14. Chest Pain

Question 1

Clinical History

Answer 1

▸History is more useful than Physical Examination

▸Assess the setting in which chest pain occurs (most important)

Question 2

Clinical History

What to ask about pain

Answer 2

▸Duration
▸Quality
▸Location
▸Radiation
▸Frequency
▸Alleviating or precipitating factors (exercise)
▸Associated symptoms

Question 3

Clinical History

Specific pain characteristics

Answer 3

▸Tightness heaviness, pressure: Stable angina / ACS.
▸Vagal reflexes (Nausea and vomiting): Inferoposterior wall ischemia
▸Pain >20-30 mins: MI
▸Responsive to nitrates: Transient ischemia / esophageal spasm
▸Worse with nitrates: GERD (open the sfinter ∴ ↑acid)
▸Sharp, knife-like: Less likely related to heart

Question 4

Clinical History

Signs and Symptoms of MI mnemotechnic

Answer 4

-PULSE-
P Persistent chest pain
U Upset stomach
L Lightheadedness
S Shortness of Breath
E Excessive sweating

Question 5

Physical Examination

Specific findings

Answer 5

▸Initial impression (most important)
▸Tachypnea + Tachycardia: Pulmonary Embolism
▸sBP ≠ 2 arms by 20mmHg: Aortic Dissection
▸Absence of pedal pulses: Aortic Dissection
▸Tenderness in same location as pain with palpation: Musculoskeletal
▸Heart sounds splitting wider with inspiration: Right bundle branch block or RV infraction
▸Asymmetric breath sounds: Spontaneous pneumothorax
▸S₃: CHF → Diuretic, β-blocker, ACEI

Question 6

Tests

Answer 6

▸ECG (Single most important test) - compare with previous
▸CK-MB (early Dx) repeat every 6-12 hrs
▸Troponins I and T (repeat every 6-12 hrs)
▸CXR (compare previous)

Question 7

Tests

ECG

Answer 7

▸↑ST or Q waves: Acute MI
▸↓ST or T wave inversion: Ischemia
▸If ACS → Emergency Reperfusion (just with ECG)

Question 8

Tests

CK-MB

Answer 8

▸↑ 4-6 hrs (peaks 12-24 hrs)
▸↓ 2-3 days
▸Doesn’t predict size, but detects early reinfraction

Question 9

Tests

Troponins

Answer 9

▸Specific for myocardial injury
▸Troponins > CK-MB: minor myocardial damage (microinfraction)
▸Troponins = CK-MB: Acute MI
▸↑2 weeks (late markers of recent acute MI)
▸Help to identify low risk px

Question 10

Tests

CXR

Answer 10

▸Pneumothorax
▸Pneumomediastinum (esophageal rupture)
▸Pleural effusion
▸Infiltrates
▸Aortic dissection (widening of mediastinum)
▸Pulmonary embolism (↓lung volume or unilateral ↓vascular)

Question 11

DDx

Noncardiovascular Disorders

Answer 11

▸Costochondritis (aching; reproduced with palpation)
▸GERD (Burning; relief with antiacids)
▸Peptic ulcer (Burning; epigastric pain worse 3 hrs after eating)
▸Gallbladder disease (burning, pressure)

Question 12

DDx

Cardiovascular Disorders

Answer 12

▸MI (pressure, tight, heavy, squeezing; >20 mins)
▸Myocarditis -Coxackie B Virus- (↑CK-MB, preceded by viral illness)
▸Angina (sharp; >2 but <10 min)
▸Pericarditis (sharp, pleuritic; pericardium not sensible ∴ is the pleura, precede by viral illness, worse with lying down and relieved by sitting up)
▸Dissecting aortic aneurysm (sharp, tearing; back)
▸Mitral valve prolapse (transient, midsystolic click murmur)

Question 13

DDx

Pulmonary Disorders

Answer 13

▸Pulmonary embolus-infarction (pleuritic; respiratory symptoms)
▸Pulmonary HTN (pressure; signs of RV failure)
▸Pneumothorax (Pleuritic; sudden onset pain + dyspnea, ↓breath sounds)

Question 14

Life-threatening causes mnemotechnia

Answer 14

-PET MAP-
P Pulmonary Embolism
E Esophageal rupture
T Tamponade
M MI / Angina
A Aortic dissection
P Pneumothorax

Question 15

Tx

Initial management

Answer 15

▸O₂ (4L/min)
▸IV
▸Monitor
▸CXR (portable if unstable)
▸ECG
▸Enzymes

Question 16

Tx

Acute MI

Answer 16

▸Initial management
▸ASA 162-325mg
▸Nitroglycerin 0.3mg SL q5min x 3
▸Morphine 2-5mg IV q5-30min if unresponsive to nitrate
▸Metoprolol 5 mg slow IV q5min x 3 (never with inferior wall MI)
▸LMWH 1mg/Kg SC bid
▸Thrombolytics or Angioplasty

Question 17

ACS Vs Stable Angina

Answer 17

▸Both have same symptoms

▸Stable Angina resolves with rest

Question 18

Which are the ACS

Answer 18

▸Unstable Angina (UA)
▸NSTEMI
▸STEMI (≥1mm in 2 contiguous lib leads OR ≥2mm in 2 precordial leads)
▸Progressive: UA→NSTEMI→STEMI

Question 19

ACS

Initial Management

Answer 19

▸ASA (↓morality)
▸Heparin (only UA and NSTEMI) (↓morality)
▸tPA (only STEMI) (↓morality)
▸β-Blocker (↓morality)
▸O₂
▸Morphin
▸Nitrate
▸ECG (changes in STEMI)
▸Cardiac enzymes (positive in NSTEMI & STEMI)
▸Angioplasty (only if no improvement)

Question 20

ACS

tPA facts

Answer 20

▸Thrombolytic drug
▸Best effect in ≤12 hrs of chest pain
▸Contraindications:
▹Qx, Melena, BP>180/100, Head trauma, Aortic dissection
▹If so → Angioplasty (within 90 min hospital)
▸Names:
▹Streptokinase (don’t give repeatedly due to alergenic)
▹Altepase
▹Reteplast
▹Tenecteplase

Question 21

ACS

Angioplasty facts

Answer 21

▸Used when no improvement
▸Within the first 90 min in hospital
▸Before procedure:
▹GP IIb/IIIa receptor antagonist (abciximab, eptifibatide, tirofiban)

Question 22

ECG

leads, areas and arteries

Answer 22

Inferior: II, III, aVF (Right coronary)
Anteroseptal: V₁-V₃ (Left Anterior Descending)
Anterior: V₂-V₄ (Left Anterior Descending)
Lateral: I, aVL, V₄-V₆ (Left Anterior Descending/Circumflex)
Posterior: V₁-V₂

Question 23

ECG

↑ST Vs ↓ST

Answer 23

↑ST = ischemia
↓ST = MI (give tPA)

Question 24

Post MI Management

Answer 24

▸5-7 days
▸Stress test (not in CHF, Pre MI)
▹Negative: Tx Drugs
▹Positive: Catheterism

Question 25

Home Tx:

Answer 25

▸ASA 81-162mg PO
▸Clopidogrel (if ASA not tolerated, or with stent)
▸β-blocker (indefinitely): Metoprolol 25-50mg, Atenolol 50-100mg
▸ACEI (if EF is normal (>40%), stop after 6 weeks)
▸Statins: Atorvastatin (stop if ↓LDL)
▸Nitrates (alleviate ischemia)

Question 26

Complications Post MI

Answer 26

▸Erectile dysfunction (due to psichological, if Viagra → suspend nitrates)
▸Dysrhytmias (Bradicardia, Premature Beat, Tachyarrhythmias)
▸Conduction abnormalitites
▸Myocardial rupture

Question 27

Prinzmetal Angina

Answer 27

▸Sudden coronary vasospasm
▸↑ST
▸Rest
▸Awaken from sleep
▸Dx: Angiography with ergonovine (triggers vasospasm)
▸TX: CCB or Nitrates