Model Answer
0 min readIntroduction
The presentation of sudden breathlessness, perspiration, and a feeling of impending doom ('Ghabarahat') in a 60-year-old male with significant cardiovascular risk factors strongly suggests an acute cardiovascular event. 'Ghabarahat' is a common Hindi term used to describe a feeling of anxiety, apprehension, or panic, often accompanying serious medical conditions. Given the patient’s history of chronic smoking, obesity, and poorly controlled diabetes mellitus, acute coronary syndrome (ACS) – encompassing unstable angina, non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI) – is the most likely diagnosis. Prompt recognition and management are critical to reduce morbidity and mortality.
Initial Assessment & Differential Diagnosis
The initial assessment should focus on stabilizing the patient and rapidly determining the cause of the symptoms. A thorough history and physical examination are paramount.
- History: Detailed questioning regarding the onset, duration, character, and radiation of chest discomfort (if present). Assess for associated symptoms like nausea, vomiting, diaphoresis, and palpitations. Inquire about prior cardiac history, medications, and allergies.
- Physical Examination: Assess vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation). Auscultate the heart and lungs for murmurs, gallops, or crackles. Look for signs of peripheral edema.
While ACS is the most likely diagnosis, other possibilities must be considered:
- Pulmonary Embolism (PE): Especially if breathlessness is prominent and there are risk factors for venous thromboembolism.
- Aortic Dissection: Considered if there is sudden, severe chest pain radiating to the back.
- Pneumothorax: Sudden onset breathlessness, especially in smokers.
- Arrhythmias: Rapid heart rate or irregular rhythm can cause breathlessness and palpitations.
Investigations
Rapid and targeted investigations are crucial for confirming the diagnosis and guiding management.
- Electrocardiogram (ECG): The first and most important investigation. Look for ST-segment elevation (STEMI), ST-segment depression, or T-wave inversion (NSTEMI/Unstable Angina).
- Cardiac Biomarkers: Troponin I or T levels should be measured serially (at presentation, 3-6 hours, and potentially 12-24 hours) to detect myocardial damage.
- Complete Blood Count (CBC): To assess for anemia or infection.
- Basic Metabolic Panel (BMP): To evaluate renal function, electrolytes, and glucose levels.
- Chest X-ray: To rule out other causes of breathlessness, such as pneumonia or pneumothorax.
- Echocardiogram: Can assess wall motion abnormalities suggestive of ischemia and evaluate overall cardiac function.
Management
Management depends on the diagnosis established by investigations. Assuming ACS is the working diagnosis:
STEMI Management
- Immediate Reperfusion Therapy: The goal is to restore blood flow to the blocked coronary artery as quickly as possible. This can be achieved through:
- Primary Percutaneous Coronary Intervention (PCI): Preferred if available within 90-120 minutes of first medical contact.
- Fibrinolytic Therapy: Considered if PCI is not readily available.
- Adjunctive Therapy: Aspirin, clopidogrel/ticagrelor/prasugrel, anticoagulation (heparin or enoxaparin), and beta-blockers.
NSTEMI/Unstable Angina Management
- Risk Stratification: Using tools like the TIMI risk score or GRACE score to assess the patient’s risk of adverse events.
- Medical Therapy: Aspirin, clopidogrel/ticagrelor/prasugrel, anticoagulation, beta-blockers, ACE inhibitors, and statins.
- Coronary Angiography: Indicated for high-risk patients or those who fail to respond to medical therapy.
Regardless of the specific ACS subtype, continuous cardiac monitoring, oxygen therapy (if oxygen saturation is <90%), and pain management are essential.
Long-Term Management
Following the acute phase, long-term management focuses on secondary prevention of cardiovascular events.
- Lifestyle Modifications: Smoking cessation, weight loss, regular exercise, and a heart-healthy diet.
- Medications: Continued use of aspirin, statins, beta-blockers, ACE inhibitors/ARBs, and potentially other medications based on individual risk factors.
- Cardiac Rehabilitation: A structured program to help patients recover and improve their cardiovascular health.
Conclusion
In conclusion, the patient’s presentation is highly suggestive of an acute coronary syndrome, necessitating immediate investigation and management. A systematic approach involving rapid ECG, cardiac biomarker assessment, and appropriate reperfusion therapy (for STEMI) or medical management (for NSTEMI/Unstable Angina) is crucial. Long-term secondary prevention strategies are essential to reduce the risk of future cardiovascular events. Addressing the patient’s underlying risk factors – smoking, obesity, and diabetes – is paramount for improving long-term outcomes.
Answer Length
This is a comprehensive model answer for learning purposes and may exceed the word limit. In the exam, always adhere to the prescribed word count.