Adams: Chest Pain

Question 1

What is the differential for chest pain?

Answer 1

Anxiety
aortic stenosis
asthma
cardiomyopathy
esophagitis
gastroenteritis
hypertensive emergency
myocarditis
pericarditis
cardiac tamponade
aortic dissection
pulmonary embolism

Question 2

What is the classical presentation for chest pain?

Answer 2

1. Pt presents in AM with substernal achy pressure pain that radiates to anterior neck, shoulders, left arm and back.
2. SOB
3. Nausea
4. Diaphoresis

Question 3

What percentage of patients have “chest pain”

Answer 3

about 50%

Question 4

What are risk factors for chest pain?

Answer 4

past hx of CAD
smoker
HTN
elevated cholesetrol
diabetes
family hx of coronary disease
(father< 55, mother < 65)
elevated CRP

Question 5

What population often presents with atypical symptoms such as: SOB, syncope, stroke, palpitation, indigestion, weakness?

Answer 5

women

Question 6

What is UA/NSTEMI?

Answer 6

Unstable angina/non ST elevation myocardial infarction

Question 7

What is STEMI?

Answer 7

ST elevation myocardial infarction

Question 8

What is angina?

Answer 8

When oxygen demand is greater than the oxygen being delivered to the cardiac muscle. It leads to ischemia.

Question 9

How long does angina usually last?

Answer 9

Less than 30 mins

Question 10

What is stable angina?

Answer 10

Can be frequent and still STABLE

Question 11

What is prinzmetal’s angina?

Answer 11

occurs at rest, often at night, and rarely with exercise

Vasospasm
associated with ST elevations

Question 12

What is unstable angina?

Answer 12

1. Increased duration, frequency and intensity of angina
2. new associated symptoms
3. occurs with increasingly less activity or at rest.

Question 13

Why do you need to be worried about unstable angina?

Answer 13

10% of people will have an MI in 7 days

Question 14

How is angina graded?

Answer 14

I-IV

I- ordinary physical activity doesn’t cause it only strenuous
II- slight limitation of ordinary activity
III- marked limitations of ordinary physical activity
IV- inability to carry on any physical activity without discomfort, may be present at rest

Question 15

What is the criteria for defining an MI?

Answer 15

Elevated troponin and at least one of the following:

1. sxs of ischemia
2. Q wave development
3. New ST/T wave changes/new LBBB
4. intracoronary thrombus
5. Loss of cardiac wall

Question 16

What percent of MIs have normal EKGs?

Answer 16

1/3!

Question 17

Why is a posterior MI unique?

Answer 17

It is the BACK of the heart so ST elevations actually appear as depressions.

Question 18

What does a STEMI look like on an EKG?

Answer 18

Greater than 1 BOX in all leads excepts V2/V3 it must be greater than 2 boxes.

Question 19

What does an NSTEMI look like on an EKG?

Answer 19

1. Horizontal or downward sloping ST depression in 2 leads

AND/OR

2. T wave inversion with prominent R wave in 2 leads

Question 20

How long does troponin last after an MI?

Answer 20

Up to 2 weeks

Question 21

What is there the lowest sensitivity for troponin after an MI?

Answer 21

only 50% at 3 hrs

Question 22

What will give a false positive on a troponin test?

Answer 22

atrial fib
sepsis
chronic kidney disease

Question 23

What is CPK MB a sign of?

Answer 23

Reinfarction

Question 24

When might you rule out cardiac disease?

Answer 24

1. normal EKG (or no change)
2. cardiac enzymes
3. another plausible diagnosis

Question 25

What is the most important consideration when making a diagnosis of MI?

Answer 25

the HISTORY

Question 26

What is low risk management of ACS?

Answer 26

ASA

observation w/ repeat troponin in 6-12 hrs

Question 27

What is moderate to high risk management for ACS?

Answer 27

nitro
heparin
repeat troponin 6-12 hrs

Question 28

What is used to treat a UA/NSTEMI?

Answer 28

PCI (percutaneous coronary intervention –better than TPA)

medications

Question 29

What is used to treat a STEMI?

Answer 29

1. fibrinolytics (tpa, reteplase)
2. PCI w/ dilation and stinting
3. CABG
4. medications

Question 30

When do you use oxygen?

Answer 30

If pt is hypoxic and O2 sat is <94%.

**It can be dangerous to give O2 to a NORMOXIC pt

Question 31

When do you use nitro?

Answer 31

Angina and selectiely MI

Question 32

What do you not want to use nitro to treat? Why?

Answer 32

RIGHT ventricular infarct (occurs in 50% of inferior MIS)

It reduces preload and causes BP to drop

Question 33

When do you use morphine?

Answer 33

For pain that is unresponsive to nitro and is a stopgap.

It can cause hypotension.

Question 34

What is the best drug used to treat MI?

Answer 34

Aspirin!!

Question 35

What does aspirin do?

Answer 35

It’s an antiplatelet!

Question 36

What should be given to a pt w/ MI if they can’t take aspirin?

Answer 36

Clopidogel

Used in all pt less than 75 yrs with UA/NSTEMI or STEMI

Question 37

What does clopidogel do?

Answer 37

Inhibits ADP dependent activation of GpIIb/IIIa complex ( a necessary step for platelet aggregation)

Question 38

What anticoagulents are used for MI?

Answer 38

1. UFH
2. Enoxaparin
3. Fondaparinux
4. Bivalirudin (direct thrombin inhibitor)

Question 39

When are glycoprotein IIb/IIIa inhibitors used? What do they do?

Answer 39

In conjunction with PCI

They inhibit the integrin GPIIb/IIIa receptor in the platelet membrane and inhibt the final common pathway to activation of platelet aggregation.

Question 40

What are common Glycoprotein inhibitors?

Answer 40

abciximab
eptifibatide
tirofiban

Question 41

What drug is important to use in the first 24 hours in pts with CHF or LV ejection < 40% and no hypotension?

Answer 41

ACE inhibitors

Question 42

What drug can cause an 11% reduction in mortality if used in the first 24 hours following MI?

Answer 42

Beta blockers