The onset of the consultation

1. Wash hands and put on PPE if necessary.
2. Introduce yourself to the patient by stating your name and role.
3. Confirm the patient’s last name, first name, and date of birth.
4. Explain what the examination will involve using language the patient can understand.
5. Get consent for consultation.
6. Adequately expose the patient for examination.
7. Ask the patient if he is in pain before proceeding with the clinical examination.

Clarification of the main complaint

8. Use open-ended questions to explore the patient’s complaints
9. Details of the main complaint
10. Analyze the patient’s thoughts, fears, and expectations
11. Summarize the patient’s complaints

Comprehensive assessment

12. Assess other symptoms to get a comprehensive picture

Medical history

13. Find out when and how the chest pain first appeared; what, according to the patient, could have caused its appearance (pay special attention to psychological or physical stress); specify whether the patient sought medical help, if so, to whom and what was the end of his appeal, if not, then specify why the patient did not seek medical help; whether he took medical drugs on his own or as prescribed by a doctor, if so, whether the nature of complaints changed against the background of treatment 
14. In the case of hospitalization for chest pain, read the extract from the patient’s medical history, pay attention to the established clinical diagnosis, the results of laboratory or instrumental examinations, the treatment and recommendations after discharge

15. If the patient has previously undergone laboratory or instrumental examinations for current complaints, analyze their results and indicate important findings
16. Find out what prompted the patient to contact you
17. Exclude other causes of chest pain by asking the patient clarifying questions

History of life

18. The accuracy of the presence of previously diagnosed cardiovascular diseases in the patient, in particular myocardial infarction, stroke, rhythm disorders, cardiomyopathy, angina pectoris, arterial hypertension
19. Find out whether the patient suffers from mental health disorders, such as depression, anxiety, or schizophrenia, which are risk factors for the development of Takotsubo syndrome
20. Determine whether the patient has chronic diseases, in particular diabetes, bronchial asthma, and chronic obstructive pulmonary disease, which are risk factors for the development of Takotsubo syndrome
21. Determine whether the patient is taking medications that stimulate the sympathetic nervous system (eg, beta 2-adrenergic receptor agonists, alpha 1-adrenergic receptor agonists, serotonin and norepinephrine reuptake inhibitors, epinephrine)
22. Determine whether the patient is abusing psychotropic substances (eg, cannabis, cannabinoids)
23. Find out whether the menstrual function is preserved; if not, find out the time of menopause and whether the patient is taking hormone replacement therapy
24. Check whether the patient has undergone surgery
25. Find out if the patient had any injuries, find out how the recovery period went
26. Find out whether the patient has a drug intolerance and specify how it manifests itself
27. Find out whether the patient has bad habits – drinking alcohol, narcotic substances, smoking
28. Find out the family status of the patient, living conditions, and psychological problems in the family; find out if there were any blood relatives of the patient with cardiovascular diseases
29. Find out whether the patient works, his profession, conditions, and nature of work, and whether the work is related to physical or psychological overload

Objective examination:

30. Assessment of the patient’s general condition (satisfactory, moderate, severe, very severe).
31. General examination of the patient:

• Consciousness, the position of the patient, gait, and posture.
• Physique, type of constitution, height, weight, body mass index.
• Skin and visible mucous membranes (color, rash, scars, scratches), elasticity and moisture of the skin, condition of skin derivatives, and development of subcutaneous adipose tissue.
• Pastiness, edema.
• Lymph nodes.
• Muscular system: development of muscles, their tone, presence of atrophy, soreness.
• Joints: examination, palpation, measurement of limbs and joints, determination of the degree of joint mobility.
• Examination of the head, face, and neck with an assessment of the state of the thyroid gland.

32. Research of organ systems

• Research of respiratory organs
• Research of circulatory organs.
• Research of digestive organs.
• Examination of the urinary system

33. Assessment of the probability of Takotsubo syndrome

Laboratory tests

34. Clinical blood count with leukocyte formula and calculation of ESR (erythrocyte sedimentation rate)
35. Biochemical blood analysis (total protein, creatinine, urea, alanine aminotransferase, aspartate aminotransferase, glucose, alkaline phosphatase, uric acid, bilirubin with fractions)
36. Blood electrolytes (K+ and Na+)
37. Lipid profile
38. Coagulogram
39. Blood test for troponin I / T
40. Blood test for creatine phosphokinase (CK)
41. Blood analysis for brain natriuretic peptide ( BNP ) or the N-terminal precursor of brain natriuretic peptide ( NT – pro-BNP )
42. Assessment of thyroid gland function (thyroid-stimulating hormone-TSH) (according to indications)
43. Urine analysis with sediment microscopy (as indicated)
44. Pregnancy test for patients of childbearing age (according to indications)

Instrumental diagnostic tests

45. Electrocardiography
46. Transthoracic echocardiography
47. Coronarography
48. Ventriculography
49. MRI of the heart
50. CT angiography of coronary arteries

Making a clinical diagnosis

51. Carrying out differential diagnosis
52. Assessment of diagnostic criteria
53. Determination of the anatomical variant
54. Definition of complications
55. Making of clinical diagnosis

Specialist consultations

56. Cardiologist
57. Interventional cardiologist
58. Radiologist
59. Psychotherapist
60. Psychiatrist
61. Endocrinologist
62. Narcologist
63. Gynecologist
64. Doctor of physical and rehabilitation medicine

Purpose of treatment

65. Supportive therapy
66. Treatment of complications
67. Prevention of relapse

Consulting and support

68. Informing the patient about the disease
69. Discussion of research results with the patient
70. Explanation to the patient of the possible cause of the disease
71. Explanation to the patient of possible symptoms that may occur during the disease
72. Explanation to the patient of the possible consequences of the disease
73. Explaining the available treatment methods, informing the patient about the risks and benefits of different treatment methods
74. Answers to the patient’s questions
75. Explanation of the scope of monitoring during and after treatment
76. Appointment of regular checks and controls to assess the effectiveness of treatment and changes in the patient’s condition

End of consultation

77. Summarize the data and ask the patient if anything important has been missed
78. Inform the patient about further tactics
79. Thank the patient
80. Dispose of PPE properly and wash hands

Key communication skills

• Active listening
• Summing up
• Selection of indicative signs

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The onset of the consultation

1. Wash hands and put on PPE if necessary.
2. Introduce yourself to the patient by stating your name and role.
3. Confirm the patient’s last name, first name, and date of birth.
4. Explain what the examination will involve using language the patient can understand.
5. Get consent for consultation.
6. Adequately expose the patient for examination.
7. Ask the patient if he is in pain before proceeding with the clinical examination.

Examination for Takotsubo syndrome is conducted when characteristic clinical symptoms and objective signs of this condition are present.

Typical clinical symptoms of Takotsubo syndrome include:

1. Symptoms of myocardial ischemia (chest pain)
2. Symptoms of heart failure (shortness of breath, sensation of air hunger)
3. Symptoms of cerebral hypoperfusion (dizziness, loss of consciousness)

Clarification of the main complaint

8. Use open-ended questions to explore the patient’s complaints
9. Details of the main complaint
10. Analyze the patient’s thoughts, fears, and expectations
11. Summarize the patient’s complaints

• Use open-ended questions to explore the patient’s complaints
• Details of the main complaint

The most common complaint of a patient with Takotsubo syndrome is chest pain. To detail this complaint, follow this algorithm:

• Localization: find out where it hurts
• Onset: find out how the pain started – suddenly or gradually
• Nature: Ask the patient to describe how he/she feels the pain.
• Irradiation: Find out if the pain is spreading
• Accompanying symptoms: find out if there are other symptoms that accompany the pain
• Dynamics over time: Determine whether the pain has changed over time
• Factors that make the pain worse or worse: Find out if there is anything that makes the pain worse or worse

“Can you show me precisely where it hurts?”

“Could you describe this pain?”

Is this pain constant or intermittent?

“How long does the pain typically last?“

“Does the pain radiate to other areas?“

“What typically triggers the onset of this pain?“

“What measures provide relief from this pain?“

“Are there any other symptoms accompanying the pain?”

To detail the complaint of chest pain, we recommend using the SOCRATES questionnaire. An example survey is given below.

Some elements of the SOCRATES acronym can be used to detail a complaint of shortness of breath.

Analyze the patient’s thoughts, fears, and expectations

A key component of history taking involves exploring the patient’s thoughts, concerns, and expectations to gain insight into how they currently perceive their condition, their worries, and what they anticipate from the consultation.

The exploration of thoughts, concerns, and expectations should be flexible throughout the consultation, responding to cues from the patient. This approach ensures that your consultation remains patient-oriented rather than formulaic.

It’s important to structure the analysis of thoughts, fears, and expectations in a way that feels natural during your consultation.

Summarize the patient’s complaints

Summarize what the patient told you about his complaint. This allows you to check how correctly you understood the patient’s complaints and gives the patient the opportunity to correct any inaccurate information.

When you have concluded, ask the patient if there is anything else you missed. Periodically, as the consultation progresses, summarize intermediate results.

Comprehensive assessment

12. Screen for symptoms of damage to other organs and systems

A comprehensive assessment includes a brief survey of the patient for symptoms of other systems that may or may not be related to the chief complaint. This comprehensive examination also helps identify symptoms that the patient may have forgotten to mention.

Deciding which symptoms to inquire about depends on the presenting complaint and your level of experience.

Here are some examples of symptoms that you might inquire about for each system:

Medical history

13. Find out when and how the chest pain first appeared; what, according to the patient, can cause its appearance (pay special attention to psychological or physical stress experienced); specify whether the patient sought medical help, if so, to whom and what was the end of his application, if not, then specify why he did not seek help; whether he took medical drugs on his own or as prescribed by a doctor, if so, whether the nature of the complaints changed against the background of treatment 

“When did the chest pain start for you?”

“What do you think might have caused it to start?”

“Did you seek medical assistance?”

14. In the case of hospitalization for chest pain, read the extract from the patient’s medical history, pay attention to the established clinical diagnosis, the results of laboratory or instrumental examinations, the treatment and recommendations after discharge

15. If the patient has previously undergone laboratory or instrumental examinations for current complaints, analyze their results and indicate important findings
16. Find out what prompted the patient to contact you

“What made you decide to reach out to me?”

17. Exclude other causes of existing symptoms by asking the patient clarifying questions

“Did you have a fever?”

“Is the chest pain accompanied by nausea or the urge to vomit?”

Other causes of chest pain:

• Acute coronary syndrome (ACS)

Acute coronary syndrome is characterized by complaints of intense chest pain radiating to the left arm, left shoulder, left scapula, neck, and epigastrium, lasting more than 20 minutes, not relieved by taking nitrates, and often accompanied by shortness of breath, a feeling of fear, and increased sweating. The pain syndrome in ACS is very similar to the pain syndrome in Takotsubo syndrome, which creates significant difficulties for differential diagnosis.

• Acute myocarditis

Clinical symptoms such as chest pain, shortness of breath, and palpitations are characteristic of both Takotsubo syndrome and myocarditis. The pain syndrome in myocarditis is very similar to the pain syndrome in Takotsubo syndrome, which makes it challenging to differentiate these two conditions based solely on this criterion. However, it should be noted that myocarditis is characterized by the presence of a recently acquired infectious disease, which is not typically associated with Takotsubo syndrome. Conversely, in Takotsubo syndrome, the onset of pain is often preceded by psychological or physical stress.

• Angina

Angina is characterized by chest pain radiating to the left arm, left shoulder, left shoulder blade, neck, and epigastrium. However, in angina, the pain typically lasts up to 20 minutes and subsides with rest or after taking nitrates. In contrast, in Takotsubo syndrome, the pain persists for a longer duration and is not relieved by nitrates.

• Thromboembolism of the pulmonary artery

For thromboembolism of the pulmonary artery and Takotsubo syndrome, chest pain often accompanied by shortness of breath and a sensation of breathlessness is characteristic. The nature of the pain in both conditions is anginal, posing a challenge for differential diagnosis. Considering that the primary cause of pulmonary embolism (PE) is typically deep vein thrombosis in the lower extremities, it’s essential to consider typical symptoms such as unilateral pain and swelling of the affected lower limb, along with an increase in its size.

• Dissecting aneurysm of the aorta

Patients with a dissecting aortic aneurysm typically present with sudden, excruciating, tearing chest pain that radiates to the neck, back, and lower limbs, often in a migratory pattern. While the pain in Takotsubo syndrome can also be intense, it is typically not as severe as in a dissecting aortic aneurysm.

• Acute pericarditis

The clinical presentation of acute pericarditis shares many similarities with that of Takotsubo syndrome, as both conditions typically involve chest pain and shortness of breath. However, acute pericarditis is distinguished by chest pain that worsens when lying down and improves when sitting, a characteristic not seen in Takotsubo syndrome. Additionally, acute pericarditis often occurs as a complication of an infectious disease, leading to symptoms such as fever and other signs of inflammation.

• Gastroesophageal reflux

Pain associated with gastroesophageal reflux typically develops gradually and is characterized by a burning sensation localized in the central part of the chest. This discomfort is often accompanied by symptoms such as heartburn, nausea, and a sour taste in the mouth, all of which typically alleviate after taking antacids. Unlike Takotsubo syndrome, dyspeptic symptoms are not a hallmark feature of gastroesophageal reflux.

• Gastric ulcer disease

In peptic ulcer disease, pain is frequently localized behind the sternum or in the epigastrium, typically occurring approximately 40 minutes after eating. This discomfort tends to diminish or disappear following the administration of antacids and is often accompanied by symptoms such as nausea and a sour taste in the mouth. Such a pain pattern is not characteristic of Takotsubo syndrome.

• Diseases of the biliary tract

These conditions are typified by the emergence of dull pain behind the sternum or in the epigastrium, typically occurring approximately 1 hour after consuming food, particularly fatty or fried fare. This discomfort is often coupled with nausea, the urge to vomit, and a bitter taste in the mouth. Conversely, chest pain in Takotsubo syndrome is not influenced by dietary intake, and dyspeptic symptoms are generally absent.

• Spontaneous pneumothorax

In spontaneous pneumothorax, intense chest pain abruptly arises, exacerbating with deep breathing, and is accompanied by pronounced shortness of breath. The aggravation of chest pain during inhalation is not a characteristic feature of Takotsubo syndrome.

• Diseases of the neuromuscular system and musculoskeletal system

Chest pain resulting from neuromuscular and musculoskeletal system disorders typically worsens with significant body movements such as turning, bending, or raising the arm, a feature not commonly associated with Takotsubo syndrome.

• Pain in herpes zoster

The pain in herpes zoster typically manifests as a constant burning sensation, often preceding the appearance of a characteristic vesicular rash. It may persist for some time after the rash disappears and is localized along the affected nerve pathway.

Learn more about the specific details of detailing chest pain as the main complaint and taking a patient’s medical history regarding chest pain by visiting the following link:

Other causes of shortness of breath:

• Bronchial asthma

Shortness of breath in bronchial asthma typically manifests as attack-like episodes with an expiratory character. It is often accompanied by wheezing, a sensation of chest tightness, and coughing, often resulting in the discharge of a small amount of glassy viscous sputum. These episodes tend to occur in the early morning hours and are typically relieved by the inhalation of a short-acting β2-agonist.

• Chronic obstructive pulmonary disease

Shortness of breath in chronic obstructive pulmonary disease (COPD) typically has a constant and progressive nature. It is often accompanied by a cough productive of mucus or sputum, particularly in the morning upon waking up.

• Pneumonia

Shortness of breath in pneumonia is often accompanied by an elevated body temperature, symptoms of intoxication, cough with productive sputum, and sometimes chest pain.

• Lung tumor

Shortness of breath associated with lung tumors typically exhibits a constant and progressive nature, often accompanied by hemoptysis, chest pain, coughing, and symptoms of tumor intoxication such as fatigue, weakness, weight loss, and loss of appetite.

• Thromboembolism of the pulmonary artery

Shortness of breath associated with pulmonary embolism typically arises suddenly, often without a known cause. It can be so severe that it impedes the patient’s ability to speak. Additionally, it is accompanied by chest pain of a coronary or pleural nature, hemoptysis, dizziness, or even loss of consciousness. Symptoms of deep vein thrombosis of the lower extremities may also be present.

• Arrhythmia

Tachyarrhythmias, particularly atrial fibrillation, frequently manifest with shortness of breath, palpitations, heart irregularities, and other symptoms indicative of hemodynamic impairment, such as sweating, dizziness, and possibly loss of consciousness. Because rhythm disturbances are typically paroxysmal, shortness of breath also tends to occur in episodes.

• Anemia

Severe anemia often presents with shortness of breath exacerbated by minimal physical exertion, accompanied by rapid heartbeat, angina pectoris-like pains, dizziness, pronounced weakness, and increased fatigue.

• Adiposity

Excess weight often leads to shortness of breath due to increased strain on the cardiovascular system, typically manifesting during physical exertion. In cases of significant excess weight, shortness of breath may even occur at rest.

• Panic attack

Shortness of breath is just one of the symptoms experienced during a panic attack. It typically occurs suddenly and is often accompanied by feelings of fear, anxiety, nausea, palpitations, dry mouth, sweating, and dizziness, which can be unexpected and uncontrollable.

• Hyperventilation

Shortness of breath is the primary symptom of hyperventilation syndrome. Patients commonly describe it as a sudden sensation of breathing dissatisfaction and a feeling of air deprivation. Due to the underlying cause of hyperventilation syndrome, shortness of breath is often accompanied by feelings of anxiety, panic, numbness, and tingling.

• Gastroesophageal reflux disease

Shortness of breath is a relatively rare symptom of gastroesophageal reflux disease and arises due to the prolonged exposure of acidic stomach contents to the respiratory tract, typically after eating, while lying down, or when bending forward. Suspect gastroesophageal reflux disease when more specific symptoms are present, such as heartburn, belching, and discomfort when swallowing food.

History of life

18. The accuracy of the presence of previously diagnosed cardiovascular diseases in the patient, in particular myocardial infarction, stroke, rhythm disorders, cardiomyopathy, angina pectoris, arterial hypertension
19. Find out whether the patient suffers from mental health disorders, such as depression, anxiety, or schizophrenia, which are risk factors for the development of Takotsubo syndrome
20. Determine whether the patient has chronic diseases, in particular diabetes, bronchial asthma, and chronic obstructive pulmonary disease, which are risk factors for the development of Takotsubo syndrome
21. Determine whether the patient is taking medications that stimulate the sympathetic nervous system (eg, beta 2-adrenergic receptor agonists, alpha 1-adrenergic receptor agonists, serotonin and norepinephrine reuptake inhibitors, epinephrine)
22. Determine whether the patient is abusing psychotropic substances (eg, cannabis, cannabinoids)
23. Find out whether the menstrual function is preserved; if not, find out the time of menopause and whether the patient is taking hormone replacement therapy
24. Check whether the patient has undergone surgery
25. Find out if the patient had any injuries, find out how the recovery period went
26. Find out whether the patient has a drug intolerance and specify how it manifests itself
27. Find out whether the patient has bad habits – drinking alcohol, narcotic substances, smoking
28. Find out the family status of the patient, living conditions, and psychological problems in the family; find out if there were any blood relatives of the patient with cardiovascular diseases
29. Find out whether the patient works, his profession, conditions, and nature of work, and whether the work is related to physical or psychological overload

Objective examination:

30. Assessment of the patient’s general condition (satisfactory, moderate, severe, very severe).
31. General examination of the patient:

• Consciousness, the position of the patient, gait, and posture.
• Physique, type of constitution, height, weight, body mass index.
• Skin and visible mucous membranes (color, rash, scars, scratches), elasticity and moisture of the skin, condition of skin derivatives, and development of subcutaneous adipose tissue.
• Pastiness, edema.
• Lymph nodes.
• Muscular system: development of muscles, their tone, presence of atrophy, soreness.
• Joints: examination, palpation, measurement of limbs and joints, determination of the degree of joint mobility.
• Examination of the head, face, and neck with an assessment of the state of the thyroid gland.

32. Research of organ systems

• Research of respiratory organs
• Organs of blood circulation.
• Research of digestive organs.
• Examination of the urinary system.

Assess for objects or equipment on or around the patient that may provide useful information about the patient’s medical history and current clinical condition.

It should be noted that physical findings depend on the severity of Takotsubo syndrome.

In patients with a severe course of Takotsubo syndrome, signs of heart failure can be detected, including wet wheezing in the lungs and tachypnea. During auscultation of the heart, tachycardia, an additional pathological third heart sound, as well as a systolic murmur over the apex of the heart due to obstruction of the outflow tract of the left ventricle and mitral regurgitation are often detected. Additionally, patients with Takotsubo syndrome often exhibit a decrease in blood pressure and low pulse pressure.

In patients with a mild course of Takotsubo syndrome, physical findings are typically unchanged.

