Causes of ST Elevation

Stanford A or B?

In case you didn’t encounter a patient with sudden onset chest pain today!

68.2 - AD CT2

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Audio files – Selected Cardiovascular Emergencies

What is your next action?

In case you didn’t encounter an elderly with chest discomfort today!

A 78-year-old male patient presented with chest discomfort and SOB. BP: 89/48 mmHg, HR: 128 bpm, RR: 26/min, T: 37, SpO2: 92% in room air. He has a history of lung cancer, hypertension and diabetes mellitus. Bed side ECG is done. What is your next action?

Feel free to give your answers at the comment box below.

608 - Figure3 - pericardial effusion - ECG

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

Cardiac Monitoring Pearls

Cardiac Monitoring chapter written by Stacey Chamberlain from USA is just uploaded to the Website!

Procedure – Pericardiocentesis

From experts to our students...

Pericardiocentesis chapter written by David Wald and Lindsay Davis from USA is just uploaded to the Website!

Selected Cardiovascular Emergencies

Cardiovascular Emergencies selected from SAEM and IFEM undergraduate curriculum recommendations are uploaded into the website. You can read, listen or download all these chapters freely. More specific disease entities are on the way.

Abdominal Aortic Aneurysm (AAA)

by Lit Sin Quek Case Presentation A 75-year-old obese man comes to the emergency department. He has history C.O.P.D., hypertension. He is a smoker and on

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Acute Coronary Syndrome (ACS)

by Khalid Mohammed Ali, Shirley Ooi – Singapore Case Presentation A 46 years old man with a past medical history of hypertension and hyperlipidemia developed

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Acute Heart Failure (AHF)

by Walid Hammad – USA Case Presentation An ambulance crew rushes into your emergency department (ED) with a 56-year-old man. He is severely short of

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Aortic Dissection

by Shanaz Sajeed Introduction Aortic dissection carries high morbidity and mortality. Although patients generally present with acute symptoms and classic signs, a subset of patients

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Deep Vein Thrombosis (DVT)

by Elif Dilek Cakal Case Presentation An 85-year-old woman, with a history of congestive heart failure, presented with right leg pain and swelling of 2

Read More »

Hypertensive Emergencies

by Sadiye Yolcu Introduction Systemic hypertension is a common medical problem. It affects over 1 million people worldwide. ER clinicians commonly encounter this problem. Rapid

Read More »

Pulmonary Embolism

by Elif Dilek Cakal Case Presentation A 45-year-old female with no prior medical history presented to the emergency department (ED) with three days of constant shortness

Read More »

Do you need more?

X-ray findings of AD

In case you didn’t encounter a patient with sharp inter scapular pain today!

A 67-year-old male patient presented with sharp interscapular pain. BP: 189/107 mmHg, HR: 118 bpm, RR: 26/min, T: 37, SpO2: 93% in room air. He has a history of hypertension and diabetes mellitus. The chest x-ray is shown below.

Let’s remember findings of aortic dissection in the chest x-ray.

  1. Depression of the left mainstem bronchus
  2. Displaced intimal calcification
  3. Indistinct or irregular aortic contour
  4. Left apical pleural cap
  5. Opacification of the “AP window” (i.e., clear space between the aorta and the pulmonary artery)
  6. Pleural effusion (left > right)
  7. Tracheal or esophageal deviation
  8. Widened aortic knob or mediastinum (present in only 63% and 56% of patients with type A and type B dissections, respectively)
71.1 - AD1

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

What is your next move?

In case you didn’t encounter an elderly with abdominal pain today!

A 72-year-old male patient presented with mild abdominal pain. BP: 145/68 mmHg, HR: 83 bpm, RR: 16/min, T: 37, SpO2: 98% in room air. He has a history of hypertension and diabetes mellitus around 25 years. On the exam, you appreciated a pulsatile mass and checked for the aorta with bedside ultrasound. Here is the cine record of the patient.

What is your next action?

Feel free to give your answers at the comment box below.

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

Sharp Chest Pain

Aortic Dissection chapter written by Shanaz Sajeed from Singapore is just uploaded to the Website!

