Definition and Causes of Atrial Flutter

In this article, we will discuss the Definition and Causes of Atrial Flutter. So, let’s get started.

Definition

It is a supraventricular arrhythmia characterised by rapid atrial rate (250-350/min) due to intra-atrial re-entry (circus movement), involves commonly the right atrium. The arrhythmia occurs commonly in patients with organic heart disease. Flutter may be paroxysmal induced by pericarditis, acute respiratory failure or it may be persistent. Atrial flutter if lasts for more than a week, it will eventually convert into atrial fibrillation.

Causes

The causes of atrial flutter are more or less same as that of atrial fibrillation with the exception that pericardial disease, severe pulmonary disease commonly lead to atrial flutter than atrial fibrillation.

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Differentiation between Cardiac Dyspnea and Bronchial Asthma (Physical Signs)

In this article, we will discuss the Differentiation between Cardiac Dyspnea and Bronchial Asthma (Physical Signs). So, let’s get started.

Physical Signs

Cardiac Dyspnea (asthma)

  • Tachypnea, tachycardia, cyanosis (central, peripheral)
  • Trachea central, normal in length
  • No retraction of supraclavicular fossae or intercostal spaces
  • Percussion note is dull at the bases
  • Crackles at the bases
  • Apex beat is normal or displaced
  • Breath sounds are normal
  • 3rd heart sound (gallop rhythm) may be present

Bronchial Asthma (dyspnea)

  • They are less marked
  • Trachea is central but palpable part is decreased
  • Retraction of supraclavicular fossae and/or intercostal spaces is marked
  • Hyper-resonant note may be present
  • Both crackles and rales throughout the lungs
  • Apex beat may not be normal
  • Normal breath sounds with prolonged expiration
  • No 3rd heart sound

Clinical Manifestations and Diagnosis of Acute Coronary Syndrome

In this article, we will discuss the Clinical Manifestations and Diagnosis of Acute Coronary Syndrome. So, let’s get started.

Clinical Manifestations/Diagnosis

The diagnosis of non-ST-elevation ACS (unstable angina) is based on clinical presentation. It is diagnosed when chest discomfort is severe and has at least one of the three following features:

1. Pain/discomfort occurs at rest or with minimal exertion lasting >10 minutes

2. It is of recent onset (<2 weeks)

3. It has crescendo pattern, i.e. it is more severe, prolonged and more frequent than previous episodes.

The diagnosis is confirmed by elevated levels of biomarkers of myocardial necrosis (CPK-MB and troponins)

There is usually no physical sign but patients with rest pain frequently develop third or fourth heart sound during the episodes, and in some instances exhibit transient left ventricular failure (murmur of mitral incompetence) due to development of heart failure. Patients with ACS (Acute Coronary Syndrome) should be explored for the precipitating cause such as uncontrolled hypertension, anemia, occult thyrotoxicosis and presence of atherosclerosis (carotid, aortic or peripheral artery disease).

Differential Diagnosis of Chest Pain

In this article, we will discuss the Differential Diagnosis of Chest Pain. So, let’s get started.

Differential Diagnosis

Cardiac chest pain may radiate to other sites:

  • Mandible (left side of jaw)
  • Chin
  • Left Shoulder
  • Retrosternal radiating to the left arm (common site of origin and radiation)
  • Epigastric region
  • Right arm
  • Interscapular back pain

Based on radiation to these sites following are the differential diagnosis of chest pain:

Retrosternal

  • Myocardial ischemia
  • Esophageal pain
  • Pericarditis
  • Aortic dissection
  • Mediastinitis
  • Pulmonary embolus

Interscapular

  • Myocardial ischemia
  • Musculoskeletal Pain
  • Gallbladder or pancreatic pain

Right lower anterior chest

  • Gallbladder disease
  • Hepatic pain (abscess, hepatitis)
  • Subdiaphragmatic disease/abscess
  • Pneumonia/pleurisy
  • Gastric duodenal ulcer
  • Pulmonary embolism
  • Trauma
  • Myalgia

Shoulder pain

  • Myocardial ischemia
  • Pericarditis, Periarthritis
  • Cervical disc disease
  • Myalgic pain
  • Subdiaphragmatic abscess/pleurisy
  • Thoracic outlet syndrome

Arms

  • Myocardial ischemia
  • Cervical/dorsal spinal pain
  • Thoracic outlet syndrome

Left lower anterior chest pain

  • Neuralgia (intercostal)
  • Pulmonary embolism
  • Myalgia
  • Pneumonia/pleurisy
  • Splenic infarct
  • Subdiaphragmatic disease/abscess

Epigastric

  • Myocardial ischemia
  • Esophageal, gastric and duodenal pain
  • Pericarditis
  • Gallbladder, liver and pancreatic disease
  • Diaphragmatic pleurisy

Criteria of Cardiogenic Shock

In this article, we will discuss the Criteria of Cardiogenic Shock. So, let’s get started.

Criteria of Cardiogenic Shock

1. Systolic BP <90 mmHg or >60 mmHg fall below baseline level.

2. Cardiac index <2.2 L/min/m2. It is calculated by cardiac output divided by body surface area. Normal cardiac index is 2.6-4.2 (L/min/m2).

3. Left ventricular filling pressure or pulmonary capillary wedge pressure >18 mmHg; and pulmonary edema is usually present.

Transthoracic echocardiography (TTE): It is a non-invasive technique, provides same information as PCWP and CVP. It also differentiate hypovolemic shock (LV filling pressure is low but contractility is preserved) from cardiogenic shock (LV filling pressure is high but contractility is low/decreases). These hemodynamic parameters with clinical evidence of peripheral circulatory failure (e.g. altered mental state, cold clammy skin and oliguria with urine output <20 ml/hr) constitute clinical syndrome of cardiogenic shock.