Файловый архив студентов. Файловый архив студентов.
1330 вузов, 5508 предметов.
/ Регистрация
FAQ Обратная связь Вопросы и предложения
Добавил:
kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Ростовский Государственный Медицинский Университет
Предмет:
Медицина общая
Файл:

Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

.pdf
Скачиваний:
0
Добавлен:
15.09.2026
Размер:
12 Мб
Скачать
☆
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
CardiovascularriskfactorsarediscussedinBox8.1.
Anginalpain:
Central,tighteningpaininthechest,neck,shoulders,jaw,orarms Induciblebyexertion ResolveswithrestorGTNwithinabout5minutes.
If the patient reports all three of the anginal pain characteristics, they have ‘typical’ angina.Iftheyhavetwoofthecharacteristics,theyhave‘atypical’angina,andifoneor nocharacteristics,theyhave‘non-anginalpain’.
Unlikelyangina:
Continuousorprolongedpainand/or Painunrelatedtoactivityand/or Pleuriticpainand/or Painassociatedwithsymptomssuchasdizziness,palpitations,tingling,ordifficultyswallowing.
Differentials:
MustexcludeACS!(seeChapter1) Hypertrophiccardiomyopathy Microvascularangina Gastro-oesophagealreflux(seeChapter30).
Box8.1Cardiovascularriskfactors
Age(>45yearsinmen,>55yearsinwomen) Smokinghistory Pastmedicalhistoryofdiabetes,hypertension,dyslipidaemia,orpreviousCAD,e.g.myocardial infarction Familyhistoryofcardiovasculardisease.
Examination
Checkfor:
https://t.me/med1917
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Indicators of elevated cardiovascular risk, e.g.obesity, diabetesor lipid deposits secondaryto hypercholesterolaemia, Signs ofother cardiac disease which mightbe causing anginal symptoms, e.g.ejectionsystolic murmur in aortic stenosis, left ventricular hypertrophy in hypertrophic cardiomyopathy, radial– femoraldelayofaorticcoarctation Signsofnon-cardiacdiseasewhichmightbecausingacutechestpain,e.g.cracklesinpneumonia, costochondraltendernessincostochondritis.
Investigations
Bedside
Pulseoximetry,pulse,andbloodpressure 12-lead ECG (check for pathological Q waves, LBBB, ST-segment and T wave flattening or inversion which would suggest underlying cardiovascular disease and check the underlying rhythm).
Bloods
FBC:
Anaemiacanexacerbateangina Araisedwhitecellcountmayindicateaninfectionandalternativecauseofthechestpain
U&E,LFT:
Baselinemeasurementbeforeinitiatingtherapy
Glucose,HbA1c,andlipids:
Toassesscardiacriskfactors,e.g.diabetesmellitusandhypercholesterolaemia
Troponin:
ToexcludeMI
CRP:
Indicatesinfectionorinflammation.
Imaging
ChestX-raytoexcludeothercausesofchestpain.
Other
CTcoronaryangiography
https://t.me/med1917
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
PatientsshouldhaveaCTcoronaryangiogramif:
They have not been previously diagnosed with CAD and have a history consistent with ‘typical’or‘atypical’anginaOR
Theyhave‘non-anginalpain’buttheirECGhasQwavesorST–Tchanges SignificantCADfoundduringCTcoronaryangiographyis≥70%diameterstenosisofatleastone majorepicardialarterysegmentor≥50%diameterstenosisintheleftmaincoronaryartery.
Non-invasivefunctionalimaging
Examplesofnon-invasivefunctionalimaginginclude:
Exercisetesting Myocardial perfusion scintigraphy (MPS) with single-photon emission computed tomography (SPECT) Stressechocardiography(withexerciseordobutamine) Adenosinestressmagneticresonanceperfusion.
Thesemaybeperformedif:
A patient has known CAD and it is unclear whether their symptoms are due to their existing diagnosis CTcoronaryangiographywasnotdiagnostic.
Invasivecoronaryangiography
Performedtodeterminecoronaryanatomy:
Iffunctionalimagingisindicativeofischaemia Iffunctionalimagingisnotdiagnostic IfcoronaryinterventionisbeingconsideredbasedonCTorfunctionalimagingfindings.
Management
Patienteducation
Explain:
Thelong-termcourseandmanagementofstableangina Factorsthatcaninduceangina,e.g.exertionalactivity,emotionalstress,exposuretocold,eatinga heavymeal Theneedtoobtainmedicalhelpifsymptomsstarttooccurmorefrequentlyormoreseverelythan previously.
Lifestyleandsimpleinterventions
https://t.me/med1917
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Adviseonexercise,smokingcessation,diet,andweightcontrol.
Pharmacologicalmanagement
Antianginaldrugtreatment
Symptomaticrelief
GTNspray(Box8.2).
Box8.2Glyceryltrinitrate
PatientsshouldknowtouseGTNpriortoexertionalactivity Theymayexperienceflushing,headaches,orlight-headednessduetothevasodilatingproperties andshouldsitdowniftheybecomelight-headed If GTN is used because of an acute pain episode, patients should wait for 5 minutes before repeating the dose if the pain is still present. If the second dose does not cause the pain to resolvewithin5minutes,theyshouldcallanambulance.
