Cadmore media player playing audio Myocardial Infarction: Akbar A. Panju, MBChB, FRCPC, discusses the clinical examination for myocardial infarction.
Audio Player
Accessibility
Using forms mode, you can utilize keyboard shortcuts to make usability more efficient.
Space bar will play and pause the audio. Pressing escape will close all displays and pressing it again will jump to the end of the player.
You can press A to open the Keyboard Shortcut Dialog which also provides an audio description of the player and all of its features.
Transcript
Result Count
of
Search
Segments
Result Count
of
Search
Name:
Myocardial Infarction: Akbar A. Panju, MBChB, FRCPC, discusses the clinical examination for myocardial infarction.
Description:
Myocardial Infarction: Akbar A. Panju, MBChB, FRCPC, discusses the clinical examination for myocardial infarction.
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/83bd8a02-429d-4dae-bb50-55efc9b488ad/thumbnails/83bd8a02-429d-4dae-bb50-55efc9b488ad.jpg?sv=2019-02-02&sr=c&sig=QklvFoQECriEnDmI4oOJhlwDPF33Pz4C5eAxDlRRwiA%3D&st=2024-12-22T04%3A46%3A09Z&se=2024-12-22T08%3A51%3A09Z&sp=r
Duration:
T00H09M55S
Embed URL:
https://stream.cadmore.media/player/83bd8a02-429d-4dae-bb50-55efc9b488ad
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/83bd8a02-429d-4dae-bb50-55efc9b488ad/6830481.mp3?sv=2019-02-02&sr=c&sig=hyDe1eCkpy04SCgactGOvbMWoN7s0pRKXCXBlgZnyPM%3D&st=2024-12-22T04%3A46%3A09Z&se=2024-12-22T06%3A51%3A09Z&sp=r
Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
>> Joan Stephenson I'm Joan Stephenson, editor of JAMA's Medical News and Perspectives Section. Today, I have the pleasure speaking with Dr. Akbar Panju about myocardial infarction, an important topic covered in a section of the Rational Clinical Examination that was co-authored by Dr. Panju. Dr. Panju, why don't you introduce yourself to our listeners? >> Dr. Akbar Panju Okay, I'm Akbar Panju. I am Deputy Chair of Medicine at McMaster University Department of Medicine and Michael DeGroot Chair of Medicine, McMaster University, and head of General Internal Medicine at McMaster University.
I'm a clinician, researcher, and an educator. >> Joan Stephenson Dr. Panju, what do we know about the incidence of myocardial infarction? And what demographic features affect the incidence? >> Dr. Akbar Panju Studies have been done to calculate the incidence for myocardial infarction overall and then, separately for ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction. And we have known that in the last 10 years, there has been a gradual decrease in the incidence of myocardial infarction, in some studies, of up to 24% relative decrease.
We also note that ST-segment elevation myocardial infarction is decreased more than the non-ST-segment elevation myocardial infarction. Compared to 10 years ago, patients presenting with myocardial infarctions are older; more likely to be female; less likely to be white; more likely to have coexisting illnesses, such as hypertension, dyslipidemia, and diabetes; and more likely to have undergone previous coronary vascularization. We also know that a decrease in incidence of myocardial infarction was greater for those who lived in the most affluent neighborhoods, compared with those in the least affluent neighborhoods.
We also know that mortality over the last 10 years, for myocardial infarction, has decreased from about 10.5% in 1999 to 7.8% in 2008. >> Joan Stephenson What findings from history, and physical examination, are helpful for identifying the patients with chest pain, who are most likely to have a myocardial infarction? And which findings are not helpful? >> Dr. Akbar Panju So, features in the history which have high likelihood ratios and therefore increases the probability of myocardial infarction in patients presenting with chest pain are Chest pain that radiates to both arms; chest pain that radiates to left arm or right arm; and chest pain that radiates to right shoulder.