Assessment of the probability of Takotsubo syndrome

33. Assessment of the probability of Takotsubo syndrome

The probability of Takotsubo syndrome is assessed in patients presenting with chest pain and/or shortness of breath in the absence of ST-segment elevation on the ECG, particularly those hospitalized in intensive care units.

The InterTAK (The International Takotsubo Diagnostic Criteria) diagnostic scale is utilized to assess the likelihood of Takotsubo syndrome. A score of >70 points on this scale indicates a high probability (approximately 90%) of Takotsubo syndrome, whereas a sum of points ≤70 points suggests a low or moderate probability.

With a high probability of Takotsubo syndrome, urgent transthoracic echocardiography is recommended. For cases with a low or moderate probability of Takotsubo syndrome, coronary angiography is recommended. This procedure allows for definitive differentiation between Takotsubo syndrome and acute myocardial infarction.

Laboratory tests

34. Clinical blood count with leukocyte formula and calculation of ESR (erythrocyte sedimentation rate)
35. Biochemical blood analysis (total protein, creatinine, urea, alanine aminotransferase, aspartate aminotransferase, glucose, alkaline phosphatase, uric acid, bilirubin with fractions)
36. Blood electrolytes (K+ and Na+)
37. Lipid profile
38. Coagulogram
39. Blood test for troponin I / T
40. Blood test for creatine phosphokinase (CK)
41. Blood analysis for brain natriuretic peptide ( BNP ) or the N-terminal precursor of brain natriuretic peptide (NT – pro-BNP )
42. Assessment of thyroid gland function (thyroid-stimulating hormone-TSH) (according to indications)
43. Urine analysis with sediment microscopy (as indicated)
44. Pregnancy test if the patient is of childbearing age (as indicated)

• Clinical blood count with leukocyte formula and calculation of ESR (erythrocyte sedimentation rate)

Clinical blood count, including the leukocyte count and calculation of the erythrocyte sedimentation rate (ESR), is one of the mandatory laboratory tests conducted in routine clinical practice for somatic patients.

• Biochemical blood analysis (total protein, creatinine, urea, alanine aminotransferase, aspartate aminotransferase, glucose, alkaline phosphatase, uric acid, total bilirubin with its fractions)

The biochemical analysis of blood, which includes measurements of total protein, creatinine, urea, alanine aminotransferase (ALT), aspartate aminotransferase (AST), glucose, alkaline phosphatase, uric acid, and total bilirubin with its fractions, is one of the mandatory laboratory examination methods performed in routine clinical practice for somatic patients.

• Blood electrolytes (K+ and Na+)

Blood analysis for electrolytes (potassium and sodium) is a mandatory laboratory method of examination carried out in routine clinical practice for patients with cardiovascular diseases to diagnose electrolyte disorders.

• Lipid profile

Lipid profile is a mandatory laboratory test for adult patients with cardiovascular diseases to diagnose lipid metabolism disorders.

• Coagulogram

Coagulation profile is a mandatory laboratory test for adult patients with cardiovascular diseases to diagnose disorders of the blood coagulation system.

• Blood test for troponin I / T

“Takotsubo syndrome” is a condition characterized by transient myocardial dysfunction, often triggered by emotional or physical stressors. While troponin levels can be elevated in Takotsubo syndrome, the degree of elevation is typically modest compared to that seen in acute myocardial infarction. It’s important to note that the elevation in troponin levels observed in Takotsubo syndrome is often disproportionate to the extent of regional myocardial dysfunction detected on imaging studies such as echocardiography.

• Blood test for creatine phosphokinase (CK)

Creatine phosphokinase (CK) is indeed an early marker of myocardial necrosis. In Takotsubo syndrome, its levels may show a moderate elevation, typically disproportionate to the extent of regional myocardial dysfunction detected on echocardiography.

• Blood analysis for brain natriuretic peptide ( BNP ) or the N-terminal precursor of brain natriuretic peptide (NT–proBNP )

B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are indeed markers of heart failure. In Takotsubo syndrome, their levels are often significantly elevated due to the overstretching of cardiomyocytes caused by the condition’s hemodynamic stress.

Appointment of instrumental methods of examination

45. Electrocardiography
46. Transthoracic echocardiography
47. Coronarography
48. Ventriculography
49. MRI of the heart
50. CT angiography of coronary arteries

• Electrocardiography

Electrocardiography (ECG) is a mandatory method of examination of patients with suspected Takotsubo syndrome. The most characteristic ECG signs include elevation of the ST segment in the precordial leads, elevation of the ST segment in the AVR lead, diffuse inversion of the T wave, prolongation of the QT interval, rarely depression of the ST segment.

Some experts note that the elevation of the ST segment in the dept. V1-V3 in combination with elevation of the ST segment in the dept. AVR is a characteristic feature of Takotsubo syndrome.

• Transthoracic echocardiography

Transthoracic echocardiography is a mandatory method of examination of patients with suspected Takotsubo syndrome. Moreover, it is diagnostically significant in patients with a high probability of Takotsubo syndrome according to the InterTAK scale.

Echocardiographic signs of Takotsubo syndrome include a decrease in the ejection fraction of the left ventricle, akinesis of the apical segments of the myocardium of the left ventricle in combination with hyperkinesis of the basal part, apical dilatation of the myocardium of the left ventricle, sometimes obstruction of the outflow tract of the left ventricle.

It should be noted that these signs are transitory in nature.

• Coronarography

Coronary angiography indeed serves as a vital diagnostic tool to distinguish Takotsubo syndrome from acute myocardial infarction, particularly in patients with a low or moderate probability of Takotsubo syndrome according to the InterTAK scale.

In individuals with Takotsubo syndrome, coronary angiography typically reveals either normal coronary arteries or coronary arteries with non-obstructive stenosis (defined as stenosis <50%). This absence of significant coronary artery disease further supports the diagnosis of Takotsubo syndrome, helping to differentiate it from acute myocardial infarction.

• Ventriculography

Ventriculography provides an assessment of the morphology and function of the left ventricle. In patients with Takotsubo syndrome, transient dysfunction and dilatation of the mid and apical segments of the left ventricle occur, resulting in a heart shape resembling that of an octopus.

• MRI of the heart

MRI of the heart is an informative examination method that allows differentiation between Takotsubo syndrome and myocarditis. Characteristic MRI signs of Takotsubo syndrome include transmural edema in regions with reduced local myocardial contractility and myocardial scarring, while the basal parts of the left ventricle remain normal.

• CT angiography of coronary arteries

CT angiography of the coronary arteries is an alternative examination method for stable patients contraindicated for cardiac MRI. It is performed to rule out significant coronary stenosis.

• Assessment of thyroid gland function (thyroid-stimulating hormone-TSH) (according to indications)

A blood test for thyroid-stimulating hormone is conducted when there is suspicion of thyroid dysfunction, which can contribute to mental health disorders and potentially act as a trigger for the development of Takotsubo syndrome.

• General urine analysis with sediment microscopy (as indicated)

A complete urine analysis with sediment microscopy is conducted when there is suspicion of kidney and/or urinary system damage.

• Pregnancy test if the patient is of childbearing age (as indicated)

It is advisable to conduct a pregnancy test for female patients of childbearing age with Takotsubo syndrome. This helps in selecting appropriate drug therapy tactics, considering that some medications used to treat Takotsubo syndrome are contraindicated during pregnancy due to their teratogenic effects.

Making a clinical diagnosis

51. Carrying out differential diagnosis

In clinical practice, it is often necessary to differentiate Takotsubo syndrome from acute coronary syndrome (ACS), acute myocarditis, as well as diseases accompanied by chest pain, in particular, angina pectoris, pulmonary embolism, dissecting aortic aneurysm, acute pericarditis, and others.

Clinical symptoms, objective data, ECG signs of Takotsubo syndrome, and acute coronary syndrome have a lot in common, which causes certain difficulties for differential diagnosis.

Both Takotsubo syndrome and acute coronary syndrome are characterized by complaints of intense radiating chest pain lasting more than 20 minutes and often accompanied by shortness of breath.

Levels of markers of myocardial necrosis, in particular troponin I/T and CK, are increased in both cases, but in Takotsubo syndrome this increase is insignificant compared to patients with acute myocardial infarction.

On the ECG of a patient with Takotsubo syndrome and a patient with ACS, ST-segment elevation and T-wave inversion can often be detected.

Echocardiography of a patient with Takotsubo syndrome and a patient with ACS revealed a decrease in the ejection fraction of the left ventricle and a local violation of myocardial contractility. However, patients with Takotsubo syndrome are characterized by akinesis of the apical segments of the myocardium of the left ventricle in combination with hyperkinesis of the basal part, which leads to apical ballooning of the left ventricle. In addition, these changes are transient and disappear within 3 weeks.

Coronary angiography definitively distinguishes Takotsubo syndrome from acute coronary syndrome. In Takotsubo syndrome, coronary arteries typically appear normal, without evidence of stenosis or hemodynamically insignificant stenosis (<50%). In contrast, acute coronary syndrome is characterized by acute occlusion of the arterial lumen.

Takotsubo syndrome develops in 90% of cases in women over the age of 50, whereas acute myocarditis most often affects young people without gender dominance.

Takotsubo syndrome in most cases is preceded by severe stress, while myocarditis is an infectious disease.

Clinical symptoms such as chest pain, shortness of breath, and palpitations are characteristic of both Takotsubo syndrome and myocarditis.

Blood troponin levels are elevated in both Takotsubo syndrome and myocarditis. However, in Takotsubo syndrome, this increase is insignificant and disproportionate to the area of ​​the affected myocardium, while in myocarditis, troponin is usually significantly increased and correlates with the area of ​​myocardial damage.

The level of brain natriuretic peptide is often elevated in Takotsubo syndrome and is usually elevated in myocarditis.

On the ECG of a patient with cardiomyopathy and myocarditis, changes in the ST segment and inversion of the T wave can often be detected. Unlike Takotsubo syndrome, myocarditis is also characterized by conduction disturbances and arrhythmias.

Echocardiography is important for differential diagnosis. Thus, in Takotsubo syndrome, swelling of the apical segments of the myocardium with intact basal sections is determined, which is not characteristic of myocarditis.

Myocardial edema can often be detected on MRI of the heart in Takotsubo syndrome and myocarditis. However, in the acute stage of Takotsubo syndrome, unlike myocarditis, there is no late accumulation of gadolinium.

Both angina and Takotsubo syndrome are characterized by radiating chest pain. However, in angina, the pain typically lasts up to 20 minutes and subsides with rest or after taking nitrates, whereas in Takotsubo syndrome, the pain persists longer and is not alleviated by nitrates.

The ECG of a patient with angina is usually normal or shows ST-segment depression, whereas patients with Takotsubo syndrome often show ST-segment elevation and T-wave inversion.

In patients with angina pectoris, the levels of markers of myocardial necrosis are normal, while in patients with Takotsubo syndrome, they are elevated.

A coronary angiography of a patient with angina usually shows significant stenosis of the coronary arteries, whereas in Takotsubo syndrome the coronary arteries are either intact or with insignificant stenosis.

Chest pain and shortness of breath are characteristic symptoms of both pulmonary embolism and Takotsubo syndrome. The chest pain in both conditions is anginal in nature.

Blood troponin levels may be mildly elevated in both pulmonary embolism and Takotsubo syndrome.

ECG in patients with pulmonary embolism and Takotsubo syndrome often shows sinus tachycardia, T-wave inversion. Pulmonary embolism is characterized by the classic S _I Q _III T _III   pattern, while Takotsubo syndrome is characterized by ST-segment elevation in the precordial leads.

Echocardiography is essential for differential diagnosis. In Takotsubo syndrome, ballooning of the apical segments of the myocardium of the left ventricle with intact basal sections is observed, while in pulmonary artery thromboembolism, akinesia or hypokinesia of the free wall of the right ventricle with preserved contractility of the apex of the right ventricle (McConnell’s sign), 60/60 sign, dilatation and dysfunction of the right ventricle, and acute tricuspid regurgitation may occur.

Patients with a dissecting aortic aneurysm typically describe sudden, excruciating, tearing pain in the chest, which often radiates to the neck, back, and lower limbs and may be migratory. Although the pain in Takotsubo syndrome is intense, it typically does not reach the same level. Physical examination of a patient with a dissecting aortic aneurysm may reveal asymmetry of the pulse and blood pressure in the extremities compared to the other side. In cases where the aortic valve is involved, a diastolic murmur over the aorta and a high pulse pressure may be detected.

On the ECG of a patient with a dissecting aortic aneurysm, as in a patient with Takotsubo syndrome, ST- segment elevation can often be detected, however, in Takotsubo syndrome, ST-segment elevation is visualized in the precordial leads, while in aortic dissection involving the right coronary artery – in leads II, III, AVF.

Echocardiography and chest X-ray have important diagnostic value. On echocardiography and chest X-ray, in the case of aortic arch dissection, dilatation of the affected part of the aorta is revealed, which is not the case with Takotsubo syndrome.

Acute pericarditis is characterized by chest pain that intensifies when lying down and diminishes when sitting up, a feature not typically observed in Takotsubo syndrome. Additionally, patients with acute pericarditis often present with a history or ongoing symptoms of an infectious disease, including fever, respiratory symptoms, and others, which are not commonly associated with Takotsubo syndrome.

Clinical blood analysis of a patient with acute pericarditis reveals signs of an inflammatory process, which is not the case with Takotsubo syndrome.

On the ECG of a patient with acute effusion pericarditis, as in a patient with Takotsubo syndrome, ST -segment elevation, and T-wave inversion can often be detected, however, in Takotsubo syndrome, these changes are visualized in the precordial leads, while in acute pericarditis, ST-segment elevation is diffuse.

Echocardiography is important for differential diagnosis. Thus, in Takotsubo syndrome, ballooning of the apical segments of the myocardium of the left ventricle with intact basal sections is determined, while in pericarditis – thickening and compaction of the pericardial leaves, free fluid in the pericardium, signs of diastolic dysfunction.

52. Assessment of diagnostic criteria

Diagnostic criteria are used to establish a clinical diagnosis. Among the existing criteria, the diagnostic criteria of the Mayo Clinic are of the greatest practical importance:

• transient dyskinesia of the middle segments of the left ventricle; local violation of the contractility of the myocardium, which goes beyond the blood supply of one epicardial artery;
• absence of obstructive coronary artery disease or angiographic signs of acute plaque rupture;
• the appearance of new changes on the ECG (elevation of the ST segment and/or inversion of the T wave) or a moderate increase in the level of troponins;
• absence of pheochromocytoma or myocarditis.

In addition to the Mayo Clinic diagnostic criteria, you can use the Takotsubo International Diagnostic Criteria:

• patients with transient dysfunction of the left ventricle in the form of apical, mid-ventricular, basal or focal dilatation; in some cases, the right ventricle is involved in the process; the area of ​​the affected myocardium goes beyond the area of ​​blood supply by one epicardial artery;
• an emotional, physically, or combined trigger preceding the onset of symptoms, but not necessarily;
• neurological disorders (subarachnoid hemorrhage, stroke/transient ischemic attack, convulsions), in particular, pheochromocytoma can serve as a trigger for Takotsubo syndrome;
• the appearance of new changes on the ECG (elevation/depression of the ST segment, inversion of the T wave, prolongation of the QT interval), in rare cases the ECG remains normal;
• a moderate increase in the level of cardiac biomarkers (troponin, CPK) in most cases; a significant increase in the level of BNP and NT-proBNP;
• severe coronary artery disease does not exclude the diagnosis of Takotsubo syndrome;
• absence of signs of infectious myocarditis;
• menopausal women are most often affected.

As well as the criteria of the Heart Failure Association and the European Community:

• transient regional myocardial contractility disorder of the left and right ventricle, which often, but not always, develops as a result of experienced emotional or physical stress;
• the area of ​​the affected myocardium goes beyond the area of ​​blood supply by one epicardial artery and often leads to circular dysfunction of the involved segments of the ventricles;
• absence of obstructive coronary artery disease, including acute plaque rupture, thrombus formation, coronary artery dissection, or other diseases that could explain transient left ventricular dysfunction (eg, hypertrophic cardiomyopathy, viral myocarditis);
• new and reversible changes on the ECG (elevation/depression of the ST segment, inversion of the T wave, prolongation of the QT interval, complete blockade of the left leg of the bundle of His) during the acute phase (3 months);
• significant increase in the level of BNP and NT-proBNP during the acute phase;
• moderate increase in the level of cardiac troponin;
• restoration of the systolic function of the left ventricle, confirmed by MRI of the heart, in dynamics from 3 to 6 months.

53. Determination of the anatomical variant

To date, there are several anatomical variants of Takotsubo syndrome: apical or typical (75-80%), mid-left ventricular (10-20%), basal or inverted (5%), biventricular (<0.5%), focal (very rarely).

54. Definition of complications

When formulating a clinical diagnosis, it is necessary to indicate the complications that have arisen in the patient, in particular, arrhythmias, heart failure, thromboembolic complications.

55. Making of clinical diagnosis

Here is an example of the formulation of the diagnosis in Takotsubo syndrome:

Takotsubo syndrome, apical variant. Ventricular polymorphic polytopic extrasystole, class III according to Laun. ACS-pulmonary edema.

Specialist consultations

56. Cardiologist

Given that Takotsubo syndrome is a cardiovascular condition, consulting with a cardiologist for timely diagnosis and appropriate treatment is essential.

57. Interventional cardiologist

Considering that Takotsubo syndrome must be differentiated from acute coronary syndrome, it is recommended to perform coronary angiography, which necessitates the involvement of an interventional cardiologist.

58. Radiologist

A radiologist is an important member of a multidisciplinary medical team, involved in the implementation of imaging methods of research when Takotsubo syndrome is suspected, particularly magnetic resonance imaging of the heart.

59. Psychotherapist

Patients with a confirmed diagnosis of Takotsubo syndrome and mental health disorders are recommended to be referred to a psychotherapist, considering that stress, depression, and anxiety are triggers for the development of Takotsubo syndrome.

60. Psychiatrist

Patients with a confirmed diagnosis of Takotsubo syndrome and symptoms of mental disorders are recommended to be referred to a psychotherapist, considering that some of these disorders, including depression, anxiety disorder, and schizophrenia, are factors in the development of Takotsubo syndrome. Additionally, if a depressed patient is taking serotonin and norepinephrine reuptake inhibitors, a psychiatrist should consider replacing them with other drugs, as serotonin and norepinephrine reuptake inhibitors can also trigger the development of Takotsubo syndrome.

61. Endocrinologist

Given the established association between hormonal disorders and Takotsubo syndrome, consultation with an endocrinologist is recommended if symptoms of an endocrine disease are present.

62. Narcologist

If a patient with suspected Takotsubo syndrome is suspected of using psychotropic substances, they should be referred to a narcologist for consultation. This is because some substances, such as cannabis, cannabinoids, and amphetamines, can provoke the development of Takotsubo syndrome.

63. Gynecologist

Considering that Takotsubo syndrome most often occurs in women during menopause, consulting a gynecologist to determine treatment tactics can be beneficial as part of the comprehensive therapy for such patients.

64. Doctor of physical and rehabilitation medicine

A physical and rehabilitation medicine physician plays an important role in maintaining the physical well-being of patients with Takotsubo syndrome, assisting them in their recovery process.

Purpose of treatment

65. Supportive therapy
66. Treatment of complications
67. Prevention of relapse

• Supportive therapy

Patients with Takotsubo syndrome require inpatient treatment, the main goal of which is to maintain hemodynamics until normal left ventricular function is restored and to prevent complications. As a rule, supportive treatment lasts several weeks.

Patients with signs of lung congestion, but without hypotension, are prescribed diuretics and nitrates to reduce venous return to the heart. Additionally, ACE inhibitors, ARB II, and beta-blockers are prescribed to help alleviate congestion, reduce myocardial load, and regulate blood pressure.

Patients with unstable hemodynamics require urgent echocardiography to diagnose obstruction of the left ventricular outflow tract. If signs of obstruction are detected, the administration of beta-blockers and IV fluid infusion is recommended, while inotropic drugs are contraindicated. Inotropes such as dopamine, dobutamine, milrinone, and levosimendan are indicated for patients without signs of left ventricular outflow tract obstruction. In severe cases, mechanical circulatory support is necessary, including extracorporeal membrane oxygenation for patients with left ventricular outflow tract obstruction or intra-aortic balloon counterpulsation for patients without obstruction.

An essential aspect of treating patients with Takotsubo syndrome is the prevention of thromboembolic complications, particularly when there is a large area of akinesis or hypokinesis in the myocardium of the left ventricle. To mitigate this risk, anticoagulant therapy is typically prescribed for a duration of 3 months.

• Treatment of complications

The most prevalent complications of Takotsubo syndrome include acute heart failure, left ventricular outflow tract obstruction, arrhythmias, and thromboembolic events.

For acute heart failure, refer to the previously outlined therapy. In cases of arrhythmias or thromboembolic complications, treatment should be administered following established guidelines.

• Prevention of relapse

Considering the high incidence of mental health disorders among Takotsubo syndrome patients, such as depression, anxiety disorders, and substance use, it’s crucial to address these conditions to prevent relapse.

Certain experts advocate for the prolonged use of beta-blockers to mitigate sympathetic nervous system tone, which can serve as adjunctive therapy for anxiety disorders. Retrospective analyses of extensive international registries have shown a beneficial effect of ACE inhibitors, ARBs, and calcium channel antagonists.

Consulting and support:

68. Informing the patient about the disease
69. Discussion of research results with the patient
70. Explanation to the patient of the possible cause of the disease
71. Explanation to the patient of possible symptoms that may occur during the disease
72. Explanation to the patient of the possible consequences of the disease
73. Explaining the available treatment methods, informing the patient about the risks and benefits of different treatment methods
74. Answers to the patient’s questions
75. Explanation of the scope of monitoring during and after treatment
76. Appointment of regular checks and controls to assess the effectiveness of treatment and changes in the patient’s condition

End of consultation

77. Summarize the data and ask the patient if anything important has been missed
78. Inform the patient about further tactics

Hospitalization to a specialized cardiology hospital is recommended for a comprehensive examination and selection of optimal treatment tactics. Obtain the patient’s Informed Voluntary Consent for diagnosis and treatment, and agree to the Patient’s Informed Voluntary Consent for processing personal data.

79. Thank the patient
80. Dispose of PPE properly and wash hands

Key communication skills

• Active listening
• Summing up
• Selection of indicative signs

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Сообщение Сounseling a patient with suspected Takotsubo-syndrome OSCE guides появились сначала на ClinCaseQuest.

1. Wash hands and put on PPE if necessary.
2. Introduce yourself to the patient by stating your name and role.
3. Confirm the patient’s last name, first name and date of birth.
4. Explain what the examination will involve using language the patient can understand.
5. Get consent for consultation.
6. Adequately expose the patient for examination.
7. Ask the patient if he is in pain before proceeding with the clinical examination.

Clarification of the main complaint

8. Use open-ended questions to explore the patient’s complaints
9. Details of the main complaint
10. Analyze the patient’s thoughts, fears, and expectations
11. Summarize the patient’s complaints

Comprehensive assessment

12. Screen for symptoms of damage to other organs and systems

Medical history

13. Find out when and how complaints first appeared; 
14. Clarify what preceded the appearance of complaints
15. Find out the possible reason for the appearance of these complaints (the fact of a tick bite, contact with an infectious patient, a violation of the diet, taking medications, etc.) ;
16. Did the patient seek medical help, if so, to whom and how did his appeal end, if not, then specify why he did not seek medical help; 
17. Did the patient take medical drugs independently or as prescribed by a doctor, and if so, how did the symptoms change
18. In the case of inpatient treatment for existing complaints, read the extract from the patient’s medical history, pay attention to the results of laboratory or instrumental examinations, the established diagnosis, treatment and recommendations after discharge
19. If the patient has previously undergone laboratory or instrumental examinations for current complaints, analyze their results and indicate important findings
20. Find out what prompted the patient to contact you
21. existing complaints , asking the patient clarifying questions

History of life

22. Find out if the patient suffers from chronic diseases, including diabetes, autoimmune diseases, immunodeficiency conditions and others

23. Find out whether the patient has recently been in natural areas with a high prevalence of ixodid ticks (steppe grass, bushes, shrubs)
24. Find out if the patient has had previous surgeries and find out how the post-operative period was
25. Find out whether the patient is constantly taking drugs, if so, indicate the doses of the drugs
26. Find out if the patient has a drug or food intolerance and how it manifests itself
27. Find out if the patient has bad habits – drinking alcohol, drugs, smoking
28. Find out the patient’s marital status, living conditions
29. Find out whether the patient works, find out his profession, working conditions, the presence of harmful occupational factors 

Objective review

30. Assessment of the patient’s general condition

31. Conducting a general inspection
32. Evaluation of the constitution  
33. Estimation of the degree of obesity
34. Skin and mucous membranes
35. Evaluation of hypothyroid glands​
36. Assessment of peripheral lymph nodes
37. Assessment of the locomotor system
38. Assessment of respiratory organs
39. Evaluation of the cardiovascular system
40. Assessment of abdominal organs
41. Evaluation of organs of the genitourinary system

Appointment of laboratory methods of examination

42. Clinical blood analysis with leukocyte formula and calculation of ESR (erythrocyte sedimentation rate)
43. Biochemical analysis of blood (total protein, creatinine, urea, alanine aminotransferase, lactate dehydrogenase, aspartate aminotransferase, glucose, alkaline phosphatase, uric acid, bilirubin with fractions)
44. Blood electrolytes (K+ and Na+)
45. Enzyme immunoassay (ELISA) to determine the titer of IgM and/or IgG antibodies to Borrelia burgdorferi
46. Immunofluorescence reaction (IF) to determine the titer of IgM and/or IgG antibodies to Borrelia burgdorferi
47. Polymerase chain reaction (PCR) for identification of the causative agent Borrelia burgdorferi
48. Western blotting
49. Blood analysis for troponin- I
50. Synovial fluid analysis
51. Analysis of cerebrospinal fluid

52. Evaluation of thyroid function (TSH) (according to indications)
53. General urine analysis with sediment microscopy (as indicated)
54. Pregnancy test for patients of childbearing age (according to indications)

Appointment of instrumental methods of examination

55. Electrocardiography
56. Daily Holter ECG monitoring

57. Transthoracic echocardiography
58. Magnetic resonance imaging of the heart
59. X-ray of chest organs
60. X-ray of joints
61. Ultrasound examination of joints
62. Arthrocentesis

Specialist consultations

63. Infectionist

64. Cardiologist
65. Dermatologist
66. Rheumatologist
67. Neurologist
68. Ophthalmologist
69. Psychotherapist

Establishing a clinical diagnosis

70. Differential diagnosis
71. The main disease

• Determination of the period of the disease
• Determination of the form of the disease
• Setting the run option
• Assessment of the severity of the course of the disease

72. Assessment of the presence of complications of the disease
73. Assessment of the presence of comorbid pathology
74. Formulation of clinical diagnosis

Purpose of treatment

75. Drug therapy
76. Other methods of treatment

Consulting and support

77. Inform the patient about the disease
78. Explain to the patient the possible causes of the disease
79. Inform the patient of the symptoms that may occur with the identified disease
80. Discuss the results of the examinations with the patient
81. Explain to the patient the possible consequences of the disease
82. Educate the patient about available treatments
83. Help the patient understand the risks and benefits of different treatments
84. Answer the patient’s questions
85. Provide an explanation of the extent of monitoring during and after treatment
86. Schedule regular check-ups and follow-up to assess the effectiveness of treatment and changes in the patient’s condition

Monitoring the effectiveness of treatment

87. Clinical assessment
88. Laboratory assessment
89. Instrumental assessment
90. Control over side effects of therapy

Prevention of re-infection

91. Individual protection measures
92. Use of repellents to prevent tick bites
93. Removing an attached tick
94. Antibiotic prophylaxis

End of consultation

95. Summarize the data and ask the patient if anything important has been missed

96. Inform the patient about further tactics
97. Thank the patient
98. Dispose of PPE properly and wash hands

Key communication skills

• Active listening

• Summing up
• Selection of indicative signs

The beginning of the consultation

1. Wash hands and put on PPE if necessary.
2. Introduce yourself to the patient by stating your name and role.
3. Confirm the patient’s last name, first name and date of birth.
4. Explain what the examination will involve using language the patient can understand.
5. Get consent for consultation.
6. Adequately expose the patient for examination.
7. Ask the patient if he is in pain before proceeding with the clinical examination.

Suspicion that a patient has Lyme disease occurs in the presence of characteristic clinical symptoms, which include:

• symptoms of intoxication (increased body temperature, chills, body aches, general weakness, increased fatigue, decreased appetite);
• skin symptoms (erythema migrans, benign lymphocytoma of the skin, chronic atrophic acrodermatitis);
• symptoms of damage to the musculoskeletal system (pain and swelling of large joints, periodic muscle and tendon pain);
• symptoms of damage to the nervous system (headache, stiffness of the neck, asymmetry of the face in the case of damage to the facial nerve, shooting pain, numbness and tingling in the hands and feet in the case of damage to the peripheral nerves);
• symptoms of damage to the cardiovascular system (chest pain, shortness of breath, heart rhythm and/or conduction disturbances);
• symptoms of eye damage (pain that worsens when palpating the eye, feeling of sand in the eyes, photophobia, decreased visual acuity).

Clarification of the main complaint

8. Use open-ended questions to explore the patient’s complaints

9. Details of the main complaint
10. Analyze the patient’s thoughts, fears, and expectations
11. Summarize the patient’s complaints

• Use open-ended questions to explore the patient’s complaints
• Details of the main complaint

The leading symptom of Lyme disease is erythema migrans.

To detail the complaint, it is recommended to follow the following algorithm :

• Localization: find out the localization of the skin rash
• Dynamics over time: specify whether the nature and localization of the skin rash have changed over time
• Exacerbating factors for skin manifestations: find out if there is anything that, according to the patient, aggravates the skin manifestations (dietary disorders, taking medications, etc.)
• Factors that help reduce the rash: Find out if there is anything that helps reduce the rash (medications, diet, etc.)
• Accompanying symptoms: determine whether the skin rash is accompanied by other symptoms, in particular, itchy skin, joint pain, increased body temperature, catarrhal phenomena

” Tell me, where is the rash localized? “

Did the nature and localization of the skin rash change over time ? “

“Is there anything that aggravates the skin manifestations?”

“Is there anything that helps reduce the rash?”

Is the skin rash accompanied by itching, increased body temperature, catarrhal symptoms? “

To detail the pain complaint, it is recommended to use the SOCRATES questionnaire .

When conducting surveys, be polite, use “Can you tell me…?” for questions. or “Can you describe…?”

Analyze the patient’s thoughts, fears, and expectations

A key component of history taking is exploring the patient’s thoughts, concerns, and expectations to gain insight into how the patient currently perceives their condition, their concerns, and what they expect from the consultation.

The exploration of thoughts, concerns, and expectations should be  fluid  throughout the consultation in response to  the patient’s cues  . This will help to make your consultation  patient-oriented , and not formulaic.

It is necessary to use the structure of analyzes of thoughts, fears and expectations so that it sounds natural in your consultation.

Summarize the patient’s complaints

Summarize what the patient told you about his complaint. This allows you to check how correctly you understood the patient’s complaints and gives the patient the opportunity to correct any inaccurate information.

When you have concluded, ask the patient if there is anything else you missed. Periodically, as the consultation progresses, summarize intermediate results.

Comprehensive assessment

12. Screen for symptoms of damage to other organs and systems

A comprehensive assessment includes a brief survey of the patient for symptoms of other systems that may or may not be related to the chief complaint. A comprehensive examination also allows you to identify symptoms that the patient forgot to mention.

Some examples of symptoms that you might monitor for each system are presented below.

Medical history

13. Find out when and how complaints first appeared; 
14. Clarify what preceded the appearance of complaints
15. Find out the possible reason for the appearance of these complaints (the fact of a tick bite, contact with an infectious patient, a violation of the diet, taking medications, etc.) ;
16. Did the patient seek medical help, if so, to whom and how did his appeal end, if not, then specify why he did not seek medical help; 
17. Did the patient take medical drugs independently or as prescribed by a doctor, and if so, how did the symptoms change

“When did you first develop a rash ?”

What , in your opinion, could have caused its appearance? “

” Have you sought medical help for this? “

18. In the case of inpatient treatment for existing complaints, read the extract from the patient’s medical history, pay attention to the results of laboratory or instrumental examinations, the established diagnosis, treatment and recommendations after discharge

19. If the patient has previously undergone laboratory or instrumental examinations for current complaints, analyze their results and indicate important findings
20. Find out what prompted the patient to contact you

” What prompted you to contact me? “

“What made you turn to me?”

21. Exclude other causes of existing complaints by asking the patient clarifying questions

” Does itchy skin bother you ?”

Did you have a fever ? “

Other causes of erythematous rash :

• A hypersensitivity reaction to a tick bite

A hypersensitivity reaction to a tick bite is characterized by the appearance of a rash at the site of the bite, which is accompanied by itching and swelling of the skin. As a rule, these symptoms last for several days and disappear without a trace. In severe cases, an allergic reaction to a tick bite can cause hemodynamic disturbances.

• Nummular eczema

Nummular eczema is characterized by the appearance on the limbs and trunk of bright red foci of inflammation, about 5 cm in diameter, round in shape, which are accompanied by wetting and severe itching. Nummular eczema is characterized by recurrence of the skin rash.

• Dermatomycosis

Dermatomycosis is characterized by the appearance of an area of ​​erythema, which is accompanied by skin itching and exudation. In the anamnesis, such patients may have long-term use of antibiotics, steroid drugs, cytostatics, the presence of comorbid pathology (diabetes mellitus, diseases of the cardiovascular system, HIV infection and other immunodeficiency states), insufficient hygiene.

• Annular granuloma

Ring-shaped granuloma is characterized by the appearance of dense ring-shaped rashes of a flesh-colored or pink color, with a diameter of 1 to 5 cm, which are localized mainly on open areas of the body, in particular on the limbs. Such patients have a history of comorbid pathology (diabetes, thyroid disease, etc.), sunburn, chronic stress, taking certain medications (gold preparations, diclofenac, quinidine, calcitonin, amlodipine, ACE inhibitors, calcium channel blockers). Granuloma annulare usually goes away on its own without treatment.

• Erythema multiforme

Erythema multiforme is characterized by the appearance of an erythematous rash on the skin in the form of a target or bull’s eye with a dark center and a light rim, which is most often localized on the extremities and tends to spread to the skin of the body, accompanied by itching and a burning sensation. The mucous membranes of the lips and cheeks are often involved in the pathological process. Patients with erythema multiforme have a history of persistent herpes simplex virus, chronic autoimmune diseases (in particular, Crohn’s disease, nonspecific ulcerative colitis, systemic lupus erythematosus) or talk about taking certain medications (nonsteroidal anti-inflammatory drugs, antibiotics, anticonvulsants).

History of life

22. Find out if the patient suffers from chronic diseases, including diabetes, autoimmune diseases, immunodeficiency conditions and others
23. Find out whether the patient has recently been in natural areas with a high prevalence of ixodid ticks (steppe grass, bushes, shrubs)
24. Find out if the patient has had previous surgeries and find out how the post-operative period was
25. Find out whether the patient is constantly taking drugs, if so, indicate the doses of the drugs
26. Find out if the patient has a drug or food intolerance and how it manifests itself
27. Find out if the patient has bad habits – drinking alcohol, drugs, smoking
28. Find out the patient’s marital status, living conditions
29. Find out whether the patient works, find out his profession, working conditions, the presence of harmful occupational factors 

Objective review

30. Assessment of the patient’s general condition

31. Conducting a general inspection
32. Evaluation of the constitution  
33. Estimation of the degree of obesity
34. Skin and mucous membranes
35. Evaluation of hypothyroid glands​
36. Assessment of peripheral lymph nodes
37. Assessment of the locomotor system
38. Assessment of respiratory organs
39. Evaluation of the cardiovascular system
40. Assessment of abdominal organs
41. Evaluation of organs of the genitourinary system

Assess for objects or equipment on or around the patient that may provide useful information about the patient’s medical history and current clinical condition.

During the examination of the patient, carefully examine the skin. In the early stage of Lyme disease, a migrating erythema appears at the site of a tick bite, with a light center that resembles a target or a bull’s eye, with a diameter of more than 5 cm, which is accompanied by an increase in local temperature. A rare manifestation of early borreliosis is also a borreliosis lymphocytoma – a single bluish-red nodular formation that is localized on the earlobe, near the nipple or on the skin of the scrotum. In the late stage of Lyme disease, chronic atrophic acrodermatitis can often be detected, which is characterized by the appearance of bluish-red spots mainly on the extensor surfaces of the distal parts of the limbs, followed by atrophy of the affected skin.

When the central nervous system is affected, in particular, aseptic meningitis, stiffness of the neck muscles is observed; in case of damage to the peripheral nervous system, in particular, Bell’s palsy, there is asymmetry of the face, the disappearance of the nasolabial fold and the lowering of the affected corner of the mouth; impaired sensitivity and decreased muscle strength in peripheral neuropathy.

In patients with Lyme arthritis, during a physical examination, hyperemia of the skin, swelling over the affected joint, usually a large joint of the lower limb, is determined.

When the eyes are affected, lacrimation, hyperemia of the conjunctiva draws attention.

During auscultation, patients with borreliosis myopericarditis can detect congestion in the lungs, such as wheezing in the lower parts, arrhythmicity, muffled or pathological III heart tone. When a large amount of exudate accumulates in the pericardial cavity, deafness of heart sounds and hypotension are observed.

In patients with heart failure caused by borreliosis myopericarditis, positive hepatojugular reflux, ascites, and swelling of the lower extremities can also be detected.

Appointment of laboratory methods of examination

42. Clinical blood analysis with leukocyte formula and calculation of ESR (erythrocyte sedimentation rate)
43. Biochemical analysis of blood (total protein, creatinine, urea, alanine aminotransferase, lactate dehydrogenase, aspartate aminotransferase, glucose, alkaline phosphatase, uric acid, bilirubin with fractions)
44. Blood electrolytes (K+ and Na+)
45. Enzyme immunoassay (ELISA) to determine the titer of IgM and/or IgG antibodies to Borrelia burgdorferi
46. Immunofluorescence reaction (IF) to determine the titer of IgM and/or IgG antibodies to Borrelia burgdorferi
47. Polymerase chain reaction (PCR) for identification of the causative agent Borrelia burgdorferi
48. Western blotting
49. Blood analysis for troponin- I
50. Synovial fluid analysis
51. Analysis of cerebrospinal fluid

52. Evaluation of thyroid function (TSH) (according to indications)
53. General urine analysis with sediment microscopy (as indicated)
54. Pregnancy test for patients of childbearing age (according to indications)

• Clinical blood analysis with leukocyte formula and calculation of ESR (erythrocyte sedimentation rate)

Clinical blood analysis with leukocyte formula and calculation of ESR is one of the mandatory laboratory methods of examination, which are carried out in routine clinical practice for somatic patients. In patients with Lyme disease, an increase in the level of leukocytes and acceleration of ESR can be detected.

• Biochemical analysis of blood (total protein, creatinine, urea, alanine aminotransferase, lactate dehydrogenase, aspartate aminotransferase, glucose, alkaline phosphatase, uric acid, bilirubin with fractions)

Biochemical analysis of blood (total protein, creatinine, urea, alanine aminotransferase, aspartate aminotransferase, glucose, alkaline phosphatase, uric acid, total bilirubin with its fractions) is one of the mandatory laboratory examination methods performed in routine clinical practice for somatic patients.

• Blood electrolytes (K+ and Na+)

Blood analysis for electrolytes (K+ and Na+) is a mandatory laboratory method of examination, which is carried out in routine clinical practice for the diagnosis of electrolyte disorders.

• Enzyme immunoassay (ELISA) to determine the titer of IgM and/or IgG antibodies to Borrelia burgdorferi

Enzyme immunoassay to determine the titer of IgM and/or IgG antibodies to Borrelia burgdorferi is a mandatory laboratory test when Lyme disease is suspected.

A positive result of a test for the presence of antibodies can indicate both an active infectious process and a previous infection, because both classes of immunoglobulins can persist in the blood serum for a long time. That is why a serological test is performed only in case of high probability of Lyme disease.

A negative ELISA result reliably excludes Lyme disease if more than 2-4 weeks have passed since the bite of the ixodid tick. If less than 2-4 weeks have passed since the bite of the ixodid tick, conduct the serological test again after 4-6 weeks.

• Immunofluorescence reaction (IF) to determine the titer of IgM and/or IgG antibodies to Borrelia burgdorferi

The immunofluorescence reaction, which is used to determine the titer of IgM and/or IgG antibodies to Borrelia burgdorferi, is an alternative serological test for suspected Lyme disease.

A positive result of a test for the presence of antibodies can indicate both an active infectious process and a previous infection, because both classes of immunoglobulins can persist in the blood serum for a long time. That is why a serological test is performed only in case of high probability of Lyme disease.

A negative RIF result reliably excludes Lyme disease if more than 2-4 weeks have passed since the bite of the ixodid tick. If less than 2-4 weeks have passed since the bite of the ixodid tick, conduct the serological test again after 4-6 weeks.

• Polymerase chain reaction (PCR) for identification of the causative agent Borrelia burgdorferi

According to existing recommendations, the polymerase chain reaction is of secondary importance for the identification of the causative agent of Lyme disease.

• Western blotting

Western blotting is performed to confirm a positive or doubtful result of ELISA or RIF at the second stage of serological diagnosis.

• Blood analysis for troponin- I

A blood test for troponin-I is performed in patients with suspected borreliosis myocarditis. An increase in the level of troponin-I indicates the benefit of acute damage to cardiomyocytes.

• Synovial fluid analysis

In patients with Lyme arthritis, the synovial fluid is usually inflammatory, with cell counts ranging from 500 to 98,000/μl. There are no uric acid crystals and calcium pyrophosphate crystals in the synovial fluid.

• Analysis of cerebrospinal fluid

In the cerebrospinal fluid of patients with Lyme disease, moderate pleocytosis (up to 1000 cells/μl) with a predominance of lymphocytes, an increased protein concentration (more than 50 mg/dL), and a normal glucose level (45-80 mg/dL) are found.

• Evaluation of thyroid gland function (thyroid-stimulating hormone-TSH) (according to indications)

A blood test for thyroid-stimulating hormone is performed to rule out thyroid dysfunction as a possible cause of some symptoms. For example, both patients with borreliosis myocarditis and patients with thyroid gland dysfunction may complain of shortness of breath, palpitations, and a feeling of heart failure. The similarity of the clinical picture requires laboratory exclusion of pathology of the thyroid gland.

• General urine analysis with sediment microscopy (as indicated)

A general analysis of urine with sediment microscopy is performed when kidney and/or urinary system damage is suspected.

• Pregnancy test if the patient is of childbearing age (as indicated)

It is advisable to perform a pregnancy test on patients of childbearing age to exclude the fact of pregnancy, because some antibacterial drugs used in the treatment of Lyme disease have a teratogenic effect.

Appointment of instrumental methods of examination

55. Electrocardiography
56. Daily Holter ECG monitoring

57. Transthoracic echocardiography
58. Magnetic resonance imaging of the heart
59. X-ray of chest organs
60. X-ray of joints
61. Ultrasound examination of joints
62. Arthrocentesis

• Electrocardiography

Electrocardiography is a mandatory method of examination of patients with suspected heart damage in Lyme disease. Most often, rhythm and conduction disturbances, in particular AV blockades of various degrees, are registered on the ECG.

• Daily Holter ECG monitoring

Daily Holter ECG monitoring is performed for patients with borreliosis heart disease to diagnose rhythm and/or conduction disorders.

• Transthoracic echocardiography

Transthoracic echocardiography is a mandatory method of examination of patients with suspected heart damage in Lyme disease. In patients with borreliosis myopericarditis, echocardiography can detect areas of local myocardial contractility disorders, effusion in the pericardial cavity.

• Magnetic resonance imaging of the heart

Magnetic resonance imaging of the heart is performed to assess the morphology, kinetics, and function of the heart in suspected borreliosis myocarditis. For MR confirmation of myocarditis, the Lake Louis criteria are used, which confirm the presence of edema and/or the classic pattern of late gadolinium accumulation in the heart tissues.

• X-ray of chest organs

Chest radiography is performed to detect signs of pulmonary congestion in patients with severe Borrelia myopericarditis and symptoms of heart failure.

• X-ray of joints

X-rays of the joints are performed when Lyme arthritis is suspected. In the acute stage of the disease, changes in periarticular tissues are found, with a long course – thinning of cartilage, subcartilaginous cysts, peri-articular osteoporosis, erosions, osteophytes.

• Ultrasound examination of joints

Ultrasound examination of the joints is performed when Lyme arthritis is suspected. Borreliosis arthritis is characterized by thickening of the synovial membrane, an increase in the amount of synovial fluid, and changes in periarticular tissues.

• Arthrocentesis

In case of borreliosis of the joints, in some cases it is advisable to perform an arthrocentesis followed by an examination of the synovial fluid.

Specialist consultations

63. Infectionist

64. Cardiologist
65. Dermatologist
66. Rheumatologist
67. Neurologist
68. Ophthalmologist
69. Psychotherapist

• Infectionist

Given that Lyme disease is an infectious disease, consultation with an infectious disease specialist aimed at timely diagnosis and the appointment of appropriate treatment is mandatory.

• Cardiologist

Lyme disease is often accompanied by heart damage with the development of myocarditis or myopericarditis, which requires consultation with a cardiologist. The cardiologist prescribes additional examination, including electrocardiography, daily Holter heart rate monitoring, echocardiography, and appropriate treatment.

• Dermatologist

One of the earliest and most specific manifestations of Lyme disease is erythema migrans, a ring-shaped rash that appears at the site of a tick bite and resembles a target or bull’s eye. In addition to erythema migrans, patients in the early stage of the disease may complain of the appearance of a red nodular formation – borreliosis lymphocytoma, and in the late stage of the disease – a slowly progressive skin lesion with the appearance of blue-red spots mainly on the extensor surfaces of the distal parts of the limbs – chronic atrophic acrodermatitis. With this in mind, patients with Lyme disease often first consult a dermatologist, who in turn should refer the patient to an infectious disease specialist in a timely manner.

• Rheumatologist

Joint damage is one of the frequent manifestations of lymoborreliosis, which is accompanied by the appearance of severe pain and swelling of mainly large joints. Pronounced symptoms of Lyme arthritis often require consultation with a rheumatologist to choose the optimal therapy.

• Neurologist

Lymoborreliosis can cause damage to the central and/or peripheral nervous system, which leads to the development of meningitis, encephalitis, polyneuropathy, neuritis. In case of neurological symptoms, the patient must be consulted by a neurologist.

• Ophthalmologist

Consultation of an ophthalmologist is necessary for borreliosis of the eyes, which in the early stage of Lyme disease manifests itself in the form of conjunctivitis, episcleritis; in the stage of dissemination – uveitis; in the chronic stage of lymoborreliosis in the form of keratitis, endophthalmitis, oculomotor disorders.

• Psychotherapist

In cases where the symptoms of Lyme disease affect the emotional state and mental well-being of the patient, a consultation with a psychotherapist is necessary.

Establishing a clinical diagnosis

70. Differential diagnosis
71. The main disease

• Determination of the period of the disease
• Determining the form of the disease. Establishing the course of the disease
• Assessment of the severity of the course of the disease

72. Assessment of the presence of complications of the disease
73. Assessment of the presence of comorbid pathology
74. Formulation of clinical diagnosis

Differential diagnosis

Most often, Lyme disease has to be differentiated from other tick-borne diseases, including tick-borne encephalitis, granulocytic anaplasmosis, babesiosis, and monocytic ehrlichiosis.

Tick-borne encephalitis is a viral disease caused by a flavivirus. The first symptoms of infection appear 7-14 days after a tick bite and are characterized by the appearance of general weakness, fever, headache, vomiting, and sometimes ring-shaped erythema. With a favorable course, these symptoms disappear after a few days. With a severe course, these complaints are accompanied by impaired consciousness, impaired coordination of movements, pronounced weakness in the arms and legs, convulsions, and impaired speech. Important in the differential diagnosis of tick-borne encephalitis is virological and serological research, which allows to finally confirm the diagnosis.

Granulocytic anaplasmosis is a bacterial disease caused by the bacterium Anaplasma. 7-10 days after the bite, the first symptoms of the disease appear: fever, chills, headache, myalgia, arthralgia, nausea, unproductive cough, decreased appetite. Given the non-specificity of the clinical picture of anaplasmosis, laboratory diagnosis is important in diagnosis. To verify the diagnosis, patients undergo a serological test and polymerase chain reaction. It should also be noted that patients with anaplasmosis often have leukopenia and thrombocytopenia in a clinical blood test.

Babesiosis is an acute infectious disease caused by babesiosis, which is accompanied by intoxication, fever, and the development of anemia. Clinical manifestations of babesiosis usually occur in patients with immunodeficiency, while the course is asymptomatic in people with good immunity. In addition to intoxication and anemic syndromes, babesiosis is often complicated by acute kidney and liver failure. To confirm the diagnosis, serological tests (indirect immunofluorescence reaction, complement binding reaction) and detection of hemoparasites in a smear and a thick drop of blood are used.

Monocytic ehrlichiosis occurs when a person is bitten by a tick infected with Ehrlichia. Clinical manifestations of monocytic ehrlichiosis are similar to symptoms of granulocytic anaplasmosis, but skin rash is much more common in patients with monocytic ehrlichiosis. In addition to the skin, monocytic ehrlichiosis often affects the central nervous system and bone marrow. The main methods of diagnosis are serological research and polymerase chain reaction.

The main disease

When formulating a diagnosis of Lyme disease, it is necessary to indicate the period, form of the disease, variant and severity of the course of the disease.

• Determination of the period of the disease

The following periods of the disease are distinguished:

• early (early localized stage, early disseminated stage)
• late.

Patients in the early localized stage of the disease complain of fever and the appearance of migrating erythema at the site of the tick bite, which resembles a target or bull’s eye.

Patients in the early disseminated stage of the disease complain of general weakness, fever, muscle pain, and the appearance of neurological, joint, eye, and cardiac symptoms.

When the central nervous system is affected, patients complain of a severe headache, neck stiffness; facial asymmetry occurs when the facial nerve is damaged; when peripheral nerves are affected, there is a shooting pain, numbness and tingling in the hands and feet.

Lyme arthritis is accompanied by the appearance of severe pain and swelling of mainly large joints, periodic muscle and tendon pain.

Heart damage in Lyme disease is characterized by the development of myocarditis or myopericarditis. Patients complain of chest pain, shortness of breath, heart rhythm and/or conduction disturbances. Often patients with Lyme carditis have a violation of AV conduction. The degree of AV block can rapidly progress from first-degree AV block to complete AV block.

A rare skin manifestation of early Lyme borreliosis is the so-called borreliosis lymphocytoma – a single bluish-red nodular formation that can be localized on the earlobe, near the nipple or in the scrotum.

Patients in the late period of the disease may have symptoms of aseptic meningitis, Bell’s palsy, impaired cognitive functions, dilated cardiomyopathy, recurrent arthritis of large joints, chronic atrophic acrodermatitis.

• Determination of the form of the disease

Depending on the clinical symptoms, skin, joint, cardiac, neurological, and mixed forms are distinguished.

• Determination of the course of the disease

Depending on the variant of the course, the following are distinguished:

• acute course (lasts up to 3 months),
• subacute course (lasts from 3 to 6 months),
• chronic course (lasting more than 6 months).
• Determination of the severity of the course of the disease

Depending on the severity, the following are distinguished:

• easy run
• medium difficulty course,
• hard run

A mild course of lymoborreliosis is characterized by a moderately pronounced intoxication syndrome, an increase in body temperature up to 38 0 ^C , the presence of migratory erythema in the absence of damage to the nervous system, heart or joints.

A moderately severe course of lymoborreliosis is characterized by a pronounced intoxication syndrome, an increase in body temperature to 38-39 ⁰ C, the presence of migratory erythema, minor damage to the nervous system, heart or joints.

A severe course of lymoborreliosis is characterized by a pronounced intoxication syndrome, an increase in body temperature above 39 ⁰ C, moderate or severe damage to the nervous system (meningitis) or heart (AV-blockade II-III stage, pronounced myocarditis).

• Assessment of the presence of complications of the disease

In the clinical diagnosis, it is necessary to indicate all complications of Lyme disease, guided by existing classifications.

The most common complications of Lyme disease include: acute neurological complications (radiculopathy, cranial neuropathy, mononeuropathy, facial nerve palsy, lymphocytic meningitis, encephalomyelitis), late neurological complications (encephalomyelitis, peripheral neuropathy or encephalopathy), cardiac complications (AV blocks, myopericarditis) , late musculoskeletal complications (arthritis of large joints), borreliosis lymphocytoma.

• Assessment of the presence of comorbid pathology

When formulating a clinical diagnosis, it is necessary to indicate comorbid diseases that the patient has, guided by existing classifications.

• Formulation of clinical diagnosis

Here is an example of the formulation of a diagnosis of Lyme disease:

Lyme (tick-borne) borreliosis, early period, mixed (cutaneous-articular-cardiac) form, acute, severe course. Acute borreliosis diffuse myocarditis, severe course. SN II A Art. with preserved left ventricular ejection fraction, II FC according to NYHA.

Purpose of treatment

75. Drug therapy
76. Other methods of treatment

• Drug therapy

The main method of treatment for Lyme disease is antibiotic therapy.

Most often, amoxicillin, doxycycline, cefuroxime axetil and, as an alternative, azithromycin are used.

The choice of one or another drug and route of administration depends on the clinical manifestations and severity of the course of Lyme disease.

• Other methods of treatment

For patients with symptomatic bradycardia due to heart damage in Lyme disease that is not amenable to medical treatment, temporary electrical cardiostimulation is recommended.

Consulting and support

77. Inform the patient about the disease
78. Explain to the patient the possible causes of the disease
79. Inform the patient of the symptoms that may occur with the identified disease
80. Discuss the results of the examinations with the patient
81. Explain to the patient the possible consequences of the disease
82. Educate the patient about available treatments
83. Help the patient understand the risks and benefits of different treatments
84. Answer the patient’s questions
85. Provide an explanation of the extent of monitoring during and after treatment
86. Schedule regular check-ups and follow-up to assess the effectiveness of treatment and changes in the patient’s condition

Monitoring the effectiveness of treatment

87. Clinical assessment

Clinical evaluation of the effectiveness of treatment consists in evaluating the patient’s subjective symptoms and objective parameters of the body’s functioning against the background of therapy.

88. Laboratory assessment

In order to monitor the effectiveness of the treatment, markers of inflammation in the blood are re-determined. A decrease in these indicators against the background of treatment indicates the effectiveness of therapy.

89. Instrumental assessment

In the case of borreliosis damage to the heart, joints or nervous system, during the treatment it is advisable to carry out a repeated instrumental examination, in particular electrocardiography, echocardiography in myopericarditis; ultrasound examination of joints in arthritis; lumbar puncture with subsequent analysis of cerebrospinal fluid in borreliosis meningitis.

90. Control over side effects of therapy

Lyme disease drug therapy can cause side effects such as nausea, diarrhea, abdominal pain, allergic reactions, and antibiotic resistance. In order to detect these side effects in a timely manner, inform the patient of their symptoms and warn of the need to seek medical help immediately if they occur.

Prevention of re-infection

To avoid re-infection, it is recommended to take a number of measures.

91. Individual protection measures

When going to an area with a high probability of contact with ticks, it is recommended to wear light-colored clothes with long sleeves and pants, tuck your pants into socks or high shoes, and conduct a thorough check of your clothes and body after returning.

92. Use of repellents to prevent tick bites

For the prevention of tick bites, it is recommended to use products containing N,N-diethyl-meta-toluamide (DEET), picaridin, ethyl 3-(Nn-butyl-N-acetyl) aminopropionate (IR3535), oil of lemon eucalyptus (OLE), p-methane-3,8-diol (PMD), 2-undecanone or permethrin.

93. Removing an attached tick

Given that the length of time a tick is attached to the skin is an extremely important predictor of developing Lyme disease (the likelihood of Lyme disease increases significantly after 36-48 hours), immediate removal of the attached tick is recommended. This is best done with clean, fine-tipped tweezers (or similar device) inserted between the body of the tick and the skin.

It is not advisable to burn the attached tick (with a match or other thermal intervention) or to use harmful chemicals or petroleum products to detach it.

After removing the tick, it is recommended to carry out a study to identify its species. But at the same time, it is not advisable to test the removed tick for B. Burgdorferi, because the presence or absence of this microorganism is not a reliable sign of the presence of infection.

94. Antibiotic prophylaxis

It is recommended to prescribe prophylactic antibiotic therapy for adults and children within 72 hours after removal of a high-risk tick.

The patient is prescribed a single dose of doxycycline at a dose of 200 mg for adults or 4.4 mg/kg (up to 200 mg) for children.

A tick bite is considered high-risk if it meets the following three criteria: the removed tick belongs to the Ixodes species; the bite occurred in a highly endemic area; the tick was attached for ≥36 hours. If the tick bite is not high-risk, observation is recommended.

End of consultation

95. Summarize the data and ask the patient if anything important has been missed
96. Inform the patient about further tactics

Obtain the patient’s Informed Voluntary Consent for diagnosis and treatment (form No. 003-6/o), agree to the Patient’s Informed Voluntary Consent for processing personal data (Insertion sheet to the accounting form No. 003/o).

97. Thank the patient
98. Dispose of PPE properly and wash hands

Key communication skills

• Active listening

• Summing up
• Selection of indicative signs

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Сообщение Counseling of a patient with suspected Lyme disease – osce-guide появились сначала на ClinCaseQuest.

Lyme disease is an infectious disease caused by the spirochete Borrelia burgdorferi, which is transmissible during a tick bite.

Prevalence

Lyme disease is the most common transmissible disease in the northern hemisphere, affecting thousands of people each year. For example, about 40 cases of Lyme disease per 100 thousand population are registered in the USA every year. Outbreaks of infection are usually registered in the spring-autumn period.

Etiology

The causative agent of Lyme disease is the spirochete Borrelia burgdorferi, which enters the human body when bitten by an ixodid tick.

Pathogenesis

When a spirochete enters the body, the following occurs:

• the immune system of an infected person destroys the spirochete or
• The spirochete remains viable and causes erythema migrans, a skin lesion characteristic of Lyme disease or
• the spirochete spreads for several weeks through the lymphatics or blood.

After entering the bloodstream, the spirochete shows a distinct tropism to the skin, heart, central nervous system (CNS), joints, and eyes.

Clinical picture

The interval between a tick bite and the appearance of the first symptoms of the disease is usually from 7 to 14 days, but in some cases it can increase to several months.

In the course of Lyme disease, early and late periods are conventionally distinguished. The early period consists of an early localized stage and an early disseminated stage.

The early localized stage is characterized by fever and migrating erythema at the site of the tick bite. Gradually increasing in diameter over several days (usually more than 5 cm in diameter), the center of the spot becomes lighter, resembling a “target” or “bull’s eye”. Erythema migrans is accompanied by an increase in local temperature, but rarely itches or hurts. Erythema migrans persists for several days or weeks, then disappears, leaving behind pigmentation or scaling.

In one-third of patients, the disease ends on its own at this stage, and in two-thirds, it turns into a disseminated one, which is characterized by the appearance of signs of damage to the nervous system, heart, joints, and eyes.

The early disseminated stage develops 3-12 weeks after the primary infection and is characterized by the appearance of general weakness, fever, muscle pain, neurological symptoms, joint, eye, and cardiac symptoms.

When the central nervous system is affected, patients complain of a severe headache, neck stiffness; facial asymmetry occurs when the facial nerve is damaged; when peripheral nerves are affected, there is a shooting pain, numbness and tingling in the hands and feet.

Lyme arthritis is accompanied by the appearance of severe pain and swelling of mainly large joints, periodic muscle and tendon pain.

Heart damage in Lyme disease is characterized by the development of myocarditis or myopericarditis. Patients complain of chest pain, shortness of breath, heart rhythm and/or conduction disturbances. Often patients with Lyme carditis have a violation of AV conduction. The degree of AV block can rapidly progress from first-degree AV block to complete AV block.

A rare skin manifestation of early Lyme borreliosis is the so-called borreliosis lymphocytoma – a single bluish-red nodular formation that can be localized on the earlobe, near the nipple or in the scrotum.

Late-stage Lyme disease occurs months or years after the onset of the disease. At the late stage of the disease, patients develop aseptic meningitis, Bell’s palsy, impaired cognitive functions, and arthritis. In addition, chronic atrophic acrodermatitis often occurs – a slowly progressive skin lesion with the appearance of blue-red spots mainly on the extensor surfaces of the distal parts of the limbs and subsequent skin atrophy.

Classification

Depending on the period of the disease, the following are distinguished: early (localized and disseminated stages) and late period.

The early period of Lyme Borreliosis is characterized by the development of migratory erythema at the site of tick suction and spread of infection, which is manifested by the development of benign lymphocytoma of the skin, damage to the nervous system (neuritis of the facial nerve, polyradiculopathy, acute meningoencephalitis), heart (myocarditis with AV conduction disorders), and joints.

The late period of Lymboreliosis is characterized by various organ lesions of autoimmune genesis, in particular, recurrent arthritis of mainly large joints, chronic encephalomyelitis, dilated cardiomyopathy, chronic atrophic acrodermatitis.

Depending on the stage of the disease, the following are distinguished: early localized, early disseminated, late stage.

Depending on the variant of the course, they are distinguished: acute (lasts up to 3 months), subacute (lasts from 3 to 6 months), chronic course (lasts more than 6 months).

Depending on the predominant clinical symptoms, the following are distinguished: skin, joint, cardiac, neurological, mixed forms.

Depending on the severity, the following are distinguished: mild, moderate, and severe.

A mild course of lymoborreliosis is characterized by a moderately pronounced intoxication syndrome, an increase in body temperature up to 38 0 ^C , the presence of migratory erythema in the absence of damage to the nervous system, heart or joints.

A moderately severe course of lymoborreliosis is characterized by a pronounced intoxication syndrome, an increase in body temperature to 38-39 ⁰ C, the presence of migratory erythema, minor damage to the nervous system, heart or joints.

A severe course of lymoborreliosis is characterized by a pronounced intoxication syndrome, an increase in body temperature above 39 ⁰ C, moderate or severe damage to the nervous system (meningitis) or heart (AV-blockade II-III stage, pronounced myocarditis).

Diagnostics

The diagnosis of Lyme borreliosis is established on the basis of a characteristic clinical picture, anamnestic data and serological confirmation.

When analyzing the results of a serological test, it is important to take into account the dynamics of the serological response to infection.

During the first 2-4 weeks from the moment of the tick bite in patients with erythema migrans, the result of the serological test may be false-negative. In this case, in the case of a high probability of Lyme disease, it is recommended to repeat the serological examination after 4-6 weeks.

A positive result of a test for the presence of antibodies can indicate both an active infectious process and a transferred infection, because both classes of immunoglobulins can persist in the blood serum for months and even years.  

In some cases, a Borrelia antibody test result may be false-positive due to the presence of cross-reactive antibodies to other microbes or an autoimmune disease. That is why it is appropriate to conduct a serological examination only in case of high probability of Lyme disease.

In view of the above, the following two-level procedure is recommended for serological confirmation of the diagnosis:

• Stage 1: Enzyme immunoassay (IFA) or immunofluorescence assay (IFA) to determine the titer of IgG and/or IgM

• Stage 2: Western blotting, which is carried out in case of a positive or doubtful result of a blood test for antibody titer

To identify the DNA of the causative agent, polymerase chain reaction (PCR) is performed, however, according to existing recommendations, it is of secondary importance in the diagnosis of Lyme borreliosis.

In addition to laboratory confirmation of Lyme disease, patients undergo additional examination methods depending on clinical symptoms.

In case of heart damage, it is advisable to conduct electrocardiography, transthoracic echocardiography, blood test for troponin-I and others. In patients with Lyme carditis, signs of myopericarditis, heart rhythm and/or conduction disturbances are found.

When joints are affected, in some cases, it is advisable to perform an arthrocentesis followed by an examination of the synovial fluid. In patients with Lyme arthritis, the synovial fluid is usually inflammatory, with cell counts ranging from 500 to 98,000/μl. In adult patients, the fluid should also be checked for crystals to rule out gout and pseudogout. Detection of B. burgdorferi DNA in synovial fluid is not a reliable test for active joint infection in Lyme disease.

In the case of damage to the central nervous system, in particular, when meningitis is suspected, a lumbar puncture is performed followed by analysis of the cerebrospinal fluid. In patients with meningitis caused by Lyme disease, analysis of the cerebrospinal fluid (CSF) often shows moderate pleocytosis (< 1000 cells/μl) with a predominance of lymphocytes. Patients with meningitis usually have an elevated protein concentration (>50 mg/dL) but a normal glucose level (45-80 mg/dL). Oligoclonal bands specific for B burgdorferi may be present.

Differential diagnosis

Depending on the clinical manifestations, Lyme disease is differentiated into the following conditions:

• Ankylosing spondylitis and rheumatoid arthritis

• Contact dermatitis

• Gout and pseudogout

• Annular granuloma

• Prion diseases

• Bell’s palsy

• Chronic fatigue syndrome (myalgic encephalomyelitis)

• Fibromyalgia

• Juvenile rheumatoid arthritis

• Systemic lupus erythematosus (SLE)

• Other diseases transmitted by ticks

Specialist consultations

In some cases, in particular when it is necessary to exclude other causes of existing complaints, there is a need to consult related specialists, such as a rheumatologist, dermatologist, cardiologist, neurologist, psychotherapist.

Treatment

The main goals of treatment are to eliminate the symptoms and signs of infection, prevent the development of complications and relapses of active infection.

For this, patients with confirmed Lyme disease are prescribed antibiotic therapy. The drugs of choice are doxycycline, amoxicillin, cefuroxime axetil. In case of intolerance to doxycycline and beta-lactams, azithromycin is used.

Drug therapy of erythema migrans

The duration of antibiotic therapy for patients with erythema migrans depends on the selected drug: doxycycline is prescribed at a dose of 100 mg 2 times a day for 10 days, amoxicillin is prescribed at a dose of 500 mg 3 times a day for 14 days or cefuroxime axetil at a dose of 500 mg 2 times for day for 14 days. In case of intolerance to doxycycline or beta-lactams, azithromycin is used for 5-10 days.

Antibiotic therapy of other clinical manifestations of Lyme disease has certain features.

Drug therapy of acute neurological manifestations

In patients with meningitis associated with Lyme disease, cranial neuropathy, radiculoneuropathy, or other manifestations of peripheral nervous system involvement, intravenous ceftriaxone, cefotaxime, penicillin G, or oral doxycycline should be used instead of other antimicrobial agents. The recommended duration of antibiotic therapy is 14–21 days.

Drug therapy of carditis

Outpatient treatment is indicated for patients: without clinical manifestations of myopericarditis, without arrhythmia, without II or III degree AV blockade, without I degree blockade with a PR interval ≥0.3 seconds. Outpatients with heart damage are prescribed oral antibacterial drugs: doxycycline, amoxicillin, cefuroxime, azithromycin.

Inpatient treatment is indicated for patients: with clinical manifestations of myopericarditis, with arrhythmias, with II or III degree AV block, with I degree AV block with a PR interval ≥0.3 sec. Inpatient patients with heart damage are prescribed parenteral antibacterial drugs: ceftriaxone in IV, cefotaxime IV, benzylpenicillin IV or IV. After the appearance of positive dynamics, it is possible to switch to oral antibiotics.

The duration of antibiotic therapy for Lyme carditis should be 14-21 days.

For patients with symptomatic bradycardia due to heart damage in Lyme disease that is not amenable to medical treatment, temporary electrical cardiostimulation is recommended.

Drug therapy of arthritis

Patients with Lyme arthritis are prescribed doxycycline, amoxicillin, or cefuroxime. The duration of antibiotic therapy for joint damage should be 28 days.

Borreliosis lymphocytoma

Antibiotic therapy with doxycycline, amoxicillin or cefuroxime for 14 days is recommended for patients with borreliosis lymphocytoma.

Chronic atrophic acrodermatitis

Antibiotic therapy with doxycycline, amoxicillin or cefuroxime for 21-28 days is recommended for patients with chronic atrophic acrodermatitis.

Tactics in case of ineffectiveness of antibiotic therapy

Patients who have persistent or recurrent nonspecific symptoms such as fatigue, pain, or cognitive impairment after recommended Lyme disease treatment, but who do not have objective evidence of reinfection or treatment failure, should not be given additional courses of antibiotic therapy.

Evidence of persistent infection or ineffectiveness of treatment is the preservation of objective signs of disease activity, such as arthritis, meningitis, or neuropathy.

Prevention

Individual protection measures

Persons at risk of infection should take personal protective measures to reduce the risk of being bitten by ticks and contracting the pathogens they transmit. To do this, when going to an area with a high probability of contact with ticks, it is recommended to wear light-colored clothes with long sleeves and pants, tuck your pants into socks or high shoes, and conduct a thorough check of your clothes and body after returning.

Use of repellents to prevent tick bites

For the prevention of tick bites, it is recommended to use products containing N,N-diethyl-meta-toluamide (DEET), picaridin, ethyl 3-(Nn-butyl-N-acetyl) aminopropionate (IR3535), oil of lemon eucalyptus (OLE), p-methane-3,8-diol (PMD), 2-undecanone or permethrin.

Removal of attached ticks

Given that the length of time a tick is attached to the skin is an extremely important predictor of developing Lyme disease (the likelihood of Lyme disease increases significantly after 36-48 hours), immediate removal of the attached tick is recommended. This is best done with clean, fine-tipped tweezers (or similar device) inserted between the body of the tick and the skin.

It is not advisable to burn the attached tick (with a match or other thermal intervention) or to use harmful chemicals or petroleum products to detach it.

After removing the tick, it is recommended to carry out a study to identify its species. But at the same time, it is not advisable to test the removed tick for B. Burgdorferi, because the presence or absence of this microorganism is not a reliable sign of the presence of infection.

Antibiotic prophylaxis

It is recommended to prescribe prophylactic antibiotic therapy for adults and children within 72 hours after removal of a high-risk tick.

The patient is prescribed a single dose of doxycycline at a dose of 200 mg for adults or 4.4 mg/kg (up to 200 mg) for children.

A tick bite is considered high-risk if it meets the following three criteria: the removed tick belongs to the Ixodes species; the bite occurred in a highly endemic area; the tick was attached for ≥36 hours.

If the tick bite is not high-risk, observation is recommended.

Post-Treatment Lyme Disease Syndrome ( PTLDS )

Post-treatment Lyme disease syndrome (PTLDS) is characterized by the presence of persistent (more than 6 months) symptoms (pain, fatigue, difficulty thinking) after the end of Lyme disease treatment.

The cause of this syndrome is unknown. Some experts believe that Borrelia burgdorferi can trigger an “autoimmune” reaction, causing symptoms that persist even after the infection has cleared. Other experts suggest that PTLDS is the result of a persistent but difficult-to-detect infection. Finally, some believe that the symptoms of PTLDS are due to other causes unrelated to Borrelia burgdorferi infection.

Unfortunately, there is no specific treatment for PTLDS. Studies have shown that long-term outcomes are no better for patients who receive additional long-term antibiotic treatment than for patients who receive placebo. Prolonged antibiotic treatment of Lyme disease is associated with serious, sometimes fatal, complications.

Patients with PTLDS usually improve over time, but this may take many months.

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Resources:

1. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. Clinical Infectious Diseases, Volume 72, Issue 1, 1 January 2021, Pages e1-e48. https://doi.org/10.1093/cid/ciaa1215
2. Official site of the Centers for Disease Control and Prevention. https://www.cdc.gov/lyme/treatment/index.html

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Сообщение Lyme disease появились сначала на ClinCaseQuest.

The onset of the consultation

1. Wash hands and put on PPE if necessary.
2. Introduce yourself to the patient by stating your name and role.
3. Confirm the patient’s last name, first name and date of birth.
4. Explain what the examination will involve using language the patient can understand.
5. Get consent for consultation.
6. Adequately expose the patient for examination.
7. Ask the patient if he is in pain before proceeding with the clinical examination.

Clarification of the main complaint

8. Use open-ended questions to explore the patient’s complaints
9. Details of the main complaint
10. Analyze the patient’s thoughts, fears, and expectations
11. Summarize the patient’s complaints

Comprehensive assessment

12. Assess other symptoms to get a comprehensive picture

Medical history

13. Find out when and how complaints first appeared; specify the possible reason for the appearance of these complaints; detailed identification of the circumstances that preceded bradycardia, for example, stress, physical exertion, taking medication or food; did the patient seek medical help, if so, to whom and how did his appeal end, if not, then specify why he did not seek medical help; whether the patient took medical drugs independently or as prescribed by the doctor, if so, whether the nature of the complaints changed
14. In case of a history of hospitalization due to symptomatic bradycardia, read the extract from the patient’s medical history, pay attention to the established clinical diagnosis, the results of the laboratory or instrumental examinations, the treatment and recommendations after discharge
15. If the patient has previously undergone laboratory or instrumental examinations for current complaints, analyze their results and indicate important findings
16. Find out what prompted the patient to contact you
17. Exclude other causes of existing complaints by asking the patient clarifying questions

History of life

18. Clarify whether the patient has previously been diagnosed with cardiovascular diseases, in particular myocardial infarction, angina pectoris, cardiomyopathy, congenital heart defects, myocarditis

19. Find out if the patient has previously been diagnosed with a rhythm and/or conduction disorder
20. Find out whether the patient suffers from infiltrative diseases, in particular sarcoidosis, hemochromatosis, amyloidosis; systemic diseases of connective tissue, such as rheumatoid arthritis, scleroderma, systemic lupus erythematosus; endocrine diseases, in particular hypothyroidism; neurological diseases accompanied by increased intracranial pressure
21. Find out if the patient has had previous surgical interventions, including prosthetic heart valves, coronary artery bypass grafting, Maze procedure, and find out how the post-operative period was
22. Find out whether the patient is taking medications, in particular digoxin, beta-adrenergic blockers, calcium channel antagonists, antiarrhythmics, potassium, magnesium, calcium preparations; specify the doses of the drugs
23. Find out if the patient has recently had an infectious disease and if the patient has been bitten by a tick
24. Find out if the patient has a drug or food intolerance and how it manifests itself
25. Find out if the patient has bad habits – drinking alcohol, drugs, smoking
26. Determine whether the patient’s blood relatives have had cardiovascular disease, including rhythm and/or conduction disorders
27. Find out the patient’s marital status, living conditions
28. Clarify whether the patient works, his profession, working conditions, the presence of harmful occupational factors 

Objective examination

29. Assessment of the patient’s general condition
30. Conducting a general inspection
31. Evaluation of the constitution  
32. Estimation of the degree of obesity
33. Skin and mucous membranes
34. Evaluation of thyroid glands
35. Assessment of peripheral lymph nodes
36. Assessment of respiratory organs
37. Evaluation of the cardiovascular system
38. Assessment of abdominal organs
39. Evaluation of organs of the genitourinary system

Laboratory examination

40. Blood analysis for electrolytes
41. Blood test for thyroid hormones and TSH
42. Clinical blood count (if needed)
43. Coagulogram (if necessary)
44. Blood test for creatinine and urea (if needed)
45. Blood test for troponin- I (if necessary)
46. Blood test for IgM and IgG antibodies to Borrelia (if necessary)
47. PCR for Borrelia burgdorferi DNA detection (if necessary)
48. Assessment of blood pH (if necessary)
49. Genetic testing (if needed)
50. Toxicological screening (if necessary)

Diagnostic tests

51. Electrocardiography in 12 leads
52. Transthoracic echocardiography
53. Ambulatory ECG monitoring (if necessary)
54. ECG test with dosed exercise (if necessary)
55. Coronary angiography (if necessary)
56. MRI of the heart (if necessary)
57. Positron emission tomography (if necessary)
58. Electrophysiological examination (if necessary)
59. Polysomnography (if necessary)

Making a clinical diagnosis

60. Identification of the underlying disease
61. Indication of the nature of the conduction disturbance that caused the bradycardia
62. Indication of comorbid pathology

Specialist consultations

63. Cardiologist
64. Cardiac surgeon
65. Arithmologist
66. Rheumatologist
67. Neuropathologist _
68. Endocrinologist
69. Nephrologist
70. Geneticist
71. Infectious Disease Specialist

Treatment

72. Emergency therapy
73. Long-term therapy (permanent cardiac stimulation)

Explain the procedure for cardiac stimulation

74. Check the patient’s understanding of the reason for the procedure
75. Check the patient’s understanding of the procedure
76. Inform about the stages of the procedure
77. Tell about the risks and complications
78. Carry out work on mitigating fears
79. Suggest an additional source of information

Consulting and support

80. Inform the patient about the disease
81. Explain to the patient the possible causes of the disease
82. Inform the patient of the symptoms that may occur with the identified disease
83. Discuss the results of the examinations with the patient
84. Explain to the patient the possible consequences of the disease
85. Educate the patient about available treatments
86. Help the patient understand the risks and benefits of different treatments
87. Answer the patient’s questions
88. Provide an explanation of the extent of monitoring during and after treatment
89. Schedule regular check-ups and follow-up to assess the effectiveness of treatment and changes in the patient’s condition

Monitoring the effectiveness of treatment

90. Clinical assessment
91. Instrumental assessment
92. Control over side effects of therapy

End of consultation

93. Summarize the data and ask the patient if anything important has been missed
94. Inform the patient about further tactics
95. Thank the patient
96. Dispose of PPE properly and wash hands

Key communication skills

97. Active listening
98. Summing up
99. Selection of indicative signs

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The beginning of the consultation

1. Wash hands and put on PPE if necessary.
2. Introduce yourself to the patient by stating your name and role.
3. Confirm the patient’s last name, first name, and date of birth.
4. Explain what the examination will involve using language the patient can understand.
5. Get consent for consultation.
6. Adequately expose the patient for examination.
7. Ask the patient if he is in pain before proceeding with the clinical examination.

Symptoms of bradycardia typically manifest when the heart rate falls below 50 beats per minute, often indicating signs of hypoperfusion in critical organs such as the brain and heart.

Clinical signs may include:

• Symptoms indicative of cerebral hypoperfusion (e.g., dizziness, blurred vision, loss of consciousness).
• Manifestations of compromised cardiac perfusion (e.g., chest pain, dyspnea, sensation of air insufficiency, diminished tolerance to physical exertion).
• General symptoms suggestive of inadequate blood supply to other organs and systems (e.g., weakness, heightened fatigue).

Clarification of the main complaint

8. Use open-ended questions to explore the patient’s complaints
9. Details of the main complaint
10. Analyze the patient’s thoughts, fears, and expectations
11. Summarize the patient’s complaints

• Use open-ended questions to explore the patient’s complaints
• Details of the main complaint

The most common complaints of a patient experiencing bradycardia often involve dizziness and potential loss of consciousness.

To further investigate complaints of dizziness, consider the following algorithm:

1. Circumstances preceding the onset of dizziness: Inquire about recent physical activity, body position changes, emotional stressors, food or drink consumption, and medication intake.
2. Onset: Determine if the dizziness occurs suddenly or develops gradually.
3. Description: Prompt the patient to articulate the sensations experienced during the episode of dizziness.
4. Intensity: Ask the patient to rate the severity of their dizziness on a scale from 0 to 10.
5. Associated symptoms: Inquire about any additional symptoms accompanying the dizziness.
6. Duration: Establish whether the dizziness occurs periodically or persists continuously.
7. Aggravating or alleviating factors: Identify any factors that exacerbate or relieve the intensity of dizziness, particularly changes in body position.

“Could you describe what happened before you started feeling dizzy?”

“Does the dizziness come on suddenly or does it develop gradually?”

“Can you please explain what sensations you experience when you feel dizzy?”

“On a scale from 0 to 10, how would you rate the severity of your dizziness?”

“Are there any other symptoms that occur along with the dizziness?”

“Does the dizziness occur constantly or does it happen periodically?”

“Are there any factors that make the dizziness worse or better?”

If the main complaint of your patient is an episode of loss of consciousness, follow this algorithm:

• Circumstances preceding loss of consciousness: physical activity, prolonged standing, change in body position, emotional stress, intake of food or medication, intense cough.
• Start: Find out if any symptoms preceded the loss of consciousness (dizziness, visual disturbances, sweating, nausea, palpitations, shortness of breath).
• Concomitant symptoms: Ask the person who witnessed the fainting episode if the fainting episode was accompanied by other symptoms (including convulsions, involuntary defecation or urination).
• Duration: Ask the witness about the duration of the episode of unconsciousness.
• Factors contributing to faster recovery of consciousness: horizontal position of the body, use of medication.

“Tell me what you were doing before you lost consciousness?”

“Tell me, was loss of consciousness preceded by dizziness, sweating, nausea, palpitations, shortness of breath?”

“How long was the patient unconscious?”

“Was the episode of unconsciousness accompanied by other symptoms?”

“Was there anything that helped you to restore the consciousness of the patient?”

Analyze the patient’s thoughts, fears, and expectations

A key component of history-taking is exploring the patient’s thoughts, concerns, and expectations to gain insight into how the patient currently perceives their condition, their concerns, and what they expect from the consultation.

The exploration of thoughts, concerns, and expectations should be fluid throughout the consultation in response to cues from the patient. This will help to make your consultation patient-oriented, rather than formulaic.

It is essential to structure the analysis of thoughts, fears, and expectations so that it sounds natural in your consultation.

Summarize the patient’s complaints

Summarize the patient’s complaint to ensure understanding and provide an opportunity for the patient to correct any inaccuracies. After summarizing, ask if there’s anything else the patient would like to add or clarify. Throughout the consultation, periodically summarize intermediate findings

Comprehensive assessment

12. Screen for symptoms of damage to other organs and systems

A comprehensive assessment involves briefly surveying the patient for symptoms of other systems, which may or may not be related to the chief complaint. This approach can help identify symptoms the patient may have overlooked.

Here are some examples of symptoms to monitor for each system:

Medical history

13. Find out when and how complaints first appeared; specify the possible reason for the appearance of these complaints; did the patient seek medical help, if so, to whom and how did his appeal end, if not, then specify why he did not seek medical help; whether the patient took medical drugs independently or as prescribed by the doctor, if so, whether the nature of the complaints changed

“When did you first experience these symptoms?”

“What do you think might be causing these symptoms?”

“Have you consulted a healthcare professional about this issue?”

14. In case of a history of hospitalization due to symptomatic bradycardia, read the patient’s medical history, pay attention to the established clinical diagnosis, the results of the laboratory or instrumental examinations, the treatment and recommendations after discharge
15. If the patient has previously undergone laboratory or instrumental examinations for current complaints, analyze their results and indicate important findings
16. Find out what prompted the patient to contact you

“What led you to reach out to me?”

“What prompted you to seek my assistance?”

17. Exclude other causes of existing complaints by asking the patient clarifying questions

“Do you experience shortness of breath or a sensation of air hunger?”

“Are you experiencing any chest pain?”

Other causes of dizziness:

• Cerebrovascular disorders

Dizziness is a relatively common symptom of impaired blood flow to the brain, but it’s not the only one. Alongside dizziness, patients typically report numbness or weakness in one side of the body, difficulty understanding speech or speaking, double vision, unsteadiness while walking, loss of balance, or coordination problems. Patients with impaired cerebral circulation often have a medical history of hypertension, rhythm disturbances (such as atrial fibrillation), diabetes mellitus, and dyslipidemia. Neurological examination may reveal deficits such as hemiparesis or hemiplegia, sensory or motor aphasia, nystagmus, facial asymmetry, deviation of the tongue from the midline, inability to perform the thumb-nose test, instability in Romberg’s sign, among others. Blood pressure and heart rate typically remain normal or may show slight increases.

• Hypoglycemia

Patients experiencing hypoglycemia often report severe hunger, pronounced weakness, and increased sweating alongside dizziness. They typically have a history of taking hypoglycemic medications, prolonged fasting, or engaging in excessive physical activity. These patients may appear agitated, with cold, clammy skin, and the doctor may observe tachycardia and a moderate increase in blood pressure. The initial agitation can rapidly transition to central nervous system depression, leading to loss of consciousness.

• Arterial hypertension

Dizziness commonly accompanies high blood pressure. Additionally, patients with arterial hypertension often report a throbbing or aching headache, nausea, and visual disturbances like flickering. During the physical examination, the doctor typically observes elevated blood pressure readings ≥140/90 mm Hg and often notes tachycardia.

• Arterial hypotension

Dizziness can manifest as a symptom of both high and low blood pressure. Patients with hypotension also commonly experience pronounced weakness, lethargy, drowsiness, and reduced tolerance to physical exertion. These patients often have a history of taking vasodilators, diuretics, experiencing repeated vomiting, diarrhea, bleeding, or adhering to a diet with limited salt and water intake. During the physical examination, the doctor may observe pallor of the skin, increased sweating, cold extremities, and a decrease in blood pressure ≤90/60 mm Hg, accompanied by reduced urine output.

• Anemia

Dizziness is a common symptom of chronic anemia. Alongside dizziness, patients with anemia often report persistent pronounced weakness, increased fatigue, palpitations, shortness of breath, brittle nails and hair, pain in the tongue, and alterations in food preferences and taste. In their medical history, patients may mention dietary changes, avoidance of animal protein, gastrointestinal diseases, gastrointestinal surgeries, pregnancy, chronic hemorrhoidal bleeding, or prolonged menstruation. Physical examination typically reveals pallor of the skin and mucous membranes, tachycardia, a small, frequent pulse, and a functional systolic murmur.

• Meniere’s disease

Characteristic symptoms of Ménière’s disease include systemic dizziness, tinnitus, and progressive hearing loss. Typically, these symptoms occur in an episodic manner, often in the morning or at night, triggered by psychological or physical stressors. During an episode, patients may experience nausea, vomiting, and coordination disturbances. The duration of these episodes can range from a few minutes to several days, with the average being several hours.

Other reasons for episodes of loss of consciousness:

• Vasovagal syncope

Vasovagal syncope is a type of reflex syncope triggered by severe stress (such as fear, pain, the sight of blood, or medical procedures) or prolonged standing in an upright position. It typically develops gradually and is often preceded by symptoms like dizziness, visual disturbances, nausea, and increased sweating. During a vasovagal syncope episode, patients may experience involuntary movements, hypotension, and a decrease in heart rate. The duration of the episode usually does not exceed 1 minute, and patients typically regain consciousness spontaneously.

• Situational syncope

Situational syncope is another type of reflex syncope that occurs due to a sudden increase in intra-abdominal pressure, such as during a forceful cough, defecation, urination, or after eating a large meal. Similar to vasovagal syncope, situational syncope tends to develop gradually, with preceding symptoms like dizziness, nausea, and visual disturbances. During the episode, the patient may exhibit pallor, bradycardia, and hypotension. Situational syncope episodes typically last no more than 1 minute, and patients often regain consciousness spontaneously.

• Carotid sinus syndrome

Carotid sinus syndrome is characterized by hypersensitivity of the carotid sinus, often triggered by actions like a sharp turn of the head, wearing a tight collar, or shaving the neck. Before losing consciousness, patients may experience symptoms such as visual dimming and dizziness. During an episode of carotid syncope, marked pallor of the skin, along with a decrease in heart rate and blood pressure, is typically observed.

• Syncope due to orthostatic hypotension

Syncope due to orthostatic hypotension, on the other hand, occurs when there is a sudden drop in blood pressure upon moving from a horizontal to a vertical position. This type of syncope is commonly seen in the elderly and in individuals taking medications like diuretics, vasodilators, and antidepressants. Patients may also have hypovolemia due to conditions such as bleeding, repeated diarrhea, or vomiting. Diagnosis involves measuring blood pressure in both horizontal and vertical positions. A difference in systolic pressure of ≥20 mm Hg and/or diastolic pressure of ≥10 mm Hg upon changing positions suggests orthostatic hypotension. Unlike carotid sinus syndrome, patients with syncope due to orthostatic hypotension typically exhibit tachycardia rather than bradycardia.

• Syncope due to cerebrovascular disease

Syncope resulting from cerebral ischemia is typically accompanied by various neurological symptoms, including speech disorders, facial asymmetry, hemiparesis or hemiplegia, meningeal symptoms, ataxia, and others.

History of life

18. Clarify whether the patient has previously been diagnosed with cardiovascular diseases, in particular myocardial infarction, angina pectoris, cardiomyopathy, congenital heart defects, myocarditis
19. Find out if the patient has previously been diagnosed with a rhythm and/or conduction disorder
20. Find out whether the patient suffers from infiltrative diseases, in particular sarcoidosis, hemochromatosis, amyloidosis; systemic diseases of connective tissue, such as rheumatoid arthritis, scleroderma, systemic lupus erythematosus; endocrine diseases, in particular hypothyroidism; neurological diseases accompanied by increased intracranial pressure
21. Find out if the patient has had previous surgical interventions, including prosthetic heart valves, coronary artery bypass grafting, Maze procedure, and find out how the post-operative period was
22. Find out if the patient is taking medications, including digoxin, beta-adrenergic blockers, calcium channel antagonists, antiarrhythmics, psychoactive drugs, clonidine, potassium, magnesium, calcium drugs; specify the doses of the drugs
23. Find out if the patient has recently had an infectious disease and if the patient has been bitten by a tick
24. Find out if the patient has a drug or food intolerance and how it manifests itself
25. Find out if the patient has bad habits – drinking alcohol, drugs, smoking
26. Determine whether the patient’s blood relatives have had cardiovascular disease, including rhythm and/or conduction disorders
27. Find out the patient’s marital status, living conditions
28. Clarify whether the patient works, his profession, working conditions, the presence of harmful occupational factors 

Objective examination

29. Assessment of the patient’s general condition

30. Conducting a general inspection
31. Evaluation of the constitution  
32. Estimation of the degree of obesity
33. Skin and mucous membranes
34. Evaluation of thyroid glands
35. Assessment of peripheral lymph nodes
36. Assessment of respiratory organs
37. Evaluation of the cardiovascular system
38. Assessment of abdominal organs
39. Evaluation of organs of the genitourinary system

Assess for objects or equipment on or around the patient that may provide useful information about the patient’s medical history and current clinical condition.

The key, and sometimes the only, objective sign of symptomatic bradycardia is a slowing of the heart rate (HR) to less than 60 beats per minute.

In the case of a moderate decrease in heart rate, blood pressure remains normal, but with a significant decrease in heart rate, hypotension often occurs.

With a significant decrease in heart rate, acute heart failure may occur with the appearance of moist rales in the lungs, tachypnea, and cyanosis.

In the case of a disruption of the blood supply to the brain, a disturbance of consciousness is often observed.

Additionally, during the physical examination, it is important to pay attention to signs of a disease that has led to a decrease in heart rate.

Thus, additional III or IV heart sounds, gallop rhythm, systolic noise of mitral regurgitation, paradoxical splitting of the II sound, congestive rales in the lungs can suggest coronary heart disease.

In patients with myocarditis, weakening of the I heart tone, an additional III heart tone is often detected, and in those with congestion alongside myocarditis, an accent of the II tone is heard over the pulmonary artery, wet fine-vesicular rales, and swelling of the lower extremities.

In patients with restrictive cardiomyopathy, the systolic murmur of mitral regurgitation, weakening of the first heart sound, wet, small bubbling rales in the lungs, ascites, edema of the lower extremities, hepatomegaly, and swelling of the jugular veins can be detected in the late stages of the disease.

Endocarditis may be indicated by the detection during a physical examination of a characteristic skin shade similar to coffee with milk, systolic or diastolic regurgitation noise over the affected valve, Osler nodules (painful, red nodules on the fingers and toes), Janeway spots (painless hemorrhagic spots on the palms and soles), hepato- and splenomegaly.

In patients with sarcoidosis, skin changes such as erythema nodosum, papular or spot-papular rashes, small ulcers, generalized lymphadenopathy, moist rales in the lungs, hepatomegaly, and enlargement of the parotid salivary gland can be observed.

Bronze skin shade, ascites, swelling of the lower extremities, and signs of liver cirrhosis may indicate hemochromatosis.

Rheumatoid arthritis should be suspected in patients with signs of inflammation and deformation of the metacarpophalangeal and proximal interphalangeal joints.

Discoloration of the skin of the fingers and toes, thickening and atrophy of the skin, formation of radial wrinkles around the mouth, ulcers on the tips of the fingers, and telangiectasia may indicate scleroderma.

Dry skin, hair loss, hoarseness of voice, facial swelling, and hypotonia can indicate hypothyroidism.

Laboratory examination

40. Blood analysis for electrolytes (required)

41. Blood test for thyroid hormones and TSH (required)
42. Clinical blood count (if needed)
43. Coagulogram (if necessary)
44. Blood test for creatinine and urea (if needed)
45. Blood test for troponin- I (if necessary)
46. Blood test for IgM and IgG antibodies to Borrelia (if necessary)
47. PCR for Borrelia burgdorferi DNA detection (if necessary)

48. Assessment of blood pH (if necessary)
49. Genetic testing (if needed)
50. Toxicological screening (if necessary)

• Blood test for electrolytes (required )

A blood test for potassium, calcium, and magnesium levels is a crucial laboratory assessment in patients presenting with symptomatic bradycardia to diagnose electrolyte imbalances. Hypokalemia, hyperkalemia, hypercalcemia, and hypermagnesemia are recognized causes of significant bradycardia.

• Blood test for thyroid hormones and TSH ( required )

A blood test for thyroid hormones and TSH is a crucial laboratory assessment in patients with symptomatic bradycardia, as hypothyroidism frequently manifests with a slow heart rate and conduction disturbances.

• Clinical blood test (if needed)

Clinical blood count is not typically considered mandatory for patients presenting with symptomatic bradycardia. However, it becomes necessary as part of pre-procedural preparations for pacemaker implantation.

• Coagulogram (if necessary)

A coagulogram is indeed included in the list of laboratory tests performed on patients with symptomatic bradycardia before a permanent cardiac pacing procedure to assess blood coagulation activity.

• Blood test for creatinine and urea (if needed)

Blood tests for creatinine and urea are indeed included in the list of laboratory tests performed in patients with symptomatic bradycardia before the procedure of permanent cardiac pacing.

• Blood test for troponin- I (if necessary)

A blood test for troponin-I is indeed performed in patients with symptomatic bradycardia when myocardial ischemia is suspected.

• Blood test for IgM and IgG antibodies to Borrelia (if necessary)

A blood test for IgM and IgG antibodies to Borrelia is indeed performed in patients with symptomatic bradycardia when Lyme disease is suspected.

• PCR for Borrelia burgdorferi DNA detection (if necessary)

Additionally, PCR for Borrelia burgdorferi DNA detection may be necessary in certain cases.

• Assessment of blood pH level (if necessary)

Assessment of blood pH level is also important in patients with symptomatic bradycardia, especially when metabolic acidosis is suspected, as it can contribute to bradycardia.

• Genetic testing (if needed)

Genetic testing for SCN5A and TRPM4 gene mutations may be needed in patients with symptomatic bradycardia, particularly when there is suspicion of a hereditary component to the rhythm or conduction disorder, especially in patients under the age of 50 who are experiencing symptoms.

• Toxicological screening (if necessary)

Toxicological screening is indeed indicated for suspected bradycardia induced by the action of a toxic substance or drug. For instance, when an overdose of cardiac glycosides is suspected, determining the level of digoxin in the blood is essential. Other tests aimed at detecting toxic substances in the body exist, but they typically require the involvement of a toxicologist.

Diagnostic tests

51. Electrocardiography in 12 leads (required)

52. Transthoracic echocardiography (mandatory)
53. Ambulatory ECG monitoring (if necessary)
54. ECG test with dosed exercise (if necessary)
55. Coronary angiography (if necessary)
56. MRI of the heart (if necessary)
57. Positron emission tomography (if necessary)
58. Electrophysiological examination (if necessary)
59. Polysomnography (if necessary)

• Electrocardiography in 12 leads ( required )

Electrocardiography (ECG) in 12 leads is indeed a crucial method of examination for all patients with symptomatic bradycardia.

The primary causes of symptomatic bradycardia typically involve sinus node weakness syndrome and atrioventricular conduction disorders.

Manifestations of sinus node weakness syndrome encompass various abnormalities such as persistent sinus bradycardia, ectopic atrial bradycardia, sinoatrial block of different degrees, pacemaker migration, sinus node arrest with a pause lasting more than 3 seconds, bradysystolic form of atrial fibrillation, tachy-brady syndrome, and chronotropic incompetence.

ECG signs of persistent sinus bradycardia manifest as a sustained reduction in heart rate to less than 50 beats per minute.

Figure 1. Atrial fibrillation. Image sourced from litfl.com internet resource. https://litfl.com/sinus-bradycardia-ecg-library

ECG signs of second-degree sinoauricular block include periodic loss of the PQRST complex, with the duration of the pause equal to the sum of two or more normal RR complexes of the underlying rhythm. During these pauses, substitute complexes originating from the AV node or ventricles may appear.

Figure 2. Second-degree sinoauricular block. Image sourced from litfl.com internet resource. https://litfl.com/sinoatrial-exit-block-ecg-library

ECG signs of complete sinoauricular block include the complete cessation of sinus rhythm with the appearance of a replacement rhythm, typically originating from the AV node.

Figure 3. Complete sinoauricular block. Image from litfl.com internet resource. https://litfl.com/sinus-node-dysfunction-sick-sinus-syndrome

ECG signs of pacemaker migration include a gradual change in the shape and polarity of the P wave from cycle to cycle.

Figure 4. Migration of the pacemaker. Image https://therapy.odmu.edu.ua/ecg-online-course/wandering-pacemaker

ECG signs of tachy-brady syndrome include alternating episodes of acceleration and deceleration of the heart rate.

Figure 5. Tachy-brady syndrome. Image from litfl.com internet resource. https://litfl.com/sinus-node-dysfunction-sick-sinus-syndrome

ECG signs of Mobitz I second-degree AV block include progressive lengthening of the PQ interval with periodic loss of QRS complexes.

Figure 6. Second-degree AV block II, Mobitz I. Image from the internet resource litfl.com. https://litfl.com/av-block-2nd-degree-mobitz-i-wenckebach-phenomenon

ECG signs of Mobitz II second-degree AV block include stable prolongation of the PQ interval with periodic loss of QRS complexes.

Figure 7. Second-degree AV-block, Mobitz II. Image from litfl.com internet resource. https://litfl.com/av-block-2nd-degree-mobitz-ii

ECG signs of third-degree AV block include complete dissociation of atrial and ventricular waves, with the atrial contraction frequency significantly exceeding the frequency of ventricular activation.

Figure 8. Third-degree AV block. Image from litfl.com internet resource. https://litfl.com/av-block-3rd-degree-complete-heart-block

• Transthoracic echocardiography (mandatory)

Transthoracic echocardiography is a crucial examination method for all patients presenting with symptomatic bradycardia. It aids in identifying myocardial structural abnormalities that could contribute to heart rate slowing, assessing left ventricular systolic function, and diagnosing potentially reversible causes of cardiac conduction disturbances.

• Ambulatory ECG monitoring (if necessary)

Ambulatory ECG monitoring is recommended when there’s a need to confirm the direct relationship between ECG changes and clinical manifestations.

• ECG test with dosed exercise (if necessary)

An ECG test with dosed exercise is conducted for patients who develop bradycardia during or immediately after physical activity. If symptoms arise during exercise, it may suggest a cardiac cause, while post-exercise bradycardia could indicate a reflex mechanism.

• Coronary angiography (if necessary)

Coronary angiography is indicated for patients with suspected ischemic causes of bradycardia or those with a significant family history.

• MRI of the heart (if necessary)

MRI of the heart is performed to investigate suspected inflammatory or infiltrative heart diseases contributing to bradycardia.

• Positron emission tomography (if necessary)

Positron emission tomography aids in complex cases by detecting myocardial inflammation foci.

• Electrophysiological examination (if necessary)

Electrophysiological examination serves as an adjunct when non-invasive methods fail to record bradycardia. It’s particularly useful for identifying sinus node dysfunction or pinpointing the site of impaired AV conduction.

• Polysomnography (if necessary)

Polysomnography is conducted for patients experiencing nocturnal bradycardia episodes, often associated with obstructive sleep apnea syndrome.

Differential diagnosis

Diagnosing symptomatic bradycardia typically isn’t challenging, but determining its cause can be more complex.

Common causes include acute myocardial ischemia, overdose of medications like cardiac glycosides, beta-blockers, and calcium channel antagonists, hyperkalemia, hypothermia, and hypoxia.

Acute myocardial ischemia presents with chest pain radiating to the left arm, scapula, or epigastrium. Elevated myocardial necrosis markers (troponin-I/T, CK-MB), along with characteristic ECG changes (ST segment elevation/depression, pathological Q wave, T wave inversion), are observed. Heart conduction issues often accompany ischemia affecting the lower left ventricular wall, considering the shared vascular supply.

Glycoside intoxication manifests as dyspeptic symptoms (anorexia, nausea, vomiting, diarrhea), visual disturbances (yellowish perception), and pulse slowing to asystole. ECG findings include ventricular extrasystoles, PQ interval prolongation, pacemaker migration, and trough-like ST segment depression. Suspected cases warrant digoxin-level assessment.

Beta-adrenergic blockers or calcium channel antagonist overdose leads to sinus and AV node depression with a substitute rhythm. Symptoms range from mild fatigue to dizziness and syncope. Detailed history-taking aids in diagnosis.

Hyperkalemia occurs in severe renal impairment, ACE inhibitor/sartan use, potassium supplements, aldosterone receptor blockers, rhabdomyolysis, metabolic acidosis, and sepsis. Diagnosis involves serum potassium assessment, and ECG may show high-amplitude T waves and intraventricular conduction abnormalities.

Hypothermia-induced bradycardia arises from prolonged cold exposure, typically exhibiting Osborne waves on the ECG.

Hypoxia, with blood oxygen saturation below 95%, presents with headache, dizziness, pallor, rapid breathing, and impaired memory and attention. Pulse oximetry is the primary diagnostic tool. Identifying the underlying cause of hypoxia – cardiovascular or respiratory diseases, anemia, vasculitis, altitude exposure, suffocation, drowning – is crucial. The effectiveness of oxygen therapy in restoring normal heart rhythm confirms the link between hypoxia and AV conduction slowing.

Making a clinical diagnosis

60. Identification of the underlying disease
61. Indication of the nature of the conduction disturbance that caused the bradycardia
62. Indication of comorbid pathology

• Identification of the underlying disease

Given that bradycardia is typically a manifestation or complication of an underlying disease, it’s crucial to first specify the primary diagnosis and then the associated rhythm disturbance. This approach aligns with existing classifications and ensures clarity in diagnosis.

• Indication of the nature of the conduction disturbance that caused the bradycardia

When identifying the conduction disturbance causing bradycardia, denote its type and degree: first-, second-, or third-degree sinoauricular block or atrioventricular block.

• Indication of comorbid pathology

In formulating the clinical diagnosis, specify any comorbid conditions according to established classifications.

Specialist consultations

63. Cardiologist
64. Cardiac surgeon
65. Arithmologist
66. Rheumatologist
67. Neuropathologist _
68. Endocrinologist
69. Nephrologist
70. Geneticist
71. Infectious Disease Specialist

A cardiologist serves as the primary specialist overseeing the management of bradycardia. They lead the diagnostic and treatment process, conducting thorough examinations, taking medical histories, prescribing treatment protocols, monitoring patient progress, and making necessary adjustments.

• Cardiac surgeon

Consultation with a cardiac surgeon becomes necessary when bradycardia is suspected to be induced by myocardial ischemia or a heart defect. The cardiac surgeon performs surgical corrections for these conditions, which can help alleviate bradycardia.

• Arithmologist

Given that pathological heart rate slowing often stems from sinus node weakness syndrome or AV conduction disturbances, an arrhythmologist’s assistance is invaluable. They determine the nature of existing rhythm or conduction disorders, including through electrophysiological studies, and if required, perform pacemaker implantation.

• Rheumatologist

If collagenosis is suspected as the cause of bradycardia, consulting a rheumatologist is necessary. Through additional laboratory or instrumental examinations, this specialist can confirm or rule out autoimmune connective tissue pathology.

• Neurologist

A neurologist’s consultation is necessary if a neurogenic cause of bradycardia is suspected, particularly due to central nervous system injuries or tumors leading to increased intracranial pressure. Additionally, since symptomatic bradycardia often coincides with alterations in mental status, a neurologist aids in differential diagnosis, especially against acute cerebral circulation disruptions.

• Endocrinologist

If hypothyroidism is suspected as the cause of symptomatic bradycardia, consultation with an endocrinologist is warranted.

• Nephrologist

Hyperkalemia is a common cause of slow heart rate, particularly in patients with severe renal impairment, necessitating consultation with a nephrologist.

• Geneticist

When hereditary conduction system disorders are suspected, especially if symptoms manifest before the age of 50 and progress over time, genetic consultation is essential.

• Infectious Disease Specialist

Consultation with an infectious disease specialist is advisable if an infectious disease is suspected as the cause of symptomatic bradycardia, such as Lyme disease or diphtheria.

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Treatment

72. Emergency therapy
73. Long-term therapy (permanent cardiac stimulation)

• Emergency therapy

When administering emergency care to a patient with symptomatic bradycardia, it’s crucial to adhere to the following algorithm of actions:

1. Ensure the patency of the respiratory tract.
2. Initiate oxygen therapy for hypoxemia (blood oxygen saturation <90%).
3. Monitor heart rate and blood pressure.
4. Establish intravenous access.
5. Consider potential causes of symptomatic bradycardia (discontinue drugs and, if possible, administer their antidotes; perform myocardial revascularization in acute ischemia; correct hyperkalemia).

In case of the development of hypotension, impaired consciousness, symptoms of acute heart failure, or myocardial ischemia, medical treatment is indicated:

• Administer atropine in a dose of 0.5-1.0 mg IV, with the possibility of repeated administration every 3-5 minutes if necessary (maximum dose – 3 mg).
• If atropine is ineffective, consider using dopamine at a dose of 5-20 μg/kg/min. or epinephrine at a dose of 0.02-0.2 μg/kg/min. IV drip.

If drug treatment proves ineffective, electrocardiostimulation is indicated, with preference given to temporary transvenous cardiostimulation. If transvenous cardiostimulation is not feasible, transcutaneous cardiostimulation may be considered.

It’s worth noting that administering aminophylline in a dose of 250 mg IV as a bolus is recommended for patients with second or third-degree AV block occurring against the backdrop of an acute lower myocardial infarction.

In cases of overdose with calcium channel antagonists, consider administering a 10% solution of calcium chloride in a dose of 1-2 g every 10-20 minutes intravenously or as an intravenous infusion at a rate of 0.2-0.4 ml/kg/h; alternatively, a 10% solution of calcium gluconate can be given in a dose of 3-6 g every 10-20 minutes intravenously or as an intravenous infusion at a rate of 0.6-1.2 ml/kg/h.

For beta-adrenergic blocker overdose, glucagon may be used at a dose of 3-10 mg IV as an infusion at a rate of 3-5 mg/h.

In cases of digoxin overdose, consider administering digibind at a rate of 1 vial to bind 0.5 mg of digoxin in the blood.

Patients with a transplanted heart or those with sinus node weakness syndrome due to spinal cord injury may benefit from aminophylline at a dose of 6 mg/kg, dissolved in 100-200 ml of physiological solution IV drip over 20-30 minutes, or theophylline 300 mg IV followed by oral administration at a dose of 5-10 mg/kg.

ACLS Bradycardia Algorithm

• Long-term therapy (permanent cardiac stimulation)

The choice of long-term therapy for patients with sinus node weakness syndrome depends on the presence of bradycardia symptoms:

• Observation is indicated for asymptomatic patients with sinus bradycardia or sinus pauses caused by sinus node syndrome, vagotonia, or nocturnal sleep apnea syndrome. Continuous cardiac stimulation may cause more harm than good in these cases.
• Symptomatic patients with bradycardia caused by sinus node syndrome are indicated for continuous pacing to increase heart rate and improve symptoms.

The choice of cardiac stimulation type depends on the frequency of necessary stimulation and the presence of concomitant pathology:

• For infrequent stimulation or in the presence of severe concomitant pathology, single-chamber ventricular cardiostimulation is advisable.
• If frequent stimulation is necessary, and there is no severe concomitant pathology with normal AV conduction, single-chamber atrial cardiostimulation is recommended.
• If frequent stimulation is necessary without severe concomitant pathology but with impaired AV conduction, two-chamber cardiostimulation is recommended.

Long-term therapy for patients with AV conduction disorders depends on the severity of the blockade and bradycardia symptoms:

• Asymptomatic patients with first-degree AV block or Mobitz type I second-degree AV block are observed; continuous cardiac stimulation may not be beneficial.
• Symptomatic patients with first-degree AV block or Mobitz type I second-degree AV block may consider permanent pacing.
• Symptomatic patients with Mobitz type II second-degree AV block and third-degree AV block are recommended for permanent cardiac stimulation.

The choice of cardiac stimulation type depends on the required frequency of stimulation and concomitant pathology:

• For infrequent stimulation or severe concomitant pathology, single-chamber ventricular cardiostimulation is advisable.
• For frequent stimulation without severe concomitant pathology, single-chamber ventricular cardiostimulation is recommended, especially for patients with a permanent form of atrial fibrillation.
• For frequent stimulation without severe concomitant pathology and without a permanent form of atrial fibrillation, two-chamber cardiostimulation is recommended.

Explain the procedure for cardiac stimulation

74. Check the patient’s understanding of the reason for the procedure

• “Do you understand the reason for performing this procedure on you?”
• “Do you understand the importance of carrying out this procedure for you?”

75. Check the patient’s understanding of the procedure

“Did you understand the procedure?”

76. Inform about the stages of the procedure

“I would like to explain to you what electrical cardiostimulation is and how it is performed. Electrical cardiac stimulation is a medical procedure aimed at normalizing the heart rhythm. Before conducting electrical cardiostimulation, you will be given a sedative and painkiller so that you feel comfortable and do not have any unpleasant sensations. After that, the surgeon will make a small skin incision under your collarbone and insert a special electrode into the subclavian vein. Under X-ray control, the doctor will lead this electrode to your heart and fix it in the right place. Then the surgeon will make a small pocket under your skin on the chest where a special pacemaker device will be located. This device will generate electrical impulses that will be conducted through the electrode to your heart. Thanks to this, your heart will contract in the correct rhythm. During the entire procedure and for some time after it, an experienced medical staff will be by your side, who will carefully monitor your condition.”

77. Talk about the risks and complications

“This procedure is quite safe, but sometimes patients may experience complications, for example, hematoma in the area of the formed subcutaneous pocket, infection, or displacement of the electrode. However, we will do everything possible to minimize the risk of their development.”

78. Do the work of mitigating fears

• “This procedure is routine for our clinic.”
• “This procedure is constantly performed in our department.”

79. Suggest an additional source of information

“You can learn more about the cardiac pacing procedure by reading the information in this booklet“

Consulting and support

80. Inform the patient about the disease
81. Explain to the patient the possible causes of the disease
82. Inform the patient of the symptoms that may occur with the identified disease
83. Discuss the results of the examinations with the patient
84. Explain to the patient the possible consequences of the disease
85. Educate the patient about available treatments
86. Help the patient understand the risks and benefits of different treatments
87. Answer the patient’s questions
88. Provide an explanation of the extent of monitoring during and after treatment
89. Schedule regular check-ups and follow-up to assess the effectiveness of treatment and changes in the patient’s condition

Monitoring the effectiveness of treatment

90. Clinical assessment

The effectiveness of treatment is clinically assessed by evaluating both subjective symptoms reported by the patient and objective parameters of the body’s functioning. Effective treatment should alleviate or significantly reduce symptoms associated with insufficient organ and system blood supply due to bradycardia. These symptoms may include fatigue, decreased tolerance to physical activity, dizziness, fainting, chest discomfort, and shortness of breath.

91. Studies to assess the presence of bradycardia

Objective assessment of bradycardia severity requires regular electrocardiography and, if necessary, daily Holter ECG monitoring. These tests provide valuable information about heart rhythm patterns and any fluctuations in heart rate over time.

92. Control over side effects of therapy

Following pacemaker implantation, patients should be monitored for potential side effects or complications. Common complications include discomfort or pain at the implantation site, hematoma formation, infection at the pacemaker site, systemic infection, allergic reactions to pacemaker materials, and impaired wound healing. Patients should be educated about these potential side effects and instructed to seek immediate medical attention if they experience any symptoms suggestive of these complications. Early detection and intervention are crucial for managing complications effectively.

End of consultation

93. Summarize the data and ask the patient if anything important has been missed
94. Inform the patient about further tactics

Hospitalization in a specialized cardiology hospital is recommended for a comprehensive examination and the selection of optimal treatment strategies. Ensure the patient’s Informed Voluntary Consent for diagnosis and treatment and obtain agreement for processing personal data.

95. Thank the patient
96. Dispose of PPE properly and wash hands

Key communication skills

97. Active listening
98. Summing up
99. Selection of indicative signs

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In this consultation model, five stages are distinguished, successively replacing each other (beginning of the consultation, gathering information, review, explanation, and planning, and conclusion of the consultation). At each stage, there are tasks that must be solved using certain skills. There are also two continuous processes that go from the beginning to the end of the consultation (structuring, and building a trusting relationship).

INITIATING THE SESSION

Establishing initial rapport

1. Greets patient and obtains patient’s name

2. Introduces self, role, and nature of interview; obtains consent if necessary

3. Demonstrates respect and interest, attends to patient’s physical comfort

Identifying the reason(s) for the consultation

4. Identifies the patient’s problems or the issues that the patient wishes to address with an appropriate opening question (e.g. “What problems brought you to the hospital?” or “What would you like to discuss today?” or “What questions did you hope to get answered today?”)

5. Listens attentively to the patient’s opening statement, without interrupting or directing the patient’s response

6. Confirms list and screens for further problems (e.g. “so that’s headaches and tiredness; anything else……?”)

7. Negotiates agenda taking both patient’s and physician’s needs into account

GATHERING INFORMATION

Exploration of patient’s problems

8. Encourages patient to tell the story of the problem(s) from when first started

to the present in own words (clarifying the reason for presenting now)

9. Uses open and closed questioning techniques, appropriately moving from open to closed

10. Listens attentively, allowing the patient to complete statements without interruption and leaving space for the patient to think before answering or go on after pausing

11. Facilitates patient’s responses verbally and non–verbally e.g. use of encouragement, silence, repetition, paraphrasing, interpretation

12. Picks up verbal and non–verbal cues (body language, speech, facial expression, affect); checks out and acknowledges as appropriate

13. Clarifies patient’s statements that are unclear or need amplification (e.g. “Could you explain what you mean by light-headed”)

14. Periodically summarises to verify own understanding of what the patient has said; invites the patient to correct interpretation or provide further information.

15. Uses concise, easily understood questions and comments, avoids or adequately explains jargon

16. Establishes dates and sequence of events

Additional skills for understanding the patient’s perspective

17. Actively determines and appropriately explores:

• patient’s ideas (i.e. beliefs re cause)
• patient’s concerns (i.e. worries) regarding each problem
• patient’s expectations (i.e., goals, what help the patient had expected for each problem)
• effects: how each problem affects the patient’s life

18. Encourages patient to express feelings

PROVIDING STRUCTURE

Making organization overt

19. Summarises at the end of a specific line of inquiry to confirm understanding

20. Progresses from one section to another using signposting, and transitional statements; includes the rationale for next section

Attending to flow

21. Structures the interview in a logical sequence

22. Attends to timing and keeping interview on task

BUILDING RELATIONSHIP

Using appropriate non-verbal behavior

23. Demonstrates appropriate non–verbal behavior

• eye contact, facial expression
• posture, position & movement
• vocal cues e.g. rate, volume, tone

24. If reads write notes, or uses a computer, does in a manner that does not interfere with dialogue or rapport

25. Demonstrates appropriate confidence

Developing rapport

26. Accepts legitimacy of patient’s views and feelings; is not judgmental

27. Uses empathy to communicate understanding and appreciation of the patient’s feelings or predicament; overtly acknowledges patient’s views and feelings

28. Provides support: expresses concern, understanding, and willingness to help; acknowledges coping efforts and appropriate self-care; offers partnership

29. Deals sensitively with embarrassing and disturbing topics and physical pain, including when associated with physical examination

Involving the patient

30. Shares thinking with patient to encourage patient’s involvement (e.g. “What I’m thinking now is….”)

31. Explains rationale for questions or parts of physical examination that could appear to be non-sequiturs

32. During physical examination, explains process, asks permission

EXPLANATION AND PLANNING

Providing the correct amount and type of information

33. Chunks and checks: gives information in manageable chunks, checks for understanding, uses patient’s response as a guide to how to proceed

34. Assesses patient’s starting point: asks for patient’s prior knowledge early on when giving information, discovers extent of patient’s wish for information

35. Asks patients what other information would be helpful e.g. aetiology, prognosis

36. Gives explanation at appropriate times: avoids giving advice, information or reassurance prematurely

Aiding accurate recall and understanding

37. Organises explanation: divides into discrete sections, develops a logical sequence

38. Uses explicit categorisation or signposting (e.g. “There are three important things that I would like to discuss. 1st…” “Now, shall we move on to.”)

39. Uses repetition and summarising to reinforce information

40. Uses concise, easily understood language, avoids or explains jargon

41. Uses visual methods of conveying information: diagrams, models, written information and instructions

42. Checks patient’s understanding of information given (or plans made): e.g. by asking patient to restate in own words; clarifies as necessary

Achieving a shared understanding: incorporating the patient’s perspective

43. Relates explanations to patient’s illness framework: to previously elicited ideas, concerns and expectations

44. Provides opportunities and encourages patient to contribute: to ask questions, seek clarification or express doubts; responds appropriately

45. Picks up verbal and non-verbal cues e.g. patient’s need to contribute information or ask questions, information overload, distress

46. Elicits patient’s beliefs, reactions and feelings re information given, terms used; acknowledges and addresses where necessary

Planning: shared decision making

47. Shares own thinking as appropriate: ideas, thought processes, dilemmas

48. Involves patient by making suggestions rather than directives

49. Encourages patient to contribute their thoughts: ideas, suggestions and preferences

50. Negotiates a mutually acceptable plan

51. Offers choices: encourages patient to make choices and decisions to the level that they wish 52. Checks with patient if accepts plans, if concerns have been addressed

CLOSING THE SESSION

Forward planning

53. Contracts with patient re next steps for patient and physician

54. Safety nets, explaining possible unexpected outcomes, what to do if plan is not working, when and how to seek help

Ensuring appropriate point of closure

55. Summarises session briefly and clarifies plan of care

56. Final check that patient agrees and is comfortable with plan and asks if any corrections, questions or other items to discuss

OPTIONS IN EXPLANATION AND PLANNING (includes content)

Discussing investigations and procedures

57. Provides clear information on procedures, eg, what patient might experience, how patient will be informed of results

58. Relates procedures to treatment plan: value, purpose

59. Encourages questions about and discussion of potential anxieties or negative outcomes

Discussing opinion and significance of problem

60. Offers opinion of what is going on and names if possible

61. Reveals rationale for opinion

62. Explains causation, seriousness, expected outcome, short and long-term consequences

63. Elicits patient’s beliefs, reactions, concerns re opinion

Negotiating mutual plan of action

64. Discusses options eg, no action, investigation, medication or surgery, non-drug treatments (physiotherapy, walking aides, fluids, counselling, preventive measures)

65. Provides information on action or treatment offered. Name steps involved, how it works benefits and advantages possible side effects

66. Obtains patient’s view of need for action, perceived benefits, barriers, motivation

67. Accepts patient’s views, advocates alternative viewpoint as necessary

68. Elicits patient’s reactions and concerns about plans and treatments including acceptability

69. Takes patient’s lifestyle, beliefs, cultural background and abilities into consideration

70. Encourages patient to be involved in implementing plans, to take responsibility and be self-reliant

71. Asks about patient support systems, discusses other support available

References:

1. Kurtz SM, Silverman JD, Draper J (1998) Teaching and Learning Communication Skills in Medicine. Radcliffe Medical Press (Oxford)
2. Silverman JD, Kurtz SM, Draper J (1998) Skills for Communicating with Patients. Radcliffe Medical Press (Oxford)

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Opening the consultation

1. Wash your hands and don PPE if appropriate
2. Introduce yourself to the patient including your name and role
3. Confirm the patient’s name and date of birth
4. Explain the reason for the consultation
5. Obtain consent for counseling and care

Ensure the correct position of the patient, lying with his head slightly raised, to reduce the load on the myocardium, limit physical activity and provide psychological peace.

Confirm the patient’s name and date of birth using the next questions:

Availability of a defibrillator

6. Provide the availability of a defibrillator
7. Start ECG monitoring

When caring for a patient with suspected acute myocardial infarction, a defibrillator should be available to the patient as early as possible, which may be needed for immediate defibrillation if necessary!

As soon as possible, it is necessary to start ECG monitoring, and provide constant monitoring of vital signs.

If the patient is unconscious or unresponsive, start a basic life support (BLS) algorithm in accordance with resuscitation guidelines.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint

• “What’s brought you in to see me today?”
• “What`s brought you along today?“
• “What`s brought you here?“
• “Tell me about the issues you’ve been experiencing.”
• “Can you tell me what seems to be bothering you?”
• “What seems to be the problem?”
• “What can I do for you?“

History of presenting complaint

Take additional information about the patient’s chest pain using the abbreviation SOCRATES. It is important to determine the time of onset of chest pain, its nature, localization, duration, irradiation, the effectiveness of nitroglycerin, provoking factors, comparison of this pain syndrome with previous ones.

SOCRATES

The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most commonly used to explore pain, but it can be applied to other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms.

8. Site: ask where the pain is
9. Onset: clarify when the pain first started and if it came on suddenly or gradually
10. Character: ask the patient to describe how the pain feels
11. Radiation: ask if the pain moves anywhere else
12. Associated symptoms: ask if there are any other associated symptoms
13. Time course: ask how the pain has changed over time
14. Exacerbating or relieving factors: ask if anything makes the pain worse or better
15. Severity: ask how severe the pain is on a scale of 0-10

Be polite, use for questions “Can you tell me…?” or “Can you describe…?”

For example:

• “Can you tell me where it hurts?”
• “Can you tell me what your pain is like?”
• “Can you tell me where she works?”
• “Can you tell me what your symptoms are?”

Adjectives for pain

Shortness of breath can accompany cardiac pain. For the assessment of shortness of breath ask the patient “Have you had any shortness of breath?“

Past medical history

16. Screen for conditions that may be associated with chest pain
17. Ask about other medical diagnoses and previous surgical history
18. Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance

Cardiovascular risk factors

When taking a cardiovascular history it’s essential that you identify risk factors for cardiovascular disease as you work through the patient’s history (e.g. past medical history, family history, social history).

Important cardiovascular risk factors include:

• Hypertension
• Hyperlipidemia
• Diabetes
• Family history of cardiac disease
• Smoking

If the patient has a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.

Examples of relevant medical conditions

Cardiovascular disease:

• Hypertension
• Hyperlipidemia
• Angina
• Myocardial infarction
• Obesity
• Chronic kidney disease
• Atrial fibrillation
• Stroke
• Peripheral vascular disease
• Rheumatic fever

Respiratory disease:

• Pneumonia
• Pneumothorax
• Pulmonary embolus

Gastrointestinal disease:

• Gastro-oesophageal reflux
• Oesophageal spasm

Drug history

19. Ask the patient is currently taking any prescribed medications or over-the-counter remedies
20. Ask the patient if they’re experiencing any side effects from their medication

Medication examples

Medications commonly prescribed to patients with medical conditions relevant to chest pain:

• Anticoagulants (e.g. pulmonary embolism)
• Antiplatelets (e.g. coronary artery disease)
• Statins (e.g. coronary artery disease)
• Glyceryl trinitrate spray (e.g. angina, oesophageal spasm)
• Calcium channel blockers (e.g. hypertension)
• ACE inhibitors (e.g. hypertension)
• Antibiotics (e.g. pneumonia)
• Colchicine (e.g. pericarditis)

Physical examination

21. Assessment of general condition and vital functions according to the ABCDE algorithm
22. Visual assessment of the color of the skin, the presence of swelling of the cervical veins, and edema.
23. Assessment of the state of the cardiovascular system.
24. Assessment of the state of the respiratory system.
25. Pulse oximetry to determine blood oxygen saturation (normal ≥ 95%).
26. Oxygen therapy (supporting saturation over 94-95%).

Assessment of the general condition and vital functions according to the ABCDE algorithm (A – airway patency, B – breathing, C – blood circulation, D – impaired state of consciousness, E – additional information);

Visual assessment of the color and moisture of the skin, the presence of swelling of the cervical veins, edema;

Assessment of the state of the cardiovascular and respiratory system of the patient.

Check the patient’s respiratory rate:

The normal respiratory rate is 12-20 breaths per minute. Patients with ACS may have tachypnea in an attempt to increase myocardial tissue oxygenation.

Check the patient’s oxygen saturation (SpO2):

The normal SpO₂ range is 94-98% in healthy individuals and 88-92% in COPD patients at high risk of CO₂ retention.

Hypoxemia may occur due to heart failure and secondary pulmonary edema.

Oxygen therapy at a saturation of 95% is carried out with humidified oxygen using a mask or through a nasal catheter at a rate of 3-5 l/min.

Auscultation of the lung sounds

Wheezing or crepitus on auscultation may be a sign of pulmonary edema due to impaired cardiac function. If the patient is conscious, sit him upright. To increase oxygen saturation, a mask with an oxygen flow rate of 15 liters can be used. If the patient has COPD and a history of CO₂ retention, switch to a Venturi mask as soon as possible and properly titrate oxygen.

A decrease in air intake from both sides indicates the need for emergency care.

Pulse

Assess the patient’s pulse:

• Tachycardia is a common sign of ACS.
• Bradycardia is a late sign and often precedes cardiac arrest.

Blood pressure

Assess the patient’s blood pressure:

• Patients may have hypertension due to increased sympathetic activity and pain.
• Hypotension is a late sign and means heart failure.

Auscultation of heart sounds

Identification of pathological heart murmurs.

If the patient has a reduced level of consciousness, review the patient’s medications for drugs that can cause a decrease in the level of consciousness (eg, opioids, sedatives, anxiolytics, insulin, oral hypoglycemic drugs).

Intravenous access

27. Intravenous access
28. Starting the infusion of Ringer’s lactate solution

Peripheral vein catheterization (providing intravenous access); initiation of Ringer’s lactate solution.

Registration of a 12-channel ECG

29. Recording ECG
30. Assess the presence/absence of pathological ST-elevation according to formal STEMI criteria;
    • Exclusion of other causes of benign ST-elevation in the presence of such ST-elevation – to exclude a possible non-coronary or acute coronary origin: early ventricular repolarization syndrome, left ventricular aneurysm, secondary ST-changes in LVH, recording artifacts, and others;
    • Assessment of additional ECG patterns and conditions that may be caused by critical coronary artery occlusion (STEMI-equivalents) – in the absence of ST-elevation – make sure that there are no other signs of coronary artery occlusion (STEMI equivalents);
31. Identification of the localization of myocardial ischemia

Assess for the presence of right ventricular myocardial infarction

ECG recording and evaluation must be carried out within at least 8-10 minutes (from first medical contact to diagnosis)!

ECG recording should not be given priority over providing emergency care if necessary (resuscitation)!

After the ECG recording an assessment should made of the presence of ST segment elevation and other ECG patterns associated with critical occlusion of the coronary arteries.    

  Pathological ST segment elevation is considered:

• new ST segment elevation in two consecutive limb leads ≥0.1 mV (≥1 mm)
• elevation
  • ≥0.2 mV in men ≥40 years old, ≥0.25 mV in men <40 years old in leads V2-V3,
  • ≥1.5 mV in women (≥ 1.5 mm) in leads V2-V3.
• In patients with inferior wall myocardial infarction (ST-segment elevation in II, III, AVF), it is recommended to record the right precordial leads (V3R and V4R) to exclude ST-segment elevation, which indicates right ventricular myocardial infarction.

In patients with inferior wall myocardial infarction (ST-segment elevation in II, III, AVF), it is recommended to record the right precordial leads (V3R and V4R) to exclude ST-segment elevation, which indicates right ventricular myocardial infarction.

When evaluating elevation, if there is elevation in II, III, avF leads, and if there is elevation in V4R, do not prescribe nitroglycerin!

If ST segment depression is detected in leads V₁-V₃, additionally take an ECG in V₇-V₉

Patients with STEMI usually have acute chest pain and sustained (>20 minutes) ST-segment elevation.

ST-elevation is a sign of complete occlusion of the epicardial coronary artery by a thrombus, which causes immediate myocardial death in the affected area of ​​the myocardium::

• Anterior: V1-V4
• Lower: II, III, aVF
• High lateral: I, aVL
• Low lateral: V5, V6
• Posterior: dominant R wave in V1-3 with ST depression in V1-3 (mirror image of anterior MI)

In the absence of characteristic ECG signs against the background of clinical manifestations of ACS, it is necessary to repeat the ECG registration with an interval of 20-30 minutes, paying attention to the presence of sharp T waves, which may precede ST segment elevation;

Once the electrodes are positioned and the wires are properly attached, the patient should be covered with a sheet for moral purposes.

However, traditional STEMI criteria often fail us, as more than 30% of cases of acute coronary occlusion are misclassified and interpreted. In addition, the STEMI/NSTEMI paradigm depends on ST elevation as defined by millimeter criteria, however, many occlusive myocardial infarctions (OMIs) do not have ST elevation at all.

In the current paradigm of STEMI and NSTEMI, 25–30% of patients with STEMI have an unrecognized acute total occlusion (OMI) on delayed angiography (24 hours after symptom onset) and is twice as high in patients with STEMI without OMI (MI without occlusion or NOMI). Conversely, 15–35% of catheter labs are activated through probable STEMI criteria that are false positive and unsupported by angiographic assessments of causative coronary artery disease.

«NSTEMI» – 25% false negative (skipping occlusions with 2x mortality)
«STEMI» – 15-35%  false positive (iatrogenic harm and waste of resources)

Assessment of additional ECG patterns and conditions that may be accompanied by critical coronary artery occlusion

ECG signs suggestive of coronary artery occlusion in the absence of ST-elevation have long been known. They are called “STEMI equivalents”:

• LBBB combined with Sgarbosa’s original/modified criteria
• Posterior MI
• ST-elevation in aVR
• Pattern De Winter
• Wellens Syndrome
• Sharp T waves
• Pacemaker rhythm combined with Sgarbosa’s original/modified criteria

It is also known that so-called benign (non-ischemic) ST-elevation can occur, for example:

• syndrome of early repolarization of the ventricles;
• recording artifacts simulating ST segment elevation;
• secondary ST changes against the background of LV myocardial hypertrophy, LBBB;
• imitation of ST deviations due to the superimposition of waves of atrial fibrillation/trembling, etc.

The algorithm for differential diagnosis depends on the presence (Table 2.) or absence of ST segment elevation (Table 3.), which meets the STEMI criteria.

Table 2. ST-elevation meeting STEMI criteria

Table 3. Absence of ST-elevation that meets STEMI criteria

A complex display of the discussed algorithm is presented in the images:

Therefore, ECG data can recognize coronary occlusion without ST-segment elevation (“STEMI equivalents”), and also be able to distinguish ST-elevation in acute coronary occlusion from elevation due to other causes (early ventricular repolarization syndrome, ST artifacts, subacute stage acute myocardial infarction, that is, with conditions that do not require thrombolysis or emergency coronary angiography.

Express test for the determination of cardiac troponin, myoglobin, creatine phosphokinase-MB, if possible

32. The timing of the increase in markers of myocardial damage
33. Analysis of other causes that may lead to increased markers of myocardial necrosis

The timing of the increase in markers of myocardial necrosis is presented in the table. It should be noted that the levels of Myoglobin and creatine phosphokinase, the creatine phosphokinase-MB (CPK-MB) isoform, are the first to increase.

Other causes of increased markers of myocardial necrosis

There are many causes of elevated troponin levels, including:

• Myocardial infarction
• Tachy/bradyarrhythmias
• Aortic dissection
• Severe aortic valve disease
• Hypertrophic cardiomyopathy
• Severe respiratory failure
• Severe anemia
• Coronary spasm
• Heart failure
• Takotsubo cardiomyopathy
• Sepsis
• Kidney failure
• Stroke
• Subarachnoid hemorrhage

Preliminary diagnosis

34. Criteria for ACS with ST-segment elevation (STEMI)
35. STEMI Equivalents
36. Localization
37. Killip score

Classification of acute heart failure Killip

Interpretation:

* From Khot 2003 who combined class III/IV due to the relatively smaller number of patients in class IV (0.3% of patients).

** From Killip 1967. This classification was developed as early as the 1960s, before being introduced into the clinical practice of reperfusion therapy (thrombolytics, PCI); however, since then, several studies have shown that the Killip classification still predicts mortality for both STEMI and NSTEMI. However, there is certainly a significant decrease in mortality compared to the original study.

Drug therapy (basic)

38. Acetylsalicylic acid
39. Anticoagulant
40. Nitroglycerin
41. Beta-blocker
42. Administering solutions as needed
43. Pain relief
44. Midozalom administration for cocaine-induced STEMI
45. Concomitant therapy as needed

Evaluation of the door-balloon time (the choice of further reperfusion strategy aimed as soon as possible to restore the coronary blood flow in the infarct-dependent artery)

46. Primary PCI
47. Hospital thrombolysis followed by PCI

Evaluation of the door-balloon time (the choice of further reperfusion strategy aimed as soon as possible to restore the coronary blood flow in the infarct-dependent artery)

• Primary PCI
• Hospital thrombolysis followed by PCI

If the criteria for ACS are met, the patient should be taken to the nearest reperfusion center as soon as possible!

When providing medical care to a patient with acute coronary syndrome with ST-segment elevation or its equivalent, the distance to the center of percutaneous coronary intervention is assessed.

The optimal method of reperfusion therapy for ACS with ST-segment elevation is percutaneous coronary intervention (PCI). Primary PCI should be performed as early as possible, preferably within 60-90 minutes (in high-risk cases in patients with large anterior myocardial infarction, preferably no later than 60 minutes). If it is impossible to transport the patient to the PCI center within 60-90 minutes, pre-hospital thrombolysis is recommended in the absence of contraindications.

If the time from the onset of pain is less than 90 minutes and the time to transport the patient to the center is <120 minutes, the patient should be immediately transported to the PCI center without prior thrombolysis.

Scheme of patient with STEMI transportation (ACS with ST-segment elevation)

Algorithm for providing assistance at the prehospital stage

• An initial PCI is warranted within the first 3-24 hours.
• Don’t forget the golden hour rule.
• Reperfusion of the balloon door is desirable in less than 60 minutes.
• Total ischemic time – the time from symptom onset to reperfusion – preferably less than 120 minutes.

Call the nearest reperfusion center

48. Activation of the intervention team of the reperfusion center

If the patient meets STEMI criteria or STEMI equivalents, then the patient is a priority patient requiring immediate notification to the nearest reperfusion heart center to allow the hospital to prepare.

In some countries, there is a verbal statement called “STEMI ALERT” indicating that the patient meets the criteria for acute coronary syndrome with ST-segment elevation (STEMI).

Based on the report of the emergency doctor, the doctor on the duty at the hospital, who is also responsible for communication with the emergency medical service, informs and activates the team of interventional cardiologists.

P2Y12 receptor inhibitor prescription depending on the chosen strategy of reperfusion therapy

49. Choice of P2Y12 inhibitor for medical care

P2Y12 receptor inhibitors: pharmacological properties

The use of P2Y12 antagonists in acute coronary syndrome (ACS) has potential advantages: reduction in the incidence of intraprocedural and postprocedural stent thrombosis, and reduction of periprocedural myocardial infarction.

Clopidogrel, prasugrel, or ticagrelor are the most commonly used P2Y12 receptor antagonists.

Clopidogrel is an irreversible P2Y12 receptor antagonist. The onset of action is dose-dependent (loading dose 600 mg versus loading dose 300 mg) with onset 2-6 hours later. This dynamic makes clopidogrel less effective in preventing stent thrombosis before PCI.

Prasugrel is another irreversible oral P2Y12 antagonist. Its onset of action is faster compared to clopidogrel (30 minutes – 4 hours versus 2-6 hours).

Ticagrelor is a reversible oral P2Y12 antagonist that, unlike clopidogrel and prasugrel, does not require in vivo conversion to an active metabolite.

Therefore, the onset of action is much faster (30 minutes – 2 hours). Ticagrelor has been approved for use in patients with ACS (both NSTEMI and STEMI).

Loading dosage of ticagrelor 180 mg.

Carrying out thrombolytic therapy as needed

50. Criteria for selecting patients for thrombolytic therapy
51. Evaluation of success criteria for fibrinolytic therapy
52. Choice of the drug for thrombolysis
53. Assessment of absolute contraindications for thrombolysis
54. Assessment of relative contraindications for thrombolysis

Prehospital thrombolysis

Criteria for selecting patients for thrombolytic therapy:

• diagnosis of STEMI (ACS with ST-segment elevation);
• symptoms onset 12 hours;
• lack of opportunities for providing PCI within up to 90 minutes from the first medical contact with the patient to the introduction of the balloon;
• absence of contraindications to thrombolysis;
• availability of informed consent of the patient.

An important criterion for the success of fibrinolytic therapy is the reduction of ST-segment elevation by at least 50% within 60-90 minutes from the start of fibrinolytic administration.

Before the introduction of streptokinase and alteplase, a bolus of heparin 5000 IU IV is recommended.

If fibrinolytic therapy is necessary, preference is given to fibrin-specific drugs.

Contraindications for thrombolysis:

It is necessary in the first 24 hours from the onset of symptoms of myocardial infarction to transfer the patient after fibrinolytic therapy to the hospital with PCI opportunities.

Transportation to the nearest reperfusion center

55. Analysis of delays in the medical care of a patient with acute coronary syndrome
56. Monitoring of vital signs during the transfer
57. Pain management as needed
58. Reporting in the emergency department of the hospital during the patient’s hospitalization

A generalized algorithm for transporting a patient with ST-segment elevation ACS is presented below.

Note: EMS – emergency medical service, PCI – percutaneous coronary intervention

Every patient with ACS with ST-segment elevation after receiving emergency care at the prehospital stage should be immediately admitted to the hospital.

At the same time, hospitalization in a healthcare facility with the possibility of emergency percutaneous coronary intervention (PCI) is an absolute priority. Unfortunately, this possibility is not always available, and sometimes patients are admitted to healthcare facilities without this possibility.

When transporting patients, it is recommended to carefully monitor all vital signs, and, most importantly, to record a series of ECGs – preferably every 15 minutes (rather than an hour or two), if possible, perform a troponin test. Hospital physicians should be notified that the arrival of such a patient is being prepared so that they can activate the entire reperfusion center team and prepare the catheter laboratory for intervention. When hospitalized in a hospital, it is necessary to continue to record ECG series and evaluate troponin in dynamics, if possible, perform an Echo-ECG.

In the management of the patient with ST-segment elevation, delay reduction is critical, as early reperfusion is critical and has been proven to improve the prognosis of these patients.

• Patient delay – the delay between the onset of symptoms and the initial medical contact.
• The delay between initial medical contact and diagnosis – is the time required to record the first ECG. The goal should be to get this delay down to 10 minutes or less – preferably 8 minutes.
• System delay – the delay between the initial medical contact and reperfusion therapy (initial medical contact before the guidewire is inserted into the infarct-dependent artery).
  • If the reperfusion strategy has chosen primary percutaneous intervention, then the goal should be to reduce system delay to ≤90 min, and in high-risk cases with large anterior infarction and symptoms within 2 hours, this time should be reduced to less than 60 min).
  • If reperfusion therapy is fibrinolysis, the goal is to reduce this delay (primary medical contact to the needle) to ≤30 min.
• Total ischemic time. From the patient’s point of view, the delay between the onset of symptoms and the provision of reperfusion therapy (either onset of fibrinolysis, or insertion of a guidewire into an infarct-dependent artery) is a total ischemic time that should be minimized as much as possible (preferably less than 120 minutes).

The graphic scheme of time delays is shown in the figure:

When reporting in relation to the patient to the duty cardiologist of the emergency medical center in the emergency department of the hospital during the patient’s hospitalization:

• Complaints of the patient;
• Data of the physical examination at the time of FMC and during transportation;
• Identified ECG changes;
• Provision of ECG archives recorded during FMC and transportation of the patient to the hospital;
• Amount of care provided and patient response to the treatment;
• Provision of relevant records of the patient’s medical history.
  

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Date

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• Opening the consultation

Wash your hands and don PPE if appropriate

Introduce yourself to the patient including your name and role

Confirm the patient's name and date of birth

Explain the reason for the consultation

Obtain consent for counseling and care

• Availability of a defibrillator

Provide the availability of a defibrillator

Start ECG monitoring

• Presenting complaint

Use open questioning to explore the patient’s presenting complaint

• History of presenting complaint

Site: ask where the pain is

Onset: clarify when the pain first started and if it came on suddenly or gradually

Character: ask the patient to describe how the pain feels

Radiation: ask if the pain moves anywhere else

Associated symptoms: ask if there are any other associated symptoms

Time course: ask how the pain has changed over time

Exacerbating or relieving factors: ask if anything makes the pain worse or better

Severity: ask how severe the pain is on a scale of 0-10

• Past medical history

Screen for conditions that may be associated with chest pain

Ask about other medical diagnoses and previous surgical history

Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance

• Drug history

Ask the patient is currently taking any prescribed medications or over-the-counter remedies

Ask the patient if they’re experiencing any side effects from their medication

• Physical examination

Assessment of general condition and vital functions according to the ABCDE algorithm

Visual assessment of the color of the skin, the presence of swelling of the cervical veins, and edema

Assessment of the state of the cardiovascular system

Assessment of the state of the respiratory system

Pulse oximetry to determine blood oxygen saturation (normal ≥ 95%)

Oxygen therapy (supporting saturation over 94-95%)

• Intravenous access

Intravenous access

Starting the infusion of Ringer's lactate solution

• Registration of a 12-channel ECG

Recording ECG

Assess the presence/absence of pathological ST-elevation according to formal STEMI criteria

Exclusion of other causes of benign ST-elevation in the presence of such ST-elevation – to exclude a possible non-coronary or acute coronary origin: early ventricular repolarization syndrome, left ventricular aneurysm, secondary ST-changes in LVH, recording artifacts, and others

Assessment of additional ECG patterns and conditions that may be caused by critical coronary artery occlusion (STEMI-equivalents) – in the absence of ST-elevation - make sure that there are no other signs of coronary artery occlusion (STEMI equivalents)

Identification of the localization of myocardial ischemia

Assess for the presence of right ventricular myocardial infarction

• Express test for the determination of cardiac troponin, myoglobin, creatine phosphokinase-MB, if possible

The timing of the increase in markers of myocardial damage

Analysis of other causes that may lead to increased markers of myocardial necrosis

• Making preliminary diagnosis

Criteria for ACS with ST-segment elevation (STEMI)

STEMI Equivalents

Localization

Killip score

• Drug therapy (basic)

Acetylsalicylic acid

Anticoagulant

Nitroglycerin

Beta-blocker

Administering solutions as needed

Pain relief

Midozalom administration for cocaine-induced STEMI

Concomitant therapy as needed

• Evaluation of the door-balloon time (the choice of further reperfusion strategy aimed as soon as possible to restore the coronary blood flow in the infarct-dependent artery)

Primary PCI

Hospital thrombolysis followed by PCI

• Call the nearest reperfusion center

Activation of the intervention team of the reperfusion center

• P2Y12 receptor inhibitor prescription depending on the chosen strategy of reperfusion therapy

Choice of P2Y12 inhibitor for medical care

• Carrying out thrombolytic therapy as needed

Criteria for selecting patients for thrombolytic therapy

Evaluation of success criteria for fibrinolytic therapy

Choice of the drug for thrombolysis

Assessment of absolute contraindications for thrombolysis

Assessment of relative contraindications for thrombolysis

• Transportation to the nearest reperfusion center

Analysis of delays in the medical care of a patient with acute coronary syndrome

Monitoring of vital signs during the transfer

Pain management as needed

Reporting in the emergency department of the hospital during the patient's hospitalization

Total

Result:

Total: 0 / 62

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