukin - 6 Leukocyte and Endothelial cell activation Hepatic Acute- phase reactants production Increased Liver Enzymes (SGPT) Monocyte Chemoreactant Protein-1 Leukocyte- Endothelium binding Migration to site of inflammation Mononuclear phagocyte activation Increased WBC count Complete Blood Count Interleukin-18 and 10 Expression of interferon- Endothelial adhesion molecule activation Intercellular Adhesion Molecule (ICAM) Formation Vascular Cell Adhesion Molecule (VCAM) E-selectin Formation Monocyte Adhesion Leukocyte diapedesis into extravascular space Adhesion of molecules Increase von Willebrand Factor Developing fatty Streak Oxidative Stress LDL Oxidation Oxidized LDL attracts monocytes and macrophages to the site Plaques begin to form from cells which embedded into the endothelium Blood Tests (Cardiac Enzymes Test) COMPREHENSIVE PATHOPHYSIOLOGIC BASIS OF CLIENTs CONDITION
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Development of Foam cells Lipids are engulfed by the foam cells Development of smooth muscle cells ATHEROSCLEROTIC PLAQUE FORMED Increased inflammatory stress Continuous inflammatory response ANGIOGENESIS Vascular endothelial growth factor (VEGF), Placental Growth Factor (PlGF), and hepatocyte growth factor (HGF) Intraplaque Hemorrhage Conversion of Stable plaque to unstable plaque Intraplaque Inflammation Degradation of fibrous cap Plaque Instability Platelet Activation Plaque Erosion THROMBUS FORMATION Thrombus occluding vessel Prevention of myocardial perfusion Decreased Myocardial Oxygen Supply Anaerobic Metabolism of Glycogen Failure of Sodium- Potassium and Calcium pump Accumulation of hydrogen ions and lactate Acidosis Altered electrical conduction Altered Repolarization Inverted T-wave Ischemic Phase Myocardial cells are sensitive to acidic pH Myocardial Injury ST Segment Elevation Myocardial Ischemia Myocardial Cell Necrosis Absence of depolarization current from dead tissues Presence of opposing currents from other areas of the heart Abnormal Q Wave Injury Phase Infarction Phase ECG ECG CHEST PAIN Cardiac Catheterization (Reveals 50% Occlusion of Right Coronary Artery and 50% Occlusion of Left Anterior Descending Artery)
Increased Troponin I and T; Mrocardium-Specific Creatinine Kinase (CK-MB) Cardiac Biomarkers NTG or Morphine to Control pain Fibrinolytic Therapy Lipitor
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Inflammatory Response to Necrotic Myocardial Cell Impaired Myocardial Contractility
Increased WBC Released of Endogenous Pyrogens Release of Prostaglandins Prostaglandins will reset hypothalamic thermostat FEVER Scar Tissues replacing healthy tissues Decrease Cardiac Output Decrease Blood Pressure Release of Epinephrine and Norepinephrine Increased Blood Pressure Increased Heart Rate Increased Afterload Stimulation of Baroreceptors Peripheral Vasoconstriction Increased Pumping Action of Heart Decreased Renal Perfusion RAAS Activation Increased Myocardial oxygen Demand ADH and Aldosterone Release Sodium and Water reabsorption Increased Blood Volume Increased Preload Increased Myocardial Workload Cardiomegaly Chest X-Ray and 2D Echo with Doppler studies Deterioration of Hearts ability to pump Moderate Left Ventricular Failure Continuous blood flow to the lungs from Right side of the heart Left Ventricle unable to pump out blood Pulmonary back flow of the blood Pulmonary Congestion Dyspnea Shortness of Breath Widespread Crackles Ocassional Wheeze (Cardiac Asthma) Increased Right Ventricular Pressure (Above Systolic-20-30 mmHg Diastolic 0-5 mmHg) Hemodynamic Monitoring Increased CVP (Above 2-6mmHg)
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Fluids leak into alveolar space Lymphatic system drains excess interstitial fluid volume
Additional fluid in the pleural space drains into titer lymph nodes Fluid moves from the interstitial space in the alveolar walls Damaged to alveolar epithelium Further fluid accumulation in the alveolar space Alveolar Edema Impaired gas exchange Hypoxemia Hypercarbia Decrease lung compliance Decrease oxygen diffusion Use of Accessory Muscle Bradypnea Poor cerebral oxygenation Altered Level of consciousness Agitation / Restlesness Poor Peripheral oxygenation Pallor Sweaty cool periphery Reduced capillary return Increased work of breathing Exhaustion Fatigue Decreased PO2 (PO2 61mmHg) Increased Pulmonary Artery Pressure (Above 25mmHg) and Pulmonary Artery Wedge Pressure (PAWP) (Above 4-12mmHg)
Decreased SaO2 (SaO2 85%) Hemodynamic Monitoring Arterial Blood Gas Analysis
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Identify the learning issues (at least 7) related to pathophysiology (Focus on CV) that you can draw out from this case.