If there is nausea or vomiting, associated with chest pain that increases the likelihood of chest pain being due to myocardial infarction. A recent history, or a past history, of myocardial infarction also increases the likelihood that the patient, with chest pain, is probable myocardial infarction. Now, physical findings that have the high likelihood ratio, and therefore increases the probability of myocardial infarction, are chest pain associated with hypotension, particularly if the systolic blood pressure is less than 80 or if they are diaphoretic, or sweating, or if they have pulmonary crackles on auscultation, or if they have a third heart sound on auscultation of the cardiac pericardium.
Now, physical findings and features that decreases the probability of a myocardial infarction in a patient presenting with chest pain include chest pain that is pleuritic in nature; chest pain that's described as sharp or stabbing; chest pain that is positional; and chest pain that can be reproduced by palpation. We also know that cardiac risk factors, like hypertension, smoking, diabetes, family history, and none of these cardiac respecters emerge as independent predictors in a patient with chest pain suggestive of myocardial infarction.
>> Joan Stephenson I understand there are three management strategies used to determine the diagnostic groupings of acute chest pain. Would you describe these for us? >> Dr. Akbar Panju So, the available therapeutic options, that we have, create the categories for patients presenting to the emergency department with chest pain or other symptoms suggesting of myocardial ischemia. So, the three distinct management strategies determine the diagnostic groupings clinicians use clinically at the present time. So, the first group of patients are patients who present with chest pain and whose electrocardiogram shows ST-segment elevation features or a new left bundle branch block.
The current treatment, for those patients, would include percutaneous coronary intervention or thrombolytic therapy. The second group of patients are patients who present with chest pain and who have myocardial infarction without ST-segment elevation. In other words, non-ST elevation MI or new left bundle branch block. These are patients who will also have unstable angina, with high risk features. And this group requires intensive monitoring, most likely in the coronary care unit; immediate administration of anti-platelet agents, use of anticoagulation and probably coronary intervention, if they become unstable.
The last group, the third group of patients are low risk, unstable angina or patients in whom chest pain may have some atypical features and they may have known ischemic chest pain. And these are patients who could be admitted to an intermediate care setting or a ward bed and have non-invasive diagnostics testing work done to establish the diagnosis and the plan of treatment. >> Joan Stephenson What other conditions can present with symptoms suggestive of acute myocardial infarction? >> Dr. Akbar Panju A chest pain can be produced by multiple conditions.
And this is because a lot of structures in the thoracic cavity share the nerve supply and nerve path with-- with the cardiac afferent fibers. Broadly, one can divide chest pain into two categories, and these are cardiac chest pain or non-cardiac chest pains. And cardiac chest pains can be further divided into cardiac chest pain secondary to ischemia or to non-ischemia. And chest pain due to ischemia are angina, unstable angina and myocardial infarction.
Cardiac non-ischemic chest pain are pain secondary to pericarditis, aortic dissection, or some valvular problem. On the other hand, the non-cardiac chest pain can be divided into two broad categories. These are gastroesophageal chest pains or non-gastroesophageal chest pain. In gastroesophageal chest pain, one has pain secondary to gastroesophageal reflux, esophageal spasm or peptic ulcer disease, And, in known gastroesophageal, non-cardiac chest pain, one has chest pains secondary to pulmonary embolus, to pneumothorax due to muscular skeletal problem.
And maybe some other form of panic disorder. >> Joan Stephenson What are the current reference standard tests for myocardial infarction? >> Dr. Akbar Panju Well, the current reference standards used to make a diagnosis of myocardial infarction uses the use of cardiac markers. These are troponin levels. Troponin levels now are used to make a diagnosis of myocardial infarction, with the electrocardiographic findings. So, after clinical symptoms are used to identify patient with possible ischemia, the ECG and troponin results take precedence in making the diagnosis of myocardial infarction.
