Homework 1: How to investigate coronary ischaemia?

Coronary ischaemia is the most common manifestation of coronary heart disease (CHD).

There are a few investigations which are most available and frequently used tests to identify coronary ischemia in clinical practice.

Exercise testing — Exercise testing appears to be the most suitable laboratory diagnostic test to document coronary ischemia in asymptomatic individuals (eg, patients with no history of CHD) and in those with a history of CHD or exertional angina. Exercise testing is frequently used to screen high risk, asymptomatic persons to identify those with asymptomatic CHD. Conventional ST segment analysis during ETT is moderately sensitive in detecting CHD. As a result, the diagnosis of myocardial ischemia by ETT in asymptomatic individuals must be confirmed by radionuclide imaging techniques (eg, thallium perfusion scintigraphy or exercise ventriculography) before the subject is labeled as having coronary ischemia.

Holter monitoring — Holter monitoring is the second most frequently used diagnostic test for coronary ischemia. It has the advantage of providing long-term ECG recording of ischemic and arrhythmic events while patients are engaged in routine daily activities out of the hospital. Episodes of transient ischemia during Holter monitoring are diagnosed by a sequence of ECG changes that include a flat or downsloping ST depression of at least 1 mm, with a gradual onset and offset that lasts for at least one minute.

Nuclear and echocardiographic imaging studies — Tests other than routine ETT and ambulatory monitoring may be necessary in certain circumstances. As an example, nuclear imaging tests such as stress thallium scintigraphy or exercise radionuclide ventriculography are recommended for the evaluation of coronary ischemia in patients who have an abnormal baseline ECG (eg, left ventricular hypertrophy or strain, bundle branch block, preexcitation syndrome), and those receiving digitalis, phenothiazines, or other drugs that produce repolarization changes. Pharmacologic stress tests with dipyridamole or adenosine plus thallium scintigraphy, or dobutamine stress echocardiography, can be utilized in those patients who are unable to ambulate or exercise (eg, due to advanced peripheral vascular disease)

Electron beam computed tomography — The severity of coronary artery calcification (CAC) on electron beam computed tomography (EBCT), as determined by a calcium score, can identify asymptomatic patients at high risk for coronary heart disease. However, it is not certain if this translates into identification of asymptomatic patients who have coronary ischemia.

In summary, these are the tests one can do to investigate coronary ischaemia:
Exercise treadmill test
Continuous ECG (Holter) monitoring
Exercise myocardial perfusion scintigraphy
Radionuclide angiocardiography
Pharmacologic stress scintigraphy
Hemodynamic monitoring

My 3 months holidays

On the 2nd of December, I finished my EOS 5. My shoulders suddenly felt very light. The first week after my EOS 5, I was busy finding a house to stay in Seremban. I finally found one in Seremban 3 and I will be staying with my other 3 friends. The house is rm800 per month but it is unfurnished. Anyway, after settling the accomodation, I was busy packing and moving all my things to the new house. Man, moving house is definitely very tiring.

I took a short break with my family and relatives after that. It was a great reunion indeed. =)

After the short break, I have been slacking around in Kuching till today. Haha Well, at least I go for hospital attachment at SIMC and I get to learn new things every morning. I can say that is the most beneficial thing I have done so far during my holidays. In the afternoon, I will be baking cookies and cakes with my cousin and his wife while being a babysitter as well. Haha

I watched movies in the cinema very frequent till there is no more movie for me to watch right now and I have to wait for new movies to be out.

Anyway, that is just a bit of update since I have not blogged for a long time. =)

Short case: Heart murmurs

Throughout my attachment in SIMC, I have learned how to present a short case on heart murmurs. When patient comes to you, first, identify the age. If patient is old, it is more likely to be aortic stenosis. If patient is young, it can be mitral regurgitation, aortic regurgitation, mitral stenosis or congenital defects such as ventricular septal defect, atrial septal defect and patent ductus arteriosus. Second, check for clubbing and scars. If none is present, congenital defects are unlikely to occur. Next, palpate or auscultate for the apex beat. If it is displaced, it is either mitral regurgitation or aortic regurgitation and hence, mitral stenosis can be ruled out. Now, one is left with either mitral regurgitation or aortic regurgitation. Auscultate the back for murmur. If a systolic murmur is heard from the back, it is mitral regurgitation since that is the only murmur which can be heard from the back.

Till we meet again

Time flies! It is time to start blogging again! I was so busy throughout this whole semester that I did not even have the time to blog. My final semester before going to clinical years was a really stressful semester. I had to memorise all the systems with only 2 weeks of study break. It was crazy! I am glad I passed and it is over now. Thanks to my helpful friends, lecturers and not to forget, my mentor from Kuching. =D I will miss my friends who will be going to overseas instead of Seremban to do their clinical years especially Sin Dee and Hui Hwen. Not to forget Jonathan as well who was so willing to be my patient for me to practise my clinical skills.









I love you all! Happy Holidays!