[gwenith]

Okay this is a bit of exploratory "research" if you will. I recently was asked to write some core competencies for Coronary Care and in the process did some literature reviews. Some of which have brought to light what is called "practice wisdom" - those hints and tricks that may or may not be in the textbook but are handed down from nurse to nurse and which are true!! I don't want to post what I found straight up because I don't want to "contaminate" any answers but I will post the information along with references later

So the topic is Assessment of Acute Coronary Syndrome (ACS) and in particular how to differentiate between the patient who has chest pain and Non-cardiac Chest pain as well as differentiating between Angina and MI pain.

Hints:- don't confine it to pain think about patient behaviours, attitudes, expressions, topics of conversation, skin colour, etc.

[c.wicks]

Initial diagnosis of acute coronary syndrome is almost entirely based on history, risk factors, and, to a lesser extent, ECG. The symptoms are due to myocardial ischemia, which has an underlying cause of an imbalance between supply and demand for myocardial oxygen.

History
• Typically, angina is a symptom of myocardial ischemia that appears in circumstances of increased oxygen demand. It usually is described as a sensation of chest pressure or heaviness that is reproduced by activities or conditions that increase myocardial oxygen demand.
• Not all patients experience chest pain. Some present with only neck, jaw, ear, arm, or epigastric discomfort.
• Other symptoms, such as shortness of breath or severe weakness, may represent anginal equivalent symptoms.
• A patient may present to the ED because of a change in pattern or severity of symptoms. A new case of angina is more difficult to diagnose because symptoms are often vague and similar to those caused by other conditions (eg, indigestion, anxiety).
• Patients may have no pain and may only complain of episodic shortness of breath, weakness, lightheadedness.
Patients may complain of the following:
• Palpitations
• Pain, which is usually described as pressure, squeezing, or a burning sensation across the precordium and may radiate to neck, shoulder, jaw, back, upper abdomen, or either arm
• Exertional dyspnea that resolves with pain or rest
• Diaphoresis from sympathetic discharge
• Nausea from vagal stimulation
• Decreased exercise tolerance
• Patients with diabetes and elderly patients are more likely to have atypical presentations and offer only vague complaints, such as weakness, lightheadedness, and nausea.ess, diaphoresis, or nausea and vomiting

Risk Factors
• Male gender
• Diabetes mellitus (DM)
• Smoking history
• Hypertension
• Increased age
• Hypercholesterolemia
• Hyperlipidemia
• Prior cerebrovascular accident (CVA) - These patients constitute 7.5% of patients with ACS and have high-risk features (Hasdai, 2003).
• Inherited metabolic disorders (Wilken, 2003)
• Methamphetamine use (Turnipseed, 2003)
• Occupational stress (Panagiotakos, 2003)
• Connective tissue disease (Soejima, 2004)

ECG
• Transient ST segment elevations (fixed changes suggest acute MI): In patients with elevated ST segments, consider LV aneurysm, pericarditis, Prinzmetal angina, early repolarization, and Wolff-Parkinson-White syndrome as possible diagnoses.
• Dynamic T-wave changes, either inversions, normalizations, or hyperacute changes: In patients with deep T-wave inversions, consider also CNS events or drug therapy with tricyclic antidepressants or phenothiazines.
• ST depressions that may be junctional, downsloping, or horizontal
• Diagnostic sensitivity may be increased by performing right-sided leads (V4R), posterior leads (V8, V9), and serial recordings
http://www.emedicine.com/emerg/topic31.htm

[angelique777]

Originally Posted by c.wicks

Initial diagnosis of acute coronary syndrome is almost entirely based on history, risk factors, and, to a lesser extent, ECG. The symptoms are due to myocardial ischemia, which has an underlying cause of an imbalance between supply and demand for myocardial oxygen.