469 - wide mediastinum - chest X-ray

A 56-year-old male presented to the emergency department with sudden onset of severe tearing chest pain radiating to the back. He had a history of hypertension and hyperlipidemia. He was a smoker. Upon arrival, he appeared to be diaphoretic and in severe pain. He denied any prior history of chest pain. He had been without any infective symptoms lately. He was compliant with his medications, namely, amlodipine and simvastatin. At triage, his blood pressure was noted to be 80/60 mmHg with a pulse rate of 130 bpm. His oxygen saturation was 95% on room air, and his respiratory rate was 22 breaths per minute. On examination, he had muffled heart sounds, jugular venous distention, and radio-radial pulse delay.

Shanaz Matthew Sajeed
by Shanaz Matthew Sajeed from Singapore.

I…can’t…breathe!

A New Chapter Is Just Uploaded To The Website!

35.3 - pulmonary congestion

An ambulance crew rushes into your emergency department with a 56-year-old man. He is severely short of breath, sitting upright on the stretcher, using his accessory respiratory muscles, and gasping for air. You find that he is diaphoretic, tachypneic, and in severe respiratory distress. You ask him, “What’s going on?” He replies: “I…can’t…(pauses and inhales a shallow breath)…breathe!”

The paramedics inform you that they received a call from the patient’s wife about 6:30 that morning, saying that her husband was short of breath and sweaty and that he had vomited once. The wife told them that she and her husband had returned from a long trip the night before and that her husband had not taken his “water pills” because he did not want to stop for frequent restrooms breaks during their drive. When they got home, he still did not take his pills because he wanted to sleep through the night. His breathing problems woke him during the night, and he tried to get more comfortable by adding pillows under his head to the point that he was almost sitting up in bed.

You thank the paramedics and turn back to the patient, who now looks even worse. He is more short of breath, and you sense that he is getting tired, about to give up. He looks like he is about to collapse. What is your next step?

by Walid Hammad from USA

Is Troponin Enough?

You are the emergency doc working in a rural ED. It is the Saturday night at 23:25 and you have three patients with chest pain. All have unchanged ECGs and normal troponins. All feel well now and want to go home if you think their results are okay. What is your plan for each of them?

Patient 1. Isabel D. is a 45-year old female with a history of hypertension. She presented to the emergency department with left-sided sharp chest pain. Her pain started after his evening run, and she vomited once. Her pain continued for one hour, but then it lessened spontaneously. Now she is feeling well, and she wants to go home. Her ECG is completely normal. Her 0- and 3-hour troponins are negative.

Paint 2. Daniel B. Is a 65-year old male with a history of smoking, hypotension and left bundle branch block (LBBB). He is obese. He presented to the emergency department with left-sided heavy chest pain, radiating to his left arm, chin, and back. He went to bed early today, and his chest pain woke him up. For half an hour, he has felt sweaty and nauseated but now he is feeling well, and he wants to go home. His ECG shows LBBB, unchanged compared to his previous ECGs and without Sgarbossa Criteria. His 0- and 3- hour troponins are negative.

Patient 3. Hank P. is a 54-year old male with a history of hypertension, diabetes mellitus and prior stroke with no sequel. For twenty minutes, he experienced a sharp pain in the middle of his chest. His pain had started while he was watching TV and he felt sweaty all in a sudden. he had His ECG shows findings related to left ventricular hypertrophy.  His 0- and 3- hour troponins are negative.

HEART Score

HEART Score was developed to predict the 6-week risk of a major adverse cardiac event of patients with chest pain, precisely in the emergency department setting (1). It outperformed the others, especially in exclusion of low-risk patients (2) Patients with a combination of HEART score of 0-3 and two negative troponins can be safely discharged from ED with no major adverse cardiac events (3). Patients with HEART Score of 4-6 requires admission and are candidates for further noninvasive investigations (1). Patients with HEART Score of ≥7 requires admission and are candidates for early invasive strategies (1).

