MEDICINEnotes

All DOACs Inhibit Factor ×a except Dabigatran( direct thrombin inhibitor) All DOACs antidote Andexanet alpha except Dabigatran (Idarucizumab)

سؤال سريع RTA patient. Pulse +ve Bradycardia Breathing -ve Generalised cyanosis What should we do first? https://t.me/MediNote47

The following day, the patient suddenly develops severe crushing chest pain at rest with profuse sweating, nausea, hypotension, and signs of acute distress. ECG now demonstrates marked ST-segment elevation in leads II, III, and aVF with reciprocal depression in I and aVL, indicating an acute inferior wall infarction. Cardiac biomarkers are markedly elevated. This represents a ST-elevation myocardial infarction (STEMI) caused by complete thrombotic occlusion of a coronary artery and requires immediate reperfusion therapy.

Six months later, the same patient presents to the emergency department with worsening chest pain over the past week. The pain now occurs with minimal exertion and occasionally at rest, lasting longer than before and only partially relieved by nitrates. On arrival, he has ongoing chest discomfort with diaphoresis and anxiety. ECG shows ST-segment depression and T-wave inversion, but initial cardiac troponin is normal. This change in pattern from predictable exertional pain to rest pain without biomarker elevation indicates unstable angina, part of the non-ST elevation acute coronary syndrome spectrum. ​Several hours later, despite medical therapy, his chest pain persists and repeat testing shows rising cardiac troponin levels. ECG continues to show ST depression without ST elevation. He appears pale and tachycardic, and lung examination reveals mild basal crackles. The presence of myocardial necrosis evidenced by elevated troponin in the setting of ischemic symptoms and non-ST elevation ECG changes confirms progression to a non-ST elevation myocardial infarction (NSTEMI) due to subtotal coronary artery occlusion.

A 58-year-old man presents to the outpatient clinic with a 6-month history of central chest tightness that occurs predictably when he walks uphill or climbs stairs and is relieved within a few minutes by rest. The pain is pressure-like, sometimes radiating to the left shoulder and jaw, and never occurs at rest. He has hypertension, diabetes, hyperlipidemia, and a smoking history. Physical examination is unremarkable, resting ECG is normal, troponin is negative, and an exercise stress test reproduces his pain with horizontal ST depression in the lateral leads. These findings are consistent with chronic stable angina.

بداية موفقة 🐳

Ischemic Heart Disease (IHD) Overview #Significance ​One of the most common causes of death ​The most common cause of heart failure #Definition of Ischemia ​An imbalance between blood supply and demand in a portion of the myocardium ​It occurs when blood is "not enough" for tissue due to: 1. ​↓ Amount (Supply) 2. ​↓ Quality (e.g., oxygen carrying capacity) 3. ​↑ Tissue requirements (Demand) #Nature of Ischemia ​It is a Regional disease (affects a specific wall/area) ​It is "impossible" for ischemia to affect the whole heart simultaneously (unlike Pericarditis, which is Global) #Causes_and_Differential_Diagnosis Coronary Artery Disease (CAD): 1. ​The most common heart disease 2. ​The single most important cause of death 3. ​The most common cause of ischemia Ischemia with Normal Coronary Arteries ​Can occur due to: 1. ​Vasospastic: Prinzmetal Angina (Variant) 2. ​Aortic Stenosis / Aortic Regurgitation: Leads to ↓ COP (Cardiac Output) ↓ PSAD (Phasic Systolic Arterial Delivery) 3. ​HOCM (Hypertrophic Obstructive Cardiomyopathy): Sub-valvular stenosis and hypertrophy 4. ​Thyrotoxicosis, Pheochromocytoma, Acromegaly: Leads to tachycardia and ↑ demand 5. ​Takotsubo Cardiomyopathy: "Broken-heart syndrome" Weakening of the left ventricle often triggered by severe emotional/physical stress 6. ​Severe Anemia: ↓ Blood quality #Clinical_Pearls Perfusion Timing: ​The whole body receives blood during Systole ​The heart receives its blood supply during Diastole ​Therefore, Aortic Regurgitation (AR) can cause ischemia #Diagnosis ​When diagnosing MI (Myocardial Infarction), other conditions must be excluded, such as: 1. ​Aortic valve lesions 2. ​Severe anemia 3. ​HOCM ​etc. #Pathophysiology_of_CAD Mechanism ​CAD is most commonly due to Atheroma (ATH) Lipid deposition in the subintimal layer → Arterial narrowing → ↓ Diameter #Atheroma_Progression 1. ​Fixed: Leads to Stable Angina (size remains constant) 2. ​Rupture: Leads to thrombosis → Unstable Angina 3. ​Emboli: Leads to Unstable Angina or M.I 4.​ Aneurysm #Risk_Factors ​The risk factors for CAD are the same as those for IHD and CVA (Cerebrovascular Accident)