1. STAGES OF PATHOPHYSIOLOGIC BASIS OF CORONARY ARTERY DISEASE
Coronary artery disease (CAD) also known as atherosclerotic heart disease, coronary heart disease, or ischemic heart disease (IHD),is the most common type of heart disease and cause of heart attacks.The disease is caused by plaque building up along the inner walls of thearteries of the heart, which narrows the arteries and reduces blood flow to the heart. Atherogenesis in humans typically occurs over a period of many years, usually many decades. Growth of atherosclerotic plaques probably does not occur in a smooth, linear fashion but discontinuously, with periods of relative quiescence punctuated by periods of rapid evolution. It undergoes different steps; Initiation, Leukocyte recruitment and Foam Cell formation.
A. INITIATION
Studies of human atherosclerosis suggests that the "fatty streak" represents the initial lesion of atherosclerosis. These early lesions most often seem to arise from focal increases in the content of lipoproteins within regions of the intima. Our patient being a smoker without exercise and with a susceptible age predisposes him to atherosclerotic plaque formation which is heralded by the Fatty streak formation from lipoprotein accumulation. This accumulation of lipoprotein particles may not result simply from increased permeability, or "leakiness," of the overlying endothelium. Rather, the lipoproteins may collect in the intima of arteries because they bind to constituents of the extracellular matrix, increasing the residence time of the lipid-rich particles within the arterial wall. Lipoproteins that accumulate in the extracellular space of the intima of arteries often associate with glycosaminoglycans of the arterial extracellular matrix, an interaction that may slow the egress of these lipid-rich particles from the intima. Lipoprotein particles in the extracellular space of the intima, particularly those retained by binding to matrix macromolecules, may undergo oxidative modifications. Considerable evidence supports a pathogenic role for products of oxidized lipoproteins in atherogenesis. Lipoproteins sequestered from plasma antioxidants in the extracellular space of the intima become particularly susceptible to oxidative modification, giving rise to hydroperoxides, lysophospholipids, oxysterols, and aldehydic breakdown products of fatty acids and phospholipids. Considerable evidence supports the presence of such oxidation products in atherosclerotic lesions.
B. LEUKOCYTE RECRUITMENT
Accumulation of leukocytes characterizes the formation of early atherosclerotic lesions. Thus, from its very inception, atherogenesis involves elements of inflammation, a process that now provides a unifying theme in the pathogenesis of this disease. The inflammatory cell types typically found in the evolving atheroma include monocyte-derived macrophages and lymphocytes. A number of adhesion molecules or receptors for leukocytes expressed on the surface of the arterial endothelial cell probably participate in the recruitment of leukocytes to the nascent atheroma. Constituents of oxidatively modified low-density lipoprotein can augment the expression of leukocyte adhesion molecules. This example illustrates how the accumulation of lipoproteins in the arterial intima may link mechanistically with leukocyte recruitment, a key event in lesion formation.
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Once captured on the surface of the arterial endothelial cell by adhesion receptors, the monocytes and lymphocytes penetrate the endothelial layer and take up residence in the intima. In addition to products of modified lipoproteins, cytokines (protein mediators of inflammation) can regulate the expression of adhesion molecules involved in leukocyte recruitment. For example, interleukin 1 (IL- 1) or tumor necrosis factor (TNF-) induce or augment the expression of leukocyte adhesion molecules on endothelial cells. Because products of lipoprotein oxidation can induce cytokine release from vascular wall cells, this pathway may provide an additional link between arterial accumulation of lipoproteins and leukocyte recruitment. Chemoattractant cytokines such as monocyte chemoattractant protein 1 appear to direct the migration of leukocytes into the arterial wall.
