MEDICAL DIARY - The Federation of Medical Societies of Hong Kong

VOL.11 VOL.14 NO.5 NO.1 MAY JANUARY 2006 2009
My Tips for Management:
Once you know all the above points, the management
of ACS is simple. I have 3 last tips for all my dearest
family doctors:
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2.
3
For ACS patients with
- Short Term risk of Death or Nonfatal Myocardial
Ischaemia likelihood is high to intermediate:
immediate transfer to a private/ Hospital Authority
hospital with prior notification to
cardiologist/Emergency doctors, for the urgent
management of ACS
For chest pain/angina patients with
- Short Term risk of Death or Nonfatal Myocardial
Ischaemia likelihood is low
refer to Private specialist (may take hours to days) /
Hospital Authority Specialist Clinics (may take
weeks to months), for further investigations and risk
stratification
The most important key for success is a good history
taking, meticulous physical examination, carefully
selected rapid investigations with a prompt and
precise management; delivered within a mutual
understanding and intimate trust between patients
and doctors.
In a Nutshell
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Chest pain is a very common presentation in our
daily practice
Heart disease is the 2nd Killer in HK
The key for differentiation is
- Character
- Location
- Precipitating Factors
Before reaching a definite diagnosis, we must first
ask ourselves
- Clinical stability
- Immediate prognosis
- Safety of referral
ECG Should be obtained and interpreted within 10
mins of presentation in a patient with ongoing chest
pain
Cardiac Troponin I & T
- are the preferred 1st line markers,
- if the first set of blood is negative ' repeat in 6 to 12
hours
Treadmill Stress ECG examination is a very useful
diagnosing and risk stratification tool for low risk
patients on Day 1 of presentation
Refer the ACS patients to a private/Hospital
Authority hospital immediately for urgent
management of ACS:
- if the Short Term risk of Death or Nonfatal
Myocardial Ischaemia likelihood is high to
intermediate.
Every adversity, every failure and every heartache carries
with it the seed of an equivalent or a greater benefit.
~ Napoleon Hill (1883 - 1970)
References
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Medical Bulletin
Braunwald E, Antman EM, Beasley JW, et al: ACC/AHA
guidelines for the management of patients with unstable
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Pope JH, Aufderheide TP, Ruthazer R, et al: Missed diagnoses
of acute cardiac ischemia in the emergency department. N
Englant J Med 342:1163-70, 2000
Angina, 4th edition, Graham Jackson, 2008 Informa UK Ltd.
www.healthyhk.gov.hk/phisweb/en/healthy_facts/
disease_burden/major_causes_death/major_causes_death/
Statistical Report 2003/2004, Hospital Authority
The History of Cardiology Louis J. Acierno, 1994, The
Parthenon Publishing GroupThe History of Cardiology Louis J.
Acierno, 1994, The Parthenon Publishing Group
National Heart Attack Alert Program Coordinating Committee
- 60 Minutes to Treatment Working Group. Emergency
department: Rapid identification and treatment of patients
with acute myocardial infarction. Ann Emerg Med 23: 311-329,
1994
Braunwald E, Antman EM, Beasley JW, et al:ACC/AHA
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College of Cardiology/American Heart Association Task Force
on Practice Guidelines (Committee on the Management of
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Antman EM, Anbe DT, Armstrong PW, et al: ACC/AHA
guidelines for the management of patients with ST-elevation
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American College of Cardiology/American Heart Association
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Lee TH, Goldman L. Evaluation of the patient with acute chest
pain. N Engl J Med 342:1187-95,2000
Amsterdam EA, Kirk JD, Diercks DB, et al: Exercise testing in
chest pain units: Rationale, implementation, and results.
Cardiol Clin 23:503-16, 2005
Stein RA, Chaitman BR, Balady GJ, et al: Safety and utility of
exercise testing inenergency roon chest pain centres: An
Advisory from the Committee on Exercise, Rehabilitation snf
Prevention, Council on Clinical Cardiology, American Heart
Association. Circulation 102:1463-7, 2000.
Modified from Fleet RP, Dupuis G, Marchand A, et al:
ACC/AHA 2002 guideline update for the management of
patients with unstable angina and non-ST segment elevation
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American College of Cardiology/American Heart Association
Task Force on Practice Guidelines ( Committee on the
Management of Patients With Unstable Angina).Circulation
106:1893, 2002.
Erratum
Clinical Management of COPD. Medical
Bulletin 2008, vol 13, no 12 (Dec) page 7: In
column 2, paragraph 3 (oxygen therapy), line 9
"LTOT should be considered for patients with
COPD who have chronic respiratory failure
when assessed at least twice during a stable
period of 3 to 4 weeks apart, and who have an
arterial oxygen tension (PaO2) of >/= 7.3kPa
(54.8mmhg) or....... ". It should be "/= 7.3kPa".
9