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Hailey CRRAB I > Adams "Chest Pain" > Flashcards

Adams "Chest Pain" Flashcards

1
Q

Heart shows something is wrong by:

A

chest pain

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2
Q

Differential of Chest pain

A 
anxiety
ASS
asthma
cardiomyopathy
esophagitis
gastroenteritis
hypertensive emergency
myocarditis
pericarditis
cardiac tamponade
aortic dissection
PE
shingles
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3
Q

Brain says something is wrong by:

A

HA and vomiting

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4
Q

“Never let clothing stand between you and the diagnosis”

A

Shingles

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5
Q

“Doc, I think an elephant is on my chest and I am going to die!”

A

Classic MI presentation

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6
Q

ACS

A

Acute Coronary Syndrome

-non-cardiac disease
-stable angina
-unstable angina (60%
-definite ischemic event
STEMI 30%, NSTEMI 25%)

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7
Q

Unstable angina worries

A

hard to diagnose because no elevated troponin AND will go on to have an MI in next 10 days

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8
Q

MI Classic presentation

A

Hx: early AM presentation with substernal achy pressure
pain radiates to anterior neck, shoulders, left arm, and back
- “chest pain”
- dyspnea (SOB)
- nausea
- diaphoresis (sweating)

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9
Q

What percentage of MI presentations will have “chest pain?”

A

about 50%

  • the other 50% will have SOB, nausea, sweating or other weird symptom
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10
Q

Classic MI Qs to ask

A

RISK FACTORS

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11
Q

Risk Factors for MI

A
  • past hx of CAD
  • smoker
  • HTN
  • elevated cholesterol
  • family hx of CAD (mom died before
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12
Q

Typical physical exam findings of MI

A

*doesn’t lend much info most of the time

  • chest clear
  • RRR without murmur, S3, S4 or rub
  • abdomen soft, guaiac negative stool
  • no peripheral edema
  • diaphoretic skin
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13
Q

Alternative presenations of MI

A
  • no “pain”
  • SOB
  • sweaty
  • syncope
  • stroke
  • palpitation
  • indigestion
  • weakness
  • pain in referred areas, such as right arm/hand or abdomen

*use adjectives to help them describe their chest: heart burn? pressure? squeezing? burning? numbness?

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14
Q

Alternative presenations in populations…

A
  • syncope and weakness in elderly

- women, young, and elderly present atypical

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15
Q

Alternative physical

A

S3: LV dysfunction
S4: decreased LV compliance
new murmur: papillary muscle tear/dysfunction
CHF: crackles, hepatojugular reflux, leg edema

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16
Q

___ and ___ (of ACS) can look same initially on EKG

A

UA and NSTEMI look same initially on EKGs
vs.
STEMI

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17
Q

NSTEMI and q waves…

A

No Q wave MI

Q wave MI

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18
Q

STEMI and q waves…

A

No Q wave MI

Q wave MI**most

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19
Q

Angina

A
  • symptom rather than a diagnosis

- mismatch of oxygen demand and delivered oxygen to cardiac muscle –> ischemia (reversible)

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20
Q

How long does angina last

A

30 minutes = ischemia (no longer angina)

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21
Q

Types of angina

A
  • stable angina (can be very freq and still stable, less predictive of CAD in women)
  • prinzmetal’s (vasospasm, assoc with ST elevations, occurs at rest, often night, rarely with exercise)
  • unstable angina (increasing duration, freq, intensity, new associated symptoms, occur with increasly less activity and rest)

*10% of unstable angina will have MI in 7 days

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22
Q

grade I angina

A

“ordinary physical activity doesn’t cause angina” (walking, stairs, etc.)
angina occurs with strenuous, rapid or prolonged exertion at work or recreation

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23
Q

grade II angina

A

“slight limitation of ordinary activity”
occurs on walking or climbing stairs rapidly, walking uphill, walk/stair after meals, cold/wind, under emotional stress, few hours after awakening
*walking more than 2 blocks on level ground and climibng more than 1 flight of ordinary stairs at normal pace and normal conditions

24
Q

grade III angina

A

“marked limitations of ordinary physical activity”
angina occurs on walking
1-2 blocks on the level and climbing 1 flight stairs under normal conditions and normal pace

25
Q

grade IV angina

A

“inability to carry on any physical activity w/o discomfort - anginal symptoms may be present at rest.”

26
Q

Defining criteria of MI

A

elevation of TROPONIN and at least one of the following:

  • symptoms of ischemia
  • q wave development
  • new ST/T wave changes or new LBBB
  • intracoronary thrombus (angiogram or autopsy)
  • loss of cardiac wall (ECHO)
27
Q

EKG in MI

A
  • normal in 30% of early MI
  • compare to older EKGs
  • if inferior MI, can get right side leads EKG looking for RV infarct
28
Q

STEMIs and EKGs

A
  • *ST elevation >0.1mV (one box) in all leads BUT V2 and V3 >0.2mV (two boxes)
  • new LBBB (hard to diagnose because LBBB have ST elevation normally)
  • posterior MI: unique bc “back of the heart” infarct –> ST elevations appear as ST depressions
29
Q

NSTEMIs and EKGs

A
  • T wave inversion >0.1mV (one box) with prominetn R wave or R/S wave ratio >1 in two contiguous leads
  • ST depression >0.05mV in 2 contiguous leads
30
Q

