Approach to Chest Pain Flashcards
cardiac causes of chest pain
- CAD
- aortic valve disease
- pulmonary hypertension
- MVP
- pericarditis
- HOCM
- myocarditis
valvular causes of chest pain
aortic aneurysm or dissection
pulmonary causes of chest pain
- PE
- pneumonia
- pleuritis
- pneumothorax
neuro causes of chest pain
cervical nerve root
zoster
GIT causes of chest pain
- peptic ulcer
- GORD
- pancreatitis
- cholecystitis
how does an atheroma form
oxidised LDL taken up by macrophage that leads to in inflammatory cascade - endothelial dysfunction
non-modifiable risk factors for atherosclerosis
- age
- gender
- family hx
describe angina
A crushing retrosternal pain that is severe, may radiate to jaw and left arm. Can be associated with autonomic symptoms: diaphoresis, nausea and vomiting. Worse on activity and relieved by rest or nitrates
Life threatening conditions to rule out
- ACS
- aortic dissection
- pulmonary embolism
- tension pneumothorax
- pericardial tamponade
- mediastinal inflammation
manifestations of ACS
> MIs
angina
unstable angina
death
underlying cause of ACS
Atherosclerosis
- plaque disruption – platelet activation – occlusion
a. plaque rupture
b. plaque erosion
Initial evaluation in ACS
Typical angina
or
Atypical angina - some have silent
- old
- DM
- women
- renal failure
- dementia
HENCE: look at other risk factors if vague chest pain is presenting complaint
ACS + persistent ST elevation
STEMI
ACS + ST abnormalities with troponin changes
NSTEMI
ACS + ST abnormalities and normal troponin
unstable angina
normal ECG with troponin changes
NSTEMI
normal ECG and normal troponin, but presents with chest pain and ACS
Unstable angina
Initial therapy for chest pain
- suspect ACS
- do an ECG
> sublingual nitrates
> opiates ** ensure no resp depression
> O2 if required
> aspirin
> clopidogrel
why should STEMI be treated timeously
outcome worsens by each 15 minutes - EXTREMELY time sensitive. Hence, timely reperfusion is essential
how long does it take for troponin to elevate
after 4 hours from symptom onset - can last up to 2 weeks.
Early presentation will escape detection, hence must test after 3 hrs
is troponin specific for MI?
no - for myocardial damage ( many causes )
Indications for urgent invasive rx
- refractory angina
- recurrent angina with high risk ECG = deep ST depression or arrow head T-waves
- clinical HF or shock
- VF or VT
High risk patients
- hemodynamic instability
- risk in troponin
- other
–> refer to Cath lab
risk scores for urgent care
GRACE or TIMI