HEART Score

CategoryScoreExplanationRisk Features
HistoryHigh-risk features
• Middle- or left-sided chest pain
• Heavy chest pain
• Diaphoresis
• Radiation
• Nausea and vomiting
• Exertional
• Relief of symptoms by sublingual nitrates

Low-risk features
• Well localized
• Sharp pain
• Non-exertional
• No diaphoresis
• No nausea and vomiting
Slightly Suspicious 0Mostly low-risk features
Moderately Suspicious+1Mixture of high-risk and low-risk features
Highly Suspicious+2Mostly high-risk features
ECG
Normal0Completely Normal
Non-specific Repolarization Disturbance+1Non-specific repolarization disturbance• Repolarization abnormalities
• Non-specific T wave changes
• Non-specific ST wave depression or elevation
• Bundle branch blocks
• Pacemaker rhythms
• Left ventricular hypertrophy
• Early repolarization
• Digoxin effect
Significant ST Depression+2Significant ST depression• Ischemic ST-segment depression
• New ischemic T wave inversions
Age
<450
45-64+1
≥ 65+2
Risk Factors• Obesity (Body-Mass Index ≥ 30)
• Current or recent (≤ 90 days)smoker
• Currently treated diabetes mellitus
• Family history of coroner artery disease (1st degree relative < 55 year old)
• Hypercholesterolemia

OR

Any history of atherosclerotic disease earn 2 points:
• Know Coroner artery Disease: Prior myocardial infarctions, percutan coronary intervention (PCI) or coronary artery bypass graft
• Prior stroke or transient ischemic attack
• Peripheral arterial disease
No known risk factors0
1-2 risk factors+1
≥ 3 risk factors or history of atherosclerotic disease+2
Initial Troponin
≤ normal limit0
1-3 x normal limit+1
> 3x normal limit+2
Please read articles 1,2,4 for more information.

Now, let’s look back on our patients.

Isabel’s pain has both high-risk (exertional, left-sided pain with vomiting) and (sharp pain, no diaphoresis) features; therefore, her pain is moderately suspicious. (H: +1) Her ECG is completely normal. (E: 0) She is 45 years old. (A: +1). She has one risk factor, hypertension. (R: +1) Her troponins are normal. (T: 0) Her HEART score is 3, and she can safely go home from the emergency department. The expected MACE rate in 30 days is 0%.

Daniel’s pain has mostly high-features (left-sided, radiating heavy chest pain with nausea and vomiting); therefore his pain is highly suspicious. (H: +2) His ECG is not completely normal but free of new ischemic changes. (E: +1) He is 65 years old. (A: +2). He has three risk factors, smoking, obesity, and hypertension. (R: +2) His troponins are normal. (T: 0) His HEART score is 7, and he is a candidate for early invasive intervention. You should admit him and call the cardiologist.

Hank’s pain has both high-risk (middle-sided chest pain with diaphoresis) and low-risk (non-exertional, sharp pain) features; therefore, his pain is moderately suspicious. (H: +1) His ECG is not completely normal but free of new ischemic changes. (E: +1) He is 54 years old. (A: +1). He has three risk factors, hypertension, diabetes mellitus and prior stroke. (Note that prior stroke alone earns two points) (R: +2) His troponins are normal. (T: 0) His HEART score is 5, and he is a candidate for noninvasive investigation. You should admit him.

PEARLS and PITFALLS

  1. ECG: If the ECG shows STEMI, do not wait for troponin or consider the HEART score. Call the cardiologist and consider activating angiography unit for the primary PCI.
  2. Troponins: If you first troponin is highly abnormal, do not wait for the second troponin or consider the HEART score. Call the cardiologist and consider activating angiography unit for the primary PCI. Additionally, the magnitude of change between the first and the second troponin is important in diagnosing acute myocardial infarction (5).
  3. Clinical Gestalt: You will gain a clinical gestalt over the years. If your clinical gestalt and any scoring disagree, always stay on the safe side for the patient’s benefit (4).
  4. Patient Safety: In the original study, the HEART score was combined with only one troponin. The adverse event rate was 2.5% for the HEART score 0-3 patients, 20.3% for the HEART score 4-6 patients and 72.7% for the HEART score ≥7 patients. Therefore, the author believes, the HEART score combined with two troponins is safer in the discharge of low-risk patients. Low-risk patients (i.e., HEART Score 0-3) with negative two troponins had no MACE within 30 days (3).

