Read the summary and the most important questions on Acute Myocardial Ischaemia

• Introduction AMI

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• With which symptoms do patients with myocardial ischaemia often present?

  • Chest pain or pressure
  • Syncope
  • Palpitations
  • Dyspnoea
  • Sudden death.

• Describe the typical pain of myocardial infarction.

  • Severe
  • Constant
  • Retrosternal
  • Spreading across the chest. May radiate to the throat and jaw, down the ulnar aspect of both arms or to the interscapular area
  • Duration >20 minutes
  • Sweating, nausea, pallor, dyspnoea and anxiety often present.

• In which percentage of patients are prodromal symptoms of myocardial ischaemia present in the days preceding the infarct?

  In 20–60% of patients

• The pain of unstable angina may be similar, although it is often milder. Features indicating myocardial ischaemia may include:

  • Waxing and waning
  • Often reproducible upon minimal exertion or with emotion
  • Often associated with autonomic symptoms.

• The 'pain' may sometimes be atypical in terms of location or perception. It may be:

  • Epigastric
  • Confined to jaw, arms, wrists or interscapular region
  • Perceived as burning or as a 'pressure'
  • Sharp or stabbing in nature (uncommon)
  • Reproduced by chest pressure (uncommon) in some patients.

• Pain may not be the pre-eminent symptom and in many patients other symptoms may be more troublesome. Which are these?

  nausea and vomiting, collapse, dyspnoea and diaphoresis

• Which are important differential diagnoses that can have life threatening consequences

  Aortic dissection,
  Pericarditis
  Pulmonary embolus

• Early risk stratification of chest pain is based on which simple criteria:

  • History, clinical symptoms and signs
  • ECG
  • Biochemical markers (serial).

• Which measures should be immediately iniated in order to rapidly evaluate a patient complainingof chest pain.

  non-invasive blood pressure measurement,
  pulse oximetry
  continuous ECG monitoring.

• Immediate management of ACS

  • 12-lead ECG (within 5 minutes of arrival).
  • Oxygen via face mask or nasal cannula.
  • Venous access. Blood is drawn for cardiac biomarkers, biochemical and haematological work-up.
  • Sublingual nitroglycerin 0.4 mg (repeated once or twice as necessary) may have beneficial effects. Side effects include hypotensive reactions and a hypotensive bradycardic response (Bezold–Jarisch Reflex).
  • Analgesia. Often oxygen, nitroglycerin and lessening of anxiety by reassurance, are sufficient. If not, administer small incremental boluses of intravenous morphine (1–2 mg), repeated until pain is relieved.
    
  • Aspirin 160–325 mg should be chewed and swallowed on arrival.