Troponin

A
  • *take over time
  • low sensitivity early in MI (50% at 3 hours)
  • up to 7-10 days after MI
  • if normal at 6 hours, AMi can be excluded (unless very high risks, then get a 12 hours also)
  • false + = anything stressing the heart, such as a fib, sepsis, chronic kidney disease = troponin not specific to heart only
31
Q

High sensitivity troponin

A

NEW KID ON THE BLOCK
- more rapidly positive
higher sensitivity at price of lower specificity (inc SNOUT, low SPIN)
- can still be normal with unstable angina

32
Q

Other MI markers

A
  • CPK-MB/CPK-MD ratio with total CPK *no longer used
  • CRP: increase in mortality if elevated, but diagnostic/predictive value is not clear
  • myoglobin and CK-MB isoforms not used
33
Q

ECHO

A

specifically: if perform ECHO on patient with ongoing chest pain and find no wall motion abnormality –> low probability the chest pain is cardiac in origin
- prior heart disease –> show wall motion abnormality
- SNOUT: can be used to rule OUT if NORMAL** not an MI

34
Q

When can you send a patient home with chest pain?

A

“Management of patient depends on potential risk of having cardiac disease.”

*HISTORY THAT IS NOT CONCERNING = WILL ALLOW YOU TO SEND A PATIENT HOME
= decision to send patient home is based on Hx

35
Q

If have little chance of cardiac disease…

A

must have a plausible diagnosis upon discharge

  • normal EKG (or no change)
  • cardiac enzymges constant
  • document follow up
36
Q

If have possible cardiac disease…

A
  • let history drive you
  • use caution with: normal EKG, nitro trials, cocktails of lidocaine and antacid (10% MI will feel beter after gi cocktail), cardiac enzymes
  • admit/discharge (have diagnosis, clear patient instrux, early follow up)
37
Q

Treat low risk ACS

A
  • ASA
  • conservative observation
  • repeat troponin in 6-12 hours

*possibly repeat EKG before repeat troponin (don’t be shy to ask for repeat, can see changes, eg inc ST elevations)

38
Q

Treat moderate/high risk ACS

A
  • nitroglycerin
  • heparin
  • repeat troponin in 6-12 hours
  • possibly repeat EKG before repeat troponin (don’t be shy to ask for repeat, can see changes, eg inc ST elevations)
39
Q

Manage UA/NSTEMI

A
  • PCI (percutaneous coronary intervention) CATH LAB

- meds

40
Q

Manage STEMI (ST elevations or new LBBB)

A
  • fibrinolytics* (tPA, reteplase IF FIRST STAGES OF MI)
  • PCI with dilation and stinting
  • CABG (coronary artery bipass graft(s))
  • meds
41
Q

Give oxygen if…

A

hypoxic

*may be harmful if patient is normoxic (>94%): INCREASED MORBIDITY AND MORTALITY IF USE WRONGLY

42
Q

Nitroglycerin if…

A

angina and selecively for MI

  • not for RV ventricular infarct, it decreases preload and cause BP to drop
  • give NO to decrease preload for CHF
43
Q

Morphine if…

A

pain unresponsei to NO and is stopgap

*can cause hypotension

44
Q

What about MONA?

A

The Death of MONA

***AAAAA
Keep the A = ASPIRIN

45
Q

Antiplatelets

A

Aspirin***

Thienopyridines (CLOPIDOGREL) if unable to give aspirin, use in all patients less than 75 yo with UA/NSTEMI or STEMI

46
Q

Clopidogrel

A

inhibits ADP (adenosine 5-diphosphate) dependent activation of glycoprotein IIb/IIIa complex = INHIBITS PLATELET AGGREGATION

also: prasugrel, ticagrelor

47
Q

New MONA

A

Aspirin
Clopidogrel
send to cath lab

48
Q

Anticoagulants

A

UFH (unfactionated heparin)
Enoxaparin (low molecular weight heparin)
Fondaparinus (like Enoxaparin)
Bivalirudin (direct thrombin inhibitor)

49
Q

Give LMWH if…

A

DVT, PE

*can’t reverse, so don’t give in AMI

50
Q

GIve UFH if…

A

unfractionated heparin, can use acutely, can reverse

51
Q

Glycoprotein IIb/IIIa inhibitors

A

Abciximab, Eptifibatide, Tirofiban

  • use primarily in conjunction with PCI
  • best in acute STEMI when going to cath lab
  • inhibits integrin gp IIb/IIIa receptor in platelet membrane
    INHIBTS PLATELET AGGREGATION
52
Q

Manage in first 24 hours

A
  • ACE inhibitor
  • B blocker (have been shown to decrease mortality after MI)
  • (also aspirin, duh)

*start within first day or so

53
Q

Greatest impact on morbidity and mortality in presence of acute MI

54
Q

Tako-tsubo syndrome

A
  • “broken heart syndrome”
  • MI
  • heart loks like a luging balloon appearance
  • surge of stress hormones cause MI
  • chest pain
    elvated troponin
  • ECHO would support wall abnormal
  • HISTORY WILL HELP
  • vessels will be normal, heart itself just gets stressed
  • send to cath lab
55
Q

Myocarditis

A
  • 1/3 end up with significant heart issues…need transplant
  • causes: parvovirus, chagas
  • diffuse ST elevation***
  • super high troponin
56
Q

key points:

A
  1. offer other adjectives when eliciting a history
  2. not all patients have “chest pain”
  3. epigastric pain with no findings…consider cardiac ischemia
  4. got a lot of EKGs and repeat them
  5. ASA
  6. EKGs and labs should not be used to decide if a patient is sent home

Hailey CRRAB I (5 decks)

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