Suggested Chapters

Chest Pain by Asaad S Shujaa

Acute Coronary Syndrome (ACS)

by Khalid Mohammed Ali, Shirley Ooi

REFERENCES

  1. Six, A. J., Backus, B. E., & Kelder, J. C. (2008). Chest pain in the emergency room: value of the HEART score. Netherlands Heart Journal, 16(6), 191-196. – link
  2. Radecki, R. (2013). Time to Move to the HEART Score. Available at: http://www.emlitofnote.com/?p=440 (Accessed: 17/07/2018) – link
  3. Mahler, S. A., Riley, R. F., Hiestand, B. C., Russell, G. B., Hoekstra, J. W., Lefebvre, C. W., … & Herrington, D. M. (2015). The Heart Pathway Randomized Trial: Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge. Circulation: Cardiovascular Quality and Outcomes, 8(2), 195-203. – link
  4. Hyunjoo, L., & Rodriguez, C. (n.d.). HEART Score for Major Cardiac Events. Available at: https://www.mdcalc.com/heart-score-major-cardiac-events#evidence (Accessed: 17/07/2018) – link
  5. Roffi, M., Patrono, C., Collet, J. P., Mueller, C., Valgimigli, M., Andreotti, F., … & Gencer, B. (2016). 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). European heart journal, 37(3), 267-315. – link

FURTHER READING

  1. https://catalyst.nejm.org/wp-content/uploads/Acute-Chest-Pain-HEART-Score-Reference-MI.png – link
  2. https://canadiem.org/tiny-tips-heart-score-a-tool-for-acute-coronary-syndrome/ – link
  3. https://www.mdcalc.com/heart-pathway-early-discharge-acute-chest-pain – link

My Leg Is Swollen!

A New Chapter Is Just Uploaded To The Website!

An 85-year-old woman, with a history of congestive heart failure, presented with right leg pain and swelling of 2 days’ duration. She had been hospitalized for pneumonia one week earlier. Her vitals on arrival were: Blood Pressure: 138/84 mmHg, Pulse Rate: 65 beats per minute, Respiratory Rate: 14 breaths per minute, Body Temperature: 37°C (98.6°F), Oxygen Saturation: 96%. On examination, her right calf was reddish, tender, edematous and 4 cm greater in circumference than the left when measured 10 cm below the tibial tuberosity. Her Wells’ Score for deep vein thrombosis (DVT) was 4 and suggested high-risk for DVT. Compression ultrasonography showed a thrombus in the popliteal vein. Enoxaparin (1 mg/kg, twice a day, SC) was started. No signs and symptoms of pulmonary embolism were observed. The patient was referred to a cardiovascular surgeon as an outpatient after discussion and confirmed understanding of discharge instructions.

Turkey
by Elif Dilek Cakal from Turkey.

Three days of constant shortness of breath

Do you recognize these findings in the US and CT scan?

Turkey
by Elif Dilek Cakal from Turkey.

ACS in 12 minutes!

by Khalid Mohammed Ali, Shirley Ooi from Singapore.

A 46 years old man with a past medical history of hypertension and hyperlipidemia developed central crushing chest pain associated with sweating and shortness of breath while driving. He presented to the emergency department 1 hour after the onset of chest pain. On physical examination, his vital signs were as follows; pulse rate: 60 beats per minute, blood pressure: 100 over 50 mmHg, respiratory rate: 20 per minute, Oxygen Saturation: 98% on room air. Patient has no leg edema, new murmur or features of heart failure. ECG is given on the side.

ACS 1

What is your diagnosis?

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ECG

ECG features are ST elevation in inferior leads with reciprocal changes in lateral leads of I, aVL and ST depression in lead V1, V2. The ECG is diagnostic of inferior and posterior wall ST elevation MI.
Answer