Approach to Chest Pain Flashcards
Non-Emergent Chest Pain
Musculoskeletal (costrochondritis) GI (reflux esoph.) Cardiac (stable angina, MI) Psychiatric Pulmonary Other
Killer Chest Pains
Acute Coronary Syndrome
Pulmonary Embolism
Aortic Dissection
Tension Pneumothorax
Common Cardiac Causes of Chest Pain
Angina MI Aortic valve disease Hypertrophic or congestive cardiomyopathy Aortic dissection Pericarditis Mitral valve prolapse
Angina Pectoris
After eating, cold weather, carrying weight,w alking up stairs
Substernal chest pain with pain radiating left down the arm
Physical Signs in Acute CAD
Pallor Sweating Anxiety Tachycardia Rise in blood pressure S4 gallop (stiff heart ventricle) Mitral regurgitation murmur Paradoxically split S2 Pulsus alternans
Acute Coronary Syndrome
Unstable angina
NSTEMI
STEMI
Give these patients anti-inflammatories and statins
EKG Features of Acute Infarction
Elevated ST segments
Inverted T waves
Development of Q waves (within 12 hours)
EKG Imposters
Pericarditis
J-Point elevation
W-P-W Syndrome
EKG Limitations
LBBB
Permanent pacemaker
Posterior infarction: reciprocal changes in anterior leads (depressed ST segments, tall upright T wave, prominent R waves)
Troponin
Specific for cardiac injury
Most sensitive when you take it out to 24 hours
NOT AN EARLY MARKER (no elevated in first few hours)
Remains elevated for many days
Stable Angina
Occurs at a predictable amount of energy expenditure or emotion
Goes away with sublingual nitro
Stress Testing
Evaluation of chest pain
Estimating progress and severity of disease
Evaluation of therapy
Screening for latent coronary disease
Evaluation of arrhythmias
ST depression/flattening indicates ISCHEMIA
Pericarditis
Continuous chest pain and fever
Feels better when standing or sitting forward (lets heart hang)
ST Elevation everywhere
Aortic Stenosis
CHF, Syncope, Angina pectoris
If asymptompatic the patient can die suddenly
Creates pressure gradient between LV and aorta
LVH and angina (muscle demand is greater than blood supply)
IHSS
Idiopathic hypertrophic subaortic stenosis
Marked LVH with asymmetrical hypertrophy of IV septum
Dynamic obstruction of LV outflow
Myocardial fiber disarray
Noncardiac causes of chest pain
GI
GERD
Diffuse esophageal spasm
Cholecystitis and cholelithiasis
Noncardiac causes of chest pain
Pulmonary
Pulmonary hypertension
Pneumothorax
Pulmonary embolism
Noncardiac causes of chest pain
Emotional
Anxiety states (hyperventilation) Depression
Noncardiac causes of chest pain
Neuromusclar
Herpes zoster
Cervical arthritis
Chest wall pain and tenderness
Aortic Dissection
Cataclysmic pain onset Tearing, stabbing, tendency to migrate Anterior thorax (proximal) Interscapular (distal) Pulce deficit and aortic regurg, nuero defects like CVA, paraparesis, peripheral neuropathy (proximal)
Pulmonary Embolism
Severe hypoxia or death
Infarction or death of lung tissue
D-dimer test will be elevated when there is activation of thrombin to form crosslinked fibrin and fibrinolysis
Negative predictive value - helps rule out PE
Pneumothorax
Air in plural space
Spontenous
Tension pneumo can be fatal
Tension pneumothorax
Progressive deterioration of a simple pneumothorax
Formation of one-way valve at the point of rupture
Complete collapse of the lung