C. FOAM-CELL FORMATION
Once resident within the intima, the mononuclear phagocytes mature into macrophages and become lipid-laden foam cells, a conversion that requires the uptake of lipoprotein particles by receptor- mediated endocytosis. One might suppose that the well-recognized "classic" receptor for LDL mediates this lipid uptake; however, humans or animals lacking effective LDL receptors due to genetic alterations (e.g., familial hypercholesterolemia) have abundant arterial lesions and extraarterial xanthomata rich in macrophage-derived foam cells. In addition, the exogenous cholesterol suppresses expression of the LDL receptor; thus, the level of this cell-surface receptor for LDL decreases under conditions of cholesterol excess. Candidates for alternative receptors that can mediate lipid loading of foam cells include a growing number of macrophage "scavenger" receptors, which preferentially endocytose modified lipoproteins, and other receptors for oxidized LDL or very low-density lipoprotein (VLDL). Monocyte attachment to the endothelium, migration into the intima, and maturation to form lipid-laden macrophages thus represent key steps in the formation of the fatty streak, the precursor of fully formed atherosclerotic plaques.
D. ARTERIAL REMODELING DURING ATHEROGENESIS
During the initial part of the life history of an atheroma, growth is often outward, preserving the caliber of the lumen. This phenomenon of "compensatory enlargement" accounts in part for the tendency of coronary arteriography to underestimate the degree of atherosclerosis. Rupture of the plaque's fibrous cap causes thrombosis. Physical disruption of the atherosclerotic plaque commonly causes arterial thrombosis by allowing blood coagulant factors to contact thrombogenic collagen found in the arterial extracellular matrix and tissue factor produced by macrophage-derived foam cells in the lipid core of lesions. In this manner, sites of plaque rupture form the nidus for thrombi. The normal artery wall has several fibrinolytic or antithrombotic mechanisms that tend to resist thrombosis and lyse clots that begin to form in situ. Such antithrombotic or thrombolytic molecules include thrombomodulin, tissue- and urokinase-type plasminogen activators, heparan sulfate proteoglycans, prostacyclin, and nitric oxide. When the clot overwhelms the endogenous fibrinolytic mechanisms, it may propagate and lead to arterial occlusion. The consequences of this occlusion depend on the degree of existing collateral vessels. In a patient with chronic multivessel occlusive coronary artery disease (CAD), collateral channels have often formed. In such circumstances, even a total arterial occlusion may not lead to myocardial infarction (MI), or it may produce an unexpectedly modest or a non-ST-segment elevation infarct because of collateral flow. In a patient with less advanced disease and without substantial stenotic lesions to provide a stimulus for collateral vessel formation, sudden plaque rupture and arterial occlusion commonly produces an ST-segment elevation infarction. These are the types of patients who may present with MI or sudden death as a first manifestation of coronary atherosclerosis. In some cases, the thrombus may
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lyse or organize into a mural thrombus without occluding the vessel. Such instances may be clinically silent. The subsequent thrombin-induced fibrosis and healing causes a fibroproliferative response that can lead to a more fibrous lesion that can produce an eccentric plaque that causes a hemodynamically significant stenosis. In this way, a nonocclusive mural thrombus, even if clinically silent or causing unstable angina rather than infarction, can provoke a healing response that can promote lesion fibrosis and luminal encroachment. Such a sequence of events may convert a "vulnerable" atheroma with a thin fibrous cap that is prone to rupture into a more "stable" fibrous plaque with a reinforced cap. Angioplasty of unstable coronary lesions may "stabilize" the lesions by a similar mechanism, producing a wound followed by healing.
E. MYOCARDIAL ISCHEMIA AS CAUSE OF PATIENTS CHEST PAIN
Central to an understanding of the pathophysiology of myocardial ischemia is the concept of myocardial supply and demand. In normal conditions, for any given level of a demand for oxygen, the myocardium will control the supply of oxygen-rich blood to prevent underperfusion of myocytes and the subsequent development of ischemia and infarction. The major determinants of myocardial oxygen demand are heart rate, myocardial contractility, and myocardial wall tension (stress).The normal coronary circulation is dominated and controlled by the heart's requirements for oxygen. This need is met by the ability of the coronary vascular bed to vary its resistance (and, therefore, blood flow) considerably while the myocardium extracts a high and relatively fixed percentage of oxygen. By reducing the lumen of the coronary arteries, atherosclerosis limits appropriate increases in perfusion when the demand for flow is augmented, as occurs during exertion or excitement. During episodes of inadequate perfusion caused by coronary atherosclerosis, myocardial tissue oxygen tension falls and may cause transient disturbances of the mechanical, biochemical, and electrical functions of the myocardium. Coronary atherosclerosis is a focal process that usually causes nonuniform ischemia. During ischemia, regional disturbances of ventricular contractility cause segmental hypokinesia, akinesia, or, in severe cases, bulging (dyskinesia), which can reduce myocardial pump function.