The case definition for myocardial infarction has changed with the validation of troponin levels. This means that the new definition diagnosed more patients with myocardial infarction to the point that the new definition of myocardial infarction with troponin would lead to an absolute increase of 7.7% in the incidence of myocardial infarction. >> Joan Stephenson When reviewing the literature, how do the more accurate reference standards affect our interpretation of data from older studies? Are the clinical features more important or less important with current biomarkers?
>> Dr. Akbar Panju So, the change in myocardial infarction definition, using the troponin levels or other cardiac markers, affect the sensitivity and specificity for clinical symptoms and signs. But, unfortunately, the direction and the magnitude of the effect are presently unpredictable. All the data on the clinical examination apply to the current diagnostic standards may lead to either underestimate or overestimate of the utility of symptoms and signs. So, the most reliable estimates for clinical examination will come from studies that compare the results to current definition of myocardial infarction.
So, at the present time, we await the results of further studies that could use the new markers and new definition of myocardial infarction in estimating the sensitivity and specificity of the clinical features. So, at the present time, the value of individual clinical symptoms and signs, in the decision to admit or discharge the patient, has not been evaluated with troponin-based case definition. >> Joan Stephenson Dr. Panju, is there anything else you'd like to tell our listeners about diagnosing myocardial infarction?
>> Dr. Akbar Panju All I can say is that, over the last couple of decades, we have come to understand myocardial infarction a lot better. With the new case definition and the use of biomarkers, I believe that history and physical examination, combined with the biomarkers, will help a clinician in making the right decision for the patient and then institute the right management strategies for patients presenting with chest pain to an emergency department. >> Joan Stephenson Thank you, Dr. Panju, for this overview of myocardial infarction.
For additional information about this topic, JAMAevidence subscribers can consult the Rational Clinical Examination. This has been Joan Stephenson, of JAMA, talking with Dr. Akbar Panju for JAMAevidence.
Segment:0 .
>> Joan Stephenson I'm Joan Stephenson, editor of JAMA's Medical News and Perspectives Section. Today, I have the pleasure speaking with Dr. Akbar Panju about myocardial infarction, an important topic covered in a section of the Rational Clinical Examination that was co-authored by Dr. Panju. Dr. Panju, why don't you introduce yourself to our listeners? >> Dr. Akbar Panju Okay, I'm Akbar Panju. I am Deputy Chair of Medicine at McMaster University Department of Medicine and Michael DeGroot Chair of Medicine, McMaster University, and head of General Internal Medicine at McMaster University.
I'm a clinician, researcher, and an educator. >> Joan Stephenson Dr. Panju, what do we know about the incidence of myocardial infarction? And what demographic features affect the incidence? >> Dr. Akbar Panju Studies have been done to calculate the incidence for myocardial infarction overall and then, separately for ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction. And we have known that in the last 10 years, there has been a gradual decrease in the incidence of myocardial infarction, in some studies, of up to 24% relative decrease.
We also note that ST-segment elevation myocardial infarction is decreased more than the non-ST-segment elevation myocardial infarction. Compared to 10 years ago, patients presenting with myocardial infarctions are older; more likely to be female; less likely to be white; more likely to have coexisting illnesses, such as hypertension, dyslipidemia, and diabetes; and more likely to have undergone previous coronary vascularization. We also know that a decrease in incidence of myocardial infarction was greater for those who lived in the most affluent neighborhoods, compared with those in the least affluent neighborhoods.
We also know that mortality over the last 10 years, for myocardial infarction, has decreased from about 10.5% in 1999 to 7.8% in 2008. >> Joan Stephenson What findings from history, and physical examination, are helpful for identifying the patients with chest pain, who are most likely to have a myocardial infarction? And which findings are not helpful? >> Dr. Akbar Panju So, features in the history which have high likelihood ratios and therefore increases the probability of myocardial infarction in patients presenting with chest pain are Chest pain that radiates to both arms; chest pain that radiates to left arm or right arm; and chest pain that radiates to right shoulder.