First-linepreventativetherapy
Beta-blocker,e.g.bisoprolol2.5mgOD,oracalciumchannelblocker,e.g.amlodipine5mgOD Ifineffective,acombinationofthetwooptionsmaybetried.
Second-line/additionalmedicaltherapy
Anyofthefollowing:
Isosorbidemononitrate,20mgBDorTDSinitially,thentitratedoseupwardsasrequired
Ivabradine2.5–5mgBDinitially(use2.5mgifage>75years)
Nicorandil5–10mgBDinitially
Ranolazine375mgBDinitially.
Preventionofcardiovasculardisease
Aspirin75mg Statintherapy,e.g.atorvastatin20mgOD Antihypertensive(seeChapter6)anddiabetictherapyifneeded.
Surgical/interventionalmanagement
If medicaltherapy fails to control the symptoms, consider coronaryarterybypass graft
https://t.me/med1917
•
•
•
(CABG)orpercutaneouscoronaryintervention(PCI).SeeTable8.1foracomparisonof theinterventions.
Table8.1Coronaryarterybypassgraftversuspercutaneouscoronaryintervention
CABG PCI
PotentialsurvivaladvantageofCABGoverPCIforpeoplewith multivesseldiseaseandwho:
HavediabetesOR Areaged>65yearsOR Have anatomicallycomplex three-vessel disease ± involvement oftheleftmainstem
Avoidsrisksofopen-heartsurgeryandgeneral anaesthetic:
Maybe bettertoleratedby elderlyand those with↑comorbidities
Source:datafromNICECG126.
Psychosocialconsiderations
Impactonpatient’squalityoflife:howdoesanginalimittheirdailyliving,work,andexercise?
Complications
ACS:considerifsuddenworseninginthefrequencyorseverityofsymptoms(seeChapter1).
Furtherreading
1.FirthJ,ConlonC,CoxT(eds)(2020).Managementofstableangina.In:OxfordTextbookofMedicine, 6th ed (Chapter 16.13.3). Oxford: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780198746690.003.0366
2.RamrakhaP,HillJ(eds)(2012).Coronaryarterydisease.In:OxfordHandbookofCardiology,2nded (pp. 211–308). Oxford: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780199643219.003.0005
https://t.me/med1917
Chapter9
Transientlossofconsciousness
Guideline: NICE CG109 (Transient loss of consciousness (‘blackouts’) in
over16s):https://www.nice.org.uk/guidance/cg109/
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Transientlossofconsciousness(TLoC)isacommonpresentationandcausesrangefrom vasovagalsyncopetomoreseriousetiologiessuchascardiacarrhythmiasandepilepsy.A goodhistoryisessentialindiagnosingtheunderlyingpathophysiology.
Diagnosis
Differentialdiagnosis
https://t.me/med1917
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Neurocardiogenic:
Vasovagal(simplefaint) Situationalsyncope
Orthostatichypotension:
Antihypertensivesorothermedicationswhichmaycausehypotension
Hypovolaemia(e.g.dehydration,gastrointestinal(GI)bleed) Autonomicdysfunction/failure(e.g.autonomicneuropathy,Parkinson’sdisease) Cardiovascular:
Arrhythmia
Structuralheartdisease(e.g.AS,hypertrophicobstructivecardiomyopathy) Carotidsinussyncope Epilepticseizure Non-epilepticattackdisorder(alsoknownaspsychogenicseizuresorpseudosyncope) Unexplainedsyncope.
Remember,thesyncopalepisodemaybemultifactorial.
History
Itisimportanttogetadetailedhistoryfromthepatientandanywitnesses.Table9.1lists detailsthatmaybeelicitedinthe historytohelpdistinguish between differentcauses of TLoC.Box9.1describesthecriteriafordiagnosinguncomplicatedvasovagalsyncope.
Check:
HowthepatientappearedandwhattheyweredoingbeforetheTLoC HowtheyappearedduringTLoCandafterwards Howlongbeforethepatientregainedconsciousness Didtheysustainanyinjuries? DidtheyrecalltheeventsbeforeandaftertheTLoC? AnypreviousepisodesofTLoC? Past medical history (including if the patient has a pacemaker) and family history of cardiac disease,inheritedcardiacconditions,orsuddendeath Medicationhistoryincludinganyrecentdosagechanges.
Make a note of any medications which could cause hypotension. Common examples include diuretics, e.g. bendroflumethiazide, furosemide, and bumetanide and alpha­blockers,e.g.tamsulosinanddoxazosin.
https://t.me/med1917
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Table9.1HowtodifferentiatetypesofTLoCfromthehistory
TypeofTLoC Salientdetailsinthehistory
Vasovagal(simplefaint)
3Ps:
Posture—prolongedstanding Provokingfactors—suchaspainoramedicalprocedure Prodromalsymptoms—e.g.feelinghot
Briefseizure-likeactivitycanoftenoccur Immediaterecoveryofconsciousnesswithoutconfusion
Situationalsyncope
Syncope occurs following straining during urination or after coughing or swallowing
Orthostatichypotension
Light-headedness/TLoCusuallyoccurswhenpatientstandsupfromsitting It is confirmed by a fall in blood pressure on standing of >20mmHg systolic and/or>10mmHgdiastolic Considercontributingdrugsandiftheycanbestopped
Epilepticseizure(seeChapter
50)
Pre-TLoC:prodromaldéjàvuorjamaisvu During TLoC: tongue biting (biting the side of the tongue is particularly suggestive),headturnedtooneside,absenceofpallor,abnormalposturing,limb shaking Post TLoC: confusion, focal weakness (Todd’s paresis), amnesia for events beforeandafterTLoC
Non-epilepticattackdisorder
Repeatedeventswithoutaconsistentpattern Multipleunexplainedphysicalsymptoms Eventsareunusuallyprolonged Can be difficult to differentiate from epileptic seizures, requiring specialist assessment
Carotidsinussyncope
Triggeredbyheadturning,tight-fittingcollars,shaving(actionscausingpressure onthecarotidsinus)
Structuralheartdisease,e.g. hypertrophiccardiomyopathy, AS
Exercise-inducedsyncope
Arrhythmicsyncope
Suddenonset,littlewarning MaypresentwithfacialinjuriesasnowarningpriortoTLoC Maybeprecededbypalpitations Rapidrecovery
Source:datafromNICECG109.
Box9.1Diagnosinguncomplicatedvasovagalsyncope
https://t.me/med1917
•
•
•
•
•
•
•
•
•
•
•
•
Thiscanbedoneif:
Thereisnothinginthehistoryorexaminationtoindicateanalternativecause TLoC occurred after standingorwas provoked,e.g.bypainoramedical procedureandwas precededbyprodromalsymptoms.
Inthissituation,apatientshouldbeadvisedtoseetheirgeneralpractitioner(GP)foran ECGifonehasnotalreadybeenperformed.
Note that syncope soonafter stopping exercise is morelikely tobe due toa vasovagalsyncope but syncopeduringexerciseismorelikelytohaveacardiovascularcause.
Source:datafromNICECG109.
Examination
Bedsideobservationsincludingheartrateandlyingandstandingbloodpressure General examination for injuries from fall, evidence of tongue biting, bladder or bowel incontinence Cardiacexamination(evidenceofarrhythmiasorstructuralheartdisease,e.g.AS) Neurologicalexamination(checkforfocaldeficitwhichmightbepostictaliftemporaryorsuggest chronicneurologicalpathologyifpermanent) ConsiderrectalexaminationifsuspicionofupperGIbleed.
Callforhelp?
Ifthepatienthasnotmadeafullrecoveryofconsciousness,contactaseniorclinician.
Investigations
Bedsidetests
ECG:
Conductionabnormality(e.g.rightbundlebranchblock(RBBB)/LBBBorheartblock)
LongQT(QTc>450ms)orshortQT(QTc<350ms)interval
STsegmentorTwaveabnormalities
Arrhythmia,e.g.bradycardia,Brugadasyndrome,Wolff–Parkinson–Whitesyndrome.
Bloods
https://t.me/med1917
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
FBC(anaemia) U&E(AKI/dehydration/GIbleed) Glucose(hypoglycaemia) Venousbloodgas(lactateoftenraisedfollowingseizures) Groupandsaveifbleedissuspected.
Imaging
PlainfilmX-raystoassessforanysuspectedfracturessustainedinfall CTscanifheadinjuryidentified(seeChapter120),orstrokesuspected(seeChapter56).
Other
Echocardiogramifstructuralheartdiseaseissuspected.
Acutemanagement
Patienteducation
Patientsmustnotexerciseuntilinvestigated/assessedunlessdiagnosedwithasimplefaint OffersafetyadviceforpeoplewhohavehadTLoC,advisethemonwhattodoiftheyhaveanother event(i.e.whentoseekmedicaladviceagain)andstrategiesforavoidingtheirtriggers Patientsmustnotdriveuntilassessed:
Followingcardiology/neurologyspecialistassessment,patientsmustreporttheTLoCeventto
theDriverandVehicleLicensingAgency(DVLA)(seeChapter115) Some cardiacandneurological diseaseslimitpeoplefrom certainoccupations,e.g.professional athleteswithcardiacsyncopemustbeadvisedtostopexercising,heavygoodsvehicledriverscan havetheirdrivinglicencesrevokedbytheDVLA.
Pharmacologicalmanagement
ConsiderstoppingantihypertensivesandprescribingIVfluids Treatanyconcurrentpathology(e.g.sepsis,GIbleed,aorticdissection).
Specialistreferral
Cardiology
InvestigationsmaybecarriedoutasperTable9.2.
Usethefollowingcriteriatoconsiderwhetherthepatientrequiresanurgentreferralor
not.
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана
Помощь Обратная связь Вопросы и предложения Пользовательское соглашение Политика конфиденциальности