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CAD CLINICAL MANIFESTATIONS CHRONIC STABLE ANGINA PECTORIS UNSTABLE ANGINA PECTORIS (Preinfarction) Chest pain or discomfort provoked by EXERTION or EMOTIONAL STRESS. Relieved by REST or NITROGLYCERIN. Characteristics substernal chest pain, pressure, heaviness or discomfort pain may be mild or severe gradual buildup of discomfort and subsequent gradual fading numbness or weakness in arms, wrists, or hands diaphoresis tachycardia increased BP Location Behind middle or upper third of sternum + Levine Sign Radiation Radiates to neck, jaw, shoulders, arms, hands, and posterior intracapsular area Duration 2-15 minutes (after stopping activities) 1 minute after NITROGLYCERINE Other Precipitating Factor Exposure to hot or cold weather Eating heavy meal Coitus (increase workload of the heart, increase oxygen demand) Chest pain occurring at REST, no OXYGEN DEMAND is placed on the heart, but an ACUTE LACK of BLOOD FLOW to the HEART occurs because of: Coronary artery spasm Presence of an enlarge plaque Hemorrhage / ulceration of a complicated lesion Critical narrowing of the vessel lumen occurs A change in FREQUENCY, DURATION, and INTENSITY of stable angina symptoms Pain lasts longer than 10 MINUTES Pain UNRELIEVED by rest or Nitroglycerine Mimics S&S of MI CAN CAUSE SUDDEN DEATH OR RESULT IN MI. SILENT ISCHEMIA Absence of chest pain with documented evidence of an imbalance between myocardial oxygen supply and demand (ST DEPRESSION of 1mm or more). CIRCADIAN EVENT (occurs during the first few hours after awakening due to an increase in sympathetic nervous system activity) o Increase heart rate o Increase BP o Increase coronary vessel tone o Increase blood viscosity
2. Significant clinical presentation of the disease presented by the patient:
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3. Possible Complications of Acute Coronary Syndrome.
The complications of acute coronary syndromes depend on how much, how long, and where a coronary artery is blocked. If the blockage affects a large amount of heart muscle, the heart will not pump effectively. If the blockage shuts off blood flow to the electrical system of the heart, the heart rhythm may be affected. Pumping problems: In a heart attack, part of the heart muscle dies. Dead tissue, and the scar tissue that eventually replaces it, does not contract. The scar tissue sometimes even expands or bulges when the rest of the heart contracts. Consequently, there is less muscle to pump blood. If enough muscle dies, the heart's pumping ability may be so reduced that the heart cannot meet the body's need for blood and oxygen. Heart failure, low blood pressure, or both develop. If more than half of the heart tissue is damaged or dies, the heart generally cannot function, and severe disability or death is likely. Drugs such as beta-blockers and especially angiotensin-converting enzyme (ACE) inhibitors can reduce the extent of the abnormal areas by reducing the workload of and the stress on the heart. Thus, these drugs help the heart maintain its shape and function more normally. The damaged heart may enlarge, partly to compensate for the decrease in pumping ability (a larger heart beats more forcefully). Enlargement of the heart makes abnormal heart rhythms more likely. Rhythm problems: Abnormal heart rhythms (arrhythmias) occur in more than 90% of people who have had a heart attack. These abnormal rhythms may occur because the heart attack damaged part of the heart's electrical system. Sometimes there is a problem with the part of the heart that triggers the heartbeat, so heart rate may be too slow. Other problems can cause the heart to beat rapidly or irregularly. Sometimes the signal to beat is not conducted from one part of the heart to the other, and the heartbeat may slow or stop. In addition, areas of heart muscle that have poor blood flow but that have not died can be very irritable. This irritability can cause heart rhythm problems, such as ventricular tachycardia or ventricular fibrillation. These rhythm problems greatly interfere with the heart's pumping ability and may cause the heart to stop beating (cardiac arrest). A loss of consciousness or death can result. These rhythm disturbances are a particular problem in people who have an imbalance in blood chemicals, such as a low potassium level. Other problems: Pericarditis (inflammation of the membranes enveloping the heart) may develop in the first day or two after a heart attack or about 10 days to 2 months later. Pericarditis is more common in people who have not had the blocked artery opened by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). People seldom notice symptoms of early developing
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Acute Coronary Syndromes Rupture, fissuring, or ulceration Exposing Highly thrombogenic plaque constituents Underlying subendothelial basement membrane Hemorrhage into the core of plaques Expansion of plaque volume Worsening of the luminal occlusion Plaque rupture Intrinsic factors Large atheromatous core Thickness of the fibrous cap Extrinsic factors Adrenergic stimulation Intense emotional stress collagen synthesis collagen degradation pericarditis because their heart attack symptoms are more prominent. However, pericarditis produces a scratchy rhythmic sound that can sometimes be heard through a stethoscope 2 to 3 days after a heart attack. Sometimes, the inflammation causes a small amount of fluid to collect in the space between the two layers of the pericardium (pericardial effusion). Later developing pericarditis is usually called Dressler (post-myocardial infarction) syndrome. This syndrome causes fever, pericardial effusion, inflammation of the membranes covering the lungs, pleural effusion (extra fluid in the space between the two layers of the pleura), and joint pain. Other complications after a heart attack include malfunction of the mitral valve,rupture of the heart muscle, a bulge in the wall of the ventricle (ventricular aneurysm), blood clots (emboli), and low blood pressure (hypotension). Nervousness and depression are common after a heart attack. Depression after a heart attack may be significant and may persist. 4. Triggering factors for Myocardial infarction from Acute Coronary Syndrome
Role of Acute Plaque Changes
In most patients, unstable angina, infarction, and many cases of SCD all occur because of abrupt plaque change followed by thrombosis. Hence the term acute coronary syndrome.