#Cardio@MediNote47

What is Atherosclerosis شنو؟ عملية تتراكم فيها الــــ lipid (خصوصاً cholesterol) في Intima (most inner layer) → Atheroma 🧱 Atheroma 👈 يضيق ال-lumen تدريجياً 👈 نقص Supply → Ischemia and Necrosis الــ Heart يحاول يفتح collaterals لتجاوز الجزء اللي صارله الضيق 🔀 #Risk_Factors Non-modifiable ما نقدروس نغيروها الزيادة في العمر، الكبر ببساطة الـ Age ماحدش يقدر يغير العمر ولا انه يوقف عمره عنده عمر صغير الجنس Gender (ذكر غالباً أكثر خطورة) ومافش حد يقدر يديرها Genetics Family history Type A personality Modifiable – نقدروا نغيروها رغم انها صعبة ع بعض الناس 1. Hypertension 2. Diabetes 3. Dyslipidemia 4. Obesity 5. Smoking / Alcohol 🚬🥃 6. Microalbuminuria 7. Physical inactivity 8. Diet غير صحي 9. Inflammation 4️⃣ Complications of Atherosclerosis 1. CVD – Cerebrovascular disease (Stroke) 🧠 2 CAD – Coronary artery disease 💓 3. PAD – Peripheral arterial disease (Limbs) 🦵 4. RAS – Renal artery stenosis (Kidneys) 🩺 5. Aneurysm – especially Aortic aneurysm

💓 Ischemic Heart Disease أمراض الذبحة الصدرية 😂 في ليبيا اللي يحس قلبه يقولوا عنده القلب 1️⃣ Etiology – أسباب A) Decreased Myocardial Oxygen Supply الاكسجين نقص عن القلب والنقصان هذا يا أما نقصان كمية يا نقصان في جودة الأكسجين A1) Decreased Quantity of Coronary Blood Coronary Artery Disease (CAD): Coronary Atherosclerosis أكثر سبب وهو Most common cause of IHD على سبيل المثال رجل عمره 55 سنة، يدخن، عنده سكر وضغط مرتفع تتراكم عنده الدهون في شرايينه 💥 أسباب أخرى زي Other Causes: 1. Arteritis: PAN، SLE 🌡️ 2. Blood diseases (Hypercoagulable): PRV، DIC 🩸 3. Congenital anomalies 4. Dissection 5. Emboli: بسبب جلطة انسد الشريان 5. Spasm of the coronary: (في العادة prognosis كويس) A2) Decreased Quality of Coronary Blood 1. Anemia: نقص الهيموغلوبين 👈 يقل الأكسجين 🩸 2. Cyanotic conditions: نقص الأكسجين في الدم (Hypoxia) 😮‍💨 القلب يبي أكثر وأكثر B) Increased Myocardial Oxygen Demand 1. ↑ Myocardial contractility → زي Hypertrophy 2. ↑ Preload → Hyperdynamic circulation 3. ↑ Afterload → ارتفاع ضغط الدم Hypertension 4. ↑ Heart rate → Tachycardia ⚡ 6. Severe stress: ضغط نفسي أو جسدي 💡 على سبيل المثال مريض عنده LVH بسبب الضغط ويجري بسرعة و قلبه يحتاج أكسجين أكثر من الدم المتوفر يصيرله Angina

#Ischemic_Heart_Disease (IHD)

🫁 Asthma triad 👉 "WSC" Wheeze SOB Chest tightness

🔴 Aspirin Induced Asthma Dyspnea Cough Wheezes بعد 1 ساعة من Aspirin 💊

🟢 Bronchial Asthma 1. Dyspnea 😮‍💨 2. Chest Tightness 🫀 3. Cough 🤧 4. Clear Sputum 💧 5. Triggered by Exercise 🏃‍♂️ 👈 تشخيص: Asthma

💊 Management (العلاج) 🔹 Allergen avoidance 🚫🌸 🔹 Relievers: 1. SABA 💨 (Salbutamol) 2. LABA 💨 (دائماً مع ICS) 🔹 Preventers: 1. ICS 💊 (Inhaled corticosteroids) 2. Oral steroids 💊 3. Omalizumab 💉 (anti-IgE) 🔹 🔥 حسب آخر Guidelines: ما عادش نعتمد على SABA بروحه ❗ لازم ICS حتى في mild asthma 🚑 Acute Severe Asthma 🔹 Treatment: 1. SABA 💨 2. 100% O₂ 🫁 3. Systemic steroids 💊 🔹 If no improvement: Ipratropium 💨 Magnesium Sulfate (MgSO₄) 💉 🔹 Severe: Mechanical ventilation 🫁⚠️

🧠 Mnemonic (التشخيص): 👉 "PEF 20 – FEV1 12"

🧪 Diagnostics (التشخيص) 🔹 Initial: Spirometry 📊 🔹 Sensitivity: PEF diurnal variation >20% ⏱️ 👈 يعني الفرق بين الصبح والليل كبير 🔹 Gold Standard: Reversible spirometry: FEV1 يزيد >12% بعد: SABA 💨 أو 14 days Prednisolone

😮‍💨 Presentation (الأعراض) 🔹 Classic triad: 1. Wheezing 🎶 (صفير) 2. SOB 😮‍💨 (ضيق تنفس) 3. Chest tightness 🫀 (شد في الصدر) 🔹 Features: 1. Night cough 🌙 (كحة تزيد بالليل) 2.Reversible 🔄 (مهم جداً → تتحسن بالعلاج)

🧠 Mnemonic (الأسباب): 👉 "AD-ViF + ECβA" A = Atopy D = Dust Vi = Viral F = Family E = Exercise C = Cold βA = Beta blockers + Aspirin