If there is nausea or vomiting, associated with chest pain that increases the likelihood of chest pain being due to myocardial infarction. A recent history, or a past history, of myocardial infarction also increases the likelihood that the patient, with chest pain, is probable myocardial infarction. Now, physical findings that have the high likelihood ratio, and therefore increases the probability of myocardial infarction, are chest pain associated with hypotension, particularly if the systolic blood pressure is less than 80 or if they are diaphoretic, or sweating, or if they have pulmonary crackles on auscultation, or if they have a third heart sound on auscultation of the cardiac pericardium.
Now, physical findings and features that decreases the probability of a myocardial infarction in a patient presenting with chest pain include chest pain that is pleuritic in nature; chest pain that's described as sharp or stabbing; chest pain that is positional; and chest pain that can be reproduced by palpation. We also know that cardiac risk factors, like hypertension, smoking, diabetes, family history, and none of these cardiac respecters emerge as independent predictors in a patient with chest pain suggestive of myocardial infarction.
>> Joan Stephenson I understand there are three management strategies used to determine the diagnostic groupings of acute chest pain. Would you describe these for us? >> Dr. Akbar Panju So, the available therapeutic options, that we have, create the categories for patients presenting to the emergency department with chest pain or other symptoms suggesting of myocardial ischemia. So, the three distinct management strategies determine the diagnostic groupings clinicians use clinically at the present time. So, the first group of patients are patients who present with chest pain and whose electrocardiogram shows ST-segment elevation features or a new left bundle branch block.
The current treatment, for those patients, would include percutaneous coronary intervention or thrombolytic therapy. The second group of patients are patients who present with chest pain and who have myocardial infarction without ST-segment elevation. In other words, non-ST elevation MI or new left bundle branch block. These are patients who will also have unstable angina, with high risk features. And this group requires intensive monitoring, most likely in the coronary care unit; immediate administration of anti-platelet agents, use of anticoagulation and probably coronary intervention, if they become unstable.
The last group, the third group of patients are low risk, unstable angina or patients in whom chest pain may have some atypical features and they may have known ischemic chest pain. And these are patients who could be admitted to an intermediate care setting or a ward bed and have non-invasive diagnostics testing work done to establish the diagnosis and the plan of treatment. >> Joan Stephenson What other conditions can present with symptoms suggestive of acute myocardial infarction? >> Dr. Akbar Panju A chest pain can be produced by multiple conditions.
And this is because a lot of structures in the thoracic cavity share the nerve supply and nerve path with-- with the cardiac afferent fibers. Broadly, one can divide chest pain into two categories, and these are cardiac chest pain or non-cardiac chest pains. And cardiac chest pains can be further divided into cardiac chest pain secondary to ischemia or to non-ischemia. And chest pain due to ischemia are angina, unstable angina and myocardial infarction.
Cardiac non-ischemic chest pain are pain secondary to pericarditis, aortic dissection, or some valvular problem. On the other hand, the non-cardiac chest pain can be divided into two broad categories. These are gastroesophageal chest pains or non-gastroesophageal chest pain. In gastroesophageal chest pain, one has pain secondary to gastroesophageal reflux, esophageal spasm or peptic ulcer disease, And, in known gastroesophageal, non-cardiac chest pain, one has chest pains secondary to pulmonary embolus, to pneumothorax due to muscular skeletal problem.
And maybe some other form of panic disorder. >> Joan Stephenson What are the current reference standard tests for myocardial infarction? >> Dr. Akbar Panju Well, the current reference standards used to make a diagnosis of myocardial infarction uses the use of cardiac markers. These are troponin levels. Troponin levels now are used to make a diagnosis of myocardial infarction, with the electrocardiographic findings. So, after clinical symptoms are used to identify patient with possible ischemia, the ECG and troponin results take precedence in making the diagnosis of myocardial infarction.
The case definition for myocardial infarction has changed with the validation of troponin levels. This means that the new definition diagnosed more patients with myocardial infarction to the point that the new definition of myocardial infarction with troponin would lead to an absolute increase of 7.7% in the incidence of myocardial infarction. >> Joan Stephenson When reviewing the literature, how do the more accurate reference standards affect our interpretation of data from older studies? Are the clinical features more important or less important with current biomarkers?