A. Events that trigger the abrupt plaque changes Rupture reflects the inability of a plaque to withstand mechanical stresses. Triggers may be intrinsic or extrinsic
B. Integrity of the Plaque Fibrous caps are continuously remodeling
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Collagen produced by smooth muscle cells Collagen degraded by the action of metalloproteinases (macrophages) Inflammation Neutrophil infiltration Release of metalloprotein ases Breakdown of collagen in the fibrous cap Plaque destabilization & rupture Within minutes the thrombus can evolve to completely occlude the coronary lumen of the coronary vessel Vasospasm (platelet aggregation and mediator release) Other mediators activate the extrinsic pathway of coagulation Release potent secondary aggregators(thromboxane A 2 , adenosine diphosphate, and serotonin) Platelets adhere, aggregate, become activated A sudden disruption of an atheromatous plaque
Role of Inflammation
Inflammation plays an essential role at all stages of atherosclerosis. Whats the contribution of Inflammation to acute coronary syndromes?
Role of Thrombus o Formation of a thrombus on a disrupted atherosclerotic plaque o Significant rapid stenosis o Complete occlusion of the coronary arteries o Mural thrombus in a coronary artery can also embolize o Small fragments of thrombotic material o Small infarcts
5. Myocardial infarction as a result of continues necrosis of heart muscles
Ischemic necrosis of a part of the myocardium In a typical MI,
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Ischemia Death of myocardium Electrical instability of the myocardium Arrhythmias (ventricular fibrillation) Reduction in the contractility of the myocardium Reduction in the ejection fraction & increase in end systolic volume & pressure (Heart failure) Or a fatal mechanical failure 6. Role of Ischemia in development of Myocardial Infarction and significant signs and symptoms.
Please see the above comprehensive pathophysiologic basis of the clients condition for further explanation.
7. Likelihood that signs & symptoms represent an ACS secondary to CAD
Normal Normal Elevated cardiac TnI, TnT or CK-MB Cardiac Marker T wave flattening or inversion in leads with dominant R wave Normal EKG Fixed Q waves Abnormal ST segments or T waves not documented to be new New or presumably new, transient ST segment deviation (0.05mV) or T wave inversion (0.2mV) with symptoms EKG Chest discomfort reproduced by palpation or respiration Extracardiac vascular disease Transient MR, hypotension, diaphoresis, pulmonary edema or rales
Exam Probable ischemic symptoms in absence of the intermediate likelihood characteristics Recent cocaine use
Chest or left arm pain or discomfort as chief symptom Age > 70 Male gender Diabetes mellitus Chest or left arm pain or discomfort as chief symptom reproducing prior documented angina Known history of CAD, including MI History Low Intermediate High Feature
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References:
McPhee SJ, Hammer GD, et al. Pathophysiology of Disease: an Introduction to Clinical Medicine 6 th Edition; 2013; 26:985-998 Huether S, McCance K, Parkinson C, et al. Understanding Pathophysiology 5 th edition; 2012; 22:782-892 Carol JR, Mattson JH, Porth JB, et al. Essentials of Pathophysiology: Concepts of Altered Health States; 2014; 18:865-872 Corwin EJ, West BJ, Lilly LS, et al. Pathophysiology of Heart Disease: A Collaborative Project of Medical Students and Faculty 5 th Edition; 2013; 8:345-356
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