Q- A patient suffers from shortness of breath, weakness, lightheadedness, and cough 24 hours after a heart surgery.ECG shows the following features.What can be the most probable diagnosis?
A. Myocardial Infarction
B. Complete Heart Block
C. Myocardial Ischemia
D. Cardiac Tamponade
Answer is D: Cardiac Tamponade.
ECG in the image shows: Electrical alternans as seen by changing QRS amplitudes best seen in lead II ,it is suggestive of Cardiac Tamponade.
Cardiac tamponade:
It is when fluid in the pericardium (the sac around the heart) builds up and results in compression of the heart.
Symptoms:
typically include those of cardiogenic shock including shortness of breath, weakness, lightheadedness, and cough.
Cause:
Cardiac tamponade is caused by a large or uncontrolled pericardial effusion, i.e. the buildup of fluid inside the pericardium.
This commonly occurs as a result of chest trauma (both blunt and penetrating), but can also be caused by myocardial rupture, cancer, uremia, pericarditis, or cardiac surgery,retrograde aortic dissection
Diagnosis:
It may be suspected based on low blood pressure, jugular venous distension, pericardial rub, or quiet heart sounds.
The diagnosis may be further supported by specific electrocardiogram (ECG) changes, chest X-ray, or Echocardiography
ECG findings shows a triad of:
-Low QRS voltage
-Tachycardia
-Electrical alternans.
Electrical alternans occurs when consecutive, normally-conducted QRS complexes alternate in height.
the heart swings backwards and forwards within a large fluid-filled pericardium.
Treatment:
When tamponade results in symptoms, drainage is necessary.
This can be done by pericardiocentesis, surgery to create a pericardial window, or a pericardiectomy
Q- A 60-year-old male is on aspirin, ACE inhibitor, nitrates and beta blocker for chronic stable angina. Since the new-year party, he is having long-lasting angina pain every day for past 3 days. ECG was normal and Troponin I levels are normal. Which is the best management of this patient?
A. Admit and start heparin
B. Admit and start thrombolysis
C. Admit and observe for rising of cardiac biomarkers
D. Increase dose of long-acting nitrates and manage as outpatient
Answer is A. Admit and start heparin
• The patient is a known case of chronic stable angina and has presented with the development of unstable angina since angina episodes have become more pronounced and more frequent.
• Antithrombotic therapy with heparin, abciximab and intravenous beta blocker is recommended.
• TIMI score is calculated subsequently to decide the need for revascularization procedure.
• Thrombolysis is contraindicated in unstable angina.
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