>> Dr. Akbar Panju So, the change in myocardial infarction definition, using the troponin levels or other cardiac markers, affect the sensitivity and specificity for clinical symptoms and signs. But, unfortunately, the direction and the magnitude of the effect are presently unpredictable. All the data on the clinical examination apply to the current diagnostic standards may lead to either underestimate or overestimate of the utility of symptoms and signs. So, the most reliable estimates for clinical examination will come from studies that compare the results to current definition of myocardial infarction.
So, at the present time, we await the results of further studies that could use the new markers and new definition of myocardial infarction in estimating the sensitivity and specificity of the clinical features. So, at the present time, the value of individual clinical symptoms and signs, in the decision to admit or discharge the patient, has not been evaluated with troponin-based case definition. >> Joan Stephenson Dr. Panju, is there anything else you'd like to tell our listeners about diagnosing myocardial infarction?
>> Dr. Akbar Panju All I can say is that, over the last couple of decades, we have come to understand myocardial infarction a lot better. With the new case definition and the use of biomarkers, I believe that history and physical examination, combined with the biomarkers, will help a clinician in making the right decision for the patient and then institute the right management strategies for patients presenting with chest pain to an emergency department. >> Joan Stephenson Thank you, Dr. Panju, for this overview of myocardial infarction.
For additional information about this topic, JAMAevidence subscribers can consult the Rational Clinical Examination. This has been Joan Stephenson, of JAMA, talking with Dr. Akbar Panju for JAMAevidence.
Form Title Download
Media
Transcript
Form Title Bookmark
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Share
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Accessibility
The cadmore media player is a professional video and audio player experience designed to deliver media as well as relevant transcript, segmentation, and metadata. On the screen is a traditional html audio player with buttons such as play, pause, forward, captioning, language and play speed selection and more. Adjacent to the audio player are generally tabs, one of which shows a scrolling transcript of the audio and the other shows any segmentation of the media, sometimes referred to as chapters. At the top of the audio player is a menu bar containing an Explore button and Tools button. The Explore button allows you to dig deeper into the audio by opening up an explore dialog which contains an about tab which contains rich metadata about the media, a segments tab which contains further information about the audio, and a related tab which contains links to other media related to this media. The tools button opens a menu with options for sharing the media on social media, creating bookmarking links, creating embed codes for your website, generating citations, and more.
Keyboard Shortcuts
Keyboard shortcuts only work while you are in forms mode. By entering forms mode, you will be able to quickly access portions of the media player with single key commands.
Spacebar: Play/Pause Toggle
E: Explore Menu,
O: Tools Menu
T: Transcript Tab,
S: Segments Tab
F: Forward 15,
R: Rewind 15
L: Languages,
P: Playspeed
M: Mute Toggle,
V: Volume Bar
N: Video Only Toggle,
B: Full Screen Toggle
C: Captions Toggle
Escape: Closes dialogs and menus
Z: Next Transcript Chapter
X: Previous Transcript Chapter
Q: Next Transcript Paragraph
W: Previous Transcript Paragraph
Form Title Embed Media
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Embed Size
-
You Size - Responsive
-
We Size - Responsive
-
Picture Overlay Popup
-
400 x 225
-
512 x 288
-
400 x 700
-
768 x 1024
-
1024 x 512
-
1280 x 608
Form Title Cite
No citation provided.
Info
Segments
Related
Thumbnails
Accessibility
Using forms mode, you can utilize keyboard shortcuts to make usability more efficient.
Space bar will play and pause the media.
You can press A to open the Accessibility Dialog.
This describes many other keyboard shortcuts for media controls.
Exit Clip Mode
The video is currently set-up to show just a clip from 0:00 to video end. You have requested to see a portion of the media outside of the clip.
Click OK to switch to the full media or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode