14. Chest Pain Flashcards
Clinical History
▸History is more useful than Physical Examination
▸Assess the setting in which chest pain occurs (most important)
Clinical History
What to ask about pain
▸Duration ▸Quality ▸Location ▸Radiation ▸Frequency ▸Alleviating or precipitating factors (exercise) ▸Associated symptoms
Clinical History
Specific pain characteristics
▸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
Clinical History
Signs and Symptoms of MI mnemotechnic
-PULSE- P Persistent chest pain U Upset stomach L Lightheadedness S Shortness of Breath E Excessive sweating
Physical Examination
Specific findings
▸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
Tests
▸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)
Tests
ECG
▸↑ST or Q waves: Acute MI
▸↓ST or T wave inversion: Ischemia
▸If ACS → Emergency Reperfusion (just with ECG)
Tests
CK-MB
▸↑ 4-6 hrs (peaks 12-24 hrs)
▸↓ 2-3 days
▸Doesn’t predict size, but detects early reinfraction
Tests
Troponins
▸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
Tests
CXR
▸Pneumothorax
▸Pneumomediastinum (esophageal rupture)
▸Pleural effusion
▸Infiltrates
▸Aortic dissection (widening of mediastinum)
▸Pulmonary embolism (↓lung volume or unilateral ↓vascular)
DDx
Noncardiovascular Disorders
▸Costochondritis (aching; reproduced with palpation)
▸GERD (Burning; relief with antiacids)
▸Peptic ulcer (Burning; epigastric pain worse 3 hrs after eating)
▸Gallbladder disease (burning, pressure)
DDx
Cardiovascular Disorders
▸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)
DDx
Pulmonary Disorders
▸Pulmonary embolus-infarction (pleuritic; respiratory symptoms)
▸Pulmonary HTN (pressure; signs of RV failure)
▸Pneumothorax (Pleuritic; sudden onset pain + dyspnea, ↓breath sounds)
Life-threatening causes mnemotechnia
-PET MAP- P Pulmonary Embolism E Esophageal rupture T Tamponade M MI / Angina A Aortic dissection P Pneumothorax
Tx
Initial management
▸O₂ (4L/min) ▸IV ▸Monitor ▸CXR (portable if unstable) ▸ECG ▸Enzymes
Tx
Acute MI
▸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
ACS Vs Stable Angina
▸Both have same symptoms
▸Stable Angina resolves with rest
Which are the ACS
▸Unstable Angina (UA)
▸NSTEMI
▸STEMI (≥1mm in 2 contiguous lib leads OR ≥2mm in 2 precordial leads)
▸Progressive: UA→NSTEMI→STEMI
ACS
Initial Management
▸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)
ACS
tPA facts
▸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
ACS
Angioplasty facts
▸Used when no improvement
▸Within the first 90 min in hospital
▸Before procedure:
▹GP IIb/IIIa receptor antagonist (abciximab, eptifibatide, tirofiban)
ECG
leads, areas and arteries
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
ECG
↑ST Vs ↓ST
↑ST = ischemia ↓ST = MI (give tPA)
Post MI Management
▸5-7 days
▸Stress test (not in CHF, Pre MI)
▹Negative: Tx Drugs
▹Positive: Catheterism
Home Tx:
▸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)
Complications Post MI
▸Erectile dysfunction (due to psichological, if Viagra → suspend nitrates)
▸Dysrhytmias (Bradicardia, Premature Beat, Tachyarrhythmias)
▸Conduction abnormalitites
▸Myocardial rupture
Prinzmetal Angina
▸Sudden coronary vasospasm ▸↑ST ▸Rest ▸Awaken from sleep ▸Dx: Angiography with ergonovine (triggers vasospasm) ▸TX: CCB or Nitrates
