9. Know when to refer a patient with coronary artery disease.

Central or epigastric chest pain radiating to

the arms, shoulders, neck or jaw
Pain is described as substernal pressure,
squeezing, aching, burning, or sharp pain
Pain lasts for more than 15 minutes
May be associated with sweating, nausea,
vomiting, dyspnea, fatigue and/or palpitations
Elderly may present with altered mental state
Elderly and diabetic patient may not have any
chest pain
Patients with pre-existing angina :
Take a second dose of Glyceryl Trinitrate (GTN)
after 5 mins if the pain has not eased
Take a third dose of GTN after a further 5 mins if the
pain has still not eased.
Immediately sent to the hospital if the pain has not
eased for another 5 mins

10. State the complications and prognosis of

patient with CAD.

Complications of CAD
Can be categorized as :
Electrical dysfunction (conduction
disturbance, arrhythmias)
Mechanical dysfunction (heart
failure, myocardial rupture or
aneurysm, papillary muscle
dysfunction)
Thrombotic complications
(recurrent coronary ischemia,
mural thrombosis)
Inflammatory complications
(pericarditis, Dressler syndrome)

10. State the complications and prognosis of

patient with CAD.

Complications
of CAD

Electrical dysfunction

Conduction disturbance

Mobitz type I block (progressive prolongation

of PR interval)1st degree

Morbitz type II block (dropped beats)2 nd

degree

Complete (3rd degree) AV block

Atrial arrhythmias (Atrial ectopic beats, atrial

fibrillation, and atrial flutter)

Occur in about 10% of MI patients

Ventricular arrhythmias

May result from hypoxia, electrolyte imbalance

(hypokalemia or hypomagnesemia), or
sympathetic overactivity in ischemic cells
adjacent to infarcted tissue

10. State the complications and prognosis of

patient with CAD.

Complications of
CAD

Mechanical dysfunction:
heart failure
myocardial rupture or aneurysm
Occurs in 1% of patients with acute MI
Causes 15% of hospital mortality

papillary muscle dysfunction

Occurs in about 35% of patients during the first few
hours of infarction
Occurs most often after an inferoposterior infarct due
to RCA occlusion
Causes acute, severe mitral regurgitation

10. State the complications and prognosis of

patient with CAD.

Complications of
CAD

Thrombotic complications

recurrent coronary ischemia

Any chest pain that remains or recurs

12 to 24 H post-MI

mural thrombosis

Occurs in about 20% of patients with

acute MI

Systemic embolism occurs in about

10% of patients with LV thrombosis

10. State the complications and prognosis of

patient with CAD.

Complications of
CAD

Inflammatory complications
Pericarditis

Results from extension of myocardial necrosis

through the wall to the epicardium
Develops in about 1/3 of patients with acute
transmural MI
Friction rub usually occur 24 to 96 H after MI onset
Acute temponade is rare

Post-MI syndrome (Dressler syndrome)

Develops in several days to weeks or even months
after acute-MI
Characterized by fever, pericarditis with a friction
rub, pericardial effusion, pleurisy, pleural effusions,
pulmonary infiltrates, and joint pain
caused by an autoimmune reaction to material from
necrotic myocytes

10. State the complications and prognosis of

patient with CAD.

Prognosis of CAD
30% of the patients with unstable angina
have an MI within 3 months of onset
Death is less common

NSTEMI and STEMI

Mortality rate is about 30%
25-30% of these patients die
before reaching the hospital
(typically due to ventricular
fibrillation)
In-hospital mortality rate is about
10% (typically due to cardiogenic
shock)

10. State the complications and prognosis of

patient with CAD.

Prognosis of CAD
Killip Classification and
Mortality Rate of Acute MI*