Subject 2 – Acute coronary syndrome (instable angina, acute
myocardial infarction
(4 hours)
Place
Training Room, Dapartment of Cardiology.
Purpose
To know:
• Classification of CHD.
• Etiology and pathogenesis of coronary heart disease, constrictive atherosclerosis and the role
"dynamic" stenosis of coronary arteries in the pathogenesis of various forms of CHD.
• Clinical manifestations of acute forms of ischemic heart disease, the clinical course of unstable
angina , acute coronary syndrome , myocardial infarction, sudden coronary death.
• Methods of diagnosis , the role of the ECG, echocardiography , drug tests , radionuclide
techniques, coronary angiography and coronary , biochemical parameters in the diagnosis and
differential diagnosis of acute forms of coronary artery disease.
• Principles of treatment and prevention , especially the treatment of acute forms of coronary
artery disease. Differentiated treatment of different variants of unstable angina , acute coronary
syndrome , myocardial infarction, sudden coronary death. Indications for surgery (CABG
transluminal angioplasty and stenting).
Be able to:
• Based on survey data of the patient with an acute form of CHD conduct differential diagnosis,
formulate and substantiate the clinical diagnosis and determine tactics and treatment.
Professional orientation of students
Gained greater prevalence of coronary artery disease, available in different shapes and variants
of the disease, the doctor often faced with the necessity of differential diagnosis with other
pathologies, it must, on the one hand, overdiagnosis prevent iatrogenic coronary artery disease
and the other - do not miss a threat to the life of the patient, Modern Methods diagnosis and
treatment of coronary artery disease, can significantly improve and speed up the diagnostic
process and improve the prognosis and quality of life.
Basic knowledge and skills
№ Discipline
To be able to know
Anatomical structure of the
arteries of the heart
To be able to do
coronary
1.
Anatomy
2.
Histology
The structure and operation of the
coronary arteries, myocardium and
conduction system of the heart
3.
Biochemistry
Basics of lipid metabolism
4.
Pathophysiology
Mechanisms of coronary circulation
disorders
5.
Pathanatomy
Morphological changes in various forms
of ischemic heart disease
1.Propedevtika
internal diseases
Semiotics of disorders of the coronary Evaluate the clinical, instrumental
circulation
and laboratory tests
Plan for practical lesson
№
Elements of practical employments
1.
Verification of present's students
5
2.
Entrance control and his analysis
15
Distributing patients for Supervision ( card or clinical tasks )
10
3. *
Time(minutes)
4. * Review patients or study of educational hospital chart
40
5.
Discussion of findings, formulation of previous diagnosis, determination of
methods of additional inspection of patient, interpretation of their results,
formulation of final diagnosis and plan of treatment
50
6.
Exercises with clinical formulations for solving clinical situation tasks
20
7.
Output control of knowledge and its evaluation
15
8.
Results and final assessment of knowledge and skills of students and tasks to
self- preparation for the next lesson
5
Note: * - in the case of patients absence in clinical, practice can be made in the form of
preparation and decision of situational tasks.
List of theoretical issues addressed in class
1. Classification of coronary artery disease. The concept of acute coronary syndrome.
2. Etiology and pathogenesis of coronary heart disease, atherosclerosis and the role of
constrictive "dynamic" stenosis of coronary arteries in the pathogenesis of various forms of
CHD.
3. Clinical manifestations of acute forms of coronary artery disease. Features of the clinical
course of unstable angina, acute coronary syndrome, myocardial infarction, sudden coronary
death.
4. Methods of diagnosis, the role of the ECG, echocardiography, drug tests, radionuclide
techniques, coronary angiography and coronary, biochemical parameters in the diagnosis and
differential diagnosis of acute forms of coronary artery disease.
5. Principles of treatment and prevention, especially the treatment of acute forms of coronary
artery disease. Differentiated treatment of different variants of unstable angina, acute coronary
syndrome, myocardial infarction, sudden coronary death. Indications for surgery (CABG
transluminal angioplasty and stenting).
Methods of practical classes *
(* On the first lesson the teacher carries out safety training (if any condition), which is celebrated
in the magazine signed by student teacher).
After reviewing the present teacher carries out a written entrance control basic knowledge. Then
the instructor carries out the distribution of students for Supervision of patients and determine
their problem.
№ Task
Instructions a student
Note teacher for students
1.
To
provide In a survey reveal:
Pay particular attention to the
supervision of patient 1. Signs of a violation of the coronary period of existence of the
diagnosed with severe circulation (clinical and more)
identified complaints and
forms of ischemic
objective data, the disease, the
2.
The
presence
of
impaired
lipid
heart disease
presence and duration of ECG
metabolism
changes,
determine
the
for
coronary
3. Characteristic of acute forms of CHD indications
angiography
changes in ECG, x-ray examination,
echocardiography
Teachers work according to the plan of studies, spend the weekend at the end of the control
knowledge. Before the end of class the teacher sums up the results of his studies on the
assessment of each student and announce the topic of the next session.
Forms and methods of self
Tests
1. Specify more typical for postinfarction cardiosclerosis changes that detected by
echocardiography :
A. Mitral valve insufficiency.
B. Regional wall dyskinesia.
C. Increased heart cavities.
D. Thickening of the walls of the myocardium.
E. Reducing heart cavities.
2. Specify the most typical for myocardial changes:
A. ST-segment elevation
B. Increased P wave amplitude
C. Negation T wave
D. Extending the segment PQ
E. Expansion of the QRS
3. What research should be conducted primarily to clarify the causes of negation T wave in leads
V2- 4 in patients without major complaints.
A. Bicycle ergomete .
B. Coronary angiography.
C. Radiography UC .
D. Echocardiography.
E. A sample of nitroglycerine.
Situational tasks
1. Male 47 years, complains of constricting chest pain during rapid walking, climbing on the 3rd
floor. Sick 7 days. Objectively: height 172 cm, weight 98 kg. In the lungs, vesicular breathing.
Limits hearts are not changed. Muted tones, the rhythm right, HR = RA = 72 per min., BP =
135/80 mm Hg. The liver was not palpable, swelling of legs there. The ECG - no change. In
blood : red blood cells - 4,5 x 1012, WBC - 7,0 x 109, ESR - 5 mm / h. Formulate the clinical
diagnosis. A plan of survey. Identify treatment strategy.
2. Women 55 years, complains of burning chest pain that increases when driving , interruptions in
the work of the heart. He considers himself sick about 2 weeks when appeared complaints gradually
strengthened over time. No Lunar 5 years. Objectively: In the lungs vesicular breathing. Limits of
the heart left + 1 cm, muted tones, isolated extrasystoles, heart rate = 86, AC = 82 per min., BP =
155 /85 mm Hg. century. Shin paste. In blood: Leukocyte - 5,6 x 109, ESR - 12 mm/h. ECG ventricular extrasystoles, left ventricular hypertrophy compared with ECG, which was filmed two
days ago is a slight ST segment depression and negative T wave in leads V3-V6. Specify the most
likely diagnosis. Is there a need for differential diagnostics? Like that, yes, it is necessary to
investigate how no, why not? Your tactics in the management of patients.
Visual material
1. Tables and slides to the classification of CHD
2. audio cassette recording of arrhythmias,
3. videotape of cardiac echocardiography and coronary angiography in coronary artery disease
4. video
5. sets of ECG tests, situational problems.
Sources of information
Basic:
Therapy. Course of lectures. Simferopol. -2003.- 444p.
Additional:
1. Harrison's Principles of Internal Medicine 18th edition.
.org)
2. ESC Guidelines. Cardiovascular medicine. (Www.escardio.org / guidelines)