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If the importance of the subject has been understood, proceed to studying the learning objectives.
Key Answer 2
Summary of procedures for the practice on the subject “Myocardial Infarction”
Pain intensity Intensive Pain continuance More than 30 min
ECG (pathological Q formation, ST-segment elevation or depression, Т invertion). Echo-CG
QIM > 12 hours from onsetQIM < 12 hours from onset
percutaneous transluminal coronary angioplasty CABG
Аоrtic stenosis Vertebral osteochondrosis Myositis Hypertrophic cardiomyopathy
M Appendix 4 anagement of cardiogenic shock
Donetsk National Medical University after M.Gorky
the students’ individual preparation for
SUBJECT: Ischaemic heart disease: Myocardial Infarction
INTENDED AUDIENCE: 5-year students
of International Medical Faculty
Donetsk – 2009
PhD, prof. ass. Sklyanna O.V.
PhD, prof. ass. Kalinkina N.V.
Parhomenko Т.А., prof. ass. of department of internal medicine №2
Basiy R.V., prof. ass. of department of humen anatomy, head of methodical room of Donetsk national medical university
Ischaemic heart disease (IHD) today is one of the most widespread and disablementing diseases in the world. It affects men more frequently than women. Encouraging cardiovascular health is not only about preventing IHD: health entails the ability to exercise, and enjoying vigorous activity (withing reason!) is one of the best ways of achieving health. Acute coronary syndromes (ACS) includes unstable angina and envolving Myocardial Infarction (MI), which share a common underlying pathology – plague rupture, thrombosis, and inflammation. Usually divided into ACS with ST-segment elevation or new onset LBBB – what most of us mean by acute MI; and ACS without ST-segment elevation – the ECG may show ST-depression, T-wave inversion, non-spesific changes, or be normal (includes non-Q wave or subendocardial MI). The degree of irreversible myocyte death varies, and significant necrosis can occur without ST-elevation. Cardiac troponins (T and I) are the most sensitive and spesific markers of myocardial necrosis, and have become the test of choice in patients with ACS.
^ . Non-modifiable: age, family history of IHD (in first degree relative < 55 yrs), mens. Modifiable: smoking, hypertension, hyperlipidaemia, obesity, sedentary lifestyle. Controversial risk factors include: stress, type A personality, LVH, increasing of apoprotein A, increasing of fibrinogen, hyperinsulinaemia, high level of homocysteine, cocaine use. Incidence: 5/1000 per annum (UK) for ST-segment elevation.
Mortality: 50% of deaths occur within 2h of onset of symptom.
II. Learning Objectives
Key objective: to develop skills in making a differential diagnosis of MI, and planning a patient management, diagnostics and treatment of complications of MI.
The information necessary for reviewing and revising the basic knowledge and skills can be found in the following references:
Pre-Practice Knowledge and Skills Test Questions
Q1. A 48-year-old patient, was delivered to the cardiological department with symptoms of anterolateral Myocardial Infarction with ST-segment elevation. Оcclusion of which artery is possible in this case?
А. Anterior intraventricular branch;
B. Circumflex branch;
C. Right coronary artery;
D. Posterior intraventricular branch;
E. Circumflex branch and Posterior intraventricular branch
Q 2. A 47-year-old patient complaints of acute chest pain, nausea, dyspnoea. Level of CK-MB is high. Which of the following is the most probable diagnosis?
А. Stable angina;
C. Dilated cardiomyopathy;
D. Miocardial Infarction;
E. Variant angina.
Q 3. Technetium perfusion scan of 47-year-old patient has shown local accumulation of Technetium in myocard. Which of the following is the most probable diagnosis?
А. Miocardial Infarction;
B. Variant angina;
D. Heart amiloidosis ;
Q 4. The blood count of the patient with a cardio-vascular disease shows changes, which are typical of MI. The blood count shows the following:
А. Increasing of ESR, leucocytosis with neutricytosis, increasing of CK-MB level;
B. Increasing of ESR, leucocytosis with lymphocytosis increasing of CK-MB level
C. Increasing of ESR, high level of LDH, neutropenia, lymphopenia;
D. high level of glucosa in the blood, increasing of ESR, lymphocytosis;
E. Decreasing of ESR, low level of LDH, leucocytosis with neutricytosis.
Q 5. At ECG testing of 39-year-old patient were present ST depression, inverted T waves. These changes were held out for 4 weeks. were accompanied by central chest pain.
Which of the following is the most probable diagnosis?
А. MI without ST-segment elevation;
B. Stable angina;
C. Cervical osteochondrosis;
D. Variant angina;
Q 6. A laboratiry tests of a 49-year-old patient, suffering from central chest pain, have shown changes in level of cardiac enzymes. Level of what enzyme was abnormal?
Q 7. At ECG tests of 56-year-old patient were observed changes typical for acute posterior MI. Where were ECG changes?