History
• Typically, angina is a symptom of myocardial ischemia that appears in circumstances of increased oxygen demand. It usually is described as a sensation of chest pressure or heaviness that is reproduced by activities or conditions that increase myocardial oxygen demand.
• Not all patients experience chest pain. Some present with only neck, jaw, ear, arm, or epigastric discomfort.
• Other symptoms, such as shortness of breath or severe weakness, may represent anginal equivalent symptoms.
• A patient may present to the ED because of a change in pattern or severity of symptoms. A new case of angina is more difficult to diagnose because symptoms are often vague and similar to those caused by other conditions (eg, indigestion, anxiety).
• Patients may have no pain and may only complain of episodic shortness of breath, weakness, lightheadedness.
Patients may complain of the following:
• Palpitations
• Pain, which is usually described as pressure, squeezing, or a burning sensation across the precordium and may radiate to neck, shoulder, jaw, back, upper abdomen, or either arm
• Exertional dyspnea that resolves with pain or rest
• Diaphoresis from sympathetic discharge
• Nausea from vagal stimulation
• Decreased exercise tolerance
• Patients with diabetes and elderly patients are more likely to have atypical presentations and offer only vague complaints, such as weakness, lightheadedness, and nausea.ess, diaphoresis, or nausea and vomiting

Risk Factors
• Male gender
• Diabetes mellitus (DM)
• Smoking history
• Hypertension
• Increased age
• Hypercholesterolemia
• Hyperlipidemia
• Prior cerebrovascular accident (CVA) - These patients constitute 7.5% of patients with ACS and have high-risk features (Hasdai, 2003).
• Inherited metabolic disorders (Wilken, 2003)
• Methamphetamine use (Turnipseed, 2003)
• Occupational stress (Panagiotakos, 2003)
• Connective tissue disease (Soejima, 2004)

ECG
• Transient ST segment elevations (fixed changes suggest acute MI): In patients with elevated ST segments, consider LV aneurysm, pericarditis, Prinzmetal angina, early repolarization, and Wolff-Parkinson-White syndrome as possible diagnoses.
• Dynamic T-wave changes, either inversions, normalizations, or hyperacute changes: In patients with deep T-wave inversions, consider also CNS events or drug therapy with tricyclic antidepressants or phenothiazines.
• ST depressions that may be junctional, downsloping, or horizontal
• Diagnostic sensitivity may be increased by performing right-sided leads (V4R), posterior leads (V8, V9), and serial recordings
http://www.emedicine.com/emerg/topic31.htm

Thanks for this post which I find important, relative to this site, and comprehensible especially to some one new to a coranary unit thanks for the information looking forward to other post of similar nature giving important information relative to symptoms and differential information

thanks Angela

[gwenith]

Thank-you very much for the information unfortunately this was NOT what I was looking for. What I am looking for are those things NOT in text books i.e. I have a rule of thumb developed from the time before lysis.

The bigger the infarct the smaller the appetite and a REALLY big one will probably be vomiting their toenails up.

This is the "practice wisdom" I am looking for.

[zambezi]

Those MI patients often seem to have this look to them...I know it when I see it but it is hard to put into describable words...it definately gives me that bad gut feeling and I do call the dr. when I see it--even without other indicators...the patient just looks not right (and not right can be different depending on the person)...kind of a greyish/asheny color, that cool/clammy look...usually kind of fidgety (in an annoying kind of way), the patient may not even be having pain but just can't put their finger on what is wrong...I seem to get complaints about being cold despite normal temps...I hate when patients get this look--I am just waiting for "the big sign" and the impending crash and burn...

I am interested in you study results since not a lot of people have responded to the thread!!

[11:11]

Its something a new nurse has to see to be able to develope that sense for the "look" of a true MI pt. Once seen it wont be forgotten.

I notice that many MI pts seem to just not be able to get comfortable no matter what you do.

I once traiged an evolving MI from tingling in the finget tips.

c.wicks forgot to add older females in the rick factor catagory for MI. Lets not forget them and the fact that they often present atypically-

11