А. II, III, aVF, V1-V2;
B. I, aVL,V2-V6;
C. I, aVL,V1-V2;
D. I, III, aVL;
E. I, II, V3-V4.
Q 8. A 67-year-old patient suffers from bafflel-apical MI without ST-segment elevation. What ECG-changes can confirm this diagnosis?
А. ST-segment depression, T-wave inversion in I, II, aVL,V1-V4;
B. ST-segment elevation, T-wave inversion in II, III, aVL,V5-V6;
C. Pathological Q-waves in I, II, aVL,V1-V4;
D. Pathological Q-waves in II, III, aVL,V5-V6;
E. ST-segment elevation in II, III, aVF.
Q 9. A 67-year-old patient, suffering from IHD, Stable angina, a central chest tightness had developed after receiving some drugs. MI was diagnosed. It is known that this drug can cause “robbing phenomenon”. Which of the following was taken by the patient?
Correct answer is D – Myocardial Infarction.
High level of CK-MB during the first 24-36 hours after the beginning of central chest pain is the consiquence of acute MI.
Key Answer 3.
Correct answer is А – Myocardial Infarction. Local accumulation of Technetium in myocard is pathognomical mark of MI, its diffusional accumulation can be observed at unstable angina, amyloidosis, pericarditis or after electric cardioversion.
IV. Subject Material
Theory Topics on the Subject:
The information necessary for mastering the theory issues may be found in the following references:
Then, proceed to solving some test questions and checking test question 5 with the key answer.
Q 1. The patient B. 53 years old entered to the cardiological department with complaints of pain in precardial area. The pain was compressing, conducted with adventure, lasted during 4 hours, hasn’t cut by sublingual nitroglycerin intake (in whole 15 tablets during 3 hours). The day before he had psychological stress at work. The patient suffers from Hypertension 12 years.
On examination there were pale skin, cyanosis of lips. Mixed dyspnea at rest. The breathing is vesicular, there were no rales. Heart borders are at LML, there were no cardiac murmurs, Pulse was 110/min, BP 160/80. Heart sounds were muffled. The blood count showed the following: erythrocytes 4,1×1012, Hb was 141 g/l, color index was 1.0, leucocytes were 10×109 , 5% eosinophils, 14% band neutrophils, 60% segmented neutrophils, 12% lymphocytes, 9% monocyte, 35% blasts, and ESR was 17 mm/h, MB-KK had high level.
Which of the following is the most probable diagnosis?
А. Stable angina FК IV;
B. Prinzmetal’s angina;
C. Myocardial Infarction;
D. Hypertension, hypertensic crisis;
Q 2. The patient B. 80 years old, admitted to the intensive care unit of cardiological department with suspicion of Myocardial Infarction. ECG showed pathological Q in II, III, avF.
What localization of MI there was?
А. inferior wall of;
B. septoanterial wall of L V ;
C. lateral wall of LV;
D. right ventricle;
E. posterior wall of L V.
Q 3. The patient B. 54 years old suffers from anterior-septal MI (the second day) suddenly has fallen, lost conscience. Pulse and BP haven’t been observed at that time.
What actions must the urgent doctor make?
А. Cardiopulmonary resuscitation,
B. Nitroglycerin, atropine intravenous,
C. Bundles on the extremities, Nitroglycerini intravenous;
D. ECG-test, intravenous Isadrini ;
E intramuscular solution of Phentanili and Droperidoli.
Q 4. Inferior non-Q-MI has developed in the patient B. 77 years old suffered from IHD, unstable angina.
What ECG changes were there?
A. ST-segment depression, T invertion in II, III, aVF;
B. ST-segment depression, T invertion in II, III, V1-V5;
C. formation of pathological Q, ST-segment elevation in II, III, aVF;
D. formation of pathological Q, ST-segment depression in II, III, aVF;
E. ST-segment depression, T invertion нверсия in I, II, aVL.
Q 5. The patient suffers from Q –MI (4 hours from onset) was delivered to the intensive care unit. What medicine should be used in treatment of this patient?
Key Answer 5.
The correct answer is C – Alteplasa. In pathogenesis of MI lies formation of thromb in the coronary artery, its occlusion and terminations of coronary blood flow. Alteplasa relates to the group of thrombolytic drugs. At intravenous or intracoronarial introduction causes thrombolysis. This procedure is effective in the first 12 hours after the development of MI.
At the beginning of the practice prior-to-practice level of knowledge and skills is assessed. Each student gets a patient for curation, examines patients in the ward, and takes part in additional methods of examination.
After fulfilling the tasks, students and the teacher perform the analysis of each student’s independent work where all the students take part.
At the end of the class final testing on the subject and summing up the results of the lesson are performed.
break-down chart on the SUBJECT:
break-down chart on the SUBJECT
Myocardial Infarction Infarction
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